Spine & Sports Medical Group429 Llewellyn Ave. Campbell, CA 95008
phone: 408-364-1616 • fax: 408-378-6775
Tip: Our Services page contains an overview of conditions we treat and procedures we perform.
Causes
The spinal column is complex. The spine consists of the vertebra, the discs, and the spinal cords and its nerves. In addition to the primary structures, the spine is held together by a complex structure of ligaments, tendons, and muscles. Injury or irritation of any of the primary components of the spine has the potential to cause spinal pain. The supporting structures (muscles, ligaments, tendons) in turn may go into spasm creating additional pain. In some patients the situation is complicated by stress and depression, which frequently accompany pain and can make pain worse.
Physicians can generally make a fairly accurate guess of where the source of pain based on the patient’s, physical examination, Xray, MRI, and EMG/NCS . However, in some cases, the source of pain is not obvious. The above tools cannot see the patient’s pain. MRI scans frequently are not helpful in these patients, as they may show only the normal age related changes that occur in most people, whether they have pain or not. The nerve supply to the spine is diffuse and overlapping, so a particular pain could have one of several possible causes. While diagnosing the exact source of pain may be difficult, if your doctor knows the source of your pain he or she may be able to treat you more effectively. This is particularly true if surgery is being considered.
Diagnosis
An alternative to relying only on the clinical evaluation and x-ray studies to diagnose the source of pain is diagnostic injections. These may be useful both in patients with nerve root pain and in patients with back or neck pain. At the time of a diagnostic injection we selectively inject individual structures of your spine with contrast dye and/or local anesthetic, and observe the effect this has on your pain. If you experience reproduction of your typical symptoms during an injection, that may be an indication that the structure being injected is the source of your pain. If your pain goes away, even for a short period of time, after we inject a specific structure with local anesthetic, that may also be an indication that the structure injected is the source of your pain.
Because the degree of pain relief that you experience immediately after a diagnostic injection is so important, following the injection you may be asked to perform certain maneuvers that usually increase your pain, to determine if that has changed. In addition to contrast dye and/or local anesthetic we often include a small amount of cortisone with diagnostic injections. The cortisone used may provide prolonged pain relief beginning one to two weeks after the injection. If you have such pain relief following a cortisone injection, that also may be important diagnostically. Examples of diagnostic injections include disc, facet, sacroiliac, sympathetic, and selective epidural or nerve root injections. Using injections, in conjunction with clinical information and imaging studies, we are able to diagnose the source of pain in approximately 75% of patients.
Treatment
In general there are four treatment options for patients with chronic spinal pain. Physical therapy can be effective for many people, particularly physical therapy that emphasizes activity and return to function. For patients that have pain despite physical therapy surgery can sometimes be effective. The success of surgery is highly dependent on an accurate diagnosis as to the source of pain. Another option for patients is to simply live with their pain as best as they can, sometimes with the assistance of pain medications or other methods such as acupuncture.
Another alternative for treating spinal pain is injections. If your doctor knows where your pain is coming from he or she may recommend a therapeutic injection. Therapeutic injections differ from diagnostic injections in that they are intended to treat pain, rather than diagnose its cause. Most therapeutic injections use local anesthetic and cortisone medications, although sometimes other substances or even heat can be applied. Examples of therapeutic injections include epidural, facet, sacroiliac, sympathetic injections, facet rhizotomy, and intradiscal electrothermal therapy.
Therapeutic injections have two potential benefits. The first is they may provide long term pain relief. The likelihood of significant, lasting pain relief after a therapeutic injection will vary according to the source of pain and the specific injection, but typically is in the 50%-60% range. The second potential benefit of a therapeutic injection is that even though it only provides short term relief of pain (e.g. 2-3 weeks), during that time other treatments such as physical therapy will be much more effective. The combination of the injection and additional treatments (as ordered by your doctor) may then lead to long term pain relief.
Risks, complications, and side effects
When done properly, spinal injection procedures are very safe. All of our procedures are done under x-ray guidance, both for safety reasons and to provide the greatest likelihood of success. However, with any medical procedure or treatment there are possible risks. Any time a needle is placed into the body there is a risk of bleeding. Usually, any bleeding that does occur after an injection is very minor. However, in rare circumstances bleeding can lead to a serious complication. To minimize this risk, we ask you to stop anti-inflammatories for 3 days prior to your procedure — aspirin for 7 days prior — and to notify us if you take blood thinning medications. Another complication that can occur with needle procedures is infection. The chance of getting a significant infection after any needle procedure is very low. However, with certain procedures involving disc injections (including discograms and intradiscal electrothermoplasty) if an infection did occur it could lead to a serious complication. For that reason, if you are having a disc injection antibiotics will be administered to you both intravenously and directly into the disc at the time of the procedure.
All of our procedures are performed using local anesthesia. Intravenous sedation may be required. It is possible to have allergic or other reactions to the medications used during the procedure, including the injection of contrast material or "dye" to make the x-ray image better and to make sure the injected medication will go to the right place. Most such reactions that do occur are minor, although serious complications are possible. For that reason it is important that you notify us of any medication allergies prior to the procedure.
Minor side effects are common after injection procedures. The sedative medications that are used may impair your coordination, so you should not drive or do other activities requiring coordination for at least 12 hours after the procedure. The local anesthetic injected into the spine may cause regional numbness or weakness for up to 6 hours after the procedure, which is another reason to limit your activity the day of the injection. You may have local soreness at the injection site for one or two days, which usually responds to ice packs. Some patients, especially those having discograms, may have an increase in their usual pain for up to 10 days following an injection. If you experience this try rest and your regular pain medication, and call us if your pain persists. If you received cortisone in your injection you may notice an improvement in your usual pain within 2-3 days, although it may take as long as 10-14 days for the medication to fully take effect. Although most patients do not have any side effects from cortisone, the following side effects are possible: sweating, flushing, palpitations, increased heart rate, insomnia, anxiety, hiccoughs, headache, menstrual changes, upset stomach, frequent urination, and slight fever with flu-like symptoms. If any of these side effects become significant or persists longer than three days please contact us.
Although serious complications are rare, they can occur. Possible serious complications include: increased pain, headache, temporary or permanent nerve damage, hip (bone) damage caused by steroids, seizures, difficulty breathing, collapsed lung, death, paralysis. It is possible that serious complications, especially those related to bleeding and infection, could occur in the recovery period at home, after you have left the clinic. For that reason, if you develop fever, progressive weakness or numbness, loss of bowel or bladder control or any other symptoms which you find concerning please notify us immediately.
Please inform your doctors if you are taking antibiotics or have any active infections.
What is an epidural and why is it helpful?
An epidural injection places anti-inflammatory medicine into the epidural space to decrease inflammation of the nerve roots, hopefully reducing the pain in the back or legs. The epidural injection may help the injury to heal by reducing inflammation. It may provide permanent relief or provide a period of pain relief for several months while the injury/cause of pain is healing.
What is the epidural space?
The membrane that covers the spinal cord and nerve roots in the spine is called the dura membrane. The space surrounding the dura is the epidural space. Nerves travel through the epidural space to the back and into the legs (or to the neck and into the arms). Inflammation of these nerve roots may cause pain in these regions due to irritation from a damaged disc or from contract in some way with the bony structure of the spine.
What happens during the procedure?
An IV is started so that relaxation medication can be given. If you do not wish to receive sedation, the IV is optional. However, as a safety precaution in case of an allergic reaction to the injected solution, an IV is highly recommended for the first injection. You are placed on your stomach on the x-ray table. For cervical injection, you will be placed on your back or your side. The skin on the back is painted with an aseptic solution Betadine. Next, the physician numbs a small area of skin with an anesthetic (numbing medicine). This medicine stings for several seconds.
After the anesthetic has been given time to be effective, the physician directs a small needle, using x-ray guidance into epidural space. A small amount of contrast (dye) is injected to insure proper needle position in the epidural space as well as to rule out any evidence of adhesion, bony narrowing, nerve root constriction, or possible nerve root inflammation. A mixture of numbing medicine (anesthetic) and anti-inflammatory (cortisone/steroid) is injected. For two level epidural, the above procedure is repeated for the second level. The procedure usually takes about 10-15 minutes.
What happens after the procedure?
You are then returned to the recovery area where they are monitored for 15-30 minutes. A follow-up appointment will be made for a repeat block if indicated. These injections are usually done in a series of three (3), about two (2) weeks apart. If you do not have any improvement with the first injection, please see your doctor prior to the second injection as it may not be necessary to perform the second injection. Approximately 10% of patients may experience slight increase of pain one (1) to three (3) days after the injection. The back or legs (or neck and arms in case of cervical injections) may feel weak or numb for a few hours. You will be given additional warning signs to look for on the day of the procedure.
Risks and Complications
Epidural injections performed under X ray guidance by an experienced physician are extremely safe. Potential complications including infections, bleeding, nerve injury, headache, paralysis could happen but they are highly unlikely to occur. Dr. Tran has performed over 3000 epidurals without any complications. Cortisone that is used, Depomedrol/Celestone/Kenalog, is the similar cortisone produced by your body, and it is not the illicit version used on the “street”. There are no known long term side effects with a series of three epidurals per year. If you are a diabetic, your blood sugar level may rise for 1-2 days after the injection.
General Pre/Post Instructions
If you choose to have IV sedation, you must not eat or drink within 6 hours of the procedure. Otherwise, you can eat a light meal within one-two hours before the procedure. You may take your routine medications with sips of water (i.e. high blood pressure and diabetic medications). You have to be hurting prior to this procedure. They may not take medications that may give pain relief or lessen their usual pain. Please inform your physician if you are taking Aspirin or blood thinner medications (Coumadine). These medications must be stopped (per the approval of your private physician) at least 7 days prior to the procedure.
You are generally asked to be at the surgery center one hour prior to the procedure and can expect to be at that facility approximately 2-3 hours. A driver must accompany you and be responsible for getting you home. No driving is allowed the day of the procedure if you receive sedation. You may drive if you do not receive sedation, though, this is not recommended. Icing of the area is recommended for the first day. You may return to your normal activities the day after the procedure, including returning to work.
If You Still Have Questions
Please call the clinic where you were seen and make an appointment with Dr. Tran so that your questions can be answered. It would be best that your questions are answered in person rather than over the phone.
What is an EMG/NCS and why is it helpful?
EMG stands for Electromyograghy and NCS stands for Nerve Conduction Study. These two studies are done together; but on occasions, the EMG portion is skipped depending on the diagnosis and the result of the NCS portion. These two tests examine the integrity and function of your nerves to make sure there is no injury to the nerves from a compression in the arms or legs (carpal tunnel, cubital tunnel, pronator teres syndrome, tarsal tunnel, nerve laceration). These tests are also very useful to determine whether you may have a nerve injury from nerve compression in your neck or back from a slipped disc or from bony overgrowth.
How does the scheduling process work?
The office will call your insurance carrier to obtain authorization for the test. This process may take from a few days to a month depending on your insurance. You may call this office in two weeks to check on the authorization status. You may also call the insurance directly to make inquiry. Once authorization is given, we will call you to come to the office to have the test performed. Please make sure to keep your appointment and be on time as the next available appointment may be in a few weeks.
What happens during the procedure?
The test is performed in the sitting or lying position. Your leg or arm will be attached with electrodes to a portable machine. For the NCS portion, small electrical stimulation similar to the TENS unit will be discharged to measure the nerve function. For the EMG portion, a small, Teflon coated, sterile needle will be inserted in the muscles. This will feel very much like acupuncture. The EMG portion is not always performed. The procedure takes between 15-30 minutes. Pain is quite minimal and it is much less than a blood drawn. Most patients describe the pain as a discomfort.
What happens after the procedure?
Local discomfort may last a few minutes to about half an hour. You may return to work on the same day.
Risks and complications
There are no known risks with the EMG/NCS. Local discomfort is very brief and transient.
General Pre/Post instructions
Please do not apply any lotion, perfume, or cream to your skins prior to the procedure. There are no precautions after the procedure.
If you still have questions
Please call the clinic where you were seen and make an appointment with Dr. Tran so that your questions can be answered. It would be best that your questions are answered in person rather than over the phone. You may also visit our sister site www.spinalmedicine.com for additional information and links to other useful sites.
What is a facet neurolytic block and why is it helpful?
Facet blocks using cortisone/Marcaine or a neurolytic agent (Dextrose 50/Phenol) will decrease the sensitivity of the facet joint capsule and the medial branch nerve, thus relieving facet pain. After a series of injections, in the case of neurolytic injections, the medial branch nerves might be destroyed for 3-6 months. It may provide permanent relief or provide a period of pain relief for several months.
What is the facet joint?
The facet joints are true joints supporting the back of your back or neck. At each level of your spine (5 in the lower back and 7 in the neck), there is a pair of facet joints. These are similar in structure to your knee and ankle joints, endowed with cartilage, capsule, meniscoid, and synovial membrane. Of course, they are much smaller joints. They can hold about 10-20 drops of fluid versus the knee joint which can hold up to 1-2 cups! Each facet joint is supplied by two small nerves called the medial branch nerves. Each facet joint has a capsule which is highly innervated with pain nerve fibers called the medial branch. It is believed that neurolytic blocks can reduce pain by decreasing the sensitivity of the medial branch nerves and strengthen the facet capsule.
How does the scheduling process work?
Our office will call your insurance carrier to obtain authorization for the procedure. This process may take from a few days to a month depending on your insurance. You may call this office in two weeks to check on the authorization status. You may also call the insurance directly to make inquiry. Once authorization is given, my scheduler will call you to set up the appointment. Injections usually are performed on Tuesdays at Spine Sports Surgery Center.
What happens during the procedure?
An IV is usually placed so that relaxation medication can be given, though this is not always necessary. If you do not wish to receive sedation, the IV is optional. However, as a safety precaution in case of an allergic reaction to the injected solution, an IV is highly recommended for the first injection. You are placed face down on the x-ray table. The skin on the back is painted with an aseptic solution Betadine. Next, the physician numbs a small area of skin with numbing medicine. This medicine stings for several seconds. After the numbing medicine has been given time to be effective, the physician directs a small needle, using x-ray guidance to the facet joint capsule or to the medial branch nerve. A mixture of numbing medicine (anesthetic) and Dextrose 50 (and occasionally Phenol) is injected. For each facet joint treated, two medial branch nerves need to be injected. This procedure will be repeated for each facet joint. The procedure is approximately 10-15 minutes.
What happens after the procedure?
You are then returned to the recovery area where they are monitored for 15-30 minutes. A follow-up appointment will be made for a repeat block if indicated. Facet blocks are usually done in a series of two (2) to three (3), about two (2) weeks apart. Additional injections will be determined based on your response to the first injection. You may have slight increase in pain for one (1) to two (2) days after the procedure. The back or legs (or neck and arms in case of cervical injections) may feel weak or numb for a few hours.
Risks and Complications
Facet injections performed under X ray guidance by an experienced physician are extremely safe. Potential complications including infections, bleeding, nerve injury could occur. These complications are disclosed as required by laws but are exceedingly rare. If you are a diabetic, your blood sugar level may rise for a few hours after the injection. There are no known side effects with Dextrose 50.
General Pre/Post Instructions
If you choose to have IV sedation, you must not eat or drink within 6 hours of the procedure. Otherwise, you can eat a light meal within one-two hours before the procedure. You may take your routine medications with sips of water (i.e. high blood pressure and diabetic medications). Please inform your physician if you are taking Aspirin or blood thinner medications (Coumadin or Plavix). These medications must be stopped (per the approval of your private physician) at least 7-14 days prior to the procedure. Please stop taking You are generally asked to be at the surgery center 30 minutes prior to the procedure and can expect to be at that facility approximately 1-2 hours. A driver must accompany you and be responsible for getting you home. No driving is allowed the day of the procedure if you receive sedation. You may drive if you do not receive sedation, though, this is not recommended. Icing of the area is recommended for the first day. You may return to your normal activities the day after the procedure.
If You Still Have Questions
Please call the clinic that you were seen and make an appointment with Dr. Tran so that your questions can be answered. It would be best that your questions are answered in person rather than over the phone. Remember that facet block is an elective procedure. Please make sure you understand the indications, risks, and benefits of the procedure before proceeding.
What is Extracorporeal Shockwave Treatment?
Extracorporeal Shockwave Treatment (ESWT) is a non-invasive (no incisions) treatment that involves the delivery of acoustical energy, or sound waves, to affected areas of the body to trigger the body’s own natural repair mechanisms and stimulate healing.
Extracorporeal Shockwave Treatment (‘extracorporeal’ meaning ‘outside the body’) is a safe and effective treatment option. The recovery period is shorter than traditional invasive surgery and the procedure eliminates many of the risks associated with traditional surgery.
Extracorporeal Shockwave Treatment has been used effectively for many years around the world. It was approved in the United States by the FDA for treatment of Plantar Fasciitis in 2000 and for Lateral Epicondylitis in 2003.
What is it Used For?
Millions of people suffer from pain caused by inflammation of tendons and other soft tissues attached to bones. ESWT has been used effectively worldwide to treat these conditions:
- Heel Pain (Plantar Fasciitis)
- Tennis Elbow (Lateral Epicondylitis)
- Golfers Elbow (Medial Epicondylitis)
- Shoulder Calcifications (Calcific Tendonitis)
- Achilles Tendonitis
- Knees (Patellar Tendonitis)
ESWT has also been used to treat bone pathologies such as Delayed-Union and Non¬Union Fractures - conditions where broken bones do not properly heal back together.
How Does it Work?
The widely accepted theory is that ESWT causes microtrauma and controlled injury at the affected area, thereby leading to the formation of blood vessels (revascularization) which triggers the body’s natural healing process and repair mechanisms. Studies have shown an 80% and higher success rate in significantly reducing or eliminating pain.
What are Alternative Treatments?
We will first pursue conservative treatment options to reduce or eliminate pain. Conservative treatment may include such measures as rest, non-steroidal anti-inflammatory medications (NSAIDs), steroid injections, over-the-counter pain relievers, physical therapy, and shoe inserts (for heel pain). When pain has been persistent for 6 months or longer and conservative treatment has failed, ESWT is increasingly being used to avoid traditional invasive surgery.
Is This Treatment Right for Everyone?
This must be determined on a case-by-case basis. Regardless, ESWT is not recommended for use on pregnant women, children, anyone with a pacemaker, or anyone on anti-coagulant therapy or who has a history of bleeding problems.
What Happens Before, During and After Treatment?
BEFORE: Patients will be instructed to discontinue medication containing aspirin or non-steroidal anti-inflammatory medications (e.g. Motrin) for several days before treatment (and most likely for up to 30 days following treatment) unless otherwise instructed by the treating doctor. Patients will be asked to stop eating and drinking a number of hours prior to treatment due to the use of anesthesia.
DURING: Treatment typically lasts 20 to 30 minutes and is performed on an outpatient basis in a surgical center. To avoid discomfort during treatment, most doctors administer a local anesthetic at the point of pain and perform the procedure with the patient under intravenous (conscious) sedation.
AFTER: Patients may experience discomfort in the treated area after the effects of anesthesia have subsided. Some bruising, swelling, and temporary numbness is normal and expected. In the immediate days following treatment, many doctors will recommend RICE — Rest, Ice, Compression, Elevation. For 1 to 2 weeks following treatment, patients may continue to have the same type of pain experienced prior to treatment.
For 4 weeks following treatment, patients are advised not to participate in stressful activities (e.g. jogging, heavy housework, yard work, participating in sports) involving the affected area. Patients can then typically resume normal activity. Heel pain patients are typically instructed to avoid flat shoes such as sandals and slippers; continued use of orthotics may be encouraged.
Healing is generally complete at about 12 weeks, although patients may continue to experience additional reduction in pain thereafter.
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Spine & Sports Medical Group, Inc.
429 Llewellyn Ave.
Campbell, CA 95008
phone: 408-364-1616
fax: 408-378-6775
map & directions
429 Llewellyn Ave. Campbell, CA 95008 • phone: 408-364-1616 • fax: 408-378-6775 • map & directions
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