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Epidural Steroid Injection (ESI)
- Combines steroid medication w/ local anesthetic to provide immediate pain relief
- Injected into epidural space, does not penetrate theca sac
- May provide short-term relief from extremity pain w/ spinal stenosis
- Most research suggests max of 3 injections per year/per site
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Epidural Steroid Injection (ESI): Side Effects
- 2-4 days of soreness
- Nausea/vomiting
- Dizziness
- Headache
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Epidural Steroid Injection (ESI): Complications
- Infection
- Dural puncture w/ or w/o headache
- Aseptic meningitis
- Arachnoiditis
- Epidural abscess/cyst
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Trigger Point Injection
Jump sign confirms needle has entered TrP
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Facet Joint Injection/Medial Branch Block
- (Medial branch innervates facet joints)
- Injected 1st w/ anesthesia, if pain relieved --> cortisone is injected
- Used as gold standard to diagnose segmental involvement
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SI Joint Injection
- Injected w/ anesthesia, if pain relieved --> cortisone is injected
- Should be pain free immediately due to anesthesia
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Glucocorticoid Injections (Steroid Injections)
- Epidural Steroid Injections
- Trigger Point Injection
- Facet Joint Injection/Medial Branch Block
- SI Joint Injection
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Discography
- Diagnosis by pain provocation
- Multiple discs injected w/ contrast medium
- Study: resulted in accelerated disc degeneration, disc herniation, loss of disc height and signal and development of reactive endplate changes
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Botulinum Toxin A (Botox)
- Stops/reduces spasm when injected into muscle in small amounts
- Not permanent - 3-4 months of pain relief has been reported
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Electrothermal & Radiofrequency Therapies
- Intradiscal Electrothermal Therapy (IDET)
- Percutaneous Intradiscal Radiofrequency Thermocoagulation (PIRFT)
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Intradiscal Electrothermal Therapy (IDET)
- Flexible catheter inserted into disc in ring-like fashion
- Slowly heated to 194 degrees F (kills nerve fibers, toughens disc tissue, and seals small tears)
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Percutaneous Intradiscal Radiofrequency Thermocoagulation (PIRFT)
- Radiofrequency probe placed into center of disc, activated for 90s at 70 degrees C
- Minimal research performed on this technique, some studies suggest no better than placebo
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Selective Dorsal Rhizotomy (Radiofrequency Nerve Ablation)
- Ventral and dorsal roots separated from each other
- Electrical current produced by radio waves to ablate the dorsal (sensory) nerve roots --> kills proprioceptive contra of segment
- Nerve roots regenerate within 5-8 months
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Prolotherapy
- Dextrose solution injected into ligament/tendon @ enthesis --> causes local inflammation
- Increase blood flow and nutrient supply to area
- Rationale: strengthens damaged tissue by sclerosing the area
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Spinal Stimulators
- Leads are inserted over SC in epidural space
- Pulse generator implanted into abdomen or gluteal region
- Pulsed current may provide analgesic effect
- Used predominantly for FBSS (Failed Back Surgery Syndrome) and CRPS (Chronic Regional Pain Syndrome)
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Opiods
- Only intended for pain that is constant and acute
- Hindrance to MMI (maximum medical improvement)
- Substance abuse common
- Frequently prescribed despite contraindications
- Narcotics reliably cause an abnormally severe sensitivity to pain (termed "hyperalgesia")
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Opiods: Side Effects
- Immune system compromise
- Cognitive impairment
- Sleep abnormalities
- Generalized ill health and disability
- Erectile dysfunction
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"Iatrogenic Vortex"
Pattern of increasing over-medicalization throughout a patient's care
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