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GENERAL TERMINOLOGY
Electrodiagnostic testing (EMG and nerve conduction studies)
What are EMG and nerve conduction studies?
This testing is used to record the electrical activity of nerves and muscles. The test is done to evaluate how your nerves and muscles are functioning.
This testing can be used to detect abnormal nerve or muscle electrical activity that can occur in many diseases and conditions including muscular dystrophy, inflammation of muscles, pinched nerves, peripheral nerve damage (damage to nerves in the arms and legs), amyotrophic lateral sclerosis (ALS) (also known as Lou Gehrig disease), as well as many other conditions.
Why is an electrodiagnostic test done?
This testing is most often performed when patients have unexplained muscle weakness, numbness, or pain. The testing helps to distinguish between various nerve or muscle disorders that you may have.
Are there any risks or side effects associated with this test?
There may be some mild temporary soreness or bruising but typically this is minimal.
How do I prepare for the test?
Do not use lotions on the hands or feet that are being tested on the day of the testing. If testing is being done on hands, please remove jewelry if possible. You may eat before the test. You may continue to take medications as usual.
What happens before the test?
There is usually a brief physical exam before the test
How long does it take?
This varies depending on the situation but the testing typically takes about an hour to complete.
How is it done?
It is done by different techniques. Small electrical stimuli are administered to different nerves and their response is analysed. To test muscle function, a very small disposable needle (an electrode) is inserted in your muscles, and electrical activity is recorded. These data are analysed by the doctor doing your test.
What will I feel?
The electrical stimulation feels like an electrical shock. You may experience some discomfort when the needle is inserted into each of the muscles to be tested.
Will I be "put out" for the procedure?
No this procedure is done with your participation, there are no medications used to put you to sleep. You will be fully awake through out the procedure. Though many people undergo testing without any medication, your doctor (at your request) may prescribe medication for pain to be taken at the time of testing or medication for anxiety to be taken at the time of testing.
Will the procedure help me? How?
Yes. In order to better treat you, your doctor needs to know what is causing your symptoms. The test information allows your doctor to better choose an appropriate treatment more specific to you and your needs.
How many EMGs do I need to have?
Usually just one. However there are occasional exceptions when a second EMG may be required.
Can I go to work the same day? The next day?
Typically you should be able to immediately return to your work. If prior to the testing , you were given a prescription for medication to be taken at the time of testing, then returning to work may be difficult because of that medication. As stated above, taking medication during the testing is optional.
Who should not have this test done?
The most common reasons not to have the test done are concurrent infection, a bleeding disorder or if you are taking a blood thinning medication, such as, coumadin, lovenox, etc.
Will I be able to drive myself home following this test?
Typically you should be able to drive following the testing. However, if you have elected to have medications for anxiety or pain in conjunction with the testing, then you should not drive and will need to have a driver come with you to the testing.
Is anything injected into my body?
No. Nothing is injected into your body. .
What happens after the test?
You may return home unless given other instructions.
How will I receive the results of my test?
The doctor who ordered your test will explain the results at your following visit. (please allow a few days for them to receive the results)
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Epidural Blood Patch
Epidural blood patches are done to relieve headache pain that may rarely occur after spinal injections. In an epidural blood patch procedure, the doctor will inject some of the patients’ own blood into the epidural space. The epidural space refers to a potential space between layers of the covering of the spinal cord. |
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Epidural Steroid Injection
What is an Epidural Steroid Injection?
ESI - The epidural steroid injection is the placement of cortisone, a powerful anti-inflammatory agent, into the epidural space to relieve pain caused by irritated nerves and discs.
How long does the injection take?
The actual injection takes only a few minutes.
What is actually injected?
The injection consists of a mixture of local anesthetic (like lidocaine or bupivacaine) and the steroid medication (triamcinolone - Aristocortor methylprednisolone - Depo-medrol).
Will the injection hurt?
The procedure involves inserting a needle through skin and deeper tissues (like a "tetanus shot"). So, there is some discomfort involved. However, we numb the skin and deeper tissues with a local anesthetic using a very thin needle prior to inserting the Epidural needle. Also, the tissues in the midline have less nerve supply, so usually you feel strong pressure and not much pain.
Will I be "put out" for this procedure?
No. This procedure is done under local anesthesia.
How is the injection performed?
It is done either with the patient sitting up or on the side, or on your stomach. The skin in the back is cleaned with antiseptic solution and then the injection is carried out.
What should I expect after the injection?
Immediately after the injection, you may feel that your legs are slightly heavy and may be numb. Also, you may notice that your pain may be gone or quite less. This is due to the local anesthetic injected. This will last only for a few hours. Your pain will return and you may have a "sore back" for a day or two. This is due to the mechanical process of needle insertion as well as initial irritation form the steroid itself. You should start noticing pain relief starting the 3rd or 5th day or so.
What should I do after the procedure?
You should have a ride home. We advise the patients to take it easy for a day or so after the procedure. Perform the activities as tolerated by you.
Can I go back to work the next day?
You should be able to unless the procedure was complicated. Usually you will feel some back pain or have a "sore back" only.
How long does the effect of the medication last?
The immediate effect is usually from the local anesthetic injected. This wears off in a few hours. The cortisone starts working in about 3 to 5 days and its effect can last for several days to a few months.
How many injections do I need to have?
If the first injection does not relieve your symptoms in about a week to two weeks, we may recommend that you have one more injection. Similarly If the second injection does not relieve your symptoms in about a week to two weeks, you may be recommended to have a third injection.
Can I have more than three injections?
In a six month period, we generally do not perform more than three injections. This is because the medication injected lasts for about six months. If three injections have not helped you much, it is very unlikely that you will get any further benefit from more injections. Also, giving more injections will increase the likelihood of side effects from cortisone.
Will the Epidural Steroid Injection help me?
It is very difficult to predict if the injection will indeed help you or not. Generally speaking, the patients who have "radicular symptoms" (like sciatica) respond better to the injections than the patients who have only back pain. Similarly, the patients with a recent onset of pain may respond much better than the ones with a long standing pain. Also, the patients with back pain mainly due to bony abnormality may not respond adequately.
What are the risks and side effects?
Generally speaking, this procedure is safe. However, with any procedure there are risks, side effects, and possibility of complications. The most common side effect is pain - which is temporary. The other risk involve spinal puncture with headaches, infection, bleeding, etc. The other risks are related to the side effects of cortisone. These include weight gain, increase in blood sugar (mainly in diabetics), water retention, suppression of body`s own natural production of cortisone etc.
Who should not have this injection?
If you are allergic to any of the medications to be injected, if you are on blood thinning medications (e.g. Coumadin, Plavix, Ticlid), or if you have an active infection going on near the injection site, you should not have the injection. |
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Facet Joint
The cervical facet joints (or zygapophysial joints) are located in pairs in the back of the spine. These nerves are roughly the size of a fingernail. They help with motion and provide stability. If these joints became aggravated, they can cause pain in several different areas—head, neck, shoulders, and arms. |
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Facet Joint Arthritis
This diagnosis is given to patients whose pain arises from the z- joints (zygapophysial joints), small joints located in the back of the spine. These nerves are roughly the size of a fingernail. They help with motion and provide stability. If these joints became aggravated, they can cause pain in several different areas—head, neck, shoulders, and arms.
Arthritis is acute or chronic inflammation of a joint, often accompanied by pain and structural changes and having diverse causes, such as infection, crystal deposition, or injury. |
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Facet Joint Syndrome
This diagnosis is given to some patients who have an irritation of one or more joints in the spinal area. Facet joints are pairs of joints (about the size of a finger nail) that are located on the back side of the spine at each disc level. These joints add stability and help the spine from moving too far. There are nerve endings both on the outside and inside of each of these joints.
Normal wear and tear, auto accidents, or other neck/back injuries can damage the facet joints, also known as zygapophysial joints. When damaged, facet joints can result in headache, neck, and/or back pain.
Nexus Paincare has many different treatment options—depending on which area of the spine is causing pain. |
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Facet Joint Injection
What is a Facet Joint Injection?
Facet Joint Injection is an injection of long lasting steroid ("cortisone") in the Facet joints - which are located in the back area, as a part of the bony structure.
What is the purpose of it?
The steroid injected reduces the inflammation and/or swelling of tissue in the joint space. This may in turn reduce pain, and other symptoms caused by inflammation / irritation of the joint and surrounding structures.
How long does the injection take?
The actual injection takes only a few minutes.
What is actually injected?
The injection consists of a mixture of local anesthetic (like lidocaine or bupivacaine) and the steroid medication (celestone or betamethasone or dexamethasone)
Will the injection(s) hurt?
The procedure involves inserting a needle through skin and deeper tissues (like a "tetanus shot"). So, there is some discomfort involved. However, we numb the skin and deeper tissues with a local anesthetic using a very thin needle prior to inserting the needle into the joint.
Will I be "put out" for this procedure?
No. This procedure is done under local anesthesia.
How is the injection performed?
It is done either with the patient lying on the stomach. The entire procedure is done under live X-ray. After the injection, you are placed on your back or on your side.
What should I expect after the injection?
Immediately after the injection, you may feel that your pain may be gone or quite less. This is due to the local anesthetic injected. This will last only for a few hours. Your pain will return and you may have a "sore back" for a day or two. This is due to the mechanical process of needle insertion as well as initial irritation form the steroid itself. You should start noticing pain relief starting the 5th day or so.
What should I do after the procedure?
You should have a ride home. We advise the patients to take it easy for a day or so after the procedure. You may want to apply ice to the affected area. Perform the activities as tolerated by you.
Can I go to work to work the next day?
Unless there are complications, you should be able to return to your work the next day. The most common thing you may feel is sore back.
How long the effect of the medication lasts?
The immediate effect is usually from the local anesthetic injected. This wears off in a few hours. The cortisone starts working in about 5 to 7 days and its effect can last for several days to a few months.
How many injections do I need to have?
If the first injection does not relieve your symptoms in about a week to two weeks, you may be recommended to have one more injection. If you respond to the injections and still have residual pain, you may be recommended for a third injection.
Can I have more than three injections?
In a six-month period, we generally do not perform more than three injections. This is because the medication injected lasts for about six months. If three injections have not helped you much, it is very unlikely that you will get any further benefit from more injections. Also, giving more injections will increase the likelihood of side effects from cortisone.
Will the Facet Joint Injection help me?
It is very difficult to predict if the injection will indeed help you or not. Generally speaking, the patients who have recent onset of pain may respond much better than the ones with long standing pain.
What are the risks and side effects?
Generally speaking, this procedure is safe. However, with any procedure there are risks, side effects, and possibility of complications. The most common side effect is pain - which is temporary. The other risks involve, infection, bleeding, worsening of symptoms, spinal block, Epidural block etc. The other risks are related to the side effects of cortisone: These include weight gain, increase in blood sugar (mainly in diabetics), water retention, suppression of body`s own natural production of cortisone etc. Fortunately, the serious side effects and complications are uncommon.
Who should not have this injection?
If you are allergic to any of the medications to be injected, if you are on a blood thinning medication (e.g. Coumadin), or if you have an active infection going on, you should not have the injection. |
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Failed Back Surgery Syndrome
This generalized term describes patients who have had back surgeries are and still feeling pain. Some patients claim their back pain is worse after having back surgery, while others claim it is the same. Depending on what type of back surgery a patient has previously had, our doctors can help create individualized treatment plans that will effectively provide our patients with pain relief. Our physicians specialize in minimally invasive procedures—no operations. |
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Intrathecal Pump Implant ("Spinal Morphine Pump")
What is an Intrathecal Pump Implant ("Spinal Morphine Pump")?
An Intrathecal Pump is a specialized device, which delivers concentrated amounts of medication(s) into spinal cord area via a small catheter (tubing).
Am I a candidate for Intrathecal Pump Implant ("Spinal Morphine Pump")?
The Intrathecal Pump is offered to patients with; Chronic and severe pain, who have not adequately responded to any other treatment modalities. Some of the examples may be failed back syndrome, cancer pain, RSD. However other options may still exist for these conditions that may be safer.
What is the purpose of it?
This device delivers concentrated amounts of medication into spinal cord area allowing the patient to decrease or eliminate the need for oral medications. It delivers medication around the clock, thus eliminating or minimizing breakthrough pain and/or other symptoms.
How long does the procedure take?
It is done in two stages. In the first stage, a single injection is made to assess effectiveness and screen for unwanted side effects. If this trial is successful in relieving symptoms, then the permanent device is placed under the skin by a surgeon that you would be referred to. The patients have to meet certain other screening criteria before implanting the pump.
Will the procedure hurt?
The procedure involves inserting a needle through skin and deeper tissues (like a "tetanus shot"). So, there is some discomfort involved. However, we numb the skin and deeper tissues with a local anesthetic using a very thin needle prior to inserting the injection needle. Most of the patients also receive intravenous sedation and analgesia, which makes the procedure easier to tolerate.
Will I be "put out" for this procedure?
The placement of the tubing is done under local anesthesia with patients mildly sedated. The amount of sedation given generally depends upon the individual patient tolerance.
How is the procedure performed?
It is usually done with the patient lying on their side. Sometimes the tubing is placed with the patient sitting up. The patients are monitored with EKG, blood pressure cuff and blood oxygen-monitoring devices. The skin is cleaned with antiseptic solution and then the procedure is carried out. X-ray (fluoroscopy) is used to guide the needle for inserting the tubing.
Where is the tubing inserted? Where is the pump placed?
Tubing is inserted in the midline of the lower back. The pump is then placed on the side of the abdomen.
What should I expect after the procedure?
If the procedure is successful, you may feel that your pain may be controlled or at least better controlled. The pump is adjusted electronically to deliver an adequate amount of medication to optimize the pain control as safely as possible.
What should I do after the procedure?
This procedure is normally a day-surgery procedure and patients are kept overnight for observation and pump adjustment.
How long will the pumps last?
The medication contained within the pump will last about 1 to 3 months depending upon the concentration and amount infused. It is then refilled via a small needle inserted into the pump chamber. This is done in the office or at your home and it takes only a few minutes.The batteries in the pump may last 3 to 5 years depending upon the usage. The batteries can not be replaced or recharged. The pump is replaced at that time.
Will the Intrathecal Pump Implant ("Spinal Morphine Pump") help me?
It is very difficult to predict if the procedure will help you or not. For that reason a trial is carried out to determine if a permanent device (pump) will be effective to relieve your pain or not.
What are the risks and side effects?
Generally speaking, this procedure is safe. However, with any procedure there are risks, side effects, and possibility of complications. The pump itself has risks as well - Including, but not limited to; cessation of therapy due to end of device service life or component failure, change in flow performance due to component failure, inability to program the device due to programmer failure, CAP component failure; inaccessible refill port due to inverted pump, pocket seroma, hematoma, erosion, infection, post-lumbar puncture (spinal headache), CSF leak, radiculitis, arachnoiditis, bleeding, spinal cord damage, meningitis (intrathecal applications), anesthesia complications, damage to the pump, catheter and catheter access system due to improper handling and filling before, during, or after implantation; change in catheter performance due to catheter kinking, disconnection, leakage (which can result in overdose and death), breakage, occlusion, dislodgement, migration, or catheter fibrosis; body rejection phenomena, surgical replacement of pump or catheter due to complications; local and systemic drug toxicity and related side effects, complications due to use of unapproved drugs and/or not using drugs in accordance with drug labeling, or inflammatory mass at the tip of the catheter in patients receiving intraspinal morphine or other opioid drugs.
Who should not have this procedure?
When infection is present; when the pump cannot be implanted 2.5 cm or less from the surface of the skin; when body size is not sufficient to accept pump bulk and weight; when contraindications exist relating to the drug, such as an allergy, or if you are on blood thinning medications (e.g. Coumadin, Plavix, Ticlid). Patients also have to meet certain other screening criteria before implanting the pump.
Where can I get additional information?
More detailed information is available from the manufacturer of this device. At the time of consultation you will receive a SynchromedInfusion System Patient Education Booklet. Additional information is also available at the MedtronicsWeb Site @ http://www.medtronics.com/neuro/apt/faq.html. |
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Medial Branch Block
What is a Medial Branch?
Facet Joints are innervated or "supplied" by nerves called "medial branches". These nerves carry the pain signals to the spinal cord and the signals eventually reach the brain, where the pain is noticed.
What is the purpose of it?
If the nerves are "blocked" or "numbed", they will not be able to carry pain sensation to the spinal cord. It is like temporarily cutting off "wires". Therefore, if the pain is due to facet joint arthritis, you should have relief from pain and stiffness.
Once it is determined that the pain is indeed due to facet joint disease, we can use a procedure called "Radio-Frequency Lesioning" and prevent the conduction of pain information for several weeks to months.
So, in a way, medial branch block is a temporary and diagnostic procedure.
How long does the injection take?
The actual injection takes only a few minutes. More nerves to be blocked, more time it takes.
What is actually injected?
The injection consists of a local anesthetic (like lidocaine or bupivacaine).
Will the injection hurt?
The procedure involves inserting a needle through skin and deeper tissues (like a "tetanus shot"). Therefore, there is some discomfort involved. However, we numb the skin and deeper tissues with a local anesthetic using a very thin needle before inserting the needle into the joint.
Will I be "put out" for this procedure?
No. This procedure is done under local anesthesia. The amount of sedation given generally depends upon the patient’s tolerance.
How is the injection performed?
It is done either with the patient lying on the stomach for the upper and low back pain, or for the cervical (neck area) injections - lying on the back, under x-ray control. The patients are monitored with EKG, blood pressure cuff and blood oxygen-monitoring device. The skin in the back is cleaned with antiseptic solution and then the injection is carried out.
What should I expect after the injection?
Immediately after the injection, you may feel that your pain may be gone or quite less. This is due to the local anesthetic injected. This may last only for a few hours. Your pain will return and you may have a "sore back or neck" for a day or two. This is due to the mechanical process of needle insertion. It is very important for you to keep a track of your pain and stiffness for the next 2 to 12 hours following injections. Your response to the injections will determine if the facets are the cause of your pain or not.
What should I do after the procedure?
You should have a ride home. We advise the patients to take it easy for a day or so after the procedure. You may want to apply ice to the affected area. Perform your usual activities as tolerated.
Can I go to work to work the next day?
Unless there are complications, you should be able to return to your work the next day. The most common thing you may feel is sore back.
How long does the effect of the medication last?
The immediate effect is from the local anesthetic injected. Depending upon the medication injected, it can last from 2 hours to 8 hours. Of course, if the facet joints are not the source of your pain, you may not have much relief.
How many injections do I need to have?
Usually one session is enough to determine if the facet joints are the most likely source of your pain or not. However, the "placebo response" can be as high as 30 to 40 % and some patients may be recommended to have repeated diagnostic injections. In addition, "False Positive" responses can occur.
Will the procedure help me?
If the pain is originating mostly from the facet joints, you should benefit from this procedure on a temporary basis. Some do get a "placebo response" and others may get a "False-Positive" response. Please remember that these are diagnostic injections only and last only for a few hours. These are done to determine if the pain is coming from the facet joints or not, and if the pain is coming from the facet joints, we will recommend "Radio-Frequency Lesioning" - which will "numb" the same nerves for many weeks to months.
What are the risks and side effects?
Generally speaking, this procedure is safe. However, with any procedure there are risks, side effects, and possibility of complications. The most common side effect is pain - which is temporary. The other risks involve, infection, bleeding, worsening of symptoms, spinal block, epidural block etc. Fortunately, the serious side effects and complications are uncommon.
Who should not have this injection?
If you are allergic to any of the medications to be injected, if you are on blood thinning medications (e.g. Coumadin, Plavix, Ticlid), or if you have an active infection going on near the injection site, you should not have the injection. |
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Radio Frequency Lesioning
What is a Radio Frequency Lesioning?
Radio Frequency Lesioning is a procedure using a specialized machine to interrupt nerve transmission originating from a painful structure within the spine. The procedure usually relieves the pain for 9-14 months after which a second procedure can be performed. The procedure takes only 15-20 minutes and will again work for a period of 9-14 months.
Am I a candidate for Radio Frequency Lesioning?
Patients are first screened with a local anesthetic injection to determine what structure is generating the pain. If this gives good but temporary relief, a radiofrequency procedure can be expected to procedure the same amount of relief on a long term basis
What are the benefits of Radio Frequency Lesioning?
The procedure disrupts nerve conduction (such as conduction of pain signals), and it may in turn reduce pain, and other related symptoms. Approximately 70-80% of patients will get good relief of the intended nerve. This should help relieve that part of the pain that the blocked nerve controls. Sometimes after a nerve is blocked, it becomes clear that there is pain from the other areas as well.
How long does the procedure take?
Depending upon the areas to be treated, the procedure can take from about twenty minutes to a couple of hours when we include preparation and observation following the procedure.
Where is the procedure performed?
The procedure is usually performed in an operating room, sometimes in a fluoroscopy (x-ray) room.
How is it actually performed?
Since nerves cannot be seen on x-ray, the needles are positioned using bony landmarks that indicate where the nerves usually are. Fluoroscopy (x-ray) is used to identify those bony landmarks. A local anesthetic (like Lidocaine) is injected to confirm proper placement. After confirmation of the needle tip position, a special needle tip is inserted.
When the needle is in good position, as confirmed by x-ray, electrical stimulation is done before any lesioning. This stimulation may produce a buzzing or tingling sensation or may be like hitting your "funny bone". You may also feel your muscles jump. You need to be awake during this part of the procedure so you can report what you’re feeling. The tissues surrounding the needle tip are then heated when electronic current is passed using the Radio Frequency machine, for a few seconds. This "numbs" the nerves semi-permanently.
Will the procedure hurt?
Nerves are protected by layers of muscle and soft tissues. The procedure involves inserting a needle through skin and those layers of muscle and soft tissues, so there is some discomfort involved. However, we numb the skin and deeper tissues with a local anesthetic using a very thin needle prior to inserting the needle.
Will I be "put out" for this procedure?
No. This procedure is done under local anesthesia. Most of the patients also receive intravenous sedation and analgesia, which makes the procedure easier to tolerate. The amount of sedation given generally depends upon the patient tolerance. It is necessary for you to be awake enough to communicate easily during the procedure.
How is the procedure performed?
It is done either with the patient lying on the stomach when working on the facet joints, low back for lumbar sympathetic nerves, and the back when lesioning the cervical (neck) area (e.g. Stellate Ganglion). The patients are monitored with EKG, blood pressure cuff, and blood oxygen-monitoring device. The skin on the back is cleaned with antiseptic solution and then the procedure is carried out. X-ray (fluoroscopy) is used to guide the needles.
What should I expect after the procedure?
Initially there will be muscle soreness for up to a week afterward. Ice packs will usually control this discomfort. After that first week is over, your pain may be gone or quite less.
What should I do after the procedure?
You should have a ride home. We advise the patients to take it easy for a day or so after the procedure. You may want to apply ice to the affected area. Perform the activities as tolerated by you.
Can I go to work the next day?
You should be able to return to your work the next day. Sometimes soreness at the injection site causes you to be off work for a day or two.
How long will the effects of the procedure last?
If successful, the effects of the procedure can last from 3-18 months, usually 6-9 months.
How many procedures do I need to have?
If the first procedure does not relieve your symptoms completely, you may be recommended to have a repeat procedure after re-evaluation. Because these are not permanent procedures, they may need to be repeated when the numbness wears off (often 6-12 months).
Will the Radio Frequency Lesioning help me?
It is very difficult to predict if the procedure will indeed help you or not. Generally speaking, the patients who have responded to repeated local anesthetic blocks will have better results.
What are the risks and side effects?
Generally speaking, this procedure is safe. However, with any procedure there are risks, side effects, and the possibility of complications. The risks and complications are dependent upon the sites that are lesioned. Any time there is an injection through the skin, there is a risk of infection. This is why sterile conditions are used for these blocks. The needles have to go through skin and soft tissues, which will cause soreness. The nerves to be lesioned may be near blood vessels or other nerves which can be potentially damaged. Great care is taken when placing the radio frequency needles, but sometimes complications occur. Please discuss your specific concerns with your physician.
Who should not have this procedure?
If you are allergic to any of the medications to be injected, if you are on blood thinning medications (e.g. Coumadin, Plavix, Ticlid), or if you have an active infection going on near the injection site, you should not have the procedure.
If you have not responded to local anesthetic blocks, you may not be a candidate for this procedure. |
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Reflex Sympathetic Dystrophy (RSD)
RSD is a condition which involves burning pain, swelling and limited movement of an extremity that is associated with an injury such as a broken limb. In patients with RSD, these symptoms can linger for months, years or a lifetime unless treatment is sought. |
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Rotator Cuff Syndrome
Sometimes, after surgery on the rotator cuff (a group of muscles that hold the shoulder in place), the patient can still have pain. This pain is typically called rotator cuff syndrome. |
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