Non-Surgical Treatments

Joint Drainage

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Myofascial Trigger Point Injection

Trigger point injection (TPI) are used to treat intense pain in the muscles containing trigger points. Trigger points are tight bands or knots that are formed when the muscle fails to relax after the contraction. A trigger point may also cause referred pain (pain in another part of the body) by irritating the adjacent nerves.

Trigger point injections can be used to relieve pain in conditions such as myofascial pain syndrome when other treatments are a failure, fibromyalgia, and tension headaches.

During this procedure, nerve block will be administered by the orthopedist or pain specialist to numb the area of needle penetration and keep you comfortable during the procedure. Further, a small needle containing local anesthetic (lidocaine, procaine) which may or may not containing corticosteroid is directly injected to the trigger point. This makes the trigger point inactive and the pain is relieved.

This is a short procedure and may just take a few minutes. The injection may cause mild pain for a short time. If you are allergic to the local anesthetic medication, a dry-needle technique (without medications) is used.

Numbness at the site of injection may persist for about an hour after the procedure. A bruise may even form at the site of injection. Applying moist heat and ice alternatively to the area for two days relieve the pain. Your orthopedist may also recommend stretching exercises and physical therapy after trigger point injections.

Peripheral Nerve Block

Introduction

The peripheral nervous system carries signals of movement and sensations such as heat, cold and pain from different parts of your body to the central nervous system formed by the spinal cord and brain. Injecting an anesthetic around a peripheral nerve can block the transfer of pain signals from the region it supplies to the brain. This is called a peripheral nerve block and can be used to manage chronic pain.

A common peripheral nerve block is the celiac plexus block. The celiac plexus is a bundle of nerves around the aorta that carry pain impulses from various abdominal organs.

The greater occipital nerve is a peripheral nerve that travels through the muscles at the back of the head and into the scalp providing sensation to the back and top of the scalp. A greater occipital nerve block involves injecting medication around the greater occipital nerve to relieve pain.

Indications

A celiac plexus block is indicated to relieve chronic pain in the abdominal region, most often due to pancreatic cancer or pancreatitis.

Greater occipital nerve blocks are commonly used for patients with a unilateral headache, mainly at the back of the head. This block may also be used in patients with occipital neuralgia experiencing shooting, zapping, stinging, or burning pain in the back of the head. Patients with migraines, cluster headaches, and other painful conditions may also obtain temporary relief with this block.

Surgical procedure

A celiac plexus block is carried out under local anesthesia and sometimes sedation. You will lie on your stomach on an X-ray table and your blood pressure, oxygen and heart activity are monitored. The region of skin to be injected is cleansed with an antiseptic solution and local anesthesia is administered. X-ray images are taken to guide the needle to the correct position of the nerve plexus. A test dye is injected to ascertain the correct location. Then the anesthetic is injected gradually over a couple of minutes. Sometimes, the anesthetic is combined with a steroid to prolong pain relief, or alcohol or phenol to destroy damaged nerves. Once the medication has been injected completely, the needle is removed and a bandage is placed. The entire procedure takes about 10 to 30 minutes.

For an occipital nerve block, you will lie down on an examination table. Your doctor then locates the greater occipital nerve by palpation of the scalp. The skin is cleansed with alcohol and your doctor injects a local anesthetic and steroid mix with a fine needle over the area of the trunk of the nerve. The injected region becomes numb and pain is relieved.

Post procedure

After a celiac plexus block, you may feel warmth in your abdomen, and experience pain relief that will last for a few days. For a better outcome, you are advised to have a series of 2 to 10 injections at varying intervals. The duration of relief tends to get longer after each injection.

Following the occipital nerve block, the anesthetic effect wears off over several hours and the steroid begins to act over the next few days. This helps provide pain relief for several days to a few months.

Risks and complications

Although celiac plexus nerve block is a safe procedure, it may be associated with certain side effects and risks such as temporary pain and soreness at the injection site, temporary weakness or numbness near the abdominal wall or legs, bleeding, infection or injection of the anesthetic at other regions of the spine, blood vessels and surrounding tissues.

Risks and complications are rare following an occipital block but can include infection, nerve or blood vessel injury, and allergic reaction to medications. You may also feel dizzy for a short period. Sometimes, thinning of the scalp at the injection site and hair loss may also occur.

Viscosupplementation with Hyaluronate

Viscosupplementation refers to the injection of a hyaluronan preparation into the joint. Hyaluronan is a natural substance present in the joint fluid that assists in lubrication. It allows smooth movement of the cartilage covered articulating surfaces of the joint.

Synvisc is one of the most commonly used hyaluronan preparations. It is indicated in the management of shoulder, knee, hip or ankle osteoarthritis that has not responded to non-surgical treatment options such as pain medications, physical therapy and corticosteroid injections.

Synvisc provides symptomatic relief and delays the need for surgery. It is injected directly into the joint to replenish the diminished synovial fluid, thereby enhancing its lubricating properties. A single dose or a total of three separate doses of Synvisc, over several weeks, may be required for optimum benefit.

Some patients may experience mild pain, swelling, warmth and redness at the injection site for up to 48 hours following a Synvisc injection. Headache and joint stiffness may also occur in some cases. Ice packs and an analgesic may be used, if required, to ease the discomfort. Any strenuous activity such as jogging or tennis should be completely avoided for 48 hours to a week after the injection and should be resumed only after consultation with your doctor.

Synvisc injection not only supplements the hyaluronan in the joint but also stimulates the production of hyaluronan in the treated knee. This provides gradual symptomatic relief over the course of the injections. This effect may last for several months.

Please note: Immediately consult your doctor if you develop fever or the pain and swelling fail to resolve after 48 hours following the injection.

Steroid Injection

Steroids are medications with anti-inflammatory properties that may be injected into areas of the body such as the joints to relieve pain and swelling. They are fast-acting and more effective than oral anti-inflammatory medications which can sometimes cause stomach upset.

Steroids may be injected into the major joints such as the knees, hips, spine, ankles, wrists and elbows as well as the minor joints of the hands and feet. They are usually combined with a local anesthetic to enhance pain relief.

Steroid injections are mainly used for the relief of joint pain due to arthritis but may be used to treat a variety of inflammatory diseases including gout, carpal tunnel syndrome, rotator cuff injuries, frozen shoulder, tennis elbow, and lupus.

To perform a steroid injection, the skin over the joint is cleansed and anesthetized. You are adequately positioned to facilitate easy insertion of the needle. Some injections are performed under live X-ray or ultrasound imaging to help your doctor guide the needle to the precise location. You will probably feel pressure when the needle is inserted. Following the injection of medication, there may be pain or redness at the injection site. Ice packs are applied to the injection area to reduce pain. Ice should be applied over a towel for 20 minutes every hour.

Following a cortisone shot, there may be an increase in pain and inflammation which may last a few hours to 2 days. After this, the medication takes effect and results can last for weeks to months.

You are advised to rest for a day or two and observe for signs of inflammation (pain, redness, swelling). Any prolonged symptoms should be reported to your doctor.

Steroids injections may be associated with certain complications especially with prolonged use. These include joint tissue damage, nerve irritation, bone weakening, and infection. To reduce the risk of complications, a limited number of steroid injections are administered in a year.

Synovial Biopsy

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