Pain Management Physicians of South Florida
A careful history and physical along with x-rays, CAT scans, and MRI assist in making the diagnosis. Spinal stenosis can occur everywhere in the spine and impact different areas i.e. significant stenosis in the cervical spine (neck) and impact the ability to walk which is essentially a lumbar (low back) function.
Spinal stenosis is a degenerative and age related condition that results in narrowing of the spinal canal. It occurs in the cervical (neck), thoracic, and/or lumbar (low back) segments of the spine.
Typically, it presents with low back pain when standing and walking combined with discomfort, and heaviness in the legs. It can present as a tired, heavy feeling in the back, buttocks and legs. There can be a cramping sensation along with numbness and an unsteady gait. The narrowing of the spinal canal is usually caused by increased overgrowth of ligaments and bone. Occasionally, disk material can also be involved.
The narrowing of the spinal canal can temporarily impede blood flow which leads to symptoms. In itself this is not dangerous but limits a patient’s ability to stand and walk for any significant amount of distance interfering with life and daily activity. The pain and discomfort usually can be relieved by leaning forward as on a shopping cart, sitting, or reclining. Over time, the atrophy with loss of strength in the legs may develop further impact ambulation.
A non-surgical procedure was recently introduced to the market called MILD (minimally invasive lumbar decompression). Developed to avoid open surgery with general anesthesia, small tools are used through a cannula (large needle) to remove excess ligaments and bone to improve blood flow in the spinal canal when a patient is standing and walking. It can be accomplished under sedation without a scalpel and does not have the issue such as post-operative scarring that can occur with larger open operations.There is no blood loss with the MILD procedure. The procedure takes 30-40 minutes and results are almost immediate.
There are risks as with any procedures which needs to be discussed with your physician. At this time only lumbar spinal stenosis may be treated with MILD. The physicians of Pain Management Physicians of South Florida work closely with neurosurgical teams if the patient is not a candidate for any of the less invasive techniques or has failed to progress after having these techniques provided.
After the diagnosis of spinal stenosis, although physical therapy cannot alleviate pain and discomfort, it should be utilized and combined with pool walking if available to prevent atrophy. Epidural steroids can be placed anywhere in the spine and work by reducing inflammation and shrinking certain tissues to provide more room for blood flow within the spinal canal. The success rate depends on the severity of the spinal stenosis. Epidural steroids should be accomplished by live x-ray guidance (fluoroscopy) and with a contrast (dye) study to assess the patency of the canal. The contrast study also allows your physician to determine if other techniques (such as the MILD procedure ) can be utilized in the future should the epidural steroid fail to provide adequate relief. There are risks with epidural steroids as with any procedure and your physician will go over these risks with you.
Unfortunately medications have not been deemed significantly helpful in treating spinal stenosis. A small percentage of patients obtain some relief with medication, but the vast majority of patients either sit or lay down after standing and walking for relief. Decreased ambulation negatively impacts daily living activities and often leads to atrophy. Surgery is often reserved for only the most extreme, non-responsive cases.
After recovering from COVID-19, a significant proportion of symptomatic and asymptomatic individuals develop Long COVID. Fatigue, orthostatic intolerance, brain fog, anosmia, and ageusia/dysgeusia in Long COVID resemble “sickness behavior,” the autonomic nervous system response to pro-inflammatory cytokines. Aberrant network adaptation to sympathetic/parasympathetic imbalance is expected to produce long-standing dysautonomia. Cervical sympathetic chain activity can be blocked with local anesthetic, allowing the regional autonomic nervous system to “reboot.”
Long COVID patients have been successfully treated using a stellate ganglion block, implicating dysautonomia in the pathophysiology of Long COVID.
Treatments: Stelate Ganglion Blocks
Keywords: Long COVID/PASC, Myalgic encephalitis/chronic fatigue syndrome (ME/CFS), Postural orthostatic tachycardia syndrome (POTS), Dysautonomia, Stellate ganglion block, Cerebral blood flow
Used for muscle tightness and muscle injury in conjunction with a stretching program. Involves the injection of local anesthetic (and/or steroid/Botox) when appropriate.
Back pain effects more than 85% of all Americans during their lifetime. It can have many causes such disc, joint, ligament/bone or muscular pathology. Acute pain (less than six weeks onset) is usually self-limited. Immediate medical attention should be sought when weakness, loss sensation, or bladder/bowel changes accompany the pain. Tumors and malignant causes of pain are rare, occurring in less than 1% of those people suffering from back pain. However, this should be further looked at if neurologic changes occur and the pain doesn’t resolve with treatments. While acute pain is usually recognized as only lasting approximately 6 weeks, chronic pain is generally termed after 12 weeks. Bed rest is not advised, nor is the use of a lumbar support belt for more than two weeks. Most sources of pain respond to conservative treatments, which may include physical therapy, anti-inflammatory medications, topical pain relievers and cortisone injections. Unfortunately, there is a subset of people whose pain is so severe that activities or work are extremely limited during the first six weeks. Or, the pain extends beyond six weeks and approaches the chronic stages of a condition. For these groups of patients, many will respond to interventional pain procedures.
There is no blood test for pain. The diagnosis and treatment require the performance of a careful history and physical exam, along with the use of radiographs (xray, MRI, CT). EMG and nerve conduction studies may also be indicated.
Common causes of back pain include: lumbar disc bulge, lumbar disc herniation, degenerative disc disease, joint inflammation (both facet and sacroiliac), sciatica (pinched nerve), fractures of vertebrae, lumbar spinal stenosis, and prior back surgery (also known as post laminectomy syndrome.
Treatments: Many patients will not respond to the conservative treatments as described above. For those non-responders, interventional pain procedures may be indicated. These interventional treatments, determined by the condition, may include: epidurals, facet blocks, sacroiliac joint injections, MILD procedure, radiofrequency lesioning, neuroplasty/lysis of adhesions, kyphoplasty, and spinal cord stimulator.
Used to improve mobilization, strengthening and range of motion, mobilization, stabilization and strengthening. Ultrasound, electrical stimulation, ice, heat, bracing and exercise are utilized by trained physical therapists.
Neck pain may not just be limited to the neck but can extend to the head, shoulder and arms. The neck, like the lower back, is composed of many parts, including joints, discs, muscles and nerves. Any of these components can lead to inflammation and pain. For acute pain (less than six weeks onset), most sources of pain respond to conservative treatments, which may include physical therapy, anti-inflammatory medications, topical pain relievers and cortisone injections. Unfortunately, there is a subset of people whose pain is so severe that activities or work are extremely limited during those first six weeks. Or, the pain extends beyond six weeks and approaches the chronic stages of a condition. For these groups of patients, many will respond to interventional pain procedures.
Common causes of neck pain include: spinal stenosis, herniated, disc, degenerative disc, muscle spasms, facet joint disease, whiplash type pain, occipital neuralgia, atlantoaxial joint disease, cervicogenic headaches, and prior neck surgery (also known as post laminectomy syndrome.)
Treatments: Many patients will not respond to the conservative treatments as described above. For those non-responders, interventional pain procedures may be indicated. These interventional treatments, determined by the condition, may include: epidurals, facet blocks, radiofrequency lesioning, atlantoaxial joint injections, and occipital nerve blocks.
Injections of local anesthetic and steroid to target an inflamed spinal nerve or disc under fluoroscopic (x-ray) guidance. Often used for sciatica, pinched nerves, radiculopathy, degenerative disc disease, bulging or herniated discs. Can also be referred to as a nerve block or selective root block. May aid in diagnostic workup or therapeutic treatment. Can be accomplished in the cervical (neck), thoracic (mid back) and the low back (lumbar) segments. May be accomplished with sedation when requested.
Sciatica can be referred to as a pinched nerve. It can be experienced as a radiating leg pain with electric shocks, walking pain, standing pain, or bending over pain.
Common causes of sciatica include disc bulge, disc herniation, ruptured disc, slipped disc, and pinched nerve.
Treatments: For those patients that do not respond to conservative measures, interventional treatments may provide considerable relief. These treatments include transforaminal epidural steroid injections and neuroplasty (lysis of adhesions).
Targeting of the joints and their innervations to help diagnose pain generation from spinal joints in the cervical (neck), thoracic (mid-back), lumbar (low back) segments. This is commonly referred to as mechanical spine pain. Some forms of sciatica and radiculopathy are actually a referred pain from a spinal joint that can mimic a pinched nerve. Accomplished under fluoroscopy (x-ray) and sedation when requested.
Degenerative spine changes occur in most people as they age. For many, the changes do not cause pain. However for some, this can lead to considerable discomfort.
Common causes of degenerative spine pain can be related to spinal bone spurs, degenerative disc disease, spinal stenosis, facet arthritis, arthritic spine. Many people refer to this as walking or standing pain, and discomfort when getting out of bed.
Treatments: Many patients will not respond to the conservative treatments as described above. For those non-responders, interventional pain procedures may be indicated. These interventional treatments, determined by the condition, may include: epidurals, facet blocks, sacroiliac joint injections, MILD procedure, radiofrequency lesioning, neuroplasty/lysis of adhesions and spinal cord stimulator.
Used after a diagnosis of joint pain generators are made for more long-lasting results. Small lesions using radio waves are applied by small needles to destroy pain fibers in the joints of the spine (facets), knees and hips. Fluoroscopic (x-ray) guidance is used with sedation when requested.
Spinal stenosis generally occurs over time and leads to narrowing of bone around the spinal cord or spinal nerve roots. The pain that results from lumbar spinal stenosis may include lower back and leg pain. For the cervical region, the pain may involve both the neck and arm.
A subcategory of spinal stenosis includes neurogenic claudication. This condition leads to pain with walking or standing for no more than 10 minutes. Frequently, patients must sit for a period of time before the pain will resolve. Characteristically, the act of walking in a shopping mall requires frequent breaks of sitting. The act of cooking a meal requires sitting breaks during the food preparation.
Treatments: With the combination of conservative treatments and epidural steroid injections, many patients will have the pain well controlled. For those people that continue to have considerable limitations to walking and standing, options may include spinal surgery or the nonsurgical route of the MILD procedure (minimally invasive lumbar decompression).
Catheter guided placement of epidural steroids and enzymes to break up surgical and non-surgical adhesions in the epidural space. This allows greater mobility of an impinged nerve root by adhesive material. Used for post laminectomy syndrome, sciatica, radicular pain, and degenerative disc disease. Can be used in the cervical (neck), thoracic (mid-back), lumbar(low back) segments. Utilizes fluoroscopy (x-ray) and sedation when requested.
This condition is also known as Reflex Sympathetic Dystrophy/Complex Regional Pain Syndrome or sympathetic pain. The discomfort usually involves the arms, hands, legs or feet.
Telltale signs frequently include: sensitivity to touch, swelling, color changes, temperature changes of the painful area.
Successful treatment of this condition is dependent on early recognition and early intervention. Workup is essential and may include but is not limited to radiologic studies and nerve studies.
Treatments: May include therapy and medications. If ongoing pain continues, therapy is not tolerated, or progressively decreasing function of the effected body part is noted, the patient would then be considered for therapeutic sympathetic nerve blocks. Such examples include a stellate ganglion block or lumbar sympathetic block, performed under fluoroscopic guidance. These injections provide treatment for the pain, increased tolerance to physical therapy, and increased function. The use of IV sedation or monitored anesthesia care is frequently provided during these procedures to avoid any discomfort from the procedure itself.
A concentrated dose of local anesthetic and steroid to reduce inflammation within the joint is used for diagnosis and treatment with the aid of fluoroscopy (x-ray).
Facet pain originates at the facet joint. In the cervical spine, one experiences neck pain that can possibly extend to the shoulder, upper arm, head and side of the face. This type of discomfort can be brought on with changes of neck position and may disrupt one’s sleep.
In the lower back, one experiences lower back pain that can possibly extend to the buttock and upper legs. This type of pain is frequently brought on with getting out of bed, get up from a chair, or leaning over. This diagnosis is more dependent upon history and physical exam. Radiologic findings may or may not show any obvious changes at the facet joint.
Treatments: When conservative treatments such as therapy and anti-inflammatory drugs fail to provide relief, fluoroscopic directed injections may provide considerable and long term relief. These injections include diagnostic facet medial branch nerve blocks and more long term approaches via a rhizotomy (also known as radiofrequency lesioning).
Sacral pain can be experienced in the buttock region and can extend to the tailbone, lower back and possibly the upper legs
Common causes of sacral pain include: sacroiliac joint inflammation, and less commonly coccydynia, and sacral fracture. This location of pain can be associated with sitting pain, lying down pain, or pain experienced with crossing the legs.
Treatments: When conservative treatments such as therapy and anti-inflammatory drugs fail to provide relief, fluoroscopic directed injections may provide considerable and long term relief. Such treatments, based upon the cause, may include sacroiliac joint injections, COOLIEF procedures, rhizotomies, or coccyx injections.
Are you suffering from Parosmia, Anosmia, Dysgeusia, or long COVID symptoms? We can help. We perform stellate ganglion blocks under fluoroscopic guidance for treatment of this debilitating condition.
Dr. Andrew Goldberg and Dr. Seth Wachsman are board certified in both Pain Management and Anesthesiology. They have been performing stellate ganglion blocks for more than 25 years each.
Stellate Ganglion Blocks are injections for sympathetic pain issues in the upper extremity (complex regional pain syndrome (CRPS) and reflex sympathetic dystrophy (RSD). The blocks assists with diagnostics and therapeutic treatment. These injections are placed under the skin in the anterior neck with x-ray (fluoroscopy) and with sedation, identify and treat sympathetic symptoms after trauma and surgery as well as peripheral vasculature disease and Raynaud’s Syndrome including pain, swelling, color change, temperature change, hair and nail bed changes and inability to touch the effected limb.
The placement of a needle into the center of a disc to determine whether the disc is a possible pain generator. Procedure is accomplished with x-ray (fluoroscopy) and sedation. Contrast is placed in center of the disc (nucleus) to assess for leaks and pain reproduction as well as measuring the pressures in the disc. Allows for further surgical and non-surgical treatment planning. Used for disc herniation, disc bulge, degenerative disc disease.
The occipital pain is routinely experienced at the base of the skull, It can radiate to the top of the head. In fact, occipital neuralgia can mimic other types of headaches. This problem, may be associated with cervicogenic headaches, and degenerative cervical spine.
Treatments: Coanalgesic medications may help, such as antiseizure medications, antidepressants, muscle relaxants as well as physical therapy.
When this condition persists, the patient may then respond to focus directed injections such as occipital nerve blocks or C2 nerve blocks.
Minimally invasive lumbar decompression is used for lumbar spinal stenosis by using small tools without surgical scalpels to remove excess bone and tissue with is restricting blood supply when a patient stands and walks leading to pain and cramping in the back and lower extremities.
Also referred to as midback pain, upper back pain. This condition may or may not be accompanied by pain spreading to the sides or chest.
Common causes may include: degenerative disc disease , thoracic disc herniation, facet joint or vertebral fracture, spinal lesion and spinal stenosis. A comprehensive work up should be included for this type of pain and may include radiologic studies.
Treatments: Based upon the specific cause, treatments may include conservative approaches, spinal injections, kyphoplasty, and possible surgery.
Placement of electrodes through a needle to block pain signals from the spine and extremities. Used in the lumber (low back), thoracic (mid back) and cervical neck segments.
A 7-day trial begins with a small electrode (wire) placed with an epidural needle and while the needle is removed the electrode is left in the epidural space and attached to an external power source. The initial electrode is removed easily after 7 days in all cases. If the trial is deemed successful, then a new set of electrodes are place with or without a generator (pacemaker battery) or a Bluetooth setup for a ore permanent placement.
The electrodes are controlled by a small handheld controller that the patient can carry. Used for post-laminectomy syndrome in all areas of the spine, failed back syndrome, complex regional pain syndrome/ reflex sympathetic dystrophy, peripheral neuralgia, extremity nerve injury and pain from peripheral vasculature.
For those patients already diagnosed with arthritis of the knee or with ongoing knee pain despite having knee surgery, multiple treatment options have likely already been considered. These treatments may have included therapy, anti-inflammatory agents, cortisone injections, viscosupplementation injections and consideration of a knee replacement.
Treatments: For patients that have failed conservative treatment, are reluctant to undergo surgery, are at high risk for surgery or already failed surgery, they may be a candidate for genicular nerve block and subsequent neurotomy/COOLIEF nerve lesioning.
Conditions: For those patients already diagnosed with arthritis of the hip, multiple treatments options have already been considered. These treatments may have included therapy, anti-inflammatory agents, cortisone injections, viscosupplementation injections and consideration of a hip replacement.
Treatments: This category of treatments apply to those patients who have failed conservative treatment, are reluctant to undergo hip surgery, failed to obtain improvement from hip surgery or are too high of a risk medically to undergo surgery. These patients may be a candidate for a femoral and obturator articular branch nerve block and subsequent neurotomy/COOLIEF nerve lesioning.
Targeting collapsed vertebral bodies with bone cement to treat the fracture. Accomplished under Xray (fluoroscopy) with needle placement into the bone which is then followed by a ballon spacer which is followed by a bone cement.
Injections on the side of the lumbar spine to assist diagnosis of sympathetic pain issues (complex regional pain syndrome (CRPS) and reflex sympathetic dystrophy (RSD). These injections help lower extremity pain that presents with limb pain, color change, temperature change, swelling, inability to touch the limb, loss of hair and nail bed changes.
They can additionally assist therapeutically and be used in combination with radio frequency lesioning if necessary for longer acting relief. Can occur after surgery or trauma to the limb. Accomplished under x-ray (fluoroscopy) and with sedation. Can additionally be used for peripheral vasculature disease pain.
With this condition, one can experience neck pain with or without shoulder pain, upper arm pain, headaches or facial pain. This type of discomfort can be brought on with changes of neck position and may disrupt one’s sleep.
Radiologic findings may or may not show obvious changes at the facet joint
Treatments: When conservative treatments, such as therapy and anti-inflammatory drugs fail to provide relief, fluoroscopic directed injections may provide considerable and long term relief. Such injections may include facet medial branch nerve blocks and more long term treatments via a rhizotomy.
For pain relief to the shoulder, arm, wrist, hand, leg, and knee when most other procedures have failed. Surgery may have already been performed. This approach allows us to place a specialized catheter under the skin and adjacent to the irritated or abnormal nerves. The device sends a painless electric impulse across several layers of tissue until it reaches the painful nerves. The electric impulse suppresses the painful nerves and can minimize or eliminate the pain.
This is a two step process. The first part includes a temporary trial, lasting about five days. The second part includes permanent placement of the catheter, with the excess placed under the skin. With the approach used, this type of treatment is always reversible, with removal of the catheter/lead if necessary.
Groin pain can include discomfort that extends to the lower belly or hips. By the time a patient has made an appointment to see a pain physician, more significant causes such as kidney stones, hernias, or gastrointestinal issues have already been ruled out.
Conditions for groin pain may include hip arthropathy, and post surgical inguinal hernia repair.
A specialized technique that helps with chronic knee pain, and arthritis where the patient does not wish to proceed with a total knee replacement. It addresses considerable hip pain, where the patient failed a hip replacement or wishes to avoid surgery.
With this technique the painful nerves are eliminated or broken down under live x-ray (fluoroscopy) , providing long term relief. This relief can last a full year. This procedure only affects the pain nerves. It does not cause numbness, or weakness.
This condition may or may not include buttock or leg pain
Sources of this pain may include, spinal stenosis at other levels, facet arthritis, sacroiliac joint inflammation or even scar tissue. Conservative treatments may frequently be dictated by your spine surgeon. If pain persists beyond reasonable expectations, an MRI post surgery will likely be required.
Used for chest wall pain from trauma/rib fracture. Used for diagnostic to distinguish from abdominal issues versus abdominal wall issues. Utilizes fluoroscopy (x-ray) and sedation when requested.
Ongoing pain in the face can be due to numerous conditions. Some of these causes include trigeminal neuralgia, supraorbital neuralgia, infraorbital neuralgia, and temporomandibular joint dysfunction (TMJ). For most people suffering from chronic facial pain, multiple medical specialists have already been consulted.
Treatments: For those people that continue to suffer from considerable pain despite proper treatment, specialized nerve blocks under fluoroscopic guidance may be considered, based upon the diagnosis made.
Nerves such as the ilioingual (groin pain/post hernia surgery), lateral femoral cutaneous nerve (thigh pain), sciatic/piriformis (leg pain), suprascapular block (shoulder). Fluoroscopic (x-ray) guidance utilized along with sedation.
This condition occurs following a painful Shingles outbreak. This type of exquisite pain can be constant, sensitive to touch and travels along the site of the healing rash.
Common locations of this type of pain include the thoracic spine, chest wall, and near the eye and scalp. Initial treatments should include an antiviral medication. Other agents may include topical agents, oral neuropathic medications and possibly analgesics. With the persistence of severe pain, this condition then moves into the chronic stage, known as Post Herpetic Neuralgia.
Treatments: Interventional pain treatments, when performed in these early stages, may break the pain cycle and assist with resolution of the pain syndrome. These include specialized injections called sympathetic blocks, and possibly epidural placed injections.
Nerve blocks used for trigeminal neuralgia and facial pain. Fluoroscopic (x-ray) guidance utilized along with sedation.
Injections in the shoulder, hip, knees, wrists, ankles for diagnostic and therapeutic purposes. Can utilize fluoroscopy or ultrasound guidance.