Interventional Pain Management

An intervention is a strategy to step in (intervene) when other more routine methods are not working. For either acute or chronic pain, there are options of injection interventions to manage the pain, or to eliminate the pain. Prolotherapy and PRP therapy are interventional pain management procedures that we emphasize as having the greatest effect of permanently resolving pain by regenerating and repairing damaged tissue. On this page we describe other interventional pain management procedures. The first is actually another tissue regeneration procedure with additional purposes. The others are not for regrowing tissue, yet are extremely valuable in the right situation.

Tenotomy/Fasciotomy

A first step in gardening is breaking up the soil. With painful, broken down tendons, just breaking up the tissue in a calculated manner gets the growth process off to a good start. This process of tendon remodeling is called tenotomy; in cases of fascia it may be called fasciotomy. After anesthetizing the given area, needling of the tendon or fascia does several things:

• breaks up any calcium deposits in the tendon that would be in the way of growing healthy tissue
  
• breaks up foreign fibrocartilage tissue that often infiltrates degenerating tendons, making way for growing healthy tendon tissue
  
• breaks up some of the irregularities on the degenerated bony surface where the tendon must reattach; this may be compared to cleaning off old dried glue that has failed before re-gluing an object to a surface
  
• immediately brings blood to the area - blood carries growth factors and stem cells
  
• stimulates development of new, extra blood vessels in the area for increased nourishment during the healing phase

The medical term for such needle stimulation of tendon is "percutaneous needle tenotomy." Such needle stimulation of fascia is "percutaneous needle fasciotomy."

This treatment may be useful alone or best in a series of interventions that may later include other types of injection. Recent studies have provided strong medical evidence of the effectiveness of tenotomy or fasciotomy in repair, regeneration, and pain management.

Neurolysis

It is a common strategy in interventional pain management to destroy some nerves that are causing pain. The nerves do grow back over part of a year and hopefully behave better. We believe such strategies have a place, yet we approach this process of neurolysis or neuroablation with some caution. We use milder, safer versions of these techniques in a few clinical situations. For example, a Morton's neuroma is a painful enlargement of nerve tissue in the foot near the toes. We find neurolysis to be a reasonable strategy for this disfigured nerve. While destruction of the neuroma is sometimes attempted all at once using stronger methods with risk of surrounding tissue damage and side-effects, we use a mild 4% alcohol injection, repeated comfortably over several occasions, to accomplish the same goal more safely.

Autonomic Nerve Blocks

There are two nervous systems

Somatic nervous system – normal, voluntary motor and sensory nerves that most people are familiar with, organized like a centralized federal government, with the brain and spinal cord in charge.

Autonomic nervous system - works unconsciously, on automatic, to control blood flow, sweating, other secretions, digestion, heart beat and other organ functions. It also has significant influence on pain. It is divided into two parts.

• The parasympathetic nervous system is the part of the autonomic system that helps us relax, secrete and digest.
• The sympathetic nervous system is the part of the autonomic system that makes the heart race and chokes off digestion and blood flow in response to stress

The autonomic nervous system is organized in a less centralized manner. The brain and spinal cord participate, but there are also powerful regional offices, like local or state governments. These regional offices are larger masses of nerve tissue called ganglia, situated in front of the spine, from the neck to the tail bone. Using ultrasound guidance, we have the option of calming one or another of these nerve centers with a local anesthetic. Such autonomic injection, most commonly sympathetic injection, can change pain and function in select regions of the body.

Somatic Nerve Blocks and Tissue Bed Blocks for Regional Anesthesia

On some occasions we may use local anesthetic blocks for anesthetizing the region where a tissue regenerating procedure will occur. This is not always necessary, but if we decide to seek such pre-anesthetization, it may be locally (called a tissue bed block) or upstream on the nerve that innervates the region to have a procedure (somatic nerve block). Because we seek to keep local anesthetic volumes modest, and because we preferably try to avoid motor block (the ability to subsequently use the limb in question), the amount of block that we chose to effect may be partial.

Somatic Nerve Blocks for Pain Management

The nerves that people usually think of are somatic nerves. Injection of these nerves with local anesthetic can block nerve impulses to some degree. Blocking pain impulses in a nerve may have some value in management of pain. After the somatic nerve block wears off, the pain will most likely return unless the cause of the nerve pain is addressed. Thus we emphasize tissue regeneration procedures as longer-term solutions. However, the good news is that after pain injection, some of the time return of pain may be less, at least for some period of time. And it is reasonable to repeat such somatic nerve blocks at some time after the pain escalates once again.

Each situation is unique. The nerve in question, the patient's overall medical condition, and other factors may determine how aggressively we chose to block the nerve in question. Our preference is for lesser, milder blocks for a number of reasons, but each unique situation has to be considered as it presents itself.

Nerve Release

Injury, trauma, or repetitive overuse may in some people cause soft tissues to pinch on a nerve in an extremity. In some cases, scar tissue develops to bind the free movement of nerves. Is other cases, structures without scar tissue are chronically pulled tight onto a nerve passing through. In either case, pain, tingling, numbness or weakness may result. With ultrasound imaging, we may be able to see changes in the width of the nerve near where it might be pinched. We may be able to see scar tissue in some of the cases. Using the ultrasound to guide us, we are able, in some areas of the body, to soften the binding tissue overlying the nerve, or break up some or all of the scar tissue. In one to several procedures, the goal would be to reduce or eliminate pressure on the nerve in question. Nerves in the wrist, elbow and ankle are most common sites for nerve release of this sort. The medical term for this procedure is sonographically guided percutaneous needle neuroplasty. What you need to know is that it may at times be an option for relieving pain that you have.

Scar Release

We soften and reduce scar tissue from cuts, scrapes, burns and surgery. Such scars may not be a problem for some people, but in some cases the scars may be painful or they may subtly or frankly limit full and easy motion of the involved body part.

Furthermore, autonomic nerves spread through the body like rivers or networks of thinner and thinner wires. If they bump up against a scar they have been known to continue building up a hundred fold near the dead scar tissue. In the case of such small autonomic nerves, they may not hurt locally but may send strong signals back to their regional office (autonomic ganglion). Acting on this strong feedback, the ganglion may alter blood flow or other functions on erroneous information coming from the scar. In other words, some scars can be responsible for pain or other symptoms in distant areas of the body. While it is difficult to verify if such feedback is occurring or altering regional function, this possibility increases our reasons for considering your scars when we build a plan to ameliorate your pain.

Many substances can be injected into the scars: water, local anesthetic, or a scar tissue dissolving agent such as a natural enzyme. Patients often don't feel a needle going into scar tissue.

Trigger Point Release

Trigger points are muscle knots that most adults have experienced in places such as the upper back. The knots are contracted muscle tissue where the muscle's pulling action is more focused. And, such knots are always part of a taut band that extends from one end of the muscle to the other. Such trigger points are a problem for at least the following reasons:

• local pain at the trigger point
  
• referred pain from the trigger point, even far from the trigger point
  
• muscle shortening
  
• muscle weakening and atrophy because the muscle can't be used and strengthened through its full range of motion
  
• simple or complicated dysfunction of other muscles and joints in the region effected by the dysfunctional, shortened muscle
  

For a variety of reasons, we feel that injections are often the most effective means of releasing these taut bands and trigger points.

Like any medical method, such myofascial trigger point injection has some limitations. Stretching may also be needed right after, and perhaps long after, most such injections. We avoid trigger point injection in some areas because of greater technical difficulty or risk. In some simple situations release of trigger points with injection may lead to long or seemingly permanent relief, but more commonly the causes of the stress on the muscle also need to be studied and treated.