TREATMENTS

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Treatments

Chronic pain is one of the most challenging conditions to manage. However, when it comes to finding a treatment for these symptoms, there are numerous options available. We understand that each patient’s pain is unique and therefore, treatment recommended to each patient will also be unique. We offer advanced interventional and minimally invasive techniques to help treat chronic complex pain. There is no guarantee that a certain treatment will cure a patient’s pain, therefore we promise to explore as many options as possible to ensure that the pain can be diminished to a level that allows a patient to feel comfortable.

We also utilize other approaches besides specialized procedures such as myofascial therapy, biofeedback, counseling and life style changes. Moreover, we recommend rehabilitation and reconditioning which focuses on biomechanical, postural and strength deficits, commonly associated with spine pain.

“Dr. Kim was able to reduce the pain I had in my head, neck and back with the use of a pain pump. I can now do things I was unable to do for a very long time. Dr. Kim listens…he is compassionate and made me feel like he truly cared.”

– Anthony F.

RADICULAR PAIN (LEG OR ARM PAIN) – EPIDURAL STEROID INJECTIONS

What is radicular pain?
Radicular pain originates as a result of irritation of a nerve root due to a herniated disc or
degenerative arthritis of the spine that causes pinching of the nerve root. Patients
typically experience a shooting pain into the leg or arm, usually on one side of the body.
Numbness, tingling, and/or weakness may accompany the pain. The most commonly
affected levels in the lower back are L4-5 and L5-S1 and C5-6 and C6-7 in the neck,
although any level can be involved.
How is radicular pain diagnosed? Do I need an MRI?
Radicular pain is diagnosed by history and physical examination, but an MRI is
oftentimes required to correlate the findings and plan injections or even surgery. MRIs
are not magical pictures of pain. There are many people who have terrible-looking MRIs,
but have no pain. On the contrary, there are many people who have perfect-appearing
MRIs with lots of pain. Your doctor will use all the information at his or her disposal to
assess where your pain is most likely coming from and plan a targeted treatment to that
area.
What is the treatment of radicular pain?
Treatment of radicular pain is initially conservative, with physical therapy, a short course
of opioid pain medicine (e.g. Percocet), NSAIDs (e.g. ibuprofen, naproxen), and nerve
pain medications (e.g. gabapentin). Epidural steroid injections have been shown to
provide short-term pain relief in patients with acute radicular pain.
What is an epidural steroid injection?
An epidural steroid injection is a targeted minimally invasive procedure that can help
relieve radicular pain in the neck, arm, back, and leg. There are multiple approaches to
the epidural space, and your doctor will choose the one most appropriate for your
anatomy. The doctor will use x-ray guidance to place 1-3 needles into the area(s) that
correspond to your pain complaint. The doctor will then use a small amount of contrast
dye to ensure the medication will spread to the appropriate area. Thereafter, he or she will
inject a mixture of steroid and numbing medicine into the area.
What are the risks of epidural steroid injections?
Any time we break the skin, there is risk of bleeding or infection. These are minimal if
patients are not on any blood thinners and have no current infections. Any time we put
steroids into the body, there are effects from the steroids, including increased blood sugar
and worsening of any existing infection. In the low back, there are risks of back pain,
headache, worsening the pain, not helping the pain, and causing persistent numbness and/
or weakness. In most individuals, the spinal cord ends at L1-2, so any injections below
those levels have essentially no risk of spinal cord injury or paralysis. Cervical and
thoracic spine (neck and mid-back) injections are done in an area where the spinal cord is
present, so there is a very rare chance of injury to the spinal cord including paralysis.
Your doctor will take great care and uses X-ray guidance to ensure that this is done safely
without any injury to the spinal cord.
Do I need anesthesia for an epidural steroid injection?
You may have your epidural steroid injection with local or with sedation. Most
individuals do well with just local, in which numbing medicine is used to reduce any
discomfort from the needle. Individuals who have a fear of needles or who are extremely
sensitive to pain may benefit from sedation. Your doctor will discuss the options with you
and come to a mutual decision.
What should I expect during an epidural steroid injection?
First, your back will be cleaned with an antiseptic solution and a sterile drape will be
placed. Next, the doctor will identify the area he or she will inject using an x-ray
machine. Once the location is identified, you will feel a pinch and a burn as numbing
medicine is injected into that spot using a fine needle. After the numbing medicine takes
effect, you should only feel pressure as the doctor places an epidural needle into the
correct position using multiple x-rays. Once the needle is in the epidural space, you may
feel pressure or even worsening of your typical pain as the doctor injects the medication.
Are there any restrictions after an epidural steroid injection?
There are very few restrictions after this type of injection. The only restriction is that you
should not soak in a tub or other body of water for 24 hours.

SELECTIVE NERVE ROOT BLOCKS

What is a selective nerve root block?
A selective nerve root block procedure is a targeted injection that is typically used by
your surgeon and pain doctor to diagnose and/or treat the cause of pain. A small amount
of numbing medicine and/or steroid medication is deposited around a specific nerve
root(s) in the neck, chest, or low back. This is performed using X-ray guidance and is
highly specific to a certain area.
What should I expect after a selective nerve root block?
As this is a diagnostic procedure, it is important for you to pay close attention to your
pain complaint during the initial 24 hours after the block and document this in the
provided pain diary.
Ok, I had a selective nerve root block and I feel better. Now what?
Depending on the context, the information from the selective nerve root block may be
used to plan additional interventional procedures or even surgery. Be sure to discuss the
specifics of your response with your doctor, so that you can make a plan moving forward.

AXIAL SPINE PAIN (MIDDLE OF BACK OR NECK) – MEDIAL BRANCH BLOCKS

What is axial spine pain?
Pain localized to the low back or neck is known as axial pain. This pain may even extend
towards the shoulders in the neck or the buttocks in the back. The small joints of the
spine that allow you to bend, flex, and twist are called the facet joints. These are
frequently the cause of axial spine pain as they develop arthritis and inflammation with
aging. In low back pain, it has been estimated that the facet joints are the cause in up to
45% of cases.
What are the facet joints?
The main function of the facet joints is to limit rotation and resist compression when
extending the back. Facet joint pain results from conditions that increase the load on
them, such as arthritis, decreased disk space, and increased extension (as in obesity).
What are medial branch blocks?
Medial branches are the nerves that supply the facet joints. Since we cannot make the
spine younger or less degenerative, what we aim to do is turn off the painful signal that
comes from those joints. The medial branch nerves are the messengers of this painful
signal, and by blocking them with numbing medicine we can oftentimes turn off the pain.
These nerves do not provide any other significant function other than to tell you that you
have arthritis in your joints. This is one instance where we want to ‘kill the messenger’,
so to speak.
What should I expect during medial branch blocks?
During the procedure, the doctor will first clean off the skin and use X-ray guidance to
identify the area where the medial branch nerves live. Then, the doctor will numb up the
skin with a pinch and a burn at four sites. The doctor then places the needles down to the
area where the nerves run and double-checks with more X-rays. Once in satisfactory
position, the doctor injects a long-acting numbing medication onto the medial branch
nerves.
What should I expect after medial branch blocks?
This is a diagnostic procedure, which means that we are testing to see if it takes away
your pain. As such, you will be asked to fill out a pain diary documenting any relief you
experience every hour for the first 12 hours after the injection, and also at several time
points thereafter. We want you to be active during this time to really test whether or not
the injections relieve your pain.
Ok, the medial branch blocks took away my pain temporarily. Now what?
If the medial branch blocks relieve your pain while the numbing medicine is working,
then you may be a candidate for a long-acting procedure called a radiofrequency ablation
or rhizotomy.

SACROILIITIS – PAIN AT THE JUNCTION OF THE HIP AND SPINE – SACROILIAC JOINT INJECTIONS

What is the sacroiliac (SI) joint?
The SI joint connects the large triangular-shaped bone at the end of the spine (the sacrum)
to the two hipbones (iliac bones). The SI joints are designed for stability, not mobility.
However, it is subject to degenerative and inflammatory arthritis as well as mechanical
dysfunction.
How is SI joint pain diagnosed?
The history may reveal a precipitating injury, such as a fall, lifting a heavy object, or
turning. The pain is a one-sided ache that radiates to the buttock, groin, and/or thigh area.
It rarely goes below the knee. The pain is worsened by loading the joint, as occurs during
prolonged sitting, standing, or bending. There is tenderness over the joint area, and the
crossing the leg of the affected side typically reproduces the pain. The diagnosis is
confirmed if an SI joint injection with numbing medicine takes away the pain completely.
What should I expect during an SI joint injection?
In an SI joint injection, the doctor will use X-ray guidance to visualize the joint. He or
she will clean off the skin overlying the joint, then you will feel a pinch and burn while
the doctor numbs up the skin. Then the doctor will place a needle into the joint itself. If
the joint is inflamed, oftentimes the patient will experience a familiar zing of pain in the
area. It is not uncommon for the patient to say “that’s the spot!”. Then, the doctor will
confirm they are in the joint using contrast dye. Once confirmed, the doctor will injection
numbing medicine and steroid into the joint.
What should I expect after an SI joint injection?
The SI joint injection is both diagnostic and therapeutic. If this is the cause of the pain,
then it should feel better right away while the numbing medicine is working. The
numbing medicine wears off after 6-12 hours, and patients may experience a return of
their pain. The steroid medications take 3-7 days to treat the inflammation in the joint
and give long-lasting relief.
Ok, I had an SI joint injection and my pain was better the first day but I did not
experience any long-lasting relief. Now what?
This confirms that the SI joint is likely the pain generator, but it may be too degenerative
or inflamed to respond to steroids. In this case, you may be a candidate for a procedure
called an SI neurotomy.

OSTEOARTHRITIS – HIP, KNEE, SHOULDER JOINT INJECTIONS

What is osteoarthritis?
Osteoarthritis (OA) is the most common joint disorder, is one of the most common
chronic diseases in the elderly, and is a leading cause of disability. In the US, it is
estimated that one-third of people over the age of 65 have OA. Obesity is the most
significant independent predictor of both incidence and progression of OA as well as the
need for surgery. The risk for development of OA is also increased by high-impact
repetitive activities, smoking, and osteoporosis.
How is osteoarthritis diagnosed?
OA is diagnosed by history and physical examination. The typical initial complaint is
joint pain in middle-aged or older patients. The typical pain pattern is reported as a
stiffness and joint pain in the morning that improves with activity. X-rays and blood tests
may be needed to confirm the diagnosis and rule out other types of arthritis.
How is osteoarthritis treated?
In 2012, the Chronic Osteoarthritis Management Initiative (COAMI) of the US Bone and
Joint Initiative* performed a systematic review of recommendations and guidelines in the
literature and identified five main areas of treatment:
1. Education and self-management (joint protection, stretching)
2. Exercise and weight loss (low-impact aerobic exercise)
3. Assistive devices (walking aids or assist devices to improve activity)
4. Alternative and complementary approaches (injections, heat, ice)
5. Surgical interventions (joint replacement)
Your doctor will design a comprehensive treatment plan taking into account these five
areas of treatment.
*Nelson AE, Allen KD, Golightly YM, Goode AP, Jordan JM. A systematic review of recommendations and guidelines for the
management of osteoarthritis: The chronic osteoarthritis management initiative of the U.S. bone and joint initiative. Seminars in
Arthritis & Rheumatism. 2014;43(6):701-712.
What is an intra-articular joint injection?
Intra-articular joint injections utilize X-ray guidance to place numbing medication and
steroids in a joint space, most commonly hips, knees, or shoulders. These are broadly
recommended in societal guidelines as part of a comprehensive treatment plan. The goal
of the intra-articular injection is to reduce inflammation, thereby relieving pain and
increasing function.
What should I expect during an intra-articular joint injection?
After confirming the site and side of the injection, the doctor will clean the skin overlying
the joint space so as to ensure the procedure is done under sterile conditions. Numbing
medicine will be placed into the skin overlying the injection site – you will feel a pinch
and a burn while it is administered. Thereafter, you should only feel pressure as the
doctor uses X-ray guidance to place a needle into the joint space. Contrast dye is
administered to ensure appropriate spread into the joint space. Once confirmed, the
doctor will inject a mixture of numbing medicine and steroid into the joint and remove
the needle.

What is intra-articular pulsed radiofrequency neuromodulation?
Pulsed Radiofrequency Neuromodulation is a needle-based, non-narcotic treatment that
can be used for many purposes, one of which is chronic shoulder, knee, and other joint
pain. Over time, inflammation in joints and ligaments is believed to cause small nerve
endings to grow into the joint structures. These are not found in normal joints. These
nerves can be treated using this advanced, minimally invasive, outpatient procedure, in
which the physician directs the needle into the area of inflammation (the joint or other
structure). Once the area is identified, pulsed electricity is used to create an
electromagnetic field at the tip of the needle. This electromagnetic field is thought to
change the balance between inflammatory (pain-causing) and inhibitory (pain-relieving)
factors in the immediate area to reduce pain.
Studies have shown that Pulsed Radiofrequency Neuromodulation reduced joint pain by
50-70% for up to 1 year, which was associated with increased function and better quality
of life.

SYMPATHETIC BLOCKS

What is a sympathetic nerve block?
The sympathetic nerves are a part of the autonomic nervous system, which control a
number of different functions in the body as part of the “fight or flight” response. In
some conditions, these nerves can also carry pain signals or maintain painful states. This
is called sympathetically-maintained pain, and it is seen in Complex Regional Pain
Syndrome, Post-Herpetic Neuralgia, nerve entrapment syndromes, certain types of facial
pain and even peripheral vascular disease.
Where in the body are sympathetic nerve blocks performed?
Sympathetic nerve blocks can be targeted to a number of anatomic areas, including the
legs (lumbar sympathetic block), arms and face (stellate ganglion block), as well as the
abdominal and pelvic organs (superior and inferior hypogastric plexuses and ganglion of
impar).

PIRIFORMIS INJECTIONS

What is the piriformis muscle and why does it matter?
The piriformis muscle is involved in rotation of the thighbone. In its course running from
the sacrum to the outside of the hip, it can compress the sciatic nerve. This results in pain
that runs down the back of the leg into the sole of the foot. This is called piriformis
syndrome. In some cases, the relationship to the nerve is more complicated, and imaging
may be required to better characterize whether the nerve runs under, through, or even
around the piriformis muscle.
What is the treatment for piriformis syndrome?
Piriformis syndrome is initially treated conservatively with physical therapy, heat, and
NSAIDs. Stretching exercises are critical to lengthening the piriformis muscle so that it
does not continue to compress the sciatic nerve. If conservative measures are ineffective,
or if pain is so severe that stretching is too painful, piriformis injections can be
performed.
What is a piriformis injection?
During a piriformis injection, the doctor will place a needle into the lateral aspect of the
piriformis muscle. After confirming appropriate spread of contrast dye, a small amount of
numbing medicine and steroid is placed into the muscle. This can allow for relatively
painless stretching and also relief of any inflammation around the nerve itself.
What should I expect after a piriformis injection?
As with any injection, the doctor will first obtain informed consent. Then he or she will
use X-rays to target the area where the muscle typically courses. The skin will be cleaned
and sterilely draped. A small needle will be used to anesthetize the skin with numbing
medicine. Thereafter, a needle is placed into the belly of the muscle and position
confirmed with injection of contrast dye. Once confirmed, a mixture of numbing
medicine and steroid is placed into the muscle.
What are the precautions after a piriformis injection?
As the sciatic nerve runs close to the area we inject, we require that you have someone to
drive you home from this injection. It is not uncommon for the sciatic nerve to be numb
for a few hours afterwards. This would cause a temporary foot drop and weakness of the
affected leg. For this reason, we would not perform piriformis injections on both sides at
the same time.

MYOFASCIAL PAIN SYNDROME – TRIGGER POINT INJECTIONS

What is Myofascial Pain Syndrome?
Myofascial pain syndrome (MPS) is a common cause of soft tissue pain. MPS can occur
primarily, or can present as a reactive component to other conditions. The primary feature
of MPS is the trigger point, a localized, tender, and firm or taut region within muscles or
their fascia. These are thought to arise from trauma or microtrauma to the area that
causes the muscle fibers to shorten. When shortened for a prolonged period, the muscle
fibers become sore, tender, and even develop firm/crunchy knots due to calcium deposits.
Patients with MPS can also develop central sensitization, a state of increased pain
perception resulting from increased gain of the painful signals.
What is the treatment for Myofascial Pain Syndrome?
Treatment of MPS focuses on the deactivation of the trigger points themselves as well as
addressing any causative factors. Eliminating trigger points to break the cycle that
enhances chronic pain and to restore normal tone and function of the affected muscles is
the overarching goal. Trigger Point Injections (TPIs) have been widely used to facilitate
this process and are the gold standard for the treatment of MPS. Relying on TPIs as sole
treatment is not recommended – they should be used in conjunction with post-injection
stretching or exercise therapy as part of a comprehensive, multidisciplinary pain
management regimen.
What are Trigger Point Injections?
Trigger Point Injections (TPIs) have been widely used to facilitate this process and are
the gold standard for the treatment of MPS. They are relatively safe when performed by
clinicians with appropriate training.
What should I expect during Trigger Point Injections?
During the Trigger Point Injection procedure, the doctor will identify the trigger points
by feeling them. After cleaning the area with an alcohol swab, the doctor will place a thin
needle into the trigger point and move it around to break up the knot. As the doctor is
moving the needle around, he or she will inject numbing medicine into the area.
What should I do after the Trigger Point Injections?
Post-injection stretching, kneading, and movement are an important part of the procedure.
The patient should plan to go home or to physical therapy in order to get the maximum
benefit from the procedure.

INTERCOSTAL BLOCKS

What is an intercostal nerve block and when are they indicated?
Intercostal Nerve Blocks numb up the nerves that run underneath the lower edge of each
rib. They are typically used when an injury to the nerve or associated rib has occurred.
This is most frequently in the setting of rib fractures or chest surgery, but may also be
used in the treatment of post-herpetic neuralgia (pain after shingles).
What should I expect during an intercostal nerve block?
During the procedure, you will be placed facedown on the X-ray table. The doctor will
map out the area of your pain and use X-rays to make sure the correct ribs are being
blocked. Then, your skin will be cleansed and the area will be sterilely draped. Your
doctor will then numb up the skin overlying the planned injection site(s) with a pinch and
burn. Next, a needle will be placed with X-ray guidance to contact the lower edge of the
rib and walk just slightly forward to where the nerve lives. The doctor will confirm
placement with a small amount of X-ray contrast, and then inject numbing medicine with
or without steroid around the nerve.
What are the risks of intercostal nerve blocks?
As with any procedure that breaks the skin, there is a small risk of bleeding or infection.
For this type of injection, patients do not need to stop any blood thinners or aspirin as
clinically significant bleeding is extraordinarily rare. Other risks include not helping the
pain, worsening the pain, injury to the artery or vein that runs with the nerve (very rare),
and puncturing the lung. The doctor uses X-ray guidance to perform the procedure as
safely as possible and uses a variety of techniques to minimize any complications.
What should I expect after intercostal nerve blocks?
You may notice that the skin overlying the ribs and extending down to the front of the
chest or abdomen may be numb – this is normal. You will be given a Pain Diary to keep
track of how the injection affected your pain so that you can discuss it with your doctor at
the next visit. It is important that you also pay attention to whether or not you feel the
level above or level below needs to be blocked at another time – i.e., you get excellent
pain relief but there is an area above/below the numb area that is still painful.

SPINAL CORD STIMULATION

What is Spinal Cord Stimulation?
A Spinal Cord Stimulator is an advanced implantable device that can be used to interrupt
or mask painful signals coming from the body on their way to the brain. Spinal Cord
Stimulation can be thought of as a white noise machine for pain – it drowns out painful
signals along certain neural pathways using wires that are placed inside the bony spine
into the epidural space.
Am I a candidate for Spinal Cord Stimulation?
Spinal Cord Stimulation is an option for patients with chronic and severe nerve pain that
have not responded to other treatment modalities. It is most commonly used in patients
who have had spine surgery and continue to have chronic back/neck and/or arm/leg pain.
It has been shown to be as effective as repeat surgery in patients, and is much less
invasive. It is also an excellent treatment for Complex Regional Pain Syndrome, which is
a type of chronic nerve pain typically affecting a particular extremity. It has been studied
in a variety of conditions, and your doctor may discuss this as a treatment option
How do I know if Spinal Cord Stimulation is for me?
Spinal Cord Stimulation is a two-stage procedure, and the first stage is really the most
important as it determines whether or not the procedure works for you. The first stage is
the trial phase, during which a temporary stimulator wire is placed into the spine. After
placement, it is connected to an external battery that is worn on the belt during the trial
period, typically 3-7 days. During the trial period you will have the opportunity to test the
system to find out if it works for you.
How is the trial procedure performed?
The trial procedure is performed in an operating room with an anesthesiologist to provide
sedation as needed. The procedure itself is very much like having an epidural steroid
injection, which many patients have experienced before. The only difference is that
instead of injecting medications into the epidural space, a wire is inserted instead. After
the wire is inserted, your doctor and the representative from the stimulator manufacturer
will talk to you to make sure that the stimulation covers your painful areas. Sometimes
this will require some adjustments of the wires, but this is typically not painful.
What should I expect during the trial period?
During the trial, you will assess if this is a therapy that improves your pain and allows
you to more comfortably perform your daily activities. You will be given extensive
instructions on the day of the trial on the restrictions and goals of the trial. In addition,
you will be in constant communication with the representative from the device
manufacturer, who will answer any questions and troubleshoot any issues that may arise.
This may require meeting in person at a mutually convenient location, typically the
doctor’s office or a nearby hospital or surgical center.
Can I control the stimulation?
Yes, you can control the stimulation very much like you can control your television at
home. You will be given a remote control that allows you to turn the device on or off,
increase or decrease the intensity (volume) of the stimulation, and choose amongst
several programs (channels) that are customized for you by the doctor and representative
from the manufacturer.

TARGETED DRUG DELIVERY – INTRATHECAL PUMP

What is targeted drug delivery with an intrathecal pump?
Intrathecal drug delivery is a route of medication administration that delivers the
medicine directly into the spinal fluid. This is achieved using a small pump that is
surgically implanted under the skin and connected to a thin catheter inserted into the
fluid-filled sac that houses the spinal cord. Intrathecal drug delivery is typically used for
patients with chronic pain that has failed multiple conservative treatment options,
including medication, injections, and physical therapy. It can also be used in patients in
whom medications effectively treat the pain but cause intolerable side effects. Since the
medication is delivered directly into the spinal fluid, pain relief can be achieved with very
small doses of medication.
Am I a candidate for an intrathecal pump?
The decision to introduce an intrathecal pump into your treatment is an individual one,
and should be discussed with your physician. In general, you may be a candidate for an
intrathecal pump if:
• Conservative treatment has failed (medications, injections, physical therapy)
• Surgery is not indicated for your pain complaint
• Pain medications are effective but cause significant side effects
• You do not have any uncontrolled psychiatric problems
• You have had a trial dose of intrathecal medication and it was effective
RADIOFREQUENCY TREATMENTS
Medial Branch
SI Neurotomy
Pulsed RF

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