Dr. Amr specializes in relieving your pain through a variety of different interventional techniques, procedures and clinical approaches. He will invest time and care with you to completely understand your injury or condition and develop a personalized treatment plan to get you moving faster.
Brachial plexus block is an injection into a network of nerves called the brachial plexus. These nerves lend sensation and muscle supply from the spine to the shoulder, arm, and down into the wrist and hand. Patients who have suffered brachial plexus injuries may experience pain relief and increased mobility in the arm following this type of injection. There are four conventional access points used for performing these injections, depending on the the patient's symptoms:
- Axillary - often the more commonly performed injection, the axillary block affects more the forearm and hand
- Interscalene - the most proximal approach to the brachial plexus affects more the upper arm and shoulder
Ilioinguinal and iliohypogastric nerve blocks are directed into the iliohypogastric and ilioinguinal nerves that arise from the lumbar plexus. The iliohypogastric nerve supplies the skin of the buttock and muscles of the abdominal wall and the ilioinguinal supplies the skin at the base of the perineum and adjoining portion of the inner thigh.
Lateral femoral cutaneous nerve block is an injection into the lateral femoral cutaneous nerve that supplies the upper leg and outer thigh. This technique may be beneficial to patients who suffer with myalgia paresthetica (linkMedial branch nerves are small nerves that feed out from the facet joints in the spine, and therefore carry pain signals from those joints. Facet joint injections are often used to identify a pain source; however, these injections, and other treatments that may be tried, do not always provide lasting pain relief. In such cases, it might be beneficial to confirm that the facet joint is the source of a patient’s pain so that a radiofrequency medial branch neurotomy may be considered for longer term pain relief.
A Medial Branch Nerve Block temporarily interrupts the pain signal being carried by the medial branch nerves that supply a specific facet joint. If the patient has the appropriate duration of pain relief after the medial branch nerve block, that individual may be a candidate for a neurotomy
Sciatic nerve block is an injection into the sciatic nerve which supplies feeling to the posterior thigh, leg, foot, and toes. The sciatic is a sensory and motor nerve that originates in the sacral plexus and runs through the pelvis and upper leg. This injection might be used for diagnosis and treatment of piriformis syndrome (sciatic nerve entrapment). While one might assume sciatica is treated by injection of the sciatic nerve, it is generally not. This is more readily treated by an epidural approachSelective Nerve Block
A selective nerve block may be performed to help diagnose and/or treat radicular pain (pain related to irritation and inflammation of a nerve serving a particular area of the body). You may need these injections to decrease your pain so that appropriate physical therapy and exercises can be performed for your long-term treatment. Also the nerve blocks allow identification of target sites to direct future care. You may experience numbness and/or relief from your symptoms for up to 6 hours after the injection. Your usual symptoms may then return and may possibly be worse than usual for a day or two.
It may take 3-7 days before you will be able to feel any effects from the medication. If there is no change in your symptoms after 2 weeks, your doctor may want to investigate other possible sources for your pain.Stellate Ganglion Block
A stellate ganglion block is an injection of a local anesthetic (numbing medication) around the stellate group of nerves in the neck under fluoroscopic (x-ray) guidance to relieve pain. The pain relief will affect one side of the head and neck, the upper arm and the upper part of the chest on the same side of the body. A stellate ganglion block may be performed to decrease pain and increase the circulation and blood supply to the affected arm.
InjectionsTrigger point injections
Trigger points are soft tissues (usually muscle) which when palpated cause a reproduction of the patient’s pain. Sometimes the trigger point is palpable as when a band of muscle is contracted. Usually local anesthetic (e.g. Novocaine) is injected; sometimes Botox (botulinum toxin) is used.Facet Joint Injection
A facet joint injection is a procedure that identifies the source of irritation in the small joints at each segment of the spine. These joints provide stability and help guide motion. A cervical (neck), thoracic (upper back) or lumbar (lower back) facet joint injection involves injecting a steroid (anti-inflammatory) medication, which can anesthetize (numb) the facet joints and block the pain.
If multiple levels of pain exist within the facets, several injections may be required to pinpoint the pain source in each location. This pain relief will enable you to undergo necessary conventional treatment, such as physical therapy, to rehabilitate your back.Epidural Steroid Injection
Epidural steroid injections provide diagnostic data and pain relief by delivering local anesthetic (numbing medication) and anti-inflammatory steroid medications into the spinal area on the surface of the spinal column. This procedure may reduce inflammation, resulting in long-term pain relief, and can provide valuable information on the source of your pain.Facet Nerve Injection
Facet nerve injections are diagnostic procedures that identify the source of irritation in the nerves that run along the outer edge of the facet joints within the spine. If multiple levels of pain exist within the facets, several injections may be required on different days to pinpoint the pain source in each location.Peripheral Joint Injection
Peripheral Joint Injection is an injection of a local anesthetic into a joint is also a useful diagnostic technique and may be performed with or without the simultaneous administration of steroid. Such injections are particularly common in the hip and can help distinguish pain originating from the joint itself from referred back pain. Steroid injections have been shown to have therapeutic benefit in the following conditions:
- rheumatoid arthritis
- seronegative spondyloarthropathies
- osteoarthritis with associated effusion
- crystalline arthritis
- traumatic synovitis
Patients who have long-standing arthritic pain are typically referred for intraarticular steroid injections only when other modalities (non-steroidal anti-inflammatory drugs, analgesics, various modes of physical therapy, etc) have failed to adequately control symptoms.Sacroiliac Joint Injection
A sacroiliac joint injection places local anesthetic (pain-relieving medication) in the sacroiliac joint, which is the region of your low back and buttocks where your pelvis joins the spine. Once the sacroiliac joints become painful, they may cause pain in the low back, buttocks, abdomen, groin, or legs. The amount of immediate relief experienced during the injection will help confirm or deny the joint as a source of pain. The cortisone (steroid) will help to reduce any inflammation that may exist within the joint(s).
A discogram is an x-ray procedure that deliberately provokes the patient’s pain symptoms in order to pinpoint its source in the intervertebral discs. The procedure is designed to create a pain “road-map,” making the discogram an excellent fusion surgery-planning tool.
Discography is reserved for patients who have not responded to medications and conservative treatments, such as bed rest, traction, or physical therapy, and for whom the possibility of lumbar (lower back) surgery is being considered. Besides studying abnormal discs, discograms can detect problems within intervertebral discs that appeared normal on the CT or MRI scan.Radiofrequency Rhizotomy
Radiofrequency (RF) rhizotomy or neurotomy is a therapeutic procedure designed to decrease and/or eliminate pain symptoms arising from degenerative facet joints within the spine. The procedure involves destroying the nerves that innervate the facet joints with highly localized heat generated with radiofrequency. By destroying these nerves, the communication link that signals pain from the spine to the brain can be broken. By anesthetizing these nerves, the physician can determine whether the nerve irritation should be treated with medication or by radiofrequency (RF) rhizotomy. Pain relief varies for each patient ranging from short-term to long-term relief.
Most painful disorders can be treated safely and effectively with a blend of medications, injections, physical therapy, and behavioral and lifestyle counseling.
Pain management is always an individualized process. A plan that works for one person can be very different from what works for another. Medication management, therefore, often involves time, patience, and a course of repeated trials and re-assessments. It is your responsibility to understand the prescribed medication regimen, take medications only as directed, and communicate their effectiveness to your provider. In order to manage medications effectively, it is necessary to be seen by your provider at regular intervals. Medication changes over the telephone are discouraged.
Most chronically painful disorders can safely benefit from a medication of some sort:
- NSAIDS/acetaminophen (Tylenol)
- transdermal lidocaine
- opioid analgesics
Spinal Cord StimulationWhat is a spinal cord stimulator?
A spinal cord stimulator is a tiny electrical device which creates an electrical field over a small region of the spinal cord where the pain nerves are found. It mutes pain by interfering with the transmission of pain signals travelling along the pain nerves. It does not block pain completely so you are not at risk of hurting yourself without knowing it. It reduces pain, usually far more effectively than medications. Although it is called a spinal cord stimulator, the device is not placed in the spinal cord. It is placed in the epidural space which is the “service road” to the spinal cord. The spinal cord stimulator is controlled by the patient. It can be turned on and off and the amount of stimulation controlled by the patient. The patient is always in control of the spinal cord stimulator. One attractive feature of spinal cord stimulation is that you can do a temporary “trial” of a device just to see how well your pain is relieved by it. The trial procedure is a minor procedure all done through a needle. There is no incision involved. The trial procedure is performed on an outpatient basis. Patients go home the same day that the procedure is performed, usually within 2 hours after the procedure. Patients get to “test drive” the spinal cord system for 5 days and then the temporary system is removed. There is no need even for a bandage after it is removed. If a patient decides they want to have an implanted system with a battery placed, they can have it done.What is the purpose of a spinal cord stimulator?
Spinal cord stimulators offer a better alternative to medications to relieve chronic pain.
Research shows that over time, pain medications lose their ability to relieve pain. There is a limitation to pain medications. Spinal cord stimulators have the ability to give good pain relief for many years. They are also removable, so the term “permanent” does not apply to them. The goal for using spinal cord stimulation to treat pain is to allow a patient to have good pain relief without the need for pain medications for many years. Spinal cord stimulation is an alternative to pain medications. Some people still need some pain medications, but usually significantly less. If in the future, a cure is found for your pain, you can have the device removed. It only has to be inside of you for as long as it takes for something better to come along. That is what it boils down to.Am I a candidate for a spinal cord stimulator?
There are a number of factors involved in deciding if a person is a good candidate for a spinal cord stimulator. Spinal cord stimulators can relieve pain in limited parts of the body. A device placed in the neck can help for headaches, neck pain, and upper extremity pain. A device placed in the back can help for back pain, leg pain, or foot pain. The device works very well for problems involving nerve pain or for patients who have had prior surgery for their pain which did not help enough. Patients have to be motivated, cooperative, and willing to make the commitment to their care. Issues with Depression and Anxiety have to be under control.
Uncontrolled Depression and Anxiety cause increased activity in the Pain centers of the brain. You cannot relieve Depression or Anxiety with spinal cord stimulation. Ultimately, you need to have a face to face consultation with one of our providers who performs spinal cord stimulation. They will need to review your history and perform a physical exam to make that decision.Who should NOT have a spinal cord stimulator?
There are a number of reasons to disqualify a patient from spinal cord stimulation. If they are unable to accurately report their pain, if their anxiety or depression are not controlled, if they are uncooperative and unreliable, or if they are addicted to their pain medications and refuse to reduce their dose. Other reasons are if they need frequent MRI’s, or if they have such severe medical problems that the risk of General Anesthesia is too high. These are the main reasons. Our goal is to produce success, not failure. If a person wants to spend the rest of their lives lying around and taking high dose pain medications, then this is not the procedure for them. Our goal is to enable patient to have better control of their pain, reduce or eliminate the need for pain medications, and become productive and responsible members of society.What is the difference between a spinal cord simulator trial and a spinal cord stimulator implant?
The trial is done with needles in an ambulatory surgery center. Gentle sedation is given, just enough to keep people calm, but not asleep. After numbing the skin and muscles, a needle is inserted into the epidural space. The needle is a tunnel. The spinal cord stimulator electrode is threaded through the needle and into the epidural space. Then the needle is removed, leaving the electrode half inside and half outside the body. Usually we place three electrodes: one for the center, one for the right, and one for the left sides of the body. No incision is made. We test the location of the electrodes with the patient awake and talking to us. When we are confident that they are in the correct place to help the pain, we stitch them in place and put a bandage on the skin. The electrodes are connected to a hand held device which is a remote control for the system and provides the energy for the system. Within a couple of hours, people usually go home with someone to drive them.
The implant is performed surgically in the hospital, usually by a Neurosurgeon. Patients are under General Anesthesia for the procedure so they are totally unconscious for the surgery. The surgeon makes two incisions, one for the implanted electrode, one for the battery which provides the power for the device. It is very similar to having a pacemaker placed. Most patients go home the same or the following day. If a patient has other severe medical problems, they may have to stay longer.System Components and Functions
Leads: The Trial leads are thin strands with electrodes built into them. One end has the contact points from which the energy comes from. The other end is plugged into the power source, which is outside the body. The implanted version is far more sophisticated than the trial version. It contains five rows of electrodes which allow it to target the pain nerves more accurately. If you think about digital cameras, the trial lead is like a 3 megapixel camera found on a cell phone. The implanted lead is like a 15 megapixel camera made by Nikon for professional photographers. The Nikon takes sharper pictures, even in low light! The implanted lead is physically larger. That is why it needs a surgeon to make an incision to place. The incision is small – about 3 inches. The implanted lead is connected to the battery which sits under the skin, just like a pacemaker battery. The battery is small enough that it needs about a 3 inch incision to place it too. The lead is connected to the battery under the surface of the skin through a small tunnel the surgeon creates so you usually don’t see any wires.
Battery: The battery is very sophisticated. Not only is it a battery, it also is a computer. It is more powerful than the batteries you find in stores, and it is rechargeable. It can be recharged many times over and still hold enough power to last for weeks to months in between the need to recharge it. The way you recharge a battery is with another device that beams energy through the skin to recharge the battery. The recharging unit is portable and is battery powered itself. So you can literally recharge your internal battery while eating or watching TV. It takes about an hour to recharge the internal battery, much faster than a cell phone. The internal batteries usually last at least ten years, depending how much power you need. For some people the battery can last decades. Since the battery sits under the skin, if it needs to be replaced, the skin is numbed with local anesthetic over the battery and with a small incision the old battery can be taken out and a new one placed where the old one was. This is a minor procedure.The surgical procedure
As stated above, there are two phases to spinal cord stimulation. The first phase is the trial phase. That is done in the ambulatory surgery center and you go home within a couple of hours. During the trial phase, patients are given a diary to keep about their pain and their activities. The trial is usually five days long. After that, the trial leads are removed. If a patient reports that they felt at least 50% pain relief and had improvement in their activities, we recommend having the implant performed by a surgeon. The patient is referred to the surgeon for a consultation. The surgeon may want to see a new MRI just to make sure there are no anticipated problems to performing the surgery, and also to see if there is a significant problem that requires a separate operation to fix. The surgery is performed in the hospital and under General Anesthesia. Patients are able to go home the same day but those with other problems may need to stay overnight or longer for observation, depending upon the severity of those other problems. Due to the fact that high dose opioids cause the body to be more sensitive to pain, patients on high dose opioids will experience more pain after surgery than those on low dosages, or none.Take a shower with an antibacterial soap such as Dial. Try to get a good night’s sleep. Please have nothing to eat or drink after midnight. This includes candy or gum. You may have a few sips of water to take your medications the morning of the procedure. Remember, only sips of water, nothing else. You will want to wear loose comfortable clothing the day of the procedure. Shirts with zippers or buttons are preferred so you don’t have to worry about snagging the leads on your clothes when you put them on or take them off. This means no turtlenecks especially! Remember to bring every medication you take with you since we do not have any of your medications in the Ambulatory Surgery Center. Bring a spare pair of underwear in case the antiseptic soap stains yours.Getting ready for surgery
The night before: Take a shower with an antibacterial soap such as Dial. Try to get a good night’s sleep. Please have nothing to eat or drink after midnight. This includes candy or gum. You may have a few sips of water to take your medications the morning of the procedure. Remember, only sips of water, nothing else. You will want to wear loose comfortable clothing the day of the procedure. Shirts with zippers or buttons are preferred so you don’t have to worry about snagging the leads on your clothes when you put them on or take them off. This means no turtlenecks especially! Remember to bring every medication you take with you since we do not have any of your medications in the Ambulatory Surgery Center. Bring a spare pair of underwear in case the antiseptic soap stains yours.
The day of surgery: You Absolutely Must Have A Driver! If you do not, we will not perform the procedure. You must arrive one hour before the actual surgery time, this will allow the staff adequate time to get you ready for your procedure. You will have an IV started and you will receive a dose of antibiotic. We often run ahead of schedule so you will be glad you showed up when you did! You will be escorted to the operating room where the staff will help you lie down on your stomach on the operating table and position you as comfortably as possible. You will be connected to equipment to monitor your vital signs. You will then receive some medication to help you relax through your IV. Once the leads are placed, you will be asked to let us know where you feel the stimulation from the device so we can make sure everything is in the right place. After the procedure, you will be transferred by stretcher to the recovery room. You will have your device programmed and you will be taught how to handle the device. Usually people are able to leave within a couple of hours.How long does a spinal cord stimulator trial placement take?
We allow 90 minutes for the procedure. However the actual procedure itself takes anywhere from 45-60 minutes. The more cooperative the patient, the quicker the procedure.Will the spinal cord stimulator placement hurt?
The trial procedure is not very painful. The local anesthesia stings, just like at the Dentist. We inject a generous amount of local anesthetic at the beginning and end of the procedure. The sedation helps keep people calm and relaxed. People are sore for about 3 days after the procedure. We recommend a combination of Tylenol and Motrin for the soreness.Will I be "put out" for a spinal cord stimulator?
For the trial, no. This is because we need your cooperation during the procedure. We need you to hold still so the procedure can be performed safely and accurately. We like to say that it’s like cutting a diamond. If you are cutting a diamond and shake the table, you will end up with a diamond you can buy at Walmart (no offense meant to Walmart). If you hold still, you’ll end up with a Tiffany diamond.
For the surgical implant, you will receive General Anesthesia so you will be unconscious for the surgery. As we like to say, “One second you are awake and the next second you are awake, but done.” We will prescribe your pain medications for the surgery so you won’t have to go to the Pharmacy on the way home from the hospital. You will already have them.How do you know where to place the spinal cord stimulator and the battery?
We know where to place the spinal cord stimulator based upon the results of the trial procedure. The decision where to place the battery is made by the patient in consultation with the surgeon.How long does it take to recover after the trial, and how long does it take to recover from the implant?
People usually recover within 3 days of the trial procedure. Some people return to work at that time. Some people just need more time and take the week off from work. It’s an individual choice.
People usually recover within 2 weeks of the implant procedure. Some people return to work at that time. Some people just need more time off and take off another week or two. Again, it depends on the individual. One trend we see is that people who are on high dosages of opioids experience more pain and it takes longer for them to recover than people who are either not on opioids, or who are on modest dosages.Do I have to come off my medications before the trial of spinal cord stimulation?
No you do not. This is because even though people are on pain medications, they are still in significant pain. We do not recommend any changes be made in preparation for the trial. If there is less pain during the trial, then people can use less of their medications. We have found that it is very obvious if spinal cord stimulation is helping a patient’s pain. If someone is unsure, then we advise against having the implant performed. Sometimes it is after the trial when the pain returns to its former intensity that people realize how much relief they were getting. That is why it is important for people to be able to accurately judge their pain. If someone is unable to accurately report their pain, they are not a candidate for spinal cord stimulation.Your responsibilities:
During the trial, you want to avoid any twisting, bending, or strenuous activity. You can walk, drive, and act like you are on vacation. After the implant is performed you need to be very careful for 6 weeks. If you move excessively or fall early on, you may cause your implant to move and then the whole surgery needs to be repeated. So you will have to have a “healthy paranoia.”
Remember to keep all post-surgical and programming appointments. They are essential for the success of this treatment!
After the implant, carry your identification card with you at all times. The card will arrive from the manufacturer 4-6 weeks after surgery. Please watch for it. It is useful when traveling and going through security checkpoints. And no, the device will not “zap” you when you go through a security arch at a store or an airport.Can a spinal cord stimulator be removed?
Absolutely. The system can stay inside you for as long as you need it, but it is removable. It is actually easier to remove one than to place one and it is less painful.Can I have an MRI if I have a spinal cord stimulator?
No, because the device contains metal, like a pacemaker. You can have CT scans, Ultrasound, PET scans, X-Rays, and Mammograms, however. If you absolutely had to have an MRI, the system can be removed and then put back in after you had the MRI performed.Information regarding dental work
If you require dental work and you have a spinal cord stimulator implant, you will need to let your dental provider know! The same rules that apply to pacemakers apply to patients with spinal cord stimulators. Your Dentist will need to prescribe an antibiotic prior to procedures. Some choices are: Amoxicillin 2 grams, 1 hour prior to procedure; or Cleocin 600mg, 1 hour prior to procedure.
Opioid addiction treatment with suboxone (buprenorphine/naloxone)
The Drug Addiction Treatment Act was passed by Congress in 2000 allowing qualified physicians to treat opioid addicted patients with specifically approved narcotics in settings other than traditional treatment centers, e.g. methadone clinics. Sublingual buprenorphine was approved for use at this time and has since become a major drug of choice in the effective outpatient treatment of opioid addiction.How does Suboxone work?
Strong opiates, such as morphine, work by temporarily attaching to receptors in the brain that stimulate the release of dopamine, producing a short-lived euphoric feeling. Once the opiate detaches from these receptors, the patient begins to experience strong and long-lasting withdrawal symptoms that include cravings and an urge to repeat the experience. Suboxone, a combination of the drugs buprenorphine and naloxone, works by firmly attaching to the receptors thus blocking the opiates from attaching. Buprenorphine is a partial opioid agonist which produces a very limited opiate effect - enough to stop withdrawal but not enough to cause euphoria. It is long acting, continuing to block other opiates from attaching to the receptors for a period of 24-72 hours after a simple dose. Naloxone is an opioid antagonist which also competes to block the opiate receptors but without producing any opiate effects.
A prescription for Suboxone is given at the first office visit. Initially the patient may be seen often over several days, or on a weekly basis, in order to assess symptoms and to adjust the dosage. Once the most effective dose is established, the patient begins the maintenance phase of treatment and is considered stable. Patients are carefully monitored for withdrawal symptoms and frequent urine tests are obtained to verify the absence of opioids in their system and compliance with treatment.How long will I stay on Suboxone?
It is up to you and your provider to determine the length of your treatment course. The degree of physical dependence, psychological and behavioral components all play a role in opioid dependence and affect the duration of treatment. There is concern that short-term treatment does not allow for the behavioral changes necessary for maintaining an opioid-free lifestyle. Support, counseling, and suppressing cravings for as long as necessary are each important elements in the successful treatment of dependency.
Once it is determined by you and your provider that you no longer need Suboxone, your dose may be slowly tapered until you are no longer taking any medication. Abruptly stopping the Suboxone will very likely result in some mild withdrawal symptoms.What determines successful treatment?
Open and honest communication between the patient and the healthcare team is important to optimize the success of treatment. Our providers and nursing staff have been specially trained to understand opioid addiction and the nuances of how best to treat dependence. It is imperative for safety that you follow specific guidelines and instructions while in treatment. Your doctor may also prescribe other medications to help control addiction symptoms.
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