NON-SURGICAL TREATMENTS FOR BACK, NECK PAIN
AND DISC HERNIATIONS

Epidural steroid injections are a non-surgical interventional pain treatment option used to relieve pain in the neck, arm, lower back and leg regions due to nerve compression and stimulation. It is used to control pain in conditions such as disc herniations (herniated discs), slipped discs and narrowing of the spinal canal. With an epidural injection, a mixture of a long-acting steroid is injected around the damaged spinal nerve through the epidural space. The injection also contains a local anesthetic to provide relief in the early period after the treatment and to prevent reflex activity afterwards.

Although the effect of epidural steroid administration varies from patient to patient, interventions performed within the first six months after the onset of the problem provide improvement in 80-90% of patients with new onset of symptoms and do not require further treatment. In cases where treatment is more delayed, relief is achieved in 50-70% of patients for a period of 2 months to 1.5 years or more.

The aim of an epidural steroid injection is to relieve pain, allow the patient to return to their normal daily activities and, if necessary, to participate in physical therapy and exercise programs without pain.

What are epidural steroid injections?

Epidural injections contain a long-acting depot steroid and a local anesthetic agent. The medication reaches the pinched or affected spinal nerve through the epidural space and relieves pain by reducing inflammation and edema in the area while removing pressure and interference on the nerve.

The intervention is performed under continuous radiologic imaging with C-arm scope control using either of two techniques:

Interlaminar technique: The drug is administered into the epidural space through the middle of the spine. The medicine is distributed freely around the nerves.

Transforaminal technique: The medication is administered around the affected nerve by inserting a needle through the hole where the problematic spinal nerve exits the spine in an attempt to target the specific nerve to be treated. It is also known as pinpoint therapy.

Who can receive epidural steroid injections?

Patients with neck, arm, lower back and leg pain may benefit from an epidural steroid injection. The procedure is particularly useful in the following cases:

Herniated disc: Patients in whom the gelatinous inner nucleus of the intervertebral disc herniates out of the disc and presses on the lumbar and cervical nerves.

Spondylolysis – Spodylolisthesis: Patients with pain due to fractures, weakening and slipping between the upper and lower joints of the spine.

Narrow spinal canal – Spinal Stenosis: Patients with pain, especially with walking, due to nerve compression in the spinal canal and spinal nerve canal.

How are epidural steroid injections performed?

The goal of epidural steroid injections is to deliver the drug as close as possible to the area causing the pain. The procedure is performed in completely sterile and aseptic environment in the operating room and under surgical conditions and under continuous visualization with a C-arm scope. There is no need for general anesthesia, that is, the patient does not need to be anesthetized during the procedure. The procedure takes approximately 10 – 45 minutes.

Phase 1: Preparation of the patient:

The procedure is an out-patient procedure, which means that the majority of patients do not need to be hospitalized before or after the procedure. The patient arrives 15 minutes before the time of the procedure and is prepared for the procedure.

The patient dresses in a hospital gown and is taken to the operating room. If the transforaminal intervention technique is to be applied, the patient is placed face down on the special table where the intervention will be performed. A thin pillow is placed under the abdomen to correct the waist curve. Patients who will be operated on using the interlaminar technique are placed on their side.

Blood pressure and blood oxygen levels are continuously monitored by the anesthesiologist through monitors. The anesthesiologist sedates the patient with sedatives and anti-anxiety drugs. The waist-neck area to be intervened is wiped several times with an antiseptic solution and the skin is cleaned to eliminate germs. The intervention area is covered with sterile surgical drapes and the patient is then ready for phase 2 of the procedure.

Phase 2: Implementation of the initiative:

The area to be intervened is anesthetized with a thin needle. A special needle is inserted through the skin into the area where the injection is planned to be performed under continuous visualization with computer-aided C-armed scopy, and the needle is advanced into the epidural space under continuous visualization.

In some cases where the transforaminal technique is applied, the proximity to the targeted nerve using the stimulator can be adjusted according to the discomfort felt by the patient with the low electric current given from the tip of the needle. During this process, the patient may feel an electrifying and pulsating movement in the leg. In both techniques, a very small amount of radio-opaque substance, which is visible under X-ray, is administered to confirm the location of the needle and the proper spread of the drug. Once the optimal position of the needle is confirmed, the injection of the drug is started. The patient may feel a slight fullness and pressure in the lower back. After the injection is finished, the needle is removed and the procedure is completed.

What happens after an epidural steroid injection procedure?

The patient is taken to rest in the recovery room for 1 to 3 hours. After the injection, the patient may feel pain in the lower back and temporary numbness and pain in the leg where the intervention was performed. Pain can decrease or disappear after the intervention but may start again within 4-6 hours due to the effect of the local anesthetic wearing off. The long-acting steroid actually takes effect within 24-48 hours after the injection with the patient’s pain starting to disappear within 12-24 hours post intervention.

We recommend that the patient rests for the remainder of the day of the procedure and that they avoid movements that overly strain the back and neck for the following two days post procedure. The patient can continue to take painkillers initially after the injection. After 2 weeks, the patient comes in for a follow-up visit.

What are the results of epidural steroid injections?

A positive response is obtained in 70 – 90% of patients whose initial complaints started recently (up to several months) and who are treated in the early period. Depending on the response of the patient, the intervention can be repeated after 2 weeks, but any more than 2 injections in 1 month are not recommended. Patients can remain pain-free anywhere from 6 months to 2 years or more.

Patients who are careful to protect their back and neck after the intervention and who perform the recommended exercises and physical therapy movements have a much more satisfactory and long-lasting result.

Who should not receive epidural steroid injections?

Patients with the conditions below should not be considered as candidates for this intervention:

• Active infection during the intervention period,
• Pregnant or likely to become pregnant,
• Bleeding, clotting disorders,
• Patients with infection at the intervention site

What are the risks of epidural steroid injections?

In patients with diabetes, deterioration in sugar regulation may be observed for 1-2 weeks, and additional medication may be required, although rare.

According to the literature, there is a possibility of infection in patients undergoing epidural steroid injection therapy with a frequency of approximately one in 40-60 thousand patients, but we minimize this risk by performing the procedure in the operating room under absolutely sterile conditions and taking all necessary precautions to minimize any risk of infection.

Very rarely, a transient headache may occur. Nerve damage is also very rare.

Depending on the steroids used, fluid retention in the body may occur. This can be prevented by consuming a salt-free diet in the first week after the intervention.

Facet joint steroid injection is an interventional treatment method applied in low back problems related to facet joints, which provide mobility and flexibility of the spine, which are four between each 2 vertebrae right and left.

Facet joint steroid administration is used for the treatment of problems related to facet joints and is also a diagnostic method used to determine whether lower back pain is caused by facet joints. If the patient’s lower back pain disappears after a facet joint injection, this is a reliable indication that the problem is caused by the facet joints.

What is a facet joint steroid injection?

This injection contains a long-acting steroid and a local anesthetic agent. It is performed by administering medication into the facet joint or around the nerve that is thought to be causing the pain.

The intervention can be performed using two different approaches under C-arm scope control under immediate radiologic imaging:

1. Intra-facet joint injection: The medicine is injected directly into the affected, problematic facet joints.
2. Medial nerve injection: The drug is injected around the nerves of the problematic facet joints. Since there are 2 or 3 nerves belonging to each facet joint, it is done at 2 – 3 levels. The medial nerve to be intervened is located using a nerve stimulator. In order to locate the medial nerve, first, the appropriate point for the intervention is determined with a scope. The targeted point is reached by passing through the skin with the stimulation needle. The exact location of the medial nerve is determined by observing the muscle movements in the lumbar region by giving a very low-level electrical stimulus with the nerve stimulator. It is understood that the medial nerve is reached when there are small muscle movements in the lumbar region and the patient feels slight tingling in that area.

Who can receive facet joint steroid injections?

Facet joint steroid injections are especially applied to patients with facet syndrome, who have lower back pain when bending backwards and/or bending or turning to the right or left, and whose pain is usually concentrated in the waist, hips or upper parts of the leg but does not spread all the way to the feet, and especially to patients whose lower back pain increases with turning in bed at night.

Other details of this injection, including the application stages, patients who cannot undergo the procedure, and its possible side effects are similar to those of an epidural steroid injection.

Herniated discs between the bones of the spine can be attributed to many personal factors. These include age, race, obesity, smoking and occupational stress factors. Many different interventions can be performed for the treatment of persistent neck, shoulder, arm, back and leg pain caused by a combination of any or all of these factors. In the past, surgical treatment was considered to be the only option of treatment if the patient’s pain could not be relieved with conservative treatment. Recently, however, patients are presented with many treatment options, one of which is defined as percutaneous disc decompression technique, also known as the nucleoplasty procedure. According to the results of many scientific studies, the success rate of this method of treatment is over 80% when applied in appropriate cases.

What is nucleoplasty?

Nucleoplasty is a minimally invasive procedure that removes the nucleus pulposus tissue in a controlled manner using radiofrequency energy. This reduces the pressure on the crushed nerve roots as well as relieving the pressure inside of the disc. In this method, a special needle is inserted into the disc and radiofrequency energy is applied to a permeable medium to create 40-70oC heat around the electrode at the top of the rod. This heat contains enough energy to decompose the molecular bonds in low molecular weight gases such as oxygen, nitrogen, hydrogen and carbon dioxide, along with many elemental molecules in the disk content in the region. These gases vaporize through the introducer needle. The pressure reduction caused by the evaporation of the disc content allows the protruding part of the disc to be pulled back into the disc. Approximately 1 cc of disc content is evacuated with this method, which is approximately equivelant to 10% of the total nucleus pulposus. This procedure can be performed with radiofrequency or diode laser.

Who can undergo nucleoplasty?

• Patient with leg pain and MRI-measured disc herniation occupying less than 33% of the sagittal diameter of the spinal canal
• Patients who have not responded to conservative treatment options for more than 6 weeks
• Patients with a positive discogram revealing axial and/or leg pain

How is nucleoplasty performed?

The intervention is performed in a completely sterile environment such as an operating room and under operating conditions, under continuous visualization with a C-armed scope. There is no need for general anesthesia, that is, the patient does not need to be put to sleep with narcosis for the procedure. The procedure takes approximately 60 minutes.

What happens after a nucleoplasty procedure?

After nucleoplasty, patients are sent home with the following rules:

• 1-3 days of rest, limited sitting and walking exercises for no more than 10-20 minutes at a time
• No driving for at least 48 hours
• No lifting more than 2.5-5 kg for the first 2 weeks
• Restrain from bending the lower back
• No massage or traction should be applied to the area for 12 weeks following the procedure
• Gentle flexion and extension with home exercises may begin 2-3 weeks after nucleoplasty
• At 3-5 weeks after nucleoplasty, physical therapy can be started
• After discharge, individual home exercise programs should be implemented on a daily basis.

What are the results of nucleoplasty?

Success rates of the technique have been reported to be between 50-80%.

Who cannot undergo nucleoplasty?

• Patients with a shrinkage of disk space by more than 50%
• Patients with extruded and sequestered discs (ruptured hernias)
• Patients suffering from disc herniations occupying more than 33% of the sagittal diameter of the spinal canal
• Patients with spinal stenosis or spondylolisthesis (spinal canal stenosis and slipped back)
• Patients who have a fracture or tumor in the spine
• Patients with coagulation disorders

Ozone discectomy, or ozone nucleolysis, is the application of the ozone gas into the disc in lumbar or cervical herniations. In appropriate cases, there is a success rate of this procedure is over 80%. The patient can return home the same day after the procedure. Ozone discectomy is a method that can be applied in lumbar-cervical disc herniation cases without neurological deficits, meaning that the herniations haven’t caused significant weakness in the arms or legs. It is a method similar to other intra-disc methods, but in this procedure ozone gas is injected into the disc. The application areas of ozone nucleolysis are almost the same as those of intra-disc nucleoplasty. This procedure can also be combined with nucleoplasty. Complication rates are insignificant.

Lesions in the epidural region (outside the membrane of the brain and spinal cord) can cause pain for a variety of reasons. Among the reasons for the formation of lesions in the epidural region include: bleeding in this area after surgical operation and scar tissue forming during the healing process, disc rupture after herniated disc surgery, leakage of the disc content to the affected area after disc rupture, or a spinal body fracture. Scar tissue formation after the surgical procedure is the most common reason for the formation of lesions. The scar tissue causes permanent pain by compressing or continuously stimulating the nerve roots.

Epidural lesions are very difficult to recognize by conventional methods such as MRI (magnetic resonance imaging) or CT (computed tomography). Epidurogram (real-time fluoroscopic imaging produced as radiopaque material is injected into the epidural space) and epidurography (imaging of the epidural space in the spine) can best reveal epidural lesions.
In previous cases where patients were administered one-time injections into the epidural space using a needle to relieve pain associated with an epidural lesion, it has been observed that the injected fluid follows the path of least resistance and does not necessarily reach the lesion. Therefore, the preferred method is to enter the lesion with the help of a catheter and administer the necessary medication to effectively relieve the lesion.

How is epidural lysis performed?

Epidural lyis, or epidural lysis of adhesions (LOA), is a minimally invasive procedure to remove or break down scar tissue (adhesions). This procedure can also help alleviate pain or discomfort caused by these lesions. The procedure involves a catheter being inserted into the epidural lesion that is causing pain. Hypertonic saline solution is then injected into the lesion through this catheter to remove the lesion and adhesions. Depending on the location of the epidural lesion, caudal (coccyx), cervical (neck) and thoracic (back) epidural lysis methods can be applied.

The patient is placed in the prone position. A pillow support is placed under the abdomen to flatten the lumbar region. The area where the procedure will be performed is cleaned and prepared in sterile conditions. Under scopy (a device that provides imaging using X-rays) control, the area of the intervention is visualized. The epidural catheter is advanced to the area of the lesion. Adhesion releaser hyaluronidase is injected into the area. Afterwards, the adhesion area is mechanically opened with the help of a catheter. Hypertonic solution or epidural steroid is injected into the area. Special epidural catheters are used for this procedure.

Who can undergo epidural lysis?

The epidural lysis method can be used to relieve pain and open adhesions, especially in patients who have undergone unsuccessful back surgery due to lower back pain). This procedure can also be administered to patients with pathologies such as spinal column metastatic cancers, disc tears, spinal fractures, or facet joint syndrome, which can all cause lesion formation in the epidural area of the spine.

What happens after epidural lysis?

After epidural lysis, 80% of patients experience a decrease or complete improvement of pain along with significant improvement in motor functions. Once pain disappears and muscle strength increases with recovery, patients are enrolled in a physical therapy program. It is important to note that as some patients might have extensive scar tissue formation, it may not always be possible release all of the lesions. This procedure can be repeated as necessary.

Who cannot undergo epidural lysis?

• Patients with coagulation disorders
• Patients with a decreased amount of body fluid (hypovolemia)
• Patients with an infection at the intervention site
• Patients suffering from a systemic infection.

What are the possible risks of epidural lysis?

While side effects for this procedure are rare, possible side effects that may occur are as follows:

• Paralysis (loss of muscle strength)
• Impaired bowel-bladder function
• Infection (meningitis, abscess, etc. )
• Heart rhythm disorder
• Partial paralysis, including loss of sphincter control
• Brain hemorrhage, visual impairment, or headaches due to rapid injection

The caudal area is an opening formed when the laminae of the sacral 5th and sometimes sacral 4th vertebrae do not meet. Injections and catheterization in this area are used for regional anesthesia and analgesia, especially in children, adults and pregnant patients. Anatomically, 7.7% of patients may not have a sacral hiatus.

How is a caudal block performed?

The patient is placed in prone position. A pillow support is placed under the abdomen to flatten the lumbar region. The area where the procedure will be performed is sterilely cleaned and prepared. The area where the intervention will be performed is visualized with a scopy (a device that provides imaging using X-rays) control. A special needle is inserted into the epidural space through the opening called the sacral hiatus and after using a radiopaque substance to verify that the needle is in the epidural space, a long acting steroid is administered along with local anesthetic medication.

Who can receive a caudal block?

• Patients with persistent pain in these areas after surgeries
• Patients with pain in the coccyx region.

Who cannot receive a caudal block?

• Patients with local infections
• Patients with bleeding disorders and those taking blood thinners
• Patients with anatomical defects.

What are the risks associated with a caudal block?

• Excessive spread of local anesthetic agent
• Nerve damage
• Persistence of pain
• Temporary inability to urinate
• Infection
• Neurological side effects, although very rarely.

Facet joints are the joints that provide the mobility and flexibility of the spine and are located between every 2 vertebrae, at both the left and right sides. These joints may lose their normal structure due to aging, traumas, certain occupations that require intense physical activity or certain surgical interventions. Disruptions in the structure of the facet joints can lead to neck and back pain and this occurrence can be a source of chronic pain in patients.

What is facet joint denervation?

The nerve that provides sensation to the facet joints is called the medial nerve. Facet joint denervation is the process of finding the nerves of the problematic facet joints and burning the facet joint nerves with the help of radiofrequency energy.

The intervention is performed under radiologic imaging with C-arm scope control. The medial nerve is located using a nerve stimulator. In order to locate the medial nerve, The point of intervention is initially determined by scopy. The targeted point is reached by passing through the skin with a needle. The exact location of the medial nerve is determined with a nerve stimulator by giving a very low-level electrical stimulus and observing muscle movements in the lumbar region. Small muscle movements in the lower back and a slight tingling sensation in that area indicate that the medial nerve has been reached. The medial nerve is the nerve that transmits pain signals from this area and radiofrequency energy is used to burn the nerve to prevent it from producing pain signals.

Who can undergo facet joint denervation?

Facet joint denervation can be applied to patients with those suffering from “facet joint syndrome”, who have lower back pain when bending the waist backwards, to the right, to the left and turning to the right and to the left, whose pain is usually concentrated in the waist, hips or upper parts of the leg but does not spread to either of the feet, and those suffering especially from lower back pain that increases with turning in bed at night.

What happens after facet joint denervation?

The patient is taken to rest in the recovery room for 1 to 3 hours. They can go home on the condition that they rest on the first day after facet joint denervation. After a full day of rest, the patient is free to return to their usual daily activities.

Who cannot undergo facet joint denervation?

• Patients with an active infection during the intervention period,
• Patients who are pregnant or likely to become pregnant,
• Patients with a bleeding disorder,
• Patients with an infection at the site of the intervention that has not been intervened.

What are the risks in facet denervation?

Facet joint denervation is a procedure with very few risks or side effects. Very rare complications can include infection and bleeding at the intervention site.