Treat your pain and live a better life…

best-pain-doctor-nycWelcome to my blog about pain. Unfortunately, many people suffer from chronic pain. As a board certified physician in physical medicine and rehabilitation, my specialty is treating these people with both acute and chronic pain.

A majority of my practice is working with patients that are experiencing back and neck pain.

My goal with this blog is to help patients who are experiencing any type of back or neck pain to understand what is causing their pain and discuss options that are available to end their pain. I hope to be able to provide readers with a portal that they can can use to educate themselves and facilitate treatment.

My specialty is my Interventional Spine Skills including cervical and lumbar epidural steroid injections, facet injections, medial branch blocks, Radiofrequency ablation, sympathetic ganglion blocks, spinal cord stimulator trials, sacroiliac joint injection, piriformis muscle block and musculoskeletal joint injection. I also perform many other procedures to alleviate acute and chronic pain.

I hope you enjoy reading my blog as much as I enjoy writing it and observing people from all over the world reading it.

– Matthew Grimm, M.D.

Category Archives: Epidural Steroid Injection

What Is an Epidural Steroid Injection?

Epidural Steroid Injection for Back Pain

Best-Epidural-Doctor-NYC-2An epidural steroid injection is commonly used to treat unremitting spinal nerve root irritation (e.g., a “pinched” nerve in the neck or low back). Spinal nerve root irritation most frequently occurs either in the cervical or lumbar spine and is due to compression of the nerve root by a protruding or herniated disc.

Cervical and lumbar disc disease affects millions of Americans each year. Conservative treatment consists of oral nonsteroidal anti-inflammatory drugs (e.g., ibuprofen), stronger painkillers such as opioids and often, physical therapy. When this regimen fails to relieve pain, epidural corticosteroid injections are frequently the next chosen step.

Anatomy of the Spinal Cord

Best-Epidural-Doctor-NYC-1The spinal cord is suspended in cerebrospinal fluid and encased in three membranes. The outermost membrane is the toughest and is called the dura. Each spinal nerve exits the membrane-enclosed sac just below its corresponding vertebra. Thus, an “epi”-dural injection bathes the spinal nerve after it exits the outermost membrane.

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The injection is performed with the aid of fluoroscopy which is a real-time x-ray technique that allows the physician to visualize the placement of the needle. The injection is localized to the spinal level that is clinically suspected to be involved.

Injection of the corticosteroid medication in this way allows the use of a high dose for maximal anti-inflammatory action directed to the affected nerve root. The rest of the body is spared exposure to such a high dose.

Limitations of Epidural Injections

Epidural steroid injections are typically limited to a series of three. Deleterious effects of the hormone on the spinal tissues are thus minimized.

If you suffer from back pain you may be a candidate for an epidural injection. Contact one of NYC’s most experienced pain doctors, Dr. Matthew Grimm, for more information about epidural injections.

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Radiofrequency Ablation of the Medial Branch Nerves

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Radiofrequency Ablation of the Medial Branch Nerves

is a safe and effective way to relieve chronic lumbar (lower back) pain using radio waves to create heat. These radiofrequency waves are electromagnetic waves that travel at the speed of light and Radiofrequency Ablation of the Medial Branch Nerves 03blocks nerve tissue from transmitting pain signals to the brain. The medial branch nerves are sensory nerves that carry pain signals from injured facet joints to the brain. Facet joints are parts of the spinal bones (vertebrae) that allow one to do a wide range of motions. Injury or degenerative changes in these joints, particularly in the lower back, can cause inflammation and severe pain, which may not respond to conservative medical therapy. (click picture to enlarge)

How Radiofrequency Ablation Works

Radiofrequency ablation provides long-term pain relief that exceeds the effects of a nerve block or other types of injections. Various types of chronic pain conditions respond well to radiofrequency ablation including pain from previous spinal surgery, whiplash injury, complex regional pain syndrome and spondylitis (arthritis of the spine).

The procedure involves the placement of insulated needles with a tiny electrode next to the medial nerve branch. A small radiofrequency current is directed to the medial branch nerve of the facet joint for 60-90 seconds, which generates heat (60-80 degrees Celsius) that destroys the nerve tissue. The result is blockage of pain signals to the brain.

Radiofrequency Ablation of the Medial Branch Nerves 05Radiofrequency ablation is a relatively safe and common technique that can provide dramatic and long-lasting pain relief without systemic side effects. Patients benefit from this procedure because pain is reduced for several months, allowing the patient to resume normal activities and undergo rehabilitation or physical therapy while healing takes place.

Radio Frequency Ablation for Back Pain: General Procedure

Radiofrequency ablation is an outpatient procedure performed by a qualified Chronic Pain Specialist who is an expert with the treatment. The patient is initially briefed about the procedure and prepared beforehand so that he is relaxed.

The patient needs to be relaxed but alert during the procedure to help the doctor correctly place the electrode used during nerve ablation. The procedure will take 20-45 minutes, with the patient lying on their stomach (prone). After the skin is properly sterilized, local anesthesia is injected to numb the area.

Radiofrequency Ablation of the Medial Branch Nerves 02Using x-ray guidance, insulated needles are directed next to the targeted medial nerves. The doctor will use X-rays to guide twin, insulated needles with an electrode are placed next to the nerve. During the procedure, the doctor asks the patient if he feels a tingling sensation or a muscle twitching. These signs will help ensure the electrode isRadiofrequency Ablation of the Medial Branch Nerves 04 properly positioned. Once the needle and electrode are placed correctly, the nerve is heated with radio waves until pain signals to the brain are blocked.

Post Operative Recovery after Radiofrequency Ablation Procedure for Back Pain:

After the procedure, the patient is monitored in a recovery area and discharged when stable. The patient may feel some local pain for several days after the procedure, which may be relieved by oral medications. Some swelling or bruising may occur where the needle was inserted and this may be reduced by applying a cold pack. It may take weeks for the full effects of radiofrequency ablation to be felt, but the pain relief may last for six months or even longer. Some nerves grow back, and radiofrequency ablation may need to be repeated.

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Radiofrequency Ablation of the Medial Branch Nerves is a minimally invasive, safe, and effective means of treating low back pain that is unresponsive to other forms of treatment. If you want more information about treating chronic low back pain, contact our Pain Management Specialist who will examine you and conduct tests to determine the cause of your back pain.  Make an appointment with the NYC’s top board-certified interventional pain management physician to know if radiofrequency ablation is a treatment option for you.

Cervical Epidural

Cervical Spine Epidural Injection 01Cervical epidural injections are commonly given to patients who suffer from nerve root inflammation and irritation in the neck, causing them to experience neck pain and arm pain. These symptoms may be caused by a neck injury or normal wear and tear, which leads to damage of the discs found between the cervical or neck bones. These changes affect the nearby nerve roots that give sensation to the neck, shoulders, and arms, thereby causing severe pain that is often unrelieved by medications or conservative management.

How a Cervical Epidural Works

The aim of treatment with a cervical epidural is to reduce inflammation from the damaged intervertebral discs, which is causing irritation to the spinal nerves. An anti-inflammatory medication consisting of local anesthetics and steroids is therefore injected into the upper spine or neck, to bathe the affected nerves and discs, targeting the painful areas in the neck and arms. Since the treatment uses locally administered medications, it does not have a widespread effect on the body; rather, only painful areas are targeted, and no systemic side effects are expected.

Cervical Spine Epidural Injection 02Patients benefit from this procedure because after the injection, inflammation and pain are reduced for several months, allowing the patient to resume normal activities and undergo rehabilitation or physical therapy while healing takes place.

General Procedure

A cervical epidural is an outpatient procedure performed by a qualified Chronic Pain Specialist who is an expert with the treatment. The patient is initially briefed about the procedure and prepared beforehand so that he is relaxed.

Cervical Spine Epidural Injection 03The patient sits on a chair in a position that allows the physician to visualize the cervical vertebrae (neck bones) using x-ray guidance. The skin at the back of the patient’s neck is cleansed thoroughly with sterile scrub. A small amount of local anesthesia is administered on the skin and underlying tissues to numb the area before treatment.

When ready, the physician directs a special needle with x-rayCervical Spine Epidural Injection 04 guidance into the epidural space, which surrounds the outer covering of the spinal cord in the neck. Proper positioning of the needle is ensured with the use of a small amount of contrast medium or dye injected before the medication is given.

Finally, a small mixture of local anesthetic and anti-inflammatory (steroid) drug is injected into the epidural space. The patient may experience temporary numbing and weakness of the arms and hands for a few hours, which is an expected result.

Patients are allowed to stay in a recovery area where they will be monitored for about an hour. After discharge, they will be asked to evaluate their improvement in the succeeding week and report for follow-up. Repeat injections may be performed up to three times, if needed, every two weeks.

 

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A cervical epidural injection is a minimally invasive, safe, and effective means of treating neck pain that is unresponsive to other forms of treatment. If you want more information about treating chronic pain in the neck and arms, contact our Pain Management Specialist who will examine you and conduct tests to determine the cause of your neck pain.  Make an appointment with the NYC’s top board-certified interventional pain management physician to know if cervical epidural injections are a treatment option for you.

Low Back Pain AKA Lumbago

…is a common disorder affecting over 80% of the general population at some point in their life.  In addition to causing emotional and physical strain onthe body, it also causes a great amount of financial strain as it is the number one cause of job-related disability.

In this blog I hope to discuss various treatment options as well as explain why I feel that I am best suited to treat your low back pain and how I am the best low back pain specialist!

Causes of Low Back Pain:

First lets discuss one of the most common causes of  low back pain.  It can be acute, subacute or chronic.  Acute low back pain duration is generally less than 4 weeks, subacute is from 4-12 weeks and chronic is low back pain lasting longer than 12 weeks.  Also in addition to the duration of low back pain it can be defined as axial or radicular low back pain.

In this first article we will discuss radicular or radiating lower extremity low back pain. Radicular low back pain is pain that originates in your low back and shoots in an electricity like sensation down your posterior legs, at times all the way to your toes.

Back Anatomy:

Next we will discuss some basic anatomy of your lumbar spine. The Lumbar spine (or lower back region) is made up of five vertebrae (L1-L5) and in between each of these vertebrae lies fibrocartilage discs called intervertebral discs.  These discs act as cushions or “shock absorbers” for the spine, preventing the vertebrae from rubbing together allowing the vertebrae to comfortably protect the spinal cord as well as provide active range of motion for your lower back.

Your bodies motor and sensory functions are controlled by nerves.  These nerves stem from the spinal cord and exit the cord through small holes called foramina which lie within the vertebrae.

Ligaments and musculature of the lower back and abdomen provide stability for the spine and small joints, called facet joints, direct the motion of the spine and is how each vertebrae interact with each other.  Facet joints can be thought of like any other joint in the body, just like your finger joint is made up of a number of small bones each connecting with each other through a joint.

Radiculopathy:

Now that we have the basic anatomy of the Lumbar Spine down, we can discuss one of the most common causes of low back pain which are caused by one of the above mentioned structures. One of the most common causes radiating lower extremity or “radicular” low back pain as due to a disc herniation impinging on your spine or nerve roots as they exit the spine.

Herniated Disc:

What is a herniated disc you may ask?  Well let me explain.  As described above in your spine in between each vertebrae lies a fibrocartilage disc which acts as a shock absorber for the spine.  You can think of the discs structure as a jelly donut, with a soft center encased within a tougher exterior. The cause of a disc herniation can result from general wear and tear on the disc,such as while performing jobs that require constant sitting.  Disc herniations often result from jobs that require any type of lifting or repetitive bending activities.

If you are someone with complaints of general minor back pain or chronic back tiredness it makes you susceptible to a herniation from only a mild activity such as bending over to pick up a pencil or simple gardening!  Disc herniations can also occur from trauma to the body when subjected to any type of accident, be it from a motor vehicle accident or a slip and fall accident.

Lumbar Disc Herniation:

I will now discuss pain symptoms related to lumbar disc herniations.  Pain can range from little or no pain if the disc is the only tissue injured, to severe and unrelenting low back pain that radiates into the lower leg regions innervated by the affected nerve roots or spinal cord segments irritated or impinged by the herniated disc material.

Pain complaints often are described to the thighs, knees, calves or all the way to the toes.  Other pain symptoms include numbness, tingling, muscular weakness and decreased weakness in the same affected areas as the pain complaints.

Treatment for Radicular Low Back Pain:

Now lets discuss treatment of radicular low back pain.  If a disc herniation causes extreme weakness, paralysis or bowel or bladder dysfunction it is considered a surgical emergency and treatment should be sought at the nearest emergency department.

If your symptoms are less severe which is the case in 99% of radiating low back pain patients we start with conservative management of the pain with anti-inflammatory medication treatment, muscle relaxer medication treatment and physical therapy with emphasis on core abdominal muscle strengthening, heat, ice, massage and ultrasound with transition into a home exercise program.

If symptoms persist despite conservative management as detailed above the next step is further diagnostic steps to confirm the location of the disc herniations.  To do this generally Magnetic Resonance Imaging or MRI is utilized.

The most common locations of lumbar disc herniations is at L4-L5 or L5-S1 as diagnosed by MRI.  Your pain complaints will be to your posterior legs at times all the way to your toes as described above with associated numbness and tingling in the same areas.

Once diagnosis has been confirmed by MRI and conservative treatment measures have failed with anti-inflammatory medications and physical therapy the next step in treatment in treatment is injections directly to the location of the nerve impingement utilizing epidural steroid injections which are performed by a pain management specialist.  Of which I consider myself to be one of the best in Manhattan.

Epidural Steroid Injection:

An epidural steroid injection is a minimally invasive  procedure that can help relieve radiating low back and leg pain caused by inflamed spinal nerves.  Medicines are delivered to the affected spinal nerve through the epidural space, which is the area between the protective covering of the spinal cord, known as the dura, and the vertebrae.  The medicine used is generally a combination of a long acting corticosteroid and either saline or a anesthetic numbing agent.

Expected Results:

You may ask what results can be expected with lumbar epidural injections.  The relief is dependent on both the severity of the herniation as well as each individual patient as well as the expertise and technique of the physician performing the procedure which it is very important to choose a physician who has been fellowship trained in pain management, which I have been, rather than someone who just took a weekend course in epidural injection treatment.

After Epidural Injection:

Following a first epidural injection you will have a follow up appointment to evaluate your response.  Pending your bodies response to the first injection up to 3 injections spaced 1-3 weeks apart may be needed for maximum efficacy.

How Long Does an Epidural Last?

Duration of pain relief varies from weeks to years.  Most importantly post injection therapy should be instituted for transition into a home exercise program focusing on strengthening abdominal and low back muscles in hopes of preventing future low back pain episodes. Now finally patients need to know the risks of epidural steroid injections.

Risks of Epidural Injection:

If you choose the correct physician there are few risks involved with the procedure.  The correct pain management specialist knows how to screen patients for the appropriate patients for this procedure to ensure that it is not performed on a patient in which it is not beneficial.  The proper physician also knows proper technique to ensure appropriate needle position for steroid placement.

Complications generally involve risks associated with needle insertion which involve bleeding, dural puncture, infection, allergic reaction and nerve damage.  As described above risk can be mitigated with selection of a skilled physician who knows proper technique and proper patient selection.

The Top Doctor for Epidural Injection?

I have performed thousands of epidural steroid injection procedures without a single complication.  So you can be sure you are in skilled hands.  Should a complication ever arise, be rest assured that I have been trained to deal with any and every complication. Contact Us today to schedule an appointment.

Epidural Steroid Injection for Back Pain: A Real Patient’s Story…

In this post I will described a patient encounter in which one of my patients had great success with an epidural injection for back pain. She presented to my office this week one year after injection and reported that she is pain free.bp1

This patient is a 34-year-old female that had been suffering from intermittent back pain for more than a year which increased in severity over the past month. She complained of severe lower back slouch-computerpain that limited her ability to exercise and perform regular activities. She also complained of occasional shooting pain down her leg consistent with “sciatica” pain. She thinks that her back pain started due to working longer than usual hours on her computer.

Back pain due to sitting position for long periods of time is a common problem I see in my practice for the relatively young population. The cause is often due to increase in pressure occurring in the disk that causes bulges and herniations. These can be painful on their own, however if they are large enough, patients may complain of pain shooting down the leg which is often termed “sciatic pain.”

This patient had tried anti-inflammatories and muscle relaxants prescribed previously. She also had failed physicalPill therapy. I recommended epidural injection for treatment after failing to receive relief from the use of traditional treatment modalities.

Conservative treatments such as NSAIDS (Non-steroidal Anti inflammatory Drugs), physical therapy and TENS unit (Transcutaneous Electrical Nerve Stimulation) can be useful for mild back pain, patients usually find epidural injection provide safe and immediate relief when it comes to symptoms that become constant or unbearable.

The epidural injection was done with a real-time x-ray called fluoroscopy to ensure proper needle position within the epidural space. Patients usually only feel a mild pinching pain when I apply the superficial anesthetic injection.

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The epidural injection works by placing anti-inflammatory steroid medicine into the epidural space which encompasses the exiting nerve that’s responsible for the pain shooting down the legs. The steroid portion of the medication clears the inflammation quickly often relieving the symptoms permanently.

The epidural injection treatment usually takes 15 minutes as it did in this case.

As the patient walked out of the outpatient surgery room she reported immediate relief. She said that it had been more than a year since she was in no pain.

At her first follow-up visit she reported that she had some discomfort for a few days after the injection however, shortly after the pain went away and never came back. At her most recent visit, one year after her injection, she reported complete relief since that time. She said that the result of the treatment had been more positive than she thought it would be.

In conclusion, steroid epidural injection is a quick, minimally invasive procedure that helps ease the pain immediately and provide long-lasting relief of back pain. Patients typically return to their normal activities within one to two days after the treatment with their back pain alleviated.

Epidural steroid injection for back pain is a safe, comfortable, relatively painless and effective early treatment option for many patients. By doing an epidural steroid injection early in the treatment plan, patient’s can bypass NSAIDs and oral steroids which often have GI side effects. Than participation in physical therapy is not limited. Epidural steroid injection treatment for early back pain symptoms is effective and recommended in the medical literature.

If you are experiencing back pain you may be a candidate for epidural steroid injection. I encourage you to call my office for a consultation. I assure you that you are in the hands of a competent, well-trained, compassionate an experienced physician.

Epidural Steroid Injection for Back Pain

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Epidural steroid injections are a safe and efficient way to treat common back pain symptoms that can arise from the disks, the exiting nerves or the narrowing of the spinal canals.

ESI-translaminalEpidurals are now recommended to be done earlier vs. later as a treatment option to prevent pain symptoms from becoming chronic conditions.

In order to provide the highest level of care, our procedures are done at an outpatient surgery center. Patients lay comfortably on a surgical table. The area is prepped in a sterile fashion. Fluoroscopic guidance (live x-ray) is used to ensure proper needle position within the epidural space and is confirmed using a contrast material that is visualized on the fluoroscopy.

epidural1The whole procedure takes less than 15 minutes in most circumstances. Patients are asked to relax that day and may perform their normal activities the following day.

The steroid (Depomedrol) will start to work within 24-48LESI AP hours. Patients usually receive immediate relief from the local anesthetic injected.

We recommend patients follow-up after one week of injection in our office and usually recommend continued physical therapy to prevent recurrence of symptoms.