Transcription:
What You Need to Know About Spinal Injections for Spinal Pain

Melanie Cole (Host): Welcome to Back To Health, your source for the latest in heath, wellness and medical care; Keeping you informed so you can make informed healthcare choices for yourself and your whole family. Back to Health features conversations about trending health topics, and medical breakthroughs from our team of world-renowned physicians at Weill Cornell Medicine. I am Melanie Cole and our topic today is spinal injections for spinal pain, and my guest is Dr. Jaspal Ricky Singh. He's the Director of Interventional Spine in the Rehabilitation Department at Weill Cornell Medicine, and the Co-Director of the Weill Cornell Center for Comprehensive Spine Care. Welcome to the show, Dr. Singh. If someone suffers from pain, what is the first line of defense? Explain a little bit about how you approach pain management and pain medicine with a new patient.

Dr. Jaspal Ricky Singh, MD (Guest): Well I appreciate that question and thank you for having me today. You know, when it comes to back pain or neck pain, most of these conditions tend to be self-limiting. And what I mean by that is a lot of patients probably don't need to seek medical attention to get these symptoms treated, and we know that because there's always a lag between the onset of symptoms and when the patient actually ends up seeing us in the office, and many times by the time we see them, the symptoms have resolved. So about 80% to 90% of back pain and neck pain situations will resolve without an intervention.

When it comes to what we do when we evaluate a patient, the biggest thing is the history and the physical exam. When the pain started, where is it located, what makes it better, what makes it worse, and at Weill Cornell we try to remain somewhat conservative in our treatment approach whether it's physical therapy and exercise first, if that doesn't fully help, maybe using some medications to help alleviate the pain, and then following that up with some type of intervention whether it's an injection, an orthotic, a brace, all the way up to a surgical management if needed.

Melanie: So you've just mentioned a few of the early interventions, but when does the subject of spinal injections come up? How does that fit into a comprehensive pain management program? And what does someone have to have tried before this is what you discuss with them?

Dr. Singh: You know, in training we're taught to do what's conservative first, which is physical therapy, exercise. If that doesn't quite work, then step it up with medications, and if that doesn't work then talk about injections. And with practice, which is what we call when a physician completes their training, it's still called practice because we learn with every patient that we see. And if we follow this conservative algorithm every time, many times it takes four weeks, six weeks, twelve weeks for a patient to feel better because we're following a somewhat conservative algorithm. So when it comes to injection treatment and injection therapy, I think every patient is individualized.

There might be a patient who comes in with acute back pain, they were doing a fitness class, or they bent over and picked up their grandchild, and all of a sudden they have sharp back pain radiating into their leg, the symptoms have been there for only a week. Conventionally we could use the conservative approach and start with therapy and medications, however the patient may suffer for weeks. So in those situations, I might offer an injection early, telling the patient, "Listen, this is not the cure for your problem, but if I can minimize your pain earlier, then get you enrolled in a physical therapy and exercise program, your recovery will probably be much faster."

Melanie: What an interesting point that you make. So when it comes time for an injection, whether it's early or after they've tried other interventions, speak about an epidural spinal injection first, Dr. Singh, and is it the same thing that someone might receive in childbirth? They've heard that term 'epidural.' Tell us a little bit about what it is.

Dr. Singh: So when we talk about epidural spinal injections, basically we are treating back pain caused by some type of disc herniation, pinching on a nerve causing what lay folk call sciatica, and basically this presents with pain shooting down the leg, and an epidural steroid injection, or epidural spinal injection, can alleviate that pain, it can decrease the inflammation around the nerve, decrease some of the inflammation around the disc. And again, I stress that I'm not curing anyone with these injections, but more speeding up the recovery so that they can participate in a rehabilitation program.

To answer your second question about is this epidural injection similar to those that one might receive during childbirth, it's a little similar and a little different. The biggest difference is that when we do epidural injections, they're all guided with x-ray camera, and that basically allows me full confidence in where I'm putting the medication, it makes the procedure that much less painful because the entire procedure is guided with an x-ray. And instead of using an epidural for childbirth for more just pain relief, these epidural spinal injections have a little bit of cortisone or steroid to help with inflammation. So those are the fundamental differences between those two types of epidurals.

Melanie: Can injections also be used to diagnose certain types of pain?

Dr. Singh: Yeah, that's a great question, and that's something we talk a lot about when I evaluate patients. You know, a lot of times patients come in with back pain. We obtain an MRI or some other type of advanced imaging, and we see arthritis, we see ligament problems, we see disc degeneration, and many times we don't exactly know where the pain is coming from just by looking at the pictures. So we can use diagnostic injections, which compose mostly of lidocaine which is a numbing medicine similar to when someone goes to the dentist and they numb up the mouth with Novocain. Basically we can use the same medication, place that at certain locations, and if the patient's pain is relieved for a short period of time, two hours or six hours, then we can more confidently say, "Hey your pain is coming from this source," and then we can go after that source and treat it.

Melanie: How do these injections really work? And how do they work to relieve back pain? What's going on? You mentioned cortisone a little bit, and so what is actually happening in there?

Dr. Singh: So when it comes to spinal injections, like we talked about, there's many different kinds. There's epidurals that are used more to treat back and leg pain, there are injections into the small joints that are mostly for back pain. There could be trigger point injections for muscle pain. Basically the goal of these injections is to help with pain either by decreasing inflammation, for which I use cortisone, or simply by numbing up the structure with lidocaine either into the muscle, or the nerve, or the joint. And again, I want to stress that any time we do these injections, we are not curing the patient from arthritis or curing them from a disc herniation. We're simply creating an environment in that area to decrease inflammation, help with pain, optimize their function and mobility, and then definitely get involved in some type of exercise program.

Melanie: Who can benefit from one of these? Are there certain people for whom this is not something they can choose?

Dr. Singh: Anytime a patient comes in for an evaluation we need to think about their other medical history and other medical problems. Certainly patients with diabetes or poorly controlled blood sugars, we want to be really careful with cortisone as steroids can elevate blood sugar. If patients have other medical problems such as heart disease, high blood pressure, again we want to be really careful about the medications we use. Most of the medications, most of the injections we perform are very, very safe. Very rarely is there a pure contraindication to having one of these, but again they must be evaluated on a case-by-case basis.

Melanie: How long do they take to work, Dr. Singh? And how long do they typically last? People heard when they hear about cortisone shots in their shoulder, for example, you can only have a certain number of them each year. But what about something like an epidural steroid injection? How long does that take to work and how long does it last?

Dr. Singh: So when it comes to epidural steroid injections specifically, so what I tend to tell patients is, "By the time you get off the table, you may feel some relief, and that's because the anesthetic, the lidocaine has begun to work." And that relief might last the rest of that day or the rest of that afternoon. After that, typically the normal residual pain may return, and then the cortisone that I injected doesn't quite work right away. Usually it takes three to five days, sometimes a little bit longer, and the steroid will tend to work for about six weeks. That doesn't necessarily mean the relief only lasts six weeks, it means the medication is exerting its effect for that long, during which I've enrolled the patient in some type of rehabilitation program, so that even when the medication is done working, hopefully the pain doesn't return.

Now to answer the question about how many you can get in a year, there have been some studies that show if you give excess steroid to patients there can have some deleterious effects on them such as bone loss, hair loss, muscle loss, the blood sugar is being poorly controlled. So we try to, again, be very conservative on how much steroid we give a patient. In my practice I try to limit it to no more than four injections per year of steroid independent on where I inject it. So if the patient comes in for a knee problem or a shoulder problem, they'll still count toward the total number. So I do limit it to about four per year.

Melanie: Tell us about some of the other kinds of injections for pain. We've been speaking about epidural steroid injections, but what about an SI joint block, or a selective nerve root block? Some of these other kinds of injections you might administer.

Dr. Singh: So epidural steroid is basically for anyone who comes in with sciatica, a disc pinching a nerve causing pain going down the leg. The other types of injection such as sacroiliac joint or even facet joint, these are for patients with primarily back and butt pain. When we talk about doing those diagnostic blocks that we were discussing earlier, that's more focused on the facet and the sacroiliac joint, and basically what we want to accomplish is a temporary relief of pain in this area, to diagnose that the pain is in fact coming from these structures, and then we can go on to more advanced procedures known as a rhizotomy, or neurotomy, or ablation. Basically this is a procedure where I use that diagnostic injection to help guide me, and if there is that temporary relief of pain, then I go in again to those specific structures, and I 'destroy' those nerves, and that can provide some long-term pain relief to the patient.

Melanie: Is it painful to get one of these injections, Doctor?

Dr. Singh: You know, I've been doing this now for seven plus years and I don't use any sedation on the patients. I do local anesthetic, I numb the skin. There is a little pinch when I do numb the skin, and after that it's usually pretty painless. The patients are awake so they're talking to me. If they tell me that, "Hey Doc, it's hurting a little bit more," I do inject more anesthetic. But it's usually very, very well-tolerated. The majority of these injections that we do, when we're done, the patient didn't even realize that we had finished, so they tend to have a very positive experience. And I want them to have a positive experience because if it provides help with their pain, I don't want them to be afraid to ask for another one three months or six months down the road. So I hope that these are as painless as I believe they are, and I think they are just based on the patient's response.

Melanie: What about after the injection? How soon can a patient return to activity following injection therapy? Are there any limitations for the first few days?

Dr. Singh: It kind of depends on what type of injection we're talking about. When it comes to epidural steroid injection, I have the patient take it easy for the first day or two, they can shower the day after. I have them not soak, no hot tubs, baths, or jacuzzis for a couple days just to make sure the small needle puncture wound closes nicely. And then soon after that I have them start physical therapy or exercise about forty-eight hours afterwards.

When it comes to those diagnostic injections that I mentioned such as the sacroiliac joint block, with the facets, I actually want the patients to be very active the day of. So I have patients that report back pain while they play golf. So I will tell the patient, "Come in the morning, we will do that diagnostic block, and then why don't you plan to play golf that day for the next four to six hours to really give us a test of whether or not your pain is coming from those joints." So the level of activity and the post-procedure care really depends on the procedure that we're doing.

Melanie: Are there any side effects that patients should be on the lookout for?

Dr. Singh: Most of the side effects are related to the medication given. So when it comes to just using a local anesthetic such as lidocaine or Novocain, the side effects are pretty few. If we do use steroid, I have the patients monitor their blood sugar if they do have diabetes. Sometimes patients can get a little hyper or revved up due to the steroid, maybe facial flushing is also a pretty common side effect. Most of these side effects are short-lived and they should self-resolve within a few days. And again, these procedures are very, very safe. The biggest challenge is picking the right patient for the right indication.

Melanie: Dr. Singh, please describe for us a patient case study where your patient had tried many other specialties and treatments before coming to see you, and how you were able to help them in a way that some other specialties might not have been able to.

Dr. Singh: You know what? I believe the benefit of physiatrists and physical medicine and rehabilitation specialists is that we don't just look at one structure. Many times we will see patients reporting knee pain, and they have seen many providers with knee MRIs, and knee x-rays, even cortisone injections in the knee, and when you really look at the patient walk, you figure out quickly that the problem isn't the knee, it's actually coming from the hip or it's actually coming from the spine. So it's not uncommon that I see a patient coming with knee or even groin pain, where the specialists they had seen before them have focused their attention on those joints, but the problem is actually more central coming from the spine, which is why I think physiatry can add real value to the orthopedic specialty. We really look at the whole structure, we look at the gait, we look at the mechanics to really figure out where the problem is.

Melanie: Give us a little blueprint, Doctor, for future treatment for spinal pain, and speak about some of the new and exciting things going out there such as regenerative medicine.

Dr. Singh: You know, as I mentioned before, there is a limit to how much steroid we give the patient because despite the benefit that patients get from these epidural steroid injections, and even steroid injections in the joints, we know that in the long term we're not really providing the patient a long-term benefit. In addition, steroids can have some negative effects such as bone loss, and hair loss, and muscle loss, and things like that. And I think the future is really going to be in this field of regenerative medicine. And basically when we talk about regenerative medicine, and marketing, and ads you see, stem cell clinics popping up, we want to be really careful in calling it regenerative versus restorative medicine. We're not really rebuilding cartilage. We're not really rebuilding the tendons, but we're restoring those structures to optimize function. I think the future in what we do is going to be focused on using the patient's own blood, and their own growth factors, and really harnessing that opportunity to restore some of the function and the degeneration that naturally happens with time.

Melanie: What a fascinating field of study that you're in, Doctor. Wrap it up for us with your best advice and information on if somebody is asking themselves that question, should they have a spinal injection, and what you would like patients to ask you when this discussion comes up.

Dr. Singh: My first and primary goal whenever I evaluate a patient is to give them the tools and the education for them not to need me long-term, and if that requires an injection or two or three in a short period of time to really minimize their pain and get them on a good track of exercise, and diet, and nutrition, and overall health and wellness, then that's really my goal.

I don't think of every patient needing an injection or even needing a medication. Most patients need a plan, and whether that plan is a simple diet and nutrition counseling, or an exercise program, anything to get them on the right track is really the goal of what we seek at The Spine Center.

Melanie: Thank you so much, Dr. Singh, for being with us today, for sharing your expertise on this topic. It's such an interesting topic and not everyone has a true understanding and you've cleared it up so very well for us today. Thank you again for joining us. This concludes today’s episode of Back To Heath. We’d like to thank our listeners and invite our audience to download, subscribe, rate and review Back To Health on Apple Podcast, Spotify, and Google Play Music. For more health tips go to weillcornell.org and search podcasts. Parents – don’t forget to check out Kids Health Cast!