There are many procedures which could be done to help your pain. After considering the benefit and risk and of the procedure, your consultant recommended “Occipital Nerve Block” (ONB) to help your headache.
If you feel uncomfortable to proceed with as a treatment as planned, you are welcome to discuss the other available alternative therapy with your consultant or member of the Multi-Disciplinary Team.
What is Occipital Nerve (ON)?
Occipital nerves are two pairs of nerves that originate in the area of the second and third cervical (neck) vertebrae. ON are located beneath the scalp at the occiput (base of the skull) over the occipital lobe of the brain.
Most people who experience migraine and headache syndrome on a regular basis also have tenderness over the sub-occipital region of their skulls.
What is Occipital Nerve Block (ONB)?
It is injection of local anaesthetic (numbing agent) and steroids (anti-inflammatory) at the site of greater occipital nerve to reduce headache.
What is the aim of ONB?
Occipital Nerve is injected to block the pain messages sent to the brain along the occipital nerves and consequently help:
- Diagnosis of the type of headache (ON irritation) and
- Therapeutic: reduces the frequency, duration and severity of your headache
What are the benefits of ONB?
- Reduce headache (number of attacks, duration of each attack and/or severity of the pain during the headache attack). It important to measure those parameters before and after ON block to assess success of the block.
- Improvement of headache will help to improve your function, sleep and consequently your quality of life.
- Reduce headache medications and consequently side effects.
How long will the effect of ONB last?
- The success rate depends on the cause of headache especially if ON is involved in the pathogenesis.
- The success rate is variable, however, we usually get >50% improvement for few weeks to several months.
- If the diagnostic block was positive (>50% improvement of Headache frequency, severity & duration) but for short time, the benefit of the block could be prolonged by doing ON Radio-frequency lesion denervation.
- Denervation of ON effect last few months up to year.
Can all headaches be treated by GON block?
- Some patients have multiple cause of their headache and GON block can help in the diagnosis if GON is a factor for their headache.
- People who experience migraine, cluster headache and cervicogenic headache (neck-related headache) can benefit from the ON block.
What are potential risks of ONB?
It is generally safe procedure and usually well tolerated by patients, however:
- Some people experience a temporary warm sensation or increase in pain at the base of the head after the procedure but this is short-lived (few hours)
- Accidental hit of the occipital blood vessels can cause local bruise and haematoma (collection of blood) which usually resolve in few days.
- Use of steroids may have some risks including temporary increase in your blood sugar if you are diabetic or some disturbances in women periods.
- Infection is rare as procedure is done under full aseptic conditions.
What are Contra-Indications of ONB?
- Known allergy to local anaesthetic & steroids.
- Patients with bleeding disorders
- Patients taking anti-coagulant therapy
- Local infection or inflammation at the painful area.
How the procedure will be done?
- The doctor locates ON by feeling the most tender area at the base of the head.
- The injection will be performed by the Doctor in clinic under full aseptic technique. A local anaesthetic often in combination with a type of steroid is then injected.
- Ultrasound guidance can help to avoid trauma to occipital blood vessels.
- The injection can be repeated after several weeks.
- You may be required to stay for up to half an hour after the procedure
- A follow up appointment will be booked few weeks later to check effect ONB.
- It is better that you arrange for someone to drive you home after the procedure.
- Usually we recommend 2 days rest before you go back to your normal daily activities.
- We advise measuring frequency, duration and severity of headache daily.
- If your headache starts to get better you can start to reduce pain killer medications
Important Advice:
Please inform the pain clinic/ your doctor if;
- You take any anti-coagulant drugs (blood thinning drugs). They may have to stop 5 days before the procedure (Warfarin) or stop 7 days before the procedure (other anticoagulants: e.g. Clopidogrel, Abixiban)
- If you are allergic to any medications.
- If you have an infection near the injection site.
- If you have had any recent steroid/cortisone injection in hospital or surgery.
- If you think you might be
- If you are a diabetic especially on insulin
- If you have had a recent heart attack or vaccination.
- The information contained in this leaflet is for educational purposes only. Please discuss with you doctor if you require further information. If there are any concerns or queries please contact the Chronic Pain Clinic
There are many procedures which could be done to help your pain. After considering the benefit and risk and of the procedure, your consultant recommended “”Sacroiliac joint injection” (SIJI) to help your back pain.
If you feel uncomfortable to proceed with as a treatment as planned, you are welcome to discuss the other available alternative therapy with your consultant or member of the Multi-Disciplinary Team.
What is the sacroiliac joint (SIJ)?
There are two sacroiliac joints in the region of the low back and buttocks. They connect the lower part of the spine (sacrum) to the pelvis (iliac bone). They do not move very much but have a critical role as shock absorber and in transmitting and balancing the weight of the upper part of the body to the hips and legs.
If these joints become painful they may cause pain in the lower back region, buttocks and possible referred pain to the lower abdomen, groin or legs.
SIJ is a common cause of back pain but it is also a site for referred pain as well. The pain may begin spontaneously or following trauma.
What is the SIJ injection?
It involves injecting a mixture of local anaesthetic (numbing medicine) and long lasting steroid cortisone (anti-inflammatory) into the irritated/inflamed joint(s).
What is the aim of the SIJ Injection?
SIJ injections will help:
- Diagnosis if SIJ is a main cause of your pain and
- Therapeutic: the aim is to reduce pain and inflammation of the joint. This will help to move the joint more comfortably.
What are the benefits of SIJ injections?
- The local anaesthetic, as it works quickly, will help to diagnose the source of your pain.
- The steroid will help to reduce any inflammation that may exist within the joint(s). The steroid can take up to a few days to work.
- The temporary relief may help to improve your ability to move the joints improve your function.
How long the effect of SIJ injection last?
- The success rate depends on how many factors are causing your back pain. If sacroiliac joint(s) is/are the main cause, you usually get dramatic relief of back pain and leg pain following the injection. However,
- If there are multiple causes for your pain, you may get no help or limited help for a short period of time, but not everyone is cured.
- The duration of the effect of sacroiliac joint injection is variable. Help can lasts for few days, weeks or months.
- The injection could be repeated for diagnostic purpose or for a longer help.
- If diagnosis is confirmed, Radiofrequency lesion denervation (burning the nerves) of the SI joint could be done which result in long lasting effect (around 6 months).
What are potential risks of ONB?
It is generally safe procedure and usually well tolerated by patients, however, some side effects can happen including:
- Bruising or tenderness at the site of the injection
- Discomfort, your pain may get worse for few days after injection.
- Infection – rare
- Leg sometimes feels numb & week after the injection- very rare.
- Allergy to the injected drugs – rare
- Repeated injections at short periods of time there can lead to risk of steroids building up in the body which has been linked to facial flushing, osteoporosis and menstrual problems in women.
- It may not help your pain
What are Contra-Indications of SIJ injection?
- Known allergy to local anaesthetic & steroids.
- Patients with bleeding disorders
- Patients taking anti-coagulant therapy
- Local infection or inflammation at the painful area.
How the procedure will be done?
- The doctor locates SIJ by feeling, US (ultrasound) or X-ray guidance.
- The injection will be performed by the Doctor in clinic under full aseptic technique.
- A local anaesthetic often in combination with a type of steroid is then injected.
- The injection can be repeated after several weeks.
- You may be required to stay for up to half an hour after the procedure
- A follow up appointment will be booked few weeks later to check effect of the injection.
- It is better that you arrange for someone to drive you home after the procedure.
- Usually we recommend 2 days rest before you go back to your normal daily activities.
- We advise measuring your pain daily on a pain diary.
- If your pain starts to get better you can start to reduce pain killer medications
Important Advice:
Please inform the pain clinic/ your doctor if;
- You take any anti-coagulant drugs (blood thinning drugs). They may have to stop 5 days before the procedure (Warfarin) or stop 7 days before the procedure (other anticoagulants: e.g. Clopidogrel, Abixiban)
- If you are allergic to any medications.
- If you have an infection near the injection site.
- If you have had any recent steroid/cortisone injection in hospital or surgery.
- If you think you might be pregnant.
- If you are a diabetic especially on insulin
- If you have had a recent heart attack or vaccination.
The information contained in this leaflet is for educational purposes only. Please discuss with you doctor if you require further information. If there are any concerns or queries please contact the Chronic Pain Clinic
What is the aim of this information sheet?
The aim of this information sheet is to provide you with information relating to Rhizolysis/Radio Frequency Lesioning (Denervation) and to answer some questions that you may have. Please note that practice may vary. Your doctor will be able to explain fully what to expect.
What is Rhizolysis/Radio Frequency Lesioning?
Rhizolysis/Radio Frequency Lesioning (Denervation) is a procedure where nerves to facet joints (medial branch nerves) are destroyed (sometimes called lesioning or denervation). The procedure is usually undertaken when medial branch blocks have proven to produce significant pain relief for a short duration. The purpose is to try and produce more prolonged pain relief sometimes even lasting a number of years. The probe is heated to disrupt the nerves, however some doctors may use other techniques to do this. In addition, local anaesthetic and/or steroid is injected to reduce any post procedural discomfort. Usually, several injections are undertaken during the same procedure. It is used for localised spinal pain in the lumbar or cervical area where simpler measures have not helped.
Is this the right treatment for me?
Other treatment options will be discussed with you before deciding to go ahead with the injections and your consent is needed. The decision on whether or not to go ahead with the injection(s) is a shared decision between you and your doctor. Your doctor will be able to provide you with up-to-date information about the likelihood of this being a successful treatment for you and how this treatment fits into the best pathway of care. If you are undecided about whether or not to have injections then further advice and information to make this informed decision can be provided. Please speak to your doctor for
more information.
If your health has changed, it is important to let your doctor know:
- If you have an infection in your body or on the skin of your back, your doctor will postpone the treatment until the infection is cleared
- If you have been started on anticoagulant or antiplatelet medicines that “thin the blood” such as warfarin, heparin or clopidogrel, this may require extra preparation
- If you suffer from diabetes, the use of steroids during injections may cause your blood sugar to change requiring monitoring and adjustment of your diabetic medication
- If you have any allergies
You must also inform the doctor if there is any chance that you could be pregnant.
Finally, if you are planning to travel abroad or fly within two weeks after the injections, please let your doctor know as it may be best to change the date of the injections.
I have heard that steroids are being used unlicensed/off-label, what does this mean?
Steroids (corticosteroids) are commonly used in managing chronic pain but are licensed for specific routes of adminstration only. Some routes of adminstration to treat pain are not on license. This is referred to as off-label use. The manufacturer of the medicine may not have applied for a specific licence to extend its usage. MANY medicines used in pain medicine are used off-label. Your doctor will be able to discuss this with you further.
What will happen to me during the treatment?
Before the injection, your doctor will discuss the procedure with you. Your doctor will either obtain your consent before the injection or confirm this consent if it was previously given. The treatment will take place in a dedicated area with trained personnel. An X-ray machine (or other forms of image guidance) will be used to enable accurate injection. Not all doctors undertake these injections in exactly the same way but the following usually happens.
You will be prepared for the procedure as per local protocol:
- Observations such as blood pressure and pulse rate may be made
- A small needle (cannula) may be placed in the back of your hand
- You will be carefully positioned and the skin around the injection site(s) will be cleaned with an antiseptic solution or spray; this can feel very cold
- X-ray (or an alternative way of guiding the needles) will be used
- You will feel a stinging sensation as local anaesthetic is injected to numb the skin and surrounding tissues. Your doctor will warn you of this first
- The doctor will direct the special needles to the area(s) suspected to be a source of pain
- Electricity is applied to the needle tip to test if the needle is correctly placed next to the sensory nerve to be destroyed. You will be asked to say when you feel a tingling sensation as the doctor tests the radio frequency machine on different settings though some doctors use a technique without the need for this step. When undertaken in the lumbar region, it is common to get twitching of the muscles in the back when this is done. For lumbar treatment, you will be asked whether you are experiencing any tingling or discomfort or twitching in your leg to make sure that the needle is not too close to these nerves. The doctor will also observe for any movements of muscles in your foot or leg, which may indicate that the needle needs repositioning
- Injections of local anaesthetic are made. You may feel pressure, tightness or a pushing sensation. The doctor will then treat the nerves. If there is any discomfort, do let the doctor know. It is important to keep very still during this part of the treatment
What will happen to me after the treatment?
After treatment you will be taken to a recovery or ward area where nursing staff will observe you.
Sometimes you will be asked to lay flat for about 30 minutes or longer. You may be assisted to sit up and your blood pressure and pulse may be checked. You will be advised when to get dressed and be given assistance to help to ensure that you can stand safely after the procedure.
When will I be able to go home from hospital after my treatment?
You will usually be able to return home within a few hours after the injection and in some cases much sooner, depending on how many injections are needed and how long your doctor or nurse want you to stay for recovery. Please ensure that you have made arrangements for someone to collect you after the procedure. Failure to do so will likely result in your procedure being cancelled. It is unsafe for you to drive home immediately after the procedure. If you do so your motor insurance will be invalid.
What can I do after my procedure?
Ideally, you should arrange for someone to stay with you for 24 hours but, failing that, you should at least have access to a telephone. You should not drive, operate machinery, sign legal documents, provide childcare unsupervised or drink alcohol until fit to do so.
If in doubt, please discuss these issues with your doctor for further advice.
When can I return to work after the procedure?
This will vary between individuals and may depend on the nature of your work. It is difficult to give general advice and so you should discuss this with your doctor.
Will I experience any side-effects?
As with any procedure, side-effects may occur. However, these are usually minor and there is little risk of serious harm.
Side-effects may include:
- Mild local tenderness and / or bruising at the site of the injection, that usually settles over the first few days
- A prickling sunburn-like sensation over the skin of the back, that usually settles with time but may last a few months
- Numbness and/or weakness in your legs for lumbar injections, due to the local anaesthetic spread, which may happen very rarely. Should this occur, the effect is temporary and will rapidly resolve over minutes or rarely hours
- Infection. This is rare. You should seek medical help if there is local warmth or redness over the site of injection with tenderness and/or you feel hot and unwell. This may require antibiotic treatment
- There are important nerves in the spine, but serious nerve injury is extremely rare (less than 1 in 10,000 cases). Injury to nerves that supply muscles to your leg can lead to foot drop for lumbar injections causing you to be unable to lift your foot up. Great care is taken during the procedure to avoid this very rare complication by placing the needles carefully under x-ray and only treating the nerves when the doctor is confident that they are in the right position
- Injection treatments are not always effective and may not help your pain
- Injury or collapse of the lung may occur (pneumothorax) from injections in the thoracic area only. This is very rare. If you get chest pain or breathlessness, you should seek immediate medical help
- In rare circumstances, steroid use can damage your eyesight. You should report any new visual disturbance (such as blurred or distorted vision) to your doctor
What can I expect in the days afterwards?
You may find your pain gets worse for a few weeks before it gets better. You may notice a feeling of numbness, heaviness or pins and needles. This is normal and will wear off. Take your regular painkillers and try and move about the house, but do not do anything too strenuous. Please keep the area of the injections dry for 24 hours following the procedure. Take your regular pain killers and medications as normal and this should settle down. Try to keep on the move about the house whilst avoiding anything too strenuous.
What should I do in the weeks after the injections?
As your pain decreases, you should try to gently increase your exercise. Simple activities like a daily walk, using an exercise bike or swimming on your back will help to improve your muscle tone. It is best to increase your activities slowly. Try not to overdo things on a good day so that you end up paying for it with more pain the following day. Your doctor will give specific advice which may differ depending on which nerves are treated e.g. nerves in your back or neck.
What follow-up will be arranged?
Though practice may vary, a letter will usually be sent to your GP and your doctor will advise on what to do after the procedure. You may be asked to make a call to the pain department, be given a form to fill in, or given a telephone review or other appointment.
Is there anything else I need to consider before the procedure?
- Please bring your glasses if you need them for readin
- Always bring a list of all current medication
- Continue to take your medication as usual on the treatment day
Finally…
The information in this leaflet is not intended to replace your doctor’s or health care team’s advice. If
you require more information or have any questions or concerns please speak to your GP or contact your
Pain Clinic
Cervical (Neck), Thoracic (upper back), or lumbar (Lower Back)
There are many procedures which could be done to help your pain. After considering the benefit and risk and of the procedure and discussing other alternative therapies, your consultant recommended an Epidural or Specific Nerve Root Block (NRB) to help your pain.
What is a Steroid Epidural injection?
The epidural space is located around the outer covering of the spinal cord. It runs from the base of the skull to the bottom of the spine, along the entire length of the spinal canal. Nerve fibres carrying pain signals to the spinal cord and the brain pass through this space.
An epidural injection is an injection of local anaesthetic (temporarily numb the nerves) and/or type of steroids (anti-inflammatory) into the epidural space.
What is a Nerve Root Block (NRB)?
It is injection of local anaesthetic and steroids near/around the origin of a specific nerve at certain level of the epidural space (cervical, thoracic, lumbar or sacral) and at specific side (right, left or both/bilateral). The selection of nerve/s to be blocked is based on the clinical examination and the abnormal findings on radiological investigation (MRI or CT) as a likely cause or your pain.
Injecting drugs near the pain-producing nerve/s (NRB) is more specific (selective) and generally more useful than non-specific epidural steroid injection.
What are the drugs injected?
It involves injecting a mixture of local anaesthetic (temporary numbing medicine) and long lasting steroid/ cortisone (anti-inflammatory) around the irritated/inflamed nerve(s).
Is it a cortisone injection?
Cortisone is a type of drugs called “Steroids”. Steroids have good anti-inflammatory effect. The steroid used for the injection should not be confused with anabolic steroids that athletes have used for building up muscle mass.
Unfortunately, no company produces a steroid specifically licensed for the epidural space. However, standard steroid preparations have been used in the epidural space for long time and are considered to be safe by the national and international pain organisations.
What are the aims/ Benefits of the Epidural Steroid Injection (ESI) or Nerve Root Block (NRB)?
- Epidural Steroid injection (ESI) has a potential therapeutic effect. The aim is to reduce inflammation of the nerve/s or intervertebral disc or ligaments or facet joints arthritis. This will help to improve pain & function.
- Nerve Root Block (NRB) can help to diagnose the main cause of your pain and also has the potential therapeutic effect. A significantly positive nerve root block may help the decision of surgery
- ESI and NRB can help reduce pain and increase function to facilitate physiotherapy.
- Improving pain can help improving your function & daily activities & work, improve sleep, lessen frustration & depression and may reduce your medications.
- Improving pain generally can improve your quality of life
How long the effect of ESI or NRB last?
- The success rate depends on how many factors are causing your pain (Neck, shoulder & arms pain or Low back pain & sciatica)
- If specific disc bulge/ Nerve/s root irritation is/are the main cause, you usually get dramatic relief of neck/back pain and arm/leg pain following the injection. However,
- If there are multiple causes for your pain, you may get no help or limited help for a short period of time, but not everyone is cured.
- The duration pain relief reduction of pain is variable. Help can lasts for few days, weeks or months.
- The injection could be repeated for diagnostic purpose or for a longer period of help.
- If a Nerve Root Block (NRB) gave the patient positive (diagnostic) response (>50% improvement) but for a short period of time, Pulsed Radiofrequency Lesion Denervation (PRFLD) of the specific nerve/s can result in long lasting pain-relieving effect (around 6 months).
What are potential risks of ESI or NRB?
It is generally safe procedure and usually well tolerated by patients, however, some side effects can happen including:
- Bruising, pain or tenderness at the site of the injection. It is usually temporary and easily controlled by simple painkillers
- Discomfort, your pain may get worse for few days after injection.
- Arm or Leg feeling numb & week after the injection is expected until the effect of local anaesthetics wears off but sometimes last foe few days. Prolonged limb (arm or leg) weakness is uncommon.
- Potential side effects of steroids: Some side effects can happen with single or with repeated steroids injections (steroids building up in the body). These include facial flushing, osteoporosis, menstrual irregularities in women, feeling sick, some abdominal pain and difficulty in controlling diabetes. These symptoms usually settle in few days.
- Some patients develop reduction of blood pressure. This can make you feel light headed. It is easily treated by lying down and sometimes IV fluids and other drugs if needed.
- Postural headache: occasionally accidental tear of the spinal cord coverings (Dural tap) can lead to leek of the CSF (fluid around the spinal cord). This can cause post- procedure headache. It is usually worse sitting or standing and gets better lying down. This headache usually settles down with bed rest, pain killers and drinking plenty of fluids. If the headache persists, please contact the pain clinic and the consultant will discuss other treatment options.
- Infection, bleeding, nerve damage and allergy to the injected drugs are rare
- It may not help your pain if there are other multiple causes for your current pain
What are Contra-Indications of ESI or NRB?
- Known allergy to local anaesthetic & steroids.
- Patients with bleeding disorders
- Patients taking anti-coagulant therapy
- Local infection or inflammation at the painful area.
- Systemic infection (infection in the blood)
How the procedure will be done?
- The procedure is usually done with the help of laser-guided mobile X-ray machine (fluoroscopy) or ultrasound guidance.
- The injection will be performed by the consultant in theatre under full aseptic technique.
- IV (inside the vein) cannula (plastic tube) will be inserted at the back of your hand for sedation (drugs to make you comfortable) during the procedure.
- The injection site will be marked then numbed with local anaesthetic. A special needle will be introduced into your neck or back. The doctor will confirm the position of the needle then the drugs (mixture or local anaesthetic and steroid) will be injected.
- You be required to stay for up to few hours after the procedure till adequate recovery. If numbness or weakness persists, you may stay longer.
- A follow up appointment will be booked few weeks later to check effect of the injection.
- Please arrange for someone to drive you home and stay for 24hours with you after the procedure.
- Usually we recommend few days rest before you go back to your normal daily activities.
- We advise measuring your pain daily on a pain diary.
- If your pain starts to get better you can start to reduce pain killer medications
Important Advice:
Please inform the pain clinic/ your doctor if:
- You take any anti-coagulant drugs (blood thinning drugs). They may have to stop 5 days before the procedure (Warfarin) or stop 7 days before the procedure (e.g. Clopidogrel, Abixiban). Other drugs could be stopped at a shorter interval. The consultant will inform you.
- If you are allergic to any medications.
- If you have an infection near the injection site.
- If you have had any recent steroid/cortisone injection in hospital or surgery.
- If you think you might be pregnant.
- If you are a diabetic especially on insulin
- If you have had a recent heart attack or stroke or vaccination.
- If you have any concerns or questions, please contact the Pain Clinic.
The information contained in this leaflet is for educational purposes only. Please discuss with your doctor if you require further information.