New England Spine Care

 

Overview and Indications for Procedure

 

Shoulder is a complex joint consistent of bones, joints in between, ligaments that hold the structure together and multiple muscles around the joint which allows the joint to move within available range of motion.

 

There are different areas within this complex structure that could be painful. The pain may come from the "acromioclavicular portion of the shoulder. Your pain may be coming from the bursa called subacromial bursa. The pain may be coming from the glenohumeral joint (actual shoulder joint). Some people have pain from the rotator cuff tendons or the biceps tendon which enters the joint. Following this painful spots may create pain around the shoulder girdle but they are distant targets for treatment.

 

AC joint often causes pain on top of the shoulder especially with activities that require his arm to go across her body. The pain related to subacromial bursa is usually at the side or to backside of the shoulder associated with shoulder motion and laying on the shoulder. Bringing arms up to your side can trigger pain related to the bursa or the rotator cuff structure. The biceps tendon pain is often in the front side of the shoulder.

 

Procedural Treatments: Hallmark of shoulder pain treatment includes physical therapy program, use of anti-inflammatory medications, and at times localized injection. Depending on what specific target within the shoulder is painful, injecting that target can reduce pain, improve function and increase range of motion.

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Risks Associated with Procedure

 

It is important to know the risks associated with any medical or surgical treatment. There are a few risks associated with caudal epidural steroid injections but they tend to be rare. The potential risks include:

 

• Immediate or delayed allergic reaction to medication used

• Infection

• Bleeding

• Nerve Injury

• Temporary increase in pain

• Osteoporotic bone fracture

• Avascular necrosis

• High blood sugar levels

• Transient vaginal spotting

• Transient facial flushing

 

Infection rate is less than 1% in patients receiving spinal injections performed under sterile conditions. The bleeding complication is more common in patients with a history of a bleeding disorder. This includes patients being treated with anticoagulant/antiplatelet medications and patients taking over the counter medications like Motrin and Aspirin. The frequency of injury to the nerve has substantially reduced with use of fluoroscopy and contrast material. Elevated blood sugar is a known effect of steroid medication and may last for 2-4 days after the injection of steroids. Patients on insulin will need to follow sliding scale to adjust for elevated sugar levels. Patients on oral medication should follow primary care advice regarding temporary increase in oral medication to accommodate for blood sugar levels. The following side effects tend to be rare, though they become more common when steroids are taken daily for several months. These risks and side effects may include:

 

• A transient decrease in immunity

• Stomach ulcers

• Severe arthritis of the hips

• Avascular necrosis of joints

• Cataracts

• Increased appetite

• Agitation and irritability

• Negative effect on bone density and fractures

 

Who should avoid Steroid Injections?

 

Steroid Injections should not be performed on persons with the following conditions:

 

• Individuals with known allergies to local anesthetics, steroids or contrast material

• Patients with local or systemic bacterial infection

• Pregnant patients

• Patients with bleeding disorders

• Patients suffering from a tumor or infection of the spine

• Uncontrolled congestive heart failure or diabetes

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Prepare for your Procedure

 

Certain medications have to be held before elective procedures. We will provide you with the list of medications that has to be held with the exact number of days it needs to be held. Do not hold such medication on your own. Consult your Primary Care Physician (or Cardiologist) before stopping those medications. Ask your PCP if it is safe to stop the medication. Continue to take all other medications, especially your Blood Pressure medications.

 

A sample of medications that have to be held includes:

 

1. Aggrenox® (dipyridamole)

2. Aspirin

3. Coumadin® (warfarin)

4. Effient® (prasugrel)

5. Fragmin® (dalteparin)

6. NSAIDS (see sample below)

7. Herbal blood-thinners

8. Heparin

9. Eliquis ® (apixaban).

10. Lovenox® (enoxaparin)

11. Plavix® (clopidogrel),

12. Pradaxa® (dabigatran)

13. Ticlid® (ticlopidine)

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Examples of NSAIDS to be held: Ibuprofen, Motrin, Naproxen, Advil, Nabumetone, Diclofenac, Etodolac, Indomethacin, Ketorolac, Meloxicam, Piroxicam, Ketoprofen, and Oxaprozin/

 

Please let us know if you have had fevers, antibiotic treatment, any illness, or hospitalization within the last 4 weeks. You must be healthy and off all antibiotics on the day of the procedure.

 

Make sure you are not pregnant at the time of procedure. Do a Urine Pregnancy Test the night before your spinal injection and report the results to the nurse before the procedure. Exposure to X-ray (used during spinal procedure) is known to result in birth defects and possible miscarriage. If in doubt, cancel and reschedule your procedure until you can confirm that you are not pregnant

 

Day of your Procedure

 

• Please take a shower, wash the skin with normal soap and DO NOT put skin lotions or mediated creams in the area of the injection. Wear dark and loose clothing and undergarment.

• Arrive 30 minutes early and come with someone that can give you a ride home. Your procedure should take less than 30 minutes and your total time from greeting to end should be less than 90 minutes.

• Bring an updated list of your medications and allergies. Please point out if you are allergic to Contrast, Iodine or Latex.

• Bring your latest imaging studies (x-ray, MRI or CT) and the report with you.

• Do not eat or drink for 2 hours before your appointment. Diabetics may have a light meal.

• After check-in, an ID wristband containing your name and allergies will be placed on your wrist. A nurse or medical assistant will go over your meds and allergies and ask few screening questions. Then a nurse will go over final preparation before the procedure. If necessary, an IV line will be placed, particularly if this is your first spinal procedure.

• In rare cases, oral sedation is needed to reduce anxiety associated with the procedure. This will slow down the entire process. Take medication 1 hour before the procedure and you must have someone drive you to and from the procedure. Without the ride, procedure would likely be canceled.

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During the Procedure

 

• You will change into a gown. You will be escorted to the procedure by a nurse and a consent form will be reviewed/ signed before the procedure. You will be asked to lay on your back.

• Blood pressure and heart rate monitor will be placed on your arm/finger. All the medical equipment produces loud noises (beeping, alarms) and you should not be concerned.

• Intermittently your doctor will talk to staff in the procedure room and instruct them to perform a task. Your physician will guide you step by step through the procedure.

• After standard time out, your skin will be disinfected with a cool solution, and sterile sheet of paper or plastic will be placed on your skin.

• When your physician is ready, X-ray unit is placed over your spine to identify the target.

• Skin will be marked near the intergluteal cleft and anesthetized (you will feel a small pinch and burning sensation). It is normal to feel pressure or muscles twitching as needles are advanced to the final target.

• Once needle is at radiographic target, a small amount of contrast is injected to confirm final needle position before injecting steroid medication. You may feel transient pressure in your spine or arm.

• Once procedure is completed, needle is removed, skin is cleaned and bandage is applied. You are then transferred back to the recovery area for observation.

 

Right after the Procedure

 

• You will be observed for 15-45 minutes.

• If you have an IV line, it will be removed.

• A nurse will check your vitals and review the discharge instructions with you and will answer any questions you may have. A responsible adult must be present to drive you home after discharge.

• You will leave with a pain log and a copy of the discharge instruction which contains Emergency contact numbers. Please do not discard your discharge instructions.

• A responsible adult must drive you home.

 

Discharge Instructions

 

• Make a follow-up 2-3 weeks after the procedure and bring your pain log with you.

• For 24 hours after the procedure, do not drive or operate machinery.

• If sedation is used, for 24 hours after the procedure, do not make financial or important life decisions until the effect of such medication is cleared.

• For 24 hours after the procedure, do not participate in strenuous activity.

• It is okay to shower after the procedure. No bathing /submerging under water for 24 hours.

• You may remove the bandages 24 hours after the injection. Call if there is excessive redness or signs of infection like warmth, discharge or collection of pus at the site of injection.

• You may resume your normal diet and medications after procedure.

• Resume your Blood Thinners/ Anticoagulants / Antiplatelet as instructed by PCP or Cardiologist. You may need to check INR/PT/PTT 2-3 days after your procedure. Contact your primary care and ask when you should have the blood work.

• Diabetics should monitor blood sugar levels 3 times a day for 3 days after the procedure.

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Call your doctor if you develop these symptoms. You may be directed to ER, if you experience:

 

• Shortness of breath or palpitation after procedure

• Sudden weakness

• Fever over 101°F within 5 days after procedure

• Persistent redness, increased localized pain, or discharge from the site of injection.

• Possible allergic reaction within 5 days of the procedure

• Intractable headache

• Significant increased pain not responding to ice, NSAIDS and pain meds or associated with fever • Newly developed weakness in the legs, face or arm following procedure

• Newly developed incontinence of urine or stool following procedure

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