Frequently Asked Questions

FAQ’s2017-12-05T21:59:56+00:00

Should I talk with the insurance company?

  • NO! You should NOT talk with the insurance company, let Attorney Javier Marcos & Associates take care of talking to them.
    If not, you could give information which the insurance company or the company you work for will you use against you to give you the minimum amount of money.
  • The insurance company or the company where you were hurt are not your friends, they are your enemies.
  • You are the victim in this accident.
  • Don’t trust anyone, speak only with Attorney Javier Marcos & Associates.

Should I accept money from the company or the insurance company?

  • Do not accept money from anyone, speak with Attorney Javier Marcos & Associates.
  • Since he will see to it that the amount of money that they offer you is the fair amount that you deserve.

How much will this cost me?

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What do I do if I’ve had an accident and I can’t move?

  • You need to call 911.
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  • We’ll go to the accident scene.
  • We’ll visit you at home or in the hospital.

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Pain Management Guidelines

ALL CONSULTATIONS: Patient must bring photo ID and arrive 15 minutes early. Patient must also bring a list of their medications.

PROCEDURE DAY: If you do not follow the guidelines, we may not be able to proceed with scheduled procedure.

• Patient must bring photo ID and arrive 15 minutes early.

• Patient must bring a driver.

• Patient must stop taking blood thinners 6 days before the procedure day. Common blood thinners are alcohol, Aspirin, Ibuprofen, Advil, Excedrin, Bayer, Motrin.

• Do NOT consume food or drinks 6 hours before the injection.

• Patient must not be pregnant and/or breastfeeding.

• Patients with high blood pressure or diabetes should continue their medications and may take their medications with a small amount of water the day of the procedure.

Pain Management 101

How Injections Relieve Back Pain

For pain relief, injections can be more effective than an oral medication because they deliver medication directly to the anatomic location that is generating the pain. Typically, a steroid medication is injected to deliver a powerful anti-inflammatory solution directly to the area that is the source of pain. Depending on the type of injection, some forms of low back pain relief may be long lasting and some may be only temporary.

Different Kinds of Injections for Pain Relief

Common types of injections for back pain relief include:

• Epidural steroid injection

• Selective nerve root block (SNRB)

• Facet joint block

Medical Representations

Please be aware that the information provided on this sheet is to supplement the care provided by your physician. It is not intended nor implied to be a substitute for professional medical advice.

Epidural Steroid Injection

An epidural steroid injection is a very common procedure with a long history of safety and success. The epidural space is a small space conveniently located next to the spinal fluid, the spinal cord, and the nerve roots. Steroid and local anesthetic medication, when injected into the epidural space, can help to calm inflamed nerve roots and other structures. When conservative therapy has failed, an epidural steroid injection can accelerate the healing process and facilitate a return to work or previous activities. In order to achieve maximum effect, often repeated injections are needed – typically three injections over 3 months.

Side effects of Epidural Steroid Injections are rare and your physician will discuss them with you. You will be asked to sign a written consent prior to the procedure. Please make sure you fully understand the risks and benefits of any procedure prior to signing the consent form.

Epidural steroid injections, as with most other procedures, are performed in our in-office fluoroscopy suite. X-ray or fluoroscopy is used for nearly all injections. Intravenous sedation is typically not offered but a mild oral sedative may be offered, depending on your medical condition.

You will not be able to drive following your procedure, so please make arrangements for transportation. You may resume normal activities the day after the procedure, unless otherwise directed by your physician. It may take a week or more for you to feel relief.

While some patients will require more advanced interventions, an epidural steroid injection is a very common, simple, and relatively safe procedure. Please contact our office if you have additional questions regarding this procedure.

Selective Nerve Root Block (SNRB)

In an SNRB, the nerve is approached at the level where it exits the foramen (the hole between the vertebral bodies). The injection is done both with a steroid (an anti-inflammatory medication) and lidocaine (a numbing agent). Fluoroscopy (live X-ray) is used to ensure the medication is delivered to the correct location. If the patient’s pain goes away after the injection, it can be inferred that the back pain generator is the specific nerve root that has just been injected. Following the injection, the steroid also helps reduce inflammation around the nerve root.

Facet Joint Block

In cases where the facet joint itself is the pain generator, a facet block injection can be performed to alleviate the pain. Facet block injections are a diagnostic tool used to isolate and confirm the specific source of back pain for the patient. Additionally, facet blocks have a therapeutic effect as they numb the source of pain and soothe the inflammation for the patient.

The facet joints are paired joints in the back that have apposing surfaces of cartilage (cushioning tissue between the bones) and a surrounding capsule. Twisting injuries can cause damage to one or both facet joints, and cartilage degeneration associated with aging may also cause pain.

In a facet block procedure, a physician uses fluoroscopy (live X-ray) to guide the needle into the facet joint capsule to inject lidocaine (a numbing agent) and/or a steroid (an anti-inflammatory medication). If the patient’s pain goes away after the injection, it can be inferred that the pain generator is the specific facet joint capsule that has just been injected. If the facet block procedure is effective in alleviating the patient’s low back pain, it is often considered reasonable for the procedure to be done up to three times per year. There are very few risks associated with this technique.


Injections for Back Pain Relief

By Peter F. Ullrich, Jr., MD, Orthopedic Surgeon (retired)

Injections comprise another nonsurgical treatment option for low back pain. They are typically considered as an option to treat low back pain after a course of medications and/or physical therapy is completed, but before surgery is considered. Injections can be useful both for providing pain relief and as a diagnostic tool to help identify the source of the patient’s back pain.

How Injections Relieve Back Pain

For pain relief, injections can be more effective than an oral medication because they deliver medication directly to the anatomic location that is generating the pain. Typically, a steroid medication is injected to deliver a powerful anti-inflammatory solution directly to the area that is the source of pain. Depending on the type of injection, some forms of low back pain relief may be long lasting and some may be only temporary.

Injections to Diagnose Causes of Back Pain

Diagnostically, injections can be used to help determine which structure in the back is generating pain. If lidocaine or similar numbing medication is used, and the patient feels temporary relief after an anatomic region is injected (e.g. facet joint or sacroiliac joint), it can then be inferred that the specific region is the source of the pain. When considered in conjunction with a patient’s history, physical exam, and imaging studies, injections used for diagnostic purposes can be very helpful in guiding further treatment for the patient.

Different Kinds of Injections for Pain Relief

  • Common types of injections for back pain relief include:
  • Epidural steroid injection
  • Selective nerve root block (SNRB)
  • Facet joint block
  • Facet rhizotomy
  • Sacroiliac joint block

The most commonly performed injection is an epidural steroid injection. In this approach, a steroid is injected directly around the dura, the sac around the nerve roots that contains cerebrospinal fluid (the fluid that the nerve roots are bathed in). Prior to the injection, the skin is anesthetized by using a small needle to numb the area in the low back (a local anesthetic).

Epidural Injections Help Reduce Inflammation

Injecting around the dura sac with steroid can markedly decrease inflammation associated with common conditions such as spinal stenosis, disc herniation, or degenerative disc disease. It is thought that there is also a flushing effect from the injection that helps remove or “flush out” inflammatory proteins from around structures that may cause pain.

Epidural Steroid Injection Success Rates

An epidural steroid injection is generally successful in relieving lower back pain for approximately 50% of patients. While the effects of the injection tend to be temporary (one week to one year), an epidural can be very beneficial in providing relief for patients during an episode of severe back pain and allows patients to progress in their rehabilitation.

Frequency for Epidural Steroid Injections

There is no definitive research to dictate the frequency of the epidural steroid injections; however, a limit of three injections per year is generally considered reasonable. There is also no general consensus in the medical community as to whether or not a series of three injections need always be performed. If one or two injections resolve the patient’s low back pain, some physicians prefer to save the one or two additional injections for any potential recurrent low back pain.

Generally, there are few risks associated with epidural injections. The risks are remote and include:

  • A wet tap may occur, which means that the needle has penetrated the dural sac into the cerebral spinal fluid (CSF). A wet tap may result in a CSF leak and a spinal headache.
  • Infection into the epidural space is also a remote risk.
  • While there is no risk of paralysis (since the spinal cord ends at a higher level in the spine), there is a remote risk of damage to a nerve root.

Patients Who Should Avoid Epidural Injections

Epidural steroid injections should not be performed on patients whose pain is from a tumor or infection, and if suspected, an MRI scan should be done prior to the injection to rule out these conditions.


Selective Nerve Root Blocks (SNRB) and Facet Joint Injections

Another common injection, a selective nerve root block (SNRB), is primarily used to diagnose the specific source of nerve root pain and, secondarily, for therapeutic relief of low back pain and/or leg pain (see Figure 1). When a nerve root becomes compressed and inflamed, it can produce back and/or leg pain. Occasionally, an imaging study (e.g. MRI) may not clearly show which nerve is causing the pain and an SNRB injection is performed to assist in isolating the source of pain. In addition to its diagnostic function, this type of injection for pain management can also be used as a treatment for a far lateral disc herniation (a disc that ruptures outside the spinal canal).

Selective Nerve Root Block (SNRB) for Diagnosis and Back Pain Management

In an SNRB, the nerve is approached at the level where it exits the foramen (the hole between the vertebral bodies). The injection is done both with a steroid (an anti-inflammatory medication) and lidocaine (a numbing agent). Fluoroscopy (live X-ray) is used to ensure the medication is delivered to the correct location. If the patient’s pain goes away after the injection, it can be inferred that the back pain generator is the specific nerve root that has just been injected. Following the injection, the steroid also helps reduce inflammation around the nerve root.

Success rates vary depending on the primary diagnosis and whether or not the injections are being used primarily for diagnosis. While there is no definitive research to dictate the frequency of SNRBs, it is generally considered reasonable to limit SNRBs to three times per year.

Technically, SNRB injections are more difficult to perform than epidural steroid injections and should be performed by experienced physicians. Since the injection is outside the spine, there is no risk of a wet tap (cerebrospinal fluid leak). However, since the injection is right next to the nerve root, sometimes an SNRB will temporarily worsen the patient’s leg pain.

Facet Joint Block for Back Pain Management

In cases where the facet joint itself is the pain generator, a facet block injection can be performed to alleviate the pain. Similar to SNRBs, facet block injections are a diagnostic tool used to isolate and confirm the specific source of back pain for the patient. Additionally, facet blocks have a therapeutic effect as they numb the source of pain and soothe the inflammation for the patient.

The facet joints are paired joints in the back that have apposing surfaces of cartilage (cushioning tissue between the bones) and a surrounding capsule. Twisting injuries can cause damage to one or both facet joints, and cartilage degeneration associated with aging may also cause pain.

In a facet block procedure, a physician uses fluoroscopy (live X-ray) to guide the needle into the facet joint capsule to inject lidocaine (a numbing agent) and/or a steroid (an anti-inflammatory medication). If the patient’s pain goes away after the injection, it can be inferred that the pain generator is the specific facet joint capsule that has just been injected. If the facet block procedure is effective in alleviating the patient’s low back pain, it is often considered reasonable for the procedure to be done up to three times per year. There are very few risks associated with this technique.


Facet Rhizotomy and Sacroiliac Joint Block Injections

In some low back pain programs, if three facet block injections provide good but temporary relief of the patient’s pain, a facet rhizotomy injection may be recommended. The purpose of a facet rhizotomy injection is to provide lasting low back pain relief by disabling the sensory nerve that goes to the facet joint.

In this injection procedure a needle with a probe is inserted just outside the joint. The probe is then heated with radio waves and applied to the sensory nerve to the joint in order to disable the nerve. Theoretically, by deadening the sensory nerve to the facet joint, a facet rhizotomy effectively prevents the pain signals from getting to the brain.

A facet rhizotomy injection is successful in providing lasting pain relief for approximately 50% of patients.

Sacroiliac Joint Block Injection

Sacroiliac (SI) joint blocks are injections that are primarily used for diagnosing and treating the low back pain associated with sacroiliac joint dysfunction. The SI joint lies next to the spine and connects the sacrum (bottom of the spine) with the pelvis (hip).

In an SI joint block injection approach, a physician uses fluoroscopic guidance (live X-ray) and inserts a needle into the sacroiliac joint to inject lidocaine (a numbing agent) and a steroid (an anti-inflammatory medication). It takes a highly skilled and experienced physician to be able to insert a needle into the sacroiliac joint.

An SI joint block injection may be repeated up to three times per year. For the treatment to be successful, the injection should be followed by physical therapy and/or chiropractic adjustments to provide mobilization and range of motion exercises.


How Epidural Steroid Injections Work

By Richard A. Staehler, MD

An epidural steroid injection delivers steroids directly into the epidural space in the spine. Sometimes additional fluid (local anesthetic and/or a normal saline solution) is used to help ‘flush out’ inflammatory mediators from around the area that may be a source of pain.

The epidural space encircles the dural sac and is filled with fat and small blood vessels. The dural sac surrounds the spinal cord, nerve roots, and cerebrospinal fluid (the fluid that the nerve roots are bathed in).

Typically, a solution containing cortisone (steroid) with local anesthetic (lidocaine or bupivacaine), and/or saline is used.

  • A steroid, or cortisone, is usually injected as an anti-inflammatory agent. Inflammation is a common component of many low back conditions and reducing inflammation helps reduce pain. Triamcinolone acetonide, Dexamethasone, and Methylprednisolone acetate are commonly used steroids.
  • Lidocaine (also referred to as Xylocaine) is a fast-acting local anesthetic used for temporary pain relief. Bupivacaine, a longer lasting medication, may also be used. Although primarily used for pain relief, these local anesthetics also act as ‘flushing’ agents to dilute the chemical or immunologic agents that promote inflammation.
  • Saline is used to dilute the local anesthetic or as a ‘flushing’ agent to dilute the chemical or immunologic agents that promote inflammation.

Epidural Steroid Injection Pain Relief Success Rates

Patients will find that the benefits of an epidural steroid injection include a reduction in pain, primarily in leg pain (also called sciatica or radicular pain). Patients seem to have a better response when the epidural steroid injections are coupled with an organized therapeutic exercise program.

Epidural Steroid Injection Success Rates

While the effects of an epidural steroid injection tend to be temporary (lasting from a week to up to a year) an epidural steroid injection can deliver substantial benefits for many patients experiencing low back pain.

  • When proper placement is made using fluoroscopic guidance and radiographic confirmation through the use of contrast, > 50% of patients receive some pain relief as a result of lumbar epidural steroid injections.
  • Pain relief is more often felt for primary radicular (leg) pain and, less prominently, low back pain.
  • The pain relief and control brought on by injections can improve a patient’s mental health and quality of life, minimize the need for painkiller use, and potentially delay or avoid surgery.

Success rates can vary depending on the condition that patient has and the degree of radicular leg pain that accompanies it:

  • Recent research reports that lumbar epidural steroid injections are successful in patients with persistent sciatica from lumbar disc herniation, with more than 80% of the injected group with disc herniation experiencing relief (in contrast to 48% of the group that received a saline placebo injection)1.
  • Similarly, in a study focused on a group of patients with lumbar spinal stenosis and related sciatica symptoms, 75% of patients receiving injections had more than 50% of pain reduction one year following the injections. The majority also increased their walking duration and tolerance for standing.

Nonetheless, there is still some skepticism about the efficacy of injections and the appropriateness of injections for most patients. As noted previously, much of the controversy is generated by studies that analyze injection outcomes where fluoroscopy and radiographic contrast were not used to ensure accurate placement of the steroid solution at the level of pathology, or do not confirm that the injection was in fact made directly into the epidural space, which would diminish its effectiveness considerably.

Epidural Steroid Injections: Risks and Side Effects

There are several risks associated with epidural injections, and although they are all relatively rare, it is worth discussing each with the professional who will be conducting the procedure to determine the incidence of prevalence in their practice.

Potential Risks of Epidural Steroid Injections

As with all invasive medical procedures, there are potential risks associated with lumbar epidural steroid injections. In addition to temporary numbness of the bowels and bladder, the most common potential risks and complications include:

  • Infection. Severe infections are rare, occurring in 0.1% to 0.01% of injections.
  • Dural puncture (“wet tap”). A dural puncture occurs in 0.5% of injections. It may cause a post-dural puncture headache (also called a spinal headache) that usually improves within a few days. Although infrequent, a blood patch may be necessary to alleviate the headache. A blood patch is a simple, quick procedure that involves obtaining a small amount of blood from a patient from an arm vein and immediately injecting it into the epidural space to allow it to clot around the spinal sac and stop the leak.
  • Bleeding. Bleeding is a rare complication and is more common for patients with underlying bleeding disorders.
  • Nerve damage. While extremely rare, nerve damage can occur from direct trauma from the needle, or from infection or bleeding.

Possible Side Effects of Lumbar Epidural Steroid Injection

In addition to risks from the injection, there are also potential side effects from the steroid medication itself. These tend to be rare and much less prevalent than the side effects from oral steroids. Nonetheless, reported side effects from epidural steroid injections include:

  • Localized increase in pain
  • Non-positional headaches resolving within 24 hours
  • Facial flushing
  • Anxiety
  • Sleeplessness
  • Fever the night of injection
  • High blood sugar
  • A transient decrease in immunity because of the suppressive effect of the steroid
  • Stomach ulcers
  • Severe arthritis of the hips (avascular necrosis)
  • Cataracts

When to Report Epidural Side Effects to a Doctor

While physicians will have different approaches to patient follow-up depending on their practice and the patient’s clinical situation, some conditions that always warrant a call to a doctor following an epidural steroid injection include:

  • Experiencing a painful headache while sitting up or standing that feels better after lying down, which may indicate a dural puncture
  • Having a fever of 101 degrees or greater for more than 24 hours, which may be indicative of infection
  • Losing function or feeling in the legs or arms
  • Loss of bowel or bladder control (meaning either the inability to produce or hold urine or stools) after the local anesthetic and temporary numbness wear off
  • Severe pain not controlled by over-the-counter pain medication or other measures used in the past

All of these symptoms are atypical effects, and need to be assessed and addressed immediately by a professional.

In general, epidural steroid injections are a low risk, useful, non-surgical tool to combat lower back pain and sciatica (radicular pain) caused by inflammation. A conservative analysis of patient outcomes suggests that at least 50% of patients will experience pain relief, although the exact degree of relief enjoyed depends on a number of factors. Their relative safety and efficacy makes epidural steroid injections an integral part of the non-surgical treatment of low back and radicular pain.

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