Pomona Pain Management Doctor | epidural injection, ganglion impar block, impar ganglion block, lumbar sympathetic block, joint injection, sacroiliac joint pain, steroid injection, cortisone, spine pain, Southern California Center for Pain Management, Dr. Bryan Lee, MD Pomona

Picture: Knee Joint Injection

Joint Injections for Painful Joints:  Joint Injections are usually given for various “arthritis” of the joints, usually osteoarthritis. When your joint (e.g. knee) is “inflamed” due to “arthritis”, you will experience pain in the joint. One good treatment for a painful joint is injection of local anesthetic and a steroid into the joint to decrease or eliminate the inflammation causing your pain.

Indications for Joint Injections: Any joint in your body can become inflamed and painful. Some common painful joints experienced by patients are the shoulder, hip and knee joints. These joints under a tremendous amount of motion and “wear and tear” from use.

Technique: At Southern California Center for Pain Management, Dr. Bryan Lee can perform steroids injections into your joints and relief your pain. Depending on your situation and the joint involved, your injection(s) can be performed either in the office or at a surgery center with X-ray guidance (for accuracy and safety) +/- conscious sedation (“twilight sleep”) for your comfort.

If your joint injection is performed in the office, it will be a simple affair in which Dr. Lee does the injection under local anesthesia with the aid of your anatomical landmarks for needle placement. There is usually minimal recovery time needed. When you are ready, Dr. Lee will give you instructions for post-procedure care and discharge you home.

If your procedure is to be performed at a surgery center, you will be checked in at the surgery center and brought into the operating suite, where you will be greeted by the doctor and registered nurse.  After placing monitors (e.g. blood pressure cuff, EKG, pulse oximeter, etc) on you, the nurse will give you IV sedation (if ordered).  Afterwards, the doctor will begin by “numbing” the injection site with a local anesthetic.  Afterward, with the aid of the fluoroscope, Dr. Lee will perform the actual injection(s), in which a local anesthetic and steroid combination is injected into your painful joint.  After appropriate monitoring, you will then be transferred to the recovery unit before going home with a family member or friend.  You are encouraged to “take it easy” for the rest of the day, and to follow the post-procedure instructions ordered by Dr. Lee.  You will be able to resume your normal activities the next day.

Pain Relief Response and Duration: Most patients can expect joint injection(s) either alone or in a series to provide relief for months and even years, in some cases. But, like any medication, the steroid will “wear off” with time and you may require repeat injection(s). There will be a minority of patients who do not respond or only get relief for days to weeks. Unfortunately, Dr. Lee cannot always predict how long your pain relief will be or how you will respond, as different patients respond differently.

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Radiofrequency Ablation or Lesioning: Radiofrequency ablation (RFA) is a procedure in which a special machine (i.e. the RFA machine) that uses high temperature “radiofrequency energy” to destroy the small nerve fibers carrying pain signals, thus interrupting those pain signals from reaching the brain, where pain is perceived (i.e. felt by you). RFA will usually give you pain relief for a peroid of months (e.g. 6-9 months), although many patients report relief for up to years. It is only a “semi-permanent” procedue, because the “destroyed” nerves can regenerate over time.

Indications for Radiofrequency Ablation: At SCCPM, Dr. Lee performs radiofrequency ablation for mechanical neck and back pain due to facet pain (i.e. facet joint disease). A variation of RFA, called “Pulsed Radiofrequency Ablatation” is very effectively used for patients suffering from occipital neuralgia (a type of headache), ilioinguinal neuralgia (i.e. groin pain), and other types of neuralgia or neuritis (pain due to abnormal nerve activity).

Technique: At SCCPM, radiofrequency ablations are performed at the surgery center under live x-ray (fluoroscopy) for safety and accuracy.  The doctor will usually order IV sedation (i.e. “twilight sleep”) as an option for your comfort.  You will be checked in at the surgery center and brought into the operating suite, where you will be greeted by the doctor and registered nurse.  After placing monitors (e.g. blood pressure cuff, EKG, pulse oximeter, etc) on you, the nurse will give you IV sedation (if ordered).  Afterward, the area of interest will be sterilely prepped, and then the doctor will begin by “numbing” the injection sites with a local anesthetic.  Afterward, with the aid of the fluoroscope, Dr. Lee will use RFA needle(s) placed at the sites where the painful nerves of interest are located. To further pinpoint the painful nerves, Dr. Lee will perform a “sensory test” and a “motor test” in which he will use the RFA machine to confirm with you that he has found the correct, painful pain fibers to destroy.  Once all confirmations are positive, the RFA machine will be programmed to deliver radiofrequency energy to the tips of the RFA needles, which in turn destroys the painful nerve fibers at high temperatures.  After RFA is completed, you will then be transferred to the recovery unit before going home with a family member or friend.  You are encouraged to “take it easy” for the rest of the day, and to follow the post-procedure instructions ordered by Dr. Lee.  You will be able to resume your normal activities the next day.

Pain Relief Response and Duration:Generally, RFA can lead to longer lasting pain relief than local anesthetic-steroid based nerve blocks. Furthermore, using RFA minimizes the use of steroid medications, which can have side effects. Dr. Lee will generally offer RFA if the nerve blocks are effective but not long lasting for the patient. As mentioned earlier, this is a semi-permanent procedure as the painful nerve fibers can regenerate over time. When this happens, Dr. Lee can repeat the RFA, as with other nerve blocks.

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Ganglion Impar: This funny name is for a cluster of nerve generally located directly in front of the tailbone. This nerve cluster receives pain signals from the tailbone, perineum, rectum, anus, urethra, and vagina. So, in general, the ganglion impar mediates pain from the pelvic organs and your tailbone.

Indications for a Ganglion Impar Block: A ganglion impar block is an excellent injection to treat pain from the tailbone. Also, it is very effective for blocking pain from the perineal and pelvic organs mentioned above, including due to cancer.

Technique: At SCCPM, lumbar sympathetic blocks are performed at the surgery center under live x-ray (fluoroscopy) for safety and accuracy.  The doctor will usually order IV sedation (i.e. “twilight sleep”) as an option for your comfort.  You will be checked in at the surgery center and brought into the operating suite, where you will be greeted by the doctor and registered nurse.  After placing monitors (e.g. blood pressure cuff, EKG, pulse oximeter, etc) on you, the nurse will give you IV sedation (if ordered).  Afterward, the area of interest will be sterilely prepped, and then the doctor will begin by “numbing” the injection site (in the tailbone region) with a local anesthetic.  Afterward, with the aid of the fluoroscope, Dr. Lee will use thin needle(s) for the actual injection(s), in which a local anesthetic +/- steroid combination is injected.  After appropriate monitoring, you will then be transferred to the recovery unit before going home with a family member or friend.  You are encouraged to “take it easy” for the rest of the day, and to follow the post-procedure instructions ordered by Dr. Lee.  You will be able to resume your normal activities the next day.

Pain Relief Response and Duration: Most patients can expect a response at the first injection. In fact, the local anesthetic will usually provide relief immediately. The steroid medication is meant to prolong and improve the relief with the local anesthetic. You may require more than one injection for long term relief, depending on the severity and duration of your pain. You and Dr. Lee will decide exactly on the number and course of your treatment. Like any medication, the local anesthetic and steroid will “wear off” with time and you may require repeat injection(s). For most patients, one or a series of injections will allow pain relief for months and even years. Unfortunately, Dr. Lee will not be able to predict your response as each patient’s disorder and severity is unique.

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Lumbar Sympathetic Block (LSB): This is a “nerve block” or injection of local anesthetic +/- steroid into the “sympathetic nerve” bundle that is located along both sides of your spinal column.
Indications for a Lumbar Sympathetic Block (LSB): This is an excellent injection for patients suffering lower extremity pain (i.e. leg/foot) due to a sympathetically mediated pain, such as Reflex Sympathetic Dystrophy (RSD) or Complex Regional Pain Syndrome (CRPS). The injection will reduce not only pain, but swelling, color changes, and sweating associated with this very painful condition. This nerve block is also used for patients suffering from Shingles related pain of the lower trunk (lower body) or lower extremity (i.e. leg/foot).
Technique: At SCCPM, lumbar sympathetic blocks are performed at the surgery center under live x-ray (fluoroscopy) for safety and accuracy.  The doctor will usually order IV sedation (i.e. “twilight sleep”) as an option for your comfort.  You will be checked in at the surgery center and brought into the operating suite, where you will be greeted by the doctor and registered nurse.  After placing monitors (e.g. blood pressure cuff, EKG, pulse oximeter, etc) on you, the nurse will give you IV sedation (if ordered).  Afterwards, the doctor will begin by “numbing” the injection site (in your lower back, close to the spine) with a local anesthetic.  Afterward, with the aid of the fluoroscope, Dr. Lee will perform the actual injection(s), in which a local anesthetic +/- steroid combination is injected.  After appropriate monitoring, you will then be transferred to the recovery unit before going home with a family member or friend.  You are encouraged to “take it easy” for the rest of the day, and to follow the post-procedure instructions ordered by Dr. Lee.  You will be able to resume your normal activities the next day.
Pain Relief Response and Duration: Most patients can expect a response at the first injection. In fact, the local anesthetic will usually provide relief immediately. The steroid medication is meant to prolong and improve the relief with the local anesthetic. You may require more than one injection for long term relief, depending on the severity and duration of your pain. You and Dr. Lee will decide exactly on the number and course of your treatment. Like any medication, the local anesthetic and steroid will “wear off” with time and you may require repeat injection(s). For most patients, one or a series of injections will allow pain relief for months and even a year or more. Unfortunately, Dr. Lee will not be able to predict your response as each patient’s disorder and severity is unique.

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Stellate Ganglion: The stellate ganglion is a “star shaped” nerve bundle in the front of the cervical spine (neck), near the “Adam’s apple” and voice box.  It is a relay system that sends nerve signals, including pain, from the head, face, neck, upper extremity (i.e. arm, hand) and even the heart to the brain.  By “blocking” these pain signals at the stellate ganglion with a nerve block, they will no longer travel up to the brain and cause you to “feel” the pain.

Indications for Stellate Ganglion Block (SGB): This injection is usually performed for patients with upper extremity (i.e. hand/arm) pain from a “sympathetically mediated” pain, such as that due to Reflex Sympathetic Dystrophy (RSD) or Complex Regional Pain Syndrome (CRPS). This injection is also very effective for patients suffering from shingles related pain of the face, neck and upper extremity (i.e. arm/hand) regions.

Technique: At SCCPM, stellate ganglion blocks are performed at the surgery center under live x-ray (fluoroscopy) for safety and accuracy.  The doctor will usually order IV sedation (i.e. “twilight sleep”) as an option for your comfort.  You will be checked in at the surgery center and brought into the operating suite, where you will be greeted by the doctor and registered nurse.  After placing monitors (e.g. blood pressure cuff, EKG, pulse oximeter, etc) on you, the nurse will give you IV sedation (if ordered).  Afterwards, the doctor will begin by “numbing” the injection site (at an area in front of your neck, near the “Adam’s Apple”) with a local anesthetic.  Afterward, with the aid of the fluoroscope, Dr. Lee will perform the actual injection(s), in which a local anesthetic and steroid combination is injected.  After appropriate monitoring, you will then be transferred to the recovery unit before going home with a family member or friend.  You are encouraged to “take it easy” for the rest of the day, and to follow the post-procedure instructions ordered by Dr. Lee.  You will be able to resume your normal activities the next day.

Pain Relief Response and Duration: Most patients can expect a response at the first injection. In fact, the local anesthetic will usually provide relief immediately. The steroid medication is meant to prolong and improve the relief with the local anesthetic. You may require more than one injection for long term relief, depending on the severity and duration of your pain. You and Dr. Lee will decide exactly on the number and course of your treatment. Like any medication, the local anesthetic and steroid will “wear off” with time and you may require repeat injection(s). For most patients, one or a series of injections will allow pain relief for months and even a year or more. Unfortunately, Dr. Lee will not be able to predict your response as each patient’s disorder and severity is unique.

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Facet Joint Injections                Facet Medial Branch Nerve Injections

Facet Blocks/Injections: these are injections into either the facet joints directly, or on the “medial branch” nerves to go into the facet joints. Facet blocks (i.e. nerve blocks for facet pain) can be done in all levels of the spine, including the cervical (neck), thoracic (upper and mid back), and lumbar (low back) spine.
Common Indications for Facet Blocks: Facet blocks are used to treat facet mediated pain. The “facet” joints are small joints between two connecting vertebrates. The vertebrates are the spine bones that make up your spine. These facet joints, like all bony joints in your body, can become “inflamed” and develop “arthritis”. Consequently, you will develop pain in the area of the diseased facet joints. For example, if the cervical facets (in the neck) become diseased, you will develop pain in the neck. Likewise, lumbar (low back region) facet disease would lead to pain in the low back. Facet pain is usually localized to the area of the spine where the facet joint is inflamed (i.e. diseased). There are currently no definitive radiological or blood test to diagnose facet mediated pain. One of the best method to diagnose facet mediated pain is with facet blocks. Facet Blocks can be both “diagnostic” (i.e. confirm the diagnosis of facet mediated pain) and “therapeutic” (i.e. provide pain relief).
Technique:  At SCCPM, facet blocks are performed at the surgery center under live x-ray (fluoroscopy) for safety and accuracy.  The doctor may order IV sedation (i.e. “twilight sleep”) as an option for your comfort.  You will be checked in at the surgery center and brought into the operating suite, where you will be greeted by the doctor and registered nurse.  After placing monitors (e.g. blood pressure cuff, EKG, pulse oximeter, etc) on you, the nurse will give you IV sedation (if ordered).  Afterwards, the doctor will begin by “numbing” the injection site with a local anesthetic.  Afterward, with the aid of the fluoroscope, Dr. Lee will perform the actual injection(s), in which a local anesthetic +/- steroid combination is used.  After appropriate monitoring, you will then be transferred to the recovery unit before going home with a family member or friend.  You are encouraged to “take it easy” for the rest of the day, and to follow the post-procedure instructions ordered by Dr. Lee.  You will be able to resume your normal activities the next day.
Pain Relief Response and Duration: Most patients can expect pain relief immediately or 1-2 days after the injection(s). The immediate relief is due to the local anesthetic, while the long term relief comes from the steroid.  If a steroid mixture is used, most patients can expect to have duration of pain relief for months or even year(s). However, there will be a minority of patients who do not respond or respond only temporarily. Again, there is no way for Dr. Lee to predict your response as each patient’s pain and response differs. However, if you indeed have facet mediated pain, you should have pain relief with this type of injection.

As with all medications, the steroid drug will wear off with time and you may require repeat injections. There are currently no rule as to how many injections a patient will need and how often. It is up to the patient and Dr. Lee to decide on the number and course of treatment needed. In general, if the facet blocks prove beneficial, Dr. Lee can then recommend Radiofrequency Ablation of the facet medial branch nerves for long lasting pain relief.

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Sacroiliac Joint (SIJ) Dysfunction: There are symmetrical sacroiliac joints on each side of your pelvis, and if these joints become inflamed or diseased, they could be another cause of back pain. Some experts believe up to 25-30% of low back pain come from SIJ dysfunction. Patients with SIJ pain usually describe pain localized to the buttock/low back area. This pain often spreads to the hip, thigh, and groin. In some cases, it may even radiate down the leg. SIJ pain is often confused with hip pain or even “sciatica”. Unlike many spinal pain disorder, there is no definitive radiological or blood test to diagnose SIJ pain. Your doctor uses your symptoms and physical exam to diagnose SIJ pain (e.g. sacroiliitis).

Sacroiliac Joint Injections: One very effective treatment for SIJ pain is to inject a combination of steroid and local anesthetic into the affected joint. Often, this procedure is both “diagnostic” (i.e. confirm the diagnosis of SIJ pain) and “therapeutic” (i.e. provide pain relief).

Technique: At SCCPM, SIJ injections are performed at the surgery center under live x-ray (fluoroscopy) for safety and accuracy.  The doctor may order IV sedation (i.e. “twilight sleep”) as an option for your comfort.  You will be checked in at the surgery center and brought into the operating suite, where you will be greeted by the doctor and registered nurse.  After placing monitors (e.g. blood pressure cuff, EKG, pulse oximeter, etc) on you, the nurse will give you IV sedation (if ordered).  Afterwards, the doctor will begin by “numbing” the injection site with a local anesthetic.  Afterward, with the aid of the fluoroscope, Dr. Lee will perform the actual injection(s), in which a local anesthetic and steroid combination is injected.  After appropriate monitoring, you will then be transferred to the recovery unit before going home with a family member or friend.  You are encouraged to “take it easy” for the rest of the day, and to follow the post-procedure instructions ordered by Dr. Lee.  You will be able to resume your normal activities the next day.
Pain Relief Response and Duration: Most patients can expect SIJ injection(s) either alone or in a series to provide relief for months and even years, in some cases. But, like any medication, the steroid will “wear off” with time and you may require repeat injection(s). Unfortunately, Dr. Lee cannot give you a prediction on how long your pain relief will be, as different patients respond differently.

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Picture Courtesy of spinesurgeon.co.uk

Transforaminal Epidural Steroid Injections/Selective Nerve Blocks (TFESI/SNB): These two types of injections are very similar.  For the sake of simplicity, Dr. Lee will concentrate on TFESI.  You can assume that SNB have the same purpose and the procedure is done very similar to TFESI.  TFESIs are a variation of the regular Epidural Steroid Injections, but are more specific to treatment of affected nerve roots causing your pain.

Common Indications for TFESIs: There are many indications for Transforaminal Epidural Steroid Injections.  Some of the more common ones include cervical radiculopathy (arm/hand pain spreading from the neck) and lumbar radiculopathy (leg/foot pain spreading from the low back).   They also work well for thoracic radiculopathy (e.g. chest wall or rib pain spreading from your mid back).  TFESIs are indicated for disc degeneration, spinal stenosis, herniated discs, and radiculopathy/sciatica.  The injections deposit medication directly to the source of the diseased nerve root (e.g. origin of the nerve at the spinal cord), thus allowing for direct relief of the nerve inflammation causing your pain.

Technique:  At SCCPM, transforminal epidural steroid injections are performed at the surgery center under live x-ray (fluoroscopy) for safety and accuracy.  We will also give you moderate IV sedation (i.e. “twilight sleep”) as an option for your comfort, although many patients have had the procedure performed with local anesthetic alone without discomfort.  You will be checked in at the surgery center and brought into the operating suite, where you will be greeted by the doctor and registered nurse.  After placing monitors (e.g. blood pressure cuff, EKG, etc) on you, the nurse will give you IV sedation (if ordered).  Afterwards, the doctor will begin by “numbing” the injection site with a local anesthetic.  Afterward, with the aid oof the fluoroscope, Dr. Lee will perform the actual TFESI, in which a long acting steroid solution and local anesthetic will be injected adjacent to the diseased spinal nerve(s), where the inflammation causing your pain is located.  After appropriate monitoring, you will then be transferred to the recovery unit before going home with a family member or friend.  You are encouraged to “take it easy” for the rest of the day, and to follow the post-procedure instructions ordered by Dr. Lee.  You will be able to resume your normal activities the next day.

Pain Relief Response and Duration: Most patients can expect pain relief to set in 1-2 days after the first injection.  There will be some who will get immediate relief, while others may take 1-3 weeks for the relief to set in.  There will be a small % of patients who may not respond to the injection at all.  Unfortunately, the doctor cannot always predict your individual response beforehand.  Likewise, the duration of pain relief is variable.  Most patients can expect relief for months, and some have reported relief for even years.  There will be a minority who responds short-term, with relief for only days to weeks, or not at all.  Again, each patient’s response is different, just as each patient’s pain condition is unique.

Injection Series: Most patients get relief with just one injection, although a minority of patients will require more to get relief.  There is no set rule on the number of injections required.  In general, most pain doctors (including Dr. Lee) may perform up to a “series of 3″ TFESIs.  A  “series of 3″ injections may be performed to ensure pain relief as well as prolong the duration of pain relief (as mentioned above).  There are no set guidelines to the number of ESIs a patient can get in a year or “life time”.  But, in general, patients may need to repeat the ESI or ESI injection series when the pain returns over time (e.g. weeks to month to years).  As each patient’s pain condition is unique, it is best to discuss with the doctor about your pain condition and the best course of treatment.

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  (Image from Dr. Patricia Grant)

Epidural Steroid

Injections (ESIs): these are the most common injections performed in pain management. Usually, when your doctor plans to perform an “epidural”, they are referring to this injection.  Epidural steroid injections are usually done via the “interlaminar” route, which is between the spinous process/lamina of two vertebral bodies (i.e. spine bone).

Common Indications for ESIs: There are many indications for ESIs.  Some of the more common ones include neck and back pain.  They also work very well for patient with radicular symptoms, such as neck pain radiating (i.e. “spreading”) to the arms and hands, or back pain spreading to the legs and feet.  These injections can be done in the cervical spine for neck and arm/hand related pain, thoracic spine for mid back, rib pain, and chest/abdomen related pain, and the lumbar spine for low back and leg/foot related pain.  ESIs are indicated for disc degeneration, spinal stenosis, herniated discs, radiculopathy/sciatica, spondylosis, vertebral fractures, shingles related pain, etc.

Technique:  At SCCPM, most epidural steroid injections will be performed at the surgery center under live x-ray (fluoroscopy) for safety and accuracy.  We will also give you moderate IV sedation (i.e. “twilight sleep”) as an option for your comfort, although many patients have had the procedure performed with local anesthetic alone without discomfort.  You will be checked in at the surgery center and brought into the operating suite, where you will be greeted by the doctor and registered nurse.  After placing monitors (e.g. blood pressure cuff, EKG, etc) on you, the nurse will give you IV sedation (if ordered).  Afterwards, the doctor will begin by “numbing” the injection site with a local anesthetic.  Afterward, with the aid of the fluoroscope, Dr. Lee will perform the actual ESI, in which a long acting steroid solution will be injected into your spine, where the inflammation causing your pain is located.  After appropriate monitoring, you will then be transferred to the recovery unit before going home with a family member or friend.  You are encouraged to “take it easy” for the rest of the day, and to follow the post-procedure instructions ordered by Dr. Lee.  You will be able to resume your normal activities the next day.

Pain Relief Response and Duration: Most patients can expect pain relief to set in 1-2 days after the first injection.  There will be some who will get immediate relief, while others may take 1-3 weeks for the relief to set in.  There will be a small % of patients who may not respond to the injection at all.  Unfortunately, the doctor cannot always predict your individual response beforehand.  Likewise, the duration of pain relief is variable.  Most patients can expect relief for months, and some have reported relief for even years.  There will be a minority who responds short-term, with relief for only days to weeks, or not at all.  Again, each patient’s response is different, just as each patient’s pain condition is unique.

Injection Series: Most patients get relief with just one injection, although a minority of patients will require more to get relief.  There is no set rule on the number of injections required.  In general, most pain doctors (including Dr. Lee) perform up to a “series of 3” ESIs.  A  “series of 3” injections may be performed to ensure pain relief as well as prolong the duration of pain relief (as mentioned above).  There are no set guidelines to the number of ESIs a patient can get in a year or “life time”.  But, in general, patients may need to repeat the ESI or ESI injection series when the pain returns over time.  As each patient’s pain condition is unique, it is best to discuss with the doctor about your pain condition and the best course of treatment.

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We have moved to a brand new office right across the hall from my old office.  The new suite is 307.

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