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Diplomate American Board of Anesthesiology
and Pain Management

Newsday - Long Island, N.Y. Author: Ellen Mitchell.
Date: Mar 20, 2000 Start Page: C.05 Section: HEALTH & DISCOVERY.

Injections focus on the symptom rather than the cause — ADELE WOLFSON is back at the gym. True, she's given up teaching folk dancing because she can't leap anymore. But, at age 70, the Great Neck woman is free of the "vicious" back and leg pain that had invaded her life.

Wolfson is one of a growing number of people who are savoring relief from severe back, leg and neck pain after a relatively simple series of injections done on an outpatient basis.

The nonsurgical procedure focuses on alleviating pain rather than on curing its root cause. As such, it is indicative of a new medical priority. Chronic pain has historically frustrated patients and their physicians who have tried unsuccessfully to treat it. Now, however, doctors are recognizing the elimination of chronic pain as a specialty in and of itself.

"Pain management is now being welcomed by the medical community," said Dr. Nolan Tzou, medical director of the Center for Pain Treatment at Huntington Hospital. "But, up until about five years ago, the public was undertreated for pain."

This particular procedure is a nerve block involving the delivery of a powerful anti-inflammatory agent directly into the membranes of the spine and the disk where the inflammation process begins.

"What we're doing is an X-ray guided injection technique. We put the medication right where the disk meets the nerve, within a millimeter of the pain generator," said Dr. Jason Lipetz, director of spine rehabilitation for the North Shore-Long Island Jewish Health System. Lipetz works out of the Center for Spine Rehabilitation in East Meadow.

Tzou and Lipetz both perform two types of blocks, one diagnostic, the other therapeutic. Some patients arrive having already undergone MRIs, CT scans and other electrodiagnostic studies. They have been prescreened by their primary care physician, and perhaps an orthopedist and a neurosurgeon. They may have undergone "every test known to mankind," said Tzou.

When the source of the pain is still unclear, a diagnostic block, which is an anesthetic agent such as Lidocaine or Bupivacaine, is injected into specific areas of the back to see where it provides relief. Once the source of pain is established, treatment begins.

The treatment block consists of a series of three injections of an anesthetic combined with a steroid such as Triamcinolone or Depo- Medrol. The steroid reduces local inflammation, stabilizes the neural membranes and lessens pain. The dosage is kept to a minimum to avoid the serious side effects commonly associated with steroids, such as elevated blood sugar, weight gain and swelling. According to the physicians, steroids given by directed injection are far less likely to result in adverse side effects than steroids taken orally.

have had multiple surgeries," said Lipetz. "The most challenging cases are those who have had surgery before."

Tzou and Lipetz have each administered the injections to hundreds of patients. Candidates for the procedure include young and old. The majority have suffered for years from disk degeneration resulting in leg and even arm pain. Some of the younger patients are athletes who are having back and neck pain as a result of injuries and herniated disks.

The success of each outcome depends upon the original diagnosis. But, according to Tzou, about two-thirds of his patients who get the injections see significant improvement. On a national average, reports cite a 50 percent success rate. If the pain returns, the procedure can be redone, but only after a six-month interlude and a thorough re-evaluation.

The injection takes about 15 minutes to administer and is usually given after the patient has had a local anesthetic. Most patients are in and out of an ambulatory setting in an hour. For some, relief comes within a day or so, for others it may take a few days to a week to see initial results. The series of three injections is usually spaced at two-week intervals.

"If a patient has a 100 percent result and their pain is gone after the first, we forgo further injections," said Tzou.

Such was the case of Mark Lubroth of Dix Hills, who has some arthritis of the spine and disk degeneration. In January he twisted his back and felt excruciating pain. "When I sat down, it took me 20 seconds to get up again. Then I started dragging my foot; my sciatic nerve was affected," said Lubroth.

His daughter, Ilene Schapero of Centerport, had gone to Tzou for relief of chronic leg and back pain caused by scar tissue left from tumor surgery nine years ago. While her experience with the injections has not been totally successful, she improved enough to recommend the procedure to her father.

"He gave me one shot and said, 'Wait 48 hours for something to happen,'" said Lubroth. "But 24 hours later there was great improvement. I'm 99 percent better and I'm amazed."

All patients who undergo the injections are advised that the treatment should be part of an overall back rehabilitation plan. Lubroth has been told to lose weight, strengthen his abdominal muscles and do a lot of walking. He just purchased a treadmill.

"The injections are a good one-, two-, three-punch. But they shouldn't be considered a quick fix. The patient has to combine them with spine-specific physical therapy," said Lipetz.

Not everyone is a candidate for the spinal injections. Steroids are very strong medication. According to Tzou, diabetics whose blood sugar level could be affected should not undergo the procedure. Also, patients with a bleeding abnormality or those taking blood thinners for unrelated ailments should not get the spinal injections. The procedure is more difficult when performed on patients with spinal abnormalities such as scoliosis (curvature of the spine), but with X-ray guidance of the needle, it is not impossible.

A small number of patients experience a headache after the procedure. This can range from mild to severe, and is treatable, Tzou said.

Adele Wolfson, who is Lipetz' patient, is now using an exercise bike and doing stretching exercises. Her three injections have lessened the extreme pain, numbness and burning sensation down her right leg caused by spinal stenosis.

"My condition will never go away. But we're controlling it. The vicious pain is gone," she said.