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On physical exam the patient has difficulty standing from a seated position and stands hunched
over. She has postural relief of her symptoms by leaning forward and her legs get tired and heavy
with walking. Strength 5/5 with decreased sensation in the left medial calf. She has trace ankle
and knee reflexes with downgoing toes.
Diagnosis: MRI shows severe Stenosis at levels L4-S1.
Plan: Transforaminal Epidural Steroid Injections for neuroforaminal Spinal Stenosis. Pain Medication
management consult with Nurse Practitioner to manage Pain Medications..
Results: Martha had 70% pain relief after her first Injection. Martha was asked to come back in
2 weeks for a 2nd Transforaminal Epidural Steroid Injection. If she experiences another positive
outcome the patient can call to schedule another appointment when pain returns. Patients can
have up to 3 injections in a six month period. If Martha continues to experience long term pain
then she will be referred to a Spine Surgeon for a surgical consult.
Spinal Stenosis
and Interventional Pain Management
Martha reports a long history
of low back and leg painwith
difficulty walking upright, especially during the
last several months. Pain extends from her low
back down through the posterior calves. She can
no longer tolerate prolonged walking or standing.
She reports pain 9/10. Martha is currently taking
Vicodin 5/500mg but does not get pain relief.
She has failed 6 physical therapy sessions.
4582 N 1st Ave, Suite 170
Tucson, AZ 85718-8607
Phone: (520) 318-6035
Fax: (520) 795-9953
www.pisapain.com
Hours: Monday- Friday
8:00 a.m. - 4:30 p.m.
A. Reid Bullock, MD, was trained in Canada and received his M.D. from the
University of Alberta Canada in 1977. He graduated in Family Medicine and
later with his family, immigrated to the United States. After 5 years of Family
Medicine and Obstetrics in Utah, he returned for a residency in Anesthesiology
at Mayo Clinic in Rochester Minnesota where he was trained in Anesthesia
and Pain Management. Upon graduation, Dr. Bullock and his family moved to
Tucson where he has been practicing Pain Management for 18 years. He is a
founding member of The Pain Institute of Southern Arizona and has a special
interest in Radiofrequency treatments for neck and back pain. He is board
certified in anesthesiology and pain management. Dr. Bullock was selected
one of the best doctors in America 2005-2006, 2007-2008 and 2009-2010.
Kenneth B. Gossler, M.D. is board certified in anesthesiology and
pain management. He received his medical degree with high honors from
the University of Arizona. He performed his anesthesiology residency at the
University of Arizona winning awards for research. Dr. Gossler then completed
a one year fellowship in interventional pain management at The Mayo Clinic.
He has been practicing pain management in Tucson, Arizona since 1997. He is
a founding member of The Pain Institute of Southern Arizona and has special
interest in interventional pain management for the treatment of spinal pain.
Dr. Bullock
Dr. Gossler
Pain Institute of Southern Arizona
“Giving patients Non-Surgical options
for Pain Management”
Pain relief is our specialty, and helping your patients resolve their pain issues is our main concern.
n	The Pain Institute of Southern Arizona is the only Interventional Pain Management center to
have two fluoroscopy suites in our clinic.
n	Patients pay only their office co-pay/deductible and not a large ASC or Hospital facility fee in
addition to the office co-pay. Patients easily save time and money at our clinic.
n	Pain Institute of Southern Arizona physicians are Mayo Clinic trained fellows in Anesthesia and
Pain Management. All physicians are Board Certified in Anesthesiology and Pain Management
with ABA sub-specialty certification trained to diagnose and treat very difficult pain problems.
n	Dr. Bullock was selected one of the Best Docs of America 2005-2006, 2007-2008. 2009-2010
Epidural Injections: Interlaminar epidural approach
is performed by placing an epidural needle between the
lumbar lamina. Used most often for central spinal stenosis
where bilateral symptoms result. This may present as back
pain or bilateral lower extremity pain. Disadvantage can be
layering dorsally of the medication in the epidural space
and inadequate coverage of lumbar disc protrusion. Higher
volume injections can promote spread to multiple stenotic
levels. Moderately challenging.
Transforaminal Epidural Steroid Injections:
Transforaminal epidural approach is performed largely
for unilateral radicular syndromes due to herniated disc.
Additional indications are neural impingement due to
neuroforaminal spinal stenosis or lateral recess stenosis.
It places the medicine in the ventral epidural space where
the herniations arise and traverses the neuroforamen where
nerve root swelling and inflammation occur. Technically
more challenging.
Caudal Steroid Injections: Caudal epidural is performed
by placing a needle in the caudal epidural space often
in association with a catheter to direct medications to
inflamed nerve roots. This is often the best approach in
patients who have undergone lumbar laminectomy with
persistent back or leg pain due to epidural scarring. As a
modification to this technique, hypertonic saline can be
injected with catheter dissection of epidural scar tissue
known as caudal epidural neurolysis. This is a more
effective technique in patients with pain resistant to other
minimally invasive treatments.
Facet Joint Injections: Facet joints are a frequent cause
of chronic low back and neck pain. Diagnostic facet joint
injections are used in the cervical and lumbar spine to
identify the specific joint causing the pain prior to a facet
denervation procedure. Therapeutic facet steroid injections
can be effective for facet mediated of short duration or due
to trauma. Facet steroid injections can provide pain relief
for a few weeks to help patients tolerate physical therapy
and prescribed exercise programs. Patients who obtain
dramatic but short term relief with diagnostic or therapeutic
facet injections are candidates for radiofrequency
neurotomy to provide long term pain relief.
Radiofrequency Neurotomy: A minimally invasive
procedure that disables small sensory nerves. The radio-
frequency generator produces a localized heat lesion to
either destroy the nerve, while leaving the surrounding region
and larger nerves unaffected. Overall, 70-80% of patients
report satisfaction with the procedure. The nerves do have
the capacity to grow back in time. Patients may require
repeat lesioning as early as 6 months, usually not for 1-2
years. There are many causes for pain, and this procedure
is used mainly to treat the facet joints.
Spinal Cord Stimulation: Involves the placement of
stimulating electrodes in the epidural space. Initially the
patient has temporary electrodes placed percutaneously
for a three to five day trial period. If the patient experiences
substantial relief then they have the leads surgically
implanted via a small laminotomy by a spine surgeon.
SCS is most commonly used for patients with persistent
or recurring leg pain after lumbar laminectomy but can be
effective for neuropathic pain of the trunk or limbs.
For back pain sufferers, the Pain Institute of Southern Arizona offers interventional pain management
techniques that can be particularly useful. In addition to a thorough medical history and physical examination,
our interventional pain management physicians have a wide array of treatments that can be used:
Spinal
Stenosis
Tranforaminal
Epidural
Injections
Negative Pain
Outcome
Refer for
Surgery Options
Refer for
Surgery Options
Refer for
Surgery Options
Negative Pain
Outcome
Negative Pain
Outcome
Positive Pain
Relief
Positive Pain
Relief
Positive Pain
Relief
Caudal Steriod
Injections
Epidural Steriod
Injections
Results of randomized trials of effectiveness of lumbar transforaminal epidural injections.
Results of effectiveness of Cauldal Epidural Injections in managing Spinal Stenosis
RA = randomized; DB = double blind; P = prospective; C = control; T = treatment; PG = pre-ganglionic; G = ganglionic; SICH = significant improvement in contained disc herniation;
NSI = no significant improvement; vs. = versus; NA = not available; P = positive; N = negative.
Adapted from Buenaventura RM et al. Systematic review of therapeutic lumbar transforaminal epidural steroid injections. Pain Physician 2009; 12:233-251 (37).
*Indicates use of fluoroscopy
RA = randomized; DB = double blind; NA = not available; SI = significant improvement; vs = versus; P = positive; N = negative
Adapted and modified from Conn A et al. Systematic review of caudal epidural injections in the management of chronic low back pain. Pain Physician 2009; 12:109-135 (34).
	 Study	 Study	 Methodological	 Participants				 Short-term	 Long-term
		 Characteristics	 Quality Scoring		 3 months	 6 months	 12 months	 relief ≤ 6 	 relief  6
								 months	 months
	 Study	 Study	 Methodological	 Participants				 Short-term	 Long-term
		 Characteristics	 Quality Scoring		 3 months	 6 months	 12 months	 relief ≤ 6 	 relief  6
								 months	 months
	 Pain Relief	 Results
	 Pain Relief	 Results
Manchikanti et al 2008		
(254)*	
RA, DB	 70	 40	 50% - 65%	 60% - 65%	 55% - 65%	 P	 P
Ciocon et al 1994						
(255)	
O	 57
	
30
	
SI	SI	NA	 P	NA
Botwin et al 2007						
(258)*	
O	 61	 34	 65%	 62%	 54%	 P	 P
Karppinen et al 2001			 C = 80
(855,856)	
RA, DB	 81
	T = 80	
SICH	NSI	NSI	 P	N
Riew et al 2000/2006						 33% vs. 71%
(857,858) 	
P, RA, DB	 68	 55	NA	NA
	 (avoided surgery)	
P	 P
Jeong et al 2007				 PG 99 of 112	 PG 64 of 106
(854)	
RA, DB	 63	 239
	 G 90 of 127	 G 78 of 116	
NA	 P	NA
Vad et al 2002
(859) 	
RA	 58	 48	NA	NA	 48% vs. 84%	 P	 P

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PISA_SpinalStenosisPainMgmnt_042611[1]

  • 1. On physical exam the patient has difficulty standing from a seated position and stands hunched over. She has postural relief of her symptoms by leaning forward and her legs get tired and heavy with walking. Strength 5/5 with decreased sensation in the left medial calf. She has trace ankle and knee reflexes with downgoing toes. Diagnosis: MRI shows severe Stenosis at levels L4-S1. Plan: Transforaminal Epidural Steroid Injections for neuroforaminal Spinal Stenosis. Pain Medication management consult with Nurse Practitioner to manage Pain Medications.. Results: Martha had 70% pain relief after her first Injection. Martha was asked to come back in 2 weeks for a 2nd Transforaminal Epidural Steroid Injection. If she experiences another positive outcome the patient can call to schedule another appointment when pain returns. Patients can have up to 3 injections in a six month period. If Martha continues to experience long term pain then she will be referred to a Spine Surgeon for a surgical consult. Spinal Stenosis and Interventional Pain Management Martha reports a long history of low back and leg painwith difficulty walking upright, especially during the last several months. Pain extends from her low back down through the posterior calves. She can no longer tolerate prolonged walking or standing. She reports pain 9/10. Martha is currently taking Vicodin 5/500mg but does not get pain relief. She has failed 6 physical therapy sessions. 4582 N 1st Ave, Suite 170 Tucson, AZ 85718-8607 Phone: (520) 318-6035 Fax: (520) 795-9953 www.pisapain.com Hours: Monday- Friday 8:00 a.m. - 4:30 p.m. A. Reid Bullock, MD, was trained in Canada and received his M.D. from the University of Alberta Canada in 1977. He graduated in Family Medicine and later with his family, immigrated to the United States. After 5 years of Family Medicine and Obstetrics in Utah, he returned for a residency in Anesthesiology at Mayo Clinic in Rochester Minnesota where he was trained in Anesthesia and Pain Management. Upon graduation, Dr. Bullock and his family moved to Tucson where he has been practicing Pain Management for 18 years. He is a founding member of The Pain Institute of Southern Arizona and has a special interest in Radiofrequency treatments for neck and back pain. He is board certified in anesthesiology and pain management. Dr. Bullock was selected one of the best doctors in America 2005-2006, 2007-2008 and 2009-2010. Kenneth B. Gossler, M.D. is board certified in anesthesiology and pain management. He received his medical degree with high honors from the University of Arizona. He performed his anesthesiology residency at the University of Arizona winning awards for research. Dr. Gossler then completed a one year fellowship in interventional pain management at The Mayo Clinic. He has been practicing pain management in Tucson, Arizona since 1997. He is a founding member of The Pain Institute of Southern Arizona and has special interest in interventional pain management for the treatment of spinal pain. Dr. Bullock Dr. Gossler
  • 2. Pain Institute of Southern Arizona “Giving patients Non-Surgical options for Pain Management” Pain relief is our specialty, and helping your patients resolve their pain issues is our main concern. n The Pain Institute of Southern Arizona is the only Interventional Pain Management center to have two fluoroscopy suites in our clinic. n Patients pay only their office co-pay/deductible and not a large ASC or Hospital facility fee in addition to the office co-pay. Patients easily save time and money at our clinic. n Pain Institute of Southern Arizona physicians are Mayo Clinic trained fellows in Anesthesia and Pain Management. All physicians are Board Certified in Anesthesiology and Pain Management with ABA sub-specialty certification trained to diagnose and treat very difficult pain problems. n Dr. Bullock was selected one of the Best Docs of America 2005-2006, 2007-2008. 2009-2010 Epidural Injections: Interlaminar epidural approach is performed by placing an epidural needle between the lumbar lamina. Used most often for central spinal stenosis where bilateral symptoms result. This may present as back pain or bilateral lower extremity pain. Disadvantage can be layering dorsally of the medication in the epidural space and inadequate coverage of lumbar disc protrusion. Higher volume injections can promote spread to multiple stenotic levels. Moderately challenging. Transforaminal Epidural Steroid Injections: Transforaminal epidural approach is performed largely for unilateral radicular syndromes due to herniated disc. Additional indications are neural impingement due to neuroforaminal spinal stenosis or lateral recess stenosis. It places the medicine in the ventral epidural space where the herniations arise and traverses the neuroforamen where nerve root swelling and inflammation occur. Technically more challenging. Caudal Steroid Injections: Caudal epidural is performed by placing a needle in the caudal epidural space often in association with a catheter to direct medications to inflamed nerve roots. This is often the best approach in patients who have undergone lumbar laminectomy with persistent back or leg pain due to epidural scarring. As a modification to this technique, hypertonic saline can be injected with catheter dissection of epidural scar tissue known as caudal epidural neurolysis. This is a more effective technique in patients with pain resistant to other minimally invasive treatments. Facet Joint Injections: Facet joints are a frequent cause of chronic low back and neck pain. Diagnostic facet joint injections are used in the cervical and lumbar spine to identify the specific joint causing the pain prior to a facet denervation procedure. Therapeutic facet steroid injections can be effective for facet mediated of short duration or due to trauma. Facet steroid injections can provide pain relief for a few weeks to help patients tolerate physical therapy and prescribed exercise programs. Patients who obtain dramatic but short term relief with diagnostic or therapeutic facet injections are candidates for radiofrequency neurotomy to provide long term pain relief. Radiofrequency Neurotomy: A minimally invasive procedure that disables small sensory nerves. The radio- frequency generator produces a localized heat lesion to either destroy the nerve, while leaving the surrounding region and larger nerves unaffected. Overall, 70-80% of patients report satisfaction with the procedure. The nerves do have the capacity to grow back in time. Patients may require repeat lesioning as early as 6 months, usually not for 1-2 years. There are many causes for pain, and this procedure is used mainly to treat the facet joints. Spinal Cord Stimulation: Involves the placement of stimulating electrodes in the epidural space. Initially the patient has temporary electrodes placed percutaneously for a three to five day trial period. If the patient experiences substantial relief then they have the leads surgically implanted via a small laminotomy by a spine surgeon. SCS is most commonly used for patients with persistent or recurring leg pain after lumbar laminectomy but can be effective for neuropathic pain of the trunk or limbs. For back pain sufferers, the Pain Institute of Southern Arizona offers interventional pain management techniques that can be particularly useful. In addition to a thorough medical history and physical examination, our interventional pain management physicians have a wide array of treatments that can be used: Spinal Stenosis Tranforaminal Epidural Injections Negative Pain Outcome Refer for Surgery Options Refer for Surgery Options Refer for Surgery Options Negative Pain Outcome Negative Pain Outcome Positive Pain Relief Positive Pain Relief Positive Pain Relief Caudal Steriod Injections Epidural Steriod Injections Results of randomized trials of effectiveness of lumbar transforaminal epidural injections. Results of effectiveness of Cauldal Epidural Injections in managing Spinal Stenosis RA = randomized; DB = double blind; P = prospective; C = control; T = treatment; PG = pre-ganglionic; G = ganglionic; SICH = significant improvement in contained disc herniation; NSI = no significant improvement; vs. = versus; NA = not available; P = positive; N = negative. Adapted from Buenaventura RM et al. Systematic review of therapeutic lumbar transforaminal epidural steroid injections. Pain Physician 2009; 12:233-251 (37). *Indicates use of fluoroscopy RA = randomized; DB = double blind; NA = not available; SI = significant improvement; vs = versus; P = positive; N = negative Adapted and modified from Conn A et al. Systematic review of caudal epidural injections in the management of chronic low back pain. Pain Physician 2009; 12:109-135 (34). Study Study Methodological Participants Short-term Long-term Characteristics Quality Scoring 3 months 6 months 12 months relief ≤ 6 relief 6 months months Study Study Methodological Participants Short-term Long-term Characteristics Quality Scoring 3 months 6 months 12 months relief ≤ 6 relief 6 months months Pain Relief Results Pain Relief Results Manchikanti et al 2008 (254)* RA, DB 70 40 50% - 65% 60% - 65% 55% - 65% P P Ciocon et al 1994 (255) O 57 30 SI SI NA P NA Botwin et al 2007 (258)* O 61 34 65% 62% 54% P P Karppinen et al 2001 C = 80 (855,856) RA, DB 81 T = 80 SICH NSI NSI P N Riew et al 2000/2006 33% vs. 71% (857,858) P, RA, DB 68 55 NA NA (avoided surgery) P P Jeong et al 2007 PG 99 of 112 PG 64 of 106 (854) RA, DB 63 239 G 90 of 127 G 78 of 116 NA P NA Vad et al 2002 (859) RA 58 48 NA NA 48% vs. 84% P P