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Pain Management

Don’t let pain take over your life! There is a way to conquer it.

Everyday, millions of people suffer from pain and even the simplest activities can be a struggle for them. There are many different kinds of pain caused by injury, illness, disease or surgery. Chronic, persistent pain can have profound effects on a patient’s health and well-being and learning to live with it can be difficult. However, with proper medical evaluation, diagnosis and treatment, pain disorders can be improved and controlled effectively so patients can get back to the more important things in life. At Avosant Surgical Associates, we strive to help all of our patients feel pampered, function again, and truly enjoy life!

Advanced Pain Management Techniques to Improve Your Quality of Life The Pain Management Center at Avosant Surgical Associates offers the most advanced treatment options and proven techniques for the diagnosis and treatment of acute post-operative, chronic and cancer-related pain in both adults and children. By taking an integrated and rational approach to pain management, our highly skilled medical staff is committed to helping patients treat, relieve and manage their pain in order to enhance and restore their quality of life.

We can treat the following conditions:
  • Arthritic Pain
  • Cancer Pain
  • Chest Wall Pain
  • Chronic Abdominal Pain
  • Complex Regional Pain Syndrome (RSD)
  • Head, Neck and Shoulder Pain
  • Low Back Pain
  • Multiple Sclerosis Pain
  • Myofacial Pain
  • Nerve Root Damage Pain and Arachnoiditis
  • Pain of the Spine and Hip
  • Sciatic Nerve Pain
  • Peripheral Nerve Pain
  • Phantom Limb Pain
  • Post Surgical Pain
  • Shingles Pain
  • Shoulder and Arm Pain
  • Spasticity
  • Temporomandibular Joint Pain (TMJ)
  • Tic Douloureux and Facial Pain
  • Work Related Injuries

Head, Neck and Shoulder Pain

Because of the many joints, nerves, bones and muscles in the head, neck and shoulder area of the body, pain in this location can be described and classified in a variety of ways. Patients may experience pain in only one area or multiple areas at once. The many causes of pain may include the following:
  • Muscle Strain
  • Pinched Nerves
  • Bone or Joint Abnormalties
  • Poor Posture
  • Degenerative Diseases
  • Arthritis
  • Tendonitis
  • Tumors
  • Trauma such as Dislocations, Fractures and Slipped Discs
Head, neck and shoulder pain can be diagnosed using several techniques including X-rays, an MRI, CT scanning and electrodianbostic studies including electromyography (EMG) and nerve conduction velocity (NCV). The treatment of soft tissue neck, shoulder and head pain may include a variety of non-surgical procedures, such as epidurals and facet blocks, as well as anti-inflammatory medication, corticosteroid injections and if necessary, surgical procedures.

Low Back Pain

Low back pain is one of the most common medical problems affecting millions of Americans each year. There are many types of pain associated with this area. Two common types include mechanical pain, which originates from problems associated with muscles, joints, discs and ligaments, and nerve root pain, which may start in the lower back and travel down the sciatic nerve to cause additional discomfort in the leg and foot.

In many cases, pain in the low back cannot only cause a limited range of motion of the entire body but also a dull or sharp pain that may be localized in nature or referred from other parts of the body. It can even be the primary reason for other problems including certain medical illnesses, fever and headache, lost work days, depression and numerous visits to the physician’s office. In some cases, patients with chronic low back pain have other specific pain syndromes such as degenerative joint disease, arthritis and myofascial pain.

For the majority of back pain sufferers, the actual cause of their pain is sometimes difficult to diagnose as there may not be an obvious reason for their symptoms. There are many different structures of the back including the vertebrae, muscles, ligaments, facet joints and a rich nerve supply, that are sensitive to pain. Any injury, fracture or infection to them can cause chronic pain in the low back area that can spread to other parts of the body or be localized in nature.

Muscle and ligament sprains, inflammation and strains cause the majority of low back pain and muscle spasms. Damage, tears or ruptures to the discs in the lower back may also produce pain by causing a viscous substance to leak out and press against nerve roots. The result is sharp, stabbing pain or numbness in the area. In addition, the pain may travel all the way down to the leg along the sciatic nerve. Pain in the low back can also be a symptom of other health problems including diseases that affect the spine such as arthritis, tumors, Paget’s disease or osteoporosis. If left untreated, chronic low back pain can lead to unnecessary suffering and disrupt the patient’s life.

Our board-certified pain management specialists and experienced medical staff use a wide range of treatment options to successfully manage and reduce lower back pain. These treatments provide safe, effective and long-lasting relief for chronic back pain. In addition to a thorough physical examination, diagnostic, imaging and electrical studies such as CT scans, myelography, electromyography (EMG), fluoroscopy and MRI scans may be used to evaluate bones, muscles and nerves in the back as well as determine the origin of pain and identify specific conditions that may exist. Interventional therapy is one way to treat and alleviate persistent and chronic low back pain in patient. This includes non-surgical, invasive treatments such as epidural steroids, nerve blocks, joint or nerve injections, spinal cord stimulation and analgesic pump devices. Prescribed medication including non-steroidal anti-inflammatory drugs (NSAIDs) and opioids may also be used for low back pain relief.

Sciatic Nerve Pain

The sciatic nerve is formed by the bundle of nerve roots coming out of the lower back in the lumbar region. This main nerve branches out of the spine, extends through the buttocks and travels down the back of each leg to the foot. Sciatic nerve pain or discomfort, also known as Sciatica, originates when any of the nerve roots are damaged, inflamed or compressed.

A fairly common disorder, Sciatica has several root causes. The most prevalent cause is a herniated, slipped disc between the bones of the spine. Twisting, turning and bending movements, heavy lifting, poor posture and obesity can place strain and pressure on the disk causing it to become weak, bulge out or rupture and eventually push up against the nerve roots or the sciatic nerve. Other conditions such as inflammation of the Piriformis muscle, bone spur growth along the joints, arthritis, back strain, tumors and pinched nerves can also cause Sciatica. Symptoms of Sciatica may include numbness, tingling, dull pain or a sharp, burning sensation that radiates from the lower back and continues along the sciatic nerve’s entire length down the leg, ankle and foot. This pain may intensify during certain physicial activities such as lifting or bending.

To relieve sciatic nerve pain, it is common for patients to turn to a variety of treatments such as taking simple pain medications and anti-inflammatory drugs, applying heat to the affected area, or perfoming specific exercises. However, in the end, these treatments are limited in relieving the pain. Our board-certified pain specialists will perform a thorough examination to diagnose the cause of your sciatic nerve pain and administer non-invasive treatments, such as epidrual spinal injections, to relieve it. In some cases, surgery may be recommeneded but only if Sciatica lasts for an extended period of time or the the pain becomes too severe.

Shingles Pain

Shingles, also known as acute herpes zoster, is a viral infection of the nerve roots, specifically the dorsal root ganglia. Visually, shingles causes a skin rash that can develop on any part of the body, such as the stomach, back or face. This rash can appear as a strip or band spread along one side of the chest and wrapping around to the middle of the back. Shingles is most common in people with weak immune systems, which may develop as a result of stress, certain medications and injury or in older adults.

A shingles rash is often very painful and can be long-term. Though patients experience different degrees of pain, chronic shingles pain, medically known as postherpetic neuralgia (PHN), is often described as unbearable, throbbing, aching and burning. Intense itching and severe skin sensitivity may occur in the painful rash area and it is possible for the shingles rash to spread. Some patients may develop depression and anxiety due to the severe pain associated with shingles.

Several treatments to relieve the pain of shingles are available including nerve blocks, nerve root injections, epidural steroid injections and certain medications. These treatments can decrease the duration and intensity of pain. Because the effect of pain treatments vary from patient to patient, it is important to work with our board-certified pain physicians to develop a pain management plan that works specifically for you.

Work Related Injuries

Most work-related injuries involve the muscle, ligaments, nerves, joints and intervertebral discs. Some work injuries may heal quickly but others may re-occur or last for weeks, months or even years. Pain is often associated with a work injury and can prevent a patient from doing their job. Therefore, it is important to address any chronic pain in order to treat the condition and return patients to full work status.

Avosant Surgical Associates’ board-certified pain management physicians have extensive experience in diagnosing and treating the long-term and chronic pain associated with work-related injuries. We specialize in creating individualized pain treatment plans best suited for workers and their specific condition. In addition, our staff is highly experienced in California workman's compensation care and is dedicated to assisting our patients’ with all of their insurance and worker’s compensation needs.

Treatments for Managing Pain
Medication alone may not be enough to manage certain kinds of pain. Some medicines, when combined with other methods of treatment, such as physical therapy, chiropractic referral and alternative medicine, are also effective in treating pain. In some cases, the patient's pain condition may respond to other modalities instead of medication and over time, these treatments may even replace the need for taking any pain medication. Because there are many ways to treat and manage pain, Avosant’s Pain Management Center is dedicated in providing a comprehensive, detailed medical evaluation to ensure that each patient is prescribed an individually-tailored treatment plan that is best in treating their specific condition. Each patient is treated with utmost respect and confidentiality. During the initial pain consultation, time is taken to understand, analyze, and discuss the findings, possible options for treatment, all risks, complications, and alternative methods of management. No consultation is rushed and time is allowed to address all of the patient's concerns.

Treatment options and procedures include: Epidural Steroid Injections
An epidural steroid injection is an injection of corticosteroids and/or local anesthetics into the epidural space. Most of the body’s nerves, especially those associated with the arms and legs, pass through the epidural space, which is located in the spine just outside of the dural sac containing spinal fluid. This injection into the epidural space can provide pain relief by treating pain caused by the irritation of the spinal nerves, due to a herniated disc or arthritis, and thus, reducing the inflammation and pain of the nerve roots that exit the spine.

Utilizing fluoroscopy (x-ray imaging guidance), our Pain Specialist injects the steroid into the epidural space as the patient lies on his or her stomach. It takes approximately 15 minutes and most patients feel little pain during the treatment as the injection is performed under local anesthetic. The effect of the epidural steroid injection usually starts within a few days and can last up to several months.

Facet Injections

Located in the entire spine, cervical, thoracic, and lumbar regions, facet joints form the connections between each vertebra to support your back and the weight of your body. They extend from the neck to the low back region and enable the back and neck to bend, twist and turn. Problems with these small vertebral joints may cause chronic back or neck pain. A facet joint injection can help relieve and decrease this type of joint pain. With this procedure, the pain physician will inject local anesthetic and medication into the facet joints under fluoroscopy (x-ray imaging guidance).

Lumbar Sympathetic Blocks

Lumbar sympathetic blocks are injections of local anesthetic into the sympathetic nerves. This complex network of nerves extends the length of the spine and helps to control the involuntary (autonomic) nervous system and its functions such as sensation. Performed under fluoroscopy (x-ray imaging guidance) by Avosant’s board-certified Pain Management Physicians, this treatment blocks the sympathetic nerves from receiving pain triggers. It is frequently repeated to provide sufficient relief from pain. Lumbar sympathetic blocks are often used to treat painful neurological conditions such as Reflex Sympathetic Dystrophy (RSD) and Complex Regional Pain Syndrome (CRPS).

Medial Branch Blocks
Medial branch nerves are very small nerve branches that supply sensation to the small facet joints in the back. These branches of nerves also send messages to the brain to indicate that there is pain present in the cervical, thoracic or lumbar areas of the spine. This type of pain may be associated with problems stemming from ligament, arthritis or burse trauma as well as pain following spinal surgery which can cause irritation and inflammation of the supportive bones, muscles and joints of the spine.

A medial branch block can be used to help manage the pain. Performed with the assistance of fluoroscopy (a special x-ray machine), an Avosant Pain Specialist will inject a local anesthetic, such as lidocaine or novocaine, into the nerves to numb or “block” the pain messages moving from the joints to the brain. Additionally, a medial branch block can be used to assist in the diagnosis of a facet joint pain problem. This non-surgical, invasive procedure is performed to confirm facet joint disease and whether facet joints are the source of the patient’s pain. With a proper diagnosis, the physicians at Avosant’s Pain Management Center will be able to accurately control and relieve the pain by implementing a long-term treatment plan which may involve radiofrequency ablation of the medical branch nerves.

Nerve Root Injections

A nerve root injection is an injection of steroid and /or local anesthetic into the roots of the nerves that are located between the vertebrae. Utilizing the fluoroscopy (x-ray) guiding technique, this injection often targets one or more nerves that are associated with pain in the neck, arm, low back or leg.

Nerve root injections can be diagnostic and/or therapeutic. When performed for diagnostic purposes, this non-surgical, invasive procedure can help Avosant’s Pain Physicians determine the origin of a patient’s pain. Therapeutic nerve root injections are performed more frequently to provide long-term relief to chronic pain. Because the effects of pain management techniques can vary from patient to patient, one injection may be enough to provide sufficient relief. However, most patients require more than one injection if the pain persists or returns.

Occipital Nerve Blocks

An occipital nerve block is an injection of local anesthetic into the occipital nerves located on the back of the head at the base of the skull. The two main occipital nerves are on each side of the head. They emerge from the spine into the upper neck and through the muscles at the back of the head into the scalp. Their main purpose is to supply feeling, including pain, to the top and back of the head as well as to convey these sensations to the brain.

Inflammation and irritation of the occipital nerves as well as swelling of its tissue can be felt on one side at the back of the head and may cause painful headaches, and a variety of other pain that can be described as shooting, stinging or burning. The scalp may be tender indicating an inflamed occipital nerve.

Like many of the other nerves in the body, the occipital nerves can be numbed or “blocked” with a local anesthetic. This nerve block injection reduces the swelling and inflammation to relieve irritation and pain associated with the greater occipital nerves. However, these nerve blocks are considered to be a temporary relief of pain that can last up to a few months. If patients achieve good results with them, Avosant’s Pain Specialists may recommend more permanent pain-relieving procedures including radio-frequency energy treatments and stimulation or decompression of the nerve.

Spinal Cord Stimulation
Spinal cord stimulation is used to treat low back, leg, neck, arm pain and headaches as well as chronic pain associated with nerve damage and injuries. This treatment utilizes a spinal cord stimulator (SCS) which is an implantable medical device that delivers low voltage electrical stimulation to the spinal cord. One or two wires are carefully placed in the epidural space that is adjacent to the spinal cord and the SCS sends low energy currents to replace pain with a pleasant, tingling sensation called “parenthesis.”

The stimulator is permanently implanted under the skin and connected to a battery-operated Implantable Pulse Generator (IPG). The IPG is a signal generator that the patients are able to control and little care is required for the system. It does not make any noise, and because it is approximately the same size as a pacemaker battery, it does not show through clothing.

The spinal cord stimulator can benefit patients with certain kinds of chronic pain including:
  • Failed Back Surgery Syndrome
  • Arachnoiditis
  • Phantom Limb or Stump Pain
  • Neuropathic Pain
  • Complex Regional Pain Syndrome (CRPS)
  • Reflex Sympathetic Dystrophy (RSD)
  • Peripheral Neuropathy
  • Causalgia
  • Occipital Headaches
It is important to remember that the goal of this therapeutic approach is to reduce rather than eliminate pain. It is common for pain to be reduced by 50% or more. In addition, the spinal cord stimulator does not interfere with normal sensations, muscular ability or function. It can actually increase a patient’s activity level and quality of life while reducing the use of narcotic medications.

Trigger Point Injections

A trigger point, also known as a trigger site, is essentially an area of the body that is feeling increased muscle soreness or sensitivity. Medical researchers believe that trigger points are small contraction knots that cause pain, local tenderness, muscle spasms and/or a twitching response. These points can usually cause radiation of pain into other nearby areas. In many cases, a tight muscle band or hard nodule can be felt at the area of maximal tenderness.

A trigger point injection is an injection of anesthetic and steroid into localized areas of pain. Avosant’s Pain Medicine Specialists perform injections to provide immediate relief. Injections in the trigger points of the body are typically repeated until the patient obtains sufficient relief and they may help patients increase movement while healing the involved muscle.

Pain Management Insurance
Pain problems are commonly covered to varying degrees by medical insurance companies. Avosant’s experienced insurance specialists are dedicated in assisting our patients with the preparation of insurance forms, claims and payment issues in order to efficiently use the time to concentrate on caring for their medical needs. We provide them with advice while walking them through the step-by-step process in order to maximize the chances of their insurance company paying for the pain management procedure. In addition, Avosant Surgical Associates will also work with patients if their primary insurance is a managed-care Medicare plan. Our Insurance Specialists will help them to obtain a predetermination review for payment of any pain management procedures and/or treatments.

About Avosant’s Pain Management Specialist
Hussam Antoin, M.D., the Director of Pain Management Services at Avosant Surgical Associates, is a board certified Anesthesiologist and a fellowship-trained Pain Management physician. Following Residency at Boston University Medical Center, he completed a pain medicine fellowship at Dartmouth-Hitchcock Medical Center, one of the nation's renowned pain centers specializing in interventional pain management and highly specialized spinal injections. He has extensive training in treating spine injuries and pain, cancer pain, occipital headaches, musculoskeletal pain and Spacticity.

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