Physiatry

What is physiatry?

Introduction

Physiatry – also called physical medicine and rehabilitation – is a branch of medicine that specializes in diagnosis, treatment and management of various neurological and musculoskeletal injuries. Physiatrists specialize in a wide variety of conservative (non-surgical) treatments for sports injuries and spine related problems.

The specialty of physiatry is approximately 50 years old. Today, there are over 6,000 physicians practicing physical medicine and rehabilitation. Because the back is the locus of most of our musculoskeletal system, most physiatrists are specialists in treating back pain.

At Orthopaedic Specialists of the Carolinas, the physiatrists that perform various spinal injections and procedures are board certified and fellowship trained, including David O'Brien Jr., MD and Benjamin Chasnis DO.  They have served as instructors for various spinal injection courses around the country.  Dr. David O'Brien Jr., who is the director of physiatry, started the first interventional physiatry spine fellowship in North Carolina, which is recognized by the Physiatric Association of Spine, Sports and Occupational Rehabilitation.  He serves as an adjunct associate professor at the University of North Carolina and has been a course director for a number of spine-related injection courses nationally with participants throughout the United States and other countries.  Dr. O'Brien is active in the North American Spine Society and has been named co-chair for their annual convention in 2009.  He serves as an associate editor for The Spine Journal and is an editorial reviewer for the new PM&R Journal.

Using injections for back pain relief

Spinal injections are relatively conservative procedures used in the diagnosis and treatment for low back pain and radicular (leg) pain.  They are often used in conjunction with oral medicines and physical therapy, especially if the back or radicular pain is severe.  They are often recommended prior to considering surgery.  In a majority of cases, surgery can be avoided with the use of spinal injections along with physical therapy and oral medications.

 At Orthopaedic Specialists of the Carolinas, the spinal injections are performed using fluoroscopic guidance (live x-ray).  This not only increases patient safety but allows the physician to use very small gauge needles, making the procedures much more comfortable for the patients. 

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 an anesthetic (numbing medication) is used, and the patient feels 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. Some injection procedures, such as discography or nerve blocks are helpful and used in planning where the surgeon should operate, if that is a consideration.

Different kinds of injections for pain relief

Epidural steroid injections

Epidural injections are used to treat radicular pain caused by nerve irritation. This type of pain is usually caused by herniated disc or spinal stenosis. A herniated disc occurs when pressure or degeneration produces a tear in the disc's outer ring (the annulus), and some of the nucleus ruptures (squirts) into the spinal canal. The bulging disc can protrude into the spinal canal, placing pressure or causing a chemical inflammation of the spinal nerve roots. Spinal stenosis is a narrowing of the spinal canal that can cause pressure on the spinal cord and spinal nerves.  It may be necessary to have more than one epidural injection over a period of a few weeks or months to see a full benefit. It is not uncommon to have up to three lumbar epidural injections, for a specific episode of back and radicular pain, although the average patient usually requires only 1-2 epidurals to quite down their radicular pain.

Facet Joint Injections and facet nerve blocks

Twisting injuries can cause damage to one or both facet joints, and cartilage degeneration associated with aging may also cause pain.  Facet joint injections and nerve blocks are helpful in the evaluation and treatment of low back pain due to arthritis of the spinal facet joints. The medication is injected into and/or around the joint to reduce the inflammation in the joint. Diagnostically, the injections are sometimes aimed at the small nerves that supply the joints to see how much relief you may get.  Facet blocks 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.

Selective nerve root block (SNRB)

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.  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).

Hip joint injections for pain relief

The hip joint is a large joint where the leg joins the pelvis. If this joint experiences arthritis, injury or mechanical stress, one may experience hip, buttock, leg or low back pain. A hip joint injection may be considered for patients with these symptoms. The injection can help relieve the pain, as well as help diagnose the direct cause of pain.

Hip joint arthrograms are injections involve injecting medicine directly into the joint under fluoroscopic guidance. These injections can help diagnose the source of pain, as well as alleviate the discomfort:

• Diagnostic function: By placing numbing medicine into the joint, the amount of immediate pain relief experienced will help confirm or deny the joint as a source of pain. If complete pain relief is achieved while the hip joint is numb it means this joint is likely to be the source of pain.
• Pain relief function: Along with the numbing medication, time-release cortisone is also injected into these joints to reduce inflammation, which can often provide long-term pain relief.