Pain Treatments & Procedures

General information about the injection procedures

Dr Nikolic will go through the relevant details about the specific intervention that you require during the outpatient consultation. He will discuss this further prior to your signing the consent form on the day of the procedure.

Dr Nikolic will inform you about both the benefits and the risks of the particular procedure well in advance. You will have a chance to ask any questions about the procedure during the consultation and also before the actual procedure. You can also contact Dr Nikolic at any point should you have any additional queries.

The procedure is done in an operating theatre at the chosen hospital.

The procedure is a Day Case procedure. You will be admitted on the day of the procedure (usually two hours before your allocated procedure time) and will be discharged home on the same day. It is important that you have an escort (a responsible adult) who will accompany you back home. This ensures your safety and is in accordance with the nationally accepted standards of clinical care.

Most procedures are done under X-ray guidance and Intravenous sedation.

Dr Nikolic will send you an information leaflet that addresses various important issues about the procedure itself and the associated risks as well as some guidelines as to what to expect and or do after the procedure.

Dr Nikolic’s secretary will contact you the next working day after the procedure to arrange a follow up appointment. This will take place a minimum of two weeks after the procedure. Should you have any concerns while you are waiting for the follow up, please feel free to contact Dr Nikolic.

General information about the Spinal Cord Stimulation (Neuromodulation) procedure

Dr Nikolic will go through the relevant details well in advance of the actual date of the procedure. This procedure is usually done in two stages: The trial stage and the second stage.

You will receive additional detailed information about the procedure in writing well in advance.

You will have numerous opportunities to discuss any questions or concerns about the procedure.

Both the trial and the second stage procedures are done in an operating theatre at a chosen hospital.

Both stages are usually a Day Case procedure. You will be admitted on the same day (usually two hours before the allocated time) and will be discharged home on the same day. Occasionally, if the procedure finishes late in the day, you may need to be admitted for an overnight stay in the hospital and will then be discharged home the following morning. It is essential that a responsible adult accompanies you back home when ready to be discharged from the hospital. This ensures your safety and is in accordance with the nationally accepted standards of clinical care.

The procedure is done under X-ray guidance and General Anaesthesia. You will meet your anaesthetist prior to the procedure.

You will also meet a company representative (depending on the device used) before the procedure and again once you are back on the ward after the procedure. The company representative will activate the implanted system and give you detailed information about it and how to use it.

Dr Nikolic’s secretary will contact you the following day to arrange a follow up.

Dr Nikolic’s secretary and the company representative will be contacting you regularly during the spinal cord stimulation trial to assess your progress.

Should you have any concerns, please feel free to contact Dr Nikolic.

Facet joint injections and facet joint medial branch blocks

A facet joint injection is an injection around or into the facet joint. A medial branch block is an injection around a small nerve to the facet joint.

Facet joints are small joints that stabilise the spine and allow movement. It is not uncommon that wear and tear, inflammation and irritation around these joints results in ongoing spinal pain that is in some cases resistant to conservative treatment (physiotherapy and ordinary painkillers).

Facet joint injections are likely to reduce the inflammation and irritation within the joints.

The aim is to improve the pain, break the pain cycle and facilitate further rehabilitation and recovery.

A medial branch block gives us valuable information about whether your pain is likely to stem from these joints.

Usually, more than one joint is injected and this depends on your clinical presentation, examination and scan results. Dr Nikolic will be discussing this with you in detail prior to the procedure.

The substance that is injected is a mixture of a small amount of steroid and local anaesthetic. Dr Nikolic will discuss this with you prior to the procedure.

You will have a chance to discuss any queries you may have with Dr Nikolic in advance of the procedure.

Facet joint radiofrequency treatment (Rhizolysis, Lesioning, Denervation)

This procedure is usually considered for patients who have had benefit from facet joint injections/medial branch blocks but found that the effect was short-lived.

This procedure is likely to significantly prolong the duration of the beneficial effect of the injections. It is also likely to break the pain cycle and facilitate further rehabilitation and recovery.

An electromagnetic (radiofrequency) current is applied to the needles and which raises the temperature locally at the tip of the needle. The needle tips are positioned closely to the irritated nerves around the facet joints. This raised temperature disrupts and stuns the nerves and renders them inactive. A small amount of steroid and local anaesthetic is injected through the same needle at the end of the procedure. The beneficial effect usually lasts for a long time.

Dr Nikolic will discuss all relevant details about this procedure well in advance and you will have a chance to discuss any questions prior to your hospital appointment.

Transforaminal injection/Dorsal root ganglion block

These injections are designed for patients who have either radicular pain (sciatica or arm pain) or whose pain is likely to stem from wear and tear in the discs.

The dorsal root is a small swelling within the nerve before it joins the spine. These nerves and roots carry sensory information and pain signals to the spine. The roots are located in small bony openings on each side of the spine called intravertebral foramina. As these foramina are connected to the epidural space, these injections are also called transforaminal epidural injections.

The needles are placed within the foramina and the substance injected is usually a mixture of a steroid and a local anaesthetic.

This is likely to reduce inflammation, irritation and hypersensitivity of these nerves and in doing so, break the pain cycle and facilitate rehabilitation and recovery.

Dr Nikolic will be discussing all relevant details about this procedure in advance of your hospital appointment and you will have a chance to discuss any questions about the procedure beforehand.

Pulsed radiofrequency treatment to the dorsal roots

This procedure is designed for patients who have had benefit from dorsal root injections/transforaminal epidural injections but the beneficial effect was short-lived.

The special needles are placed generally in the same area as the needles used for the dorsal root/transforaminal injections.

In addition to the small amount of a steroid and local anaesthetic, through the needle a radiofrequency current is passed in short bursts. There is no significant increase in temperature and there is no structural damage to the nerves.

This treatment is likely to significantly prolong the duration of the beneficial effect of the injections.

This is likely to break the pain cycle and facilitate rehabilitation and recovery.

Dr Nikolic will be discussing this in detail prior to the procedure date and you will have a chance to discuss any questions you may have beforehand.

Epidural steroid injections (caudal injection, lumbar epidural injection, thoracic epidural injection, cervical epidural injection)

The epidural space is a small space that surrounds the spine and the spinal nerves. It can be used to treat radicular pain (sciatica or arm or any other radicular pain) and is sometimes used to treat pain that is likely to stem from the discs.

It can be accessed by a needle at different spinal levels depending on a patient’s symptoms. The common entry points are caudal (space just above the tailbone), lower back, thoracic or the neck.

The drug that is injected is usually a steroid mixed with a local anaesthetic and or saline. This drug then bathes the irritated nerves and/or the discs, and reduces inflammation and irritation.

This is likely to break the pain cycle and facilitate rehabilitation and aid overall recovery although the effect in some cases may wear off.

Dr Nikolic will be discussing all relevant details about the procedure in advance of your appointment and you will have a chance to discuss any questions you may have beforehand.

Sympathetic blocks (lumbar sympathetic block, stellate block, splanchnic nerve block, hypogastric blocks)

Sympathetic nerves are sometimes involved in pain generation and transmission. In some cases, these nerves are quite hyperactive and hypersensitive, which significantly contributes to overall pain.

Sympathetic nerves may be involved in pain affecting any area of the body. Common problems are leg and arm pain, abdominal and pelvic pain and complex regional pain syndromes.

The needles are placed around the specific area of these nerve clusters (commonly cervical/stellate or lumbar).

Usually a local anaesthetic is injected, occasionally with a small amount of steroid. Sometimes other substances are injected.

Sometimes, pulsed radiofrequency treatment is used in patients who have had some benefit from the sympathetic blocks but the beneficial effect was short-lived. Should that be required, special needles are placed in the same area as the needles used for the injections and the radiofrequency current is passed down the needles in short bursts.

The above procedure is likely to improve pain and facilitate rehabilitation and recovery. However, the effect may be temporary.

Dr Nikolic will discuss all relevant details about this procedure well in advance and you will have a chance to discuss any questions you may have beforehand.

Peripheral nerve injections

• Occipital nerve block
• Suprascapular nerve block
• Ulnar/medial/radial nerve block
• Epicondyle blocks (tennis and golfer’s elbow pain)
• Paravertebral and intercostal nerve block
• Ilioinguinal and genitofemoral nerve block
• Blocks to the neural supply of the hips
• Pudendal nerve block
• Lateral cutaneous nerve block
• Genicular (knee) nerve block
• Ankle nerve block
• Infiltration of the plantar fascia

These injections are used to improve pain that stems from the irritation and hyperactivity of a specific nerve.

The needles are placed around the particular nerve, sometimes under ultrasound guidance, and a small amount of a steroid and local anaesthetic is injected.

This is likely to reduce the inflammation and irritation, break the pain cycle and facilitate rehabilitation.

Sometimes, pulsed radiofrequency treatment is used in patients who have had some benefit from the nerve blocks but the duration of the beneficial effect was short-lived.

Special needles are placed in the same area and in addition to a steroid and local anaesthetic, radiofrequency current is delivered down the needle in short bursts. This is likely to prolong the beneficial pain relief effect.

Dr Nikolic will discuss all relevant details about the procedure in advance of your appointment and you will have a chance to ask any questions you may have before the procedure.

Trigger point injections and Botox injections

A trigger point is a small area within a muscle that remains in permanent spasm and thus contributes to pain felt over certain muscle groups. Common areas affected are the neck and shoulders as well as the lumbar area. These points are usually sensitive to touch.

Small needles are placed within each muscle trigger point and a small amount of a steroid and local anaesthetic is injected.

This is likely to reduce the muscle spasm, break the pain cycle and facilitate rehabilitation.

If the effect of these injections is short-lived, Botox injections may be considered.
A very small amount of Botox diluted in normal saline is injected to trigger points. This is likely to significantly prolong the beneficial effect of trigger point injections with steroid and local anaesthetic.

It is important that this period when the muscle spasm and pain is reduced is used to optimise muscle function usually through further physiotherapy.

Dr Nikolic will be discussing the relevant details about the procedure in advance of your appointment and you will have a chance to ask any questions beforehand.

Neuromodulation/Spinal cord stimulation

Spinal cord stimulation works by delivering a small amount of electromagnetic energy to specific areas of the spine.

This selectively modifies and significantly reduces chronic pain signal trafficking across the spine and in doing so, significantly improves pain long term.

For the majority of those patients for whom this procedure is suitable, this leads to improvement in day-to-day function and quality of life. It may also improve sleep patterns and facilitate weaning off from any painkillers patients would normally need to take to manage their pain.

This procedure is done in 2 stages. Stage 1 is called the trial. You are put off to sleep under general anaesthetic and two needles are placed in your back (not into the spine) and through the needles two fine leads (wires) are threaded in. The leads do not go into the spine but come close to it. There is a small cut (midline on your back) and another small cut just below the waist line (upper buttock). There are two dressings put on at the end, one above the midline cut and a larger one over the buttock. There is normally one cable that comes out of the buttock dressing and this is connected to a device that you need to wear on a belt for the duration of the trial (usually one to two weeks).

The company representative will activate and “programme” the device once you are fully awake after the procedure and will give you full instructions on how to use it.

Dr Nikolic and the company representative will be in touch regularly during the trial to assess your progress and the pain relief gained.

On average, 80% of suitable patients are likely to have a positive trial and proceed to implantation.

The second stage is also done under general anaesthetic. If the trial is negative (no significant pain relief), the wires are removed and the skin sutured. You will be seen in the clinic two weeks later so that the dressing can be removed and also to discuss further management.

If the trial is positive (>50% improvement in your pain), then once you are anaesthetised, the external leads are removed and the internal leads are connected to a small device the size of a pacemaker which is implanted under the skin in the buttock area. The company representative will activate the system and programme it once you are fully awake and back on the ward. Dr Nikolic’s secretary will contact you the following day to arrange a follow up appointment, usually two weeks after the second stage, so that the dressings can be removed.

Dr Nikolic will discuss this with you in detail well in advance of the procedure and you will have many opportunities to discuss all aspects of this procedure beforehand.

Intravenous Lignocaine infusion

Intravenous Lignocaine infusion is used to reduce the widespread myofascial pain commonly associated with Fibromyalgia. It is also sometimes used to treat widespread neuropathic pain.

A predetermined amount of local anaesthetic called Lignocaine (Lidocaine) is diluted in normal saline and this is given into the patient’s vein over a period of one hour.

This is normally done in the theatre recovery area with full monitoring of blood pressure, pulse and the heart (ECG).

This sometimes improves the pain and facilitates rehabilitation. Sometimes, the infusion needs to be repeated.

Dr Nikolic will be discussing this procedure in detail prior to your appointment time and you will have a chance to ask any questions you may have beforehand.