Information on Specific Procedures

Epidural Injections

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What is an Epidural Steroid Injection?

Epidural steroid injection is a term applying to a variety of techniques performed to deliver corticosteroid medication around a nerve coming out from the spinal cord in an epidural space. This epidural space is the space between the dural sac – which surrounds the spinal cord and exiting spinal nerves – and the boney spinal column. This is the space into which disc material can potentially herniate ( just out unnaturally) and cause pressure and inflammation around spinal nerves. Corticosteroids are medications that have strong anti-inflammatory properties, and spinal injections of the corticosteroids significantly reduce inflammation around an irritated nerve that is causing pain and discomfort.

Who can benefit from an epidural steroid injection?

Patients with several common conditions – including a lumbar disc herniation, degenerative disc disease, and lumbar spinal stenosis – may benefit from an epidural injection. For these and other conditions that can cause acute or chronic pain, an epidural steroid injection may be an effective non-surgical treatment option.

Who performs these injections?

These injections are performed by specialty-trained physicians. Board certified radiologists are physicians with specific training in performing these procedures and in the safe and efficient utilization of the imaging equipment. Fluoroscopic or CT guidance is used to avoid or minimize the possibility of this complication.

What should I do to prepare for the procedure?

Wear loose, comfortable clothing. You may want to have someone accompany you to the appointment to make sure you get home safely. Stop taking the following blood thinners before the procedure:

ANTICOAGULATION GUIDELINES:

  • Coumadin (Warfain) – stop intake 4-5 days prior to procedure and PT/INR must be measured within 24 hours prior to the procedure.
  • Plavix (Clopidrogel) – stop intake 7 days prior to procedure.
  • Ticlid (Ticlopindine) – stop intake 14 days prior to procedure.
  • LMWH (Low Molecular Weight Heparin ) Lovenox:
    • Patients on 30-40mgs stop intake 10-12 hours before procedure.
    • Patients on higher than 40mgs stop intake 24 hours before procedure.
    • Patients on medication for high blood pressure and/or heart disease should continue their medication as usual
  • NSAIDS (including ASA) – do not need to be stopped.

Is any anesthesia used for the procedure? Will there be any pain?

Typically a local anesthetic is injected into the skin, numbing the area where the epidural needle is placed. Patients may experience a mild discomfort but not severe pain.

What is the recovery period like?

If you experience a loss of sensation or muscle strength at the end of the procedure, you will be observed at the hospital until the anesthesia sufficiently wears off and are able to get around safely. There may be some soreness at the injection site and usually last for just a few hours but may last as long as a few days. Exercise restrictions: Dr. Metzl advises you to lay low for a couple of days and start moving comfortably when you feel able. You should be back to regular activity about 1 week after the injection, but it does differ patient to patient.

Address and phone number:

These procedure are done at the main hospital, Hospital for Special Surgery

535 East 70th Street, 3rd Floor Interventinal Radiology

New York, NY 10021 (right off York Avenue)

Ph: 212-774-2052

M.E.L.T.: Myofascial Elongation and Lengthening Technique

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What is MELT?

The M.E.L.T. Method® is a self-treatment technique that simulates the techniques – and the results- of manual therapy. The M.E.L.T. Foot Treatment is a systematic approach to releasing myofascial trigger points and restoring the integrity of the tissue in the feet. This system is easy to learn and requires a small investment of your time each day. Typical results include relief from foot pain and improvement in mobility.

Cost/Insurance?

MELT is not covered by insurance. The cost for the session is $90 ($40 for the instruction and $50 for the MELT kit which includes 2 sets of the specialized MELT balls, written instructions, a DVD, and a carrying case.)

Duration:

It takes about 30 minutes to learn the MELT technique but once you have learned it, it takes only a few minutes a day. Dr. Metzl generally advises doing MELT 1-2x/day for 4-6 weeks until the symptoms are gone and then 1 – 2x/week to keep the feet healthy.

Address for MELT:

Sports Rehab Center at the main hospital, Hospital for Special Surgery

525 East 71st Street (off of York Avenue)

To schedule either call or email:

PH: 212-606-1005

Email: demillep@hss.edu , Polly DeMille, Exercise Physiologist

Platelet Rich Plasma (PRP)

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What is PRP?

PRP stands for platelet-rich plasma, which is taken from a person’s own blood and delivered into an injured area of bone or soft tissue. Bone and soft tissue injuries heal in many stages, which is initiated by inflammation and an increase in cells essential for healing. Platelets are specialized cells that circulate through the blood as a source of both growth and cellular signaling factors that are required for healing. For this reason, the use of PRP treatment in sports medicine is becoming a more popular option for non-healing or chronic injuries given its potential to give a biological boost to the healing process using only one’s own blood.

Who is a candidate for PRP?

PRP is a second line treatment for chronic injuries, usually in patients who have pain for more than several months. These injuries can include tennis elbow, hamstring strains, Achilles tendinits, rotator cuff tears, and plantar fasciitis.

How is PRP performed?

PRP can be done in the office during one visit. A sample of blood is obtained from the patient, and the blood is put into a centrifuge, which is a tool that separates the blood into many components. The portion of concentrated platelets is then injected into the site of injury with ultrasound guidance if needed.

What happens after PRP?

It is usually necessary to avoid strenuous exercise at the site of injection for a short period of time after PRP, after which physical therapy or a rehabilitation exercise program is started to strengthen the muscles around the injury. Patients usually return to normal activity within 3-4 weeks.   Anti-inflammatory medications (motrin, advil, aleve, ibuprofen) should be stopped a week before and after PRP treatment because they block the initial inflammatory response that PRP is designed to stimulate and optimize. Most patients respond well to only one treatment, but there are rare cases that require multiple treatments.

Is PRP effective?

Studies in animal models suggest that PRP treatment can improve healing in soft tissue and bone, noting increased number of healing cells and improved tendon strength after injection. Overall, more studies are needed to prove the effectiveness of PRP treatment, but because PRP is created from the patient’s own blood, it is considered a relatively low-risk treatment with the potential to improve or speed healing.

Sources: Kenneth Mautner, Ricardo E. Colberg, Gerard Malanga, Joanne P. Borg-Stein, Kimberly G. Harmon, Aisha S. Dharamsi, Samuel Chu, Paul Homer, Outcomes After Ultrasound-Guided Platelet-Rich Plasma Injections for Chronic Tendinopathy: A Multicenter, Retrospective Review, PM&R, Available online 8 February 2013, ISSN 1934-1482, 10.1016/j.pmrj.2012.12.010. (http://www.sciencedirect.com/science/article/pii/S1934148213000038)

Ultrasound Guided Injections

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What is an ultrasound?

An ultrasound is an imaging method that uses high frequency sound waves to produce precise images of structures within the body. Sound waves are sent and received through a small hand held device known as a transducer.

Why use ultrasound?

Ultrasound is a way to look at soft tissue and it shows the anatomy better. It allows the injection to be more precise. The ultrasound helps your doctor locate where the needle should enter the skin and improves the accuracy of the injection. There is no radiation involved.

How is the ultrasound performed?

A clear gel is applied to the area being examined and the ultrasound transducer is placed directly on the gel to produce images.

Is any anesthesia used for the procedure? Will there be any pain?

Typically a local anesthetic is injected into the skin, numbing the area where the injection is administered. Patients may experience a mild discomfort but not severe pain.

What should I do to prepare for the ultrasound?

In most instances, no particular preparation is required.

What is the recovery period like?

Following an ultrasound examination performed only for diagnostic purposes, you will be able to immediately resume your

pre-examination activities. If a therapeutic procedure (injection or aspiration) is performed utilizing ultrasound guidance, in most cases you will be able to resume regular activities within a day.