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Pain Management

Chronic pain affects every aspect of a person’s life and requires a comprehensive approach. The Pain Center at CMC helps people find relief so they can feel more like themselves again. To get you back to a lifestyle you can enjoy, we explore a range of treatment options that leverage many different resources. To be successful in finding relief from pain, patients must be committed and open minded. For some, it is a challenging journey. Our goal is to work with you to precisely diagnose and treat the underlying causes of your pain and find the right treatment so you can get back to a lifestyle you enjoy.
 

How do we treat our patients?

1. A thorough history and clinical examination
2. Review of previous imaging and interventions
3. Develop a treatment plan
4. Precisely target the pain causes utilizing the most advanced interventional pain management options
 

Common types of pain treated:
  • Back and lower extremity pain
  • Cervicogenic headache
  • Chronic pelvic and genital pain
  • Complex regional pain syndrome (CRPS)
  • Epidural scarring after back surgery
  • Fibromyalgia
  • Joint pain related to osteoarthritis
  • Myofascial pain (muscular pain)
  • Neck and upper extremity pain
  • Neuropathy pain
  • Occipital neuralgia
  • Pain due to disc herniation, spinal stenosis or facet joint disease
  • Pain from degenerative disc disease
  • Painful surgical scars
  • Post-laminectomy (failed back) syndrome
  • Sacroiliac joint pain
  • Tailbone pain (Coccygodynia)
  • Thoracic pain
  • Vertebral compression fractures

 

Pain can be described in a variety of ways, including:
  • Aching or soreness
  • Bloating or cramping
  • Burning
  • Constant
  • Comes and goes
  • Cutting
  • Dull
  • Numbing
  • Pressing
  • Pulling
  • Radiating or searing
  • Sharp, shooting, or stabbing
  • Throbbing
  • Tightness

 

Making an appointment

Your provider must refer you to the Pain Center. Once we receive a referral from your provider, we'll contact you and send you a welcome packet to complete and bring to your initial assessment.

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Why choose CMC?

Our team of specialists includes physicians and nurse practitioners with advanced training in treating pain. CMC's Pain Center team is dedicated to developing an individual pain plan for you to help discover the root cause of your chronic pain, reduce suffering and improve your overall quality of life. In assessing causes and solutions for your pain, we will evaluate the medical, physical, emotional, social and behavioral effects on your life. For some patients, this may mean a “new normal” that includes modifications for a chronic condition. You may be able to lead a much more rich and rewarding life than one that is restricted by pain.

A few visits put an end to 20-years of pain

"They made a huge difference to my quality of life,” shared Floyd. “I have tried a lot of different pain management over the course of 20 years of discomfort. Nothing really worked for very long and I just couldn’t keep taking more and more pills. The Pain Center helped me and I am so grateful to Dr. El-Ansary and Ally LeGacy, APRN. They are simply wonderful.”

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Safe & Effective Treatment Options

At CMC’s Pain Center, we draw from a range of traditional and nontraditional treatment therapies to treat your pain. Pain management is about looking at the whole person and how pain is affecting your entire life. We focus on providing a blend of non-invasive treatment options coupled with behavioral and physical therapy. Common treatment options include:

Acupuncture is a form of traditional Chinese medicine involves the insertion of very thin needles through the skin at specific points on the body, known as acupuncture points or acupoints. These points are believed to correspond to different organs and bodily functions. Acupuncture is widely recognized for its effectiveness in treating various types of pain, including:

  • Chronic pain, such as back pain, neck pain, and osteoarthritis
  • Migraines and tension headaches
  • Menstrual cramps
  • Dental pain
  • Postoperative pain

Intervertebral discs lie between the adjacent spinal vertebral bodies. They are made of fibrocartilage with a central softer gelatinous portion called “nucleus pulposus”. The disc nucleus make it act as cushion between the two vertebrae. Disc degeneration may sometimes cause pain that is called “discogenic pain”.

Spinal discography: This is a minimally invasive spinal procedure intended to diagnose spinal discogenic pain. A needle is inserted into the nucleus of the target disc, x-ray contrast injected inside, images are taken, and the patient’s response to increasing the pressure inside the disc is evaluated and recorded. Tears, cracks, herniation, and degeneration of the discs can be seen with more accuracy and the patient’s pressure response is obtained.

VIA Disc Procedure: This is a percutaneous minimally invasive disc procedure intended to relieve pain from disc degeneration. The procedure is done by injecting nucleus pulposus allograft to replace the disc material lost from disc degeneration.

Other percutaneous disc procedures for discogenic pain include:
  1. Intradiscal Biacuplasty (IDB):  This is a minimally invasive percutaneous spinal procedure for pain resulting from disc degeneration. In this procedure, two electrodes are placed, one from each side, inside the target disc and radiofrequency waves flow between them. The generated heat, applied to the outer layer of the disc (annulus), ablates the tiny nerves that carry pain sensation from the disc.
  2. Intradiscal Electrothermal Therapy procedure (IDET):  This is a minimally invasive percutaneous spinal procedure for pain from disc degeneration. Heat is applied to the outer layer of the disc (annulus) using  a special catheter placed inside the disc to thicken and strengthen the disc wall and to ablate the tiny nerves that carry pain sensation from the disc
All of the above procedures are minimally invasive, done percutaneously under local anesthesia with IV sedation if needed.

Dorsal Root Ganglion (DRG) Stimulation is a minimally invasive spinal procedure intended to stimulate the dorsal root ganglia of the spine. This procedure is commonly used for refractory focal neuropathic pain in specific areas of the lower body. Examples include: Complex Regional Pain Syndrome (CRPS) Types I and II of the lower extremities, neuropathic foot pain, postsurgical pain in the groin, hip, and knee and pelvic pain. It works by sending electrical impulses to stimulate the dorsal root ganglia (DRG) which are structures located near the spinal nerve roots and act as regulators of its sensory input. Failure of more conservative treatment options and psychological evaluation are needed for authorization.

A DRG neurostimulation system is composed of two parts:
  1. Stimulation leads: These are thin wires placed in the epidural space to stimulate the dorsal root ganglia of the nerves controlling the painful area.
  2. Pulse generator: A small device implanted under the skin and connected to the stimulation leads to provide electrical stimulation.
DRG stimulation involves two stages:
  1.  Trial of stimulation: Temporary stimulating trial lead(s) are placed in the epidural space using X-ray guidance in an outpatient procedure. The patient is sent home with an external stimulator to try the stimulation for few days then the leads are taken out.
  2. Permanent Implantation: If the stimulation is successful in relieving the patient’s pain, new permanent leads and an internal pulse generator are implanted in an outpatient surgical procedure.  

Epidural steroid injections are common spinal injections utilized for pain management. In this injection, a steroid medication is injected precisely using x-ray guidance into the epidural space of the level causing the symptoms. The epidural space is located just outside the spinal sac throughout the whole spine from the neck down to the tailbone region. These injections are commonly used to treat radiculopathies and/or spinal stenosis at the different spinal levels. Radiculopathies are painful conditions caused by pinched or irritated spinal nerve root(s) producing radiating and shooting pain and/or numbness to the extremities , in case of the cervical and lumbar spine ,or to the front of the abdominal or chest wall, in case of the thoracic spine. Spinal stenosis is a condition where there is narrowing of the main spinal canal or one of its foramina where nerve roots exit the spine. Epidural injections are usually done under local anesthesia and patients go home shortly after the procedure.

Epidural injections are named according to the targeted spinal level as follow:

  1. Cervical epidural steroid injection ( in the neck)
  2. Thoracic epidural steroid injection (In the upper and mid-back)
  3. Lumbar epidural steroid  injection ( In the lower back)
  4. Caudal epidural steroid injection ( lowest part of epidural space above the tailbone)

Epidural injections are also named according to the place where the needle enters the epidural space as follows:

  1. Interlaminar epidural (entry is from midline in between the spines of the spine.)
  2. Transforaminal epidural (entry is from the foramen where the nerve root exit the spine.)

The spine has two small joints at each vertebral level. They lie one on each side between the two adjoining vertebrae, these joints are called facet joints.  Facet joints in the lumbar, cervical and less commonly the thoracic region are frequent causes of back pain that does not radiate to the extremities. These joints are amenable to treatment. Treatment protocol for these joints include:

  1. Medial branch blocks: This is done by numbing the nerves that take the feeling of pain from these joints (medial branches) two blocks are done to confirm that the target facets are the definite source of pain.
  2. Radiofrequency ablation of the medial branches:  If both of the two medial branch blocks are successful in relieving the patient’s pain, ablation or burning of these nerves (Radiofrequency ablation) can be done. This treatment provides a longer lasting pain relief.
Both medial branch blocks and radiofrequency ablations are done precisely using small needles, under x-ray guidance, with local anesthesia, and the patient goes home shortly after the procedure.

This is a minimally invasive spinal procedure intended to relieve chronic low back pain resulting from vertebral endplate Modic changes seen in the lumbar spine MRI (vertebrogenic pain). This pain is due to inflammation and cracks in the vertebral body bone adjacent to the disc (end plates). In this procedure, a special probe is introduced through an introducer cannula into the vertebral body to ablate the basivertebaral nerve to provide relief of vertebrogenic chronic low back pain. This procedure is done as an outpatient procedure and using x-ray guidance and the patient goes home shortly after conclusion of the procedure.

This is a minimally invasive spinal procedure intended to treat painful compression fractures of the spine.  In this procedure, one or two cannulas are inserted into the collapsed vertebral body under x-ray guidance. A special balloon catheter(s) is/are inserted through the cannula(s) and the balloon is inflated inside the collapsed vertebral body to create a cavity and restore the height of the collapsed vertebra. The balloon is subsequently deflated and medical cement is injected into the created cavity. This procedure is done most of the time on an outpatient basis, under IV sedation or general anesthesia, and the patient gets discharged home on the same day after the procedure.

This is a minimally invasive spinal procedure intended to break up some of the excessive scar tissue that results from previous back surgeries. This scar tissue may cause nerve root irritation and prevent spread of epidural injections to the affected areas. In this procedure a special catheter is inserted under x-ray guidance to break up adhesions in the epidural space followed by injection of medications that decrease inflammation around the treated nerve roots. This procedure is done under x-ray guidance, with local anesthesia, and the patient goes home shortly after the procedure.

MILD procedure is a minimally invasive spinal decompression procedure done for lumbar spinal stenosis. Spinal decompression means lifting the pressure exerted by the narrowed spinal canal on the spinal nerves. This situation is present in lumbar spinal stenosis. It is an outpatient procedure and is usually done under X-ray guidance, local anesthesia and IV sedation. A tiny skin incision is used and the patient usually goes home few hours after the procedure. The procedure involves removing small pieces of bone and thickened ligament that narrows the spinal canal. This alleviates the pressure on the spinal nerves at the treated level(s) and as a result significantly improves the patient’s symptoms of spinal stenosis. The expected result is decreasing back and leg pain and increasing the patient’s walking distance.

These are therapeutic injections targeting the musculoskeletal system to treat various musculoskeletal painful conditions. Ultrasound or x-ray guidance is used in most of these injections.  They include the following:
  1. Trigger point injections: These are used to treat localized areas of painful muscle spasms called trigger points. It involves needling and Injection of the painful trigger points in the affected muscles of the body. The Piriformis and Psoas muscles are usually done under X-ray or ultrasound guidance.
  2. Peripheral joint steroid injections (and /or Hyaluronidase gel for knee): These are used to treat joint pains. Examples include, knee, hip, shoulder, acromioclavicular, ankle, wrist, symphysis pubis, and small joints of the hands and feet.
  3. Bursa Injections: These are used to treat pain from inflamed bursa or the fluid sacs present in the body near muscles and tendons. Examples include trochanteric bursa, iliopsoas bursa, sub acromial bursa, Pes anserine bursa, Knee bursa, Olecranon or elbow bursa, and Hamstring or ischial bursa.
  4. Tendon sheath Injections: These are used to treat pain from inflamed tendons. Injection is precisely done around the inflamed tendon. Examples include: Biceps tendon in the shoulder, and Achilles tendon in the heel
  5. Tendon Insertion Injections: These are used to treat pain from inflamed tendon insertions. Examples include injection of Tennis elbow (lateral epicondylitis) and Golfer’s elbow (medial epicondylitis).
  6. Fascia and ligament injections: These are used to treat pain from inflamed ligaments or fascia. Examples include Plantar fasciitis and sacrococcygeal ligament
Most musculoskeletal system are done precisely using small needles, under x-ray guidance, with local anesthesia, and the patient goes home shortly after the procedure.

Osteopathic manual manipulation is a hands-on therapeutic treatment that is focused on restoring structure and function to a patient suffering from any number of ailments. It can be a good option for those looking to avoid medications or wean off pain medications. Conditions are not restricted only to neuromusculoskeletal system, but also can treat lymphedema, abdominal disorders and respiratory restrictions. Practitioners rely on knowledge of anatomy and physiology, formal training, and therapeutic contact with our patients. 

Treatment techniques include:
  • Myofascial Release
  • Articulatory Technique
  • Strain/Counterstrain
  • Active Isolated Stretch Technique
  • Cold Spray and Stretch Technique
  • Ligamentous Balance
  • Muscle Energy Release
  • Soft Tissue Release
  • Craniosacral Technique
  • Progressive Inhibition of Neuromuscular Structures
  • Neurokinetic Therapy
After initial examination and assessment, treatment goals primarily involve restoring mobility and function.  Treatment generally lasts 15–20 minutes. Risks are very low and may include temporary worsening of symptoms, mild discomfort during treatment, skin reaction and ineffectiveness of treatment. Post treatment hydration and stretching is recommended. 

Percutaneous Electrical Nerve Stimulation (PENS) treatment has only recently been approved by Medicare to treat chronic low back pain. It is very similar to Transcutaneous Electrical Nerve Stimulation that involves pads and therapeutic electrical current over targeted region. Percutaneous electrical nerve stimulation involves skilled use of acupuncture needles specifically arranged in the low back region with and without electrical stimulation.  

Acupuncture needles have long been utilized in therapeutic treatment.  Acupuncture can stimulate blood flow, endogenous pain neurotransmitters and a healing cascade. Effective treatments typically provides relief for several weeks.   

During this treatment, the patient is positioned laying face down on an exam table. Treatment time can vary from 15 minutes to 45 minutes. Risks are low, including discomfort with application of sterile acupuncture needles and treatment, temporary local skin reaction, and ineffectiveness of treatment. Limitations on number of treatments may vary by insurance. 

The PENS modality can be a therapeutic treatment option for people who want to avoid pain medications and/or wean off pain medications.     

These are minimally invasive procedures that are done to decrease chronic pain from severely osteoarthritic joints that no longer respond to steroid injections and require joint replacement. These procedures may be done in cases where surgery is not feasible for reasons such as high risk for anesthesia/surgery, extremes of age, obesity, or patient refusal. They are also done to treat persistent chronic pain that continued after joint replacement. It is to be noted that these procedures only help with the pain and they are not intended to be done instead of joint replacements. 

Radiofrequency ablate the nerve branches that transmit the feeling of pain of the treated joint. Pain relief usually last between six months to one year and can be repeated if needed. A successful diagnostic block is usually needed before these procedures are scheduled.  Examples include:
  1. Radiofrequency ablation of the genicular nerves: done for knee joint ablation
  2. Radiofrequency ablation of the articular branches of the femoral and obturator nerves: done for hip joint ablation.
  3. Radiofrequency ablation of the articular branches of the suprascapular, axillary nerve, and lateral pectoral nerves for shoulder joint ablation.
All these procedures are done on an outpatient basis, using radiofrequency needles that are placed under X-ray guidance, and done under local anesthesia.

These procedures involve injection of local anesthetic and steroid around the peripheral nerve that is involved in the patient’s chronic nerve pain. Peripheral nerves are any nerves that are not considered as cranial or spinal nerve roots. They are present throughout our trunk and our extremities. Peripheral nerve blocks are used very frequently to treat peripheral nerve compression neuropathies and pain from peripheral nerve irritation or injuries. These injections are done on an outpatient basis, using either landmarks, ultrasound or x-ray guidance and done under local anesthesia. 

Examples include:
  • Anterior cutaneous nerve block
  • Brachial plexus block
  • Carpal tunnel block
  • Femoral nerve block
  • Genitofemoral nerve block
  • Ilioinguinal nerve block
  • Intercostal nerve block
  • Lateral femoral cutaneous nerve block
  • Lumbar plexus block
  • Morton’s neuroma injection
  • Obturator nerve block
  • Occipital nerve block
  • Peroneal nerve block
  • Pudendal nerve block
  • Saphenous nerve block
  • Sciatic nerve block
  • Superficial radial nerve block
  • Supraorbital nerve block
  • Suprascapular nerve block
  • Sural nerve block
  • Tarsal  tunnel block
  • Tibial nerve block

Peripheral nerve stimulation (PNS)
This procedure involves placing a small electrode next to the peripheral nerve that is involved in the patient’s chronic nerve pain. Peripheral nerves are any nerves that are not considered as cranial or spinal nerve roots. They are present throughout our trunk and our extremities. Peripheral nerve stimulation works by sending electrical impulses to stimulate the target nerve using a pulse generator. Failure of more conservative treatment options and psychological evaluation are needed for authorization.

A peripheral nerve stimulation system is composed of two parts:
  1. Stimulation leads: These are thin wires placed next to the target peripheral nerve.
  2. Pulse generator: A small device that provides electrical stimulation. At CMC's Pain Center, we use the “Curonix Freedom System” of peripheral nerve stimulation. This advanced system has a non-implantable pulse generator that works wirelessly to stimulate a small implanted stimulation lead. 
Peripheral nerve stimulation involves two stages:
  1. Trial of stimulation: Temporary stimulating trial lead is placed and the patient is sent home with an external stimulator to try the stimulation for few days then the lead is taken out.
  2. Permanent Implantation: If the stimulation is successful in relieving the patient’s pain, new permanent leads are implanted in an outpatient surgical procedure.   
Examples of peripheral nerve stimulation for management of chronic pain include:
  1. Suprascapular nerve for chronic shoulder pain
  2. Infrapatellar saphenous nerve for chronic knee pain
  3. Tibial nerve for chronic foot and ankle pain
  4. Cluneal nerves for chronic buttock and low back pain
  5. Occipital nerve stimulation for occipital neuralgia

Sacroiliac joints are located in both sides of the lower back where the spine joins the pelvis. They are large joints and they are a common source of low back and hip pain. Sacroiliac joint steroid injection and radiofrequency ablation are utilized to treat sacroiliac joint pain as follows:
  1. Sacroiliac joint steroid injection:  Injection of sacroiliac joints with local anesthetic and steroids serves to diagnose and treat sacroiliitis. Injection is done precisely under X-ray guidance and the patient goes home shortly after the procedure.
  2. Sacroiliac joint Radiofrequency ablation: If the diagnosis of sacroiliitis is established but the steroid injections provide very short term pain relief, radiofrequency ablation or burning of the small nerves that innervate the sacroiliac joint is a treatment option with potential longer term of pain relief. The procedure is done precisely using small needles, under x-ray guidance, with local anesthesia, and the patient goes home shortly after the procedure.
  3. Sacroiliac joint Stabilization/Fusion: This is a minimally invasive procedure that is done for patients with proved diagnosis of Sacroiliitis but their pain does not respond adequately to steroid injections. We utilize a simple and safer posterior approach to the joint using the “LinQ procedure”. The procedure is done precisely using under x-ray guidance, with local anesthesia, and IV sedation and the patient goes home few hours after the procedure.

This is a minimally invasive spinal procedure intended to treat painful fractures of the sacral vertebral body or the sacral ala. In this procedure, one or two cannulas are inserted into the sacrum under x-ray guidance and medical cement is injected into the sacrum to stabilize the fracture. This procedure is done most of the time on an outpatient basis, under IV sedation or general anesthesia, and the patient gets discharged home on the same day after the procedure.

These are diagnostic spinal procedures that are used to pinpoint the spinal nerve root implicated in production of the patient’s pain. This procedure may be needed in the process of finding the source of pain by the pain physician or requested by the spine surgeons before planning a spinal surgical procedures. In these procedures, a spinal needle is placed precisely at the exit of the target nerve root from the spinal canal and small amount of local anesthetic is injected to numb that nerve root. If the pain disappears for 1-2 hours, even if it returns later, it confirms that this nerve is the one that is involved in the patient’s pain. The procedure is done precisely using small needles, under x-ray guidance, with local anesthesia, and the patient goes home shortly after the procedure.

Spinal Cord Stimulation is commonly utilized for refractory neuropathic trunk and/or extremity pain. Examples include failed back surgery syndrome, arachnoiditis, peripheral neuropathy, and Complex Regional Pain Syndrome (CRPS) Types I and II. It works by sending Electrical impulses to stimulate the spinal cord using an implantable device. Failure of more conservative treatment options and psychological evaluation are needed for authorization.

A spinal cord stimulation system is composed of two parts:
  1. Stimulation leads:  These are thin wires placed in the epidural space to stimulate the spinal cord.
  2. Pulse generator: A small device implanted under the skin and connected to the stimulation leads to provide electrical stimulation.
Spinal cord stimulation involves two stages:
  1. Trial of stimulation: Temporary stimulating trial lead(s) are placed in the epidural space using X-ray guidance in an outpatient procedure. The patient is sent home with an external stimulator to try the stimulation for few days then the leads are taken out.
  2. Permanent Implantation: If the stimulation is successful in relieving the patient’s pain, new permanent leads and an internal pulse generator are implanted in an outpatient surgical procedure.   

These are nerve blocks in which local anesthetic medications are precisely injected under x-ray guidance to block or numb the sympathetic nervous system network of nerves or ganglia that supply different parts of the body. These blocks are effective in certain chronic painful conditions in which pain is mediated by sympathetic hyperactivity. Complex regional pain syndrome is one example of these diseases. 

Examples of sympathetic nerve blocks include:
  1. Sphenopalatine ganglion Block for migraines and head pain
  2. Stellate ganglion block for head and upper extremity pain.
  3. Lumbar sympathetic block for lower extremity pain.
  4. Celiac plexus block for upper abdominal visceral pain.
  5. Superior hypogastric plexus block for pelvic pain.
  6. Ganglion Impar block for rectal and tailbone pain.

Vertiflex is a minimally invasive indirect spinal decompression procedure done for lumbar spinal stenosis. Spinal decompression means lifting the pressure exerted by the narrowed spinal canal on the spinal nerves. This situation is present in lumbar spinal stenosis. It is an outpatient procedure and is usually done under x-ray guidance, local anesthesia and IV sedation.  A very small skin incision is used and the patient usually goes home a few hours after the procedure. The procedure involves placement of a small metallic implant called Superion at the narrowed spinal level(s). This implant is designed to work as an extension blocker at the treated lumber spinal level(s) where there is significant spinal stenosis. Blocking extension at the narrowed spinal level(s) prevents the additional narrowing that would happens to the already narrowed lumbar spinal canal with spine extension, as during standing and walking. This effect keeps the spinal canal open, alleviates the pressure on the spinal nerves at the treated level(s) and as a result significantly improves the patient’s symptoms of spinal stenosis. The expected result is decreasing back and leg pain and increasing the patient’s walking distance.

Pain Evaluation

Your primary care doctor provides us with your medical history and the results of your physical examination. To fully understand your pain, we also conduct our own comprehensive physical evaluation and pain assessment. We ask you to complete a pain inventory to describe the type, location, frequency and intensity of your pain. We also want to learn about the emotional toll pain is taking on your life. To match patients with the right type of medical care, we will also assess your risk for dependence on a pain medication.

Safe Medication Monitoring

Proper pain medication use is imperitive. The Pain Center at CMC monitors medication use with pill counts, prescription refill reviews and random urine samples. It is important to use pain medication exactly as it is prescribed. That’s why we take every precaution to ensure your health and well-being.