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A. Regional Anesthesia and Analgesia for Surgery - TOP

Analgesia is the full or partial relief of painful sensations. Postoperative analgesia refers to the full or partial relief of painful sensation after surgery. Anesthesia is usually considered to be a more intense blockage of all sensations, including muscle movement. Your wishes as well as those of your surgeon and your medical condition are important in selecting the type of anesthesia and pain relief you will receive.

1. What are the types of anesthesia?
There are three main categories of anesthesia: general, regional and local. Each has many forms and uses. Your anesthesiologist, in consultation with your surgeon, will determine the best type of anesthesia for you, taking your desires into consideration whenever possible. These options will be discussed during your preoperative interview with the anesthesiologist.

General Anesthesia, which involves the total loss of consciousness, pain sensation and protective airway responses.

Local Anesthesia, which provides numbness to a small area of the body, such as a dermatologist might use to numb the skin around a mole before removing it. For some surgical procedures, a local anesthetic may be injected into the skin and tissues to numb a specific location.

Regional Anesthesia, which can include spinal blocks, epidural blocks or (peripheral [arm, leg or head] nerve) blocks. If you have regional anesthesia, your anesthesiologist injects medication near a cluster of nerves to numb only the area of your body that requires surgery. You may remain awake or you may be given a sedative. Spinal and epidural blocks involve interrupting sensation from the legs or abdomen by injecting local anesthetic medication in or near the spinal canal. Other blocks can be performed for surgery on your extremities, or limbs, blocking sensations from the arm or leg.

2. How is regional anesthesia different from general anesthesia?
In general anesthesia, you are unconscious and have no awareness or other sensations. In regional anesthesia, your anesthesiologist makes an injection near a cluster of nerves to numb the area of your body that requires surgery.

3. If I choose regional anesthesia, does that mean I am awake during the surgery?
You may remain awake, or you may be given a sedative. You do not see or feel the actual surgery take place. Your anesthesiologist, after reviewing your individual situation, will discuss the appropriate amount of sedation for you. Although this sedation analgesia was once referred to as “twilight sleep”, the term “conscious sedation” has become more popular to describe a semi-conscious state that allows patients to be comfortable during certain surgical procedures.

During minimal sedation, you will feel relaxed, and you may be awake. You can understand and answer questions and will be able to follow your physician’s instructions. When receiving moderate sedation, you will feel drowsy and may even sleep through much of the procedure, but will be easily awakened when spoken to. You may or may not remember being in the operating room. During deep sedation, you will sleep through the procedure with little or no memory of the procedure room. Your breathing can slow, and you might be sleeping until the medications wear off.

While you receive sedation during surgery, your vital signs, including heart rate, blood pressure and oxygen level, will be watched closely in order to avoid sudden changes or complications. You may also receive supplemental oxygen during the surgery.

4. What are the different types of blocks performed for regional anesthesia?
In regional anesthesia, your anesthesiologist makes an injection near a cluster of nerves to numb the area of your body that requires surgery. There are several kinds of regional anesthesia. Two of the most frequently used are spinal anesthesia and epidural anesthesia, which are produced by injections made with great exactness in the appropriate areas of the back. They are frequently preferred for childbirth and prostate surgery. Another common type of regional anesthesia is a peripheral nerve block, which is produced by injections made with great exactness near a cluster of nerves to numb the appropriate area of your body extremity (arm, leg, head) that requires surgery. Two of the most frequently used are femoral nerve block, which is produced by injection in the leg region, and brachial plexus block, which is produced by injection in the arm and shoulder region. These blocks are frequently performed for surgery in the knee, shoulder, or arm.

5. May I request what type of anesthesia I will receive? Yes, in certain situations. Some operations can be performed using different anesthetic procedures. Your anesthesiologist, after reviewing your individual situation, will discuss any available options with you. If there is more than one type of anesthetic procedure available, your preference should be discussed with your anesthesiologist in order for the most appropriate anesthetic plan to be made.

6. What types of surgical procedures would be amenable for regional anesthesia?
If there are no medical contraindications, anesthesiologists are able to perform regional anesthesia techniques (with either sedation or general anesthesia) for a wide variety of surgical procedures. Some examples of surgeries utilizing regional techniques are:

• Gastrointestinal (stomach)/hepatic (liver): epidural, spinal or paravertebral nerve blocks and catheters may provide effective anesthesia and analgesia for colon resections and surgeries of the stomach, intestines, or liver.
• Gynecology (female reproductive organ): epidural, spinal or paravertebral nerve blocks and catheters may provide effective anesthesia and analgesia for hysterectomy, pelvic procedures, Cesarean sections, and other gynecologic procedures.
• Ophthalmology (eye): injection of local anesthetics may provide anesthesia and analgesia for many types of eye procedures.
• Orthopedics (bone and joint): epidural, spinal, and many types of peripheral nerve blocks and catheters may be used depending on the limb/joint being operated upon.
• Thoracic surgery (chest): epidural, paravertebral or intercostal nerve blocks and catheters may be especially useful in controlling pain following procedures of the chest or esophagus.
• Urology (kidney, prostate, and bladder): epidural, spinal or paravertebral nerve blocks and catheters may provide effective anesthesia and analgesia for radical prostatectomy, nephrectomy, and other procedures involving the kidneys, prostate, or bladder.
• Vascular surgery (blood vessel): cervical (neck) blocks may be used for incisional pain for carotid surgeries; epidural or paravertebral nerve blocks may be used for abdominal aortic endovascular procedures or lower extremity graft bypass procedures.

As with any other medical procedure, each type of regional/local block carries with it its own risks and benefits, which should be carefully considered and discussed with your anesthesiologist each time an anesthetic plan is chosen for a particular procedure.

7. How is the epidural or spinal block performed?
An epidural or spinal block is given in the back. You will either be sitting up or lying on your side. Before the block is performed, your skin will be cleansed with an antiseptic solution. The anesthesiologist will use local anesthesia to numb an area of your back.

For the epidural block, a special needle is placed in the epidural space just outside the spinal sac. A tiny flexible tube called an epidural catheter is inserted through this needle. Occasionally, the catheter will touch a nerve, causing a brief tingling sensation down one leg. Once the catheter is positioned properly, the needle is removed and the catheter is taped in place. Additional medications are given as needed through the epidural catheter without another needle being inserted. The medication bathes the nerves and blocks out the pain. This produces epidural anesthesia and analgesia.

For the spinal block, a small needle is placed in spinal sac. Occasionally, the needle will touch a nerve, causing a brief tingling sensation down one leg. Once the needle is positioned properly, medication is administered. The medication bathes the nerves and blocks out the pain. This produces spinal anesthesia and analgesia.

8. How is a peripheral nerve block performed?
Depending on the location of surgery, a peripheral nerve block can be given in the shoulder-arm, back or leg regions. Typically, you will either be lying flat on your back (supine) or lying on your side (lateral) but occasionally may even be on your stomach (prone). The block is administered at an appropriate location to provide anesthesia for the surgery. Before the block is performed, your skin will be cleansed with an antiseptic solution. The anesthesiologist will use local anesthesia to numb an area of where the peripheral nerve block will be administered.

For peripheral nerve blocks, a special needle or catheter is placed near the cluster of nerves that need to be numbed for surgery. Occasionally, the needle will touch a nerve, causing a brief tingling sensation down the extremity where the regional block is being performed. The needle may also be used to temporarily obtain muscle twitches in the extremity where surgery will occur.

9. Specific Nerve Blocks  
This section will provide you with more detail on specific nerve blocks that can be used for anesthesia and analgesia.

Spinal and Epidural Anesthesia
Spinal and epidural blocks are forms of anesthesia that temporarily interrupt sensation from the trunk (chest and abdomen) and legs by injection of local anesthetic medication in the vertebral canal, which contains the spinal cord and spinal nerves.  The spinal cord and spinal nerves are contained within a fluid-filled sac. The fluid-filled sac is called the dural sac and the fluid is known as cerebrospinal or spinal fluid

Prior to performing a spinal or epidural block, your anesthesiologist may place monitors to watch your vitals signs. You will be placed either on your side with your knees and chin pulled as close to your chest as possible or sit with your arms and head resting on a small table. At this time, your anesthesiologist may choose to inject a small amount of relaxing medicine into your intravenous line if you require sedation. The anesthesiologist will feel your back, clean your skin with an antiseptic (bacteria-killing) solution, and place a sterile drape around the area. Your anesthesiologist may first inject some local anesthesia into the skin and then into the deeper tissues of the lower back – this may cause a slight burning or pressure sensation.  Your anesthesiologist will then carefully insert the needle and advance it into the space between your vertebrae (backbones).  Occasionally, you may feel a brief tingling sensation (paresthesia) during the procedure.

For spinal anesthesia, the anesthesiologist advances the needle until he or she is able to inject some local anesthesia into the spinal fluid.  Since a spinal block typically involves a one-time injection, the duration of your spinal anesthesia will depend on the type and amount of local anesthetic medication administered by your anesthesiologist.

For epidural anesthesia, the anesthesiologist advances the needle into the epidural space which is located just outside of the dural sac containing the spinal fluid. Your anesthesiologist may insert a small flexible catheter to allow for continuous injections or infusions of local anesthesia.  The needle is removed and only the catheter remains at the end of the procedure.  Epidural analgesia is most commonly used to provide pain relief during childbirth or after painful surgical procedures of the chest, abdomen, and lower extremities.

After your anesthesiologist has performed the spinal or epidural block, you will generally feel numbness and may notice that your legs will become weak to the point where you may not be able to move them. This is normal. The surgery will be allowed to start only when your anesthesiologist is certain that the site of surgery is completely numb. During the surgery, you will have the option of being awake or sedated. If you choose to be sedated, the anesthesiologist will administer sedatives through your intravenous line to help you sleep lightly during the operation.

After surgery, you will be taken to the recovery room and monitored closely by recovery room nurse until your spinal or epidural block wears off. Typically, a spinal block lasts 2-6 hours depending the type and amount of local anesthetic given by the anesthesiologist. If you received an epidural catheter, it can be left in place for several days after surgery to allow a continuous infusion of pain relieving medications.  Your epidural catheter is generally removed once you are able to keep down oral pain-relieving medications.

Brachial Plexus Block:
The brachial plexus is the major nerve bundle going to the shoulder and arm.  Depending on the level of surgery, your anesthesiologist will decide at what level he wants to block the brachial plexus. For example if you have surgery at the shoulder, your anesthesiologist may choose a nerve block (interscalene or cervical paravertebral block) performed at a location above the clavicle. For surgeries below the shoulder joint or clavicle, an infraclavicular or axillary technique may be used. Your anesthesiologist may use ultrasound, a nerve stimulator or other techniques to help identify the appropriate location along the brachial plexus to inject the local anesthetic. If a nerve stimulator is used, you may feel the muscles in your shoulder or arm twitch. This is normal. If you experience any sharp pain or any type of paresthesia (“shock-like” sensation similar to if you were to hit your “funny-bone” in your elbow) shortly before or during the injection you should notify your anesthesiologist immediately. You should also notify your anesthesiologist before performing any brachial plexus block if you have any type of pain below the elbow, preexisting pain, or preexisting nerve injury. If you have serious respiratory (lung, breathing) problems you should notify your anesthesiologist before proceeding with the block. Your anesthesiologist will then decide whether a brachial plexus block is safe for you and will provide adequate analgesia for the surgery.

Paravertebral Block:
Paravertebral blocks can be utilized to numb a specific area in one part of the body depending on where the block is performed. For example, paravertebral blocks at the level of the neck can be used for thyroid gland or carotid artery surgery. Paravertebral blocks at the level of the chest and abdomen can be used for many types of breast, thoracic, and abdominal surgery. Paravertebral blocks at the level of the hip can be used for surgeries involving the hip, knee, and the front of the thigh.

In general, all paravertebral blocks are performed with a similar technique. Your anesthesiologist will feel your back, clean your skin with an antiseptic (bacteria-killing) solution, and may inject some local anesthesia into the skin and then into the deeper tissues of the back – this may cause a slight burning or pressure sensation. Your anesthesiologist will then carefully insert and advance a needle and inject local anesthesia to numb the nerves. If a nerve stimulator is used to help locate the nerves, you may feel the muscles in your chest, abdomen, or legs twitch. This is normal. If paravertebral blocks are utilized for thoracic and abdominal surgery, more than one injection may be needed to provide achieve adequate anesthesia. Your anesthesiologist may insert a small flexible catheter to allow for continuous injections or infusions of local anesthesia. The needle is removed and only the catheter remains at the end of the procedure if this is the case. As with other blocks, always let your anesthesiologist know if you experience any sharp or radiating pain during the procedure or injecting of the local anesthetic. Always notify your anesthesiologist if you experience sudden numbness, bilateral numbness or warmness with the injection of your local anesthetic

Femoral Nerve Block:
The femoral nerve provides sensation and motor function to the front of the thigh and knee. This block is commonly used for procedures that cover this area (such as surgery of the knee). If you receive a femoral nerve block, you generally will be positioned on lying on your back. Your anesthesiologist will feel your back, clean your groin area with an antiseptic (bacteria-killing) solution, and may inject some local anesthesia into the skin– this may cause a slight burning or pressure sensation. Your anesthesiologist will then carefully insert and advance a needle and inject local anesthesia to numb the nerves. A nerve stimulator is generally used to help your anesthesiologist determine the appropriate location to inject the local anesthetic. You may feel the muscles in your leg twitch – this is normal. Your anesthesiologist may insert a small flexible catheter to allow for continuous injections or infusions of local anesthesia. The needle is removed and only the catheter remains at the end of the procedure if this is the case. As with other blocks, always let your anesthesiologist know if you experience any sharp or radiating pain during the procedure or injecting of the local anesthetic. You may have difficulty with weight bearing on the blocked leg and you should have help in attempting to get up and care should be taken not to prevent falls.

Sciatic and Popliteal Nerve Block:
This sciatic nerve provides sensation and motor function to the back of the thigh and most of the leg below the knee. This block is commonly used for surgery on the knee, calf, Achilles tendon, ankle, and foot. If you receive a sciatic nerve block, you generally will be place on your belly or side but occasionally you may be lying on your back. Your anesthesiologist will clean your skin with an antiseptic (bacteria-killing) solution, and may inject some local anesthesia into the skin and then into the deeper tissues– this may cause a slight burning or pressure sensation. Your anesthesiologist will then carefully insert and advance a needle and inject local anesthesia to numb the nerves. A nerve stimulator is often used to help your anesthesiologist determine the appropriate location to inject the local anesthetic. You may feel the muscles in your leg twitch – this is normal. Your anesthesiologist may insert a small flexible catheter to allow for continuous injections or infusions of local anesthesia. The needle is removed and only the catheter remains at the end of the procedure if this is the case. As with other blocks, always let your anesthesiologist know if you experience any sharp or radiating pain during the procedure or injecting of the local anesthetic. As with other blocks, always let your anesthesiologist know if you experience any sharp or radiating pain during the procedure or injecting of the local anesthetic. You may have difficulty with weight bearing on the blocked leg and you should have help in attempting to get up and care should be taken not to prevent falls.

B. Pain Relief after Surgery - TOP

1. What are the choices for pain relief after surgery? There are several choices for pain relief after surgery:

Intravenous “I.V.” or Intramuscular “I.M.” Medications: Pain-relieving medications that are injected into a vein or muscle will help to dull your pain but may not eliminate it completely. These medications are usually prescribed by your surgeon.

Local Anesthesia: Other pain-relieving medications may be injected into the surgical incision by your surgeon. These medications are local anesthetics. They provide numbness or loss of sensation in a small area.

Regional Blocks: Regional blocks can reduce the pain after surgery and can provide either analgesia or anesthesia. Local anesthetics and other drugs are used for these procedures to reduce or “block” pain and other sensation over a wider region of the body.

2. It is possible to combine regional and general anesthesia and in what situations would this combination be desirable?
Often, both general anesthesia and regional anesthesia are combined during the procedure, especially if the one of the intentions of the regional technique is to help control pain after surgery. If you have regional anesthesia in addition to general anesthesia, this may possibly allows your anesthesiologist to use less general anesthesia which might allow you to recovery faster after the surgery is finished. The types of regional anesthesia techniques that are commonly used in combination with general anesthesia are single-shot (one time) injections of nerve blocks and continuous catheters.

If you receive a single-shot nerve block, you can expect up to 4-24 hours of pain relief after surgery; however, the exact duration of analgesia depending on many factors. For adults, single-shot nerve blocks are a one time injection of local anesthesia given typically under sedation but before general anesthesia is started. A single-shot nerve block may also be given to children to help with pain control after surgery but in most cases, your anesthesiologist will perform the block while your child is already asleep (after general anesthesia has started). Single-shot nerve blocks are often used for pain control after orthopedic (bone and joint) surgery.

3. What if I need pain control for more than 24 hours after surgery?
If you require pain control for more than 24 hours after surgery, for many types of surgery then your anesthesiologist can place a continuous catheter to allow the continuous deliver of pain relieving medications. If you receive a continuous catheter, you can generally expect analgesia for as long you have the catheter. Insertion of a continuous catheter for postoperative pain is typically done under sedation but before general anesthesia is started in adults and generally placed after general anesthesia is started in children. 

4. What are some of the possible side effects from the medications used for pain relief after surgery?
The two commonly used types of medications are opioids (narcotics) and local anesthetics. In normal doses, narcotics may cause some itching, nausea, retching, or drowsiness. Local anesthetics may cause some numbness or, heaviness. There will be some difficulty with weight-bearing on the blocked leg afterwards, and patients should take care not to fall; however, the pain control lasts longer than the motor effects.

5. Can the regional block used for my surgery also help with pain relief after surgery?
The regional block used for the surgery may last for some time after the end of surgery and may help with pain relief during this time. Occasionally, a catheter may be placed during the nerve block to extend the duration of pain relief after surgery.

6. What will I feel after the block takes effect?
No matter what regional anesthesia technique you receive, whether it be a single-shot or a continuous catheter technique, you might some degree of temporary numbness, heaviness or weakness in your legs at the end of surgery. You might also not have the full muscle control of the affected part of your body. Please be sure to always check with your physician or nurse before you start to use any affected extremities for standing up or try to do other motor tasks. Also make sure that you don’t put pressure on any extremity which feels numb from your regional analgesic technique.

7. How long will the block last?
Depending on the type of medication used for the regional block, the block may last for several hours after the conclusion of surgery. This may help with pain relief after surgery. If a catheter was placed during the nerve block, then the duration of analgesia can be extended for as long as you need it. After the catheter is placed, medication can be administered through it as necessary. After the catheter is removed, sensations will return to normal typically within a few hours.

8. Can I keep my regional block catheter when I go home after surgery?
Depending on your anesthesiologist, surgeon and hospital, continuous peripheral nerve catheters have been used for analgesia at home after surgery. These outpatient or ambulatory catheters need some special attention and preparation and not all hospitals will provide this service. First, your anesthesia provider will check with your insurance company whether they cover the costs of the home going catheter and the nursing visits required for its care. You will then receive formal instructions in the process of catheter care including a list of emergency contact phone numbers. You will also receive a special pump which will be connected to your catheter and deliver the local anesthetic. Depending on the protocol utilized at your healthcare facility, you can change the reservoir of that pump yourself or it will be changed by a visiting nurse.

For most types of orthopedic surgeries, these peripheral catheters may stay in for an average of 3-4 days. You should inspect the catheter entry site for any signs of redness, swelling or purulent discharge. Whenever you notice one of those symptoms, contact your anesthesia provider or the visiting nurse immediately. Visiting nurses will inspect your catheter site with every visit. They will also be able to adjust the flow rate of your pump if needed. If no visiting nurse service is used by your institution, you will receive the appropriate instructions for managing the pump and removal of the catheter. Always make sure the catheter is completely removed. The most common reason for peripheral nerve catheter failure to provide adequate pain control is dislocation of the catheter. In order to lessen the chances of this happening, you might want avoid any pulling or tension on the infusion line and catheter.  

C. Risks and Benefits of Regional Anesthesia - TOP

1. What are the benefits of a regional block?
Frequently, there is less nausea from regional blocks and patients generally awaken faster after regional blocks. Regional blocks can also be used to reduce the pain after surgery. Generally, regional nerve blocks and catheter will provide better pain control than intravenous or intramuscular opioids (narcotics).

Epidural analgesia for pain control after surgery might provide you with some specific benefits:

• Better pain control than intravenous narcotics,
• Earlier recovery of bowel function,
• Less need for systemic opioids (narcotics) and less nausea as a result,
• Easier breathing resulting from better pain control,
• Easier participation in physical therapy

2. What are the risks of a regional anesthesia block?
Like any other medical procedures, there are risks associate with regional anesthesia. Complications or side effects can occur, even though you are monitored carefully and your anesthesiologist takes special precautions to avoid them. To help prevent a decrease in blood pressure, fluids may be administered intravenously. Although not common, a headache may develop following the block procedure. By holding as still as possible while the needle is placed, you may help to decrease the likelihood of a headache. The area where the nerve block was administered may be sore or tender for a few days. These discomforts, if they do occur, often disappear within a few days. If they do not disappear or become severe, additional treatments are available.

There are veins in the epidural space and other areas where epidural nerve blocks are administered. There is a risk that the anesthetic medication could be injected into one of them. To help avoid unusual reactions stemming from this, it is important to notify your doctor or nurse immediately if you notice any dizziness, rapid heart beat, funny taste or numbness around your mouth.

Nerve blocks of the brachial plexus are generally well tolerated but there may be signs and symptoms that you may notice. You might experience a change of your pupil size on the affected side, this is called Horner’s syndrome. You also might experience a light drop of your eyelid (ptosis). These are normal reactions which typically go away after the nerve block is gone. You might experience a stuffy nose and may experience a certain degree of hoarseness.
You might have the feeling that you might have to make a stronger effort to take deep breaths because one of the nerves going to your diaphragm will be affected as part of the normal block. An important, although very rare, complication of the cervical paravertebral, interscalene, or infraclavicular blocks, is the development of a pneumothorax (air trapped between the lung and the rib cage). In the unlikely case you do develop a pneumothorax, you may not notice any changes immediately but you might develop respiratory symptoms like persistent coughing, chest pain, or problems breathing and shortness of breath within 24 hours after performance of the block. If any of those symptoms occur you should contact your anesthesiologist or your nearest emergency room immediately. An x-ray will confirm the diagnosis of pneumothorax and sometimes the evacuation of the air with a chest tube is necessary. Because this is a rare but serious side effect, you should be aware of those symptoms.

Any time a needle or catheter is inserted under the skin and near a blood vessel, bruising, infection, or bleeding may occur. An uncommon complication of the axillary approach to the brachial plexus can be the formation of large hematomas. You should notify your anesthesiologist about any expanding hematoma in the puncture area immediately.
The specific risks of anesthesia vary with the particular procedure and the condition of the patient. You should ask your anesthesiologist about any risks that may be associated with your particular anesthesia. Your anesthesiologist carefully evaluates your condition, makes medical judgments, takes safety precautions and provides special treatment throughout the procedure. You should feel free to talk with your anesthesiologist about your options for anesthesia, pain control after surgery, their benefits and their possible side effects.

a. What is a spinal (postdural puncture) headache? What are the treatments for spinal headache?
A spinal or postdural puncture (PDPH) (or also sometimes called a meningeal puncture headache) may occur after spinal or epidural anesthesia when puncture of the dural sac allows for spinal fluid to leak out of the dural sac. If enough spinal fluid leaks out, a headache may occur especially when standing or sitting. A spinal headache may occurs any time after spinal or epidural anesthesia but most cases generally show themselves within 3-5 days after a spinal or epidural anesthetic. The characteristics and severity of the headache may vary. With improvements in needle design, the risk of a spinal headache after anesthesia is much less than a few decades ago. 

If you have a headache after spinal or epidural anesthesia, you need to contact your surgeon or primary care physician if you are at home or notify the health care providers caring for you if you are still in the hospital. If you are at home and do not have a physician contact person, you should be evaluated at an emergency room. There are many possible causes for headache other than spinal headache from spinal or epidural anesthesia and your physician may need to examine you and perform several tests to see what is causing your headache.  

If your headache is the result of spinal or epidural anesthesia, then there are several treatment options depending on the severity of your symptoms. If your headache is mild, treatment is conservative and includes taking oral pain-relieving medications, drinking fluids, and consuming caffeine (usually in the form of caffeinated beverages). The leaking puncture will normally repair itself in a few days-weeks and your symptoms will gradually improve. If your symptoms are severe or your symptoms do not improve, your anesthesiologist may recommend an “epidural blood patch” . This involves carefully takes a small amount of blood from one of your veins and injecting it into the epidural space in your back. The injected blood in the epidural space will form a clot and seal the puncture site. After the epidural blood patch, your spinal headache should improve within 12-24 hours. If after this time period, you still have symptoms compatible with a spinal headache, your anesthesiologist may recommend repeating the epidural blood patch one more time. Your anesthesiologist will discuss the balance between the risks and benefits of an epidural blood patch.

b. How common is nerve injury after a regional block?
Nerve injury after a regional block is a rare occurrence, which can occur anywhere from 1 in 4000 blocks to 1 in 200.000 blocks depending in the type of block and specific risk factors. It can be related to direct needle injury of the nerve or to secondary complications like bleeding or infection. In order to prevent nerve injury, please inform your anesthesiologist if you experience any sharp or radiating pain during needle placement or injection. If you experience any new symptoms like tingling, numbness, or motor dysfunction after a nerve block has already worn off you should seek medical attention immediately because this can be a sign of secondary damage by hematoma or infection. Because recovery of nerve function depends on timely initiation of diagnosis and treatment, do not take any unexpected changes lightly.

c. Can the epidural or regional block catheter become infected?
Every time a foreign body like a needle or catheter is introduced into your body, there is the risk of infection. Bacteria can enter the body through the primary puncture or along the catheter site. The risk of infection increases over time but the chance of a serious infection leading to abscess formation and requiring surgical intervention or damage to the nerve secondary to an infection is extremely rare.

Careful monitoring of the catheter insertion site is required to detect early signs of infection. Redness, swelling and purulent discharge should lead to immediate inspection of the catheter site and removal of the catheter. While most often no other treatment than removal of the catheter is required, sometimes systemic antibiotics might be administered or surgical drainage of an abscess can be necessary. Abscess formation in the epidural space is extremely rare bit it can be a very dangerous complication leading to permanent paralysis. If you experience any fevers or chills, one of the described local symptoms or any change in your neurologic status like increased numbness or loss of motor function, bladder and bowel disturbances, you need to contact you anesthesiologist or health provider immediately.

3. Will I receive a separate bill from the anesthesiologist?
Your anesthesiologist is a physician specialist like your surgeon or internist, and you will receive a bill for your anesthesiologist's professional service as you would from your other physicians. If you have any financial concerns, your anesthesiologist or an office staff member will answer your questions. You will note that your hospital charges separately for the medications and equipment used for your anesthetic.

Many people are apprehensive about surgery or anesthesia. If you are well-informed and know what to expect, you will be better prepared and more relaxed. Talk with your anesthesiologist. Ask questions. Discuss any concerns you might have about your planned anesthetic care. Your anesthesiologist is not only your advocate but also the physician uniquely qualified and experienced to make your surgery and recovery as safe and comfortable as possible.

NOTE: Material on this page does not constitute medical advice. Consult with your physician concerning specific medical conditions.

D. The Specialty of Chronic Pain Management - TOP

1. What does a pain management specialist do?
A pain management specialist is a physician with special training in evaluation, diagnosis, and treatment of all different types of pain.   Pain is actually a wide spectrum of disorders including acute pain, chronic pain and cancer pain and sometimes a combination of these.  Pain can also arise for many different reasons such as surgery, injury, nerve damage, and metabolic problems such as diabetes.  Occasionally, pain can even be the problem all by itself, without any obvious cause at all. 

As the field of medicine learns more about the complexities of pain, it has become more important to have physicians with specialized knowledge and skills to treat these conditions.  An in-depth knowledge of the physiology of pain, the ability to evaluate patients with complicated pain problems, understanding of specialized tests for diagnosing painful conditions, appropriate prescribing of medications to varying pain problems, and skills to perform procedures (such as nerve blocks, spinal injections and other interventional techniques) are all part of what a pain management specialist uses to treat pain.  In addition, the broad variety of treatments available to treat pain is growing rapidly and with increasing complexity.  With an increasing number of new and complex drugs, techniques, and technologies becoming available every year for the treatment of pain, the pain management physician is uniquely trained to use this new knowledge safely and effectively to help his or her patients.  Finally, the pain management specialist plays an important role in coordinating additional care such as physical therapy, psychological therapy, and rehabilitation programs in order to offer patients a comprehensive treatment plan with a multidisciplinary approach to the treatment of their pain. 

2. What should I look for in a pain management specialist?
The most important consideration in looking for a pain management specialist is to find someone who has the training and experience to help you with your particular pain problem and with whom you feel a comfortable rapport.  Since many types of chronic pain may require a complex treatment plan as well as specialized interventional techniques, pain specialists today must have more training than in the past, and you should learn about how your pain physician was trained and whether he or she has board certification in pain management.

The widely accepted standard for pain management education today is a fellowship (additional training beyond residency which occurs after graduating from medical school) in pain management.  Most fellowship programs are associated with anesthesiology residency training programs.  There are also fellowship programs associated with neurology and physical medicine and rehabilitation residency programs.  The fellowship consists of at least one year of training in all aspects of pain management after completion residency training.  When a physician has become board certified in their primary specialty and has completed an accredited fellowship, they become eligible for subspecialty board certification in pain management by the American Board of Anesthesiology, The American Board of Psychiatry and The American Board of Neurology, or the American Board of Physical Medicine and Rehabilitation.  These three are the only board certifications in pain management recognized by the American College of Graduate Medical Education.  

In addition to learning about your pain physicians training and board certification, you also should ask whether they have experience with your specific pain condition and what types of treatments they offer.  Do they only perform procedures or do they use a multidisciplinary approach to pain management?  Who do they refer to for other treatment options such as surgery, psychological support or alternative therapies?  How can they be reached if questions or problems arise?  What is their overall philosophy of pain management? 

3. How can I be referred to a pain management specialist?
The best way to be referred to a pain management specialist is through your primary care physician.  Most pain physicians work closely with their patients’ primary care physicians to insure good communication, which in turn helps provide the optimum treatment for their patients.  Patients are also often referred by specialists who deal with different types of pain problems.  Back surgeons, neurologists, cancer doctors, as well as other specialists usually work regularly with a pain physician and can refer you to one.

4. What should I expect during my first visit to a pain management specialist?
On your first visit to a pain management specialist, he or she will get to know you and begin to evaluate your particular pain problem.  This will usually involve a detailed history, a physical exam and review of tests that you have had performed.  The questions you are asked and the physical examination will focus on your particular problem, but your pain physician will want to know about past and current medical history as well. 

Often you will be given a questionnaire before your first visit that will ask detailed questions about your pain problem, and you will probably be asked to bring any imaging studies (such as X-rays, computed tomography [CAT] scans, or magnetic resonance imaging [MRI] scans) or other tests that have already been done.  You should know before your first visit whether or not a procedure is anticipated.  If so, you may need a driver to take you home. 

Most importantly, this visit is an opportunity for your pain physician to begin to analyze all of this new information and discuss with you an initial assessment of your pain problem.  He or she may know exactly what is causing your pain, or perhaps further diagnostic procedures will be needed.  But no matter what type of problem you have, you should leave this first visit with a clearer understanding of your pain and the course of further evaluation and treatment that is planned.

E. Types of Chronic Pain - TOP

1. Why am I having persistent pain?  Why doesn’t it go away like pain after a paper cut or muscle sprain?
Most of the time pain goes away after an injury heals.  However, if pain persists more than a month or two, it can become chronic pain.  Sometimes pain becomes chronic because the underlying problem does not heal.  For instance, arthritis causes long term inflammation and damage to the joints, and it may hurt as long as the inflammation lasts.  Unfortunately, chronic pain may also occur despite healing and with no obvious injury to tissues.  This may be the result of damage to the nerves that transmit pain (neuropathic pain), but chronic pain also affects the entire nervous system, sometimes in a permanent way.  When any type of pain lasts a long time there can be changes in the spinal cord and the brain that change how we perceive painful sensations.  These changes may result in severe pain with little or no painful stimulus.  Some chronic pain can be very difficult to treat and can become so frustrating for patients that it is often accompanied by depression or other emotional problems.  It is this type of pain that represents some of the most challenging problems a pain management specialist can face. 

2. What is neuropathic pain and how is it different from musculoskeletal pain (like a muscle sprain)?
We usually think of pain in terms of an injury or inflammation.  This pain can serve a useful purpose, because when we are hurt we also protect ourselves to allow healing and to prevent further injury.  Neuropathic pain, on the other hand, has no benefit.  It occurs because of abnormal function of the nervous system.  This includes a wide variety of disorders affecting any part of the nervous system from the brain to the spinal cord to the smallest nerves in the toes.  In some cases, pain sensation fibers send a signal even if there is no painful stimulus.  In other cases, sensory signals get crossed and “misread” as pain.  A stroke can leave a patient unable to process sensation properly.  And sometimes, the parts of our nervous system that help us manage pain stop working. 

3. What are some neuropathic pain syndromes?
There are many types of neuropathic pain.  Some of the more common syndromes are diabetic neuropathy, shingles and post herpetic neuralgia, painful scars (neuromas), phantom limb pain, trigeminal neuralgia (tic doloreaux) and pain associated with multiple sclerosis.  Spinal nerve injury, or radiculopathy, is a type of neuropathic pain associated with neck or low back problems.  This is the pain that “shoots” down the arm or leg, because the nerve root is compressed or irritated at the spinal column. 

Since neuropathic pain is different than injury related pain, it also needs to be treated differently.  For instance, opioids like morphine may not be as effective for neuropathic pain for some people, but other types of drugs such as membrane stabilizers (gabapentin, carbemazepine) or tricyclics (amitriptyline) can be very effective for neuropathic syndromes.  One specialized type of treatment for neuropathic pain is a spinal cord stimulator.  This device helps control pain by delivering precise electrical pulses to the spinal cord and blocking pain signals before they reach the brain.

4. What is sympathetically-mediated pain (complex regional pain syndrome)?
Complex regional pain syndrome (CRPS) is another type of neuropathic pain.  It is also know as reflex sympathetic dystrophy (RSD), causalgia, sympathetically maintained pain, as well as several other names.  This serious pain disorder may result from a major injury, but it also can be caused by a relatively minor trauma.  Why CRPS occurs still remains unknown, but no matter what the cause CRPS is associated with severe, debilitating pain.  The pain can be so intense that even lightest touch can be excruciating.  In addition, the affected limb will usually show signs of abnormal circulation, temperature, and sweating (all associated with abnormal function of the sympathetic nervous system, hence the name reflex sympathetic dystrophy), loss of function, and eventually atrophy of muscles and changes in the hair and skin.

Diagnosing CRPS may often be difficult, because a patient’s symptoms and physical findings can mimic other disorders.  Unfortunately, there is no specific test for CRPS.  The diagnosis is likely if the patient meets certain criteria based on the kind of pain they are having and the symptoms associated with their pain.  A block of the sympathetic nerves using local anesthetic has been used to help with the diagnosis, but CRPS can be present even if there is no pain relief after a sympathetic block.

CRPS can sometimes be cured in the early stages with physical therapy, sympathetic nervous system blocks and medication.  The longer it remains untreated, however, the less likely the chances of reversing the symptoms.  Recognition and treatment should take place as early as possible in the course of the syndrome, but the most important treatment at any stage of CRPS is physical therapy to assist with pain control and to preserve function. 

5. How is cancer pain different from chronic pain?
Cancer pain is different from other types of pain for several reasons, and there are special considerations that pain management specialists need to be aware of with cancer patients.   Pain associated with cancer can actually arise from many different causes.  A tumor can be painful and as it spreads, it can injure other tissues, causing increased pain.  Bone pain in particular can be especially severe.  Cancer can also affect nerves, resulting in the shooting, burning, or aching characteristics of neuropathic pain.  There can be pain associated with some cancer treatments such as chemotherapy, radiation, or surgery.  Complications from cancer such as infection, bone fractures or even bruises from multiple intravenous lines can cause additional pain.  In addition, weakness and fatigue (which may occur with chemotherapy) may make any type of pain worse, and this can be especially true for cancer patients.

Unlike many chronic pain syndromes, cancer pain will often progress, sometimes rapidly, so treatment has to be adjusted frequently, and opioids (like morphine) may need to be prescribed at higher and higher doses.  Unfortunately, patients may develop tolerance to these pain medications, making them less effective at the same time that their pain is increasing.  When this happens, interventional techniques such as spinal pain pumps or destroying pain nerves may offer significant relief for some cancer patients while allowing the dosage of pain medicines to be lowered.  This in turn can help avoid the side effects of opioid medicines, such as sedation or confusion.  Ultimately, the pain specialist and primary care physician should work as a team to not only control pain but also help patients maintain dignity, quality of life and the ability to be with family and friends.  

F. Treatment Options for Chronic Pain - TOP

1. What general options do I have to treat my pain?
There are a variety of options for the treatment of chronic pain.  Under the general category of medications, there are both oral and topical therapies for the treatment of chronic pain.  Oral medications include those that can be taken by mouth, such as nonsteroidal anti-inflammatory drugs, acetaminophen, and opioids.  Also available are medications that can be applied to the skin, whether as an ointment or cream or by a patch that is applied to the skin.  Some of these patches work by being placed directly on top of the painful area where the active drug, such as lidocaine, is released.  Others, such as fentanyl patches, may be placed at a location far from the painful area.  Some medications are available over the-counter (OTC) while others may require a prescription. 

There are many things that may help with your pain which do not involve medications.  These things may help relieve some pain and reduce the medications required to control your pain.  Examples include exercises, best performed under the direction of a physical therapist.  There are also alternative modalities, such as acupuncture.  Transcutaneous Electro-Nerve Stimulator (TENS) units use pads that are placed on your skin to provide stimulation around the area of pain and may help to reduce some types of pain symptoms. 

Finally, there are interventional techniques that involve injections into or around various levels of the spinal region.  These can involve relatively superficial injections into the painful muscles, called trigger point injections, or may involve more invasive procedures.  There are multiple procedures that range from epidural injections for pain involving the neck and arm or the back and leg, facet injections into the joints that allow movement of the neck and back to injections for burning pain of the arms or legs due to a syndrome called Complex Regional Pain Syndrome or Reflex Sympathetic Dystrophy (CRPS). 

2. What are some of the typical medications used for the treatment of chronic pain?  What are some of the common side effects associated with these medications?
There are several categories of medications that are used for the treatment of chronic pain.  In general, your primary physician, patient management specialist, or pharmacist may be to answer any questions about the dosage and side effects from these medications.  The most commonly used medications can be divided into the following broad categories:

1. Nonsteroidal Anti-inflammatory Drugs and Acetaminophen:  There are many different types of nonsteroidal anti-inflammatory medications (NSAIDs), some of them (such as ibuprofen) may be obtained over-the-counter.  NSAIDs can be very effective for acute muscular and bone pain as well as some types of chronic pain syndromes.  When taken for an extended period of time or in large quantities, they may have negative effects on the kidneys, clotting of blood, and gastrointestinal system.  Bleeding ulcers is a risk of these medications.  Long-term use of cyclooxygenase II (COX II) inhibitors may be associated with an increase in cardiovascular (heart) risks.  Acetaminophen is easily obtained over-the-counter, however, care should be taken not to take more than 4000 mg in 24 hours; otherwise, several liver failure may occur.  There are some opioid medications that combine acetaminophen within the medication.  You should be aware that many over-the-counter medications have acetaminophen as one of their ingredients and when taken in combination with prescribed medication, this may result in an overdose of acetaminophen.
2. Antidepresssants:  Some of the older categories of antidepressants may be very helpful in controlling pain; specifically the tricyclic antidepressants.  The pain relieving properties of these medications are such that they can relieve pain in doses that are lower than the doses needed to treat depression.  These medications are not meant to be taken on an “as needed” basis but must be taken every day whether or not you have pain.  Your physician may attempt to lessen some of the side effects, particularly sedation, by having you take these medications at night.  There are some other side effects like dry mouth that can be treated with drinking water or fluids.  These medications may not be given to patients with certain types of glaucoma.  In addition, these medications should never be taken in larger doses than are prescribed.
3. Anticonvulsants (Anti-seizure) Medications:  These medications can be very helpful for some kinds of nerve type pain (such as burning, shooting pain).  These medications also are not meant to be taken on an “as needed” basis.  They should be taken every day whether or not you feel pain.  Some of them may have the side effect of drowsiness which often improves with time.  Some have the side effect of weight gain.  If you have kidney stones or glaucoma, be sure to tell your doctor as there are some anticonvulsants that are not recommended to be given under those conditions.  The newer anticonvulsants do not need liver monitoring but required caution if given to patients with kidney disease.
4. Muscle Relaxants: These medications are most often used in the acute setting of muscle spasm.  The most common side effect seen with these medications is drowsiness. 
5. Opioids:  When used appropriately, opioids may be very effective in controlling certain types of chronic pain.  They tend to be less effective or require higher doses in nerve type pain.  For pain is present all day and night, a long acting opioid is usually recommended.  One of the most frequent side effects is constipation, which if mild may be treated by drinking lots of liquids, but may need to be treated with medications.  Drowsiness is another side effect which often gets better over time as you get used to the medication.  Excessive drowsiness should be discussed with your physician.  Nausea is another side effect which may be difficult to treat and may require changing to another opioid.

3. If I am taking narcotic (opioid) medication for chronic pain, does that mean I am addicted?
Taking opioids in the way that they have been prescribed by your doctor for the treatment of chronic pain is associated with a very low risk of becoming addicted to those opioids.  There are some predisposing factors to opioid addiction.  These include having a history or a family history of substance abuse or of certain psychiatric illnesses.  The following are definitions for addiction, tolerance, and physical dependence according to the American Pain Society: 
Addiction has a genetic basis in addition to a psychological aspect to the behavior.  Addiction is associated with a craving for the abused substance (such as an opioid), and continued, compulsive use of that substance despite harm to the person using the substance.  In addition to having a genetic predisposition, there may be an environmental influence affecting both the development and manifestation of the additive behavior. 
Tolerance occurs after prolonged exposure to a drug.  The effects of that drug results in progressive decrease in its effectiveness. 
Physical Dependence is usually seen in the form of drug withdrawal after the drug has been abruptly stopped or rapidly reduced.  It can also be seen when an opioid antagonist is given to someone who is taking an opioid.  It is a state of adaptation.  Withdrawal symptoms last from approximately 6 to a peak of 24 to 72 hours after the drug has been withdrawn.  Some of the symptoms include nausea, vomiting, sweating, abdominal pain or diarrhea and can occur after taking the opioid for as short a period as 2 weeks.  It is not a sign of addiction.

If you are prescribed opioids by your doctor, you are to take the opioids as they have been prescribed.  If your pain continues despite taking the opioid, it is inadvisable to take more opioid than prescribed without first seeking the advice of your doctor.  Taking a long-acting opioid a few times per day is less likely to give the sensation of euphoria that may be associated with some short acting opioids.  Long-acting opioids are not meant to be taken on an “as needed” basis and should be taken whether or not you have pain and should not be taken more frequently than prescribed by your doctor.  Constipation is one of the more frequently seen side effects of chronic opioid use, remedies, such as stool softeners and stimulants, are available.

4. What are some of the more common nerve block procedures for the treatment of chronic pain?  What are some of the common side effects associated with these nerve blocks?
The vast majority of injections done for the diagnosis or treatment of chronic pain are performed on an outpatient basis.  Some are performed on inpatients, who may be already hospitalized for other reasons.  All of them may be performed under fluoroscopic (x-ray) guidance but are sometime performed in the office without x-ray.  For any nerve block, you need to tell your doctor if you are allergic to contrast dye or if you think you may be pregnant.  Below is a brief description of some of the more commonly performed nerve blocks by pain management specialists.

Epidural Steroid injection: Epidural steroid injection is an injection performed in the back or neck in an attempt to place some anti-inflammatory steroid with or without a local anesthetic into the epidural space close to the inflamed area that is causing the pain.  These injections are generally done for pain involving the back and leg or the neck and arm/hand.  They may be done under x-ray guidance.  Common side effects include soreness of the back or neck at the point where the needle enters the skin, there may be some temporary numbness in the involved extremity but persistent numbness or weakness (lasting over 8 hours) should be reported to your doctor.  Epidural steroid injections may be placed in the lumbar (low back), thoracic (mid back), or cervical (neck) regions.  

Facet Joint Injection: The facet joints assist with movement of the spine both in the neck and back.  Injection into these joints can provide relief of neck and back pain; these injections are always performed under x-ray guidance.  Common side effects include soreness in the neck or back when the needle was inserted.  You will be on your stomach for this injection if it is done for back pain; however you may either be on your stomach or back if the injection is performed for neck pain, depending on the preference of the physician.  A needle is placed in your neck or back and advanced to the level of the joint under x-ray visualization.  Contrast dye is used if the needle is put within the joint, and sometimes used if the injection is designed to numb the nerves to the joint.  This block is often a diagnostic block and a more long lasting injection may be indicated if you have significant pain relief from this injection.

Lumbar Sympathetic Block: A lumbar sympathetic nerve block is performed for pain in the leg that is thought to be caused by complex regional pain syndrome type I (or CRPS I).  These injections are often performed under fluoroscopic (x-ray) guidance.  Local anesthetic is placed near to the lumbar sympathetic chain in order to relieve the pain.  Your leg will likely become warm immediately following the injection: this is an expected effect and not a complication.  Back soreness is one of the more common side effects.  If you feel any sharp pains down your leg or to your groin during the injection, you should let the physician know immediately.  There may be some temporary numbness following the injection but if there is persistent numbness or weakness (> 8 hours) the doctor should be notified.  You will be lying on your stomach for this injection.  The injection is done from the back, in the lower aspect of the back.  A needle is placed, often under x-ray guidance, to a spot just to the side and approaching the front part of the spine where the ganglion is located.  If it is done under x-ray, a small amount of dye is injected to make sure the needle is in the right spot.  After the doctor is satisfied that the contrast dye is in the right place, they will inject numbing medicine then remove the needle. 

Celiac Plexus Block: A celiac plexus block is generally performed to relieve pain in patients with cancer of the pancreas or other chronic abdominal pains.  A needle is placed via your back that deposits numbing medicine to the area of a group of nerves called the celiac plexus.  This injection is often performed as a diagnostic injection to see whether a more permanent injection may help with the pain.  If it provides significant pain relief then the more long lasting injection may be done.  This injection is usually performed under x-ray guidance.  You will be lying on your stomach for this injection.  The needle is place via the mid back and placed just in front of the spine.  Contrast dye is injected to confirm that the needle is in the right spot; followed by some numbing medicine.

Stellate Ganglion Block: A stellate ganglion block is an injection that can be performed for the diagnosis of complex regional pain syndrome of the arm or hand or for treatment of pain to that area.  It can also be used to help to improve blood flow to the hand or arm in certain conditions that result in poor circulation of the hand.  Side effects may include soreness in the neck where the needle was placed.  In some instances the side effects may include droopiness of your eyelid on the side that is injected, along with a temporarily stuffy nose and sometimes temporary difficulty in swallowing.  This injection is performed with or without x-ray guidance.  You will be lying on your back for this injection with your mouth slightly open.  It is very helpful to the doctor if you try not to swallow during the injection.  If this injection is performed under x-ray the doctor will first inject a small amount of contrast to confirm the placement of the needle then inject some numbing medicine. 

5. Will I receive a bill from the pain management specialist?
Your pain management specialist is a physician specialist like your surgeon or internist, and you probably will receive a bill for your pain management specialist's professional service as you would from your other physicians. If you have any financial concerns, your pain management specialist or an office staff member will answer your questions.

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