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Services

The Peregrine Institute performs the following interventional pain management treatments:

PATIENT SERVICES

Treating pain has become a free­ standing specialty of Medicine. Becoming a Fellowship­ Trained, Board­ Certified Pain Doctor requires subspecialty training beyond our primary specialty. It involves learning a multidimensional approach to the patient suffering from chronic pain and combining different treatment alternatives to obtain better results than the simplistic paradigm of giving pain pills. Further experience is required to expand into the realm of Palliative Care Medicine, which deals not only with pain but many other symptoms that coexist in serious illness conditions. Depression and anxiety, weight loss and lack of appetite, nausea, insomnia, chronic fatigue, shortness of breath, needs for rehabilitation, all of these can contribute to a poor quality of life. Cancer survivors may also suffer from these chronic ailments and it is Palliative Care doctors that help them get better and move on with their lives.

Supportive Care is the modern name for Palliative Care Medicine. It is an attempt to detach the negative perception of end-­of­-life care that has prevented so many patients from accessing the benefits of medical professionals that can help improve their lives. Supportive Care doctors will follow their patients at outpatient clinics, at the hospital and many even do routine house calls. I believe the services of these physicians are underutilized, frequently sought only in the late stages of disease, thus preventing the benefits of specialized pain and symptom management from optimizing how patients afflicted with serious illness live their lives and frankly, how they die.

Hospice is not a place, certainly not a place for the dying but rather an institution organized around the concept of providing medical care toward the goal of maintaining the best possible quality of life for those who suffer from an illness unlikely to be cured. Most Hospice care occurs in the patient’s home. When somebody is enrolled in Hospice, they receive coordinated care in the form of visits to the patient’s location by the hospice physician, nurse, medical social worker, home­health aide and chaplain/spiritual adviser

∙ Medication for pain relief and symptom control

∙ Physical and occupational therapy

∙ Medical equipment like wheelchairs or walkers and medical supplies like bandages and catheters

∙ Dietary counseling

∙ Short­term inpatient care

∙ Short­term respite care (relief from caregiving to avoid “caregiver burnout”)

∙ Grief and loss counseling for patient and loved ones

All of this is typically covered under the Hospice program at no cost.

Most patients with terminal illness never enroll in Hospice and the most common reason for that is they were not told about it, they just did not know. As a
consequence, the moment of passing more commonly occurs at the hospital instead of at home surrounded by loved ones. An expert Hospice team that addresses the symptoms and issues of end­of­life can ensure a better transition.
At The Peregrine Institute, we provide you with everything you need to know about Hospice when the time is right. We help you make the decision of when to consider it and facilitate enrolment.

At The Peregrine Institute we treat chronic pain conditions, particularly those that have proved resilient to conventional management.

∙ Arthritis pain in the knees, shoulders, hips and other joints

∙ Chronic postoperative pain

∙ Phantom limb/post­amputation pain

∙ Back pain and sciatica

∙ Neck pain

∙ Chronic Abdominal or Pelvic pain

∙ Genital (penile, testicular, vaginal) pain

∙ Rectal/anal pain

∙ Intractable leg pain from insufficient blood flow

∙ Reflex sympathetic dystrophy (RSD), now called Complex Regional Pain Syndrome (CRPS)

∙ Headaches

∙ Facial Pain (Trigeminal Neuralgia)

We do not use pills only but a more individualized treatment plan for each case.

Procedures we offer:

Musculoskeletal:

∙ Trigger Point Injections

∙ Joint Injections (knee, shoulder, hip, sacroiliac, TMJ and others)

∙ Joint Injections to Bursa (trochanteric, bicipital, deltoid, rotator cuff and others)

Facial Pain (Trigeminal Neuralgia) and Headaches:

∙ Trigeminal Nerve Blocks and Neurolysis

∙ Sphenopalatine Ganglion Block and Neurolysis

∙ Botox Injections for Migraines and Cervical Dystonia

∙ Occipital Nerves Neurostimulation

∙ Trigeminal Peripheral Branches Neurostimulation

∙ Epidural Blood Patch

Spine:

∙ Epidural Steroid injections

∙Nerve Blocks

∙Radiofrequency Ablation

∙ Vertebroplasy/Kyphoplasty and Vertebral body RFA for Pain control

∙ Percutaneus Disc Decompression

∙ Spinal Cord Stimulation

∙ Intrathecal Pumps

∙ Sacroilliac Joint Injection

Pelvic and Genital Pain:

∙ Superior Hypogastric Plexus Block and Neurolysis

∙ Pudendal Nerves Block and Neurolysis

∙ Ganglion Impar Block

∙ Ilioinguinal/Genitofemoral Nerves Block and Neurolysis

Chest and Abdominal Wall Pain:

∙ Intercostal Nerves Block and RFA

∙ Scar Treatment with RFA for pain

∙ Neurostimulation

Cancer Pain:

∙ Celiac Plexus Block and Neurolysis

∙ Superior Hypgastric Plexus Block and Neurolysis

∙ Tunneled Implanted Epidural Catheters

∙ Intrathecal pumps

RSD (Complex Regional Pain Syndrome)

∙ Stellate Ganglion Block and Neurolysis

∙ Lumbar Sympathetic Block and Neurolysis

∙ Ketamine Intravenous Infusion

Neuromodulation:

∙ Spinal Cord Stimulation for Post­laminectomy syndrome, Painful Peripheral Neuropathy, CRPS type 1, Peripheral Vascular Disease, Intractable Angina, upper and lower extremities intractable pain, post­amputation pain

∙ Peripheral Nerve Stimulation for Intractable Headaches (Occipital and Trigeminal), Trigeminal nerve main branches stimulation, Neuropathies

∙ Intrathecal Pumps for intractable spasticity (Baclofen pumps), Neuropathic Pain, Cancer pain

For years, Dr. Sarria has been at the forefront of the newest treatments for intractable headaches and facial pain, including:

∙ Trigeminal nerve blocks and Neurolysis: Main branches (Mandibular and Maxillary, Gasserian Ganglion) and peripheral branches (Supraorbital, supratrochlear, Auriculo­Temporal, Occipital)

∙ Sphenopalatine Ganglion block and Neurolysis

∙ Botox Injections for Migraines and Cervical Dystonia

∙ Occipital Nerve and Peripheral Nerve Stimulation. These techniques apply Pacemaker technology to the treatments of severe headache syndromes that have not responded to conventional treatment.

Much information about this therapeutic modality can be found through this support group’s Facebook page: Occipital and Peripheral Nerve Stimulation. The Facial Pain Association (http://fpa­support.org) also offers information and support for patients afflicted with chronic facial pain such as Trigeminal Neuralgia.

play43Watch video Trigeminal Neuralgia

PAIN MANAGEMENT PROCEDURES

MUSCULOSKELETAL:

What is a Trigger Point Injection?

Trigger Point Injection (TPI) may be an option for treating pain in certain patients. TPI is a procedure that treats painful areas of muscle that contain trigger points or knots of muscle that form when muscles do not relax. These trigger points can irritate the nerves around them and cause pain. A small needle is inserted into the trigger point area. The injection contains medication, such as, a local anesthetic, saline, and/or a steroid that will inactivate the pain at the trigger point. Several areas may be injected at one visit. TPI can be used to treat many muscle groups, especially those in the arms, legs, lower back, jaw and neck. Your pain may resolve after one injection or you may need injections on a regular basis.

TPIs are used in conditions that produce painful muscle spasms such as arthritis of the spine.

This procedure is typically done in the clinic room. There is no need to fast and the patient can drive afterwards.

If you take blood thinners or have any condition that reduces your ability to stop bleeding (p.e. low platelets, hemophilia), please let your physician at The Peregrine Institute know

What to expect/common symptoms with this procedure

∙ Pain at the injection site after the procedure. This usually resolves in a few hours

∙ Bleeding or bruising at the injection site(s).

∙ If a steroid medication is used and you are a diabetic, monitor your blood sugar levels closely for the next two days as higher than usual levels may occur.

Wound Care

∙ Monitor the injection site(s) for signs and symptoms of infection: redness, swelling, drainage.

∙ You may shower after your procedure.

∙ Ice, heat, or over-the-counter medications such as acetaminophen, ibuprofen, or naproxen sodium may help the post-injection pain. Check with your doctor first before taking any new medication.

Activity

∙ You may gradually return to your normal activity immediately after the procedure or as your doctor permits.

When to call the doctor

∙ Redness, swelling, and/or drainage at the injection site(s).

∙ Pain at the injection site(s) that does not resolve in a few days.

∙ Fever of 100.5°F or greater.

∙ Significant bleeding at the injection site (s).

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play43Watch Video Trigger point injections

What is a Joint Injection?

It is an injection of local anesthetic and steroid into joints that are painful due to arthritis or other conditions. It is injected into a specific joint to reduce inflammation and relieve pain. Typical joints that benefit from these injections include the Hip, Knee, Shoulder and others.

The procedure may be performed in the clinic or in the procedure room under X-rays. It is outpatient and unless sedation is required, there is no need to fast and the patient can drive afterwards.

If you take blood thinners or have any condition that reduces your ability to stop bleeding (p.e. low platelets, hemophilia), please let your physician at The Peregrine Institute know.

What to expect/common symptoms with this procedure

∙ You may have immediate pain relief from the local anesthetic, but this may only last for a few hours. The longer lasting relief may take 48 to 72 hours. Pain relief varies from person to person and can last from weeks to months.

∙ The joint injected may feel numb, weak, or lose its sensation for a few hours after the procedure. This is caused by the local anesthetic.

∙ Dizziness, flushing, or temporary elevation in blood sugar may occur when steroids are injected.

Wound Care

∙ Monitor the injection site for signs and symptoms of infection.

∙ You may shower the same day you had the procedure.

∙ You may apply an ice pack to the injection site for 15 minutes every hour for the next 24 hours while awake.

Activity

∙ You may gradually return to your normal activity level within 24 hours or as directed by your doctor.

When to call the doctor

∙ Signs and symptoms of infection: redness, swelling, foul odor or drainage at your injection site.

∙ Fever of 100.5°F or greater.

∙ Significant bleeding from your injection site.

∙ If your pain symptoms get worse.

∙ Weakness or numbness in your arms and/or legs for longer than 4 hours.

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play43Watch Video Joint injection (shoulder Therapeutic)

play43Watch Video Fluoroscopic Guided Hip Injection

play43Watch Video Platelet Rich Plasma (PRP) Injection Treatment for Knee Arthritis

play43Watch Video Visco-supplementation for Arthritis of the Knee

Bursa injection can help soothe joint pain caused by arthritis, bursitis and other painful inflammatory diseases. A bursa is a gel-filled sac that helps muscles and tendons glide over bones. You have bursae in your shoulders, elbows, hips, knees and other parts of your body. When bursae get swollen, they can cause joint pain. But a steroid medication injected into your bursa can help reduce the inflammation and alleviate the pain.

What is a Joint Injection?

It is an injection of local anesthetic and steroid into joints that are painful due to arthritis or other conditions. It is injected into a specific joint to reduce inflammation and relieve pain. Typical joints that benefit from these injections include the Hip, Knee, Shoulder and others.

The procedure may be performed in the clinic or in the procedure room under X-rays. It is outpatient and unless sedation is required, there is no need to fast and the patient can drive afterwards.

If you take blood thinners or have any condition that reduces your ability to stop bleeding (p.e. low platelets, hemophilia), please let your physician at The Peregrine Institute know.

What to expect/common symptoms with this procedure

∙ You may have immediate pain relief from the local anesthetic, but this may only last for a few hours. The longer lasting relief may take 48 to 72 hours. Pain relief varies from person to person and can last from weeks to months.

∙ The joint injected may feel numb, weak, or lose its sensation for a few hours after the procedure. This is caused by the local anesthetic.

∙ Dizziness, flushing, or temporary elevation in blood sugar may occur when steroids are injected.

Wound Care

∙ Monitor the injection site for signs and symptoms of infection.

∙ You may shower the same day you had the procedure.

∙ You may apply an ice pack to the injection site for 15 minutes every hour for the next 24 hours while awake.

Activity

∙ You may gradually return to your normal activity level within 24 hours or as directed by your doctor.

When to call the doctor

∙ Signs and symptoms of infection: redness, swelling, foul odor or drainage at your injection site.

∙ Fever of 100.5°F or greater.

∙ Significant bleeding from your injection site.

∙ If your pain symptoms get worse.

∙ Weakness or numbness in your arms and/or legs for longer than 4 hours.

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FACIAL PAIN (TRIGEMINAL NEURALGIA) AND HEADACHES:

Sphenopalatine, Supraorbital, Supratrochlear, and Trigeminal Nerve Block/Radiofrequency ablation

What are these nerve blocks?

A Sphenopalatine nerve block is an injection of a local anesthetic close to the sphenopalatine ganglion nerve. This nerve carries pain signals to the head and face and is located in the back portion of your nasal cavity. A Supraorbital / Supratrochlear nerve block is an injection of a local anesthetic close to these nerves located under your eyebrow but above the eye. These nerves carrie pain signals to the scalp, forehead, and upper eyelid. These injections are typically used for headache syndromes such as Migraines, Cluster headaches and many others. They can also be beneficial for certains types of nerve pain such pain after shingles when it is located in the face.

A Trigeminal nerve block is an injection of a local anesthetic close to the trigeminal nerve located in the inside of your face to treat facial pain such as Trigeminal Neuralgia and other types of facial pain.

When any of these blocks prove significantly beneficial, the patient may be a candidate for a Radiofrequency ablation which is a very similar procedure with needles in the same place as the block described above but instead of injecting local anesthetic, an electrical probe is passed through the needle to provide a Radiofrequency treatment on the nerves that may provide prolonged pain relief (average 3-6 months) and can repeated as needed. Radiofrequency ablation, although commonly referred to as “burning the nerve” is a very mild treatment that does not cause any permanent damage on nerves but rather acts as a stun gun that slows the processing of pain signals without interfering with normal functions of the nerve. The result is typically pain relief without areas of numbness or weakness.

The procedure is outpatient with minimal recovery time. It requires minimal or no sedation.

If you take blood thinners or have any condition that reduces your ability to stop bleeding (p.e. low platelets, hemophilia), please let your physician at The Peregrine Institute know before you undergo any of these procedures.

What to expect/common symptoms with this procedure

∙ Tenderness at the injection site.

∙ Minimal bleeding at the injection site.

∙ Bruising at the injection site.

∙ Puffiness around your eye.

∙ Droopy eye from temporary eyelid weakness.

Wound care

∙ Monitor injection site for signs and symptoms of infection.

∙ You may shower the same day you had the procedure.

∙ You may apply an ice pack to the injection site for 15 minutes every hour for the next 24 hours, while awake if neeeded

Activity

∙ You may gradually return to your normal activity level within 24 hours or as directed by your doctor.

When to call the doctor

∙ Signs and symptoms of infection: redness, swelling, foul odor or drainage at your injection site.

∙ Fever of 100.5°F or greater.

∙ Significant bleeding from your injection site.

∙ Uncontrolled pain.

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Sphenopalatine, Supraorbital, Supratrochlear, and Trigeminal Nerve Block/Radiofrequency ablation

What are these nerve blocks?

A Sphenopalatine nerve block is an injection of a local anesthetic close to the sphenopalatine ganglion nerve. This nerve carries pain signals to the head and face and is located in the back portion of your nasal cavity. A Supraorbital / Supratrochlear nerve block is an injection of a local anesthetic close to these nerves located under your eyebrow but above the eye. These nerves carrie pain signals to the scalp, forehead, and upper eyelid. These injections are typically used for headache syndromes such as Migraines, Cluster headaches and many others. They can also be beneficial for certains types of nerve pain such pain after shingles when it is located in the face.

A Trigeminal nerve block is an injection of a local anesthetic close to the trigeminal nerve located in the inside of your face to treat facial pain such as Trigeminal Neuralgia and other types of facial pain.

When any of these blocks prove significantly beneficial, the patient may be a candidate for a Radiofrequency ablation which is a very similar procedure with needles in the same place as the block described above but instead of injecting local anesthetic, an electrical probe is passed through the needle to provide a Radiofrequency treatment on the nerves that may provide prolonged pain relief (average 3-6 months) and can repeated as needed. Radiofrequency ablation, although commonly referred to as “burning the nerve” is a very mild treatment that does not cause any permanent damage on nerves but rather acts as a stun gun that slows the processing of pain signals without interfering with normal functions of the nerve. The result is typically pain relief without areas of numbness or weakness.

The procedure is outpatient with minimal recovery time. It requires minimal or no sedation.

If you take blood thinners or have any condition that reduces your ability to stop bleeding (p.e. low platelets, hemophilia), please let your physician at The Peregrine Institute know before you undergo any of these procedures.

What to expect/common symptoms with this procedure

∙ Tenderness at the injection site.

∙ Minimal bleeding at the injection site.

∙ Bruising at the injection site.

∙ Puffiness around your eye.

∙ Droopy eye from temporary eyelid weakness.

Wound care

∙ Monitor injection site for signs and symptoms of infection.

∙ You may shower the same day you had the procedure.

∙ You may apply an ice pack to the injection site for 15 minutes every hour for the next 24 hours, while awake if neeeded

Activity

∙ You may gradually return to your normal activity level within 24 hours or as directed by your doctor.

When to call the doctor

∙ Signs and symptoms of infection: redness, swelling, foul odor or drainage at your injection site.

∙ Fever of 100.5°F or greater.

∙ Significant bleeding from your injection site.

∙ Uncontrolled pain.

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What is a Botox® injection?

Botox® (BotulinumToxin) injections are used to relieve pain and relax chronic muscle spasm. Botox® blocks the nerve signals that trigger muscle hyperactivity. Botox® injections may be repeated, but no more frequent than every 12 weeks.

In Pain Medicine, these injections are used to treat headaches, spasm of the muscles in the neck and to alleviate contractures in conditions that cause muscle spasm such as multiple sclerosis, spinal cord injury or cerebral palsy.

The procedure is usually performed in a clinic room, it takes about 5 minutes, the patient does not need to fast and can drive afterwards.

If you take blood thinners or have any condition that reduces your ability to stop bleeding (p.e. low platelets, hemophilia), please let your physician at The Peregrine Institute know

What to expect/common symptoms with this procedure

∙ It may take up to three weeks to feel the full effect of the injection, results are different for each person and can last around three months.

∙ Tenderness and/or bruising at the injection site.<

∙ Temporary drooping of eyelids and/or eyebrows from facial injections.

∙ Temporary dry eye and reduced blinking from facial injections.

Wound Care

∙ Monitor injection site for signs and symptoms of infection (see below).•You may shower the day of the procedure.

∙ Apply an ice pack to the injection site for 15 minutes every hour for the next 24 hours, while awake, to minimize bruising.

Activity

∙ You may gradually return to normal activity within 24 hour or as your doctor permits.

When to call the doctor

∙ Signs and symptoms of an infection: redness, foul odor and/or drainage at injection site.

∙ Fever of 100.5°F or greater.

∙ Persistent drooping of eyelid and/or eyebrow that does not go away within seven days.

∙ Persistent dry eyes and/or reduced blinking that does not go away within three days.

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What is an occipital nerve stimulator trial?

Occipital nerve stimulation or ONS is the use of mild electrical impulses to stimulate one or both of the occipital nerves. These nerves are located at the back of the head (base of the skull). ONS is an innovative modality to treat severe, intractable headaches such as migraines, cluster and many others. Occipital nerve stimulation does not remove the source of pain; it simply interferes with the nerve pain signal to the brain. ONS uses the same equipment as a Spinal Cord Stimulator which has similar technology to Pacemakers and is comprised of the leads (cables with electrodes) and a generator unit, all implanted under skin. ONS is not approved by the FDA, so its use is called “off-label”. Many insurance companies do not cover ONS because of this. All the equipment utilized has been FDA-approved for Spinal Cord Stimulation for many years. That should reassure you that no experimental equipment is being used on you, what is not approved by the FDA is the placement of the leads on the occipital nerves. They are requiring more evidence that this technique works in the form of research clinical trials.

ONS has been approved in Europe for treatment of headaches.

Before you undergo the Occipital Nerve Stimulator Implant procedure, you must have a Trial in order to establish that the system will work for you. A lead (wire) is inserted through the skin with a needle, close to the occipital nerves. The lead will now be connected to a small generator outside of your body. The generator will be programmed to send signals via the lead(s)to the area of your pain. Hopefully, this signal will help decrease your pain. This trial will last approximately 3-7 days at home. After the procedure, you will return to remove the electrode(s) and to discuss the results of the trial with your doctor.

What to expect/common symptoms with this procedure

∙ Pain relief is different from person to person.

∙ You may experience discomfort at the electrode insertion site.

∙ Minimal bleeding and/or bruising at the electrode insertion site.

∙ When you change position (lying to sitting, sitting to standing, moving in bed) you may feel changes in the intensity of the nerve stimulation. This is normal. Nothing is wrong with the occipital nerve stimulator. It is trying to adjust to movement of your body.

Wound Care

∙ Monitor lead insertion site for signs and symptoms of infection(see below).

∙ Avoid bending, overhead reaching and sharp twisting of the neck.

∙ Avoid strenuous exercise, including lifting anything over 10 pounds.

∙ Keep dressing clean and dry. Reinforce dressing with additional tape if it becomes loose.

∙ Sponge bathing is allowed. Do Not shower or use a bathtub, pool, or Jacuzzi until your doctor says it is okay. Usually after your first clinic visit after the procedure.

Activity

∙ You may gradually return to your normal activity level as directed by your doctor.

When to call the doctor

∙ Signs and symptoms of infection: redness, swelling, foul odor and/or drainage at the surgical site.

∙ Fever of100.5°For greater.

∙ Significant bleeding from the surgical site.

∙ Uncontrolled pain.

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SPINE:

What is an Epidural Steroid Injection?

An Epidural Steroid Injection or ESI is a common minimally invasive procedure utilized to treat pain and inflammation in the spine, neck and limbs. The epidural space is located outside the spinal cord within a bony canal created by the vertebral column or spine. Many of the nerves that go from the spine to different parts of the body cross through the epidural space in a predictable location. That is why ESI’s are performed very frequently.

The most common reason to do an ESI is when a herniated disc (a gel-like structure within the spine) impinges and irritates one of the nerves that go to the legs, causing Sciatica or to the arms.

During an ESI, a needle is advanced towards the epidural space under X-ray guidance. The proper final position of the needle is confirmed using X-ray contrast material. Once position is certain, a mix of a local anesthetic (Novocaine-type medicine) and a steroid (anti-inflammation medicine) is injected into the space close to the nerves being targeted. The numbing and anti-inflammatory effect of the injectate will hopefully provide the desired effect of pain relief. There is often the need to repeat ESI’s up to 3 times in a 6 month period in order to obatain maximum benefit. Some insurance companies do not allow but a fixed number of treatments per year.

There are different approaches to doing an ESI:

∙ Interlaminar: Needle is inserted midline at the appropriate level of the spine that targets the pain being treated.

∙ Transforaminal: Needle is inserted on the side of the midline at the appropriate level of the spine that targets the pain being treated.

∙ Caudal: Needle is inserted through the tailbone and sometimes a catheter is advanced through the needle to reach a specific site within the spine.

There are many factors involved in the decision of what approach to use. Your physician at The Peregrine Institute will explain the procedure in detail.

An ESI is is outpatient with minimal recovery time. It requires minimal or no sedation.

If you take blood thinners or have any condition that reduces your ability to stop bleeding (p.e. low platelets, hemophilia), please let your physician at The Peregrine Institute know before you undergo an ESI.

What to expect/common symptoms with this procedure

∙ Pain relief may occur immediately following the procedure; however, it is temporary due to the local anesthetic.Longer lasting pain relief occurs in 3 to 5 days and may last from weeks to months

∙ Tenderness at the injection site.

∙ Minimal bleeding/bruisingat the injection site.

∙ Dizziness, flushing, or temporary elevation in blood sugar may occur when steroids are injected.

Wound Care

∙ Monitor the injection site for signs and symptoms of infection.

∙ You may shower the same day you had the procedure.

∙ You may apply an ice pack to the injection site for 15 minutes every hour for the next 24 hours while awake.

Activity

∙ You may gradually return to your normal activity level within 24 hours or as directed by your doctor.

When to call the doctor

∙ Signs and symptoms of infection: redness, swelling, foul odor or drainage at your injection site.

∙ Fever of 100.5°F or greater.

∙ Significant bleeding from your injection site.

∙ If your pain symptoms get worse.

∙ If you feel numbness and weakness in your limb(s) for more than 4 hours.

∙ Persistent headache.

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play43Watch Video Caudal Epidural Steroid Injection

play43Watch Video Cervical Epidural Steroid Injection

play43Watch Video Lumbar Epidural Steroid Injection

play43Watch Video Lumbar Transforaminal Epidural Steroid Injection

What is a Nerve Block?

A nerve block is an injection of local anesthetic (Novovaine-type medicine) and sometimes a steroid. It is injected into a specific area of the body to help numb a nerve or group of nerves causing pain. Nerve blocks provide only temporary pain relief, rarely they may provide a prolonged effect. In many cases, a nerve block is a diagnostic tool to help figure out the pain generator in a specific area.

Some of the nerve blocks typically performed at The Peregrine Institute include:

∙ Pudendal Nerve for pain in the genital and anal area.

∙ Trigeminal Nerve for pain in the face.

∙ Ilioinguinal Nerve for pain in the groin.

∙ Occipital Nerve for headcahes and pain in the neck.

∙ Supraorbital/Supratrochlear Nerves for headaches and pain in the face.

∙ Medial Branch Nerves for pain in the spine, either low back, neck or mid-back.

∙ Intercostal nerves for pain in the breast and ribcage area

These are just a few examples, many other nerves can be blocked in the course of a pain management treatment plan.

The procedure is outpatient with minimal recovery time. It requires minimal or no sedation.

When any of these blocks prove significantly beneficial, the patient may be a candidate for a “Neurolytic block”, typically Radiofrequency ablation which is a very similar procedure, with needles in the same place as the blocks described above but instead of injecting local anesthetic, an electrical probe is passed through the needle to provide a Radiofrequency treatment on the nerves that may provide prolonged pain relief (average 3-6 months) and can repeated as needed. Radiofrequency ablation, although commonly referred to as “burning the nerve” is a very mild treatment that does not cause any permanent damage on nerves but rather acts as a stun gun that slows the processing of pain signals without interfering with normal functions of the nerve. The result is typically pain relief without areas of numbness or weakness.

If you take blood thinners or have any condition that reduces your ability to stop bleeding (p.e. low platelets, hemophilia), please let your physician at The Peregrine Institute know before you undergo any of these procedures.

What to expect/common symptoms with this procedure

The most important aspect of a nerve block is the ability of the patient to evaluate whether or not the procedure provided meaningful pain relief for any length of time. It does not matter how long the relief lasts. Many patients, when asked about the results of a block on a follow-up visit, state it did not work because the pain came back when, in fact, this is expected. If the patient does not pay attention to the pain in the few hours following the procedure, for example by falling asleep on the ride home or going straight to bed, the procedure was pointless, a waste of time. The purpose of the nerve block is to find the culprit for your pain and the only way it can do that is by your ability to establish relief of the pain. We will ask you that question in your follow-up appointment with us and if you cannot answer it, no benefit was derived.

∙ Frequently, blocks are repeated within 15 days of one another, in order to confirm the results. Many insurance companies, including Medicare, require these confirmation blocks before allowing the Radiofrequency ablation.

∙ Pain relief may occur immediately following the procedure; however, it is temporary when only a local anesthetic is injected. Pain relief may occur in 3 to 5 days and may last from weeks to months if a steroid medication is used with the local anesthetic.<

∙ Tenderness at the injection site.

∙ Minimal bleeding/bruisingat the injection site.

∙ Dizziness, flushing, or temporary elevation in blood sugar may occur when steroids are injected.

Wound Care

∙ Monitor the injection site for signs and symptoms of infection.

∙ You may shower the same day you had the procedure.

∙ You may apply an ice pack to the injection site for 15 minutes every hour for the next 24 hours while awake.<

Activity

∙ After the block, you should do things you would normally do and even those you avoid doing because of pain. This will help you get a better understanding of how the block affected your pain.

When to call the doctor

∙ Signs and symptoms of infection: redness, swelling, foul odor or drainage at your injection site.

∙ Fever of 100.5°F or greater.

∙ Significant bleeding from your injection site.

∙ If your pain symptoms get worse.

∙ If you had an intercostal nerve block, call if you develop shortness of breath.

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play43Watch Video Facet Joint Injections

play43Watch Video Medial Branch Block

 

What is a Radiofrequency Ablation?

A Radiofrequency Ablation or RFA is a needle-based procedure where a needle is placed close to a nerve that has been proven to be involved in the generation of a chronic painful condition. The most common way to predict an RFA will produce long-lasting (3-6 months or more) pain relief is by obtaining shor-lasting relief with nerve blocks (see information on Nerve Blocks). After successful Nerve Blocks, an RFA is the next step in the management of your chronic pain.

Some of the nerves that may benefit from RFA include:

∙ Pudendal Nerve for pain in the genital and anal area.

∙ Trigeminal Nerve for pain in the face.

∙ Ilioinguinal Nerve for pain in the groin.

∙ Occipital Nerve for headaches and pain in the neck.

∙ Supraorbital/Supratrochlear Nerves for headaches and pain in the face.

∙ Medial Branch Nerves for pain in the spine, either low back, neck or mid-back.

∙ Intercostal nerves for pain in the breast and ribcage area

These are just a few examples, many other nerves can benefit from RFA’s in the course of a pain management treatment plan.

The procedure is outpatient with minimal recovery time. It requires minimal or no sedation.

Radiofrequency ablation is a very similar procedure to the Nerve Block, with needles in the same place but instead of injecting local anesthetic, an electrical probe is passed through the needle to provide a Radiofrequency treatment on the nerves that may provide prolonged pain relief (average 3-6 months) and can repeated as needed. Radiofrequency ablation, although commonly referred to as “burning the nerve” is a very mild treatment that does not cause any permanent damage on nerves but rather acts as a stun gun that slows the processing of pain signals without interfering with normal functions of the nerve. The result is typically pain relief without areas of numbness or weakness.

If you take blood thinners or have any condition that reduces your ability to stop bleeding (p.e. low platelets, hemophilia), please let your physician at The Peregrine Institute know before you undergo any of these procedures.

What to expect/common symptoms with this procedure

∙ Pain relief may occur immediately following the procedure; however, it is temporary because a local anesthetic is injected at the end of the RFA treatment, but that relief will be short-lived, just a few hours. The long-lasting benefit of the RFA may take up to a week, more commonly 2-3 days to take effect.

∙ t is uncommon but it may happen that after an RFA there will be a temporary flare-up of the pain. This is because of an initial irritating effect on the nerve. This will pass in a few days.

∙ Tenderness at the injection site.

∙ Minimal bleeding/bruising at the injection site.

Wound Care

∙ Monitor the injection site for signs and symptoms of infection.

∙ You may shower the same day you had the procedure.

∙ You may apply an ice pack to the injection site for 15 minutes every hour for the next 24 hours while awake.

Activity

∙ You may gradually return to your normal activity level within 24 hours or as directed by your doctor.

When to call the doctor

∙ Signs and symptoms of infection: redness, swelling, foul odor or drainage at your injection site.

∙ Fever of 100.5°F or greater.

∙ Significant bleeding from your injection site.

∙ If your pain symptoms get worse for longer than a week or the pain is too severe.

∙ If you had an intercostal nerve RFA, call if you develop shortness of breath.

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play43Watch video Cervical Facet Radiofrequency Neurotomy

play43Watch video Lumbar Radiofrequency Neurotomy

What is a Kyphoplasty?

This is a minimally invasive procedure used to treat fractures of the spine. The bony part of your spine (the vertebrae) when fractured can cause significant pain. During this procedure, bone cement is injected into the fractured vertebra using X-ray guidance called Fluoroscopy. As the cement hardens it will provide bone stabilization (support to your spine) and reduce your pain.

The procedure consists of one or two needles inserted through the skin and advanced towards the fractured vertebra. Once in proper placement the, the bone cement is injected. The needles are then removed and the procedure finished. Sometimes a staple or adhesive tape is used to close the skin where the needle was inserted and then covered with dressings.

The pain relief is typically almost immediate and profound.

A Kyphoplasty is an outpatient procedure with minimal recovery time. It requires sedation.

If you take blood thinners or have any condition that reduces your ability to stop bleeding (p.e. low platelets, hemophilia), please let your physician at The Peregrine Institute know before you undergo a Kyphoplasty.

What to expect/common symptoms with this procedure

∙ Relief of pain can be immediate or it may take up to two days to reduce your pain and/or completely eliminate it.<

∙ Discomfort at the surgical site.

∙ Minimal bleeding and/or bruising at the surgical site.

Wound Care

∙ Monitor surgical site for signs and symptoms of infection.See below.

∙ Keep dressing clean and dry. Do not get it wet. Do not submerge yourself in a bathtub, pool, or jacuzzi until your doctor says it is okay.

∙ You may shower the day after your procedure. Make sure to cover your dressing while showering.

∙ Reinforce dressing with additional tape if it becomes loose.

Activity

∙ Avoid strenuous exercise, including heavy lifting (anything over 10 pounds) for one week.

∙ You may gradually return to your normal activity level as directed by your doctor.

When to call the doctor

∙ Signs and symptoms of an infection: redness, swelling, foul odor and/or drainage at the surgical site.

∙ Fever of 100.5°F or greater.

∙ Significant bleeding from the surgical site.

∙ Uncontrolled pain.

∙ Shortness of breath.

∙ Weakness in one or both legs.

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play43Watch video Kyphoplasty

What is a spinal cord stimulator trial?

Spinal cord stimulation involves the use of mild electrical impulses to stimulate the nerves near the spinal cord. Spinal cord stimulation does not eliminate the source of pain; it simply interferes with the signals that carry the sensation of pain to the brain. Spinal Cord Stimulation is one the best alternatives for treating chronic intractable pain, particularly the type caused by nerve damage.

A Spinal Cord Stimulator system has similar technology to Pacemakers and is comprised of the leads (cables with electrodes) and a generator unit, all implanted under skin.

Before you undergo the Spinal Cord Stimulator Implant procedure, you must have a Trial in order to establish that the system will work for you. A lead (wire) is inserted through the skin with a needle, close to an area near the nerves of your spinal cord. The lead will now be connected to a small generator outside of your body. The generator will be programmed to send signals via the lead(s)to the area of your pain. Hopefully, this signal will help decrease your pain. This trial will last approximately 3-7 days at home. After the procedure, you will return to remove the electrode(s) and to discuss the results of the trial with your doctor.

The procedure is outpatient with minimal recovery time. It requires minimal or no sedation.

If you take blood thinners or have any condition that reduces your ability to stop bleeding (p.e. low platelets, hemophilia), please let your physician at The Peregrine Institute know before undergoing this procedure.

What to expect/common symptoms with this procedure

∙ Pain relief is different from person to person.

∙ You may experience discomfort at the electrode insertion site.

∙ Minimal bleeding and / or bruising at the electrode insertion site.

∙ When you change position (lying to sitting, sitting to standing, moving in bed) you may feel changes in the intensity of the nerve stimulation. This is normal. Nothing is wrong with the spinal cord stimulator. It is trying to adjust to movement of your body. This is not the way it will behave long term.

Wound Care

∙ Monitor surgical site for signs and symptoms of infection. See below.

∙ Avoid bending, overhead reaching, and twisting motions that can cause electrode wire movement or cause it to break.

∙ Avoid exercise, including lifting anything over 10 lbs.

∙ Keep dressing clean and dry. Reinforce dressing with additional tape if it becomes loose.

∙ Sponge bathing is allowed. Do Not shower or use a bathtub, pool, or Jacuzzi until the trial leads are removed.

Activity

∙ You may gradually return to your normal activity level as directed by your doctor.

When to call the doctor

∙ Signs and symptoms of infection: redness, swelling, foul odor and/or drainage at the surgical site.

∙ Fever of 100.5°F or greater.

∙ Significant bleeding from the surgical site.

∙ Uncontrolled pain.

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play43Watch video Spinal Cord Stimulator Implant (Trial Procedure)

What is a spinal cord stimulator implant?

A spinal cord stimulator is a device that sends mild electrical impulses to stimulate nerves close to the spinal cord. Stimulation of these nerves does not eliminate the source of pain; it simply interferes with the pain signal to the brain. The amount of pain relief varies from person to person, therefore a trial is usually performed and if the patient obtains significant, meaningful pain relief implant of the system is scheduled. During the spinal cord stimulator implant procedure, permanent electrode wires are inserted close to an area near your spinal cord. The electrodes are connected to a generator which is implanted under the skin in your back or abdomen. Your implanted generator will send signals via the electrode wires to the area of your pain. These signals will help decrease your pain.Your generator will be programmed over the following days and weeks so that the nerve stimulation you receive is specific to your pain needs.

The procedure is outpatient with minimal recovery time. It requires the patient to be asleep for the majority of the procedure.

If you take blood thinners or have any condition that reduces your ability to stop bleeding (p.e. low platelets, hemophilia), please let your physician at The Peregrine Institute know before undergoing this procedure.

What to expect/common symptoms with this procedure

∙ Discomfort at surgical site.

∙ Minimal bleeding and/or bruising at the surgical site.

∙ When you change position (lying to sitting, sitting to standing, moving in bed), you may feel changes in the intensity of the nerve stimulation. This is normal. Nothing is wrong with the spinal cord stimulator implant. It can take up to 6 weeks for the stimulator to adjust to movement of your body.

Wound Care

∙ Monitor surgical site for signs and symptoms of infection. See below.

∙ Avoid bending, overhead reaching, twisting, or lifting objects over 10 pounds for 6 weeks.

∙ Keep dressing clean and dry. Reinforce with additional tape if it becomes loose.

∙ Sponge bathing is allowed. Do Not shower or use a bathtub, pool, or Jacuzzi until your doctor sees you postoperatively.

Activity

∙ You may gradually return to your normal activity level as directed by your doctor.

When to call the doctor

∙ Signs and symptoms of infection: redness, swelling, foul odor and/or drainage at the surgical site.

∙ Fever of 100.5°F or greater.

∙ Significant bleeding from the surgical site.

∙ Uncontrolled pain.

∙ If your dressing becomes wet.

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play43Watch video Spinal Cord Stimulator Implant

What is an intrathecal pump?

An intrathecal pain pump is a small battery-powered programmable device that is surgically placed under the skin of your abdomen and connected to a thin catheter (tube) that is placed directly into the intrathecal space (the fluid around the spinal cord). The pump sends pain medication through the catheter directly into your intrathecal space where the medication has a powerful pain relieving effect.

In other cases, the medication in the pump is given to patients that have stiff muscles in order to loosen them up.

In order to test if this treatment modality works for you, you may have a trial before considering a permanent implant.

An intrathecal trial consists of a single injection of the medication to be used for your pain or stiffness to evaluate your response to it. A trial is usually performed as an outpatient procedure, under x-rays and monitoring your response in the next few hours. After that, the effect will be gone and we need to discuss whether there was benefit enough to proceed to a permanent implantation.

The permanent implantation is also an outpatient procedure, under anesthesia, that consists of an incision in your back to place and secure the catheter in your spinal fluid and an incision in your abdomen where the pump will be placed directly under the skin. The catheter will be connected to the pump by tunneling it under the skin from the back incision.

The pump is filled with the medication previously chosen for your needs during the trial. It may contain 20 or 40 cc. You will need to return for pump refills on a regular basis, typically at 1, 2 or 3 months intervals.

During refills, we check the information electronically stored in your pump and dose adjustments can be made. You receive a printout of the pump settings every time.

You should carry the latest printout with you, in case anybody needs that information on an emergency basis.

What to expect/common symptoms with this procedure

∙ Discomfort at the surgical site.

∙ Minimal bleeding and/or bruising at the surgical site.

∙ Headache, possibly when you move or change positions.

Wound Care

∙ Monitor surgical site for signs and symptoms of infection (see below).

∙ Drink plenty of water after the procedure and lie flat if you develop a headache.

∙ Avoid bending, overhead reaching, twisting, or lifting objects greater than 10 pounds.

∙ Keep dressing clean and dry. Reinforce dressing with additional tape if it becomes loose.

∙ You may take a sponge bath after the procedure. Do not shower or submerge yourself in a bathtub, pool, or jacuzzi until your doctor says it is okay. Usually after your first clinic visit after your procedure.

Activity

∙ You may gradually return to your normal activity as your doctor permits.

When to call the doctor

∙ Signs and symptoms of an infection: redness, swelling foul odor and/or drainage at site.

∙ Fever of 100.5°for greater.

∙ Significant bleeding from the surgical site.

∙ Uncontrolled pain.

∙ Headache that lasts for more than 48 hours.

∙ Unusual sleepiness, feeling groggy, not alert.

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play43Watch video Intrathecal Pump Implant

What is sacroiliac joint injection?

The sacroiliac joint is one the biggest joints in the body. It is located in the low back, between the upper part of the tailbone and the pelvic bone. When it becomes inflamed from degenerative disease and arthritis, it is a frequent cause of chronic low back pain. Injecting this joint with a combination of local anesthetic (Novocaine type medicine) and a steroid (potent anti-inflammatory) will help reduce the pain, hopefully for a prolonged period of time. There is a sacroiliac joint on the right and left sides of the tailbone.

The procedure is outpatient with minimal recovery time. It requires minimal or no sedation.

If you take blood thinners or have any condition that reduces your ability to stop bleeding (p.e. low platelets, hemophilia), please let your physician at The Peregrine Institute know before you undergo any of these procedures.

What to expect/common symptoms with this procedure

∙ There may be initial relieve of the pain from the local anesthetic in the first few hours but the long-lasting effect may be a few days to take effect, usually 2-3 days. The duration of relief varies and it may be weeks to months.

∙ You may feel heaviness or numbness on the leg of the side as the injection. Sometimes you may also experience weakness of the leg for a few hours

∙ Tenderness at the injection site.

∙ Minimal bleeding at the injection site.

∙ Bruising at the injection site.

Wound care

∙ Monitor injection site for signs and symptoms of infection.

∙ You may shower the same day you had the procedure.

∙ You may apply an ice pack to the injection site for 15 minutes every hour for the next 24 hours, while awake if neeeded

Activity

∙ You may gradually return to your normal activity level within 24 hours or as directed by your doctor.

When to call the doctor

∙ Signs and symptoms of infection: redness, swelling, foul odor or drainage at your injection site.

∙ Fever of 100.5°F or greater.

∙ Significant bleeding from your injection site.

∙ Severe weakness or numbness of the leg putting you at risk of falls, especially if lasts for longer than 4 hours.

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play43Watch video Sacroiliac Joint Steroid Injection

PELVIC AND GENITAL PAIN:

What is a superior hypogastric neurolysis?

A superior hypogastric neurolysis is an injection of a local anesthetic and sometimes a neurolytic agent (disrupts nerve pain signals) causing a deliberate numbing effect to the nerves that supply the organs in the pelvis. These nerves are located on each side and in front of your lower spine. The hypogastric plexus nerves carry sensation to the bladder, uterus, ovaries, prostate, lower intestines, rectum and other areas within the pelvis. The use of a neurolytic agent such as alcohol or an electric energy called Radiofrequency interrupts the nerve fibers and produces long-lasting pain relief. Superior hypogastric block is typically performed for severe, chronic pelvic pain caused by cancer or other diseases.

The technique is simple. The patient lies face down on an X-ray table, the back is cleaned and one or two needles are advanced through the skin towards the above mentioned nerves under X-ray guidance. Once proper position of the needles is confirmed with contrast solution, the anesthetic injection is given. If pain relief is achieved, the neurolytic agent or Radiofrequency are applied.

This is an outpatient procedure, minimal recovery time and low incidence of side-effects, requires minimal or no sedation.

If you take blood thinners or have any condition that reduces your ability to stop bleeding (p.e. low platelets, hemophilia), please let your physician at The Peregrine Institute know.

What to expect/common common symptoms with the procedure?

∙ Inmediate relief can be expected within 20 minutes of the injection with a variable duration of effect from a few hours to weeks. If a neurolytic technique is used, it may take up to one week to experience pain relief after the initial effect wears off but may last for 3 to 6 months. And can be repeated if necessary.

∙ Tenderness at the injection site.

∙ Temporary diarrhea.

∙ Minimal bleeding and/or bruising at the injection site.

∙ Numbness and/or weakness of the legs which can be very alarming but temporary

∙ Wound Care

∙ Monitor injection site for signs and symptoms of infection (see below).

∙ You may shower the day of the procedure.

∙ Apply an ice pack to the injection site for 15 minutes every hour for the next 24 hours, while awake if needed.

Activity

∙ You may gradually return to your normal activity within 24 to 48 hours or as your doctor permits.

When to call the doctor

∙ Signs and symptoms of an infection: redness, swelling, foul odor and/or drainage at the injection site.

∙ Fever of100.5°For greater.

∙ Uncontrolled pain.

∙ Significant bleeding at the injection site.

∙ Weakness or numbness in your legs that lasts longer than 4 hours.

∙ Severe dizziness when moving.

∙ Loss of control of your bowel or bladder.

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CHEST AND ABDOMINAL WALL PAIN:

What is an Intercostal Nerve Block?

An Intercostal Nerve Block is an injection of local anesthetic (Novovaine-type medicine) and sometimes a steroid into one or more Intercostal Nerves to relieve pain in the chest or abdominal wall. The Intercostal nerves are located under each rib. When one of these nerves or the tissue around it gets irritated or inflamed, it can cause pain.

These Nerve blocks provide only temporary pain relief, rarely they may provide a prolonged effect. In many cases, a nerve block is a diagnostic tool to help figure out the pain generator in a specific area. When any of these blocks prove significantly beneficial, the patient may be a candidate for a “Neurolytic block”, typically Radiofrequency ablation which is a very similar procedure, with needles in the same place as the blocks described above but instead of injecting local anesthetic, an electrical probe is passed through the needle to provide a Radiofrequency treatment on the nerves that may provide prolonged pain relief (average 3-6 months) and can repeated as needed. Radiofrequency ablation, although commonly referred to as “burning the nerve” is a very mild treatment that does not cause any permanent damage on nerves but rather acts as a stun gun that slows the processing of pain signals without interfering with normal functions of the nerve. The result is typically pain relief without areas of numbness or weakness.

The procedure is outpatient with minimal recovery time. It requires minimal or no sedation.

If you take blood thinners or have any condition that reduces your ability to stop bleeding (p.e. low platelets, hemophilia), please let your physician at The Peregrine Institute know before you undergo any of these procedures.

What to expect/common symptoms with this procedure

∙ The most important aspect of a nerve block is the ability of the patient to evaluate whether or not the procedure provided meaningful pain relief for any length of time. It does not matter how long the relief lasts. Many patients, when asked about the results of a block on a follow-up visit, state it did not work because the pain came back when, in fact, this is expected. If the patient does not pay attention to the pain in the few hours following the procedure, for example by falling asleep on the ride home or going straight to bed, the procedure was pointless, a waste of time. The purpose of the nerve block is to find the culprit for your pain and the only way it can do that is by your ability to establish relief of the pain. We will ask you that question in your follow-up appointment with us and if you cannot answer it, no benefit was derived.

∙ Frequently, blocks are repeated within 15 days of one another, in order to confirm the results. Many insurance companies, including Medicare, require these confirmation blocks before allowing the Radiofrequency ablation.

∙ Pain relief may occur immediately following the procedure; however, it is temporary when only a local anesthetic is injected. Pain relief may occur in 3 to 5 days and may last from weeks to months if a steroid medication is used with the local anesthetic.

∙ Tenderness at the injection site.

∙ Minimal bleeding/bruising at the injection site.

∙ Dizziness, flushing, or temporary elevation in blood sugar may occur when steroids are injected.

Wound Care

∙ Monitor the injection site for signs and symptoms of infection.

∙ You may shower the same day you had the procedure.

∙ You may apply an ice pack to the injection site for 15 minutes every hour for the next 24 hours while awake

Activity

∙ After the block, you should do things you would normally do and even those you avoid doing because of pain. This will help you get a better understanding of how the block affected your pain.

When to call the doctor

∙ Signs and symptoms of infection: redness, swelling, foul odor or drainage at your injection site.

Fever of 100.5°F or greater.

∙ Significant bleeding from your injection site.

If your pain symptoms get worse.

If you had an intercostal nerve block, call if you develop shortness of breath.

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CANCER PAIN:

What is a Celiac Plexus Block/Neurolysis?

Celiac Plexus Neurolysis or CPN is a needle-based, outpatient procedure, performed to alleviate abdominal pain from certain conditions such as cancer, chronic pancreatitis, chronic pain after surgery and others. It has been extensively studied for the pain of cancer of the pancreas. It consists of an injection of local anesthetic (Novocaine-type medicine) around the nerves of the upper abdomen. In order to prolong the pain relieving effect of the anesthetic, an additional medication may be injected, typically alcohol (Ethanol), this way achieving 3-6 months of relief in many cases, sometimes longer. When the pain comes back, the procedure can be repeated.

The technique is simple. The patient lies face down on an X-ray table, the back is cleaned and one or two needles are advanced through the skin towards the above mentioned nerves under X-ray guidance. Once proper position of the needles is confirmed with contrast solution, the anesthetic injection is given and if enough pain relief is obtained, the alcohol is injected as well.

The procedure is outpatient with minimal recovery time. It requires minimal or no sedation.

If you take blood thinners or have any condition that reduces your ability to stop bleeding (p.e. low platelets, hemophilia), please let your physician at The Peregrine Institute know

What to expect/common symptoms with this procedure?

∙ It may take up to 1 week to feel the full effect of the injection, results are different for each person and can last up to six months.

∙ The most common side-effects are:

∙ Increased bowel transit (sometimes diarrhea) which is frequently a welcome event in patients who were constipated by the pain pills, this is self-limited and should not last for more than a couple of days.

∙ Orthostatic hypotension, a condition where the patient feels light-headed when sitting or standing up from lying or sitting down, this is best treated by drinking lots of fluids and typically goes away in a few days.

∙ Irritation of nerves other than the ones intended by the alcohol which can cause self-limited pain in the groin, back or shoulder.

∙ Rare but possible complications include puncturing a kidney or a lung with the needle, both of which are not typically serious. The most feared event, mentioned in the literature only a few times, is injury to the spinal cord by the alcohol. I have not ever witnessed this complication.

Wound Care

∙ Monitor injection site for signs and symptoms of infection (see below).

∙ You may shower the day of the procedure.

∙ Apply an ice pack to the injection site for 15 minutes every hour for the next 24 hours, while awake, to minimize bruising.

Activity

∙ You may gradually return to normal activity within 24 hour or as your doctor permits.

When to call the doctor

∙ Signs and symptoms of an infection: redness, foul odor and/or drainage at injection site.

∙ Fever of 100.5°F or greater.

∙ Shortness of breath

∙ Severe diarrhea for more than 3 days

∙ Pink-colored urine

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play43Watch video Celiac Plexus Block

What is a superior hypogastric neurolysis?

A superior hypogastric neurolysis is an injection of a local anesthetic and sometimes a neurolytic agent (disrupts nerve pain signals) causing a deliberate numbing effect to the nerves that supply the organs in the pelvis. These nerves are located on each side and in front of your lower spine. The hypogastric plexus nerves carry sensation to the bladder, uterus, ovaries, prostate, lower intestines, rectum and other areas within the pelvis. The use of a neurolytic agent such as alcohol or an electric energy called Radiofrequency interrupts the nerve fibers and produces long-lasting pain relief. Superior hypogastric block is typically performed for severe, chronic pelvic pain caused by cancer or other diseases.

The technique is simple. The patient lies face down on an X-ray table, the back is cleaned and one or two needles are advanced through the skin towards the above mentioned nerves under X-ray guidance. Once proper position of the needles is confirmed with contrast solution, the anesthetic injection is given. If pain relief is achieved, the neurolytic agent or Radiofrequency are applied.

This is an outpatient procedure, minimal recovery time and low incidence of side-effects, requires minimal or no sedation.

If you take blood thinners or have any condition that reduces your ability to stop bleeding (p.e. low platelets, hemophilia), please let your physician at The Peregrine Institute know.

What to expect/common symptoms with this procedure?

∙ Inmediate relief can be expected within 20 minutes of the injection with a variable duration of effect from a few hours to weeks. If a neurolytic technique is used, it may take up to one week to experience pain relief after the initial effect wears off but may last for 3 to 6 months. And can be repeated if necessary.

∙ Tenderness at the injection site.

∙ Temporary diarrhea.

∙ Minimal bleeding and/or bruising at the injection site.

∙ Numbness and/or weakness of the legs which can be very alarming but temporary

Wound Care

∙ Monitor injection site for signs and symptoms of infection (see below).

∙ You may shower the day of the procedure.

∙ Apply an ice pack to the injection site for 15 minutes every hour for the next 24 hours, while awake if needed.

Activity

∙ You may gradually return to your normal activity within 24 to 48 hours or as your doctor permits.

When to call the doctor

∙ Signs and symptoms of an infection: redness, swelling, foul odor and/or drainage at the injection site.

∙ Fever of100.5°For greater.

∙ Uncontrolled pain.

∙ Significant bleeding at the injection site.

∙ Weakness or numbness in your legs that lasts longer than 4 hours.

∙ Severe dizziness when moving.

∙ Loss of control of your bowel or bladder.

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What is an intrathecal pump?

An intrathecal pain pump is a small battery-powered programmable device that is surgically placed under the skin of your abdomen and connected to a thin catheter (tube) that is placed directly into the intrathecal space (the fluid around the spinal cord). The pump sends pain medication through the catheter directly into your intrathecal space where the medication has a powerful pain relieving effect.

In other cases, the medication in the pump is given to patients that have stiff muscles in order to loosen them up.

In order to test if this treatment modality works for you, you may have a trial before considering a permanent implant.

An intrathecal trial consists of a single injection of the medication to be used for your pain or stiffness to evaluate your response to it. A trial is usually performed as an outpatient procedure, under x-rays and monitoring your response in the next few hours. After that, the effect will be gone and we need to discuss whether there was benefit enough to proceed to a permanent implantation.

The permanent implantation is also an outpatient procedure, under anesthesia, that consists of an incision in your back to place and secure the catheter in your spinal fluid and an incision in your abdomen where the pump will be placed directly under the skin. The catheter will be connected to the pump by tunneling it under the skin from the back incision.

The pump is filled with the medication previously chosen for your needs during the trial. It may contain 20 or 40 cc. You will need to return for pump refills on a regular basis, typically at 1, 2 or 3 months intervals.

During refills, we check the information electronically stored in your pump and dose adjustments can be made. You receive a printout of the pump settings every time.

You should carry the latest printout with you, in case anybody needs that information on an emergency basis.

What to expect/common symptoms with this procedure

∙ Discomfort at the surgical site.

∙ Minimal bleeding and/or bruising at the surgical site.

∙ Headache, possibly when you move or change positions.

Wound Care

∙ Monitor surgical site for signs and symptoms of infection (see below).

∙ Drink plenty of water after the procedure and lie flat if you develop a headache.

Avoid bending, overhead reaching, twisting, or lifting objects greater than 10 pounds.

Keep dressing clean and dry. Reinforce dressing with additional tape if it becomes loose.

You may take a sponge bath after the procedure. Do not shower or submerge yourself in a bathtub, pool, or jacuzzi until your doctor says it is okay. Usually after your first clinic visit after your procedure.

Activity

∙ You may gradually return to your normal activity as your doctor permits.

When to call the doctor

∙ Signs and symptoms of an infection: redness, swelling foul odor and/or drainage at site.

Fever of 100.5°for greater.

Significant bleeding from the surgical site.

Uncontrolled pain.

Headache that lasts for more than 48 hours.

Unusual sleepiness, feeling groggy, not alert.

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play43Watch video Intrathecal Pump Implant

RSD (Complex Regional Pain Syndrome):

What is a Ketamine Infusion?

Ketamine is a common anesthetic (pain-blocking) medicine. An intravenous (IV) infusion of this medicine can block pain receptors in the brain and spinal cord. This may decrease chronic pain by altering the pain messages coming from the nerves around your painful area.

Ketamine can be delivered as an inpatient continuous infusions for days, often referred as a “Ketamine comma” or as an outpatient 4-6 hours infusion everyday for 2-4 days. The Ketamine comma is rarely performed in the United States but it is currently available in Germany and Mexico.

At The Peregrine Institute, we offer the 2-4 day outpatient infusions.

Who should get a Ketamine Infusion?

People with chronic pain from different sources but typically intractable that doesn’t respond to other treatments may experience pain relief from a Ketamine infusion. The most common condition treated with Ketamine infusions is Reflex Sympathetic Dystrophy (RSD) now called Complex Regional Pain Syndrome (CRPS).

Intravenous Ketamine is now used for Severe Depression as well.

What are the side effects?

If you experience any of the following during your Ketamine infusion, the dosage of your can be decreased to help control these side effects. In any event, all of these are temporary and will revert to normal shortly after your infusion is over.

A tired or drowsy feeling

Numbness in your arms and legs

A feeling of out of body experience, as if you are looking at yourself from outside of your body.

Some people experience dreams, mood swings, or hallucinations

Memory loss, disorientation, dizziness

Your blood pressure or heart rate may increase

Nausea

How do I prepare?

Do not eat any food within 8 hours of your appointment.

Do not drink any liquids within 3 hours before your appointment.

Continue to take your usual daily medications with a small sip of water. Bring all your medications with you so you can take scheduled medications after the infusion.

Do not take any pain medications without talking to your doctor first.

What happens during a Ketamine Infusion?

You will meet with the doctor performing the Ketamine infusion and he/she will explain the procedure and review any side effects with you.

You will have a needle inserted into a vein of your arm and a bag of fluid containing Ketamine
will be attached.

The infusion will take 4-6 hours.

You will be sedated but not completely asleep, you can talk and express any discomfort you may be feeling.

Your blood pressure, heart rate, and oxygen level will be monitored during the infusion every
15 minutes.

You will be in a room with low lighting where you can relax.

You cannot have anything to eat or drink during the Ketamine infusion except ice chips.

You will be asked to stay for a short while after the infusion so that we know you are well
enough to leave.

What happens after the infusion?

You need someone to drive you home and who will be with you the next 24 hours.
Do not drive or operate heavy machinery for 24 hours following the infusion.

Take any scheduled medications as usual.

You will have follow-up appointments within 2-3 weeks.

Can I resume normal activities after the infusion?

You may return to work, activities, and regular diet the day after the infusion.

Follow your doctor’s advice regarding physical exercise.

Follow-up visits

If your pain is helped by the Ketamine infusion, it is a treatment that can be repeated at set intervals
depending on your individual response to the infusion. Your doctor will discuss this with you.

Contact information: If you have any questions or concerns after your Ketamine infusion, please call
The Peregrine Institute at 813-873-7777.

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NEUROMODULATION:

What is a spinal cord stimulator trial?

Spinal cord stimulation involves the use of mild electrical impulses to stimulate the nerves near the spinal cord. Spinal cord stimulation does not eliminate the source of pain; it simply interferes with the signals that carry the sensation of pain to the brain. Spinal Cord Stimulation is one the best alternatives for treating chronic intractable pain, particularly the type caused by nerve damage.

A Spinal Cord Stimulator system has similar technology to Pacemakers and is comprised of the leads (cables with electrodes) and a generator unit, all implanted under skin.

Before you undergo the Spinal Cord Stimulator Implant procedure, you must have a Trial in order to establish that the system will work for you. A lead (wire) is inserted through the skin with a needle, close to an area near the nerves of your spinal cord. The lead will now be connected to a small generator outside of your body. The generator will be programmed to send signals via the lead(s)to the area of your pain. Hopefully, this signal will help decrease your pain. This trial will last approximately 3-7 days at home. After the procedure, you will return to remove the electrode(s) and to discuss the results of the trial with your doctor.

The procedure is outpatient with minimal recovery time. It requires minimal or no sedation.

If you take blood thinners or have any condition that reduces your ability to stop bleeding (p.e. low platelets, hemophilia), please let your physician at The Peregrine Institute know before undergoing this procedure.

What to expect/common symptoms with this procedure

∙ Pain relief is different from person to person.

∙ You may experience discomfort at the electrode insertion site.

∙ Minimal bleeding and / or bruising at the electrode insertion site.

∙ When you change position (lying to sitting, sitting to standing, moving in bed) you may feel changes in the intensity of the nerve stimulation. This is normal. Nothing is wrong with the spinal cord stimulator. It is trying to adjust to movement of your body. This is not the way it will behave long term.

Wound Care

∙ Monitor surgical site for signs and symptoms of infection. See below.

∙ Avoid bending, overhead reaching, and twisting motions that can cause electrode wire movement or cause it to break.

∙ Avoid exercise, including lifting anything over 10 lbs.

∙ Keep dressing clean and dry. Reinforce dressing with additional tape if it becomes loose.

∙ Sponge bathing is allowed. Do Not shower or use a bathtub, pool, or Jacuzzi until the trial leads are removed.

Activity

∙ You may gradually return to your normal activity level as directed by your doctor.

When to call the doctor

∙ Signs and symptoms of infection: redness, swelling, foul odor and/or drainage at the surgical site.

∙ Fever of 100.5°F or greater.

∙ Significant bleeding from the surgical site.

∙ Uncontrolled pain.

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What is a spinal cord stimulator implant?

A spinal cord stimulator is a device that sends mild electrical impulses to stimulate nerves close to the spinal cord. Stimulation of these nerves does not eliminate the source of pain; it simply interferes with the pain signal to the brain. The amount of pain relief varies from person to person, therefore a trial is usually performed and if the patient obtains significant, meaningful pain relief implant of the system is scheduled. During the spinal cord stimulator implant procedure, permanent electrode wires are inserted close to an area near your spinal cord. The electrodes are connected to a generator which is implanted under the skin in your back or abdomen. Your implanted generator will send signals via the electrode wires to the area of your pain. These signals will help decrease your pain.Your generator will be programmed over the following days and weeks so that the nerve stimulation you receive is specific to your pain needs.

The procedure is outpatient with minimal recovery time. It requires the patient to be asleep for the majority of the procedure.

If you take blood thinners or have any condition that reduces your ability to stop bleeding (p.e. low platelets, hemophilia), please let your physician at The Peregrine Institute know before undergoing this procedure.

What to expect/common symptoms with this procedure

∙ Discomfort at surgical site.

∙ Minimal bleeding and/or bruising at the surgical site.

∙ When you change position (lying to sitting, sitting to standing, moving in bed), you may feel changes in the intensity of the nerve stimulation. This is normal. Nothing is wrong with the spinal cord stimulator implant. It can take up to 6 weeks for the stimulator to adjust to movement of your body.

Wound Care

∙ Monitor surgical site for signs and symptoms of infection. See below.

∙ Avoid bending, overhead reaching, twisting, or lifting objects over 10 pounds for 6 weeks.

∙ Keep dressing clean and dry. Reinforce with additional tape if it becomes loose.

∙ Sponge bathing is allowed. Do Not shower or use a bathtub, pool, or Jacuzzi until your doctor sees you postoperatively.

Activity

∙ You may gradually return to your normal activity level as directed by your doctor.

When to call the doctor

∙ Signs and symptoms of infection: redness, swelling, foul odor and/or drainage at the surgical site.

∙ Fever of 100.5°F or greater.

∙ Significant bleeding from the surgical site.

∙ Uncontrolled pain.

∙ If your dressing becomes wet.

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What is an occipital nerve stimulator trial?

Occipital nerve stimulation or ONS is the use of mild electrical impulses to stimulate one or both of the occipital nerves. These nerves are located at the back of the head (base of the skull). ONS is an innovative modality to treat severe, intractable headaches such as migraines, cluster and many others. Occipital nerve stimulation does not remove the source of pain; it simply interferes with the nerve pain signal to the brain. ONS uses the same equipment as a Spinal Cord Stimulator which has similar technology to Pacemakers and is comprised of the leads (cables with electrodes) and a generator unit, all implanted under skin. ONS is not approved by the FDA, so its use is called “off-label”. Many insurance companies do not cover ONS because of this. All the equipment utilized has been FDA-approved for Spinal Cord Stimulation for many years. That should reassure you that no experimental equipment is being used on you, what is not approved by the FDA is the placement of the leads on the occipital nerves. They are requiring more evidence that this technique works in the form of research clinical trials.

ONS has been approved in Europe for treatment of headaches.

Before you undergo the Occipital Nerve Stimulator Implant procedure, you must have a Trial in order to establish that the system will work for you. A lead (wire) is inserted through the skin with a needle, close to the occipital nerves. The lead will now be connected to a small generator outside of your body. The generator will be programmed to send signals via the lead(s)to the area of your pain. Hopefully, this signal will help decrease your pain. This trial will last approximately 3-7 days at home. After the procedure, you will return to remove the electrode(s) and to discuss the results of the trial with your doctor.

What to expect/common symptoms with this procedure

∙ Pain relief is different from person to person.

∙ You may experience discomfort at the electrode insertion site.

∙ Minimal bleeding and/or bruising at the electrode insertion site.

∙ When you change position (lying to sitting, sitting to standing, moving in bed) you may feel changes in the intensity of the nerve stimulation. This is normal. Nothing is wrong with the occipital nerve stimulator. It is trying to adjust to movement of your body.

Wound Care

∙ Monitor lead insertion site for signs and symptoms of infection(see below).

∙ Avoid bending, overhead reaching and sharp twisting of the neck.

∙ Avoid strenuous exercise, including lifting anything over 10 pounds.

∙ Keep dressing clean and dry. Reinforce dressing with additional tape if it becomes loose.

∙ Sponge bathing is allowed. Do Not shower or use a bathtub, pool, or Jacuzzi until your doctor says it is okay. Usually after your first clinic visit after the procedure.

Activity

∙ You may gradually return to your normal activity level as directed by your doctor.

When to call the doctor

∙ Signs and symptoms of infection: redness, swelling, foul odor and/or drainage at the surgical site.

∙ Fever of100.5°For greater.

∙ Significant bleeding from the surgical site.

∙ Uncontrolled pain.

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What is an intrathecal pump?

An intrathecal pain pump is a small battery-powered programmable device that is surgically placed under the skin of your abdomen and connected to a thin catheter (tube) that is placed directly into the intrathecal space (the fluid around the spinal cord). The pump sends pain medication through the catheter directly into your intrathecal space where the medication has a powerful pain relieving effect.

In other cases, the medication in the pump is given to patients that have stiff muscles in order to loosen them up.

In order to test if this treatment modality works for you, you may have a trial before considering a permanent implant.

An intrathecal trial consists of a single injection of the medication to be used for your pain or stiffness to evaluate your response to it. A trial is usually performed as an outpatient procedure, under x-rays and monitoring your response in the next few hours. After that, the effect will be gone and we need to discuss whether there was benefit enough to proceed to a permanent implantation.

The permanent implantation is also an outpatient procedure, under anesthesia, that consists of an incision in your back to place and secure the catheter in your spinal fluid and an incision in your abdomen where the pump will be placed directly under the skin. The catheter will be connected to the pump by tunneling it under the skin from the back incision.

The pump is filled with the medication previously chosen for your needs during the trial. It may contain 20 or 40 cc. You will need to return for pump refills on a regular basis, typically at 1, 2 or 3 months intervals.

During refills, we check the information electronically stored in your pump and dose adjustments can be made. You receive a printout of the pump settings every time.

You should carry the latest printout with you, in case anybody needs that information on an emergency basis.

What to expect/common symptoms with this procedure

∙ Discomfort at the surgical site.

Minimal bleeding and/or bruising at the surgical site.

Headache, possibly when you move or change positions.

Wound Care

∙ Monitor surgical site for signs and symptoms of infection (see below).

Drink plenty of water after the procedure and lie flat if you develop a headache.

Avoid bending, overhead reaching, twisting, or lifting objects greater than 10 pounds.

Keep dressing clean and dry. Reinforce dressing with additional tape if it becomes loose.

You may take a sponge bath after the procedure. Do not shower or submerge yourself in a bathtub, pool, or jacuzzi until your doctor says it is okay. Usually after your first clinic visit after your procedure.

Activity

∙ You may gradually return to your normal activity as your doctor permits.

When to call the doctor

∙ Signs and symptoms of an infection: redness, swelling foul odor and/or drainage at site.

Fever of 100.5°for greater.

Significant bleeding from the surgical site.

Uncontrolled pain.

Headache that lasts for more than 48 hours.

Unusual sleepiness, feeling groggy, not alert.

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