We have created this section to provide you with additional information about conditions we commonly treat, diagnostic tests and procedures we perform. This section is not designed to diagnose or treat your ailments. Please ask for doctor if you have any further questions not answered in this section. At the bottom of this section we have provided links to websites we feel may be of interest to you. Discography or a discogram is a diagnostic procedure used to help diagnose the source of neck or back pain. There are many structures in the spine which may become painful. A discogram is a test used to identify a painful disc. During a discogram a needle is inserted into a disc and a liquid dye is injected. If the dye causes a reproduction of the pain, it is very likely that the disc injected is the source of the pain. If the dye does not cause pain, it is unlikely that the disc is the source of pain. This test is usually performed when more than one disc looks abnormal on the MRI and surgery is being considered. The goal is to determine which disc is the painful one so that surgery can target the appropriate disc.

FREQUENTLY ASKED QUESTIONS:

• Does it hurt? Can I be "put out" for it? You may have some mild sedation during the placement of the needles, but you need to awake for the test part of the procedure to tell us how you feel. You will also have a local anesthetic to numb your back before the needles are placed.
• How long does it take? The procedure usually takes 20 to 30 minutes depending on how many discs need to be tested, but you will need to be at the hospital or surgery center for about 60 to 90 minutes from check-in and check-out.
• What gets injected? A contrast dye which is mixed with an antibiotic to prevent infection. It there is pain, this can be followed by a local anesthetic to numb it.
• There are no steroids? It's not a cortisone shot? No. There are no steroids injected. It is a diagnostic test, not a treatment.
• What are the side effects? Side effects are rare, but may include a temporary increase in pain or vasovagal reaction (fainting).
• What are the potential complications? There potential main complications include: bleeding, infection, allergic reaction, or nerve damage. These are all very rare when the appropriate precautions are taken. Injections in the cervical spine (neck) are always inherently riskier than injections in the lower back. The main risk of discography is an infection of the disc called diskitis. In order to prevent this, intravenous antibiotics are given before the procedure and more antibiotics are injected into the disc (mixed with the dye) during the procedure.
• Do I need to stop my medication before the injection? You must stop any blood thinning medication 7 to 10 days before the procedure to prevent bleeding. This includes aspirin (and 81mg "baby aspirin"), coumadin, plavix, advil, motrin, aleve, naprosyn/naproxen, ibuprofen, excedrin, any cold or sinus medication containing these, and other anti-inflammatory medications. If you are not sure if you need to stop a medication, you should ask. Diabetes medication may need to be held the morning of the procedure if you do not eat breakfast. Blood pressure and other heart medications should be continued.
• Do I need to stay in bed all day after the injection? When can I go back to work? No. You may feel soreness for the next few hours and want to "take it easy," but there is no need to stay in bed. You may return to work the next day.
• Can I shower after the procedure? You should avoid submerging your back in water for 2-3 days after the injection. This includes a bath, hot tub, swimming pool, or the ocean. You may shower the night after the injection, unless told not to by the doctor.
• When can I travel after the injection? You should not travel long distance for one week after the injection.
• How many injections have you performed? What is your training? Both Dr. Baker and Dr. Marrinan have many years of experience performing these injections. Dr. Marrinan has completed a one year fellowship (sub-specialty training) in spinal injections, learning from one of the top interventional spine physicians in New York City. Drs. Baker and Marrinan are both members of the International Spine Intervention Society and regularly attend meetings, conferences, and workshops to remain up to date on the latest innovations in spine care.
• How many complications have you had? To date, neither Dr. Baker nor Dr. Marrinan has had any major complications from a spinal injection.

Epidural Steroid Injections are an effective adjunct to treatment for patients with pain of spinal origin. Commonly, nerves in the neck or back are compressed or irritated near the spine by a bulging or herniated disc, a bone spur, or scar tissue. This causes the nerve to become swollen, causing pain, numbness, tingling or weakness in the arms or legs. The purpose of the epidural injection is to decrease inflammation and provide pain relief, thereby facilitating active rehabilitation. Their primary use is as one component of a comprehensive treatment plan that includes medication, physical therapy, and education in body mechanics. For relief of pain, epidural steroid injections have a success rate of 75-85% in the short term. Long term relief is variable and appears to depend on compliance with treatment plan and back-sparing activities of daily living.

There are two approaches to the epidural space: interlaminar and transforaminal (also known as selective nerve root block). Depending on the location of the problem, your physician will select the approach with higher likelihood of relieving your problem.

Any procedure carries an inherent risk. These are minimized by using fluoroscopic (X-ray) guidance, sterile technique, and avoidance of medications that increase bleeding. However, infection, bleeding, allergic reactions to medications or contrast dye, vasovagal reaction (ie. fainting), spinal headache, nerve injury, or temporary increase in pain, although rare, are possible.

The procedure is performed while lying on an x-ray table. One may have an intravenous line inserted to provide sedation. The injection site is anesthetized through a very thin needle. The epidural needle is slowly advanced into the epidural space under x-ray guidance. Once the space is identified, contrast dye is injected for confirmation of placement and the medication (cortisone with/without anesthetic) is slowly injected. The entire procedure usually takes less than 10 minutes.

After the procedure, one may notice a decrease or disappearance of pain and may feel a mild numbness, tingling or heaviness in the leg or arm. This effect is due to the anesthetic and is transient. After monitoring for 20-30 minutes and receiving something to eat and drink, you will be allowed to walk with a nurse. Once the staff determines you are stable, you will be discharged with written instructions.

Over the next few hours, as the local anesthetic wears off, pain may return, although frequently not to the level it was before, and discomfort at the injection site may be noted. The anti-inflammatory effects of the steroid can take 2-4 days to take effect. It may take that long to help your pain. You should see your doctor 5-10 days after the injection to discuss your progress and future therapy. If pain relief is not complete, the injection can be repeated after two weeks. Your doctor may select the same or a different approach to the epidural space. If no relief is appreciated after 3 injections, it is not usually continued.

If you are on any blood thinners (Coumadin, Plavix, Aggrenox, Aspirin), are taking any anti-inflammatory medicines, have any disorders of blood clotting, or have any questions regarding medications to take, please discuss it with the doctor.

Do not eat or drink after midnight the day prior to injection if sedation is contemplated. You may eat a light breakfast if you are sure you are not receiving any sedation.

Regular medications should be taken with a sip of water the morning of the procedure. If you are taking medications for diabetes, please consult with your doctor for instructions.

You should not drive after the procedure. Please arrange for transportation. Prepare to spend around 1 1/2 to 2 hours.

Do not plan on working or traveling the day of the procedure.

What are facet joints?
The spine is full of joints (called Z-joints or "facet" joints) which allow you to bend forward and back, or nod your head. Like any other joint in the body, these joints have joint fluid and cartilage that can develop arthritis or other painful conditions. Every spine segment is connected to the adjacent segment (above and below) by two joints; one on each side. A few of these joints, because of their location, are more prone to injury or arthritis than the rest. Facet joint injections, medial branch blocks and radiofrequency neurotomy are ways of diagnosing and treating pain coming from these joints.

Making the diagnosis:
Although some clues can be detected during the history and physical exam, these are not enough to make the diagnosis. Similarly, x-rays and MRIs can show arthritic joints, but not all arthritic joints are painful, and not all painful joints are arthritic. To really be sure that a joint is responsible for your pain, diagnostic blocks must be performed.

Diagnostic blocks consist of injecting a local anesthetic into the joint in question, or onto the nerves (medial branches) that supply sensation to that joint. When the joint is injected ,typically a small amount of cortisone goes with it, which can provide long acting pain relief. In either case, the joint will become anesthetized for the duration of action of the anesthetic. If your pain disappears during that time, we have found our painful joint. If the pain does not disappear, or the relief does not last long enough, we must continue looking. In order to prevent a "false positive" response, or a placebo effect from misleading us, the diagnostic block is always performed twice. If a joint injection does not provide long lasting relief, and the facet joints are the source of the pain, RFA can be considered.

Quick anatomy lesson:
Sensation (and therefore, pain) is transmitted from the facet joints to the spinal cord (and then the brain) first through tiny nerves called Medial Branches. These medial branches also supply sensation to small patches of skin in the back, and movement to tiny muscles on the spine, called multifidi. Blocking these nerves would block sensation from the joint they supply. Because the multifidi muscles are so small, an individual muscle does very little by itself, and blocking the nerves to one or two of them has no effect on movement or stability of the spine.

RFA: How does it work?
"Neurotomy" means cutting a nerve. "Radiofrequency" is the method of cutting that nerve. Essentially it involves burning or cauterizing the nerve. Under x-ray guidance, a special needle with insulation all along it's length except for a tiny exposed tip is placed into position so that the tip is lined up with the medial branches. A small electrical current is then passed through the needle to verify its placement. Once verified, the tip is heated so that the underlying nerve is burned. A local anesthetic is given to relieve pain during the procedure.

Are there any risks?
All medical procedures have risks. As in all injections, there is a small risk of infection and of bleeding (you must stop all blood thinners before this procedure). In this case, there is a risk of burning an unintended structure; this risk is minimized by using x-ray guidance and test stimulations.

How long will it last?
Typically, pain relief will last from a year to eighteen months and then can gradually return. This is a sign that the nerve has grown back. The procedure may be repeated as many times as is necessary.

If you are on any blood thinners (Coumadin, Plavix, Aggrenox, Aspirin), are taking any anti-inflammatory medicines, have any disorders of blood clotting, or have any questions regarding medications to take, please discuss it with the doctor.

Do not eat or drink after midnight the day prior to the procedure.

Regular medications should be taken with a sip of water the morning of the procedure. If you are taking medications for diabetes, please consult with your doctor for instructions.

You should not drive after the procedure. Please arrange for transportation. Prepare to spend around 2 hours.

Do not plan on working or traveling the day of the procedure.

Do not sit in a bathtub, pool, or hot tub for at least 48 hours after the procedure-showering is okay the day after.

Your back may be sore from the needles when the anesthetic wears off. Ice is best for relieving this. Wrap some ice in a towel and try 15 minutes on and 15 minutes off for an hour or so.

Electodiagnostic medicine is the study of diseases of nerves and muscles. Your doctor has recommended an EMG test to see if your muscles and nerves are working right. You can have problems in only one part of your body or throughout your body. The results of the tests will help your doctor decide what is wrong and how it can be treated.

Why am I being sent for an EMG?
If you have numbness, tingling, pain, weakness, or muscle cramping. Some of the tests that the EMG doctor may use to diagnose your symptoms are nerve conduction studies (NCSs) and needle EMG.

Nerve Conduction Studies
NCSs show how well the body's electrical signals are traveling to a nerve. This is done by applying small electrical shocks to the nerve and recording how the nerve works. These shocks cause a quick, mild, tingling feeling. The doctor may test several nerves.

Needle EMG
For this part of the test, a small, thin needle is inserted in several muscles to see if there are any problems. A new needle is used for each patient and it is thrown away after the test. There may be a small amount of pain when the needle is put in. The doctor tests only the muscles necessary to decide what is wrong. The doctor will look at and listen to the electrical signals that travel from the needle to the EMG machine. The doctor then uses his medical knowledge to decide what could be causing your problem.

How long will these tests take?
The tests usually take 30 to 60 minutes. You can do any of your normal activities, like eating, driving, and exercising, before the tests. There are no lasting effects. You can also do your normal activities after the tests.

How should I prepare for the tests?
Tell the EMG doctor if you are taking blood thinners (like Coumadin*), have a pacemaker, or have hemophilia. Take a bath or shower to remove oil from your skin. Do not use body lotion on the day of the test. If you have myasthenia gravis, ask your EMG doctor if you should take any medications before the test.

When will I know the test results?
The EMG doctor will discuss your test results with you or send them to your regular doctor. After the exam, check with the doctor who sent you to for the EMG for the next step in your care.

There are many structures in and around the spine which can become painful. One of the most important aspects of treating low back pain is correctly identifying the primary pain generator. Some of the most common pain generators include muscles, joints, discs, nerves, and bones.

MUSCLE PAIN:
Muscle strains (or "pulled muscles") are probably the most common causes of low back pain in younger people. A muscle strain occurs when a forceful contraction causes some muscle fibers to tear. This pain comes on suddenly and is typically exacerbated by any movement. Muscles in the low back can usually repair themselves, so treatment is focused on reducing pain and inflammation, and preventing future episodes. This is done with a combination of physical therapy, medications, and muscle injections.

JOINT PAIN:
The spine has many joints which allow us to flex (bend forward) and extend (lean back) the spine. Arthritis, trauma, and routine daily wear and tear can cause these joints to become painful over time. Depending on the cause, there may be only one painful joint in the back, or many. Joint pain can be exacerbated by any position or activity, but is usually worse when the spine is extended. Once joint pain is diagnosed, treatment can range anywhere from physical therapy and medications, to injections (see below), radio-frequency ablation (see below), or surgery.

DISC PAIN:
The intervertebral discs allow for all the bending, twisting,, and turning in the spine, while also acting like shock absorbers. During certain activities (bending, lifting, twisting) these discs can be put under tremendous amounts of pressure. The disc is like a jelly donut, with a firm outer ring enclosing a material of toothpaste-like consistency. A disc can become painful in a number of ways. It can herniate, or "pop out" of it's normal position. It can get a tear in the outer ring, allowing some of the chemicals on the inside to leak out and irritate nearby structures. And it can get worn down and dehydrated altering the mechanics of the spine and causing inflammation in the region. Not all herniated or degenerative discs are painful, however, so it is important to determine which disc is painful when many appear abnormal on an MRI. Discography is a diagnostic tool that can be useful for this purpose. Disc pain (like joint pain) can be treated with everything from physical therapy and medication, up through injections (see below), to surgery.

NERVE PAIN:
Sometimes problems in the low back can cause pain in the buttocks or legs. A "pinched nerve" in the spine is often felt as a burning, aching, or cramping sensation wherever that nerve ends (in the foot, calf, knee, etc.). In severe cases, there may also be numbness and tingling or even weakness in the leg or foot. Sometimes the nerve is actually "pinched" by a herniated disc, or narrowing of the spine (stenosis). In other cases, the nerve is irritated and inflamed by chemical irritants. When it is not clear which nerves are affected, tests such as MRI or EMG can help determine the cause and extent of the problem. Nerve pain is treated with anti-inflammatories, with medications that quiet over-sensitive nerves, and with injections next to the nerve. In cases of severe narrowing, surgery may be needed to create more space for the nerve(s).

BONE PAIN:
Bone pain is usually due to fractures or as a complication of certain cancers. Fractures in the low back can occur as a result of trauma, or spontaneously in people with osteoporosis (low bone density). Depending on the site of the fracture, treatment ranges from medication and physical therapy, to bracing the spine, to injections or surgery. Cancer pain is usually treated with painkillers or radiation. In people without osteoporosis, bone pain is rare.

SPINE INJECTIONS:
Spine injections may be purely for diagnosis or for treatment as well. For diagnosis, an anesthetic is injected at the presumed source of pain and the response to this is observed. If there is no response to this injection, it is clear that the medication was not put at the site of pain. For longer lasting relief, an anti-inflammatory steroid (like cortisone) is added to the anesthetic. See the Epidural Steroid Injection brochure for more detail on these procedures.

RADIO-FREQUENCY ABLATION:
RFA is a method of "burning" nerves. In some cases of joint pain, RFA can prevent pain signals from reaching the brain by burning the nerves that carry them. Pain relief can last up to 12 to 18 months, until the nerves grow back.

PHYSICAL THERAPY:
Physical therapy is an important aspect of spine rehabilitation from all causes. Good posture, strong spinal musculature, and proper lifting and exercise techniques are essential for preventing future injuries. A good home exercise program can keep you pain free for a long time.

Lift with your legs, not with your back-your knees should always bend more than your low back when lifting something off the floor.

Avoid prolonged sitting-sitting puts a lot of pressure on your discs; get up and stretch out every half hour when working, traveling, or watching TV.

Stay in shape - exercising daily will help keep your muscles strong and gentle stretching can help prevent injuries as well.

Sleep and eat right - lack of sleep and low levels of certain vitamins can increase your perception of pain. A healthy diet and full night's sleep can do more for chronic pain than any medicines.

Medial branch block injections are a diagnostic procedure used to help diagnose the source of neck or back pain. The medial branch nerves of the spine are tiny nerves whose primary function is to allow sensation from the facet joints. There is a right and left facet joint at each level of the spine. These joints can become painful in the same ways that knee, hip, shoulder, or finger joints do. It is often very difficult to determine if a particular joint is painful based only on MRI and physical exam, so medial branch blocks (and sometimes facet joint injections) serve as diagnostic procedures to help identify where the pain is coming from. The procedure "blocks" (with local anesthetic) your ability to feel any sensation coming from whichever joint is targeted. This is not meant to cure the problem. It is only a diagnostic test to identify the source of the pain. You must pay careful attention to how you feel after the injection. A positive response occurs when your pain disappears for the expected length of time (which is different for different anesthetics). Once the painful joint or joints is/are identified, a procedure called radiofrequency ablation (RFA) or radiofrequency neurotomy may be used to achieve long lasting pain relief.

FREQUENTLY ASKED QUESTIONS:

• Does it hurt? Can I be "put out" for it? You will feel the pinch of the needle on your back, but a very small needle is used and it is not inserted very deep. You may have some medication to reduce anxiety, which may allow you to nearly sleep through the procedure, but heavier anesthesia cannot be used as it may impede the diagnostic accuracy of the test.
• How long does it take? The actual injection usually takes 10 to 20 minutes, but you will need to be at the hospital or surgery center for about 60 to 90 minutes from check-in and check-out.
• What medication gets injected? The medication injected is a local anesthetic (usually lidocaine or bupivicaine).
• There are no steroids? It's not a cortisone shot? No. There are no steroids injected. It is a diagnostic test, not a treatment.
• How is this different from a facet injection? Facet injections are combination diagnostic and therapeutic procedures, which may provide pain relief for days, weeks, months, or longer. Medial branch blocks (MBBs) are purely diagnostic procedures done in preparation for a possible radiofrequency ablation. Pain relief will usually only last a few hours. MBBs are generally done when a previous facet injection provided only short-term relief.
• What are the side effects? Side effects are rare, but may include a temporary increase in pain or vasovagal reaction (fainting).
• What are the potential complications? There are three main complications: bleeding, infection, allergic reaction, or nerve damage. These are all very rare when the appropriate precautions are taken. Injections in the cervical spine (neck) are always inherently riskier than injections in the lower back. When properly performed, the needle does not enter the spinal canal during a medial branch block injection, and therefore risk of complication is much less than in other types of spinal procedures. Fluoroscopy (low power X-ray) is used for safety and to verify appropriate needle placement.
• Do I need to stop my medication before the injection? You must stop any blood thinning medication 7 to 10 days before the procedure to prevent bleeding. This includes aspirin (and 81mg "baby aspirin"), coumadin, plavix, advil, motrin, aleve, naprosyn/naproxen, ibuprofen, excedrin, any cold or sinus medication containing these, and other anti-inflammatory medications. If you are not sure if you need to stop a medication, you should ask. Diabetes medication may need to be held the morning of the procedure if you do not eat breakfast. Blood pressure and other heart medications should be continued.
• Do I need to stay in bed all day after the injection? When can I go back to work? No. In fact, you should perform usual activities which cause pain to see if the local anesthetic blocks the pain in the first few hours after the injection. This will help with the diagnosis - to determine if the joints blocked are truly the source of your pain.
• Can I shower after the injection? Depending on the type of injection, you should avoid submerging your back in water for 2-3 days after the injection. This includes a bath, hot tub, swimming pool, or the ocean. You may shower the night after the injection, unless told not to by the doctor.
• When can I travel after the injection? You should not travel long distance for one week after the injection.
• How many injections have you performed? What is your training? Both Dr. Baker and Dr. Marrinan have many years of experience performing these injections and have each performed over 1,000 injections. Dr. Marrinan has completed a one year fellowship (sub-specialty training) in spinal injections, learning from one of the top interventional spine physicians in New York City. Drs. Baker and Marrinan are both members of the International Spine Intervention Society and regularly attend meetings, conferences, and workshops to remain up to date on the latest innovations in spine care.
• How many complications have you had? To date, neither Dr. Baker nor Dr. Marrinan has had any major complications from a spinal injection.

WHAT IS OSTEOARTHRITIS?
Osteoarthritis (OA), also called "degenerative joint disease (DJD)," is the most common type of arthritis. It is essentially a wearing down of the joint surfaces. Joints are lined with cartilage that is very smooth and helps the bones glide in the joint. As the cartilage gets worn down, movement can become painful and the range of motion restricted. Osteophytes, or "bone spurs," can form, causing pain and limited motion.

HOW DO YOU GET IT?
Osteoarthritis affects both men and women and becomes more common with advanced age. It is the most common form of arthritis, affecting from 20 to 40 million Americans. Risk factors including a family history of OA, obesity, or past trauma to a joint increase the chances of developing OA.

WHAT ARE THE SYMPTOMS?
The most common symptoms of OA are stiffness, pain, swelling, or hearing and feeling "crunching " when moving the joints. Small "bumps" may develop in the fingers. Warmth, redness of the skin, or fever is not typically associated with OA and may suggest a different kind of arthritis or an infection and should be evaluated by a doctor urgently.

WHICH JOINTS ARE AFFECTED?
Any joint can be affected by OA, especially if it has been subject to trauma in the past. The most commonly affected joints are the knees, hips, hands, wrists, and the spine. Less commonly affected are the feet, shoulders, and elbows.

HOW IS IT DIAGNOSED?
A complete evaluation, including the patient's description of the symptoms and a physical exam, is performed to diagnose OA. Even though the history and physical exam are usually sufficient, imaging studies such as x-rays or MRI can confirm the diagnosis and evaluate the severity of the condition. Blood tests can be performed to rule out other causes of joint pain or kinds of arthritis.

HOW IS OSTEOARTHRITIS TREATED?
Treatment of OA is focused on three main objectives: pain control, maintenance of function, and prevention of further degeneration. Pain control is achieved with the use of physical therapy and exercise, medications, joint injections, braces or splints. Weight loss can alleviate symptoms in large joint arthritis, such as knees and hips. Other treatments such as acupuncture, can help relieve pain. If the above are not successful, surgical treatment consisting of joint replacement is warranted.

WHICH MEDICATIONS ARE HELPFUL?
Tylenol is a painkiller (analgesic) without many side effects, that can be taken as needed. NSAIDs (non-steroidal anti-inflammatories), which include Advil, Motrin, Aleve, have both analgesic and anti-inflammatory effects. NSAIDs may cause multiple side effects and should be taken with care. Opiates are stronger painkillers, and range from the mild (Ultram, Codeine) to the very potent. These medications can also have serious side effects. Topical treatments including anti-inflammatory creams, patches, and coolant sprays and gels may help relieve pain with little or no side effects. Dietary supplements such as Glucosamine are unproven, but appear to be beneficial in slowing the progression of arthritis.

HOW DOES PHYSICAL THERAPY HELP?
The therapist can perform modalities, such as electrical stimulation, ultrasound, ice or heat, to help reduce pain and inflammation. Massage and joint mobilization helps to restore flexibility. Strengthening of the muscles around the affected joint has been shown to reduce pain. Proper posture, pacing of activities, are also part of a good PT program.

WHAT ABOUT INJECTIONS?
There are two kinds of injections available for the treatment of arthritis. The first is corticosteroids. They reduce inflammation and swelling, thereby resulting in pain relief and the ability to participate in a rehabilitation program. Their effectiveness can be short-lived and variable. The second kind consist of viscosupplementation, or hyaluronate injections (such as Synvisc, Supartz). They act as anti-inflammatories and joint lubricants and provide the advantage of longer lasting relief, 9-12 months, and fewer side effects than steroids.

IS THERE A CURE?
There is no definitive way to stop the progression of OA or to reverse the damage. Treatment is focused on controlling pain and maintaining flexibility and strength. If the pain becomes unbearable and quality of life is unacceptably diminished, the "cure" is a surgical replacement of the joint. Knee and hip replacements are now commonplace and are typically very successful. Post-operative physical therapy is essential for restoration of range of motion, strength and a return to full, pain-free function.

Control Weight - maintaining a healthy body weight reduces the stress on weight bearing joints (hips, knees and spine). Losing weight, if you are overweight, can significantly reduce pain and is believed to slow joint degeneration.

Exercise Regularly - The stronger the muscles around a joint are, the more stable and efficient the joint can be. Muscles also act to "unload" a joint and reduce pain. Exercise helps maintain flexibility and range of motion. Non-impact or low-impact exercise (such as swimming, biking, elliptical) does not stress weight-bearing joints and is recommended.

Medications - Discuss with your physician which medication is best for you. Arthritis medications can have side-effects and should be taken with caution.

Injections - Discuss with your doctor whether injections, corticosteroid or viscosupplementation, can help your condition.

Regenerative Injection Therapy with Growth Factors in Platelet Rich Plasma (PRP) is an alternative approach to healing tendon and ligament injuries.

WHAT IS PLATELET RICH PLASMA?
Platelet rich plasma, or PRP, is blood plasma with concentrated platelets. The concentrated platelets found in PRP contain huge reservoirs of bioactive proteins, including growth factors that are vital to initiate and accelerate tissue repair and regeneration. These bioactive proteins initiate connective tissue healing, bone regeneration and repair, promote development of new blood vessels, and stimulate the wound healing process.

WHAT ARE TENDONS AND LIGAMENTS?
Tendons connect the muscle to the bone making it possible to make coordinated movements while assisting and supporting the joints. They are composed of collagen fibers that hold one bone to another, stabilizing the joint and controlling the range of motion. When a ligament is damaged it is no longer able to provide support, weakening the joint. Overuse or damage to tendons over a long period of time causes collagen fibers in the tendons to form small tears, a condition called tendinosis. Commonly this occurs in knees, elbows, ankles, shoulders, wrists, Achilles tendons.

Tendons and ligaments have poor blood supply. Combined with the stress of day-to-day activities, they do not easily heal from damage. As a result the tendons and ligaments become inefficient causing chronic pain and weakness.

WHAT CAN BE TREATED?
PRP injections can be performed in tendons and ligaments all over the body. Sports injuries, arthritic joints, tennis elbow, carpal tunnel syndrome, ACL tears, shin splints, rotator cuff tears, plantar fasciitis, and iliotibial band syndrome (runner's knee) may all be effectively treated with PRP.

HOW DOES PRP THERAPY WORK?
To prepare PRP, a small amount of blood is taken from the patient. Blood is placed in a centrifuge to produce the PRP. The process takes 10-15 minutes and increases the concentration of platelets and growth factors up to 500%. When PRP is injected into the damaged tissue it stimulates the tendon or ligament causing mild inflammation that triggers the healing cascade. As a result new collagen begins to develop. As this collagen matures it begins to shrink causing the tightening and strengthening of the tendons or ligaments of the damaged area.

IS THIS THE SAME AS CORTISONE SHOTS?
Studies have shown that cortisone injections may actually weaken tissue. Cortisone shots may provide temporary relief and stop inflammation, but may not provide long term healing. PRP therapy is healing and strengthening these tendons and ligaments. Thus strengthening and thickening the tissue up to 40% in some cases.

WHAT ARE THE POTENTIAL BENEFITS?
Patients can see a significant improvement in symptoms. This may eliminate the need for more aggressive treatments such as long term medication or surgery as well as a remarkable return of function.

HOW MANY TREATMENTS & HOW OFTEN IS THIS THERAPY?
While responses to treatment vary, most people will require 3-6 sets of injections. Each set of treatments is spaced approximately 4 to 6 weeks apart. There is no limit to the number of treatments you can have, the risk and side effects do not change with the number of injections.

IS PRP RIGHT FOR ME?
If you have a tendon or ligament injury and traditional methods have not provided relief, then PRP therapy may be the solution. The procedure is less aggressive and less expensive than surgery. It will heal tissue with minimal or no scarring and alleviates further degeneration of the tissues. There will be an initial evaluation with your doctor to see if PRP therapy is right for you.

ARE THERE ANY SPECIAL INSTRUCTIONS?
You are restricted from the use of non-steroid anti-inflammatory medications (NSAIDs) one week prior to the procedure and throughout the course of treatments. If you are on anticoagulants or blood thinners, depending on the injection site, you doctor may instruct you to stop this medication prior to the procedure.

Initially the procedure may cause some localized soreness and discomfort. Most patients only require some extra-strength Tylenol to help with the pain. Ice and heat may be applied to the area as needed. The discomfort is usually minimal and one can expect as much as any other office injection. Most of these injections are performed in the office. If performed in the spine, fluoroscopy equipment may be necessary which will require a visit as an outpatient to the hospital or the surgery center.

The first week after the procedure, patients will typically start a rehabilitation program with physical therapy. However, aggressive physical activity is discouraged.

HOW SOON CAN I GO BACK TO REGULAR PHYSICAL ACTIVITIES?
PRP therapy helps regenerate tendons and ligaments but it is not a quick fix. This therapy is stimulating the growth and repair of tendons and ligaments requiring time and rehabilitation. Through regular visits, your doctor will determine when you are able to resume regular physical activities.

DOES INSURANCE PAY FOR PRP?
With the exception of Medicare, most PPO insurance companies will cover partial reimbursement after pre-authorization.

A sacroiliac joint injection is a "cortisone shot" for the sacroiliac joint. The sacroiliac joints are two joints (right and left) which connect the lower spine or coccyx to the pelvis. These joints do not move much, but they can become inflamed and painful, especially after trauma. The only way to determine if a sacroiliac joint is causing pain is to fill the joint with anesthetic and see if the pain disappears. If the joint is inflamed, the anti-inflammatory steroid (the "cortisone") can provide long term pain relief. If the injection is effective, but does not last long, radiofrequency neurotomy can be performed to provide longer lasting pain relief.

FREQUENTLY ASKED QUESTIONS:

• Does it hurt? Can I be "put out" for it? You will first get local anesthetic to numb your back. Depending on where the injection is performed, you may also request intravenous sedation to put you in a "twilight" sleep for the procedure. You may feel a pinch in the back for the local anesthetic and pressure or tingling in the back or leg as the medication goes in. At any time during the procedure, more anesthetic can be given to make you more comfortable.
• How long does it take? The actual injection usually takes 15 to 20 minutes, but you will need to be at the hospital or surgery center for about 60 to 90 minutes from check-in and check-out.
• What medication gets injected? The medication injected is usually a combination of a local anesthetic (lidocaine or bupivicaine) and an anti-inflammatory steroid (betamethasone, or triamcinalone).
• Is it the kind of steroids athletes take to get stronger? Will I gain weight? No. Anti-inflammatory steroids are totally different than the anabolic steroids that athletes use to get bigger and stronger. It will not make you gain weight.
• When will I start to feel better? The local anesthetic will usually start immediately and provide pain relief for the six to eight hours after the procedure. The steroids may take anywhere from one day to two weeks to reach peak effectiveness. In some cases the pain will return the day after the injection and then gradually improve again over the next week.
• How long will it last? Every case is different and it is impossible to predict how effective the injection will be. Sometimes one injection will relieve the pain forever. Sometimes repeat injections are needed every six months or yearly. If the injection is effective, but lasts only a few days or weeks, a radiofrequency neurotomy may provide longer lasting relief.
• What are the side effects? Side effects are rare, but may include a temporary increase in pain, hot flashes or sweating for 1-2 days, vasovagal reaction (fainting), headache, or hiccups. Some injections may also cause mild numbness or weakness in the leg(s) for 30 to 40 minutes after the injection.
• What are the potential complications? There are four main complications: bleeding, infection, allergic reaction, or puncture of the large intestine. These are all very rare when the appropriate precautions are taken. When properly performed, the needle does not enter the spinal canal during a sacroiliac joint injection, and therefore risk of complication is much less than in other types of spinal procedures. Fluoroscopy (low power x-ray) is used for safety and to verify appropriate needle placement.
• Do I need to stop my medication before the injection? You must stop any blood thinning medication 7 to 10 days before the procedure to prevent bleeding. This includes aspirin (and 81mg "baby aspirin"), coumadin, plavix, advil, motrin, aleve, naprosyn/naproxen, ibuprofen, excedrin, any cold or sinus medication containing these, and other anti-inflammatory medications. If you are not sure if you need to stop a medication, you should ask. Diabetes medication may need to be held the morning of the procedure if you do not eat breakfast. Blood pressure and other heart medications should be continued.
• Do I need to stay in bed all day after the injection? When can I go back to work? You should take the day off from work for the injection. You don't need to be in bed, but you should "take it easy" for the rest of the day after the injection. You may return to work the day after the procedure.
• Can I shower after the injection? Depending on the type of injection, you should avoid submerging you back in water for 2-3 days after the injection. This includes a bath, hot tub, swimming pool, or the ocean. You may shower the night after the injection, unless told not to by the doctor.
• When can I travel after the injection? You should not travel long distance for one week after the injection.
• How many injections have you performed? What is your training? Both Dr. Baker and Dr. Marrinan have many years of experience performing these injections and have each performed over 1,000 injections. Dr. Marrinan has completed a one year fellowship (sub-specialty training) in spinal injections, learning from one of the top interventional spine physicians in New York City. Drs. Baker and Marrinan are both members of the International Spine Intervention Society and regularly attend meetings, conferences, and workshops to remain up to date on the latest innovations in spine care.
• How many complications have you had? To date, neither Dr. Baker nor Dr. Marrinan has had any major complications from a spinal injection.

American Academy of Physical Medicine and Rehabilitation
Information on Spinal Conditions
Information on Spinal Conditions
Information on Spinal Conditions
Information on Spinal Conditions
Information on Orthopedic Conditions
Information on Rheumatologic Conditions
National Osteoporosis Foundation