Pain Management Center

Procedural Therapy




Stanford offers a variety of procedures to treat pain, including various neural blocks and several innovative procedures available at only Stanford or a few institutions nationwide. Depending on your particular condition, you may be referred for single or ongoing procedural appointments. These procedures may also be used in combination with other therapies.

The procedures available at the Pain Management Center include:



Epidural Steroid Injection

What is epidural steroid injection?

Epidural steroid injection is a medical procedure that involves the administration of a dose of pain-killing medication into a small space in your back or neck. Epidural steroid treatment usually involves a series of up to three injections, repeated at regular (weekly) intervals. This treatment has brought relief to many patients who suffer from pain caused by local inflammation, such as bulging discs, arthritis or ligament strain.

How quickly can I expect pain relief?

Relief is not instantaneous, but most patients report that initial benefit is felt two to five days after the first injection and maximum relief is reached one or two weeks after the last injection.

How should I prepare for the procedure?

The epidural steroid injection is a safe medical procedure but, as with any procedure, it has risks as welt as benefits. To minimize the chance of complications, we ask that you follow a few simple guidelines:

Do nor eat or drink anything six hours prior to the procedure. An exception is always made for routine scheduled medication, which you can take with a sip of water.

We require that a responsible adult driver accompany you to and from the Pain Management Center. Physicians at the Pain Management Center may offer a small dose of relaxing medication prior to the injection, which could impair your driving ability.

Plan on spending about 90 minutes at the Pain Management Center. This includes time for patient registration, preparation, performance of the procedure and observation.

What happens during the procedure?

First, an intravenous line will be placed, generally in your hand or arm. We will initiate continuous monitoring of your heart, breathing and blood pressure. You will then be asked to either sit or lie on your side on the treatment bed. Sometimes, x-ray guidance aids in appropriate placement of the medication. Once the equipment has been positioned, you may be offered a sedative medication to help you relax.

After cleaning a small patch of your skin, a local anesthetic is injected into the skin to decrease any pain associated with performance of the procedure. The steroid medication is then administered through a small needle. The procedure itself is very brief, usually less than five minutes.

Occasionally, patients describe a recurrence of their normal back pain during administration of the medication. This is viewed as a reassuring sign that the medication is going to the right place, and the sensation usually disappears quickly.

What happenss afterwards?

After the epidural steroid medication has been injected, we will continue to monitor you for about 20 minutes. If there are no signs of problems, you will be ready to leave. You may go to the reception area and schedule your follow-up injections. We will provide your physician with a written record of the procedure and will keep him/her informed of your progress during the entire course of treatment. If you have any questions after your procedure, the medical staff of the Pain Management Center is on call 24 hours a day, seven days a week. During normal business hours, you can reach either the nurse or physician by calling (650) 723-623 8. After hours, the physician on call can be reached by calling the Stanford University Hospital page operator at (650) 723-6661.

Will my insurance cover the procedure?

The epidural steroid injection is a well-established medical procedure and is reimbursed by most insurance companies. Any need for preauthorization of services or copayments depends on your insurance carrier. Our office staff will assist you in obtaining preauthorization whenever possible. The same copayments you make at your family physician’s office will often apply at the Pain Management Center.

How do I make an appointment?

Your physician should send a referral note to the Pain Management Center. The referral must include your name, address and phone number; a brief description of your condition; the physician’s request for this specific procedure; and the physician’s name, address and phone number. When we have received this information, we will call you to set up an appointment, often within 24 hours. For fastest service, your physician should FAX his request to us at (650) 725-7743.



Hypogastric Plexus Block

What is a hypogastric plexus block?

The hypogastric plexus is a collection of nerves that is located in front of the fifth lumbar and first sacral vertebral bodies. This means that the plexus is located near the lower part of your abdomen in the upper front of your pelvis. A hypogastric plexus block involves the administration of a dose of pain killing medication near the region of this nerve collection. The hypogastric block usually involves a series of several injections, repeated at weekly intervals. This treatment has brought relief to many patients who suffer from pain located in the pelvic structures, to include pain located in the region of the bladder, lower intestines, as well as the uterus, ovaries and vagina in women, and the prostate and testicles in men.

How quickly can I expect pain relief?

Most patients can expect pain relief within the first 15 to 20 minutes after the injection of local anesthetic. This pain relief may only last several hours; however, if the physician has also used steroid medication, you may also receive some pain relief that will begin roughly 36 hours after the injection. Duration of pain relief is somewhat variable, as it differs from patient to patient.

How should I prepare for the procedure?

The hypogastric plexus block is a safe medical procedure; but, as with any procedure, it has risks as well as benefits. To minimize the chance of complications, we ask that you follow a few simple guidelines:

Do not eat or drink anything for (6) six hours prior to the procedure.

It is required that you be accompanied to and from Stanford Ambulatory Surgery Center by a responsible adult driver. Most likely you will be offered a small dose of intravenous medication during the procedure which will act to not only decrease nxiety, but provide you some pain relief from the minor discomfort of the procedure itself. This intravenous medication that you receive will impair your driving ability; therefore, it is imperative that you be accompanied by a responsible adult driver.

Plan on spending roughly two to three hours at the Stanford Ambulatory Surgery Center. This allows for time for registration, preparation, performance of the procedure and observation after the procedure.

What happens during the procedure?

First, an intravenous line will be placed, generally in your hand. We will then bring you to the operating room and place several monitors on you, such as a heart, blood pressure and a pulse. These will enable us to monitor your vital signs throughout the procedure. Following placement of the monitors we will begin to give you some intravenous medication in order to decrease anxiety, as well as provide you with some pain relief.

You will then be placed in the prone position (on your stomach). The physicians will then use x-ray guidance to aid in appropriate placement of the medication. After clearing a small patch of your skin, a local anesthetic is injected into the skin to decrease any pain associated with performance of the procedure. The medication will then be administered through a needle near your hip bones on both sides. The procedure itself usually lasts 10 to 15 minutes. Occasionally, patients describe a very transient recurrence of their pelvic pain during administration of their medication. This is viewed as a reassuring sign that the medication is going to the right place, and the sensation usually disappears very quickly.

What happens afterwards?

After the hypogastric plexus block is performed, we will continue to monitor you in the recovery room for 30 to 40 minutes. If there are no signs of any problems, you will be ready to leave. If you have any questions after your procedure, the medical staff of the Pain Management Center is on call 24 hours a day, seven days a week. During normal business hours, you can reach either the nurse or physician by calling (650)723-6238. After hours, the physician on call can be reached by calling the Stanford University Hospital page operator at (650)723-6661.

Will my insurance cover the procedure?

The hypogastric plexus block is a well, established medical procedure, and is reimbursed by most insurance companies. Any need for preauthorization of services or copayments, depends on your insurance carrier. Our office staff will assist you in obtaining preauthorization whenever possible.

What should I expect from this procedure?

Expect the block to provide you with several hours of pain relief. After this time, the pain will likely return. If the physicians have used steroid medication in addition to the local anesthetic, this may provide you with further pain relief after 36 to 48 hours. Sometimes, this block is performed for diagnostic reasons. This means that your physicians have chosen to do this block in order to determine a possible cause for your pain. In this instance, you may or may not experience any pain relief.

What possible side effects might I see?

The most common side effect from this procedure is a sore back in the region where the blocks were performed. There is a very small chance of the needle puncturing a blood vessel. This potentially could lead to blood clot formation in your pelvis; however, this is extremely rare and your physician will take extra precautions to attempt to avoid this complication. There is also a very rare chance of injury to either the kidney or urethras. The urethras are the structure that connects your kidneys to your bladder. These risks are, again, extremely small and are even less likely when the procedure is performed under x-ray guidance.

What should I do if any problems develop after I leave the hospital?

If you have any questions after the procedure, the medical staff of the Pain Management Center is on call 24 hours a day, seven days a week. During normal business hours, you can reach either the nurse or physician by calling (650)723-6238. After hours, the physician on call can be reached by calling the Stanford University Hospital page operator at (650)723-6661.

Postprocedure instructions:

These will be provided for you, in further detail, by the recovery room nurse, prior to your discharge from the Ambulatory Surgery Center. These instructions should include; no driving or operating heavy machinery for 24 hours after the procedure. This is recommended secondary to the fact that you have received intravenous medication during a procedure which may impair your ability to perform these tasks.



Intrathecal Programmable Pump Placement

What is an intrathecal programmable pump placement?

The intrathecal programmable pump is an implanted medical device which is used to deliver medication directly into the spinal fluid. The system consists of an infusion pump, a spinal catheter, and an external programmer.

This treatment has brought relief to many patients who suffer from chronic, severe pain from multiple causes and also from chronic, severe spasticity of spinal cord origin.

How quickly can I expect pain relief?

The pump is programmed immediately upon placement, before leaving the surgical suite. The effect of the medication occurs within minutes to hours, depending on the choice of medication placed in the pump.

How should I prepare for the procedure?

The intrathecal programmable pump is a safe medical procedure; but, as with any procedure, it has risks as well as benefits. The pump placement is a relatively minor surgery preformed under general anesthesia. To minimize the chance of complication, we ask that you follow a few simple guidelines:

Do not eat or drink anything for (6) six hours prior to the procedure.

We require that you be accompanied to and from Stanford Hospital by a responsible adult driver. Following the procedure, you will be admitted to the hospital for an overnight stay for observation.

What happens during the procedure?

First, an intravenous line will be placed, generally in your hand. We will then bring you to the operating room and place several monitors on you, such as a heart, blood pressure and a pulse. These will enable us to monitor your vital signs throughout the procedure. Following placement of the monitors we will begin to give you some intravenous medication in order to decrease anxiety, as well as provide you with some pain relief.

You will be asked to lie on your side in the surgical suite. An x-ray is used to help guide the intrathecal catheter to the correct position.

After cleaning your skin, the skin is anesthetized with local anesthetic to decrease any pain associated with performance of the procedure. By this point, you will already have received sedation by the anesthesiologist, as well. The intrathecal catheter is placed through a small incision in your back. The programmable pump is placed under the skin in the right or left abdomen where there is sufficient skin and soft tissue to support the pump. A pocket is created underneath the skin to contain the pump. The catheter is tunneled from the back, underneath the skin to the abdomen where it is connected to the programmable pump. Both incisions are then closed with sutures. The pump is filled with the medication while you are in the surgical suite, and the programming is initiated. It will be functioning before you leave the surgical suite.

What happens afterwards?

The pump is filled with the medication while you are in the surgical suite, and the programming is initiated. It will be functioning before you leave the surgical suite.

We will assess that the pump is functioning correctly by observing for signs of pain relief from the medications, as well as development of numbness from the local anesthetic. You will be monitored for 20 to 40 minutes by a Recovery Room nurse and a Pain Management physician. If there are no signs of problems, you will be ready to leave the recovery area and be transferred to your room in the Ambulatory Treatment Unit for observation overnight. You will be monitored for correct functioning of the newly placed intrathecal pump, as well as for any complications related to the procedure and the anesthesia. If there are no signs of problems, you will be ready to leave by the next day.

You will need to return to the Pain Management Center for refills of the pump approximately every 30 days. Also, your pump can be reprogrammed at anytime by the Pain Management physicians using an external programmer. You will also be taught how to turn the pump on and off yourself while at home, using a magnet.

Will my insurance cover the procedure:

The intrathecal programmable pump placement is a well established medical procedure, and is reimbursed by most insurance companies. Any need for preauthorization of services or copayments, depends on your insurance carrier. Our office staff will assist you in obtaining preauthorization whenever possible.

What should I expect from this procedure?

You will require a short period of recovery from this minor surgical procedure. You may notice soreness in the abdominal wall where the intrathecal pump is placed, and some soreness in the back where the catheter is inserted; this is usually quite minimal. There will be some bruising which may last up to a week, but will resolve. Your home nursing agency will assist in monitoring the two sites for any evidence of infection. Signs to monitor are redness and/or increased pain or swelling of the two incision sites. The stitches will be removed at the Pain Management Center in approximately one week, provided that the incisions are well healed.

What possible side effects might I see?

The intrathecal pump placement is a safe surgical procedure but, as with any procedure, it has risks as well as benefits. The major risks of an in dwelling foreign device is infection and/or local bleeding. Usage of such a device over the long term requires vigilance to maintaining clean technique and decrease the likelihood of infection.

The intrathecal pump accesses the intrathecal space. The medications delivered there may cause numbness and/or weakness and/or sedation depending on which medication is used and what dose is administered. These side effects are normally reversible. You may have some local tenderness at the pump insertion site once the numbing medicine has worn off.

What should I do if any problems develop after I leave the hospital?

If you have any questions after the procedure, the medical staff of the Pain Management Center is on call 24 hours a day, seven days a week. During normal business hours, you can reach either the nurse or physician by calling (650)723-6238. After hours, the physician on call can be reached by calling the Stanford University Hospital page operator at (650)723-6661

Post procedure instructions:

These will be provided for you, in further detail, by the nurse, prior to your discharge from the hospital.

Signs to monitor are redness and/or increased pain or swelling of the two incision sites. The stitches will be removed at the Pain Management Center in approximately one week, provided that the incisions are well healed.



Implanted Intrathecal Portal Placement

What is an implanted intraqthecal portal?

An intrathecal portal (or port) is a implanted device which allows access to the intrathecal space in your spine. It us used for the delivery of medications for pain management. A port is a small, stainless steel disc (about the size of a half dollar) with a raised “septum” in the center. Because the section is raised, it is easily felt through the surface of the skin. The port is usually implanted under the skin on the chest. Attached to the base of the port is a narrow flexible tube, called a catheter. The catheter runs beneath the skin from the intrathecal space in the space around to the front of the chest where it is attached to the port. Since the entire device is placed under the skin, the risk of infection is greatly reduced. The septum is made of a remarkable self sealing rubber material. Over years of use, the septum may be punctured many hundereds of times and reseals itself instantly after use. This procedure is done only after a trial of epidural medications has been proven to be useful in managing your pain.

How quickly can I expect pain relief?

Once the intrathecal port is placed, an infusion of medications (local anesthetics and/or narcotics) is initiated. These medications should bring about pain relief within minutes. It may, however, take a few days to adjust the dose for the optimal pain relief.

How should I prepare for the procedure?

The implanted intrathecal portal placement is a safe medical procedure; but, as with any procedure, it has risks as well as benefits. To minimize the chance of complications, we ask that you follow a few simple guidelines:

Do not eat or drink anything for (6) six hours prior to the procedure.

Following placement of the epidural portal you will be required to stay overnight for observation in the Ambulatory Treatment Unit (ATU).

It is required that you be accompanied to and from Stanford Hospital by a responsible adult driver.

What happens during the procedure?

First, an intravenous line will be placed, generally in your hand. We will then bring you to the operating room and place several monitors on you, such as a heart, blood pressure and a pulse. These will enable us to monitor your vital signs throughout the procedure. Following placement of the monitors we will begin to give you some intravenous medication in order to decrease anxiety, as well as provide you with some pain relief.

Your back will be cleaned and the insertion point of the intrathecal port will be anesthetized with local anesthesia. The epidural needle is placed through a small incision in your back and the catheter is threaded through the needle under the guidance of x-ray. A second small incision is made on the upper part of your chest wall and a pocket is created in the tissues beneath the skin. The small circular epidural port is inserted into this pocket and connected to the catheter which is tunneled underneath the skin from you back. The two incisions, on the chest wall and on your back, are closed with stitches and both are dressed with a sterile dressing. The port is then accessed with a access needle and connected to an external infusion pump containing the intrathecal medications. The intrathecal port will be functioning before you leave the surgical suite to provide you pain relief.

A majority of this procedure is performed under a local anesthesia, thereby providing minimal discomfort at the time of the surgery, and also providing pain relief for 6 to 12 hours afterwards. You will also receive sedation to provide optimal comfort during the procedure.

What happens afterwards?

Once the port is placed, it will be accessed with a special needle and connected to an external infusion pump containing the intrathecal medications. We will assess that the port is functioning correctly by observing for signs of pain relief from the medications, as well as development of numbness from the local anesthetic. You will be monitored for 20 to 40 minutes by a Recovery Room nurse and a Pain Management physician. If there are no signs of problems, you will be ready to leave the recovery area and be transferred to your room in the Ambulatory Treatment Unit for observation overnight. You will be monitored for correct functioning of the newly placed intrathecal port, as well as for any complications related to the procedure and the anesthesia. If there are no signs of problems, you will be ready to leave by the next day.

A home nursing agency will be required to provide care for your intrathecal port. The medication cassette will need to be changed daily. The dressing, needle, and the infusion tubing will need to be changed every three days by a home visiting nurse. The visiting nurse will also monitor for any signs of infection.

Your port will be dosed with medications on either an intermittent or continuous basis based on the determination of the Pain Management physician.

Will my insurance cover the procedure?

The implanted intrathecal portal is a well established medical procedure, and is reimbursed by most insurance companies. Any need for preauthorization of services or copayments, depends on your insurance carrier. Our office staff will assist you in obtaining preauthorization whenever possible.

What should I expect from this procedure?

You will require a short period of recovery from this minor surgical procedure. You may notice soreness in the chest wall where the intrathecal port is placed, and some soreness in the back where the catheter is inserted; this is usually quite minimal. There will be some bruising which may last up to a week, but will resolve. Your home nursing agency will assist in monitoring the two sites for any evidence of infection. Signs to monitor are redness and/or increased pain or swelling of the two incision sites. The stitches will be removed at the Pain Management Center in approximately one week, provided that the incisions are well healed.

What possible side effects might I see?

The intrathecal portal placement is a safe minor surgical procedure but, as with any procedure, it has risks as well as benefits. The major risks of an in dwelling foreign device is infection and/or local bleeding. Usage of such a device over the long term requires vigilance to maintaining clean technique and decrease the likelihood of infection.

The intrathecal portal accesses the intrathecal space. The medications delivered there may cause numbness and/or weakness and/or sedation depending on which medication is used and what dose is administered. These side effects are normally reversible. You may have some local tenderness at the portal insertion points once the numbing medicine has worn off.

What should I do if any problems develop after I leave the hospital?

If you have any questions after the procedure, the medical staff of the Pain Management Center is on call 24 hours a day, seven days a week. During normal business hours, you can reach either the nurse or physician by calling (650)723-6238. After hours, the physician on call can be reached by calling the Stanford University Hospital page operator at (650)723-6661

Post procedure instructions:

Prior to leaving the hospital, the incision areas will be dressed with a dry sterile dressing, which is clear. You will be see directly through the dressing and can watch for any signs of infection. The visiting nurses will change the access needle and tubing for the infusion pump every three days. They will also monitor to make sure the wounds are healing appropriately.



Occipital Nerve Block

What is an occipital nerve block ?

Occipital nerve block is a medical procedure that involves administration of a dose of medication into an area in the back of your head. It is most frequently used to diagnose and treat a type of tension headache most likely due to occipital neuralgia or an irritation of a nerve in the back of one’s head. This treatment has brought relief to many patients who suffer from pain caused by occipital tension headaches.

How quickly can I expect pain relief?

Pain relief is usually felt fairly quickly after the injection of medication. If your doctor uses a local anesthetic followed by a steroid type of medication, you can expect to feel some initial pain relief that may then dissipate when the local anesthetic has worn off (several hours later). You can then expect to feel some additional pain relief roughly 48 hours later when the steroid medication begins to take effect.

How should I prepare for the procedure?

The occipital nerve block is a safe medical procedure; but, as with any procedure, it has risks as well as benefits. To minimize the chance of complications, we ask that you follow a few simple guidelines:

Do not eat or drink anything for (6) six hours prior to the procedure.

It is required that you be accompanied to and from Stanford Ambulatory Surgery Center by a responsible adult driver. Most likely you will be offered a small dose of intravenous medication during the procedure which will act to not only decrease anxiety, but provide you some pain relief from the minor discomfort of the procedure itself. This intravenous medication that you receive will impair your driving ability; therefore, it is imperative that you be accompanied by a responsible adult driver.

Plan on spending roughly two to three hours at the Stanford Ambulatory Surgery Center. This allows for time for registration, preparation, performance of the procedure and observation after the procedure.

What happens during the procedure?

First, an intravenous line will be placed, generally in your hand. We will then bring you to the operating room and place several monitors on you, such as a heart, blood pressure and a pulse. These will enable us to monitor your vital signs throughout the procedure. Following placement of the monitors we will begin to give you some intravenous medication in order to decrease anxiety, as well as provide you with some pain relief.

You will then be asked to sit on the side of the bed . After cleaning a small patch of your skin, a local anesthetic will be injected into the skin to decrease any pain associated with performance of the procedure. The medication is then administered through a small needle in the occipital region of your head and neck. The procedure itself is very brief, and usually lasts less then 10 minutes. Occasionally, patients describe a transient worsening of their headache after the medication is administered. This is viewed by the physicians as a reassuring sign that the medication is going into the right area, and this sensation should disappear very quickly.

What happens afterwards?

After the occipital nerve block is performed, we will continue to monitor you in the recovery room for 30 to 40 minutes. If there are no signs of any problems, you will be ready to leave. If you have any questions after your procedure, the medical staff of the Pain Management Center is on call 24 hours a day, seven days a week. During normal business hours, you can reach either the nurse or physician by calling (650)723-6238. After hours, the physician on call can be reached by calling the Stanford University Hospital page operator at (650)723-6661.

Will my insurance cover the procedure?

The occipital nerve block is a well established medical procedure, and is reimbursed by most insurance companies. Any need for preauthorization of services or copayments, depends on your insurance carrier. Our office staff will assist you in obtaining preauthorization whenever possible.

What should I expect from this procedure?

Occasionally, patients will describe a transient worsening of their headache, as the injection is made. This is viewed by the physicians as a reassuring sign that the medication is going to the right place, and the sensation usually disappears very quickly. This should then be followed by a pain free interval of several hours. After the local anesthetic has worn off, your headache may return for up to 1 1/2 days. After this time, the steroid medication that was also injected for your occipital nerve block, should begin to work and provide you with further pain relief.

What possible side effects might I see?

As stated above, after the local anesthetic that was injected as part of your occipital nerve block wears off, your headache may return for roughly 24 to 36 hours. After this time, you should receive some pain relief from the medication that was also injected during the time of your occipital nerve block. You may also experience some slight soreness at the sight of the injection. This is very normal, and should go away within a couple of days.

What should I do if any problems develop after I leave the hospital?

If you have any questions after the procedure, the medical staff of the Pain Management Center is on call 24 hours a day, seven days a week. During normal business hours, you can reach either the nurse or physician by calling (650)723-6238. After hours, the physician on call can be reached by calling the Stanford University Hospital page operator at (650)723-6661.

Postprocedure instructions:

These will be provided for you, in further detail, by the recovery room nurse, prior to your discharge from the Ambulatory Surgery Center. These instructions should include; no driving or operating heavy machinery for 24 hours after the procedure. This is recommended secondary to the fact that you have received intravenous medication during a procedure which may impair your ability to perform these tasks.



Implanted Epidural Portal Placement

What is an implanted epidural portal?

An epidural portal (or port) is a implanted device which allows access to the epidural space in your spine. It us used for the delivery of medications for pain management. A port is a small, stainless steel disc (about the size of a half dollar) with a raised “septum” in the center. Because the section is raised, it is easily felt through the surface of the skin. The port is usually implanted under the skin on the chest. Attached to the base of the port is a narrow flexible tube, called a catheter. The catheter runs beneath the skin from the epidural space in the space around to the front of the chest where it is attached to the port. Since the entire device is placed under the skin, the risk of infection is greatly reduced. The septum is made of a remarkable self sealing rubber material. Over years of use, the septum may be punctured many hundereds of times and reseals itself instantly after use. This procedure is done only after a trial of epidural medications has been proven to be useful in managing your pain.

How quickly can I expect pain relief?

Once the epidural port is placed, an infusion of medications (local anesthetics and/or narcotics) is initiated. These medications should bring about pain relief within minutes. It may, however, take a few days to adjust the dose for the optimal pain relief.

How should I prepare for the procedure?

The implanted epidural portal placement is a safe medical procedure; but, as with any procedure, it has risks as well as benefits. To minimize the chance of complications, we ask that you follow a few simple guidelines:

Do not eat or drink anything for (6) six hours prior to the procedure.

Following placement of the epidural portal you will be required to stay overnight for observation in the Ambulatory Treatment Unit (ATU).

It is required that you be accompanied to and from Stanford Hospital by a responsible adult driver.

What happens during the procedure?

First, an intravenous line will be placed, generally in your hand. We will then bring you to the operating room and place several monitors on you, such as a heart, blood pressure and a pulse. These will enable us to monitor your vital signs throughout the procedure. Following placement of the monitors we will begin to give you some intravenous medication in order to decrease anxiety, as well as provide you with some pain relief.

Your back will be cleaned and the insertion point of the epidural port will be anesthetized with local anesthesia. The epidural needle is placed through a small incision in your back and the catheter is threaded through the needle under the guidance of x-ray. A second small incision is made on the upper part of your chest wall and a pocket is created in the tissues beneath the skin. The small circular epidural port is inserted into this pocket and connected to the catheter which is tunneled underneath the skin from you back. The two incisions, on the chest wall and on your back, are closed with stitches and both are dressed with a sterile dressing. The port is then accessed with a access needle and connected to an external infusion pump containing the epidural medications. The epidural port will be functioning before you leave the surgical suite to provide you pain relief.

A majority of this procedure is performed under a local anesthesia, thereby providing minimal discomfort at the time of the surgery, and also providing pain relief for 6 to 12 hours afterwards. You will also receive sedation to provide optimal comfort during the procedure.

What happens afterwards?

Once the port is placed, it will be accessed with a special needle and connected to an external infusion pump containing the epidural medications. We will assess that the port is functioning correctly by observing for signs of pain relief from the medications, as well as development of numbness from the local anesthetic. You will be monitored for 20 to 40 minutes by a Recovery Room nurse and a Pain Management physician. If there are no signs of problems, you will be ready to leave the recovery area and be transferred to your room in the Ambulatory Treatment Unit for observation overnight. You will be monitored for correct functioning of the newly placed epidural port, as well as for any complications related to the procedure and the anesthesia. If there are no signs of problems, you will be ready to leave by the next day.

A home nursing agency will be required to provide care for your epidural port. The medication cassette will need to be changed daily. The dressing, needle, and the infusion tubing will need to be changed every three days by a home visiting nurse. The visiting nurse will also monitor for any signs of infection.

Your port will be dosed with medications on either an intermittent or continuous basis based on the determination of the Pain Management physician.

Will my insurance cover the procedure?

The implanted epidural portal is a well established medical procedure, and is reimbursed by most insurance companies. Any need for preauthorization of services or copayments, depends on your insurance carrier. Our office staff will assist you in obtaining preauthorization whenever possible.

What should I expect from this procedure?

You will require a short period of recovery from this minor surgical procedure. You may notice soreness in the chest wall where the epidural port is placed, and some soreness in the back where the catheter is inserted; this is usually quite minimal. There will be some bruising which may last up to a week, but will resolve. Your home nursing agency will assist in monitoring the two sites for any evidence of infection. Signs to monitor are redness and/or increased pain or swelling of the two incision sites. The stitches will be removed at the Pain Management Center in approximately one week, provided that the incisions are well healed.

What possible side effects might I see?

The epidural portal placement is a safe minor surgical procedure but, as with any procedure, it has risks as well as benefits. The major risks of an in dwelling foreign device is infection and/or local bleeding. Usage of such a device over the long term requires vigilance to maintaining clean technique and decrease the likelihood of infection.

The epidural portal accesses the epidural space. The medications delivered there may cause numbness and/or weakness and/or sedation depending on which medication is used and what dose is administered. These side effects are normally reversible. You may have some local tenderness at the portal insertion points once the numbing medicine has worn off.

What should I do if any problems develop after I leave the hospital?

If you have any questions after the procedure, the medical staff of the Pain Management Center is on call 24 hours a day, seven days a week. During normal business hours, you can reach either the nurse or physician by calling (650)723-6238. After hours, the physician on call can be reached by calling the Stanford University Hospital page operator at (650)723-6661

Post procedure instructions:

Prior to leaving the hospital, the incision areas will be dressed with a dry sterile dressing, which is clear. You will be see directly through the dressing and can watch for any signs of infection. The visiting nurses will change the access needle and tubing for the infusion pump every three days. They will also monitor to make sure the wounds are healing appropriately.



Temporary Epidural Catheter Placement

What is a temporary epidural catheter?

An epidural catheter is a very fine plastic catheter (tube) that is placed through the skin into the epidural space in your spine. This temporary catheter is left in place for a defined period of time; normally less than (2)two weeks. The catheter allows access to the epidural space to inject medication such as local anesthetics and/or narcotics for relief of pain. Temporary epidural catheters are used for tempory treatment of painful conditions that require pain control for intensive physical therapy and/or joint mobilization. They are also used prognostically for trials of spinal medications prior to placement of permanent implanted ports or programmable pumps.

How quickly can I expect pain relief?

With an epidural catheter, patients can obtain pain relief within minutes. It may, however, take a few days to adjust the dose for the optimal pain relief. The catheter gives your Pain Management physician the ability to adjust the medication and determine the appropriate dosage.

How should I prepare for the procedure?

The temporary epidural catheter placement is a safe medical procedure; but, as with any procedure, it has risks as well as benefits. To minimize the chance of complications, we ask that you follow a few simple guidelines:

Do not eat or drink anything for (6) six hours prior to the procedure.

Following placement of the temporary epidural catheter you will be admitted to the hospital for approximately (5) five days for observation.

It is required that you be accompanied to and from Stanford Hospital by a responsible adult driver.

What happens during the procedure?

First, an intravenous line will be placed, generally in your hand. We will then bring you to the operating room and place several monitors on you, such as a heart, blood pressure and a pulse. These will enable us to monitor your vital signs throughout the procedure. Following placement of the monitors we will begin to give you some intravenous medication in order to decrease anxiety, as well as provide you with some pain relief.

You will then be asked to either sit or lie on your side on the bed. Sometimes, x-ray guidance aids in the appropriate placement of the catheter, and an x-ray may be used.

After cleaning a small patch of skin along your spine, a local anesthetic is injected into the skin to decrease any pain associated with the placement of the catheter. A small needle is then used to locate the epidural space, and the catheter is threaded through the needle. The needle is then withdrawn and a second patch of skin is anesthetized with local anesthetics. A similar needle is placed in the second spot in order to bring the catheter from the middle of your back to the side. This allows the catheter to be tunneled underneath the skin for a distance of four to five inches in order to provide stability. Two or three stitches may be placed to secure the catheter. The procedure itself is very brief, and associated with minimal discomfort.

The catheter is then covered with sterile dressing and taped to the skin of your back.

What happens afterwards?

Once the catheter is placed, it will be injected with medication, usually a local anesthetic and/or a narcotic. We will assess that the catheter is functioning correctly by observing for signs of pain relief from the medications, as well as development of numbness from the local anesthetic. You will be monitored for 20 to 40 minutes by a nurse and a Pain Management physician. If there are no signs of problems, you will be ready to leave the recovery area and return to your hospital room. Your epidural catheter will be dosed with medications on either an intermittent or continuous basis based on the determination of the Pain Management physician. The catheter is designed for short term use only and is normally removed prior to discharge from the hospital. In some cases patients are discharged home with the catheter and are managed at home with the assistance of a home nursing agency. If you have any questions after the procedure, the medical staff of the Pain Management Center is on call 24 hours a day, seven days a week. During normal business hours, you can reach either the nurse of physician by calling (650)723-6238. After hours, the physician on call can be reached by calling the Stanford University Hospital page operator at (650)723-6661.

Will my insurance cover the procedure?

The temporary epidural catherter placement is a well, established medical procedure, and is reimbursed by most insurance companies. Any need for preauthorization of services or copayments, depends on your insurance carrier. Our office staff will assist you in obtaining preauthorization whenever possible.

What should I expect from this procedure?

The catheter allows access to the epidural space to inject medication such as local anesthetics and/or narcotics for relief of pain.

What possible side effects might I see?

The temporary epidural catherter placement is a safe minor surgical procedure but, as with any procedure, it has risks as well as benefits. The major risks of an in dwelling foreign device is infection and/or local bleeding. Usage of such a device even over the short term requires vigilance to maintaining clean technique and decrease the likelihood of infection.

The temporary epidural catherter accesses the epidural space. The medications delivered there may cause numbness and/or weakness and/or sedation depending on which medication is used and what dose is administered. These side effects are normally reversible. You may have some local tenderness at the catheterl insertion site once the numbing medicine has worn off. .

What should I do if any problems develop after I leave the hospital?

If you have any questions after the procedure, the medical staff of the Pain Management Center is on call 24 hours a day, seven days a week. During normal business hours, you can reach either the nurse or physician by calling (650)723-6238. After hours, the physician on call can be reached by calling the Stanford University Hospital page operator at (650)723-6661.

Postprocedure instructions:

These will be provided for you, in further detail, by the nurse, prior to your discharge from the hospital. Before going home, the catheter will be removed and the insertion site will be dressed with a gauze dressing.

If you go home with the temporary epidural catheter in place, the catheter insertion site will be dressed with a clear plastic dressing. This allows you to be able to monitor the site for any signs of infection such as redness or swelling. Your home nursing agency will change the dressing as ordered and also inspect the site for any evidence of infection or problems.



Brachial Plexus Block

What is a brachial plexus block?

A brachial plexus block is a medical procedure that involves the administration of a dose of local anesthetic into an area either in your neck, above your collarbone or into your upper arm (near the armpit). This block may be performed as a single injection or a very small catheter may be inserted into one of these areas in order to provide continuous or repeated administration of medication. This treatment has brought relief to many patients who suffer from chronic pain of their arm and shoulder.

How quickly can I expect pain relief?

Relief is fairly quick (within 10 to 15 minutes) after the injection of medication.

How should I prepare for the procedure?

The brachial plexus block is a safe medical procedure; but, as with any procedure, it has risks as well as benefits. To minimize the chance of complications, we ask that you follow a few simple guidelines:

Do not eat or drink anything for (6) six hours prior to the procedure.

It is required that you be accompanied to and from Stanford Ambulatory Surgery Center by a responsible adult driver. Most likely you will be offered a small dose of intravenous medication during the procedure which will act to not only decrease anxiety, but provide you some pain relief from the minor discomfort of the procedure itself. This intravenous medication that you receive will impair your driving ability; therefore, it is imperative that you be accompanied by a responsible adult driver.

What happens during the procedure?

First, an intravenous line will be placed, generally in your hand. We will then bring you to the operating room and place several monitors on you, such as a heart, blood pressure and a pulse. These will enable us to monitor your vital signs throughout the procedure. Following placement of the monitors we will begin to give you some intravenous medication in order to decrease anxiety, as well as provide you with some pain relief.

After cleaning a small patch of your skin in the region of your neck, your collar bone or your upper arm, the local anesthetic is injected into the skin to decrease any pain associated with the performance of this procedure. After exact placement of the needle is confirmed, your physician will administer the medication through a small needle. If you and your physician had decided pre-operatively to place a catheter for more continuous administration of medication after the procedure, this will then be placed in the correct position. The procedure itself usually lasts 20 minutes. Occasionally, patients describe a recurrence of their normal arm or shoulder pain during the administration of the medication. This is viewed as a reassuring sign that the medication is going to the right place, and the sensation should disappear very quickly.

What happens afterwards?

After the brachial plexus block is performed, we will continue to monitor you in the recovery room for 30 to 40 minutes. If there are no signs of any problems, you will be ready to leave. If you have any questions after your procedure, the medical staff of the Pain Management Center is on call 24 hours a day, seven days a week. During normal business hours, you can reach either the nurse or physician by calling (650)723-6238. After hours, the physician on call can be reached by calling the Stanford University Hospital page operator at (650)723-6661.

Will my insurance cover the procedure?

The brachial plexus block is a well, established medical procedure, and is reimbursed by most insurance companies. Any need for preauthorization of services or copayments, depends on your insurance carrier. Our office staff will assist you in obtaining preauthorization whenever possible

What should I expect from this procedure?

A dose of local anesthetic will be administered through a small needle into an area either located in your neck, above your collar bone, or in the upper part of your arm. Your physician then may place a small catheter into one of these locations. This would have been discussed with you before the procedure, and would enable to position to administer a more continuous delivery of medicine. In some instances, despite the medicine being administered to correct location, the patient is not experiencing any pain relief. Although this is unfortunate, it may give your doctor some valuable information

What possible side effects might I see?

Occasionally patients will describe recurrence of their normal arm or shoulder pain during administration of the medication. This is viewed as a reassuring sign that the medication is going to the right place and sensation usually disappears very quickly. Other possible risks of this procedure include, bleeding, infection, or the injection of medication into a blood vessel which potentially can cause seizures. These risks are extremely rare, and your physicians will be continually monitoring your vital signs in order to guard against these complications.

What should I do if any problems develop after I leave the hospital?

If you have any questions after the procedure, the medical staff of the Pain Management Center is on call 24 hours a day, seven days a week. During normal business hours, you can reach either the nurse or physician by calling (650)723-6238. After hours, the physician on call can be reached by calling the Stanford University Hospital page operator at (650)723-6661.

Postprocedural instructions.

These will be provided for you, in further detail, by the recovery room nurse, prior to your discharge from the Ambulatory Surgery Center. These instructions should include; no driving or operating heavy machinery for 24 hours after the procedure. This is recommended secondary to the fact that you have received intravenous medication during a procedure which may impair your ability to perform these tasks.

Also, some patients notice weakness in the arm or shoulder that has been “blocked”. It is important, therefore, for you not to attempt to lift heavy objects with this arm for 12 to 24 hours after the procedure.



Peripheral Nerve Block

Trigeminal
Occipital
Axillary
Illioinguinal
Illiohypogastric
Sciatic
Interscalene
Infraclavicular
Femoral

Who might be a candidate for a peripheral nerve block?

Peripheral nerve blocks may be indicated for a variety of pain conditions and may be performed for diagnostic and/or therapeutic effect.  The area injected will depend on the location of your pain. I t is not possible to predict how much help, if any, this procedure will be for your pain.   Results vary with each person.

What happens during the procedure?

With this procedure, an IV will be placed in your hand or arm and you will be given some intravenous medicine to help you relax and have less pain from the needle used for the procedure. You will not be asleep. An X-ray machine is used to locate the area(s) of the spine to be injected.   Your doctor will use a local anesthetic to numb the area(s) to be injected. You will feel a pinprick and then a burning feeling as the local anesthetic is injected.  Once the area is numb, the spinal epidural needle will be placed and the steroid injected.

What should I expect after the procedure?

Initially, you may experience several hours of pain relief as a result of the local anesthetic. After that time the pain will return. If steroids are used, t may take 7 to 10 days for the anti-inflammatory effect of the steroid to be effective and for you to experience pain relief.

You may experience soreness or a feeling of fullness at the injection site
You may experience muscle spasms.
You may experience a neck ache or backache.
Your blood pressure may decrease or increase.
You may feel increased warmth of the upper or lower extremity.
You may feel some numbness or tingling of the upper or lower extremity.
The effected area may be numb for a few hours and should be protected from injury.
.
Post procedure instructions:

These will be provided for you, in further detail, by the recovery room nurse prior to your discharge from the Ambulatory Surgery Center. These instructions should include; no driving or operating machinery for 24 hours after the procedure. This is recommended because the intravenous medication given during the procedure may impair your ability to safely perform tasks.  A Pain Clinic follow up appointment should be scheduled.

What should I do if any problems develop after I leave the Surgery Center?

If you have any questions after the procedure, the medical staff of the Pain Management Clinic is on call 24 hours a day, seven days a week. During normal business hours you can reach either a physician or nurse by calling (650)723-6238. After hours, the physician on call can be reached by calling the Stanford Hospital and Clinics page operator at (650) 723-6661.

You should call the physician if you experience any of the following:

You get a headache that will not go away.   
Your arms, hands or legs get numb or weak.  
You have any problems with bowel or bladder control.         
Your thighs, groin, legs, or feet become numb or lose feeling.
You develop fevers, chills, stiff neck or redness at the injection or IV site.
Your pain progressively worsens.                          
You become short of breath.                                                                             



Gasserian Ganglion Block

What is a gasserian ganglion block?

A gasserian ganglion block is a medical procedure using administration of a dose of local anesthetics directly to a bundle of nerves that supplies sensation to your face and scalp. This nerve block may bring relief to patients who suffer from trigeminal neuralgia and other syndromes of facial pain, as well as patients who suffer from pain caused by cancer. In some instances, in patients who suffer from facial pain from cancer, a small dose of medication to kill the nerve going to the gasserian ganglion, can be used. This is not an option for patients who do not have cancer.

How quickly can I expect pain relief?

Relief is instantaneous, if the pain that you are experiencing is related only to the nerves which go to the gasserian ganglion. Total duration of pain relief will be six to 12 hours. If a nerve killing medication is used, maximum relief starts in one to two days, and may last up to three to six months.

How should I prepare for the procedure?

The gasserian ganglion block is a safe medical procedure, but as with any procedure it has risks, as well as benefits. To minimize the chance of complications, we ask that you follow a few simple guidelines:

Do not eat or drink anything for six hours prior to the procedure. An exception is always made for routine scheduled medication, which you can take with a sip of water.

We ask that you be accompanied to and from the Ambulatory Surgery Center by a responsible adult driver. Pain Management physicians, or a nurse in the Ambulatory Surgical Center may offer a small dose of relaxing medication prior to the procedure, which could impair your driving ability.

Plan on spending approximately 90 minutes in the Ambulatory Surgical Center. This includes time for registration, preparation, performance of the procedure and observation period.

What happens during the procedure?

First, an intravenous line will be placed, generally in your hand or arm. We will initiate continuous monitoring of your heart, breathing and blood pressure. You will be asked to lie on the treatment table. X-ray guidance will be used to help with placement of the medication. Once the equipment has been positioned, you will be offered sedative medications to help you relax and minimize discomfort.

A patch of skin over your face will be cleaned, using an antiseptic solution, and local anesthetic injected into the skin to decrease any pain associated with performance of the procedure. A needle will be placed adjacent to the gasserian ganglion using x-ray guidance. The procedure takes approximately 10 to 15 minutes to perform once the monitors and x-ray machine are in place. Occasionally, because the gasserian ganglion is adjacent to blood vessels, swelling or bruising of the face may occur. Should this occur, we would recommend that you rest in a seated position and use an ice pack.

What happens afterwards?

After the gasserian ganglion block has been performed, we will continue to monitor you for approximately 30 minutes. If there are no signs of problems, you will be ready to leave. We will provide your physician with a written record of the procedure, and will keep him/her informed of your progress during the entire course of treatment. You will be provided with a set of postprocedure instructions to help guide you following the procedure. If you have any questions after your procedure, the medical staff of the Pain Management Center is on call 24 hours a day, seven days a week. During normal business hours, you can reach either the nurse or the physician by calling (650) 723-6238. After hours, the physician on call can be reached by calling the Stanford University Hospital page operator at (650) 723-6661.

Will my insurance cover the procedure?

The gasserian ganglion block is a well established medical procedure and is reimbursed by most insurance companies. Any need for preauthorization of services or copayments depends on your insurance carrier. Our office staff will assist you in obtaining preauthorization whenever possible. The same copayments you make at your family physician’s office will often apply at the Pain Management Center.

How do I make an appointment?

Your physician should send a referral note to the Pain Management Center. The referral must include your name, address and phone number; a brief description of your condition; the physician’s request for this specific procedure; and the physician’s name, address and phone number. When we have received this information, we will call you to set up an appointment, often within 24 hours. For faster service, your physician should FAX his request to us at (650) 725-7743.

The Pain Management Center
Stanford University Clinic
Room A-408 Boswell Building
300 Pasteur Drive
Stanford, CA 94305-5340
Phone: (650) 723-6238
FAX: (650) 725-7743

What should I expect from this procedure?

This is usually a diagnostic procedure that allows us to pinpoint, more accurately, the location of the origin of your pain syndrome. Sometimes repeated gasserian ganglion blocks can be used to decrease certain types of facial pain syndromes. In general, nerve killing procedures are not performed or recommended except in certain instances of patients with cancer pain. In general, local anesthetic is used to block the nerves that go to your pain. You might have some numbness of your face and gums, and decreased ability to chew. This might last between six to 12 hours. When the numbness resolves, your pain might return or you might have pain control that extends beyond the duration of the local anesthetic. It will be important for you to tell your pain management doctor about your pain control, following the block.

What possible side effects might I see?

In general, the most frequent complication includes, facial swelling, bruising because of the proximity of blood vessels to the gasserian ganglion. This should be treated with ice and elevation, should it occur. In addition, other nerves are adjacent to the gasserian ganglion and can, in very rare circumstances, develop weakness from the local anesthetic medication. In general, this would be noticed in the recovery room. However, if you had difficulty with breathing or swallowing following the procedure, we would want you to inform one of the recovery room nurses or physicians. Sometimes, despite the use of an x-ray machine, we are unable to place the medication in the appropriate space because of technical difficulty. Finally, while most patients get pain relief, in rare instances, sometimes there is an aggravation of the current pain symptoms. This is likely secondary to the facial swelling or bruising as stated, and is likely to last for several days.

What should I do if any problems develop after I leave the hospital?

Call the Pain Management Service at (650)723-6238 (Monday through Friday 9-5, or after hours dial the page operator at Stanford, 723-6661 and ask for the Pain Service physician on call).

Postprocedure instructions:

Use Tylenol, ice and apply to the facial region for several hours following the procedure. Try to keep your head elevated for several hours until you are sure that no significant swelling will occur. Non steroidal medication, such as aspirin and Motrin, is not recommended for the first 24 hours because this may increase swelling. Please call the Pain Clinic at (650) 723-6238 to report your total duration of pain relief tomorrow. If you do not have a follow up appointment, or a specific plan, then you need to discuss this with the pain management physician who has been taking care of you.



Spinal Chord Stimulation

Spinal cord stimulation can relieve chronic pain in the back, arms or legs. It works by electrically stimulating the spinal cord. Instead of pain, the patient feels a tingling or buzzing sensation. Substitution of one sensation for another is something w do almost instinctively. For example, if we strike our hand on something, we rub it almost immediately, substituting the rubbing sensation for the pain sensation.

The spinal cord stimulation system consists of several parts:



Intravenous Lidocaine Infusion

What should I expect from this procedure?

The intravenous lidocaine infusion is used to assess the potential benefits of lidocaine and related medications on managing your pain. Depending on the specific cause of your pain, some patients report immediate and long continued relief associated with the intravenous administration of lidocaine. Other patients with different reasons for their pain indicate that their pain relief is slow in coming on and may last only as long as the medication is being infused. Yet another group of patients receiving the intravenous lidocaine describe some unpleasant or non-beneficial response from the lidocaine. However, prior to the performance of the procedure, your physicians have no way of identifying to which group you may belong. If you noted significant improvement in your pain or change in the way your pain feels during the course of the infusion, your evaluating physicians request that you pay special attention to how long the beneficial effects of this medication last and report this to us either with a telephone call, after you leave the Pain Management Center, or at the time you are scheduled to see us next for further evaluation and/or treatment.

What possible side effects might I see?

Generally, following the intravenous infusion of lidocaine, there are no side effects once the procedure has been completed. Because of the nature of this procedure, the maximum effects of the medicine are seen during the time you are being carefully observed by the physicians and staff of the Pain Management Center. Occasionally, patients do describe some peculiar feelings for hours following an intravenous lidocaine infusion. Such feelings can include, general fatigue, persistent dizziness or a headache. All of these symptoms that have been previously reported, however, seem to dissapear within the first day following the procedure. While we would like to reassure you that such side effects are not dangerous, if you have concerns regarding any particular side effect, or potential complication to the lidocaine infusion that you received, we would appreciate you contacting the physicians and staff of the Pain Management Center to ask us specific questions.

What should I do if any problems develop after I leave the Pain Management Center?

Call the Pain Management Service at (650)723-6238 Monday through Friday, 9 - 5 PM, or after hours dial the page operator at Stanford at (650)723-6661 and ask for the pain service physician on call.

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