Pain Management

Overview
This outpatient procedure is an injection of a steroid-anesthetic medication through an opening in the sacrum. The medication can reduce swelling and inflammation of irritated spinal nerves. The injection takes only a few minutes to complete.

Preparation
In preparation for the procedure, the patient lies face down. A cushion is placed under the abdomen to elevate the sacrum.

Anesthetic Injected
The physician administers a local anesthetic to numb the skin and the tissue above the small opening at the base of the sacrum. This opening is called the sacral hiatus.

Needle Inserted
When the area is numb, the physician guides a needle through the sacral hiatus and into the caudal epidural space. This is the open space in the sacrum where the irritated nerve rootsare located.

Contrast Solution Injected
The physician injects contrast solution through the needle. The physician uses a fluoroscope (a type of x-ray device) to confirm that the tip of the needle is positioned correctly within the epidural space.

Overview
This injection relieves pain in the neck, shoulders, and arms caused by a pinched nerve (or nerves) in the cervical spine.
Conditions such as herniated discs and spinal stenosis can compress nerves, causing inflammation and pain. The medication injected helps decrease the swelling of nerves.

Patient Sedated
The procedure is performed with the patient lying down. Intravenous sedation may be administered, and a region of skin and tissue of the neck is numbed with a local anesthetic delivered through a small needle.

Needle Inserted
Using x-ray guidance (also called fluoroscopy), the physician guides a larger needle to the painful area of the neck. The needle is inserted into the epidural space, which is the region through which spinal nerves travel.

Contrast Dye Injected
Contrast dye is injected into the space to make sure the needle is properly positioned near the irritated nerve or nerves.

Steroid Injected
A combination of an anesthetic and cortisone steroid solution is injected into the epidural space. The steroid is an anti-inflammatory medication. It is absorbed by the inflamed nerves to decrease swelling and relieve pressure. The needle is removed and a small bandage is applied.

End of Procedure
The patient goes to a recovery room and is given food and drink and discharged with post treatment instructions. Some patients may need only one injection, but it may take two or three injections (administered weeks apart) to provide significant pain relief.

Overview
This minimally-invasive procedure, also called radiofrequency (or RF) rhizotomy, reduces or eliminates the pain of damaged facet joints by disrupting the medial branch nerves that carry the pain signals. This procedure is performed with local anesthetic.

Preparation
The neck and shoulder are cleaned and sterilized. Local anesthesia is administered to numb the tissue at the injection site down to the spinal column.

Inserting the Cannula
The physician uses an x-ray device called a fluoroscope to carefully guide a needle-like tube called a cannula to the irritated medial branch nerves.

Injecting the Radiofrequency Electrode
A radiofrequency electrode is inserted through the cannula. The physician tests the electrode's position by administering a weak electric current. If the stimulation recreates the pain without any other muscular effects, the electrode is positioned correctly.

Heating the Nerve
The physician uses the electrode to heat and cauterize the nerve. This disrupts its ability to communicate with the brain, blocking the pain signals. Multiple nerves may require treatment.

End of Procedure
The electrode and cannula are removed, and the injection site is covered with a small bandage. Although pain may increase for the first week after the procedure, the patient usually has full relief from pain within a month. Successful RF neurotomies can last longer than steroid block injections.

Overview
This injection relieves pain in the neck, shoulders, and arms caused by a pinched nerve (or nerves) in the cervical spine. It can be used to treat conditions such as herniated discs, spinal stenosis, and radiculopathy.

Preparation
The procedure is performed with the patient lying face down or face up to expose the neck. The patient may be sedated but awake during the procedure. A region of skin and tissue of the neck is numbed with a local anesthetic delivered through a small needle.

Inserting the Needle
The physician uses an x-ray device called a fluoroscope to guide a needle to the painful area of the neck. The needle is inserted into the neural foramen space, which is the region through which spinal nerves travel.

Confirming the Needle Placement
Contrast dye is injected into the space to make sure the needle is properly positioned near the irritated nerve or nerves.

Injecting the Medication
An anesthetic solution is injected into the foramen space, bathing the irritated nerve.

End of Procedure and After Care
The needle is removed and a small bandage is applied. Some patients may need only one injection, but two or three injections may be needed to provide significant pain relief.

Overview
This injection procedure is performed to relieve neck, shoulder and arm pain related to compression of a nerve root in the cervical spine. Conditions such as herniated discs and spinal stenosis can compress nerves, causing inflammation and pain. The medication injected helps decrease the swelling of nerves.

Vertebra and Nerve Root Located
The physician uses a fluoroscope to locate the appropriate cervical vertebra and nerve root. A local anesthetic is applied to numb the skin.

Tissue Anesthetized
All the tissue down to the surface of the vertebral transverse process is anesthetized.

Needle Inserted
The physician slides a thin needle with a slightly curved tip through the anesthetized track.

Foraminal Space Accessed
With the aid of the fluoroscope, the physician carefully guides the needle into the foraminal space near the nerve root.

Contrast Dye Injected
The physician injects a contrast solution and uses the fluoroscope to confirm the correct position of the needle tip.

Steroids Injected
A steroid-anesthetics mix is injected into the foraminal epidural space, bathing the painful nerve root with soothing medication.

End of Procedure
The needle is removed, and a small bandage is applied. In most cases, the patient will be able to return home the same day.

Overview
This minimally-invasive procedure uses a small needle and probe device to reduce a herniated disc, quickly relieving pain in most patients. The procedure may be performed on an outpatient basis using a gentle, relaxing medicine and local anesthetic.

Cannula Inserted
After some anesthetic is injected to numb the area, a thin needle called a cannula is inserted through the back and into the herniated disc. The surgeon uses x-ray images to guide the placement of the cannula.

Disc Nucleus Treated
The small probe is carefully inserted through the cannula and into the disc. When the probe is turned on, its rotating tip removes small portions of the disc nucleus. Because only enough of the disc is removed to reduce pressure inside the disc, the spine remains stable.

Herniation Relieved
The empty space created by the probe allows the disc to reabsorb the herniation.

End of Procedure and After Care
The probe and needle are removed, and the insertion area in the skin is covered with a small bandage. Because no muscles or bone are cut during the procedure, recovery is fast and scarring is minimized. The patient may need a day of bed rest after the procedure, as well as physical therapy. Most may return to normal activity within one to six weeks.

Overview
This diagnostic procedure, also called discogram, is used to determine whether back pain is caused by one or more spinal discs. The procedure involves pressurizing suspect discs with an injection of sterile liquid to induce pain. Discography helps the specialist plan a course of treatment.

IV Inserted
In preparation for the procedure, the patient lies on the side or stomach on a table equipped with a type of x-ray unit called a fluoroscope. Medication is administered through an intravenous (IV) line to relax the patient. It is important for the patient to be awake enough to tell the physician what he or she is feeling. A local anesthetic is used to numb the skin and all the tissue down to the disc area.

Guide Needles Inserted
A guide needle is inserted through the anesthetized track to the outer edge of the disc. The physician uses the fluoroscope to identify the target disc. A smaller needle is inserted through the guide needle into the center of the disc. This may be repeated for several discs.

Discs Tested
Once all the needles are placed, the discs are pressurized one at a time with injections of contrast dye. With each injection, the patient may feel either pressure or pain. If the patient feels pain, the physician will ask the patient to compare it to the pain the patient has been experiencing. If the pain is the same, this may indicate a diseased disc. After each disc is tested, images are taken with the fluoroscopic unit.

Needles Removed
The needles are removed. The patient may be taken for a CT scan to obtain additional images of the inside of the discs.

End of Procedure
Discography usually takes less than an hour to perform. The procedure may cause soreness for a few days. The patient is usually advised to take acetaminophen or ibuprofen and to ice the affected area for several minutes each day until the soreness subsides.
www.viewmedica.com © 2013 Swarm Interactive. Unauthorized duplication is strictly forbidden.

Overview
The facet joints, found on both sides of the back of the spine, can become painfully irritated or inflamed. A facet joint injection may help diagnose the source of a patient's pain. It can also relieve pain and inflammation.

Skin Numbed
In preparation for the procedure, the physician numbs the skin and tissue above the facet joint with an injection of local anesthetic.

Placement Confirmed
With the aid of an x-ray device called a fluoroscope, the physician guides a needle through the numbed tissue and into the facet joint. Contrast dye is injected into the joint to confirm the needle's placement.

Medication Injected
Once the needle is positioned properly, the physician injects a soothing mixture of numbing anesthetic and anti-inflammatory steroid medication. One or more facet joints may be treated. If this causes the pain to subside, it suggests that the facet joint (or joints) injected were the cause of pain.

End of Procedure
Back or neck pain may disappear immediately after a successful injection because of the anesthetic that is administered. As this anesthetic wears off, pain may return. The steroid will begin to take effect in the days after the injection. The steroid will reduce inflammation and pain. The injection can provide relief for a span ranging from several days to several months. Up to three injections may be given per year.

Overview
This non-operative, outpatient procedure is designed to provide relief for patients with arthritis of the hip joint. The technique allows the physician to inject numbing and anti-inflammatory medications with maximum accuracy.

Preparation
The physician swabs the front of the hip and injects a numbing medication. A special X-ray device called a fluoroscope is positioned over the hip.

Injecting the Dye
To make sure the medicine injection is in the hip joint, the physician first uses an injection of dye. The dye shows up on the fluoroscope image. If the dye pools in the soft tissue at the front of the hip joint, the physician adjusts the needle placement.

Finding the Target Area
When the dye reaches the target area - the space inside the joint - the physician is ready to inject the medication.

Injecting the Medication
The syringe is removed from the needle and a syringe filled with medication is attached. The physician injects the medication into the joint.

End of Procedure
The needle is removed and a small bandage is applied. The numbing medication will provide short-term pain relief, while the
anti-inflammatory medication will aid in long-term relief.

Overview
This injection procedure is performed to diagnose and relieve the pain of piriformis syndrome, an irritation of the sciatic nerve caused by a contraction of the piriformis muscle in the buttocks.

Preparation and Approach
In preparation for the procedure, the patient lies on the stomach, and the skin at the injection site is numbed. Then, the physician uses a fluoroscope to carefully guide a needle into the piriformis muscle. A small amount of contrast dye is injected to confirm that the needle is positioned properly.

Injection
When the needle is correctly positioned, an anesthetic and steroid mediation is injected into the muscle. The medication will reduce the inflammation, relieving pain.

End of Procedure
Once the injection is complete, the patient is taken to a recovery area. If the injection is used for diagnostic purposes, the physician will wait to see if muscle pain temporarily subsides after the injection, which would confirm that the piriformis muscle is the source of the pain.

Overview
This non-operative, outpatient procedure is designed to provide relief for patients with arthritis of the knee. The technique allows the physician to inject an inflammation-reducing steroid with maximum accuracy.

Preparation
The physician swabs the knee, injects a numbing medication and positions a special X-ray device called a fluoroscope.

Injecting the Dye
To make sure the medicine injection gets to the space inside the joint, the physician first uses an injection of dye. The dye shows up on the fluoroscope image. If the dye pools in the soft tissue at the front of the knee, the physician adjusts the needle placement.

Finding the Target Area
When the dye reaches the target area - the space inside the joint - the physician is ready to inject the medication.

Injecting the Medication
The rear of the syringe is removed from the needle and a syringe filled with a local anesthetic and steroid is attached. The physician injects the medication into the joint.

End of Procedure
The local anesthetic and steroid solution in the knee joint will reduce inflammation and pain. The injection can be repeated if necessary.

Overview
During this non-operative, outpatient procedure, the physician injects a pain relief medication called HYALGAN@ into the knee joint. The HYALGAN will help the knee move smoothly, reducing or relieving the pain of osteoarthritis.

Preparation
In preparation for the injection, the physician swabs the knee and administers a local anesthetic. The physician positions a device called a fluoroscope over the knee. The fluoroscope will display a moving x-ray image of the inside of the knee. This will ensure that the HYALGAN is injected into the joint space.

Injecting the Dye
The physician carefully guides a needle into the knee joint. The physician confirms the needle's placement with an injection of dye. The dye is clearly visible on the fluoroscope. If the dye pools in the soft tissue at the front of the knee, the physician adjusts the placement of the needle. When the dye successfully reaches the space inside the joint, the physician is ready to inject the HYALGAN.

Injecting the Medication
While leaving the needle in position, the physician removes the dye syringe and replaces it with a HYALGAN syringe. The physician injects the HYALGAN into the space within the knee joint. The HYALGAN will bond with the synovial fluid inside the joint. It will help cushion and lubricate the joint.

End of Procedure
When the injection is complete, the physician removes the needle and bandages the knee. HYALGAN is administered in a series of three to five injections given one week apart. Patients typically begin to feel pain relief after the third injection, and pain relief can last for up to six months. Physical therapy will enhance the effects of the medication.
HYALGAN® is a registered trademark of Fidia Farmaceutici S.p.A., which is not responsible for this content.

Overview
This injection procedure is performed to relieve low back and radiating leg pain. Steroid medication can reduce the swelling and inflammation caused by spinal conditions.

Patient Positioning
The patient lies face down. A cushion under the stomach area provides comfort and flexes the back. In this position, the spine opens and allows for easier access to the epidural space.

Tissue Anesthetized
A local anesthetic is used to numb the skin. All the tissue down to the surface of the lamina portion of the lumbar vertebra bone is anesthetized. The physician slides a thicker needle through the anesthetized track.

Fluoroscopic Guidance
Using a fluoroscope for guidance, the physician slides the needle toward the epidural space between the L-4 and L-5 vertebra. A contrast solution is injected. The physician uses the fluoroscope to confirm the correct location of the needle tip.

Steroids Injected
A steroid-anesthetics mix is injected into the epidural space, bathing the painful nerve root with soothing medication.

End of Procedure
The needle is removed, and a small bandage is applied to cover the tiny needle surface wound. In some cases it may be necessary to repeat the procedure as many as three times to get the full benefit of the medication. Many patients get significant relief from only one or two injections.

Overview
This minimally-invasive procedure, also called radiofrequency (RF) rhizotomy, reduces or eliminates the pain of damaged facet joints by disrupting the medial branch nerves that carry the pain signals. This procedure is performed with local anesthetic.

Cannula Inserted
A needle-like tube called a cannula is inserted and positioned near the irritated medial branch nerves. An X-ray or fluoroscope is used to help position the cannula properly.

Electrode Inserted
A radiofrequency electrode is inserted through the cannula. The surgeon tests the electrode's position by administering a weak electric jolt. If the stimulation recreates the pain without any other muscular effects, the electrode is positioned correctly.

Nerve Treated
The surgeon uses the electrode to heat and cauterize the nerve. This disrupts its ability to communicate with the brain, blocking the pain signals. The surgeon may treat multiple nerves if needed.

End of Procedure
After the procedure, the electrode and cannula are removed. Although pain may increase for the first week after the procedure, the patient usually has relief from pain within a month. Successful RF neurotomies can last longer than steroid block injections.

Overview
This outpatient procedure is an injection of a steroid-anesthetic medication. The medication can reduce swelling and inflammation of irritated spinal nerves. This procedure is performed to relieve pain in the lower back and pain that radiates from the back to the legs. The injection takes only a few minutes to complete.

Preparation
In preparation for the procedure, the patient lies face down. A cushion is placed under the abdomen, which causes the spine to bend in a way that opens the spaces on the sides of the spine. These spaces are called the foramina.

Anesthetic Injected
A local anesthetic is administered to numb the skin and the tissue that covers the spine.

Needle Inserted
When the area is numb, the physician carefully guides a needle into the foraminal space that surrounds the irritated nerve root.
Contrast Solution Injected
A contrast solution is injected through the needle. The physician uses a fluoroscope (a type of x-ray device) to confirm that the tip of the needle is positioned correctly.

Medication Injected
After the needle's position has been confirmed, the physician injects a steroid-anesthetic medication. This medication bathes the irritated nerve roots. It will help alleviate the patient's pain.

End of Procedure
When the procedure is complete, the physician removes the needle and bandages the insertion site. The patient may feel significant relief after one injection. Some patients may need multiple injections before they feel the full benefit of the medication.
www.viewmedica.com © 2013 Swarm Interactive. Unauthorized duplication is strictly forbidden.

Overview
This diagnostic procedure is performed to identify a painful facet joint. The facet joints are the joints between the vertebrae in the spine. They allow the spine to bend, flex and twist.

Preparation
In preparation for the procedure, the patient is positioned on his stomach. The physician injects a local anesthetic. This numbs the skin and tissue around the facet joint that is suspected of causing the patient's pain.

Contrast Dye Injected
Once this tissue is numb, the physician inserts a needle into the skin. The needle is carefully guided down to the facet joint. The physician injects a contrast solution through this needle. The contrast solution helps the physician see the area on a camera called a fluoroscope. The fluoroscope provides live x-ray images. The physician uses the fluoroscope to confirm the location of the needle's tip.

Anesthetic Injected
Once the physician has confirmed that the needle is positioned correctly, the physician attaches a syringe containing an anesthetic medication. This medication is injected around small nerves called the medial branch nerves. These carry signals to and from the facet joints. The anesthetic will temporarily block sensation in these nerves.

End of Procedure
If the temporary injection relieves the patient's pain, the physician may inject a more
long-lasting anesthetic. If the temporary injection does not relieve the pain, the physician may test nearby facet joints to identify the correct one.

Qualifying Conditions for Medical Marijuana

Patients can qualify for a variety of illnesses or conditions where medical marijuana has been proven to be effective for alleviating symptoms. If you have been diagnosed with one or more of the conditions below, Dr. Friedman can prescribe medical cannabis to help you find relief. Prescriptions can be edible, oil, spray, or tincture form. You can access up to a 70-day supply of the medication with each prescription.

Conditions for which medical cannabis can be prescribed in Florida include the following:

• Amyotrophic Lateral Sclerosis (ALS); Also known as: Lou Gehrig’s disease
• Arthritis
• Cachexia
• Cancer and the side effects of chemotherapy and other cancer treatments
• Chronic pain
• Chronic non-malignant pain
• Crohn’s disease
• Depression and anxiety
• Epilepsy
• Fibromyalgia
• Glaucoma
• Hepatitis C
• HIV/AIDS
• Insomnia
• Migraines
• Multiple sclerosis
• Muscle spasms
• Nausea
• Neuropathy
• Post-traumatic stress disorder
• Seizures
• Terminal Conditions

There may be other conditions. We recommend you schedule an appointment at CoreSmart where we can help you determine if your ailment or illness qualifies for medical marijuana.

FAQ

Can anyone in Florida purchase or consume medical marijuana?
No. In order to legally purchase or consume medical marijuana in the state of Florida, you must have been diagnosed with one of the qualifying medical conditions listed in this page. There may be exceptions to the list, which Dr. Friedman can better explain during a medical consultation.

Can any doctor in Florida prescribe medical marijuana?
No. In order to prescribe medical marijuana in Florida, the physician must be certified by the Florida Department of Health's Medical Marijuana Use Registry (MMUR) as a marijuana doctor.

What is the process for being able to use medical marijuana in Florida?
You must have a marijuana evaluation conducted by a doctor certified to prescribe medical marijuana. If after the evaluation the doctor concludes that you qualify, he or she issues a certificate and enters your information into the MMUR database. Only people who are registered in the MMUR database can purchase and consume medical marijuana in Florida.

In Florida, who can be a medical marijuana patient's qualified legal representative?
The following people can be a qualified medical marijuana patient's legal representative in the State of Florida:

• The patient's parent, if the patient is under 18 years old.
• A legal guardian pursuant to a court's authorization as required under section 744.3215(4) of the Florida Statutes.
• A healthcare surrogate pursuant to the qualified patient's written consent or a court's authorization as required under section 765.113 of the Florida Statutes.
• An individual who is authorized under a power of attorney to make healthcare decisions on behalf of the qualified patient.

If I have one of the qualifying medical conditions for medical marijuana, am I automatically certified for a prescription?
No. Before you can enroll in Florida’s medical marijuana program, you must be evaluated by a physician who is licensed and certified by Florida's Department of Health as a medical marijuana doctor. Dr. Friedman is certified by the State of Florida as a medical marijuana doctor.

If I have a medical marijuana prescription or license from another state, can I use it in Florida?
No. Florida’s medical marijuana program is independent from those in other states. As such, you must be evaluated by a licensed medical marijuana doctor in Florida in order to determine if you qualify for the program here.

What is the Office of Medical Marijuana?
The Office of Medical Marijuana is the office within Florida's Department of Health that regulates the Florida medical marijuana program. The Office of Medial Marijuana administers the Medical Marijuana Use Registry.

What is the Medical Marijuana Use Registry (MMUR)?
The MMUR is a database of medical patients who have enrolled in Florida's medical marijuana program. This database is used by state and local law enforcement to verify that a patient is a valid medical marijuana patient and therefore immune from being arrested for use or possession of marijuana.

Is Dr. Jarrod Friedman certified as a medical marijuana doctor in Florida?
Yes. Dr. Friedman is certified to evaluate you and determine if you qualify for medical marijuana. After the evaluation, Dr. Friedman will enter a recommended dosage amount into the Medical Marijuana Use Registry, which will allow you to purchase medical marijuana from a licensed dispensary.

What can I expect during my medical marijuana consultation at CoreSmart?
Dr. Jarrod Friedman is certified by the State of Florida as a medical marijuana doctor. During your office visit to CoreSmart, Dr. Friedman will evaluate you and determine if you qualify for medical marijuana. The evaluation includes examining any current conditions that may affect you, as well as current or new diseases or disorders. After the evaluation, if Dr. Friedman determines that you qualify for medical marijuana, he will enter a recommended dosage amount into the Medical Marijuana Use Registry, which will allow you to purchase medical marijuana from a licensed dispensary.