If you are being treated by us, you may be invited to take part in one of our studies related to your particular health condition.

Our research studies often seek many recruits, but in order to participate they must meet certain eligibility criteria. These criteria may concern a patient’s type of disease, history, age, gender, etc. They can also be quite specific to ensure that the people who take part are not exposed to avoidable risks. At North Bristol NHS Trust, we regularly identify participants for research based on these factors, informing patients of any treatments we may have in development that may benefit them.

Why take part?

Clinical research is essential for developing better treatments and improving healthcare. Many patients take part in clinical research to help us to find the best ways to:

• Prevent disease and reduce the number of people who become ill.
• Treat an illness to improve survival or increase the number of people cured.
• Improve the quality of life for people living with an illness, including reducing symptoms of disease or the side effects of other treatments, such as cancer chemotherapy.

Health professionals and patients need the evidence from trials to know which treatments work best. Without trials, there is a risk that people could be given treatments which have no advantage, waste resources and might even be harmful. Many treatments that are now in common use in health care were tested in clinical trials.

Is it safe to take part?

All clinical research undertaken at North Bristol NHS Trust is reviewed by an NHS Research Ethics Committee and approved by the Health Research Authority before it can start. This ensures the rights, dignity, safety and wellbeing of the patients who take part are protected.

Each study is designed to keep risk to a minimum. The people who take part are actively monitored throughout, with their safety and wellbeing always coming first.

If you have any questions or concerns about a trial you wish to take part in, speak to the clinician in charge of your care.

It is ok to ask about research.

To see the full range of research that is currently taking place across the hospital, please visit Our Research pages.

What is a molar pregnancy?

Molar pregnancy (also called hydatidiform mole) occurs when a pregnancy does not develop properly. In healthy pregnancies, an embryo (baby) develops when a sperm fertilises an egg and the genetic material (chromosomes) from each combines to produce a baby which has half of its genes from each parent. A molar pregnancy is abnormal from the very moment of conception as a result of an imbalance in the number of chromosomes supplied from the mother and the father.

There are two types of molar pregnancy - complete mole and partial mole.

• Complete moles usually occur when a single sperm fertilises an ‘empty’ egg with has no genetic material inside, and then divides to give the fertilised egg a normal number of chromosomes, all of which have come from the father. Complete moles can also occur when two sperm fertilise an ‘empty’ egg.
• Partial moles occur when two sperm fertilise a normal egg and the developing pregnancy then has three sets of chromosomes or more. In a partial mole, there are usually some early signs of development of a fetus on ultrasound but it is always abnormal and cannot develop into a baby.

Molar pregnancy is more likely to develop in women of Asian origin, teenagers and women over 40 years.

If left untreated, molar pregnancy can continue to grow and change into cancerous cells. Therefore when molar pregnancy is diagnosed, it is important that this is promptly treated and carefully monitored.

It is important for you to know that a molar pregnancy is not caused by anything that you/your partner have or haven’t done.

How common is molar pregnancy?

Molar pregnancies are rare, happening with roughly 1 case for every 600 pregnancies in the UK.

When might a molar pregnancy be suspected?

If you have a molar pregnancy you may have irregular or heavy bleeding from the vagina, or excessive morning sickness (hyperemesis). Your womb (uterus) may feel larger than your midwife or doctor would expect in early pregnancy. Less commonly, you may develop raised blood pressure, symptoms of an overactive thyroid gland or abdominal pain because of large ovarian cysts.

If your doctor suspects that you may have a molar pregnancy, you will be referred to an early pregnancy clinic for an ultrasound scan.

If you have a complete mole, there will be no baby present inside the pregnancy sac and there may be other signs that suggest the presence of a molar pregnancy. Ultrasound may also help in diagnosing partial moles, but it is not as reliable as in cases of complete moles.

A blood test which measures the amount of the pregnancy hormone human chorionic gonadotrophin (hCG) may also raise the suspicion that you have a molar pregnancy. Usually, the levels of this hormone are much higher than would be expected in a healthy pregnancy.

A molar pregnancy may be found after what is suspected to be a miscarriage.

How is it diagnosed?

Most molar pregnancies are diagnosed at the first ultrasound scan then confirmed by a laboratory analysis of the pregnancy tissue. In some cases, the pregnancy tissue may have been sent to a laboratory for analysis following surgery for miscarriage or termination for other reasons. This may confirm that the pregnancy was molar, even if a molar pregnancy was not initially suspected.

How is it treated?

Once a molar pregnancy is confirmed, the first step is to remove the cells from the womb. This is usually done surgically using a suction evacuation procedure. Medication may be used to soften the cervix (neck of the womb) prior to your operation. You will usually need a general anaesthetic for this type of operation. During the operation, the cervix is stretched slightly and a suction device is used to remove all of the abnormally formed tissue from inside your womb.

In some unusual cases, you may be recommended to have a miscarriage induced with medication. The doctors looking after you will discuss this with you in detail if this is the case.

What happens after the treatment?

After the initial treatment, all people with a molar pregnancy should be in a follow-up programme that monitors what is happening to any cells that remain in the womb and picks out those people that need further treatment. In the UK, all people who have a molar pregnancy are enrolled into a national surveillance programme. The closest surveillance centre to Bristol is Charing Cross Hospital in London.

Molar pregnancy cells produce pregnancy hormone called hCG. This is why people with molar pregnancies have a positive pregnancy test despite not having a normal pregnancy.

Measuring the level of hCG after removal of molar pregnancy allows the surveillance team to follow exactly what is happening with any molar pregnancy cells left in the womb. The level of hCG in the blood gives a really accurate picture of what these cells are doing. If the level of hCG is falling then the number of cells are reducing and no treatment is needed. If the level is static or rising then the number of abnormal cells is increasing and additional treatment may be needed.

People on the surveillance programme will be contacted directly by Charing Cross Hospital and typically asked to send in blood and/or urine samples until hCG level has fallen to a reassuring level. It is very unlikely that you will need to seen in person at Charing Cross Hospital in London.

What if I need further treatment?

The majority of people who have a molar pregnancy will not need any further treatment after the initial suction evacuation procedure. However, approximately 15% of people with complete molar pregnancy and around 1% with partial molar pregnancy will require additional treatment.

The two main reasons patients need further treatment is because either the hCG level starts to rise or reaches a plateau or because there is heavy vaginal bleeding.

The two choices of treatment are a further surgical evacuation procedure or chemotherapy treatment. The majority of patients are treated with chemotherapy as this has a much higher success rate.

Fortunately the overall cure rate for women who need treatment after a molar pregnancy is over 99%.

When can I try for pregnancy?

We advise that a further pregnancy is deferred until the end of the follow-up period, as a new pregnancy may mask the evidence of the relapse of the molar pregnancy that can happen in a very small number of people.

The length of follow-up will depend on your individual needs. The follow-up will be for at least 6 months and possibly longer depending on how quickly your hCG level returns to a reassuring level.

Once the treatment is completed, the fertility rate is expected to be normal.

Is contraception safe to use?

Yes, both hormonal and non-hormonal type contraception are safe to use.

Is this going to affect my future pregnancy?

People who have had one molar pregnancy do have an increased risk of developing another in future pregnancy. However this risk is still low; estimated at around 1 in 100.

Even more unusually the surge of hormones in a later pregnancy can cause a relapse of the old molar pregnancy and start any cells still present to grow again and potentially cause problems. Whilst this problem is very rare, we screen for it by testing the urine 6 weeks after delivery and the blood and urine 4 weeks later after this.

We would also offer an early scan in any subsequent pregnancy from when you are approximately 6 weeks pregnant via the Early Pregnancy Clinic.

Links for useful information:

Charing Cross Hospital Trophoblast Disease Service
/www.hmole-chorio.org.uk/index.html

My Molar Pregnancy: mymolarpregnancy.com/

Molar Pregnancy Support and Information: www.molarpregnancy.co.uk/

Miscarriage Association: www.miscarriageassociation.org.uk

Glossary of terms

Gestational trophoblastic disease (GTD): A group of conditions that may occur when a pregnancy does not develop properly. GTD includes complete and partial molar pregnancy.

Molar pregnancy: An abnormal pregnancy which develops as a result of an imbalance in the amount of genetic material when the embryo first develops. Molar pregnancy is best though of as a pre-cancerous illness which can occasionally progress to a cancerous form of GTD known as gestational trophoblastic neoplasia (GTN).

Complete molar pregnancy: A molar pregnancy where there is no fetus present.

Partial molar pregnancy: A molar pregnancy where there are usually some early signs of development of a fetus on ultrasound but it is always abnormal and cannot develop into a baby.

Gestational trophoblastic neoplasia (GTN): A rare form of cancer which develops from a molar pregnancy. GTN includes invasive mole, chriocarcinoma, placental site trophoblastic tumour and epithelioid trophoblastic tumour.

If you or the individual you are caring for need support reading this leaflet please ask a member of staff for advice.

How to contact us:

Cotswold ward, Brunel building
Southmead Hospital
Westbury-on-Trym
Bristol
BS10 5NB
Cotswold ward (24 hours)

0117 414 6785

© North Bristol NHS Trust. This edition published March 2020. Review due March 2022. NBT003056

Rheumatology research taking place at North Bristol NHS Trust

Please speak to the person treating you to see if there is a research study that may be able to help you.

Current Studies:

BSRBR-RA

BSRBR-PsA

MINIMISE

UKIVAS

BILAG

Paused Studies:

MYOPROSP

Multiple Sclerosis research taking place at North Bristol NHS Trust

Please speak to the person treating you to see if there is a research study that may be able to help you.

Current Studies:

MS-STAT2

A prospective, real world pharmacovigilance study in Multiple Sclerosis

Immunology research taking place at North Bristol NHS Trust

Please speak to the person treating you to see if there is a research study that may be able to help you.

Current Studies:

Hereditary Angioedema (HAE) studies a disorder that results in recurrent attacks of severe swelling.
Please speak to the person treating you to see if you can take part in our current research studies listed below.

Oasis - IONIS CS7

Chapter-1 Pharvaris

This leaflet has been written for people who have a personal or family history of breast cancer that could have an inherited cause, and who are considering having a genetic test. It has been written for use with a Clinical Genetics appointment and may answer some of your questions.

Is breast and ovarian cancer inherited?

It is rare for breast and ovarian cancer to be inherited. However, breast cancer occurs in many women, with around one in every seven in the UK developing the disease during their lifetime. Ovarian cancer develops in around one in 50 women in their lifetime. In about 5 - 10% of these cases, a specific gene alteration plays a part. We currently test for 5 genes: BRCA1, BRCA2, PALB2, ATM and CHEK2 in the R208 test. If any of these genes are altered, that person has a substantially increased risk of developing certain types of cancer, depending on which gene is affected.

What are genes?

Our genes can be found in almost every cell in our body. They are the instructions that enable our bodies to grow and function correctly. BRCA1, BRCA2, PALB2, ATM and CHEK2 are tumour suppressor genes that help to protect us from developing cancer. An alteration can affect the function of the gene. This can increase the chance of developing, for example, breast, ovarian and prostate cancer, which is more likely to occur at a younger age.

How are these genes inherited?

All our genes come in pairs; we inherit one of each pair from our mother and the other from our father. Alterations in the genes in the R208 test are inherited in an ‘autosomal dominant’ manner. This means that the children (male or female) of a person with an alteration in one of these genes have a 1 in 2 (50%) chance of inheriting it. An alteration can be inherited from either parent.

If a person has not inherited an alteration, they cannot pass it on to their children.

Can genetic test results be uncertain?

Sometimes we find an alteration in a gene, but we are not sure of its significance. This is called a variant of uncertain significance (VUS). If we are uncertain whether the gene alteration found is the cause of the cancers in your family, we will not be able to offer a predictive genetic test to other family members. However, we may ask for extra samples from you or other family members to try to gather more information. Often these extra tests help to establish whether or not the VUS is the explanation for your family history of cancer.

What if a relative who has had cancer is not available for testing?

In some cases, where there is no affected family member available for testing we may:

1. Offer testing to someone in the family who has not had a cancer. This may be offered if the family history gives a high enough chance that there is a gene alteration. (The relative without cancer must have a 10% chance of having a gene alteration). Testing someone who has not had cancer may make some results harder to interpret. For example, if no gene alteration is found we would not know whether there is a gene alteration that this relative has not inherited or there is another cause for the family history.
2. It may be possible to test a tumour sample from a relative who has passed away. Testing tumour samples is more technically difficult than testing a blood sample. It is possible that this test will not work because of the way the tumour samples are stored.

Does everyone who has an alteration in one of these genes get breast cancer?

No. The chance of developing breast and other cancers associated with the genes is not 100%. We do not yet know why some people with an alteration develop cancer and some do not. Lifestyle or other genetic factors are likely to play a role. It is important to note that developing cancer is not the same as dying from cancer. Even if cancer develops, there is a chance that the disease can be cured if it is found and treated early.

What are the genes in the R208 test and the risks associated with them?

BRCA1:

Breast cancer

• Female carriers - 60% to 80%
• Male carriers - 1%
• Members of the general population - 14% (female), 1% (male)

Ovarian cancer

• Female carriers - 40% to 60%
• Male carriers - men do not have ovaries
• Members of the general population - 1% to 2% (female)

 Prostate cancer

• Female carriers - women do not have a prostate gland
• Male carriers - minimal increased risk
• Members of the general population - 12%

Pancreatic cancer

• Female carriers - up to 3%
• Male carriers - up to 3%
• Members of the general population - 1.8%

BRCA2:

Breast cancer

• Female carriers - 60% to 80%
• Male carriers - 6%
• Members of the general population - 14% (female), 1% (male)

Ovarian cancer

• Female carriers - 10% to 30%
• Male carriers - men do not have ovaries
• Members of the general population - 1% to 2% (female)

 Prostate cancer

• Female carriers - women do not have prostate gland
• Male carriers - 25% (often more aggressive in younger men)
• Members of the general population - 12%

Pancreatic cancer

• Female carriers - 2% to 7%
• Male carriers - 2% to 7%
• Members of the general population - 1.8%

Remember, 10 per cent means one person in every 10 will develop this cancer in their lifetime.

For women who have already been affected with breast cancer, we know there can be an increased chance of developing a completely new cancer. This is different to a cancer which recurs or spreads from the first (original) cancer. Please discuss this with your clinician.
 

PALB2:

Breast cancer

• Female carriers - 13% to 21% by age 50, 44-63% by age 80
• Male carriers - less than 1% by age 50, around 1% by age 80
• Members of the general population - 14% (female), 1% (male)

Ovarian cancer

• Female carriers - less than 1% by age 50, around 5% by age 80
• Male carriers - men do not have ovaries
• Members of the general population - 1% to 2% (female)

 Prostate cancer

• Female carriers - women do not have prostate gland
• Male carriers - minimal increased risk
• Members of the general population - 12%

Pancreatic cancer

• Female carriers - less than 1% by age 50, 2-3% by age 80
• Male carriers - less than 1% by age 50, 2-3% by age 80
• Members of the general population - 1.8%

Family history is taken into account to calculate an individualised risk assessment
 

ATM:

Breast cancer

• Female carriers - 17% to 30% (Except c.7271T>G which is over 30%)
• Male carriers - minimal increased risk
• Members of the general population - 14% (female), 1% (male)

CHEK2:

Breast cancer

• Female carriers - around 25%
• Male carriers - minimal increased risk
• Members of the general population - 14% (female), 1% (male)

What are the implications of the R208 test?

This testing can sometimes tell you that your chance of developing cancer is increased, but we cannot tell you for certain when, or even if, you will develop cancer. 

If an alteration is found in any of the genes in the panel, there is an increased chance of developing cancer. Some people may worry that genetic testing will affect insurance prospects (for example, health, life, or disability insurance). Currently, the insurance industry cannot ask about genetic testing for most policies. This position may change in the future. 

Some people feel a range of emotions when they are told that they have a gene alteration which increases their chance of cancer. They may feel angry, shocked, anxious or guilty about the possibility of passing the gene alteration on to their children. Some people may also feel guilty if they do not have the gene alteration when other close relatives do.

Genetic testing in a family can affect other family members, who may need to be told that they too are at an increased risk of developing cancer and may be eligible for genetic testing and/or screening. Different family members may have different reactions to this information, and genetic testing may therefore affect relationships within families. Your clinician will provide you with a letter that you can pass onto relatives to help them to access genetic testing.

Can having a BRCA1 or 2 gene alteration affect cancer treatment?

There are new drugs available called PARP inhibitors (Olaparib and Niraparib) which have been shown to improve survival in individuals diagnosed with breast or ovarian cancer who have a BRCA1 or 2 gene alteration. PARP inhibitors are not currently used for carriers of PALB2, ATM or CHEK2.

What screening is available for women with alterations identified through the R208 test?

MRI (magnetic resonance imaging)

Breast MRI is the most effective form of breast screening for younger women. Breast MRI is offered to women with a BRCA1, BRCA2, PALB2 or ATM c.7271T>G gene alteration every year from 30 until 49 years of age. Women who have a 50% or 1 in 2 chance of having these specific gene alterations are also eligible for this screening. 

Mammography

This form of screening has not been proven to be effective in women under the age of 40. It has been shown to be beneficial over the age of 40, especially alongside breast MRI. 

Women with a BRCA1, BRCA2, PALB2 or ATM c.7271T>G gene alteration are offered annual mammograms from 40 until 69 years of age. Women who have a 50% or 1 in 2 chance of having these specific gene alterations are also eligible for this screening. 

Women with a CHEK2 or any other ATM gene alteration are offered annual mammograms from 40 until 49 years of age. They are then enrolled into the NHS breast screening programme to have mammograms every 3 years from 50-69 years of age.

From 70 years of age, women can request to have a mammogram every three years by contacting their local breast unit or GP.

Is there any screening for ovarian cancer?

Some recent evidence suggests that ovarian cancer may help to detect ovarian cancer at an earlier stage. However, there is not enough evidence yet that this screening saves lives. Therefore, it is not currently offered as part of NHS treatment.

Is there any other recommended screening?

If you have a family history of pancreatic cancer, you could talk to your clinician about whether or not pancreatic screening is an option for you.

Having an alteration in one of the genes on the R208 test may be associated with increased risks of developing other types of cancer. The risks of these are likely to be small and there is no additional screening recommended currently.

Risk reducing breast surgery (risk reducing bilateral mastectomy)

This is the surgical removal of healthy breasts to prevent a cancer developing. This has been shown to reduce the chance of developing breast cancer by 90-99%. It does not remove all the risk, as the surgery cannot remove every breast cell. It is a major operation that can have serious complications, so it requires careful consideration. This is only available to women whose lifetime risk of developing breast cancer exceeds 30%.

Risk reducing removal of the ovaries and fallopian tubes (risk reducing bilateral salpingo-oophorectomy)

This is the surgical removal of healthy ovaries and fallopian tubes to prevent cancer developing, which reduces the risk of ovarian cancer by 95%. There is still a small chance of an ovarian-like cancer developing in the surrounding tissue that is left. This is estimated to be between 2 to 5% in a lifetime. In some circumstances, this may also help to reduce the risk of breast cancer if carried out before the natural menopause. Having ovaries removed will start an immediate menopause. Therefore it may be appropriate to have some form of hormone replacement therapy (HRT) until 50 years of age. HRT may not be recommended for women who have had hormone receptor positive breast cancer.

Is there any medication which can reduce the risk of developing breast cancer?

Taking certain medications for five years has been shown to reduce the risk of breast cancer in women at increased risk. Tamoxifen can be offered prior to the menopause, or Raloxifene and Anastrazole after the menopause. These drugs are associated with side effects. Please ask your clinician if interested, and/or see our separate chemoprevention leaflet.

Symptom awareness

We also recommend breast and ovarian cancer awareness for women, and breast and prostate awareness for men. Your clinician will provide you with the relevant booklets from Macmillan with more information about this. Alternatively, there is more information online at www.macmillan.org.uk. These booklets also include information about lifestyle factors which can help to reduce cancer risk in general.

What screening is available for men with alterations identified through the R208 test?

There is currently no national screening programme for prostate cancer in the UK. This is because it has not been proven that the benefits outweigh the risks. Instead of a national screening programme, there is an informed choice programme called prostate cancer risk management. The PSA test is a blood test to help detect prostate cancer. It measures the level of prostate-specific antigen (PSA) in your blood. This is available to healthy men aged 50 or over, who ask their GP about PSA testing. It aims to give men good information about the pros and cons of the PSA test. 

BRCA2

Given the increased risk, men with a BRCA2 alteration can be referred to a Urologist to discuss the option of prostate screening in more detail. Currently prostate screening involves measuring PSA levels, but may also involve an initial MRI.

BRCA1, PALB2, ATM and CHEK2

The risk of developing prostate cancer is not greatly increased. Therefore, prostate screening is not currently offered to men with these gene alterations, although they could discuss with their GP about prostate cancer risk management.

Are there any options for people with an altered gene who are planning a family?

Many people with an altered gene opt to have children in the usual way. Alternatively, women or men with a BRCA1, BRCA2 or PALB2 gene alteration may have the option of having Pre-implantation Genetic testing (PGT) involves undergoing the fertility treatment in-vitro fertilisation (IVF). PGT has the extra step of genetic testing of the embryos (fertilised eggs). The aim is to only put embryos into the womb which have not inherited the gene alteration. The Genetic Counsellor or Clinical Genetics Doctor can discuss this in more detail with individuals who are keen to consider this option. Testing in pregnancy is theoretically possible, but not often considered for conditions that affect people as adults.

Is there an alternative to genetic testing?

You may decide not to have genetic testing. Whether or not you are tested, you should talk to your clinician about screening options for you and your relatives.

I’ve heard of research studies involving people with a family history of cancer. How can I find out more?

There may be research studies that you are eligible to take part in if you wish. It is important to remember that research studies may not benefit you directly but may help future generations.

How to contact us:

Gates 24A
Brunel building
Southmead Hospital
Westbury-on-trym
Bristol
BS10 5NB

© North Bristol NHS Trust. This edition published March 2023. Review due March 2026. NBT003389

Your doctor has requested that you have a nerve root block either to help diagnose the cause of your pain or try to relieve it. 

We hope that the following information will answer some of the questions you may have about this procedure.

What is a nerve root?

Nerve roots exit the spinal cord and divide into nerves that travel to your arms and legs. These nerve roots can become inflamed due to pressure from nearby bone spurs or intervertebral discs. Inflammation of nerve roots may cause pain in the back, neck/arms and/or the legs. A nerve root block provides important information for your doctor and may also provide you with some relief from pain.

Why do I need to have a nerve root block done?

The procedure is designed to prove which nerve is causing your pain by placing temporary numbing medicine over the nerve root of concern. If your pain improves after the injection then that nerve is the most likely cause of your pain. If your pain remains unchanged, then that nerve is probably not the cause of your pain.

What is injected around the nerve root?

The injection is a combination of local anaesthetic (a numbing agent) and steroid (an anti-inflammatory agent). The local anaesthetic works immediately and the steroid begins to work within 2-3 days.

How do I prepare for a nerve root block?

There is no preparation for this procedure; you can continue to eat and drink as normal.

If you are diabetic please inform the doctor before the examination as there is a possibility that your sugar levels will vary after the injection. It is important that you continue to monitor your levels carefully for several days and consult your GP if necessary.

What will happen during the procedure?

You will be shown to a cubicle where you will be asked to undress in private and put on a gown. If you need assistance we can provide it.

You will then be shown into the X-ray room for the examination and introduced to the staff performing the procedure. You will be cared for by a small team including a radiologist/pain physician, radiographer and nurses.

Before the examination begins the radiologist/pain physician will explain what they are going to do and then ask you to sign a consent form.

You will then be asked to lie on your front or back on the X-ray couch. The skin will be cleaned and the doctor will inject a small amount of local anaesthetic under the skin. This stings for a few seconds and the area then goes numb.

The radiologist/pain physician will then direct a very small needle just next to the nerve root using the X-ray machine to guide the needle. Sometimes the needle can touch the nerve itself in which case you may feel a sharp pain going down your leg. This will only last for a second or two. A special dye called contrast medium is then injected around the nerve root. This shows up on the X-ray machine to confirm the needle is in the correct position. When the pain consultant/radiologist is satisfied with the needle position, the pain killing medicine will be injected along the nerve root.

How long will it take?

You will be awake throughout the procedure, which lasts about 15 – 30 minutes.

Will it hurt?

You may feel a little pressure or discomfort, which may travel down the arm/leg, during the injection of the pain killing medicine. This will last for only a few seconds.

Afterwards your leg may feel numb or weak for up to 24 hours. You will be asked to wait for 30 to 60 minutes before going home and you should not drive for the rest of the day. You will need to arrange for someone to take you home. Some people find that their pain feels worse for 2-3 days after the procedure. This is because the steroid can sometimes irritate the nerve. Do not worry if this happens, as it will settle down by itself. 

If your leg becomes numb you may need to stay in hospital overnight.

Are there any risks associated with a nerve root block?

Generally it is a very safe procedure. Potential complications are uncommon and include:

• Bleeding or haematoma (a bruise under the skin) – this should settle down by itself.
• Infection – contact your GP if you experience any redness or tenderness at the injection site.
• An allergic reaction to the contrast dye – please inform the doctor doing the nerve root block if you have any allergies.

Please inform your pain consultant if you take any blood thinning medication such as Warfarin, Clopidogrel, Rivaroxaban, Dipyridamole, Dabigatran. It is very important you contact us PRIOR to attending your procedure. Please note this list is not exhaustive.

Please also inform the pain consultant if you are a diabetic as there is a possibility the steroid may affect your blood sugar levels. It is therefore important you monitor your levels carefully for several days after the procedure and consult your GP if necessary.

The procedure uses X-rays to confirm that the needle is in the correct place. The amount of X-rays used is very small however female patients who are or who may be pregnant should inform the department before attending for 
their appointment.

Finally

We hope this information is helpful. If you have any questions either before, during or after the procedure the staff at the Pain Clinic or X ray department will be happy to answer them.

The telephone number of the X-ray department can be found on your appointment letter.

Additional Information for Pain Clinic patients having a lumbar sympathetic block.

What is Lumbar Sympathetic Block?

There are nerves running either side of the lumbar spine, that control blood supply to the muscles and  skin of the legs. Injecting these nerves with local anaesthetic and/or a drug, may help your pain and improve your mobility.

What will happen during the procedure?

The procedure is done in the same way as a Nerve Root Block, except a dye is not injected.

What will happen after the procedure?

You will be asked to stay for approximately 30-60 minutes in the recovery area/Medirooms.

Your blood pressure, pulse and temperature will be monitored and you may need to lie down for a little while.

You should not drive after this procedure. You will need an escort to take you home and stay with you overnight. 

If your leg becomes numb, you may have to stay in hospital overnight.

You can restart your normal activities the following day.

References

Botwin et al (2002) Fluoroscopically guided lumbar transforaminal epidural steroid injections in degenerative lumbar stenosis: an outcome study. American Journal of Physical Medicine and Rehabilitation 81(12) 898-905

Vad et al (2002) Transforaminal epidural steroid injections in lumbosacral radiculopathy: A prospective randomised study. Spine 27(1) 11-15

Waldman S (2004) Atlas of Interventional Pain. 2nd Edition. Saunders. Philadelphia

NHS Constitution. Information on your rights and responsibilities. Available at www.nhs.uk/aboutnhs/constitution

How to contact us:

Pain Clinic
Gloucester House
Southmead Hospital
Westbury-on-Trym
Bristol
BS10 5NB

0117 4147361

PainClinicClinical@nbt.nhs.uk

If you or the individual you are caring for need support reading this leaflet please ask a member of staff for advice.

What is a medial branch block? 

This procedure is for diagnosis only and is not for permanent pain relief. Your pain is likely to return a few hours after the procedure. 

Facet joints are found between each of the spinal bones and allow the spine to move. The medial branches are nerves that carry information, including pain, from the facet joints to the brain. 

Sometimes back pain arises from these joints. A medial branch block uses local anaesthetic to numb these small nerves. If the pain is coming from the joints the pain may be reduced for some hours following these injections. 

Following this procedure we can determine whether the facet joints are the cause of your pain. Depending on the results, your consultant may offer a longer-lasting treatment that could be done after your follow up call or visit. 

How do I prepare for the medial branch blocks? 

There is no preparation for this procedure. You can eat and drink on the day as normal. You are advised not to drive for that day.

Please tell us before attending for the procedure if you take any blood thinning medication such as: warfarin, clopidogrel, rivaroxaban, dipyridamole, dabigatran. Please note this list is not exhaustive.

What will happen during the procedure? 

You will be shown to a cubicle in one of the medi-rooms where you may be asked to change in to a gown, if you need assistance please ask. The nurse will ask you some questions and record your observations.

You will be taken to the room where your procedure will be performed under X-ray. The doctor will explain the procedure and ask you to sign a consent form. You will be asked to lie on your front on the X-ray trolley. The skin around the site of the injection will be cleaned and you will be given a local anaesthetic. The number of injections will depend on your symptoms. 

Will it hurt?

 You may have some discomfort during the procedure. If you feel uncomfortable, let the doctor or nurse know and they will try to make you more comfortable. 

How long will it take? 

You will be awake throughout the procedure, which lasts about 15 – 30 minutes. What happens after my injections? After your injections you will be taken back to the medi-room, where a nurse will check and record your observations. You will be able to have something to eat and drink and then you can go home. You will have a small dressing on the area that has been treated that you can take off later that day.

How will I feel after the injections? 

Remember that medial branch blocks are not a treatment. They are done to help us diagnose the source of your pain. Immediately after the injections you may feel less pain but it will probably return after a few hours. 

Are there any risks or side effects? 

Generally it is a very safe procedure but as with any treatment there are risks or side effects. 

The doctor will discuss these more fully with you before you sign your consent form. The procedure is performed under X-ray to confirm the needle is in the correct place. 

Female patients who are or may be pregnant should inform the department before attending their appointment. 

What should I look out for when I go home? 

Anyone having an injection is at risk of infection. This is very rare but some of the signs of infection include: 

• Redness, swelling, and heat around the injection site.
• Increased temperature.
• Generally feeling unwell.

Increase in pain

• It is not unusual for your pain to worsen temporarily, but it can also remain the same.
• Take your painkillers as normal.
• Apply heat/cold to the affected area.
• Try to keep active.

Who should I contact if I have any concerns? 

If you have any concerns please contact the Pain Clinic on: 

0117 4147380 

Monday- Friday 9am - 5pm 

Please contact your GP at any other time.

How to contact us:

Pain Clinic
Gloucester House
Southmead Hospital
Westbury-on-Trym
Bristol
BS10 5NB

0117 4147361

PainClinicClinical@nbt.nhs.uk

© North Bristol NHS Trust. This edition published February 2024. Review due February 2027. NBT002592.

Spinal cord stimulation may have been offered to you as a treatment for your pain. This page tells you about spinal cord stimulation, the procedures and the after care.

Spinal cord stimulation

Spinal cord stimulation works by sending small electrical impulses to your spinal cord. An electrode is placed over the spinal cord and is powered by a battery which is implanted in the buttock or abdomen. Stimulation helps to block the pain signals travelling to the brain. It may feel like a tingling sensation which may help reduce your pain. Or you may not feel any tingling sensation. The amount your pain that may be reduced varies from person to person.

Stage one: trial stimulation

To establish if spinal cord stimulation may give you pain relief you will have a trial period of stimulation.

This involves an electrode being inserted under local anaesthetic over your spinal cord. The procedure is performed with you awake as we need you to be able to tell us in which areas you are experiencing the stimulation and whether or not they are in the area of your pain.

You will be required to lie face down. This may be from one to two hours. You will have a needle placed in the back of your hand through which you will be given a dose of antibiotics. A needle will be placed in your back and a fine wire is threaded up through this needle. You may experience pain in your back/neck or leg/arm during the passage of this wire. When this has reached a suitable position as judged by the image on an X-ray screen, you may be tested with a trial stimulation.

We will keep you as comfortable as possible. The procedure can feel uncomfortable but in rare circumstances it can be quite painful when the electrode is introduced and may leave you uncomfortable for a time after the procedure.

When a suitable position for the electrode has been achieved, the wire is then brought out through the skin and attached to your back with a stitch.

When we have moved you onto a trolley we will attach the lead to a temporary battery and give you a remote control type device to trial the stimulation. We like you to have a trial of about 5-10 days. This is best done at home where you can continue the activities that may make your pain worse. You should keep the stimulator on whilst you are in pain. There is no limit to the length of time the stimulator can be on. If you live locally you will be able to go home later on the day of your procedure. If you live a distance away then you will need to stay overnight.

You will return to the Pain Clinic for us to remove the lead and to determine whether or not the pain is relieved at all.

During your trial

You will need to remain lying down on the trolley or bed for 1 to 2 hours and gently mobilise for the rest of the day.

You should try to move around, getting back to your normality while being careful not to do too much in case the lead moves the next day and for the remainder of the trial. 

Ongoing

The injection site may be sore once the local anaesthetic has worn off. You can take painkillers for this.

• The dressings should be kept dry and intact. 
• Your activities need to be restricted to avoid the lead moving.
• Do not raise your arms above your head.
• Do not twist, bend or stretch at the waist. 
• Do not lift heavy items.
• Avoid sitting for long periods of time or driving a car.
• Be careful not to catch the lead, make sure it is tucked inside your clothes and secured well to your body.

Stimulation 

If you are feeling  tingling this may increase when you bend back or when you lie down or sit. (Decrease the stimulation by lowering the amplitude). Stimulation may decrease when you stand up. (Increase the stimulation by increasing the amplitude). If the stimulation is uncomfortable at any time turn the stimulator off.

If you are at home for the trial and experience any of the following you should go to your nearest Accident and Emergency Department, or GP who will contact the Neurosurgical team:

• Increasing severe pain in the back or neck.
• New pain/weakness/numbness in the legs or arms.
• Feeling unwell/flu-like symptoms/high temperature.

Stage two: permanent system

If the trial was a success then you will go on to have a full implant of the system. This may be performed under general anaesthetic/sedation or local anaesthetic. A small incision will be made in your back and the electrode will be implanted against your spinal cord. The connecting wire will be placed under the skin and attached to a battery. You will have a further incision in your skin either in your buttock or your abdomen to place the battery.

The stimulator is programmed post operatively and you will be able to go home the following day. The stimulation may not be as good immediately after this stage as when the temporary wire was in place but stimulation should improve over the next few weeks as healing takes place. The sutures or clips will be removed by the practice nurse 7 to 10 days after the operation.

Complications

As with all surgery there are a number of potential complications, some of which are fairly common:

• Infection. Approximately 5% of cases. This would require the system being removed.
• Bleeding.
• Failure to relieve pain or increase in pain.
• No stimulation or intermittent stimulation.
• Headache.
• Allergic reaction.
• Stimulation in the wrong area.
• Stimulation failure.
• Nerve damage - rare.
• Paralysis. This is very rare.

Following your implant of a spinal cord stimulator

You will remain in bed until the day following surgery and then start to gently mobilise. The Nurse Specialist or company technician will programme your stimulator and show you how to use your hand held programmer.  

You can use your programmer to:

• Turn your generator on and off.
• Increase and decrease the voltage within the 
  boundaries set.

The hand held programmers are expensive. We therefore advise that you have it insured. Please inform us if you have any problems with your programmer. 

What can I expect when I initially go home?

You may feel tired for about 2 to 4 weeks after the implant but it is important to build up you physical strength if possible by walking for brief periods of time each day.

You must tell your GP and Nurse Specialist if you notice any of the following, which may indicate an infection that needs treatment:

• Any leakage from either wound. This may be brown, green or clear.
• Redness or any swelling/pain at the wound site.
• Any raised temperature.

For 4 to 6 weeks after implant it is important to avoid the following activities to prevent the lead from moving:

• Avoid putting your arms above your head.
• Try to avoid bending and twisting and lifting heavy weights.
• Do not sit for too long in a chair.
• Avoid driving for at least 2 weeks.
• Do not operate motor vehicles, power tools or equipment while your stimulator is on. Turn the stimulator off to reduce safety risks associated with sudden sensation changes. 
• Continue to take your normal pain medication for the first 6 weeks.  

General advice

• Advice should be sought regarding Magnetic Resonance Imaging (MRI) as it can cause harm to you and the generator.
• Diagnostic ultrasound is allowed but therapeutic ultrasound is not.
• If you need further surgery you must tell the surgeon that you need BIPOLAR diathermy.
• Stimulators may activate airport detectors and anti-theft devices in shops. These along with strong magnets can turn the generator off.
• It is important to carry your identity card and programmer with you at all times.

Who will be responsible for my care?

After your permanent spinal cord stimulator has been implanted, you will not receive a routine follow-up in the joint pain neurosurgery clinic with Dr Love-Jones or Mr Williams. A phone follow up with the specialist nurses will be arranged and if any reprogramming is required this will be done by the Nurse specialists or company representatives. If you have a problem with your stimulator or you think it is not working properly then you can contact the Pain Clinic nurses on 0117 414 7379 and arrangements for assessment will be made.

If your GP would like any information you can give them the relevant contact details.

Contact details:

Nurse specialists  0117 414 7379

Mr Williams’ secretary 0117 414 6706

Dr Love-Jones’ secretary 0117 414 7364

It is very important that you inform us if you are taking any of the following anticoagulation/ blood thinning drugs before your procedure. These may include: warfarin, clexane, clopidogrel, rivaroxaban, dipyridamol, dabigatran.
Please note that this list is not exhaustive.

References

www.medtronic.co.uk
www.Bostonscientific.com
www.nice.org.uk
www.nevro.com 
www.abbott.co.uk
www.polarmedical.co.uk
NHS Constitution. Information on your rights and responsibilities. Available at: 
www.gov.uk/government/publications/the-nhs-constitution-for-england

© North Bristol NHS Trust. This edition published March 2024. Review due March 2027. NBT002348.

Clinicians in the West have used acupuncture since the 1970s. They believe that acupuncture helps reduce pain by stimulating the brain to release the body’s natural pain killers called endorphins and encephalins, which can reduce pain and inflammation.

Acupuncture appears to be effective in a wide range of painful conditions for example neck, arm, back and leg pain. It has been successfully used to treat headaches, migraines, trapped nerves and various kinds of rheumatic, arthritic and muscular pain.

Some people however may not feel any benefit.

Treatment

• Your consultant has recommended that you receive a course of acupuncture, a nurse specialist will perform the treatment.
• The needles used are sterile and disposable and are left in situ for approximately 20 minutes (except for the first time they are left in situ for 10 minutes to assess your response).
• The acupuncture needles may cause a mild temporary discomfort on insertion and you may experience an ache or tingling whilst the needles are in situ. If you experience any pain during your treatment please notify the nurses.

Possible side effects

These are rare but may include:

• Drowsiness/fatigue.
• Increased pain (usually temporary).
• Faint/light headed.
• Mild sickness.
• Needle site bleed/bruise.

Possible benefits

Acupuncture is not a cure, but can help relieve your pain. It can:

• Decrease the pain after 3/4 sessions.
• Decrease the amount of painkillers you need to take.
• Improve sleep.
• Increase your sense of wellbeing, daily activities and mobility.

You will be asked at your first appointment if you:

• Take any blood thinning medication such as: Warfarin, Clopidogrel, Rivaroxaban, Dipyridamole, Dabigatran…. please note this list is not exhaustive.
• Are diabetic.
• Suffer with epilepsy.
• Are pregnant.
• Suffer with allergies.
• Have a pace maker.

Risks

• Pneumothorax. Very rarely. 10 in 200,000.
• Increased pain.
• Infection.

Please note if you fail to attend your first appointment without notifying the number on this leaflet, your course will be cancelled.

If you are unable to attend two or more sessions, your course will be cancelled.

For further help

If you have any other worries or questions about your acupuncture, please discuss them with your practitioner.

References

BMAS (British Medical Acupuncture Society)
www.medical-acupuncture.co.uk

If you or the individual you are caring for need support reading this leaflet please ask a member of staff for advice.

How to contact us:

Pain Clinic
Gloucester House
Southmead Hospital
Westbury-on-Trym
Bristol
BS10 5NB

Telephone: 0117 4147361

Email: PainClinicClinical@nbt.nhs.uk

© North Bristol NHS Trust. This edition published February 2024. Review due February 2027. NBT002108.