Nerve Block Consent Form

Nerve Block therapy consent form

What is nerve block therapy? It is a medical treatment which involves injecting substances related to sugar near nerves which carry pain signals, to turn off the pain receptors, shutting down the transmission of pain messages to the brain, and reducing nerve swelling.

What is injected and where? Usually, a 5% solution of dextrose (a kind of sugar), or mannitol (dextrose with water molecules added) in water, is injected under the skin near nerves which carry the pain signal. These nerves, to get to the skin, have to cross the thick membrane, which covers the body, through tiny holes. When these nerves are injured or supply areas which are injured, they swell. When they are swollen, they are too big for the holes they have to cross to get to the skin, and they injure themselves on the walls of these holes. This causes them to swell more, and injure themselves again, causing a vicious cycle of persistent pain.

What medical conditions does it treat? Any condition associated with nerve injury: neuralgia, neuropathy (such as diabetic neuropathy), or causing persistent pain, from persistent headaches to burning mouth to whiplash injury to persistent back pain, to frozen shoulder to postherpetic neuralgia to “sciatica” to Morton’s neuroma. If your pain is made worse by pressing on the area, chances are it will respond to this treatment.

What are the risks? Bruising occurs frequently. The injections are made using minute needles, so they produce very little pain, but many injections have to be made, particularly in the first few treatments, as all the painful nerve areas have to be treated. Very rarely, there is a risk of allergic reaction to the injection solution, particularly if you are allergic to corn. There is also a very remote risk of skin infection.

What are the benefits? 89% of those treated leave the office with no pain at all. This pain-free time will last anywhere from two hours to four days after the first treatment. With each subsequent treatment, you will need fewer injections as some of the nerves do not get reactivated, and you will remain pain-free for longer and longer. Eventually, your pain will not return.

What are the costs? Nerve block therapy (nerve blocks) are covered by MSP. The only costs are those of the materials used: $25 for every 50 mL of solution injected. Usually, 25 to 100 mL are injected at each session. Some extended benefit plans will cover a portion of your costs. Treatments have to be given once a week until the pain-free period lasts longer than one week. When this happens, treatment is given as needed.

I have read and understand this consent form and agree to be treated with nerve block therapy.

Signed __________________________________      Date____________