Interventional and Procedural Pain Management
Interventions succeed only when the target is correct
Interventional care begins with a diagnosis, not a procedure. Identify the presumed pain generator - facet joint, nerve root, sympathetic chain, joint, muscle, or disc - and confirm that conservative care has been optimized. Common procedures include epidural corticosteroid injections for radicular pain, medial branch blocks followed by radiofrequency ablation for facet-mediated pain, trigger point and joint injections, sympathetic blocks for complex regional pain syndrome, and neuromodulation or intrathecal therapy for refractory cases.
Know contraindications: local or systemic infection, coagulopathy, anticoagulation without an appropriate hold, allergy to injectate, and uncontrolled medical instability. Obtain informed consent that includes realistic expectations and alternatives. Use sterile technique and image guidance where indicated. Corticosteroids have cumulative systemic effects (hyperglycemia, adrenal suppression, bone loss), so track total dose. Local anesthetic systemic toxicity presents with tinnitus, perioral numbness, seizures, or arrhythmia; stop injection, support the airway, and give lipid emulsion.
Traps: injecting before checking anticoagulation, treating an abnormal MRI rather than the patient, repeating epidural steroids without reassessing benefit, and assuming radiofrequency ablation works without diagnostic blocks. Evidence for long-term benefit of many injections is modest; document functional response.
Worked example: a patient on apixaban needs an epidural steroid injection. Review renal function and bleeding risk, follow guideline-based interruption, coordinate with the prescriber, and document the shared decision.
Rule of thumb: block the pain generator, not the image - and stop if two procedures fail to help.