Interventional and Procedural Pain Management
Procedural fundamentals
Interventional pain medicine rests on patient selection, informed consent, image guidance, and complication management. Know indications and contraindications for epidural steroid injections, facet medial branch blocks and radiofrequency neurotomy, sacroiliac joint injections, sympathetic blocks, trigger-point injections, joint injections, spinal cord stimulation, and intrathecal drug delivery. Absolute contraindications often include local or systemic infection at the site, coagulopathy when the procedure carries bleeding risk, and allergy to required agents; relative issues include uncontrolled diabetes, immunosuppression, and pregnancy.
Image guidance with fluoroscopy or ultrasound improves accuracy; contrast confirms needle position and rules out intravascular or intrathecal spread before injecting. Aspirate before every injection. Particulate steroids should be avoided in transforaminal cervical injections because of catastrophic spinal cord infarction risk. Follow ASRA anticoagulation guidance for neuraxial procedures, and recognize local anesthetic systemic toxicity-treat with airway support and lipid emulsion.
Common traps: over-sedating older adults; injecting into an area of cellulitis; forgetting to review anticoagulants and antiplatelets; attributing post-procedure fever or severe headache to flu; and performing repeated epidural steroids without reassessing benefit. Post-dural puncture headache is positional and may require a blood patch.
Worked example: a patient on warfarin (INR 2.4) for atrial fibrillation is scheduled for a lumbar transforaminal epidural. The INR must be within the ASRA-specified range and the medication held appropriately, with documentation of the plan and a fallback analgesic. Rule of thumb: no image, no contrast, no aspiration-no injection; and document benefit and complications at every follow-up.