ABPS Interventional Pain Management cheat sheet

Pain history should capture onset, quality, radiation, temporal pattern, aggravating/relieving factors, and functional impact.

Numeric Rating Scale (0-10) and Visual Analog Scale are unidimensional; the Brief Pain Inventory adds functional interference.

Neuropathic pain screen: burning, electric, lancinating quality with allodynia or hyperalgesia suggests a neuropathic mechanism.

Red flags mandating urgent workup: progressive motor deficit, bowel/bladder dysfunction, saddle anesthesia, fever, unexplained weight loss, night pain.

Straight leg raise is positive for radiculopathy when ipsilateral leg pain reproduces below the knee between 30 and 70 degrees.

Provocative sacroiliac testing requires at least 3 of 5 positive maneuvers for acceptable diagnostic specificity.

Diagnostic imaging is indicated when red flags, progressive neurologic deficit, or failure of conservative care are present.

Acetaminophen maximum is generally 3-4 g/day in healthy adults; lower the ceiling with hepatic disease or alcohol use.

NSAIDs inhibit COX-1 and COX-2; risk rises for GI bleeding, renal injury, and cardiovascular events with chronic use.

Tramadol is a weak mu agonist with serotonin-norepinephrine reuptake inhibition; it lowers seizure threshold and risks serotonin syndrome.

Opioid conversion: oral morphine 30 mg is approximately equianalgesic to oral oxycodone 20 mg and to oral hydromorphone 6 mg.

Methadone is long-acting with QT prolongation risk; it requires ECG monitoring at higher doses.

Gabapentinoids reduce neuropathic pain; dose-adjust for renal function and monitor for sedation and edema.

Topical lidocaine 5% patch is first-line for localized postherpetic neuralgia with minimal systemic absorption.

Naloxone reverses opioid respiratory depression; titrate to restore ventilation, not full arousal.

Medial branch blocks are diagnostic for facet-mediated pain; comparative or placebo-controlled blocks raise specificity.

A block is positive when pain relief exceeds a defined threshold (commonly 50-80%) with concordant functional improvement.

Contrast injection under fluoroscopy confirms needle position and excludes intravascular or intrathecal placement.

Provocative discography is positive with concordant pain reproduction at low pressure and a negative control level.

Diagnostic block specificity increases with controlled comparative blocks and use of a sham or placebo arm.

Lumbar transforaminal epidural steroid injection is both diagnostic and therapeutic for radicular pain.

Sympathetic blocks (stellate, lumbar) aid diagnosis of complex regional pain syndrome and sympathetically maintained pain.

Epidural steroid injections target radicular pain; interlaminar, transforaminal, and caudal approaches differ in risk profile.

Fluoroscopic guidance with contrast is standard for epidural, facet, and sacroiliac injections.

Transforaminal cervical injection carries catastrophic risk of vertebral artery or spinal cord infarction; particulate steroids are avoided.

Facet joint pain is treated with intra-articular steroid or medial branch radiofrequency neurotomy.

Sacroiliac joint injection is diagnostic and therapeutic; intra-articular placement is confirmed with contrast.

Anticoagulation must be held per ASRA guidelines before neuraxial procedures to prevent spinal hematoma.

Steroid dose and frequency should be minimized; repeated epidural steroids carry adrenal suppression and bone loss risk.

Peripheral nerve blocks provide targeted analgesia and can be diagnostic for focal neuropathy.

Ultrasound guidance improves block accuracy and reduces local anesthetic volume and vascular puncture risk.

Local anesthetic maximum doses: lidocaine without epinephrine ~4.5 mg/kg; bupivacaine ~2.5 mg/kg.

Intra-articular corticosteroid is effective for inflammatory arthritis and osteoarthritis flares; limit frequency per joint.

Hyaluronic acid injection is an option for knee osteoarthritis when conservative therapy fails.

Nerve blocks of the suprascapular, genicular, and ilioinguinal nerves are common peripheral targets for chronic pain.

Lasting relief after a diagnostic block supports proceeding to radiofrequency ablation of the same nerve.

Spinal cord stimulation uses epidural leads to deliver paresthesia or subperception therapy for refractory neuropathic pain.

A trial of stimulation (commonly days to weeks) precedes permanent implantation; trial success predicts long-term benefit.

High-frequency and burst waveforms reduce or eliminate paresthesia and may improve back pain coverage.

Dorsal root ganglion stimulation targets focal neuropathic pain with a dermatomal distribution.

Intrathecal drug delivery is considered for refractory pain or spasticity; catheter tip position determines drug distribution.

Infection, lead migration, and hardware failure are the most common complications of implanted systems.

MRI compatibility depends on device and lead configuration; verify before ordering imaging.

Radiofrequency ablation of medial branches relieves facet pain; cooled RF enlarges the lesion for larger nerves.

Pulsed radiofrequency delivers energy without thermal destruction and is used near sensitive neural structures.

Thermal RF lesion temperature is typically 80 degrees Celsius for 60-90 seconds per lesion.

Regenerative options include platelet-rich plasma and prolotherapy; evidence varies by indication and site.

Cryoneurolysis ablates nerve via cold injury and is used for focal neuropathic and postsurgical pain.

Ablation near motor nerves risks weakness; map motor responses before lesioning.

Denervation durability depends on nerve regeneration; relief often lasts months to a year.

Spinal hematoma presents with new back pain, progressive weakness, and bowel/bladder dysfunction; emergent decompression is required.

Post-dural puncture headache is treated with conservative measures, caffeine, and epidural blood patch if persistent.

Infectious risks include epidural abscess and discitis; fever with focal spinal pain after injection warrants urgent imaging.

Vasovagal syncope is common during needle procedures; supine positioning and monitoring mitigate it.

ASRA anticoagulation guidelines govern timing of neuraxial procedures to prevent bleeding complications.

Allergy history, anticoagulant use, and pregnancy status must be documented before any injection.

Radiation safety: minimize fluoroscopy time, use pulsed fluoroscopy, and collimate the beam.

Multidisciplinary care combining physical therapy, psychology, and medical management improves chronic pain outcomes.

Cognitive behavioral therapy targets maladaptive pain beliefs and catastrophizing and reduces disability.

Graded exercise and activity pacing are core rehabilitation strategies for chronic musculoskeletal pain.

Pain neuroscience education improves understanding of central sensitization and reduces fear-avoidance.

Functional restoration programs improve return-to-work in chronic low back pain.

Interdisciplinary care is recommended for chronic pain before or alongside interventional escalation.

Opioid tapering is best supported with behavioral and rehabilitative co-interventions.

Controlled substance prescribing requires compliance with DEA registration, state licensure, and prescription monitoring programs.

PDMP review is required or recommended in most states before prescribing controlled substances.

Documentation must support medical necessity for procedures, including diagnosis, failed conservative care, and response to prior blocks.

Informed consent, procedure notes, and fluoroscopy images should be retained per state and payer requirements.

Billing uses CPT codes for injections, nerve blocks, and radiofrequency ablation; documentation must match the code.

HIPAA governs protected health information; minimum necessary access applies to clinical records.

Medicare and payer rules govern frequency limits and prior authorization for interventional procedures.

Nociceptors are free nerve endings that transduce noxious stimuli; A-delta fibers are myelinated and fast, C fibers are unmyelinated and slow.

Nociceptive signals synapse in the dorsal horn; glutamate and substance P are key neurotransmitters.

Ascending pathways (spinothalamic tract) carry pain to thalamus and cortex; descending pathways modulate via serotonin and norepinephrine.

Central sensitization involves NMDA receptor activation, wind-up, and reduced inhibition, producing hyperalgesia and allodynia.

Peripheral sensitization lowers nociceptor threshold after tissue injury and inflammation.

Neuropathic pain arises from nerve injury with ectopic firing and altered ion channel expression.

Sympathetically maintained pain involves sympathetic nervous system contribution and is targeted by sympathetic blocks.

A comprehensive pain assessment includes medical history, prior treatments, psychosocial factors, and functional status.

Physical examination should include inspection, palpation, range of motion, and neurologic screening.

Dermatomal and myotomal mapping localizes radicular involvement and guides injection level.

Diagnostic criteria for complex regional pain syndrome include disproportionate pain, sensory and vasomotor changes, and no better explanation.

Screening tools such as the Pain Catastrophizing Scale and PHQ-9 identify psychosocial risk factors.

Consistency of pain behavior and functional capacity informs prognosis and treatment planning.

Repeat evaluation after each intervention documents response and guides escalation or discontinuation.

Tricyclic antidepressants at low dose are effective for neuropathic pain; anticholinergic and cardiac effects limit use in older adults.

Duloxetine is an SNRI with evidence for diabetic peripheral neuropathic pain and fibromyalgia.

Corticosteroids reduce inflammation but chronic use risks hyperglycemia, osteoporosis, and immunosuppression.

Muscle relaxants and benzodiazepines cause sedation and dependence; limit duration.

Topical capsaicin and lidocaine provide localized analgesia with minimal systemic effects.

Opioid risk mitigation includes urine drug testing, PDMP checks, and treatment agreements.

Anticonvulsants such as carbamazepine are used for trigeminal neuralgia; monitor for hyponatremia and drug interactions.

Epidural steroid injections are generally limited in frequency; spacing and total steroid dose should be minimized.

Caudal epidural access uses the sacral hiatus and avoids the interlaminar space, useful in postsurgical spines.

Fluoroscopic confirmation of epidural spread uses contrast; intravascular spread requires needle repositioning.

Medial branch block should precede radiofrequency ablation for facet pain.

Intradiscal procedures have limited evidence and should be selected carefully.

Vertebroplasty and kyphoplasty treat osteoporotic compression fractures with refractory pain.

Post-procedure monitoring should assess motor function and new neurologic symptoms before discharge.

Spinal cord stimulation trial success is typically defined as 50% or greater pain reduction.

Lead placement at the anatomic midline and appropriate spinal level determines paresthesia coverage.

Device programming can adjust amplitude, frequency, and pulse width to optimize analgesia.

Battery type (rechargeable vs primary cell) affects replacement interval and patient burden.

Intrathecal pumps require refill schedules and monitoring for granuloma formation and catheter complications.

MRI conditional labeling varies; verify device and lead compatibility before imaging.

Patient selection includes psychological screening and failure of conservative therapy.

Local anesthetic systemic toxicity presents with perioral numbness, tinnitus, seizures, and cardiac arrest; treat with lipid emulsion.

Anaphylaxis to contrast or medication requires epinephrine, airway support, and monitoring.

Infection control includes sterile technique, skin antisepsis, and appropriate draping.

Pneumothorax is a risk with thoracic and cervical procedures; monitor for dyspnea and chest pain.

Sedation should be minimized to allow neurologic monitoring during neuraxial procedures.

Document informed consent, allergies, and anticoagulant status before every injection.

Post-procedure instructions should include warning signs requiring urgent evaluation.

Physical therapy targets strength, flexibility, and functional restoration in chronic pain.

Behavioral therapy addresses catastrophizing, fear-avoidance, and coping skills.

Multidisciplinary programs combine medical, physical, and psychological components for best outcomes.

Sleep hygiene and stress management are adjuncts in chronic pain care.

Motivational interviewing improves adherence to rehabilitation and self-management.

Return-to-work planning should be integrated early in chronic pain management.

Patient education about pain mechanisms reduces fear and improves engagement.

Accurate CPT and ICD-10 coding requires documentation of diagnosis, procedure, and medical necessity.

Controlled substance agreements and urine drug testing support safe opioid prescribing.

PDMP review is required in many states before prescribing controlled substances.

Informed consent and procedure documentation protect against liability.

HIPAA compliance requires safeguarding protected health information.

Prior authorization and payer rules affect procedure scheduling and reimbursement.

Maintain fluoroscopy and procedure records per regulatory retention requirements.

A-delta fibers are myelinated and mediate sharp, fast pain; C fibers are unmyelinated and mediate dull, slow pain.

Dorsal horn processing involves glutamate, substance P, and NMDA receptor activation in sensitization.

Descending modulation from brainstem uses serotonin and norepinephrine to inhibit pain.

Central sensitization produces hyperalgesia and allodynia via increased synaptic efficacy.

Peripheral sensitization follows inflammation and lowers nociceptor thresholds.

Neuropathic pain results from nerve injury with ectopic discharges and altered ion channels.

Sympathetic nervous system contributes to sympathetically maintained pain.

Ultrasound guidance improves accuracy and safety of peripheral nerve blocks.

Local anesthetic dosing must respect maximum safe doses to avoid systemic toxicity.

Intra-articular steroid provides short-term relief for inflammatory joint pain.

Hyaluronic acid injection is an option for knee osteoarthritis.

Diagnostic nerve blocks guide subsequent ablation.

Suprascapular and genicular nerve blocks are common chronic pain targets.

Monitor for vascular puncture and nerve injury during blocks.

Radiofrequency ablation creates thermal lesions at 80 degrees Celsius for 60-90 seconds.

Cooled RF enlarges lesion size for larger nerves.

Pulsed RF avoids thermal destruction near sensitive structures.

Cryoneurolysis uses cold injury for focal neuropathic pain.

Platelet-rich plasma and prolotherapy have variable evidence by indication.

Motor nerve mapping prevents weakness before ablation.

Denervation durability is limited by nerve regeneration.

Red flags include progressive motor deficit, bowel/bladder dysfunction, fever, and unexplained weight loss.

Straight leg raise between 30 and 70 degrees suggests radiculopathy when it reproduces leg pain.

At least 3 of 5 positive SI joint maneuvers improve diagnostic specificity.

Brief Pain Inventory adds functional interference to pain intensity.

Neuropathic descriptors include burning, electric, and lancinating pain.

Psychosocial screening identifies catastrophizing and depression risk.

Repeat assessment after intervention documents response.

Acetaminophen ceiling is 3-4 g/day in healthy adults.

NSAIDs carry GI, renal, and cardiovascular risks with chronic use.

Tramadol lowers seizure threshold and risks serotonin syndrome.

Methadone requires QT monitoring at higher doses.

Gabapentinoids require renal dose adjustment.

Topical lidocaine 5% patch is first-line for localized postherpetic neuralgia.

Naloxone reverses opioid respiratory depression.

Fluoroscopy with contrast confirms needle placement for epidural and facet injections.

Cervical transforaminal injection risks vertebral artery and spinal cord infarction; avoid particulate steroids.

Caudal access avoids the interlaminar space in postsurgical spines.

Medial branch block precedes radiofrequency ablation.

ASRA guidelines govern anticoagulation timing before neuraxial procedures.

Vertebroplasty treats osteoporotic compression fractures.

Post-procedure neurologic monitoring is required before discharge.

SCS trial success is commonly defined as 50% or greater pain reduction.

Lead position determines paresthesia coverage.

High-frequency and burst waveforms reduce paresthesia.

DRG stimulation targets focal dermatomal neuropathic pain.

Intrathecal pumps require refill monitoring and granuloma surveillance.

MRI compatibility depends on device and lead configuration.

Infection and lead migration are common complications.

LAST presents with perioral numbness, tinnitus, seizures, and cardiac arrest; treat with lipid emulsion.

Spinal hematoma requires emergent decompression.

Post-dural puncture headache may need epidural blood patch.

Fever with focal spinal pain after injection warrants urgent imaging.

Vasovagal syncope is managed with supine positioning and monitoring.

Minimize sedation to allow neurologic monitoring.

Document allergies and anticoagulant status before injection.

CBT reduces catastrophizing and disability.

Graded exercise and pacing are core rehabilitation strategies.

Pain neuroscience education reduces fear-avoidance.

Functional restoration improves return-to-work.

Interdisciplinary care is recommended before interventional escalation.

Motivational interviewing improves adherence.

Early return-to-work planning improves outcomes.

CPT and ICD-10 coding must match documentation.

PDMP review is required before controlled substance prescribing in many states.

Controlled substance agreements and urine drug testing support safety.

Informed consent and procedure notes protect against liability.

HIPAA governs protected health information access.

Prior authorization affects procedure scheduling.

Retain fluoroscopy and procedure records per regulation.

A-delta fibers are myelinated and fast; C fibers are unmyelinated and slow.

Dorsal horn uses glutamate and substance P; NMDA activation drives sensitization.

Descending modulation uses serotonin and norepinephrine.

Central sensitization produces hyperalgesia and allodynia.

Peripheral sensitization follows inflammation.

Neuropathic pain involves ectopic firing and ion channel changes.

Sympathetic contribution defines sympathetically maintained pain.

Ultrasound improves block accuracy and safety.

Lidocaine maximum without epinephrine is ~4.5 mg/kg.

Bupivacaine maximum is ~2.5 mg/kg.

Intra-articular steroid treats inflammatory joint flares.

Hyaluronic acid is an option for knee osteoarthritis.

Diagnostic blocks guide ablation planning.

Monitor for vascular puncture and nerve injury.

Thermal RF lesion temperature is typically 80 degrees Celsius for 60-90 seconds.

Cooled RF enlarges lesion size.

Pulsed RF avoids thermal destruction.

Cryoneurolysis uses cold injury.

PRP and prolotherapy evidence varies by indication.

Motor mapping prevents weakness before ablation.

Relief duration is limited by nerve regeneration.

Medial branch blocks are diagnostic for facet pain.

A positive block requires defined pain relief threshold, commonly 50-80%.

Contrast confirms needle position and excludes intravascular placement.

Provocative discography requires concordant pain at low pressure with a negative control.

Comparative blocks raise specificity.

Transforaminal epidural steroid injection is diagnostic and therapeutic.

Sympathetic blocks aid diagnosis of CRPS.