Interventional and Procedural Pain Management
Before the needle
Interventional care begins with indication, consent, anticoagulation review, and image guidance. Common procedures include epidural steroid injections (interlaminar, transforaminal, caudal), facet medial branch blocks and radiofrequency ablation, sacroiliac joint injection, trigger point injection, sympathetic blocks (stellate, lumbar, celiac, ganglion impar), peripheral nerve blocks, spinal cord stimulation trials, and intrathecal drug delivery.
Anatomy and risk
Know the anatomy and risk profile of each route. Transforaminal epidural injection risks spinal cord infarction from particulate steroid or radicular artery injury; cervical procedures carry higher catastrophic risk. Interlaminar injection risks dural puncture and epidural hematoma. Stellate ganglion block can cause Horner syndrome, hoarseness, and pneumothorax; celiac plexus block can cause orthostasis and diarrhea.
Manage anticoagulants and antiplatelet agents using procedure-specific guidelines. Stop agents for recommended intervals, document, and use the smallest effective needle. Always aspirate and use contrast under fluoroscopy; a negative blood aspiration does not exclude intravascular placement.
Complications
Recognize local anesthetic systemic toxicity early: perioral numbness, tinnitus, seizures, and dysrhythmia, treated with lipid emulsion. Epidural hematoma presents with new weakness and bowel or bladder change and requires emergent MRI and decompression. Also watch for infection and pneumothorax.
Trap: diagnostic blocks are not therapeutic, and radiofrequency ablation commonly requires concordant response to two medial branch blocks. Another trap: steroid has delayed onset and modest duration, so judge benefit against functional goals.
Rule of thumb: image, aspirate, contrast, then inject, and know your anticoagulation window.