| One-Minute Clinician

Interventional Pain Management--What and When?

The use of interventional procedures is probably going to increase due to the CDC guidelines, because they are emphasizing non-opioid, and non-pharmacological therapies. So this is an important area for primary care doctors to understand, specifically if we look at patients with low back pain, one of the top three pain conditions. If patients have back pain and shooting leg pain, for example, they are typically good candidates for epidural steroid injections. If patients have neck pain and shooting arm pain, that can be treated with the epidural injection. Another cause can be the facet joint. These are stabilizing joints in the low back, and they can become arthritic, or hypertrophied from injury, older age, or stress. Patients will present with axial lumbar pain, low back pain that is on either side of the low back. Those patients can benefit from what we call medial branch blocks, targeting the small nerve that provides sensation to those joints. We can block those with a little bit of local anesthetic. If patients respond well to those blocks, the follow-up procedure is radiofrequency denervation with a device that uses heat therapy to deactivate that small sensory nerve to provide more sustained relief.

If the pain is in the low, low back, say L5 and below, the sacroiliac joint can be the source. These patients typically report pain around the buttock, low and the lumbar spine maybe down to the posterior thigh. Often patients will say they have been in an accident or sustained a stress injury. We can do a diagnostic block inside that joint, and if the patient responds, there is an interesting procedure called a cooled radiofrequency procedure which uses heat energy to deactivate the nerves that supply that joint. The market is skyrocketing with respect to the use spinal cord stimulation for the reduction of pain. I think it’s important for primary care doctors to keep in mind that patients who have had spine surgery, and who continue to have low back pain and shooting leg pain are good candidates for spinal cord stimulator procedures. For patients who have cancer-related pain that is intractable, and opioids are not reducing the pain enough, or they’re causing side effects, consider an intrathecal pump that use tiny doses of morphine, or a local anesthetic like bupivacaine directly to the spinal fluid. Because the doses are small, the medication bypasses the gastrointestinal tract, so the side effect profile is much better than it is for opioid therapy or other medications that are taken by mouth.