Interventional pain therapies continue to play an important role for patients with chronic pain. Their continued use is likely to increase due to advances in technology, as well as the marginal efficacy of medical treatments in providing sustained relief for select pain conditions. Joint injections, nerve blocks, epidural injections, and implantable devices for chronic pain have been associated with functional improvements and cost savings, and typically require little or no downtime.
As an interventional pain physician, I work hand in hand with primary care providers (PCPs) from various disciplines, treating patients with acute, chronic, or acute-on-chronic pain. This collaborative relationship has proven to be an effective method to address the many dimensions of a patient’s pain, often occurring in concert with increasingly long lists of medical comorbidities that PCPs are simultaneously tackling.
Acute, Chronic, or Acute-on-Chronic Pain: No One Size Fits All
A variety of acute pain conditions are amenable to treatment by the interventional pain physician. Epidural steroid injections administered for acute disc herniations provide superior efficacy when compared to treating these same radiculopathies if present for decades. Conversely, implanted pain therapies, such as spinal cord stimulation, are reserved for chronic or subacute pain pathologies that have proven refractory to more conservative interventional approaches. When obtaining a history and conducting a physical examination of a patient with pain, assessment of chronicity of symptoms enables the pain physician to identify a treatment course.
Sorting through acute-on-chronic pain can be particularly challenging since some patients are unable to differentiate new-onset pain from their chronic pain condition. To a patient, “pain is pain,” and sorting through a complex pain history often requires a physician-directed history to define these nuances.
Bleeding Risk During Interventional Pain Procedures
Though bleeding complications rarely occur following interventional pain procedures, pain physicians are paying closer attention to an expanding list of anticoagulants in contemporary use. Pain physicians are tasked with considering newer anticoagulant agents with heterogeneous half-lives and diverse mechanisms of action. Of late, barely a year elapses without the introduction of one or more anticoagulant agents that each warrant specific consideration prior to spinal injections.
Though established guidelines exist indicating the duration and settings for discontinuation of anticoagulant therapy, these general statements often neglect patient-specific variables: most notably the indication for therapy and the potential risks posed with interrupting therapy. As a result, interventionalists collaborate with PCPs to weigh the risk-benefit ratio of moving forward or abstaining from select pain procedures that require a period of abstinence from anticoagulants prior to neuraxial injections.
There Is More to Interventional Pain Management Than Epidural Steroid Injections
The diversity of spinal and neuraxial injections continues to expand. The distinctions between approaches, indications, and techniques are the focus of the contemporary pain physician who tailors a treatment approach for discrete pain conditions. The nuances of these technical details are often the purview of the pain physician alone, much the same way as the diversity of cardiac stents is of little interest to the clinician outside of the cardiac catheterization lab. Nonetheless, a growing number of PCPs are becoming aware of the types of procedures and indications for commonly encountered pain conditions and are referring patients for consideration of specific treatments.
In general, interventional pain procedures are reserved for a focal pain area: a particular joint rather than diffuse polyarthralgias or focal radiculopathy rather than whole-body pain. Data are scarce to support the effectiveness of interventional treatments such as trigger point injections for widespread pain conditions. When considering referral to a pain physician, identifying the presence of a reasonably focal pain area accompanied by a brief note indicating “consideration for interventional pain treatment” will help guide treatment. On the other hand, referrals from spine surgeons may often dictate a desire for a particular selective nerve root block that can help to target their surgical approach, answer a specific clinical question, or prevent the need for more extensive surgery.