Pain Management and Opioids

Common Interventional Pain Procedures

PAIN INTERVENTION FUNDAMENTALS…page 2

SPINAL INJECTIONS & INTERVENTIONS…page 4

1. Interlaminar Epidural Glucocorticoid Injection (Lumbar/Cervical)…page 5
2. Transforaminal Epidural Glucocorticoid Injection (Lumbar)…page 6
3. Facet Injection/Medial Branch Block (Cervical, Thoracic, or Lumbar)…page 7
4. Radiofrequency Lesioning/Neurotomy (Lumbar/Cervical)…page 8
5. Sacroiliac Joint Injection…page 9

SYMPATHETIC NERVE BLOCKS…page 10

6. Stellate Ganglion Block…page 11
7. Celiac Plexus Block (With or Without Neurolysis)…page 12
8. Lumbar Sympathetic Block…page 13

HEAD AND NECK NERVE BLOCKS…page 14

9. Occipital Nerve Block…page 15
10. Trigeminal Nerve Block…page 16

PERIPHERAL NERVE BLOCKS…page 18

11. Ilioinguinal Nerve Block…page 19
12. Lateral Femoral Cutaneous Nerve Block…page 20
13. Pudendal Nerve Block…page 21

DRY NEEDLING AND TRIGGER POINT INJECTIONS…page 22

14. Dry Needling and Trigger Point Injections…page 22

SURGICAL PAIN MANAGEMENT…page 23

15. Intrathecal Drug Delivery…page 24
16. Neuromodulation (Spinal Cord Stimulation)…page 25

© 2021 Massachusetts Medical Society. All rights reserved.

 Pain Management and Opioids

COMMON INTERVENTIONAL PAIN PROCEDURES

A range of interventional procedures for pain can be useful in patients with chronic pain who
have not achieved adequate relief with conservative treatments. Typically, given the invasive
nature of these procedures, they are not first-line treatments for pain. Instead, they are
considered only after failure to achieve pain relief with adequate trials of medication, at least
6 weeks of physical therapy, or both.

More than 200 interventional procedures are routinely performed, most often by clinicians
who have received additional fellowship-level training. The types of procedures range from
simple peripheral nerve blocks to spinal interventions to more-invasive surgical procedures
that involve implantation of devices. In each subsection below, the most common
interventions are outlined.

PAIN INTERVENTION FUNDAMENTALS

Most interventional pain procedures do not require intravenous access unless the patient
has a known history of vasovagal syncope; nor do they require sedation unless the
patient is very anxious. Most interventional procedures for pain involve injecting a local
anesthetic, such as lidocaine or bupivacaine, combined with a glucocorticoid, such as
methylprednisolone or dexamethasone. The local anesthetic provides rapid pain relief;
the addition of a glucocorticoid enhances longer-term therapeutic efficacy, given the
antiinflammatory property of glucocorticoids.

Injection of a local anesthetic alone can be done, typically when the sole goal of the
procedure is temporary reduction of pain conduction. This may be the case in a diagnostic
block, performed to confirm the analgesic benefit before implementation of more-invasive
interventions such as radiofrequency ablation. Another use of local anesthetic alone is in
patients for whom glucocorticoids are relatively contraindicated; some studies have shown,
in certain pain conditions such as lumbar stenosis, equal efficacy with local anesthetic alone,
compared to a local anesthetic combined with glucocorticoids.

Another broad category of interventional pain procedures are ablation procedures, whereby
the conduction of pain signals is interrupted through destruction of the nerves, typically
using radiofrequency ablation. These procedures provide longer-term benefit but are more

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 invasive than injections of a local anesthetic with or without a glucocorticoid.

Complications of interventional pain procedures. Complications are rare and are discussed
below with each procedure, but some general considerations are worth highlighting:
■ Infection is sufficiently rare that prophylactic antibiotics are rarely used.
■ Adverse effects of local anesthetics are usually temporary and include dizziness,
headaches, blurred vision, muscle twitching, and localized numbness, tingling, or
weakness. An allergic reaction to the local anesthetic or a serious adverse effect such as a
seizure or cardiac arrest is very rare.
■ Ifa glucocorticoid is used, the patient is at risk for systemic glucocorticoid exposure with
resulting adverse effects (e.g., hyperglycemia, suppression of the hypothalamic–pituitary–
adrenal axis, and cushingoid features), especially with repeated injections.
■ Vessel occlusion with resulting ischemia also can occur in the case of inadvertent
intravascular injection, especially with particulate glucocorticoid solutions such as
methylprednisolone or triamcinolone.

Contraindications to interventional pain procedures. Contraindications are common among

most of the interventions outlined below. They include:
■ Active systemic infection or infection of the skin overlying the area where the needle will
enter
■ Anticoagulation or problems with coagulation. This is especially important with neuraxial
procedures, as hemorrhage can lead to irreversible neurologic damage. It is of less concern
with peripheral or joint injections (including facet joint injections of the spine), as the
risk for nerve compression is low. Anticoagulants should be stopped for a period of time
before the procedure, sufficiently adequate to reverse the anticoagulant state. This step is
necessary for most anticoagulants, including direct oral anticoagulants and warfarin. For
patients taking warfarin, INR should be measured on the day of the procedure. Antiplatelet
agents such as P2Y12 inhibitors (e.g., clopidogrel, prasugrel, ticagrelor) are also stopped
before these procedures. Low-dose aspirin and nonsteroidal antiinflammatory drugs carry a
low risk for bleeding and do not need to be stopped before these procedures.
■ Hypersensitivity to glucocorticoids, contrast dye, or anesthetic medications
■ Local malignancy at the site of injection
■ Special considerations should be made in patients with uncontrolled diabetes (injection
with local anesthetic alone may be considered), heart failure, pregnancy (fluoroscopy is
contraindicated but ultrasound guidance can be used) — and in patients with cardiac
device implantation, in cases of radiofrequency ablation (defibrillator may need to be
turned off during the ablation process).

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SPINAL INJECTIONS & INTERVENTIONS

1
Nearly every adult experiences back pain at some point
during their lives, but most episodes resolve spontaneously.
In approximately 10% of people, pain persists despite
conservative measures and results in significant individual
disability and societal cost; within this subgroup, interventional
therapies can be considered as treatments for both axial and
radicular back pain.

2
Interlaminar Glucocorticoid injections (first described in 1953 and
commonly referred to as epidural steroid injections) are the
first-line invasive procedure for treating spine-generated
pain. Despite widespread use of these injections, controversy
remains about their efficacy and uncertainty remains about
the mechanism of therapeutic benefit. Several mechanisms
have been proposed, including antiinflammatory effects, direct

3
neural membrane stabilization effects, and modulation of
Transforaminal peripheral nociceptor input. The vast majority of patients who
respond favorably do so within 6 days of injection.

A lumbar MRI is strongly recommended before these neuraxial

procedures, to help determine the point of interest for the
injection and to rule out conditions that are considered to be
Facet contraindications, such as diskitis or epidural fluid collections.

4
The desired site of injection is also determined through
physical examination (to identify dermatomal distribution) and,
occasionally, neurophysiological studies. Injection of contrast
medium is strongly recommended to confirm correct needle
placement.

In addition to various approaches for performing epidural

Radiofrequency glucocorticoid injections, there are other interventional
procedures that are used in the management of back pain. The

5
patient’s history, physical examination, and MRI findings — as
well as the expertise and experience of the clinician performing
the procedure — all help to determine the best procedure for
any given scenario.

Sacroiliac

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1
SPINAL INJECTIONS & INTERVENTIONS
Interlaminar
Epidural Straight line
Glucocorticoid
Injection (Lumbar/
Needle tip parallel
Cervical) to dura

C7

Ligamentum flavum

Spinal cord

T1 Dura

Epidural space

INDICATIONS POTENTIAL CLINICAL PEARLS HOW TO PERFORM

COMPLICATIONS

■ Lumbar/cervical ■ Epidural
bleeding or ■ Prepare the patient to ■A small needle is placed
radiculopathy hematoma expect a series of three into the epidural space
■ Lumbar/cervical stenosis ■ Local infection, including injections, typically 4 through the midline
epidural abscess, weeks apart. under fluoroscopic
■ Lumbar/cervical disk guidance.
herniation without which can compress ■ Limit injections to 4 to 6
myelopathy nerve roots or the per year. ■ Once the needle is in
spinal cord and lead ■ Commonly used position, 3 to 5 cc of the
to a radiculopathy or glucocorticoids are injectate is administered
myelopathy methylprednisolone or slowly, to prevent acute
■ Directspinal cord dexamethasone. compression of the
trauma nerves or spinal cord.

■ Dural puncture,
leading to injection of
medications into the
subarachnoid space with
adverse effects such as
high spinal anesthesia
and respiratory
depression

References:
1. Friedly JL et al. A randomized trial of epidural glucocorticoid injections for spinal stenosis. N Engl J Med 2014; 371:11.
2. C
 hang-Chien GC et al. Transforaminal versus interlaminar approaches to epidural steroid injections: A systematic review of comparative studies for lumbosacral
radicular pain. Pain Physician 2014; 17:E509.

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SPINAL INJECTIONS & INTERVENTIONS
Transforaminal
Dorsal root ganglion
Epidural
Glucocorticoid
Injection (Lumbar)

Needle

Final needle position for a lumbar transforaminal injection

INDICATIONS POTENTIAL CLINICAL PEARLS HOW TO PERFORM

COMPLICATIONS

■ Lumbar radiculopathy ■ Epiduralbleeding or ■ Dexamethasone is ■A small needle is placed

■ Lumbar stenosis hematoma commonly used, given into the epidural space
■ Local infection, including reports of catastrophic lateral to the midline
■ Lumbar disk herniation neurologic injury with (allowing some of the
without myelopathy epidural abscess,
which can compress other glucocorticoid injectate to spread
nerve roots or the solutions that are more along the nerve, thereby
spinal cord and lead particulate. providing a selective
to a radiculopathy or ■ In unilateral nerve block at the same
myelopathy radiculopathy, the time). Fluoroscopic
transforaminal or guidance is used.
■ Direct spinal cord or
nerve trauma interlaminar approaches ■ Once the position
are equally effective is confirmed, 1 to 2
■ Dural puncture, in reducing pain and mL of the injectate is
leading to injection of improving function; the administered slowly,
medications into the choice usually depends to prevent nerve
subarachnoid space with on clinician preference compression.
adverse effects such as and experience.
high spinal anesthesia
■ In bilateral
and respiratory
depression radiculopathy, the
interlaminar approach
is preferable, as a
single injection can
affect both sides, while
transforaminal injections
would need to be done
on both sides.

References:
1. Ghahreman A et al. The efficacy of transforaminal injection of steroids for the treatment of lumbar radicular pain. Pain Med 2010; 11:1149.
2. Buenaventura RM et al. Systematic review of therapeutic lumbar transforaminal epidural steroid injections. Pain Physician 2009; 12:233.

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3
SPINAL INJECTIONS & INTERVENTIONS
Facet Injection/ Location of
Medial Branch medial branch
nerves
Block (Cervical,
Thoracic, or
Lumbar)
Facet joint

Sagittal view of an L3-L4 joint, showing the location of the facet joints and medial
branch nerves. I, inferior articular process of L3. S, superior articular facet L4.

INDICATIONS POTENTIAL CLINICAL PEARLS HOW TO PERFORM

COMPLICATIONS

■ Spondylosis ■ Epiduralbleeding or ■ The triad of axial neck ■A 3.5-inch spinal needle

■ Facet arthropathy hematoma pain, muscle spasms, is placed into the area
■ Local infection, including and posterior headaches of the facet joints or the
■ Postlaminectomy often points to cervical medial branch nerves,
syndrome epidural abscess,
which can compress facet arthropathy. under fluoroscopic
■ Disk degeneration nerve roots or the ■ Diagnostic medial guidance.
spinal cord and lead branch blocks to ■ Once in position, 0.5 to
to a radiculopathy or determine candidacy for 1.0 mL of the injectate
myelopathy. radiofrequency ablation is administered at the
■ Direct spinal cord or should use low volumes, target site.
nerve trauma to reduce confounding
spread to adjacent
■ Dural puncture, structures.
leading to injection of
■ Glucocorticoids are
medications into the
subarachnoid space with typically used in the
adverse effects such as injectate to prolong
high spinal anesthesia pain relief. However,
and respiratory diagnostic blocks prior
depression to radiofrequency
ablation are done with a
local anesthetic.
■ Some patients elect to
get repeated medial
branch blocks rather
than proceed to
radiofrequency ablation.

References:
1. Falco FJ et al. Systematic review of the therapeutic effectiveness of cervical facet joint interventions: An update. Pain Physician 2012; 15:E839.
2. P
 atel VB and Data S. Chapter 23: Facet joint Interventions: Intra-articular injections, medial branch blocks, and radiofrequency ablations. In: Atlas of pain medicine
procedures. New York: McGraw-Hill Education; 2015.

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SPINAL INJECTIONS & INTERVENTIONS
Radiofrequency
Lesioning/ L1 vertebra

Neurotomy
L2 vertebra
(Lumbar/Cervical) L1 nerve

L3 vertebra
L2 nerve

L4 vertebra
L3 nerve

L5 vertebra
L4 nerve

L5 nerve Sacrum

Medial branch anatomy, showing the curve of the medial branches of the
lumbar dorsal rami (left) with articular branches to the facet joints

INDICATIONS POTENTIAL CLINICAL PEARLS HOW TO PERFORM

COMPLICATIONS

■ Significant pain relief ■ Postprocedural pain ■ Prior to ablation, ■A 22-g or 18-g

(>50%) after an ■ Cutaneous numbness perform at least 2 radiofrequency needle
intraarticular facet rounds of medial branch is placed into the area
injection or medial ■ Dysesthesias blocks to determine the of the facet joints under
branch block ■ Dizziness and likelihood of response to fluoroscopic guidance.
ataxia (with cervical ablation. ■ Sensory and motor
radiofrequency ■ The average duration stimulation are usually
lesioning) of >50% pain relief performed before
■ Infection for radiofrequency denervation, to ensure
neurotomy is 6 to 12 proper positioning of
■ Nerve or vascular Injury
months. the needles close to the
(rare)
target areas and away
from the motor fibers.
■A small amount of local
anesthetic (typically
lidocaine) is injected
first. Denervation is
then achieved using
radiofrequency thermal
ablation.

References:
1. MacVicar J at al. Lumbar medial branch radiofrequency neurotomy in New Zealand. Pain Med 2013; 14:639.
2. Schofferman J and Kine G. Effectiveness of repeated radiofrequency neurotomy for lumbar facet pain. Spine 2004; 29:2471.

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5
SPINAL INJECTIONS & INTERVENTIONS
Sacroiliac Joint Sacrum
Injection
Joint space

Interosseous
sacroiliac ligament

Ilium

Dorsal sacroiliac ligament

Cross section of the sacroiliac joint showing the entry of the needle at the dorsal
inferior aspect of the joint.

INDICATIONS POTENTIAL CLINICAL PEARLS HOW TO PERFORM

COMPLICATIONS

■ Sacroiliac (SI) joint pain ■ Bleeding ■ Diagnostic analgesic ■A 3.5-inch spinal needle
■ SI joint inflammation ■ Infection
blocks in patients is placed along and/
with suspected SI or into the sacroiliac
■ SI joint dysfunction ■ Nerve injury joint pain can provide joint under fluoroscopic
■ Transient increased valuable information guidance. A small
postprocedural pain about pathologies of amount of contrast
joint origin, but pain is commonly used
secondary to pathologies to confirm needle
in structures around the positioning.
SI joint can be missed ■ Once correct positioning
and are best diagnosed is confirmed, the
with provocation tests. injectate is administered
■A multitest regimen of along or into the SI joint.
3 or more positive SI
joint pain provocation
tests (distraction,
compression, Gaenslen,
Patrick, and thigh
thrust tests) is a reliable
method for assessing SI
joint disease.
■ Radiofrequency
ablation of the SI joint
can be considered for
patients who receive
only temporary relief
from diagnostic SI joint
injections.

References:
1. Rupert MP et al. Evaluation of sacroiliac joint interventions: A systematic appraisal of the literature. Pain Physician 2009; 12:399.
2. Simopoulos TT et al. A systematic evaluation of prevalence and diagnostic accuracy of sacroiliac joint interventions. Pain Physician 2012; 15:E305.

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6
SYMPATHETIC NERVE BLOCKS
Sympathetic nerve blocks are effective for treating painful
conditions that are thought to be mediated by the sympathetic
nervous system. The most common indications for the
procedure are complex regional pain syndrome (CRPS) and
visceral pain (especially visceral pain associated with cancer).
Depending on the pain’s location, the sympathetic nerves can
Stellate Ganglion be blocked at the stellate ganglion for upper-extremity pain,
or in the abdomen (celiac, superior, and ganglion impar) for
visceral pain.

7 Celiac Plexus

8
Lumbar Sympathetic

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6
SYMPATHETIC NERVE BLOCKS
Stellate Ganglion Thyroid cartilage
Common
Block carotid
artery Cricoid cartilage

Patient position

Location of needle entry for a stellate ganglion block

INDICATIONS POTENTIAL CLINICAL PEARLS HOW TO PERFORM

COMPLICATIONS

Sympathetically mediated Vascular injury or ■ Although it is considered ■A needle is placed along

painful conditions: hematoma: a side effect, the the stellate ganglion.
■ Complex regional pain ■ Carotid artery, internal presence of Horner Positioning can be
syndrome (CRPS) type jugular vein, inferior syndrome is a sign of guided by anatomic
1 and 2 of the upper thyroid artery successful block. landmarks, fluoroscopy
extremity ■ Other possible side (most common),
■ Ascending cervical artery or ultrasound; a
■ Herpes zoster effects of this block
■ Retropharyngeal include hoarseness of combination of
■ Postherpetic neuralgia hematoma voice, phrenic nerve fluoroscopy and
block resulting in ultrasound is used to
■ Peripheral nerve lesions
Neurological injury: ipsilateral diaphragmatic increase safety and avoid
■ Phantom limb pain vascular structures.
■ Vagus nerve, brachial paralysis, and brachial
■ Postmyocardial, plexus root (C6, C7) plexus block resulting in ■A small amount of
sympathetically injury arm weakness. However, contrast may be used if
mediated pain all of these side effects fluoroscopy is utilized
■ Locked-in syndrome,
■ Malignant, are transient. to confirm positioning
stroke
sympathetically ■ In CRPS of the upper and to ensure there is no
■ Neuraxial injection vascular uptake.
mediated pain extremity, if stellate
ganglion block provides ■ Once correct positioning
Vascular conditions: Others:
good but short-term is confirmed, 5 to 10
■ Pneumothorax, relief, neuromodulation mL of the injectate is
■ Refractory angina
chylothorax is a reasonable next administered slowly,
■ Raynaud disease
■ Infection option to consider. in small increments,
■ Peripheral vascular to ensure there is no
disease systemic spread of the
injectate.

References:
1. W
 aldman SD. Ultrasound-guided stellate ganglion block. In: Ultrasound-guided pain management injection techniques, 1st ed. Philadelphia: Lippincott Williams &
Wilkins; 2014. pp. 156–62.
2. Day M. Sympathetic blocks: The evidence. Pain Pract 2008; 8:98. continued on next page ↓

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7
SYMPATHETIC NERVE BLOCKS L1 transverse process

Celiac Plexus
Rib 12
Block (With
Diaphragm
or Without
Neurolysis)

Upper pole of
Liver
left kidney

Aorta
Pancreas
Right celiac
ganglion
Left celiac
ganglion

Cross section of celiac plexus block

INDICATIONS POTENTIAL COMPLICATIONS CLINICAL PEARLS

■ Acute or chronic abdominal pain ■ Orthostatic hypotension ■ Celiac plexus block can be
due to pancreatitis or pancreatic, ■ Diarrhea
done with local anesthetic and
gastric, esophageal, or biliary glucocorticoids, or a neurolytic
malignancies. ■ Backache agent such as alcohol or phenol,
■ Pain related to mesenteric vascular ■ Uncommon: retroperitoneal for prolonged relief (3 months or
occlusive disease hemorrhage, paraplegia, transient more).
cord damage, aortic dissection, ■ In patients with cancer pain,
■ Acute pain after liver embolization sexual dysfunction related to there is an increased tendency to
sympathetic chain neurolysis, and proceed with neurolysis from the
fistula formation start, given the high efficacy of
the blocks and to avoid repeated
procedures and delayed pain relief.

HOW TO PERFORM
■A 15-cm spinal needle is placed along the celiac plexus (at the level of the L1 vertebra) under fluoroscopic guidance.
The celiac plexus is at the level of the L1 vertebra and can be approached in several manners, but transcrural or
retrocrural approaches are used most often. A small amount of contrast is commonly used to confirm needle
positioning and lack of vascular uptake.
■ After correct needle placement is confirmed, a local anesthetic (bupivacaine or lidocaine) is injected with or without
a glucocorticoid (methylprednisolone). If the initial test dose relieves the pain, neurolysis can be performed using
50% to 95% alcohol (10–20 mL on each side) or 5% to 10% phenol (10–15 mL on each side).

References:
1. Eisenberg E et al. Neurolytic celiac plexus block for treatment of cancer pain: A meta-analysis. Anesth Analg 1995; 80:290.
2. Jain P et al. Celiac plexus blockade and neurolysis: An overview. Indian J Anaesth 2006; 509:169.

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8
SYMPATHETIC NERVE BLOCKS
Lumbar
Sympathetic Block Spinal
nerve root

Rami
communicantes

Sympathetic trunk

Cross section of lumbar sympathetic block

INDICATIONS POTENTIAL CLINICAL PEARLS HOW TO PERFORM

COMPLICATIONS

■ Complex regional pain ■ Postprocedural back ■A one-needle technique ■A 5- to 7-inch bent-

syndrome (CRPS) and pain (approaching from one tip spinal needle
other sympathetically ■ Bleeding
side only) at L2 or L3 is is placed along the
mediated neuropathic usually used. However, if sympathetic chain at
pain phenomena ■ Infection contrast spread to both the level of the L2 or L3
affecting the lower limb ■ Intravascular injection of sides is not observed, vertebral body, under
■ Early postherpetic medication a 2-needle approach fluoroscopic guidance.
neuralgia (repeating the procedure A small amount of
■ Local anesthetic
on the contralateral side) contrast is commonly
■ Early phantom limb pain systemic toxicity, if
is used at L2 and L4 used to confirm needle
iatrogenic overdose
■ Vascular insufficiency concurrently. positioning.
combined with
affecting the lower intravascular injection ■ If block provides good ■A skin-temperature
extremities but short-term relief, probe is usually placed
■ Disk puncture and
neurolysis with phenol or distally on the affected
possible diskitis
alcohol can be used as a side; an increase in skin
■ Genitofemoral neuritis next step. temperature of at least
■ Renal or ureter puncture ■ In CRPS, lumbar 2°C is used to confirm
sympathetic block good blockade.
■ Transient neural
blockade from posterior should be combined with ■ Intravenous access is
spread of local alternative treatments, needed in case of an
anesthetic to epidural including extensive adverse event and for
or subarachnoid spaces physical therapy (as moderate sedation if
(rare) desensitization therapy) needed.
to provide best results.
■ Retrograde ejaculation if
bilateral sympathectomy
is performed

References:
1. S
 traube S et al. Cervico-thoracic or lumbar sympathectomy for neuropathic pain and complex regional pain syndrome. Cochrane Database Syst Rev 2013;
9:CD002918.
2. M
 anjunath PS et al. Management of lower limb complex regional pain syndrome type 1: An evaluation of percutaneous radiofrequency thermal lumbar
sympathectomy versus phenol lumbar sympathetic neurolysis — a pilot study. Anesth Analg 2008; 106:647.

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HEAD AND NECK NERVE BLOCKS

9
Nerve blocks of the head and neck can be used for regional
anesthesia and postoperative pain control, as well as for
diagnostic and therapeutic purposes in managing conditions
that cause chronic headaches. In the algorithm for treating
chronic pain, the blocks are indicated when pharmacologic
therapy is partially effective or ineffective in alleviating the
Occipital patient’s pain. Detailed knowledge of the relevant anatomy and
of the use of fluoroscopy and ultrasound improves efficacy and
minimizes complications.

10 Trigeminal

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9
HEAD AND NECK NERVE BLOCKS
Lesser occipital nerve

Occipital Nerve
Block

Greater occipital nerve

Sternocleidomastoid muscle Trapezius muscle

Location of greater and lesser occipital nerves

INDICATIONS POTENTIAL CLINICAL PEARLS HOW TO PERFORM

COMPLICATIONS

■ Occipital neuralgia ■ Infection ■ In patients with occipital ■A small needle is

■ Cluster headache ■ Vasovagal reaction or neuralgia and clear but placed along the greater
syncope short-lasting response occipital nerve while the
■ Cervicogenic headache to greater occipital nerve patient is seated.
■ Small area of alopecia blocks (ONBs), longer-
■ Migraine ■ No imaging is typically
with cutaneous atrophy term relief options
■ As an adjuvant to at glucocorticoid required. However, given
include botulinum tremendous anatomic
medication-overuse injection sites toxin injection, occipital variability of the
headache
■ Puncture of occipital nerve subcutaneous greater occipital nerve,
artery resulting in neurostimulation, ultrasound or electric
hematoma and occipital nerve nerve stimulation may
radiofrequency ablation. be utilized.
■ Peripheral facial nerve
palsy ■ Response to ONB in ■ The lesser occipital nerve
patients with chronic (located 1 cm lateral to
migraine and chronic the inferior aspect of the
cluster headache mastoid process) may
does not reliably also be blocked.
predict occipital nerve
stimulator response.

References:
1. Voigt CL and Murphy MO. Occipital nerve blocks in the treatment of headaches: Safety and efficacy. J Emerg Med 2015; 48:115.
2. Blumenfeld A et al. Expert consensus recommendations for the performance of peripheral nerve blocks for headaches — A narrative review. Headache 2013; 53:437.

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10
HEAD AND NECK NERVE BLOCKS
Trigeminal Nerve
Block

Trigeminal ganglion

Foramen ovale

Needle direction for trigeminal nerve block

continued on next page ↓

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10
HEAD AND NECK NERVE BLOCKS
Trigeminal Nerve ↑ continued from previous page

Block

INDICATIONS POTENTIAL CLINICAL PEARLS HOW TO PERFORM

COMPLICATIONS

■ Trigeminal neuralgia ■ Dysesthesias ■ Interventional pain ■A 2.5- to 3.5-inch spinal

■ Palliation of cancer pain ■ Anesthesia dolorosa procedures are needle is placed near the
in head and neck usually considered trigeminal nerve under
■ Weakness of the only after failure of fluoroscopic guidance.
■ Acute herpes zoster muscles of mastication more-conservative A small amount of
■ Postherpetic neuralgia ■ Facial hematoma interventions. As contrast is commonly
trigeminal nerve block used to confirm needle
■ Acute facial pain ■ Secondary facial
is a particularly complex positioning.
emergencies asymmetry
procedure with a higher ■ The injectate is a
■ Meningitis risk for complications, combination of a local
■ Intracranial hemorrhage reserving its use to cases anesthetic (lidocaine
with inadvertent where conservative or bupivacaine) and a
intracranial needle interventions have failed glucocorticoid (typically
placement to adequately control dexamethasone). If
pain is particularly chemical neurolysis is
■ Total spinal anesthesia important. considered, a neurolytic
■ Trigeminal nerve agent such as phenol,
block may be a useful alcohol, or glycerol may
tool for treating acute be used.
exacerbations of
trigeminal neuralgia,
rather than chronic
management. For
longer-term relief,
radiofrequency ablation
or neuromodulation may
be a viable option.

References:
1. Raj P et al., editors. Interventional pain management: Image-guided procedures, 2nd ed. Philadelphia: Saunders Elsevier; 2008.
2. Waldman S, editor. Atlas of interventional pain management, 4th ed. Philadelphia: Saunders Elsevier; 2015.

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PERIPHERAL NERVE BLOCKS

11
Peripheral nerve blocks are commonly used for perioperative
and chronic pain management. Almost any peripheral nerve
can be blocked, if needed, guided by ultrasound or fluoroscopy.
Peripheral nerve blocks are used for both diagnostic and
therapeutic purposes.

Ilioinguinal

12 Lateral Femoral

13
Pudendal

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11
PERIPHERAL NERVE BLOCKS
Ilioinguinal nerve
Ilioinguinal Nerve
Block

Anterior superior
iliac spine

Location of needle entry for ilioinguinal nerve block

INDICATIONS POTENTIAL CLINICAL PEARLS HOW TO PERFORM

COMPLICATIONS

■ Pain in the inguinal ■ Inadvertent bowel ■ The procedure is ■A small needle is placed
region, most commonly perforation typically done under along the ilioinguinal
postoperative neuralgia ■ Infection
ultrasound guidance, but nerve under ultrasound
after herniorrhaphy or it may be performed by guidance.
lower abdominal surgery ■ Bleeding or hematoma anatomical landmarks. ■ Once the needle is
in the region of the ■ Postprocedural pain and In this case, a large in position, 5 to 10
ilioinguinal nerve paresthesia volume of injectate is mL of the injectate is
recommended to ensure administered along the
■ Nerve injury
proper blockade. nerve.
■ Nerve block offers
a prognosis for the
effectiveness of
neuroablative or
neurolytic therapies for
longer-term relief.

Reference:
Brown DL. Ilioinguinal nerve block. In: Atlas of regional anesthesia, 4th ed. Philadelphia: Saunders; 2010.

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12
PERIPHERAL NERVE BLOCKS
Lateral Femoral Lateral femoral Femoral nerve
Cutaneous Nerve cutaneous nerve Femoral artery
Block Anterior superior
Femoral vein
iliac spine

Ilioinguinal ligament
Iliopsoas muscle

Pectineus muscle

Sartorius muscle

Location of needle entry for lateral femoral cutaneous nerve block

INDICATIONS POTENTIAL CLINICAL PEARLS HOW TO PERFORM

COMPLICATIONS

■ Useful in diagnosing and ■ Bleeding or ecchymosis ■ The procedure is ■ With the patient supine,
treating the entrapment ■ Concomitant femoral typically done under a small needle is placed
neuropathy of the lateral nerve blockade ultrasound guidance. along the LFCN using
femoral cutaneous Undergoing the either anatomical
nerve (LFCN), known as ■ Trauma to the LFCN or procedure by only landmarks or (highly
meralgia paresthetica femoral nerve anatomic landmark recommended) under
■ Can be used for surgical is not recommended ultrasound guidance.
anesthesia and/or given the highly variable ■ Once correct positioning
postoperative pain anatomic course of the of the needle is
control for procedures LFCN. confirmed, 5 to 10
on the anterolateral ■ Given the superior mL of the injectate is
thigh, such as skin graft efficacy of the administered.
harvesting ultrasound-guided
LFCN block, if a
patient with symptoms
consistent with meralgia
paresthetica does not
respond to blockade of
the nerve, lesions in the
lumbar plexus or L2–3
radiculopathy should be
considered.

References:
1. H
 urdle M et al. Ultrasound-guided blockade of the lateral femoral cutaneous nerve: Technical description and review of 10 cases. Arch Phys Med Rehabil 2007;
88:1362.
2. T
 agliafico A et al. Ultrasound-guided treatment of meralgia paresthetica (lateral femoral cutaneous neuropathy): Technical description and results of treatment in 20
consecutive patients. J Ultrasound Med 2011; 30:1341.

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13
PERIPHERAL NERVE BLOCKS
Pudendal nerve
Pudendal Nerve
Block
Sacrospinous
ligament
Ischiofemoral
ligament

Neck of femur

Sacrotuberous
ligament

Landmarks to identify the course of the pudendal nerve

INDICATIONS POTENTIAL CLINICAL PEARLS HOW TO PERFORM

COMPLICATIONS

Pudendal neuralgia: ■ Intravascular injection of The five essential ■ Pudendal nerve block
■ Diagnostically (a positive medication diagnostic criteria for can be attained by
response is part of ■ Sciatic nerve injury pudendal neuralgia a transvaginal or a
the diagnostic Nantes by pudendal nerve transrectal approach
■ Hematoma entrapment (Nantes (landmark technique),
criteria)
■ Perforated rectum criteria): a fluoroscopy- or
■ Therapeutically, to ultrasound-guided
(infection, fistula) 1. Pain in the anatomical
provide analgesia transgluteal approach, or
territory of the pudendal
nerve as a fluoroscopy-guided
transsacral S2–S4 block.
2. Worsened by sitting
■ With fluoroscopy
3. The pain does not guidance, a small
awaken the patient at amount of contrast
night is commonly used
4. No objective sensory to confirm needle
loss on clinical positioning; then 3 to
examination 5 mL of the injectate
is administered slowly
5. Positive anesthetic
along the nerve.
pudendal nerve block
(pain relief with this
procedure)

References:
1. Bellingham GA et al. Randomized controlled trial comparing pudendal nerve block under ultrasound and fluoroscopic guidance. Reg Anesth Pain Med 2012; 37:262.
2. Peng PWH. Pudendal nerve. In: Peng PWH, editor. Ultrasound for pain medicine intervention: A practical guide, volume 2: Pelvic pain. Electronic book; 2014.

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14
DRY NEEDLING AND TRIGGER POINT INJECTIONS
Dry Needling Trigger points refer to taut bands of skeletal muscle that can
cause point tenderness or referred pain and, sometimes,
and Trigger Point twitching of the muscle when it is compressed. Risk factors
Injections for development of myofascial pain include acute trauma
or repetitive microtrauma, overextension of a muscle, poor
posture, or sports or occupational injuries. Insertion of a
needle (dry needling) or injection of local anesthetic (trigger
point injections) into the trigger points can be used to help
relieve this pain.

INDICATIONS POTENTIAL COMPLICATIONS CLINICAL PEARLS

■ Pain secondary to the presence of ■ Increased pain ■ Myofascial trigger points are
myofascial trigger points ■ Nerve damage identified by palpation causing
localized pain, referred pain, or a
■ Infection local twitch response. These trigger
■ Bleeding points are often seen or palpated
as “bands” or “knots” of muscle.
■ Vasovagal syncope
■ Myofascial pain syndrome is
■ Pneumothorax
diagnosed clinically through history
and physical examination, though
new techniques such as pressure
algometry and ultrasound can be
utilized.
■ Anticoagulants do not need to
be stopped prior to trigger point
injections, although less “fanning”
is recommended to avoid
significant hematoma formation.

HOW TO PERFORM
■ An appropriately sized needle is repeatedly inserted into the myofascial trigger point in a fan-like manner (“fanning”)
to cause muscle-fiber relaxation and lengthening, and disrupt the connective tissue.
■ Larger needles are used for larger muscle groups such as the lumbar paraspinal muscles. Shorter needles (1/2- to
5/8-inch needles) are used for smaller muscles or if there is increased risk for pneumothorax (e.g., in the cervical or
thoracic paraspinal region).
■ Dry needling is the insertion of the needle without any injection, whereas trigger point injections involve injection
of saline or a local anesthetic (avoiding long-acting anesthetics such as bupivacaine, as they can be myotoxic).
Glucocorticoids are generally also best avoided given concerns about systemic side effects and myotoxicity.

References:
1. Alvarez DJ and Rockwell PG. Trigger points: Diagnosis and management. Am Fam Physician 2002; 65:653.
2. Borg-Stein J and Iaccarino MA. Myofascial pain syndrome treatments. Phys Med Rehabil Clin N Am. 2014; 25:357.

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SURGICAL PAIN MANAGEMENT
Minimally invasive surgical procedures represent
an essential, evolving approach to treating chronic
pain. Currently, there are two broad categories of
these procedures: intrathecal drug delivery and
neuromodulation.

15
Intrathecal Drug Intrathecal Drug Delivery. These procedures directly deliver
Delivery medications into the cerebral spinal fluid, thereby having
potent analgesic effects without the systemic adverse effects
from oral administration of medication. The only FDA-
approved medications for intrathecal delivery are morphine,
ziconotide, and baclofen. In practice, however, other agents
are also used; these include hydromorphone, fentanyl,
clonidine, and a local anesthetic (such as bupivacaine).
When monotherapy fails to provide adequate analgesia,
combinations of several classes of medications are used
instead, most commonly in the form of mixed opioid and
local anesthetic solutions.

16
Neuromodulation Neuromodulation (Spinal Cord Stimulation). The mechanism
(Spinal Cord of action of neuromodulation is only partially understood.
Stimulation) One proposed mechanism is based on the “gate-control”
theory of pain: The neuromodulation device provides an
electric signal, which serves as a nonpainful stimulus,
thereby modulating pain transmission in the central nervous
system. This “closing the gate” to the transmission of
painful sensations leads to analgesia.

Common Interventional Pain Procedures knowledgeplus.nejm.org 23

SURGICAL PAIN MANAGEMENT
Intrathecal Drug Delivery

INDICATIONS POTENTIAL COMPLICATIONS CLINICAL PEARLS

■ Malignant pain ■ Intraoperative injury to the nerve ■ Intrathecal therapy, especially in

■ Nonmalignant pain roots or spinal cord advanced cancer and in patients
■ Bleeding and hematoma with upper neuron spasticity, has
■ Spasticity been shown to provide improved
formation
analgesia with fewer side effects,
Patients must have persistent, ■ Infection: Deeper infection may compared with oral therapy.
debilitating pain or spasticity require explantation of the entire
that is not responsive to more- system.
conservative treatments. ■ Catheter-related malfunctions
(e.g., kinks)
■ Intrathecal granuloma (rare but
serious)

HOW TO PERFORM

Patients for whom intrathecal drug delivery is being considered must first undergo a trial of neuraxially
administered medication (local anesthetic ± opioid or baclofen) to determine whether therapy will provide an
adequate clinical effect. Although epidural and intrathecal single-shot trials can be done, the preferred method
involves placement of an intrathecal catheter to best mirror potential implant conditions. Hospital admission
is generally recommended to monitor for adverse effects while adjusting the continuous epidural infusion to
achieve efficacy. A successful trial is usually defined as an at least 50% improvement in pain or functional status.

If there is benefit, the patient is taken to the operating room, where the procedure is done under fluoroscopic
guidance. Intravenous access is required. Depending on physician preference and patient comorbidities, the
procedure can be performed with local anesthesia and sedation or general anesthesia. Prophylactic antibiotics
(e.g., cefazolin) also are required before surgery.

A catheter is first placed into the epidural space under fluoroscopic guidance. The location is chosen to
correspond to the dermatome that corresponds to the center of the patient’s pain. Up to 6 spinal segments are
usually covered well by an intrathecal opioid infusion, but as many as 10 segments may be reached.

The catheter is tunneled under the skin of the abdominal wall and connected to the infusion pump. The pump is
typically placed in the anterior abdominal wall for easy access. Patients recover quickly after surgery and usually
return to their normal activities within one month.

The patient needs follow-up every 1 to 3 months for pump refills, whereby leftover medicine is extracted by a
needle percutaneously from the reservoir, and replaced with new medication(s). The pump reservoir needs to be
exchanged every 7 to 10 years via a minimal surgical procedure.

References:
1. D
 eer TR et al. Comprehensive consensus guidelines on intrathecal drug delivery systems in the treatment of pain caused by cancer pain. Pain Physician 2011;
214:E283.
2. D
 eer TR et al. Consensus guidelines for the selection and implantation of patients with noncancer pain for intrathecal drug delivery. Pain Physician 2010;
13:E175.

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SURGICAL PAIN MANAGEMENT
Neuromodulation (Spinal Cord Stimulation)
INDICATIONS POTENTIAL COMPLICATIONS CLINICAL PEARLS

Spinal cord stimulation (SCS) ■ Bleeding and hematoma ■ Neuromodulation has shown
is a treatment option for severe formation (around pocket area or substantial advancement in
neuropathic pain that is not epidural space) the past several years, with
responsive to more-conservative ■ Infection (deeper infections may significant improvement in the
treatments. require explantation of the entire device itself and inclusion of
system) more indications.
Common indications: ■ However, it remains a technically
■ Postdural headache
■ Failed back surgical syndrome challenging surgical pain-
■ Spinal cord or nerve root damage management procedure that
■ Complex regional pain syndrome
(CRPS) types 1 and 2 ■ Lead migration and lead fracture, merits extensive training and
evidenced by loss of analgesia understanding of neuroanatomy,
■ Painful radiculopathies surgical technique, and
■ Painful diabetic neuropathy perioperative patient care.
■ When performed by experienced
Other indications: providers, it offers a viable
■ painful peripheral vascular alternative to patients who
disease have persistent pain despite
maximizing other treatments,
■ postherpetic neuralgia
with fewer overall side effects.
■ axial low-back pain

HOW TO PERFORM

Patients in whom spinal cord stimulation is being considered must first undergo a 7- to 10-day trial. One or two
leads are inserted percutaneously under fluoroscopic guidance and advanced in the epidural space to the desired
locations. For low-back or lower-extremity pain, a common epidural entry site is L1–L2 with the leads located
at the top of T8 and mid-T9 vertebrae. For upper-extremity pain, a common epidural entry site is T1–T2 with an
electrode tip at C2. During the trial, the leads are attached to an external generator, and the patient’s pain level,
function, and quality of life are assessed. A successful trial is defined as showing at least a 50% improvement in
pain or functional status. At the end of the trial, the leads are removed and discarded.

If there is benefit, the patient returns for implantation of the permanent device. This procedure is done in the
operating room under monitored anesthesia care and fluoroscopic guidance. Prophylactic antibiotics (cefazolin)
are required before the trial and permanent surgical implant.

A lead is placed in a similar manner to the placement during the trial, and it is tunneled subcutaneously to the
implantable pulse generator. The pulse generator is usually placed in the lower abdominal wall area, either on the
left or right side depending on patient preference. Generally, the device is not turned on until the 1-week follow-
up appointment (when surgical pain subsides).

Patients have quick surgical recovery. They usually return to light work within 5 to 7 days and can perform graded
strenuous activities after one month. The generator is charged externally every 1 to 3 days, and it needs to be
exchanged every 7 to 10 years via a minimal surgical procedure.

Reference:
Kumar K et al. The effects of spinal cord stimulation in neuropathic pain are sustained: A 24-month follow-up of the prospective randomized controlled
multicenter trial of the effectiveness of spinal cord stimulation. Neurosurgery 2008; 63:762.

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COMMON INTERVENTIONAL PAIN PROCEDURES

Last reviewed Oct 2021. Last modified Oct 2021.

The information included here is provided for educational purposes

only. It is not intended as a sole source on the subject matter or as
a substitute for the professional judgment of qualified healthcare
professionals. Users are advised, whenever possible, to confirm the
information through additional sources.

Figures:
Raj PP et al. Interventional pain management: Image-guided
procedures, 2nd ed. Philadelphia: Saunders/Elsevier 2008.
All figures republished with permission.

© 2021 Massachusetts Medical Society. All rights reserved.