Common procedures
An overview of the most common interventional pain treatments with detailed information for patients.
Overview of Procedures
We have compiled a list of common procedures including details for you. Each procedure is performed by SSIPM-certified pain specialists.
Disc Nerve Blockade
An extremely interesting alternative to provocative discography is the disc nerve block (blockade of the sinuvertebral nerve), which innervates the dorsal (mostly pain-relevant) region of the intervertebral disc. Although the concept is promising, there are hardly any validation studies for this very new procedure, so its significance should not be overestimated.
Literature:
Schliessbach J, Siegenthaler A, Heini P, Bogduk N, Curatolo M: Blockade of the sinuvertebral nerve for the diagnosis of lumbar diskogenic pain: an exploratory study. Anesth Analg 2010.
Fluoroscopy-guided cervical epidural infiltration
Fluoroscopy-guided cervical epidural infiltration in a patient with cervical disc herniation using a so-called "contralateral oblique" approach, which allows optimal assessment of needle penetration depth.
Literature:
Landers MH, Dreyfuss P, Bogduk N .On the geometry of fluoroscopy views for cervical epidural injections. Pain Med 2012
Gill JS, Aner M, Jyotsna N, Keel JC, Simopoulos TT: Contralateral oblique view is superior to lateral view for interlaminar cervical or cervicothoracic acces. Pain Med 2014
Fluoroscopy-guided C1-2 intra-articular infiltration
The lateral atlantoaxial joint (C1-2) is a possible cause of cervicogenic headaches. The needle tip is located in the joint, and the contrast medium spread extends to the atlanto-dental joint, with which it often communicates. The puncture carries a slightly increased risk and should only be performed according to the strict guidelines of the "International Spinal Intervention Society."
Literature:
Practice Guidelines for Spinal Diagnostic and Treatment Procedures. 2nd Edition, edited by Nikolai Bogduk 2014
The longitudinal effectiveness of lateral atlantoaxial intraarticular steroid injection in the treatment of cervicogenic headache. Narouze et al. Pain Med 2007
BV-guided infiltration of the ganglion impar
The ganglion impar is the most caudal sympathetic ganglion and can be responsible for pain transmission of non-oncological or oncological pain in the pelvic and perineal region (visceral pain component). It is located with great anatomical variability approximately anterior to the sacrococcygeal joint. Neurolysis with phenol can eliminate it for several months, especially in tumor pain. Steroid infiltrations or radiofrequency ablations are effective in certain patients with persistent coccydynia.
Literature:
Coccygodynia: Patjin et al. Pain Practice 2010
Siegenthaler A, Eychmüller S, Pfander G, Streitberger K: Sinn und Unsinn der WHO-Stufen bei der Behandlung von Tumorschmerzen. Schweiz Med Forum 2014.
Lumbar Facet Nerve Blockade, fluoroscopy-guided
The illustration shows a fluoroscopy-guided anesthesia of the sensory facet joint nerve (Medial Branch). This temporarily numbs the facet joint. If the back pain subsequently disappears completely, the corresponding facet joint can be held responsible for the pain.
Therapy: Thermocoagulation
This facet nerve block can also be performed under ultrasound guidance (i.e., without any radiation exposure).
Literature:
Siegenthaler A. Interventional pain management, indications and results. Ther Umsch 2011
Practice Guidelines for Spinal Diagnostic and Treatment Procedures. 2nd Edition, edited by Nikolai Bogduk 2014
Lumbar transforaminal epidural infiltration
For subacute lumbar radicular pain due to disc herniations, transforaminal epidural nerve root infiltration is an effective therapy. To avoid the feared complications associated with accidental intravascular needle placement, digital subtraction angiography (DSA) represents the ideal imaging method.
Literature:
MacVicar et al. The Effectiveness of Lumbar Transforaminal Injection of Steroids: A Comprehensive Review with Systematic Analysis of the Published Data. Pain Med 2013
Lumbar Facet Joint
Both periarticular facet joint infiltrations and facet nerve blocks (Medial Branch, target point corresponds to the arrowhead) can be performed easily under ultrasound guidance, without any radiation exposure, in patients who are not excessively obese.
Literature:
Siegenthaler A: Ultrasound in Chronic Pain Therapy. Trends in Anesthesia and Critical Care 2011
Greher M et al: Ultrasound-guided lumbar facet nerve block: accuracy of a new technique confirmed by computed tomography. Anesthesiology 2004
Piriformis Muscle
Directly below the SIJ, one encounters the piriformis muscle, which typically shows a slightly hypoechoic structure. In cases of piriformis syndrome, ideally combined with specific physiotherapy, this can be infiltrated under ultrasound guidance.
Literature:
Peng et al. Ultrasound-guided interventional procedures for patients with chronic pelvic pain - a description of techniques and review of literature. Pain Physician 2008
Suprascapular Nerve
Repetitive blocks of the suprascapular nerve are an effective therapy for frozen shoulder or other shoulder pains originating from the joint or joint capsule. It is either blocked at the classic location in the suprascapular fossa under the fascia of the supraspinatus muscle (where it is not well visible on ultrasound), or in the supraclavicular region, where it runs very superficially and is well visible on ultrasound directly under the omohyoid muscle (arrowhead at the nerve).
Literature:
Favejee et al. Frozen shoulder: the effectiveness of conservative and surgical interventions--systematic review. Br J Sports Med. 2011
Siegenthaler A, Moriggl B, Mlekusch S, Schliessbach J, Haug M, Curatolo M, Eichenberger U. Ultrasound-guided suprascapular nerve block, description of a novel supraclavicular approach. RAPM 2012
Provocative Discography
In patients younger than approximately 50 years, intervertebral discs are the most common cause of isolated back pain. The diagnostic gold standard is provocative discography, in which the discs are irritated by injecting contrast medium under applied pressure, and it is observed whether the patient's target pain can be provoked.
Literature:
Does discography cause accelerated progression of degeneration changes in the lumbar disc: a ten-year matched cohort study. Carragee et al. Spine (Phila Pa 1976) 2009
Sacral Block
At the sacral hiatus, the epidural space can be safely and easily accessed by penetrating the sacrococcygeal membrane (arrow) and flooded with steroids. The sacral hiatus is also a useful landmark in ultrasound, from which other pain-relevant structures (e.g., SIJ, piriformis) can be located.
Stellate Ganglion Block, ultrasound-guided
The stellate ganglion block is classically performed either blindly or under fluoroscopic guidance, with this procedure being used, for example, in certain forms of CRPS of the hand. In recent years, it has also been successfully used for bothersome postmenopausal hot flashes. Thanks to ultrasound imaging, the feared complications (accidental puncture of an extraforaminal vertebral artery or esophagus) can be avoided as much as possible.
Literature:Siegenthaler A, Mlekusch S, Schliessbach J, Curatolo M, Eichenberger U. Ultrasound imaging to estimate risk of esophageal and vascular puncture after conventional stellate ganglion block. RAPM 2012Siegenthaler A, Mlekusch S, Schliessbach J, Curatolo M, Eichenberger U. Ultrasound imaging to estimate risk of esophageal and vascular puncture after conventional stellate ganglion block. RAPM 2012
Partial Denervation of the Hip Joint
Fluoroscopy-guided thermocoagulation of the sensory nerve branch of the obturator nerve supplying the hip joint. This nerve innervates approximately 50% of the hip joint. This procedure is suitable for patients with hip pain who are too young for a prosthesis or for severely polymorbid patients for whom surgery poses too great a risk.
Literature:
Locher S, Burmeister H, Böhlen T, Eichenberger U, Stoupis C, Moriggl B, Siebenrock K, Curatolo M. Radiological anatomy of the obturator nerve and its articular branches: basis to develop a method of radiofrequency denervation for hip joint pain. Pain Med 2008
Rivera F1, Mariconda C, Annaratone G. Percutaneous radiofrequency denervation in patients with contraindications for total hip arthroplasty. Orthopedics. 2012
Thermocoagulation of ISG-supplying nerves
Often, intra-articular SIJ infiltrations with steroids only lead to short-term pain reduction. Following the same concept as with facet joints, the sensory nerves of the SIJ can first be anesthetized and, with a correspondingly positive block result, permanently disabled by thermocoagulation. The sensory nerves involved are the dorsal ramus of L5 and the lateral rami of S1-3. The procedure is extremely complex, as a total of about 20 thermolesions are necessary to reach the enormous multitude of sensory nerve fibers. Although the procedure is still new, there are already 2 positive randomized placebo-controlled studies available.
Literature:
Patel et al: A randomized, placebo-controlled study to assess the efficacy of lateral branch neurotomy for chronic sacroiliac joint pain. Pain Med 2012
Cohen et al: Randomized placebo-controlled study evaluating lateral branch radiofrequency denervation for sacroiliac joint pain. Anesthesiology 2008
Thermocoagulation of a lumbar facet joint nerve
Following a previous positive facet nerve block, the nerve can be coagulated by thermocoagulation (heating the electrode tip to 85°C). This makes the joint insensitive. The nerve regenerates after about 1 year, and the procedure can be repeated without problems and with the same probability of success. Critical is the correct execution of the intervention with several lesions (approx. 6 per nerve) and a strictly tangential insertion direction to the nerve to ablate it over the longest possible distance. Only in this way can a long pain-free interval be achieved.
If the patient behaves optimally during the pain-free year (i.e., engages in rehabilitative physiotherapy for core stabilization), the pain often does not return despite nerve regeneration.
Literature:
Bogduk et al. A Narrative Review of Lumbar Medial Branch Neurotomy for the Treatment of Back Pain. Pain Med 2009
Thermocoagulation of a cervical facet joint nerve
Following a previous positive facet nerve block, the nerve can be ablated by thermocoagulation (heating the electrode tip to 85°C). This makes the joint insensitive. The nerve regenerates after about 1 year, and the procedure can be repeated without problems and with the same probability of success. Critical is the correct execution of the intervention with several lesions (approx. 6 per nerve) and a strictly tangential insertion direction to the nerve to ablate it over the longest possible distance. Only in this way can a long pain-free interval be achieved. Since the nerves are visible on ultrasound, the number of necessary thermolesions can be reduced by exact localization of the nerve, thus shortening the intervention.
Literature:
Siegenthaler A, Eichenberger U, Curatolo M. A shortened radiofrequency denervation method for cervical zygapophysial joint pain based on ultrasound localization of the nerves. Pain Med 2011
Lord et al. Percutaneous radio-frequency neurotomy for chronic cervical zygapophyseal-joint pain. NEJM 1996
Ultrasound-guided foraminal infiltration of a cervical nerve root
For radicular pain in cervical disc herniation, the nerve roots can also be infiltrated extraforaminally under ultrasound guidance, thus without any radiation exposure. With appropriate practice, transforaminal epidural medication spread can be achieved despite extraforaminal puncture, thereby reducing the risk of the rare but serious complications of this intervention.
Literature:
Yamauchi et al: Ultrasound-Guided Cervical Nerve Root Block: Spread of Solution and Clinical Effect. Pain Med 2011
Siegenthaler A: Ultrasound in Chronic Pain Therapy. Trends in Anesthesia and Critical Care 2011
Narouze SN: Ultrasound-guided cervical spine injections: ultrasound "prevents" whereas contrast fluoroscopy "detects" intravascular injections. RAPM 2012
Ultrasound-guided SIJ infiltration
The SIJ can be safely and effectively infiltrated under ultrasound guidance without any radiation exposure.
Literature:
Harmon et al. Ultrasound-guided sacroiliac joint injection technique. Pain Physician 2008
Ultrasound-guided cervical facet joint infiltration
Both periarticular facet joint infiltrations and facet nerve blocks (Medial Branch, target point corresponds to the arrowhead) can be performed easily under ultrasound guidance, without any radiation exposure.
Literature:
Siegenthaler A: Ultrasound in Chronic Pain Therapy. Trends in Anaesthsia and Critical Care 2011
Siegenthaler A, Schliessbach J, Curatolo M, Eichenberger U: Ultrasound anatomy of the nerves supplying the cervical zygapophyseal joints: an exploratory study. RAPM 2011
Siegenthaler A, Mlekusch S, Trelle S, Schliessbach J, Curatolo M, Eichenberger U: Accuracy of ultrasound-guided nerve blocks of the cervical zygapophysial joints. Anesthesiology 2012
Cervical Facet Nerve Blockade, fluoroscopy-guided
The illustration shows a fluoroscopy-guided anesthesia of the sensory facet joint nerve (Medial Branch). This temporarily numbs the facet joint. If the neck pain subsequently disappears completely, the corresponding facet joint can be held responsible for the pain. Therapy: Thermocoagulation (see Thermocoagulation of a cervical facet joint nerve) This facet nerve block can also be performed under ultrasound guidance (see Ultrasound-guided cervical facet joint infiltration) (i.e., without any radiation exposure).
Literature:
Siegenthaler A. Interventional pain management, indications and results. Ther Umsch 2011
Practice Guidelines for Spinal Diagnostic and Treatment Procedures. 2nd Edition, edited by Nikolai Bogduk 2014
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