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Therapeutic Injections for Pain Management

Types of Therapeutic Injections

This article focuses on the use of therapeutic injections (see the image below) to treat acute and chronic pain syndromes. Discussion of this topic begins with an overview of regional anesthesia, which includes the pharmacology of frequently administered medications and basic information regarding equipment and safety. The spectrum of injection procedures and their indications for specific pain disorders and pathoanatomic regions is addressed to include therapeutic options for the various tissues or structures characteristic of each area or syndrome.

Lateral view showing needle position of lumbar par

Lateral view showing needle position of lumbar paravertebral somatic block technique.

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See Pain Management: Concepts, Evaluation, and Therapeutic Options, a Critical Images slideshow, to help assess pain and establish efficacious treatment plans.

The following anatomical divisions are somewhat arbitrary and overlap in some cases; however, this mode of presentation should prove relevant and accessible by using a format to address pain complaints by region and target tissues located in the spine, extremities, head and face, autonomic nervous system, and some viscera. A discussion of the clinical use of botulinum toxin is incorporated at the end of the article.

Neural blockade and similar injection procedures often are prescribed for therapeutic benefits; however, they also can be useful for diagnostic, prognostic, or prophylactic indications, or for a combination of these purposes.

Therapeutic blocks are appropriate for alleviating acute pain, especially in a self-limiting disorder (eg, postoperative, posttraumatic, or acute visceral pain syndromes). In general, they have been advocated to alleviate acute pain or an exacerbation of chronic pain and to provide direct and localized therapeutic action, especially in patients in whom pain is accompanied by swelling and inflammation. They help the patient (1) maintain an ambulatory or outpatient treatment status; (2) maintain participation in a physical therapy or rehabilitation program; (3) decrease the need for analgesics; and (4) in some cases, avoid or delay surgical intervention.

Sympathetic blocks in causalgia and reflex sympathetic dystrophy (ie, complex regional pain syndromes) permit more effective application of adjunctive treatment techniques including physical therapy and medication. In some cases, therapeutic injections help the practitioner gain patient cooperation, which may have been compromised not only by pain but also by fear, poor nutrition, and deconditioning.

Diagnostic blocks often help the treating practitioner determine the anatomic origin(s) of the patient’s pain. These procedures also may facilitate differentiation of a local from a referred somatic pain source, a visceral from a somatic pain source, or a peripheral from a central etiology. Selective blocks can help determine which peripheral tissues are primary pain generators. In cases of presumed complex regional pain syndromes, neural blockade can be used to establish relative contributions of somatic and sympathetic nervous systems.

Prognostic blocks are intended to provide information regarding the efficacy of a planned neurolytic or neurosurgical ablative procedure or potential surgical outcomes. These blocks also may help the practitioner and patient decide whether to proceed with surgery or ablative procedures.

Prophylactic blocks are used to delay and reduce postoperative pain, to prevent complications caused by posttraumatic or visceral pain, to decrease the duration of hospitalization and convalescence, and to prevent development of certain chronic pain syndromes such as autonomic dystrophy and phantom limb pain.

For patient education resources, see the patient education articles Chronic Pain, BOTOX® Injections, and Pain After Surgery.

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