Pain procedures are a useful adjunct in managing pain and functional problems. The pain physician, as a diagnostician, can derive valuable information from the results of these procedures and from patient responses. This information can be invaluable in directing future treatment. Knowledge of the fundamentals of procedural care is important to novices and experienced physicians who provide such treatment to reduce complications, eliminate unnecessary procedures, and maximize patient recovery.
Procedure Planning
The patient work-up should begin with a detailed history and a physical examination that focuses on the body part involved. Historical emphasis on the duration of symptoms, previous attempts at procedures, and pending litigation should be well documented. Signs of symptoms magnification and malingering should be noted.
A thorough functional, social, and psychological history should be included. A comparison of historical and physical findings with available imaging studies is essential to complete the evaluation. During the evaluation period, diagnostic procedures can be useful in providing valuable insight into the patient’s pain generator, anatomic defect, threshold for pain, and psychological response to treatment.
When a provisional diagnosis is made, treatment objectives should be outlined. Conservative, nonprocedural-oriented treatment should be undertaken initially if symptoms are not disabling. This treatment should include correction of underlying biomechanical disorders, activity modification in the workplace, technique changes in athletes, and flexibility and strengthening programs. Concomitant psychological disorders also should be treated. Upon deciding to proceed with a therapeutic procedure, the physician should be certain it is performed within the context of a well-designed rehabilitation program.
General Procedure Techniques
Positioning and Relaxation
Positioning the patient for comfort and physician accessibility is an important step in good technique. Multiple pillows, foam plinths, and pads can be used to increase the patient’s tolerance on hard procedure tables, provide some degree of relaxation, and optimize positioning. This is especially important for the patient with cardiac or pulmonary compromise. For the physician, chairs and procedure tables for proper height prevent fatigue during lengthy procedures and improve manual dexterity.
Constant communication with the patient, including explanations of approaching procedural steps, helps reduce anxiety. Inappropriate conversation with assisting medical personnel should be avoided, thereby confirming the physician’s total attention to the patient. The patient’s gown should fit properly, enhancing relaxation and comfort. If these techniques do not lead to relaxation, oral or parenteral sedation should be provided.
Skin Preparation
Because skin cannot be sterilized without damage, the goal of antiseptics is to remove transient and pathogenic microorganisms while reducing resident flora to a low level. These agents should be safe, rapid-acting, inexpensive, and effective on a broad spectrum of organisms. Multiple agents, including iodophors (Betadine), hexachlorophene (pHisoHex), chlorhexidine (Hibiclens, Hibitane), and alcohols, are commercially available and accomplish these desired goals.
The preferred agent remains controversial. Clinically, the most commonly used agents are alcohol and iodine, with the latter being superior for skin decontamination. Application of 70% isopropyl alcohol destroys 90% of the cutaneous bacteria in 2 minutes, whereas the usual single wipe without waiting procedure destroys, at most, 75% of cutaneous bacteria.
Skin regions with hair should not alter one’s method of skin decontamination. Hair removal by shaving increases wound infection rate and is contraindicated. If absolutely necessary, clipping hair or applying depilatory creams can be safe. The overall risk of wound infection with most pain procedures is low and mostly depends on the technique that the practitioner employs during the procedure.
Needle Insertion and Local Anesthesia
Steps should be taken to make all procedures as pain-free as possible. The liberal use of local anesthetics in adequate concentrations will promote this goal while minimizing repeat needle sticks. Small diameter needles, 28 to 30 gauge, are initially used to anesthetize the skin and subcutaneous tissue. Distracting the skin with one’s fingers while slowly advancing the needle helps to reduce pain. The tip of the needle can be placed in the subcutaneous fat and, upon injection, less pain is noted than with intradermal injections because of the distensibility of fat. Rapid infusion of medication, especially with large volumes, causes tissue distention and results in pain. Lidocaine and bupivacaine, buffered with 8.4% sodium bicarbonate causes less pain than plain anesthetics and is equally efficacious. A 1:10 to 1:20 ratio of sodium bicarbonate to anesthetics can be used. Morris and colleagues found that, when injected, subcutaneous procaine and lidocaine were the least painful anesthetics. Only etidocaine was found to be more painful than bupivacaine. Varelmann and coworkers found that patients who were told “We are going to give you a local anesthetic that will numb the area and you will be comfortable during the procedure” perceived less pain than patients who were told “You are going to feel a big bee sting; this is the worst part of the procedure.”
Other preparations used to reduce pain with initial needle injections include topical anesthetics (eutectic mixtures of local anesthetics, or EMLA), vapocoolant sprays, and preheated local anesthetics. If the patient is intolerant of or allergic to anesthetic agents, 0.9% intradermal saline or dilute antihistamines such as diphenhydramine (Benadryl) in 10 to 25 mg/mL injections can be used as alternatives; however, they are often considered painful, especially when injected intradermally.
Before administering injection anesthetics, one should aspirate to prevent inadvertent injection into a vascular structure. Small-gauge needles are unreliable when aspirating for blood. Needles of 25 gauge or larger rotated in two planes are necessary for this purpose. Continual movement of the needle tip makes injection into a vessel less likely. Slow, fractionated dosing is recommended while monitoring the patient for early signs of anesthetic toxicity.
Precautions
Good technique not only reduces the risk of wound infection, but also lowers the rate of viral transmission between patient and physician. Physicians who perform exposure-prone procedures should know their own human immunodeficiency virus (HIV) and hepatitis B virus (HBV) antibody status. The risk to the patient of contracting the HIV virus ranges from 1 in 42,000 to 1 in 420,000; the risk of contracting fatal HBV infection from an HBeAg positive surgeon during a procedure ranges from 1 in 76,000 to 1 in 1.4 million. Universal precautions should be understood and include the use of gloves, protective eyewear, masks, (optional), and gowns (optional). Recapping used needles should be avoided and is seldom necessary.
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