FAQ: Interventional Pain Services

What is interventional pain management?
Interventional pain management is a medical specialty that uses targeted procedures, diagnostic testing, and coordinated treatment plans to help identify the source of pain, reduce symptoms, improve function, and support recovery. It is often used along with conservative care, medications, rehabilitation, and other medical or surgical evaluations when appropriate.

Why might my doctor recommend interventional pain services?
Your doctor may recommend a pain procedure, additional diagnostic testing, and/or other treatments to help reduce pain, improve movement, and support your recovery. These treatments are often used with conservative care, such as home exercises, physical therapy, chiropractic care, medications, activity modification, and follow-up with your treating doctors.

What is an occipital nerve block?
An occipital nerve block is an injection near the nerves at the back of the head. It may be recommended for headaches, occipital neuralgia, or pain that starts in the upper neck and travels toward the scalp.

What is a facet joint injection or medial branch block?
Facet procedures target the small joints of the spine or the nerves that carry pain from those joints. They may be recommended for neck, mid-back, or low back pain that worsens with extension, rotation, posture, or activity.

What is radiofrequency ablation?
Radiofrequency ablation, also called RFA, uses heat from radiofrequency energy to reduce pain signals from targeted nerves. It may be recommended when diagnostic facet or joint-related blocks provide meaningful temporary relief and longer-lasting relief is desired.

What is an epidural steroid injection?
An epidural injection places anti-inflammatory medication near irritated spinal nerves. It may be recommended for neck, back, arm, or leg pain caused by disc herniation, stenosis, or nerve-root inflammation.

What are joint and bursa injections?
Joint or bursa injections may be recommended for painful inflammation or injury involving areas such as the sacroiliac joint, hip, knee, wrist, shoulder, or bursa. These injections may help reduce pain, improve motion, and support daily activity.

What other diagnostics or treatments may be recommended?
Your doctor may also recommend additional testing or treatment options, depending on your symptoms, exam findings, imaging, and response to care. These may include EMG/NCT testing to evaluate nerve function, bracing for the neck, back, or joints, additional physical therapy and/or chiropractic care, lifestyle modifications, medication review, updated imaging, or consultation with other specialists.

What are the goals of these procedures?
Your doctor may recommend a procedure to help identify the pain source, reduce inflammation, decrease pain intensity, improve function, and help you participate more comfortably in rehabilitation. The goal is not always to cure the condition, but to improve pain control, activity tolerance, and quality of life.

What should I expect during a pain procedure?
Most procedures are performed using sterile technique and may use imaging guidance, such as fluoroscopy or ultrasound. Local anesthetic may be used to numb the area. Some patients feel improvement quickly, while others notice gradual improvement over several days. Relief may be temporary, partial, or longer lasting depending on the condition and treatment response.

What should I tell my medical team before a procedure?
Tell your medical team if you take blood thinners, have diabetes, have an infection, are pregnant, have allergies to medications or contrast dye, or have had a prior reaction to steroids or anesthesia. All procedures have risks, including bleeding, infection, increased pain, allergic reaction, nerve injury, medication side effects, or incomplete relief. Your doctor will review the risks, benefits, and alternatives before treatment.

What should I do after the procedure?
Follow your post-procedure instructions carefully. Avoid strenuous activity until cleared. Track your pain relief, activity tolerance, and any changes in symptoms. Contact the office or seek urgent care for fever, severe headache, new weakness, loss of bowel or bladder control, chest pain, shortness of breath, or worsening neurologic symptoms.

Why is follow-up important?
Your follow-up visit helps determine how well the treatment worked and whether additional care is needed. Your doctor may recommend continued conservative care, repeat injection, RFA, further testing, specialist referral, or other treatment options based on your response.

 ****    Important Reminder - FOR REFERENCE ONLY

SEEK INSTRUCTIONS FROM YOUR DOCTORS    ****

***For Spine AND HIP INJECTIONS - here are instructions to stop bloodthinners. 

For SI joint injections - no need to stop your blood thinner. 

Do not stop taking your anticoagulant until you have been cleared to do so by the medical provider prescribing that medication.

Anticoagulants

• Coumadin (warfarin): Stop 5 days before procedure; INR must be obtained on the day of the procedure.

• Pradaxa (dabigatran): Stop 4 days before procedure.

• Eliquis (apixaban): Stop 3 days before procedure.

• Xarelto (rivaroxaban): Stop 3 days before procedure.

• Bevyxxa (betrixaban): Stop 6 days before procedure.

Antiplatelets / Platelet Inhibitors

• Aspirin / Excedrin (any dose “baby” or otherwise): Stop 7 days before procedure.

• Plavix (clopidogrel): Stop 7 days before procedure.

• Effient (prasugrel): Stop 10 days before procedure.

• Ticlid (ticlopidine): Stop 5 days before procedure.

• Pletal (cilostazol): Stop 2 days before procedure.

NSAIDs (Nonsteroidal Anti-inflammatory Drugs)

• Advil (ibuprofen): Stop 1 day before procedure.

• Arthrotec (diclofenac): Stop 1 day before procedure.

• Indomethacin: Stop 2 days before procedure.

• Lodine (etodolac): Stop 2 days before procedure.

• Mobic (meloxicam): Stop 4 days before procedure.

• Aleve (naproxen): Stop 4 days before procedure.

• Relafen (nabumetone): Stop 6 days before procedure.

• Feldene (piroxicam): Stop 10 days before procedure.

Supplements

• Fish oil: Stop 6 days before procedure.

• Garlic: Stop 7 days before procedure.

• Vitamin E: Stop 7 days before procedure.

• Turmeric: Stop 7 days before procedure.

Again, confirm these timelines with the provider who prescribed your medication.

**** Recordatorio importante - SOLO PARA REFERENCIA

BUSQUE INSTRUCCIONES DE SU MÉDICO ****

Para inyecciones en la columna vertebral Y la cadera – aquí están las instrucciones para suspender anticoagulantes.

Para inyecciones en la articulación sacroilíaca (SI) – no es necesario suspender su anticoagulante. 

No deje de tomar su anticoagulante hasta que haya sido autorizado por el proveedor médico que le recetó ese medicamento.

Anticoagulantes

• Coumadin (warfarina): Suspenda 5 días antes del procedimiento; el INR debe obtenerse el día del procedimiento.

• Pradaxa (dabigatrán): Suspenda 4 días antes del procedimiento.

• Eliquis (apixabán): Suspenda 3 días antes del procedimiento.

• Xarelto (rivaroxabán): Suspenda 3 días antes del procedimiento.

• Bevyxxa (betrixabán): Suspenda 6 días antes del procedimiento.

Antiplaquetarios / Inhibidores de Plaquetas

• Aspirina / Excedrin (cualquier dosis “baja” o normal): Suspenda 7 días antes del procedimiento.

• Plavix (clopidogrel): Suspenda 7 días antes del procedimiento.

• Effient (prasugrel): Suspenda 10 días antes del procedimiento.

• Ticlid (ticlopidina): Suspenda 5 días antes del procedimiento.

• Pletal (cilostazol): Suspenda 2 días antes del procedimiento.

AINEs (Antiinflamatorios No Esteroides)

• Advil (ibuprofeno): Suspenda 1 día antes del procedimiento.

• Arthrotec (diclofenaco): Suspenda 1 día antes del procedimiento.

• Indometacina: Suspenda 2 días antes del procedimiento.

• Lodine (etodolaco): Suspenda 2 días antes del procedimiento.

• Mobic (meloxicam): Suspenda 4 días antes del procedimiento.

• Aleve (naproxeno): Suspenda 4 días antes del procedimiento.

• Relafen (nabumetona): Suspenda 6 días antes del procedimiento.

• Feldene (piroxicam): Suspenda 10 días antes del procedimiento.

Suplementos

• Aceite de pescado: Suspenda 6 días antes del procedimiento.

• Ajo: Suspenda 7 días antes del procedimiento.

• Vitamina E: Suspenda 7 días antes del procedimiento.

• Cúrcuma: Suspenda 7 días antes del procedimiento.

Vital signs matter because they are the earliest and most reliable objective indicators of physiologic stability or deterioration, serving as the foundation for safe procedural decision-making. In the context of an interventional pain clinic, each vital sign provides specific, actionable clinical information:

Blood Pressure — Reflects cardiovascular reserve and end-organ perfusion. Uncontrolled hypertension (preoperative diagnosis) is associated with a 35% increase in cardiovascular complications in a meta-analysis of 30 observational studies. 

 Intraoperative hypotension (MAP <65 mm Hg or SBP <90 mm Hg for ~15 minutes) is associated with postoperative myocardial injury, acute kidney injury, and mortality. 

 In a Vanderbilt study of 57,389 elective procedures, the relationship between preoperative blood pressure and adverse events was U-shaped — risk increased both above SBP 173 mm Hg and below SBP 93 mm Hg. 

 Uncontrolled hypertension also increases myocardial oxygen demand via elevated LV end-diastolic pressure, leading to subendocardial ischemia, and increases the risk of cerebrovascular events and bleeding. 

Heart Rate — Detects arrhythmias, autonomic dysfunction, and hemodynamic compromise. Tachyarrhythmias or bradyarrhythmias associated with hypotension are considered active cardiac conditions that are generally contraindications to elective procedures. 

 Heart rate monitoring is also critical because vasovagal reactions are the most common adverse event during interventional pain procedures, occurring in 1.1–2.6% of cases across large multi-institutional studies of over 26,000 and 8,000 procedures respectively. 

 These reactions involve reflex bradycardia and hypotension that, if unrecognized, can rarely progress to asystole. 

Oxygen Saturation — Detects hypoxemia before clinical cyanosis becomes apparent. Sedative and analgesic agents used during procedures can cause respiratory depression, and early detection via pulse oximetry enables timely intervention. In the POISE-2 trial, more than 40% of patients had postoperative SBP <90 mm Hg, and a study of continuous monitoring found that >90% of prolonged desaturation episodes (SpO₂ <90% for a continuous hour) were missed by routine intermittent nursing assessments. 

 The ASA Task Force on Moderate Procedural Sedation states that regular monitoring of vital signs reduces the likelihood of adverse outcomes during both moderate and deep sedation. 

Respiratory Rate — Often called the most sensitive early predictor of clinical deterioration. Abnormal respiratory rate is an independent predictor of adverse events, and changes in respiratory rate are observable in documented vital signs 1–4 hours prior to cardiac arrest. 

 Respiratory rate is particularly important in the pain clinic setting because opioid-tolerant patients receiving additional sedation or anxiolytics are at risk for ventilatory depression.

Temperature — Identifies active infection, which is a contraindication to procedures involving neuraxial injections, joint injections, or device implantation due to the risk of seeding an infection into the procedural site. Hypothermia signals potential hemodynamic instability, sepsis, or metabolic derangement. 

Blood Glucose — Identifies metabolic instability. Severe hypoglycemia (<54 mg/dL) causes neuroglycopenia with altered mental status, seizures, and loss of consciousness — all of which compromise patient safety and the ability to provide procedural feedback. Severe hyperglycemia (>400 mg/dL) may indicate DKA or HHS, which carry significant morbidity and mortality if a procedure is performed without recognition and treatment. 

The Overarching Principle

Vital signs represent the simplest, cheapest, and most widely accepted signs of clinical change and are the core component of early warning systems. 

 The Society of Critical Care Medicine (2023) emphasizes that clinical deterioration leads to measurable changes from baseline conditions, with severity reflected by the degree of vital sign changes. 

 In the procedural setting specifically, sedative and analgesic agents may blunt appropriate autonomic compensation for hypovolemia and procedure-related stresses, while inadequate sedation can trigger harmful autonomic stress responses (hypertension, tachycardia). 

 Vital sign monitoring bridges this gap by enabling real-time detection and intervention.

Evidence from large databases demonstrates that up to 20–30% of hospital ward patients receive substandard care prior to ICU admission, with up to 70% of adverse events being potentially avoidable — largely due to missed, misinterpreted, or mismanaged vital sign changes. 

 In the interventional pain clinic, where procedures are performed on an outpatient basis without the safety net of prolonged postoperative monitoring, pre-procedure vital sign assessment serves as the primary gatekeeper for identifying patients whose physiologic status places them at unacceptable risk.

I. Blood Pressure

A. Generally Acceptable

• 90–179/60–109 mm Hg

• Patient asymptomatic

• Stable compared with baseline

• Note: The 2024 AHA/ACC Perioperative Guidelines indicate little evidence for increased perioperative risk at blood pressure below 180/110 mm Hg in the absence of Revised Cardiac Risk Index components (coronary artery disease, heart failure, cerebrovascular disease, creatinine greater than 2.0 mg/dL, insulin-dependent diabetes) 

• [1]

B. Reassess Before Proceeding

• Systolic 180–199 mm Hg or diastolic 110–119 mm Hg without cardiovascular risk factors

• Systolic 90–99 mm Hg

• Repeat after rest and assess pain, anxiety, hydration, medication adherence, and baseline blood pressure

• Elective procedures should not be cancelled based solely upon a preoperative arterial pressure value; clinical context must be considered 

• [2]

C. Usually Unacceptable for Elective Procedures

• Systolic blood pressure ≥180 mm Hg and/or diastolic blood pressure ≥110 mm Hg with cardiovascular risk factors, persistent after reassessment

• Systolic blood pressure less than 90 mm Hg

• Mean arterial pressure less than 60–65 mm Hg

• Blood pressure ≥180 and/or ≥120 mm Hg with concerning symptoms (headache, visual changes, chest pain, dyspnea) requires emergency evaluation for hypertensive crisis; note that either value alone qualifies 

• [1]

II. Heart Rate

A. Generally Acceptable

• 50–100 beats per minute

• Regular rhythm or documented stable chronic rhythm (e.g., rate-controlled atrial fibrillation)

• Asymptomatic sinus bradycardia of 45–49 beats per minute may be acceptable in conditioned athletes or patients on beta-blocker therapy

B. Reassess Before Proceeding

• 40–49 beats per minute

• 101–120 beats per minute

• Repeat measurement and consider ECG

• Evaluate for pain, anxiety, dehydration, fever, medication effect

C. Usually Unacceptable

• Persistent heart rate less than 40 beats per minute

• Persistent heart rate greater than 120 beats per minute

• New irregular rhythm not previously documented

• High-grade heart block

• Associated syncope, chest pain, dyspnea, or hypotension

III. Respiratory Rate

A. Generally Acceptable

• 12–24 breaths per minute

• Unlabored breathing

B. Reassess Before Proceeding

• 10–11 breaths per minute

• 25–29 breaths per minute

• Evaluate for anxiety, pain, opioids, sedatives, or pulmonary disease

C. Usually Unacceptable

• Respiratory rate less than 10 breaths per minute (pre-procedure, before any sedation)

• Respiratory rate 30 breaths per minute or greater

• Apnea or shallow breathing

• Accessory muscle use

• Altered mental status

• Inability to speak in full sentences

IV. Oxygen Saturation

A. Generally Acceptable

• SpO₂ 94% or greater on room air

• SpO₂ 88–92% may be acceptable when this is the documented target for COPD or chronic hypercapnic respiratory disease

B. Reassess Before Proceeding

• SpO₂ 90–93% in a patient without known chronic lung disease

• Significant decrease from documented baseline (even if above 90%)

• Confirm waveform quality and probe placement

C. Usually Unacceptable

• SpO₂ less than 90% without a documented chronic baseline at that level

• Oxygen saturation below prescribed target despite supplemental oxygen

• New or increasing oxygen requirement

• Cyanosis or respiratory distress

V. Temperature

A. Generally Acceptable

• 36.0–37.9°C (96.8–100.2°F)

• No systemic symptoms

B. Reassess Before Proceeding

• Borderline elevation (37.5–37.9°C or 99.5–100.2°F) with recent infection, chills, or current antibiotic use

• Unexpectedly low temperature (35.5–35.9°C or 95.9–96.7°F)

C. Usually Unacceptable

• Temperature 38.0°C (100.4°F) or greater with suspected or confirmed infection; defer and evaluate infection source, especially before neuraxial injections, joint injections, or device implantation 

• [3]

• Temperature less than 35.5°C (95.9°F) with illness, hemodynamic instability, or altered mental status

VI. Blood Glucose

Note: The Society for Ambulatory Anesthesia (2024) states there are insufficient data to recommend a specific blood glucose level above which elective ambulatory surgery should be postponed. The thresholds below represent a practical framework derived from ADA, Endocrine Society, and SAMBA guidelines. 

[4-5]

A. Generally Acceptable

• 80–180 mg/dL (ideal preprocedural target per ADA and Endocrine Society)

B. Reassess or Treat

• 70–79 mg/dL: treat with oral glucose, recheck in 15 minutes; proceed only when 80 mg/dL or greater and stable

• 181–250 mg/dL: may proceed for short procedures if long-term control is adequate (HbA1c less than 8%), no ketones, and patient is asymptomatic; administer correctional insulin and recheck in 1–2 hours

C. Caution — Strongly Consider Deferral

• 251–400 mg/dL: check for ketones (urine or serum); if negative and patient is asymptomatic with adequate long-term control, may proceed for short clinic procedures with insulin correction on a case-by-case basis; for ambulatory surgery center procedures, strongly consider deferral

• Note: Preoperative glucose 200 mg/dL or greater has been associated with greater than 2-fold higher all-cause mortality in noncardiac surgery 

• [1]

D. Usually Unacceptable

• Less than 70 mg/dL until treated and glucose is stable at 80 mg/dL or greater

• Less than 54 mg/dL: clinically significant hypoglycemia requiring emergent treatment

• Greater than 400 mg/dL: defer and evaluate urgently for diabetic ketoacidosis or hyperosmolar hyperglycemic state (check ketones, basic metabolic panel, anion gap)

• Any glucose level associated with ketones, vomiting, dehydration, acidosis, altered mental status, diabetic ketoacidosis, or hyperosmolar hyperglycemic state

E. Preoperative HbA1c

• Target less than 8% within 3 months of elective procedure (recommended but not mandatory for cancellation; postponing surgery based on HbA1c alone is not recommended per ADA 2026 and AHA/ACC 2024) 

• [1][5]

• 
  

VII. Office Clinic Setting

A. Appropriate Cases

• Stable vital signs within parameters above

• Local anesthesia or minimal anxiolysis (e.g., oral benzodiazepine, nitrous oxide)

• No evidence of acute cardiopulmonary or metabolic instability

B. Reasons to Defer

• Persistent blood pressure ≥180 and/or ≥110 mm Hg with cardiovascular risk factors

• Systolic blood pressure less than 90 mm Hg or mean arterial pressure less than 60–65 mm Hg

• Significant arrhythmia (new or hemodynamically significant)

• SpO₂ less than 90% without documented chronic baseline

• Respiratory distress

• Temperature 38.0°C (100.4°F) or greater with suspected infection

• Blood glucose less than 70 mg/dL or greater than 400 mg/dL

• Altered mental status

VIII. Ambulatory Surgery Center Setting

A. Additional Capabilities

• Monitored anesthesia care

• General anesthesia

• Advanced airway equipment

• Continuous monitoring (ECG, pulse oximetry, capnography, blood pressure)

• Intravenous medications and vasopressors

• Prolonged postoperative observation

B. Conditions That Remain Unacceptable for Elective Procedures

• Hemodynamic instability (systolic blood pressure less than 90 mm Hg, mean arterial pressure less than 60–65 mm Hg)

• Persistent severe uncontrolled hypertension (≥180 and/or ≥120 mm Hg) with end-organ symptoms

• Significant untreated arrhythmia

• Acute coronary syndrome

• Acute stroke or transient ischemic attack

• Active respiratory compromise or persistent hypoxemia

• Diabetic ketoacidosis or hyperosmolar hyperglycemic state

• Active systemic infection or sepsis

IX. Symptoms That Override Numeric Values

Urgent evaluation is required regardless of vital sign values for:

• Chest pain or pressure

• Acute shortness of breath

• Focal neurologic deficit

• Syncope or presyncope

• Confusion or altered mental status

• Cyanosis

• Severe headache with neurologic symptoms

• Signs of diabetic ketoacidosis or hyperosmolar hyperglycemic state (nausea, vomiting, abdominal pain, Kussmaul breathing, fruity breath, dehydration)

• Anaphylaxis signs (urticaria, angioedema, wheezing with hypotension)

• Active bleeding or signs of hemorrhage

• Acute abdominal pain with hemodynamic instability

X. Discharge Criteria (Post-Procedure)

Discharge requires meeting all of the following:

• Blood pressure and heart rate within 20% of preoperative baseline

• SpO₂ at baseline or 92% or greater on room air

• Awake, alert, and oriented (or at patient's baseline mental status)

• Pain controlled (numeric rating scale 4 or less, or acceptable to patient)

• Nausea and vomiting minimal or absent

• Able to ambulate without dizziness (or at baseline mobility)

• Minimal procedural bleeding

• For diabetic patients: blood glucose 80 mg/dL or greater and able to tolerate oral intake before discharge