Interventional Approaches to Pain

Interventional approaches remain a mainstay of chronic pain treatment despite the many challenges to the study of their efficacy. When less invasive analgesic modalities provide inadequate relief, these techniques often play a complementary role. Interventional strategies typically target the neural structures that are presumed to mediate the experience of pain. The varied mechanisms of action range from reversible blockade with local anesthetics, to augmentation with spinal cord stimulation, and ablation with radiofrequency energy or neurolytic agents. Other techniques access intraspinal routes of medication delivery to improve an effective drug’s therapeutic index. Many of the most common approaches are uniquely suited to offer rapid, potent, local control of pain with reduced systemic side effects. Clinical indications for interventional pain management strategies encompass a broad range of conditions, from intractable neuropathic symptoms caused by advanced cancer to chronic, noncancer pain involving the spine. Each technique bears specific risks that pertain to its anatomic targets and therapeutic mechanism of action. Review of the evidence for the interventions considered raises practical issues common to virtually all procedures for chronic pain: (1) the validity of extending an indication for cancer pain to noncancer pain, (2) the timing and repeated use of a strategy with temporary benefit in the perioperative setting to a chronic pain condition, (3) the impact of neuroplasticity on the development of tolerance