Imaging in Interventional Pain Management

Interventional pain procedures are commonly performed either with image-guidance ­fluoroscopy, computed tomography (CT), or ultrasound (US) or without image guidance utilizing surface landmarks. Recently, three-dimensional rotational angiography (3D-RA) suites, also known as flat detector computed tomography (FDCT) or cone beam CT (CBCT) and digital subtraction angiography (DSA) have been introduced as imaging adjuncts. These systems are indicative of a trend toward increased use of specialized visualization techniques. Pain medicine practice guidelines suggest that most procedures require image guidance to improve the accuracy, reproducibility (precision), safety, and diagnostic information derived from the procedure. Historically, pain medicine practitioners were slow adopters of image-guidance techniques, largely because the most common parent specialty (anesthesiology) had a culture of using surface landmarks to aid the perioperative performance of various nerve blocks and vascular line placements. Indeed, some pain medicine practitioners in the 1980s and early 1990s felt that studies advocating the inaccuracy of epidural steroid injections performed with surface landmarks were published more for specialty access than to increase patient safety or improve outcomes.