Interventional Pain Management Program

What is a nerve block?

Peripheral nerve blocks address pain in a discrete area of the body. They are one of the most frequently used interventional treatments for headache. A nerve block is performed by injecting a numbing local anesthetic using a small needle and syringe in the area of nerves involved. For headache, these nerves are located at the back of the skull (occipital nerves) as well as near the temples and above the eyebrows (trigeminal nerve branches). A related form of nerve block involves applying medication via cotton-tipped applicator, or sprayed with an atomizer, to the "sphenopalatine ganglion" (a group of nerve cells located behind the nose and linked to the trigeminal nerve, the main nerve involved in headache).

Other kinds of nerve blocks can include brachial plexus nerve blocks for arm pain, femoral or sciatic nerve blocks for leg pain, intercostal nerve blocks for localized chest pain, among others. 

Medications used include a local anesthetic for numbing the painful area, and occasionally a steroid to reduce inflammation.
 

How does a nerve block work?

Nerve blocks work by effectively “shutting down” overactive pain signals. Parts of the head will become numb for several hours; however, benefits can last longer due to a decrease in pain signals being sent to the brain. A successful nerve block can last from several days to several weeks, and may be more effective with each subsequent injection. Nerve blocks can be helpful for many different types of headache including migraine, cluster headache, occipital neuralgia and cervicogenic headache.
 

Who should NOT have a nerve block?

There are very few contraindications to nerve blocks; they are safe, well-tolerated and can even be used during pregnancy. One of the few reasons to avoid a nerve block would be a serious skin or soft tissue infection at the site of the proposed injection.  Another reason would be allergy to the numbing medication itself.
 

How quickly do nerve blocks work?  How long do they last?

Nerve blocks produce relief quickly, in a matter of days.  The effects last a variable length of time.  If needed, injections can be done every few weeks, depending on the recommendations from your healthcare provider. For patients who require frequent nerve blocks, a longer-lasting procedure known as nerve ablation could be considered.  Ablation uses extreme cold or radiofrequency to disable pain signals and can treat the pain for a longer duration, usually around 6 months.
 

What is BOTOX?

Onabotulinum toxin (or Botox) is a preventive treatment for individuals with chronic migraine (those who have 15 or more headache days per month.) Botox injections can help to reduce frequency and severity of migraines when injected around pain fibers involved in headaches. Botox enters the nerve endings around where it is injected and blocks the release of chemicals involved in pain transmission. This prevents activation of pain networks in the brain.

A round of Onabotulinum A treatment involves injecting a small amount of the medication into 31 specific points in the forehead, temples, back of the head and top of the neck using a small needle. These are all points where nerves are active during migraine. 

Who can get Onabotulinum toxin injections? 

Onabotulinum A is FDA-approved for the treatment of chronic migraine in adults, although most insurance companies require that patients fail to respond to at least 2 other daily preventive medications first before authorizing the treatment.  Onabotulinum toxin is used "off label" in pediatric patients for migraine.  A patient who has tried other oral preventives but not experienced a therapeutic response or had severe side effects, can move on to trying Onabotulinum A, which is an interventional headache procedure.  

Who should not get Onabotulinum toxin?

Onabotulinum injection treatment does not interact with other common headache medications, so it works well as part of a comprehensive treatment plan.  Botox can be particularly useful in patients who take medication for other non-headache health issues.  There are some patients for whom Botox is not appropriate, including individuals with a history of neuromuscular disorders, pre-existing conditions such as myasthenia gravis and females who are pregnant or trying to become pregnant.

How quickly does Onabotulinum toxin work?

Patients initially may notice a reduction in headache severity or that an abortive medication works better. Results may take a week or more to become noticeable. Patients often see greater improvement with the second or third round of Botox injections.

How long does Onabotulinum toxin last?

Patients typically receive a round of injections every 12 weeks (3 months). 

What are the side effects of Onabotulinum toxin?

In terms of side effects, patients sometimes report neck discomfort in the week following the procedure. This is due to other muscles compensating for the muscles injected with the medicine. Other side effects may include a headache the day of or day after the procedure.  Onabotulinum A may also temporarily change cosmetic appearance (such as wrinkle reduction and change in the arch of the eyebrow). Occasionally, Onabotulinum toxin injections in the forehead may lead to a reversible drooping of the eyelid.  Botulinum toxin can affect areas far away from the injection site, but there has not been a confirmed serious case of spread of toxin effect away from the injection site when Botox has been used at the recommended dose to treat chronic migraine.
 

What should I expect from a Lidocaine Infusion?

Intravenous lidocaine infusion has been has been shown to be successful in controlling chronic pain for some individuals where other agents have failed. 

Depending on individual factors, some patients report immediate and long continued relief associated with the intravenous administration of lidocaine. Other patients indicate that their pain relief from lidocaine is slow in coming on and may last only as long as the medication is being infused. Yet another group of patients receiving the intravenous lidocaine describe some unpleasant or non-beneficial response from the lidocaine. 

Until an individual undergoes the lidocaine infusion procedure, the clinical team will not have a way of identifying to which group a particular patient will belong.

If you experience significant improvement in your pain or change in the way your pain feels during the course of the infusion, please pay attention to how long the beneficial effects last, and let us know either with a telephone call or MyChart message or at the time of your next follow-up.

How does a Lidocaine Infusion work?

Lidocaine infusion has been used to treat both acute and chronic pain conditions. It was first used for burn-related pain in the 1940s. Since then, lidocaine has been used in several other conditions, such as diabetic neuropathy and complex regional pain syndromes. 

Neuropathic pain is chronic pain that occurs when there is damage or disorder of sensory system.  It can involve changes in the release of certain neurotransmitters which signal pain, combined with an impaired ability of the nerves to regulate these signals.  These changes result in inappropriate pain. 

Lidocaine has effects in both the peripheral and central nervous system related to its ability to block sodium ion channels in cells.  Lidocaine also has anti-inflammatory properties that are more potent than traditional anti-inflammatory drugs, with fewer side effects.

What are some of the possible side effects?

Because of the nature of this procedure, the maximum effects of the medicine are seen during the time you are being carefully observed by the physicians and staff at the medical center. 

Generally, following the intravenous infusion of lidocaine, there are no side effects once the procedure has been completed. Occasionally, patients do describe some peculiar feelings for hours following an intravenous lidocaine infusion. Such feelings can include general fatigue, persistent dizziness or a headache.  

Symptoms due to the procedure seem to disappear within the first day following the procedure. 
 

Questions or Concerns?

If you have concerns regarding any particular side effect, or potential complication to the lidocaine infusion that you received, please contact the clinical staff of the Pain Medicine clinic.
 

What is an epidural steroid injection?

Epidural steroid injection is a diagnostic and therapeutic injection. It can aid in determining if degenerative disc disease is a component of back pain or radicular pain (pain radiating down the leg, typically), and if that is the case, will alleviate symptoms partially or completely. 

Typically, epidural steroid injections are done with x-ray fluoroscopic guidance. The patient lies face down, receives sedatives if needed, x-rays are done to localize the appropriate site of injection, and a needle is guided to the site and placement is confirmed with contrast injection. Then local anesthetic and particulate steroids are injected into the epidural space. If the space is compressed due to disc disease, the patient may feel a pressure sensation as the medications are injected. 

Who can get epidural steroid injections? 

Patients with degenerative disc disease resulting in back and radicular (radiating to the leg) pain who do not improve adequately with appropriate conservative treatments such as rest, physical therapy, and oral medications may be candidates for epidural steroid injection.

Who should not get epidural steroid injections?

The epidural space exists within the spine, and patients with bleeding or clotting problems may need to be treated before an epidural injection is done. Special consideration may be made for patients with spine deformities. 

How quickly does epidural steroid injection work?

The local anesthetic may provide some pain relief on the day of the injection but wears off by the next day. The long-lasting particulate steroids take approximately 2 weeks to take effect. 

How long does epidural steroid injection last?

Epidural steroids can have an effect for several months. If needed, the injection can be repeated several times per year, but typically adolescent patients have 1-2 injections before either getting sustained relief or needing surgical consideration.

What are the risks of epidural steroid injection?

Risks include bleeding, infection, nerve damage, weakness (also known as paresis), sensory changes, and headache related to dural puncture (spinal headache).

What is a trigger point injection?

Trigger point injection is therapeutic injection of local anesthetic, and occasionally steroids, into muscle and soft tissues that is painful. Part of the process is needling the area, which can help tight taut tissue to relax through direct mechanical effects, and through inducing the body to release its own pain-relieving molecules.  

Who can get trigger point injections? 

Patients with myofascial pain that has not responded adequately to conservative therapies such as massage, TENS unit, PT and home exercise, and oral and topical medications may be suitable for trigger point injections.

Who should not get trigger point injections?

Trigger point injections are a low risk procedure and most patients are suitable for this kind of injection.  

How quickly does trigger point injection work?

The local anesthetic may provide some pain relief on the same day of the injection. 

How long does trigger point injection pain relief last?

While the local anesthetic numbing medication may wear off by the next day, the relaxation of tight muscle and connective tissues may last days, weeks, or even months. Trigger point injection may be repeated multiple times throughout the year, if needed. 

What are the risks of trigger point injection?

Risks include bleeding, infection, nerve damage, weakness (also known as paresis), sensory changes, post-procedural injection site pain. 
 

Your provider referred you for an Interventional procedure.  The Interventionalist will review the referral within two business days of receiving it and decide if further evaluation is necessary or if you may proceed to have your procedure scheduled.  If so, s/he will place an order to schedule your procedure.  Then, a procedure scheduler will call you to schedule the procedure within five business days.  

If you have not received a call within seven business days of meeting with your provider, please call our office at 860.837.5207.  
 

Please expect that your procedure will be scheduled within a minimum of two weeks to allow us enough time to complete prior authorization with your insurance and for you to complete any necessary pre-procedure work-up.  Our typical wait list is at least one month long, and this could vary depending on the procedure type, clinical volume, and provider availability.

We encourage our patients to keep their scheduled procedures.  If a procedure is canceled, we will offer that time to another patient on our wait list.  We cannot guarantee that patients would be able to reschedule a procedure at the same time, and you may need to reschedule several weeks out or join our wait list to be contacted if a sooner time becomes available.

When patients visit us to undergo Botox injections, they can expect to leave with an appointment for the next scheduled injection three (3) months later.  In some circumstances, if the next injection cannot be scheduled that day, patients should call the Pain Management Department within the next week to do so.

Other procedure types will be scheduled as indicated by your provider.
 

Once your procedure is scheduled, our Financial Clearance Department will submit a request to your insurance company for authorization.  If your insurance company deems the procedure experimental, non-covered, we will notify you as soon as possible.  We always encourage you to contact your insurance with any questions about coverage and benefits. To contact Financial Clearance: Call: 860-837-6001; Email: Authorizations [at] connecticutchildrens.org (Authorizations[at]connecticutchildrens[dot]org).

Please note that the prior authorization process may take up to two weeks or more.  For this reason, please expect that your procedure will be scheduled no sooner than two weeks from the time your provider referred you to this program.  (Urgent procedures will be addressed on a case-by-case basis).

It is very important for you to update us as soon as possible if your insurance coverage changes.  This includes if you change jobs, add a secondary coverage, or have no coverage at all.  Please do not wait until your next appointment to update us – call your care team right away!  We also have Financial Assistance for those who qualify.  You can reach our Financial Counselors Monday-Friday from 8:00am – 4:30pm to request an estimate or complete an application for Financial Assistance: Call: 860.545.8086; Text: 860.891.2726; Email: FinCounselors [at] connecticutchildrens.org (FinCounselors[at]connecticutchildrens[dot]org).  

If you have questions about a bill that you receive after your procedure, please contact our Billing Office: Call: 860.837.6170; Text: 860.390.5010; Email: ccpatientbilling [at] connecticutchildrens.org (ccpatientbilling[at]connecticutchildrens[dot]org).

Sedation 

What is Sedation?

Connecticut Children’s Sedation team provides sedation (medication that calms the nervous system) prior to a wide range of tests or procedures that cause pain, provoke anxiety or require a patient to be still. When children get sedation that means they are given medicine to make them feel more relaxed or sleepy. The team uses medicines and delivery methods that allow your child to have a more natural sleep state.

Compassionate, Personalized Care

Our board-certified sedation specialists evaluate every child before a scheduled test or procedure to determine whether a child will need sedation and what type of sedation to offer. Considerations include the child’s age and developmental level, length of time it takes to perform the test or procedure, amount of discomfort expected during the test or procedure, and the child’s medical condition. Learn more here.

Pre-Procedure Instructions

If your child is receiving sedation, the Sedation team will call you before the procedure to provide instructions, including what your child can and cannot eat or drink before the procedure, what medications your child can or cannot take (if applicable), post-procedure recovery, etc.

Arrival Time

A member of our Sedation team will call you before the procedure to confirm your arrival time.  

Location

Please allow ample time for traffic, parking, and navigating your way to the main entrance of the hospital, located at 282 Washington St, Hartford, 1st Floor.

When you arrive, you will check-in at the Security desk and then proceed to the Sedation Unit, located in 1G.  You will check-in at registration and will then be escorted to the area where they will obtain consent and perform the procedure.  

Packing List

• Please bring your insurance card(s) and photo ID
• Please bring a parent or legal guardian who will consent to the procedure
• Please ensure to have a designated driver; patients may not drive themselves home
• Wear comfortable clothing
• If you wish, you may bring comfort items to help your child feel more at ease during the procedure, such as a stuffed animal, toy, blanket, book, tablet, or hand-held gaming device

Length of Stay

You can expect to be in our facility for less than one (1) hour if you are receiving a procedure without sedation.  If you are receiving sedation, your length of stay will be longer and will vary based on your personal recovery time from the sedation.  

If you are receiving a Lidocaine Infusion, you can expect to be in our facility for at least four (4) hours.

Sedation Recovery

The Sedation team will explain discharge instructions prior to leaving the Sedation Unit.

Follow Up Care

We will discuss follow up care with you upon conclusion of the procedure.  Your child can return to normal activities the following day.  Any localized pain or skin irritation is common and should begin to decrease about two days after the injection.  Please refer to your After Visit Summary for further details and instructions.

When to Call Us

Call the Pain Management Department at 860.837.5207 to speak with a nurse if you experience any of the following:

• Bleeding at the site
• An increase in pain
• Any signs of infection, such as swelling or redness at the site or a fever greater than 101F

Follow Up Appointments

All patients receiving interventional procedures should schedule a follow-up appointment with their referring provider within 3-6 months after their procedure to assess your treatment progress.  Your insurance carrier may not authorize future procedures without completing a routine follow-up.  We will notify you if/when you need to schedule this visit.