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Sedation is a thorny issue on which there is no agreement among a broad range of practitioners. I typically use heavy sedation, practically general anesthesia, on 99% of my patients due to the relatively low cost of bolus propofol and the proven relatively high safety factor of anesthesia administration. ISIS Guidelines consider sedation to be unnecessary for any procedure. So as usual, the more common practice lies between these extremes. At the last ISIS course ( I am an instructor), we polled the ISIS participants and found nearly all used some sedation and half have chosen light sedation, half very heavy but brief sedation. All agreed that getting into "no mans land" with moderate sedation and a disinhibited mobile patient is contraindicated. The degree of sedation offered typically depends on several factors:
1. Background training as an anesthesiologist vs. neurologist vs PM&R
2. Privileges of th injectionis for general anesthesia if administered in a hospital or ASC (JCAHO standards do not preclude an anesthesiologist performing and injection from also administering propofol or a general anesthetic). Some ASCs and hospitals require the presence of a separate anesthesiologist for the use of propofol.
3. Pain management training background...some programs use virtually no sedation
4. Patient population....a chronic pain population with difficulty assuming the prone position and with hypersensitized skin and muscles perceives light sedation or no sedation as completely ineffective and perceive the procedure as torture. This is quite contrary to an acute pain situation such as with acute disc herniation in which there is no allodynia or hyperpathia. The latter tolerate procedures without sedation much better.
5. Denial of the injectionist as to what is tolerated. The patient's perception is the only one that matters. Often physicians believe any patient who is able to lie still enough to have long needles stuck into the spine tolerated the procedure well without anesthesia when from the patient's perspective, nothing could be further from the truth. The physician is in denial, doesn't really want to know or care about how the patient perceives the injection, and is more interested in rapid turnover rates than providing adequate analgesia for these procedures, some of which are intensely painful. I have had many many patients that received injections from other physicians (non-discogram injections) that were perceived as torture, and the patient swore "never again". But when offered sedation, they not only accepted but commented on how astonished they were that no pain was involved with the injection and they would not at all remind repeating the injections in the future.
6. Finances. Sometimes the sedation of patients requires additional staff for monitoring post injection or to prepare patients and the physician determines in the office setting, it is not worth providing sedation. In an ASC, sedation with versed/fentanyl when given in heavy doses can cause protracted recovery area visits and nausea, thereby gumming up the works of the ASC. Also turnover may be slower, and titrating to effect may require 5 minutes. All these factors slow down the physician's progress and ultimately cost him money in the inability to schedule as many patients.
7. Experience and techniques. Use of blunt needles may significantly reduce the risk of sharp needle nerve injury since the nerves cannot be pithed or transected by blunt needles. Use of "danger view" fluoroscopic images during needle advancement, experience of the physician in needle placement, etc. all permits the use of general anesthesia or deep sedation without any demonstrated increased risk. It is widely and incorrectly assumed that general anesthesia increases the risk of procedure performance but other than a few case reports of disasters which were due to incompetence rather than the general anesthetic, there are no studies supporting the any enhanced safety through the use of no sedation or light sedation for procedures.
8. Time of procedure, number of needle sticks (eg. performing a 3 level bilateral medial branch nerve block vs performing a trochanteric bursa injection, size of needles used, etc. may all influence the degree of sedation necessary.
9. Equipment availability. No patient should be given sedation without the ability to fully resuscitate a patient including use of an ACD or defibrillator, appropriate monitoring, oxygen, suction, intubation equipment, etc.
10. Airway and anesthesia risks. If these are elevated, then it is prudent to have an anesthesiologist provide any heavy sedation/general anesthesia.
1. Background training as an anesthesiologist vs. neurologist vs PM&R
2. Privileges of th injectionis for general anesthesia if administered in a hospital or ASC (JCAHO standards do not preclude an anesthesiologist performing and injection from also administering propofol or a general anesthetic). Some ASCs and hospitals require the presence of a separate anesthesiologist for the use of propofol.
3. Pain management training background...some programs use virtually no sedation
4. Patient population....a chronic pain population with difficulty assuming the prone position and with hypersensitized skin and muscles perceives light sedation or no sedation as completely ineffective and perceive the procedure as torture. This is quite contrary to an acute pain situation such as with acute disc herniation in which there is no allodynia or hyperpathia. The latter tolerate procedures without sedation much better.
5. Denial of the injectionist as to what is tolerated. The patient's perception is the only one that matters. Often physicians believe any patient who is able to lie still enough to have long needles stuck into the spine tolerated the procedure well without anesthesia when from the patient's perspective, nothing could be further from the truth. The physician is in denial, doesn't really want to know or care about how the patient perceives the injection, and is more interested in rapid turnover rates than providing adequate analgesia for these procedures, some of which are intensely painful. I have had many many patients that received injections from other physicians (non-discogram injections) that were perceived as torture, and the patient swore "never again". But when offered sedation, they not only accepted but commented on how astonished they were that no pain was involved with the injection and they would not at all remind repeating the injections in the future.
6. Finances. Sometimes the sedation of patients requires additional staff for monitoring post injection or to prepare patients and the physician determines in the office setting, it is not worth providing sedation. In an ASC, sedation with versed/fentanyl when given in heavy doses can cause protracted recovery area visits and nausea, thereby gumming up the works of the ASC. Also turnover may be slower, and titrating to effect may require 5 minutes. All these factors slow down the physician's progress and ultimately cost him money in the inability to schedule as many patients.
7. Experience and techniques. Use of blunt needles may significantly reduce the risk of sharp needle nerve injury since the nerves cannot be pithed or transected by blunt needles. Use of "danger view" fluoroscopic images during needle advancement, experience of the physician in needle placement, etc. all permits the use of general anesthesia or deep sedation without any demonstrated increased risk. It is widely and incorrectly assumed that general anesthesia increases the risk of procedure performance but other than a few case reports of disasters which were due to incompetence rather than the general anesthetic, there are no studies supporting the any enhanced safety through the use of no sedation or light sedation for procedures.
8. Time of procedure, number of needle sticks (eg. performing a 3 level bilateral medial branch nerve block vs performing a trochanteric bursa injection, size of needles used, etc. may all influence the degree of sedation necessary.
9. Equipment availability. No patient should be given sedation without the ability to fully resuscitate a patient including use of an ACD or defibrillator, appropriate monitoring, oxygen, suction, intubation equipment, etc.
10. Airway and anesthesia risks. If these are elevated, then it is prudent to have an anesthesiologist provide any heavy sedation/general anesthesia.
