Choosing the Right Image: Tailoring Interventional Pain Procedures to the Patient
AUSTIN, TX — Imaging has become indispensable in interventional pain management, offering clinicians a roadmap to improve diagnostic accuracy, procedural precision, and patient safety. Through case-based insights presented at the American Academy of Pain Medicine PainConnect 2025 annual meeting in Austin, TX, Scott Pritzlaff, MD, associate professor and pain fellowship program director at the University of California, Davis, detailed how imaging should guide diagnosis, device placement, and patient selection.
“I think it’s important to know that in 2025, we have an unprecedented amount of procedural and diagnostic approaches for patients, so it’s never been more critical to understand imaging, understand MRI, and make good decisions for diagnostic and procedural planning to avoid complications,” Dr Pritzlaff said.
Dr Pritzlaff also highlighted the value of integrating imaging throughout clinical workflows, particularly in spinal procedures, neuromodulation, and peripheral nerve interventions. Pain conditions that benefit from imaging-guided diagnosis and treatment include spinal syndromes (eg, radiculopathy, facet joint pain), joint pathologies (eg, osteoarthritis, tendinopathy), neuropathic pain (eg, complex regional pain syndrome), and post-surgical syndromes such as failed back surgery or sacroiliac joint dysfunction. Imaging supports more accurate identification of underlying pain generators and helps ensure targeted, efficient interventions.
Fluoroscopy is particularly effective in spinal procedures, providing real-time visualization for epidural injections and sacroiliac joint interventions. Its spatial resolution allows for precise needle placement. Ultrasound, in contrast, is optimal for peripheral nerve blocks and regenerative procedures due to its dynamic imaging capability and radiation-free operation. MRI excels in visualizing soft tissue structures like herniated discs and nerve entrapments, while CT offers detailed bony anatomy, which is useful in surgical planning. Combining these modalities—such as integrating MRI with contralateral oblique fluoroscopic views—further enhances procedural accuracy.
Case studies throughout the presentation illustrated the practical application of imaging. For example, in dorsal root ganglion stimulation, preoperative MRI was critical to assess neuroforaminal space—information not typically quantified by radiologists. In a percutaneous image-guided lumbar decompression (PILD) procedure, measuring ligamentum flavum thickness determined candidacy. Similarly, interspinous spacer placement for lumbar stenosis required evaluation of spinal curvature using Cobb angle measurements.
Other procedures, such as multifidus stimulation, benefit from imaging to assess muscle atrophy and fatty infiltration. In sacroiliac joint fusion, imaging guides implant angles, and in basivertebral nerve ablation, MRI aids in detecting Modic changes and pedicle angles. Even peripheral nerve stimulation benefits from ultrasound visualization to ensure electrode placement accuracy—essential for outcomes, particularly in complex patients such as those on antiplatelet therapy.
“It’s extremely important to have a preoperative CT or MRI so you can plan ahead and know what that angle is from posterior to anterior at the intended location that you are going to place your allografts,” Dr Pritzlaff said.
While the presentation did not list limitations explicitly, the case examples underscore challenges, such as the need for clinician proficiency in image interpretation and variability in radiologist reporting. Clinicians are encouraged to articulate specific anatomic concerns when collaborating with radiologists and to refine their own interpretive skills for faster and more tailored treatment decisions.
“Do not be afraid to make relationships with your radiologist colleagues,” Dr Pritzlaff said.
He concluded his presentation by reinforcing that as technologies evolve—including AI-assisted imaging and novel modalities—clinicians must continue to adapt to deliver precise, patient-specific pain care.
Reference
Pritzlaff S. Appreciating imaging: choosing the right procedure for the right patient. Presented at: American Academy of Pain Medicine PainConnect 2025. Accessed April 3, 2025. https://painconnect.org/