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The Importance of Studying Complications in Pain Medicine

Peter S. Staats MD, FIPP, MBA¹ and Serdar Erdine MD, FIPP²

¹World Institute of Pain, Atlantic Beach, FL, USA
2Medical Faculty of Istanbul University, Istanbul Pain Center, Istanbul, Turkey

It is terrifying to have complications following procedures performed to help patients. A complication can be as minor as a local skin infection, or much more severe with hematomas, paralysis and even death following a neuraxial or visceral nerve block. No physician ever goes to work, thinking “Today, I am going to injure someone”. Rather, physicians may believe that a complication is simply an unfortunate event that was just unavoidable or unlucky. But luck favors the prepared. Even without mal-intent, the truth is, many complications are avoidable. With an appropriate understanding of indications contraindications, anatomy, physiology, and techniques, the risk of most complications can be mitigated.

Over the past several years, as the number of interventional procedures for pain management has increased, so has the number and types of complications that occur. When we entered the field of pain medicine, there were few therapeutic strategies available to the pain physician, and patients suffered in silence, or underwent much more invasive and far less effective strategies than we have to date. In fact, the field of pain medicine was at such a state of infancy that randomized controlled trials (RCTs), and long-term follow up was considered rare. As the field has expanded to the breadth of what pain physicians offer, the complexity of therapies and the frank number of procedures offered, so has the rate of complications. The length of training has not increased, making the rate of knowledge acquisition much quicker than was expected a mere 20 years ago.

While some complications are relatively minor, others can be severe and debilitating. Unfortunately, these complications are rarely reported. The medicolegal system discourages reporting of complications, and physicians may be embarrased or fearful of legal or disciplinary action. For this reason, many physicians under report the true complications. Thus, the true incidence and severity of complications is also likely to be under reported. In order to provide true informed consent and make the most appropriate recommendation to patients, it is important to understand the scope and severity of any problems. Moreover, if we understand the scope of the problem, we can proactively develop safer tools and approaches to avoid such complications.

Several textbooks cover the techniques, indications, contraindications, and mechanism of action of interventional pain management techniques, but only a few textbooks have focused on the complications, how to avoid them, their impact on patients, and the psychology of the treating team, as well as their medicolegal consequences. The combination of interventional pain physicians with quite diverse training backgrounds, as well as the recent significant increase in the use of interventional diagnostic and therapeutic techniques, raises the potential for increased complications. Unfortunately, there are major limitations in the analysis of complications. This text intends to provide pearls and strategies to avoid complications, as well as strategies to treat them and avoid long-term injury.

Historically, physicians have a tendency not to report poor outcomes; therefore, the true incidence of complications is not fully known. Only a fraction of the total number of complications that occur following procedures are reported. Health privacy issues and fear of litigation prevent some physicians from reporting the complications of interventional techniques. Further, any complications may be reported to different databases, making a general analysis even more difficult. Although the overall incidence of significant complications in interventional pain medicine is low, some catastrophic complications do occur.

Interventional pain management physicians and staff must clearly explain these complications in layman’s terms to the patient so as to reduce the occurrence of claims. Written preoperative instructions explaining the procedure and potential complications should be given and signed by the patient before the procedure, allowing time for review. The informed consent before all procedures should include a discussion about the indications, complications, risks, and available alternative therapies.

Most importantly, complications are inevitable and it is imperative to identify and treat these problems promptly to minimize their impact when they do occur and to communicate these issues with the patient.

Although pain medicine is now an established subspeciality in many countries, residency or fellowship training in the field of interventional pain medicine does not universally exist. Without a universally accepted curriculum necessary for establishing competency in the specialty, greater variability in indications, techiques, and outcomes will be noted. This of course will also translate into great variability in the occurence of complications.

There are several ways for physicians entering the field of pain medicine to gain necessary experience. Of course a full fellowship curriculum is ideal, with hands-on training, slowly increasing responisibility and complexity of training over time. However, many physicians are learning a specific technique, which may involve simple observation of experienced physicians, taking a weekend cadaver course, or careful review of techniques written in interventional pain procedures techniques. Over several decades, we have seen a dramatic increase in the number of physicians performing interventional pain procedures, with a concomittent exponential increase in the performance of procedures to treat pain. This has, unfortunately, also led to a rise in the number of complications [1] and an increase in malpractice claims [2].

Interventional pain procedures may be minimally invasive but have the potential to be maximally dangerous. Serious complications are devastating for the patient, devastating and expensive for the physician and are often avoidable.

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