American Society of Anesthesiologists – Pain Medicine

View all recommendations from this society

Released January 21, 2014

Don’t use intravenous sedation for diagnostic and therapeutic nerve blocks, or joint injections as a default practice.*

Intravenous sedation, such as with propofol, midazolam or ultrashort-acting opioid infusions for diagnostic and therapeutic nerve blocks, or joint injections, should not be used as the default practice. Ideally, diagnostic procedures should be performed with local anesthetic alone. Intravenous sedation can be used after evaluation and discussion of risks, including interference with assessing the acute pain relieving effects of the procedure and the potential for false positive responses. American Society of Anesthesiologists Standards for Basic Anesthetic Monitoring should be followed in cases where moderate or deep sedation is provided or anticipated.

*This recommendation does not apply to pediatric patients.

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

How The List Was Created

The American Society of Anesthesiologists (ASA) Committee on Pain Medicine was charged with developing the “Top 5 List” on pain medicine for the Choosing Wisely® campaign. Committee members submitted potential recommendations for the campaign, and from this list voted on which recommendations should be included in the final “Top 5 List.” The literature was then searched to provide supporting evidence. The Committee communicated electronically and met in person during the development and approval process. Once approved by the Committee, the “Top 5 List” was reviewed by ASA’s Chair of the Section on Subspecialties, Vice President for Scientific Affairs, Executive Committee and Administrative Council. ASA’s “Top 5 List” for pain medicine has been endorsed by the American Pain Society.

ASA’s disclosure and conflict of interest policy can be found at


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Cohen SP, Raja SN. Pathogenesis, diagnosis and treatment of lumbar zygapophysial (facet) joint pain. Anesthesiology. 2007 Mar;106:591–614.

Dreyfuss P, Cohen S, Chen AS, Bohart Z, Bogduk N. Is immediate pain relief after a spinal injection procedure enhanced by intravenous sedation? PM R 2009;1:60–3.

Manchikanti L, Pampati V, Damron KS, McManus CD, Jackson SD, Barnhill RC, Martin JC. The effect of sedation on diagnostic validity of facet joint nerve blocks:an evaluation to assess similarities in population with involvement in cervical and lumbar regions. Pain Physician. 2006;9:47–52.

Smith HS, Colson J, Sehgal N. An update of evaluation of intravenous sedation on diagnostic spinal injection procedures. Pain Physician. 2013;16:SE17–28.