Pain simulator can improve the training of residents and pain fellows in performing pain management procedures.

We would like to describe a simple simulated practice that we have found to be advantageous in the understanding, and comfort with which multiple pain procedures are performed. The simulated practice utilizes both anatomy and its visualization under fluoroscopy to teach the resident/pain fellow how to perform multiple pain procedures as well as to gain proficiency. The simulated technique not only allows a close simulated experience in every aspect to true patient care but serves to familiarize the resident/pain fellow with the necessary steps employed in each procedure and the necessary radiographic views for spatial orientation. The resident/pain fellow is given several procedures to review prior to attending a simulator session and then is able to apply the knowledge with practical experience. It serves to cement relationships and procedural knowledge when a visual representation and hands-on-experience intertwine with the textbook readings. The resident/fellow becomes proficient in the procedures listed below. An incredible advantage is gleaned since the resident/fellow is able to not only practice common procedures but also procedures that are less frequently observed. The simulator allows the resident/fellow to ask questions that may not be as appropriate given a patient setting. The simulator permits the resident/ fellow to practice the procedures as many times as he would like. Furthermore, the more comfortable or acclimated the resident becomes with the process then the more time is spent learning important clinical aspects and troubleshooting rather than the more menial aspects given a true patient clinical setting. The necessary components that we use in our institution are a spinal injection simulator dummy by Smith LaboratoriesTM, a portable C-Arm by Siemens Model Siromobil 2000TM, and a fluoroscopy table by US Imaging Tables IncorporatedTM. The skin of the dummy is made of material that can be used indefinitely without destroying its integrity. Also, the contour of the dummy is equivalent to an obese patient making the identification of the anatomical landmarks such as the spinous processes hard to feel and giving the resident/pain fellow a better opportunity to practice on difficult cases. Examples of procedures that can be simulated: 1. Lumbar epidural steroid injection midline approach. 2. Lumber epidural steroid injection para-median approach. 3. Trans-Foraminal lumbar epidural injection. 4. Lumbar facet joint injection. 5. Sacroiliac joint injection. 6. Medial branch block of the lumbar facet joints. 7. Percutaneous discectomy and all other disc procedures. 8. Discogram. 9. Lumbar sympathetic block. 10. Hypogastric plexus block. There are some limitations of the simulator and the few that we have found are: 1. The dummy tissue is slightly more rigid than human skin and subcutaneous tissue and for this reason we use an 18g spinal needle by Havel’s IncorporatedTM in training for all the procedures versus the 22g needle that may be used in some procedures in the real patient. 2. Under fluoroscopy the bony anatomy appears slightly darker than in an actual patient but overall the procedure can be visualized easily under fluoroscopy. 3. The dummy spine that we use only ranges from L1 to the sacrum with visualization of the SI joints, so we are only able to simulate procedures in the lumbar and sacral area. 4. We cannot achieve loss of resistance to Epidural steroid injections. 5. We can not inject dye to confirm the needle location or the spread of the dye. The following pictures will give the readers an idea about the simulator and how it works.