Chronic back, leg, and pelvic pain frequently result from degenerative spine conditions, disc herniations, spinal stenosis, facet arthropathy, sacroiliac joint dysfunction, or vertebrogenic pain. When conservative measures such as physical therapy, medications, and activity modification fail, interventional pain procedures provide targeted, minimally invasive options to address specific pain generators.

These techniques are typically performed on an outpatient basis with image guidance, offering shorter recovery times and lower risk compared to open surgery. Patient selection relies on detailed history, physical examination, and MRI findings. Below is a concise review of key procedures.

Injection-based procedures

Epidural steroid injection (ESI)

Corticosteroids and local anesthetics are delivered into the epidural space to reduce inflammation and relieve nerve root irritation.

• Typical presentation: Radicular pain radiating to the extremity, worsened by sitting or Valsalva maneuvers. May include numbness, tingling, or weakness.
• Exam findings: Positive straight leg raise, dermatomal sensory deficits, reduced reflexes, or mild motor weakness.
• MRI indicators: Disc herniation with nerve root compression, central or foraminal stenosis, or inflammatory changes.

Facet joint blocks and radiofrequency ablation (RFA)

Diagnostic and therapeutic injections of anesthetic (with or without steroid) into the facet joints or medial branch nerves. Positive responders may advance to RFA for longer-term denervation (typically 6 to 18 months).

• Typical presentation: Axial low back pain aggravated by extension, rotation, or prolonged standing; usually non-radiating.
• Exam findings: Paraspinal tenderness, positive extension-rotation (Kemp’s) test, preserved neurological exam.
• MRI indicators: Facet hypertrophy, osteoarthritis, joint effusion, or subchondral sclerosis.

Sacroiliac joint (SIJ) injections and fusion

Injections into the SI joint for diagnosis and temporary relief. Recurrent pain may warrant minimally invasive SIJ fusion.

• Typical presentation: Unilateral low back and buttock pain radiating to the groin or posterior thigh, worsened by single-leg stance or transitional movements.
• Exam findings: Positive provocation tests (thigh thrust, Gaenslen’s, compression).
• MRI indicators: Sacroiliitis with bone marrow edema, erosions, or degenerative changes.

Ablation and decompression procedures

MILD procedure (minimally invasive lumbar decompression)

Removes small portions of hypertrophied ligamentum flavum through a 5.1 mm incision to decompress the central spinal canal in lumbar spinal stenosis.

• Best for: Neurogenic claudication, leg pain or cramping, or heaviness with walking or standing, relieved by forward flexion. Suitable for older patients or those with comorbidities.
• Outcomes: High satisfaction rates (approximately 85 percent), meaningful improvement in ambulation, and approximately 88 percent of patients avoiding open surgery for at least five years. Low complication rate.
• Evidence: Supported by the MiDAS ENCORE trial and long-term data.

Intracept procedure (basivertebral nerve ablation)

Radiofrequency ablation of the basivertebral nerve within the vertebral body to treat vertebrogenic pain.

• Best for: Chronic axial low back pain (more than six months) with Modic Type 1 or 2 endplate changes on MRI, unresponsive to conservative care.
• Outcomes: Significant pain reduction (often more than 50 percent at 12 months) lasting five years or more.
• Evidence: Strong data from the SMART trial and Level I studies.

Endoscopic discectomy

Endoscope-assisted removal of herniated disc material through a quarter-inch incision (transforaminal or interlaminar approach).

• Best for: Radiculopathy due to contained or extruded disc herniations.
• Outcomes: Over 90 percent success for leg pain relief, rapid recovery, and minimal tissue disruption compared to traditional microdiscectomy.

Neuromodulation

Spinal cord stimulation (SCS)

An implantable device delivering electrical impulses to the dorsal columns to modulate pain signals. Particularly useful for failed back surgery syndrome and refractory neuropathic pain.

Peripheral nerve stimulation (PNS)

Targeted stimulation of specific peripheral nerves for focal neuropathic pain (e.g., cluneal or ilioinguinal nerve distribution).

Key considerations

These procedures are most appropriate for patients with chronic symptoms persisting beyond 3 to 6 months despite conservative therapy, and with identifiable pain generators on exam and imaging. Diagnostic blocks are often used to confirm the pain source prior to ablation or implantation.

Benefits include targeted relief, reduced opioid dependence, improved function, and preservation of spinal anatomy. Risks are generally low (infection, bleeding, or nerve injury typically less than 1 to 5 percent) when performed by experienced specialists.

A comprehensive evaluation by a fellowship-trained interventional pain physician or spine specialist is essential to determine the most suitable approach based on individual anatomy and pathology.

Kayvan Haddadan is a physiatrist and pain management physician, and president and medical director of Advanced Pain Diagnostic & Solutions, a multidisciplinary pain management practice in California that he founded in 2012. A physician and surgeon licensed by the Medical Board of California, he is double board-certified in pain medicine and physical medicine and rehabilitation. He is also certified in controlled substance registration through the DEA and serves as a qualified medical examiner through California’s Department of Industrial Relations Division of Workers’ Compensation.

Dr. Haddadan earned his Bachelor of Science degree from the College of Alborz in Tehran, Iran, and his medical degree from Shahid Beheshti University of Medical Sciences. He later received his Educational Commission for Foreign Medical Graduates certification in Philadelphia, completed an internship in medical surgery at Loyola University Medical Center’s Stritch School of Medicine in Illinois, and finished his residency in physical medicine and rehabilitation at the same institution. He completed his fellowship in pain medicine at California Pacific Medical Center’s Pacific Pain Treatment Center and also trained in medical acupuncture for physicians at the University of California, Los Angeles David Geffen School of Medicine.

Dr. Haddadan has contributed to 29 research publications across multiple specialties, including pain management, cardiology, pulmonology, endocrinology, gastroenterology, and infectious disease. His work has examined topics such as hyperlipidemia in high cardiovascular risk patients, hyperuricemia and gout management, type 2 diabetes and hypertension, chronic obstructive pulmonary disease and asthma therapies, influenza treatment, irritable bowel syndrome, and opioid related complications in chronic pain care. His research has also included clinical outcome studies in spinal cord stimulation and award-winning presentations on neuropathic pain management and neuromuscular disorders.