Chronic neck and back pain remain among the most common reasons patients present to primary care, and a substantial subset will fail conservative management with physical therapy, pharmacotherapy, and activity modification. For these patients, interventional pain procedures offer a middle path between conservative care and surgery. Familiarity with the available options — their indications, evidence base, and limitations — helps referring physicians set appropriate expectations and select patients most likely to benefit.
Epidural Steroid Injections
Epidural steroid injections (ESIs) are the most frequently performed spinal interventions, indicated primarily for radicular pain from disc herniation or spinal stenosis. Three approaches exist: interlaminar, transforaminal, and caudal. Transforaminal injections deliver medication closest to the affected nerve root and are often preferred for unilateral radiculopathy, while interlaminar and caudal approaches provide broader coverage. Evidence supports meaningful short- to intermediate-term relief of radicular symptoms, with more modest benefit for axial pain. In the cervical spine, many proceduralists favor the interlaminar route with particulate-free steroid given the vascular risks of the transforaminal approach. ESIs are best framed as a means of facilitating rehabilitation rather than a definitive cure.
Percutaneous and Endoscopic Discectomy
For contained disc herniations producing radicular pain refractory to injections, minimally invasive disc decompression bridges the gap between ESIs and open surgery. Percutaneous discectomy techniques — mechanical, laser, or radiofrequency-based nucleus decompression — remove a small volume of nucleus pulposus through a needle-based approach, reducing intradiscal pressure and nerve root compression. Candidates are patients with contained herniations and preserved disc height; extruded or sequestered fragments are not amenable. Endoscopic discectomy, via transforaminal or interlaminar approach, has advanced considerably and permits direct visualization and removal of herniated fragments through a working-channel endoscope under local anesthesia with sedation. Compared with open microdiscectomy, endoscopic techniques offer comparable outcomes for properly selected herniations with less tissue disruption, same-day discharge, and faster return to function, though outcomes remain operator-dependent and the learning curve is real.
Facet Joint Interventions and Radiofrequency Ablation
Facet (zygapophyseal) joint arthropathy is a common source of axial neck and low back pain, classically presenting with paraspinal pain worsened by extension and rotation, without radicular features. Because imaging correlates poorly with facet-mediated pain, diagnosis rests on medial branch blocks — anesthetic injections of the nerves supplying the joint. Patients with substantial relief from two confirmatory blocks are candidates for radiofrequency ablation (RFA), which thermally lesions the medial branches. Successful RFA typically provides six to twelve months or more of relief; because the nerves regenerate, the procedure can be repeated. Cervical RFA for facet-mediated neck pain, including whiplash-associated disorders, has some of the strongest outcome data in interventional pain medicine when patients are selected with rigorous dual blocks. For patients with recurrent pain after repeated RFA, or anatomy that limits percutaneous lesioning, endoscopic rhizotomy offers direct visualization and transection of the medial branch under endoscopic guidance. The more complete neurotomy may extend the duration of relief beyond that of conventional RFA, and the technique is increasingly used in patients seeking a longer-lasting alternative to serial ablations.
Sacroiliac Joint Procedures
The sacroiliac joint accounts for a meaningful proportion of low back pain, particularly below L5 with referral to the buttock. Diagnostic intra-articular injection with anesthetic confirms the joint as the pain generator, and corticosteroid can extend relief; lateral branch RFA is an option for recurrent pain. For patients with confirmed SI joint pain refractory to these measures, minimally invasive SI joint fusion has emerged as a durable option. Lateral transiliac approaches place triangular titanium implants across the joint, while newer posterior and posterolateral approaches use allograft or screw-based fixation through a smaller corridor, often in an ambulatory setting. Randomized trials of lateral fusion demonstrate sustained improvement in pain and function versus conservative care at two years and beyond. Selection remains critical: patients should have at least a majority reduction of pain on diagnostic block and exclusion of competing lumbar pathology.
Vertebral Augmentation
For painful osteoporotic or malignant vertebral compression fractures refractory to conservative care, vertebroplasty and kyphoplasty deliver polymethylmethacrylate cement into the fractured vertebral body. Kyphoplasty adds balloon-assisted cavity creation with partial height restoration. Best outcomes occur when augmentation is performed within weeks of acute fracture in patients with focal tenderness and MRI evidence of edema.
Neuromodulation
Spinal cord stimulation (SCS) is indicated for persistent spinal pain syndrome after surgery (formerly failed back surgery syndrome), painful diabetic neuropathy, and complex regional pain syndrome. Percutaneous epidural leads deliver electrical stimulation to the dorsal columns; newer paradigms — high-frequency 10 kHz, burst, and closed-loop stimulation — provide paresthesia-free analgesia with improved outcomes over traditional tonic stimulation. A successful externalized trial precedes permanent implantation, offering an unusual advantage: patients test the therapy before committing. Dorsal root ganglion stimulation targets focal neuropathic pain. Intrathecal drug delivery systems remain an option for refractory pain, particularly in cancer populations.
Emerging and Adjunctive Procedures
Basivertebral nerve ablation targets vertebrogenic pain associated with Modic type 1 and 2 endplate changes on MRI, with randomized data showing durable relief in this phenotype. Minimally invasive lumbar decompression (MILD) and interspinous spacers address neurogenic claudication from lumbar stenosis with ligamentum flavum hypertrophy in patients who are poor surgical candidates. Regenerative injectates, including platelet-rich plasma, remain investigational for discogenic pain, and current evidence does not support routine use.
Patient Selection and Referral
The success of interventional pain management hinges less on the procedure than on matching the intervention to the pain generator. A focused history distinguishing axial from radicular pain, correlation with imaging, and a stepwise diagnostic approach improve outcomes considerably. Anticoagulation management, infection risk, and psychological comorbidities warrant attention before referral. Interventional procedures work best embedded within multimodal care that includes rehabilitation and, where appropriate, behavioral health support — a framing that serves both referring physicians and their patients well.
Dr. V.K. Puppala, MD, is a double-board certified anesthesiology and pain medicine specialist and the founder and medical director of Comprehensive Spine & Pain in Metro Atlanta. A Washington University School of Medicine graduate, he serves as Clinical Assistant Professor of Anesthesiology at the Medical College of Georgia and on the Editorial Board of Pain Physician Reports. He specializes in interventional techniques including epidurals, percutaneous discectomies, endoscopic procedures, nerve blocks & ablations, kyphoplasty, and spinal cord stimulation to treat complex pain conditions at their source to avoid relying solely on medications that merely mask the symptoms.
