Spinal pain is very difficult to diagnose, the more so as patients get older. They present with different things on their MRI, different findings on exam, and they’ve had chronic pain for many years. Unfortunately, a lot of the physical exam and history findings are very generalizable, so it’s hard to tease out where the actual pain is coming from. The most common procedures that we do for spinal pain are epidural steroid injections, lumbar facet interventions, including medial branch blocks which is numbing the nerves that go to these facet joints, as well as radiofrequency ablation which is burning those nerves that go to the facet joints to hopefully provide longer pain relief than just the facet joint blocks. For epidural steroid injections, the most common indication is pain that travels down the legs from either spinal stenosis or a herniated disc which is impinging on a nerve root. Facet joint pain typically presents with more lower back pain and so unfortunately physical exam and history findings are not very specific. Doing diagnostic nerve blocks or medial branch blocks can help make that diagnosis, and if positive, a radiofrequency ablation may provide the patient with longer term relief.
Patients at risk for poorer outcomes from interventional procedures would include those on high-dose opioids or on chronic opioid therapy. Also, patients that have failed every other modality; patients you’ve sent to physical therapy, acupuncture; you’ve tried medications on them. Typically, interventional procedures don’t tend to do as well in these patients. It doesn’t mean we don’t do them, but typically your outcomes are going to be less favorable than somebody who’s responded in the past to other procedures.