Chronic pain patients usually need prescription medication, which is the next step on the progression of drugs and medications. What the doctor prescribes is dependent on your pain level, treatment goals, and general health. He or she will take into consideration other medications (and herbal remedies and supplements) that you’re taking. Be sure to tell your doctor about everything you’re on because of possible drug interactions.

Medial Branch Blocks target the medial branch nerves. Medial branch nerves are very small nerves that communicate pain from the spine’s facet joints (fah-set joints)

Discography, or discogram, is a diagnostic tool used to determine the structural integrity of an intervertebral disc (or discs) and if a particular disc is responsible for the patient’s back pain. Provocative Discography is a form of discography that replicates the patient’s ‘discogenic’ pain. The term discogenic is defined as a pain syndrome characterized by local or radicular pain cause by nerve root compression.


Steroid injections are potent anti-inflammatory agents injected directly into the epidural space located close to the affected nerve roots. The epidural space is the area surrounding the spinal cord and nerve roots. These injections are most effective in the presence of nerve root compression.

Radiofrequency is a means of interrupting pain signals. An electrical current produced by radio waves is used to heat up a small area of nerve tissue, thereby decreasing pain signals from that specific area supplied by that nerve. The nerve facet joint is the target for RFA. Clinical data shows that radiofrequency ablation can effectively provide lasting pain relief.


The entire decompression is performed percutaneously through a needle. Patients who can benefit from percutaneous disc decompression or ‘percutaneous discectomy’ as it is called, are those with pain arising from a contained herniated disc – that is a bulging disc where there is no rupture in the outer wall.


Other Treatments

Intradiscal electrothermal therapy is a minimally invasive treatment in which the physician applies controlled levels of thermal energy (heat) to a broad section of the affected disc wall. This heat contracts and thickens the collagen of the disc wall, and raises the temperature of the nerve endings.

A block that is performed under fluoroscopy to determine if there is damage to the sympathetic nerve chain and if it is the source of the patient’s arm pain. This is primarily a diagnostic block but it may provide pain relief in excess of the duration of the anesthetic.

A sympathetic nerve block involves injecting numbing medicine around the sympathetic nerves in the low back or neck. By doing this, the sympathetic nervous system in that area is temporarily ‘switched’ off in hopes of reducing or eliminating pain. If pain is substantially improved after the block, then a diagnosis of sympathetically mediated pain is established.

Kyphoplasty is an innovative technique that combines vertebroplasty with balloon catheter technology developed for angioplasty. The procedure demonstrates positive outcomes in the treatment of painful, progressive osteoporotic or osteolytic vertebral compression fractures. Cleveland Clinic orthopaedic surgeons have been instrumental in its development and clinical evaluation.


Kyphoplasty is an innovative technique that combines vertebroplasty with balloon catheter technology developed for angioplasty. The procedure demonstrates positive outcomes in the treatment of painful, progressive osteoporotic or osteolytic vertebral compression fractures. Cleveland Clinic orthopaedic surgeons have been instrumental in its development and clinical evaluation.

A Hypogastric Plexus Block is a pain management treatment, as well as a simple technique, elected by patients who are experiencing pain. The hypogastric plexus is a collection of nerves that is located near the lower part of your abdomen in the upper front of your pelvis. A hypogastric plexus block is a specialty procedure which involves placing an anesthetic near the region of the plexus.

Indications for celiac plexus block include use as a diagnostic tool to determine whether flank, retroperitoneal, or upper abdominal pain is sympathetically mediated via the celiac plexus, to palliate pain secondary to acute pancreatitis and intra-abdominal malignancies, and to reduce the pain of abdominal “angina” associated with visceral arterial insufficiency.

Neurolysis of the celiac plexus with alcohol or phenol is indicated to treat pain secondary to malignancies of the retroperitoneum and upper abdomen and in some chronic benign abdominal pain syndromes, such as chronic pancreatitis, in carefully selected patients.

Additional Facts:
The celiac plexus arises from the preganglionic splanchnic nerves, vagal preganglionic parasympathetic fibers, sensory fibers from the phrenic nerve and postganglionic sympathetic fibers. The celiac plexus is anterior to the diaphragmatic crura. It extends in front of and around the aorta, with the greatest concentration of fibers anterior to the aorta. Blockade of these neural structures, which include the afferent fibers carrying nociceptive information, is properly termed celiac plexus block. Note that the phrenic nerve also transmits nociceptive information from the upper abdominal viscera that may be perceived as poorly localized pain referred to the supra-clavicular region.

The normal configuration of these structures may be dramatically distorted owing to organomegaly or tumor. The aorta lies anterior and slightly to the left of the anterior margin of the vertebral body. The inferior vena cava lies to the right of the midline, and the kidneys are posterolateral to the great vessels. The pancreas lies anterior to the celiac plexus. All of these structures lie within the retroperitoneal space.


By placing numbing medicine into the joint, the amount of immediate pain relief you experience will help confirm or deny the joint as a source of your pain. That is, if you obtain complete relief of your main pain while the joint is numb it means this joint is more likely than not your pain source. Furthermore, time-release cortisone will be injected into the joint to reduce any presumed inflammation, which on many occasions can provide long-term pain relief.


To make sure the patient will benefit from SCS, a temporary system is implanted and tried for a few days or a week. For the SCS trial, leads are placed beneath the skin and attached to a small generator the patient carries. The generator is similar to a pager or cell phone.


Peripheral Nerve Stimulation is a technique that is considered to be very similar to SCS except that the neural elements being stimulated lie outside of the spinal column. This method has been successfully applied in the treatment of refractory transformed migraines. It has also been successfully applied in an anecdotal manner by the authors and others for the treatment of focal, intense low back pain. This technique involves the placement of an epidural needle immediately beneath the skin peripheral to the center of a focal region of pain. The needle is then directed into the long axis of the pain so that the distal 5 cm of the needle crosses through the middle of the most intense pan. An eight-channel SCS lead is then advanced into the needle and the needle is removed. The lead is then trialed for efficacy in a manner similar to an SCS trial. This method of PNS provides a very dense, focused parasthesia and is often successful at relieving intense low back pain when SCS alone failed. As a result, when a patient with an intense, focused region of low back pain has poor result from a trial SCS, a PNS trial should be considered in lieu of or in addition to a traditional SCS trial. The authors have had several anecdotal cases in which a combination of PNS and SCS has succeeded in patients who have had a poor result from the antegrade placement of a percutaneously placed lead despite coverage of the patient’s pain pattern with paresthesia. Studies focused on the combination of PNS and SCS in selected cases may improve long-term success rates.


A Intrathecal pump or spinal pump is round and about the size of a hockey puck. During the surgery, it will be placed under the fat in your abdomen or buttock, and then a catheter will run from the pump to the thecal sac (the area around your spinal cord that’s filled with cerebrospinal fluid). Generally, this is an outpatient surgery that takes just one to two hours, so you should be able to go home the same day.


Peripheral nerves are the nerves outside of the brain and spinal cord. These nerves transmit sensation and motor (movement) control. They can be damaged by trauma, surgery, scar tissue, or illness. Blocks of peripheral nerves can help provide relief.

Intra-articular injections are but one of the clinician’s many tools for the treatment of musculoskeletal disorders. Injections should be considered an adjunct to the overall treatment plan-never the sole component of therapy. Injections may be used diagnostically as well as therapeutically and are generally safe when used judiciously by a skilled practitioner.

Additional Facts:
Peripheral joint injections (upper extremity/ lower extremity are usually done in the inflamed joint of concern, i e. shoulder, elbow, hip, wrist, ankle and knee. Joint pain may be caused by bursitis, tendonitis, or arthritis. These disorders may be acute or chronic in nature. The physician may direct these joint injections with or without needle guidance. Many times musculoskeletal ultrasound will be used for specific needle guidance. The medications used in these are anesthetic and steroids/Sarapin. The standard of care is 1-3 injections within a nine to twelve month period. Small joint injections can also be beneficial wrist elbows, ankles and finger/toe joints.

Epidural adhesiolysis is a catheterization procedure used to treat chronic back pain by eliminating from the epidural space fibrous tissue that can prevent direct application of drugs to nerves or other tissues. A 16-guage RK needle followed by the advancement of a Racz catheter enters the epidural space either caudally, using an interlaminar approach, or by a transforaminal approach. Under radiographic control utilizing nonionic contrast medium, local anesthetic and steroid are injected into the epidural space through the catheter. Lysis of adhesions is then carried out by slow and intermittent injections of hypertonic saline. Catheter manipulation and hypertonic saline both aid in adhesion disruption.