Radu Physiatry · Patient education

The Complete Procedure Reference

Every procedure offered in modern pain medicine, explained the same way: what it is, who it helps, and what actually happens — step by step where it matters. Illustrations are simplified; your physician will tailor everything to you. All 52 of them are here — what each one is, what the research shows, and what it feels like to have it done.

💉 Epidural steroid injections · 5

Anti-inflammatory medicine delivered into the epidural space — the protective sleeve around the spinal nerves — to calm an inflamed nerve root. Different doorways, same destination.

Lumbar Epidural — Interlaminar

The classic approach for sciatica, entering between the laminae at the midline

Anti-inflammatory medicine placed into the epidural space of the low back through the midline window between two vertebrae.

Often used for: Sciatica from disc herniation or stenosis, often with back pain.

~15 minutesX-ray guidedHome the same day🖨 Printable handout
📚Epidurals reliably shorten severe sciatica flares; large reviews show the biggest benefit in the first weeks to months. Liu C et al. · BMJ 2023 ↗
The anatomy — medical illustration
1The anatomy

The epidural space (teal) surrounds and cushions the nerves of the low back.

Where the pain starts — medical illustration
2Where the pain starts

A herniated disc presses on a nerve root and inflames it — pain shoots down the leg.

The procedure — medical illustration
3The procedure

Face down, skin numbed, a very thin needle guided by X-ray between the vertebrae.

Relief delivered — medical illustration
4Relief delivered

Steroid and anesthetic bathe the inflamed root — outside the nerve sac — so it can settle.

▶ Watch how it works (10-second animation)
What to expect: Home the same day; relief typically builds over 3–7 days.

Cervical Epidural — Interlaminar

The neck version, for nerve pain radiating into the shoulder or arm

The same medicine delivered into the epidural space of the neck, entering at its widest, safest level near the base.

Often used for: Pinched cervical nerves — arm pain, tingling, numbness from disc herniation or spondylosis.

~15 minutesX-ray guidedHome the same day🖨 Printable handout
📚Reviews of cervical interlaminar ESI report meaningful relief in radicular arm pain with careful technique. House LM et al. · Phys Med Rehabil Clin N Am 2018 ↗
The anatomy — medical illustration
1The anatomy

Nerve roots exit between the neck vertebrae toward the shoulders and arms; the epidural space cushions the cord.

Where the pain starts — medical illustration
2Where the pain starts

A worn or herniated disc inflames an exiting root — pain travels along its path into the arm.

The procedure — medical illustration
3The procedure

Face down with the forehead supported; a thin needle advanced under continuous X-ray at the base of the neck.

Relief delivered — medical illustration
4Relief delivered

Medication spreads gently upward through the epidural space; the needle never touches the spinal cord.

What to expect: Mild soreness for a day or two; relief builds over the week.

Transforaminal Epidural (Nerve Root Injection)

Medicine delivered through the nerve's own doorway — the most targeted epidural

Instead of the midline, the needle approaches the small side window (foramen) where one specific nerve root exits — placing concentrated medicine exactly at the inflamed root.

Often used for: Sciatica or arm pain clearly traced to one nerve level; also used as a diagnostic test of which level is the culprit.

~15 minutesX-ray + contrastMost targeted option
📚Head-to-head trials show transforaminal delivery concentrates medicine along the exact inflamed root. Ozturk EC et al. · Pain Med 2023 ↗
The nerve's doorway — medical illustration
1The nerve's doorway

Each nerve root leaves the spine through its own small window between the vertebrae — the foramen.

A crowded doorway — medical illustration
2A crowded doorway

A disc bulge or bone spur can narrow the foramen and pinch the root right in the doorway.

The procedure — medical illustration
3The procedure

From an oblique angle, a thin needle rests at the outer opening of the foramen; contrast dye confirms it outlines the nerve sleeve.

Relief delivered — medical illustration
4Relief delivered

Medication flows inward along the root sleeve into the epidural space — full strength, exactly where the problem lives.

▶ Watch how it works (10-second animation)
What to expect: Brief pressure or a familiar 'zing' down the limb can happen as contrast spreads — expected and useful. Relief builds over days.

Caudal Epidural

Entering from below through the tailbone's natural opening

The epidural space is reached through the sacral hiatus — a natural opening at the very base of the spine — letting a larger volume of medicine wash upward over many nerve roots.

Often used for: Multi-level stenosis, post-surgical backs where scar changes the anatomy, and when other windows are hard to enter safely.

~15 minutesX-ray guidedGood after prior surgery
📚Trials support the caudal route as a safe, effective option — especially after previous surgery. Ibrahim ME et al. · BJR Open 2020 ↗
The anatomy — medical illustration
1The anatomy

At the bottom of the sacrum sits a small natural opening between two bony horns — the sacral hiatus.

The procedure — medical illustration
2The procedure

A thin needle slips through the hiatus at a shallow angle into the sacral canal — far below where the nerve sac ends.

Relief delivered — medical illustration
3Relief delivered

A generous volume of medication spreads upward through the epidural space, bathing several roots at once.

▶ Watch how it works (10-second animation)
What to expect: Pressure at the tailbone during injection is normal. Home the same day.

Epidural Lysis of Adhesions (Racz)

Frees nerves trapped in post-surgical scar tissue

A steerable catheter is guided into the epidural space to mechanically open scarred compartments and deliver medication directly to nerve roots that standard epidurals can no longer reach.

Often used for: Post-laminectomy pain, epidural scarring, failed standard epidurals.

~45 minutesSteerable catheterTargets scarred segments
📚Controlled studies support percutaneous adhesiolysis when post-surgical scarring blocks standard epidurals. Manchikanti L et al. · Anesth Pain Med 2016 ↗
How it works — medical illustration
How it works

Frees nerves trapped in post-surgical scar tissue

What to expect: Sometimes done as a series. Relief comes from freeing the root and bathing it in medication where scar had walled it off.

🦴 Facet & SI joint treatments · 5

For the small joints of the spine and the two large joints where it meets the pelvis — test first, then treat.

Lumbar Medial Branch Blocks → RFA

Test the joints, then switch off their pain nerves with precise heat

Each facet joint reports pain through two tiny medial branch nerves. Numbing them is the test; radiofrequency heat is the durable treatment.

Often used for: Facet arthritis pain — worse standing, arching, twisting.

Two visitsX-ray guidedRelief often 9–18 months🖨 Printable handout
📚Randomized trials show radiofrequency denervation gives months-long relief when diagnostic blocks confirm facet pain. Chen YS et al. · Pain Physician 2022 ↗
The pain source — medical illustration
1The pain source

Arthritic facet joints ache through their tiny medial branch nerves.

The test block — medical illustration
2The test block

A drop of numbing medicine at each branch. Substantial relief for hours = joints confirmed.

Radiofrequency ablation — medical illustration
3Radiofrequency ablation

A heated tip creates a millimeters-wide lesion alongside each confirmed nerve.

Lasting relief — medical illustration
4Lasting relief

The joint's message no longer reaches the spine; nerves regrow slowly and it can be repeated.

What to expect: Up to a week of soreness after ablation, then steady relief over 2–4 weeks.

Cervical Medial Branch Blocks → RFA

The neck version — including headaches that start at the skull base

The identical two-step logic applied to the neck's facet joints.

Often used for: Facet-driven neck pain, stiffness, and cervicogenic headaches.

Two visitsX-ray guidedRelief often 9–18 months🖨 Printable handout
📚The classic randomized trial of cervical radiofrequency neurotomy showed durable relief in confirmed facet-mediated neck pain. Lord SM et al. · Neurosurgery 1995 ↗
The pain source — medical illustration
1The pain source

Arthritic neck facets — commonly behind neck pain that's worse looking up or turning.

The test block — medical illustration
2The test block

Thin needles place numbing drops where each medial branch crosses its bony pillar.

Radiofrequency ablation — medical illustration
3Radiofrequency ablation

One small, controlled heat lesion per confirmed nerve.

Lasting relief — medical illustration
4Lasting relief

Typically 9–18 months; repeatable when the nerves regrow.

▶ Watch how it works (10-second animation)
What to expect: A test block wearing off same-day is expected — it's a diagnostic.

Facet Joint Injection (Intra-articular)

Medicine placed directly inside the joint itself

A thin needle enters the facet joint capsule and delivers steroid directly inside — sometimes chosen for younger joints, inflammatory flares, or cysts.

Often used for: Painful facet joints, especially inflammatory flares; also confirms the joint as the source.

~15 minutesX-ray + contrastJoint-targeted
📚Intra-articular facet injections can calm an inflamed joint, though blocks of the nerves predict RFA response better. Suputtitada A et al. · Medicina (Kaunas) 2023 ↗
Into the joint — medical illustration
Into the joint

Under X-ray, the needle slips into the small joint space; a crescent of contrast confirms it's inside the capsule.

What to expect: Relief from the anesthetic within hours (diagnostic), steroid effect over the week.

Sacroiliac Joint Injection

Where the spine meets the pelvis

Image-guided anti-inflammatory injection into the SI joint.

Often used for: One-sided low-back/buttock pain — standing from a chair, stairs, rolling in bed.

~15 minutesX-ray guidedAlso diagnostic🖨 Printable handout
📚Image-guided SI injections both confirm the diagnosis and deliver relief in sacroiliac dysfunction. Newman DP et al. · Am Fam Physician 2022 ↗
The anatomy — medical illustration
1The anatomy

Two strong, ligament-wrapped joints transfer your upper-body weight into the legs.

Where the pain starts — medical illustration
2Where the pain starts

An inflamed SI joint causes one-sided buttock pain, sometimes to the thigh.

The procedure — medical illustration
3The procedure

A thin needle enters the lower joint; contrast confirms placement.

Relief delivered — medical illustration
4Relief delivered

Medication fills the joint and calms the inflammation.

▶ Watch how it works (10-second animation)
What to expect: Anesthetic may give hours of early relief; steroid builds over the week.

SI Joint Radiofrequency (Lateral Branch RFA)

For SI pain that returns after successful injections

The SI joint's small lateral branch nerves along the sacrum's edge are quieted with a row of precise heat lesions — the longer-lasting follow-up when injections work but wear off.

Often used for: Recurrent, injection-confirmed SI joint pain.

~30–45 minutesX-ray guidedRelief often 9–12+ months
📚Cooled lateral-branch radiofrequency extends relief for block-confirmed SI pain in controlled studies. Lee DW et al. · Interv Pain Med 2023 ↗
A row of quiet switches — medical illustration
A row of quiet switches

Small cannulae line the sacral edge where the joint's tiny branches cross, each making one controlled lesion.

What to expect: Soreness up to a week, then durable relief for many patients.

🔥 Targeted nerve ablations · 3

When a specific small nerve is proven to carry the pain, precise heat or cold can silence it for months to years — while everything around it is protected.

Genicular Nerve Block → RFA (Knee)

Quieting the knee's pain wiring — without touching the joint

Three small genicular nerves carry pain from the knee capsule. After a numbing test confirms them, radiofrequency heat quiets each one at its bony landmark.

Often used for: Painful knee arthritis when surgery isn't wanted or isn't an option — and persistent pain after knee replacement.

Two visitsX-ray or ultrasoundWalk the same day
📚Randomized data show genicular nerve ablation reduces knee OA pain for 6–12 months in well-selected patients. Soetjahjo B et al. · Pain Physician 2024 ↗
The knee's pain wiring — medical illustration
1The knee's pain wiring

Three small nerves curve around the knee — above-inner, above-outer, below-inner — carrying its pain signals.

The worn joint — medical illustration
2The worn joint

Arthritic cartilage and bone spurs make the joint ache; its little nerves report every step.

Radiofrequency ablation — medical illustration
3Radiofrequency ablation

Three slender cannulae — one per nerve — each create a small, precise heat lesion.

Walking comfortably — medical illustration
4Walking comfortably

With the pain wiring quiet, the same knee carries you further; relief often lasts 6–12+ months.

▶ Watch how it works (10-second animation)
What to expect: The knee itself is unchanged — this treats the pain, so keep strengthening (see the knee exercise program).

Basivertebral Nerve Ablation (Intracept)

For 'vertebrogenic' back pain that lives inside the bone itself

Some chronic low-back pain comes from the endplates of a worn disc's neighboring bone, reported by a tiny nerve INSIDE the vertebra. A one-time probe quiets that nerve at its trunk.

Often used for: Chronic midline low-back pain with characteristic endplate changes on MRI (Modic changes), present for 6+ months despite conservative care.

One sessionImplant-freeDurable in trials (5+ yrs)
📚Five-year pooled trial data show durable relief from basivertebral nerve ablation in vertebrogenic low back pain. Khalil JG et al. · Interv Pain Med 2024 ↗
A nerve inside the bone — medical illustration
1A nerve inside the bone

The basivertebral nerve branches like a small tree inside each vertebra, reporting wear at the endplates.

The ablation — medical illustration
2The ablation

Through the pedicle, a curved probe reaches the nerve's trunk and quiets it with contained heat — nothing is left behind.

▶ Watch how it works (10-second animation)
What to expect: Improvement typically consolidates over 6–12 weeks; trial data show multi-year durability.

Cryoneurolysis (Nerve Freezing)

A tiny ice ball pauses a painful nerve — it regrows over months

A probe forms a small precise ice ball around a painful peripheral nerve, pausing its signal for weeks to months while it slowly regrows — a gentle, repeatable option.

Often used for: Focal nerve pain: around the knee, occipital region, intercostal/post-thoracotomy pain, some neuromas.

Office-basedUltrasound guidedReversible by design
📚Growing trial data support cryoneurolysis for months of relief in knee and other focal nerve pain. Diep D et al. · Interv Pain Med 2023 ↗
The freeze — medical illustration
The freeze

A frosted micro-ice-ball forms around the nerve, pausing conduction without cutting anything.

What to expect: Numbness in that nerve's small territory is expected and temporary.

🕸️ Sympathetic & visceral blocks · 7

The sympathetic chains are the body's 'automatic' nerves — circulation, sweating, visceral pain. Blocking the right junction box can switch off pain that ordinary nerves don't explain.

Stellate Ganglion Block

The neck's sympathetic junction box — for CRPS and nerve pain of the arm and face

Local anesthetic placed beside the stellate ganglion — the sympathetic relay at the base of the neck — resetting overactive circuits to the arm, face, and heart region.

Often used for: Complex regional pain syndrome of the arm, some facial and post-herpetic pain, circulation disorders; being studied for PTSD.

~15 minutesUltrasound/X-rayEffects can outlast the drug
📚Systematic review supports stellate ganglion blocks for sympathetically-maintained arm CRPS. Tian Y et al. · Pain Physician 2024 ↗
The junction box — medical illustration
1The junction box

A chain of small ganglia runs in front of the spine; the stellate sits at the neck's base, wired to the arm and face.

The overactive circuit — medical illustration
2The overactive circuit

In CRPS the automatic wiring misfires — the hand burns, swells, changes color and temperature.

The block — medical illustration
3The block

A thin needle from the front of the neck bathes the ganglion in anesthetic — vessels and airway kept safely aside.

The reset — medical illustration
4The reset

The arm warms and calms as the circuit resets. A droopy eyelid for a few hours means the block worked.

▶ Watch how it works (10-second animation)
What to expect: Temporary hoarseness or eyelid droop = expected signs of success. Blocks are often given as a series while therapy retrains the limb.

Lumbar Sympathetic Block

The same reset for the leg

Anesthetic placed along the sympathetic chain on the front-side of the lumbar spine — the relay for the leg's automatic circulation and pain amplification.

Often used for: CRPS of the leg, some vascular and post-herpetic pain, phantom limb pain.

~20 minutesX-ray guidedOften a series
📚Lumbar sympathetic blocks remain the standard test — and often treatment — for sympathetically-maintained leg pain. Xu Y et al. · Pain Ther 2023 ↗
The chain — medical illustration
The chain

Beads of sympathetic ganglia run along the front of the lumbar vertebrae, wired to the leg.

What to expect: A warm, flushed leg right after = the block is working.

Celiac Plexus Block / Neurolysis

For deep upper-abdominal pain — especially cancer pain

The celiac plexus — the nerve web in front of the aorta serving the upper abdominal organs — is bathed in anesthetic (block) or, for cancer pain, longer-acting agents (neurolysis).

Often used for: Pancreatic and other upper-abdominal cancer pain; select chronic pancreatitis.

~30 minutesImage guidedCan cut opioid needs
📚Meta-analysis: celiac plexus neurolysis reduces pancreatic cancer pain and opioid needs. Okita M et al. · Pain Pract 2022 ↗
The web — medical illustration
1The web

A delicate nerve web wraps the aorta below the diaphragm, carrying pain from stomach, pancreas, liver.

The block — medical illustration
2The block

Two thin needles from the back meet the web from both sides and envelop it in medication.

What to expect: Temporary blood-pressure dip or looser stools can follow — monitored. Many patients need less opioid after.

Ganglion Impar Block

The single midline junction for tailbone and pelvic-floor pain

A solitary ganglion in front of the tailbone serves the deep pelvis. One drop of medicine there can quiet coccyx and perineal pain.

Often used for: Coccydynia, perineal/rectal pain syndromes.

~10 minutesX-ray guidedSmall but mighty
📚Case series and cohorts consistently report meaningful relief from ganglion impar blocks in coccydynia. Saldanha J et al. · Cureus 2025 ↗
One small target — medical illustration
One small target

The ganglion impar nestles in front of the last coccyx segment; a fine needle reaches it from below.

What to expect: Often combined with a tailbone cushion + pelvic-floor therapy plan.

Superior Hypogastric Plexus Block

Quiets the nerve relay station for the pelvic organs

Local anesthetic (sometimes followed by neurolysis) placed at the nerve web in front of the lowest lumbar vertebra — the relay station carrying pain from bladder, uterus, prostate and rectum.

Often used for: Pelvic pain from cancer, endometriosis, or chronic pelvic pain syndromes.

~30 minutesX-ray or CT guidedOften repeated or made longer-lasting
📚Controlled series show superior hypogastric neurolysis reduces pelvic cancer pain and opioid use. Rocha A et al. · Pain Physician 2020 ↗
How it works — medical illustration
How it works

Quiets the nerve relay station for the pelvic organs

What to expect: Home the same day. A diagnostic block that helps strongly may be followed by a longer-lasting version.

Splanchnic Nerve Block / RFA

The upper-abdomen pain pathway, treated where it crosses the spine

The splanchnic nerves carry pain from the pancreas, stomach and liver along the lower chest vertebrae. They can be numbed, and then treated with radiofrequency heat for durable relief.

Often used for: Pancreatic and other upper-abdominal cancer pain; chronic pancreatitis pain.

~30–45 minutesX-ray guidedBlock first, RFA if it works
📚Radiofrequency of the splanchnic nerves provides durable relief in chronic pancreatitis series. Garcea G et al. · ANZ J Surg 2005 ↗
How it works — medical illustration
How it works

The upper-abdomen pain pathway, treated where it crosses the spine

What to expect: Home the same day. When the diagnostic block works well, radiofrequency can extend relief for months.

Sphenopalatine Ganglion Block

A nerve cluster behind the nose that drives face and head pain

A tiny nerve bundle just behind the nasal cavity feeds many headache and facial pain syndromes. It can be reached with a soft applicator through the nostril — no needle through skin.

Often used for: Cluster headache, certain migraines, facial pain (including some trigeminal patterns).

~15 minutesThrough the nostrilCan be repeated
📚Reviews support sphenopalatine ganglion blocks across several headache and facial pain disorders. Ho KWD et al. · J Headache Pain 2017 ↗
How it works — medical illustration
How it works

A nerve cluster behind the nose that drives face and head pain

What to expect: Quick and surprisingly gentle: numbing medicine wicks to the ganglion through the thin nasal wall. Some clinics teach self-administration.

⚡ Neuromodulation · 5

Instead of blocking or burning, these therapies talk to the nervous system in its own language — electricity — and are always test-driven first.

Spinal Cord Stimulation

A pacemaker for pain — trialed for a week before any implant

Gentle electrical pulses delivered over the spinal cord mask pain signals before they reach the brain. A no-incision trial week always comes first.

Often used for: Persistent nerve pain after back surgery, painful neuropathy, CRPS.

Trial ≈ 1 weekReversibleYou stay in control🖨 Printable handout
📚The SENZA randomized trial: 10-kHz spinal cord stimulation outperformed traditional stimulation for back and leg pain. Kapural L et al. · Anesthesiology 2015 ↗
How pain travels — medical illustration
1How pain travels

Chronic nerve pain climbs the spinal cord to the brain — soften it on the way up and the brain receives less.

The trial — no incision — medical illustration
2The trial — no incision

Temporary leads through a needle; a small external stimulator on a belt; you live your normal week.

How it works — medical illustration
3How it works

Gentle pulses scramble the ascending signal — soft tingling, or simply less pain.

The implant — medical illustration
4The implant

If the trial earns it (≥50% relief), a pacemaker-like battery goes under the skin. Remote controlled, removable.

What to expect: The trial IS the decision: you judge the benefit at home before anything permanent.

Peripheral Nerve Stimulation

The same idea, miniaturized to a single nerve

A fine lead placed alongside one painful peripheral nerve delivers gentle pulses that mask its signal — some systems are temporary (60 days), some permanent.

Often used for: Focal nerve pain: shoulder (suprascapular/axillary), knee, occipital, post-amputation, post-surgical.

Needle placementUltrasound guidedTemporary or implanted
📚Systematic reviews support percutaneous peripheral nerve stimulation for focal chronic nerve pain. Xu J et al. · Pain Physician 2021 ↗
One painful nerve — medical illustration
1One painful nerve

A single nerve segment misfires; the rest of the limb is fine.

The lead — medical illustration
2The lead

Through a needle, a fine lead comes to rest alongside the nerve — no incision.

Masking the signal — medical illustration
3Masking the signal

Gentle waves wash the nerve's red signal quiet; a wearable or small implant powers it.

▶ Watch how it works (10-second animation)
What to expect: 60-day temporary systems can 'retrain' pain lastingly; implanted versions are for durable focal pain.

Intrathecal Pain Pump

Medicine delivered where it works — at a fraction of the oral dose

A small implanted pump feeds tiny, precise doses of medication directly into the spinal fluid — often achieving with milligrams what pills need grams to do, with fewer systemic side effects.

Often used for: Refractory cancer pain; select severe chronic pain and spasticity (baclofen).

Trial firstRefilled in officeProgrammable
📚A randomized trial in cancer pain: intrathecal pumps improved pain control AND reduced medication toxicity. Smith TJ et al. · J Clin Oncol 2002 ↗
The target compartment — medical illustration
1The target compartment

The fluid-filled intrathecal space bathes the spinal cord — medication here acts directly on pain pathways.

Why so little goes so far — medical illustration
2Why so little goes so far

Oral dosing floods the whole body; intrathecal dosing whispers directly to the spine at ~1/100th the dose.

The system — medical illustration
3The system

A slim pump under the abdominal skin, a fine catheter curving to the spine.

Living with it — medical illustration
4Living with it

Refills by a simple office needle-stick every few months; dosing adjusted wirelessly.

What to expect: Always preceded by a trial dose that proves benefit first.

Dorsal Root Ganglion (DRG) Stimulation

Pinpoint neurostimulation for focal nerve pain

A cousin of spinal cord stimulation that parks a tiny electrode on the dorsal root ganglion — the nerve’s "junction box" — letting very focused areas like one foot, knee or the groin be treated precisely.

Often used for: CRPS of a foot or knee, groin pain after hernia surgery, other focal nerve injuries.

Trial first, like SCSImplanted if the trial worksVery focal coverage
📚The ACCURATE randomized trial: DRG stimulation beat conventional SCS for focal CRPS of the lower limb. Deer TR et al. · Pain 2017 ↗
How it works — medical illustration
How it works

Pinpoint neurostimulation for focal nerve pain

What to expect: You test-drive it for about a week first. DRG stimulation has landmark-trial evidence in focal CRPS.

Restorative Neurostimulation (Multifidus)

Retrains the spine’s deep stabilizing muscle

For chronic mechanical low back pain, an implanted device twitches the multifidus — the deep stabilizer that "switches off" in chronic back pain — twice a day, rebuilding its function over months.

Often used for: Chronic mechanical low back pain with poor muscle control, when therapy alone has stalled.

Implanted device30-minute sessions at homeBenefit builds over months
📚Five-year data show restorative multifidus stimulation produces accumulating, durable improvement in mechanical low back pain. Gilligan C et al. · Neuromodulation 2024 ↗
How it works — medical illustration
How it works

Retrains the spine’s deep stabilizing muscle

What to expect: Different philosophy from SCS: instead of masking pain signals it restores muscle control, so improvement accumulates gradually.

🏗️ Vertebral, disc & structural procedures · 8

When the problem is the architecture — a cracked vertebra, a canal grown too tight — these restore the structure through instruments the width of a pencil.

Kyphoplasty / Vertebroplasty

Stabilizing a painful spinal compression fracture from within

Through a pencil-width cannula, a small balloon re-expands the collapsed vertebra and medical cement stabilizes it — often turning severe movement-pain off within days.

Often used for: Painful osteoporotic (or tumor-related) vertebral compression fractures.

~30–45 minutesX-ray guidedOften rapid relief
📚The FREE randomized trial showed faster pain and function recovery with kyphoplasty versus non-surgical care. Svedbom A et al. · Osteoporos Int 2013 ↗
The fracture — medical illustration
1The fracture

A vertebral body collapses into a wedge — every movement grinds the crack, and posture tips forward.

The balloon — medical illustration
2The balloon

Via the pedicle, a small balloon gently lifts the collapsed bone back toward its height.

The cement — medical illustration
3The cement

The space is filled with bone cement — the crack is knitted, the pain generator stabilized.

▶ Watch how it works (10-second animation)
What to expect: Many patients feel dramatically better within 24–72 hours. Bone-health treatment matters just as much afterward.

MILD / Interspinous Spacer (Vertiflex)

More room for the nerves in lumbar stenosis — without open surgery

Two implant-light options for stenosis: MILD trims the thickened ligament through a tiny port; a Vertiflex spacer props open the space between spinous processes. Both aim to let you stand and walk longer.

Often used for: Lumbar spinal stenosis with classic 'shopping-cart' walking limitation.

OutpatientX-ray guidedMotion preserved
📚Reviews support percutaneous image-guided decompression (mild®) for stenosis with thickened ligament. Kaye AD et al. · Adv Ther 2021 ↗
Making room — medical illustration
Making room

Through a pencil-width tube, excess ligament is trimmed — the canal visibly opens and the nerves decompress.

What to expect: Walking distance is the scoreboard — most gains show over the first weeks as the nerves calm.

Provocation Discography

A diagnostic test that asks each disc directly: 'is it you?'

Contrast is injected into individual discs to see their internal structure and — crucially — whether pressurizing a specific disc reproduces YOUR familiar pain. Purely diagnostic, usually before surgical decisions.

Often used for: Selecting (or ruling out) discs before fusion or other structural decisions.

Diagnostic onlyX-ray + CTAnswers, not treatment
📚Provocation discography remains debated: reviews stress careful technique and selection. Wolfer LR et al. · Pain Physician 2008 ↗
What to expect: A positive test = your exact pain reproduced at low pressure in one disc while neighbors stay quiet.

Sacroplasty

Cement reinforcement for a fractured sacrum

The sacral cousin of kyphoplasty: medical bone cement stabilizes insufficiency fractures of the sacrum — a common, underdiagnosed cause of severe sitting and walking pain in osteoporosis.

Often used for: Sacral insufficiency fractures, some sacral tumor-related fractures.

~45 minutesCT or X-ray guidedOften rapid relief
📚Series report rapid, substantial relief after sacroplasty for sacral insufficiency fractures. Collins AP et al. · J Bone Joint Surg Am 2025 ↗
How it works — medical illustration
How it works

Cement reinforcement for a fractured sacrum

What to expect: Like kyphoplasty, pain relief can be dramatic within days as the fracture is internally splinted.

Interspinous Spacer

A small implant that holds the "standing room" open

For lumbar stenosis, a small H-shaped spacer placed between two spinous processes keeps the segment slightly flexed — preserving the canal space that opens when you sit — without removing bone.

Often used for: Neurogenic claudication from lumbar stenosis in patients who get relief by sitting or leaning forward.

~1 hour, outpatientSmall midline incisionReversible; preserves anatomy
📚Randomized data support interspinous spacers for claudication that eases with sitting. Zaina F et al. · Cochrane Database Syst Rev 2016 ↗
How it works — medical illustration
How it works

A small implant that holds the "standing room" open

What to expect: Walk-in, walk-out decompression: standing and walking tolerance typically improve because the segment can no longer pinch shut in extension.

Minimally Invasive SI Joint Fusion

Stops the painful micro-motion of a failed SI joint

When a sacroiliac joint keeps failing diagnostic blocks-and-relief cycles, small titanium implants placed across the joint through a 2–3 cm incision stop its painful micro-motion permanently.

Often used for: Refractory SI joint dysfunction confirmed by repeated diagnostic blocks.

~1 hourImplants across the jointFor block-confirmed SI pain
📚The INSITE randomized trial: minimally invasive SI fusion beat conservative management for confirmed SI pain. Polly DW et al. · Int J Spine Surg 2016 ↗
How it works — medical illustration
How it works

Stops the painful micro-motion of a failed SI joint

What to expect: Reserved for well-confirmed SI pain. Most patients mobilize the same day with a walker during early healing.

Intradiscal Biacuplasty / IDET

Treats pain arising inside the disc itself

Two cooled radiofrequency probes placed in the back wall of a painful disc heat and quiet the small nerves that have grown into annular tears — treating discogenic pain at its source.

Often used for: Discogenic low back pain confirmed by exam, MRI pattern, and sometimes discography.

~1 hourX-ray guidedFor disc-origin pain
📚A randomized multicenter trial favored intradiscal biacuplasty over conventional care for discogenic pain. Desai MJ et al. · Spine (Phila Pa 1976) 2016 ↗
How it works — medical illustration
How it works

Treats pain arising inside the disc itself

What to expect: A niche but real option when the disc itself is the pain generator and surgery feels like too big a step.

Percutaneous Disc Decompression

Shrinks a contained herniation from the inside

A thin device removes a small channel of disc material from the center of a contained herniation, lowering the internal pressure so the bulge can retract off the nerve.

Often used for: Small contained herniations with leg pain, when ESIs help but keep wearing off.

~45 minutesOne thin deviceContained herniations only
📚Systematic review reports good outcomes for contained herniations treated with percutaneous decompression. Ong D et al. · Pain Pract 2016 ↗
How it works — medical illustration
How it works

Shrinks a contained herniation from the inside

What to expect: The disc stays intact; only a few percent of its core volume is removed — enough to decompress the nerve in well-chosen cases.

💪 Muscle, tendon & small-nerve treatments · 10

The everyday workhorses of a pain clinic — quick, office-based, and often paired with the exercise programs in this site.

Trigger Point Injections

Releasing the knots that refer pain elsewhere

A fine needle (with or without medication) releases the taut, tender knots in muscle that ache locally and refer pain in predictable patterns.

Often used for: Myofascial pain of the neck, shoulders, and back — including 'headaches' that start in the trapezius.

Office-basedMinutesPairs with stretching
📚Reviews show trigger point needling relieves myofascial pain, best when paired with stretching. Dach F et al. · Arq Neuropsiquiatr 2023 ↗
The knot — medical illustration
1The knot

A taut band with a dense, irritable knot — the trigger point.

Referred pain — medical illustration
2Referred pain

Trigger points send pain elsewhere along predictable maps — a shoulder knot can 'become' a temple headache.

The release — medical illustration
3The release

A fine needle reaches the knot; a local twitch and a drop of medication let the band release.

After — medical illustration
4After

The muscle lies smooth again. Stretching and posture work keep it that way.

▶ Watch how it works (10-second animation)
What to expect: Post-injection soreness for a day is normal; heat and gentle stretch help.

Botox for Chronic Migraine

31 tiny injections, every 12 weeks, fewer headache days

OnabotulinumtoxinA placed in a standardized pattern across forehead, temples, back of head, neck and shoulders reduces headache frequency in chronic migraine (15+ headache days/month).

Often used for: Chronic migraine; also used medically for severe spasticity elsewhere.

Every 12 weeksOffice-basedFDA-approved pattern
📚The PREEMPT trials established onabotulinumtoxinA as preventive therapy for chronic migraine. Dodick DW et al. · Headache 2010 ↗
The pattern — medical illustration
The pattern

Hair-fine needles place micro-doses at the standardized sites; most patients rate it far easier than expected.

What to expect: Benefit builds across the first two cycles — judge it at 24 weeks, not 2.

Occipital Nerve Blocks

For headaches that climb the back of the skull

Anesthetic and steroid placed beside the greater/lesser occipital nerves at the skull base.

Often used for: Occipital neuralgia, cervicogenic headache, some migraine patterns.

MinutesLandmark/US guidedOften immediate
📚Comparative trials support greater occipital nerve blocks in occipital neuralgia and some headaches. Kissoon NR et al. · Clin J Pain 2022 ↗
The block — medical illustration
The block

A drop of medication where the occipital nerves emerge — scalp numbness right after means the target was hit.

What to expect: Relief within minutes (anesthetic phase) predicts steroid-phase benefit.

Suprascapular Nerve Block

The shoulder's main sensory line

Medication placed at the scapular notch where the shoulder's chief sensory nerve passes — useful when the joint itself can't be settled.

Often used for: Frozen shoulder, cuff arthropathy, post-stroke shoulder pain.

MinutesUltrasound guidedRehab enabler
📚Randomized data support suprascapular nerve block for adhesive capsulitis and chronic shoulder pain. Shanahan EM et al. · RMD Open 2022 ↗
The block — medical illustration
The block

The nerve is bathed at its notch — often unlocking enough comfort to make therapy possible.

What to expect: Best used as a bridge INTO the shoulder exercise program.

Ilioinguinal / Iliohypogastric Block

For groin pain — often after hernia surgery

Ultrasound-guided medication placed in the muscle plane where these two nerves travel toward the groin.

Often used for: Post-herniorrhaphy groin pain, some chronic pelvic/groin neuralgias.

MinutesUltrasound guidedDiagnostic + therapeutic
📚Ultrasound-guided ilioinguinal/iliohypogastric blocks reduce chronic post-hernia groin pain in trials. Sahoo RK et al. · Korean J Pain 2024 ↗
The plane — medical illustration
The plane

Medication spreads in the layer between abdominal muscles, enveloping both nerves.

What to expect: If relief is real but temporary, cryo or PNS of the same nerves is the logical next step.

Pudendal Nerve Block

For deep pelvic pain with sitting

Image-guided medication beside the pudendal nerve at the ischial spine.

Often used for: Pudendal neuralgia — perineal burning worse with sitting, spared by standing.

~15 minutesImage guidedDiagnostic + therapeutic
📚The Nantes criteria formalize diagnosis; image-guided pudendal blocks are both test and treatment. Labat JJ et al. · Neurourol Urodyn 2008 ↗
The block — medical illustration
The block

The nerve is reached deep in the pelvis where it rounds the ischial spine.

What to expect: Paired with pelvic-floor physical therapy for lasting change.

Carpal Tunnel Injection

Calming the median nerve in its tunnel

A small dose of steroid placed inside the carpal tunnel (beside, never into, the nerve).

Often used for: Carpal tunnel syndrome — night numbness, tingling thumb-to-ring fingers.

MinutesUS or landmarkSplint + glides after
📚Meta-analysis supports ultrasound-guided corticosteroid injection for carpal tunnel syndrome. Wang H et al. · Clin Rehabil 2021 ↗
The tunnel — medical illustration
The tunnel

Medication spreads through the crowded tunnel, shrinking the swelling around the median nerve.

What to expect: Night splinting and tendon-glide exercises extend the benefit.

Lateral Femoral Cutaneous Nerve Block

The burning-thigh nerve, calmed at the hip crease

The nerve that supplies the outer thigh skin gets pinched under the inguinal ligament (tight belts, pregnancy, weight change), causing meralgia paresthetica. Ultrasound guides medicine right around it.

Often used for: Meralgia paresthetica — burning, tingling outer thigh.

~15 minutesUltrasound guidedDiagnostic + therapeutic
📚Ultrasound-guided LFCN blocks reliably confirm and calm meralgia paresthetica. Baron-Franco B et al. · J Clin Med 2026 ↗
How it works — medical illustration
How it works

The burning-thigh nerve, calmed at the hip crease

What to expect: Numbness of the outer thigh for a few hours confirms the diagnosis; steroid quiets it longer. Loose waistbands do the rest.

Intercostal Nerve Block / RFA

The rib nerves, numbed along their groove

Each rib carries a nerve in a groove along its lower edge. Blocks (and radiofrequency or cryo for longer relief) treat pain after rib fractures, chest surgery, or shingles of the chest wall.

Often used for: Rib fracture pain, post-thoracotomy pain, chest-wall neuralgia.

~20 minutesUltrasound or X-ray guidedCan be extended with RFA/cryo
📚Intercostal blocks rival epidurals for rib-fracture analgesia in comparative studies. Sheets NW et al. · J Am Coll Surg 2020 ↗
How it works — medical illustration
How it works

The rib nerves, numbed along their groove

What to expect: Relief is often immediate. Because the lung sits just deep to the nerve, imaging guidance is standard.

Piriformis Injection

Relaxes the deep muscle that irritates the sciatic nerve

The piriformis crosses directly over (or around) the sciatic nerve deep in the buttock. Image-guided injection of anesthetic and steroid — or botulinum toxin for stubborn cases — releases its grip.

Often used for: Piriformis syndrome: deep buttock pain with sciatica-like radiation.

~20 minutesUltrasound or X-ray guidedBotox for recurrences
📚Reviews support image-guided piriformis injection when stretching-based rehab stalls. Vij N et al. · Anesth Pain Med 2021 ↗
How it works — medical illustration
How it works

Relaxes the deep muscle that irritates the sciatic nerve

What to expect: Pairs naturally with the stretching program — the injection opens a window; the exercises keep it open.

🦵 Joint & bursa injections · 4

Image guidance turns a good injection into a precise one — medicine lands exactly in the joint or bursa, every time.

Hip Joint Injection

The deep joint that needs image guidance most

Steroid (or viscosupplement/PRP) delivered into the hip joint under X-ray or ultrasound — the hip is too deep for reliable blind injection.

Often used for: Hip osteoarthritis, labral irritation; also a diagnostic test before surgery decisions.

~10 minutesAlways image-guidedDiagnostic value
📚Ultrasound-guided hip injections deliver accurate, effective relief in hip osteoarthritis. Micu MC et al. · Clin Rheumatol 2022 ↗
Into the capsule — medical illustration
Into the capsule

A long thin needle from the front-side; medication spreads between ball and socket.

What to expect: If numbing the joint erases your pain, the hip is confirmed as the generator.

Shoulder Injections (Subacromial / Glenohumeral)

Two different targets in one joint

The bursa above the rotator cuff (impingement) and the ball-and-socket joint itself (arthritis, frozen shoulder) are separate targets — guidance puts medicine in the right one.

Often used for: Impingement/bursitis, cuff tendinopathy, adhesive capsulitis, OA.

MinutesUS guidedPairs with rehab
📚A Cochrane review examined image-guided versus landmark shoulder injections — accuracy favors imaging. Bloom JE et al. · Cochrane Database Syst Rev 2012 ↗
The bursa — medical illustration
The bursa

Medication floods the inflamed bursa beneath the shoulder's bony roof — the classic impingement target.

What to expect: In frozen shoulder, injections buy the comfort that makes stretching possible.

Knee Injections — Steroid, Gel, PRP

From calming a flare to biologic repair signals

Corticosteroid calms flares; hyaluronic 'gel' supplements lubrication; platelet-rich plasma concentrates your own growth factors for a regenerative signal.

Often used for: Knee osteoarthritis across its spectrum; patellar tendinopathy (PRP).

MinutesUS guidedOptions ladder
📚Randomized comparisons help match knee injection type (steroid, HA, PRP) to the right patient. Tschopp M et al. · Invest Radiol 2023 ↗
The regenerative option — medical illustration
The regenerative option

Your own platelets, concentrated and returned to the joint — a biology-based signal rather than a suppressive one.

What to expect: PRP typically means a few days of achy fullness, then gradual gains over weeks; steroid = faster but shorter.

Bursa Injections (Trochanteric & friends)

The inflamed cushions

Direct medication into an inflamed bursa — most commonly the outer-hip trochanteric bursa.

Often used for: Greater trochanteric pain syndrome, olecranon/pes anserine and other bursitides.

MinutesUS guidedLoad management after
📚Ultrasound-guided bursa injections outperform blind injections on accuracy and cost-effectiveness. Mitchell WG et al. · Rheumatol Int 2018 ↗
The cushion — medical illustration
The cushion

The bursa under the outer-hip tendon band is bathed in medication.

What to expect: Lasting fix = the hip-strengthening program; the injection opens the window.

🩸 Regenerative & orthobiologic injections · 2

Treatments that try to change the tissue itself — concentrating your body’s own healing signals onto tendons, ligaments and joints that have stalled mid-repair.

Platelet-Rich Plasma (PRP)

Your own platelets, concentrated onto a struggling tendon or joint

A small draw of your blood is spun down to concentrate platelets and their growth factors, then injected precisely into a degenerated tendon or arthritic joint to stimulate a healing response.

Often used for: Tennis elbow and other tendinopathies, mild-to-moderate knee arthritis, some hip/gluteal tendon pain.

~45 minutes totalUltrasound guidedSoreness first, benefit over weeks
📚Meta-analyses favor PRP over hyaluronic acid for pain and function in knee OA at 6–12 months. Tang JZ et al. · J Orthop Surg Res 2020 ↗
How it works — medical illustration
How it works

Your own platelets, concentrated onto a struggling tendon or joint

What to expect: Expect a sore week (the point is a controlled re-injury), then gradual gains over 6–12 weeks. Usually not covered by insurance.

Prolotherapy

Small irritant injections that provoke ligaments to remodel

Concentrated dextrose is injected at ligament and tendon attachments over a series of sessions, provoking a mild inflammatory response that stimulates tightening and remodeling.

Often used for: Ligamentous laxity, chronic SI or spinal enthesis pain, some tendinopathies.

Series of 3–6 sessionsUltrasound guidedOlder but persistent technique
📚Systematic review supports dextrose prolotherapy for knee OA and selected tendinopathies. Waluyo Y et al. · J Rehabil Med 2023 ↗
How it works — medical illustration
How it works

Small irritant injections that provoke ligaments to remodel

What to expect: A slower-burn cousin of PRP with a long clinical history; best evidence is in knee OA and some tendinopathies.

🧪 Infusions & special procedures · 3

For pain that has outgrown local fixes — or problems with their own special solutions.

Ketamine Infusion Therapy

Resetting an over-sensitized nervous system

Carefully monitored low-dose IV ketamine can dial down NMDA-mediated central sensitization — the 'volume knob' problem behind CRPS and some refractory neuropathic pain.

Often used for: CRPS, severe refractory neuropathic pain; (depression protocols exist separately).

Monitored suiteSeries of sessionsSpecialist protocol
📚Consensus guidelines support supervised ketamine infusions for refractory chronic pain syndromes. Cohen SP et al. · Reg Anesth Pain Med 2018 ↗
The setting — medical illustration
The setting

A reclined, monitored infusion over hours — most patients describe it as strange but tolerable, with staff steps away.

What to expect: Dream-like sensations during infusion are expected and wear off; benefits accrue across a series.

Epidural Blood Patch

The definitive fix for spinal-headache leaks

A small volume of your own blood, placed into the epidural space, seals a spinal-fluid leak — the cause of severe positional headaches after dural puncture.

Often used for: Post-dural-puncture headache; spontaneous intracranial hypotension.

~30 minutesOften immediateYour own blood
📚Epidural blood patch remains the definitive treatment for post-dural-puncture headache. Thon JN et al. · Curr Opin Anaesthesiol 2024 ↗
The seal — medical illustration
The seal

The blood settles over the leak like a living patch — many headaches lift within hours.

What to expect: Lie flat briefly after, avoid straining for 24–48h.

IV Lidocaine Infusion

A body-wide reset for wound-up nerve pain

Lidocaine given slowly through a vein calms overactive sodium channels throughout the nervous system — a systemic treatment for pain that has spread beyond any single nerve’s territory.

Often used for: Widespread neuropathic pain, fibromyalgia flares, refractory nerve pain.

~1–2 hours, monitoredIV in a chairRelief can outlast the drip
📚Systematic review: IV lidocaine relieves neuropathic pain, with effects that can outlast the infusion. Lee JH et al. · Clin J Pain 2022 ↗
How it works — medical illustration
How it works

A body-wide reset for wound-up nerve pain

What to expect: You sit monitored while it runs. In responders, relief often lasts days to weeks beyond the infusion itself — and predicts which oral medicines may help.
A note on choosing: no one gets all of these. The list exists so you can understand the full menu — your physician narrows it to the one or two options that match your diagnosis, your anatomy, and what has already been tried. Diagnostic blocks often come first on purpose: they are how we prove a target before treating it.
This page is educational material only and is not medical advice, a diagnosis, or a treatment recommendation. Illustrations are simplified artistic renderings; photos and exercise videos are AI-generated demonstrations. Evidence summaries are simplified — read the linked studies for details. Your own plan always comes from your physician. In an emergency, call 911.