Pain Management From a Spine Doctor’s View: Understanding Diagnosis, Procedures, and Treatment Options

This table shows how spine doctors decide when to relieve pain, when to suppress pain, and when pain procedures are used.

Situation	What’s happening	What we do	Where pain procedures fit
Problem will get better	The spine is healing	Pain relief	Sometimes used
Problem cannot be fixed	Permanent changes	Pain suppression	Main option
Problem can be fixed with surgery	Correctable cause	Treat the cause	Not the main treatment
Pain without clear cause	Many small factors	Pain procedures + rehab	Used to control symptoms

Pain procedures should never be the first step. The first step is always a proper diagnosis. A spine-trained orthopaedic surgeon can:

• Identify whether the pain comes from a nerve, disc, joint, bone, or muscle
• Check if the problem is reversible, permanent, or surgically correctable
• Ensure no serious condition is missed
• Guide you to the safest and most effective treatment

Some spine surgeons — including Dr Lau — also perform pain procedures. This means diagnosis and treatment come from someone who understands the entire spine pathway.

Many spine problems improve naturally. Pain relief helps patients stay active while the body recovers.

• NSAIDs
• Physiotherapy
• Activity modification
• Short-term injections
• Bracing (selected cases)

Some spine problems cannot be reversed. In these cases, the goal is long-term pain control and improved function.

A. Procedures That Help Identify the Pain Source

• Selective Nerve Root Block (SNRB) — numbs one nerve to confirm the level
• Facet Joint Block — checks if the facet joint is the pain source
• Medial Branch Block — confirms facet pain before RFA
• Sacroiliac Joint Block — identifies SIJ pain
• Discography — rarely used today

Pars Defects (Spondylolysis) and Their Role in Diagnosis

Pars defects — also known as spondylolysis — are stress fractures in the spine that often mimic disc or facet pain. They may irritate the nerve root or overload the facet joints, making diagnostic blocks especially useful.

• Common in adolescents and athletes
• Pain worsens with extension (bending backwards)
• May coexist with apophyseal ring fractures

Learn more: Spondylolysis / Pars Defects

B. Procedures That Treat or Suppress Pain

• Nerve root injections
• Facet joint injections
• Medial branch radiofrequency ablation
• Sacroiliac joint injections
• Epidural steroid injections
• Trigger point injections
• Spinal cord stimulation
• Dorsal root ganglion stimulation
• Intrathecal pain pumps

C. Disc Pain Procedures (Biacuplasty & Nucleoplasty)

1. Biacuplasty (Disc Pain Treatment)

Biacuplasty uses two cooled radiofrequency probes inside the disc to reduce disc pain. It is useful for discogenic pain, especially when Modic changes are present.

2. Nucleoplasty (Percutaneous Disc Decompression)

Nucleoplasty is a minimally invasive procedure that removes a small amount of disc material to reduce pressure inside the disc. It is considered for contained disc protrusions that cause persistent back or leg pain despite conservative treatment.

D. Procedures That Do Both (Diagnose + Treat)

Procedure	Identify?	Treat?	Notes
Selective nerve root block	✔️	✔️	Confirms level + short relief
Facet joint injection	✔️	✔️	Confirms + treats
SI joint injection	✔️	✔️	Confirms + treats
Medial branch block	✔️	❌	Diagnostic before RFA
Biacuplasty	✔️ (selected)	✔️	Disc pain diagnosis + treatment
Nucleoplasty	✔️ (indirect)	✔️	Reduces disc pressure; useful for contained protrusions

1. When does a pain specialist come into the picture?

You should first see an orthopaedic surgeon with a spine interest. They will make the diagnosis, determine the underlying cause, and outline the treatment plan. If the problem does not improve with appropriate treatment, a pain procedure or surgery may be suggested depending on the objective — whether the goal is to relieve pain while the body heals, suppress pain when the problem cannot be fixed, or treat the cause directly.

2. Why do I need a pain procedure after surgery?

Surgery may not always achieve its full objective. This can be due to anatomical constraints, the severity of the condition, or the patient’s overall health. In such cases, pain suppression may still be necessary after surgery to improve comfort and function. Pain procedures help manage residual symptoms when further surgical correction is not appropriate or not possible.

3. Who can perform pain procedures?

Pain procedures should only be performed by a qualified clinician who is properly trained in this area. These procedures are commonly performed by orthopaedic surgeons with an interest in spine surgery or by pain specialists. Both groups are trained to understand the underlying diagnosis, select the appropriate procedure, and perform it safely.