By Dr. Ara J. Deukmedjian, MD
Board Certified Neurosurgeon
Updated: Sep 29, 2026
Medical disclaimer: This content is for educational purposes only and does not constitute medical advice. Individual results vary. Always consult a qualified healthcare provider about your specific condition and treatment options before making decisions about care.
Key Points
- Pain management controls pain signals. It doesn’t repair the underlying spinal damage.
- Research shows injections, ablations, and spinal cord stimulators offer only modest, short-term relief.
- CDC guidelines and Florida HB 21 now steer chronic pain care away from long-term opioids.
- Repeat epidural steroid injections are typically capped at 3 to 4 per level per year due to cumulative risks.
- Nerve deficits, structural pathology, or repeat injections without lasting relief warrant a spine surgery evaluation.
- Deuk Laser Disc Repair® treats the source of discogenic pain with 99% pain relief, a 0.01% complication rate, and no fusion, hardware, or opioids.
If you’ve been living with chronic back or neck pain and your primary care doctor has referred you to a “pain management specialist,” you deserve to know exactly what that means in 2026. And what the peer-reviewed evidence actually says about how well these treatments work. Modern pain management has moved well beyond opioid prescriptions, but the alternatives that replaced pills carry their own limitations that patients are rarely told about upfront.¹
Understanding What a Pain Management Doctor Actually Does
A pain management specialist is defined as a medical doctor who has board certification in one of the following fields of specialization: anesthesiology, physiatry, and neurology. A certified medical doctor who has further specialization in chronic pain diagnoses and treatments. Certification in Pain medicine subspecialty is provided by the ABMS member boards.² The subspecialty most relevant to spine patients is interventional pain management, which the National Uniform Claims Committee defines as the “discipline of medicine devoted to the diagnosis and treatment of pain-related disorders principally with the application of interventional techniques.”³
In practice, a modern interventional pain specialist offers:
- Diagnosis of medical conditions via diagnostic tests that have been utilized for localization of the anatomic source of pain. Examples of the above include selective nerve root blocks and diagnostic medial branch blocks.
- Image guided procedures, including epidural steroid injection, facet joint injection and sacroiliac joint injection.
- Neuroablation procedures, like RFA of the medial branch nerves.
- Neuromodulation techniques, like spinal cord stimulators and peripheral nerve stimulators.
- Medical management, such as non-opioid analgesia, neuropathics, muscle relaxers, and controlled substances where appropriate.
What a pain management doctor generally does not do is perform corrective spinal surgery. This distinction matters, because most interventional treatments are designed to interrupt or dampen pain signals. Not to repair the underlying disc, joint, or nerve pathology producing them.
The Research on Interventional Pain Management Outcomes
Epidural Steroid Injections: Modest, Short-Term Relief
One of the most frequently administered interventional procedures in the USA is epidural steroid injection (ESI). The data showing sustained clinical effects of ESI is not as plentiful as it may seem to patients. One of the landmark systematic reviews published in the Annals of Internal Medicine demonstrated that ESI was associated with only “small” short-term effects and “no effect” on long-term risk of surgery in patients with radiculopathy.⁴ A recent Cochrane review of epidural corticosteroid treatment of sciatica showed similar results: minor short-term effects which diminish within three months.⁵
Radiofrequency Ablation for Facet Pain
The radiofrequency ablation procedure on the lumbar medial branches nerves could potentially help certain patients in relieving their pain from the facet joints. Nevertheless, the critical results from the MINT randomized studies published in JAMA in 2017 showed that RFA in conjunction with an exercise protocol was not clinically superior to the exercise therapy alone in patients with chronic pain from the facet joints, sacroiliac joints, and intervertebral discs.⁶ Moreover, even when the patient responds to this treatment, the nerves regenerate in 6–24 months’ time, and the process has to be repeated.
Spinal Cord Stimulation
The spinal cord stimulation system (SCS) is considered to be a reliable long-lasting remedy for failed back surgery syndrome and chronic neuropathic pain. Nevertheless, a 2023 Cochrane review of 15 randomized trials found that SCS “probably does not provide clinically important benefits” compared to a placebo in the management of chronic low back pain, while long-term evidence is inadequate.⁷ Further investigation revealed an increased risk of complications of about 30% associated with SCS, including lead migration, infections, and revisions.⁸
The Broader Evidence Problem
The American College of Physicians clinical practice guideline for low back pain gives only weak recommendations for most interventional procedures, citing low- to moderate-quality evidence across the field.⁹ The pattern that emerges across systematic reviews is consistent: interventional pain treatments can offer meaningful but usually temporary relief for appropriately selected patients. And they do not modify the underlying degenerative pathology.
The Opioid Question: Why the Field Has Shifted
For almost twenty years following the late 1990s. Pain was effectively treated using opioids on a long-term basis. This approach was not sustainable in light of the current opioid epidemic that the United States is facing. The Clinical Practice Guideline for Prescribing Opioids for Pain by the CDC was released in 2022. It encourages the utilization of non-opioid approaches to treat subacute and chronic pain, especially when “benefits for pain and function are expected to outweigh risks.”¹⁰
What Florida Law Requires
Patients seeking care in Florida are treated under one of the most prescriptive state frameworks in the country. House Bill 21, enacted in 2018, sets specific limits on Schedule II opioid prescribing:¹¹
- In the case of acute pain, a first-time prescription of Schedule II opioid will be for no more than three days, extending to seven days only if there is documented evidence of medical necessity in the prescription and it is labeled “ACUTE PAIN EXCEPTION.”
- This is not true in the case of chronic non-malignant pain, cancer pain, terminal illness, palliative care, or serious trauma injury.
- Prescribers need to look at the Florida Prescription Drug Monitoring Program database before distributing any controlled substance.
- Physicians writing prescriptions for chronic non-malignant pain for controlled substances must become controlled substance prescribers and undertake board-approved continuing education.
The practical result is that in Florida, responsible pain management strongly favors interventional and non-opioid strategies as first-line therapy, with opioids introduced cautiously and monitored closely.
The Limitations Patients Are Rarely Told About
Even the best-executed interventional pain program has structural limitations that every patient should understand before beginning treatment.
- Intervention does not repair a herniated disk, a torn annular ring, or degenerated facet joint arthritis.
- Law of diminishing returns. Steroid injection is dangerous in the long run because of complications such as tissue atrophy, cartilage degradation, osteoporosis, and hyperglycemia.
- Guidelines commonly limit ESIs to three or four per year at a given level.¹²
- Radiation exposure. Fluoroscopically guided procedures involve cumulative ionizing radiation for both patient and physician.
- The treatment treadmill. Many chronic pain patients cycle through injections every few months for years without their underlying condition ever being definitively addressed. A pattern well documented in health services research on spine care utilization.¹³
- Failure to treat the actual pain generator. When the true source of pain is a torn or herniated lumbar disc, procedures aimed at the facet joints or epidural space will not resolve the problem regardless of how skillfully they are performed.
When to See a Pain Management Specialist and When to See a Spine Surgeon
Referral to interventional pain management is generally appropriate when:
- Conservative measures (activity modification, physical therapy, non-opioid analgesics) have failed after 6–12 weeks.
- Imaging and physical exam suggest a pain generator that is amenable to a targeted procedure.
- The patient is not yet a surgical candidate or wishes to postpone surgery.
Referral to a spine surgeon. Ideally one who offers a full spectrum of options including minimally invasive alternatives is generally appropriate when:
- Neurologic deficits are present (progressive weakness, sensory loss, bowel or bladder dysfunction).
- Imaging demonstrates structural pathology (significant disc herniation, high-grade stenosis, instability) that correlates with symptoms.
- Pain has not responded to a reasonable trial of conservative and interventional care.
- The patient has been on a repeating cycle of injections without durable benefit.
Practice guidelines from the North American Spine Society emphasize that surgical evaluation should not be delayed indefinitely when clear structural pathology and correlating symptoms are present, because prolonged compression can produce irreversible nerve injury.¹⁴
The Misalignment Problem: Injections as a Detour
A significant body of health services research has documented that patients often spend years and tens of thousands of dollars in interventional pain programs for conditions that ultimately require definitive structural treatment. When the underlying pain generator is a herniated disc, the disc will continue to produce pain until it is treated. Injecting steroids around it, ablating a nearby nerve, or implanting a stimulator over it does not change that fact.
This is the reason why the proper diagnosis of the exact pain generator. Determined by thorough history, physical, good MRI, and where necessary, diagnostic blocks. Remains the single most important component of evaluating any chronic spine pain problem.
What To Do If You Have Been Referred For Pain Management
Prior to embarking on any indefinite series of injections or placing any permanent implants, please remember to do the following:
Get your diagnosis straight first. Ask yourself: Which specific structure is causing my pain, and why is that so?
What You Should Do If You’ve Been Referred to Pain Management
Before agreeing to an open-ended course of injections or a permanent implant, consider the following:
- Be clear on your diagnosis first. Do you know which particular structure is causing your pain, and why?
- Be clear on what the goal is. Is the surgery diagnostic, therapeutic, or both? For how long is the relief expected to last?
- Talk about numbers. What percentage of people with your particular diagnosis get relief from the recommended surgery, and for how long?
- Determine your stop loss. How many unsuccessful surgeries will it take before you rethink your strategy?
- Seek a second opinion from a surgeon offering minimally invasive options. All second opinions aren’t alike. An orthopedic surgeon who has no other alternatives but laminectomy and fusion might recommend those surgeries, while an orthopedic surgeon also offering disc repair through endoscopic and laser techniques can compare all alternatives.
Alternative Approaches: Treating the Source, Not the Signal
At Deuk Spine Institute, our position informed by decades of clinical experience and the published evidence is that chronic discogenic back pain is best resolved by treating the diseased disc itself. Not by indefinitely interrupting the pain signals it produces. The Deuk Laser Disc Repair® (DLDR) procedure is a minimally invasive, endoscopic technique that removes herniated disc material and treats annular tears without fusion, hardware, or bone removal. For facet-mediated pain, Deuk Plasma Rhizotomy® uses plasma energy for targeted, longer-lasting relief than conventional radiofrequency techniques.
These approaches are not appropriate for every patient. That is precisely why a thorough evaluation starts with a review of your MRI. It should come before any decision about long-term interventional pain therapy.
Take Control of Your Chronic Pain Care
If you have been offered a series of shots, or a spinal cord stimulator, or even opioids without being fully explained the source of your pain and if it can be successfully treated, then you need to seek another opinion.
Submit your most recent MRI to have it reviewed for free by Dr. Ara Deukmedjian and our expert team here at the Deuk Spine Institute. We will review your imaging studies, discuss your symptoms and goals, and explore all treatment options available to you. Not just those from one particular specialty.
Systematic reviews confirm: injections provide modest, temporary relief at best
Stop treating the signal.
Start treating the source.
Epidural steroids, radiofrequency ablation, and spinal cord stimulators interrupt pain signals—but they don’t repair a herniated disc or an annular tear. If you’ve been cycling through injections without lasting relief, the problem isn’t the procedure. It’s that the pain generator was never directly treated.
epidural steroid injections
regenerate and pain returns
for spinal cord stimulators
- Injections every few months, year after year
- RFA repeated as nerves regenerate
- Disc damage continues to progress
- Cumulative steroid risks build over time
- Damaged disc tissue removed with laser precision
- Permanent relief at the structural source
- No fusion, no hardware, no narcotics
- Same-day outpatient, 0.01% complication rate
Pain confirmed to be from facet joints? Deuk Plasma Rhizotomy® delivers permanent facet relief—no repeated ablations.
Deuk Spine Institute · Board-certified neurosurgeon · Diagnosis first · Every option, not just one specialty’s
FAQ’s
Does pain management actually cure chronic back pain
Answer
However, in general, the response to that question would be negative because treatment for pain management reduces pain signals; however, it does not address the structural problem of pain. Several systematic reviews have shown that pain management procedures such as epidural steroid injection, facet joint injection, and radiofrequency ablation provide only symptomatic treatment for certain patients without changing degeneration of the disc, arthritis, or annular tear.⁴ ⁶ ⁹ The ultimate treatment for pain due to any structural problem, such as lumbar herniation, is based on treating the underlying cause of the problem.
Will a pain management doctor put me on opioids long-term?
Answer
With respect to the present national and Florida specific criteria, there is no responsible pain management program that relies on opioids for the treatment of pain on a long-term basis. As per the CDC’s Clinical Practice Guideline in 2022, the non-opioid method is recommended for the management of chronic pain. In addition, according to Florida HB 21, there are regulations set out for the utilization of Schedule II drugs for the treatment of acute pain along with the need for verification of the PDMP.
How do I know whether I need a pain specialist or a spine surgeon?
Answer
A pain expert becomes an appropriate referral option if conservative management methods have been tried and failed, and if radiographic studies suggest that the pain source is one which can be treated using an interventional procedure. Referral to a spine surgeon would become appropriate if there are any neurological deficits, or if the imaging studies reveal pathology corresponding to the patient’s symptoms, and if repeat interventions have failed to provide sustained relief. Due to the overlapping nature of these cases, the best course of action would be to refer to an expert who can compare all forms of treatment.¹⁴
How many injections is too many?
Answer
There is no universal maximum, but most guidelines discourage more than three to four epidural corticosteroid injections at the same spinal level within a 12-month period because of cumulative risks including local tissue changes, accelerated cartilage loss, systemic effects on bone density and glucose metabolism, and cumulative radiation exposure.¹² A practical rule of thumb: if two properly performed procedures have not produced meaningful, sustained benefit, a structural re-evaluation is warranted before continuing on the same treatment path.
Sources
View Sources
1: Chronic Pain Management — American Society of Anesthesiologists
2: Pain Medicine Subspecialty Certification — ABMS
3: Definition of Interventional Pain Management — NUCC
4: Epidural Corticosteroid Injections: Systematic Review — Ann Intern Med
5: Epidural Corticosteroids for Lumbosacral Radicular Pain — Cochrane, 2020
6: MINT Trials: Radiofrequency Denervation for Low Back Pain — JAMA, 2017
7: Spinal Cord Stimulation for Low Back Pain — Cochrane, 2023
8: Complications of Spinal Cord Stimulation — Pain Medicine
9: Noninvasive Treatments for Low Back Pain: ACP Guideline
10: CDC Clinical Practice Guideline for Prescribing Opioids, 2022
11: Florida HB 21 Highlights — Florida Medical Association
12: ASIPP Evidence-Based Guidelines: Epidural Interventions — Pain Physician
13: Overtreating Chronic Back Pain: Time to Back Off? — JABFM
14: Evidence-Based Clinical Guidelines for Spine Care — NASS
