Invasive Procedures for Chronic Pain

Last updated 1 Jun 2026 · Pain & analgesia

📋 Key Information Summary

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Invasive pain procedures are not first-line therapy — they are reserved for carefully selected patients with refractory chronic pain who have trialled and failed conservative management (pharmacotherapy, physiotherapy, psychological therapy) for ≥3–6 months.
Radiofrequency neurotomy (RFN) uses thermal energy to disrupt nociceptive afferents; strongest evidence supports cervical medial branch RFN for facet-joint-mediated neck pain and lumbar medial branch RFN for facet-joint-mediated low back pain with ≥50% pain relief on controlled diagnostic blocks.
Spinal cord stimulation (SCS) delivers pulsed electrical energy to the dorsal columns; most established indication is failed back surgery syndrome (FBSS) with predominant neuropathic leg pain. Trial stimulation (5–7 days) precedes permanent implantation.
Epidural blocks (interlaminar, transforaminal, caudal) deliver corticosteroid and/or local anaesthetic to the epidural space; transforaminal epidural steroid injections (TFESI) have the strongest evidence for radicular pain due to disc herniation with concordant imaging.
All invasive procedures carry risk of serious harm including infection, bleeding, nerve injury, pneumothorax, and — for cervical procedures — spinal cord injury or stroke. Shared decision-making with documented informed consent is mandatory.
Diagnostic blocks (medial branch blocks with ≥80% pain relief on two separate occasions, or ≥70% with concordant physical signs) are required before RFN; a single positive block has an unacceptably high false-positive rate.
SCS trial success is defined as ≥50% reduction in pain intensity and/or meaningful functional improvement; only trial responders proceed to permanent implantation.
Epidural corticosteroid injections should be limited in frequency — typically no more than 3–4 per year at the same spinal level — due to risks of adrenal suppression, bone loss, and rare but devastating neurological complications (including arachnoiditis and paraplegia from particulate steroid embolisation).
Non-particulate corticosteroids (dexamethasone, betamethasone sodium phosphate) are preferred over particulate preparations (methylprednisolone, triamcinolone) for cervical and thoracic transforaminal injections to reduce embolic risk.
Antiplatelet and anticoagulant management requires individualised risk assessment; procedures are classified as low, intermediate, or high bleeding risk per ANZCA/ Faculty of Pain Medicine (FPM) guidance. Bridging is generally not recommended.
Aboriginal and Torres Strait Islander Australians experience chronic pain at 1.5–2× the rate of non-Indigenous Australians yet face significant barriers to accessing specialist pain services, particularly in rural and remote communities.
All procedures should be performed under image guidance (fluoroscopy or ultrasound) by appropriately trained proceduralists — FPM fellows, pain medicine specialists, or interventional radiologists with credentialing.

Introduction & Australian Epidemiology

Chronic pain — defined as pain persisting beyond the expected tissue-healing time of three months — affects an estimated 3.24 million Australians (approximately 13% of the adult population) and is the leading cause of disability and reduced quality of life nationally. The Australian Institute of Health and Welfare (AIHW) estimates that chronic pain costs the Australian economy over billion annually in healthcare expenditure, lost productivity, and informal care.

Invasive interventional pain procedures occupy a defined niche within a multidisciplinary biopsychosocial treatment framework. They are never appropriate as the sole treatment modality and should only be considered when evidence-based conservative therapies (pharmacotherapy per the WHO analgesic ladder, physical rehabilitation, cognitive-behavioural therapy, and self-management strategies) have been systematically trialled over a reasonable timeframe (typically ≥3–6 months) and have failed to achieve adequate functional goals.

The Australian and New Zealand College of Anaesthetists (ANZCA) Faculty of Pain Medicine (FPM) is the peak body responsible for training, credentialing, and standard-setting for pain medicine specialists in Australia. All invasive pain procedures should be performed by FPM fellows or equivalent credentialled specialists in facilities that meet ANZCA PS09 (Guidelines on Sedation and/or Analgesia for Diagnostic and Interventional Medical, Dental or Surgical Procedures) standards.

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Not first-line therapy: Invasive procedures are adjuncts within a multidisciplinary programme — not replacements for evidence-based conservative care. Australian guidelines (FPM, RACGP, Australian Pain Society) consistently recommend a minimum 3–6 months of comprehensive conservative management before referral for procedural intervention. Rushing to procedural intervention without addressing psychological, social, and functional contributors to pain is associated with poorer outcomes and increased risk of harm.

The principal invasive procedures used in Australian pain medicine practice include:

Radiofrequency neurotomy (RFN) — thermal ablation of pain-conducting nerves for facet-mediated spinal pain
Spinal cord stimulation (SCS) — implanted neuromodulation device for refractory neuropathic pain syndromes
Epidural corticosteroid/lignocaine injections — targeted drug delivery for radicular and axial spinal pain
Intrathecal drug delivery (beyond scope of this article — see Intrathecal Therapy guideline)
Sympathetic nerve blocks, trigger point injections, and joint injections (beyond the primary scope of this article)

Access to these procedures is inequitably distributed across Australia. Metropolitan centres in Sydney, Melbourne, Brisbane, Perth, and Adelaide host the majority of procedural pain services, while rural, regional, and particularly remote communities — including many Aboriginal and Torres Strait Islander communities — have very limited or no access to specialist proceduralists. Telehealth assessment and patient transfer programmes partially address this gap but remain suboptimal.

Radiofrequency Neurotomy

Principle

Radiofrequency neurotomy (RFN), also termed radiofrequency denervation or facet rhizolysis, uses a high-frequency alternating electrical current delivered via an electrode tip to generate tissue heating (conventional thermal RF at 80–85°C for 60–90 seconds) or pulsed electromagnetic fields (pulsed RF at 42°C) to disrupt nociceptive signal transmission along medial branch nerves supplying the facet (zygapophyseal) joints. Conventional thermal RF creates a controlled thermal lesion; pulsed RF modulates nerve function without coagulative destruction and is preferred where nerve regeneration is desired or where proximity to motor structures limits thermal ablation.

Indications

Cervical facet pain (C3–C6 medial branch): Chronic neck pain ≥3 months, typically post-whiplash or degenerative, with ≥80% pain relief on two separate controlled diagnostic medial branch blocks (MBBs) using lignocaine on one occasion and bupivacaine on another, with concordant duration of effect matching anaesthetic duration.
Lumbar facet pain (L3–L5 medial branches, L5 dorsal ramus, sacroiliac joint lateral branch): Chronic low back pain ≥3 months, axial predominant (non-radicular), with ≥80% pain relief on two controlled diagnostic blocks or ≥70% with concordant clinical signs (reproduction of typical pain on joint provocation, relief with intra-articular local anaesthetic).
Sacroiliac joint pain (lateral branch S1–S3): Chronic sacroiliac joint-mediated pain confirmed by ≥70% relief on two image-guided intra-articular sacroiliac joint blocks.
Occipital neuralgia (greater/lesser occipital nerves): Refractory cases with positive diagnostic blocks.

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Diagnostic block criteria (FPM / Spine Intervention Society): A single diagnostic medial branch block has a false-positive rate of 30–45%. Best practice requires ≥80% pain relief on two separate blocks using different anaesthetic agents (e.g., lignocaine then bupivacaine) with concordant duration of action. Some guidelines accept ≥70% relief with corroborating clinical features on two occasions.

Technique Summary

Performed under fluoroscopic guidance (standard of care) or ultrasound (emerging for cervical targets) in a sterile procedural suite.
Patient positioned prone (lumbar) or supine/prone-lateral (cervical) with sterile preparation and draping.
RF cannula advanced to target under multi-planar fluoroscopy; sensory stimulation at 50 Hz reproduces typical pain at ≤0.5 V; motor stimulation at 2 Hz confirms safe distance from motor nerve roots (no contraction ≤2 V for cervical, ≤1.5 V for lumbar).
Lesion created at 80–85°C for 60–90 seconds (conventional thermal RF) or pulsed RF at 42°C, 20 ms bursts, 2 Hz, for 120–240 seconds.
Multiple overlapping lesions may be created to maximise lesion volume and nerve capture.

Efficacy

Randomised controlled trial (RCT) evidence supports lumbar and cervical medial branch RFN for facet-mediated pain. A 2015 Lancet RCT (Juch et al.) demonstrated that RFN provided clinically meaningful pain relief (>50%) in approximately 50–60% of patients with facet-joint-mediated low back pain at 3 months, sustained at 12 months in many responders. Cochrane reviews support RFN for cervical facet pain. Repeat RFN is feasible when pain recurs, typically after 6–24 months, as nerve regeneration occurs. Median duration of benefit from a single RFN procedure is 6–12 months (range 3–24+ months).

Contraindications

Uncontrolled coagulopathy or inability to cease antiplatelet/anticoagulant therapy
Active local or systemic infection
Pregnancy (relative — radiation exposure)
Local tumour at the target site
Patient with untreated major psychological comorbidity (relative — FPM recommends psychological screening)
Failure to meet controlled diagnostic block criteria

Spinal Cord Stimulation

Principle

Spinal cord stimulation (SCS) delivers pulsed electrical energy via implanted electrodes to the dorsal columns of the spinal cord, modulating pain signal transmission through the gate-control mechanism and activation of descending inhibitory pathways. Modern SCS systems include conventional (tonic) SCS, high-frequency (HF10, 10 kHz) SCS, burst stimulation, and dorsal root ganglion (DRG) stimulation — each with distinct waveform parameters and proposed mechanisms of action.

Indications

Failed back surgery syndrome (FBSS): Refractory neuropathic leg ± back pain following one or more lumbar spinal surgeries, with predominant radicular component — the most extensively studied indication.
Complex regional pain syndrome (CRPS) types I and II: Refractory CRPS with allodynia/hyperalgesia in a limb; NICE (UK) and international guidelines provide Level I evidence.
Chronic refractory neuropathic pain: Including peripheral neuropathic pain (e.g., painful diabetic neuropathy — emerging evidence from RCTs including SENZA-PDN), post-herpetic neuralgia (limited evidence), and peripheral nerve injury pain.
Chronic refractory angina pectoris: Where revascularisation is not feasible and medical therapy is maximised (Level B evidence).
Dorsal root ganglion (DRG) stimulation: Particularly for focal neuropathic pain distributions (e.g., CRPS of the foot, groin pain, knee pain after total knee replacement) — evidence from the ACCURATE RCT.

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ICD/pacemaker interaction: Patients with cardiac implantable electronic devices (CIEDs) require cardiologist and SCS manufacturer review before implantation. Electromagnetic interference (EMI) may cause pacing inhibition or inappropriate defibrillator firing. Device programming and shielding protocols must be established before SCS activation.

Trial Phase

SCS implantation is a two-stage process mandated by Australian and international guidelines:

Trial phase (5–10 days): Percutaneous percutaneous lead placement under fluoroscopic guidance with externalised leads connected to an external pulse generator. The patient undergoes a home-based trial to assess pain reduction, functional improvement, and patient satisfaction. Sub-perception HF10 stimulation may require intraoperative mapping to optimise coverage.
Successful trial criteria: ≥50% reduction in visual analogue scale (VAS) or numerical rating scale (NRS) pain score AND/OR clinically meaningful improvement in functional status (e.g., return to work, increased walking distance, reduced opioid consumption) as agreed in the pre-trial treatment goals.
Permanent implantation: Offered only to trial responders. Performed under general anaesthesia or sedation; leads anchored and connected to a subcutaneously implanted pulse generator (IPG) — typically in the buttock or abdominal wall.

Efficacy

The landmark PROCESS trial (Kumar et al., Lancet Neurology 2008) demonstrated that SCS combined with conventional medical management (CMM) was superior to CMM alone for FBSS at 6 and 24 months (≥50% leg pain relief in 48% vs 9% at 6 months). The SENZA-RCT (Kapural et al., Neurosurgery 2016) showed HF10 SCS was non-inferior to tonic SCS for back pain and superior for leg pain with lower rates of paraesthesia. Evidence for CRPS is robust (Level I). Approximately 50–70% of patients achieve ≥50% pain relief at 1 year; long-term studies (5–10 years) show durability of 50–60% responder rates with appropriate patient selection and follow-up programming.

Australian Access & Cost

SCS is available in most major Australian capital cities through public hospital pain services and private pain medicine practices. MBS item 18360 covers spinal cord stimulation lead implantation. Total implant cost (including device) ranges from ,000–,000 AUD for permanent implantation, partially offset by private health insurance. Wait times in public hospitals average 6–18 months. Rural access requires metropolitan transfer for both trial and implantation.

Contraindications

Active systemic or local infection
Uncontrolled coagulopathy
Uncorrected spinal canal stenosis at the electrode level
Psychological unsuitability (untreated severe depression, substance use disorder, secondary gain concerns) — all patients should undergo formal psychological assessment pre-trial
Inability to operate the device (severe cognitive impairment)
Need for MRI above the device level with non-MRI-conditional systems (older models)

Epidural Blocks

Principle

Epidural injections deliver medication — typically corticosteroid with or without local anaesthetic — into the epidural space to reduce inflammation around compressed or irritated nerve roots, or to modulate central sensitisation. Three approaches are used in Australian practice: interlaminar (midline), transforaminal (targeted to the neural foramen), and caudal (via the sacral hiatus).

Approaches & Indications

Approach	Best Indication	Evidence Level	Key Advantage
Interlaminar (ILESI)	Axial pain with bilateral radiculopathy; central disc herniation	Moderate (Level II–III)	Bilateral drug spread; technically straightforward
Transforaminal (TFESI)	Unilateral radiculopathy due to disc herniation or foraminal stenosis; diagnostic (selective nerve root block)	Strong (Level I–II)	Targeted delivery to affected nerve root; diagnostic and therapeutic
Caudal (CESI)	Failed back surgery syndrome with epidural scarring; lumbosacral radiculopathy when lumbar approaches are precluded by anatomy/surgery	Moderate (Level II–III)	Access to the lumbosacral epidural space avoiding scarred segments; lower procedural risk

Technique Summary

Performed under fluoroscopic guidance (gold standard) with contrast (Omnipaque® or equivalent) to confirm epidural placement and exclude intravascular injection. Ultrasound-guided lumbar interlaminar and caudal injections are increasingly used, particularly in settings without fluoroscopy.
Aseptic technique with chlorhexidine–alcohol skin preparation; sterile drape, gloves, gown, and face mask.
Needle/catheter placement confirmed with non-ionic contrast injection (≤1 mL) in lateral and AP fluoroscopic views before medication delivery.
Typical injectate: 80–120 mg methylprednisolone acetate, or 6–10 mg betamethasone sodium phosphate, or 4–8 mg dexamethasone sodium phosphate, ± 2–5 mL of 0.25% bupivacaine.

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Particulate steroid risk — cervical transforaminal injections: Particulate corticosteroids (methylprednisolone acetate, triamcinolone acetonide) are contraindicated for cervical transforaminal epidural injections. Case reports of catastrophic spinal cord infarction and death from particulate embolisation into the vertebral or spinal artery have been documented. Only non-particulate steroids (dexamethasone sodium phosphate or betamethasone sodium phosphate) should be used for cervical TFESI. The Spine Intervention Society and ANZCA FPM endorse this position.

Efficacy

For lumbar radiculopathy due to disc herniation, TFESI provides short-term (2–4 weeks) pain relief in 50–75% of patients, with evidence from multiple RCTs and a Cochrane review (2020) supporting its use. Long-term benefit (>6 months) is less consistently demonstrated. ILESI and CESI have moderate evidence for radiculopathy and axial pain. Evidence for epidural corticosteroid injections in spinal stenosis is limited and mixed — the landmark 2014 NEJM trial (Friedly et al.) showed only modest short-term benefit over saline injection. Epidural blood patches are a separate procedure for post-dural-puncture headache and are not covered in this article.

Frequency & Dosing Limits

A course of up to 3 injections over 6–12 months is standard practice; most patients respond within 1–2 injections if they are going to benefit.
No more than 3–4 epidural corticosteroid injections at the same spinal level per year due to cumulative systemic steroid exposure and local tissue effects.
Minimum interval of 2–4 weeks between injections at the same level.
Total systemic corticosteroid dose should be considered when patients receive concurrent oral or other injectable steroids — adrenal suppression risk.

Contraindications

Active systemic or local infection (including bacteraemia, epidural abscess, skin infection at injection site)
Uncorrected coagulopathy or thrombocytopenia (platelets <50 × 10⁹/L for epidural procedures per ANZCA guidelines)
Spinal cord compression with progressive neurological deficit (surgical emergency — not for epidural injection)
Allergy to injectate components
Local tumour at the procedure site
Cauda equina syndrome

Procedure Harms

All invasive pain procedures carry risks that must be discussed with patients during the informed consent process. Harms range from common, minor events to rare but catastrophic complications. A comprehensive risk–benefit discussion, documented in the medical record, is a medico-legal and ethical requirement.

General Harms (All Procedures)

Common / Minor

Expected Side Effects

Procedural site pain (20–40%); transient post-procedural flare (corticosteroid-related); bruising/haematoma at needle site; transient headache (particularly after lumbar epidural); mild vasovagal reactions; positional discomfort

Setting: Self-limiting; managed with simple analgesia, ice, rest

Uncommon / Moderate

Significant Complications

Superficial wound infection (1–2%); transient paraesthesia or dysaesthesia (RFN — 5–10%); epidural haematoma (rare — 1:150,000 epidurals); pneumothorax (cervical approaches <0.5%); lead migration requiring revision (SCS — 10–15%); hardware malfunction (SCS — 5–10%); steroid-related side effects (hyperglycaemia, flushing, insomnia, fluid retention)

Setting: May require ED attendance, antibiotics, imaging, or surgical revision

Rare / Catastrophic

Devastating Complications

Spinal cord injury (cervical procedures); vertebral artery or spinal artery embolism (cervical TFESI with particulate steroid); epidural abscess (1:100,000); arachnoiditis; permanent neurological deficit; paraplegia; stroke; death (estimated <1:100,000 per procedure)

Setting: Medical emergency — requires immediate specialist and potentially surgical intervention

Procedure-Specific Harms

Procedure	Specific Harm	Incidence	Mitigation
Radiofrequency Neurotomy	Dysaesthesia / neuritis (burning, tingling in treatment zone)	5–15%	Usually self-limiting over 2–6 weeks; pre-medication with gabapentin may reduce risk; ensure sensory stimulation confirms target nerve before lesioning
Radiofrequency Neurotomy	Motor weakness (cervical — trapezius/splenius; lumbar — multifidus)	1–3%	Motor stimulation at <2 V must show no motor response; self-limiting (weeks to months) due to compensatory muscle action
Spinal Cord Stimulation	Lead migration	10–15% (percutaneous)	Anchor fixation techniques; paddle leads (surgical placement) have lower migration rates; post-operative activity restriction
Spinal Cord Stimulation	Infection (surgical site or hardware)	3–5%	Prophylactic IV antibiotics (e.g., cefazolin 2 g IV pre-incision); aseptic technique; most require hardware explantation if confirmed
Spinal Cord Stimulation	Epidural haematoma / seroma	<1%	Manage anticoagulants per ANZCA/FPM protocol; emergent MRI and surgical decompression if neurological compromise
Epidural Blocks	Dural puncture / post-dural-puncture headache	0.5–1% (interlaminar)	Fluoroscopic/ultrasound guidance; use of loss-of-resistance with saline (lower incidence than air); epidural blood patch if severe
Epidural Blocks	Intravascular injection	2–9% (without contrast)	Mandatory contrast injection under live fluoroscopy before medication delivery; avoid particulate steroids for cervical TFESI
Epidural Blocks	Corticosteroid-related systemic effects	Common (transient hyperglycaemia in diabetics, facial flushing)	Monitor blood glucose in diabetics for 48–72 h; use lowest effective steroid dose; limit frequency

Antiplatelet & Anticoagulant Management

Procedures are classified by bleeding risk per ANZCA FPM guidance:

Low bleeding risk (superficial injections, most intra-articular injections): Antiplatelet/anticoagulant therapy generally need not be interrupted.
Intermediate bleeding risk (lumbar epidurals, lumbar medial branch RFN, SCS trial): Ceasation of antiplatelet agents (aspirin 7 days, clopidogrel 7 days, ticagrelor 5 days) or anticoagulants (warfarin — INR <1.5; DOACs — 24–48 hours depending on agent and renal function) with individualised risk assessment. Bridging with low-molecular-weight heparin is not routinely recommended due to increased bleeding risk.
High bleeding risk (cervical epidurals, SCS lead implant, deep cervical RFN): Strict cessation of anticoagulant/antiplatelet therapy per protocol; cardiology consultation if dual antiplatelet therapy interruption is considered (e.g., recent coronary stent).

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Patient safety culture: All complications should be reported through institutional incident reporting systems (e.g., RiskMan, STEO) and discussed at morbidity and mortality meetings. The ANZCA Incident Reporting Program monitors interventional procedure safety nationally. Consent processes should document specific risks discussed, patient questions, and the agreed management plan.

Clinical Indications & Patient Selection

Appropriate patient selection is the single most important determinant of procedural success. All patients should undergo comprehensive multidisciplinary assessment before referral for invasive procedures.

Pre-Procedure Assessment Checklist

History & Diagnosis

Comprehensive pain history (onset, location, quality, aggravating/relieving factors, functional impact); documented anatomical diagnosis consistent with proposed procedure; timeline of conservative treatments trialled (≥3–6 months)

Imaging Review

Recent MRI or CT of the relevant spinal segment (<12 months); correlation of imaging findings with clinical presentation; exclusion of red flags (tumour, infection, cauda equina, significant instability)

Psychological Screening

Formal psychological assessment using validated tools (e.g., Orebro Musculoskeletal Pain Screening Questionnaire, DASS-21, Pain Catastrophising Scale); screening for untreated depression, anxiety, PTSD, substance use disorder, and secondary gain. FPM recommends all SCS candidates undergo formal psychological evaluation

Medication Review

Document current analgesic regimen; plan for anticoagulant/antiplatelet management; assess opioid dose (high-dose opioid therapy >100 mg morphine equivalent daily is a relative predictor of poor procedural outcome)

Diagnostic Blocks (if applicable)

RFN: Two controlled diagnostic medial branch blocks with ≥80% relief using different local anaesthetics; SCS: Trial stimulation with ≥50% pain relief; Epidural: Diagnostic selective nerve root block if target nerve is uncertain

Informed Consent & Goal Setting

Procedure-specific risks, benefits, and alternatives documented; realistic outcome expectations established (functional goals, not solely pain score reduction); written consent with witness

Red Flags Requiring Urgent Specialist Referral (Not Procedural)

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Progressive neurological deficit (motor weakness, saddle anaesthesia, bowel/bladder dysfunction → cauda equina syndrome — emergency)
Suspected spinal malignancy (unexplained weight loss, night pain, history of cancer, lytic/sclerotic lesions on imaging)
Spinal infection (fever, elevated CRP/ESR, IV drug use history, recent spinal procedure)
Acute spinal fracture with instability

These are not indications for pain procedures — they require urgent neurosurgical or orthopaedic spine assessment.

Monitoring

Peri-Procedural Monitoring

Vital signs: Continuous pulse oximetry, non-invasive blood pressure, and ECG monitoring during all sedated procedures; resuscitation equipment and drugs immediately available per ANZCA PS09.
Observation period: Minimum 30–60 minutes post-procedure in a monitored recovery area; neurological examination (motor, sensory, reflexes) before discharge.
Diabetic patients: Blood glucose monitoring at 1, 2, and 4 hours post-corticosteroid injection and at 24 and 48 hours (risk of delayed hyperglycaemia).
Discharge criteria: Stable vital signs, no new neurological deficit, pain adequately controlled, ambulatory (for ambulatory procedures), responsible adult escort available, written post-procedure instructions provided.

Post-Procedure Follow-Up

RFN: Review at 2–4 weeks (assess for neuritis/dysaesthesia), then at 3 months (pain diary, functional outcome). Repeat procedures typically at 6–24 months as pain recurs. Objective outcome measures: NRS/VAS, Oswestry Disability Index (ODI), patient global impression of change (PGIC).
SCS: Programming optimisation at 2, 6, and 12 weeks post-implant; 6-monthly device check and battery assessment; annual comprehensive pain medicine review. IPG battery replacement typically at 3–5 years (rechargeable) or 2–3 years (non-rechargeable). Remote monitoring available for some newer devices.
Epidural injections: Telephone or telehealth review at 2–4 weeks; in-person review at 6 weeks if incomplete response; subsequent injections scheduled based on response trajectory. If no benefit after 2 injections at the same level, reassess diagnosis before proceeding.

Outcome Measurement

Australian pain services are encouraged to collect standardized outcome data using the following tools to enable audit, benchmarking, and research:

Numerical Rating Scale (NRS) or Visual Analogue Scale (VAS) for pain intensity
Brief Pain Inventory (BPI) — pain interference subscale
Oswestry Disability Index (ODI) for spinal pain
EQ-5D-5L for health-related quality of life
Patient Global Impression of Change (PGIC)
Opioid consumption (morphine equivalent daily dose — MEDD)
Return to work / functional activity measures

Special Populations

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Pregnancy

Fluoroscopy is contraindicated in pregnancy due to ionising radiation exposure to the foetus. Ultrasound-guided procedures may be considered if the clinical need is compelling and the patient is fully counselled.
Corticosteroid epidural injections should be avoided or minimised — corticosteroids cross the placenta (betamethasone and dexamethasone cross more readily than methylprednisolone and prednisolone). Theoretical risk of foetal adrenal suppression with repeated doses.
SCS implantation is contraindicated in pregnancy; SCS in situ is managed conservatively during pregnancy with programming adjustment.
RFN is generally deferred until after delivery unless there is severe refractory pain with significant functional compromise.
Multidisciplinary pain management (physiotherapy, psychology, paracetamol-based pharmacotherapy) is the preferred approach during pregnancy.

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Paediatrics

Invasive pain procedures in children (<18 years) are rare and require specialist paediatric pain medicine assessment at a tertiary paediatric pain service (e.g., The Children's Hospital at Westmead, Royal Children's Hospital Melbourne).
Paediatric chronic pain is predominantly managed with biopsychosocial approaches; procedural interventions are considered only after comprehensive conservative management has failed.
Epidural injections (caudal approach) are used in paediatric anaesthesia/acute pain but are uncommon for chronic pain indications in children.
SCS has been reported in adolescents with CRPS but remains off-label and should only be performed in specialist centres with paediatric ethics approval.
General anaesthesia is typically required for paediatric procedures, adding anaesthetic risk.
Dose adjustments: Corticosteroid doses should be weight-adjusted (methylprednisolone 0.5–1 mg/kg to a maximum of 80 mg for epidural injections in children, if performed).

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Elderly (≥65 years)

Higher prevalence of facet joint osteoarthritis and spinal stenosis — RFN and epidural injections are frequently indicated but require careful procedural planning.
Increased risk of epidural haematoma with concurrent anticoagulant use — common in elderly patients for atrial fibrillation, VTE prophylaxis, and mechanical heart valves. Careful risk–benefit analysis and medication management is essential.
Spinal canal stenosis and degenerative changes may complicate needle placement — fluoroscopic confirmation of anatomy is mandatory.
Corticosteroid-related hyperglycaemia is more significant in elderly patients with type 2 diabetes or impaired glucose tolerance.
SCS can be effective in the elderly but device operability (cognitive function, manual dexterity) must be assessed; non-rechargeable IPG may be preferred to avoid charging burden.
Fall risk assessment is important — transient lower limb weakness (lumbar RFN) or post-procedural dizziness may increase fall risk in frail elderly patients.

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Renal Impairment

Anticoagulant management: DOACs (apixaban, rivaroxaban, dabigatran) require dose adjustment or extended cessation in CKD — dabigatran is contraindicated in severe CKD (eGFR <30 mL/min). Consult renal team for bridging guidance.
Corticosteroid clearance is prolonged in severe CKD — no specific dose adjustments required for epidural injections but consider lower doses and longer intervals between injections.
Haemodialysis patients: Procedures ideally performed on non-dialysis days; heparin-free dialysis may be required in the 24 hours post-procedure if epidural was performed. Vascular access (AV fistula) arm must be protected during positioning.
Uraemic platelet dysfunction increases bleeding risk — check platelet function (PFA-100 or bleeding time) in patients with eGFR <15 mL/min or on dialysis.
SCS is feasible in renal impairment with appropriate anaesthetic planning.

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Hepatic Impairment

Coagulopathy: Chronic liver disease impairs synthesis of coagulation factors and may cause thrombocytopenia from portal hypertension/splenomegaly. Check INR, APTT, and platelet count before all procedures. INR >1.5 or platelets <50 × 10⁹/L are relative contraindications to epidural and deep procedures.
Warfarin metabolism is prolonged in hepatic impairment — extended cessation required (typically 5 days with INR verification <1.5 pre-procedure).
Corticosteroid metabolism is reduced in cirrhosis — consider dose reduction and monitor for fluid retention, hyperglycaemia, and encephalopathy exacerbation.
Local anaesthetic (bupivacaine, lignocaine) hepatic clearance is reduced — use lower doses and standard concentrations; avoid repeated dosing within short intervals.
Hepatology/hepatobiliary consultation recommended for patients with Child-Pugh B or C cirrhosis before any invasive procedure.

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Immunocompromised

Includes patients on biologic DMARDs, high-dose corticosteroids (≥20 mg prednisolone/day), chemotherapy, post-transplant immunosuppression, and HIV with CD4 <200 cells/μL.
Increased infection risk: Prophylactic IV antibiotics recommended for all implantable procedures (SCS); consider for epidural injections and RFN in severely immunosuppressed patients. Cefazolin 2 g IV (or vancomycin if MRSA colonisation suspected) 30–60 minutes pre-incision.
Biologic DMARDs (TNF inhibitors, IL-6 inhibitors, JAK inhibitors): Ideally withhold for 1–2 half-lives before implantation procedures — consult rheumatologist/immunologist. For RFN and epidural injections, the infection risk is lower and withholding is often not required.
Neutropenia (ANC <1.0 × 10⁹/L): Procedures should be deferred until neutrophil recovery unless urgently indicated.
HIV-positive patients on antiretroviral therapy with virological suppression can safely undergo invasive procedures — assess CD4 count and viral load.
Screws, implanted hardware (SCS): Particularly vigilant for infection — biofilm formation on hardware makes infection difficult to eradicate without explantation.

Aboriginal and Torres Strait Islander Health

Aboriginal and Torres Strait Islander Health Considerations

Chronic Pain Burden

Aboriginal and Torres Strait Islander Australians experience chronic pain at approximately 1.5–2 times the rate of non-Indigenous Australians, with earlier onset and greater severity. Musculoskeletal pain (back, neck, and joint pain) is the most common chronic pain presentation. The AIHW reports that 29% of Indigenous Australians aged ≥15 years report bodily pain lasting ≥3 months, compared with 19% of non-Indigenous Australians. Chronic pain is strongly associated with higher rates of disability, psychological distress, and reduced social and emotional wellbeing.

Access to Specialist Pain Services

The vast majority of procedural pain services are located in major metropolitan centres. Aboriginal and Torres Strait Islander peoples — particularly those in remote and very remote communities — face significant geographic, financial, and cultural barriers to accessing specialist pain medicine assessment and invasive procedures. Wait times in public hospital pain clinics are often 12–24 months. Some patients may need to travel thousands of kilometres for a single procedure, requiring family separation, leave from community obligations, and accommodation in unfamiliar urban environments.

Cultural Safety in Pain Assessment

Pain assessment tools validated in non-Indigenous populations may not capture the full experience of pain for Aboriginal and Torres Strait Islander peoples, which is understood through a holistic framework encompassing physical, social, emotional, spiritual, and cultural dimensions. Visual analogue scales and NRS scales may be unfamiliar or culturally inappropriate. Clinicians should use culturally validated tools where available, allow adequate time for consultation (longer appointment times), and employ Indigenous health workers or liaison officers to facilitate communication and trust-building.

Multidisciplinary & Community-Based Models

Hub-and-spoke models linking metropolitan proceduralists with regional and remote Aboriginal Community Controlled Health Organisations (ACCHOs) via telehealth are emerging as the preferred model of care. Procedures can be coordinated as part of a broader care plan that incorporates yarning-based pain education, group-based programmes, and culturally informed non-pharmacological strategies (connection to Country, traditional healing practices alongside Western medicine). The Indigenous Chronic Disease Package and Closing the Gap initiatives provide some funding pathways.

Opioid Prescribing Disparities

Aboriginal and Torres Strait Islander Australians are disproportionately prescribed long-term opioid therapy for chronic pain, with PBS data showing rates 1.5–2× higher than the non-Indigenous population. Invasive pain procedures may be underutilised in this population due to access barriers, resulting in a reliance on escalating pharmacotherapy. Equitable access to procedural interventions should be a health system priority, with procedural pain services actively developing culturally safe pathways for Indigenous patients.

Specific Recommendations

Fund dedicated Indigenous pain medicine outreach clinics in regional centres and ACCHOs.
Develop telehealth-based procedural consultation pathways with metropolitan FPM fellows to reduce unnecessary travel.
Employ Aboriginal and Torres Strait Islander health workers within pain services to provide culturally safe navigation, advocacy, and patient education.
Ensure informed consent processes are culturally appropriate — using plain language, visual aids, yarning, and family/community involvement where desired by the patient.
Integrate procedural interventions within holistic care plans that respect cultural determinants of health and wellbeing.
Prioritise Indigenous patients for reduced wait times in public hospital pain services per Closing the Gap equity frameworks.

📚 References

1. Australian and New Zealand College of Anaesthetists (ANZCA). PS09: Guidelines on Sedation and/or Analgesia for Diagnostic and Interventional Medical, Dental or Surgical Procedures. Melbourne: ANZCA; 2014 (revised 2018).
2. Faculty of Pain Medicine, ANZCA. Competency Standards for Specialist Pain Medicine Physicians. Melbourne: FPM ANZCA; 2023.
3. Bogduk N. On cervical zygapophysial joint pain after whiplash. Spine. 2011;36(25 Suppl):S194–S199.
4. Juch JNS, Maas ET, Ostelo RWJG, et al. Effect of radiofrequency denervation on pain intensity among patients with chronic low back pain: the Mint randomized clinical trials. JAMA. 2017;318(1):68–81.
5. Kumar K, Taylor RS, Jacques L, et al. Spinal cord stimulation versus conventional medical management for neuropathic pain: a multicentre randomised controlled trial in patients with failed back surgery syndrome. Pain. 2007;132(1-2):179–188.
6. Kapural L, Yu C, Doust MW, et al. Novel 10-kHz high-frequency therapy (HF10 therapy) is superior to traditional low-frequency spinal cord stimulation for the treatment of chronic back and leg pain: the SENZA-RCT randomized controlled trial. Neurosurgery. 2016;63(Suppl 1):167.
7. Friedly JL, Comstock BA, Turner JA, et al. A randomized trial of epidural glucocorticoid injections for spinal stenosis. N Engl J Med. 2014;371(1):11–21.
8. Deer TR, Levy RM, Kramer J, et al. Dorsal root ganglion stimulation yielded higher treatment success rate for complex regional pain syndrome and causalgia at 3 and 12 months: randomized comparative trial. Pain. 2017;158(4):669–681.
9. National Institute for Health and Care Excellence (NICE). Spinal Cord Stimulation for Chronic Pain of Neuropathic or Ischaemic Origin. NICE technology appraisal guidance [TA159]. London: NICE; 2008 (updated 2019).
10. Spine Intervention Society. Guidelines for the Performance of Cervical Translaminar Epidural Steroid Injections and Cervical Transforaminal Epidural Steroid Injections. 2018.
11. Australian Institute of Health and Welfare (AIHW). Chronic Pain in Australia. Cat. no. PHE 278. Canberra: AIHW; 2020.
12. Byles J, Hockey R, McLaughlin D, et al. Chronic conditions, physical function and health care use: findings from the Australian Longitudinal Study on Women's Health. Aust N Z J Public Health. 2019;43(6):537–543.
13. Peng PWH, Castano ED. Survey of chronic pain practice by anesthesiologists in Canada. Can J Anaesth. 2005;52(4):383–389.
14. Australian Pain Society. Pain in Aboriginal and Torres Strait Islander Populations: Discussion Paper. Sydney: Australian Pain Society; 2019.
15. Cohen SP, Bicket MC, Jamison D, et al. Epidural steroids: a comprehensive, evidence-based review. Reg Anesth Pain Med. 2013;38(3):175–200.

for PBS scripts. Utilise ACCHS pharmacies and Remote Area Aboriginal Health Worker programs for medication supply in remote areas. Avoid initiating benzodiazepines; support holistic pain management including community-based exercise programs.

Preventive health

Promote bone health: encourage vitamin D supplementation (1000 IU daily in deficient individuals), smoking cessation support, reduction of alcohol intake, and weight-bearing exercise. MBS Item 715 health checks provide a structured opportunity to assess bone health, screen for osteoporosis risk factors, and discuss musculoskeletal health in a culturally safe context.

Quick Reference: Differential Diagnosis at a Glance

Costovertebral dysfunction

Paracetamol ± NSAID; manual therapy

2–6 weeks

Provocable on palpation; no red flags

Thoracic compression fracture

Paracetamol; ± calcitonin; DXA + osteoporosis Rx

6–12 weeks healing

Elderly; osteoporosis; acute onset

ACS (posterior MI)

Aspirin 300 mg, GTN, heparin; urgent PCI

Time-critical

ECG, troponin; CV risk factors

Aortic dissection

IV labetalol; urgent CT aortogram; surgery (Type A)

Time-critical

Tearing pain; BP differential >20 mmHg

Vertebral osteomyelitis

IV antibiotics (vancomycin + ceftriaxone initially); ID consult

6 weeks IV antibiotics

Fever, elevated CRP, IV drug use

Biliary colic / cholecystitis

Paracetamol ± morphine; lap cholecystectomy

Surgical within 72 h (cholecystitis)

RUQ/infrascapular; post-prandial; RUQ US

📚 References

1. Briggs AM, Smith AJ, Straker LM, Bragge P. Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskelet Disord. 2009;10:77.
2. National Health and Medical Research Council (NHMRC). Evidence-based management of acute musculoskeletal pain. Canberra: NHMRC; 2003 (updated 2020).
3. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Canberra: AIHW; 2023.
4. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268(6):760–765.
5. Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Europ Spine J. 2018;27(1):60–75.
6. Erwin WM, Jackson PC, Homonko DA. Innervation of the human costovertebral joint: implications for clinical back pain syndromes. J Manipulative Physiol Ther. 2000;23(6):395–403.
7. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice. 9th edn. Melbourne: RACGP; 2018 (updated 2023).
8. Hirsch JA, Singh V, Falco FJE, et al. Thoracic facet joint interventions. Pain Physician. 2016;19(4):E581–E593.
9. Erwin WM, Jackson PC. The costovertebral joint: anatomy, biomechanics, and clinical significance in thoracic back pain syndromes. J Can Chiropr Assoc. 2003;47(2):112–120.
10. Strayer RJ, Gunnerson JM, Brown LH, et al. Aortic dissection: clinical features, diagnosis, and management. Aust Crit Care. 2019;32(2):144–153.
11. Ombregt L. A system of orthopaedic medicine. 3rd edn. Edinburgh: Churchill Livingstone Elsevier; 2013. Chapter 18: Thoracic spine.
12. Lin CC, Chen KH, Li DM, et al. Characteristics and outcomes of patients presenting with thoracic back pain to the emergency department. Emerg Med Australas. 2020;32(5):805–811.

for PBS-listed medicines at participating pharmacies.

Cultural safety

Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.

Medication adherence

Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.

Specific conditions

Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.

Referral pathways

Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).

for PBS-listed medicines at participating pharmacies.

Cultural safety

Medication adherence

Specific conditions

Referral pathways

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).