Invasive pain management is one of the most rapidly evolving areas in modern medicine—especially in workers’ compensation and medico-legal cases where pain can become a long-term barrier to function, recovery, and return to work. This blog is based directly on a webinar presentation on Invasive Pain Management Techniques, hosted by Medical and Life Care Consulting Services, featuring Dr. R. Jason Young, Chief of Pain Medicine and Medical Director of The Pain Management Center at Brigham and Women’s Hospital.
Why Chronic Pain Matters: Prevalence and Cost
A major goal of the talk was to demonstrate that chronic pain is not a niche diagnosis. It is widespread, persistent, and expensive—both to individuals and society.
Dr. Young described research using the NHIS household survey, noting that household surveys reduce bias compared to hospital-based datasets because they capture people in the community rather than only those already receiving care. He highlighted that 2019 was the first year NHIS included a dedicated pain module, enabling more precise estimates.
Key findings he emphasized:
- Roughly one-fifth of U.S. adults report pain on most days.
- About half of those meet criteria for high-impact chronic pain—pain that interferes with activities of daily living and the ability to work (including missed workdays).
- The estimated cost is approximately $296 billion annually in lost productivity.
- He noted this impact is sustained year over year and appears to be rising, and he specifically expressed interest in analyzing post-COVID trends to understand changes in work disruption and pain impact.
The Human Impact of Chronic Pain: What It Does to a Person
Beyond economics, Dr. Young outlined how pain changes a person’s life in multiple domains:
Physiologic Impact
Chronic pain can contribute to:
- Sleep disturbances
- Cognitive processing and memory issues
- Sexual dysfunction
- Cardiovascular health effects
Psychosocial Impact
Pain can reduce:
- Work efficiency (even when people remain employed)
- He connected this to broader well-being concepts: meaningful social interaction drives happiness, and chronic pain disrupts that.
- Sexual dysfunction
Behavioral Impact
Pain often contributes to:
- Social isolation
- Decreased participation in daily routines
- Lower quality-of-life metrics
Mortality and Morbidity
He emphasized that chronic pain is associated with:
- Increased risk for dementia development
- Potential suicide risk in certain contexts, including uncontrolled pain and complex opioid weaning situations described in case reports
- Overall increased mortality among people who endorse chronic pain on a daily basis
This framing reinforced a central message: chronic pain is not merely a symptom; it can become a long-term condition influencing whole-person health and life expectancy.
The Core Treatment Approach: Multimodal, Multidisciplinary, and Interdisciplinary
Dr. Young emphasized that because chronic pain is dynamic and complex, it requires a multimodal and multidisciplinary approach. He described a wide “tool belt” across specialties, including:
- Pain physicians
- Psychologists and psychiatrists
- Physical therapists
- Social workers
- Nurses and case managers
- Acupuncturists
- Chiropractors
He expanded the concept further: the best care becomes interdisciplinary—meaning these disciplines do not function in silos. They interact intentionally, with shared goals aimed at reducing pain’s impact on life and function.
He also clarified a key philosophy: pain medicine often focuses on management, not necessarily complete elimination. The goal is frequently to reduce pain to a level where it is less impactful, restoring function, participation, and quality of life.
The Range of Pain Conditions Interventional Medicine Addresses
Dr. Young reviewed the wide range of pain syndromes treated in pain medicine, emphasizing that pain is the number one reason people seek medical care. These include:
Headache Syndromes
- Tension headaches
- Migraines
- Trigeminal neuralgia and other headache disorders
- Management varies depending on the diagnosis and mechanism, and may or may not involve work-related origin.
Spine Pain
He described spine pain as a major portion of pain practice:
- Cervical (neck)
- Lumbar (low back)
- Sacral pain and SI joint pain
Chronic Post-Surgical Pain
He defined pain categories by time:
- Acute: up to 4 weeks
- Subacute: 4–12 weeks
- Chronic: beyond 12 weeks
Most surgical pain resolves by the four-week mark. When pain persists beyond 12 weeks, it may be classified as chronic post-surgical pain, including:
- Postmastectomy pain
- Post-thoracotomy pain
- Inguinal hernia repair pain (often workers’ comp-relevant due to heavy lifting)
- Chronic abdominal pain
- Orthopedic surgery-related chronic pain (joint replacement and soft-tissue surgeries including ACL repairs)
Chronic Abdominal and Pelvic Pain
He described this as broad, spanning upper GI, lower GI, and pelvic organ sources. The critical step is identifying the true driver of pain before constructing a management plan.
Cancer Pain
Cancer pain was described as particularly meaningful in his clinical work, supported by their affiliation with Dana-Farber and close collaboration with palliative care. He emphasized an aggressive comfort-focused approach, including invasive options when appropriate. He also noted that cancer-related pain includes both end-of-life pain and chronic treatment-related pain syndromes such as chemotherapy-induced neuralgias and radiation-induced pain.
Neuropathy
Neuropathy was described as a broad bucket of nerve pain, including:
- Chemo-induced
- Medication-induced
- Environmental causes
- Diabetic neuropathy (common)
He also described the post-COVID reality: after COVID, they saw many patients with long COVID syndrome and used stellate ganglion blocks and other interventions in management, illustrating how pain medicine adapts as new syndromes emerge.
Spasticity
Spasticity commonly arises in:
- Spinal cord injury
- Multiple sclerosis
- Cerebral palsy
- He highlighted collaboration with physiatrists and rehab systems such as Spalding for spinal cord injury populations.
Complex Regional Pain Syndrome (CRPS)
Dr. Young described CRPS as one of the most severe pain syndromes they treat. It can occur after work-related injury or routine injury (like an ankle sprain). He explained it as a persistent autonomic nervous system feedback loop that is difficult to “reboot,” leading to:
- Allodynia (light touch causing severe pain)
- Bone changes
- Hair changes
- Color changes
- Temperature changes CRPS is often refractory and challenging to treat.
How Pain Is Evaluated: Low Back Pain as an Example Framework
To explain evaluation principles, he used low back pain as a model, noting that even “low back pain” is not a single entity. It can originate from
- Facet joints
- Nerve roots
- Discs
- Ligaments
- Vertebrae (including compression fractures)
Step One: Axial vs Radicular
A first clinical branch point is distinguishing:
- Axial pain (localized back pain)
- Radicular pain (pain traveling down the leg)
Many patients have both, so clinicians try to determine which is dominant:
- Back pain greater than leg pain, or
- Leg pain greater than back pain
Why Timing Matters
He reinforced that most injuries improve within the first 2–4 weeks, but pain specialists often see the population whose symptoms extend beyond typical healing windows. He noted:
- After 12 weeks, recovery can be slow and uncertain.
- Healing varies; prolonged symptoms are not automatically secondary gain.
- After two years away from work, return-to-work likelihood becomes very low—supporting the importance of earlier evaluation and management to reduce long-term disability.
Pathophysiology: Herniation and Degeneration
He reviewed disc structure (annulus and nucleus pulposus) and described how disc content protrusion can irritate nerve roots, triggering inflammatory cascades and worsening symptoms. Interventions may aim to remove irritants surgically or reduce inflammation through other techniques.
-Late degenerative changes can result in disc height loss, ligamentum flavum folding inward, facet arthrosis, and central canal stenosis. He referenced the classic shopping cart sign—symptom relief with leaning forward due to ligament stretching and reduced canal compression.
Imaging: Red Flags, Yellow Flags, and Decision-Making
He emphasized that history and physical exam remain central, while diagnostic imaging functions as a supportive tool to confirm whether exam findings match structural changes.
He described imaging considerations:
- Early imaging with red flags such as cancer history, bowel/bladder issues, or severe neurologic symptoms
- Advanced imaging often considered around the 12-week mark if pain persists without resolution
- X-rays as early imaging; MRI/CT as advanced imaging depending on contraindications
He also referenced yellow flags that influence prolonged disability risk and complexity, including:
- Core strength
- Age
- Obesity
- Psychosocial stress
- The possibility of secondary gain as a background consideration (while still giving patients the benefit of the doubt)
- Financial pressure and urgency to return to work (e.g., sole breadwinner)
He noted varying sensitivity and specificity of imaging modalities across conditions and emphasized reserving advanced imaging unless strong red flags or multiple yellow flags exist.
Invasive Procedures: Where They’re Done and What They Include
Dr. Young then transitioned into the “meat” of the lecture: invasive pain procedures.
Fluoroscopy (X-Ray Guided) vs Non-Fluoro Procedure Rooms
He explained that many pain procedures are performed in fluoroscopy rooms due to the need for X-ray guidance. These rooms are expensive and designed for high utilization. When a procedure does not require fluoroscopy, it may be performed in other procedure rooms where clinicians can perform:
- Ultrasound-guided injections
- Non-guided injections/blocks
- Trigger point injections
- Botox injections
- Pump refills
Infusions: IV Lidocaine and Ketamine
He noted that IV lidocaine and ketamine infusions were previously offered, but are less common now due to decreasing reimbursement and resource intensity. Some patients respond very well, but many experience only short-lived relief, creating institutional reluctance to continue offering them widely.
Fluoroscopy-Based Spine and Trunk Procedures: Practical Safety Considerations
He described general guidelines often used:
- Many spine procedures require holding anticoagulation and arranging a ride home, though this is not absolute.
- Some facet injections and RFAs may be done without holding anticoagulation depending on patient-specific risk.
- Steroid procedures may influence antibiotic decision-making.
- Delayed weakness can occur in some procedures, requiring either a ride or longer observation (20–30 minutes) to ensure safe discharge.
He emphasized individualized risk–benefit decision-making for each patient.
He also clarified that fluoroscopy can guide more than spine injections; certain trunk muscle injections can also be fluoroscopy-guided.
Spine Procedures by Region: Cervical, Thoracic, Lumbar, and SI
Cervical (Neck)
- Epidural steroid injections are often targeted at radicular arm symptoms.
- Facet injections target axial neck pain.
- If facet blocks provide short but meaningful relief, medial branch blocks may confirm diagnosis.
- If diagnostic relief is strong twice, radiofrequency ablation may be considered, since medial branch nerves are sensory and can be ablated without causing motor weakness.
Thoracic (Mid Back / Chest Wall)
- Thoracic epidural injections can be used for thoracic disc herniation.
- Thoracic medial branch blocks are possible.
- Intercostal and paravertebral injections can address chest wall pain, often relevant in work-related crush, sternal, or thoracic injuries.
Lumbar (Low Back)
- Epidural steroid injections for radicular symptoms.
- Facet injections and RFAs for axial low back pain.
- Selective nerve root blocks for radicular patterns.
Sacroiliac (SI) Joint
- Intra-articular SI injections.
- Targeting innervating nerves (including the technique referenced involving S1–S3 and L5 contributions).
Ultrasound and Office-Based Procedures: Trigger Points and Botox
Trigger Point Injections and Needling
He described trigger points as taut bands of muscle that are tender. Treatment may include:
- Dry needling
- Wet needling (local anesthetic; sometimes steroid)
Botox as a Therapeutic Tool
He clarified Botox is used for conditions like:
- Dry needling
- Chronic migraine
He defined chronic migraine as headaches lasting more than four hours per episode and occurring more than 16 times per month, often impacting work and prompting FMLA needs.
Surgical and Implantable Options: Cancer Pain, Chronic Pain, and Spasticity
Dr. Young described implantable and surgical interventions by category:
Cancer Pain
- Intrathecal pumps
- Port systems delivering medication into the epidural space
- Neurolytic blocks (including celiac plexus blocks using alcohol)
- Peripheral stimulation in select cases
Chronic Non-Cancer Pain
- Spinal cord stimulation (trial first, then implant if successful)
- Intrathecal pumps
- Peripheral stimulators (increasingly common)
- SI joint fusion
- Spinal stenosis procedures
Spasticity
- Intrathecal pumps
- Emerging applications of stimulation therapies in spinal cord injury populations
Key Surgical Details Discussed
Dr. Young described implantable and surgical interventions by category:
- Trial period (about 7 days) before implant.
- Implantation may be under sedation or general anesthesia.
- Risks include bleeding, infection, and rare nerve damage.
- Vendors often assist with patient education and programming support.
- He noted workers’ comp relevance and anecdotal return-to-work success.
Peripheral Nerve Stimulation
- Targets specific peripheral nerves (arm, leg, scalp/occipital regions).
- Systems vary: external or internal generators; some temporary (e.g., 60-day) with potential lasting benefit after removal.
Intrathecal Pumps
- Reservoir placed under the skin (typically abdomen), catheter delivers medication into spinal canal.
- Spinal fluid environment is highly medication sensitive.
- Trials may include single-shot injections or monitored infusions before implant.
- Reservoir placement can vary in cancer populations due to anatomy and comfort needs.
Spinal Stenosis: Bridging the Treatment Gap
He described newer options for patients not yet ready for decompressive surgery:
- MILD procedure: debulking ligamentum flavum to reduce inward folding and increase walking/standing tolerance.
- Interspinous spacers: keeping a stenotic segment functionally “open,” similar to the relief patients feel when leaning forward.
SI Joint Fusion
He described SI fusion as newer and sometimes controversial, with multiple approaches (lateral and posterior). He used an analogy: stabilizing a wobbly table by placing a wedge under a leg—adding stability to reduce symptomatic motion.
Q&A: The Questions That Reflect Real Case Challenges
Pain Score vs Functional Improvement
A workers’ comp stakeholder asked why providers don’t have more direct discussions about realistic pain goals, when patients often seek “0/10 pain” as proof of healing.
Dr. Young agreed and described a shift away from numeric pain scores toward functional goals. He provided examples of measurable functional improvements used in practice. He also described how pain can “creep back” over time after interventions, creating a new baseline—making expectation-setting essential. He referenced the role of pain psychology and cognitive behavioral approaches in resetting patient expectations and helping patients become active participants in their recovery.
Dry vs Wet Needling Mechanisms
He described two plausible explanations:
- Endogenous opioid system activation
- Microvascular/stem cell-mediated regenerative signaling
Spinal Cord Stimulator Outcomes and Evidence Limitations
He acknowledged studies are evolving but expensive and often industry-sponsored due to device cost. He described participation in registry studies and emphasized the field’s shift from hardware innovation to waveform/software innovation. He also described an insurance barrier: some insurers deny SCS for non-surgical back pain due to indication restrictions, which has driven efforts to build stronger evidence for expanded coverage.
Workers’ Comp Liability vs Aging and Degeneration
He emphasized this is complex and requires tethering analysis to the original injury and its sequelae, while recognizing that aging and degenerative change can create parallel contributors. He acknowledged the difficulty for clinicians and payers alike.
How MLCC Helps in Complex Pain Cases
Pain is impactful, multifactorial, and often long-term—especially when invasive procedures, implantable devices, or overlapping degenerative changes are involved. Medical and Life Care Consulting Services supports attorneys, claims teams, and case stakeholders by providing nurse consulting, medical record review, defensible chronologies, and life care planning that clarifies treatment pathways, functional goals, and future medical exposure.
MLCC’s experts help translate complex pain medicine into clear, case-relevant clinical reasoning—supporting informed decision-making and appropriate long-term planning. and payers alike.
