Evidence-based advice for investigation, intervention and long-term management

Perth-based pain specialist and former GP Dr Reshad Mirnour explains some common tips (and traps to avoid) to help people with chronic pain get better outcomes.

Tip 1: Remain vigilant for red flags

Patients with chronic spinal pain often present repeatedly with exacerbations, and it can be easy to attribute these to a flare-up.

Look out for changes in presentation, particularly in older patients and those with a history of malignancy, immunocompromise, osteoporosis or intravenous drug use, Dr Mirnour advises.

“In acute presentations, we may need to focus a little bit more on biology to make sure that nothing is being missed.”

Although serious pathology is uncommon, spinal infection, metastatic disease and compression fractures still occur.

“We just have to be mindful not to miss any red flags,” he says.

Tip 2: Ask this question before imaging

Choosing whether to image can be a conundrum in chronic pain. On one hand, clinicians are encouraged to avoid unnecessary scans. On the other, you don’t want to miss significant pathology.

Dr Mirnour recommends asking yourself a question before every imaging request: Will the result change management?

Imaging is generally justified if you’re either concerned about serious pathology (e.g. a fracture or infection in an acute presentation), or if the results will inform an intervention (e.g. an epidural injection or rhizotomy), he says.

Ordering scans just to satisfy patients often creates more problems, particularly when incidental findings are identified.

What type of imaging is best?

A CT scan is often appropriate, especially if you suspect bony pathology. They’re covered by Medicare, widely available with minimal wait times, and tell you more than an X-ray. An MRI can be appropriate if you suspect nerve compression or infection/inflammation, but they are generally less accessible. There is no Medicare rebate for a GP MRI referral, except for patients with cervical pain and radiculopathy. A plain X-ray is suitable if you just want to rule out a compression fracture.

Tip 3: Treat the patient, not the pathology

Another pitfall of imaging involves assuming that abnormalities explain the patient’s pain. In fact, age-related degenerative changes are common and often unrelated to symptoms.

“The key here is do not treat the imaging,” says Dr Mirnour. “You have to treat the patient.”

This is particularly important when imaging findings and symptoms do not correlate. For example, a patient could have symptoms on one side, but a scan might find significant foraminal stenosis on the opposite side. In such cases, treatment based on imaging findings is unlikely to help.

“And if you’re very unlucky and something happens, like the patient develops nerve damage or an epidural abscess, then you really cannot justify why you’ve done that.”

Tip 4: Remember the difference between radicular and referred pain

True radicular pain follows a nerve root distribution and, in most lumbar presentations, extends below the knee.

In contrast, referred pain (e.g. from lumbar facet joints) typically extends into the buttock or posterior thigh—but rarely below the knee.

Accurately distinguishing between radicular and referred pain helps determine whether interventions such as epidural injections are likely to help.

Tip 5: Avoid intervening too early

Procedural interventions may be appropriate when conservative treatments have been exhausted and you believe a specific pathology is contributing to ongoing symptoms, Dr Mirnour says.

In general, he recommends trying conservative measures for at least three months in patients with lower back pain, with or without radicular symptoms. You may want to wait even longer in patients with thoracic symptoms.

The exception is patients with lumbar radicular symptoms and severe disabling pain that is not improving. “An epidural injection can sometimes be life-changing in the subacute phase in this kind of situation,” he says.

“If you have cervical pain with radiculopathy, then your threshold for intervention is a bit lower. I normally go with six to eight weeks of conservative treatment, because early intervention in cervical radicular symptoms can make a difference and prevent chronicity.”

It’s also important to consider the key pain drivers, he adds.

Mood disorders, family dynamics, workplace pressures, unemployment, compensation claims and social stressors can all influence pain severity, disability and recovery, he stresses.

“If you think there are a lot of psychosocial pain contributors, you don’t think as much about a biomedical issue. And hence, you’re not really thinking about an intervention.”

Tip 6: Reserve epidural injections for genuine radicular pain

“There is no evidence whatsoever that epidural injection will help with chronic axial spinal pain. Unfortunately, I still see this being done, but the results and outcomes are very poor,” Dr Mirnour says.

“They may get a bit of improvement from systemic absorption of steroids, which can help with any pain. And you’re just basically imposing the risk of an epidural injection for little meaningful benefit.”

Tip 7: Set realistic expectations for procedures

Epidural injections typically provide around three months of relief, but they’re not a cure, Dr Mirnour emphasises.

“The whole idea of doing a pain procedure is not to fix the patient. It’s to give them a window of opportunity so they can participate in rehab, they can do things that they couldn’t do, their mental health will improve, they can return to work.”

“And those interventions would help in the long term, not your needle. And the same concept applies to things like rhizotomies, which should give patients around 12 months of relief on average.”

“So if the patient is very passive, they don’t want to do anything at all, very soon, they’re going to go back to square one.”

“And again, if they have a lot of psychosocial pain contributors that are not being addressed, an injection often fails.”

Tip 8: Medications rarely have a place

Another trap involves relying on medication to manage chronic spinal pain, Dr Mirnour says, noting our understanding has changed dramatically over the past decade.

“Lots of things were done in the past about chronic back pain in terms of pharmacotherapy that we’ve realised don’t do any good at all. They do a lot of harm.”

Opioids are a prime example, he says.

“In conventional medicine, you find a pathology and treat it. For example, if you have high blood pressure, you give an antihypertensive, and the patient is fine forever. But if you find chronic pain and try to treat it with opioids, that doesn’t really get you anywhere. All people will get tolerant to opioids.”

Traditional agents like morphine, oxycodone, fentanyl and codeine are particularly problematic, but even opioids that are perceived as safer (e.g. tapentadol and tramadol) lead to tolerance.

“And after a period of time, you find a patient taking a big dose, and it would be just like placebo.”

“The best recommendation I can give you is do not start an opioid for chronic spinal pain. But if you are starting it, always go with the lowest dose and always have an exit plan.”

Caution is also required with gabapentinoids, he says.

“They are very heavy drugs. They have concerning side effects, particularly in vulnerable people like elderly people. And honestly, they don’t really provide any relief at all when it comes to chronic axial pain.”

It may be reasonable to trial them for a short time in people with true neuropathic pain, he adds.

Some evidence supports a role for duloxetine in chronic spinal pain, he says.

While the mechanism is not fully understood, duloxetine can decrease central sensitisation, and many people with chronic pain also have mental health and mood disorders, he notes

It’s therefore worth considering, especially in patients who have associated depression.

Tip 9: Refer patients to appropriate services

All patients with chronic pain should have a GP management plan for allied health and a mental health plan for pain-focused psychology, Dr Mirnour advises.

Referral to a surgeon is warranted for patients with persistent radicular symptoms, progressive neurological deficits or cauda equina syndrome—which requires urgent assessment.

“If the patient only has axial pain, surgery is better to be avoided, because it really doesn’t have any clear evidence for long-term improvement. And we have seen a lot of failed back surgeries.”

Pain specialist referral is appropriate if you’re considering an intervention (diagnostic or therapeutic), seeking a comprehensive pain assessment or wanting support with medication management.

Patients with complex biopsychosocial needs often benefit most from multidisciplinary pain services incorporating physiotherapy, psychology and specialist medical input.