Treat the source, and the medication has less to do

Pain is a signal, not a diagnosis. An opioid turns down the volume on the whole nervous system. It does nothing about the inflamed facet joint, the compressed nerve root or the damaged vertebral endplate sending the signal.

The Padda Institute Center for Interventional Pain Management, led by Dr. Gurpreet Singh Padda, MD, MBA, MHP, works the other way. Identify the generator. Prove it. Treat it. Then fix the terrain it sits in. This page is the toolkit, condition by condition. It is part of the practice's opioid stewardship work.

Why not just take a pill?

Because a pill circulates through the whole body and answers none of the questions. Where is the signal coming from? Why is the nervous system reporting it so loudly?

An interventional physician finds the precise nerve or structure and treats it directly. Done well, the procedure is diagnostic as much as therapeutic. If a targeted block relieves the pain, it confirms the source.

An injection-only model fails too. Block a nerve while ignoring chronically high insulin, systemic inflammation and broken sleep, and you have silenced the alarm for a while. The practice uses the procedure to break the cycle of acute suffering, then uses that window to fix the terrain.

How is the source diagnosed?

• Imaging: MRI, CT and X-ray, with digital whole body X-ray on site. Back-pain MRIs are read for endplate (Modic) changes, not just disc herniation.
• Electrodiagnostics: EMG and nerve conduction studies test the integrity and function of peripheral nerves.
• Diagnostic blocks: relief from a targeted anesthetic block confirms the generator.
• Metabolic and inflammatory testing: two patients with the same MRI do not have the same pain.

Ultrasound assesses a joint, tendon or nerve while it moves. Fluoroscopy gives live X-ray confirmation of needle position for spinal work. The imaging is matched to the target, and placement is confirmed before any medication goes in.

What treats back and neck pain?

The structure decides the procedure.

• Epidural steroid injection (ESI): corticosteroid placed into the epidural space around an irritated nerve root. For back pain and pain radiating from the spine. It covers about three vertebral levels on both sides.
• Selective nerve root block: a single nerve root, targeted.
• Facet joint injection, then facet radiofrequency ablation: for arthritic facet joints. When blocks confirm the joint, ablation heats the medial branch nerves that carry its pain. Relief commonly lasts six to twelve months. The nerves regenerate, so it can be repeated. It is done without sedation; do not drive the day of the procedure, and legs may feel weak or numb for a few hours.
• Basivertebral nerve ablation (Intracept): for vertebrogenic low back pain from the vertebral endplate. Deep midline pain, worse sitting and flexing, beyond six months, with Modic Type 1 or 2 changes. Nothing is implanted or fused. Outpatient, no sedation.
• Sacroiliac joint injection: anti-inflammatory medication into the SI joint under fluoroscopic guidance.
• Epiduroplasty (epidural lysis of adhesions): a catheter breaks down scar tissue tethering nerve roots after spine surgery, the most common finding when leg pain returns months after a successful decompression. One to three sessions on consecutive days, local anesthetic, no sedation.
• MILD procedure: minimally invasive lumbar decompression for stenosis from a thickened ligamentum flavum. No implant, no fusion.
• Kyphoplasty and vertebroplasty: bone cement for painful vertebral compression fractures, which are frequently missed or dismissed in osteoporosis.
• Pneumatic cervical traction: controlled, measured decompression of the neck, in the office.

What treats knee, hip and joint pain?

• Genicular nerve block, then genicular radiofrequency ablation: for chronic knee pain. Local anesthetic, no sedation, thirty to forty-five minutes. Relief is measured in months. The joint is unchanged, so a later knee replacement stays possible. In the founding sham-controlled trial, 59 percent of treated patients had at least 50 percent relief at twelve weeks. None in the sham group did.
• Viscosupplementation: hyaluronic acid injected into an osteoarthritic knee. Some products are a single injection, others a series of three to five given weekly, chosen for your knee and your coverage.
• Hip joint injection: image-guided treatment of the ball-and-socket joint.
• Trigger point injections: local anesthetic into a taut, painful band of muscle to break the spasm.
• Shockwave therapy: focused acoustic pressure waves for tendon and soft-tissue injury that has gone chronic, including plantar fasciitis. Three to five sessions about a week apart. No anesthesia, drive yourself home, normal activity the same day.

When the tissue itself is failing, Regen.MD, Suite 103 in the same building, rebuilds it. Think of the body as soil. If the soil is inflamed, under-oxygenated and poorly fueled, nothing planted in it takes root. Regen.MD restores the soil first, then repairs the structure with BMAC, Lipogems and PRP. Every case starts with a 60-minute evaluation of history, imaging and metabolic markers. See regenerative medicine and PRP.

What treats nerve pain?

This is where pills disappoint most. The options are wide, and each is scoped to its condition.

• Nerve blocks: local anesthetic, sometimes with a steroid, around a specific nerve or nerve group.
• Hydrodissection: image-guided fluid that frees an entrapped peripheral nerve from scar tissue or fascia. Awake, about twenty minutes, no incision.
• Peripheral nerve stimulation: a fine lead beside a single damaged nerve, for focal pain that injections did not fix. Local anesthetic, no sedation, drive yourself home, no activity restrictions. A trial comes first.
• Spinal cord stimulation: an implanted, programmable system that interrupts chronic nerve pain in the back, arms or legs. Nobody gets a permanent implant without a trial. The best-established indication is persistent radicular pain after spine surgery.
• Electroanalgesia (TENS and PENS): electrical stimulation that interferes with transmission, engages the pathways that dampen pain and raises the body's own opioid activity. No sedation, no incision, no recovery period.
• Piriformis syndrome and cluneal neuropathy: diagnosed by examination and image-guided injection, because both impersonate disc or sacroiliac pain.

Complex regional pain syndrome (CRPS), formerly reflex sympathetic dystrophy: chronic burning pain in an arm or leg after trauma or nerve injury. Timing matters most. Treat it within six months and no later than two years. The tools are sympathetic nerve blocks, radiofrequency thermoneurolysis, and spinal cord or peripheral nerve stimulation.

Ketamine for RSD, CRPS and refractory nerve pain: ketamine blocks the NMDA receptor that amplifies these conditions. It is used by IV infusion, sublingual preparation or topical cream once standard care has fallen short. Every use for chronic pain is off-label. The evidence does not transfer between routes. The strongest data are for a multi-day inpatient infusion; a separate trial supports topical cream for allodynia; there is no controlled efficacy evidence for sublingual, and the practice says so directly.

Diabetic peripheral neuropathy: opioids are used to treat 50 percent of these patients, and they repair nothing. Where medication and metabolic management have not controlled the pain, the practice uses the NS-100, an FDA-cleared Class II programmable peripheral electrical nerve stimulator made by Nalu. It is applied to the auricular branches at the ear and acts as a vagal stimulator, changing how pain is processed centrally. It is worn for up to 30 days, most often around 20. Local anesthetic, no sedation, drive yourself home, no activity restrictions.

Regenerve, Suite 104, treats the terrain around the nerve. Three failures drive diabetic nerve pain: starving micro-vessels, glycation cooking the nerve proteins, and myelin breaking down. Regenerve restores micro-vessel perfusion, shuts down glycation, and supplies benfotiamine, alpha-lipoic acid and methylcobalamin at clinical doses under physician evaluation. See peripheral neuropathy treatment.

What treats headache?

• Sphenopalatine ganglion block: local anesthetic to a nerve cluster behind the nose. No incision and no sedation in the transnasal approach; most patients drive themselves home.
• Occipital nerve blocks: for headache that starts in the neck.
• Stellate ganglion block: for headache and sympathetically driven pain.
• Botox for chronic migraine: FDA-approved prevention, 31 small injections across seven head and neck areas, about fifteen minutes. No sedation; you drive yourself home. It repeats every twelve weeks.

What about cancer and abdominal pain?

Cancer pain is a condition, not a diagnosis. Visceral, bone, nerve and mechanical pain coexist. The oral dose needed for relief brings sedation, confusion, constipation and nausea. Patients end up choosing between pain and being present.

• Celiac plexus block: interrupts the visceral pathway from the pancreas and upper abdomen. Its main use is chronic pancreatitis. In pancreatic cancer it has a well-established role and can substantially reduce opioid requirement. Done early, it does far more good than the same block in the final weeks.
• Ketamine: where central sensitization has developed and opioid escalation has stopped paying off.

Most of these are performed under local anesthetic with sedation and take well under an hour. Tolerability shapes the decision.

Which in-office therapies are used?

Alongside procedures, never instead of them:

• Cold laser therapy (photobiomodulation): red and near-infrared light at 650, 808, 905 and 980 nanometers.
• Whole body infrared therapy: deep warmth to cut muscle guarding, improve circulation and loosen tissue.
• Whole body vibration therapy: an oscillating platform that recruits muscle reflexively and builds load tolerance.

Why is metabolism on a pain page?

Because the terrain decides whether the procedure holds.

The cascade runs like this. Visceral fat is not storage. It is an endocrine organ pumping interleukin-6 and tumor necrosis factor alpha into the portal circulation. Those cytokines sensitize nerve endings and drive central sensitization in the spinal cord. Insulin resistance starves nerves of blood flow. Glycation stiffens collagen and can trap nerves. Broken sleep amplifies pain reactivity in the brain the next day. The nervous system ends up reporting pain at a lower threshold before any structural injury is counted.

"You can inject the right structure, in the right place, and watch it fail," Dr. Padda says. "Not because the procedure was wrong. Because you put a repair into an inflamed body and expected the body to cooperate."

At least 40 to 50 percent of treating pain here is lifestyle coaching. It is treatment, not aftercare:

• Sleep and circadian timing, including light exposure at night, which suppresses the repair window.
• Nutrition: whole food, adequate protein and healthy fat. Less refined carbohydrate and fewer industrial seed oils.
• Movement: graded activity, which also drives the body's own opioid signaling.
• Testing: metabolic and inflammatory markers, plus the magnesium, vitamin D and B vitamin deficiencies nobody checks.
• Counseling: cognitive behavioral and acceptance-based therapy from an in-house clinical psychologist, coordinated with the physician, never premised on the pain being imagined.
• Medical weight loss: physician-led, for patients whose pain and metabolic health are linked.

See also type 2 diabetes reversal and medical weight loss.

Where do implants and surgery fit?

Late. Conservative and interventional care come first. The practice performs spinal cord stimulator trials and implants, and minimally invasive sacroiliac joint fusion using the iFuse and Catamaran systems. Anyone considering a permanent implantable device, such as a dorsal column stimulator or intrathecal pump, completes psychological screening first.

What is recovery like?

For epidural steroid injections, the practice uses no sedation. You are monitored for 15 to 30 minutes, most patients drive themselves home, and most resume normal activity, including work, within two to four hours. The exception is temporary leg weakness or numbness.

Kyphoplasty, vertebroplasty and the MILD procedure use mild sedation. Arrange a driver. After MILD, plan a follow-up visit within five to ten days.

The number of injections follows your response to the first one. There is no magic in a series of three.

How do I get evaluated?

The Padda Institute is at 4477 Woodson Rd, Suite 100, St. Louis, MO 63134, next to the airport, with Regen.MD and Regenerve in the same building. Call (314) 481-5000 or text (314) 886-5902. Same-day and emergency appointments are available.

On opioids and ready to come down? Read opioid tapering for chronic pain. Not sure which clinic fits your pain? Tap the directory assistant, the light in the corner of this page, and it will point you to the right place. More on the practice: interventional pain management.

Frequently asked questions

My MRI was read as normal. Can I still have vertebrogenic pain?

Possibly. If the report never mentioned Modic changes, the study was read for a different question. It needs to be read for endplate signal change.

Does knee ablation rule out a knee replacement later?

No. Radiofrequency interrupts the genicular nerves and leaves the joint unchanged.

Why is a stimulator trial required?

The published outcomes come from patients selected by a successful trial. No convincing response in the trial means the data predicting benefit does not apply to you.

Will insurance require anything before spinal cord stimulation?

Nearly always prior authorization, usually with a psychological evaluation, documented failed conservative care, matching imaging and a successful trial result. An authorization is not a promise of payment.

Why does a procedure wear off?

Nerves regenerate along their preserved sheath at roughly one to two millimeters a day. That is why ablation relief is measured in months and why the procedure can be repeated.