Interventional Pain Management

Chronic pain is not merely a symptom — it is a condition in its own right. When pain persists beyond the expected healing period, disrupts daily function, and fails to respond to conventional treatment, it demands a specialist approach. As a neurosurgeon with subspecialty training at Oxford, Dr Nor Faizal brings a neurological perspective to pain management that goes far beyond simple symptom suppression.

Interventional pain management combines precise diagnostic techniques with minimally invasive procedures to identify the anatomical and physiological source of pain, and to deliver targeted treatment directly where it is needed. The goal is not merely pain reduction — it is the restoration of quality of life.

Pain as a Diagnostic Gateway

Pain is the body’s most powerful signal. Rather than viewing it as something to be silenced, an experienced neurosurgeon treats pain as a diagnostic gateway — a map pointing to underlying neurological dysfunction that may otherwise remain hidden.

This concept, sometimes called the “diagnostic moat”, recognises that pain often sits at the boundary between what conventional imaging reveals and what the nervous system is actually experiencing. A patient with persistent leg pain and a “normal” MRI may be experiencing early nerve root compression, central sensitisation, or arachnoiditis — conditions that require neurological expertise to identify.

By approaching pain through a neurosurgical lens, Dr Nor Faizal is able to:

• Distinguish between structural, neuropathic, and central pain mechanisms
• Identify underlying conditions — such as spinal instability, cord compression, or tumour — that require surgical rather than purely medical management
• Avoid unnecessary long-term medication dependence through targeted intervention
• Determine the correct sequence of treatment, from conservative to surgical

Conditions Treated

→ Chronic Back Pain specialist guide — RFA, SCS & nerve block

Chronic Back and Neck Pain

Mechanical low back pain and cervical pain are among the most prevalent causes of disability worldwide. When pain persists beyond three months and is associated with nerve involvement, specialised evaluation is warranted.

Neuropathic Pain

Neuropathic pain arises from injury or dysfunction of the peripheral or central nervous system. It is characterised by burning, electric-shock sensations, allodynia (pain from non-painful stimuli), and hypersensitivity. Common causes include:

• Diabetic peripheral neuropathy
• Post-herpetic neuralgia (shingles)
• Trigeminal neuralgia
• Post-traumatic nerve injury

Complex Regional Pain Syndrome (CRPS)

CRPS is a debilitating condition involving disproportionate pain, autonomic changes (skin colour and temperature changes, excessive sweating), and motor dysfunction following injury. Early specialist intervention significantly improves outcomes.

Post-Surgical Pain

A proportion of patients experience persistent pain following spinal surgery — a condition known as Failed Back Surgery Syndrome (FBSS). This is not a failure of surgery itself, but a complex pain state that responds well to interventional approaches including spinal cord stimulation.

Cancer-Related Pain

Spinal metastases, nerve plexus invasion, and pathological fractures can produce severe, refractory pain in oncology patients. Targeted interventional techniques — including intrathecal drug delivery and vertebral augmentation — can provide substantial relief and allow patients to maintain quality of life during cancer treatment.

Headache and Migraine with Red Flags

While most headaches are benign, some headache patterns require urgent neurological evaluation. These include new-onset headache after age 50, thunderclap headache, headache associated with neurological symptoms, or headache that progressively worsens over weeks.

Interventional Techniques

The selection of technique is always guided by a thorough clinical assessment and review of imaging. Dr Nor Faizal does not apply a one-size-fits-all protocol — every treatment plan is individualised.

Epidural Steroid Injections

Corticosteroid delivered into the epidural space reduces nerve root inflammation caused by disc herniation or spinal stenosis. Performed under fluoroscopic or CT guidance to ensure precision.

Nerve Blocks and Medial Branch Blocks

Targeted anaesthetic or neurolytic agents are delivered to specific nerves or nerve branches to both diagnose the source of pain and provide therapeutic relief. Facet joint medial branch blocks are used to confirm facetogenic low back and neck pain before definitive treatment.

Radiofrequency Ablation (RFA)

A minimally invasive procedure where heat generated by radiofrequency waves is used to ablate (destroy) the sensory nerve fibres transmitting pain from facet joints. RFA provides sustained relief — typically six months to two years — and can be repeated.

Spinal Cord Stimulation (SCS)

Thin electrode leads are placed in the epidural space and connected to a small implanted pulse generator. The device delivers electrical impulses that modulate pain signals before they reach the brain. SCS is particularly effective for:

• Failed Back Surgery Syndrome
• Complex Regional Pain Syndrome
• Refractory neuropathic leg or arm pain

Modern SCS systems use burst stimulation and high-frequency waveforms, providing pain relief without the paresthesia (tingling) associated with older devices.

Intrathecal Drug Delivery (Pain Pump)

A programmable pump is implanted under the skin and connected by a catheter to the intrathecal space surrounding the spinal cord. Medication — typically morphine or ziconotide — is delivered directly to the site of action at a fraction of the oral dose. This reduces systemic side effects and is particularly valuable for cancer pain and severe spasticity.

Kyphoplasty and Vertebroplasty

For vertebral compression fractures — whether from osteoporosis or spinal metastases — cement augmentation procedures restore vertebral height, stabilise the fracture, and provide rapid pain relief. Kyphoplasty additionally uses an inflatable balloon to create space before cement injection, reducing the risk of cement extravasation.

When to See a Pain Specialist

You should consider a referral to an interventional pain specialist when:

• Pain has persisted for more than three months despite conservative treatment
• Pain is interfering significantly with work, sleep, or daily activities
• You are taking increasing doses of pain medication with diminishing benefit
• You have been told surgery is not an option, but pain remains severe
• You experience electric, shooting, or burning pain suggesting nerve involvement
• You have had spinal surgery but continue to have pain

Red Flag Symptoms Requiring Urgent Evaluation

The following symptoms should not be attributed to simple back pain and require prompt specialist assessment:

If you experience any of these symptoms, seek emergency medical care immediately.

Treatment Philosophy

Dr Nor Faizal approaches pain management as a spectrum — from the most conservative to the most advanced — always beginning with the least invasive option that has a reasonable likelihood of success. Surgery is never the default recommendation; rather, it is the conclusion of a carefully considered diagnostic and therapeutic pathway.

This philosophy is grounded in three principles:

1. Diagnose before treating — Understanding the precise source and mechanism of pain is essential before any intervention.
2. Precision over volume — Targeted procedures with imaging guidance are more effective and safer than empirical approaches.
3. Continuity of care — Pain management is rarely a single event. Dr Nor Faizal works with patients over time, adjusting treatment as their condition evolves.

Frequently Asked Questions

Q: Is interventional pain management different from seeing a pain management physician? A: Yes, in an important way. As a neurosurgeon, Dr Nor Faizal can evaluate and treat the full spectrum of neurological causes of pain — including those that require surgical management. This means that if your pain has a structural cause (such as spinal cord compression, a disc fragment, or a tumour), it can be addressed within the same specialist relationship rather than requiring multiple referrals.

Q: Will I need to stop my current pain medications before an interventional procedure? A: This depends on the type of procedure. Blood-thinning medications are typically paused before injections or implants. Dr Nor Faizal will review your full medication list at consultation and provide specific guidance.

Q: How many epidural injections can I have? A: For diagnostic and therapeutic purposes, epidural steroid injections are generally limited to three in any six-month period to limit cumulative steroid exposure. If the first injection provides significant but temporary relief, this confirms the diagnosis and a longer-term solution — such as radiofrequency ablation — can be planned.

Q: Is spinal cord stimulation reversible? A: Yes. One of the major advantages of spinal cord stimulation is that it is trialled first with externally worn equipment before permanent implantation. If the trial is not beneficial, no permanent device is implanted. If implanted, the device can be removed or reprogrammed at any time.

Q: Can pain management help even if my MRI appears normal? A: Absolutely. Many pain conditions — particularly neuropathic pain and central sensitisation — do not produce visible changes on standard MRI. Clinical diagnosis, nerve conduction studies, and diagnostic nerve blocks can identify the source of pain even when imaging appears unremarkable.

Q: How do I know if I need surgery versus an interventional procedure? A: This is determined during consultation through a combination of clinical examination, imaging review, and response to previous treatments. Some conditions — such as cauda equina syndrome or large disc herniation with significant weakness — require surgery. Others respond excellently to targeted interventional approaches. Many patients benefit from both.

Chronic pain is not something you have to accept as a permanent part of your life. With accurate diagnosis and the right intervention, meaningful relief is achievable.

Contact Dr Nor Faizal’s clinic to schedule a specialist pain management consultation.

We see patients at our clinic in Kuala Lumpur. Referrals from general practitioners and other specialists are welcome. Emergency pain consultations for red flag symptoms are accommodated promptly.