PONOS Clinic · Persistent low back pain
Chronic low back pain: from causes to targeted treatment
Facet joints, discs, nerve roots, spinal stenosis and the sacroiliac joint: understanding the source of pain helps determine the role of radiofrequency, PRF and epidural adhesiolysis.
Explore the main causesWhen back pain lasts for months
Low back pain is described as chronic when it persists for more than three months. It may remain localised to the back or occur alongside leg symptoms. Several factors often contribute: joints, discs, nerves, muscles, sleep and sensitisation of the pain system.
The assessment aims to distinguish these components and establish whether there is a suitable treatment target. MRI findings of arthrosis, disc protrusion or disc degeneration do not, on their own, identify the cause of pain.
Understanding the possible causes
Where can low back pain come from?
These sections provide an overview. Symptoms can overlap and do not allow self-diagnosis.
Facet joint pain
The small joints at the back of the spine may contribute to low back pain, sometimes extending into the buttocks and thighs. Pain on extension or rotation may guide the assessment, but does not establish the diagnosis on its own.
How this relates to treatment. Thermal radiofrequency of the medial branches is considered after clinical selection and a positive response to diagnostic blocks.
Facet joint pain: symptoms and diagnosis →Facet radiofrequency: the procedure →
Discogenic pain
The intervertebral disc can be a source of low back pain even without sciatica. However, disc degeneration on MRI does not automatically mean that the disc is painful.
How this relates to treatment. Disc pain needs to be distinguished from nerve root pain because the treatment target is different.
Explore disc-related pain →Lumbar spinal stenosis
Narrowing of the spinal canal may cause pain, heaviness or other leg symptoms when walking, making it necessary to stop. Symptoms must be assessed alongside the examination and imaging.
How this relates to treatment. Selected patients may be considered for treatment of the painful component; epidural adhesiolysis does not widen the spinal canal.
Stenosis and walking difficulties (in Italian) →Radiculopathy and sciatica
Pain radiating down the leg, tingling, altered sensation or weakness call for assessment of the nerve roots. Low back pain may or may not accompany these symptoms.
How this relates to treatment. Pulsed radiofrequency of the dorsal root ganglion may be considered in selected patients with persistent radicular pain.
Lumbar radiculopathy (in Italian) →Sacroiliac pain
Pain around the lower back, buttock and pelvis may arise from the sacroiliac joint and be mistaken for lumbar pain. Clinical examination and, when indicated, a diagnostic injection help assess its role.
How this relates to treatment. Radiofrequency treatment of the relevant nerve branches may be considered in selected patients after the clinical suspicion has been supported.
Sacroiliac joint pain →Pain after lumbar surgery
Persistent or recurrent pain after surgery may have different causes: joint structures, nerve roots, residual stenosis or other problems. Scar tissue does not automatically explain every symptom.
How this relates to treatment. RF, PRF and epidural adhesiolysis have different roles and should be selected only after reassessing the cause of pain.
Persistent pain after lumbar surgery →Muscular factors and non-specific low back pain, without a single identifiable source, also occur. An integrated pain management pathway (in Italian) is central in these situations.
Three approaches, different indications
The role of RF, PRF and epidural adhesiolysis
Thermal radiofrequency
Target: the small nerve branches carrying pain signals from joints.
For facet joint pain, thermal radiofrequency creates a controlled lesion of the medial branches. It is considered when conservative treatment has been insufficient and diagnostic blocks have produced a positive response.
It does not repair a disc or decompress a nerve root. The degree and duration of relief vary.
Lumbar facet radiofrequency →PRF: pulsed radiofrequency
Target: the radicular and neuropathic component of pain.
Radiofrequency pulses are applied for neuromodulation, without aiming to produce the thermal lesion used in conventional RF. Treatment of the dorsal root ganglion may be considered in selected patients with persistent radicular pain.
Studies use different protocols and cannot guarantee an individual outcome. PRF does not remove mechanical compression.
PRF and radicular pain (in Italian) →Epidural adhesiolysis
Target: the epidural space and difficult-to-reach areas around nerve roots.
Also called epidurolysis, this procedure uses a catheter introduced under X-ray guidance to direct treatment, with contrast confirming its spread. It is considered in selected cases of persistent pain, including after surgery or in the presence of stenosis, when clinically justified.
It may address adhesions and nerve irritation. It does not remove bony stenosis or replace necessary surgical decompression.
How epidural adhesiolysis works →Diagnosis guides the choice. These procedures are not interchangeable treatments for every type of back pain. They may have a role at different stages of the same pathway when several painful components coexist.
The sacroiliac region has a specific pathway: radiofrequency treatment of sacroiliac nerve branches. Epidural and nerve root injections (in Italian) have their own indications and limitations.
Severe scoliosis: improving quality of life is a meaningful goal
Marked spinal deformity does not rule out treating a specific component of pain. In Evangelos Panagiotakos’s clinical experience, even patients with severe scoliosis may achieve a meaningful improvement in everyday life when a facet joint component is identified and treated.
Thermal radiofrequency denervation of the medial branches, the small nerves carrying pain signals from the facet joints, may be considered when conservative care has been insufficient and diagnostic blocks support a facet joint origin. The severity of imaging changes alone does not identify the treatment target.
Assessment distinguishes joint pain from radicular pain, stenosis, instability and neurological deficits, which may require different pathways.
Explore lumbar facet radiofrequency →
Selection criteria: NICE NG59, recommendations 1.3.2–1.3.3.
Discogenic pain and sciatica are not the same
Discogenic pain is pain attributed to an intervertebral disc. Radiculopathy involves a nerve root: a disc herniation may contribute to irritation or compression of that root, but the two conditions are not identical.
Assessment brings together the clinical history, examination and imaging when useful. Disc degeneration alone does not automatically justify a procedure. Medial branch RF treats facet joint pain, while radicular PRF targets the neural component; neither should be presented as a general treatment for disc disease.
Explore the spinal pain pathway →Building your PONOS care pathway
- Understand the pain: location, radiation, duration, walking, sleep, previous treatments and surgery.
- Examine and correlate: clinical and neurological assessment, review of imaging and identification of contributing factors.
- Assess a target: diagnostic tests or blocks only when they can guide treatment selection.
- Make a shared decision: expected benefits, alternatives, risks and measurable goals.
- Review progress: pain, function and the need to adjust the rehabilitation or treatment plan.
Procedures may cause temporary pain, bleeding, infection and, more rarely, neurological complications. Anticoagulant medication, allergies and other medical conditions require specific assessment before treatment.
When urgent or surgical assessment is needed
New difficulty passing urine, loss of bladder or bowel control, numbness around the perineum or rapidly progressing weakness require urgent assessment. Fever, significant trauma or a history of cancer associated with new pain require prompt medical attention.
Pain procedures must not delay surgical assessment when indicated. Where there is compression, instability or neurological deficit, decisions should be shared with a spinal specialist.
Radiofrequency and surgery: different indications (in Italian) →Clinical cases in practice
Cases describe individual decisions and outcomes; they do not predict another patient’s response.
Stenosis and radiculopathy in an older patient
A combined pathway of epidural adhesiolysis and PRF, with pain and walking assessed at one year. Anatomical stenosis remains distinct from improvement in symptoms.
Read the case (in Italian) →L5 radiculopathy after spinal fusion
A case of persistent paraesthesia after surgery, treated with PRF and reassessed at three weeks.
Read the case (in Italian) →What the NASS guideline says
The 2020 NASS guideline was developed for adults with nonspecific low back pain. Its main questions exclude, among other conditions, neurological deficits and leg pain below the knee; it therefore does not replace a specific assessment of radiculopathy, spinal stenosis or persistent pain after surgery.
- Facet-mediated pain: thermal radiofrequency is suggested in selected patients; outcomes are more reliable when stringent diagnostic criteria are used (Grade B), with relief shown to last at least six months.
- Sacroiliac pain: intra-articular steroid injection may be considered (Grade C); radiofrequency of the sacral lateral branches and L5 dorsal ramus may be considered after dual diagnostic blocks (Grade C).
- Epidural injections: for nonspecific low back pain, NASS found insufficient evidence; in radicular and stenotic presentations, the indication must be individualised using the clinical assessment, imaging and treatment goals.
- Discogenic pain: evidence for percutaneous intradiscal radiofrequency thermocoagulation is insufficient; an MRI finding alone does not identify the source of pain.
Source: North American Spine Society (NASS), Diagnosis & Treatment of Low Back Pain, 2020.
Frequently asked questions
Is radiofrequency suitable for every type of low back pain?
No. Thermal medial branch RF targets carefully selected facet joint pain. It is not a universal treatment for disc disease, sciatica or stenosis.
Are PRF and thermal RF the same procedure?
No. They differ in their aims and delivery: thermal RF creates a controlled lesion of small nerve branches, while PRF aims to provide neuromodulation without seeking that lesion.
Does epidural adhesiolysis resolve spinal stenosis?
It does not correct the anatomical narrowing. In selected patients it may be considered for the painful component, while any indication for decompression is assessed separately.
How long does relief last?
There is no guaranteed duration. It depends on the clinical situation, procedure and individual response. Follow-up also assesses walking, sleep and daily activities.
Sources and further reading
- NICE NG59 – Low back pain and sciatica: assessment, management and selection for radiofrequency denervation.
- Guy’s and St Thomas’ NHS – Epidurolysis to treat pain.
- Erken and Edipoglu – Randomised trial of PRF parameters in lumbosacral radicular pain, Neuromodulation.
- Shanthanna and colleagues – Randomised placebo-controlled pilot study of lumbar dorsal root ganglion PRF.
This information is educational. The suitability of a procedure requires individual assessment.