When should you refer a patient to pain management?

The referrals that do best here arrive before the nervous system has finished rewiring. That means radicular pain that has not settled after a reasonable course of conservative care, which the North American Spine Society guideline on lumbar disc herniation with radiculopathy and the American College of Physicians guideline on low back pain both frame in weeks rather than months. It means axial pain with a facet or sacroiliac pattern, because no scan finds those and the diagnostic block is the test. It means anything with the burning, temperature-changing signature of complex regional pain syndrome, where the interval between onset and a sympathetic block is the strongest predictor we have. And it means the patient on long-term opioid therapy you would rather taper with interventional support than alone.

• Radicular pain beyond six weeks of conservative care, or sooner with progressive weakness. Sciatica, cervical radiculopathy.
• Axial neck or back pain that is worse with extension and rotation and normal on imaging. Facet pain, sacroiliac pain.
• Post-surgical pain where the hardware is intact and the pain has moved. Failed back surgery syndrome.
• Suspected CRPS, at any stage, the sooner the better. Complex regional pain syndrome.
• Painful diabetic neuropathy that has failed first-line agents. Peripheral neuropathy.
• Osteoporotic compression fracture with pain that is not settling. Compression fracture.

What does the referring physician get back?

A consult note with four things in it: the working diagnosis and the examination findings that support it, the test planned and what result would change the plan, the metabolic labs ordered or reviewed, and the behavioral and lifestyle component with its rationale. It is sent by fax or secure message to the address on your referral, not left in a portal, and the procedure notes and block diaries follow the same route. You keep primary care. We do not take over your patient’s diabetes management; we tell you what the pain visit found and why it matters to the spine.

Expect the labs. Metabolically healthy patients are rare in a pain clinic: under 1% of the chronic pain population here, in a country where the healthy share of adults fell from under 12.2% (NHANES 2009–2016) to under 7% on the stricter post-2021 cardiometabolic criteria. The clinic figure is one of our practice-reported figures from our own population, not trial outcomes, and individual results vary. Fasting insulin, A1C, the triglyceride-to-HDL ratio and hs-CRP decide whether a steroid dose is safe and whether it can work, and they frequently uncover the diagnosis you would want to know about first.

The Anderson Hospital relationship

Dr. Padda is on staff at Anderson Hospital in Maryville with full privileges in pain, anesthesiology, surgery and addiction medicine, and on staff at SSM Health St. Clare Hospital in Fenton. For your patients that means two things. Image-guided procedures happen at 4499 Woodson Rd in St. Louis, and consultations can be scheduled either there or at the Illinois office, 505 Buckeye Dr, Suite 200, in Troy, about forty minutes from Edwardsville or Belleville with the roads clear. Procedures that need an operating room or a hospital setting, spinal cord stimulator and intrathecal pump implants, nerve decompressions and the like, can be done at Anderson on the Illinois side, close to home, with the postoperative visit coordinated with you. Surgery is offered only when conservative and interventional options for that condition are exhausted, and never as a first step.

How are patients on long-term opioids managed?

The typical patient arriving here on opioids has been in pain for two and a half years or longer and averages more than 90 MME a day. With interventional treatment underway, 21% have weaned fully by 90 days and 34% by the one-year mark; in the established population, fewer than one patient in a hundred is still above 90 MME. Those are practice-reported figures from our own population, not trial outcomes, and individual results vary. Our approach is harm reduction in the sense the 2022 CDC guideline uses: the minimum effective exposure with function preserved, tapered on the back of procedures that remove the reason for the dose, with withdrawal prevented rather than endured. We coordinate the prescribing plan with you in writing; we do not escalate, and we do not abandon.

The long-drive patient

A patient from Highland or Columbia is close to an hour away with the roads clear. We stage the diagnosis to spend fewer trips: examination, labs and the first diagnostic block are planned together where the presentation allows, and follow-up on results is by telehealth where it is clinically appropriate. The behavioral half, Acceptance and Commitment Therapy, is run inside this practice by a licensed clinician trained in pain and is scheduled around the procedure visits, so the behavioral half of the plan does not add a separate weekly crossing.

How do I refer a patient?

Frequently asked questions

Does a patient need a referral to be seen?

A referral is not required, but a note with what has been tried shortens the first visit and is described for patients in what to expect.

Should I order an MRI before referring?

Not routinely in the absence of red flags; the Lancet meta-analysis of imaging strategies found no benefit from routine early imaging, and the examination decides where to look, which the sciatica page explains.

Can procedures be done on the Illinois side?

Hospital-setting procedures can be performed at Anderson Hospital under Dr. Padda’s privileges there, as described on the Maryville page; office procedures are done in St. Louis, and consultations can also be scheduled at the Illinois office in Troy.

How do you handle a patient’s existing opioid prescription?

In writing with you, tapering on the back of interventional and behavioral treatment rather than by dose alone, according to the position on the opioid stewardship page.

Do you co-manage the metabolic findings?

We report them to you with the interpretation that matters for the spine and leave management with you, and the rationale is on the metabolic health and pain page.

What qualifies someone for pain management?

Pain that has outlasted a reasonable course of conservative care, or pain whose source no scan can find. Here that means radicular pain past six weeks, facet or sacroiliac pain, failed back surgery syndrome, suspected CRPS at any stage, painful diabetic neuropathy that failed first-line agents, compression fractures that are not settling, and patients on long-term opioids who want to taper with support.

Why is my doctor sending me to pain management?

Usually because the pain has lasted past the point where rest, therapy and medication were expected to work, and finding its source needs an examination and, where it fits, a diagnostic block. Earlier is better, before the nervous system finishes rewiring. Your own doctor keeps your primary care and gets the consult note back by fax or secure message.

Does pain management prescribe opioids?

Opioid stewardship here is harm reduction: the minimum effective exposure with function preserved. An existing prescription is coordinated with the referring physician in writing and tapered on the back of procedures that remove the reason for the dose, with withdrawal prevented rather than endured. We do not escalate, and we do not abandon a patient who arrives on opioids.

Which referrals are seen first?

Red flags and time-sensitive presentations move ahead of the queue: progressive weakness, suspected CRPS, cauda equina symptoms and fever with spinal pain. Flag them on the referral. Anything with the burning, temperature-changing signature of CRPS should come early, because the interval between onset and a sympathetic block is the strongest predictor we have.

Related reading

• Injured at work
• For Illinois attorneys
• Medial branch block
• Spinal cord stimulation
• Complex regional pain syndrome
• Opioid stewardship