Tag: Back Pain

Low Back Pain And Slip Disc With Sciatica: A Nascent Treatment

A young lady came to me with disabling back pain for last 5 years which made her leave the job. She is not marrying due to same problem.

A schoolgirl of 10th class is not able to focus on studies since past 6 months because of back pain which she relates to dance competition preparation 7 months back. She has her board exams coming making her & family all the more worried.

“Because of my back pain I can’t play with my children or sleep comfortably.” Said  a patient.

A patient had to change his job because he could not commute distances for same reason.

I keep getting this neck pain as & when I have to spend extra hour on my computer at duty in the bank.

A patient requested me to get rid of her back pain as her daughter is getting married in two months.

“Help me doctor as my married life is getting ruined” said a young back pain patient.

For all these and many like them Dr. Neeraj Jain`s massage is pain is real and treatable- there is no merit in suffering” “No one needs to suffer as so many good and effective treatments are now available at specialty pain clinics”. You must see a pain specialist if you still suffer from pain after a month of conservative treatment. Sooner your pain is managed better are the overall results.

It’s a pandemic disease having 80% of lifetime prevalence, affecting 15-20% population at any point of time, as such pain (the 5th vital sign as per W.H.O.) is the commonest symptom to consult a doctor. It is the commonest cause of young age disability (3-4% annually with 1% permanently disabled). 30-60% of all acute LBP relapse & develop chronic LBP. It has significant financial, socioeconomic, emotional & physical morbidity. It needs an integrated multidisciplinary proactive treatment approach

“Do not take your back for guaranteed” says Dr. Jain who is heading pain clinic at Sri Balaji Action Medical Institute inNew Delhi. One can avoid back pain with spine care and avoiding risk factors like osteoporosis, obesity, smoking, prolonged driving, sedentary lifestyle, too heavy or too little exercise, bad spine postures and wrong way of pushing or lifting heavy objects.

While spinal arthritis is the common reason of young age back pain at prime of their carriers including some bollywood celebrities, disc diseases including slip disc is prevalent in all age groups, in young age due to trauma & in old age due to degeneration.

With interventional pain management patients are getting back to life. It has both diagnostic and treatment values, as sometimes all investigations put together do not give the exact diagnosis.

Newer technologies like ozone injection cures most of the patients of slip disc & sciatica, as ozone’s nascent oxygen atom shrinks the disc so taking away pressure from pain sensitive nerves. It is a non surgical, outpatient procedure done under local anesthesia not requiring bed rest for more than day or two & prolonged absence from work realizing the importance of time, at much lower cost with almost no complications. This procedure is done under radiological guidance for precise needle targeting and best results. There after patient is given advice for spine care & healthy habits. This technology is latest & many people including medical caregivers don’t know about it. It has benefited millions in developed world and is now available inIndiaalso.

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CHRONIC PAIN: A MENACE

Pain is one of the most common reasons for patients to seek medical attention and one of the most prevalent medical complaints in today’s world. Chronic pain has many causes and can affect any part of the body. Conditions most associated with pain include arthritis, headache, neck and back problems, cancer, neuropathies eg. Diabetic, chronic regional pain syndromes (CRPS), pelvic pain disorders, fibromyalgia, myofacial pains, herpes and trigeminal neuralgias.

Chronic pain can lead to depression, anxiety, marital & interpersonal problems, decreased productivity, unemployment, compromised social roles, isolation, financial burden, dependence, prolonged analgesics usage, decreased self esteem with behavioral changes adversely affecting mental and physical abilities, activities of daily living  & ruining quality of life

Pain still remains inappropriate & inadequately treated. Although tremendous scientific & technological advances have been made, the knowledge & techniques are highly underutilized. Untreated pain destroys people’s lives. I have had patients come in who couldn’t work or sleep or play with their children. Good pain management gave them their lives back. It is cruel to deny people in pain access to effective pain treatment. People should not be suffering needlessly.

Thus, pain clinics are specialized areas that are now assuming the role of an essential service as they meet a need unmet by any previously existing medical facility. They help by simultaneously treating the physical, emotional, cognitive, behavioral, vocational and social aspects of chronic pain cost-effectively.

Our ultimate goal is to cure & care people suffering from pain, make them productive human beings for the society and increase their self esteem so that they can live life as normal individuals.

Interventional pain procedures scores over both medicine and surgery, as they do not have side effects like medicines. Surgeries for pain, have now limited indications, usually as a last resort.

The interventional pain procedures produce immediate pain relief, can be performed with ease by pain physicians without anesthesia as outpatient or daycare and adequate duration of pain relief obtained and suitable for surgically unfit & debilitated patients, procedure can be repeated safely if required.

In the absence of proper education among health care professionals and lack of awareness in the public mind inIndia, there is misuse of painkillers resulting in high incidence of complications like gastritis, kidney failure, bone marrow depression and bleeding from gut which can be catastrophic.

The Indian health care scene has a curious mix of paradoxes. Advances in cardiovascular surgery or high-tech investigative facilities inIndiaare on par with any advanced country, at least in some cities. Though skills, advanced equipments are available, still pain relief is not available to majority of its population. At least a million people inIndiasuffer unrelieved cancer pain. The number of people suffering other chronic pain conditions is anyone’s guess. Paradoxically,Indiastands high chance to become the health destination for pain management for the world, by using interventional pain therapies and very effective traditional therapies unique toIndia.

“Stop pain from managing you.”

“No one dies of pain but many people die in pain and even many more live with pain”

“Enjoy a pain free life”

“Pain relief is a human right.”

W.H.O. has assigned pain as 5th vital sign.

“Don’t let pain control your life. Be proactive to manage pain.

Intractable pain ruins patient’s life. It robs the patient of his life.

“Pain has the thousand teeth”.

“The pain of mind is worse than the pain of body”

“Chronic pain is something you wear on inside, not on the outside”

We work with the patient to identify the root cause of the problem and create a treatment plan to alleviate the pain.

We offer the full range of advanced treatment for chronic pain.

A good treatment improves patient’s quality of life.

State of the art pain clinic is benefiting many patients with intractable pains..

Under treatment of pain is a major public health concern.

Pain is the 1st reason for work abstinence.

Because of increase in age expectancy pain is becoming more prevalent.

Pain should be managed promptly before it gets complexed & centralized to brain.

One in every four persons suffers from pain of which 50% have serious pain issues so as to affect them physically, mentally, socially and financially.

Chronic pain is a disease in and of itself. It not only affects the patient, but also impacts the lives of family and friends.

Pain is one of the most neglected problem of the patient and has very serious and lasting consequences.

Low Back Pain

LOW BACK PAIN (LBP) is a pandemic disease having 80% of lifetime prevalence, affecting 15-20% population at any point of time, being one of the commonest reason for visit to a doctor & young age morbidity/disability/work absenteeism.

AETIOLOGY OF LBP:
LBP is not just a disease but a symptom, a syndrome with combination of multiple possible abnormalities of anterior & posterior longitudinal ligaments, vertebral body, synovia / chondropathy/ osteoarthritis of articulating facets joints, sacroiliac joint, nerve roots & foramen, paraspinal muscles, related connective tissues eg.- ligamentum flavum , spinal canal, intervetebral disc at annulus ring. It may be due to mechanical, nonmechanical, referred pain, psychological & failed back surgery (FBSS).

PERCUTANEOUS LEAST INVASIVE INTERVENTIONAL PAIN MANAGEMENT OF LBP:-
It has both diagnostic & therapeutic relevance( as there are significant false positive & negative imaging studies not correlating to symptoms)

  • Better results are obtained if treatment is started early.
  • LESI-lumbar epidural steroid injections::
    • interlamminar or transforaminal or caudal approach
  • SNRB- selective nerve root block
  • Epidural adenolysis or percutaneous decompressive neuroplasty
  • Trigger point injection
  • Botox paraspinal muscle injection
  • Facet joint or pericapsular injection
  • Spine Prolotherapy & manipulation
  • Facet RF thermal neurolysis
  • SI joint injection or denervation
  • Piriformis muscle block
  • Diagnostic provocative discography
  • Intradiscal procedures:-Ozone Discolysis/ Chemonucleolysis

– Dekompressor disc debulking
– IDET-intradiscal electrothermal therapy
– Coblation nucleoplasty
– Laser percutaneous discectomy

  • Vertebroplasty & kyphoplasty
  • Intrathecal pump neuraxial implants
  • Augmentation or neuromodulation spinal cord stimulation

ONCE THE CONSERVATIVE TREATMENT FAILS:-
Early aggressive treatment plan of pain has to be implemented to prevent peripherally induced CNS changes that may intensify or prolong pain making it a complex pain syndrome. Only 5% of total LBP patients would need surgery & 20% of discal rupture or herniation would need surgery. Nonoperative treatment is sufficient in most of the patients, although patient selection is important even then.

Depending upon the diagnosis one can perform & combine properly selected percutaneous fluoroscopic guided procedures with time spacing depending upon pt`s pathology & response to treatment.

Using precision diagnostic & therapeutic blocks in chronic LBP , isolated facet joint pain in 40%, discogenic pain in 25%(95% in L4-5&L5S1) ,segmental dural or nerve root pain in 14% & sacroiliac joint pain in 15% of the patients. This article describes successful interventions of these common causes of LBP after conservative treatment has failed.

LESI : LUMBAR EPIDURAL STEROID INJECTION
Indicated in – Acute radicular pain due to irritation or inflammation.

– Symptomatic herniated disc with failed conservative therapy
– Acute exerbation of discogenic pain or pain of spinal stenosis
– Neoplastic infiteration of roots
– Epidural fibrosis
– Chronic LBP with acute radicular symptoms

ESI TREATMENT PLAN:
Compared to interlaminar approach better results are found with transforaminal approach where drugs (steroid+ LA/saline +/- hyalase) are injected into anterior epidural space & neural foramen area where herniated disc or offending nociceptors are located. Whereas in interlaminar approach most of drug is deposited in posterior epidural space.Drugs are injected total 6-10 ml at lumbar, 3-6 ml at cervical & 20+ ml if caudal approach is selected. Lumbar ESI is performed close to the level of radiculopathy, often using paramedian approach to target the lateral aspect of the epidural space on involved side. Cervical epidural is performed at C7-T1 level .
SNRB- SELECTIVE NERVE ROOT BLOCK.

Fluoroscopically performed it is a good diagnostic & therapeutic procedure for radiculopathy pain if

  • There is minimal or no radiological finding.
  • Multilevel imaging abnormalities
  • Equivocal neurological examination finding or discrepancy between clinical & radiological signs
  • Postop patient with unexplainable or recurrent pain
  • Combined canal & lateral recess stenosis.
  • To find out the pathological dermatome for more invasive procedures , if needed

EPIDURAL ADENOLYSIS OR PERCUTANEOUS DECOMPRESSIVE NEUROPLASTY for EPIDURAL FIBROSIS OR ADHESIONS IN FAILED BACK SURGERY SYNDROMES (FBSS)
A catheter is inserted in epidural space via caudal/ interlaminar/ transforaminal approach
After epidurography testing volumetric irrigation with normal saline/ L.A./ hyalase/ steroids/ hypertonic saline in different combinations is then performed along with mechanical adenolysis with spring loaded or stellated catheters or under direct vision with EPIDUROSCOPE.

FACET SYNDROME:- FACET JOINT INJECTION OR RF MEDIAL BRANCH NEUROTOMY
It is due to mechanical stress on the Zygapophysial joints or traumatic/anatomical derangement & degenerative facet arthropathy. It is commoner in male of younger age group during active careers . CT/ MRI/ Bone scan show structural pathology, but diagnosis is confirmed by relief of pain with joint injection (1ml of LA+ 20 mg triamcinolone) which has therapeutic value also.After effective facet joint block, fluoroscopic percutaneous radiofrequency(RF) thermal rhizotomy of two level medial branches of dorsal ramus is a safe, effective & long term treatment.

SACROILIAC JOINT INJECTION & DENERVATION:
The only way to make a definitive diagnosis is pain relief with image guided joint injection of depo-steroid with L.A..This can be followed by joint denervation of L4-5 S1-3 branches to this joint providing long term pain relief.

INTRADISCAL PROCEDURES::
PROVOCATIVE DISCOGRAPHY: coupled with CT
A diagnostic procedure & prognostic indicator for surgical outcome is necessary in the evaluation of patients with suspected discogenic pain, its ability to reproduce pain(even with normal radiological finding), to determine type of disc herniation /tear, finding surgical options & in assessing previously operated spines

PERCUTANEOUS DISC DECOMPRESSION (PDD)
After diagnosing the level of painful offending disc various percutaneous intradiscal procedures can be employed:–
OZONE-DISCOLYSIS: Ozone Discectomy a revolutionary least invasive safe & effective alternative to spine surgery is the treatment of choice for prolapsed disc (PIVD) done under local anaesthesia in a day care setting. This procedure is ideally suited for cervical & lumbar disc herniation with radiculopathy. Total cost of the procedure is much less than that of surgical discectomy. All these facts have made this procedure very popular at European countries. It is also gaining popularity in our country due to high success rate, less invasiveness, fewer chances of recurrences, remarkably fewer side effects meaning high safety profile, short hospital stay, no post operative discomfort or morbidity and low cost.

DEKOMPRESSOR: A mechanical percutaneous nucleotome cuts & drills out the disc material somewhat like morcirator debulking the disc reducing nerve compression.

INTRATHECAL (SPINAL) PUMP IMPLANTS:
Opted when oral narcotics provide insufficient pain relief or side effects are troublesome in intractable cancer & chronic pain patients. It delivers drug via an implanted catheter directly into CSF needing a very small dose (1/300 of oral dose). The programmable pump is implanted in ant. lower abdomen. It delivers the drug as per the patients needs. More powerful analgesia & spasticity control is achieved using lower doses, constant relief & fewer side effects as with oral doses eg. Somnolence, mental clouding, constipation, euphoria with decreased chances of drug addiction or misuse.

NEUROMODULATION TECHNIQUES:
SPINAL CORD STIMULATION (SCS) IMPLANTS :

Done for FBSS( failed back surgery syndrome) & CRPS(comlex regional pain syndromes) inUSA. In Europe it is done for chronic intractable angina & pain of peripheral vascular diseases (PVD). The indications are expanding further in chronic pain states. A set of electrodes is placed in epidural space & connected to a pulse generator ( like a cardiac pacing device) that is implanted in upper buttock. Low level of electric impulses replace pain signals to the brain with mild tingling sensation. A trial stimulation is done before permanent SCS lead implant.

PERCUTANEOUS VERTEBROPLASTY / KYPHOPLASTY:
A NEWER APPROACH TO MANAGEMENT OF VERTEBRAL BODY FRACTURES
As life expectancy is increasing so is the incidence of vertebral body (VB) # now being the commonest # of the body. PVP is an established interventional techniques in which PMMA bone cement is injected under L.A. via a needle into a # VB with imaging guidance providing increased bone strength, stability, pain relief, decreased analgesics, increased mobility with improved QOL and early return to work.