Advances in Chronic Pain Treatment

Chronic pain is pain that has lasted more than three months and outlived the time the body needs to heal. Dr. Ashu Kumar Jain, Chief – Pain Medicine & Palliative Care, Artemis Hospitals, Gurugram, India, bases chronic pain treatment on one organising principle: find the pain generator, the specific joint, disc or nerve producing the pain, then treat that structure precisely rather than escalating painkillers and hoping the patient improves.

By the time pain becomes chronic, it is no longer a symptom confined to one joint or nerve. It erodes sleep, work and relationships, and it is very common. Dr. Jain's principle shapes everything that follows: how patients are triaged, when a needle is justified, which drugs are used and in what quantity, where procedures are performed, and where the pain physician's remit ends and the surgeon's begins.

Do most chronic pain patients need a procedure?

No. Interventional procedures are the visible edge of pain medicine, but in Dr. Jain's clinic they account for roughly 12 to 15 per cent of total outpatient volume. Between 85 and 87 per cent of patients are managed with medicines and rehabilitation alone.

How long to try NSAIDs before a procedure

Dr. Jain limits a first NSAID trial to two weeks at most. When a patient first presents with musculoskeletal pain, he does not move straight to intervention. He gives a trial of an NSAID (a non-steroidal anti-inflammatory drug such as diclofenac) and a muscle relaxant for 7 to 10 days, at most two weeks, and sets a clear target: a 50 per cent reduction in pain. A simple strain or an acute disc problem usually meets that target. If the patient returns after two weeks without that benefit, he moves to intervention rather than extending the drug course.

Why long-term NSAID use is unsafe

The ceiling on NSAID use is a safety rule, not a matter of preference. These drugs can damage the kidneys, and Dr. Jain regards anything beyond two weeks for a musculoskeletal cause as inappropriate. The opposite pattern is common in his practice: patients arriving after 5, 10 or even 20 years of daily diclofenac or over-the-counter combination analgesics. He calls this analgesic abuse, and it is one of the strongest arguments for diagnosing the source of pain early instead of suppressing it indefinitely.

How to find the pain generator

The pain generator is located in three steps, and the method is consistent across regions of the body:

1. A specific history comes first.
2. A targeted examination follows.
3. A diagnostic block with local anaesthetic then confirms which structure is responsible.

Only a positive block justifies a definitive procedure such as radiofrequency ablation (RFA), which uses heat delivered through a needle electrode to disable the nerve carrying the pain. During ablation itself, the team stimulates the nerve before burning it and asks the patient where the sensation travels. If it reproduces the patient's usual pain in the usual place, the electrode is correctly positioned.

Pain generators that are commonly missed

Much chronic pain goes untreated because its source is never identified. Dr. Jain's examples are pointed:

• Axial spinal pain (facet-joint and disc pain that does not radiate into a limb) is routinely treated with pregabalin or gabapentin. In his estimate, 8 out of 10 patients with axial pain receive these drugs, with no benefit, because gabapentinoids have no role in this type of pain.
• Facet-joint pain, which arises from the small joints linking each vertebra to the next, goes unrecognised outside specialist practice. Dr. Jain estimates that 90 per cent of doctors without training in spinal pain cannot diagnose it.
• Mid-back pain that travels from the back of the chest to the front, and wakes patients at night, often goes undiagnosed for years even though it arises from thoracic facet joints and responds well to treatment.
• Referred patterns confuse the picture further. Pain from the lower cervical facets can be felt behind the shoulder blade, far from the neck itself.

A case labelled fibromyalgia

One case shows what this discipline can change. A woman referred from abroad had been labelled with fibromyalgia and lived with what had been called unexplainable, untreatable pain in the neck and lower back. Dr. Jain's team identified two distinct pain generators and performed two radiofrequency ablations, one for the neck and one for the lower back, followed by a structured exercise and rehabilitation programme. A month later she reported 70 per cent less pain and sent the team a video of herself in a swimming pool.

Why pain procedures are done in a cath lab with DSA

Dr. Jain performs his interventions in a catheterisation lab with digital subtraction angiography (DSA), an imaging technique that shows contrast flowing through blood vessels in real time, rather than with a basic fluoroscope. He considers this central to patient safety, not a refinement.

The case he uses to make the point involved a cervical epidural injection. Contrast injected into the epidural space showed an unexpected dark streak. Running DSA on the table revealed a dense web of epidural veins, with contrast flowing into them as well as into the epidural space. In his assessment, injecting the drug at that point could have killed the patient on the table. Advanced imaging allowed the team to see the problem and avoid it.

The same reasoning applies elsewhere. Lumbar sympathectomy with chemical neurolysis is never performed without DSA to exclude intravascular spread, and bipolar intradiscal ablation requires precise electrode spacing that he considers achievable only in a cath lab. Most procedures are day-care cases: trigeminal ganglion ablation takes about half an hour.

Which drugs are used in nerve blocks and spinal injections

Dr. Jain uses ropivacaine for nerve blocks, small doses of dexamethasone in the spine and Kenacort in joints:

• Local anaesthetic for nerve blocks: ropivacaine.
• Steroid in the spine: dexamethasone, in small doses. For transforaminal epidural adhesiolysis he uses only 2 mg per level.
• Steroid in joints: Kenacort. For adhesive capsulitis of the shoulder, he gives 40 mg after releasing the capsule.

His direction of travel is towards less steroid, not more. The mechanical part of a procedure (washing inflammatory material out of the epidural space, releasing a contracted capsule, ablating a nerve) does the main work, and the steroid is a modest adjunct. For facet-joint pain, the diagnostic block contains no steroid at all.

Is radiofrequency ablation safe to repeat?

A frequent concern among referring doctors is whether repeated blocks or ablations cause nerve damage. Dr. Jain's answer is that serious nerve injury beyond the intended target is rare, because modern radiofrequency generators carry extensive safety features, and in his clinical practice he has not seen a serious complication from these blocks and ablations. The procedures are reproducible: a block can be repeated every 4 to 6 weeks, and a radiofrequency ablation is usually repeated no more often than every six months, once pain returns. Nerves treated with radiofrequency ablation can regenerate, which is why relief is temporary and the procedure may be repeated.

Will an injured nerve regenerate on its own?

He is equally direct about a related misconception: that a damaged nerve can be relied on to regenerate. In his experience, patients who come to him with a nerve injury commonly have complex regional pain syndrome type 2 (CRPS 2), a persistent, disproportionate pain that follows nerve damage; regeneration takes a very long time, and the outcomes are poor. His unit treats many patients with nerve injuries, including war injuries, and his conclusion is that the CRPS itself has to be treated. Waiting for regeneration to resolve the pain is, in present-day practice, a myth.

When chronic pain needs surgery instead of a pain procedure

For spinal pain, Dr. Jain's rule follows international spine society guidance: if pain is the primary problem, the patient does not need surgery. Surgery is indicated when there is:

• disability, such as foot drop, a motor deficit or a significant sensory deficit;
• cauda equina syndrome (compression of the nerve roots at the base of the spine) with bowel or bladder involvement;
• canal stenosis on MRI that is more than moderate or severe;
• pain that cannot be controlled by other means.

In those situations intervention may buy time, but it cannot treat the disease. At Artemis, the pain team works alongside the spine surgeons. When a patient referred for pain turns out to have a neurological deficit, Dr. Jain refers the patient to the spine surgeon immediately and does not intervene. When pain is the only presenting problem, his team treats it. The same logic extends beyond the spine: shoulder tendon tears above 50 per cent need repair first, and a severely deformed arthritic knee needs replacement unless the patient cannot undergo surgery.

The pain service is also a team effort within its own walls. Dr. Jain works with Dr. Minu, a specialist in cancer pain and palliative care, and a full-time pain and palliative care nurse. Palliative care includes end-of-life symptom management delivered in patients' homes.

Chronic pain treatments by body region

The lecture moved through the body from the face to the pelvis. Each region is covered in depth in a companion article:

• Head, face, neck, upper limb and shoulder. Trigeminal neuralgia, glossopharyngeal neuralgia, sphenopalatine ganglion ablation for cluster headache and burning mouth, cervicogenic headache, cervical radiculopathy, T2-T3 sympathectomy and the 3-in-1 shoulder block are covered in trigeminal neuralgia ablation vs surgery, with neck and shoulder pain.
• Chest wall, spine and lower limb. Thoracic facet and intercostal procedures, epidural adhesiolysis, failed back surgery, biacuplasty for discogenic pain, lumbar sympathectomy and knee, hip and heel pain are covered in back pain treatment without surgery.
• Cancer, pelvic and visceral pain, implantable devices and analgesic drugs. Splanchnic and hypogastric plexus procedures, ganglion impar and pudendal treatments, intrathecal pumps, spinal cord stimulation, sickle cell pain and the rules on opioid prescribing are covered in cancer pain management with nerve blocks, pumps and opioids.

Dr. Jain's answers to doctors' questions on these topics are collected in the live discussion from the masterclass.

When to refer a chronic pain patient: three principles

Three principles run through Dr. Jain's practice and apply wherever a patient is first seen.

Treat the structure, not the score. A patient with persistent pain needs a working diagnosis of where the pain comes from. Escalating or prolonging analgesics without one exposes the patient to kidney injury, dependence and years of lost function.

Set a time limit on conservative care. Two weeks of an NSAID with a 50 per cent relief target is a clear, auditable threshold. A patient who fails it should be assessed for a targeted procedure, not given a longer course of the same drug.

Know the red flags that change the pathway. Foot drop, a progressive motor or sensory deficit, bowel or bladder involvement and severe canal stenosis send the patient to a surgeon. When pain is the only problem, the patient usually belongs with the pain physician.