Discogenic Low Back Pain: Biacuplasty and Intradiscal Radiofrequency Ablation

Used for chronic low back pain, knee pain or similar musculoskeletal pain, yes, opioids are habit-forming. Used for cancer pain, and for sickle cell pain, which is managed on the same principles as cancer pain, they are never habit-forming in this experience. Opioids sit near the top of the WHO analgesic ladder, are safe on organ function, and are potent enough that patients do not become dependent in this context. Countries that prescribe opioids freely for ordinary chronic non-cancer pain, as parts of the United States and Europe have, do see patients become dependent. For routine non-cancer chronic pain, that risk is real and opioids should be avoided long-term.

Because sickle cell pain and cancer pain are primarily visceral pain, and viscera carry opioid receptors. Back pain, knee pain, elbow pain and shoulder pain are peripheral, musculoskeletal or neuropathic pain, and that tissue does not carry the same opioid receptor expression. Visceral pain is also carried by the body's sympathetic nervous system, which does not respond to conventional painkillers, so it needs a neuropathic agent and an opioid in combination. That is the physiological difference.

Marijuana is a safer drug than a typical opioid, including for musculoskeletal as well as visceral pain, and some countries now use synthetic formulations of it. It just is not approved for medical use in India yet.

For a musculoskeletal complaint, an NSAID and a muscle relaxant should not run past seven to ten days, at most two weeks. With a new patient, the first move is not intervention: a two-week medical trial is given first, against a target of at least 50% pain relief. If that trial fails to deliver it, the next step is intervention, straight away.

In India, opioids are scheduled drugs. Prescribing requires a competent doctor, meaning a pain specialist, anaesthesiologist or neurologist, not a general physician, general surgeon or ENT. For morphine and fentanyl specifically, the hospital needs a government licence to hold a set quantity, uses a special designated government form that gets stamped, and patients are required to bring back a consumption chart that is submitted to the drug controller. Tramadol, tapentadol and buprenorphine do not need that special licensing, but they still require a valid, stamped prescription from a competent doctor.

With provocative discography, which reproduces the patient's pain to confirm which specific disc is the source, before proceeding to ablation.

Because the distance between the two electrode tips has to be controlled precisely, which requires cathlab-level imaging rather than fluoroscopy alone.

Only the posterior third, the posterior lateral annulus, since that is where the sinuvertebral nerve carries the pain signal. The front of the disc is left untouched.