Failed Back Surgery, Sciatica and SI Joint Pain: Transforaminal Adhesiolysis and Facet RFA

First establish whether it is lateral or central canal stenosis, and check for any sensory or motor deficit on examination. Without a deficit and with lateral canal stenosis, transforaminal epidural adhesiolysis gives wonderful results. With moderate to severe central stenosis, a real sensory or motor deficit, and pain that does not respond to a block, the patient needs surgery.

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.

Only 2mg of dexamethasone per level, a deliberately minimal dose, alongside 5 to 7ml of saline and hyaluronidase to wash the epidural space.

Often, yes. A trapped nerve root in scar tissue can be released with a transforaminal approach, and pain from an adjacent facet joint or the SI joint can be treated with radiofrequency ablation, without repeat surgery.

It can appear months to years after fixation surgery as the SI joint itself becomes symptomatic. It is treated with SI joint injection and radiofrequency ablation.