Knee Pain and Spinal Cord Stimulation: Advanced Options When Surgery Isn't Right

According to international Spine Society guidelines, any pain coming from the spine where the primary problem is pain alone does not require surgery. The indications for surgery are disability — foot drop, motor or sensory deficit — or more than moderate to severe canal stenosis on MRI, where pain intervention can buy time but can't treat the disease. If a patient comes to me with a neurological deficit, I immediately refer to the spine surgeon and don't proceed with intervention. If pain is the only presenting symptom, we treat it — there's a very clear demarcation.

If you use opioids for chronic low back pain, knee pain or musculoskeletal pain, yes, they are habit-forming. But for cancer pain, and for pain like sickle cell disease — which we manage on the same lines as cancer pain — they are never habit-forming. Visceral pain is mediated by the sympathetic nervous system and doesn't respond to conventional NSAIDs, so it needs neuropathic agents and opioids in combination; back pain, knee pain and shoulder pain are peripheral musculoskeletal or neuropathic pain and don't carry the same opioid receptor expression, which is why the risk profile is so different between the two.

The nerve cannot truly regenerate in the clinical sense. When there is nerve injury, the patient can go into complex regional pain syndrome Type II. Nerve regeneration takes a very long time and the results are poor — if you believe you can treat a patient through nerve regeneration, in present-day practice that is a myth.

For nerve blocks we use ropivacaine. For steroids, we primarily use dexamethasone in spinal procedures. For joint injections, we usually use Kenacort (triamcinolone).

In India, opioids are scheduled drugs — you need a prescription from a competent doctor: a pain specialist, anaesthesiologist or neurologist, not a general surgeon or ENT. For morphine and fentanyl specifically, the hospital needs a government licence to hold a certain quantity, and we use a special designated government form that we stamp, with patients required to bring a consumption chart we submit to the drug controller. Tramadol, tapentadol and buprenorphine don't need special licensing, but you do need a valid prescription from a competent doctor.

For severely degenerated knees, joint replacement is usually the right answer. But for patients who cannot undergo surgery, whether from dilated cardiomyopathy, advanced age, or poor muscle mass, genicular nerve radiofrequency ablation offers a palliative alternative.

It offers about 70% pain reduction lasting 12 to 18 months, including in high-risk patients such as one with a 15% ejection fraction and an implanted defibrillator who had been bedridden and was walking again with a brace afterward.

It is used for neuropathic and ischaemic pain that has not responded to any other intervention, alongside intrathecal drug delivery pumps as a next step.

It delivers drugs like baclofen for severe spasticity, or a combined morphine-baclofen mix, directly to the spine. In one case involving a patient with an intramedullary tumour, gross spasticity resolved within 24 hours of implantation.