Back Pain Treatment Without Surgery: Sciatica to Knee Pain

Back pain treatment without surgery works, in the practice of Dr. Ashu Kumar Jain, Chief – Pain Medicine & Palliative Care, Artemis Hospitals, Gurugram, India, when each procedure is matched to a specific pain generator: a facet joint, a disc, an inflamed nerve root, a scarred epidural space, a sympathetic chain or the nerves of a joint. He treats most back pain, sciatica and arthritic knee pain patients this way.

Back pain, sciatica and arthritic knee pain are where the gap between a precise diagnosis and a generic prescription is widest. Dr. Jain's tools are image-guided radiofrequency ablation (RFA), epidural adhesiolysis and biacuplasty, and the same logic applies from the chest wall to the heel.

Mid-back and chest wall pain treatment

Thoracic facet RFA for mid-back pain

Thoracic facet-joint pain, pain from the small joints at the back of the mid-spine, is in Dr. Jain's experience widely missed. Patients describe pain that travels from the back of the chest to the front; they cannot sleep and wake at night in severe pain. Many have gone untreated for years. A video he posted on the condition two to three years earlier drew more than three million views, and his unit now sees a steady flow of such patients. RFA of the thoracic facets, which uses heat to disable the nerves carrying the pain, is in his assessment one of the most rewarding procedures for this type of mid-back pain.

Intercostal neuralgia and rib fracture pain

Intercostal neuralgia, nerve pain along a rib, is highly disabling. Its causes include post-herpetic neuralgia, pain after thoracotomy, idiopathic neuralgia and rib fractures. Dr. Jain's team uses intercostal nerve block, RFA or neurolysis depending on the case, and stimulates before ablating to confirm where the sensation travels.

Rib fractures are a useful example of pain medicine supporting acute care. A patient admitted with fractured ribs may have pain for two to three months, cannot breathe deeply and cannot cough. In Dr. Jain's institution, provided there is no flail segment, intercostal nerve RFA or neurolysis removes the pain for those two to three months, by which time callus has formed.

Sciatica treatment without surgery: epidural procedures

For sciatica, Dr. Jain's procedure of choice is transforaminal epidural adhesiolysis; the caudal epidural block covers a wider set of lower-spine conditions.

Caudal epidural block

The caudal epidural block, an injection into the epidural space through the base of the spine, is used for coccydynia, spinal canal stenosis, spondylolisthesis and failed back surgery. On the anteroposterior view, contrast spreads in an inverted Christmas-tree pattern, confirming coverage of the epidural space.

Transforaminal epidural adhesiolysis for sciatica

Transforaminal epidural adhesiolysis clears scarring and inflammatory material from around the nerve root, approached through the foramen where the root leaves the spine. The procedure, which he demonstrated across several lumbar levels and S1, runs in three steps:

1. Neurography. Contrast is injected to outline the nerve root, such as S1.
2. Adhesiolysis. The anterior epidural space is washed with 5 to 7 ml of saline combined with hyaluronidase. Contrast then spreads upward and towards the midline as the space opens, and inflammatory material is washed away.
3. Minimal steroid. Only 2 mg of dexamethasone is given at each level.

The emphasis on washing rather than steroid is a deliberate shift. Dr. Jain's unit has moved away from injecting large steroid doses into the epidural space; the adhesiolysis does the work, and the small steroid dose supports it.

When sciatica needs surgery

Not every compressed nerve root belongs with the pain physician. For compression at L4-L5, Dr. Jain first establishes whether the stenosis is lateral or central and examines for sensory or motor deficit. Without a deficit, he treats the pain, and transforaminal epidural adhesiolysis gives good results. Moderate or severe stenosis with a sensory or motor deficit, and severe pain that does not respond to a block, means surgery.

Lumbar facet joint pain: block vs radiofrequency ablation

For confirmed lumbar facet pain, RFA is the definitive step in Dr. Jain's practice; a facet block on its own gives only short-term relief.

The evidence and the error

Lumbar facet RFA is supported by international guidelines for patients whose facet pain has been confirmed with diagnostic blocks. Yet facet pain is routinely misdiagnosed and treated with gabapentinoids that cannot help it.

The facet RFA sequence he follows

1. History and examination. There are specific questions and specific examination findings that point to facet pain.
2. Diagnostic block. A facet block without steroid tests whether the facet joint is the source.
3. RFA if the block is positive. After RFA, he gives 4 mg of triamcinolone at each level.

A facet block on its own, without RFA, gives short-term relief of perhaps 6 to 8 weeks, sometimes 12. Practitioners who rely on blocks alone then add steroid, typically triamcinolone 4 to 8 mg per level with ropivacaine or bupivacaine. Dr. Jain does not regard this as the standard of care, because the pain comes back. RFA is the definitive step.

Pain after failed back surgery and sacroiliac joint pain

A patient who continues to have pain after spinal fixation is not a lost cause. Dr. Jain identifies several distinct generators in these patients and treats each one:

• Adjacent-level disease: transforaminal epidural treatment at the level below the fixation.
• Nerve root entrapped in scar: release of the S1 root where it has become trapped in post-fixation scar tissue.
• SI joint pain: SI joint injection and, where needed, RFA. He showed one patient whose SI joint became painful a year after fixation and was treated by ablation.
• Facet pain above the fixation: RFA of the facet joint where kyphosis develops at the adjacent level above the fused segment.

Sacroiliac (SI) joint pain, from the joint between the base of the spine and the pelvis, also occurs without prior surgery, as buttock pain from sacroiliitis, degenerative arthritis or strain. Dr. Jain's concern is that some of these patients go on to fixation for a disc at a higher level, and their pain persists because the SI joint was never identified. He regards this as a serious diagnostic dilemma that only thorough history and examination can resolve.

Discogenic back pain treatment: biacuplasty

Discogenic back pain, pain arising from the disc itself, is treated in Dr. Jain's unit with biacuplasty, with good results reported in around 80 to 85 per cent of patients.

The clinical picture

Discogenic pain is axial and non-radiating, and typically worse on sitting. In the example Dr. Jain gave, the patient could not sit for more than 10 minutes or stand for more than half an hour. MRI shows a contained disc, without significant bulging, most often at L4-L5, and the history and examination fit discogenic pain.

How biacuplasty is done

Dr. Jain treats these patients with biacuplasty, also called intradiscal RFA: cooled bipolar radiofrequency ablation of the posterior annulus of the disc.

• Find the painful disc first. Provocative discography identifies which disc is generating the pain.
• Target the posterior annulus only. The sinuvertebral nerve supplies the posterolateral annulus, which is where the pain originates, so the electrodes are placed in the posterior third of the disc and not further forward.
• Get the spacing right. Because the ablation is bipolar, the distance between the two electrode tips is critical. Dr. Jain considers this achievable only in a catheterisation lab, not under a simple fluoroscope.

His unit reports good results in around 80 to 85 per cent of patients. The procedure works by heating the posterior annulus to ablate the pain-conducting nerve fibres that have grown into it.

Lumbar sympathectomy for ischaemic and neuropathic leg pain

Lumbar sympathectomy, ablation of the sympathetic nerve chain in the lower back, is used when sympathetically maintained pain affects the lower limb. A key indication is severe atherosclerosis below the knee, or Buerger disease, where there is no run-off into the distal arteries and neither vascular surgery nor stenting is possible. In that setting, Dr. Jain regards sympathectomy as the only option. Other indications include diabetic foot, complex regional pain syndrome after lumbar plexus injury or cancer involvement, and post-amputation pain.

Three electrodes are placed along the lumbar sympathetic chain, confirmed on anteroposterior and lateral views, and the patient is stimulated to confirm the target before RFA. If chemical neurolysis is planned, it is never done without DSA to rule out intravascular spread, which is why every lumbar sympathectomy in his unit is performed in the cath lab.

Knee, hip and heel pain without surgery

Cooled RFA when a knee cannot be replaced

A severely deformed arthritic knee, with exposed nerves and severe pain, needs knee replacement surgery. But some patients cannot undergo it, because of dilated cardiomyopathy, advanced age, very poor muscle mass or other reasons, and some are unwilling. For them Dr. Jain offers a palliative procedure: cooled radiofrequency ablation of the knee. In his experience it gives on average 12 to 18 months of pain relief and around 70 per cent reduction in pain. Braces are then fitted to correct the deformity, and rehabilitation improves quality of life further.

One of his patients had a left ventricular ejection fraction of 15 per cent, an implanted defibrillator, and no surgeon willing to operate. She had been bedbound for months. After cooled RFA and bracing, she walked. The goal in such patients is concrete: being able to use the toilet, cook and move around the house independently.

Regenerative injections for early knee arthritis

For osteoarthritis up to grade 3, Dr. Jain's unit uses platelet therapies, bone marrow aspirate concentrate and other regenerative treatments, delivered under ultrasound guidance. International patients cannot return every month for platelet injections, so Dr. Jain's unit offers them a one-time mesenchymal stem cell implant; an allogeneic mesenchymal stem cell product holds Indian regulatory approval for knee osteoarthritis of grades 2 and 3. Major arthritis guidelines, including those of the AAOS and OARSI, do not recommend stem cell injections for knee osteoarthritis.

Hip pain from avascular necrosis

When avascular necrosis affects the femoral head, as it can in sickle cell disease, Dr. Jain performs RFA of the nerves supplying the hip joint and considers it a very rewarding procedure. Pain arising from bone or viscera in sickle cell disease is managed differently, with medication, as described in cancer pain management with nerve blocks, pumps and opioids.

Heel pain and plantar fasciitis

Dr. Jain has abandoned fluoroscopy-guided heel injections in favour of ultrasound guidance. For plantar fasciitis he generally uses platelet injections rather than steroid, because steroid injected into the fascia can cause it to rupture. Most patients need two to three platelet sittings, one month apart, with very good results.

Vertebral compression fractures and kyphoplasty

For vertebral compression fractures, kyphoplasty (restoring a collapsed vertebra with a balloon and bone cement) is an option, now performed by his surgical colleagues. He showed a patient with prostate cancer treated with kyphoplasty at three levels, who did very well.

Back pain treatment without surgery: choosing the procedure

Every procedure in this region depends on the same discipline: identify the generator, prove it with a block or provocation test, then treat it with the smallest effective intervention. The criteria Dr. Jain uses to decide between pain treatment and surgical referral are set out in Advances in Chronic Pain Treatment: A Complete Guide.