Spinal Cord Stimulation and Intrathecal Pumps for Pain That Doesn't Respond to Anything Else

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.

That gap exists, and it falls to drug inspectors to enforce, not to prescribing doctors. In practice it means a large number of chronic pain patients arrive in this clinic having self-medicated with over-the-counter combination painkillers for five, ten, even twenty years. This practice calls it analgesic abuse: a difficult situation created by the fact that these medicines are freely available without a prescription.

The first problem is diagnosis. Ninety per cent of doctors who are not trained for this kind of spinal pain cannot diagnose facetogenic pain. This practice groups facetogenic and discogenic pain together as axial pain, and gabapentinoids have no role in treating it, yet eight in ten axial pain patients are put on these drugs anyway, with zero results. Getting it right needs a specific history, a specific examination, and then a diagnostic block to confirm the pain is actually coming from the facet before moving to facet joint radiofrequency ablation.

A crisis needs aggressive fluid management and correction of the patient's pH and blood gases. These patients do not respond to diclofenac or similar painkillers; they need intravenous opioids, usually through patient-controlled analgesia while admitted. Once the patient stabilises and comes out of crisis, treatment switches to patches or oral medication.

Neuropathic pain, ischaemic pain, complex regional pain syndrome and phantom limb pain, generally after other treatments have not worked, and usually preceded by a trial lead.

Baclofen for spasticity, or morphine or a morphine combination for pain conditions such as failed back surgery syndrome, delivered directly into the spinal fluid rather than systemically.

In one case involving a combined morphine and baclofen pump for post-surgical spasticity, the patient was pain-free and free of spasticity within 24 hours of implantation.