Question 1

In RFA, can the treated nerves regenerate? And if so, when can pain reoccur?

Dr. Ashu Kumar Jain · Accepted Answer

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.

Question 2

Which local anaesthetics, steroids and adjuvants do you usually use for different nerve blocks?

Dr. Ashu Kumar Jain · Accepted Answer

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

Question 3

Is there a list of drugs under your remit that are specialist-prescription only, and how do you manage supply — we have supply problems for certain drugs in Zambia.

Dr. Ashu Kumar Jain · Accepted Answer

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.

Question 4

What are the most common misconceptions community doctors have about facet joint injection?

Dr. Ashu Kumar Jain · Accepted Answer

The first issue is simply diagnosis — ninety per cent of doctors not trained for this kind of spinal pain can't diagnose facetogenic pain. We call it axial pain, which includes facetogenic and discogenic pain, and gabapentinoids are of no use for it whatsoever — yet eight out of ten patients with axial pain are given these drugs with no results. It's a diagnostic challenge first: specific questions in the history, a specific examination, then a diagnostic block to confirm the pain is coming from the facet before proceeding to facet joint RFA.

Question 5

Bone marrow transplant is a cure for sickle cell disease but isn't offered to every patient, including for cost reasons. How can sickle cell patients with chronic pain from avascular necrosis of the femoral head benefit?

Dr. Ashu Kumar Jain · Accepted Answer

If the femoral head is involved, we can perform radiofrequency ablation of the hip joint, ablating the articular nerves supplying the joint — it's a very rewarding procedure. But if the pain is arising from the bone itself or visceral involvement, the best approach is opioid analgesics rather than high-dose NSAIDs, which will damage the kidneys. Primary management is opioid-based — morphine or tramadol with paracetamol and a neuropathic agent — and where there is a specific anatomical target, we address that interventionally as well.

Question 6

Quite often a patient presents in pain and there's a surgical solution, and sometimes it falls in your domain where surgery isn't required. How do physicians decide when a patient should go for surgery versus pain management?

Dr. Ashu Kumar Jain · Accepted Answer

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.

Question 7

The concern with opioids for conditions like avascular necrosis is that they can be habit-forming or cause addiction — can you address that?

Dr. Ashu Kumar Jain · Accepted Answer

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.

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