Question 1

In radiofrequency ablation, can the treated nerves regenerate, and if so, when can the pain reoccur?

Dr. Ashu Kumar Jain · Accepted Answer

No. A nerve does not regenerate in a way that matters clinically. Genuine nerve injury can push a patient into complex regional pain syndrome Type II, nerve regeneration takes a very long time, and results are poor. Believing you can treat a patient by waiting for nerve regeneration is, in present-day practice, a myth.

Question 2

Can repeated nerve blocks cause nerve damage or other long-term complications?

Dr. Ashu Kumar Jain · Accepted Answer

No. These interventions are regional and can be repeated without causing nerve damage or nerve injury. Complications are rare given how far the technology and generators have advanced, and in this practice no serious complication has ever occurred with these blocks or ablations. Blocks can be repeated every four to six weeks and radiofrequency ablation every three months.

Question 3

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

Dr. Ashu Kumar Jain · Accepted Answer

Ropivacaine for nerve blocks. For spinal procedures, dexamethasone is the primary steroid. For joint injections, Kenacort (triamcinolone).

Question 4

How do you distinguish between pain caused by dyspepsia and pain caused by angina pectoris?

Dr. Ashu Kumar Jain · Accepted Answer

That sits outside pain medicine. It belongs to cardiology and gastroenterology. This practice does not treat visceral pain originating from the heart or lungs and stays restricted to musculoskeletal and neuropathic pain.

Question 5

Patients often present with pain that has both a surgical solution and a pain-management solution. How do doctors decide when a patient needs surgery versus pain management?

Dr. Ashu Kumar Jain · Accepted Answer

Under international Spine Society guidelines, when the primary problem is pain alone, the patient does not need surgery, regardless of the degree of compression shown on imaging, as long as it is below L2. Surgery is indicated for disability: foot drop, motor deficit, sensory deficit, or more than moderate to severe canal stenosis on MRI, where an intervention can only buy time rather than treat the underlying disease. At Artemis, pain medicine and spine surgery work as a team. If a patient referred for pain turns out to have a neurological deficit, they go straight to the spine surgeon; if pain is the only presenting symptom, pain medicine treats it. The line between the two is clear.

Question 6

Bone marrow transplant cures sickle cell disease but is not offered to every patient, partly for financial 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 itself is involved, radiofrequency ablation of the hip joint, targeting the genicular nerves supplying the joint, is a very rewarding procedure. But if the pain originates from the bone itself or has a visceral component, high-dose NSAIDs risk the kidneys and the better approach is opioid-based: morphine or tramadol with paracetamol and a neuropathic agent, alongside any specific interventional target that exists.

Question 7

Can you share more about deep brain stimulation for select cases in pain management?

Dr. Ashu Kumar Jain · Accepted Answer

That is not something done from pain medicine. Deep brain stimulation is coming up fast as a field, but at Artemis it sits with the neurosurgery team, not pain medicine. That question is better asked at a neurosurgery masterclass.

Question 8

How should pain from compression of the L4 and L5 vertebrae be managed, given the overlap between spine surgery and pain management?

Dr. Ashu Kumar Jain · Accepted Answer

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.

Question 9

You mentioned opioids as a line of treatment for chronic pain from avascular necrosis in sickle cell disease. Does not that class of drug carry a risk of habit-formation or addiction?

Dr. Ashu Kumar Jain · Accepted Answer

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.

Question 10

The physiology of the drug and the brain's receptors are the same either way, so why is not it habit-forming in sickle cell disease and cancer the way it is elsewhere?

Dr. Ashu Kumar Jain · Accepted Answer

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.

Question 11

Would marijuana-based therapy sit in the same class as opioids for safety?

Dr. Ashu Kumar Jain · Accepted Answer

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.

Question 12

NSAIDs also carry a risk of kidney damage for musculoskeletal pain. What is the practical limit?

Dr. Ashu Kumar Jain · Accepted Answer

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.

Question 13

Is there a list of drugs under your remit that are specialist-prescription only, and how do you manage the supply side, including the shelf life and storage of these medicines?

Dr. Ashu Kumar Jain · Accepted Answer

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.

Question 14

Given that supply and prescription control is so tight for opioids, is not it strange that some restricted painkiller combinations are still sold over the counter in India?

Dr. Ashu Kumar Jain · Accepted Answer

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.

Question 15

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

Dr. Ashu Kumar Jain · Accepted Answer

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.

Question 16

How should pain from a sickle cell crisis be managed?

Dr. Ashu Kumar Jain · Accepted Answer

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.

Question 17

Is there evidence that adding corticosteroids improves outcomes over local anaesthetic alone for facet joint injections?

Dr. Ashu Kumar Jain · Accepted Answer

No. A purely diagnostic facet joint injection should not include steroid at all. If a facet block is being used as treatment rather than as a step toward radiofrequency ablation, relief is typically short, six to eight weeks, sometimes up to twelve, so some clinicians add triamcinolone, four to eight milligrams per level, with ropivacaine or bupivacaine. That is not standard of care here, because the pain returns. The approach in this practice is a steroid-free block first, then radiofrequency ablation, with four milligrams of triamcinolone added at every treated level after the ablation.

Question 18

For a doctor who wants a career in pain management, what is the typical training route, and do you accept fellows from other countries?

Dr. Ashu Kumar Jain · Accepted Answer

After an MD in Anaesthesiology, the route runs through a PDCC or an FNB/DNB in Pain Medicine, and a couple of institutions have now started a DM in Pain Medicine. India's national body, the Indian Society for Study of Pain, also runs a one-year residential fellowship with its own entrance exam; this doctor is the designated programme head running that fellowship at his own institution, and trainees exit through a national body examination for the FIPM degree. DNB training is due to start at this centre soon. A full one-year fellowship for a doctor from another country would need to be arranged through HR, but one-month and three-month short fellowships are already open to visiting doctors.

Advances in Chronic Pain Management

Questions Doctors Asked Dr. Ashu Kumar Jain