Question 1

After radiofrequency ablation, can the treated nerves regenerate, and if so, when can the pain recur?

Dr. Ashu Kumar Jain · Accepted Answer

Yes. After radiofrequency ablation the treated nerve does regenerate, usually over 6 to 12 months, and the pain can recur at that point; the RFA can then be repeated. A traumatic nerve injury is different: it can lead to complex regional pain syndrome type 2 (CRPS 2). Nerve regeneration after such an injury takes a very long time and the results are poor. Many patients who come to us with nerve injury, and we see many war-injury patients, have CRPS, which is a very disabling syndrome, and we have to treat the CRPS. If you believe you can treat such a patient through nerve regeneration, in present-day practice that is a myth.

Question 2

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

Dr. Ashu Kumar Jain · Accepted Answer

All the interventions I have presented can be repeated, and they do not cause nerve damage or nerve injury, because the technology has improved: the pulse generator I showed has many safety features. Complications are very rare, and in our clinical practice we have never seen a serious complication with these blocks and RFAs. They are quite reproducible: a block can be repeated when the pain returns, generally at intervals of about 2 to 3 months, and RFA at intervals of 6 months or more. That is the beauty of these procedures.

Question 3

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. As a steroid, in the spine we primarily use dexamethasone. For joints we usually use Kenacort.

Question 4

Patients often present in pain where sometimes there is a surgical solution and sometimes surgery is not required. How do doctors decide when a patient should go for surgery and when for pain management?

Dr. Ashu Kumar Jain · Accepted Answer

Take spine pain. Under the international spine society guidelines, any pain coming from the spine where the primary problem is pain alone does not need surgery. The indications for surgery are disability (foot drop, motor deficit, sensory deficit) and, going by canal size measured on MRI, more than moderate or severe canal stenosis. In those cases intervention is not the treatment: it can buy some time, but it cannot treat the disease. Patients with severe or more than moderate canal stenosis, disability such as foot drop or severe sensory deficit, or untreatable pain must undergo surgery.

At Artemis we work as a team with the spine surgeons. If a patient comes to me for pain and I find a neurological deficit, I refer the patient to the spine surgeon immediately and do not touch it. If the patient has a disability, a severe motor deficit or cauda equina syndrome with bowel and bladder involvement, we do not treat. If pain is the only presenting symptom, we treat the patient. There is a very clear demarcation.

Question 5

Bone marrow transplant is a cure for sickle cell disease, but not every patient can be offered it, for reasons including cost. 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, targeting the nerves supplying the joint. It is a very rewarding procedure. If the pain involves the bone or the viscera, the best treatment is with opioids. These patients cannot be treated with conventional painkillers, because higher doses of NSAIDs can hurt their kidneys.

Their primary management is opioid-based, with paracetamol and a neuropathic medicine. You can use tramadol, tapentadol, buprenorphine patches or sublingual tablets, morphine or a fentanyl patch. If there is a particular target, such as nerve involvement, we treat it interventionally. We see many of these patients suffering a great deal, and we treat their pain very successfully.

Question 6

How should pain caused by compression at L4 and L5 be managed?

Dr. Ashu Kumar Jain · Accepted Answer

With L4-L5 compression, we first evaluate whether it is a lateral canal stenosis or a central canal stenosis, and on clinical examination whether there is any sensory or motor deficit. If there is no sensory or motor deficit, we treat the pain; with lateral canal stenosis we can perform transforaminal epidural adhesiolysis, which gives wonderful results. If there is moderate or more than moderate, severe canal stenosis with a sensory or motor deficit, and severe pain that does not respond to our block, the patient will definitely go for surgery.

Question 7

Opioids, which you mentioned as a line of treatment for avascular necrosis, can be habit-forming or addictive. If the receptors work the same way, why would they behave differently in sickle cell disease and cancer?

Dr. Ashu Kumar Jain · Accepted Answer

If you use opioids for chronic low back pain, knee pain or similar pain, they are habit-forming; for routine non-cancer chronic pain we never give them. Sickle cell pain is managed along the same lines as cancer pain, and there opioids are among the topmost drugs on the WHO ladder: they are very potent and safe with respect to the patient's organ involvement. Many countries, including the USA and European countries, are suffering because patients with low back pain are given morphine and other opioids.

Cancer and sickle cell pain is a different set of pain: it is deep, ischaemic pain from bone and viscera. Visceral pain travels in afferent fibres that run with the sympathetic nerves, and these severe pains do not respond adequately to conventional painkillers such as diclofenac on their own. They need opioids, combined with neuropathic drugs where there is a neuropathic component. Back, knee, elbow and shoulder pain, by contrast, are peripheral musculoskeletal or neuropathic pain.

Question 8

Would marijuana-based therapy fall into the same habit-forming class as opioids?

Dr. Ashu Kumar Jain · Accepted Answer

Marijuana is not in the same class as opioids: it carries a lower risk of fatal overdose, but it can still cause dependence, and the evidence that it relieves chronic pain is weak, so international pain bodies do not currently endorse cannabinoids for chronic pain. Unfortunately it is still not approved in India; in other countries synthetic marijuana is also available. For musculoskeletal pain it may be a lower-risk alternative to opioids where it is permitted, but in India the government has not approved it.

Question 9

For musculoskeletal pain, NSAIDs can also damage the kidneys. How long can they be used?

Dr. Ashu Kumar Jain · Accepted Answer

For a musculoskeletal cause, NSAIDs should not be taken for more than 7 to 10 days, at most 2 weeks. In my clinic I do not jump to intervention at the first visit. I give a 7 to 10 day or 2-week trial, and my target is 50% pain relief. If the patient has not benefited after 2 weeks, I go to intervention. Most acute pain, such as a simple strain or an acute disc, responds very well to NSAIDs and a muscle relaxant given for 7 to 10 days, at most 2 weeks.

Question 10

Is there a list of drugs within your remit that are for specialist prescription only, and how is the supply side managed? Are they stored centrally? We have supply problems for certain drugs in Zambia.

Dr. Ashu Kumar Jain · Accepted Answer

I agree, and not only with opioids: some countries do not even allow patients to carry pregabalin or gabapentin into the country. In India, opioids are scheduled drugs. They need a prescription from a competent doctor, meaning not an MD medicine physician, an ENT surgeon or a general surgeon, but a pain specialist, anaesthesiologist or neurologist. For morphine and fentanyl specifically, the hospital must hold a government licence to keep a certain quantity. We fill in and stamp a special designated form, patients bring us their consumption chart, and we submit it to the drug controller. Tramadol, tapentadol and buprenorphine do not need that special licensing, but they do need a valid, stamped prescription from a competent doctor.

Question 11

In your experience, what are the most common misconceptions community doctors have about facet joint injection?

Dr. Ashu Kumar Jain · Accepted Answer

The first dilemma is diagnosis itself. Ninety per cent of doctors who are not trained in handling this kind of spinal pain cannot diagnose facetogenic pain. I see many patients with facetogenic pain prescribed pregabalin and gabapentin for years with zero results. We call it axial pain, which includes both facetogenic and discogenic pain, and gabapentinoids are of no use in axial pain, yet 8 out of 10 patients with axial pain are given these drugs with zero results.

So it is first a diagnostic dilemma. There are very specific questions in the patient history and a very specific examination for facetogenic pain. Once you suspect it, you give a diagnostic block to see whether the pain is coming from the facet or from another structure, and once the block is positive, you proceed to facet joint RFA.

Question 12

How is the pain of a sickle cell crisis managed?

Dr. Ashu Kumar Jain · Accepted Answer

These patients need good hydration, without overloading them with fluid, their pH has to be managed, and in crisis they need IV opioids. Diclofenac alone is not enough, though an anti-inflammatory can be added to the opioid. Their fluid status and ABGs must be managed, and the patient has to be admitted. In crisis we use intravenous infusion with patient-controlled analgesia (PCA). Once they stabilise and come out of the crisis, we switch them to patches or oral medication. Patient-controlled analgesia, primarily with opioids, is the mainstay of pain management.

Question 13

Is there evidence that corticosteroids provide better outcomes than local anaesthetic alone in facet joint injections?

Dr. Ashu Kumar Jain · Accepted Answer

For a diagnostic facet joint injection you do not need to give steroids. If you are treating the patient with a facet joint block alone, without RFA, it gives short-term relief of 6 to 8 weeks, sometimes 12 weeks, and you then have to add a steroid, usually triamcinolone 4 to 8 mg at every level with ropivacaine or bupivacaine. That is not the standard of care, because the pain will come back. What we do is a facet block without any steroid, followed by RFA, and after the RFA we give 4 mg of triamcinolone at every level.

Question 14

What is the typical route for a doctor who wants to build a career in pain medicine?

Dr. Ashu Kumar Jain · Accepted Answer

In India, after an MD in anaesthesiology you can apply for PDCC courses, or for the FNB or DNB in pain medicine, and a couple of institutions have now started a DM in pain medicine. Our national body, ISSP, also runs a full-time, one-year residential fellowship, entered through an entrance exam, after which you choose your centre. I am the designated programme head for this fellowship at my institution. We train the doctors for one year, the national body conducts the exit exam, and on clearing it you are awarded the FIAPM. I will also be starting the DNB at my centre very soon.

Question 15

Do you accept fellows from foreign countries at your institution?

Dr. Ashu Kumar Jain · Accepted Answer

I doubt that someone from abroad would be willing to come for one year, but if somebody is, we can talk to HR. We also have one-month and three-month fellowships, and fellows sometimes come for those. If you seriously want training, you need the full year.

Live Discussion with Dr. Ashu Kumar Jain