Pain Causes
A 36 year old software professional presented to the pain clinic with 3 month history of pain radiating from the neck to the left arm and hand. He was complaining of occasional tingling in the fingers.
MRI of the neck suggested disc prolapse and compression of nerve as it exits the spine. He was seen by orthopaedic surgeon and neurologist in the last 3 months who advised nerve pain medicines, oral steroids and physiotherapy. There was some improvement initially but the pain worsened and became more or less constant throughout of the day. He was on leave from work and was under pressure to resume work.
Dr. Ram Mohan performed a cervical epidural under fluoroscopic guidance on a day care basis. The patient was discharged the same and advised a neck collar for week. Over the next week the constant radiating pain subsided.
After 1 week there was no pain at rest and minimal activity. The patient was advised supervised physiotherapy to relieve neck spasm and to strengthen the neck muscles. He was advised life style modifications, regular exercise and healthy nutrition. After 1 month he was able to get back to work.
A 46-year-old lady presented to the pain clinic with a long-standing history of low back pain and right leg pain. Leg pain was much worse than the back pain. The pain started in the lower back and radiated to the foot up to the great toe. She complained of constant tingling sensation in the leg and occasional numbness in the leg. The pain was aggravated by standing and walking. Her function was significantly limited by leg pain. Sleep was also disturbed due to leg pain.
The patient had seen various specialists in the past including physiotherapists, orthopaedic surgeon, and the Neurosurgical team. Her MRI scan showed degenerative changes in the lower lumbar spine including the discs and the facet joints.
She was on different types of pain medications. She tried multiple nerve root blocks (epidural injections) in the past but unfortunately, they lasted only a month or so.
The patient was offered a fluoroscopy guided pulsed radiofrequency of the dorsal root ganglion at L5 level.
The patient responded very well to the injection treatment, with more than 90% reduction in pain within a month. She was advised physiotherapy and yoga. At the follow-up appointment 3 months after the injection treatment, the patient reported almost complete pain relief. She has managed to stop all her pain medications and was able to do all her household chores.
A 55 year old male patient presented to the pain clinic with severe pain in the right shoulder and restricted movements for the 1 year. The pain was worsened by any activity. He was unable to even button / unbutton his shirt due to pain. His pain was worse at night. He was unable to sleep on his side and his sleep was often disturbed.
He was evaluated by many specialists in the last one year. He underwent various tests including ultrasound scan and MRI scans which revealed a frozen shoulder (adhesive capsulitis). He was managed conservatively with pain medication, physiotherapy and exercise. He was unable to cooperate with physiotherapy because of intense pain. He also received a steroid injection in to the shoulder without much relief. He was finally advised surgery which he decided not to undergo.
He was evaluated by many specialists in the last one year. He underwent various tests including ultrasound scan and MRI scans which revealed a frozen shoulder (adhesive capsulitis). He was managed conservatively with pain medication, physiotherapy and exercise. He was unable to cooperate with physiotherapy because of intense pain. He also received a steroid injection in to the shoulder without much relief. He was finally advised surgery which he decided not to undergo.
At 1 month, the shoulder pain was insignificant with some restriction in shoulder movements. He was advised more physiotherapy. At 3 months follow-up, there was no pain and unrestricted shoulder movements.
A 35 year old farmer presented to the pain clinic with severe lower back pain for the last 3 months. She pointed her pain to the lower back on one side just above the buttock. She was limping in pain and was unable to cross her legs due to intense pain. She was a farmer and had a history of lifting heavy load prior to the onset of pain.
He was initially treated by a local physician who advised rest and pain medication. She later was seen by an orthopaedic surgeon who made a diagnosis of sacroiliac joint dysfunction and was advised physiotherapy and exercises. Although she noticed some pain relief, she was desperate to get back to agriculture work.
The patient was offered a fluoroscopy guided sacroiliac joint injection followed by supervised physiotherapy and back strengthening exercises.
At 3 months follow-up, there was no pain and she was able to get back to farming.
A 65 year old woman presented to the pain clinic with severe pain in the lower back associated with early morning stiffness. The pain was worse on bending backwards and sideways. There was some radiation of pain to the hips and buttocks. The patient had to frequently change position during sleep which was disturbed.
She was evaluated by many specialists in the last one year including orthopaedic surgeon, neurologists and physiotherapists. X-rays and MRI spine suggested generalized degenerative changes. There was no improvement with pain medication, physiotherapy, TENS and acupuncture. She was given a caudal epidural injection with facet injections which gave pain relief for a 2 weeks only.
After a thorough examination a provisional diagnosis of facet pain syndrome was made. The patient was offered diagnostic ultrasound guided lumbar medial branch blocks which gave here significant pain relief. This was followed by Radiofrequency neurotomy for long term pain relief.
At 1 month, the back improved significantly and she was able to walk around the house without pain. Her sleep improved and there was no morning back stiffness. She was advised supervised physiotherapy and exercise. At 3 months follow-up, she was able to do routine activities at home and felt was glad that she underwent the procedure.
A 46 year old software professional was referred to the pain clinic after undergoing a spine surgery. He complained of recurrence of left leg pain and a new onset back pain 2 months after spine surgery. He underwent a laminectomy and discectomy (for an L4/5 disc prolapse) 2 months earlier for leg pain (sciatica) due to a prolapsed disc. Immediately after surgery the patient had complete pain relief. He resumed work after a 2 weeks. Two months later he had a recurrence of left leg pain and also a new onset back pain which was worse on bending forward and walking a few yards.
He was advised pain medication and physiotherapy by the treating surgeon. However, there was not any improvement in pain. MRI of lumbar spine showed epidural fibrosis which was impinging on the nerve root.
The patient underwent epidural adhesiolysis a day care procedure to dissolve the fibrous tissue. At the time of discharge he had significant pain relief and was able to bend forward without pain.
After 10 days, the patient had no back pain but some radiating pain which was tolerable and responded to nerve pain medication. He was advised physiotherapy and was given a course of vitamin E. After a month the patient had no pain at all and was able to resume work.
A 57 year old man presented to the pain clinic with severe low back pain, early morning stiffness and a disturbed sleep. He underwent a spine fusion surgery 4 years ago which relieved his back pain and sciatica. He was able to get back to work and had no problems. Six months ago he started developing low back pain and visited the operating surgeon.
The patient was managed conservatively. Initially responded to pain medication but later when the pain was worsening, he was advised physiotherapy and back strengthening exercises by the operating surgeon. He also received a lumbar epidural steroid injection which did not provide any relief at all. Since the pain was worsening despite pain medication, physiotherapy, exercises and epidural injection he was referred to the pain clinic.
A CT scan of the lumbar spine and sacroiliac joint was done which showed facet joint degeneration above the level of the spine fusion and also evidence of sacroiliac dysfunction.
The patient was offered diagnostic facet medial branch blocks and Sacroiliac joint injection which gave him excellent pain relief. Radiofrequency ablation of medial braches, PRP injections into para-spinal muscles and Sacroiliac joint radiofrequency ablation was done in a staged manner over 2 months. He was advised physiotherapy and back strengthening exercises and yoga to improve flexibility.
At 3 months follow up, the patient had almost negligible pain and continued yoga as part of lifestyle modification.
The patient responded very well to the injection treatment, with more than 90% reduction in pain within a month. She was advised physiotherapy and yoga. At the follow-up appointment 3 months after the injection treatment, the patient reported almost complete pain relief. She has managed to stop all her pain medications and was able to do all her household chores.
The patient tried pain medication, ayurvedic medication, massage, acupuncture, TENS, physiotherapy, intra-articular steroids and lubricants (viscosupplementation). However, there was progressive worsening of pain and he was restricted to home and became withdrawn from friends and family. He was unable to walk even a few yards without pain. He refused surgery because of a bad experience in his family.
When asked about the expectations from interventional pain management, he said that as long as he is able to walk in the mornings with friends and able to do his household jobs independently, he would be happy with the intervention. The patient underwent a diagnostic ultrasound guided genicular nerve block which gave him excellent pain relief. This was followed by a combined ultrasound and fluoroscopy guided radiofrequency ablation of genicular nerves of the knee joint for a long term pain relief.
At a follow-up appointment after 3 months, the patient reported excellent pain relief. His function improved and he was able to walk without crutches. He was able to join his friends for morning walks and evening tea. He was able to perform his routine tasks independently (which was his main goal).
Further review at 1 year revealed an ongoing benefit. His pain was manageable with heat packs and massages with no requirement for pain medication.
A 53 year old female presented to the pain clinic with a 2 year history of severe pain in the bottom of her heel. The pain was worst with the first step in the morning so much so that she was scared to put her foot on the floor. She also felt the pain when she stood up to walk from her office chair at work and after other long periods of being seated. Her heel pain had been on and off for the last 2 years and had been bearable at times although it had never really subsided completely. Recently, she had increased her level of exercise to participate in a 5 km marathon. On examination the patient felt extreme pain when pressure was applied to the lateral band of the plantar fascia, just distal to the heel. An x-ray showed heel spur.
The patient was first seen by orthopaedic surgeon 2 years ago who advised physiotherapy with calf muscle and foot muscle strengthening. The patient also underwent extracorporeal shockwave therapy. There was very good improvement in her pain for a few months before a recurrence of pain. This time the surgeon gave a steroid injection which gave her significant pain relief for 6 months. A subsequent injection helped only for a couple of months. She was referred to the pain clinic for advanced pain management.
Dr Ram Mohan performed a diagnostic lateral plantar nerve block which established a diagnosis of neurogenic heel pain. Later, a radiofrequency ablation of a branch of the lateral plantar nerve was performed for long term pain relief.
The patient had no pain at all even after 1 year and was able to participate in the 5 km marathon the next year.
A 47 year old patient presented to the pain clinic with severe pain in the groin and testicle. He had no medical problems and all investigations were normal. He underwent a mesh hernia repair 2 years ago. He was particularly depressed because he was not able to have sex anymore.
He was given pain medication which did not relieve the pain. He tried alternative treatments including ayurvedic and homeopathic medication. He was also put on psychiatric medication because of depression.
Dr. Ram Mohan diagnosed it as a case of genito-femoral neuralgia due to entrapment of nerves in the scar tissue. The patient was given an ultrasound guided diagnostic genito-femoral nerve block which gave him instantaneous pain relief. Later pulsed radiofrequency of the genital branch of the genito-femoral nerve was performed.
One month after the procedure, the groin and scrotal pain disappeared. He was very happy with the procedure and the pain relief it provided. One year later he continues to have no pain and able to perform all his routine activities.
A 56 year old man presented to the pain clinic with left sided chest pain. He had chicken pox (Shingles) two months prior to presenting to us that involved chest on the left side just below the nipple line. Shortly after resolution of rash, he started experiencing very severe, burning pain in a similar distribution as the rash. Even with light touch or the shirt touching the skin triggered extremely severe pain. His sleep was disturbed and he was having suicidal thoughts.
A neurologist prescribed strong pain killers and nerve pain medicines. As there was no improvement in pain higher doses were advised. He had minimal relief with higher doses and he started to have side effects. He was referred by the neurologist to the pain clinic.
Dr. Ram Mohan performed an ultrasound guided diagnostic intercostal nerve block to map the nerve involved in the pain. Five minutes after the procedure the patient noticed a dramatic reduction in pain. He later underwent an combined ultrasound and fluoroscopy guided pulsed radiofrequency lesioning of the intercostal nerve for long term pain relief.
At 1 month after the procedure, the pain intensity had come down by 60 percent. The procedure was repeated again as day care. One month after the second intervention, there was complete resolution of pain. There was no pain at a further follow-up at 1 year.
A 65 year old man presented to the pain clinic with severe left sided facial pain for the last 4 years. The pain was felt over the cheek and jaw. The pain was described as unbearable and electric shock-like, lasting a few minutes many times in a day. The pain would come anytime of the day without any predictability. The pain was aggravated by chewing, washing face, brushing.
MRI brain showed a small blood vessel pressing on the trigeminal nerve (the nerve which carries sensations from the face) at its origin in the brain. He was prescribed nerve pain medicine by neurologist which reduced the pain for the first 2 years. Later the intensity of pain increased and the pain was not improving even with higher doses of medicines. He was offered surgery or trigeminal nerve block by the neurologist for long term pain relief. The patient chose nerve block because he did not want surgery.
Dr. Ram Mohan performed a percutaneous radiofrequency ablation of the trigeminal ganglion under fluoroscopic guidance. The patient felt no pain at all by the end of the procedure. He was observed for a few hours and discharged home.
The patient was able to slowly wean off all previous medication within a month. After 1 year he continues to be pain free and did not need any medication.
A 36 year old female presented to the pain clinic complaining of a sharp pain at the upper part the neck and radiating up to the back of the head. There was no history of falls or trauma. The pain was worsening over the last month. The patient also had migraine like headaches for many years mostly starting at the back of the head. The headaches would come on and off and lasted a few days to few weeks. She also complained of neck pain and muscle spasm.
The patient had seen many doctors for her recurrent and chronic headache. She stopped taking pain medication because it helped only for a few hours. She was later seen by a neurologist who put her on migraine medication. She underwent neck x-rays, CT and MR brain which was essentially normal. The pain improved temporarily but there was recurrence episodes of headache. She had to quit her job because she couldn’t cope with headaches and the side effects of medication.
Dr Ram Mohan noted that the patient had reduced range of neck movements, and tension in the neck muscles. The patient also had tenderness on springing the upper cervical spine and mid thoracic spine. After convincing the patient that the pain maybe coming from pinched and sensitive nerves in the neck, she was given ultrasound guided diagnostic occipital nerve blocks. The patient reported significant pain relief. Later, for long term pain relief, pulsed radiofrequency lesioning of the greater occipital nerve and conventional radiofrequency ablation of 3rd occipital nerve were performed under combined ultrasound and x-ray guidance.
After 6 months, the patient reported that she never had such a long headache free period. Although she did not get back to work, she was happy that she could spend a pain free quality life with family. She had been practicing meditation and yoga as advised by Dr Ram Mohan. She was able to stop all medication and felt very satisfied with the treatment.
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