Chronic Back Pain Treatment in Mumbai

Our Approach In Managing Chronic Back Pain

Step 1 — Comprehensive Diagnostic Evaluation and Pain Source Mapping

Chronic back pain is not a single diagnosis — it is a symptom arising from multiple potential pain generators in the spine. At Shree Hospitals, all chronic back pain patients undergo a structured evaluation: detailed history (onset, character, radiation, aggravating and relieving factors, prior treatments and their effects), neurological examination (motor power, sensation, reflexes, straight leg raise test, FABER/FADIR for SI joint, facet loading manoeuvres), and review of existing imaging. MRI of the lumbar spine is the primary imaging modality — identifying disc dehydration and protrusion, nerve root compression, facet joint arthrosis and hypertrophy, ligamentum flavum thickening, spondylolisthesis, and vertebral body changes. However, MRI findings must always be interpreted in clinical context: 30–40% of asymptomatic adults over 40 have MRI abnormalities — disc bulges, facet arthropathy — that do not cause pain. The clinical picture drives treatment, not the scan alone.

Step 2 — Targeted Diagnostic Blocks to Confirm the Pain Source

Before proceeding to therapeutic procedures, diagnostic blocks confirm the specific pain generator:

Medial branch blocks (MBB): fluoroscopy-guided injection of 0.5mL local anaesthetic at the medial branch nerves that supply the facet joints (typically 2 adjacent levels for each joint). ≥80% temporary pain relief (based on numerical pain score) confirms facet joint origin. Repeat MBB at a separate visit (comparative MBB) eliminates placebo response and confirms true facet mediation before committing to radiofrequency ablation.

Selective nerve root block (SNRB): fluoroscopy-guided injection of local anaesthetic and steroid at a specific nerve root in the neuroforamen — both diagnostic (confirms the painful nerve root matches the MRI finding) and therapeutic.

SI joint injection: intra-articular injection of local anaesthetic confirms SI joint as pain generator before considering RFA of lateral branches or SI joint fusion.

Discography: performed selectively when disc-mediated pain is suspected but MRI is equivocal, and surgical fusion is being considered — pressure-controlled injection into the disc reproduces concordant pain, confirming discogenic origin.

Step 3 — Epidural Steroid Injection for Nerve Root and Discogenic Pain

Epidural steroid injection (ESI) delivers corticosteroid (triamcinolone, betamethasone, or methylprednisolone) plus local anaesthetic into the epidural space adjacent to the inflamed nerve root, reducing nerve root oedema, inflammatory mediator activity, and spontaneous ectopic discharge. Three approaches:

Interlaminar ESI: needle placed in the posterior epidural space between laminae — widely distributed epidural spread, less specific nerve root targeting.

Transforaminal ESI (TFESI): needle placed in the intervertebral foramen at the target nerve root level — most specific, delivers medication directly to the ventral epidural space and anterior nerve root sheath. Gold standard for unilateral radiculopathy. Requires fluoroscopic or CT guidance.

Caudal ESI: needle placed via the sacral hiatus into the caudal epidural space — used for bilateral L4–S1 involvement, failed back surgery syndrome, and when superior approaches are technically difficult.

Step 4 — Radiofrequency Ablation for Facet and SI Joint Pain

Confirmed facet joint pain (post-positive comparative MBBs) is treated with radiofrequency ablation (RFA) of the medial branch nerves. A radiofrequency probe is placed at each medial branch nerve under fluoroscopic guidance and a thermal lesion is created (80°C × 90 seconds), denervating the facet joint. The ablated nerve regenerates over 12–24 months — repeat RFA may be performed at that point with equal efficacy. RFA provides ≥50% pain relief at 12 months in 60–80% of appropriately selected patients.

For sacroiliac joint pain: lateral branch RFA (cooled radiofrequency or pulsed RFA) targets the lateral branches of S1–S3 and the L5 dorsal ramus supplying the SI joint ligamentous complex. Cooled RF (SInergy system, AvaNS Cool-IQ) uses cooled electrodes to create a larger thermal lesion zone, improving coverage of the distributed lateral branch anatomy.

Step 5 — Vertebroplasty and Kyphoplasty for Osteoporotic Compression Fractures

Osteoporotic vertebral compression fractures (VCF) — common in postmenopausal Indian women on long-term steroids or with metabolic bone disease — cause severe acute back pain that can persist for months if untreated. When pain persists beyond 6–8 weeks of conservative management (analgesia, bed rest, bracing):

Vertebroplasty: percutaneous injection of polymethylmethacrylate (PMMA) bone cement into the fractured vertebral body under fluoroscopic guidance via bilateral 11G bone needles placed through the pedicles. Cement stabilises the fracture, reduces pain in 70–90% of patients within 24–48 hours.

Kyphoplasty: balloon tamp is first inflated inside the fractured vertebral body to restore height and create a cavity; cement is then injected at lower pressure into the cavity. Superior kyphosis correction compared to vertebroplasty, with potentially lower cement leakage risk. Indicated when significant kyphotic deformity or height loss is present.