Pain management

Back pain is very common, and about 95% of people have significant back pain at some point in their life. It is a frequent cause for taking time off work. Back pain is often due to age-related changes in the spinal discs, joints, ligaments or muscles, and can be termed “spondylosis”, “degenerative disc disease”, or “osteoarthritis of the spine”.

Common back pain can often be treated with physiotherapy and non-operative measures. So called red-flag symptoms which should be reviewed by a doctor include non-mechanical back pain, elderly age, history of cancer, leg pain, weakness or numbness. Bowel, bladder or sexual problems require urgent assessment to exclude cauda equina syndrome, in which the sensitive nerves to these areas can be pinched by a disc prolapse, for example, and may require urgent surgical treatment.

Uncommon but potentially serious causes of back pain include spinal tumours, spinal infection, or abdominal problems such as aortic aneurysms, kidney stones, gall-stones, pancreatic problems, rheumatological conditions or auto-immune diseases. 

Neck pain is often due to age-related changes in the spinal discs, joints, ligaments or muscles, and can be termed “spondylosis”, “degenerative disc disease”, or “osteoarthritis of the spine”. Common neck pain can be due to muscle sprains or poor posture, and can often be treated with physiotherapy and non-operative measures. So called red-flag symptoms which should be reviewed by a doctor include non-mechanical pain, night-pain, elderly age, history of cancer, arm or leg pain, weakness or numbness.

Sometimes cervical nerve roots can become pinched by a disc prolapse, causing arm pain, or the spinal cord can become compressed causing “myelopathy” – pressure on the spinal cord affecting the arm and leg function. These conditions can be treated surgically, after assessment by a neurosurgeon and appropriate investigations which usually include MRI scans. 

Many forms of facial pain exist. These include trigeminal neuralgia, neuropathy, the trigeminal autonomic cephalalgias such as cluster headache, and temporomandibular joint problems. They can all produce severe and intrusive symptoms and need to be carefully distinguished from each other as they respond differently to treatments.

Neurosurgical therapies include deep brain stimulation, microsurgery and Gamma Knife radiosurgery. It is important to screen for other conditions such as a tumour or inflammation using MRI.

Trigeminal neuralgia is one form of facial pain characterized by brief, intense bouts of stabbing or electric shock-like pain. Classic triggers include touch, cold wind, chewing and tooth brushing. Oral medications such as carbamezapine are the mainstay of treatment but in patients where there is still too much pain or the medication produces intrusive side effects, neurosurgical procedures are available.

In some patients, MRI scans reveal a blood vessel pulsating against the trigeminal nerve beside the brain. This can be treated by an operation called Microvascular decompression whereby a small hole is made at the back of the skull and the blood vessel moved away from the nerve under the operating microscope. Another option is Gamma Knife radiosurgery whereby the nerve can be treated without the need to open the skull (no incision). A frame is applied to the head temporarily and then highly accurate gamma rays are focused on the nerve as a day case procedure.

Glossopharyngeal neuralgia is another form of facial pain that also involves the inside of the mouth, which is a much rarer condition. The pain is typically in the throat and the ear. It is stabbing or shooting and can be triggered by swallowing cold drinks or yawning/talking. MRI may demonstrate a blood vessel pulsating against the glossopharyngeal nerve beside the brain and can be considered for Microvascular decompression surgery. Gamma knife radiosurgery provides a low risk alternative using highly accurate gamma rays focused on the nerve as a day case procedure with very promising results.