Chronic Back Pain: When Medication Isn’t Enough

Chronic back pain is Malaysia’s most common disabling condition. Over 80% of adults will experience significant back pain at some point. For most, it resolves. For a significant minority — perhaps 10–15% — pain persists beyond 3 months, becomes the defining feature of daily life, and resists everything thrown at it: physiotherapy, NSAIDs, nerve blocks from the GP, even back surgery.

I am a neurosurgeon who has specialised in interventional pain management. My training at the University of Malaya and my DPhil research at Oxford inform a fundamental belief: chronic pain is a medical condition, not a character flaw. It has neurobiological mechanisms. It has treatable targets. The right procedure, for the right patient, applied at the right anatomical level, changes lives.

Types of Chronic Back Pain I Treat

Facet Joint–Mediated Back Pain

The facet joints are small paired joints at the back of each vertebral level. Degenerative arthritis of these joints — a near-universal finding on MRI after age 40 — is one of the most common causes of axial (non-radiating) back pain. Pain is typically worse with extension and rotation, localised to the paraspinal region.

Treatment: Medial branch nerve block (diagnostic) → radiofrequency ablation of medial branch nerves (therapeutic, lasting 9–18 months).

Discogenic Pain

Pain originating from a degenerate intervertebral disc, without significant herniation. The annular fibres are richly innervated — disruption causes deep, dull, central back pain, often worse with prolonged sitting.

Treatment: Intradiscal procedures or spinal cord stimulation for refractory cases.

Radiculopathy (Nerve Root Pain)

Shooting pain, numbness, or weakness in the leg following the distribution of a compressed nerve root. The L4/L5 and L5/S1 levels account for over 95% of lumbar radiculopathy cases.

Treatment: Transforaminal epidural steroid injection → surgical decompression for significant motor deficit or failure of conservative management.

Failed Back Surgery Syndrome (FBSS)

Persistent or recurrent pain after technically successful spine surgery. Affects 10–40% of patients following lumbar surgery. This is not a surgical failure in the traditional sense — it reflects the complex neuroplastic changes that accompany chronic spinal pain.

Spinal cord stimulation is the evidence-based treatment for FBSS and is significantly more effective than repeat surgery or escalating opioid therapy. Multiple randomised controlled trials support this.

Sacroiliac Joint (SIJ) Pain

The sacroiliac joint — connecting the sacrum to the pelvis — is responsible for 15–30% of chronic low back pain, but is frequently overlooked. Diagnosis requires specific provocation tests and fluoroscopically guided SIJ injection.

Treatment: SIJ injection → radiofrequency ablation of lateral branch nerves.

Neuropathic Pain / CRPS

Complex Regional Pain Syndrome and neuropathic pain following nerve injury, surgery, or limb trauma. Characterised by burning, allodynia (pain from non-painful stimuli), and autonomic changes. Requires a multimodal approach including neuromodulation.

Interventional Procedures I Perform

Radiofrequency Ablation (RFA)

Controlled thermal energy delivered through a precisely placed needle to disable the nerve fibres carrying pain signals from the facet joints or sacroiliac joints. Performed under fluoroscopic guidance, local anaesthesia, day procedure.

What to expect: 30–45 minute procedure. Mild post-procedural soreness for 1–2 weeks as the nerves heal in a pain-free state. Full effect at 4–6 weeks. Duration of relief: 9–18 months. Repeatable when symptoms recur.

I perform lumbar, thoracic, and cervical medial branch RFA, as well as lateral branch RFA for sacroiliac joint pain.

Epidural Steroid Injection (ESI)

Transforaminal or interlaminar delivery of corticosteroid to reduce perineural inflammation in radiculopathy. Excellent short-term relief in acute disc herniation; less effective for chronic degenerative stenosis.

Spinal Cord Stimulation (SCS)

A small pulse generator (similar to a pacemaker) is implanted under the skin. Thin leads are placed in the epidural space, delivering electrical impulses that modulate pain signalling at the spinal cord level.

Indications: Failed back surgery syndrome, neuropathic leg pain, CRPS.

Trial period: A 5–7 day trial with external generator precedes permanent implant. If ≥50% pain reduction is achieved, permanent implant follows.

Results: 50–70% of carefully selected patients achieve >50% pain reduction, with improved function and reduced opioid use. Evidence for SCS in FBSS is robust — it is endorsed by NICE (UK) and multiple international pain guidelines.

I perform both trial lead placement and permanent SCS implant at KPJ Tawakkal Specialist Hospital.

Intrathecal Drug Delivery (Pain Pump)

For patients with refractory cancer pain or severe neuropathic pain not controlled by systemic opioids, an intrathecal pump delivers medication directly to the cerebrospinal fluid at a fraction of the oral dose. Dramatically reduces systemic side effects.

Nerve Block and Diagnostic Injections

Targeted local anaesthetic blocks to identify pain generators, provide short-term relief, and guide longer-term treatment decisions.

The Difference Between a Neurosurgeon Pain Specialist and a Pain Anaesthetist

Both can perform nerve blocks and some interventional procedures. The difference matters for complex cases:

A neurosurgeon pain specialist can:

• Review your MRI and identify structural causes that an anaesthetist may not be trained to recognise
• Determine whether your pain requires spine surgery, pain intervention, or both
• Perform spinal cord stimulator implantation and intrathecal pump placement — neurosurgical procedures that anaesthetists typically cannot
• Manage complications that may involve spinal anatomy

If you have been told by a pain clinic that “nothing more can be done,” a neurosurgical pain opinion may reveal options that have not yet been offered.

Frequently Asked Questions

Q: I had a discectomy two years ago and I’m still in pain. Is there anything left to try? Yes. Failed back surgery syndrome is exactly what spinal cord stimulation was developed for. The PROCESS trial showed SCS was more effective than reoperation in this situation. A consultation with MRI review will clarify whether you’re a candidate.

Q: How is radiofrequency ablation different from a steroid injection? A steroid injection reduces inflammation — the effect is temporary (weeks to months) and doesn’t address the nerve itself. Radiofrequency ablation thermally disables the pain-carrying nerve fibres — effect lasts 9–18 months and the procedure is repeatable. For facet joint pain, RFA is the more durable intervention.

Q: Will I need general anaesthesia? Most procedures are performed under local anaesthesia with light sedation. You’re awake but comfortable. SCS implant typically uses light general anaesthesia or sedation. You go home the same day or the following morning.

Q: Am I too old for spinal cord stimulation? Age alone is not a contraindication. The evaluation focuses on your pain phenotype, psychological readiness, and cardiorespiratory fitness for a minor surgical procedure. I have implanted SCS devices in patients in their late 70s with excellent results.

Book a Consultation

Bring your MRI scans, a list of all treatments you’ve tried, and a pain diary if you have one. Tell me what you can no longer do because of your pain — that’s the outcome we’re working toward reversing.

WhatsApp the clinic: +6011 3723 5061 Book online: KPJ Tawakkal Appointment Portal Call the clinic: +603-4026 7777 ext 5099

Educational purposes only. All treatment decisions require direct clinical consultation.