Two case reports | Sunday Observer

Two case reports

11 April, 2021

These are two patients suffering from chronic pain for over a decade. Patient No 1 with back pain and patient No 2 with knee pain.

Patient No 1

The patient is a 49–year-old gentleman. He travelled all the way from a peripheral town to see me at the ‘London Pain Clinic’ for his back pain going on for a decade or more.

He has been suffering with lower back pain with pain shooting down the legs. In a layman’s term, this is sciatica. 

In medical terms, back pain with a radiculopathy. 

He is supposed to have a L4/5 disc bulge and had spinal surgery on two occasions. Unfortunately, the symptoms have not got better following the first surgery. As a result a second surgery was carried out with no positive outcome. No improvement. Both surgeries were carried out privately in Colombo. Following the surgery he also had single level facet injections on two occasions by the same surgeon. After suffering for eight years, he came and saw me in clinic last week. Unfortunately, he did not have the scans taken prior to surgery. The scans available were scans taken following surgery.

I spent 30 minutes in the clinic with him and carried out a thorough examination of his back. The lumbar facet joints and the sacroiliac joints were tender.  

Currently he is on pain killers such as Panadeine and Diclofenac. Diclofenac is a non steroidal anti inflammatory drug (NSAIDS).  I am not keen for patients to go on long term NSAIDS as it has drastic side effects such as gastric bleeding, renal failure and higher risk of heart attacks. My approach is a one off procedure and limit the pain killers. 

Paracetamol or Panadeine long term is safe. But Panadeine can cause constipation due to its Codeine. 

As the treatment I did carry out 

Bilateral L2/3 L3/4 L4/5 L5/S1 facet injections.

Bilateral Sacroiliac joint injections 

Caudal Epidural  with an Epidurogram


All procedures were carried out under X ray guidance and pictures sent to his phone via what’s app.

Caudal Epidural plus Epidurogram

Lumbar Facet Injection

Sacro Iliac Joint Injection ®

Patient No 2 with knee pain

A 68-year-old female with osteoarthritis has suffered pain in both knees for a long time. Various treatments did not help her knee pain. She should be having a total knee replacement but not keen on surgery. She weighs over 90 kgs. 

I did carry out a radio frequency to the Genicular nerve on the left side. 

Genicular nerve is the sensory nerve supply to the knee which has three branches: Superior lateral, Superior medial and inferior medial branches. Ideally a block should be done, which should be followed by radio frequency. Due to the costs involved both were done together.

A pulse generating machine is used to generate the heat via a current. The nerve is heated up to 82 degrees for 120 seconds. This will coagulate the myelin sheath of the nerve which will prevent the transmission of pain impulses. Probably this procedure was carried out for the first time in Sri Lanka. Osteoarthritis is not curable. It’s a lifelong disease, such as diabetes.

The machine I used in Sri Lanka is the ‘Radionics’ radio frequency pulse generator.