 Good day to everybody. My name is Dr. Sharan Srinivasan. I am a senior stereotaptic and functional neurosurgeon associated with the Manipal Hospital Malaysia since the year 2009. Now neurosurgeons we are both brain and spinal surgeries and today as a functional neurosurgeon I want to give you some information about pains to droves. As a functional neurosurgeon we deal with people having movement disorders like Parkinson's disease, hand tremors, dystonia. The other things we deal with is somebody with pain. Pain is a pain for all of us. Pain is a pain for the patient who is suffering and also for the doctor to understand where the pain is coming from. So all of us have suffered with pain at some point of time in our lives so far for sure whether it's a headache or a neck pain or a tooth pain or a back pain, knee pain, any pain that could have bothered us for a few hours to a few days sometimes even longer. Now this shorter pains you know you could have a sprain, you could have it while walking or even while playing some game or something like that and those get away with the simple you know medications where you know it's a little bit of physical therapy and it will be alright. But there are a set of patients who suffer from pain for long periods of time. Three weeks, six weeks or even longer. So somebody who's having a pain for three or six weeks or longer which is not being resolved with the routine type of treatment because we categorize them in another category called chronic pain. And today I'm going to talk about that specific chronic pain which is creating a problem for so many people. And so the topic today is called deciphering pain symptoms. Let us start with headache. So headache is a headache for all of us. Like I said we don't know what is causing it. It could be as ominous as a brain tumor. It could be an impending stroke. It could be a migraine or it could be something non-specific. It could even be headache coming from some reference from the tooth pain or from the neck. So anyway so you should understand that you should never neglect a headache especially if it is not the usual type. It's very severe associated vomiting, giddyness or something like that. So you know like I'll just remember the story I want to tell you now. Imagine at two o'clock in the morning somebody at home, your father, mother, brother, sister, comrades or girls are just pain. What comes to your head? How did that happen? Will rest the patient or gynaecology hospital? Of course not. You will rest them in the hospital with cardiology services. You rest with cardiology, ECG, X-ray, ECO and whatever needs to be done and fast so that the problem gets diagnosed and quickly resolved. Correct? Of course. Imagine the same two o'clock in the morning. The same person complains of headache. Will you show the same kind of urgency? Most probably not. You know you give them a sandal, you give them a dough and they don't eat their head till morning. Let me see when we get up what's happening. So what I always say is heart is important, brain is not. But the truth is with 100% brain working today it's difficult to survive in this world. So the important message here is some of the headaches can be ominous. It could be of an impending heart attack or impounding brain attack or a stroke or even a brain tumor or something like that has to be addressed urgently in the hospital with the CT scan or NMR scan. So it's good to get, reach out to neurologists or neurosurgeon as quickly as possible so that the right diagnosis is made and then the treatment can be followed up even with a general physician. This is the first message I want to give as far as the severe critical headache is concerned. More often than not it can be a migraine headache or could be a stress-related headache. It could be headaches because of myofascial symptoms coming from the neck muscles. If that is the case that is more of the topic of today's discussion. So migraine, we will not talk today because it's a different world by itself but many headaches are not migraine settings. Common sense is called cervical genetic headache. The pain is turning the neck. Stroll is spreading to the head, going around the eye, temporal region, here, back, everywhere else. Some people even have a feeling of fullness in the ear, pain in the jaw muscles and things like that. So if you treat the neck, this headache disappears. So some of them are very stressful people. They bite the teeth when they have a lot of stress. Just be constantly biting and keeping the teeth tight if they have pain here. The temporal region, we have to find the trigger points here. We release that. I'll talk about trigger points a little later and we get better from that. Now from the head, we will go to the face. The commonest pain in the face we call is called trigeminal neuralgia. Trigeminal nerve is a fifth cranial nerve that comes out from the brain and comes into the face. It has three branches, one on top here, one in the middle here and one at the lower branch here. Any of these, all of these three can be affected with the peculiar problem of pain, of which triggers pain called trigeminal neuralgia. This pain is distressing. There are patients with severe persistent trigeminal neuralgia who have attempted or contemplated even ending their lives for suicide. Because if that's severe, they can't talk, they can't chew, they can't even swallow, they can't swallow. It's that bad. Some of them somewhere, days together, just sipping water and some food or some liquids, they can't even have food. So this can happen because of some problem in the nerve in the brain, but sometimes nothing is there, everything is normal. In that situation, if the tablets don't work, we do a special injection process called RF ablation in the face and to the nerve of the back. This is done in the OT and this can give very, very dramatic and long lasting relief from pain. So if you are somebody suffering or you know somebody who suffered from trigeminal neuralgia who's not getting help by either medicines or they don't know what to do, please reach out to us. We'll be more than happy to help them to sort them out and see how best in the pain relief that we can do. Now if you go downwards, we'll go to the neck. The neck muscles are like a spondylosis. It's another, you know, very, very well abused word. The moment your neck pain is not sure about spondylosis. Every neck pain needing this spondylosis, spondylosis is the wear and tear of the of the bones and the joints that happened over time. But the neck pain can be because of the muscle, can be because of the joint, because of the disc, or because of the nerve roots coming out or a combination of all of this. It all depends on your activities. There's somebody wanting to forward like this and working for prolonged periods of time. Somebody not sitting in the right posture. Somebody like that wants to try to kill them and look at something in the distance. Whatever the cause is. These are all many of these things have all these pains have gotten worse today. Thanks to the pandemic of the last two years, not much of physical activity. Everybody is restricted to the houses and this curse, the new curse called the work from home. You know, the doctor, we can't work from home, but many of these people are working from home, prolonged hours, and you know, probably in that equipment, you know, furniture, you know, which is not ergonomically designed for the person. This can be a big issue for us. So, neck pains can come. Neck pains can radiate either to the head, like I said, or you can come down the hand, the shoulder, the hand up to the fingers. You know, pain, numbness, burning, a subjective feeling of weakness, one hand, both hands. You don't know what it is. So, it can be a slip disc in the neck or it could be a nerve getting pinched on its way out or it could be trigger points in the in the shoulder or in the neck. How do we diagnose that? First, we start with an MRI scan. We'll look at the MRI scan to see what's going on. If there's a large slip disc and there's any surgery, if not so much, then we need a medical line of treatment and some good pain management processes with the trigger point releases, myofascial release. You know, stretching, ergonomic exercise and assessments and exercises and, you know, basic physiotherapy. Then, we go down, we go to low back pain. Now, low back pain, like I always say, is the single biggest cause of loss of man ever in the world today. Can you imagine? Not cancer, not diabetes, not heart problem, not baby, but a silly stupid problem for low back pain. Why? Again, like we have become coach potatoes. We sit in odd postures for long periods of time. We don't keep it straight like this. That can become a problem. So, low back pain has to be addressed because, again, you see better quality of life. So, low back pain can remain in the low back or can start radiating to the hip joint or all the way down to the toes. Either one side, both sides, and like I said, like the upper limit can be quite distressing. So, in that situation, again, we need medical attention. You have to go to a spine surgeon, you know, a neurosurgeon like me and you look at what's going on and we do an, we examine it clinically. It's very, very important to listen to your story, examine it clinically, see what is matching, what's going on, and look at the right investigations. Is it an x-ray? Is it an MRI scan? Whatever needs to be done. And then we match what's on the MRI to what's going on with you and see whether that's causing the problem. Many times, what happens is, you know, many of us, because of heretic, we can have small slip discs in the back. It doesn't mean that every disc needs to be surgically operated. Please keep that in mind. So, you have to make sure that you go to an expert who understands this. So, many of these things, back pains, neck pains, can be managed without surgery. It will be just good ergonomic assessment, good pain management, physical therapy and ergonomic assessments or, you know, you can do it, you can do it along with, along with, you know, along with some injections, you know, to get rid of the pain. Okay, so I was showing you about the lower back pain. Lower back pain comes down the leg. So, this is the bottom of the lower back. You know, this is the rubber spine, as you can see here, all the way down. So, I mean, you'll notice that this is the, this is the front of the spine. This is the back portion. In Bhaktali, you see these, these things coming out here. These are the nerve roots. The nerves come out, the spinal cord goes down like this. And the nerves to the legs comes out on either side. In Madhitali, what you see between the knee to bones is this rubber portion here is called like a bush or a shock absorber. This is called this disc. This disc also is slip up. It's like a shock absorber. When it slips, what happens is, it goes and pinches this nerve. In nerve pincha, wherever this nerve goes, you get pain. That is what is called a sciatica or the radicaropathy, the pain going down the leg. So, MRI picks this up. CT scan does not pick it up. So, we have to pick this up on MRI scan. Once we see it, we'll see how big it is. Tumba, it's come out too much outside. It will not go back inside. Like a slip disc, you let the toothpaste coming out of a tube. You know, even Colgate can put it back after that. Once it's out, it's out. So, that's what happens. So, if it is very significantly out, you're not able to sit, stand, walk. There's already a weakness in the leg or toes or numbness or weakness, then surgery is a must. Don't worry about spine surgery at all. A lot of people will scare you. You don't get spine surgery done. You'll get paralyzed. This will happen. Don't have any fear at all. You have thousands of patients we have operated and they've done very well. Enough of them are back at sports, work. Don't worry at all about it. That's my personal promise. So, don't worry about that. But it doesn't mean that every, every slip disc needs surgery. Not at all. You have to get evaluated by the whole team of pain physicians. You know, headed by me, we have an intervention pain physician. We have pain therapists. We have ergonomics specialists. We have psychologists in that team. All of them together will evaluate and see what is happening. And then decide what is the right plan for you. So, coming back to this model, you see how this is happening. You can press on the side or you can press in the middle. If you press this in the middle, the leg pain may not be too much. But if you have difficulty in walking, you'll have numbness in the legs while walking, that can happen. Many times it's not the disc pedal. It has these joints. These joints can have wear and tear problems. There's a called facet joints. So, this you will not know. You just come to us with back pain. Each of it has to be tested. It's like circuit checking or each joint has to be tested. And based on that, making this physiotherapy does not help or local injection doesn't help, then it gives some special injections to the back either an epidural steroid, a transferometer steroid or even a radiofrequency application. These are all things that can be done in the routine with very, very good results. And then we do, we put you through a set of therapy exercises and you get better. So, remember what is most important thing is you come to the right expert who is able to assess you, who is able to get your full story out, do a good clinical examination, come to some kind of a diagnosis, get the right investigations done, connect your diagnosis and symptoms to the scans that have been said, the investigation that has been done, come up with a comprehensive plan, then decide what has to be the right way forward. You don't need to be dramatically treating or everything surgically. Remember this is very, very important, but even if surgery is required, don't have any fear. It can be done very well and patients are being back to sports, have to act to work, don't worry about it. But, having said that, we have lot of interventions that we can do, lot of people in the back pain, neck pain, headache have got, what is called trigger points. There are knots in the muscle, they can come all over the place, you'll see the picture they put up. You know the knots are everywhere and those knots you can press yourself and feel anywhere you can feel or somebody can help you to feel. These knots are there and if there's a technique to release those knots, that's what the physiotherapist and manual therapists do. When you do that, the pain goes away. And then you stretch again, it's a good, you know, stretching the myofascial release in therapy and that works very well. If that doesn't help, sometimes the trigger part ejections have to be given, but again it's given with the team of pain experts who are there in our team. I mean that also doesn't help or if it is deeper, coming from the joint, coming from the nerve root, then we can deposit, you know, either straight out there or the worst case scenario, the pain is very severe, is not going to get better, then we do something called radiative treatment separation. We burn the nerve around the joint so the perception of pain will come down. So what is the message I'm giving you? You know, the suffering with pain, it can happen to anybody, but you know, pain can happen to everybody, but suffering is optional. So you can come to us, please don't keep on suffering from the pain and you know compromising in quality of life, saying oh my life is like this, what do I do, I can't do it, I can't do this, I can't do that, please don't do that. With today's modern life, you're able to live longer, but quality of life is equally important and please make sure pain does not interfere with the quality of life. Please come to us at Manipal Hospital in Malaysia. We'll be more than happy to do a comprehensive assessment for all the pains that you and your family have and we promise you we'll give you a great result. Thank you for watching us on Facebook Live. I hope it was valuable for you to understand the problem of pain that can happen to us or our near and dear ones. So please feel free to share this video as widely as you want, anybody in your loved ones who are suffering with this pain, so that you know they can reach out to us and make a difference. If you have any questions, please type in the chat box below. The team will get back to you and try to set up with your online call or a physical call or whatever it is as soon as possible and you know reach out to us to help you to have a pain-free life. Jai Hind.