Managing Chronic Low Back Pain Through Precision Diagnosis and Targeted Treatment
Case Study Series
Pain Medicine — Chronic Low Back Pain
From daily agony to active recovery
A Pain Spa case study showing how precision diagnosis, targeted spinal injections and rehabilitation helped a young woman regain quality of life after years of persistent low back pain.
2+ yrs
Pain duration
2
Targeted interventions
L4/5
Key disc level
✓
Significant improvement
Patient Snapshot
Woman in her mid-30s • Persistent low back pain • Discogenic and facetogenic pain • Rehabilitation-focused recovery
2+ years of painL4/5 disc changesFacet joint painExcellent benefit after epidural
The Presentation
A young woman’s life put on hold by persistent back pain
A woman in her mid-30s, who had previously worked in a physically demanding retail role, was referred to Pain Spa with persistent low back pain. She had previously enjoyed an active lifestyle but had become increasingly limited by pain, reduced mobility, poor sleep, and difficulty managing normal daily activities.
Her pain had been present for more than two years. What began as an intermittent ache had progressively worsened following a spontaneous flare-up, with no injury or fall to explain the deterioration.
By the time she sought specialist help, the pain was affecting almost every aspect of her life. She had been forced to stop working, struggled with walking on bad days, found household tasks difficult, and was unable to walk her dog regularly. Sleep was also badly affected by unrelenting discomfort.
Understanding her pain — four key clinical features
Constant low back pain
Persistent aching across the lower back, present daily and difficult to settle.
Mechanical aggravation
Standing, walking, prolonged sitting and light household tasks all increased symptoms.
Secondary leg symptoms
Intermittent pins and needles in the left leg were present, but back pain remained the dominant problem.
Functional decline
Work, sleep, walking, dog walking, and normal daily routines had all become severely restricted.
What The Imaging Showed
Understanding the anatomy behind her pain
The patient had previously seen a consultant spinal surgeon, who arranged an up-to-date MRI scan of the lumbar and thoracic spine. The imaging showed disc degeneration at L4/5 and L5/S1 with minor disc bulges, alongside mild facet joint degenerative changes from L3/4 to L5/S1.
There were also Modic type 1 and type 2 endplate changes at L4/5, suggesting an active disc-related inflammatory component. Importantly, there was no significant nerve compression and no clear surgical target.
Her spinal surgeon concluded that the pain was most likely driven by a combination of discogenic pain and facetogenic pain — pain arising from the lumbar discs and the small joints of the spine — and referred her to Dr Krishna at Pain Spa for specialist pain management.
Discogenic component
L4/5 and L5/S1 disc degeneration, with Modic endplate changes particularly at L4/5.
Facetogenic component
Mild facet joint degenerative changes from L3/4 to L5/S1.
No surgical target
No significant nerve compression was identified, making surgery inappropriate.
Pain formulation
A combined discogenic and facetogenic low back pain pattern was suspected.
Why precision diagnosis matters
Chronic low back pain is often multifactorial. Treating every patient with the same injection rarely works. The key is to identify which structures are most likely contributing to pain and then target treatment logically.
The Treatment Journey
A carefully structured, stepwise approach
Dr Krishna’s approach at Pain Spa centres on a thorough assessment followed by a logical, evidence-informed treatment plan — not a one-size-fits-all injection protocol. For this patient, this meant a phased strategy addressing both her facet joints and her discs, combined with a clear rehabilitation pathway.
Step 1 — Initial Consultation
Comprehensive assessment and formulation
Dr Krishna carried out a detailed consultation, taking a thorough history and reviewing the available imaging. A clear diagnosis was formed: combined discogenic and facetogenic low back pain, with rehabilitation as the long-term cornerstone of management.
Step 2 — First Intervention
Bilateral lumbar facet joint and sacroiliac joint injections
Under ultrasound guidance, Dr Krishna performed bilateral lumbar facet joint injections and sacroiliac joint injections as a day-case procedure. The patient experienced good initial pain relief in the first few days following treatment.
Step 3 — Follow-up and Reassessment
Recognising the discogenic component
At follow-up, the patient reported that while she had initially felt benefit, the pain had gradually returned. Dr Krishna recognised that her ongoing symptoms were likely being driven significantly by the L4/5 disc and proposed a lumbar epidural injection to target this component directly.
Step 4 — Second Intervention
Lumbar epidural injection at L4/5
A lumbar epidural injection was performed at the L4/5 level with local anaesthetic and steroid, without complication. The patient was advised to continue her rehabilitative approach while awaiting the treatment effect.
Step 5 — Subsequent Review
Significant improvement reported
At review, the patient reported excellent benefit from the lumbar epidural injection. The treatment had provided meaningful and sustained pain relief, allowing her to refocus on rehabilitation — the foundation of her long-term recovery.
The Pain Spa Approach
Four pillars of structured pain management
This case highlights the importance of matching the right intervention to the right pain generator, while keeping rehabilitation at the centre of long-term recovery.
1. Thorough assessment
A detailed clinical history and imaging review to understand the precise pain generators before any treatment decision is made.
2. Targeted intervention
Precision-guided injections directed at the specific anatomical sources of pain, performed safely under imaging guidance.
3. Honest expectation-setting
Transparent discussion of likely outcomes, limitations, and risks so patients can make genuinely informed decisions.
4. Rehabilitation pathway
Injection treatment creates a window of reduced pain, which is then used to build core stability and long-term functional strength.
Injection treatment is not the destination — it is the bridge. Our goal is to reduce pain sufficiently so that patients can commit fully to rehabilitation, which is what builds lasting recovery.
Dr Murli Krishna — Consultant in Pain Medicine, Pain Spa
Outcome
What changed for the patient
Following the lumbar epidural injection, the patient reported a significant and sustained improvement in her symptoms. For someone who had spent more than two years struggling with daily pain, the improvement was meaningful — not just physically, but in terms of her ability to engage with daily life and move towards a rehabilitation-focused future.
Key improvements reported
● Significant and sustained reduction in low back pain following lumbar epidural injection at L4/5.
● Improved tolerance of standing, walking, and daily activities.
● Able to re-engage with a rehabilitative approach, including core stability physiotherapy.
● Referral to specialist physiotherapy to consolidate long-term gains.
● Clear follow-up plan in place to monitor progress and adjust management if needed.
This case illustrates how a structured, stepwise approach — starting with careful assessment, moving through targeted interventional treatment, and transitioning into active rehabilitation — can meaningfully restore quality of life even in patients who have suffered for years.
Your Specialist
About Dr Murli Krishna
Dr Murli Krishna
Consultant in Pain Medicine — Pain Spa
MBBS • FRCA • FFPMRCA • Fellow of the Faculty of Pain Medicine
Dr Krishna is a highly experienced Consultant in Pain Medicine practising at Pain Spa’s clinics in Bristol, including Willow Surgery in Downend and the Chesterfield Nuffield Hospital in Clifton. He specialises in the diagnosis and interventional management of complex chronic pain conditions, with a particular interest in spinal pain.
His philosophy is rooted in a comprehensive, patient-centred approach: understanding the precise anatomical source of pain, applying appropriately targeted treatments, and supporting patients through a rehabilitation pathway for sustained benefit.
Dr Krishna consults both in person and via video, and sees patients on a self-pay basis. He regularly receives referrals from consultant spinal surgeons and other specialists across the UK.
Please note: This case study is published for educational and informational purposes. Patient-identifying details have been changed to protect confidentiality, while the clinical treatment described remains representative of real Pain Spa practice. Individual results from pain management treatments vary. Injection treatment does not guarantee symptom relief and carries risks, which are discussed in full during consultation. This information does not constitute medical advice. For queries write to clinic@painspa.co.uk.
Painspa
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