1. Increasing focus on diagnostics. There has been an increasing focus on utilizing injections for diagnostic purposes in helping establish the correct diagnoses for patients with spine pain before moving forward with treatment. "As more is becoming known about the different sources of spinal pain, there is a decrease in utilization of non-selective interventions for conditions where we don't know what we are treating," says Jared Greenberg, MD, an Interventional Spine specialist with Meriter Medical Group in Madison, Wis. "Now, we are able to provide a real diagnosis for the pain."
One way pain management physicians have traditionally located spine pain is through provocative discography, where the physician injects an irritating substance into the patient. However, instead of injecting an irritating substance, some pain management physicians are now injecting a numbing agent into the disc. The discogram can be performed in the lumbar, cervical and thoracic spine, says Eugene G. Lipov, MD, medical director of Advanced Pain Centers in Hoffman Estates, Ill., and is often done on an outpatient bases in ambulatory surgery centers.
2. Refinement in traditional interventions. While there hasn't been much change to the core of spine pain management interventions, the algorithms are constantly evolving. Furthermore, there may be a trend toward refining many of the procedures. More specialists are performing transforaminal epidurals, where the medicine is placed through the foramen on either or both sides of the spine, which provides a direct path for treating disc or nerve pain, says Dr. Greenberg.
Additionally, patients with facet joint pain who were traditionally treated with repeated facet joint steroid injections are now more commonly treated with radiofrequency neuroablation, which ablates medial branch nerves to block pain communication from the joints. This technique can offer longer standing relief of pain for nine months to one year.
3. Performing vertebral body augmentation. Some pain management physicians perform kyphoplasty and vertebroplasty for patients with vertebral body fractures and/or metastatic cancer to the vertebrae. "These procedures don't require open surgery and they are all done through needles, so the patients don't have an incision, which means they could cause fewer problems for patients," says Donald Roland, MD, a pain medicine physician at Kankakee (Ill.) Pain Center. Several different studies have been conducted to assess the effectiveness of spinal fusions, and while the differing outcomes of these studies are contentious, health systems and insurance companies continue to support and reimburse for these procedures when they are appropriate.
4. Spinal decompressions. Spinal decompression is another intervention some pain management physicians use with the appropriate patients. For patients with a herniated disc, surgeons and pain management physicians can perform a percutaneous decompression to reduce the herniation, resulting in pain relief, says Dr. Roland. Decompressions are cost effective because they are done in a surgery center or in the physician's office instead of a hospital, and patients are often recovered enough to return to work in three weeks.
"A lot of things we used to do in medicine were done out of habit and I think there is a better way — a more efficient and cost effective way of treating patients," he says. "However, it's sometimes difficult for the insurance companies to get on board and cover these procedures."
5. Biologic solutions. One trend that could be big in the future is biologic solutions for spine pain management. "The big thing is going to be stem cell therapies," says Jeffrey Wasserman, MD, a pain management physician with Pinnacle Pain Management in Dallas. "We'll be able to find out what the patient's condition is and then we can inject stem cells in the spine to treat the discs and help the nerves heal. Stem cell therapies are very exciting for spine pain."
There is research taking place where physicians are genetically manipulating the inside of the disc to promote cell growth. This technology is still in the development stage and several years away from coming to the market. Any potential biological solution for back pain would need to pass through the rigorous FDA clearance process before it would be an available solution for physicians.
"If you can put a needle into the disc and inject biological stuff to regenerate the nucleus, that would be fantastic," says Dr. Lipov. "However, the FDA has become extremely difficult to work with, and any new development is going to be delayed significantly."
6. Fewer disc procedures. Pain management physicians are performing fewer disc procedures, such as intradiscal electrothermy and percutaneous discectomies, in large part because the literature is mixed on the efficacy of these interventions. Insurance companies are also shying away from covering them, which make them even less attractive. "Healthcare reform certainly affects us because many of the procedures we do now won't be permitted or reimbursed in the future," says Dr. Wasserman. "There will be more responsibility placed on the patient to pay for the procedures than the insurance company."
In different geographic regions, pain management physicians are already seeing a decline in spine surgeons ordering discography. "Early research suggests that by introducing a needle into the disc, it may result in advanced degeneration of that disc," says Dr. Greenberg. "The debate continues as further research is conducted."
7. Declining reimbursements. Pain management physicians have experienced a decline in reimbursement rates, as have most physicians across the board. The declining reimbursements affect many aspects of spine care, including potential technology and future advancement in the field. "It doesn't matter how great of an idea you have if nobody is going to reimburse for it," says Dr. Lipov.
Many payors are also demanding better standards for patient selection and that physicians be fellowship trained in pain management before reimbursing for procedures, says Nileshkumar Patel, MD, a pain management physician with Advanced Pain Management in Greenfield, Wis. "For a successful practice, you want to choose people with fellowships and focus on patient experience and outcomes," he says.
8. Identifying indications for procedures. As with many medical specialists, pain management physicians are working on refining the indications for different interventional procedures. "We are coming to identify the appropriate indications for each procedure so we don't use them incorrectly. With more standardized guidelines, we would anticipate better clinical outcomes and improved data, which would be beneficial in supporting the efficacy and success of comprehensive non-surgical management of back pain," says Dr. Greenberg. "There is becoming a greater responsibility on the physician's part to employ these procedures correctly."
Pain management physicians are also now engaging in more research about the different interventions, a trend which Dr. Wasserman sees continuing in the future. "We are certainly moving more towards evidence-based medicine," he says. "Unfortunately, when it comes to these procedures, there aren't many evidence-based studies out there." It's hard for spine and pain management physicians to prove the efficacy of these procedures because the control group must undergo a "sham" procedure, which is difficult to coordinate and perform on patients who otherwise would be receiving surgery.
9. Comprehensive spine care centers. The first intervention a patient receives often depends upon which office they are referred to or visit first: a chiropractor, primary care physician, pain management specialist, physical therapist or spine surgeon. As focus increases on the cost and efficacy of spine care, specialists are coming together to form comprehensive spine care centers.
Physicians, such as anesthesiologists, pain management physicians, physical medicine and rehabilitation specialists and spine surgeons, are working in the same facilities to coordinate the patient's care. "You'd like to see more comprehensive spine centers in the future that integrate physicians of different specialties and training backgrounds who can all work together in a coordinated fashion," says Dr. Greenberg. "That will help standardize spine care, and provide optimal treatment pathways for the patient."
10. Hospital partnerships. Consolidation is a big part of today's healthcare environment, and pain management physicians are increasingly choosing hospital employment or partnering with hospitals in some fashion. Especially as more hospitals integrate and employ more primary care physicians, positive relationships with hospitals have become important. "You can either fight this reality or you can adapt to it by partnering with healthcare systems to achieve mutual gain," says Dr. Patel.
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10 Biggest Trends in Spine Pain ManagementWritten by Laura Miller | April 28, 2011
Leading pain management physicians discuss the latest trends in spine pain management.
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