Eleven spine specialists discuss advances in pain management and how it can improve outcomes in spine surgery.
Ask Spine Surgeons is a weekly series of questions posed to spine surgeons around the country about clinical, business and policy issues affecting spine care. We invite all spine surgeon and specialist responses.
Next week's question: What is your opinion on pain management physicians performing endoscopic spine surgeries?
Please send responses to Alan Condon at acondon@beckershealthcare.com by Wednesday, Jan. 22, 5 p.m. CST.
Note: The following responses were edited for length and clarity.
Question: What innovations would you like to see in pain management to improve spine surgery outcomes?
Medhat Mikhael, MD. MemorialCare Orange Coast Medical Center (Fountain Valley, Calif.): First, I would like to see pain management physicians complete a full workup of the patient and utilize nonoperative and minimally invasive surgery to achieve an accurate diagnosis. As a result, spine and neurosurgeons can perform MIS procedures that maintains the spine's mechanics and improve outcomes, instead of pain specialists being involved in patient care after multiple surgeries are performed with major changes to the spine and the development of new and different sources of pain.
Second, I would like to see pain management involved earlier in patient care once the decision for surgery is made to help optimize the patient's condition, decrease their medications to improve postoperative response to therapy and prevent the development of chronic pain.
Finally, preoperative interventions by pain specialists can help reduce the inflammatory process and possible adhesions that will facilitate spine surgery and improve patient outcomes. Also, early and aggressive postoperative pain control will help patients and expedite recovery and rehabilitation.
Paul Kramer, MD. Indiana Spine Group (Carmel): The innovation I believe has the most promise is the DRG stimulator technology, which has been very beneficial in early experience with known single- or two-level radiculopathy not amenable to decompression and/or stability. The most bang for our buck is closing the feedback loop between surgeons and non-surgeons. The hallmark of a good system is identical treatment no matter how you enter the system. We owe it to our patients to have a robust understanding of the breadth of spine care, whether surgeon or non-surgeon, and to understand what the other side knows.
I believe this burden falls more on the pain side, where understanding of surgically amenable disease — including such concepts as spinopelvic imbalance and flat back — is not taught in most pain fellowships. As primarily a revision surgeon, I see a lot of suboptimal care from both sides, and think the best way to make all of us better is not a magic implant that is just around the corner, but an understanding of what surgery or a stimulator can and can't do as well as better education and closer collaboration between specialists.
Tony Bozzio, MD. Bay Street Orthopaedics and Spine (Petoskey, Mich.): There have been some great advances in perioperative pain management in recent years. Multimodal pain control has been great for patients and will continue to evolve as the best protocols are developed. Narcotic sparing anesthesia has also helped patients by reducing postoperative nausea and vomiting and I have seen a reduction in postoperative bloating and ileus after anterior lumbar surgeries.
I've also seen a major reduction in opioid usage after overnight hospital stays. I think continuing to work on standardized multimodal protocols, local 'cocktails' of anesthetics and pain meds similar to what is done in total joints, and evolving the narcotic sparing anesthesia and the various drips given to patients intraoperatively will result in shorter hospital stays, better patient reported outcomes and help facilitate the transition to outpatient spinal surgeries.
Christian Zimmerman, MD. Saint Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): Injection therapies and their increased usage have enhanced pain and functional outcomes for some patients, while the actual risk of epidural fibrosis and potential surgical complexities have become more prevalent and cognizant among spinal surgeons. Preoperative counseling and surgical awareness apply. The biologics modalities are currently employed with recognizable results and opinions. This may be limited in scope for neurosurgeons, unless they apply to fusion enhancement technology and healing the infirmed. The most applied management necessity remains in the perioperative pain and recovery management. Maintaining accessibility and portability are key to successes in many chronic opioid dependent patients.
Vladimir Sinkov, MD. Sinkov Spine Center (Las Vegas): I would like to see any strategy that results in less opioid use for chronic pain. There are some situations when it is effective to use low dose opioids for chronic back pain that is not amenable to interventional or surgical procedures.
I see multiple cases, however, with escalating doses of opioids for mechanical pain due to structural spine abnormalities that could be managed with interventional procedures and cured with spine surgery. When such patients fail nonoperative options and need surgery, it becomes very difficult to manage their postoperative pain and wean them off narcotics since they have developed significant opioid tolerance.
In such cases, innovations such as more effective non-opioid medications for pain, more emphasis on physical therapy, exercise, weight loss, activity modifications, smoking cessation as well as more reliable and longer-lasting interventional procedures would be very beneficial to patients' overall outcomes and safety with lower risks of opioid addiction and the problems associated with it.
James Chappuis, MD. Spine Center Atlanta: I'd like to see us use alternatives to opioids for pain management. Such alternatives are medications like Exparel, which we use extensively in our outpatient spine program.
Brian Adams, MD. Spine Center Atlanta: One cannot downplay the role of diagnostic injections to aid with surgical planning. I would like to see more interventional physicians working hand-in-hand with surgeons to improve outcomes. This is especially important in revision and failed surgery cases. I think that continuing to advance the practice of regenerative medicine can also improve surgical outcomes.
Ram Mudiyam, MD. Hoag Orthopedic Institute (Irvine, Calif.): Eliminating opioid use in perioperative pain management is the ultimate but perhaps utopian goal. Most patients undergoing reconstructive spinal surgery, especially in a revision setting, are already opioid tolerant. It is unrealistic, therefore, to totally avoid opioids in the postoperative period.
Proper titration of opioids to make them patient specific would be a more realistic and achievable goal. Early transition to non-opioid drugs using multimodal analgesic treatment protocols are gaining acceptance. Sound preoperative patient education and provision of realistic expectations postoperatively will better prepare patients to avoid prolonged and unnecessary opioid use.
Fred Naraghi, MD. Comprehensive Spine Center (Klamath Falls, Ore.): The use of multimodal approaches such as pre- and postoperative gabapentin, celecoxib and intraoperative Ketamine have helped but there is still room for improvement. An ideal pain medication would be non-opioid, non-habit forming with minimal side effects and equivalent potency for pain relief. Pain management is a complex issue that needs to be addressed at multiple levels with patient expectation, alternative modalities, cognitive and mindfulness as well as legislative changes to allow appropriate treatments.
Brian Gantwerker, MD. Craniospinal Center of Los Angeles: I would like to see the improvement of judicious use of pain medication, more widespread use of safe nonsteroidal anti-inflammatory drugs and medications that act at the neural level — such as gabapentin — be available in more affordable controlled release formulations. I would also like to see more payers approve the use of COX-2 inhibitors. From a technological standpoint, spinal cord stimulation remains a useful adjunct. I would love to see more case-control trials supporting their short- and long-term efficacy. The better the data, the more payers and Medicare will remunerate these adjuncts at an appropriate level.
Issada Thongtrangan, MD. Microspine (Phoenix): I would like to see long acting medications in the form of injections that help control postoperative pain in the outpatient setting. In addition, I would like to see innovations in intravenous or oral non-opioid medications that can control postoperative pain without interfering with the spinal fusion.