Steven M. Falowski and Jason E. Pope (editors) - Integrating Pain Treatment into Your Spine Practice

Neurosurgery, Comprehensive Spine Center, Brown University Warren Alpert Medical School, Rhode Island Hospital, Providence, RI 02903, USA

Alexios G. Carayannopoulos

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Spine cases are some of the most common surgeries performed by neurosurgeons and orthopedic surgeons in the USA. Based on the literature, 40 % of patients will suffer from chronic pain following a spinal surgery. It is well established that chronic pain is undertreated and that earlier pain management intervention may lead to better clinical outcomes. Paradoxically, many spine surgeons are unaware of the extent of pain therapies available outside of surgery, nor how to engage patients in a multimodal, multidisciplinary, comprehensive, combined surgical and nonsurgical treatment paradigm. As one of this books goals is to educate spine surgeons on comprehensive care, the first chapter of this book focuses on identification of the pain patient, which is the first essential step in successfully engaging the spine patient into this treatment paradigm. Identification of the pain patient requires recognition of a patient suffering from spine-related pain early on. Because spine pain is often accompanied by loss of function and quality of life, earlier recognition and intervention will not only lead to a better clinical outcome but may also prevent disability.

Identification of the pain patient can be done through a multitude of approaches, some of which have been validated through clinical studies, others of which are more anecdotal and have been passed down through generations of spine care, based upon collective years of experience. From the providers perspective, the goal is to identify patients with spine pain, make an appropriate diagnosis, and then triage the patient into the most appropriate treatment. From the patients perspective, the goal is to provide the patient with an opportunity to share in the decision-making process with his/her provider in order to achieve the best outcome based upon individualized functional goals. Generally, commonalities of both perspectives include decreased pain, increased function, and enhanced level of satisfaction. Ultimately, working towards these goals together will lead to the best clinical outcome.

The first step in identifying the pain patient begins with clinical triage. Generally, triage is best facilitated by direct communication between two providers. Ideally, clinical triage should route patients to the appropriate surgical or nonsurgical provider and begins with initial assessment of symptoms, general review of treatment objectives, and early identification of red flags to best direct care. In the spine world, red flags include signs or symptoms of progressive motor or sensory neurological deficit, bowel/bladder dysfunction, or extreme pain, which is recalcitrant to conservative measures. Thankfully, the majority of spine cases are nonsurgical and can be successfully managed by medical or interventional options. Only patients who are candidates for and who are interested in pursuing surgery should be triaged to a surgical provider.

For continued identification of the pain patient, an appropriate in-person evaluation must then ensue. All initial evaluations begin with a thorough history, which includes a review of subjective and objective levels of pain and function, review of diagnostic studies, previous interventions, and previous responses to treatment. This is followed by a focused physical examination. Only after careful correlation of subjective and objective findings should attempts be made at an overall assessment, which includes a clinical diagnosis as well as a functional status. Finally a treatment plan, including education, and need for medical, interventional, or surgical options, is created based upon a patients individualized treatment objectives.

Although patients goals are often unique, most goals imply a reduction of pain to facilitate an increase in function. Continued clinical reassessment, which is coordinated across the medical, interventional, and surgical domains by a robust triage system, allows ongoing communication between patients and providers to ensure that patients are maintaining satisfactory gains in meeting their goals.

Because the treatment of spine-related pain is challenging, in part due to the subjectivity of pain, early use of standardized outcome assessment tools is essential in identifying the pain patient. Assessment tools should include both subjective measurements of pain and psychological distress, as well as objective measurements of function. Baseline testing establishes a reference point, from which patients pain and function levels are monitored longitudinally. Graphical displays outlining trends can be used to educate, encourage, and reassure patients. Additionally, these data points are helpful to validate progress for insurance companies, as they highlight progression through the treatment paradigm.

There are a number of outcome tools that reflect different domains important in spine care, which can be used to identify the pain patient. These measures assess pain, physical/psychosocial function, and quality of life (see Table ]. The choice of outcome measure can be daunting. Of the different domains generally assessed, it is felt that pain, function, and quality of life are the most important for identification of the pain patient in both the clinical and research setting. If cost utilization is important, preference-based measures should be used over objective measures.