The latest pain management trends in spine care


Six spine surgeons discuss key trends in spine pain management.

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.

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Question: What are some key trends in pain management for spine surgeons to notes?

Mark M. Mikhael, MD. Spine Surgeon at NorthShore University HealthSystem's Orthopaedic Institute and Illinois Bone & Joint Institute (Chicago & Glenview, Ill.): There is a nationwide push in orthopedics and pain management toward non-opioid medication pain management. Uniform education and practices are needed to minimize risks associated with opioids. One way is through an enhanced recovery after surgery program, which NorthShore is implementing. It was designed to optimize preoperative, intraoperative and postoperative patient care. Key interventions include setting expectations by providing extensive preoperative patient education; encouraging maintenance of nutrition and hydration preoperatively; standardized non-opiate analgesic and anesthetic regimens; and early reintroduction of both nutrition and mobilization for the patients postoperatively.

Patient "treatment agreements" are being used by pain management physicians, facilitating patients to enter into a mutual understanding that their treatment program will be under the direction of a particular pain management physician. This physician will control the prescribing of all types of medications related to pain management in the preop, periop and postop setting. These agreements help patients understand who to turn to for all pain-related needs while trying to minimize drug-seeking behaviors and overprescribing. In the event of tolerance or addiction, a detoxification and weaning program also can be initiated by the same pain management specialists.

Additionally, nonsurgical pain management specialists continue to utilize non-opioid treatments such as injections, ablations, nerve-modulation medications and holistic types of treatments. Many spine centers are collaborating and integrating these pain management practices to facilitate better safety and patient-centered care.

Scott Kutz, MD. Neurosurgeon at Texas Back Institute (Plano): Spinal cord stimulation employing newer stimulation parameters such as high frequency and burst is a current trend in pain management. Treatment of neck and low back pain with stimulation is more effective than ever before with these newer techniques.

Payam Farjoodi, MD. Orthopedic Spine Surgeon at Spine Health Center at MemorialCare Orange Coast Medical Center (Fountain Valley, Calif.): The main trend I see in my practice is a reduction by pain management physicians in prescribing opioids for chronic pain patients. Long term, I think this will be a huge benefit to this patient population and to society in general.

Medhat Mikhael, MD. Pain Management Specialist and Medical Director of the Non-operative Program at the Spine Health Center at MemorialCare Orange Coast Medical Center (Fountain Valley, Calif.): Pain management specialists have a tremendous amount of respect and appreciation for spine surgeons, and [I] feel that together we can benefit our patients and achieve high patient satisfaction and outstanding clinical outcomes. However, pain specialists believe that spine surgeries should only be performed when there is a clear clinical indication with the full acceptance and understanding that not every [instance of] back pain can be fixed by spine surgery.

Alden Milam, MD. Spine Surgeon at OrthoCarolina (Charlotte, N.C.): Multimodal analgesic techniques similar to joint replacement [are popular for pain management].

Brian R. Gantwerker, MD. Founder of the Craniospinal Center of Los Angeles: I think, as a neurosurgeon, functional systems such as dorsal column stimulation will be key. Keep an eye on the pacemaker industry as they are leading the charge with leadless technology. I am aware of at least one system in functional pain that exists. Look for larger players such as Nevro and Medtronic enter that space. Another trend you will see is big-box spine companies, like NuVasive and DePuy Synthes, will be jumping into that space as well. Don't be surprised to see either Nevro or another company be acquired by one of those two in the near future.

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