The future of pain management in spine

Spine

Pain management and spine surgery work hand in hand and their use is evolving, some spine physicians say. 

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. Becker's invites all spine surgeon and specialist responses.

Next question: What capital purchases or investments will you make next year? 

Please send responses to Carly Behm at cbehm@beckershealthcare.com by 5 p.m. CST Wednesday, Feb. 14.

Editor's note: Responses were lightly edited for clarity and length.

Question: How will pain management evolve?

Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: In the next few years, patients will have fewer and fewer choices due to bad payer behavior. The latest trend is insurers not approving oxycodone except for terminal and cancer pain. More and more spinal cord stimulators will go in, and some will come out. Patients will not get their proper medications and will be socialized into thinking this is acceptable, or even the physician's fault. The opioid crisis, the lion's share of which was from the Sackler family and Purdue Pharma and of course from pill farms run by bad actor physicians, has crushed the sympathy facet of our culture and erases sympathy for people in pain. I am not sure ultimately what will happen, and if the right people will ever be held accountable as they hide behind U.S. bankruptcy laws, but I do know patients in pain will be a secondary or even tertiary consideration.

Nick Jain, MD. DISC Sports & Spine Center (Newport Beach, Calif.): Pain management will continue to evolve in diagnostic capability and expanding techniques to treat focused, specific pain generators. The rapid growth of new, minimally invasive technologies will allow pain management physicians to more definitively treat individual pain generators with long-lasting, durable procedures that are evidence-based. The convergence of surgery and pain management interventions together is rapidly approaching. 

Michael Oh, MD. UCI Health (Orange, Calif.): Pain medicine is navigating an era of unprecedented progress, and one of the key driving forces behind this evolution is the collaborative relationship between pain specialists and spine surgeons. If these two disciplines can work together, innovative approaches can be fostered to enhance patient outcomes and provide a more comprehensive approach to managing spine-related pain.

This future will involve:

1. Integrated care protocols that seamlessly blend the expertise of pain specialists and spine surgeons. Collaborative decision-making processes will lead to more holistic treatment plans, considering both surgical and nonsurgical interventions to address complex spine conditions comprehensively.

2. Minimally invasive techniques: The ongoing trend toward minimally invasive techniques in both pain medicine and spine surgery is set to continue. Collaborative efforts will refine and expand these procedures with appropriate guardrails, providing patients with less invasive options that offer quicker recovery times, reduced postoperative pain and improved overall outcomes.

3. Advancements in neuromodulation: The synergy between pain medicine and spine surgery is particularly evident in the field of neuromodulation. As both disciplines contribute to refining spinal cord stimulation and other neuromodulatory techniques, patients will benefit from more effective and tailored interventions. 

4. Research and innovation: Collaborative efforts between interventional pain medicine and spine surgery will drive research initiatives at the intersection of these two disciplines. These efforts will hopefully decrease the prevalence of failed back syndrome. 

Gurtej Singh, MD. The Centers for Advanced Orthopaedics (Bethesda, Md.): There are two exciting and promising technologies being developed within the field of pain management and neuromodulation.

First is the progression of artificial intelligence. The way pain patients present to our offices varies greatly, so better treatment algorithms will help patients share more useful data and allow providers to process that data into a more accurate diagnosis.

Second is the continued pursuit of minimally invasive and ultra-minimally invasive treatment options for various conditions. What once required a large incision or spinal fusion can now be accomplished with a 2- or 3-inch incision and decompression of the spine. Instead of long hospital stays, patients return to the comfort of their home a few hours after the procedure. Additionally, what once was treated with an opioid can now be fixed without further damaging the surrounding spine structures.

William Taylor, MD. University of California San Diego Health: We have continued to see our pain management group expand into procedures, traditionally considered the realm of the surgeons. However, we have not seen their interest in long-term management of spine patients and their continued reliance on procedure-based medicine.

Christian Zimmerman, MD. St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): The reflexive answer to this question depends on the political landscape in the next few years, and what emphasis is placed on administering and usage of medications. Statistically speaking, 5% to 8% of patients are chronic opioid users, but 1 in 5 American patients have filled a prescription for pain meds in the last 60 days. These facts are disturbing on all fronts, since austerity measures, metric oversight and penalties were physician-imposed a decade ago to curb use by this organization. Illicit substance/medication use, and social stigmata will also affect the public opinion, directional legislation and reaction. Postoperative pain management has become poly-pharmaceutical whereby singular prescription and timetable regimens used to be the norm.

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