BALTIMORE, Md.—Rates of spinal surgery to treat low back pain have soared over the past two decades; today, approximately 3.5 million people report significant chronic postsurgical pain. Increasingly, these patients are referred for multidisciplinary pain management, necessitating clinicians recognize the diversity of chronic pain syndromes so they can optimize outcome by matching each patient to the best available treatment, symposium presenters told those attending The American Pain Society’s 29th Annual Scientific Meeting here.
One of the primary challenges, John Markman, MD, of Rochester, N.Y., said, is that chronic postsurgical neuropathic low back pain is poorly defined, despite the recently reported 15-fold increase in complex spinal fusion surgery. What is known, however, is that patients do not necessarily fare better with subsequent operations.
According to Jason Schwalb, MD, of Henry Ford Hospital in Detroit, Mich., postsurgical outcomes can be superb—if patients are selected properly. One of the most important steps to ensuring a good outcome, therefore, is to screen patients extensively prior to surgery, including for depression or history of abuse. Many patients experience pain such as headaches in addition to low back pain.
Why do patients have chronic pain following spinal surgery? Dr. Schwalb said reasons include that patients may be poor candidates from the beginning; the surgery may have failed to correct the initial pathology; surgical complications may have arisen; or the spinal disease is systemic. Following surgery, “listening to [patients describe] the course of events is the best way to determine which of these possibilities is the culprit.”
“Time is of the essence,” he added, citing epilepsy surgery as a model for spinal surgery. Patients with epilepsy have an average delay of 22 years between seizure onset and referral to a surgical center, by which time substantial neurophysiological harm has occurred. Spinal cord stimulation, a treatment for chronic pain following spine surgery, has been found to work best if initiated within 2 years of surgery, he noted.
Brett R. Stacey, MD, of Oregon Health Sciences University, outlined the many procedures for persistent pain, including repeat surgery, epidural steroid injections, nerve root injections, botulinum toxin, trigger point injections, facet/medial branch injection/denervation, sacro-iliac joint injections/denervation, endoscopic, minimally invasive disc procedures, spinal cord stimulation, and intrathecal medication delivery.
He said long-term data for spinal cord stimulation, which his institution uses in selected patients, is promising, with an ongoing study looking at the procedure in the context of physical examination and history.Dr. Stacey concluded that pain specialists, working within a rehabilitation model, in collaboration with surgical colleagues, are most likely to achieve good outcomes in patients who have pain that persists following spinal surgery.