Working Together: Pain Management

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It is nearly impossible to practice neurosurgery in the modern era without collaboration with our pain management colleagues. Improving this partnership has been a goal for our health care network in Pittsburgh. Here we will discuss some of the ways we have made this relationship more symbiotic as we work to distinguish ourselves both regionally and nationally in chronic pain management. This relationship is always a work in progress and we offer some suggestions and examples devoid of braggadocio.

Communication, Patient Sharing, Scrubbing Together

The opioid pandemic has taken a back seat in the news to another pandemic; however, those of us who treat chronic pain patients realize that the new virus and resultant restrictions have only worsened the United States opioid crisis. Access to medications and interventions for chronic pain, such as neuromodulation, have been severely limited in the past year as chronic pain management has been labelled elective and reasonable to postpone. The neurosurgeons, including myself, have worked closely with pain medicine colleagues to accelerate pain specialist involvement for patients taking high dose opioids.  Specifically, we have tuned our electronic medical record to identify patients taking a morphine equivalent daily dose (MEDD) above a certain threshold so that a referral to a pain management specialist in our network is immediately triggered. Moreover, those of us performing spinal surgery and prescribing opioids in neurosurgery have worked toward crafting more codified agreements with patients about how long postoperative opioids will be prescribed and what will happen if patients continue requesting opioids.

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The Pennsylvania prescription drug monitoring program (PDMP) has helped staff on both sides to verify who has written opioid scripts and for what amount. Gone, we hope, are the days of neurosurgeons and physician assistants writing for postoperative opioids without spending anytime investigating what other providers might be prescribing. We have also tried to increase our time performing procedures together for a number of reasons. First, with newer procedures, such as dorsal root ganglion stimulation for chronic pain, we believe that this collaborative approach can more quickly decrease the slope of the learning curve, improve patient selection and reduce complications. For example, we recently scrubbed together to successfully perform high cervical spinal cord stimulation on an elderly 79 year-old woman with intractable post-stroke thalamic hemi-body pain. Her age and multiple comorbidities, including atrial fibrillation on Eliquis, made her a case that each one of us would have probably avoided if there was not the ability to coordinate schedules and combine forces. We think there is no better way for tertiary centers to manage some of these real-world patients without spreading the risks between neurosurgeons and pain management specialists. Although there are different models across the country, we feel strongly that having a separate “trialing” and “implanting” clinician for modalities, such as spinal cord stimulation can help to reduce bias and improve peri-operative medication management. In addition, frequently discussing shared patients can add medico-legal protection to both parties and help to not only establish better patient expectations, but also provide a clearer roadmap of treatment options. Chronic pain is replete with litigation and it is our opinion that neurosurgeons and pain specialists who bounce patients around rather than spending the time to call each other and discuss patients are at higher risk.

Education

As director of the neurosurgical stereotactic and functional fellowship, I have had the opportunity to also spend time in the clinic and OR with pain medicine fellows. This experience has been valuable to both parties as we work towards building more evidence-based and best care pathways for diagnoses such as low back pain. The pain fellows have certainly benefitted from surgical technique education as their field has become more and more interventional and they are always appreciative of the way that neurosurgeons can help them advance their interpretation of spinal radiographic studies such as MRI and myelography. At the same time, our neurosurgical residents and fellows have gained more opportunity to scrub with experienced interventional pain specialists. Their techniques with intraoperative fluoroscopy and percutaneous spinal interventions have improved as a result. Every year, our neurosurgery department hosts a Pittsburgh Spine Summit, where we invite pain specialists, as well as surgeons, from around the country to amicably debate the pros and cons of spinal surgical technologies as well as the role of neuromodulation and non-surgical treatments, such as medical marijuana. My colleagues in pain management have also welcomed the neurosurgeons to participate in the educational and teaching opportunities in their societies, such as the Pennsylvania Pain Society.

Research

Finally, it is increasingly important for neurosurgeons to align with pain medicine specialists to advance both clinical and basic research goals. The reality is that many clinical studies in neuromodulation will only gravitate towards sites where there is a strong partnership between neurosurgeons and pain management. Approaching industry with a research idea in neuromodulation alone is, in our experience, much more prone to failure and there is little-to-no benefit working in silos when you are interested in chronic pain and new technology. Our recent successful execution of a study of surgical salvage for patients experiencing loss of efficacy with spinal cord stimulation was only possible by designing a hub-and-spoke model of referral to a single center; in this way we were able to leverage the research infrastructure of a neuroscience institute and feed rapid enrollment by sending tentacles to a wide array of pain specialists in the community.

One of our recent combined cases: MRI T2 Axial slice showing evidence of a left thalamic stroke which engendered a treatment-resistant post-stroke pain in a 79 year-old woman
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