AANS Neurosurgeon | Volume 29, Number 1, 2020


How to Painlessly Integrate Pain Therapies Into Your Practice

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The treatment of chronic pain can be very challenging but also provides opportunities of continuity of care, enhanced outcomes and expansion of repertoire. As a neurosurgeon, it is important to be able to treat your patients throughout their disease process and follow along the continuum of their care. Everyone knows that radiographic and technically successful surgery does not always translate into pain control or optimal quality of life. Potentially 30-40 percent of spine surgery patients will develop post-laminectomy/failed back surgery syndrome (FBSS). This, along with complex regional pain syndrome (CRPS) is the most common disease indications for spinal cord stimulation (SCS). 

Treating Pain With SCS and Other Therapies
SCS has been proven to produce significant pain relief in implanted patients. Level I evidence in multiple trials to demonstrate the efficacy of SCS when compared against the best medical management and surgery is of the utmost importance in the literature. New innovations have led to additional Level I evidence that improved product design and programming waveforms led to dramatic improvements in pain relief and patient outcomes. Very few other invasive modalities can claim the same success. In addition to SCS, there are other therapies, including intrathecal drug delivery (IDD), peripheral nerve stimulation (PNS), peripheral nerve field stimulation (PNfS), kyphoplasty/vertebroplasty and neuroablative procedures which can be implemented into a multidisciplinary approach.

How to Choose a Therapy for Each Patient
As the treating spine surgeon, it is important to be able to offer therapies to your patients when pain persists following surgery or perhaps when pain is present without a surgical pathology. The ability to offer your patient options fosters the doctor-patient relationship and serves as an important treatment modality in this clearly defined subset of patients within a complex spine practice.

For advanced pain care therapies, a trial of the therapy is performed prior to implant. There are several factors that are important in being aware of these therapies and having access to them for your patients. A proper referral network is an important component to offer your services in the management of pain patients, being mindful of where in the algorithm you would like your practice to be situated. This is determined by deciding whether you want to perform the therapies yourself or be willing to work with someone else who performs them.

You can quickly develop a niche by being the spine surgeon in your community who offers these neuromodulation therapies or who can help navigate a pathway to obtain them. As a neurosurgeon, your role determines the longitudinal implementation of the therapy from pre- to postoperative and beyond. In the realm of interventional pain therapies, three models prevail:

  • The pain physician performs the trial and then the neurosurgeon installs the permanent implant; this is the most common.
  • The neurosurgeon performs both the trial and the permanent implant.
  • The pain physician does the trial and implant. Though this creates additional procedures for the neurosurgeon, it can build an invaluable referral network, allowing you to share patients as well as expanding therapies available to your patients in chronic pain. 

Not All Patients Need Surgical Intervention

A typical neurosurgical practice will have many referrals for spinal surgery evaluation. In the majority of cases, the patient will not be a surgical candidate. Serendipitously, these patients may also be the same patients who would benefit from interventional pain therapies or neuromodulation. Adding pain interventions leads to diversifying your offerings, developing a niche among spine surgeons and creating a patient-centric referral network, while also delivering more cases to your practice. By developing a strong relationship with pain physicians, you can determine the roles that are mutually beneficial. A typical referral to a spine surgeon working in this capacity would be for a “surgery versus SCS” evaluation. This ensures the most appropriate therapy for the patient. The relationship can span post-surgical patients with residual pain as well as those who are not candidates for spine intervention. Depending on the practice model, this common referral will likely lead to some surgical intervention.

Determining proper candidates for pain interventions, as with any surgical procedure, is paramount to success. Early intervention in chronic pain is of crucial importance leading to improved outcomes. Therefore, SCS should not be viewed as a “last resort” therapy but rather as part of the treatment paradigm in which it fits along multiple points in the patient’s path, including prior to spinal surgery. The SCS is meant to treat the patient’s pain at the point that may or may not be related to correctable spinal surgical pathology. As the surgeon, you can help drive these therapies earlier, given exposure to the patient in the first six months following a spinal procedure. A pain physician you have built a relationship with may be able to drive the therapy implementation earlier for a non-spinal surgical candidate. Lastly, it is important to realize that these therapies are treatments for their current conditions, as spinal surgery may be warranted in the future, even after a neuromodulatory intervention. One does not preclude the other.

Physician Relationships Help Expand Practice
Clearly, building relationships with doctors in your referral network allows your practice to grow and builds your reputation as a neurosurgeon. Relationships with pain physicians are crucial in spinal surgery, as they are often involved in patient care before considering surgery. They are also the treating physicians for those patients in chronic pain following spinal surgery. Your referral network will also include primary care and neurology who are likely to be involved along with the neurosurgeon in the treatment of these patients throughout their disease process and recovery.

There are inherent benefits to implementing these therapies into your practice. Given that 30-40 percent of spinal patients will carry the diagnosis of FBSS, this constitutes a large amount of patients within a practice that can benefit from pain surgery. As an implanting surgeon, offering these therapies substantially increases case volume and reimbursement, but it will also help you build a niche in your market with a positive impact on referrals. Often, pain physicians in your community will maintain management of the patient along with stimulator adjustments. This symbiotic relationship is a win for the patient, pain doctors and the neurosurgeon. Offering these therapies allows you to have options for your patients in this drastically changing era of medicine where we have an opioid crisis and spinal surgery is under scrutiny.



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