AANS Neurosurgeon | Volume 28, Number 4, 2019


Neurosurgeons and Pain

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Relieving pain is a big part of our work as neurosurgeons. The desire to have their pain go away is what drives many patients to see us in the first place.

Pain is a very broad category, and specific types of pain can appear in many different ways. For example, a sudden, severe headache suggests a cerebrovascular cause like a ruptured aneurysm, a bleeding arteriovenous malformation (AVM) or spontaneous intraparenchymal hemorrhage. A more protracted duration of headache may indicate the presence of a subacute or chronic subdural hematoma. Subtler onset could be consistent with hydrocephalus or a neoplastic process. Some conditions, like trigeminal neuralgia, have their own characteristic symptomatology.

Historically, neurosurgical treatment of pain from spinal disease began as decompression of pinched nerve roots. Subsequently, our specialty learned to treat many types of axial spine pain. Relief of pain from peripheral nerve compression or other nerve diseases has long been part of our specialty.

Besides treating many different conditions that cause pain as part of their symptomatology, neurosurgeons have also tackled pain in more direct ways. Destructive procedures aimed at precise targets within the brain or spinal cord have brought much relief to many patients. More recent technology takes advantage of electromagnetic stimulation or augmentation.

As successful as direct surgical intervention may be for treating a broad range of painful illnesses, there are limits, hence the need to offer our patients pharmacologic therapies. Our surgical incisions are painful in the immediate post-treatment period, so obviously, effective postoperative analgesia is essential if patients are to be mobilized and recover as soon as possible after our interventions. Many types of trauma or intracranial hemorrhage may not require surgical intervention, but they can cause a great deal of pain that must be treated quickly and effectively if patients are to enjoy optimal outcomes.   

What Happened?
This all sounds very reasonable. So, how did we get to our society’s current crisis of opioid abuse and addiction? The statistics describing opioid misuse are alarming, and the personal stories of those affected are heartbreaking.

Like all complex social problems, there are many causes, and there is plenty of blame to go around. Many of us remember the heavy emphasis several decades ago on adequate treatment of pain, even having pain defined as “the fifth vital sign.” Some have blamed large pharmaceutical companies that are said to have used aggressive and misleading campaigns to boost sales of powerful and addictive opioids. Others have pointed the finger at our culture in general and at the choices and expectations of many of our patients. A common misconception is that painful health problems caused by lifetimes of sedentary lifestyles and poor personal health habits can be treated more easily with pills than by regular exercise and other health-promoting activities.

Patient satisfaction is becoming increasingly important not just on “rate your doctor” public websites but also as part of physician scorecards used by hospitals, employers and others who oversee physician performance. In some cases, patient satisfaction scores may be linked to physician compensation, creating further pressure for providers to keep patients happy – which may include refilling opioid prescriptions.

Meanwhile, state legislatures are jumping into the fray. Increased restrictions on opioid prescribing and use have already initiated cultural changes in the way physicians view narcotics and, in the bigger picture, in the way they view chronic pain. Many providers grumble about new regulations and burdensome procedures needed to prescribe opioids, even when the indications are obvious and appropriate. But such rules are part of an important first step to reassessing how our society deals with the millions of people who report that they suffer from chronic pain.

Neurosurgeons Taking Charge
The American Association of Neurological Surgeons (AANS) is actively responding to the need for greater education about this problem. Based on member feedback, the AANS is developing a webinar to address the use of opioids in neurosurgical patient care. It will cover postoperative pain management as well as the impact of new opioid legislation on neurosurgical practices.

In addition, the AANS/CNS Section on Pain’s Scientific Session from the 2017 AANS Annual Scientific Meeting is available for purchase, with 3.0 AMA PRA Category 1TM credits, to anyone who was unable to attend the meeting in person. All medical attendees who were at the 2017 meeting will have free access to the content from this session as part of the 2017 AANS Annual Scientific Meeting recordings. The AANS/CNS Washington Office has also been a leader in educating legislators, policy makers and regulators about pain management in surgical practice and about the potential effects of federal interventions on surgeons and their patients.

This is just the beginning. The opioid crisis and potential solutions will remain major issues in the public arena for years to come. As always, the AANS is proactively participating in the debate and is assisting our members and the patients they serve as they look for guidance on this rapidly evolving issue.


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