Author: Steven M. Falowski
From the Pain Section
The treatment of chronic pain can be very challenging. Spine surgeons need to be able to treat patients throughout their disease process. A radiographic and technically successful surgery does not always translate into the patient results that one desires. Thirty to forty percent of spine surgery patients will develop post-laminectomy syndrome/failed back surgery syndrome (FBSS). As the treating spine surgeon, you should be able to offer therapies to your patients when pain persists following surgery or when pain is present without a surgical pathology. The ability to offer your patient options fosters the doctor-patient relationship.
The idea and allure of neuromodulation stems from its initial direction of a reversible alteration of the nervous system. It is the idea of neural “modulation” as supposed to “ablative” or resective procedures. Treatments are reversible and have the ability to be turned off in most situations. In addition, they are far less invasive than other surgical procedures, carry little risk, and have significant success rates. The neuromodulation community is based on a multidisciplinary approach that is diverse in its delivery. Clinicians involved in the procedures include neurosurgeons, orthopedic spine surgeons, anesthesiologists, pain specialists, and rehab physicians.
Spinal cord stimulation (SCS) delivers therapeutic doses of electrical current to the spinal cord for the management of neuropathic pain. The most common indications include FBSS and complex regional pain syndrome (CRPS). The literature supports that SCS can produce at least 50 percent pain relief in 50 to 60 percent of the implanted patients, and reduce the use of more medications. Interestingly, with the proper follow-up care, these results can be maintained. Very few other invasive modalities can claim this success rate.
Of most importance in the literature is that there is Class I evidence in multiple trials to demonstrate the efficacy of SCS. It has been compared against best medical management as well as surgery. This is important in the subset of patients in a complex spine practice; the literature has shown that up to 40 percent of spinal patients will carry the diagnosis of FBSS, and there is Class I evidence demonstrating the success of SCS over repeat spinal surgery in this population.
Integration into a Spine Practice
Most physicians will utilize a screening trial prior to permanent implantation of the system. There are not many modalities that allow for a trial to determine efficacy prior to the surgical procedure. Most authors would agree that a screening trial with 50 percent pain relief would warrant permanent implantation. There are several factors that are important in being aware of these therapies and having access to them for your patients.
Referral Network. You need to set up a proper referral network. Decide whether you want to perform the therapies yourself or are willing to work with someone else who performs these therapies. You can quickly develop a niche as the spine surgeon in your community who offers these therapies. Otherwise, you can build a referral network by working with an interventional pain physician, allowing you to share patients and, more importantly, have therapies available to your patients in chronic pain.
Relationships. Building relationships with doctors in your referral network is important. It allows your practice to grow and enhances your reputation as a surgeon. Relationships with pain physicians are crucial in spinal surgery. They are usually the first-line treatment for patients with pain with conventional management prior to surgery. They are also the treating physicians for those patients in chronic pain following spinal surgery.
Pain Physicians’ and Surgeons’ Roles. As a surgeon, your role determines the surgical procedure and the post-operative care. In the realm of interventional pain therapies, such as SCS, there are variable relationships. A common setup includes surgeons who identify patients as either surgical candidates or candidates for SCS. For patients who are not spinal surgery candidates, a pain physician may then perform a trial of the therapy and either move on to permanent implantation or refer the patient back to the surgeon for permanent implantation. Another setup may be a surgeon who performs their own trial and permanent implantation.
By developing a strong relationship with pain physicians, you can determine the roles that work mutually for both sides. A common referral to a spine surgeon in this setting leads to a “surgery versus SCS evaluation.” This fosters the most appropriate therapy for the patient. The relationship can span those patients who have undergone spinal surgery and subsequently have ongoing pain following a technically successful surgery, to those patients who have not undergone previous surgery. Candidates for SCS or spinal surgery in this setting are most reliably identified from their surgeon.
Patient Identification. As with any spinal procedure, patient selection is paramount to success. Determining proper candidates for pain therapies is crucial.
Early Intervention. Early intervention in chronic pain is of great importance. SCS should not be viewed as a “last resort” therapy but rather as part of the treatment paradigm. The literature supports the premise that earlier intervention with SCS leads to improved outcomes.
Benefits to Surgeons. Literature has shown that up to 40 percent of spinal patients carry the diagnosis of FBSS. This constitutes a large amount of patients that can benefit from these therapies, which have Class I evidence to support their use. If you take on the role of an implanting surgeon, you can substantially increase your case volume and reimbursement by offering these therapies, while also building a niche in your market and expanding your referral base. Your practice can grow on both ends with common referrals being evaluations for surgery versus a SCS. As an implanting surgeon, you may share responsibility with pain physicians in your community, who can maintain management of patients while you maintain management and responsibility of the SCS implants. Lastly, regardless of the role you choose, these pain therapies provide options for your patients, which is important as medicine’s changing landscape shifts to patient-centered care.
- Implantation of SCS does not mean that spine surgery cannot be performed in the future. It is a treatment modality for their present pain.
- SCS is a procedure that, in most cases, is considered minimally invasive, a same-day procedure with a very low-risk profile.
- SCS has Class I evidence of its superiority when placed against conventional medical management and against repeat spinal surgery.
- As a spine surgeon, you should have a relationship with an interventional pain physician performing these procedures to foster the options for your patients.
Integration of pain therapies into your practice is crucial in appropriate care for your patients. If you choose not to perform these therapies, you should know how patients can access them. Your patients will appreciate that you have offered them options and continued their care.
- Kumar K, Taylor RS, Jacques L, et al. Spinal cord stimulation versus conventional medical management for neuropathic pain: a multicentre randomised controlled trial in patients with failed back surgery syndrome. Pain. 2007;132:179-188.
- North RB, Kidd DH, Farrokhi F, Piantadosi SA. Spinal cord stimulation versus repeated lumbosacral spine surgery for chronic pain: a randomized, controlled trial. Neurosurgery. 2005;56:98-106.
- Kumar K, Hunter G, Demeria D. Spinal cord stimulation in treatment of chronic benign pain: challenges in treatment planning and present status, a 22-year experience. Neurosurgery. 2006;58:481-96; discussion 481-96.