• Joint Section on Pain: Advocacy, Education, and Resources

    Author: Jason M. Schwalb, MD, FACS


    The AANS/CNS Section on Pain may be one of the smaller sections, but it has an important role in representing the interests of all neurosurgeons in this age of increased scrutiny of opioid use, prescribing, and misuse.

    Working with the Washington Committee, the Pain Section has taken an active role in interactions with other advocacy groups in making sure that the value of neurosurgical procedures is recognized throughout medicine. The American College of Occupational and Environmental Medicine (ACOEM) developed a Chronic Pain Guideline that lacked any content on neuromodulation. After receiving a letter from us, information on spinal cord stimulation and dorsal root ganglion stimulation clinical trials was added to the guideline.

    The Joint Section has also advocated for reasonable measures with the American Medical Association (AMA) and the Department of Health and Human Services (HHS). Senators McCain and Gillibrand proposed a bill to limit opiate prescribing to seven days. We wrote a letter in response that this was unreasonable for operations that were likely to generate longer duration pain and for patients on chronic opioids. More recent versions proposed by the House have excluded such patients.

    Pain Section Secretary-treasurer Jennifer Sweet has served as liaison to the AMA. We have signed onto a letter from the AMA to President Trump calling for increased treatment capacity for opioid use disorder treatment, mostly by increasing the number of Medicaid beds that are available, suspension of federal regulatory barriers to buprenorphine prescribing, and empowerment of the Attorney General to enforce the Mental Health Parity and Addiction Equity Act, which limits the insurance companies' ability to delay multimodal treatments due to excessive precertifications, fail first protocols, etc.

    Through the efforts of Joshua Rosenow and others involved in the Relative Value Scale Update Committee (RUC), reimbursement for CPT codes 64553 and 64555 (peripheral nerve stimulation) was tripled by the Center for Medicare and Medicaid Services.


    Our biennial meeting, which was held in May 2017, introduced a new theme with great success, garnering significant interest from neurosurgeons and nonneurosurgeons. Prior meetings had always taken place on the Friday prior to the AANS Annual Meeting, and focused on a major pain management topic such as back pain, trigeminal neuralgia, or neuropathic pain. The 2017 meeting, Neuro-ablation and Neuromodulation for Pain: Expanding the Neurosurgeon's Toolbox, covered varied ground with a practical cadaver lab component, and took place at the NCase Training Lab at Northwestern University in Chicago, Illinois. Kudos to past Chair, Andre Machado and Vice Chair, Bill Rosenberg, for organizing this successful event that will serve as a model for future meetings.

    Christopher Winfree, past chair of the section, has taken a major role in our educational efforts, starting with his work to integrate new training on opioid prescribing into the Boot Camp Curriculum. Dr. Winfree developed a recurring breakfast seminar aimed at educating neurosurgeons on the pharmacology of opioids and best practices. Additional webinars on opioid management have been developed for the CNS.


    The Pain Section has been maintaining a fund honoring the late John Oakley for a few years. The fund has migrated to NREF as part of the Honor Your Mentor program. Our first recipient of this fellowship, Zaman Mirzadeh, has completed his clinical fellowship with Ashwin Viswanathan at Baylor University in Houston, and Bill Rosenberg at the Center for the Relief of Pain in Kansas City. He has recently started on staff at the Barrow Neurologic Institute. He writes the following:

    "The Oakley fellowship was easily among the most influential periods of my neurosurgical training. This is despite the fact that it is only a short traveling fellowship (two to three months), compared to seven years of prior neurosurgical residency training. The focused nature of the training, under experts in the field highly committed to cultivating future generations of neurosurgeons passionate about treating pain, is what set the experience apart. Across the country, very few neurosurgical residency programs have one of these true experts in neurosurgical strategies for treating pain. For residents not at one of these programs, without one of these mentors, it is very difficult to obtain this specialty training and even more difficult to foster and refine an interest-and this is of course to the huge detriment of having future neurosurgeons advancing this field. For me, the Oakley fellowship provided not only exposure to neurosurgical operations that I had not seen or heard discussed in seven years of residency such as neuro-ablative strategies for cancer pain including cordotomy, myelotomy, and cingulotomy; ablative strategies for neuropathic face and head pain including nucleus caudalis DREZ; and peripheral and deep brain neuromodulation strategies for neuropathic pain syndromes. And of equal importance, it helped me to develop an understanding of clinical decision making and critical thinking about chronic pain, in addition to an opportunity to develop relationships with life-long mentors I now regularly consult with regarding my patients in independent practice, along with a sense of community within the pain field (akin to what is more widely available to those interested in vascular or tumor surgery) that is not otherwise pervasive for neurosurgery residents in training."


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