Authors: William S. Rosenberg
Andre Machado, MD
“What we need is more people who specialize in the impossible.” —Theodore Roethke
There is an accident. The patient is brought to the emergency room, injuries are documented, and a severe right-ankle fracture is diagnosed. Along with orthopedic stabilization and rehabilitation, the interdisciplinary pain service is consulted, as it is the standard of care for all significant pain. Genotyping reveals a strong predilection for the development of complex regional pain syndrome; a subclinical diagnosis confirmed by detailed pain phenotyping and functional MRI neuromatrix examination. An urgent microneurostimulation unit (with onboard pulse generator) is deployed percutaneously to the sciatic nerve, and spinal glial genomic modification is performed at the appropriate radicular entry zones. The patient also receives targeted, computer-assisted behavioral training during the healing process to minimize the likelihood of pain chronification. Within the next 50 years, the toolbox of pain care modalities is going to rapidly expand, while the lines of conventional professional responsibility blur into a well-orchestrated clinical choreography centered on the patient. The neurosurgeon can and must be central to this evolution.
The enabling step in advancing pain care will come through improvements in diagnosis and outcome prediction. Fifty years ago, it was thought that pain was caused by the electrical stimulation of specific axons associated with the experience of pain in the brain. Our understanding has progressed quite far from this overly simplistic notion, with the identification of peripheral mechanisms and central circuitry that modulate both the perception of pain as well as its emotional valence.
As more data accrues, a higher level of broad neural processing is becoming apparent, a neuromatrix in which multicentric fluctuations, patterns, and feedback loops account for not only pain and suffering, but perhaps the transition from acute to chronic pain as well. Improved pattern recognition—and hence diagnosis—in this field will lead to more accurate segmentation of patients into specific, homogeneous subgroups, which in turn will result in more personalized treatment on the individual level and higher quality data on the population level.
Augmenting our understanding of the neural meta-architecture of pain will be the ongoing progress in investigations on the opposite end of the spectrum at the subcellular, genomic level. Novel devices, drugs, and interventions will aim at controlling not only how much peripheral pain information is transmitted to the cerebral cortex, but also how cognitive and affective areas may interpret repetitive painful stimuli and avoid mechanisms that lead to chronification. Armed with the ability to more accurately diagnose patients and categorize them into reproducible clinical populations, the neurosurgeon of 2065 will be able to precisely identify the most effective treatment strategy. Patients at risk will receive interventions earlier in the disease process, and patients who do develop chronic pain will be treated with smarter technologies that address not only the signaling of pain but the entire pain experience.
Better segmentation of disease processes for outcome studies will facilitate the rapid technical development we are currently experiencing, ranging from battery technology to computer processor size and speed.
Ever greater miniaturization, improvements in the means of deploying implants, and a better understanding of electrophysiology will combine to allow more effective, less invasive, and earlier use of neurostimulation throughout the nervous system. Similar improvements in the technology of targeted drug delivery, using not only pharmacological compounds but also gene modifying agents, will both broaden the indications for this intervention and move it earlier in the clinical treatment paradigm.
“What has been will be again, what has been done will be done again; there is nothing new under the sun” (Ecclesiastes 1:9) is an aphorism that is certainly true in the area of neurosurgery specializing in surgical modification of the nervous system’s response to pain. Neuroablative procedures, which predate the introduction of opioid analgesia, are being transformed through the application of modern technical advances into clinical possibilities with minimal, if any, disruption and the potential for dramatic improvements in patient outcomes. Nowhere is this more evident than in the treatment of cancer-related pain, an endeavor that requires active participation on the part of the neurosurgeon to be effective. As these procedures become less invasive and incorporate more real-time patient feedback and advanced knowledge of neurophysiological monitoring, their efficacy will mandate close integration into any sophisticated approach to cancer-related pain. Moreover, implementation for non-malignant pain syndromes will become more widespread as the expected outcomes and complications of the modern form of neuroablative procedures are understood.
As we move into a more patient-centered, post-discipline era of medicine, pain care will be delivered by a well-coordinated group of specialists, each bringing wide-ranging expertise, into a merged strategy for treatment. This represents both enormous opportunity and significant risk; Hippocrates was prescient in stating that “timidity betrays want of powers and audacity want of skill.” With a solid foundation in neuroanatomy and neurophysiology, a well-honed skill in differential diagnosis, and comprehensive knowledge of the spectrum of possible interventions and their relative merits, the neurosurgeon will move toward a leadership position on the interdisciplinary pain team. Future patients are depending upon our ability to provide a perspective properly balanced between active intervention and the desire to “do no harm,” coupled with a crucial empathy for the plight of the one who is suffering.
This bright future notwithstanding, there is a cautionary tale to be heard, a dystopian alternative to consider. Neurosurgery, along with health care delivery in general, is at a crossroads, a juncture that is nowhere more apparent than in the field of pain neurosurgery. Currently, there is little support for the education and nurturing of neurosurgeons interested in pain care. Moreover, there are systemic challenges to reimbursement for technical innovations and lack of coordination of governmental regulatory bodies, with consequent difficulty in bringing novel treatments to the patient in refractory pain. With a deficit in properly trained leaders, a dearth of information on clinical outcomes, and an inability to offer state-of-the-art treatments, the promise of better and more effective treatment for patients in pain can quickly evaporate. To avoid this, organized neurosurgery and its constituents must follow the advice of Ralph Waldo Emerson to “... not go where the path may lead, go instead where there is no path and leave a trail.” In 2065, may we have blazed that trail, for the betterment of all those who suffer.
THE ENABLING STEP IN ADVANCING PAIN CARE WILL COME THROUGH IMPROVEMENTS IN DIAGNOSIS AND OUTCOME PREDICTION.< >NEUROABLATIVE PROCEDURES, WHICH PREDATE THE INTRODUCTION OF OPIOID ANALGESIA, ARE BEING TRANSFORMED THROUGH THE APPLICATION OF MODERN TECHNICAL ADVANCES INTO CLINICAL POSSIBILITIES WITH MINIMAL, IF ANY, DISRUPTION AND THE POTENTIAL FOR DRAMATIC IMPROVEMENTS IN PATIENT OUTCOMES.