James D. Kang
Hai V. Le
Kenneth C. Nwosu
Back pain is one of the most common chief complaints in the emergency room and primary care clinic. It is composed of a wide range of symptoms with varying characteristics. Patients may present with or without associated neurologic signs or symptoms. Adding to this complexity is the multiple potential pain generators that exist in the spine, which include disks, facets, bones, muscles, ligaments, and nerves. For these reasons, back pain presents a great challenge to health care providers, one where it is difficult to correctly identify an underlying cause and develop an efficacious treatment.
Anatomically, the human spine is a structure of tremendous intricacy. Consider, for example, the primary roles of the spine—support and flexibility. On one hand, it must be strong enough to maintain an upright posture. On the other, its elastic properties should permit broad motion through flexion, extension, lateral bending, and rotation. The spinal column also has a protective function to surround and cushion the delicate structures of the spinal cord and nerve roots. It is capable of accomplishing these tasks through a conglomeration of bones, joints, ligaments, disks, and neural elements. Spinal anatomy is further complicated by the number of mobile segments, the proximity of the spinal cord and nerve roots, the intricate motions of multiple small joints, and the natural changes that occur with aging.
Knowledge of the intricate biochemistry of the intervertebral disk and the role of inflammatory mediators in back pain continues to expand. There is also a significant psychological component that impacts the behaviors of patients with back pain and their recovery from injury. Considering the complexity of the spine, it is understandable that definitively diagnosing the exact source(s) of symptoms is often difficult and sometimes impossible.1 This task is made even more difficult by the strong impact of personality in reporting and dealing with pain, particularly work-related low back pain.2
The spine is continually beset by physical stresses, and once an individual reaches adulthood, it is in a constant state of degeneration. The very complexity of the human spine creates the conditions that make it so difficult to resolve back pain. With so many complex and interacting structures, pain can arise from individual structures, multiple structures, or their dynamic interaction. As noted by Jerome Groopman3 in his best-selling text, How Doctors Think, “given all of these structures, the source of the chronic … back pain is often a mystery. Doctors can be hard-pressed to identify why a patient is uncomfortable.”
Despite its complexity, back pain is nearly universal in the general population with a lifetime prevalence of 65% to 80% in the United States and an annual economic impact that ranges from $84.1 to $624.8 billion.4 Using data from the 2002 National Health Interview Survey, Strine and Hootman5 reported that the 3-month prevalence of back and/or neck pain among adults in the United States was 31%. Understandably, these subjects generally had more comorbid conditions and greater psychological distress than did subjects without back or neck pain. Supportively, some studies have indicated that psychosocial factors have an even more influential contribution than mechanical factors toward back pain.6 In addition, Fanuele et al.7 using the Short Form Health Survey (SF-36) general health status questionnaire reported back pain patients were significantly impaired, even when compared to a variety of other health conditions. In order to effectively treat such patients, one must understand the severity of the problems and appreciate that back pain may often be accompanied by a variety of comorbidities.
The patient with chronic back pain is often passed from practitioner to practitioner, at times of widely varying expertise, training, and experience, and each subjecting the patient to his or her own preferred techniques for palliation. As the patient drifts further into disability, pain, and medication use, desperation and the cost of single-modality treatments increase in parallel, whereas the probabilities of overcoming the pain and of improving function diminish. It is, according to Groopman,3 “as though each approach to diagnosis and treatment is essentially a ‘franchise’ and that too many franchises are battling for control.” Such a state of affairs leads to treatments that are increasingly expensive, unfocused, unsubstantiated, and ineffective.
Thus is the complexity of chronic back pain and the costly, untenable nature of many treatments. All point to the need for a different approach to manage back pain where improvement in value depends on improved performances and accountability among individuals who have a shared goal that unites the interests and activities of all stakeholders. The desired approach is no different now from that developed for general chronic pain by Dr. Bonica, and aptly described by Loeser et al. in the third edition of Bonica’s Management of Pain.8 They state that Dr. Bonica
… brought clinical psychologists, pharmacists and other non-physician providers to the conference table with anesthesiologists, neurologists, physiatrists, neurosurgeons, orthopedic surgeons, psychiatrists and others. This blend of perspectives kept each specialist from exercising specialty-specific tunnel vision, and in conferences a group understanding often emerged that greatly exceeded the understanding that the record would yield after a series of serial consultations.
This is an apt description of the multidisciplinary approach to care. Of course, a multidisciplinary approach alone does not guarantee either efficiency or effectiveness. In order to provide maximally effective and efficient treatment, and to limit treatment costs, a spine treatment facility must include practitioners with the highest levels of training and experience, who follow treatment guidelines that are scientifically validated yet flexible enough to address the idiosyncrasies of individual patient problems. The care needs to be carefully coordinated to avoid duplication, unnecessary expense, and use of treatments with limited possibility of success. A number of specific principles should guide the multidisciplinary spine facility:
Specific algorithms for evaluation and treatment
Ongoing multidisciplinary case management and case discussion
Active process of continuous quality improvement including outcome measurement, assessment of patient satisfaction, and use of results to improve treatment algorithms
Professional education of treatment team members
Participation in active research programs
In this chapter, we discuss the key elements needed to establish and maintain an effective multidisciplinary spine facility.
The three major components that comprise the clinical aspects of a multidisciplinary spine center are (1) a group of dedicated, highly trained physicians and allied health providers with expertise in spine care, (2) a set of treatment algorithms guiding assessment and intervention, and (3) active and aggressive case management, especially when patients fall outside of established treatment algorithms. One of the keys of a successful center is building a multidisciplinary team that understands and respects the roles and skills of individual team members. In caring for patients with acute or chronic back pain, we emphasize the importance of interprofessional communication and teamwork among all care providers (Fig. 107.1).
CONSERVATIVE CARE GATEKEEPERS
Of the many individuals who experience back pain, only about 10% ever undergo spine surgery.9 It is therefore logical that the initial evaluation of patients presenting to a comprehensive spine center should be conducted by a “conservative care” physician—one who is specially trained in the assessment and treatment of spinal disorders. These physicians should be competent in triaging patients and placing them into appropriate assessment and treatment algorithms. Complicated cases and those requiring urgent or emergent intervention can be promptly identified and referred for appropriate diagnostic workup and intervention. However, the majority of cases will be best handled using standard treatment algorithms in which resolution of the back pain is expected with minimal intervention. Such physicians may include primary care doctors or specialists in anesthesiology, physical medicine and rehabilitation (PM&R), or occupational medicine. All of these providers must be able to recognize the “red flags” of back pain, which warrant further lab or imaging studies and timely intervention.
The most ubiquitous and bothersome indication of spine injury is back pain. Unremitting pain, often fluctuating randomly, can decimate both emotional stability and physical capability. Physicians now have a diverse armamentarium of oral, topical, and injectable medications that may provide immediate, and at times prolonged, relief. The mainstay nonprescription medications for the treatment of back pain are acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs). Prescription oral medications include muscle relaxants, opioids, corticosteroids, and certain antidepressants and antiseizure medications. The opioid analgesics, even in recently developed time-release preparations, carry with them both the potential for physical dependence and addiction in up to 40% of chronic pain patients10 which have been reported to cost upward of $53 billion to treat.11 Therefore, it is imperative that only one provider in a multidisciplinary team is prescribing and managing the medications. A pain treatment agreement should be implemented early on. Targeted injections are of some value in specific conditions (see Chapters 99 and 100 for a detailed discussion), but their use requires sophisticated equipment and advanced training in order to be used safely and effectively. Physicians with subspecialty training in pain medicine, often specially trained anesthesiologists or PM&R specialists, can effectively use injection therapy, but these treatments must be used in coordination with the other evaluation and treatment efforts, including physical therapy (PT).