What are the best practices for managing acute and chronic back pain in patients as a spine surgeon?

Best Practices for Managing Acute and Chronic Back Pain in Spine Surgery Practice

Multimodal perioperative analgesia is the cornerstone of effective pain management for spine surgery patients, with specific protocols including pregabalin/gabapentin, COX inhibitors, acetaminophen, and judicious opioid use to reduce the risk of persistent opioid dependence. 1

Understanding Back Pain Categories and Prevalence

Back pain is a widespread condition affecting up to 80% of adults 2, with chronic back pain (persisting ≥12 weeks) affecting approximately 13% of U.S. adults 3. As a spine surgeon, it's crucial to recognize that:

• Up to 55% of spine surgery patients have chronic pain preoperatively 1
• Persistent post-surgical pain affects 3-40% of patients depending on intervention type and previous pain history 1
• Single-level discectomy patients experience persistent pain rates of 3-34% short-term and 5-36% long-term 1
• Persistent low back pain occurs in 7.2% of patients after posterior decompression and instrumented fusion 1

Diagnostic Approach

Initial Assessment

• Perform thorough evaluation for red flags that require immediate intervention:

  • Progressive motor or sensory loss
  • New urinary retention or overflow incontinence
  • History of cancer
  • Recent invasive spinal procedure
  • Significant trauma relative to age 4

• Identify yellow flags (psychological, environmental, social factors) that indicate risk of disability 3

• Evaluate for radicular symptoms and neurological deficits 3

Imaging Guidelines

• Reserve initial imaging for suspicion of:

  • Cauda equina syndrome
  • Malignancy
  • Fracture
  • Infection 4

• MRI is the preferred imaging modality for patients with:

  • Persistent back pain
  • Signs/symptoms of radiculopathy or spinal stenosis
  • Progressive neurologic deficits 5

Management of Acute Back Pain (<4 weeks)

Non-pharmacological Approaches

1. Avoid bed rest - maintain activity levels and function 3, 6
2. Spinal manipulation - small to moderate short-term benefits when administered by properly trained providers 1
3. Activity modification - limit positions that stretch hamstring muscle group beyond comfortable range 5

Pharmacological Approaches

1. NSAIDs - first-line medication choice 3
2. Acetaminophen - for pain relief 1
3. Muscle relaxants - effective for short-term pain relief 5
4. Judicious opioids - lowest effective dosage, with caution at any dosage, reassessing benefits/risks when increasing to 50 MME/day, and avoiding doses above 90 MME/day without careful justification 1

Management of Chronic Back Pain (>12 weeks)

Non-pharmacological Approaches (First-Line)

1. Exercise therapy - especially programs with individual tailoring, supervision, stretching, and strengthening 1
2. Motor control exercises - to restore coordination, control, and strength of spine-supporting muscles 5
3. Cognitive-behavioral therapy - moderately effective for chronic pain 1
4. Yoga - strong evidence for short-term effectiveness and moderate evidence for long-term effectiveness 4
5. Intensive interdisciplinary rehabilitation - moderately effective 1
6. Acupuncture, massage therapy, spinal manipulation - moderately effective with varying levels of supporting evidence 1

Pharmacological Approaches (Second-Line)

1. NSAIDs - initial medication of choice 3
2. Duloxetine - beneficial for chronic pain 3
3. Pregabalin - effective for neuropathic pain, with statistically significant improvement in pain scores 7
4. Gabapentin - effective for nerve-related pain 5
5. Tramadol - fair evidence of effectiveness for pain relief 5

Interventional Procedures

1. Radiofrequency ablation - for medial branch pain when previous injections provided temporary relief 5
2. Epidural steroid injections - not recommended except for short-term symptom relief in patients with radicular pain 3
3. Intradiscal Electrothermal Therapy (IDET) - may be considered for young active patients with early single-level degenerative disc disease 5

Surgical Management Considerations

Indications for Surgery

• Persistent functional disabilities and pain from:
  • Progressive spinal stenosis
  • Worsening spondylolisthesis
  • Herniated disk 3

Surgical Approaches

• Lumbar discectomy - established procedure for spinal nerve compression when conservative management fails 5
• Lumbar fusion - recommended for refractory low-back pain due to 1-2 level degenerative disc disease without stenosis or spondylolisthesis 5
• Consider fusion only in specific circumstances:
  • Recurrent disc herniations with evidence of instability
  • Chronic axial low back pain with radiographic evidence of instability
  • Manual laborers with severe degenerative changes 5

Perioperative Pain Management Protocol

Preoperative Phase

1. Patient selection and risk assessment:

   • Identify patients with preoperative pain, mental health comorbidities, or substance abuse disorders who are at higher risk for postoperative pain issues 1
   • Consider detoxification from substance abuse before surgery 1

2. Preoperative education:

   • Provide realistic expectations about surgery and pain
   • Educate patients about opioids and their risks 1

Perioperative Phase

1. Multimodal analgesia:

   • Pregabalin/gabapentin
   • COX inhibitors
   • Acetaminophen
   • Judicious opioids 1

2. Consider adjunctive therapies:

   • Local anesthetics (liposomal bupivacaine)
   • IV lidocaine or ketamine 1

Postoperative Phase

1. Continued multimodal analgesia:

   • Taper medications appropriately
   • Avoid prolonged opioid use

2. Postoperative screening:

   • Evaluate pain status and medication needs at follow-up appointments
   • Identify patients still struggling with pain who may be at risk for chronic use 1

Prevention of Opioid Dependence

• Prescribe the lowest effective opioid dosage 1
• Use caution at any dosage and carefully reassess when increasing to 50 MME/day 1
• Avoid increasing dosage to 90 MME/day without careful justification 1
• Review patient's history of controlled substance prescriptions using state prescription drug monitoring programs 1
• Consider urine drug testing before starting opioid therapy and at least annually 1
• Avoid prescribing opioids and benzodiazepines concurrently whenever possible 1
• Arrange evidence-based treatment for patients who develop opioid use disorder 1

Common Pitfalls to Avoid

1. Overreliance on imaging - Routine imaging for acute low back pain (<4 weeks) without red flags provides no clinical benefit and may lead to unnecessary interventions 5

2. Prolonged bed rest - This can worsen outcomes; maintain activity levels and function instead 3, 6

3. Extended opioid use - Up to 75% of people entering treatment for heroin addiction report that their first opioids were prescription drugs 1

4. Inadequate patient education - Patients often underestimate postoperative pain severity and may be unprepared mentally and emotionally 1

5. Delayed imaging in patients with progressive neurological symptoms - This could lead to permanent neurological damage if a serious condition is present 5

6. Failure to implement multimodal pain management - Relying solely on opioids increases risk of dependence and side effects 1