Role of Spinal Surgery in Pain Management

Abstract

Low back pain, or spinal pain, is the second most common chief complaint in the adult population seeking medical care in the ambulatory care setting. Treatment is often initiated due to the high rate of concomitant degenerative pathology seen on magnetic resonance imaging in both symptomatic and asymptomatic adults. However, in the absence of radicular pain localizing to a compressive pathology, and clear evidence of the appropriate spinal pain generator, a more thorough work-up is warranted. The algorithm for localization of the appropriate lumbar level of disease can be complex and still leave the surgeon without a definitive answer. This is in part due to the complex innervation of the spine where in the case of the facets and disc space a mixed innervation from somatic peripheral and autonomic nerve system supply is seen. Additionally, chronic compression of the neural elements and inflammation of neural fibers may result in hyperexcitability of nociceptive neuronal pathways. In this case, neuronal excitability can be spontaneous or with a greatly lowered threshold, and surgical compression may not always provide pain relief. As a result, more patients are diagnosed with failed back surgery syndrome, a loosely defined term in the spinal literature referring to painful symptoms persisting beyond the expected postoperative time course. The authors highlight several pain generators of the spine and highlight potential nonsurgical interventions that should be considered in the spinal surgeon’s armamentarium as a means of addressing this problem in the clinic.