The Basics of Spine Intervention

Effective patient relief depends on your methods, your team and your standard
By: Michael Port M.D.
Outpatient Surgery Magazine – November, 2007  

The big picture — for patients suffering from spine pain can be a demanding process

Following the increasing trend of surgical procedures migrating away from inpatient settings and toward hospital outpatient departments and ambulatory surgery centers, the comprehensive treatment of spinal disorders includes several procedures that can be appropriately performed as same-day surgeries. 

The practice of spinal pain intervention aims to identify and treat the underlying sources of pain production, sources that are typically related to intervertebral disks, facets or, less frequently, sacroiliac joints. Here are a few angles on how our practice incorporates interventional pain management to treat spinal pain as well as the requirements for performing them in the outpatient setting

Pain Management Possibilities

Our center has created a model for the multidisciplinary treatment of spine patients in an outpatient setting, although we also incorporate overnight stays when necessary. We believe there are several inherent advantages for our patients as well as ourselves in this model, including but not limited to lower costs, scheduling flexibility, the duration of surgical events, patient comfort and the overall pleasantness of the experience.

However, we're aware that the level of care must be at least commensurate to or, as we believe, exceed that of most inpatient hospital settings, One critical aspect of this patient care is the effective management of post-operative and chronic pain,

For the pain management practitioner, the spectrum of treatments at his disposal includes diagnostic as well as therapeutic interventions for pain thought to be related to the cervical, thoracic and, most frequently, the lumbar spine

At our facility, we routinely perform interventions involving epidural access, facet and medial branch injections and discography in the cervical, thoracic and lumbar spine; sacroiliac injections; sympathetic blockades; radio-frequency ablation for facet mediated pain; and spinal dorsal column stimulation.

Several spine specialty professional organizations have developed algorithms to assist clinicians in the decision of when to apply interventional procedures for spinal pain and which patients are the best potential candidates for such treatment.

Most notably, the North American Spine Society has published its Phase III clinical guidelines for multidisciplinary spine care specialists on the treatment of unremitting low back pain. Additionally, the International Spine Intervention Society has published its own set of guidelines for performing procedures to manage neck, thoracic and back pain.

These and other diagnostic and treatment algorithm strategies are based on a determination of the most likely source of pain. That source is typically classified by its relative location. That is to say, whether it is an anterior structure such as a disk, a ligament or, less commonly, a vertebra; a middle structure such as disk herniation, hematoma or spinal tumors; or posterior structures such as facets, ligaments and bone.

Our multidisciplinary treatment team of spine-qualified neurosurgeons, orthopedic surgeons, pain anesthesiologists and physiatrists use these guidelines to assist them in making the best decisions for each patient's unique situation.

Necessary Cautions

The etiology of spinal pain is complex. As a result, it is the responsibility of the spinal care professional to ensure that the benefits of any recommended treatment outweigh the risks .

These risks include both procedure-related risks such as bleeding, post-op infections, injury to underlying structures, failure to achieve pain relief and the possibility of increased pain, and the diagnostic risk of treatment in patients whose pain does not actually originate from the spine.

This latter contingency can result from the inconvenient fact that the correlation of pain to imaging findings is unfortunately not direct. Further, there is ample evidence that patients with desiccated (dark) disks and herniated disks are asymptomatic.

A sophisticated spine specialist needs to be aware of the potential role of psychosocial influences on the outcome of diagnosis and treatment. He also needs an understanding that, while a surgical procedure is a defined event, the subsequent task of caring for patients suffering from spine pain can prove to be a demanding process.

Safely performing interventional spine pain procedures requires a committed team. A well-trained physician is integral to the process, of course, but a facility stocked with the optimal equipment and supplies - and staffed with trained personnel to use them - is in the patient's best interest.

The equipment necessary for pain management - a C-arm or other fluoroscopic imaging device and a moveable imaging table - should already be familiar to facilities performing orthopedic and neurological procedures, which is one of the main reasons why pain management is frequently offered as an adjunct service line at centers focusing on those specialties. The injection supplies and resuscitation equipment also needed for pain procedures should likewise already be available in surgery center supply cabinets.

Equally essential to building your pain management service is a qualified and skilled staff to support every step of the process. The personnel on our team include pleasant intake staff; pre-op, intra-op and post-op nurses; surgical and radiological techs who are expert with the imaging equipment that guides the procedures; and anesthesiologists to ensure safe sedation when it's requested.

Remember that great effort should be directed toward providing a patient-friendly atmosphere and actively seeking patient satisfaction, because the nature and complexity of spine care typically requires more than one visit. We've invested wisely in capital equipment and personnel resources for our center because we believe that they offer our facility a competitive advantage.

The Patient Process

As with any ambulatory undertaking, having standard operating procedures for pre-op, intra-op and post-op care can maximize your facility's patient safety and work flow. At our pain center, all patients are assessed pre-operatively and the patient flow process begins with a pre-surgical telephone call from our nursing staff on the day prior to a surgical procedure.

The patient then undergoes a medical evaluation, an assessment of their vital signs and an assessment of their pain using a visual analogue symptom (or VAS) scale, a standard through which patients can verbalize an approximate measure of their perceived pain, from "no pain" to "worst pain imaginable."

From a nursing standpoint, all patients are subject to the same level of care, as appropriate to their procedures. This is true whether they're undergoing a simple lumbar epidural injection or an anterior cervical fusion.

The above-mentioned assessments are repeated post-operatively before discharge and the patient flow process culminates with a follow-up call to the patient's home and a request for a critical evaluation of our center the day after the procedure.

Developing your facility into a center of excellence for outpatient spinal interventions requires an investment in people, equipment and time, but it can pay great dividends in the treatment of patients suffering from spinal pain.