Surgical procedures in pain management

[distracted]

Hi. I've performed a search for this information, but I was unable to find any relevant threads. If there are any, I don't mean to be annoying so could you please just point me to them.

I was curious about the surgical procedures that can be performed by pain management physicians, specifically stimulators and pumps. I understand that a pain physician can percutaneously implant the electrode and then create a pocket for the stimulator unit. However, I was wondering if they are able to perform more advanced implantations where either a small laminectomy needs to be performed or a tubular retractor system used.

Additionally, I am aware that many pain physicians perform kyphoplasty and other min. inv. procedures, but I was wondering if they can also perform spinal endoscopy and other "more invasive" min. inv. procedures. If so, where does the domain of the pain specialist end and that of the spinal surgeon begin. I know there is no clear line, but it would be helpful to have a list of surgical procedures definitely able to be performed by pain physicians with the proper training.

Also, do all fellowships provide training sufficient to perform these surgical procedures or is there a big variation in the content of training?

Thanks for taking time to answer these questions. It's helpful to a med student trying to figure out what they want to do "when they grow-up".

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[Ligament]

These are all very excellent questions and as a medical student you have done your research, clearly.

I'd estimate 10% of Pain Medicine docs actually implant stims and pumps. A higher percentage "trial" these devices but do not actually implant them in the OR; they are sent to the surgeons for the implant (for some good and some bad reasons). These procedures are taught in many, but not all, pain fellowships.

About 1% do more advanced spinal procedures that you mentioned, such as spinal endoscopy. Such procedures are not taught as part of any fellowship. I believe an attending on this board, Algosdoc, does such advanced procedures and could speak more about it.

I am not aware of any pain docs performing laminectomies, but perhaps a few do...I am aware of one pain doc that assists a spine surgeon with percutaneous lumbar fusions with the sextant system.

The dividing line between pain doc and spine surgeon territory is who can best avoid the complications.

Hi. I've performed a search for this information, but I was unable to find any relevant threads. If there are any, I don't mean to be annoying so could you please just point me to them.

I was curious about the surgical procedures that can be performed by pain management physicians, specifically stimulators and pumps. I understand that a pain physician can percutaneously implant the electrode and then create a pocket for the stimulator unit. However, I was wondering if they are able to perform more advanced implantations where either a small laminectomy needs to be performed or a tubular retractor system used.

Additionally, I am aware that many pain physicians perform kyphoplasty and other min. inv. procedures, but I was wondering if they can also perform spinal endoscopy and other "more invasive" min. inv. procedures. If so, where does the domain of the pain specialist end and that of the spinal surgeon begin. I know there is no clear line, but it would be helpful to have a list of surgical procedures definitely able to be performed by pain physicians with the proper training.

Also, do all fellowships provide training sufficient to perform these surgical procedures or is there a big variation in the content of training?

Thanks for taking time to answer these questions. It's helpful to a med student trying to figure out what they want to do "when they grow-up".

 

[ampaphb]

These are all very excellent questions and as a medical student you have done your research, clearly.

I'd estimate 10% of Pain Medicine docs actually implant stims and pumps. A higher percentage "trial" these devices but do not actually implant them in the OR; they are sent to the surgeons for the implant (for some good and some bad reasons). These procedures are taught in many, but not all, pain fellowships.

About 1% do more advanced spinal procedures that you mentioned, such as spinal endoscopy. Such procedures are not taught as part of any fellowship. I believe an attending on this board, Algosdoc, does such advanced procedures and could speak more about it.

I am not aware of any pain docs performing laminectomies, but perhaps a few do...I am aware of one pain doc that assists a spine surgeon with percutaneous lumbar fusions with the sextant system.

The dividing line between pain doc and spine surgeon territory is who can best handle the complications.

Much of this is political, rather than ability related. In my area, our neurosurgeons want no part in the perms, so we place out own. On the other hand, if you are in an area where the neurosurgeons are not as busy asx they want to be, handing off the perms to them can garner some good will.

Similarly, if your referral base is generally surgical, then doing endoscopic discography could potentially step on their toes. If, on the other hand,m the majority of your referrals come from PCPs, they will not care one bit.

Privileges are also a BIG issue when it comes to these procedures, so it seems unlikely to me that most folks who do them would be doing them in a hospital setting - I suspect most are being done in ASCs

 

[Aether2000]

These numbers are constantly changing with reimbursement and with training availability.
Here is a very rough guide:

SURGICAL PROCEDURES IN PAIN MEDICINE:
1. Neurodestruction:
a. RF MB-common-probably around 35% of pain physicians; other RF is rare <1% TGG, SPG, splanchnic n, grey ramus communicans, DRG, coccygeal n, Sinergy
b. Cryoneurolysis <1% Intercostal, DRG, occipital, other peripheral nerves, coccygeal/sacral
c. Chemoneurolysis: celiac plexus 5%, peripheral nerve 3%, sympathetics <1%, SPG <1%, TGG <<<1%, epidural or intrathecal <<<1%, pituitary alcohol ablation <<<1%
d. Laser: peripheral n and medial branch <<1%
2. Neuromodulation
a. Intrathecal: Tunnelled IT trials <1%, Tunnelled epidural trial 2%, Pump implants 2%
b. SCS: Trials 20%, Implanted system 5%
c. PNS: Trials 1%, Implanted system <1%
d. Sacral stim: Trials <1%, Implant <1%
3. Disc decompression: hydrocision<1%, plasma disc decompression 5%, decompressor 5%, lase <1%, accutherm <1%, endoscopic intradiscal decompression posteriorlateral approach <1%, extradiscal endoscopic discectomy <<<1%
4. Annulus Fibrosis procedures: Biaculoplasty<<1%, IDET<1%, Disctrode<<1%
5. Intradiscal chemomodulation: Ozone<<1%, Methylene blue<<1%, intradiscal steroids 1%, chymopapain 0%, intradiscal glucose 1%, intradiscal Derby Juice 1%
6. Vertebral Augmentation: Kyphoplasty <1%, vertebroplasty 3%
7. Other surgical procedures: foraminoplasty <<<1% (laser or mechanical), spine fusion <<<1%, peripheral nerve open lysis <<1%, removal of painful lipomas or skin lesions <1%, cordotomy <<<1%, bone tumor ablation <<1%

So you see, pain medicine is largely non-surgical at this time with the exception of pumps, stims, and vertebroplasty. Some of the limitations are with lack of available training in these arenas and some is due to reimbursement issues. Hopefully a full residency program will rectify the lack of training in these advanced modalities

 

[Doctodd]

not just a political issue, but also a reimbursement issue depending on the state. In FLorida, most of the facility fee money is made with the trial. If you only send them the permanent, they wont be happy. Sometimes the neurosurgeon doesnt even notice/care cuz he may be employed by the hospital. But the billing department WILL CARE!...just depends on how long it takes for them to figure it out.

T

 

[Doctodd]

algos...im surprised you put chymopapain in your list...even at 0%.

T

 

[distracted]

Thanks for those replies. Just a few follow-up questions...

Do you think the field in general is moving towards more involvement in surgical procedures or is this impossible to predict? I'm very interested in pain medicine as a comprehensive multi-disciplinary specialty. It seems to me that in order to provide the widest range of pain medicine services, it would be helpful to expand the surgical procedures that can be performed by these docs.

What training programs are known for providing the most comprehensive surgical training? If I am interested in these programs, is it best to try to do residency at the same hospitals? Also, how would you add surgical procedures to your practice after residency if the training wasn't provided?

How far off do you think a full residency program is? Since there are obvious political hurdles to overcome before this can be established, do you think there will ever be a modified or streamlined residency (in either PMR or gas) similar to the IR DIRECT program offered by some rads programs?

Don't mean to barrage you with questions, but I have yet to find a good resource for info like this. Thanks again for your replies.

 

[lobelsteve]

algos...im surprised you put chymopapain in your list...even at 0%.

T

We should restart chymopapain trials in the USA, after consultation with the allergist, it should be safe- then we can assess efficacy.

 

[Aether2000]

Chymopapain is the only intradiscal procedure with 10 year randomized trial outcomes and is one of the few procedures with Level 1 evidence of efficacy. There were allergic disasters that could have been prevented by testing prior to the procedure and a few cases of transverse myelitis, probably due to doctors that had no idea where the needle tip resided or whether the annulus was competent or not (ie surgeons). The main reason chymopapain is no longer available has nothing to do with the efficacy: it was threats of litigation that killed the product.

As for the long term outcome of residencies in pain medicine: we are making a serious effort at instituting this but must follow steps to have the specialty recognized as a distinct area of medicine. This is in the works currently and is associated with intense activity over the past 6 months. I do not see anesthesiology nor PMR wanting to play ball with a residency program in pain medicine since it would gut their fellowship programs. The more progressive pain departments such as Cleveland Clinic or Mayo Jacksonville that recognize the limitations of riding on the shirt tails of the anesthesiologists could eventually be the seminal programs in a newly recognized pain residency, but their involvement is speculative at this time. I think all of pain medicine would applaud the involvement of these two programs along with other progressive thinking universities to advance the cause of delivery of a comprehensively well trained pain physician with expertise in many areas, including surgery.

 

[PAINISGOOD]

These numbers are constantly changing with reimbursement and with training availability.
Here is a very rough guide:

SURGICAL PROCEDURES IN PAIN MEDICINE:
1. Neurodestruction:
a. RF MB-common-probably around 35% of pain physicians; other RF is rare <1% TGG, SPG, splanchnic n, grey ramus communicans, DRG, coccygeal n, Sinergy
b. Cryoneurolysis <1% Intercostal, DRG, occipital, other peripheral nerves, coccygeal/sacral
c. Chemoneurolysis: celiac plexus 5%, peripheral nerve 3%, sympathetics <1%, SPG <1%, TGG <<<1%, epidural or intrathecal <<<1%, pituitary alcohol ablation <<<1%
d. Laser: peripheral n and medial branch <<1%
2. Neuromodulation
a. Intrathecal: Tunnelled IT trials <1%, Tunnelled epidural trial 2%, Pump implants 2%
b. SCS: Trials 20%, Implanted system 5%
c. PNS: Trials 1%, Implanted system <1%
d. Sacral stim: Trials <1%, Implant <1%
3. Disc decompression: hydrocision<1%, plasma disc decompression 5%, decompressor 5%, lase <1%, accutherm <1%, endoscopic intradiscal decompression posteriorlateral approach <1%, extradiscal endoscopic discectomy <<<1%
4. Annulus Fibrosis procedures: Biaculoplasty<<1%, IDET<1%, Disctrode<<1%
5. Intradiscal chemomodulation: Ozone<<1%, Methylene blue<<1%, intradiscal steroids 1%, chymopapain 0%, intradiscal glucose 1%, intradiscal Derby Juice 1%
6. Vertebral Augmentation: Kyphoplasty <1%, vertebroplasty 3%
7. Other surgical procedures: foraminoplasty <<<1% (laser or mechanical), spine fusion <<<1%, peripheral nerve open lysis <<1%, removal of painful lipomas or skin lesions <1%, cordotomy <<<1%, bone tumor ablation <<1%

So you see, pain medicine is largely non-surgical at this time with the exception of pumps, stims, and vertebroplasty. Some of the limitations are with lack of available training in these arenas and some is due to reimbursement issues. Hopefully a full residency program will rectify the lack of training in these advanced modalities

If this is true and that 80-99.9% of pain docs don't do these procedures then why do prospective fellows care about doing as many pumps and stims and advanced procedures as possible? Seems like overkill to me....any thoughts?

PAINISGOOD

 

[Aether2000]

The percentages are a rough approximation of what is currently done, but not what will be optimal in the future. Pumps definitely are more labor intensive than stims, and require tinkering with doses and treating the many complications related to medications. Stims have relatively few complications that may partially be determined on evaluation by company reps, and the patient tinkers with the system rather than requiring physician to do so in many cases...

We need better training programs that will equip pain physicians with a full array of surgical options, then impart wisdom about when not to use them.

 

[ampaphb]

intradiscal Derby Juice

More precisely, it is Björn Eek's intradiscal juice, popularized by Derby.

 

[ampaphb]

If this is true and that 80-99.9% of pain docs don't do these procedures then why do prospective fellows care about doing as many pumps and stims and advanced procedures as possible? Seems like overkill to me....any thoughts?

PAINISGOOD

99% of the procedures listed by Algos either have no literature documenting that the work, or worse, have literature documenting they don't work - THAT, in large measur, is why most of the procedures listed are not performed.

Additionally, it would be hard to qualify many of the procedures Mike listed as actually "surgical", other than pump and stim permanent placements, vertebro and kyphoplasty. I know a few guys who are considering placing their own percutaenous x-stops, and more than a few (but still not many) who do arthroscopic discectomies, but the vast majority of what keeps most of us busy (and rather well-fed) are non-surgical procedures.