The Modern Continuum of Spine Care: Synergizing Interventional Pain Management and Spine Surgery

The landscape of spine care has undergone a critical paradigm shift, moving away from a binary choice between conservative management and invasive spine surgery. Today, the ideal management of a spine patient occurs when a surgeon with expertise in minimally-invasive and motion sparing techniques is paired with a master pain interventionalist to deliver care in an interdisciplinary manner.

Since spine pathology is at times a chronic illness, it is not atypical to have a patient move back and forth in the continuum of what is traditionally offered by a pain interventionalist and a spine surgeon. As such, it is critical to have frequent discussions regarding specific patients between the specialists throughout the treatment period to ensure the best option is delivered to the patient.

Advanced Diagnostic Techniques

Effective spine care begins with precise identification of the pain generator(s), a task where advanced interventional diagnostics excel. Although MRI provides exceptional anatomical detail, it often correlates poorly with clinical symptoms, as structural abnormalities are frequently asymptomatic. To fill this gap, advanced imaging modalities such as computed tomography (CT) spectroscopy and MR spectroscopy can help with pinpointing the pain generators.

Diagnostic precision also is achieved through image-guided, volume-controlled anesthetic blocks. Techniques such as selective nerve root blocks, medial branch blocks, and epidural targets serve as functional diagnostic tools. By isolating specific nociceptive pathways, we can more definitively confirm whether axial or radicular pain stems from facet arthropathy, vertrebrogenic pathophysiology, discogenic disruption, or neural impingement, thereby dictating the most efficacious therapeutic pathway.

Basivertebral Nerve Ablation

Chronic axial low back pain has historically been challenging to treat, but the identification of vertebrogenic pain has revolutionized targeted therapy. Patients presenting with Modic changes on MRI (indicating vertebral endplate inflammation and degeneration) are ideal candidates for basivertebral nerve (BVN) ablation. This intraosseous procedure utilizes radiofrequency energy to ablate the BVN in the vertebral body, interrupting the transmission of pain signals from the damaged endplates. Level 1 evidence, including multicenter randomized sham-controlled trials, validates BVN ablation as a durable, disease-modifying intervention, demonstrating sustained, statistically significant improvements in pain and Oswestry Disability Index scores at 5-year follow-ups.¹

Endoscopic Spine Surgery

When interdisciplinary management is present, many patients who otherwise would be candidates for larger multilevel fusion procedures end up with great results undergoing much less invasive, outpatient decompressive procedures. In a decompressive procedure, the asymptote we aim for is to treat the offending agent without altering any of a patient’s native tissue.This goal has guided the field as it transitioned from mostly open procedures to minimally-invasive tubular approaches that respect tissue planes and therefore decrease morbidity. The newest and most ultra minimally invasive method on that continuum involves the use of an endoscope. Endoscopic spine surgery (ESS) has revolutionized management of certain conditions and can be used to treat disk herniations in the cervical, thoracic and lumbar spine. ESS can also treat stenosis in the cervical, thoracic and lumbar spine. Multilevel pathology is not a contraindication to ESS. Numerous studies have shown equivalent outcomes to more invasive procedures,^2,3 but with:

1. Decreased length of stay and reduced postoperative pain
2. Faster return to work and daily activities
3. Lower rates of multifidus muscle atrophy

Studies are underway that will likely prove that long-term progression to needing fusion operations will be less than traditional methods since much less native tissue is disrupted.

Motion Sparing Technologies

In patients with a structural problem or who progressed despite an adequate decompressive procedure, the goal of the interdisciplinary team is to preserve as much natural motion in the spine as possible. Technologies have been skyrocketing in this field with evidence supporting the use of disk arthroplasties in both the cervical and lumbar spine. Newer implants have also been introduced in terms of facet joint replacements in the lumbar spine with studies showing equivalence- and in some measures improved- outcomes when compared with lumbar fusions in appropriate patients. Lastly, there are multiple products at different levels of development that are likely to push this field further with total lumbar joint replacements becoming a treatment offered in the future.

Minimally-Invasive Fusion Techniques

In patients who require fusion, a strong relationship between a pain physician and surgeon is crucial to minimize the number of levels fused. Through a discussion that includes pain characteristics, advanced diagnostic interventions, traditional imaging, and the results of CT and MR spectroscopy at times, an individualized plan decreasing the levels of fusion can be formulated. The approach to a fusion is also important. In the appropriate patient, a fusion can effectively and safely be performed via tissue sparing methods. When fusion is required, tissue-sparing corridors are prioritized:

1. Anterior Corridor: Preferred for appropriate cervical and lumbar pathology.
2. Lateral Corridor: Utilized for applicable thoracic and lumbar conditions.
3. Minimally Invasive Posterolateral Approach: Selected when anterior or lateral routes are unviable.
4. Open Fusion: Reserved strictly as a last resort when less invasive options are clinically ruled out.

Neuromodulation Therapy

For patients with persistent spinal pain syndrome, failed back surgical syndrome, post-laminectomy syndrome, or refractory radiculopathy, neuromodulation therapy has emerged as a cornerstone treatment. Spinal cord stimulation (SCS) and peripheral nerve stimulation (PNS) have advanced significantly beyond traditional tonic stimulation. Current evidence supports the use of innovative spinal cord stimulation program platforms (i.e. burst, closed-loop stimulation paradigms), which provide superior, paresthesia-free pain relief by modulating dorsal horn neural processing. High-quality randomized controlled trials demonstrate that modern SCS not only reduces visual analog scale pain scores but also decreases opioid consumption and improves functional capacity.⁴ Concurrently, PNS offers a complementary, less invasive approach for localized axial pain, directly targeting afferent pain signals at the medial branch or peripheral nerve level.

Combination of Pain Interventions and Surgical Procedures

A growing field in treatment of spine patients in an interdisciplinary fashion is the combination of typical pain interventions with spine procedures. This includes:

• Endoscopic denervation of the sacroiliac joint
• Endoscopic decompression combined with endoscopic medial branch transection
• Endoscopic decompression combined with endoscopic annuloplasty
• Endoscopic decompression combined with basivertebral nerve ablation

Early experience at our institution has shown benefit in treatment of patients who otherwise would undergo fusion procedures. This exciting new treatment paradigm can only occur with a robust interdisciplinary approach between experienced pain management and surgical teams to provide for the best patient care.

Conclusion

The seamless integration of advanced interventional pain techniques and minimally invasive spine surgery represents the core of modern spine care at Cleveland Clinic. By delivering a unified vision, a shared care pathway, and an unbroken continuum of treatment, our multidisciplinary teams ensure that every patient receives the precise, evidence-based, and minimally disruptive care they require at every stage of their journey.

REFERENCES
1. Aiyer R, Noori S, Schirripa F, et al. A systematic review of full endoscopic versus micro-endoscopic or open discectomy for lumbar disc herniation. Pain Manag. 2022;12(1):87-104. doi:10.2217/pmt-2021-0037
2. Eckermann JM, Pilitsis JG, Vannaboutathong C, Wagner BJ, Province-Azalde R, Bendel MA. Systematic Literature Review of Spinal Cord Stimulation in Patients With Chronic Back Pain Without Prior Spine Surgery. Neuromodulation. 2022;25(5):648-656. doi:10.1111/ner.13519
3. Jain S, Deer T, Sayed D, et al. Minimally invasive lumbar decompression: a review of indications, techniques, efficacy and safety. Pain Manag. 2020;10(5):331-348. doi:10.2217/pmt-2020-0037
4. Smuck M, Khalil J, Barrette K, et al. Prospective, randomized, multicenter study of intraosseous basivertebral nerve ablation for the treatment of chronic low back pain: 12-month results. Reg Anesth Pain Med. 2021;46(8):683-693. doi:10.1136/rapm-2020-102259