Inadequate Pain Control After Spine Surgery is Common Interview with:
Michael M. H. Yang MD, MSc

Departments of Clinical Neurosciences, Section of Neurosurgery, 
Community Health Sciences
Icahn School of Medicine at Mount Sinai
New York, New York  What is the background for this study?

Response: Spine surgery has been ranked as one of the most painful surgical procedures. Patients who experience poor pain control have delayed recovery, take more opioids, and stay in the hospital longer. The objective of our study was to determine patient and surgical factors that increased the chance for poorly controlled pain after spine surgery. These risk factors were incorporated into a score that can be used to determine the likelihood of a poor patient pain experience. What are the main findings?

Response: Overall, 57% of patients experienced poorly controlled pain after their spinal operation in our study. We found 7 risk factors for poor pain control: younger age, female sex, daily use of opioid medication, higher neck or back pain intensity, higher depression score, surgery involving 3 or more levels, and fusion surgery. These risk factors were used to create the Calgary Postoperative Pain After Spine Surgery (CAPPS) Score. Patients identified as low-, high-, and extreme-risk by the CAPPS score had 32%, 63%, and 85% chance of experiencing poorly controlled pain, respectively.

ACP Recommends Non-Pharmacologic Treatments for Pain Relief From Acute Non–Low Back, Musculoskeletal Injuries Interview with:
Timothy Wilt, MD, MPH
Chair ACP Clinical Guidelines Committee
Professor of Medicine
Minneapolis VA Center for Care Delivery and Outcomes Research.  What is the background for this study?  What are the main findings?

Response: Acute non-low back musculoskeletal pain is common, disabling and costly. Most are treated in outpatient settings. Numerous pharmacologic and nonpharmacologic treatment options exist but there is uncertainty of their benefits, harms and costs. Additionally, opioid prescriptions are common for acute musculoskeletal injuries but have harms and can lead to chronic opioid use including dependence and overdose. ACP and AAFP developed these evidence based guidelines to assist clinicians in providing the highest quality care to their patients by considering information on benefits, harms and costs alongside patient values and preferences. Our main recommendations are as follows:

1)      ACP and AAFP recommend that clinicians treat patients with acute pain from non–low back, musculoskeletal injuries with topical nonsteroidal anti-inflammatory drugs (NSAIDs) with or without menthol gel as first-line therapy to reduce or relieve symptoms, including pain; improve physical function; and improve the patient’s treatment satisfaction.

2)      ACP and AAFP suggest that clinicians treat patients with acute pain from non–low back, musculoskeletal injuries with oral NSAIDs to reduce or relieve symptoms, including pain, and to improve physical function, or with oral acetaminophen to reduce pain.

3)      ACP and AAFP suggest that clinicians treat patients with acute pain from non–low back, musculoskeletal injuries with specific acupressure to reduce pain and improve physical function, or with transcutaneous electrical nerve stimulation to reduce pain.

4)      ACP and AAFP suggest against clinicians treating patients with acute pain from non–low back, musculoskeletal injuries with opioids, including tramadol.

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Is Spinal Manipulation Better Than Placebo for Low Back Pain Relief? Interview with:
James S Thomas, PT, PhD

Departments of Physical Therapy and Physical Medicine and Rehabilitation
Director of Motor Control Laboratory
Virginia Commonwealth University
Departments of Physical Therapy and Physical Medicine and Rehabilitation
Director of Motor Control Laboratory
Virginia Commonwealth University
Richmond, VA 23298

Dr. Thomas  What is the background for this study?

Response: While there are numerous studies on spinal manipulation which is typically defined as  high velocity short amplitude thrust procedure to treat a hypomobile vertebral segment, there are very few studies that examine spinal mobilization (typically described as non-thrust or as a muscle energy technique). There are even fewer studies on the comparative effectiveness of these interventions. 

Accordingly, the RELIEF study was designed to provide a rigorous examination of the comparative effectiveness of the two most common manual therapy techniques for treating low back pain (i.e., manipulation versus mobilization) compared to an effective placebo (i.e., Sham Cold Laser). What are the main findings?

Response: Relative to the placebo group, there was no difference in the change in pain or disability for either spinal manipulation or mobilization. 

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PET Probe Pinpoints Sites of Pain Generation to Improve Pain Management Interview with:
Sandip Biswal MD
Associate Professor of Radiology
Co-Section Chief, Musculoskeletal Imaging
Director, Musculoskeletal Imaging Fellowship
Member, Molecular Imaging Program at Stanford (MIPS) and Bio-X
Department of Radiology
Stanford University School of Medicine  What is the background for this study?
Response: Our ability to manage patients with chronic pain remains woefully inadequate. Chronic pain patients are faced with limited resources and inadequate care, and as a result, they make up the #1 disease group in the world—numbering more than heart disease, diabetes and cancer combined. Those suffering from low back pain, headache, fibromyalgia, arthritis and many other pain syndromes make up this ever-growing population. A big part of our inability to care for chronic pain patients is due to the fact that our current imaging methods for correctly identifying pain generators remain substantially inaccurate. Our ability to accurately identify the cause of a person’s pain, discomfort, inflammation or other related musculoskeletal symptom(s) using current clinical imaging approaches, such as magnetic resonance imaging (MRI), computed tomography (CT), digital radiography (x-ray) and ultrasound, is quite limited, lacks sensitivity/specificity and can even misguide treatment. As a musculoskeletal radiologist, I witness these shortcomings on a daily basis. I, for example, see firsthand how the lack of reliable diagnostic tools leads to significant misdiagnosis, mismanagement, incorrect use of opioids, unhelpful surgeries and, ultimately, therapeutic failures. We need a much better way to diagnose pain generators. 

Accordingly, our group has been developing new clinical imaging methods that pinpoint the site of pain generation using imaging probes—more specifically, positron-emission tomography (PET) tracers that specifically target “pain receptors” or “pain molecules.” These pain receptors or pain molecules are present in abundance at the site of pain generation. After injecting one of these imaging probes into a patient through the vein, we give the probe a few minutes to circulate around the body and stick to areas that have a high density of pain receptors. We can then take a picture of the patient with a special camera that will show “hot spots” on the image that signify the location of high number of pain receptors, thereby highlighting “painful” pro-inflammatory and/or pro-nociceptive tissues. With this approach, doctors and patients have information with which they can make more objective decisions about the diagnosis and treatment of one’s pain.

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Tanezumab for Chronic Low Back Pain Relief: Phase 3 study

“Tanezumab is a monoclonal antibody that is part of an investigational class of non-opioid chronic pain medications known as nerve growth factor (NGF) inhibitors.” Link

“Tanezumab 2.5 mg administered subcutaneously (SC), which is being evaluated for patients with chronic pain due to moderate-to-severe osteoarthritis (OA) who have experienced inadequate pain relief with other analgesics.” Link

Comments from Pfizer regarding the study of Tanezumab for chronic low back pain, July 21 2020.

Pfizer and Lilly made the decision to prioritize tanezumab as a potential treatment for osteoarthritis, based on an assessment of the totality of SC tanezumab data and an initial discussion with the FDA.

At this time, regulatory submissions are not planned for tanezumab in patients with moderate-to-severe chronic low back pain (CLBP), but we recognize the significant patient needs and intend to maintain an open dialogue with regulatory authorities on potential future regulatory pathways for tanezumab. Additional data analyses, and potentially further clinical study, may be required to more fully characterize tanezumab in CLBP patients.

Additional information:

Alliance announced in early March that the U.S. FDA accepted the regulatory submission for Tanezumab, a potential first-in-class treatment for patients with chronic pain due to moderate-to-severe osteoarthritis.


Markman, John D.a,*; Bolash, Robert B.b; McAlindon, Timothy E.c; Kivitz, Alan J.d; Pombo-Suarez, Manuele; Ohtori, Seijif; Roemer, Frank W.g,h; Li, David J.i; Viktrup, Larsj; Bramson, Candacek; West, Christine R.k; Verburg, Kenneth M.k Tanezumab for chronic low back pain, PAIN: June 25, 2020 – Volume Articles in Press – Issue – doi: 10.1097/j.pain.0000000000001928

Back Pain: Web-Based Self-help Intervention to Prevent Depression Interview with:

Lasse B. Sander, PhD
Institute of Psychology
Department of Rehabilitation Psychology and Psychotherapy
Albert-Ludwigs-University of Freiburg
Freiburg, Germany

Lasse B. Sander, PhD
Institute of Psychology
Department of Rehabilitation Psychology and Psychotherapy
Albert-Ludwigs-University of Freiburg
Freiburg, Germany
Dr. Sander  What is the background for this study?  What are the main findings?

Response: People with chronic pain have a significantly increased risk of developing depression. When depression and pain collide, this is a considerable burden for those affected. In addition, pain management is made more difficult due to comorbidity.

We have known for some years now that the onset of depression can be delayed or even completely prevented by means of early psychological therapies. However, until now there has been no scalable application option available for routine healthcare.

In our study we were able to show that this can be achieved by a digital self-help intervention.

Trial of Desipramine, Cognitive Behavioral Therapy, and Placebo for Low Back Pain Relief Interview with:
Thomas Rutledge, PhD, ABPP
Staff Psychologist, VA San Diego Healthcare System
Professor of Psychiatry
UC San Diego  What is the background for this study?

Response: The goal of this study was to combine our team’s pharmacy, psychiatry, and psychology expertise with chronic pain to conduct a rigorous, head-to-head efficacy trial. The clinical trial literature for chronic back pain is enormous. On the surface, this literature suggests that many medication and pain psychology treatments are effective by standards of statistical significance. These findings are difficult to interpret, however, because there are few trials comparing statistically effective chronic back pain treatments with active control treatments and nearly no trials randomizing patients with chronic back pain to medication versus pain psychology treatments. We hoped that our trial could offer data to help fill these gaps. Mindful of the increasing concerns about long-term opioid use for chronic pain, we also believed the study could have value by focusing on non-opioid agents (Desipramine) and cognitive behavioral therapy.

Surgery vs Conservative Care Pain Relief from for Persistent Sciatica Interview with:

Dr. Chris Bailey
Western Bone and Joint Institute  What is the background for this study? 

Response: Acute and subacute sciatica from a lumbar disc herniation is recognized to have a very good natural history with approximately 90% making significant improvement within 4 months of onset.  Hence, studies have shown that surgery for disc herniation has a short-term benefit over non-operative care. 

In many cases, the patients not receiving surgery will improve to the level of those receiving surgery by 6 months (Peul et al, 2007).  Chronic sciatica we felt was a different situation.  

What are the main findings?

Response: Our study confirmed that surgery has a greater advantage for these patients out to 1 year following surgery.  An unpublished stat from our work found that there is a 70% greater chance of significant improvement in sciatica with surgery compared to non-operative care (including physiotherapy, education, medications, and epidural injections).  We recommend that a referral is made to a surgeon for these patients as the likelihood of improvement without surgery is much less than for acute sciatic. What should readers take away from your report?

Response:  Previous studies have also had a difficult time controlling for cross-over and maintaining distinct treatment cohorts.  Our study was designed in such a way to utilized the inherent wait times for consultation in our Canadian health care system so to prevent crossover from the non-op group to the surgical group. What recommendations do you have for future research as a result of this work?

Response: Our plan is to perform future cost effectiveness analysis and publish on long term outcomes as well.


Surgery versus Conservative Care for Persistent Sciatica Lasting 4 to 12 Months
Chris S. Bailey, M.D., Parham Rasoulinejad, M.D., David Taylor, M.D., Keith Sequeira, M.D., Thomas Miller, M.D., Jim Watson, M.D., Richard Rosedale, P.T., Stewart I. Bailey, M.D., Kevin R. Gurr, M.D., Fawaz Siddiqi, M.D., Andrew Glennie, M.D., and Jennifer C. Urquhart, Ph.D
Nengl j med 382;12 March 19, 2020

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Chiropractic Care Linked to Lower Use of Opioids for Spinal Pain Relief Interview with:
Jim Whedon DC, MS
Director of Health Services Research
SCU Health System
Southern California University of Health Sciences
Whittier, CA  What is the background for this study?  What are the main findings?

Response: Utilization of nonpharmacological pain management may prevent unnecessary use of opioids.

Our objective was to evaluate the impact of chiropractic utilization upon use of prescription opioids among patients with spinal pain. Overall, in the states of CT, MA and NH, at any particular time in the study period of 2012-2017, between 1.55 and 2.03 times more nonrecipients of chiropractic care.filled an opioid prescription, as compared with recipients.

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Low Back Pain: AI Can Expedite Pain Relief Recommendations Through Electronic Record Interview with:

Ismail Nabeel MD, MPH
Associate Professor
Public Health and General Preventive Medicine
Mount Sinai Medical Center

Dr. Nabeel  What is the background for this study?

Response: Acute and chronic low back pain (LBP) are different conditions with different treatments. However, they are coded in electronic health records with the same International Classification of Diseases, 10th revision (ICD-10) code (M54.5) and can be differentiated only by retrospective chart reviews. This prevents an efficient definition of data-driven guidelines for billing and therapy recommendations, such as return-to-work options, etc.

In this feasibility study, we evaluated if Artificial intelligence can automatically distinguish the quality of Low Back Pain (LBP) episodes by analyzing free-text clinical notes from the treating providers. 

These clinical notes were collected during a previous pilot study evaluating an RTW tool based on EHR data that included nearly 40,000 encounters for 15,715 patients spanning from 2016 to 2018 and clinical notes written by 81 different providers. We used a dataset of 17,409 clinical notes from different primary care practices; of these, 891 documents were manually annotated as “acute low back pain” and 2,973 were generally associated with LBP via the recorded ICD-10 code. 

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