A More Synergistic Approach to Back and Neck Pain

Guy with neck pain
There are two large physician groups that treat back and neck pain. The fellowship-trained spine surgeons and pain management doctors. Each group has a different idea of how to pain based on tools and training.

The surgeon reviews the MRI or x-rays to see if there is something objective and visible to account for the painful condition, particularly something inside of the spinal canal. If there is something that can be seen and correlates with the painful condition, it makes sense to surgically remove the problem. This is a reasonable process from a medical and medico-legal point of view. The surgeon rarely does their own diagnostic evaluation with injections if there is no objective finding on the MRI.

On the other hand, it is the pain management specialist who often ends up evaluating painful spine conditions that may or may not have a visible objective finding. The pain management specialist often works in concert with a surgeon to see if an injection into the right place can relieve the pain from an objective cause, to relieve the pain sufficiently to avoid the need for surgery. More frequently they will be on the hunt for a cause of pain from something not seen on the MRI. This involves a more exhaustive look at small pain generators not typically visible on the MRI. In order to get to these pain generators, a needle must be directed with a fluoroscopic x-ray which requires practice and a developed 3-dimensional sense.

There are two very different perspectives generated by the need for “positive MRI findings”.  The surgeon will usually decline to recommend a procedure for traditional surgery without positive MRI findings. The pain management doctor, however, will often press on with injections of other smaller structures until they can find a cause of pain. The question is, what will they do when they find this pain generator? Will they attempt to manage the pain with medications or try to cure the pain with an endoscopic modality if appropriate? There isn’t that much of a difference when placing a large-bore needle or a small endoscope-so, with training, this may be the logical progression for the pain management professional.