The benefits of teamwork – Interview with Richard Assaker
Professor Richard Assaker discusses the importance of treating chronic back and leg pain patients in multidisciplinary teams
Interview by Ted Farwell
Describe the complexity of the chronic back and leg pain (CBLP) patient
Assaker: A patient who complains of chronic postoperative back and leg pain is very difficult to evaluate. The indication and the surgical strategy of the primary surgery need to be reviewed, as well as its iatrogenicity and side-effects. For these reasons the evaluation of such scenarios has to be multimodal and multidisciplinary.
Tell us about the term ‘failed back surgery syndrome’ (FBSS)
Assaker: The term FBSS refers to a failure of a therapy and obviously failure of a surgical (surgeon) treatment. In other words, from the patient’s perspective it means that something has gone wrong with the surgery and it is somehow the surgeon’s fault. In most cases, the surgery has been done technically correctly and it is not the surgeon’s fault. FBSS refers to a subset of patients complaining of persisting pain after back surgery. Pain might be a resultant of structural abnormalities (nociceptive pain), or neuropathic pain with variable psychosocial influences.
Often patients come back still having back and/or leg pain after surgery – how do you decide whether reoperation/revision surgery is needed? What other solutions are there?
Assaker: In such a case, full re-evaluation is mandatory in order to determine if the persisting pain has a source. Clinical and physical evaluation is first performed, and then radiographical work-up. If a structural abnormality that correlates with symptoms is identified, then revision surgery might be an option. Revision has to be considered only if structured rehabilitation programmes fail and after conservative pain management. In case of pain generator identification and after failure of conservative treatment, revision surgery is considered as a first option before spinal cord stimulation (SCS).
Why is a multidisciplinary approach needed to treat these patients in particular?
Assaker: There are so many potential solutions out there it is difficult for any one individual physician to know all of them. This is especially true for the chronic back and leg pain (CBLP) patient. Instead of making decisions independently, it is important to involve other specialties to make sure you are well informed on all the potential treatment options and make the best decision for the patient.
Who are the important members in a multidisciplinary team? How, in logistical terms, do these team meetings happen in your hospital?
Assaker: In our hospital, we consult with a pain specialist (an anaesthetist or a neurosurgeon), a psychologist, a physiotherapist and, of course, a spine surgeon.
How do the pain specialists help the spine surgeons? And vice versa?
Assaker: Pain specialists help spine surgeons identify and treat neuropathic pain – and can help quickly identify which patients could benefit from spinal cord stimulation. Spine surgeons can show pain specialists how to better look for a mechanical problem on an X-ray or MRI of the back.
Why is it important to identify neuropathic pain? Is there an easy way to do this?
Assaker: It is important to identify neuropathic pain because revision surgery in such a case will worsen the pain and has a negative medical economical impact – so identifying it can prevent unnecessary surgery. If the pain is neuropathic only, there should not be an operation and alternative treatments should be considered. There are proven questionnaires that can be used such as the DN4, PainDETECT and LANSS.
You are an advocate of spinal cord stimulation (SCS) – what is the evidence behind it?
Assaker: I am definitely an advocate. There are multiple randomised trials that show the evidence that SCS is an effective treatment – especially for neuropathic leg pain [1,2]. There is also evidence to show that the longer a patient waits to be treated, the less efficacious the therapy will be [3]. Fast referrals are important.
Why do you think more spine surgeons are not practising in multidisciplinary teams across Europe – and how do you see this changing?
Assaker: There are a number of reasons. Often the hospital is not set up in a way that can support the multidisciplinary team because the departments may be too segmented or physically in different parts of the city. Also, perhaps the spine surgeon and pain specialist simply don’t realise that they can truly provide better treatment when working together. I think this will change because governments and payers will demand multidisciplinary team treatment for the chronic back and leg pain patient as there becomes more evidence that it provides better treatment. Lastly, physicians need to realise they can have ‘virtual’ multidisciplinary teams over the internet or even just on the phone to talk about complex CBLP patient cases.
References
North, R.B., Kidd, D.H., Farrokhi, F., et al. (2005) Spinal cord stimulation versus repeated lumbosacral spine surgery for chronic pain: a randomized, controlled trial. Neurosurg. 56, 98–106
Kumar, K., Taylor, R.S., Jacques, L., et al. (2007) Spinal cord stimulation versus conventional medical management for neuropathic pain: a multicenter randomised controlled trial in patients with failed back surgery syndrome. Pain 132(1-2), 179–188
Kumar et al. (2013) Impact of wait times on spinal cord stimulation therapy outcomes. Pain Prac. 25 Oct 2013
Author
Richard Assaker is head of neurosurgery at CHRU Lille in France. He holds an MD from Liège Medical University in Belgium and completed his PhD in biotechnology at the University of Lille. He is currently the President of the French-speaking Neurosurgical Spine Society (SFNCR) and belongs to many other prominent spine-related groups.
