While practicing spine surgery in different countries, I was amazed how perspectives of physicians differ. If hypothetically, we have to prioritize which symptoms to treat, between neurodeficit (weakness in muscles) and pain in almost all places the former has always won. But it has been a common observation at most of the places that– the absence of neurodeficit has been used as a rationale to justify inaction even in patients with severe pain. The subjective symptom is ignored, and more time is devoted to the objective neurodeficit.
Spine is a Complex organ and commonly presents with pain. Practitioners without clear insights into spinal complex anatomy and pain generation tend to treat the patient’s with pain medicines rather than pain management. While in India, I have come across many patients with pain, being denied intervention saying that they just have pain and no neurological deficit, and physicians advising ‘-you just have to deal with it’. There is usually no attempt to make a diagnosis if the patient does not have clear signs of neurogenic pain and answer the essential question where the pain is coming from?
As spine surgeons our primary job is secondary prevention of chronic pain. Most of these pain syndromes are amenable to treatment and cure early in their course. Most of the unanswered questions lead to chronic pain syndromes. Decompression is not the only surgery that spine surgeons do. Identifying the pain generators and taking care of them in a minimally invasive way for early return to work are not any longer the newer concepts but established norms of a good spine practice. If Spine surgeons come with an answer of where the pain is coming from at that point the solutions to it become simpler. Giving due importance to pain and investigating it should be weighed against over utilization of MRI and its high false positivity rate while making the right decision.
Dr. Amit Bhandarkar