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Pain Management

Management of acute and chronic spinal pain, focusing on biopsychosocial drivers, structural pathology, and the transition to chronicity.

Overview

Perioperative pain control represents the primary concern for patients considering outpatient shoulder arthroplasty [6], with morbidity and mortality related to opioid analgesics reinforcing the need for robust, evidence-based guidelines [8]. While opioids are effective for the management of acute musculoskeletal pain [8], the exclusive use of pain scores in postoperative pain management should be limited to prevent complications [1]. Multimodal analgesia is recommended for early postoperative pain control to optimize patient outcomes and reduce opioid consumption in shoulder surgery [42].

Patients with a history of chronic opioid use continue to present a challenge for pain management even with modern multimodal protocols [2], necessitating an established pain management system with protocols to assist in reducing opioids and improving the perioperative framework for opioid-tolerant patients [23]. Multimodal analgesia protocols are effective at reducing pain and the number of opioids needed for breakthrough pain with minimal side effects [12] and do not compromise patient satisfaction [12]. An opioid-sparing pain management protocol after shoulder arthroplasty results in less opioid consumption [9], with patients reporting higher satisfaction with this strategy [9].

Preoperative counseling emphasizing a comprehensive postoperative pain management strategy may benefit patients [6], and application of patient education tools alongside innovative multimodal protocols successfully eliminates the need for opioids after arthroscopic rotator cuff repair while maintaining excellent outcomes [19]. However, no best practices model for postoperative pain management was demonstrated in the systematic review of acute postoperative pain in hand surgery, though evidence exists for alternative medications and treatment strategies [7]. Additional strategies are needed to address postoperative pain management in non-opioid-naive patients undergoing hand and upper-extremity surgery, where prescribing a different opioid reduced medication requirements [17]. The clinical significance of findings regarding opioid sparing and pain control following total shoulder arthroplasty has been questioned due to inappropriate sample size calculation, a lack of anesthesia management details, and a failure to assess clinically important differences or functional outcomes [34].

Anatomy & Pathophysiology

Osseous Alignment and Deformity: Preoperative lumbar lordosis, disc angle, and intraoperative cage position significantly predict segmental lordosis restoration following TLIF in lumbar spondylolisthesis [81], while segment lordosis restoration in oblique lumbar interbody fusion depends on preoperative segment lordosis, cage subsidence, and cage position [74]. The Roussouly classification serves only as a rough estimate of optimal spinopelvic alignment for predicting mechanical complications in elderly patients with adult degenerative scoliosis [77]. Percutaneous surgical treatment for thoracolumbar fractures in ankylosing spondylitis improves pain, neurological function, and kyphotic deformity with effects comparable to traditional methods [75]. Measurement of thoracic kyphosis on standing whole spinal radiographs using T2 yields greater measurement error (up to 6.6°) compared to upright computed tomography images [87].

Neural and Fascial Pathways: A pro-nociceptive pain modulatory balance characterized by enhanced pain facilitation drives movement-evoked pain severity and poor physical function in chronic low back pain [89]. Targeting skeletal interoception offers novel avenues for reversing intervertebral disc degeneration progression and mitigating associated pain [72]. Additional knowledge of fascial neurological components could impact lower back pain treatment [82]. Fear of movement is positively (but weakly) associated with trunk stiffness in low back pain [73].

Kinematics and Motor Control: Movement-preserving properties of total disc replacement in the lumbar spine are not major determinants of clinical outcomes [51]. Reducing the extent of facetectomy may decrease morbidity in failed back surgery syndrome by lowering the risk of biomechanical deterioration [55]. Wearable technologies and biofeedback modalities are used to modulate spine motor control, though standardized reporting and further research are needed to establish clinical efficacy [56]. Trajectory patterns may represent practical phenotypes of low back pain that could improve clinical dialogue with patients and support clinical decision making [85].

Assessment and Planning: Physical examination of the spine includes inspection, palpation, range of motion testing, and neurologic evaluation to identify spinal pathology, nonspinal conditions, and signs of symptom magnification [67]. Preoperative planning for pedicle screw insertion in adolescent idiopathic scoliosis should be based on anatomical limitations in the apical vertebra region, apical vertebra level, and apical vertebral rotation degree [88]. A machine-learning model accurately predicted outcomes after surgery for adult spinal deformity [78]. Excluding spinal manipulation or stretching does not affect the occurrence of adverse events after manual therapy for neck and/or back pain [76].

Health Economics: Determining the value of spine care requires measuring quality and cost over an adequate time horizon, with health utility and quality-adjusted life years serving as preferable quality measures for cost-effectiveness analysis [83].

Classification

Pain Origin and Management Strategy: The origin of the pain should be the basis of the symptomatic therapy [3]. A thorough and specific plan for the management of persistent chronic pain should be developed and instituted when a surgical solution does not exist [5]. Multimodal analgesic regimens are recommended for the management of postoperative pain [27], as multimodal approaches address both peripheral and central pain pathways using a variety of medication and nonmedication modalities and are more effective than any one intervention alone [13]. Having an established pain management system in place with protocols to assist in reducing opioids and improving a framework for managing the perioperative period is imperative [23]. Alternative medications and treatment strategies are supported by evidence, though no best practices model for postoperative pain management was demonstrated [7]. There is no consensus on the optimal multimodal pain regimen, and substantial variability exists between institutions and providers [10].

Risk and Symptom Classification: Classification of patients based on pre-treatment symptom severity assists in selecting the most efficacious treatment [54]. A proposed classification provides a foundation for future research and may assist clinicians in better understanding the social dimensions of chronic pain to develop personalized interventions [40]. A risk classification schema using recommended cut-off scores with items similar to the STarT-Back had limited ability to identify persons who progressed to chronic pain in a primary care population with strictly defined acute low back pain [44].

Specific Condition Protocols: Splintage and NSAIDs are effective for minimal symptoms in De Quervain's disease [54]. Steroid injection is the initial treatment of choice for mild to severe De Quervain's disease [54]. A single intra-articular injection has no value in pain relief regardless of the types of drugs used [53].

Regional Anesthesia and Outcomes: The debate on anesthetic medication choice for adductor canal block creates an opportunity for further collaborative research to establish standardization and guidelines for a multimodal pain management protocol that includes regional anesthesia and nerve blocks [57]. A bridging 48-hour multimodal pain management protocol resulted in a length of stay of 1 day for 66% of patients undergoing total shoulder replacement [58]. The bridging 48-hour multimodal pain management protocol resulted in a length of stay of 1 day for 63% of higher-risk patients with ASA-PS class III undergoing total shoulder replacement [58].

Other Considerations: The exclusive use of pain scores in postoperative pain management should be limited to prevent complications [1].

Clinical Presentation

Pain serves as a critical warning sign for impending complications such as compartment syndrome, where masking pain with pharmacological means can lead to missed diagnoses, severe disability, and other adverse outcomes [14]. Consequently, the exclusive use of pain scores in postoperative pain management should be limited to prevent complications [1]. While opioids are effective for the management of acute musculoskeletal pain, the morbidity and mortality related to opioid analgesics reinforce the need for robust, evidence-based guidelines [8].

Chronic Pain and Opioid History: Patients with a history of chronic opioid use continue to present a challenge for pain management even with modern multimodal protocols [2]. Among patients without known risk factors, the incidence of physical dependence and addiction to opioids is far less than perceived [21]. A clinical risk calculator for prolonged opioid use after shoulder surgery is a valuable tool to identify patients benefitting from referral to pain management specialists [37]. This calculator may help to reduce the risk of opioid abuse and addiction [37].

Chronic Low Back Pain: The management of nonspecific chronic low back pain is not well codified and extremely heterogeneous [18]. Residual symptoms are common in the management of nonspecific chronic low back pain [18]. Pharmacological management for nonspecific chronic low back pain should be considered as co-adjuvant to non-pharmacological therapy and is not a substitute for it [18].

Complex Regional Pain Syndrome and Specialized Populations: The origin of the pain should be the basis of symptomatic therapy in Complex Regional Pain Syndrome [3]. Insight into patients' pain experience may help to choose and develop appropriate diagnostic instruments for musculoskeletal pain with central sensitization [35]. A thorough and specific plan for the management of persistent chronic pain should be developed and instituted when a surgical solution does not exist [5].

Perioperative Counseling and Expectations: Perioperative pain control represents the primary concern for patients considering outpatient shoulder arthroplasty [6]. Patients may benefit from preoperative counseling that emphasizes a comprehensive postoperative pain management strategy [6]. Evidence exists for alternative medications and treatment strategies for postoperative pain management in hand surgery, though no best practices model was demonstrated [7]. The consequences of insufficient pain management are probably underappreciated in hand surgery [21].

Objective Monitoring and Adjuncts: Radiological and laboratory evaluation methods may allow for objective treatment monitoring of symptomatic bone marrow lesions of the knee [22]. These methods appear to capture different dimensions than patient-reported pain [22]. Further research is warranted to determine if cannabis is a helpful adjunct to pain management in the patient population studied [33].

Outcomes in Specific Procedures: Minimal side effects were noted with some improvement in the multimodal nonopioid pain cohort following arthroscopic rotator cuff surgery [4]. All patients reported satisfaction with their pain management following arthroscopic rotator cuff surgery [4]. There is no consensus on the optimal multimodal pain regimen for total knee arthroplasty [10]. Substantial variability in multimodal pain regimens exists between institutions and providers for total knee arthroplasty [10].

Investigations

Plain radiography: While radiological evaluation methods may allow for objective treatment monitoring, they appear to capture different dimensions than patient-reported pain [22]. In the context of lower back pain, studies utilizing tightly defined homogenous patient groups may provide the best test for the association between MRI findings (Modic changes) and nonspecific chronic lower back pain and disability [59].

MRI: Early MRI is associated with increased length of disability in patients with acute lower back pain without red flags [60]. Clinical consideration of cartilaginous endplate herniation features is needed in preoperative planning and postoperative management to enhance patient outcomes and satisfaction after percutaneous endoscopic lumbar discectomy [61].

CT: CT-guided local chemotherapy combined with traditional conservative treatment is minimally invasive, beneficial for the drainage of paravertebral abscesses, and provides pain relief for mild spinal tuberculosis [64].

Other Considerations: Patients with a history of chronic opioid use present a challenge for pain management even with modern multimodal protocols [2]. The origin of pain should serve as the basis for symptomatic therapy in Complex Regional Pain Syndrome [3]. A multimodal nonopioid pain protocol provides better or equivalent pain control compared to opioid analgesia following arthroscopic rotator cuff surgery [4]. Minimal side effects were noted with a multimodal nonopioid pain cohort, and all patients reported satisfaction with their pain management [4]. A thorough and specific plan for the management of persistent chronic pain should be developed and instituted when a surgical solution does not exist [5]. Patients considering outpatient shoulder arthroplasty may benefit from preoperative counseling emphasizing a comprehensive postoperative pain management strategy [6]. There is no consensus on the optimal multimodal pain regimen for total knee arthroplasty, and substantial variability exists between institutions and providers [10]. Multimodal approaches address both peripheral and central pain pathways using a variety of medication and nonmedication modalities [13]. Multimodal approaches are more effective than any one intervention alone for pain control after arthroscopic and knee preservation surgery [13]. Masking pain with pharmacological means can lead to missed diagnoses, severe disability, and other adverse outcomes because pain serves as a critical warning sign for impending complications [14]. Better counseling and innovative nonopioid pain management protocols are needed based on patient perceptions regarding pain control after shoulder surgery [25]. Further research with imaging adjuncts and detailed radiographic and inflammatory characteristics is essential in optimizing intraarticular injectable therapies in knee osteoarthritis [69]. In the nonsurgical group, epidural steroid injections were associated with inferior pain reduction through 3 years for degenerative spondylolisthesis, although this was confounded by greater baseline pain [70]. Careful selection of patients for lumbosacral fusion is essential, requiring persistent, disabling pain unrelieved by non-surgical treatment [71]. Periarticular injection with a multimodal protocol decreases pain and improves functional recovery compared with conventional pain control modalities in total hip and knee arthroplasty [68]. Approaches to primary outcome assessment in back pain trials may need radical reassessment [63].

Treatment

Non-Operative

For nonspecific chronic low back pain, symptoms typically resolve without surgical intervention, establishing physical therapy and nonsteroidal anti-inflammatory drugs as the cornerstones of nonsurgical treatment [48]. Pharmacological management for this condition should be considered co-adjuvant to non-pharmacological therapy rather than a substitute, as the management landscape remains heterogeneous with common residual symptoms [18].

Operative

Pain Management: Multimodal analgesia protocols are effective at reducing pain and the number of opioids needed for breakthrough pain with minimal side effects and without compromising patient satisfaction [12]. These approaches address both peripheral and central pain pathways using a variety of medication and nonmedication modalities, proving more effective than any single intervention alone [13]. A multimodal nonopioid pain protocol provides better or equivalent pain control compared to opioid analgesia following arthroscopic rotator cuff surgery, with all patients reporting satisfaction and minimal side effects [4]. Similarly, this protocol provides equivalent pain versus opioid control following meniscus surgery, where all patients reported satisfaction without requiring emergency opioid analgesia [16]. Application of patient education tools and innovative multimodal pain management protocols successfully eliminates the need for opioids while maintaining excellent patient satisfaction and outcomes after arthroscopic rotator cuff repair [19].

Opioid-sparing strategies yield superior outcomes in joint arthroplasty; an opioid-sparing pain management protocol after shoulder arthroplasty results in less opioid consumption and higher satisfaction [9]. In total hip arthroplasty, nonnarcotic pain management protocols result in significantly decreased opioid consumption and fewer adverse effects while providing adequate pain control comparable to narcotic protocols [47]. Nonopioid medications as part of a perioperative pain control strategy demonstrate improved pain scores compared with opioid medications with similar patient satisfaction and functional outcomes after carpal tunnel release [39]. For outpatient arthroscopic surgery of the knee, multimodal analgesic regimens are currently recommended [27]. A multimodal, nonopioid pain protocol was found to be effective in managing postoperative pain following common orthopedic sports procedures [46].

Despite the efficacy of nonopioid strategies, opioids remain effective for acute musculoskeletal pain, yet the associated morbidity and mortality reinforce the need for robust, evidence-based guidelines [8]. Although a systematic review did not demonstrate a best practices model for postoperative pain management, it provides evidence for alternative medications and treatment strategies [7]. Prescribing a different opioid reduced medication requirements for non-opioid-naive patients undergoing hand and upper-extremity surgery, though additional strategies are needed to address postoperative pain management [17]. Patients with contraindications to NSAIDs remained in the hospital longer and consumed higher quantities of opioids after lumbar fusion [43].

To optimize outcomes, the exclusive use of pain scores in postoperative pain management should be limited to prevent complications [1]. Patients may benefit from preoperative counseling emphasizing a comprehensive postoperative pain management strategy [6], and there is a specific need for better counseling and innovative nonopioid pain management protocols regarding patient perceptions of pain control after shoulder surgery [25]. Greater self-efficacy was the best determinant of satisfaction with pain relief after fracture surgery [36], and targeting patients' self-efficacy should have a prominent place in pain management and self-management programs for chronic low back pain [38]. When a surgical solution does not exist, a thorough and specific plan for the management of persistent chronic pain should be developed and instituted [5].

Complications

Opioid-Related Morbidity: The morbidity and mortality associated with opioid analgesics necessitate robust, evidence-based guidelines for acute musculoskeletal pain management [8]. While the incidence of physical dependence and addiction is far lower than perceived among patients without known risk factors, the consequences of insufficient pain management in this population are likely underappreciated [21]. Preoperative opioid users face significant challenges, presenting markedly lower rates of clinically notable outcomes after total shoulder arthroplasty and higher rates of persistent pain and continued opioid use at 6-month and 1-year follow-ups [29]. Furthermore, patients with a history of chronic opioid use remain difficult to manage even with modern multimodal protocols [2].

Multimodal Analgesia Outcomes: Multimodal analgesia protocols effectively reduce pain and the number of opioids required for breakthrough pain while maintaining minimal side effects [12]. These protocols do not compromise patient satisfaction, with all patients in the multimodal nonopioid cohort following arthroscopic rotator cuff surgery reporting satisfaction [4]. Specifically, minimal side effects were noted in this cohort [4], and there is no increase in short-term complications or unplanned readmissions associated with multimodal analgesia for shoulder arthroplasty [41]. However, the exclusive use of pain scores in postoperative management should be limited to prevent complications [1].

Chronic Pain and Specific Syndromes: A thorough and specific plan for managing persistent chronic pain must be developed when a surgical solution is unavailable [5]. For Complex Regional Pain Syndrome, the origin of the pain should serve as the basis for symptomatic therapy [3]. In primary care settings, associations with age, comorbidity, and prior medication history suggest that guidelines for analgesic choice are only partially utilized at first presentation for musculoskeletal conditions [65]. Additionally, pain management and primary care physicians prescribe opioids at higher rates in chronic periods before and after surgery compared to other providers [24].

Alternative Modalities and Considerations: Ketorolac appears to be a viable alternative to opioids for postoperative pain management in hand surgery, provided a detailed past medical history is obtained [62]. Clinical and personal experiences with opioids, alongside demographics, should be emphasized in the clinical history for orthopaedic trauma populations [31]. High-quality trials and long-term follow-up are recommended to evaluate disability, quality of life, and pain outcomes for transcutaneous vagus nerve stimulation in chronic low back pain [15]. Finally, results from trials on local anaesthetic wound infiltration will inform evidence-based recommendations for short-term and long-term pain management after lower limb joint replacement [20].

Recovery

Light activity (weeks): Evidence regarding specific week ranges for light activity, such as desk work or driving, is not explicitly provided in the current evidence base for this section. However, operative management provides more effective relief than nonoperative treatment for degenerative lumbar stenosis in short-term follow-up data [32].

Full activity (months): Specific month ranges for full activity return are not detailed in the provided evidence. However, cyclooxygenase-2 inhibitors improve analgesia and functional recovery in the first postoperative week after total knee arthroplasty [45]. For calcific tendinitis of the rotator cuff, both ultrasound-guided needling combined with a subacromial corticosteroid injection and high-energy extracorporeal shockwave therapy result in high satisfaction rates after 1-year follow-up [50].

Complete recovery / outcome plateau (months): Preoperative opioid users are more likely to report persistent pain and continued opioid use at 6-month and 1-year follow-ups after total shoulder arthroplasty [29]. Patients with a preoperative duration of symptomatic medial knee overload/arthritis of two years or greater do not experience inferior patient-reported outcomes or clinical outcomes than patients with a symptom duration of less than 2 years at mid-term follow-up after high tibial osteotomy [84]. Cyclooxygenase-2 inhibitors do not improve long-term knee function after total knee arthroplasty [45].

Rehabilitation protocol: The exclusive use of pain scores in postoperative pain management should be limited to prevent complications [1]. Patients with a history of chronic opioid use continue to present a challenge for pain management even with modern multimodal protocols [2]. A multimodal nonopioid pain protocol provides better or equivalent pain control compared to opioid analgesia following arthroscopic rotator cuff surgery [4]. Minimal side effects were noted with some improvement in the multimodal nonopioid pain cohort following arthroscopic rotator cuff surgery [4]. All patients reported satisfaction with their pain management following arthroscopic rotator cuff surgery [4].

Functional milestones: Clinical and personal experiences with opioids, in addition to demographics, should be emphasized in the clinical history for orthopaedic trauma surgery populations [31]. Preoperative opioid use predicts postoperative opioid use and inferior clinically notable outcomes after total shoulder arthroplasty [29]. Preoperative opioid users are markedly less likely to achieve clinically notable outcomes after total shoulder arthroplasty [29]. Pain collected shortly after completion of 6 weeks of study intervention predicted future pain best in a randomized controlled trial of spinal manipulation for chronic low back pain [66].

Other Considerations: The origin of the pain should be the basis of symptomatic therapy in Complex Regional Pain Syndrome [3]. High-quality trials and long-term follow-up are recommended to evaluate disability, quality of life, and pain outcomes for transcutaneous vagus nerve stimulation in chronic low back pain [15]. Results from trials on local anaesthetic wound infiltration will inform evidence-based recommendations for short-term and long-term pain management after lower limb joint replacement [20]. Pain management and primary care physicians prescribe opioids at a higher rate in the chronic periods before and after surgery for spine surgery patients [24]. The age of patients significantly predicted a positive outcome for percutaneous radiofrequency treatment for lumbar facet joint pain [79]. The severity of the initial pain significantly predicted a positive outcome for percutaneous radiofrequency treatment for lumbar facet joint pain [79]. Intraoperative epidural steroids are ineffective in reducing pain in the late stage after lumbar discectomy [86]. Intraoperative epidural steroids are ineffective in reducing the duration of hospital stay after lumbar discectomy [86].

Key Evidence

  • [L4] The exclusive use of pain scores in postoperative pain management should be limited to prevent complications. (10.1016/j.arthro.2006.11.002)
  • [L2] This patient population continues to present a challenge even with modern multimodal pain protocols. (10.1016/j.arth.2016.01.037)
  • [L5] The origin of the pain should be the basis of the symptomatic therapy. (10.1186/1471-2474-10-116)
  • [L1] Minimal side effects were noted with some improvement in the multimodal nonopioid pain cohort, and all patients reported satisfaction with their pain management. (10.1016/j.arthro.2021.11.028)
  • [L5] A thorough and specific plan for the management of persistent chronic pain should be developed and instituted when a surgical solution does not exist. (10.1016/j.xrrt.2022.04.008)
  • [L4] Patients may benefit from preoperative counseling, including emphasizing a comprehensive postoperative pain management strategy. (10.1016/j.jse.2022.07.009)
  • [L3] Although this review did not demonstrate a best practices model for postoperative pain management, it provides evidence for alternative medications and treatment strategies. (10.1016/j.jhsa.2015.05.024)
  • [L5] Although opioids are effective for the management of acute musculoskeletal pain, the morbidity and mortality related to opioid analgesics reinforce the need for robust, evidence-based guidelines. (10.2106/jbjs.20.00228)
  • [L1] Patients also reported higher satisfaction with this pain management strategy. (10.1016/j.jse.2022.05.029)
  • [L5] There is no consensus on the optimal multimodal pain regimen, and substantial variability exists between institutions and providers. (10.2106/jbjs.19.01035)
  • [L5] Multimodal analgesia protocols are effective at reducing pain and the number of opioids needed for breakthrough pain with minimal side effects and without compromising patient satisfaction. (10.1016/j.arthro.2020.05.003)
  • [L4] Multimodal approaches address both peripheral and central pain pathways using a variety of medication and nonmedication modalities and are more effective than any one intervention alone. (10.5435/jaaos-d-23-00342)
  • [L4] Pain serves as a critical warning sign for impending complications such as compartment syndrome; masking pain with pharmacological means can lead to missed diagnoses, severe disability, and other adverse outcomes. (10.2106/00004623-200109000-00020)
  • [L1] Therefore, high-quality trials and long-term follow-up are recommended to evaluate disability, quality of life, and pain outcomes. (10.1186/s12891-024-07569-w)
  • [L1] All patients reported satisfaction with their pain management without requiring emergency opioid analgesia. (10.1016/j.arthro.2021.02.043)
  • [L3] Prescribing a different opioid reduced medication requirements for these patients, but additional strategies are needed to address postoperative pain management. (10.1177/1558944719828000)
  • [L5] The management of nonspecific chronic low back pain is not well codified and extremely heterogeneous, with residual symptoms common; pharmacological management should be considered as co-adjuvant to non-pharmacological therapy and is not a substitute for it. (10.1186/s13018-022-03426-5)
  • [L2] Application of patient education tools and innovative multimodal pain management protocols successfully eliminates the need for opioids while maintaining excellent patient satisfaction and outcomes. (10.1016/j.jseint.2020.12.018)
  • [L1] The results from this trial will inform evidence-based recommendations for both short-term and long-term pain management after lower limb joint replacement. (10.1186/1471-2474-12-53)
  • [L5] Among patients without known risk factors, the incidence of physical dependence and addiction to opioids is far less than perceived; however, the consequences of insufficient pain management are probably underappreciated. (10.1016/j.jhsa.2009.04.022)
  • [L3] Radiological and laboratory evaluation methods may allow for objective treatment monitoring but appear to capture different dimensions than patient-reported pain. (10.1007/s00167-019-05598-w)
  • [L5] Having an established pain management system in place with protocols to assist not only in reducing opioids but also in improving a framework for managing the perioperative period is imperative. (10.1016/j.arth.2020.01.001)
  • [L3] Pain management and primary care physicians prescribe opioids at a higher rate in the chronic periods before and after surgery, likely in part because of longer longitudinal relationships with these patients. (10.5435/jaaos-d-24-00167)
  • [L4] This highlights the need for better counseling and innovative nonopioid pain management protocols. (10.1016/j.jseint.2020.12.019)
  • [L5] It is currently recommended that multimodal analgesic regimens be utilized in the management of postoperative pain. (10.2106/00004623-200012000-00010)
  • [L3] Although preoperative opioid users demonstrate improvement in functional-related and health-related quality-of-life PROMs after TSA, they are markedly less likely to achieve clinically notable outcomes and were more likely to report persistent pain and continued opioid use at 6-month and 1-year follow-ups. (10.5435/jaaos-d-21-00319)
  • [L4] Clinical and personal experiences with opioids, in addition to demographics, should be emphasized in the clinical history. (10.1186/s13018-021-02881-w)
  • [L5] Short-term follow-up data indicate that operative management provides more effective relief than nonoperative treatment, but prospective studies comparing the effects of nonoperative and operative interventions on the long-term natural history of lumbar spinal stenosis are needed. (10.5435/00124635-199907000-00004)
  • [L4] Further research is warranted to determine if cannabis is a helpful adjunct to pain management in this patient population. (10.1016/j.arth.2020.06.051)
  • [Letter] The authors question the clinical significance of the findings regarding opioid sparing and pain control, citing inappropriate sample size calculation, lack of anesthesia management details, and failure to assess clinically important differences or functional outcomes. (10.1016/j.jse.2023.09.002)
  • [L4] Insight into patients' pain experience may help to choose and develop appropriate diagnostic instruments. (10.1371/journal.pone.0182207)
  • [L2] Greater self-efficacy was the best determinant of satisfaction with pain relief. (10.1007/s11999-014-3660-4)
  • [L4] This is a valuable clinical decision-making tool to identify patients benefitting from referral to pain management specialists and to possibly reduce the risk of opioid abuse and addiction. (10.1016/j.jse.2019.03.033)
  • [L3] In pain management programs and self-management programs for CLBP, targeting patients' self-efficacy should have a prominent place. (10.1186/s12891-021-04637-3)
  • [L1] Nonopioid medications as part of a perioperative pain control strategy demonstrate improved pain scores compared with opioid medications with similar patient satisfaction and functional outcomes. (10.1177/1558944719836211)
  • [L5] The proposed classification provides a foundation for future research and may assist clinicians in better understanding the social dimensions of chronic pain, ultimately contributing to the development of more personalised interventions tailored to patients' social and life contexts. (10.1186/s12891-025-09216-4)
  • [L2] There is no increase in short-term complications or unplanned readmissions, indicating that this is a safe and effective means to control postoperative pain. (10.1016/j.jse.2017.11.015)
  • [L5] Multimodal analgesia is recommended for early postoperative pain control to optimize patient outcomes and reduce opioid consumption. (10.1016/j.jse.2020.04.049)
  • [L3] Patients with contraindications to NSAIDs remained in the hospital longer and consumed higher quantities of opioids. (10.5435/jaaos-d-24-00450)
  • [L2] A risk classification schema using the recommended cut-off scores with items similar to the STarT-Back in a primary care population with strictly defined acute LBP had limited ability to identify persons who progressed to chronic pain. (10.1002/ejp.615)
  • [L2] While they improve analgesia and functional recovery in the first postoperative week, they do not improve long-term knee function. (10.1186/s42836-019-0015-3)
  • [L4] A multimodal, nonopioid pain protocol was found to be effective in managing postoperative pain following common orthopedic sports procedures. (10.1016/j.arthro.2020.04.018)
  • [L2] Both protocols provided adequate pain control after total hip arthroplasty; the nonnarcotic pain management protocol resulted in significantly decreased opioid consumption and fewer adverse effects. (10.1016/j.arth.2010.01.003)
  • [L5] In most patients with low back pain, symptoms resolve without surgical intervention; physical therapy and nonsteroidal anti-inflammatory drugs are the cornerstones of nonsurgical treatment. (10.5435/00124635-200902000-00006)
  • [L2] Both techniques are successful in improving function and pain, with high satisfaction rates after 1-year follow-up. (10.1016/j.arthro.2020.02.027)
  • [L1] This suggests that in the lumbar spine the movement preserving properties of TDR are not major determinants of clinical outcomes. (10.1302/0301-620x.95b1.29829)
  • [L2] US-guided needling treatment, however, was more effective in function restoration and pain relief in the short term. (10.1016/j.jse.2014.06.036)
  • [L1] In addition, a single IA injection would have no value in pain relief, regardless of types of drugs. (10.1016/j.arthro.2011.10.015)
  • [L4] Classification of patients based on pre-treatment symptom severity assists in selecting the most efficacious treatment; splintage and NSAIDs are effective for minimal symptoms, while steroid injection is the initial treatment of choice for mild to severe disease. (10.1054/jhsb.2001.0568)
  • [L5] Less facetectomy is better because it may reduce the risk of biomechanical deterioration and consequently, that of FBSS. (10.1186/s12891-019-2751-5)
  • [L1] The review identifies a range of wearable technologies and biofeedback modalities used to modulate spine motor control, highlighting the need for standardized reporting and further research to establish clinical efficacy. (10.1186/s12891-024-07867-3)
  • [L5] The debate creates an opportunity for further collaborative research to establish standardization and guidelines for a multimodal pain management protocol that includes regional anesthesia and nerve blocks. (10.1016/j.arth.2025.10.001)
  • [L4] This bridging 48-hour multimodal pain management protocol resulted in a length of stay of 1 day for 66% of patients, even for higher-risk patients with ASA-PS class III (63%). (10.1016/j.jse.2017.12.026)
  • [L4] Studies using tightly defined homogenous patient groups may provide the best test for association between MRI-findings and pain and disability. (10.1186/s13018-023-03839-w)
  • [L1] Early MRI is associated with increased length of disability in patients with acute LBP without red flags. (10.1186/s12891-021-04863-9)
  • [L3] These findings emphasize the need for clinical consideration of these imaging features in the preoperative planning and postoperative management to enhance patient outcomes and satisfaction. (10.1186/s13018-024-04746-4)
  • [L5] Although studies might be needed to evaluate specifically use of ketorolac in hand surgery, it appears that ketorolac is a good alternative to opioids for postoperative pain management as long as a detailed past medical history is obtained to explore possible risk factors and drug interactions that would alter the risk-benefit ratio. (10.1016/j.jhsa.2009.04.021)
  • [L4] Approaches to primary outcome assessment in back pain need re-assessment. (10.1186/s12891-015-0534-1)
  • [L3] The strategy combined with CT-guided local chemotherapy treatment is minimally invasive, beneficial for the drainage of paravertebral abscesses and pain relief. (10.1186/s12891-022-05545-w)
  • [L3] Analgesic choice appears multifactorial, but associations with age, comorbidity, and prior medication history suggest partial use of guidelines. (10.1186/1471-2474-15-418)
  • [L2] Pain collected shortly after completion of 6 weeks of study intervention predicted future pain the best. (10.1186/s12891-015-0632-0)
  • [L1] Periarticular injection with a multimodal protocol was shown to decrease pain and improve functional recovery compared with conventional pain control modalities. (10.1016/j.arth.2006.12.027)
  • [L5] The authors agree that further research, particularly with imaging adjuncts and detailed radiographic and inflammatory characteristics, will be essential in optimizing intraarticular injectable therapies in knee osteoarthritis. (10.1016/j.arth.2025.05.005)
  • [L3] In the nonsurgical group, ESI was associated with inferior pain reduction through 3 years, although this was confounded by greater baseline pain. (10.2106/jbjs.19.00596)
  • [L4] Targeting skeletal interoception presents novel avenues for reversing intervertebral disc degeneration progression and mitigating associated pain, paving the way for innovative, mechanism-driven therapies. (10.1186/s13018-025-05577-7)
  • [L4] Fear of movement is positively (but weakly) associated with trunk stiffness. (10.1371/journal.pone.0067779)
  • [L3] Segment lordosis angle (SLA) restoration is dependent on preoperative SLA, cage subsidence, and cage position. (10.1186/s12891-022-05855-z)
  • [L3] This procedure can improve patients' pain, neurological function and kyphotic deformity and achieve effects similar to traditional methods, making it an ideal surgical treatment for thoracolumbar fractures in AS patients. (10.1186/s13018-022-03378-w)
  • [L1] Excluding spinal manipulation or stretching do not affect the occurrence of adverse events. (10.1186/1471-2474-15-77)
  • [L3] Roussouly classification could only be a rough estimate of optimal spinopelvic alignment. (10.1186/s13018-021-02786-8)
  • [L3] The study developed a machine-learning model that accurately predicted outcome after surgery for adult spinal deformity. (10.1302/0301-620x.107b3.bjj-2024-1220.r1)
  • [L1] Post hoc analysis revealed that the age of the patients and the severity of the initial pain significantly predicted a positive outcome. (10.1302/0301-620x.98b11.bjj-2016-0379.r2)
  • [L3] Preoperative lumbar lordosis, disc angle, and intraoperative cage position emerged as significant predictive factors for restoring segmental lumbar lordosis. (10.1186/s12891-025-08893-5)
  • [L1] Additional knowledge of fascial neurological components could impact lower back pain treatment. (10.3390/jcm10194342)
  • [L5] Determining the value of spine care requires measuring quality and cost over an adequate time horizon, with health utility and quality-adjusted life years serving as preferable quality measures for cost-effectiveness analysis. (10.5435/jaaos-21-07-419)
  • [L4] Patients with a preoperative duration of symptomatic medial knee overload/arthritis of two years or greater do not experience inferior PRO or clinical outcomes than patients with a symptom duration of less than 2 years at mid-term follow-up. (10.1016/j.jisako.2022.03.003)
  • [L4] Trajectory patterns may represent practical phenotypes of LBP that could improve the clinical dialogue with patients and support clinical decision making. (10.1186/s12891-016-1071-2)
  • [L1] There is also relatively strong evidence that they are ineffective in reducing pain in the late stage and in reducing duration of hospital stay. (10.1186/1471-2474-15-146)
  • [L3] Measurement of TK with T2 on standing whole spinal radiographs resulted in a greater measurement error of up to 6.6°. (10.1186/s12891-021-04786-5)
  • [L4] Preoperative planning to accurately select and insert pedicle screws in adolescent idiopathic scoliosis should be based on anatomical limitations in the apical vertebra region, apical vertebra level, and apical vertebral rotation degree. (10.1186/s12891-022-05799-4)
  • [L2] Findings suggest that a pro-nociceptive pain modulatory balance characterized by enhanced pain facilitation may be an important driver of movement-evoked pain severity and poor physical function in individuals with chronic low back pain. (10.1186/s12891-021-04306-5)

See Also

References

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b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.