INTRODUCTION TO SPINOLOGY

Ever since our ancestors developed the ability to walk on two human spines became vulnerable to gravitational challenges. Granted, humans created defending mechanisms shaping their spines into four gentle curvatures that helped to absorb mechanical stress. Furthermore, hunters and gatherers’ strong paraspinal (around the spine) muscles protected them from shifts and slips in their back and neck. Modern humans are different. We sit a lot and eat a lot, are either inactive or engage in unnatural physical activities, and are stressed over many things that have nothing to do with core survivorship. People are pawns of their habits and prone to automated behaviour. Most of us do not realize self-harm until it is too late. Even when we do, we rarely change our patterns. The examples of the former are strenuous sports challenges, while smoking represents an example of the latter.

On the other hand, there is a generations-long fallacy concerning the medical treatment of back pain. A typical scenario includes a visit to a family doctor or emergency room following by recommendations to take anti-inflammatories, rest and see physiotherapist and orthopedic surgeon. Moreover, patients usually receive “good news,” reassuring them they have a 70% chance of getting better in 4-6 weeks. The alternative news is every third patient will not get better! Generic remedies do not usually work, and orthopedic surgeons do not treat back and neck pain unless they see a reason to operate. Referring all back and neck patients to spine surgeons does not make sense. It is a historically wrong automated medical decision pattern. Indeed, no one considers sending a patient with a common headache to a neurosurgeon. Still, people with back pain are doomed to wait to see an orthopedic specialist only to receive the same chant: “take an anti-inflammatory, do physio and give some time.” In recent years, surgeons initiated and developed programs led by physiotherapists and chiropractors that evaluate and triage patients without doctors. These programs work but to a certain extent. Patients do not need a surgeon but want to see a spine specialist anyway to guide non-physicians, advise, and offer advanced technical non-surgical methods. Unfortunately, traditional medical training does not have a “spinology” pathway. A neurologist may elect to specialize in treating headaches and receive formal education and coaching. Still, none of the residency programs include comprehensive education in spine health. Usually, doctors evolve and acquire skills and philosophy of spinology later in their career in orthopedics, rehabilitation or pain medicine. Spinology rejects the concept of “non-specific back/neck pain.” Therefore, the first pursuit is to establish a precise anatomical diagnosis. “If you alter the structure, you alter the function.” Almost any functional problem has an anatomical cause. Even when the cause cannot be fixed, diagnosing it allows finding detours and solutions to restore health. Spinology embraces a viewpoint and practical methods to help the spine function at its best possible level. Spinology program focused on two goals. The first is to alleviate pain and even address the pain source. It works as a reset button, helping brain to refocus from pain and fear to repair and function. The next step is to cater to individual needs by implementing a tailored approach to prevent re-injury and promote innate regenerative mechanisms. The program addresses habits and lifestyles by determining benchmarks and helping participants to achieve them via constant support of their needs and forming new habits. 

Chronic Pain Assessment After MVA

Chronic Pain Assessment is a perplexing task.  How can one possibly verify the existence of a subjective, highly individual experience? That is possibly why numerous experts retreated to a typical formula stating that “from a purely physical” or “strictly psychological” point, nothing can support the client’s complaints. Although it can be convenient, these pleas do not hold well from philosophical (i.e., dualism), legal (i.e., court obligations), or medical (i.e., establishing diagnosis) aspects. Moreover, as the Supreme Court of Canada said in Nova Scotia (Workers’ Compensation Board) v. Martin; Nova Scotia (Workers’ Compensation Board) v. Laseur, [2003] 2 S.C.R. 504, 2003 SCC 54: “There is no authoritative definition of chronic pain. It is, however, generally considered to be pain that persists beyond the normal healing time for the underlying injury or is disproportionate to such injury and whose existence is not supported by objective findings at the site of the injury under current medical techniques. Despite this lack of objective findings, there is no doubt that chronic pain patients are suffering and in distress and that the disability they experience is real... Despite this reality, since chronic pain sufferers are impaired by a condition that cannot be supported by objective findings, they have been subjected to persistent suspicions of malingering on the part of employers, compensation officials, and even physicians”.

One of the best examples of such misconception is the so-called “whiplash-associated disorder.” While most insurance-hired experts prefer to label it “neck sprain/strain,” the majority of pain doctors name the condition “chronic cervical facet joint syndrome.” The difference is not just semantical. The former “diagnosis” is considered a minor injury and no extensive treatments are recommended. The latter is a more severe form of the same disorder that requires complex rehabilitation and interventional methods. Two case-law decisions supported diagnostic image-guided nerve blocks to differentiate between these two diagnoses. Positive results (pain reduction) can strengthen the evidence provided to courts of law and tribunals and state, with solid support, that there is a physical source of the pain due to the injury. These procedures should be used as a standard protocol in preparing legal cases involving cervical pain as a result of trauma. Unfortunately, Ontario lawyers are mainly oblivious to these matters.

It is time to change the way chronic pain and related disability is assessed. Perhaps it is also time for the insurance system to acknowledge the existence of Pain Medicine and stop dismissing Pain as a symptom. Certainly, it is the right time to offer practical strategies to facilitate recovery and regain functionality. These methods exist beyond the usual one size fits all routine of rehab centres and needle shop pain clinics.

Chronic Pain

Chronic pain is a confusing term. Most people have difficulty grasping the meaning and significance of daily pain experiences. It has been perplexing even for doctors, specifically when patient complaints seem detached from an appearance. There is no simple way to verify that a person is indeed in pain. A measuring instrument when a person is asked to grade the severity of pain on a so-called numeric scale between 0 and 10 is utterly meaningless in a non-acute setting. Chronic pain is an individual contextual experience, mostly obscured from an observer's eyes. The phenomenon has also become medicalized in modern society. A half-century ago, a 70-year-old would certainly expect to have some "inconveniences" such as morning back stiffness and joint pain. He would never consider visiting a doctor. Currently, people expect to find medical solutions for any age or physiology-related discomfort, let alone pain. We thrive to live pain-free. Nonetheless, allegedly 20-30% of the population affected by chronic pain. It would be wise to examine a cause of this seemingly unsolvable problem. Aside from the obvious reasons, such as the brain, spinal cord or peripheral nerve injuries, cancer and other debilitating conditions, chronic pain may be explained as a maladaptive (dysfunctional) behaviour.  In 1987 American Medical Association (AMA) argued that chronic pain syndrome, as opposed to chronic pain, "has the added component of certain recognizable psychological and socioeconomic influences." The AMA stated that chronic pain syndrome has its origin in both iatrogenic (caused by medical treatment) factors, such as prolonged use of passive physiotherapy and inactivity, and nomogenic factors (nomogenesis refers to abnormal illness behaviour functionally related to social legislation that rewards complaints of pain, suffering, and disability).

It was initially assumed that psychological factors would require some time to have an impact following an acute injury, possibly due to avoidance learning leading to disuse, a concept now challenged. For example, a longitudinal evaluation of the recovery of 117 individuals from an acute back pain episode discovered that "there was no evidence of chronic pain evolving and growing, but rather of the persistence of the acute presentation." Although the AMA clearly stated that chronic pain syndrome does not constitute a mental health problem, the diagnosis is often equated with the psychiatric diagnosis of pain disorder associated with psychological factors.

A common delineator of chronic pain syndrome is individual suffering endorsed by medical, societal, and environmental factors. Pain is an essential and evolutionary useful sensation alerting individuals to avoid further injury (e.g., quickly remove finger from a stove) and provide an educational experience (e.g., to mix hot and cold water before taking a shower). Chronic pain has no adaptogenic role. It is a nuisance, an obstacle, and an enemy. Yet, it has a physiological, or more accurate, pathophysiological role in modifying human behaviour. Consciously or subconsciously, it can be useful to avoid responsibilities, receive attention, obtain disability benefits, and escape into artificial existence supported by chemical coping (e.g., opioids). Pain is a function of the brain. Thus, chronic pain syndrome is a disease of the central nervous system with its somatic (e.g., diffuse pain, decreased range of motion, sensory and motor abnormalities), psychological (e.g., depression, catastrophizing, poor sleep, personality changes, memory loss) and social (e.g., loss of income, social withdrawal) aspects. There is no doubt that social contracts play a significant role in the development and maintaining of chronic pain syndrome. However, the affected person has a lower quality of life on the individual level than a patient with a heart attack.

Although multidisciplinary pain management has demonstrated efficacy for pain reduction and functional recovery, only motivated patients are deemed to benefit from these costly and lengthy programs. Therefore, there is a need for socially responsible and effective actions focused on the support and transformation of people suffering from chronic pain. Humans should learn from social animals. A flock of geese will not carry a weak bird on their wings but rather surround it and encourage it to keep flying to the destination. Motivation for goal setting and cheering up personal achievements are probably the most critical steps to recovery. There is no doubt any beginning is complicated and thorny. Daily ratification and encouragement would often be necessary to change harmful habits and to break self-damaging routines. However, as new patterns are developed, people may observe positive changes that will establish positive-loop feedback, encouraging further progress. People who could reconnect with themselves and society may not stop having pain because of the underlying conditions. Still, they may become merely detached from the construct of suffering. Once the issue regressed to an unpleasant but mundane experience, no medical attention is necessary. The doctor's role is not just to treat the ill when medically possible but also to facilitate personal and community transformation as an educator and public advocate. 

Interventional pain: to whom, by whom and in what circumstances

The selection of candidates for interventions may be daunting. The desire to apply advanced methods to cure or manage chronic pain often outweigh clinical reasoning and sometimes contradicts the fundamental principle “do no harm”.

When the patient side of the story is critically dissected, the best way to keep with medically sound recommended approach of matching the subjective, objective and imaging to construct the diagnosis. When one of these components does not make sense, invasive methods are better to be avoided. Social problems and mental disorders respond to other strategies lying outside the operating theatre and procedure room.

Once a patient is deemed to be a candidate for intervention, the physician's expertise and qualifications became the next crucial question. No one deserves a surgeon who performed just a few operations. Hands-on training is an essential part of medical education, but it should not be done on patients. At the very least, a physician must disclose his limited experience to the patient.

Finally, when an experienced physician administers an invasive procedure, other vital elements of care must be thought out, such as education with building self-management tools, functional rehabilitation, nutrition, etc.

Interventional pain procedures are rarely successful in isolation. Physicians must avoid using invasive methods as a placebo. They should be adequately educated and train to select the best methods and apply them to patients who may benefit. Support care and ancillary services should be available to achieve better and long-lasting results.  

Orange is a new black: a short story about ketamine

Once upon a time, I started General Surgery rotation in urgent care. It was around 2am when we admitted a healthy muscular young fellow with perianal abscess. He needed a so-called I&D (incision and drainage), or, put it simply, to get the pus out. In 1986, not every surgical intervention required the attendance of an anesthetist. Nurses or medical students would take blood pressure and measure pulse and administer sedative drugs. My surgeon asked me, at that time, medical student,  to inject "Calypsol" a drug that I subsequently learnt had another name - ketamine. The surgeon explained the medication will allow him to make incision without knocking the patient completely out. The surgery went well, and after 15 min, we were on our way to the recovery room. Here things went unexpectedly odd. The patient became somewhat agitated, his muscles tensed, and he developed a visible erection.  He was mumbling something incomprehensible. Only after he woke up, he broke into a slew of emotional comments full of profanities and described vivid dreams, hallucinations and "out of body experience." 

Later in my work as an anesthetist, I used ketamine so often in trauma setting when an accidental drop of the blood pressure and depression of breathing were undesirable.  At that time, I already knew about "funny" sides of ketamine and always added medications to prevent or forget psychedelic experiences. 

Fast forward into my later years, we started using ketamine during and after surgeries for patients on high doses of opioids. It resulted in a dramatic decrease in morphine consumption and better pain control. 

My fourth and ongoing encounter with ketamine started one year ago. I finally overcame my skepticism related to reported miracles after ketamine infusions for chronic pain. As a matter of fact, I was familiar with publications concerning high-dose administration in an intensive care setting over several days for managing severe pain due to so-called Chronic Regional Pain Syndrome (CRPS). However, ketamine low-dose infusions in an ambulatory setting just did not sit well with me. Anyhow, after persuasion by colleagues and reading more literature, I tried it on a very carefully selected patient. I anxiously waited for her next appointment fearing to hear a horror movie story with hallucinations and other adventures. To my astonishment, the lady assured me that "it was the best experience" and her burning pain of the past 5 years disappeared. She also commented her mood and vitality have dramatically improved. Ever since I became a strong advocate for this therapy. In my experience, neuropathic pain (e.g., diabetic neuropathy, CRPS, phantom pain) is the most appropriate indication, following by a widespread fibromyalgia-type.  Even when the severity of pain remained the same, pain unpleasantness and other disturbing sensations tend to diminish.

Last but not least positive side effect is antidepressive. I do not treat depression, and when asked, send patients to mental health specialists. Nonetheless, chronic pain and depression are interwoven. Improved mood results in a decreased perception of suffering, gives more willpower for self-management and reactivation. 

Who would believe that the old drug with hallucinogenic properties similar to LSD and "magic mushrooms" will be a powerful remedy to fight chronic pain? 

Chronic Pain Syndrome vs Somatic Symptom Disorder

The College of Physicians and Surgeons of Ontario policy states that “physicians must only practice in the areas of medicine in which they are educated and experienced.”

Chronic Pain specialists are often encountering challenges related to the scope of practice in both clinical and legal fields. It is not surprising given the complexity of chronic pain, its biopsychosocial phenomena and interdisciplinary approaches.

In this essay, I will try to differentiate the two most commonly confused entities, Chronic Pain Syndrome and Somatic Symptom Disorder.

The diagnosis of chronic pain is based on syndrome analyses and recommendations of the International Association for the Study of Pain (IASP). The IASP defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” The definition of chronicity is not bound. Chronic pain was traditionally defined by the length of time that pain persists, but a time-based approach ignores many other essential features. Attempts to conceptualize resulted in more confusion. The IASP currently defines chronic pain as “pain without apparent biological value,” pain “that has persisted beyond the normal tissue healing time . . . as determined by common medical experience,” and (or) as “a persistent pain that is not amenable, as a rule, to treatments based upon specific remedies.”

The traditional view on the Chronic Pain Syndrome (CPS) is a presence of pathological conditions that for poorly understood reasons resulted in complex neuropsychological changes in the central nervous system leading to physical and emotional suffering and social dysfunction. The chronic pain syndrome construct was delineated in 1987 when it was argued that chronic pain syndrome, as opposed to chronic pain, “has the added component of certain recognizable psychological and socioeconomic influences.” The presence of at least four of the following eight characteristics was said, by the American Medical Association (AMA), to establish the diagnosis of chronic pain syndrome:

• Duration (more than six months)

• Dramatization

• Drugs

• Despair

• Disuse

• Dysfunction

• Diagnostic dilemma

• Dependence on others and/or on passive physical therapy

 The American Medical Association (AMA) stated that CPS has its origin in both iatrogenic factors, such as prolonged use of passive physiotherapy modalities and prolonged inactivation, and nomogenic factors (nomogenesis refers to abnormal illness behaviour functionally related to social legislation that rewards complaints of pain, suffering, and disability). CPS is a biopsychosocial chronic, and, in many cases, irreversible condition. Potentially noxious event, particularly if occurred in certain stressful situations (e.g., trauma, surgery, assault, motor vehicle accident), coupled with neuropsychological traits or overt psychopathology and amplified by social factors (e.g., low level of education, substance dependency, low income job) may create negative loop of suffering, pain behavior and disability. Pain is a function of brain, and in this construct the chronic pain syndrome is a disease of the central nervous system with its somatic (e.g., regional or diffuse pain, decreased range of motion,  sensory and motor abnormalities), psychological (e.g., depression, catastrophizing, poor sleep, personality changes, memory loss) and social (e.g., loss of income, social withdrawal) aspects. Conceivably, social contracts pay a significant role in the development and maintaining of the chronic pain syndrome. However, on the individual level, the affected individual has a lower quality of life than a patient with an acute myocardial infarct. This condition may result in complete vocational and social disability.

Although the AMA clearly stated that chronic pain syndrome does not constitute a psychiatric disorder, the diagnosis is often equated with the psychiatric diagnosis of pain disorder associated with psychological factors.

Notwithstanding the relevance of CPS as the diagnosis, in some instances, the biomechanical derangement cannot be defined based on the available clinical and other supporting evaluations. For example, low-velocity car accidents have minimal impact on the musculoskeletal system. These injuries have similar or less probability of creating severe lasting anatomical damage than a minor domestic mishap. However, the context is different, which by itself may trigger subsequent development of widespread pain and psychological symptoms. To address this conundrum, the American Psychiatric Association (APA), introduced Somatic Symptom Disorder (SSD) with predominant Pain into DSM-V. SSD was previously known as Pain Disorder or Somatization Disorder. Here are the actual diagnostic criteria as set out on page 311 of DSM-5:

Somatic Symptom Disorder 300.82 Diagnostic Criteria

A.  One or more somatic symptoms that are distressing or result in significant disruption of daily life. B.  Excessive thoughts, feelings, or behaviours related to the somatic symptoms or associated health concerns as manifested by at least one of the following:

Disproportionate and persistent thoughts about the seriousness of one’s symptoms.

Persistently high level of anxiety about health or symptoms.

Excessive time and energy devoted to these symptoms or health concerns.

C.  Although anyone somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically more than six months).

With predominant pain (previously pain disorder): This specifier is for individuals whose somatic symptoms predominantly involve pain.

The similarity between CPS and SSD is evident. Both conditions are related to chronic regional or widespread pain that is disproportional to the inciting event or illness and includes psychosocial problems and dysfunction.

As a chronic pain specialist, I encounter and treat patients with either CPS or SSD. In many cases, the approach is similar and encompasses regular meetings and counselling, careful pharmacological management and allied health support (e.g., sleep hygiene, nutritional advice, alleviation of fear to inflict more damage with exercises). While interventional approaches may be considered in CPS, only after addressing psychosocial burdens, these methods are contraindicated for SSD patients. Invasive procedures reinforce negative beliefs related to somatic complaints and fixation.

Generally speaking, a presence or absence of anatomical problem can differentiate CPS from SSD. CPS includes a significant biomechanical component (e.g., subluxation of the cervical facet joint, herniated lumbar disc) that was not adequately and effectively treated on acute or subacute stages and, therefore, progressed into biopsychosocial derangement. SSD is a mental health condition that has maladaptive behavioural expressions. It is a diagnosis by exclusion of other possible medical and/or mental disorders. Although a chronic pain specialist may and should offer help to these patients, expert opinion and therapeutic input of a psychologist and/or psychiatrist is invaluable for both clinical and medicolegal purposes.

Nerve Blocks

Anytime people talk about "pain clinic" this issue keeps coming up. For a reason, unbeknownst to me, patients are expected to submit themselves to needling. Often these injections are performed weekly yet providing either no or very short-term pain relief. For the sake of argument, a placebo effect will not be discussed here, although, indeed there is a lot to do with the so-called expectations and other behavioural effects.

Physiologically, injected local anesthetics (hopefully, without corticosteroids) produce some pleasant warming numbness and muscle relaxation. Rarely, they offer long-lasting pain relief, but the mechanism is not clear. We can speculate that when these drugs are injected very close to the target nerve, or into the nerve, they cause neurotoxicity (poisoning) and slowing conduction of electric impulses through this nerve. There is another hypothesis of a so-called "pain reset," some magical Microsoft-like solution: if something doesn't work, and you don't know what to do, just click "restart." There is also a strong belief that with repeated nerve blocks, the pain will be diminishing. All these hypotheses have never been experimentally confirmed. On the other hand, tissue toxicity was documented in laboratory studies, and conscientious, ethical pain physicians published their experience disproving nerve injections (Arne Johansson and Bengt Sjolund. J Pain Symptom Manage 1996).

On the other hand, nerve blocks can be extremely helpful to identify “pain culprit”. These injections are done to temporary freeze small sensory nerves conducting different feelings including pain. For example, chronic low back pain may be related to intervertebral discs, supportive joints (facets) or other non-spinal structures, such as the sacroiliac joint. Anesthesia of these nerves helps doctors to determine the pain source. Once the diagnosis is made, a more definitive procedure can be considered.

Medicolegal Expert

Let’s face an inconvenient truth: there are no independent medicolegal experts. We, physicians, are paid by either the plaintiff or defence to produce our medical opinions. We are called to remain impartial and nonpartisan. It contradicts human nature. People respond to incentives, and doctors are not immune to this. Even in seemingly transparent academic endeavours, financial incentives play a significant role. Numerous studies and literature reviews show a substantial influence of industry, with a correlation found between funding by the manufacturers and findings that show positive results for efficacy and safety of the benefactor’s products.

Why lawyers have an opportunity to take one's side, but experts can’t? It’s okay to be part of a team, either in daily life or even in court. Even a judge may implicitly sympathize with an accused perpetrator. Empathy or antipathy cannot be rationalized. We endlessly connect with other people because we are social creatures. Thus, if we were programmed to like someone and dislike another based on individual synaptic connections in our cortex, how we are supposed to act when the main reward center in our brain is involved? When a doctor is paid, the amygdala (e.g., Reward Centre) is pleased. Moreover, it will work hard to receive the same reward all over again and make everything possible to eliminate obstacles in this process.

The ethical standards should stand safeguards and suppress the rewarding circuit. However, when ethics are vague in politics, society, culture and religion, why doctors are expected to remain immune, especially when a personal report does not threaten anyone’s life?

The solution is logical and straightforward. Doctors, like attorneys, should be allowed to defend their clients. In the absence of any other superior judgment, courts and mediators should unravel medical casuistic the same way they deal with other legal matters.

My expertise is Chronic Pain, and because pain experience is personal and cannot be measured the same way as the blood pressure or cholesterol level, people are perceived not trustful. Granted, malingerers and con artists are out there, but what would be a reason for any human being to retreat from personal and social life, and hide in a cocoon of suffering if they are not indeed suffering. The reason for such horrific consequences may be different, including the expected compensation, but it will be very naive and mechanistic to assign all physical, emotional and social decline to one cause.

As an Expert, I have been following a simple rule to deal with convoluted issues: trust the patient unless evidence proved otherwise.

The first Health Canada approved PNS device has been implanted

https://www.medgadget.com/2018/06/experiences-from-the-first-stimrouter-implanted-in-patients-in-canada.html

Peripheral Nerve Stimulation for Nerve Injuries

Peripheral Nerve Stimulation (PNS) method is older than any other neuromodulation technique. Pioneers of PNS experimented on themselves stimulating their infraorbital nerves, and achieving pleasant numbness in the face. Here is how they described the first treatment: "On October 9, 1965, Dr. Wall and one of us (Dr. W.H. Sweet) implanted a pair of silastic ring platinum electrodes around the ulnar and another pair around the median nerve in the arm carrying the wires out of the skin at the mid-forearm. On the median nerve 0.1- ms pulses at 100/s and 0.6 V provoked a pleasant tingling in the lateral three fingers and corresponding hand and stopped the pain in the medial three fingers and hand as well as tenderness in the third finger and palm."
White JC, Sweet WH: Pain and the Neurosurgeon:  A Forty-Year Experience. Springfield, Thomas, 1969, pp 894–899.

I started using PNS to treat intractable pain 15 years ago. Since I moved back to Canada in 2013, I have done only R&D work to develop new devices. Three of them are already FDA approved, and Health Canada approval is pending. 

I'm excited to have this modality here to make patients' lives better.

One of my patients from Seattle sent me this note a couple of weeks ago: Hello Dr. Gofeld. I'm the patient that you implanted the IPG into the calf of my leg to alleviate nerve pain in my left ankle. The nerve damage occurred during an ankle replacement. You SAVED my life!! Remembering how desperate I was for some solution, remembering being sent to you after a couple different appointments at the U of W, remembering the day that you told me, "I think I can help you". You don't know the impact your care of me had on my life and those around me! At this time, yes, I still use my IPG on a regular basis. My ankle tells me when to turn it on/off..........I find that so interesting. I just really want you to know that you're thought of and I am an eternally grateful former patient of yours. Sincerely, Sue Q"

Pain Specialist, eh?

A pain specialist, a specialist in chronic pain management, an algologist - all these and other definitions of a doctor who deals with individuals suffering from chronic pain do not make sense for the public. Does a family physician treat chronic pain? Yes, of course, as well as orthopedic surgeons, neurologists, oncologists, and the rest of medical specialties. Even dermatologists and ophthalmologists. So what makes this Pain Medicine special? Why can't each and everyone manage the pain of her/his patients? Perhaps, my view is unconventional, but I believe in accountability and commitment to patient well-being. If my esteemed colleagues did the same, many chronic pain conditions would be extinguished. For example, if spine surgeons would commit to staying with their patients, no surgeries for low back pain would ever happen. The reality is different: patients are promised miracles and cure, and then are thrown away back to their family doctors loaded with narcotics and more pain issues than before the surgery. But, let me come back to definitions.

Chronic Pain Specialist is the one who should be finally able to make a correct anatomically sound diagnosis and treat the problem. Unfortunately, patients get to us after months and often years of physical and, subsequently, emotional suffering. When a clear bio-anatomical cause is not addressed, pain is transformed brain of the sufferer, starting off a vicious cycle of pain-depression-social isolation-drug dependency-pain. Therefore, we, Pain Specialists, should have seen patients with sciatica, acute back and neck pain, and other conditions, way before orthopedic and other surgeons; we should have consulted patients with shingles and traumatic nerve injuries before it is too late. Pain Specialists should be seen as a new Palliative Care model. Just until recently, only dying cancer patients would be referred to Palliative team. With the paradigm shift, these patients are being routinely assessed by palliative care doctors to address their symptoms - pain, fatigue, constipation, etc. It resulted not only in better care, but in significant improvements in the quality of life and, often, survival.