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Centralizing and reporting of complex endovascular interventions

In his article, neurosurgeon Andrew Zacest has taken a brave stance. On the one hand, his call for surgeons to become more informed about the remarkable recent developments in the biology of nociception and pain is more than timely. By definition, the necessary and respected art of surgery incurs nociception and so understanding and management of acute post-operative pain and the potential for preventing chronic pain should be a surgical responsibility. At the neurophysiological level, appreciation of the mechanisms underlying central sensitization of nociception should be a minimum ‘basic science’ requirement for all medical practitioners but especially those whose work necessarily involves application of noxious stimuli to patients. Indeed many operative techniques have been modified to limit not only nerve damage but also the afferent nociceptive barrage inherent in surgery. However, Professor Zacest also turns his sights onto surgical ‘remedies’ for chronic pain, in particular spinal pain. The assumption that such pain is directly attributable to a structural abnormality that might be amenable to surgical intervention is now inconsistent with neuroscientific insights and with evidence. The former reveal that chronic pain is associated with altered central nociceptive function – a changed ‘pain-signalling’ apparatus (for want of a technically more accurate term) – and with a change, often permanent, in that person’s interaction with the world. Such is the pervasive nature of persistent pain that the psychological (what is happening to the person) and the social (what is happening in the person’s world) dimensions are just as if not more important in determining the experience of pain as may be the somatic dimension (what is happening to the person’s body). The discrepancy between (radiologically) demonstrable structural ‘abnormality’ and the presence of symptoms has long been recognized and applies not only to spinal pain: what is new is recognition of the role that the central nervous system plays in the generation of pain, irrespective of any altered anatomy. These considerations may help to explain why well-executed, apparently rational procedures are often associated with poor outcomes in patients with chronic pain. This is not to doubt the genuine intent of surgeons to improve the lot of their patients by influencing anatomy. However, even for those procedures that are claimed to ‘work’, the role of contextual (placebo) effect – in all therapies but especially those with high face validity, requiring complex technical skills and technology and, it has to be said, often with a hefty price tag – must be taken into account when interpreting outcomes. Professor Zacest might be seen to be arguing against his own interests by advocating for better evidence – no matter how difficult studies may be to perform – in order to distinguish verum effect from placebo effect, but awareness of this area of critical inquiry should be required of all proceduralists. Those of us in pain medicine so often wish that patients we see had not been subjected to procedures that, although well-intentioned, turned out to be based on insufficient appreciation of the nature of the experience of chronic pain.