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Pain Management

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

83 citationsUpdated Jul 2026

Overview

Perioperative pain control is the primary concern for patients considering outpatient shoulder arthroplasty [6]. Opioids remain effective for managing acute musculoskeletal pain [8], yet their associated morbidity and mortality reinforce the need for robust, evidence-based guidelines [8]. Multimodal analgesia is recommended for early postoperative pain control to optimize patient outcomes and reduce opioid consumption in shoulder surgery [42].

Multimodal nonopioid pain protocols provide better or equivalent pain control compared to opioid analgesia following arthroscopic rotator cuff surgery [1]. These protocols result in minimal side effects, with some improvement noted in the multimodal cohort [1]. All patients reported satisfaction with their pain management in this group [1]. Similarly, opioid-sparing pain management protocols after shoulder arthroplasty result in less opioid consumption and higher patient satisfaction [9]. Patients reported higher satisfaction with these opioid-sparing strategies [9]. 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].

An integrated educational and multimodal approach successfully eliminates the need for opioids after arthroscopic rotator cuff repair while maintaining excellent patient satisfaction and outcomes [19]. Patients may benefit from preoperative counseling that emphasizes a comprehensive postoperative pain management strategy [6]. However, the exclusive use of pain scores in postoperative pain management should be limited to prevent complications [2]. For patients with a history of chronic opioid use, perioperative pain control presents a challenge even with modern multimodal protocols [3]. Having an established pain management system with protocols to reduce opioids and improve the framework for managing the perioperative period is imperative for opioid-tolerant patients [23].

In hand surgery, a systematic review of acute postoperative pain management did not demonstrate a best practices model but provided 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, but additional strategies are needed to address postoperative pain management [17].

Anatomy & Pathophysiology

Low-back pain possesses a defined epidemiology, natural history, pathology, and pathogenesis [32]. Trajectory patterns may represent practical phenotypes of low back pain that could improve clinical dialogue with patients and support clinical decision making [84]. 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]. Neuromuscular deficits are present in people with low back pain, and core stability contributes to these deficits [71]. Fear of movement is positively (but weakly) associated with trunk stiffness in low back pain [73].

Osseous Alignment and Deformity: * Spinopelvic Alignment: Roussouly classification could only be a rough estimate of optimal spinopelvic alignment in predicting mechanical complications in elderly patients with adult degenerative scoliosis [77]. * Kyphosis Measurement: Measurement of thoracic kyphosis (TK) with T2 on standing whole spinal radiographs resulted in a greater measurement error of up to 6.6° compared to upright computed tomography images [86]. * Lordosis Restoration: Segment lordosis angle (SLA) restoration is dependent on preoperative SLA, cage subsidence, and cage position [74]. Preoperative lumbar lordosis, disc angle, and intraoperative cage position are significant predictive factors for restoring segmental lumbar lordosis following TLIF surgery in lumbar spondylolisthesis patients [80]. * Scoliosis Planning: 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 [87].

Neural and Soft Tissue Pathophysiology: * Interoception and Degeneration: Targeting skeletal interoception presents 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 [81]. * Motor Control: 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].

Surgical Biomechanics and Outcomes: * Disc Replacement: In the lumbar spine, movement-preserving properties of total disc replacement (TDR) are not major determinants of clinical outcomes [51]. * FBSS Morbidity: Reducing the extent of facetectomy may decrease morbidity in failed back surgery syndrome (FBSS) by reducing the risk of biomechanical deterioration [55]. * Ankylosing Spondylitis: Percutaneous surgical treatment of thoracolumbar fractures in ankylosing spondylitis patients can improve pain, neurological function, and kyphotic deformity with effects similar to traditional methods [75]. * Manual Therapy Safety: Excluding spinal manipulation or stretching does not affect the occurrence of adverse events after manual therapy among patients seeking care for neck and/or back pain [76].

Predictive Modeling and Value Assessment: * Outcome Prediction: A machine-learning model accurately predicted outcome after surgery for adult spinal deformity [78]. * Cost-Effectiveness: 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 [82].

Classification

Multimodal Framework: Multimodal analgesic regimens are currently recommended for postoperative pain management [27]. 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]. However, there is no consensus on the optimal multimodal pain regimen, with substantial variability existing between institutions and providers [10]. The debate highlights the need for further collaborative research to establish standardization and guidelines for multimodal protocols that include regional anesthesia and nerve blocks [57]. Establishing an established pain management system with protocols to reduce opioids and improve perioperative management is imperative [23].

Symptom-Based Stratification: The origin of pain should dictate symptomatic therapy [4]. Classification based on pre-treatment symptom severity assists in selecting efficacious treatment: splintage and NSAIDs are effective for minimal symptoms, while steroid injection is the initial treatment of choice for mild to severe disease [54].

Chronic Pain Management: A thorough and specific plan for managing persistent chronic pain must be developed and instituted when a surgical solution does not exist [5]. The proposed classification provides a foundation for future research, helping clinicians understand the social dimensions of chronic pain to develop personalized interventions tailored to patients' social and life contexts [40].

Other Considerations: Risk Stratification: A risk classification schema using 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 [44]. Limitations of Metrics: The exclusive use of pain scores in postoperative pain management should be limited to prevent complications [2]. Injection Efficacy: A single IA injection has no value in pain relief, regardless of the types of drugs used [53].

Clinical Presentation

Acute Postoperative Pain: Multimodal nonopioid pain protocols provide better or equivalent pain control compared to opioid analgesia following arthroscopic rotator cuff surgery [1]. Minimal side effects were noted with some improvement in the multimodal nonopioid pain cohort following arthroscopic rotator cuff surgery [1]. All patients reported satisfaction with their pain management following arthroscopic rotator cuff surgery [1]. Similarly, multimodal nonopioid pain protocols provide equivalent pain versus opioid control following meniscus surgery [16]. All patients reported satisfaction with their pain management following meniscus surgery without requiring emergency opioid analgesia [16]. Opioid-sparing pain management protocols after shoulder arthroplasty result in less opioid consumption and higher patient satisfaction [9]. Patients reported higher satisfaction with opioid-sparing pain management strategies after shoulder arthroplasty [9].

Chronic and Complex Pain Syndromes: Patients with a history of chronic opioid use continue to present a challenge for pain management even with modern multimodal protocols [3]. The origin of the pain should be the basis of symptomatic therapy in Complex Regional Pain Syndrome [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 for painful shoulder arthroplasty [5]. The management of nonspecific chronic low back pain is not well codified and extremely heterogeneous, with residual symptoms common [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]. Insight into patients' pain experience may help to choose and develop appropriate diagnostic instruments for musculoskeletal pain with central sensitization [35].

Risk Assessment and Counseling: Perioperative pain control represents the primary concern for patients considering outpatient shoulder arthroplasty [6]. Patients may benefit from preoperative counseling emphasizing a comprehensive postoperative pain management strategy for outpatient shoulder arthroplasty [6]. 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]. A clinical risk calculator for prolonged opioid use after shoulder surgery may help to reduce the risk of opioid abuse and addiction [37]. Among patients without known risk factors, the incidence of physical dependence and addiction to opioids in hand surgery is far less than perceived [21]. The consequences of insufficient pain management are probably underappreciated among patients without known risk factors in hand surgery [21].

Monitoring and Red Flags: Pain serves as a critical warning sign for impending complications such as compartment syndrome [14]. Masking pain with pharmacological means can lead to missed diagnoses, severe disability, and other adverse outcomes [14]. Radiological and laboratory evaluation methods may allow for objective treatment monitoring of symptomatic bone marrow lesions but appear to capture different dimensions than patient-reported pain [22].

Guideline Variability: There is no best practices model for postoperative pain management in hand surgery, but evidence supports alternative medications and treatment strategies [7]. There is no consensus on the optimal multimodal pain regimen for total knee arthroplasty, and substantial variability exists between institutions and providers [10]. The exclusive use of pain scores in postoperative pain management should be limited to prevent complications [2]. Opioids are effective for the management of acute musculoskeletal pain, but their morbidity and mortality reinforce the need for robust, evidence-based guidelines [8]. Further research is warranted to determine if cannabis is a helpful adjunct to pain management in the studied patient population [34].

Investigations

Plain radiography: Radiological evaluation methods may allow for objective treatment monitoring of symptomatic bone marrow lesions of the knee, although these findings appear to capture different dimensions than patient-reported pain [22].

MRI: Early MRI is associated with increased length of disability in patients with acute lower back pain without red flags [60]. Studies using tightly defined homogenous patient groups may provide the best test for the association between Modic changes on MRI and nonspecific chronic lower back pain and disability [59]. Clinical consideration of cartilaginous endplate herniation 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 is minimally invasive, beneficial for drainage of paravertebral abscesses, and provides pain relief in mild spinal tuberculosis [65].

Bone scan: There is a lack of agreement between the segmental level affected determined from a patient's pain drawing and the affected level identified on MRI for cervical radiculopathy [64].

Other Considerations: Multimodal nonopioid pain protocols provide better or equivalent pain control compared to opioid analgesia following arthroscopic rotator cuff surgery, with minimal side effects noted and all patients reporting satisfaction with their pain management [1]. 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 for pain control after arthroscopic and knee preservation surgery [13]. Periarticular injection with a multimodal protocol decreases pain and improves functional recovery compared with conventional pain control modalities after total hip and knee arthroplasty [68]. Better counseling and innovative nonopioid pain management protocols are needed for pain control after shoulder surgery [25].

Patients with a history of chronic opioid use present a challenge for pain management even with modern multimodal protocols in total knee arthroplasty [3]. There is no consensus on the optimal multimodal pain regimen for total knee arthroplasty, with substantial variability existing between institutions and providers [10]. Epidural steroid injections were associated with inferior pain reduction through 3 years in the nonsurgical group for degenerative spondylolisthesis, although this was confounded by greater baseline pain [69]. Careful selection of patients for lumbosacral fusion is essential, requiring persistent, disabling pain unrelieved by non-surgical treatment [70].

The origin of the pain should be basis of symptomatic therapy in Complex Regional Pain Syndrome [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 for painful shoulder arthroplasty [5]. Perioperative pain control is the primary concern for patients considering outpatient shoulder arthroplasty, and these patients may benefit from preoperative counseling emphasizing a comprehensive postoperative pain management strategy [6]. 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 [14]. Approaches to primary outcome assessment in back pain trials need reassessment [63].

Treatment

Pain Management

Multimodal nonopioid pain protocols provide better or equivalent pain control compared to opioid analgesia following arthroscopic rotator cuff surgery [1]. These protocols are associated with minimal side effects and result in all patients reporting satisfaction with their pain management [1]. An integrated educational and multimodal approach successfully eliminates the need for opioids after arthroscopic rotator cuff repair while maintaining excellent patient satisfaction and outcomes [19]. Similarly, multimodal nonopioid pain protocols provide equivalent pain versus opioid control following meniscus surgery, with all patients reporting satisfaction without requiring emergency opioid analgesia [16]. A multimodal, nonopioid pain protocol was found to be effective in managing postoperative pain following common orthopedic sports procedures [46].

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]. Multimodal approaches address both peripheral and central pain pathways using a variety of medication and nonmedication modalities [13]. These approaches are more effective than any one intervention alone for pain control [13]. For outpatient arthroscopic surgery of the knee, it is currently recommended that multimodal analgesic regimens be utilized in the management of postoperative pain [27].

Opioid-sparing pain management protocols after shoulder arthroplasty result in less opioid consumption and higher patient satisfaction [9]. Patients reported higher satisfaction with opioid-sparing pain management strategies after shoulder arthroplasty [9]. In total hip arthroplasty, both narcotic and nonnarcotic pain management protocols provided adequate pain control [47]. However, the nonnarcotic pain management protocol resulted in significantly decreased opioid consumption and fewer adverse effects after total hip arthroplasty [47]. Nonopioid medications as part of a perioperative pain control strategy demonstrate improved pain scores compared with opioid medications after carpal tunnel release [39]. These nonopioid strategies also result in similar patient satisfaction and functional outcomes compared with opioid medications after carpal tunnel release [39].

Opioids are effective for the management of acute musculoskeletal pain, but their associated morbidity and mortality reinforce the need for robust, evidence-based guidelines [8]. The exclusive use of pain scores in postoperative pain management should be limited to prevent complications [2]. Prescribing a different opioid reduced medication requirements for non-"opioid-naive" patients undergoing hand and upper-extremity surgery, but 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].

Patients considering outpatient shoulder arthroplasty have perioperative pain control as their primary concern [6]. Patients may benefit from preoperative counseling that emphasizes a comprehensive postoperative pain management strategy [6]. Better counseling and innovative nonopioid pain management protocols are needed based on patient perceptions regarding pain control after shoulder surgery [25]. A systematic review on acute postoperative pain in hand surgery did not demonstrate a best practices model but provided evidence for alternative medications and treatment strategies [7].

Greater self-efficacy was the best determinant of satisfaction with pain relief after fracture surgery [36]. In pain management programs and self-management programs for chronic low back pain, targeting patients' self-efficacy should have a prominent place [38]. 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]. The management of nonspecific chronic low back pain is not well codified and extremely heterogeneous, with residual symptoms common [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]. In most patients with low back pain, symptoms resolve without surgical intervention [48]. Physical therapy and nonsteroidal anti-inflammatory drugs are the cornerstones of nonsurgical treatment for low back pain [48].

Complications

Opioid-Related Morbidity: Opioid analgesics are associated with morbidity and mortality, reinforcing the need for robust, evidence-based guidelines for acute musculoskeletal pain [8]. Among patients without known risk factors, the incidence of physical dependence and addiction to opioids is far less than perceived [21]. However, the consequences of insufficient pain management are probably underappreciated [21]. Preoperative opioid users are markedly less likely to achieve clinically notable outcomes after total shoulder arthroplasty [29] and were more likely to report persistent pain and continued opioid use at 6-month and 1-year follow-ups [29]. Patients with a history of chronic opioid use present a challenge for pain management even with modern multimodal protocols [3]. Pain management and primary care physicians prescribe opioids at a higher rate in the chronic periods before and after surgery, likely due to longer longitudinal relationships with these patients [24].

Multimodal Analgesia Efficacy: Multimodal nonopioid pain protocols provide better or equivalent pain control compared to opioid analgesia following arthroscopic rotator cuff surgery [1]. Minimal side effects were noted with some improvement in the multimodal nonopioid pain cohort following arthroscopic rotator cuff surgery [1], and all patients reported satisfaction with their pain management in this cohort [1]. 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]. Multimodal analgesia decreases opioid consumption after shoulder arthroplasty [41], with no increase in short-term complications or unplanned readmissions [41].

Specific Modalities and Considerations: The exclusive use of pain scores in postoperative pain management should be limited to prevent complications [2]. Ketorolac appears to be a good alternative to opioids for postoperative pain management in hand surgery, provided a detailed past medical history is obtained to explore possible risk factors and drug interactions [62]. Tailored neck-shoulder pain treatment based on a decision model guided by clinical assessments and standardized functional tests is hypothesized to have better short, intermediate, and long-term effects on pain and function than non-tailored treatment or treatment-as-usual [26].

Other Considerations: The origin of the pain should be the basis of symptomatic therapy in Complex Regional Pain Syndrome [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]. 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]. The results of 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]. Studies should assess whether local anaesthetic infiltration can prevent long-term pain after total hip and knee replacement [28].

Recovery

Light activity (weeks): Evidence does not specify a week range for light activity or return to desk work.

Full activity (months): Evidence does not specify a month range for full activity, manual work, or sport.

Complete recovery / outcome plateau (months): Evidence does not specify a month range for complete recovery or outcome plateau.

Rehabilitation protocol: Evidence does not specify PT phasing, immobilisation duration, weight-bearing/ROM progression, or sling/brace removal timing.

Functional milestones: Evidence does not specify validated PROM trajectories or outcome-measure benchmarks.

Other Considerations: Multimodal nonopioid pain protocols provide better or equivalent pain control compared to opioid analgesia following arthroscopic rotator cuff surgery [1]. Minimal side effects were noted with some improvement in the multimodal nonopioid pain cohort following arthroscopic rotator cuff surgery [1]. All patients reported satisfaction with their pain management following arthroscopic rotator cuff surgery [1]. The exclusive use of pain scores in postoperative pain management should be limited to prevent complications [2]. Patients with a history of chronic opioid use present a challenge even with modern multimodal pain protocols in total knee arthroplasty [3]. The origin of the pain should be the basis of symptomatic therapy for Complex Regional Pain Syndrome [4]. 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]. Tailored neck-shoulder pain treatment based on a decision model guided by clinical assessments and standardized functional tests is hypothesized to have better short, intermediate, and long-term effects on pain and function than non-tailored treatment or treatment-as-usual [26]. Local anaesthetic infiltration for peri-operative pain control in total hip and knee replacement requires further assessment to determine if it can prevent long-term pain [28]. Preoperative opioid users are markedly less likely to achieve clinically notable outcomes after total shoulder arthroplasty [29]. 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]. Clinical and personal experiences with opioids, in addition to demographics, should be emphasized in the clinical history for orthopaedic trauma surgery patients [31]. Operative management provides more effective relief than nonoperative treatment for degenerative lumbar stenosis in short-term follow-up data [33]. Cyclooxygenase-2 inhibitors improve analgesia and functional recovery in the first postoperative week after total knee arthroplasty [45]. Cyclooxygenase-2 inhibitors do not improve long-term knee function after total knee arthroplasty [45]. Ultrasound-guided needling combined with a subacromial corticosteroid injection is successful in improving function and pain for calcific tendinitis of the rotator cuff [50]. High-energy extracorporeal shockwave therapy is successful in improving function and pain for calcific tendinitis of the rotator cuff [50]. Both ultrasound-guided needling with subacromial corticosteroid injection and high-energy extracorporeal shockwave therapy result in high satisfaction rates after 1-year follow-up for calcific tendinitis of the rotator cuff [50]. Ultrasound-guided needling is more effective than extracorporeal shock wave therapy in function restoration and pain relief in the short term for calcific tendinitis of the shoulder [52]. 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]. The age of patients and the severity of the initial pain significantly predicted a positive outcome for percutaneous radiofrequency treatment for lumbar facet joint pain [79]. Preoperative symptom duration of two years or greater does not result in inferior patient-reported outcomes or clinical outcomes compared to less than 2 years after high tibial osteotomy at mid-term follow-up [83]. Intraoperative epidural steroids are ineffective in reducing pain in the late stage after lumbar discectomy [85]. Intraoperative epidural steroids are ineffective in reducing the duration of hospital stay after lumbar discectomy [85].

Key Evidence

  • [L1] Minimal side effects were noted with some improvement in the multimodal nonopioid pain cohort, and all patients reported satisfaction with their pain management. [1] (10.1016/j.arthro.2021.11.028)
  • [L4] The exclusive use of pain scores in postoperative pain management should be limited to prevent complications. [2] (10.1016/j.arthro.2006.11.002)
  • [L2] This patient population continues to present a challenge even with modern multimodal pain protocols. [3] (10.1016/j.arth.2016.01.037)
  • [L5] The origin of the pain should be the basis of the symptomatic therapy. [4] (10.1186/1471-2474-10-116)
  • [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. [5] (10.1016/j.xrrt.2022.04.008)
  • [L4] Patients may benefit from preoperative counseling, including emphasizing a comprehensive postoperative pain management strategy. [6] (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. [7] (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. [8] (10.2106/jbjs.20.00228)
  • [L1] Patients also reported higher satisfaction with this pain management strategy. [9] (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] (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. [12] (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. [13] (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. [14] (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. [15] (10.1186/s12891-024-07569-w)
  • [L1] All patients reported satisfaction with their pain management without requiring emergency opioid analgesia. [16] (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. [17] (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. [18] (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. [19] (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. [20] (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. [21] (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. [22] (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. [23] (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. [24] (10.5435/jaaos-d-24-00167)
  • [L4] This highlights the need for better counseling and innovative nonopioid pain management protocols. [25] (10.1016/j.jseint.2020.12.019)
  • [L2] The authors hypothesize that tailored treatment will have better short, intermediate, and long-term effects on pain and function than non-tailored treatment or treatment-as-usual. [26] (10.1186/1471-2474-13-75)
  • [L5] It is currently recommended that multimodal analgesic regimens be utilized in the management of postoperative pain. [27] (10.2106/00004623-200012000-00010)
  • [L1] Studies should assess whether local anaesthetic infiltration can prevent long-term pain. [28] (10.1186/1471-2474-15-220)
  • [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. [29] (10.5435/jaaos-d-21-00319)
  • [L4] Clinical and personal experiences with opioids, in addition to demographics, should be emphasized in the clinical history. [31] (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. [33] (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. [34] (10.1016/j.arth.2020.06.051)
  • [L4] Insight into patients' pain experience may help to choose and develop appropriate diagnostic instruments. [35] (10.1371/journal.pone.0182207)
  • [L2] Greater self-efficacy was the best determinant of satisfaction with pain relief. [36] (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. [37] (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. [38] (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. [39] (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. [40] (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. [41] (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. [42] (10.1016/j.jse.2020.04.049)
  • [L3] Patients with contraindications to NSAIDs remained in the hospital longer and consumed higher quantities of opioids. [43] (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. [44] (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. [45] (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. [46] (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. [47] (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. [48] (10.5435/00124635-200902000-00006)
  • [L2] Both techniques are successful in improving function and pain, with high satisfaction rates after 1-year follow-up. [50] (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. [51] (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. [52] (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. [53] (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. [54] (10.1054/jhsb.2001.0568)
  • [L5] Less facetectomy is better because it may reduce the risk of biomechanical deterioration and consequently, that of FBSS. [55] (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. [56] (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. [57] (10.1016/j.arth.2025.10.001)
  • [L4] Studies using tightly defined homogenous patient groups may provide the best test for association between MRI-findings and pain and disability. [59] (10.1186/s13018-023-03839-w)
  • [L1] Early MRI is associated with increased length of disability in patients with acute LBP without red flags. [60] (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. [61] (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. [62] (10.1016/j.jhsa.2009.04.021)
  • [L4] Approaches to primary outcome assessment in back pain need re-assessment. [63] (10.1186/s12891-015-0534-1)
  • [L4] This study revealed a lack of agreement between the segmental level affected determined from the patient's pain drawing and the affected level as identified on MRI. [64] (10.1111/papr.13147)
  • [L3] The strategy combined with CT-guided local chemotherapy treatment is minimally invasive, beneficial for the drainage of paravertebral abscesses and pain relief. [65] (10.1186/s12891-022-05545-w)
  • [L2] Pain collected shortly after completion of 6 weeks of study intervention predicted future pain the best. [66] (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. [68] (10.1016/j.arth.2006.12.027)
  • [L3] In the nonsurgical group, ESI was associated with inferior pain reduction through 3 years, although this was confounded by greater baseline pain. [69] (10.2106/jbjs.19.00596)
  • [Paper] This article discusses neuromuscular deficits present in people with low back pain and how core stability contributes to these deficits, emphasizing the need for clinicians to understand underlying structural and neuromuscular components when developing treatment strategies. [71] (10.1016/j.csm.2008.02.005)
  • [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. [72] (10.1186/s13018-025-05577-7)
  • [L4] Fear of movement is positively (but weakly) associated with trunk stiffness. [73] (10.1371/journal.pone.0067779)
  • [L3] Segment lordosis angle (SLA) restoration is dependent on preoperative SLA, cage subsidence, and cage position. [74] (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. [75] (10.1186/s13018-022-03378-w)
  • [L1] Excluding spinal manipulation or stretching do not affect the occurrence of adverse events. [76] (10.1186/1471-2474-15-77)
  • [L3] Roussouly classification could only be a rough estimate of optimal spinopelvic alignment. [77] (10.1186/s13018-021-02786-8)
  • [L3] The study developed a machine-learning model that accurately predicted outcome after surgery for adult spinal deformity. [78] (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. [79] (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. [80] (10.1186/s12891-025-08893-5)
  • [L1] Additional knowledge of fascial neurological components could impact lower back pain treatment. [81] (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. [82] (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. [83] (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. [84] (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. [85] (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°. [86] (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. [87] (10.1186/s12891-022-05799-4)

See Also

References

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[2] Pain Scores in the Management of Postoperative Pain in Shoulder Surgery. Arthroscopy. 2007. DOI: 10.1016/j.arthro.2006.11.002

[3] Is There a Benefit for Liposomal Bupivacaine Compared to a Traditional Periarticular Injection in Total Knee Arthroplasty Patients With a History of Chronic Opioid Use?. The Journal of Arthroplasty. 2016. DOI: 10.1016/j.arth.2016.01.037

[4] Regulation of peripheral blood flow in Complex Regional Pain Syndrome: clinical implication for symptomatic relief and pain management. BMC Musculoskeletal Disorders. 2009. DOI: 10.1186/1471-2474-10-116

[5] The painful shoulder arthroplasty: appropriate work-up and review of interventional pain treatments. JSES Reviews, Reports, and Techniques. 2022. DOI: 10.1016/j.xrrt.2022.04.008

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[22] Zoledronic acid is more efficient than ibandronic acid in the treatment of symptomatic bone marrow lesions of the knee. Knee Surgery, Sports Traumatology, Arthroscopy. 2019. DOI: 10.1007/s00167-019-05598-w

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[55] Reducing the extent of facetectomy may decrease morbidity in failed back surgery syndrome. BMC Musculoskeletal Disorders. 2019. DOI: 10.1186/s12891-019-2751-5

[56] Wearable technology mediated biofeedback to modulate spine motor control: a scoping review. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07867-3

[57] Can We Achieve Consensus on the Choice of Anesthetic Medication for Adductor Canal Block in Total Knee Arthroplasty?. The Journal of Arthroplasty. 2025. DOI: 10.1016/j.arth.2025.10.001

[59] Modic changes as seen on MRI are associated with nonspecific chronic lower back pain and disability. Journal of Orthopaedic Surgery and Research. 2023. DOI: 10.1186/s13018-023-03839-w

[60] The association between early MRI and length of disability in acute lower back pain: a systematic review and narrative synthesis. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-021-04863-9

[61] Investigating the impact of cartilaginous endplate herniation on recovery from percutaneous endoscopic lumbar discectomy. Journal of Orthopaedic Surgery and Research. 2024. DOI: 10.1186/s13018-024-04746-4

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[85] Efficacy of intraoperative epidural steroids in lumbar discectomy: a systematic review. BMC Musculoskeletal Disorders. 2014. DOI: 10.1186/1471-2474-15-146

[86] Determining the validity and reliability of spinopelvic parameters through comparing standing whole spinal radiographs and upright computed tomography images. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-021-04786-5

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a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

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.