Pain is among the oldest challenges in medicine, yet we still often get it wrong. Not because we do not care, but because we have fractured its meaning. Across disciplines, pain is treated as a symptom, sign, disease, or dysfunction. For patients, however, it is something more: an existential crisis, a threat to identity, a loss of self. In this gap between the lived experience of pain and the siloed responses of our health systems, something essential is being missed.
Spine at the Crossroads: Enduring Perspective on Pain and Stewardship in Spine Care.1
As guest editor for this special pain issue of the International Journal of Spine Surgery (IJSS), I invite readers to step back and ask: What, exactly, are we treating when we say we are treating “pain”? For whom, and toward what end?
Spine surgeons, by training, address mechanical lesions. They decompress, stabilize, and fuse while attempting to preserve motion. Pain interventionalists apply ablative or neuromodulatory techniques to interrupt nociceptive signaling. Psychiatrists often encounter pain as a comorbidity, intertwined with depression or trauma. Patients, for their part, present with something messier—an aching, immobile body layered with loss, fear, dependence, and often despair.
Each specialty touches truth—but none alone holds the whole. Our treatment paradigms have become increasingly precise while our diagnostic categories remain coarse. In our well-intentioned focus on the visible—stenosis, degeneration, nerve root compression—we risk neglecting the invisible: reward dysfunction, emotional collapse, and spiritual crisis (Box 1).
A Warning for Spine Surgeons.
In 2015, I cautioned that spine surgery faced an “extinction event” if it failed to expand beyond compartmentalized techniques (Figure). A decade later, that warning remains urgent. The path forward demands proactive models—early identification, neurochemical restoration, and functional integration—over reactive reliance on procedural widgets. The choice is stewardship or irrelevance.
Recent advances in neurogenetics have deepened this insight. Chronic pain, substance use, and even certain behavioral syndromes may share a common thread: disrupted dopamine tone. What Blum et al describe as Reward Deficiency Syndrome2,3 represents a shift in how we might understand not just addiction, but pain itself. That is, for some patients, persistent pain may not stem from persistent injury but from a brain incapable of registering reward, safety, or relief.
From this perspective, opioids may offer not just analgesia but temporary emotional homeostasis—albeit at enormous cost. Procedures may work anatomically but fail emotionally. Recurrent pain may signal not pathology alone but a profound neurochemical or even spiritual imbalance. None of this invalidates the contributions of surgery or intervention, but it demands that we place them in context. We must ask: Does this procedure move the patient toward wholeness? Does this injection restore function and meaning? Are we treating pain or simply interrupting its signal?
We also must confront systemic failure. Reimbursement models privilege procedures over presence. Interdisciplinary collaboration is rare, fragmented, and often poorly incentivized. The result is that pain care, despite technological sophistication, often feels impersonal—fragmented into parts, with no one treating the person. Stigma deepens the wound: patients whose pain persists after surgery are too often labeled as “failures,” while surgeons themselves internalize stigma when procedures do not translate into relief. Both are casualties of a system that still struggles to see pain in its full complexity. This failure is not abstract; it echoes in the lived inequities of care. As Bhagat recently described, patients on medications for opioid use disorder are still routinely denied admission to skilled nursing facilities—not because of their medical needs, but because of stigma attached to their treatment.4
What would a better model look like? It would be one that:
integrates dopaminergic assessment with structural diagnosis
values meaning-making as much as mechanics
embraces precision neurogenetic tools alongside proven surgical or interventional techniques
empowers patients—not as passive recipients of care but as co-navigators in the restoration of function, motion, purpose, and identity
Encouragingly, models of care that personalize intervention at the level of pain generators are emerging. Lewandrowski et al SpineScreen study illustrates how endoscopic decompression, minimally invasive fusion, and open laminectomy can be thoughtfully compared within a unified framework.5 This is the type of translational, precision-driven research that must inform policy, lest coding and reimbursement continue to dictate care in ways that science does not support.
This issue of IJSS brings together voices that challenge, innovate, and offer a more integrated path forward. It includes rigorous data, conceptual frameworks like Reward Deficiency Syndrome, and fresh ideas for restoring spines in motion, and it redefines what successful pain care can be—not merely reactive, but preemptive, front-loaded, and preventive in design.
We must move beyond symptom suppression and toward systems-level healing. This will require new language, new tools, and perhaps most importantly, a new humility—one that acknowledges that no single specialty owns pain, and only together can we hope to relieve it in its full, human complexity. Patients are not asking for perfection. They are asking to be seen, to be believed, and to be helped in ways that matter. If this issue helps advance that goal—even a little—it will have done its job.
It is time we listened more carefully to what pain is really trying to teach us—not just through advanced diagnostics and cutting-edge therapeutics, but through the long-lost art of the clinical encounter itself. The history and physical examination, once central to our identity as healers, now risks being eclipsed by the very technology we once imagined would liberate us. In rediscovering it, we may rediscover the patient—and ourselves. Perhaps, paradoxically, it will be artificial intelligence that helps restore our human touch—blessing us again with “ears to hear.”
Footnotes
Funding No financial support was received for this article.
Declaration of Conflicting Interests The author reports no conflicts of interest in this work.
- This manuscript is generously published free of charge by ISASS, the International Society for the Advancement of Spine Surgery. Copyright © 2025 ISASS. To see more or order reprints or permissions, see http://ijssurgery.com.
References
- 1.↵Lorio MP . Testimonial . International Society for the Advancement of Spine Surgery. December 21, 2015. https://isass.org/Testimonial/morgan-lorio/#:~:text=Most%20patients%20go%20to%20their,some%20other%20specialties%20have%20become.
- 2.↵Blum K , Braverman ER , Holder JM , et al . Reward deficiency syndrome: a biogenetic model for the diagnosis and treatment of impulsive, addictive, and compulsive behaviors. J Psychoactive Drugs. 2000;32 Suppl:i–iv. 10.1080/02791072.2000.10736099
- 3.↵Blum K , Baron D , Lott L , et al . In search of reward deficiency syndrome (RDS)-free controls: the “holy grail” in genetic addiction risk testing. Curr Psychopharmacol. 2020;9(1):7–21.
- 4.↵Bhagat S . Why do we tolerate discrimination against those with OUD? Doximity Op-Med. 2024. https://www.doximity.com/newsfeed/93c906a4-2582-4060-b0f4-bb94bac8b1f9/public.
- 5.↵Lewandrowski K-U , Abraham I , Ramírez León JF , et al . A proposed personalized spine care protocol (SpineScreen) to treat visualized pain generators: an illustrative study comparing clinical outcomes and postoperative reoperations between targeted endoscopic lumbar decompression surgery, minimally invasive TLIF and open laminectomy. J Pers Med. 2022;12(7):1065. 10.3390/jpm12071065
