Specialty Care Physicians and Pain Management

Spine Surgeons—Orthopedists and Neurosurgeons
Physiatrist (M.D. or D.O)
Anesthesiologist (M.D. or D.O.)
Neurologist (M.D. or D.O)
Rheumatologist (M.D. or D.O)

1. Spine Surgeons—Orthopedists and Neurosurgeons perform the overwhelming majority of spine surgery and frequently extend their general Orthopedic or Neurosurgical training by participating in a spine fellowship. These spine fellowships accept a select group of physicians who have completed four to seven years of a surgical residency and are either board certified or board eligible in their respective specialties and provide additional training in performing spine surgery.
   • Orthopedic Surgeon (M.D. or D.O.)—Orthopedic surgeons are either Medical Doctors or Doctors of Osteopathy who have completed a five-year residency focused on the surgical treatment of musculoskeletal conditions. Orthopedic surgeons are trained in the diagnosis and treatment of spinal disorders, arthritis, sports injuries, trauma, and fractures.
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   • Neurosurgeon (M.D. or D.O.)—Neurosurgeons are Medical Doctors or Doctors of Osteopathy who complete a five or six-year residency that focuses on the surgical treatment of patients with neurological conditions. Neurosurgeons are trained in the diagnosis and treatment of disorders of the brain, spine, spinal cord, nerves, intracranial and intraspinal vasculature.

   Both orthopedic surgeons and neurosurgeons complete training to do most types of spine surgery. There are only a few instances in which one specialty tends to be better trained for specific conditions: e.g. orthopedic surgeons do spine deformity surgery (e.g. scoliosis) and neurosurgeons do surgery for intradural (inside the thecal sac) tumors.

   In recent years, spine surgery has become increasingly specialized within the orthopedic and neurosurgical professions, and often a surgeon will focus a majority of his or her practice on spinal surgery. It is thought that the increasing level of specialization and focus on the spine has contributed to enhancements in surgical technique, which in turn has led to overall improved success rates and reduced morbidity (e.g. reduced post-operative discomfort, faster healing time).
   



2. Physiatrist (M.D. or D.O)—A physiatrist is a Medical Doctor or Doctor of Osteopathy who specializes in Physical Medicine and Rehabilitation (also called PM&R physicians). Essentially, physiatrists specialize in a wide variety of conservative treatments for the musculoskeletal system and do not perform surgery.
   
   Physiatrists complete four years of graduate medical education and four additional years of residency training. Residency training includes one year spent developing fundamental clinical skills and three additional years of training in the full scope of the specialty. Many physiatrists choose to pursue additional advanced degrees (M.S., Ph.D.) or complete fellowship training in a specific area of the specialty, such as spine medicine/musculoskeletal rehabilitation.
   
   To become board-certified in physical medicine and rehabilitation, physiatrists are required to pass both a written and oral examination administered by the American Board of Physical Medicine and Rehabilitation (ABPM&R). The ABPM&R also has agreements with each of the boards of pediatrics, internal medicine, and neurology to allow special training programs leading to certification in both specialties.
   
   Physiatrists diagnose and treat both acute pain and chronic pain and musculoskeletal disorders. They can order and interpret all types of spine imaging (x-ray, CT myelogram, MRI, bone scan) and perform specialized nerve tests (EMG, NEV, SSEP) to help assess the location and severity of nerve damage. They commonly treat patients with any kind of back pain or neck pain, work or sports-related injuries, fibromyalgia, myofascial pain, arthritis, tendonitis, spinal cord injuries. Typical treatments may include:
   • Active physical therapy (e.g. exercise, stretching)
   • Passive physical therapy (e.g. heat/ice, TENS units)
   • Prescription medications
   • Massage therapy
   • Some perform interventional medicine (e.g. epidural steroid injections, selective nerve root blocks, IDET

   Physiatrists have varying degrees of specialization and may practice in rehabilitation centers, hospitals, or private practice, and often practice as part of an integrated spine treatment center. They focus on keeping individuals as functional as possible and work to coordinate the patient’s care.
   

3. Anesthesiologist (M.D. or D.O.)—Anesthesiology is the practice of medicine dedicated to the relief of pain and total care of the surgical patient before, during and after surgery.
   
   After completing four years of medical school, they enter a four-year anesthesiology residency training program. Fellowships in an anesthesia subspecialty and in education or research may also be taken for an additional year. While anesthesiologists have been known primarily as physicians who administer anesthesia during surgery, they also provide medical care and consultations in other situations in addition to the operating room.
   
   The anesthesiologist’s role may be a perioperative ("peri-" meaning "all-around") who provides medical care to each patient throughout his or her surgical experience. This may include medical evaluation before surgery, consulting with the surgical team, providing pain control and support of life functions during surgery, and supervising care after surgery and medically discharging the patient from the recovery unit.
   
   Anesthesiologists as part of the spine team frequently diagnose and treat patients suffering from acute and chronic pain syndromes. Some anesthesiologists complete Pain Fellowships and concentrate their practice on doing injections (such as epidural steroid injections). They may practice in a variety of settings, such as a Pain management clinic or an integrated spine care center. Typically, other medical practitioners (primary care or specialists) refer patients to them.

4. Neurologist (M.D. or D.O)—A neurologist specializes in diagnosing and treating disorders of the nervous system, including diseases of the brain, spinal cord, nerves, and muscles (such as strokes, epilepsy, headaches, Alzheimer's, multiple sclerosis, Parkinson's, and various forms of pain). Neurologists may serve as a consultant to other physicians as well as providing long-term care to patients with chronic neurological disorders.
   
   Neurologists are trained to perform a detailed examination of all the important neurological structures in the body. This includes the nerves of the head and neck, the muscular strength and movement, sensation, balance testing, ambulation and reflex testing. Importantly, an examination by a neurologist can be helpful in distinguishing a primary neurological problem (e.g. multiple sclerosis) from a musculoskeletal disorder.
   
   Neurologists rely on the clinical examination along with certain other commonly used tests (such as CAT Scans and MRI/MRA scans). These tests can provide detailed anatomic pictures of the brain, spinal structures and the blood vessels. A neurologist can also perform a lumbar puncture (spinal tap) to obtain the cerebrospinal fluid for analysis. Some neurologists interpret EEG (electroencephalography) used in the evaluation of seizure disorders, or perform EMG/NCV (electromyography/nerve conduction velocity testing) which is used to diagnose nerve and muscle problems.
   
   Neurologists use many forms of medication to treat problems involving the nervous system. They may send patients to other specialists for some forms of treatment. A neurologist may refer a patient to a surgeon for a surgical evaluation, but does not perform surgery.
   
   
5. Rheumatologist (M.D. or D.O)—A Rheumatologist specializes in the diagnosis and treatment of arthritis and other musculoskeletal diseases (involving joints, muscles and bones).
   
   After four years of medical school and three years of training in either internal medicine or pediatrics, rheumatologists complete two to three years in specialized rheumatology training. Most rheumatologists who treat patients become board certified by the American Board of Internal Medicine.
   
   Rheumatologists diagnose and treat a wide variety of chronic musculoskeletal diseases, including osteoarthritis, rheumatoid arthritis, musculoskeletal pain disorders, fibromyalgia, certain autoimmune diseases, osteoporosis, and tendonitis. Many types of rheumatic diseases are difficult to identify, and rheumatologists are trained to accurately diagnose musculoskeletal disorders so that appropriate treatment can begin early.
   
   Rheumatologist sometimes act as a consultant to advise another physician about a specific diagnosis and treatment plan, and sometimes leads the patient’s treatment and may include a team approach to treatment involving as physical therapists, psychologists, or other specialists.
   
   

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• Article written By:
• Philip R. Shalen, MD

November 14, 2000

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