Commentary.

“Pain is a more terrible lord of mankind than even death itself.”- Dr. Albert Schweitzer

“Pain” the most common presenting symptoms to physician, yet many a times ignored and often leading to a chronic pain syndrome. Chronic pain is increasing in prevalence though epidemiological estimate varies largely depending on the study sample and study settings. With a more stringent definition (pain for 6 months, experiencing pain in the last month, and several times during the last week), a pan-European study reported chronic pain prevalence of 19%.[1] In contemporary society, chronic pain is the most common cause of long-term disability. As per the Global Burden of Disease Study 2010, low back pain is among the top 10 diseases and injuries that account for the highest number of DALYs worldwide.[2] However, having specific focus on chronic pain, its often masked with other diseases especially diseases with “so called” higher morbidity and diseases with higher mortality and more so in settings with limited medical resources. In fact, the chronic pain and especially low back pain is one of the major causes of poor quality of life and life dissatisfaction.

Despite growing concern for chronic pain evaluation and treatment, up to two-thirds of sufferer's report dissatisfaction with current treatment and most chronic pain persists for many years.[3] Among neurosurgeons, the low back pain is often seen with the prism of discogenic, neurogenic, or spinal degenerative diseases. Patients with no clear compressive pathology are often poorly managed or worked up. In fact, sacroiliac joint (SIJ) pain is one of the common conditions under “umbrella” back pain syndrome. In one of the retrospective studies,[4] SIJ pain was the common condition in outpatient evaluation at surgical spine clinic and in patients with residual low back pain following spinal fusion, ranging up to 40%.[56]

It is important to understand that the nature of pain from SIJ may be different from preoperative pain; however, it may be overlapping the area of pain in low back coming to the attention of a neurosurgeon and could also be contributory, especially in cases with poor or unsatisfactory response. Moscote-Salazar et al.[7] in the paper, “A clinical approach for the neurosurgeon” explored the SIJ pain and presented a nice overview of a common pain syndrome, though often ignored or missed in consideration of neurosurgical evaluation and differential diagnosis of low back pain. When medicine is evolving from therapeutic to preventive and holistic medicine, low back pain, and chronic pain should be assessed and treated appropriately. Whatever be our specialty of practice or expertise, we should always remember that pain is the “5th vital sign” and that access to pain management is a fundamental human right (Declaration of Montréal).[8]