The main objective of this study is to evaluate real-world clinical outcomes associated with intensive interdisciplinary outpatient multimodal pain treatment in patients with persistent spinal pain who were initially referred for planned spinal surgery but in whom surgical indication was not confirmed following structured interdisciplinary second-opinion assessment.
Persistent spinal pain represents a major cause of long-term disability and healthcare utilization. In routine care, treatment decisions for patients with chronic spinal pain are often strongly influenced by structural imaging findings and mono-disciplinary clinical evaluation. However, chronic spinal pain is increasingly recognized as a complex biopsychosocial condition in which structural pathology alone often does not sufficiently explain pain intensity, functional impairment, or patient disability. As a result, surgical interventions may not always represent the most appropriate therapeutic option, particularly in patients with advanced pain chronification or significant psychosocial burden.
To address this challenge, a structured interdisciplinary second-opinion model has been implemented within a specialized healthcare program in Germany. This model differs from conventional second-opinion procedures by integrating expertise from multiple disciplines, including pain medicine, pain psychology, and physiotherapy. The purpose of this interdisciplinary evaluation is to assess patients using a comprehensive biopsychosocial framework that considers structural findings, functional limitations, psychological factors, prior treatment history, and the degree of pain chronification.
Patients in whom the originally proposed spinal surgery is not confirmed may be referred to alternative treatment pathways, including an intensive interdisciplinary outpatient multimodal pain treatment program. This program is designed to address the multidimensional nature of chronic pain through coordinated interventions combining medical management, physiotherapy, psychological treatment, patient education, and self-management strategies.
Although interdisciplinary multimodal pain therapy has been shown to be effective in various clinical settings, much of the existing evidence originates from inpatient treatment programs. Data on large-scale outpatient interdisciplinary programs implemented under routine clinical conditions remain comparatively limited. Evaluating the effectiveness of such programs in real-world healthcare settings is therefore essential for informing clinical practice and healthcare policy.
The primary objective of the present study is therefore to assess short-term changes in pain-related disability following completion of a structured three-week intensive outpatient interdisciplinary multimodal pain treatment program. Pain-related disability is measured using the modified Pain Disability Index (mPDI), a validated instrument assessing the impact of pain on multiple domains of daily life.
Secondary objectives include evaluating treatment-associated changes across a range of additional biopsychosocial outcome domains that reflect the multidimensional nature of chronic pain. These outcomes include pain intensity, functional capacity, psychological distress, health-related quality of life, fear-avoidance beliefs, pain-related self-efficacy, and habitual well-being.
Another key objective of the study is to examine whether patients with different levels of baseline pain severity and chronification derive comparable benefit from outpatient interdisciplinary multimodal treatment. To address this question, outcomes are analyzed across predefined severity strata based on the Chronic Pain Grading Scale (CPGS), which categorizes patients according to pain intensity and pain-related disability.
Particular attention is given to patients with high levels of pain chronification and functional impairment, corresponding to the highest CPGS severity grade. These patients are often considered difficult to treat in outpatient settings and are frequently assumed to require more intensive inpatient care. Evaluating treatment outcomes in this subgroup therefore provides important information regarding the potential role of structured outpatient programs within stepped-care models of chronic pain management.
The study further aims to characterize the clinical complexity of patients entering the outpatient multimodal treatment program. This includes describing prior treatment exposure, including pharmacological therapies, interventional pain procedures, and previous spinal surgery. A substantial proportion of patients in the cohort have undergone prior spinal surgery and therefore fulfill the criteria for persistent spinal pain syndrome type 2 (PSPS-2), representing a particularly challenging patient population.
Finally, the study seeks to examine whether treatment-associated improvements occur consistently across participating treatment centers and patient subgroups. Multivariable statistical analyses are therefore used to evaluate whether treatment outcomes remain stable after adjustment for demographic characteristics and treatment center effects.
Overall, the study aims to generate robust real-world evidence on the clinical outcomes associated with interdisciplinary outpatient multimodal pain treatment following non-confirmation of surgical indication for persistent spinal pain. By evaluating outcomes in a large consecutive cohort of patients treated under routine clinical conditions, the study contributes to a better understanding of the potential role of structured outpatient multimodal programs as part of integrated care pathways for patients with chronic spinal pain.