Lumbar spinal stenosis as a model for the multimodal and multiprofessional treatment of mixed non-cancer pain. Survey response from a panel of experts of the Italian National Association of Osteoarticular Specialists (ASON)

Introduction
Because in degenerative diseases mixed pain represents a complex issue encompassing different types of chronic pain, a multimodal and patient-tailored approach is desirable. By using lumbar spinal stenosis as a model, the study was aimed at identifying what an expert panel believes can be helpful to treat mixed-type pain due to benign osteoarticular lesions.

Material and methods
A faculty composed of 2 orthopaedists, a neurosurgeon, and 2 pain therapists performed a literature review (PubMed/MEDLINE, EMBASE, and CENTRAL) for the development of a questionnaire on the management of mixed non-cancer pain. Subsequently, this 17-item tool was submitted to physicians (orthopaedists, physiatrists, and rheumatologists) members of the Italian National Association of Osteoarticular Specialists (ASON), before and after a meeting discussion.

Results
The database search yielded 256 records. Fifty-seven records were identified through other sources. After removal of 235 duplicates and exclusion of 52 non-pertinent records, 26 full-text articles were assessed for eligibility. Of those, 10 papers were excluded, and 13 articles were included in the qualitative synthesis for the development of the tool. The expert panel developed a 17-item questionnaire focused on 3 main thematic areas: ‘diagnostic approach, counselling, and multidisciplinary approach’, ‘therapeutic approaches’, and ‘patient communication strategies’.

Conclusions
The most desirable approach to mixed osteoarticular pain must follow a multimodal and multidisciplinary approach. Combined pharmacological and non-pharmacological strategies must be strengthened. The use of opioids in non-cancer chronic pain must follow a careful case-by-case analysis.