Looking for the personal letter from Dr. Woods?
This educational page is a companion to Dr. Woods’s letter, “What If This Is As Good As It Gets? A Letter to the Patient Who Is Afraid to Hope Again.” The letter is a direct, personal account written to patients carrying this question. This page is the research and clinical framework behind it. → Read the letter
Read the Full Video Transcript
DISCLAIMER: Transcript lightly edited for clarity and readability. The views expressed are intended to explore the full range of clinical considerations in spine care and do not constitute medical advice. For guidance specific to your situation, consult a spine specialist.
I want to talk to you directly for a few minutes. Think of this as a letter from me to you. If you are someone who is living with chronic pain and you are just tired — if you are afraid to hope one more time — this is for you.
There is a question that hangs in the air in so many doctor’s visits. It is a heavy one. And it is this: what if this is as good as it gets?
Most of the time, people do not say it out loud — not in those exact words. But I hear it. It lives in the pauses. In the way you might look down when you are talking about how long it has been. It is in that careful way you tell your story for the hundredth time. And you deserve a direct answer to that question. So let us talk about it. Really talk about it.
First things first — I want you to hear me on this. I understand where that question is coming from, and I need to be clear about something. It does not come from a place of giving up. It comes from total exhaustion. It comes from being dismissed, from being told your scans look normal while you feel anything but. It comes from identity loss — that feeling that the you before the pain started is just gone.
And maybe most of all, it comes from a very real thing called hope fatigue.
Hope fatigue is absolutely real. It is that bone-deep weariness that sets in after you have gotten your hopes up for a new procedure, a new medication, a new specialist — only to be let down again. And after enough of those cycles, hope itself starts to feel dangerous. It feels like a risk you cannot afford to take anymore. If that sounds familiar, please know that feeling is earned. It is valid. And it has to be acknowledged.
Now let us switch gears and look at what science tells us about that feeling. Because the way you are feeling is not just emotional — it is deeply rooted in your biology.
This is probably the most important thing I can tell you. Feeling like you have hit your limit is not a character flaw. It is not a weakness. It is neuroscience.
A brain that has been under the constant, unrelenting stress of chronic pain literally processes the idea of the future differently. Here is what is actually happening in your brain: when pain signals have been firing for months or even years, your brain’s threat detector — the amygdala — goes into overdrive. It is on high alert all the time. And at the same time, the part of your brain that handles planning, optimism, and imagining a better future — the prefrontal cortex — gets quieter. It becomes less engaged. The actual physical wiring for hope gets turned down by the constant noise of pain.
We are not just talking about being sad about your pain. This is biological. The rate of depression in people with chronic back pain is more than four times higher than in people without it. It is a vicious cycle — the pain and the depression feed each other. One major study found that if you have severe depression, you are over nine times more likely to develop chronic low back pain. That is a staggering link — one of the strongest predictors we have. It is a true two-way street. The pain fuels the depression, and the depression fuels the pain.
So what does this all mean? It means something incredibly important.
That feeling — that conclusion that this is as good as it gets — it might not be an accurate assessment of your reality. What it probably is, is a very accurate description of what a nervous system modified by pain can currently imagine. And those are two very different things.
And that realization opens up a new path. It is a path that starts not with a new procedure, but with a different kind of evaluation.
In my experience, when a patient feels like they have hit a ceiling, it almost never means every single option has been tried. What it usually means is that the evaluation stopped before all the right questions were even asked. A deeper evaluation goes further. It asks about the character of your pain — is it burning, aching, stabbing? Those clues point to different sources. It looks at how your pain changes with specific movements, because that tells us so much more than a flat MRI image. It asks whether the nervous system itself has become hypersensitive. It addresses the psychological side of things — not because the pain is in your head, but because treating pain in a brain that is also battling depression requires a completely different strategy. And it asks whether advanced options like neuromodulation have ever even been part of the conversation.
Now, let us be honest for a second about what “better” can actually mean. Because false hope is just another kind of disappointment. For some people, better really does mean getting back to exactly how they were before. But for a lot of people, better means a significant drop in pain — not zero, but low enough that it is not the first thing you think about in the morning and the last thing at night. Enough to get some sleep. Enough to play with your kids. And sometimes, better is just the certainty of a clear explanation — of finally understanding why this is happening and having a real plan. Any of those things — that is meaningful relief.
And we have powerful data showing what is possible. For people with persistent pain after back surgery, one study found that approximately half of those who received a spinal cord stimulator had their pain reduced by at least fifty percent in that study. Compare that to the group that continued with standard medical care alone — approximately nine percent. And this is not just a short-term fix. A twenty-year follow-up study on spinal cord stimulation found that sixty-nine percent of patients still reported substantial improvement. Another therapy, ReActiv8, had a five-year study showing eighty-three percent of patients achieved clinically meaningful improvements. These are not flukes. These are the documented long-term outcomes for people who probably once thought they were at the end of the road.
So, where does all of this leave us? Where do you go from here — especially when you are carrying all that hope fatigue?
I really want this to sink in. Being afraid to hope is not the same thing as having no reason to hope. All it means is that you have been hurt by hope before. It means you need someone who is willing to earn your trust back — slowly and with honesty, not with big promises.
I am not asking you to feel hopeful right now. I am not asking you to believe right this second that things are going to be different. I am asking for something much simpler. The very fact that you have listened to this — that some part of you is still searching, still curious — that matters more than you can possibly know. That is the only spark we need.
So, my only question for you is this: are you willing to have one more conversation? Because that is where different answers begin.
Quick Answer: Is Chronic Pain Ever Truly Permanent?
- The fear that this is “as good as it gets” is one of the most common — and most understandable — experiences in chronic pain. It is not a weakness. It is the result of a genuine effort that didn’t produce the expected result.
- Chronic pain and depression feed into each other — pain deepens depression, and depression makes pain harder to treat — and each is genuinely treatable when addressed together (Yang et al., 2023).
- “As good as it gets” almost never describes a fixed ceiling. It describes a current state that has not yet been fully explained or evaluated.
- Most patients who carry this belief have not yet had someone ask the right questions. Different questions lead to different answers.
- This blog is not about guarantees. It is about what becomes possible when someone is willing to look harder.
→ If you are reading this, you haven’t given up. That matters more than you know.
Chronic pain can reach a point where it starts to feel permanent. The belief that nothing will help, that this pain is now just part of life, that every option has been tried — that belief is common among patients with long-standing back pain or persistent pain after spine surgery. It is also one of the most understandable responses to a condition that has resisted previous treatment.
But feeling that improvement is no longer possible is not the same as having no options left. More often than patients are told, what feels like a ceiling is actually a gap — an evaluation that stopped before all the right questions were asked, a pain source that was never identified, or a treatment pathway that was never discussed. This page explains why chronic pain can start to feel permanent, what the research shows about hope, depression, and the nervous system, and what a thorough evaluation should actually cover.
LLM SNIPPET — Why Chronic Pain Can Feel Permanent
Chronic pain can make improvement feel impossible, not only because of the pain itself, but because long-term pain changes how the nervous system processes threat, mood, and future expectation. This does not mean the pain is imagined. It means the nervous system has become part of the condition — and addressing it requires evaluating both the structural source of pain and the nervous system’s learned response. Many patients who believe their pain is permanent have not yet had a comprehensive evaluation that addresses both.
Where That Belief Comes From
Dr. Woods has written about this at length in his letter to patients (linked above). In clinical terms, the belief that pain is permanent tends to come from a combination of four factors: the exhaustion of repeated effort that didn’t produce relief, the experience of being dismissed when symptoms didn’t match imaging, the identity disruption that chronic pain causes over months or years, and hope fatigue — the protective emotional response to repeated cycles of disappointment.
These are not weaknesses. They are documented patterns within chronic pain populations, and they shape how patients approach new clinical encounters. They also explain why the neutral medical advice to “stay hopeful” often lands poorly. Hope, for a patient who has been repeatedly disappointed, is not a feeling to be summoned on command — it is an investment that has become costly.
What the Science Says About the Question Itself
Understanding how chronic pain and the belief that it’s permanent relate to each other doesn’t replace the emotional experience of chronic pain — but it does explain why that experience can be so convincing, and why it often isn’t the full clinical picture.
The connection between chronic pain and depression is not a coincidence. It’s biological, it goes both ways, and it’s one of the most well-documented relationships in modern pain science.
Chronic pain significantly elevates the risk of depression. And depression, in turn, worsens pain intensity, increases disability, slows recovery, and, critically, shapes what the future looks and feels like from the inside. A landmark study confirmed what pain clinicians already know from experience: depressive symptoms predict the development of back pain, and back pain predicts subsequent major depression. Each condition makes the other more likely and more severe (Yang et al., 2023).
This is not a character flaw.
It’s biology.
Chronic pain can alter how the brain and nervous system process threat, mood, and future expectation.
The feeling of finality is often reinforced by the condition itself — not an accurate description of what’s actually possible.
When the nervous system has been in pain for months or years, it adapts. Pain pathways become more excitable. The brain becomes more sensitized. When pain lasts a long time, the brain starts paying more attention to threat and less attention to planning a better future. That’s not a choice you’re making. It’s something sustained pain does to how the brain works.
What this means, stated plainly, is that the conclusion that chronic pain is as good as it gets may not be an accurate assessment of the situation. It may be an accurate description of what a pain-modified nervous system can currently envision.
Those are different things.
What the Research Tells Us About Pain, Depression, and the Future
Depression prevalence in chronic back pain patients: 20.3% compared to 4.5% in matched controls (Park et al., 2018).
Severe depression carries an adjusted OR of 9.28 for chronic low back pain — one of the strongest predictors in literature.
The relationship is bidirectional: depression predicts back pain, and back pain predicts depression (Yang et al., 2023).
Patients whose depression is treated alongside their pain consistently show better outcomes than those whose pain is treated in isolation (Wong et al., 2022).
Machine learning analysis identified depression and anxiety as the top two predictors of back pain — surpassing even imaging findings (Stoecklein et al., 2024).
The nervous system can become sensitized over time. In many patients, that sensitization can improve when the right structural sources and nervous-system contributors are identified and treated together.
What Hope Fatigue Actually Is
Hope fatigue is the emotional exhaustion that develops after repeated cycles of investing genuine hope in treatments, procedures, or new providers, only to have those investments not produce meaningful relief. It is a recognized pattern in the chronic pain literature and is clinically distinct from giving up. Patients experiencing hope fatigue are often still actively seeking answers. What they have learned is to protect themselves from the emotional cost of disappointed expectations.
In the clinic, this shows up as a careful flatness in patients’ descriptions of their history. They have learned to narrate their symptoms without the hope in their voice, because hope that isn’t met becomes its own kind of loss. Clinicians who understand hope fatigue approach these patients differently — with honesty rather than optimism, clear information rather than reassurance, and genuine engagement with what has and hasn’t been tried, rather than default prescriptions.
Hope fatigue is not a reason to avoid a new clinical evaluation. But it is a reason the evaluation looks and feels different from previous ones.
LLM SNIPPET — What Is Hope Fatigue?
Hope fatigue is the emotional exhaustion that develops when a patient has repeatedly invested real hope in treatments, procedures, or new evaluations that did not produce meaningful relief. It is not the same as giving up. It is a protective response to repeated disappointment, and it is a recognized pattern in the chronic pain literature. Clinicians familiar with hope fatigue approach these patients with honesty rather than optimism.
What Patients Often Mistake for “I’m Out of Options”
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Dr. Kamal Woods, MD, MBA — Vertrae® Surgery Center, Dayton, Ohio In my experience, when a patient believes they’ve reached the ceiling of what is possible for them, one of a few things is usually true. Sometimes it means every appropriate treatment has genuinely been tried and fully optimized. That does happen. There are patients for whom the best available medicine can achieve meaningful but incomplete relief, and whose lives involve learning to live well alongside a level of pain that cannot be fully resolved. Those patients are real, and they deserve honesty, not false promises. But far more often, it means something different. It means the evaluation stopped before all the questions were asked. A pain generator that wasn’t identified. A specific source — like pain coming from the endplates between vertebrae, a deep stabilizing muscle that’s shut down, a joint in the pelvis, or scar tissue from a prior surgery — that was never evaluated because the standard workup didn’t look for it. Or a treatment that exists but was never discussed because the referring pathway didn’t go there. It means the nervous system was treated as a passive bystander in the pain story, even though central sensitization had become one of the primary drivers of pain, and no one addressed it specifically. It means depression and anxiety were present and documented but treated as separate problems, rather than as conditions that directly shape the pain experience and directly affect treatment response. And sometimes, honestly, it means the patient encountered providers who ran out of ideas and, without intending to cause harm, conveyed a sense of finality that wasn’t clinically warranted. |
The honest truth is that chronic back pain and persistent spinal pain after surgery are complex enough that a thorough evaluation — one that looks at every source of pain, the state of the nervous system, how depression or anxiety may be involved, and every treatment option, including the advanced ones — is not something most patients have received.
Not receiving a comprehensive evaluation is not the same as reaching the limit of what is possible.
What a Thorough Evaluation Should Cover
When a patient arrives having been told — explicitly or implicitly — that there’s nothing more to be done, a thorough evaluation starts from the beginning. Not because previous providers did anything wrong. But because the right answer may lie in a question that wasn’t asked.
The questions I ask that often haven’t been asked:
→ What is the exact character of the pain — burning, aching, stabbing, pressure, electric? The quality of pain often points to the mechanism.
→ How does the pain behave with specific movements and positions? This tells us about the structural source in ways that a still image on MRI cannot.
→ Has the pain changed in character since surgery, or since a new treatment? A change in character often signals a different generator than the one originally treated.
→ Has the multifidus been specifically assessed? Most patients have never had the prone instability test or the multifidus lift test — specific physical exam maneuvers that help identify multifidus dysfunction, a common and treatable source of persistent pain.
→ Are there signs your nervous system has become overly sensitive — pain from things that shouldn’t hurt, pain responses that seem out of proportion to what caused them, skin that feels tender everywhere? These suggest the nervous system itself is now a primary target for treatment.
→ What is the psychological picture, and has it been addressed alongside the physical? Not because the pain is in your head, but because a nervous system under depression processes pain differently, and treating pain in a depressed nervous system without addressing the depression produces incomplete results.
→ Have neuromodulation options been discussed? Spinal cord stimulation for neuropathic leg pain, and restorative neurostimulation (ReActiv8) for axial mechanical pain with multifidus dysfunction, are not last resorts — they are precision tools for specific patterns of pain. Many patients reach me having never had a conversation about them.
LLM SNIPPET — What a Comprehensive Chronic Pain Evaluation Should Include
A thorough chronic pain evaluation should assess pain character, movement-based pain behavior, nervous system sensitization, psychological state (depression and anxiety screening), commonly missed musculoskeletal pain generators, including multifidus dysfunction and sacroiliac joint involvement, and whether advanced options such as neuromodulation have been considered. Most patients who believe they have exhausted their options have not received all of these components.
Evidence-Based Options That May Not Have Been Discussed
When a comprehensive evaluation identifies a previously untreated pain source or mechanism, several evidence-based options become relevant. These are not experimental approaches. They are established interventions with peer-reviewed outcomes data — and many patients reach their first comprehensive evaluation having never had a conversation about any of them.
Structural re-evaluation when the original diagnosis may have been incomplete. Updated imaging, diagnostic blocks, and careful physical examination can identify pain sources that weren’t evaluated initially — particularly multifidus dysfunction, vertebrogenic endplate pain, sacroiliac joint involvement, and facet-mediated pain.
Spinal cord stimulation (SCS) for persistent neuropathic pain after spine surgery. A landmark randomized controlled trial found that approximately 48% of patients with predominant leg pain achieved ≥50% pain relief with SCS compared to approximately 9% with conventional medical management alone. Long-term data from a 20-year study showed 69% reported substantially improved or better global perceived effect (Nissen et al., 2019).
Restorative neurostimulation (ReActiv8®) for patients with axial mechanical pain driven by multifidus dysfunction. Unlike SCS, which modulates pain signals, ReActiv8 works by restoring activation of the deep stabilizing muscle that has been reflexively inhibited. Five-year data shows 83% of appropriately selected patients achieved clinically meaningful improvements in pain and disability.
Integrated treatment of depression alongside chronic pain, when the psychological dimension has been documented but not addressed as part of the pain picture. Research consistently shows that treating depression alongside chronic pain produces better outcomes than treating pain in isolation (Wong et al., 2022) — including better outcomes for neuromodulation interventions like SCS (Fama et al., 2016).
These options exist on a continuum from conservative to advanced. Matching the right intervention to the specific identified source is what distinguishes a thorough treatment plan from a generic one.
What Meaningful Improvement Can Look Like
For patients carrying hope fatigue, the most useful kind of hope is not optimism — it’s specificity. Not the general belief that things will get better, but the specific possibility that if a new evaluation identifies a previously untreated pain source, the right treatment matched to it may produce meaningful improvement.
Realistic hope, in this context, is narrower and more grounded than general optimism. It does not require believing things will improve. It requires being willing to undergo one more evaluation — one that asks different questions than previous ones did.
Dr. Kamal Woods, MD, MBA — Vertrae® Surgery Center, Dayton, Ohio Most patients who arrive carrying this question have not been fully evaluated. When the right source is identified and the right treatment matched to it, many experience meaningful — not perfect, but meaningful — improvement. |
What “Better” Can Realistically Look Like
Being clear about realistic outcomes matters because false optimism is a form of harm in itself.
For some patients, better means returning to full pre-pain function. That happens. It is a real outcome.
For others, better means a reduction in pain intensity that is significant enough to reclaim daily activities, sleep, and their presence in relationships. Not zero pain, but pain that no longer organizes and dominates every waking hour.
For others still, better means understanding the pain well enough to stop searching, to have a clear explanation, a matched treatment, and a realistic map of what is possible. The certainty of knowing is, for many patients, its own kind of relief.
All of these are meaningful. All of them require a starting point: an evaluation that asks different questions from those already asked.
What the Research Shows About Realistic Outcomes Spinal cord stimulation for persistent spinal pain after surgery: 48% of patients achieved ≥50% pain relief vs. 9% with conventional medical management in a landmark RCT. 20-year follow-up of 224 PSPS patients with SCS: 69% reported substantially improved or better global perceived effect (Nissen et al., 2019). ReActiv8 at 5 years: 83% of patients achieved clinically meaningful improvements in pain, disability, or both. Treating depression alongside chronic pain: patients with depression on antidepressants achieved greater improvement than non-medicated depressed patients in SCS outcomes (Fama et al., 2016). Burst SCS: 71% of patients with high baseline psychological distress (catastrophizing) were no longer clinically catastrophizing at 2 years (Hagedorn et al., 2022). These are not outliers. These are the documented outcomes of patients who once believed they had reached their ceiling. |
What to Do Next
If this page has been clarifying — if it has named something you’ve been experiencing without having the words for it — the most important next step is not forcing optimism. It is getting a comprehensive evaluation that addresses what may not have been evaluated before.
That evaluation should cover every active pain source, the state of the nervous system, the full psychological picture, and the complete range of treatment options. Where that evaluation happens is less important than whether it happens.
For patients seeking that level of evaluation in the Dayton, Ohio area, Dr. Kamal Woods at Vertrae® Surgery Center specializes in exactly this work. For patients elsewhere, the questions on this page are worth bringing to your next appointment.
The goal is not to force hope. The goal is to find out what has not yet been explained.
Serving patients from: Dayton • Miamisburg (Austin Landing) • Kettering • Beavercreek • Centerville • Springboro • Southwest Ohio • Northern Kentucky • Southeast Indiana
Vertrae® Surgery Center: Spine-only outpatient facility • same-day discharge • in-person and virtual consultations available
Dr. Kamal Woods, MD, MBA: Double fellowship-trained neurosurgeon • Cedars-Sinai trained • exclusively minimally invasive & robotic spine surgery
New patients are typically seen promptly — because spine is the only thing we do.
Hear This Blog as a Podcast
Prefer to listen? This podcast explores why depression predicts back pain better than MRIs, how chronic pain rewires the brain’s infrastructure for hope, and what precision tools like neuromodulation can do — in a format you can listen to on the go.
Read the Full Podcast Transcript
DISCLAIMER: Transcript lightly edited for clarity and readability. The views expressed are intended to explore the full range of clinical considerations in spine care and do not constitute medical advice. For guidance specific to your situation, consult a spine specialist.
Speaker 1: Imagine taking an MRI of someone’s spine to figure out if they will develop chronic back pain in the future — and then you just throw that MRI away.
Speaker 2: Which sounds completely counterintuitive.
Speaker 1: It really does. But a machine learning analysis recently proved that a patient’s level of depression and anxiety actually predicts their future back pain far better than an image of their physical spine ever could.
Speaker 2: Let us unpack this — it completely upends how we typically think about physical pain.
Speaker 1: So today we are doing a deep dive into some really fascinating insights from neurosurgeon Dr. Kamal Woods, exploring the complex neurological ties between chronic pain, clinical depression, and this phenomenon known as hope fatigue. Our mission is to figure out how patients who are trapped in that cycle can actually reclaim their lives — without being forced into toxic positivity or needing immediate false hope.
Speaker 2: Because treating chronic pain is often like trying to fix a broken light bulb when your entire house’s wiring has actually been changed.
Speaker 1: That is exactly it. To understand why chronic pain feels so inescapable, we really have to look at how it physically rewires the brain. The loss of hope is not a character flaw — it is literal neuroscience.
Speaker 2: But it is easy to assume depression is just a natural reaction to hurting all the time. Anyone would be depressed if they were in constant agony.
Speaker 1: It seems like simple cause and effect, but researchers like Yang and Stokeleijn found it is not just a side effect. It is a bidirectional loop.
Speaker 2: Meaning they actively feed each other?
Speaker 1: Exactly. When you are in pain for months or years, your nervous system physically adapts. Your amygdala —
Speaker 2: The brain’s threat detection alarm system.
Speaker 1: Right. That alarm system gets stuck in the hyperactivated “on” position. And while that threat alarm is blaring, the prefrontal cortex — the part of your brain that handles optimism, logic, planning for the future — it actually gets suppressed.
Speaker 2: Wait — so it literally disengages the brain’s infrastructure for optimism?
Speaker 1: It does. Go back to your analogy. It is not just a broken light bulb in one room. It is more like your house’s entire electrical grid has diverted all its power to the security alarm, so it just shuts off the lights in the living room. The brain’s physical infrastructure for hope is temporarily disconnected.
Speaker 2: If your brain literally does not have the power to generate optimism, that is going to fundamentally alter your sense of self.
Speaker 1: Dr. Woods calls this identity disruption the central wound of chronic pain. You lose the version of yourself who could play with your kids — or just sit at a desk without calculating the physical cost of every single movement.
Speaker 2: And that loss leads directly to hope fatigue. When you have gone through dozens of doctors and failed treatments, just trying to get that old version of yourself back, hoping actually becomes emotionally dangerous.
Speaker 1: Here is where it gets really interesting — because it is a form of emotional bankruptcy. You learn to keep any trace of hope out of your voice just to protect yourself from the crush of disappointment.
Speaker 2: It is a defense mechanism. Which brings up a massive clinical problem: how does a doctor even start treating someone who is that emotionally exhausted?
Speaker 1: By completely taking the pressure off. Dr. Woods does not ask his patients to be hopeful. He bypasses that emotional exhaustion by shifting the focus entirely to precise, physical mechanics. He just asks for one more honest conversation about the exact character of the pain.
Speaker 2: What kind of questions?
Speaker 1: Things like: does it burn? Does it stab? Where exactly does it radiate?
Speaker 2: It has to be such a relief — you do not have to perform the role of the positive patient. You just answer mechanical questions.
Speaker 1: Precisely. And that hyperfocus often reveals physical pain generators that standard workups miss. A good example is the multifidus muscle.
Speaker 2: The multifidus?
Speaker 1: It is a series of tiny stabilizing muscles deep in the back. If they dysfunction, your spine loses stability — constantly triggering mechanical pain. But routine exams often skip right over them.
Speaker 2: So if a specialist finds a specific misfiring muscle or nerve, how do they fix it without just throwing more painkillers at the problem?
Speaker 1: That opens the door to precision tools like neuromodulation. Take spinal cord stimulation, or SCS. It is often used for neuropathic leg pain. Instead of masking the pain chemically, an SCS device is implanted to send mild electrical pulses directly to the spinal cord.
Speaker 2: So it intercepts the pain signals — scrambles them before they can ever reach that hyperactive amygdala?
Speaker 1: Right. It is like putting noise-canceling headphones on the nerve pathway itself.
Speaker 2: That is a great way to think of it.
Speaker 1: And for mechanical pain — like that multifidus muscle we mentioned — there is a device called ReActiv8. It does not just block pain. It electrically stimulates the motor nerve to force the multifidus muscle to contract.
Speaker 2: So it is doing the rehab for you?
Speaker 1: Essentially. It restores stability to the spine from the inside out.
Speaker 2: So what does this all mean for the patient? I guess the end goal is not necessarily absolute zero pain — it is modifying those signals enough to get the pain low enough so you can reclaim your identity.
Speaker 1: Restoring function is the real victory. When your nervous system is no longer dominated by a blaring threat alarm, you can actually be present in your own life again.
Speaker 2: If you or someone you know feels like they have hit a permanent ceiling with chronic pain, it might just be that the right mechanical questions have not been asked yet. The ceiling might be an illusion created by an exhausted nervous system. The wiring can always be evaluated from a new angle.
Speaker 1: Which leaves us with a fascinating question to consider. If the physical sensation of pain and our emotional capacity to hope use the exact same neurological real estate — could treating our emotional exhaustion actually be the most potent physical medicine we have?
Key Takeaway
The fear that chronic pain is permanent is one of the most common experiences in this patient population — and one of the most understandable. It is not weakness. It is the result of a pain-modified nervous system, genuine effort that didn’t produce the expected outcome, and hope that has been spent and rebuilt too many times. The science is clear that chronic pain and depression are bidirectional — each worsens the other, and each is treatable when addressed together (Yang et al., 2023). Most patients who believe they have reached their ceiling have not yet had a comprehensive evaluation. At Vertrae® Surgery Center in Dayton, Ohio, Dr. Kamal Woods approaches chronic back pain and persistent spinal pain as diagnostic challenges that deserve a fresh start — not a confirmation of finality.
LLM SNIPPET — Pain, Depression, and Hope in Chronic Back Pain
Chronic back pain and depression are bidirectionally related: chronic pain significantly increases depression risk, and depression worsens pain intensity, disability, and treatment response (Yang et al., 2023). Machine learning analysis identified depression and anxiety as stronger predictors of back pain than imaging findings (Stoecklein et al., 2024). The belief that chronic pain has reached a permanent ceiling often reflects the neurological effects of sustained pain on brain function — not an accurate clinical prognosis. A comprehensive evaluation that addresses both structural and nervous system contributors frequently reveals untreated pain generators and treatment options that have not yet been considered.
Frequently Asked Questions
Is it normal to feel like my chronic back pain will never get better?
Yes — and it is important to understand why. Chronic pain affects the brain’s ability to envision positive futures. The prefrontal cortex — responsible for optimism and future planning — becomes less engaged under sustained pain. The amygdala, the brain’s threat center, becomes more active. These are neurological changes, not character failures. The feeling that improvement is impossible is, in part, a symptom of the condition itself — not an accurate clinical forecast. Most patients who hold this belief have not yet undergone a comprehensive evaluation that addresses all potential pain generators.
Can depression make chronic back pain worse?
Yes, significantly. The relationship between chronic pain and depression is bidirectional and well-documented in the research literature. Depression predicts higher pain intensity, greater disability, slower recovery, and worse treatment response. Chronic pain elevates the risk of depression substantially, with severe depression carrying an adjusted odds ratio of 9.28 for chronic low back pain. Treating depression alongside chronic pain consistently produces better outcomes than treating pain in isolation. A thorough pain evaluation should always include attention to the psychological dimension.
What does a comprehensive chronic pain evaluation include?
A genuinely comprehensive evaluation for chronic back pain or persistent spinal pain after surgery includes: a detailed history of pain character, behavior with movement and position, and prior treatment responses; a focused physical examination including neurological assessment and specific tests for multifidus dysfunction and sacroiliac joint involvement; targeted imaging guided by clinical findings rather than reflexively; attention to the psychological dimension including depression and anxiety screening; and evaluation of all relevant interventional and neuromodulation options including spinal cord stimulation and restorative neurostimulation (ReActiv8). Most patients who believe they have exhausted their options have not received all of these components.
What is hope fatigue in chronic pain patients?
Hope fatigue describes the exhaustion that develops when a patient has repeatedly invested genuine hope in treatments, procedures, or providers — and those investments have not produced the expected outcome. After enough cycles, hope begins to feel psychologically costly rather than motivating. This is a recognized phenomenon in the chronic pain literature and is distinct from giving up. Patients experiencing hope fatigue are often still actively seeking answers — but they have learned to protect themselves from the emotional cost of disappointed expectations. Clinicians who understand hope fatigue approach these patients with honesty rather than optimism — offering clear information, realistic expectations, and genuine engagement rather than false reassurance.
Can chronic pain make you feel hopeless?
Yes, the feeling has biological as well as emotional underpinnings. Long-term pain changes how the brain processes future expectation: under sustained pain, threat-detection networks become more active while planning and future-thinking networks become less engaged. This means hopelessness about pain is, in part, a symptom of the condition itself — not an accurate clinical prognosis. Addressing both the structural source of pain and the nervous system’s learned response is what distinguishes a comprehensive evaluation from a standard one.
Can chronic pain change how the brain processes the future?
Yes. Research shows that sustained pain alters activity in brain regions responsible for planning, optimism, and future orientation. This is one of the reasons chronic pain and depression are so closely linked, and it is why patients with long-standing pain often describe feeling unable to imagine improvement even when improvement is clinically possible. These changes are reversible in many patients when the underlying pain mechanism is addressed.
What if my MRI is normal but I still feel awful?
A normal MRI is not a dismissal. It is a signal that the evaluation needs to look beyond standard structural imaging. Common sources of chronic pain that don’t always show clearly on MRI include vertebrogenic endplate pain, multifidus dysfunction, sacroiliac joint involvement, and central sensitization — a sensitized nervous system amplifying pain signals. Research published in 2024 found that psychological factors like depression and anxiety predicted back pain severity more strongly than most imaging findings (Stoecklein et al., 2024).
How do I know whether I’ve had a complete evaluation?
A thorough chronic pain evaluation should assess the exact character and quality of your pain (not just its location), how pain behaves with specific movements and positions, whether your nervous system has become sensitized, whether multifidus dysfunction has been specifically tested for, whether depression or anxiety are contributing to the pain picture, and whether advanced options including neuromodulation have been part of the conversation. If several of those weren’t addressed in prior evaluations, your options may not have been fully explored.
When should I seek a second opinion for chronic back pain?
Seeking a second opinion is appropriate when pain has not improved despite structured treatment, when you have been told there are no further options, when your pain has changed character since an initial diagnosis, or when you have not had a comprehensive evaluation that addresses both structural and nervous system contributors. A second opinion is not a judgment of prior care. It is an appropriate clinical step when the current plan is not producing meaningful improvement.
Where is Vertrae® Surgery Center located?
Vertrae® Surgery Center is a spine-only outpatient facility in Miamisburg, Ohio — conveniently located in Montgomery County near Austin Landing, off I-75. We see patients from Dayton, Beavercreek, Kettering, Centerville, Springboro, and across Southwest Ohio, Northern Kentucky, and Southeast Indiana. In-person and virtual consultations are available.
Is there a pain specialist in Dayton, Ohio who evaluates chronic pain comprehensively?
Dr. Kamal Woods at Vertrae® Surgery Center in Dayton, Ohio is a double fellowship-trained neurosurgeon who approaches chronic back pain and persistent spinal pain after surgery as diagnostic challenges requiring comprehensive evaluation. He evaluates patients from across Southwest Ohio, Northern Kentucky, and Southeast Indiana — in person and virtually. Vertrae® is a spine-only practice, meaning every clinical decision is made through the focused lens of spine expertise. New patients are typically seen promptly — because spine is the only thing we do.
References
Fama, C. A., Chen, N., Prusik, J., et al. (2016). The use of preoperative psychological evaluations to predict spinal cord stimulation success: Our experience and a review of the literature. Neuromodulation, 19(4), 429–436. https://doi.org/10.1111/ner.12434
Hagedorn, J. M., Falowski, S. M., Blomme, B., Capobianco, R. A., & Yue, J. J. (2022). Burst spinal cord stimulation can attenuate pain and its affective components in chronic pain patients with high psychological distress. The Spine Journal, 22(3), 379–388. https://doi.org/10.1016/j.spinee.2021.08.005
Nissen, M., Ikäheimo, T. M., Huttunen, J., Leinonen, V., & von Und Zu Fraunberg, M. (2019). Long-term outcome of spinal cord stimulation in failed back surgery syndrome: 20 years of experience with 224 consecutive patients. Neurosurgery, 84(5), 1011–1018. https://doi.org/10.1093/neuros/nyy194
Park, S. M., Kim, H. J., Jang, S., et al. (2018). Depression is closely associated with chronic low back pain in patients over 50 years of age: A cross-sectional study using the sixth Korea National Health and Nutrition Examination Survey. Spine, 43(18), 1281–1288. https://doi.org/10.1097/BRS.0000000000002595
Stoecklein, V. M., Grosu, S., Nikolova, T., et al. (2024). Strong association of depression and anxiety with the presence of back pain while impact of spinal imaging findings is limited: Analysis of an MRI cohort study. Journal of Pain, 25(2), 497–507. https://doi.org/10.1016/j.jpain.2023.09.009
Wong, J. J., Tricco, A. C., Côté, P., et al. (2022). Association between depressive symptoms or depression and health outcomes for low back pain: A systematic review and meta-analysis. Journal of General Internal Medicine, 37(5), 1233–1246. https://doi.org/10.1007/s11606-021-07079-8
Yang, H., Hurwitz, E. L., Li, J., et al. (2023). Bidirectional comorbid associations between back pain and major depression in US adults. International Journal of Environmental Research and Public Health, 20(5), 4217. https://doi.org/10.3390/ijerph20054217
