16 Presurgical Psychological Screening

Someone once said, “There is no medical condition that cannot be made worse by surgery,” and this certainly holds true in the area of spine. Even though technologic advances in the area of spine surgery have been significant, numerous patients will undergo spine surgery for chronic low back or neck pain without benefit, or even become worse.1–9 Several studies have demonstrated that purely “structural” issues (e.g., preoperative diagnostic severity, success of arthrodesis) are not highly correlated with clinical outcomes.^1,7,9 Technical failure rarely explains a diminished surgery result⁹; rather, poor patient selection due to psychosocial variables appears paramount.^1,9 Several psychosocial variables have been found to be predictors of clinical and functional outcome to spine surgery, especially for chronic pain conditions (Table 16.1).^1,7,9 There are few unequivocal predictors, however, and these often explain a relatively low proportion of the variance in outcome.⁹ To address this problem, biopsychosocial decision-making algorithms have been developed that take into account multiple predictor variables, including demographic, lifestyle, biologic, work, psychosocial, and medical factors.¹

Comprehensive presurgical psychological screening prior to spine surgery is an extensive process usually completed by a psychologist with special expertise in this area. It is beyond the scope of this chapter to review the literature supporting psychological screening in spine surgery, and the reader is referred elsewhere.^1,9 Rather, the brief screening tools that the spine surgeon can use in his or her practice to identify patients at risk for poor outcome are the focus here. The most robust and easily assessed biopsychosocial variables will be reviewed and a rapid assessment protocol presented (the Brief Presurgical Screening [BPSS]).

Presurgical Screening

A patient’s appropriateness to undergo presurgical screening can be conceptualized as being on a continuum from not necessary to critical. As pointed out by Carragee,¹⁰ conditions such as metastatic cancer to the spine or idiopathic scoliosis progression are unlikely to have a significant psychosocial component affecting surgical outcome, and presurgical screening is not necessary. On the other hand, a disabled, work-injured, chronic low back pain patient with depression, other psychosocial issues, and equivocal structural findings, should certainly undergo presurgical screening. Between these two extremes, the need for the screening becomes less clear. The predictive power of presurgical screening in patients undergoing surgery for straightforward conditions such as a lumbar disc herniation has not been established and is likely weak.^10,11 In this patient population, although psychological distress may be present preoperatively, it often decreases postoperatively, presumably due to the fact that the nociceptive input has been successfully remedied. In general, if a pain generator can be clearly identified, there is a high correlation between subjective and objective findings, there are minimal psychosocial issues present, and the surgery is minimally invasive, then a presurgical screening is not necessary. As these variables change, presurgical screening becomes more important.

Predictor Variables

A brief presurgical screening should assess those variables that (1) have consistently been shown to be predictive of poor spine surgery outcome, and (2) are easily assessed within the context of a spine surgery practice. Lengthy presurgical screening procedures (e.g., interview, record review, and psychological testing) are more appropriately done by the psychologist upon referral from the surgeon once the patient has been identified by the initial presurgical screening. In designing a BPSS, the most important variables from each of the four major predictor categories are assessed (Table 16.2).

Biologic and Lifestyle Variables

Although several biologic, demographic, and lifestyle variables have been investigated (Table 16.1), most have shown inconsistent predictive power when assessed independently.^1,9 Of these variables, cigarette use, alcohol and substance use, and obesity are the most useful to include in a brief screening.

Cigarette use

Smoking is a frequently assessed predictive variable especially related to outcome to spinal fusion.^1,5,9,12,13 Research suggests that it is a predictor of poor outcome for two reasons: (1) habitual nicotine use is thought to decrease revascularization of the bone graft, slow healing rates, increase the risk of infection, and increase the risk of pseu-darthrosis^1,13,14; and (2) cigarette use has been correlated with other variables that may exert their own negative influence on spine surgery outcome such as “unhealthy” lifestyle behaviors (e.g., lack of exercise, poor nutrition, alcohol use, etc.), lower socioeconomic status, and heavy physical job demands.^5,9,15,16 If a spinal fusion is being considered for a patient there are no clear guidelines about preoperative cessation of smoking.17,18 Certainly, the longer a patient is abstinent from smoking preoperatively, the more likely he or she will be able to stay abstinent during the lengthy and often-stressful postoperative recovery period.

Alcohol and Substance Abuse

It is difficult to accurately assess alcohol or substance abuse in spine surgery candidates because many patients are reluctant to reveal this type of information.¹ As a result, few studies have directly examined the effect of alcohol or substance abuse on spine surgery outcome. Excessive alcohol use has the potential to negatively impact a patient’s recovery from spine surgery in several ways, including slower wound healing, sleep disruption, increased depression and anxiety, increased likelihood of smoking due to lowered impulse control, poor nutrition, amplified endocrine changes in response to surgery, and synergistic interactions with medications.^1,19,20

Substance abuse in spine surgery candidates might include use of illicit drugs (current or history) or abuse of prescription medications. With the increased acceptance of long-term opioid treatment in the management of chronic pain conditions, evaluation of the possible abuse of prescription medications becomes more difficult. As part of the BPSS, the surgeon should be aware of the following questions: what is the overall level of pain medication use, is the patient showing a need for escalating dosages, has the medication actually improved patient function, is the patient taking the medications as prescribed (compliance or noncompliance), is there any evidence of abuse of prescription medications (e.g., doctor shopping, frequent emergency room visits, getting medication from illegitimate sources), are all the patient’s medications related to the chronic pain problem being managed by one physician, and is the patient under an opioid treatment contract? If there is any evidence of alcohol or substance abuse, or if the patient has been on high doses of opioids for quite some time, it is most prudent to address these issues prior to surgery.

Obesity

Body weight has not emerged as a consistent predictor of spine surgery outcome,⁹ but recent studies have demonstrated an increased risk for surgical site infection in spinal surgery patients who were morbidly obese.^21,22 Obesity has been found to contribute significantly to several variables predictive of poor outcome to spine surgery.²³ In a workers’ compensation population, it has been correlated with greater compensation costs but not medical costs.²⁴ Elderly obese patients undergoing decompressive laminectomy and/or discectomy (fusion cases excluded), have demonstrated a greater level of being “very dissatisfied” with the surgery outcome, higher pain ratings, and lower activities of daily living relative to the nonobese comparison group.²⁵ Interestingly, studies have generally found no differences between obese and nonobese spine surgery groups in terms of duration of surgery, blood loss, duration of hospitalization, and most clinical outcomes.^25,26

The inconsistent findings of these studies are likely due to the marked differences in patient population variables (age, work status, etc.), definitions of obesity, and type of spine surgery being investigated (fusion versus nonfusion procedures). As a predictor of poor spine surgery outcome, obesity probably interacts with these other factors. As such, it is conceptualized as a variable to be assessed within the context of other more powerful predictors (e.g., disability, litigation, psychological distress).

Work-Related Variables

Work-related variables, as a group, demonstrate some of the strongest correlations with poor spine surgery outcome. Those variables amenable to a BPSS include workers’ compensation, litigation, and extended disability duration.

Workers’ Compensation

A great number of studies have demonstrated that involvement in the workers’ compensation system predicts a poorer outcome to spinal surgery.^1,9 Although it might be concluded that this is related to financial incentives for staying disabled, it is more likely due to the various difficulties experienced by the disabled worker, including such things as financial distress, loss of identity related to the job, an adversarial relationship with the employer and insurance carrier, delays in treatment, having to “prove” one is injured, among other things. The longer the patient is off of work, the more time a “system-induced functional disability syndrome” has to develop.²⁷ Although workers’ compensation status is a significant predictor of spine surgery outcome, studies suggest that this effect is mediated by other variables such as time off of work, legal representation, job satisfaction, and so forth.^1,9,27 For the patient who loves his job and is undergoing a spine surgery for a disc herniation that occurred at work just 2 months prior, workers’ compensation status will rarely be a predictor of poor outcome.

Litigation

Another predictor variable that has consistently been linked to poorer spine surgery outcome is litigation status (related to workers’ compensation, personal injury, or disability benefits).^1,5,7,9,24 Although one might surmise that this is due to symptom exaggeration for secondary gain, it must be assumed that the spine surgery is being recommended because some evidence of pathophysiology has been identified.⁵ The litigious patient might very well do poorly because of increased somatic sensitivity to pain as a consequence of financial incentives and social-contextual variables.5,9

Duration of Sick Leave

Lengthy preoperative sick leave is a consistent predictor of diminished response to spine surgery including global outcome, overall satisfaction, back-specific function, and return to work.^1,3,9,28,29 Longer duration of sick leave allows for development of the functional disability or chronic pain syndrome, which is probably the reason for the poorer spine surgery outcomes.^1,27

Psychological Factors

Psychological factors are among the most frequently investigated predictive variables for spine surgery outcome. Some of the common psychological variables assessed include pain sensitivity, depression, anxiety, anger, fear avoidance, severe psychopathology, and various personality disorders or features.^1,9 Psychological predictive variables are often assessed through the use of psychometric testing, and the most commonly researched test has been the Minnesota Multiphasic Personality Inventory (MMPI/MMPI-2).^30,31 It is beyond the scope of a brief initial presurgical screening to include an MMPI-2 (567 questions and 1.5 hours to complete), although it is often used as a component of a comprehensive presurgical screening.¹ Ideally, a BPSS would include some very brief questionnaires that assess the same predictive psychological variables captured by the MMPI-2 and other more comprehensive tests. Although many psychological variables have been identified as predictive of poor spine surgery outcome, pain sensitivity and depression have received the most attention.

Pain Sensitivity

Of all the psychological factors investigated, those falling under the rubric of “pain sensitivity” have shown the most consistent predictive power.^1,9 Pain sensitivity might be defined as a patient’s propensity to display pain behaviors beyond what would be expected due to nociceptive input and objective findings. Pain sensitivity also encompasses the idea of how much the patient is “suffering” due to the pain; or, the emotional contribution to the patient’s perception of pain and level of disability. Pain sensitivity includes such concepts as heightened somatic awareness, fear of movement (kinesophobia), somatic anxiety, and general psychological distress (but not necessarily depression). Given this conceptualization of pain sensitivity, it is not surprising that any test that assesses some component of this construct might predict poor spine surgery outcome. This is probably why many tests (aside from the MMPI-2) have been shown to correlate with spine surgery outcome, including the Distress Risk and Assessment Method (DRAM),^29,32 the Dallas Pain Questionnaire,³³ the Mental Component Score of the SF-36,¹² and the Waddell Non-Organic Signs,^1,34 among others.

The pain drawing is another purported assessment of pain sensitivity. Pain drawings are hypothesized to identify the psychological contribution to a patient’s pain and are scored in several ways.³⁵ Pain drawings that are deemed “abnormal” or “nonorganic” (unexplainable pain distribution) are thought to identify patients with a greater psychological component to their pain, although this conclusion has been contested in a recent review.³⁵ The pain drawing has been investigated as a predictor variable for spine surgery outcome but the results are inconsistent.³⁶ Even so, the pain drawing is easily administered; when it is grossly abnormal, it might be a useful piece of information to incorporate with other screening variables.¹

Assessing pain sensitivity as part of a BPSS might be done in several ways. Certainly, the pain drawing can be used adjunctively, but not as a stand-alone predictive test. The DRAM system was developed as a measure of distress in back pain patients³² and has been used as a rapid presurgical screening tool.²⁹ The DRAM consists of a modified version of the Zung Depression Inventory (ZDI; 23 items) and the Modified Somatic Perceptions Questionnaire (MSPQ; 22 somatic items). The DRAM takes ~10 minutes to complete and places patients into one of four categories based upon classification rules for the results of the two tests: Normal (N), at Risk (R), Distressed-Depressive (DD), and Distressed-Somatic (DS). Patients in the distressed groups (DD, DS) have been found to have a diminished response to spine surgery,²⁹ although results did not always rise to the level of statistical significance.^11,37 Research suggests the DRAM may be most useful in screening of chronic back pain patients rather than more acute conditions.^10,11

Another instrument that is emerging as a possible choice for quickly assessing pain sensitivity and other predictive variables is the Brief Battery for Health Improvement version 2 (BBHI-2).³⁷ This 63-item test takes ~10 minutes to complete and was developed for use with medical patients. The BBHI-2 yields scores for six scales covering three content areas: validity (defensiveness), physical symptoms (somatic complaints, pain complaints, functional complaints), and affective symptoms (depression and anxiety). The BBHI-2 assesses many areas that have been found to be predictive of poor outcome to spine surgery (e.g., somatic complaints, pain complaints, depression, anxiety); however, it has not been directly tested in any spine surgery outcome studies.³⁸

Depression

Major depression occurs frequently in patients with chronic spine pain^39,40 and has been found to predict poor spine surgery outcome in some studies^5,6,23,29 but not in others.^3,11,41 These inconsistent findings are likely due to several reasons.¹ Patients with protracted depressive symptoms (either antedating a chronic pain problem or associated with it) may be less likely to have their psychological symptoms resolve after surgery than a patient with depression that is more acute and reactive to the pain. This has been substantiated in recent studies suggesting that spine pain patients with shorter duration of symptoms and lack of other psychosocial risk factors might show preoperative depression in response to the pain (“reactive depression”) but this resolves after successful surgery.10,11 If the DRAM or BBHI-2 is used to assess pain sensitivity, a depression score is included in the test. Other rapid measures of depression are the Beck Depression Inventory-II (BDI-II) and the BDI-PC (BDI for primary care).⁴²

Medical Variables

Few studies have identified medical factors that are consistent and unequivocal predictors of poor spine surgery outcome. Of the predictive variables investigated (Table 16.1), duration of symptoms, number of previous spine surgeries, and associated medical problems have reasonable support in the outcome studies and are most amenable to a BPSS.

Duration of Symptoms

Duration of symptoms has been measured directly and as a component of other predictor variables (e.g., length of disability, workers’ compensation, sick leave).¹⁹ Consistent with theories on the development of the chronic pain syndrome,²⁷ the longer duration of symptoms allows for other psychosocial issues to emerge that adversely impact spine surgery outcome (e.g., physical deconditioning, psychological distress).

Number of Previous Spine Surgeries

It is estimated that the failed back surgery syndrome occurs in 10 to 40% of all spine surgeries,⁴³ and the probability of good surgical outcome decreases with each successive surgical intervention.^1,9 However, there is evidence that patients who have responded well to a previous spine surgery are more likely to do better with additional surgery, assuming a clear pain generator has been identified and is amenable to surgical intervention.^1,9

Associated Medical Problems

This predictive variable category is assessed by evaluating prior medical utilization and comorbid health conditions. A myriad of studies have demonstrated diminished spine surgery outcomes in patients with a history of many prior illnesses and nonspine surgeries. This may be due to the fact that prior medical utilization reflects sensitivity not only to pain, but also to physical symptoms in general.¹ Comorbid medical conditions and poor general health might impact spine surgery outcome due to such things as problems with wound healing (e.g., with diabetes) or postoperative rehabilitation (e.g., with other joint problems or systemic issues such as fibromyalgia).

The Brief Presurgical Screening

As part of the surgery decision-making process, the BPSS can help avoid the creation of a failed back surgery syndrome case. Table 16.2 summarizes those variables that are amenable to rapid screening and have, as a group, been shown to have reasonable predictive power. There are no empirical guidelines or scoring criteria for the checklist; however, the research suggests that the greater the number of risk factors the more likely the spine surgery outcome will be diminished. There are some risk factors that the surgeon might want to “weight” more heavily than others. For instance, according to the research, a patient who is in the workers’ compensation system, represented by an attorney, has been on disability for 4 years, and is facing a third surgery is at high risk for failure regardless of any other variables.

Disposition of patients identified as high risk for clinical failure might include (1) referring the patient to a qualified psychologist for more extensive screening, and possibly pain management or preparation for surgery treatment^1,44; (2) helping the patient successfully address the risk factors and then reassessing for surgery at a later date (e.g., detoxification, quitting smoking, weight loss, treating a clinical depression, etc.); and (3) avoiding spine surgery and referring the patient to an appropriate functional restoration program.^3,45

References

1. Block AR, Gatchel RJ, Deardorff WW, Guyer RD. The Psychology of Spine Surgery. Washington, DC: American Psychological Association; 2003

2. Fritzell P, Hagg O, Wessberg P, Nordwall, A; Swedish Lumbar Spine Study Group. A 2001 Volvo Award Winner in Clinical Studies. Lumbar fusion versus nonsurgical treatment for chronic low back pain: a multicenter randomized controlled trial from the Swedish Lumbar Spine Study Group. Spine 2001;26:2521–2532

3. Hagg O, Fritzell P, Ekselius L, Nordwall A. Predictors of outcome in fusion surgery for chronic low back pain: a report from the Swedish Lumbar Spine Study. Eur Spine J 2003;12:22–33

4. Turner JA, Ersek M, Herron L, et al. Patient outcomes after lumbar spinal fusions. JAMA 1992;268:907–911

5. LaCaille RA, DeBerard MS, Masters KS, Colledge AL, Bacon W Presurgical biopsychosocial factors predict multidimensional patient outcomes of interbody cage lumbar fusion. Spine J 2005;5:71–78

6. Franklin GM, Haug J, Heyer NJ, et al. Outcome of lumbar fusion in Washington state workers’ compensation. Spine 1994;17:1897–1903

7. DeBerard MS, Masters KS, Colledge AL, Schleusener RL, Schlegel JD. Outcomes of posterolateral lumbar fusion in Utah patients receiving workers’ compensation. Spine 2001;26:738–747

8. Peolsson A, Hedlund R, Vavruch L, Oberg B. Predictive factors for the outcome of anterior cervical decompression and fusion. Eur Spine J 2003;12:274–280

9. Mannion AF, Elfering A. Predictors of surgical outcome and their assessment. Eur Spine J 2005;15(suppl 1):S93-S108

10. Carragee EJ. Psychological screening in the surgical treatment of lumbar disc herniation. Clin J Pain 2001;17:215–219

11. Hobby JL, Lutchman LN, Powell JM, Sharp DJ. The distress and risk assessment method (DRAM): failure to predict the outcome of lumbar discectomy. J Bone Joint Surg Br 2001;83:19–21

12. Trief PM, Ploutz-Snyder R, Fredrickson BE. Emotional health predicts pain and function after fusion: a prospective multicenter study. Spine 2006;31:823–830

13. Andersen T, Christensen FB, Laursen M, Hoy K, Hansen ES, Bunger C. Smoking as a predictor of negative outcome in lumbar spinal fusion. Spine 2001;26:2623–2628

14. Glassman SD, Anagnost SC, Parker A, Burke D, Johnson JR, Dimar JR. The effect of cigarette smoking and smoking cessation on spinal fusion. Spine 2000;25:2608–2615

15. Droomers M, Schrijvers CTM, Mackenbach JP. Why do lower educated people continue smoking? Explanations from the longitudinal GLOBE study. Health Psychol 2002;21:263–272

16. Vogt MT, Hanscom B, Lauerman WC, Kang JD. Influence of smoking on the health status of spinal patients. Spine 2002;27:313–319

17. Fardon DF, Whitesides TE. The smoking patient: to fuse or not to fuse. Spineline 2002;Sept/Oct:10–12

18. Porter SE, Hanley EN. The musculoskeletal effects of smoking. J Am Acad Orthop Surg 2001;9:9–17

19. Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth 1997;78:606–617

20. Uomoto JM, Turner JA, Herron LD. Use of the MMPI and MCMI in predicting outcome of lumbar laminectomy. J Clin Psychol 1988; 44:191–197

21. Olsen MA, Mayfield J, Lauryssen C, et al. Risk factors for surgical site infection in spinal surgery. J Neurosurg 2003;98:149–155

22. Telfeian AE, Reiter GT, Durham SR, Marcotte P. Spine surgery in morbidly obese patients. J Neurosurg 2002;97:20–24

23. Block AR, Ohnmeiss DD, Guyer RD, Rashbaum RF, Hochschuler SH. The use of presurgical psychological screening to predict the outcome of spine surgery. Spine J 2001;1:274–282

24. LaCaille RA, DeBerard MS, LaCaille LJ, Masters KS, Colledge AL. Obesity and litigation predict workers compensation costs associated with interbody cage lumbar fusion. Spine J 2007;7: 266–272

25. Gepstein R, Shabat S, Arinzon ZH, Berner Y, Catz A, Folman Y. Does obesity affect the results of lumbar decompressive spinal surgery in the elderly? Clin Orthop Relat Res 2004;426:138–144

26. Andreshak TG, An HS, Hall J, Stein B. Lumbar spine surgery in the obese patient. J Spinal Disord 1997;10:376–379

27. Gatchel RJ, Turk DC. Psychosocial Factors in Pain: Critical Perspectives. New York: Guilford Press; 1999

28. Nygaard OP, Kloster R, Solberg T. Duration of leg pain as a predictor of outcome after surgery for lumbar disc herniation: a prospective cohort study with 1-year follow up. J Neurosurg 2000;92:131–134

29. Trief PM, Grant W, Frederickson B. A prospective study of psychological predictors of lumbar surgery outcome. Spine 2000;25:2616–2621

30. Deardorff WW. The MMPI-2 and chronic pain. In: Gatchel RJ, Wiesber JN, eds. Personality Characteristics of Pain Patients: Recent Advances and Future Directions. Washington, DC: APA Books; 2000:109–125

31. Butcher JN, Dahlstom WG, Graham JR, Tellegen A, Kaemmer B. Manual for Administration and Scoring of the MMPI-2. Minneapolis: University of Minnesota Press; 1989

32. Main CJ, Wood PLR, Hollis S, Spanswick CC, Waddell G. The distress assessment methods: a simple patient classification to identify distress and evaluate risk of poor outcome. Spine 1992;17:42–50

33. Andersen T, Christensen FB, Bunger C. Evaluation of a Dallas Pain Questionnaire classification in relation to outcome in lumbar spinal fusion. Eur Spine J 2006;15:1671–1685

34. Spratt KF, Keller TS, Szpalski M, Vandeputte K, Gunzburg R. A predictive model for outcome after conservative decompression surgery for lumbar spinal stenosis. Eur Spine J 2004;13:14–21

35. Carnes D, Ashby D, Underwood M. A systematic review of pain drawing literature: Should pain drawings be used for psychologic screening? Clin J Pain 2006;22:449–457

36. Hagg O, Fritzell P, Hedlund R, Moller H, Ekselius L, Nordwall A. Pain-drawing does not predict the outcome of fusion surgery for chronic low-back pain: a report from the Swedish Lumbar Spine Study. Eur Spine J 2003;12:2–11

37. Disorbio JM, Bruns D. Brief Battery for Health Improvement-2 Manual. Minneapolis: NCS Pearson Assessments; 2003

38. Deardorff WW. Review of the Brief Battery for Health Improvement-2. In: Gatchel RJ, ed. Compendium of Outcome Instruments for Assessment and Research of Spinal Disorders. 2nd ed. La Grange, IL: North American Spine Society; 2006:26–27

39. Currie SR, Wang J. Chronic back pain and major depression in the general Canadian population. Pain 2004;107:54–60

40. Sullivan MJ, Reesor K, Mikail S, Fisher R. The treatment of depression in chronic low back pain: review and recommendations. Pain 1992;52:249–255

41. Tandon V, Campbell F, Ross ERS. Posterior lumbar interbody fusion: association between disability and psychological disturbance in non compensated patients. Spine 1999;24:1833–1838

42. Deardorff WW. Review of the Beck Depression Inventory-2. In Gatchel RJ, ed. Compendium of Outcome Instruments for Assessment and Research of Spinal Disorders. 2nd ed. La Grange, IL: North American Spine Society; 2006:25

43. Oaklander AL, North RB. Failed back surgery syndrome. In: Loeser JD, Butler SH, Chapman CR, Turk DC, eds. Bonica’s Management of Pain. 3rd ed. Philadelphia: Lippincott, Williams & Wilkins; 2001; 1540–1549

44. Deardorff WW, Reeves JL. Preparing for Surgery. Oakland: New Harbinger Press; 1997

45. Sørensen R, Friis A, Nygaard Ø, et al. Randomized clinical trial of lumbar instrumented fusion and cognitive intervention and exercises in patient with chronic low back pain and disc degeneration. Spine 2003;28:1913–1921

Related posts:

Biomechanics of the Lumbar Intervertebral Disc The Role of Education and Back Schools Clinical Presentation of Disc Degeneration The Mechanisms of Pain from Intervertebral Discs Percutaneous Decompression Spinal Fusion: Posterior Approaches

Stay updated, free articles. Join our Telegram channel

Join