Dr. Andrew Block, a clinical psychologist at Texas Back Institute shares his commentary on the psychology of spine surgery. This was recently featured in Spinal News International.
Spine surgery is under attack in the popular media. For example, a recent issue of Consumer Reports identified spine surgery as number 1 in their list of “overused medical tests and treatments”. Indeed, several studies point to the limitations of spine surgery, such as that by Sherman, et al., (2010) who found unfavorable outcomes within 18 months of lumbar discectomy for 28% of patients. However, other facts strongly contradict a pessimistic view of spine surgery. Malter and colleagues (1996), for example, found laminectomy/discectomy patients had significantly greater quality of life at 5 years post-operation than did patients provided conservative care alone, with similar results for spinal fusion reported by Fritzell, et al., (2001). Thus, despite the negative press, it is clear that, for many patients spine surgery is an effective means of returning to a normal, healthy and happy lifestyle.
Why, then, does spine surgery go wrong? A growing body of research suggests that one answer lies in patient selection, for psychosocial factors are increasingly being recognized as critical influences on the outcome of spine surgery. Early work by Wiltse & Rocchio (1975), and Spengler et al. (1990), for example, demonstrated that patients who have excessive pain sensitivity, as assessed by the Minnesota Multiphasic Personality Inventory (MMPI), tend to have poorer surgical outcomes than patients whose pain perception more accurately reflects their underlying condition. Other emotional factors, such as depression, anxiety and anger can also exert strong adverse influences on surgical outcome. Financial incentives, too, can militate against improvement, with patients receiving workers compensation or involved in litigation tending to obtain poorer results. Further reducing outcome can be issues such as a histories of physical or sexual abuse, psychiatric treatment, and substance abuse.
Over twenty years of research by our group at Texas Back Institute, as well as research by others, has shown that when patients have a large number of such psychosocial risk factors, the chances of improvement from spine surgery are slim, even when there are clear clinical indications for surgery. We have developed an algorithm as part of our process for presurgical psychological screening (PPS), which weights psychosocial risk factors and combines them to stratify patients into high, medium and low risk for reduced spine surgery results. We find about 85% of those in the high risk category obtain poor surgical results, whereas only about 20% of those in the low risk category are unsuccessful (Block et al, 2001; Block & Sarwer, 2013).
At Texas Back Institute, we now include PPS as part of the surgical work-up, and find that it can improve outcomes in two ways. First, many psychosocial risk factors, such as depression, anxiety and active substance abuse, can be ameliorated prior to surgery. Thus, the patient is more emotionally stable going into surgery, and the odds of obtaining good results are increased. Second, for those patients who have overwhelming psychopathology, or situations that would be unresponsive to psychotherapeutic intervention, surgery can be avoided in favor of more conservative treatments, such as multidisciplinary chronic pain programs. By avoiding surgery for such psychologically recalcitrant patients, the surgeon’s overall success rate improves, and the true effectiveness of spine surgery is revealed.
The popular media attacks on spine surgery are based on research demonstrating both limitations in its effectiveness and reports that some patients go on to further surgeries or other aggressive treatments. When surgeons recognize the value PPS brings to the diagnostic process, they can provide the most-effective, individualized treatment for the patient, and improve spine surgery outcomes. Spine surgery, then, will again be recognized as a powerful tool for healing rather than a treatment to be avoided.
Sherman, et al., (2010). The Spine Journal 2010; 10: 108-116.
Malter et al., Journal of Spine 1996; 21:1048-1054.
Fritzell et al., Spine 2001; 26:2521-2532.
Wiltse & Rocchio. J Bone Joint Surg (Am) 1975;75:478–483.
Spengler et al. J Bone Joint Surg (Am) 1990;12: 230-237.
Block et al., The Spine Journal, 2001;1:274-282.
Block & Sarwer (Eds.) Presurgical Psychological Screening, 2013, APA Books