Know Thy Patient: Psych Testing for Spine
Maybe your new patient seems appropriate for a discectomy…but he has a drug problem. Another patient might seem perfect for that new implant…but she has a history of sexual abuse. With the cacophony of technological advancements all around us, it can be easy to get caught up in the excitement and lose sight of the person—the whole person—you are treating. And this, say our experts, can well be the difference between post operative success or failure.
Dr. Ray Baker, President of the North American Spine Society, notes, “Data on the relationship between psychological health and surgical outcomes has been available for years; it is some of the most validated information that we have."
We know, for example, that someone diagnosed with low back pain that is also unemployed, having marital difficulties, and other psychological stresses will not do as well postoperatively.
No, the average orthopedist isn’t a psychologist—and Dr. Baker isn’t suggesting that they add yet another responsibility to their never ending ‘to do’ list. “To expect a surgeon to sit down and ask if someone was abused as a child is incongruent; we should take these issues out of surgeons’ hands by routinely referring distressed individuals for psychological testing. As for the payment issue, if insurers are going to invest anywhere between $20, 000 and $60, 000 for a surgery, they should be willing to spend a couple of hundred dollars on psych testing. The irony is, for example, that if such testing was required for lumbar fusion, there would be far fewer surgeries that insurers would have to pay for, and more successes.”
Dr. Christopher Standaert, a physiatrist at the University of Washington in Seattle, expounds on the issue of pain. “We sometimes forget that you can’t look at an MRI and determine if the person is in pain or distress. You must talk to the patient. If necessary, refer them to someone who can identify psychosocial factors that can affect outcome. For example, if this person catastrophizes, that can lead to postop issues.”
According to Dr. Standaert, if you’re asking, “Hmm, what is the right implant for this person?” then you should reverse the order of the question. “Pain is not just about the effects of pain on the individual, but about the individual himself. The fact is that we don’t spend enough time finding the right patient"
Someone has to tease out the ‘chicken and egg’ issues, i.e., did this person develop psychological problems because of the pain or were the issues there beforehand?
"Let’s say there were two people riding in a car that was rear ended. One person reports physical pain and one doesn’t. Much of the difference is related to coping style, someone’s experience with pain in the past, substance abuse, etc. For instance, someone with a passive coping style tends to do poorly with pain.”
While inexpensive, noninvasive psychological screening would seem to be a more rational option, a patient’s response to stressful situations can act as a surrogate screening method. “That is one of the reasons that I can detect patients who will fare poorly with surgery within a few minutes of starting an interventional procedure, ” says Dr. Baker.
Dr. Baker has often made psychological issues concrete to surgeons who are ready to hit the OR by having them observe injections on their patients. “I remember one occasion when a world renowned spine surgeon was observing a discogram on one of his patients. He really felt that this person was solid, but after observing how the patient responded to the infiltration of local anesthetic even before the discography, he was astounded. He told me that I needn’t go any further…that there was no way he would operate on the patient. It was a real eye opener.”
Dr. Baker is also the kind of physician you want talking to the person who needs preop psychological treatment. “When addressing psych issues with patients I use myself as an example. I say, ‘For 12 years I have had chronic neck and arm pain emanating from my spine. Pain is a barometer for my life. When my life is out of control and I am stressed, my arm hurts more. Does this mean I am crazy? No.’ They begin to think, ‘If he is admitting to stress affecting pain, then I can too.’ Many patients shake their heads vigorously and say, for example, ‘You know, I never thought about it, but my pain started shortly after I lost my job three months ago. And now my husband’s job is on the line, etc.’ Getting to some of the underlying core stresses that a patient is experiencing is not only compassionate…it helps you move their treatment forward.”
And if someone’s test scores recommend against surgery? Dr. Standaert: “Patients who are denied surgery often say, ‘Things are a mess for me now, but if I can just have this surgery then I can put my life back together.’ I do my best to convince them that this isn’t true, and that if they can address their life issues non-operatively (counseling, eating better, sleeping better, etc.), then there is a good chance that they won’t need surgery. There is evidence in the literature showing that patients treated with comprehensive multidisciplinary non-operative care seem to do just as well as those who undergo lumbar fusion.”
And, says Dr. Baker, patients aren’t the only ones engaging in magical thinking. “Physicians often say, ‘This patient is on high dose chronic opiates, but if they detox then surgery will be successful.’ My point is that it’s what led to their taking opiates in the first place that makes them a bad surgical candidate."
It’s not just the physical pain…it’s that you can’t turn a psychological train wreck into a good surgical candidate.
Although the doctor is pulling for the patient, there are other forces going in the opposite direction. Dr. Baker notes, “I have helped design several IDE [investigational device exemption] trials in which psychological tests were a part of the screening; as it turned out, the test scores were off the charts for many subjects in these trials. The response I used to get from the companies was, ‘We cannot afford to slow enrollment; you must exclude the results of those tests.’ Now, companies are listening. Manufacturers realize that if only a small percentage of patients do well with their implant then their time on the market will be very limited. If they can increase their success rate to 60-70%, then the likelihood that their time on the market—and market share—will be improved.”
Dr. William Deardorff, Assistant Clinical Professor at the UCLA School of Medicine, is the co-author of The Psychology of Spine Surgery. He explains, “Preoperative testing is a tool to help surgeons with surgical decision making…it is a piece of the puzzle that we can give surgeons to ensure they have a complete picture of their patients. And a patient may certainly have an alternative to an elective surgery. There are several large, randomized studies where half of the patients underwent fusion and half went through a nonoperative program involving intense exercise and pain coping education. The authors found that two years out there was no difference between the two treatment groups.”
So what does Dr. Deardorff tell surgeons who are interested in the value of such testing? “Although some surgeons believe that they are unilaterally able to identify patients with psychological problems, the research suggests otherwise. Subtle, yet impactful psychosocial variables, are those that can only be picked up with the appropriate testing. The most effective spine surgery decision making approach is collaborative biopsychosocial evaluation, beginning with an astute spine surgeon who begins the process.”
Look for discrepancies, recommends Dr. Deardorff, and expect the unexpected. “We have to wonder how much symptom amplification is going on. This is not necessarily conscious—these people aren’t faking. But for whatever reason there are discrepancies between what they say and what we see on tests. For example, the MRI findings are at one level but the patient is complaining of pain at a different level. Or the person is complaining of pain that is way out of proportion to what might be expected (given the MRI results). At that point, you have to ask, ‘What else is going on?’”
“I recently interviewed a 24-year-old woman who was taking 10 pain pills daily; her surgeon was considering obtaining a discogram but was perceptive enough to get a psychological screening. She hadn’t told anyone that she was in the process of a difficult divorce, however, and no one asked about that because she was so young. It was clear that she was primarily using the medication to manage her emotional distress.”
And, says Dr. Deardorff, a brief, no-cost screening measure is available that can help assess these types of issues. “Surgeons are welcome to visit my website, where they can access a screening tool that can be used as a ‘first cut.’ This can help them determine with more accuracy what might be a ‘problem’ case. Using a screening tool doesn’t mean that the surgery can’t proceed, but it can at least help the physician make better decisions with regard to preparing the patient and delivering the appropriate postoperative care.”
Elucidating the importance of being thorough preoperatively, Dr. Deardorff states, “I once met with a 22-year-old who was scheduled for spine surgery. While it was my job to prepare him for the procedure, the clinical interview determined that he was showing symptoms of a first time schizophrenic episode. The physician cancelled the surgery and the patient was referred for the appropriate psychiatric treatment.”
Dr. Deardorff summarizes the goals of testing as follows:
By conducting preoperative psychological testing, and working collaboratively with spine surgeons, we can improve outcomes and help prevent situations where we have a technical success but a clinical failure.
For more information on preoperative screening, please visit: http://www.behavioralhealthce.com/