We generally think about surgery as an objective solution to an objective medical problem. For example, an objective problem might be that a patient is suffering from a herniated lumbar disc, and the goal of surgery is to fuse two vertebrae together to alleviate this problem. In most cases, though, the ultimate goal of surgery goes well beyond the objective goal of achieving a successful fusion. The most common goals of surgery are helping the patient to return to work, to reduce opioid use and hopefully to be satisfied with medical care. Of these three goals, the first two are behaviors and the third one is an attitude. When it comes to predicting changes in attitudes and behaviors, it makes sense that psychological tests would be stronger predictors than MRIs or CT scans. Consistent with this, in the case of spinal pain, psychological tests have been shown to be more predictive of surgical outcome than MRIs.3,4 Beyond that, a thorough review of the evidence determined that psychological tests are the scientific equal of medical tests.3
A recent study of lumbar fusion surgery found that even though surgery was objectively successful 84% of the time, following the surgery 49% of the patients had worse pain, 44% were dissatisfied with their outcome and 38% were totally disabled at follow-up.5 Similarly, another study found that opioid pain medication use actually increased following lumbar fusion surgery.6 This illustrates an important point: It is possible for an orthopedic surgery to simultaneously be an objective success and a behavioral failure. To prevent this possibility, it is helpful to evaluate nonmedical risk factors prior to surgery.
Psychological, social and behavioral variables are known to affect the outcome of surgery and other medical treatments,7 and they do so in various ways:
Depression increases the risk of nonadherence with physical therapy8 and of not taking medications as prescribed,9 and in general contributes to a poor medical treatment outcome.8
Depression prior to surgery has been shown to predict dissatisfaction with the outcome of the surgery.10
Emotional stress affects both the inflammatory response and the immune system, and this can negatively impact surgical outcome.11
Deep sleep is needed to trigger the release of human growth hormone,12 which the body requires for wound healing.13 Emotional stress can thus interfere with recovery from surgery by reducing deep sleep, and this also increases the risk of chronic pain.14
Job dissatisfaction is a significant predictor of failure to return to work.2,15
The Chronic Pain Treatment Guidelines published by the Colorado Division of Workers’ Compensation make recommendations about how and when to conduct presurgical psychological evaluations. These guidelines require or strongly recommend psychological evaluations for patients suffering from chronic pain or delayed recovery, and for patients prior to lumbar fusion, artificial disc surgery, spinal cord stimulation, discography, facet rhizotomy, IDET, some shoulder surgeries, and back surgery if Waddell signs are > 2.16
Under the guidelines, when performing a presurgical psychological evaluation, the first task of a psychologist is to look for what are called “primary risk factors.”16 Primary risk factors are psychosocial risk factors that are so severe that the presence of just one could preclude the patient from benefiting from the proposed surgery. Examples of primary risk factors would include suicidal impulses, daily use of methamphetamines or paranoid psychosis associated with mania. Patients exhibiting primary risk factors are generally thought to be too psychologically unstable to benefit from elective surgeries or to comply with treatment generally. Even though primary risk factors are extreme, one recent national study found that of patients in rehabilitation for pain or injury, over 10% exhibited one or more primary risk factor.7
Consider a case of a patient who suffers from both back pain and suicidality. Of the two, the suicidality is the more serious condition, as it is potentially fatal, whereas back pain is not. Because of that, treatment of the suicidality should take priority over the treatment of the back pain. Overall, when primary psychological risk factors are present, the patient is so psychologically unstable that there is a high risk that a surgery would have a poor outcome. It should be pointed out here that some surgeries are performed because of a medical emergency, such as a lumbar surgery for cauda equina syndrome to prevent paraplegia. In cases where there is a high level of medical necessity, the surgery is performed, and any associated psychosocial risk factors are managed perioperatively.
Under the guidelines, a presurgical psychological evaluation should also assess “secondary risk factors.”16 If primary risk factors could be thought of as “red flags,” secondary risk factors could be thought of as “yellow flags.” Secondary risk factors are moderate but significant psychosocial risk factors for surgical outcome. Examples of secondary risk factors would include moderate depression, moderate anxiety, job dissatisfaction, long-term use of prescribed opioids and excessive disability. Virtually all patients with a disabling injury will have one or more secondary risk factors. Unlike primary risk factors, where the presence of one severe risk factor may exclude the patient from being considered as a surgical candidate, in the case of secondary risk factors, it is the overall number of risk factors present that is assessed. When patients are exhibiting an elevated number of secondary risk factors,7 alternative, more conservative treatments should be considered. The presence of primary and secondary risk factors have been found to be associated with a poor outcome from medical treatment generally.
The goal of a presurgical psychological evaluation is to identify primary and secondary risk factors, and based on that and other findings, recommend the best care plan for a patient. Surgical patients with a high level of psychosocial risk are much more likely to be dissatisfied with their care.7 For these patients, conservative care is often a better alternative to elective surgical procedures. Interestingly, studies have found that a psychological pain management treatment called cognitive behavioral therapy (CBT), which is sometimes combined with physical therapy, can produce outcomes equal to surgery.17,18,19 Even though surgery and CBT are equally effective for back pain, surgery can cost up to 168 times more than CBT and is associated with both adverse outcomes and risk of death. If the presurgical psychological evaluation suggests that the patient is at high risk for being unhappy with the surgical outcome, there is little reason to expose that patient to the risk of surgery. It is important to remember, though, that the presence of a high level of psychosocial risk factors does not mean that the patient will never be a candidate for surgery, as in many cases these risk factors can be addressed through appropriate treatment.
Overall, while studies have shown that patients with a high level of psychosocial risk are unlikely to benefit from surgery alone,1,2,7 these patients can often benefit when an interdisciplinary approach to care is used that integrates psychological and medical interventions.18,19 By helping to identify the best treatment plan for a patient, presurgical psychological evaluations play an important role in the treatment of injured workers.
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