By Andrew Block
Some studies have suggested that spinal surgery is not effective, which has prompted accusations that the treatment is overused. However, lack of success after spinal surgery may due to psychosocial factors affecting the patient rather than spinal surgery per se being ineffective.
Spinal surgery is under attack in the lay press. For example, a recent issue of Consumer Reports identified spinal surgery as number one in their list of “overused medical tests and treatments”1.
Indeed, several studies have pointed to the limitations of spinal surgery. For example, Sherman, et al found that 28% of patients had unfavourable outcomes 18 months after undergoing lumbar discectomy2. However, other evidence strongly contradicts this pessimistic view of surgery.
Malter and colleagues, for example, found that patients who underwent laminectomy or discectomy had significantly better quality of life five years after surgery compared with patients who received conservative care alone3. Fritzell et al have reported similar results4. Thus, despite some negative reports, spinal surgery can be an effective means of improving patients’ quality of life.
Understanding patient influences
A growing body of research suggests that one reason why spinal surgery fails is improper selection of patients and, additionally, psychosocial factors are increasingly being recognised as critical influences on the outcome of spinal surgery. Early work, by Wiltse et al5 (1975) and Spengler et al6(1990) 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, as can a history of physical or sexual abuse, psychiatric treatment, and substance abuse. Financial incentives, too, can militate against improvement, with patients receiving workers’ compensation or involved in litigation tending to obtain poorer results7.
Research at the Texas Back Institute
More than 20 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 spinal surgery are slim even when the patient has clinical indications for surgery.
We have developed an algorithm as part of our process for presurgical psychological screening (PPS), which assesses psychosocial risk factors and combines them to stratify patients into high- medium- and low-risk for poor surgical outcomes. Our studies have found that 85% of high-risk patients (eg, someone with a job-related injury, high level of pain sensitivity as seen on the MMPI, and who is depressed and is abusing narcotics) have poor results after spinal surgery compared with about only 20% of “low-risk” patients8,9.
At the Texas Back Institute, we now include PPS as part of the surgical work-up, and find that it can improve outcomes in two ways. Firstly, 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.
Secondly, for those patients who have overwhelming psychopathology, or where there are situations that would be unresponsive to psychotherapeutic intervention, surgery can be avoided in favour of more conservative treatments, such as multidisciplinary chronic pain programmes. By avoiding surgery for such psychologically recalcitrant patients, the surgeon’s overall success rate improves and the actual rate of effectiveness of spinal surgery is revealed.
The lay press attacks on spinal surgery are based on research that has demonstrated the limitations of spinal surgery and are based on reports of some post-surgical patients having to undergo revision surgeries or undergo other invasive treatments.
When surgeons recognise the value PPS brings to the diagnostic process, they can provide the most-effective, individualised treatment for the patient, and improve spinal surgery outcomes. Spinal surgery, then, will again be recognised by the lay press as a powerful tool for healing rather than a treatment to be avoided.
2. Sherman, et al. The Spine Journal 2010; 10:108–116
3. Malter et al. Spine 1996; 21:1048–54
4. Fritzell et al. Spine 2001; 26:2521–32
5. Wiltse et al. J Bone Joint Surg (Am) 1975; 75:478–83
6. Spengler et al. J Bone Joint Surg (Am) 1990;12:230–37
7. Atlas et al. Spine 2009; 35: 85-97
8. Block et al. The Spine Journal 2001;1:274–82
9. Block & Sarwer (Eds.) Presurgical Psychological Screening, 2013, APA Books
Andrew Block is a clinical psychologist at the Texas Back Institute, Plano, USA. He has written and edited several books about presurgical psychological screening