What patient psychosocial factors may negatively influence the decision to proceed with a spinal operation

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Substance abuse (alcoholism, drug dependence), severe depression or other psychologic disturbance (e.g. borderline personality), secondary gain (litigation, financial, social), chronic pain, as well as childhood developmental risk factors (physical abuse, sexual abuse, abandonment, neglect, chemically dependent parents).

6. What is the role of Waddell signs in deciding whether or not to proceed with a lumbar spine operation?

A brief screening for nonorganic signs as described by Waddell is valuable. These signs include:

• Tenderness (superficial and/or nonanatomic)

• Simulation (low back pain with axial loading of the skull or rotation of shoulders and pelvis)

• Distraction (marked improvement of pain on straight leg raising with distraction)

• Regional disturbance (nonanatomic findings on sensory or motor examination)

• Overreaction (disproportionate pain behaviors during examination)

The presence of three of more of these signs suggests that the patient does not have a straightforward physical problem and that psychologic factors also need to be considered. Certain patients require both operative management of their spinal pathology and careful management of the psychosocial and behavioral aspects of their illness. Assessment of behavioral signs is not a complete psychological assessment and should not be used to deny appropriately indicated treatment.

7. Why is the presence of degenerative disc changes, disc herniation, or spinal stenosis on magnetic resonance imaging (MRI) an insufficient basis for determining the need for surgical intervention?

MRI of the spine is a highly sensitive but not highly specific. Many findings reported on spinal imaging studies are common in asymptomatic individuals. Decisions about the need for surgical intervention must rely on correlation of symptomatology and imaging studies.

8. A 50-year-old male executive presents to the office of a surgeon after a lumbar MRI scan ordered by his primary care physician. The patient has experienced symptoms of intermittent mechanical low back pain without radiculopathy over the past 3 months. According to the radiologist's report, the patient has severe degenerative disc disease. The patient is extremely worried and is interested in having the disease corrected with an operation. Is surgical treatment indicated?

No. Degeneration of the lumbar intervertebral disc is part of the normal aging process and is not properly termed a disease. In a study of lumbar MRI scans in asymptomatic subjects, degenerative disc changes were seen in 34% of patients between 20 and 39 years, 59% of patients between 40 and 50 years, and in 93% of patients between 60 and 80 years. This patient should be evaluated with standing radiographs of the lumbar spine and undergo a detailed history and physical examination. If evaluation reveals no serious underlying problem, the patient can be reassured and nonsurgical treatment can be initiated.

9. A 15-year-old football player is evaluated on a preseason examination and reports a history of intermittent low back pain. Presently he is not experiencing low back pain symptoms. Radiographs show an L5 spondylolysis. Is surgical treatment indicated?

No. The patient is asymptomatic, and prophylactic surgery is not indicated. Children and adolescents with spondylolysis and low-grade spondylolisthesis usually respond to nonoperative treatment measures and often can avoid surgery.

10. A 40-year-old man is referred for consultation after a lumbar MRI showed a large extruded disc fragment at L5-S1 level. The patient noted the onset of severe back and radicular pain 1 month ago. Since that time, the patient reports greater than 50% reduction in back and leg pain. The patient reported initial mild weakness of ankle plantarflexion, which has improved. The patient has no difficulty with gait and has no symptoms to suggest cauda equina syndrome. The patient is presently working at an office job. Should surgery be recommended at this time?

No. This patient is likely to experience a good outcome with nonsurgical treatment. Prognostic factors that suggest a positive outcome with nonoperative care include:

• A large disc extrusion or sequestration

• Progressive return of neurologic function within the first 12 weeks

• Relief or greater than 50% reduction in leg pain within the first 6 weeks of onset

• Absence of spinal stenosis

• Absence of pain with crossed straight leg raising

• Positive response to corticosteroid injection

• Limited psychosocial issues

11. When is revision lumbar spinal surgery contraindicated?

Revision spinal surgery is contraindicated in the absence of surgically correctable pathology. Severity of pain or disability, in and of itself, is not an indication for additional surgery. Symptomatic patients with problems such as recurrent herniated discs, spinal instability, pseudarthrosis, or spinal stenosis are potential candidates for additional surgery. Patients with symptoms due to problems such as scar tissue (arachnoiditis, perineural fibrosis), systemic medical disease, or psychosocial instability are unlikely to have positive outcomes if surgery is undertaken.

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