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Say What?: Agency Says Back Patients Should Have Mental Screening Before Surgery

Published July 30, 2017

The United States Preventative Services Task Force (USPSTF), a national group of experts who are dedicated to maintaining top-notch clinical practices, suggest that pre-surgical psychological screenings (PPS) should be practiced prior to any form of spinal surgery for approximately 25 minutes by a trained psychologist.


First and foremost, this reassures that the doctor has the correct diagnosis and will be performing the equivalent operation. In addition, PPS is used to identify those at risk for poor outcomes — to prepare the patient for all results in addition to providing an effective treatment plan for any follow-up services needed.

PPS involves referring patients — including those with chronic pain who are considering spinal surgery — to a health psychologist for further evaluation. This usually involves a semi-structured interview and psychometric testing, according to testimony from Richard L. Skolasky, ScD, director of the department of orthopedic surgery at the Spine Outcomes Research Center in Johns Hopkins Hospital.

Studies suggest (we'll get to those studies in a few) that adults with depression and anxiety rarely seek care, but these conditions may play a role in disabling back pain AND contribute to poor health outcomes. The USPSTF (that's a long abbreviation) recommendations were developed in response to the realization that many psychological disorders go untreated and surgery can exacerbate any hopeless feelings.

On top of it, if a patient is not mentally prepared for the surgery as well as the related risks, it can really diminish the healing process.

“These illnesses are often overlooked,” explained Dr. Skolasky, “They could pose serious risks to patients and may influence recovery.”

Previous research has linked depression and anxiety to longer recuperation time, delayed returns to work, more postoperative complications, and failure to comply with medication schedules after discharge. Now, not all hospitals test patients for depression partly because any form of post-operative depression may not begin until after the operation.

Depending on your back pain diagnosis, a specialized surgeon would work to straighten and strengthen any damaged or narrowed discs with bone grafts and/or metal plates. Such problems in the lumbar, or lower back region, a portion of the spine, can sometimes leave patients unable to perform normal daily activities, including lifting groceries, walking long distances or climbing stairs.

Not being able to maintain your quality of life can cause severe depression.

Bernard Vaccaro, instructor in psychiatry at Brigham and Women's Hospital in Boston, Massachusetts said, “Post-operative depression, is more likely to occur well after the crisis of surgery has ended and the patient is back at home or even at work.”

“That can make it particularly difficult for patients to cope with feelings about what they've endured and what their future is likely to be, or for family members and physicians to see and understand their feelings,” forewarned Vaccaro. “Stigma continues to surround depression, and many patients may hide their state of mind from families and caregivers alike.”

Ironically enough, a survey showed that only 10 percent of orthopedic surgeons and neurosurgeons follow recommended use of psychological screenings prior to surgery as per a report published in the April edition of the Journal of Spinal Disorders and Techniques provided by Johns Hopkins and Dr. Skolasky who was also the senior investigator on the study.

The survey responses stem from 110 licensed spinal surgeons across the U.S. Skolasky’s team e-mailed a 20-minute questionnaire to 340 licensed spine surgeons across the country. And out of that, 110 responded. Most of them had more than 15 years of experience, and just over half were based at university hospitals.

With more than 600,000 major spinal surgeries performed each year, it's shocking to hear how PPS tests are often overlooked (just like Dr. Skolasky said).

The oversight, researchers claim, may pose serious risks to a patients’ surgical recovery.

“Our survey results show that surgeons and patients still have a long way to go in recognizing and appreciating how many psychological factors and mental health can impact the success of their back surgeries,” conceited Dr. Skolasky

“It may be necessary to delay surgery in order to first treat a patient’s depression or anxiety to minimize the likelihood of prolonged recuperation after their operation.”

Among other key findings was that highly experienced spine surgeons were more likely to use the assessment tools than those with less than 15 years of experience in the field. Orthopedic and Neurosurgeons with a higher volume of patients, more than 200 a year, also favored the screening compared to colleagues who performed fewer procedures.

Researchers pointed out that they were shocked to find out spine surgeons in private practice, or community hospitals in general, carried out more psychological screenings than any counterparts in larger, university-affiliated hospitals.

Skolasky affirmed that this is counterintuitive. “Academic medical centers have ready access to psychologists and other testing resources that community hospitals usually lack.

“Some surgeons may view psychological screening as an unnecessary surgical delay, during which time a patient’s condition can deteriorate quickly, or surgeons simply may not be well-enough aware of the important role played by mental health in post-surgical recovery.”

Ultimately, Dr. Skolasky pointed out that it all comes down to training. If such testing is highlighted during surgical education, it can be better adapted to daily practice.

From the survey's findings, it's clear that a better job needs to be done in explaining the benefits of presurgical psychological screening to both surgeons and patients alike.

Skolasky and his research team are planning further research to better assess how screening and treatment for anxiety and depression before any back surgery can either speed up or prolong a patient’s road to recovery.

The study should serve as an important reminder for all surgeons to adopt pre-surgical psychological screening guidelines, and to establish protocols to ensure they are actually followed.

Whether you have post-surgical depression or have been diagnosed with any form of mental illness before surgery was even a question, it's important to speak up. If your doctor doesn't ask, ask him instead.

Ideally, patients should be able to discuss the need of a PPS exam prior to an operation as part of their own pre-surgical checklist.

Updated: January 31, 2019

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