Why Pre-Surgical Assessments are Necessary for Spine Surgery
An interview with Andrew Block, Ph.D., A.B.P.P., Clinical Health Psychologist – Behavioral Medicine, Texas Back Institute
When your spine surgeon recommends you for lumbar artificial disc replacement surgery, you may be referred to a psychologist to help you better determine your surgical readiness. This pre-surgical treatment trinity of surgeon and patient, patient and psychologist, and psychologist and surgeon has led to more successful surgeries as of late. While psychological evaluations have been ordered for three decades by some surgeons, it’s more common now, particularly as insurance providers are now requiring it more.
Despite seeming like an extra layer of red tape to cut before getting to surgery, your insurance provider and health care team recognize the mental stress that surgery presents some patients, including fears, long-term health concerns, family history, and other variables, and seek to maximize your success before your surgery.
Working with your psychologist doesn’t mean your surgeon thinks you have mental health concerns, but instead, it helps him or her identify your strengths, risk factors, and find areas where you could benefit from post-surgical support if you’re susceptible to conditions like depression. You’ll also discover that your psychologist can answer questions your surgeon cannot. If you’re worried about the outcome of your surgery, concerned about the economic impact of missing work after surgery, or worried about overburdening your care team at home, talking about these to your psychologist can allow them to teach you techniques to quiet your concerns. Psychologists and surgeons know that relaxed patients have better surgical outcomes.
Dr. Andrew Block is a board-certified clinical health psychologist who works with spine surgeons at Texas Back Institute (Plano, TX). He believes patients should be mentally and emotionally prepared for surgery to create the best outcome. Though he works with spine surgeons, he aims to help patients seek alternatives to surgery when possible. We sat down with Dr. Block and he spoke about how patients are referred to psychologists, what an evaluation is like for a patient, what psychologists look for during evaluations, and what happens after his recommendation is made to the spine surgeon.
When did the practice of psychological evaluations before surgery become common?
Dr. Block: Over the last 30 years it’s become more frequent, and it has increased in recent years. Forty percent of spine surgeons refer patients to psychologists for pre-surgical evaluations and insurance companies are requiring it. I’ve been doing pre-surgical evaluations for thirty years.
How are patients referred to pre-surgical psychologists for evaluation?
Dr. Block: There are so many factors at play that make a patient’s spine surgery successful. The spine surgeons I work with use all the tools at their disposal to physically, mentally and emotionally prepare patients for their procedure. I, and pre-surgical psychologists like me, are one of the tools surgeons have available. Surgeons will refer all patients more frequently for procedures that are more difficult to diagnose properly like lumbar disc replacement. The psychologist is another check and balance that the patient is a good candidate and will ultimately do well with the operation. It is important that spine surgeons are transparent with patients about why they are referring them to me so that the patient is bought in on the process.
Forty percent of spine surgeons refer patients to psychologists for pre-surgical evaluations and insurance companies are requiring it.
Why does a patient need a psychological evaluation prior to spine surgery?
Dr. Block: To Identify their strengths and vulnerabilities (risk factors) coming in to surgery. There are positive factors that must be considered:
- Patient activation—how engaged is the patient at maintaining their own health?
- Exercise, diet, collaborating with the physician on treatment plan
- Resilience—the ability to handle stress and bounce back
- Work ethic
- Avoidance of opioids
When a patient has some psychological vulnerabilities, their positive factors can outweigh their risk factors.
Can patients refuse an evaluation and still qualify for spine surgery?
Dr. Block: Yes and no. If it’s a situation where the surgeon feels it’s optional, then yes, the patient can refuse, and the surgeon can go ahead with the surgery. However, if it’s required by the insurer the patient will have to pay out-of-pocket in order for it to be optional.
It’s not advisable to refuse. If the patient refuses, the surgeon may see the refusal as noncompliance. In refusing, you’re denying your surgeon a piece of information that’s important to them. You’re forcing the surgeon to make a decision without all of the information necessary to make that decision.
What does a psychologist test a patient for during evaluation?
Dr. Block: Both positive (mitigating) factors and vulnerabilities. Some procedures involve psychometric testing, diagnostic, interview, and behavior and analysis. Psychometric testing looks for the following:
- Malaise, believing they won’t get better
- Sensitivity to pain
- Interpersonal problems
- Poor ability to cope with pain
The MMPI is the most widely used test, and the MMPI–2–RF is widely used now to identify psychosocial risk factors for spine surgery. It provides surgeons an accurate report on the patient.
Is there any data that stands out?
Dr. Block: In our experience at Texas Back Institute, we have found that Workers’ Comp patients do worse than non-Workers’ Comp patients. There’s a lot of conflict in that system, especially in Texas, which makes the cases complicated. Treatment is often delayed by insurance authorization, and patient’s using Workers’ Comp are often affected by economics. This does not mean that every Workers’ Comp patient is a bad candidate for spine surgery or lumbar disc replacement, it just further emphasizes the importance of using all the diagnostic tools a surgeon has at their disposal like a psychological evaluation.
Data are showing [psychological evaluations] improves outcomes when a pre-operative treatment plan includes education to reduce risk factors.
What happens after the evaluation?
Dr. Block: After the evaluation, we create a scorecard to tally up all of the risk factors as well as those that help mitigate the risks or build on the strength of the patient. We send the surgeons a report on the patient’s risk and strength factors and recommend whether or not they proceed with surgery or begin with other interventions to reduce risk factors. In 25% of cases, we recommend a delay if it is medically feasible in order to improve risk factors before surgery. We want patients to have less emotional and psychosocial issues before surgery, as this sets them up for success post-surgery.
The biggest reasons for delaying a surgery are:
- Untreated depression/demoralization
- Substance abuse (historical or current)
- Excess sensitivity to pain or physical symptoms
Is there post-op follow-up care with the patient?
Dr. Block: That depends on what happens and if I have concerns that psychological issues will recur. Unless it’s critical, I leave it up to the patient. Sometimes surgeons require follow up after surgery, but patients don’t always feel obligated to show up.
In the end, do psychological evaluations create better patient outcomes?
Dr. Block: Yes. Data are showing it improves outcomes when a pre-operative treatment plan includes education to reduce risk factors. Helping a patient create self-advocacy/health engagement works.