Get (emotionally) healthy before spinal fusion surgery

Chronic back pain can be physically draining. Any awkward movement may bring a sudden shock of pain; the work to avoid pain can be substantial. Chronic back pain can also be emotionally and psychologically exhausting. While many people hope that back surgery will make them physically and psychologically whole again, new research suggests that people with back pain may benefit from improving their mental outlook before their spinal fusion surgery.

Back pain and disability

Back pain is the leading cause of disability and lost work in the United States. The direct and indirect costs of chronic back pain likely exceed $200 billion per year, an astounding amount. One important salvation has been spinal fusion surgery, which is how many people regain the ability to function in life and return to work. Unfortunately, not everyone benefits from spinal fusion surgery. Patient satisfaction measures range from 70 to 80%, which is good, but clearly not 100%. In the remaining 20 to 30%, it is likely that spinal fusion surgery did not help at all.

Predicting benefit from spinal fusion surgery

Ideally, surgeons would have a way of determining who would benefit from spinal fusion surgery and who would not before they operate. That way, people who would likely not benefit from spinal fusion surgery could avoid the procedure and recovery and seek other treatment. On the other hand, energy and resources could be focused on those who would benefit.

Results of this research are still emerging, though it came as no surprise that people who smoke did worse after surgery. Likewise, people who are on long-term disability tend to do worse even after they have spinal fusion surgery. What has been most surprising is the effect that presurgical mental status has on pain and functional outcomes.

Emotional health linked to physical health after spinal fusion surgery

People who had better emotional health, as measured by a health-related quality of life survey called the SF-36, had significantly less pain and better physical function two years after spinal fusion surgery. Conversely, people with poor or emotional health on the survey tended to do worse. Interestingly, presurgical emotional health was a stronger predictor of outcome then presurgical physical functioning. In other words, people with worse back pain and greater disability who had better emotional health before surgery had relatively better outcomes than people with less severe disability but poorer emotional health.

Two ways to look at the data

So what should surgeons and patients do with this information? There are two ways to think about these results. The authors of the paper suggested that the SF-36 may be a way to screen out people who would not benefit from spinal fusion surgery. For example, people who have poor emotional health may be encouraged to keep trying nonsurgical options. On the other hand, it may be possible through psychotherapy and psychiatric treatment to improve psychosocial and emotional health prior to surgery (and afterwards, perhaps) so that patients are more likely to have a positive outcome. While it remains to be tested in clinical trials, it seems reasonable to assume that people who can improve their emotional health will also achieve positive pain and disability outcomes. While mental and emotional health are important in general, they may be particularly important in patients considering spinal fusion surgery.

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