Behavioral Issues in Spine Care

Because of the chronic nature of many spine conditions, emotional and psychological functioning and the influence of 'secondary gain', issues have been evaluated as predictors of outcome. Self-efficacy, the belief in one's own capability to take a course of action to influence or bring about a certain outcome, has been shown to be a significant predictor of disability in patients with chronic pain. (22) Psychological variables were found to be stronger predictors of lumbar surgery outcomes than medical variables in a prospective study of 204 patients. (155) Pre-surgical depression and anxiety were found to be significant predictors of outcome in lumbar spine surgery (fusion, decompression only, and instrumentation removal), while pre-operative employment and not receiving disability compensation were positively correlated with working at one-year follow-up. (156)

Workers Compensation status has been shown to affect outcomes in patients with spinal conditions. In a large prospective study of return-to-work rates among patients with spinal fracture, the strongest predictors of employment one year post injury were: (157)

•Worked in the year preceding injury (+)

•Employed at time of injury (+)

•Worker's compensation payments (-)

Patients receiving worker's compensation payments were more likely to be receiving disability payments at four-year follow-up, had less relief of symptoms post-operatively, and less improvement in functional status post-operatively than those not receiving worker's compensation payments, although they were only slightly less likely to be working at four-year follow-up. (158)

Worker's compensation status or disability litigation involvement was found to predict poorer outcomes in a small (n=24) retrospective study of patients undergoing uninstrumented fusion for low-grade spondylolisthesis. (159) None of the 13 patients involved with worker's compensation claims or disability litigation returned to work during the average 37-month follow-up period. All of these patients reported only 'fair' or 'poor' results. The study was limited by the small sample size and the retrospective and un-blinded nature of the review. The reliability and validity of the instruments used were not reported.

The characteristics of worker's compensation patients compared to non-worker's compensation patients were compared in a very large (n=18,389) cross-sectional study of patients enrolled at first visit in the National Spine Network (NSN). (160) The NSN was established in 1995 as a nonprofit consortium of 28 spine centers nationwide to support research related to spine care. The information was derived from the Initial Visit Health Survey questionnaire, which included demographic information and the SF-36 health status questionnaire. Eight percent (1,535 patients) were receiving worker's compensation payments. These patients scored lower on the SF-36 subscales for General Health, Physical Functioning, Role Physical, Social Functioning, and Mental Health.

They were also more likely to be male, nonwhite, divorced/separated, with lower educational status, smokers (or previous smokers), younger, higher body mass index, have positive non-organic signs, currently not working or disabled, considering or taking legal action, and without medical co-morbidities. The study limitations included its vast size, (potentially over-estimating very small differences), and its cross-sectional design (which does not allow study of causality or changes with time or interventions).

The authors concluded that an early holistic approach with interventions aimed at patients physical and mental well-being should be promoted, including stress management, psychological counseling, and skills to improve quality of life.