A Three-Step Psychologic Exam of the Spine Patient
More and more, the role of psychosocial factors in chronic low back pain (LBP) has become apparent. The interaction of biologic factors with psychologic and social factors is the focus of new research.

In this report, a three-step approach to the assessment and treatment of spine patients is presented. Studies to support the use of this evaluation method are ongoing. Using a three-step approach like this may help improve outcomes. Evidence is still needed to prove this.

The first step in the biopsychologic exam in the initial screening. The screening process helps find patients with psychosocial and functional distress. This information is useful when planning rehab. It can also be used when surgery is scheduled.

Specific tests in the screening exam include the Medical Outcomes Study 36-Item Short Form [SF-36] and the visual analog scale (VAS). Surveys to assess disability and depression (e.g., Beck Depression Inventory, Pain Disability Questionnaire) are also included.

Step two is the psychosocial interview. A psychologist or psychiatrist conducts this part of the exam. Questions are asked to look for possible barriers to recovery.

The examiner begins with family history of mental illness, personal stress, and work history. Further testing may be needed based on the results of this portion of the exam. Special tests include the Minnesota Multiphasic Personality Inventory, PRIME-MD Patient Health Questionnaire, and the 56-item Multidimensional Pain Inventory.

The third and final step is the presurgical evaluation. Anyone who is planning to have spine surgery must undergo a psychologic exam first. This assessment helps identify patients at risk for failure due to significant biopsychosocial issues.

Using the results of testing, an overall risk score is determined. Patients are placed in one of three groups: low risk for surgery, high risk for surgery, or uncertain at this time. Anyone at high or uncertain risk may be sent to a special rehab program before surgery.

Many of these at-risk patients are able to proceed ahead with surgical treatment once they've completed the rehab program. It's unclear if the patients at high risk will ever be ready for surgery. Pre- and postsurgical rehab may be needed for this group. Without enough proof that surgery can benefit this group, they just may not be candidates for surgery.
References
Robert J. Gatchel, PhD, ABPP, and Tom G. Mayer, MD. Psychological Evaluation of the Spine Patient. In Journal of the American Academy of Orthopaedic Surgeons. February 2008. Vol. 16. No. 2. Pp. 107-112.