Symptoms of distress as prospective predictors of pain-related sciatica treatment outcomes

Patterns and correlates of mental healthcare utilization during the COVID-19 pandemic among individuals with pre-existing mental disorder

How did mental healthcare utilization change during the COVID-19 pandemic period among individuals with pre-existing mental disorder? Understanding utilization patterns of these at-risk individuals and identifying those most likely to exhibit increased utilization could improve patient stratification and efficient delivery of mental health services. This study leveraged large-scale electronic health record (EHR) data to describe mental healthcare utilization patterns among individuals with pre-existing mental disorder before and during the COVID-19 pandemic and identify correlates of high mental healthcare utilization. Using EHR data from a large healthcare system in Massachusetts, we identified three "pre-existing mental disorder" groups (PMD) based on having a documented mental disorder diagnosis within the 6 months prior to the March 2020 lockdown, related to: (1) stress-related disorders (e.g., depression, anxiety) (N = 115,849), (2) serious mental illness (e.g., schizophrenia, bipolar disorders) (N = 11,530), or (3) compulsive behavior disorders (e.g., eating disorder, OCD) (N = 5,893). We also identified a "historical comparison" group (HC) for each PMD (N = 113,604, 11,758, and 5,387, respectively) from the previous year (2019). We assessed the monthly number of mental healthcare visits from March 13 to December 31 for PMDs in 2020 and HCs in 2019. Phenome-wide association analyses (PheWAS) were used to identify clinical correlates of high mental healthcare utilization. We found the overall number of mental healthcare visits per patient during the pandemic period in 2020 was 10-12% higher than in 2019. The majority of increased visits was driven by a subset of high mental healthcare utilizers (top decile). PheWAS results indicated that correlates of high utilization (prior mental disorders, chronic pain, insomnia, viral hepatitis C, etc.) were largely similar before and during the pandemic, though several conditions (e.g., back pain) were associated with high utilization only during the pandemic. Limitations included that we were not able to examine other risk factors previously shown to influence mental health during the pandemic (e.g., social support, discrimination) due to lack of social determinants of health information in EHR data. Mental healthcare utilization among patients with pre-existing mental disorder increased overall during the pandemic, likely due to expanded access to telemedicine. Given that clinical correlates of high mental healthcare utilization in a major hospital system were largely similar before and during the COVID-19 pandemic, resource stratification based on known risk factor profiles may aid hospitals in responding to heightened mental healthcare needs during a pandemic.

Multi-stakeholder perspectives regarding preferred modalities for mental health intervention delivered in the orthopedic clinic: a qualitative analysis

BACKGROUND

Although depressive and anxious symptoms negatively impact musculoskeletal health and orthopedic outcomes, a gap remains in identifying modalities through which mental health intervention can realistically be delivered during orthopedic care. The purpose of this study was to understand orthopedic stakeholders' perceptions regarding the feasibility, acceptability, and usability of digital, printed, and in-person intervention modalities to address mental health as part of orthopedic care.

METHODS

This single-center, qualitative study was conducted within a tertiary care orthopedic department. Semi-structured interviews were conducted between January and May 2022. Two stakeholder groups were interviewed using a purposive sampling approach until thematic saturation was reached. The first group included adult orthopedic patients who presented for management of ≥ 3 months of neck or back pain. The second group included early, mid, and late career orthopedic clinicians and support staff members. Stakeholders' interview responses were analyzed using deductive and inductive coding approaches followed by thematic analysis. Patients also performed usability testing of one digital and one printed mental health intervention.

RESULTS

Patients included 30 adults out of 85 approached (mean (SD) age 59 [14] years, 21 (70%) women, 12 (40%) non-White). Clinical team stakeholders included 22 orthopedic clinicians and support staff members out of 25 approached (11 (50%) women, 6 (27%) non-White). Clinical team members perceived a digital mental health intervention to be feasible and scalable to implement, and many patients appreciated that the digital modality offered privacy, immediate access to resources, and the ability to engage during non-business hours. However, stakeholders also expressed that a printed mental health resource is still necessary to meet the needs of patients who prefer and/or can only engage with tangible, rather than digital, mental health resources. Many clinical team members expressed skepticism regarding the current feasibility of scalably incorporating in-person support from a mental health specialist into orthopedic care.

CONCLUSIONS

Although digital intervention offers implementation-related advantages over printed and in-person mental health interventions, a subset of often underserved patients will not currently be reached using exclusively digital intervention. Future research should work to identify combinations of effective mental health interventions that provide equitable access for orthopedic patients.

TRIAL REGISTRATION

Not applicable.

Digital mental health intervention for orthopedic patients with symptoms of depression and/or anxiety: Pilot feasibility study

BACKGROUND

Symptoms of depression and anxiety commonly coexist with chronic musculoskeletal pain, and when this occurs, standard orthopedic treatment is less effective. Nevertheless, addressing mental health is not yet a routine part of standard orthopedic treatment, in part due to access related barriers. Digital mental health intervention offers the potential to be a scalable resource that could feasibly be incorporated into orthopedic care.

OBJECTIVE

The primary purpose of this study was to assess the feasibility of introducing a digital mental health intervention (Wysa) within an outpatient orthopedic setting to patients who endorse coexisting symptoms of depression and/or anxiety. The secondary purpose was to perform a preliminary effectiveness analysis of the intervention.

METHODS

In this single-arm, prospective cohort study, participants included adult patients (18 years and older) who presented to a non-surgical orthopedic specialist at a single tertiary care academic center for evaluation of a musculoskeletal condition and who self-reported symptoms of depression and/or anxiety (Patient-Reported Outcomes Measurement Information System (PROMIS) Depression and/or Anxiety score ≥ 55). Enrollment was performed face-to-face by a research coordinator immediately after the participant's encounter with an orthopedic clinician. Participants were provided two months of access to a mobile app called Wysa, which is an established, multi-component digital mental health intervention that uses chatbot technology and text-based access to human counselors to deliver cognitive behavioral therapy, mindfulness training, and sleep tools, among other features. For this study, Wysa access also included novel, behavioral activation based features specifically developed for users with chronic pain. Primary feasibility outcomes included the study recruitment rate, retention rate, and engagement rate with Wysa (defined as engaging with a therapeutic Wysa tool at least once during the study period). Secondary effectiveness outcomes were between-group differences in mean longitudinal PROMIS mental and physical health score changes at two-month follow-up between high Wysa users and low Wysa users, defined by a median split.

RESULTS

The recruitment rate was 61/208 (29%), retention rate was 51/61 (84%), and engagement rate was 44/61 (72%). Compared to low users, high Wysa users achieved greater improvement in PROMIS Anxiety (between-group difference -4.2 points [95% CI -8.1 to -0.2], P=.044) at two-month follow-up. Between-group differences in PROMIS Depression (-3.2 points [-7.5 to 1.2], P=.15) and Pain Interference (-2.3 points [-6.3 to 1.7], P=.26) favored high users but did not meet statistical significance. Improvements in PROMIS Physical Function were comparable between groups.

CONCLUSIONS

Delivery of a digital mental health intervention within the context of orthopedic care is feasible and demonstrates potential to improve mental health and pain-related impairment to a clinically meaningful degree. Participants' engagement rates exceeded industry standards, and additional opportunities to improve recruitment and retention were identified. Further pilot study followed by a definitive, randomized controlled trial is warranted.

CLINICALTRIAL

ClinicalTrials.gov NCT202005219.

Low-Dose Collagenase Chemonucleolysis Combined with Radiofrequency in the Treatment of Lumbar Disc Herniation: A 10-Year Retrospective Study

Objective

This study explored the 10-year efficacy, safety, and prognostic factors of low-dose collagenase chemonucleolysis (CCNL) combined with radiofrequency (RF) in the treatment of lumbar disc herniation (LDH).

Methods

The data of 167 LDH patients were collected. Modified MacNab criteria, Numerical Rating Scale (NRS), and Japanese Orthopedic Association (JOA) scores were, respectively, used to evaluate patients' excellent and good rates, pain degree, and nerve function. The preoperative and 10-year postoperative patients' pain, numbness, and muscle weakness were compared. Patients' complications in perioperative period, recurrent/reappeared LDH, and reoperations were recorded. Finally, the independent risk factors affecting the long-time efficacy were assessed.

Results

A total of 126 patients were included. The patients' excellent and good rates were 86.51%–92.86% with no significant difference (P > 0.05). Postoperative NRS and JOA scores significantly improved (P < 0.01), most obvious within 6 months postoperatively. At 10 years postoperatively, 65.08%, 83.95%, and 93.02% of patients' pain, numbness, and muscle weakness were completely relieved (P < 0.05). Perioperative complications occurred in three patients with the rate of 2.38%. Recurrent/reappeared LDH patients were 11 with the ratio of 8.73%; nine of them underwent reoperations with the rate of 7.14%. And patients' probability of fair and poor efficacy at 10 years postoperatively with the course of disease >12 months and the responsibility disc ≥2 were, respectively, 6.005 and 4.227 times that of patients with the course of disease ≤12 months and the responsibility disc = 1 (P < 0.05).

Conclusion

The combined treatment is effective and safe in the long term. A course of disease >12 months and responsibility disc ≥2 independently reduce efficacy, and a course of disease >12 months has a more significant impact.

The impact of mental health on outcome after anterior cervical discectomy: cohort study assessing the influence of mental health using predictive modelling

BACKGROUND

Depression and anxiety are common mental disorders among patients with chronic pain. It is hypothesised that patients suffering from these disorders benefit less from cervical spine surgery than mentally healthy patients. Therefore, this study aimed to quantify the effect of mental health status on functional outcome after anterior cervical discectomy in a post hoc analysis on RCT data.

METHODS

One hundred eight patients from the NECK trial, with radiculopathy due to a one-level herniated disc, underwent anterior cervical discectomy and were included into this analysis. Functional outcome was quantified using the Neck Disability Index (NDI), and mental health status was measured using the Hospital Anxiety and Depression Score (HADS) questionnaire. NDI differences were assessed using generalised estimated equations (GEE), crude means, a predictive linear mixed model (LMM) using baseline scores and over time with an explanatory LMM.

RESULTS

At baseline, 24% and 32% of patients were respectively depressed and anxious and had statistically significant and clinically relevant higher NDI scores during follow-up. However, in those patients in which the HADS returned to normal during follow-up, NDI values decreased comparably to the non-depression or non-anxiety cases. Those patients that demonstrated persisting high HADS values had convincingly worse NDI scores. A predictive LMM showed that combining baseline NDI and HADS scores was highly predictive of NDI during follow-up. The R shiny application enabled the effective, visual communication of results from the predictive LMM.

CONCLUSION

This study shows that mental health status and disability are strongly associated and provides insight into the size of the effect, as well as a way to use this relation to improve preoperative patient counselling. These findings give rise to the suggestion that incorporating mental health screening in the preoperative assessment of patients could help to adequately manage patients' expectations for functional recovery.

TRIAL REGISTRATION

Dutch Trial Register Number: NTR1289.

Trajectories of Disability and Low Back Pain Impact: 2-year Follow-up of the Groningen Spine Cohort

STUDY DESIGN

Prospective cohort study.

OBJECTIVE

The aim of this study was to identify treatment response trajectories in patients with low back pain (LBP) during and after multidisciplinary care in a tertiary spine center, and to examine baseline patient characteristics that can distinguish trajectories.

SUMMARY OF BACKGROUND DATA

Treatment response is often heterogeneous between patients with LBP. Knowledge on key characteristics that are associated with courses of disability could identify patients at risk for less favorable outcome. This knowledge will help improve shared decision-making.

METHODS

Adult patients with LBP completed questionnaires on disability (Pain Disability Index) and LBP impact (Impact Stratification of the National Institutes of Health minimal dataset) at baseline, 6, 12, 18, and 24 months' follow-up. Latent class analyses were applied to identify trajectories of disability and LBP impact. Baseline sociodemographic and clinical patient characteristics were compared between trajectory subgroups.

RESULTS

Follow-up was available for 996 patients on disability and 707 patients on LBP impact. Six trajectories were identified for both outcome measures. Three disability trajectories remained stable at distinct levels of severity (68% of patients) and three trajectories showed patterns of recovery (32%). For LBP impact there was one stable trajectory (17%), two slightly improving (59%), two recovering (15%), and one with a pattern of recovery and relapse (15%). Significant differences between trajectories were observed for almost all baseline patient characteristics.

CONCLUSION

On average, patients show moderate improvements in disability and LBP impact 2 years after visiting a multidisciplinary tertiary spine center. However, latent class analyses revealed that most patients belong to subgroups experiencing stable levels of disability and LBP impact. Differences in baseline patient characteristics were mostly associated with baseline levels of functioning, instead of (un)favorable outcome during follow-up.

LEVEL OF EVIDENCE

2.

Preoperative patient activation is predictive of improvements in patient-reported outcomes following minimally invasive lumbar decompression

PURPOSE

To determine whether there is an association between preoperative 10-Item Patient Activation Measure (PAM-10) scores and clinical outcomes following MIS LD.

METHODS

Patients undergoing a primary MIS LD were retrospectively reviewed and stratified according to their preoperative PAM-10 scores: "low PAM," "moderate PAM," and "high PAM." Preoperative PAM score cohorts were tested for improvements in Oswestry Disability Index (ODI), 12-Item Short-Form Physical Component Score (SF-12 PCS), and Visual Analog Scale (VAS) back and leg pain using multivariate linear regression.

RESULTS

Eighty-nine patients were included: 29 had a low PAM score, 32 had a moderate PAM score, and 28 had a high PAM score. Cohorts experienced similar preoperative VAS back pain, VAS leg pain, ODI, and SF-12 PCS. Patients with low PAM scores experienced a trend of higher pain scores throughout 6 months with VAS back pain being significant at 3 months and VAS leg pain being significant at 6-week and 3-month follow-up. Patients with lower PAM scores experienced a worse improvement in ODI at 6-week, 3-month, and 6-month timepoints. Lastly, patients with lower PAM scores demonstrated less improvement in SF-12 PCS at 3-month and 6-month follow-up.

CONCLUSIONS

Lower preoperative PAM scores were associated with worse improvement in clinical outcomes following MIS LD. Patients with lower PAM scores had diminished improvement in long-term patient-reported outcomes including ODI, SF-12, and VAS back and leg pain. Our investigation suggests that preoperative PAM assessments may be an effective tool to predict postoperative outcomes following MIS LD.

The influence of preoperative mental health on clinical outcomes after laminectomy in patients with lumbar spinal stenosis

OBJECTIVE

The influence of preoperative mental health on health-related quality of life (HRQOL) in patients with lumbar spinal stenosis (LSS) remains unclear. This study aims to investigate the influence of preoperative mental health HRQOL after laminectomy in patients with LSS.

PATIENTS AND METHODS

We retrospectively reviewed 122 patients who had lumbar spinous process splitting laminectomy (LSPSL) for LSS. We assessed clinical information; Japanese Orthopedic Association (JOA) score; numerical rating scale (NRS) for low back pain, for leg pain, and for leg numbness; Zurich Claudication Questionnaire (ZCQ); JOA Back Pain Evaluation Questionnaire (JOABPEQ); Roland-Morris Disability Questionnaire (RMDQ); and Short Form 8 (SF-8) as patient reported outcomes. Patients were divided into two groups (Group L ≤ 36.2 points and Group NL > 36.2 points) based on the results of the preoperative mental health (MH) score in SF-8 to examine the influence of MH in LSS. We compared the HRQOL between the two groups postoperatively.

RESULTS

The JOA score, NRS, and ZCQ score significantly improved after surgery. HRQOL outcomes including JOABPEQ, RMDQ, and SF-8 showed that the LSPSL improved not only the physical but also the mental function in patients with LSS. All HRQOL outcomes in Group L exhibited significantly worse scores preoperatively; however, no significant differences between two groups were found postoperatively.

CONCLUSIONS

LSPSL greatly reduced low back pain, leg pain, and leg numbness. LSPSL resulted in a significant improvement based on HRQOL questionnaires even in patients with preoperative depressive mood. Not only the physical status but also the mental health may improve after LSPSL even in patients with LSS with a depressive mood preoperatively.

Analysis of the depression and anxiety status and related risk factors in patients with lumbar disc herniation

Objectives:

To evaluate the depression and anxiety status and related risk factors in patients with lumbar disc herniation, and help spine surgeons better identify those patients who need psychological care.

Methods:

A cross-sectional study was performed on patients with lumbar disc herniation treated in our hospital between October 2015 and August 2018. Visual analog scale and Oswestry disability index were used to assess pain intensity and lumbar function, and Zung self-rating depression and anxiety scale were employed to evaluate the depression and anxiety status of the patients, and the demographic and clinical data including age, gender, marital status, occupation type, employment status, education level, surgery history, herniation type, disease duration, and insurance status were collected for analysis.

Results:

In the current study, 165 patients were enrolled based on the inclusion and exclusion criteria. In multivariate logistic regression analysis, gender (p=0.03), pain intensity (p=0.01), self-rating anxiety scale (SAS) (p=0.00), and disease duration (p=0.001) were identified as independent risk factors for depression status, and pain intensity (p=0.02), disease duration (p=0.002) and SDS (Zung self-rating depression scale) (p=0.003) were independent risk factors for anxiety status in patients with lumbar disc herniation. There was a significant correlation between Zung self-rating depression and anxiety scale in patients with lumbar disc herniation (p<0.05).

Conclusion:

Psychological intervention is critical for patients with lumbar disc herniation, especially for those female patients with severe pain and longer disease duration.

Evaluating psychosocial contributions to chronic pain outcomes

The biopsychosocial model of pain dominates the scientific community's understanding of chronic pain. Indeed, the biopsychosocial approach describes pain and disability as a multidimensional, dynamic integration among physiological, psychological, and social factors that reciprocally influence one another. In this article, we review two categories of studies that evaluate the contributions of psychosocial factors to the experience of chronic pain. First, we consider general psychosocial variables including distress, trauma, and interpersonal factors. Additionally, we discuss pain-specific psychosocial variables including catastrophizing, expectations, and pain-related coping. Together, we present a diverse array of psychological, social, and contextual factors and highlight the need to consider their roles in the development, maintenance, and treatment of chronic pain conditions.

Psychosocial Factors and Surgical Outcomes in Adult Spinal Deformity: Do Dementia Patients Have More Complications?

STUDY DESIGN

Retrospective analysis of a prospectively collected, national inpatient hospital database.

OBJECTIVE

We aimed to investigate comorbid psychiatric disorders in the adult spinal deformity (ASD) population. We hypothesized that a high incidence of comorbid psychiatric disorders in ASD would negatively impact perioperative outcomes.

SUMMARY OF BACKGROUND DATA

Patients with adult spinal fusion (ASF) suffer from severe back pain and often depression. Psychiatric comorbidities in the ASD population are not well understood, despite the apparent psychological effects of spinal deformity-related self-image.

METHODS

The Nationwide Inpatient Sample databases from 2001 to 2009 were queried for patients ages 18 years or older with in-hospital stays including a spine arthrodesis. Patients were divided into two groups: ASD (diagnosis of scoliosis, excluding neuromuscular and congenital) and all other ASF. Subjects were further stratified by presence of a comorbid psychiatric diagnosis. Differences between each surgical group in psychiatric frequency and complications were calculated using analysis of variance, adjusted for operative complexity. A binary logistic regression analyzed the association between psychiatric diagnoses and likelihood of complications.

RESULTS

A total of 3,366,352 ASF and 219,975 ASD patients were identified. The rate of comorbid psychiatric diagnoses in ASD was significantly higher (23.5%) compared to ASF patients (19.4%, P < 0.001). Complication rates were higher for ASD compared to ASF; patients without a psychiatric diagnosis had lower (or comparable) complication rates than psychiatric patients, across all disorder categories. Patients with psychotic disorders and dementia showed more complications than controls; patients with mood, anxiety and alcohol disorders showed fewer.

CONCLUSION

Psychiatric comorbidities are more common in the ASD population than in adult fusion patients. ASD and ASF patients with the most common psychiatric disorders (mood, anxiety, and alcohol abuse) are not at increased risk for complications compared to controls. Those patients with psychotic disorders and dementia are at a significant risk for increased complications and surgeons should be aware of these specific risks.

LEVEL OF EVIDENCE

2.

A Couple-Based Psychological Treatment for Chronic Pain and Relationship Distress

Chronic pain impacts individuals with pain as well as their loved ones. Yet, there has been little attention to the social context in individual psychological treatment approaches to chronic pain management. With this need in mind, we developed a couple-based treatment, "Mindful Living and Relating," aimed at alleviating pain and suffering by promoting couples' psychological and relational flexibility skills. Currently, there is no integrative treatment that fully harnesses the power of the couple, treating both the individual with chronic pain and the spouse as two individuals who are each in need of developing greater psychological and relational flexibility to improve their own and their partners' health. Mindfulness, acceptance, and values-based action exercises were used to promote psychological flexibility. The intervention also targets relational flexibility, which we define as the ability to interact with one's partner, fully attending to the present moment, and responding empathically in a way that serves one's own and one's partner's values. To this end, the intervention also included exercises aimed at applying psychological flexibility skills to social interactions as well as emotional disclosure and empathic responding exercises to enhance relational flexibility. The case presented demonstrates that healthy coping with pain and stress may be most successful and sustainable when one is involved in a supportive relationship with someone who also practices psychological flexibility skills and when both partners use relational flexibility skills during their interactions.

Comparison of Structural Disease Burden to Health-related Quality of Life Scores in 264 Adult Spinal Deformity Patients With 2-Year Follow-up: Novel Insights into Drivers of Disability

STUDY DESIGN

This is a review of a prospective multicenter database.

OBJECTIVE

To investigate the relationship between preoperative disability and sagittal deformity in patients with high Oswestry Disability Index (ODI) and no sagittal malalignment, or low ODI and high sagittal malalignment.

SUMMARY OF BACKGROUND DATA

The relationship between ODI and sagittal malalignment varies between each adult spinal deformity (ASD) patient.

METHODS

A prospective multicenter database of 365 patients with ASD undergoing surgical reconstruction was analyzed. Inclusion criteria entailed: age 18 years or above and the presence of spinal deformity as defined by a coronal Cobb angle≥20 degrees, sagittal vertical axis (SVA)≥5 cm, pelvic tilt (PT) angle≥25 degrees, or thoracic kyphosis≥60 degrees. Radiographic and health-related quality of life (HRQOL) variables were examined and compared, preoperatively and at 2-year postoperative follow-up. Group 1 (low disability high sagittal-LDHS) consisted of ODI<40 and SVA≥5 cm or PT≥25 degrees or pelvic incidence-lumbar lordosis≥11 degrees and group 2 (high disability low sagittal-HDLS) consisted of ODI>40 and SVA<5 cm and PT<25 degrees and pelvic incidence-lumbar lordosis<11 degrees.

RESULTS

Of 264 patients with follow-up, 58 (22.0%) patients were included in LDHS and 30 (11.4%) were included in HDLS. Both groups had similar demographics and preoperative coronal angles. HDLS had worse baseline HRQOL for all measures (P<0.05) except leg and back pain. HDLS had a higher rate of self-reported leg weakness, arthritis, depression and neurological disorder. Both groups had similar 2-year improvements in HRQOL (P>0.05), except only HDLS had a significant Scoliosis Research Society Mental improvement and a significantly higher rate of reaching minimal clinically important differences in Scoliosis Research Society Mental scores (P<0.05).

CONCLUSIONS

There is an association of worse baseline HRQOL measures, weakness, arthritis, and mental disease in HDLS. Furthermore, HDLS patients demonstrated similar improvements to LDHS. However, HDLS had greater improvements in the mental domains, perhaps indicating the responsiveness of the mental disability to surgical treatment.

LEVEL OF EVIDENCE

Level III.

A systematic review of preoperative predictors for postoperative clinical outcomes following lumbar discectomy

BACKGROUND CONTEXT

Sciatica is often caused by a herniated lumbar intervertebral disc. When conservative treatment fails, a lumbar discectomy can be performed. Surgical treatment via lumbar discectomy is not always successful and may depend on a variety of preoperative factors. It remains unclear which, if any, preoperative factors can predict postsurgical clinical outcomes.

PURPOSE

This review aimed to determine preoperative predictors that are associated with postsurgical clinical outcomes in patients undergoing lumbar discectomy.

STUDY DESIGN

This is a systematic review.

METHODS

This systematic review of the scientific literature followed the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. MEDLINE and PubMed were systematically searched through June 2014. Results were screened for relevance independently, and full-text studies were assessed for eligibility. Reporting quality was assessed using a modified Newcastle-Ottawa Scale. Quality of evidence was assessed using a modified version of Sackett's Criteria of Evidence Support. No financial support was provided for this study. No potential conflict of interest-associated biases were present from any of the authors.

RESULTS

The search strategy yielded 1,147 studies, of which a total of 40 high-quality studies were included. There were 17 positive predictors, 20 negative predictors, 43 non-significant predictors, and 15 conflicting predictors determined. Preoperative predictors associated with positive postoperative outcomes included more severe leg pain, better mental health status, shorter duration of symptoms, and younger age. Preoperative predictors associated with negative postoperative outcomes included intact annulus fibrosus, longer duration of sick leave, worker's compensation, and greater severity of baseline symptoms. Several preoperative factors including motor deficit, side and level of herniation, presence of type 1 Modic changes and degeneration, age, and gender had non-significant associations with postoperative clinical outcomes.

CONCLUSIONS

It may be possible for certain preoperative factors to be targeted for clinical evaluation by spine surgeons to assess the suitability of patients for lumbar discectomy surgery, the hope being to thereby improve postoperative clinical outcomes. Prospective cohort studies are required to increase the level of evidence with regard to significant predictive factors.

Minimally important differences for Patient Reported Outcomes Measurement Information System pain interference for individuals with back pain

Background

The minimally important difference (MID) refers to the smallest change that is sufficiently meaningful to carry implications for patients’ care. MIDs are necessary to guide the interpretation of scores. This study estimated MID for the Patient Reported Outcomes Measurement Information System (PROMIS) pain interference (PI).

Methods

Study instruments were administered to 414 people who participated in two studies that included treatment with low back pain (LBP; n=218) or depression (n=196). Participants with LBP received epidural steroid injections and participants with depression received antidepressants, psychotherapy, or both. MIDs were estimated for the changes in LBP. MIDs were included only if a priori criteria were met (ie, sample size ≥10, Spearman correlation ≥0.3 between anchor measures and PROMIS-PI scores, and effect size range =0.2–0.8). The interquartile range (IQR) of MID estimates was calculated.

Results

The IQR ranged from 3.5 to 5.5 points. The lower bound estimate of the IQR (3.5) was greater than mean of standard error of measurement (SEM) both at time 1 (SEM =2.3) and at time 2 (SEM =2.5), indicating that the estimate of MID exceeded measurement error.

Conclusion

Based on our results, researchers and clinicians using PROMIS-PI can assume that change of 3.5 to 5.5 points in comparisons of mean PROMIS-PI scores of people with LBP can be considered meaningful.

Parecoxib Possesses Anxiolytic Properties in Patients Undergoing Total Knee Arthroplasty: A Prospective, Randomized, Double-Blind, Placebo-Controlled, Clinical Study

Introduction

Intravenous administration of parecoxib could provide significant pain relief in surgical operations that require additional forms of analgesia. However, very little is known about its effects on the anxiety levels of patients before a surgical procedure. The aim of this prospective study was to investigate whether intravenous parecoxib, pre-emptively administered, has an effect on anxiety levels experienced post-surgically after total knee arthroplasty (TKA) and if it influences the reported pain of the procedure itself.

Methods

A total of 90 patients who underwent TKA under spinal anesthesia were included in the study. Prior to TKA, all patients received continuous femoral nerve block (CFNB) and were randomized into two groups: Group D consisted of 45 patients who received the drug parecoxib intravenously in addition to CFNB, whereas Group P consisted of 45 patients who received a placebo drug (N/S 0.9 %) intravenously instead of parecoxib. All patients were asked to fill in the questionnaires STAI1 and STAI2 in order to evaluate anxiety levels pre- and post-surgically, respectively. One of the main aims was to distinguish personality-trait anxiety from state anxiety, i.e., anxiety experience due to the actual perioperative events and the actual pain endured.

Results

The group receiving parecoxib had statistically significant lower anxiety levels both for personality trait anxiety and state anxiety, as compared to the placebo group.

Conclusions

Based on our findings, parecoxib had both analgesic and anxiolytic effects in patients undergoing TKA with CFNB.

Trial Registration

Current Controlled Trials: NCT02185924.

Demoralization, Patient Activation, and the Outcome of Spine Surgery

It is now well established that psychosocial factors can adversely impact the outcome of spine surgery. This article discusses in detail one such recently-identified “risk” factor: demoralization. Several studies conducted by the author indicate that demoralization, an emotional construct distinct from depression, is associated with poorer pain reduction, less functional improvement and decreased satisfaction among spine surgery patients. However, there are indications that the adverse impact of risk factors such as demoralization can be mitigated by psychosocial “maximizing” factors—characteristics that propel the patient towards positive surgical results. One of these maximizing factors, patient activation, is discussed in depth. The patient activation measure (PAM), an inventory assessing the extent to which patients are active and engaged in their health care, is associated not only with improved spine surgery results, but with better outcomes across a broad range of medical conditions. Other maximizing factors are discussed in this article. The author concludes that the past research focus on psychosocial risk factors has limited the value of presurgical psychological screening, and that future research, as well as clinical assessment, should recognize that the importance of evaluating patients’ strengths as well as their vulnerabilities.

Effect of Alexithymia and Emotional Repression on Postsurgical Pain in Women With Breast Cancer: A Prospective Longitudinal 12-Month Study

Alexithymia, the inability to identify and express emotions, and emotional repression, a defensive mechanism used to avoid unpleasant emotional experience, have been associated with chronic pain and medical illness including breast cancer, but whether these constructs might predict pain after breast cancer surgery has not been assessed. The present study was conducted to assess the predictive value of alexithymia and emotional repression in postoperative pain. Anxiety, depression, catastrophizing, and psychological adjustment were also assessed. Data were collected before surgery, and then at 2 days and 2, 3, 6, and 12 months after surgery. We included 100 pain-free women, 96% of whom were followed for up to 12 months. Separate multivariate analyses identified anxiety as a significant predictor of postsurgical pain at 3 months, alexithymia at 3, 6, and 12 months, and body image and catastrophizing predicted acute or subacute pain at 2 months. In contrast, emotional repression was not predictive of pain. The generalized estimating equation approach was used and identified alexithymia as the only significant predictor of pain during the 12-month period after surgery. Alexithymia, but not emotional repression, predicted the development of persistent pain after breast surgery independently of anxiety and depression. Thus, alexithymia might be involved in mechanisms of pain chronicity.

PERSPECTIVE

This prospective study, conducted in women with breast cancer surgery, showed that alexithymia but not emotional repression predicted postsurgical pain. These results highlight the role of dysfunction in emotional processing in the development of postsurgical pain.

Trajectories of symptoms and function in older adults with low back disorders

STUDY DESIGN

Prospective cohort study.

OBJECTIVE

To determine whether there are distinct trajectories of back pain and function among older adults and to identify characteristics that distinguish among patients with substantially different prognoses.

SUMMARY OF BACKGROUND DATA

Although the differential diagnosis and course of low back pain among older adults may differ from middle-aged adults, there is little evidence. Better understanding variability in recovery among older adults may help target patients for more intensive clinical interventions, plan resource use, and design clinical studies of more homogeneous patient groups.

METHODS

Patients aged 65 years or older with a new episode of care for back pain were recruited at 3 geographically diverse sites. Patients completed pain intensity and Roland-Morris Disability measures at baseline and 3, 6, and 12 months later. We used latent class analysis to identify distinct trajectories of pain and function and then logistic regression to identify predictors of membership in the improving trajectories.

RESULTS

There were 3929 participants who completed outcome measures at every follow-up interval. Latent class analysis identified subgroups with low, intermediate, or high pain or disability scores who remained relatively stable over time. However, small subgroups showed dramatic improvement from baseline to 1 year (17% with major improvement in Roland score, pain intensity, or both). Shorter pain duration, higher patient confidence in improvement, and fewer comorbid conditions at baseline were each associated independently with favorable prognosis.

CONCLUSION

Although most patients remained relatively stable over a year, latent class analysis identified small groups with major improvement in pain, function, or both. This technique may, therefore, be useful for studying back pain prognosis. Our results should help assemble more prognostically homogeneous groups for research, and the technique may help identify subgroups of patients with uniquely successful responses to investigational interventions.

LEVEL OF EVIDENCE

3.

The Relationship Between Preoperative General Mental Health and Postoperative Quality of Life in Minimally Invasive Lumbar Spine Surgery

BACKGROUND:

In assessing poor lumbar surgery outcomes, researchers continue to investigate psychosocial predictors of patient postoperative quality of life. This is the first study of its kind to investigate this relationship in an exclusively minimally invasive patient sample.

OBJECTIVE:

To determine the association between preoperative mental health and postoperative patient-centered outcomes in patients undergoing minimally invasive lumbar surgery.

METHODS:

In 83 adults undergoing single-level minimally invasive lumbar spine surgery, Pearson correlation and partial correlation analyses were conducted between all demographic and clinical baseline variables and Oswestry Disability Index (ODI), Visual Analogue Scale (VAS), and 36-item Short-Form Health Survey Version 2.0 (SF-36v2) scores at 6 to 12 months postoperatively. SF-36v2 mental component summary scores (MCS) were used to assess pre- and postoperative general mental health. Post hoc analysis consisted of Pearson correlations between baseline SF-36v2, ODI, and VAS scores, and an identical set of correlations at outcomes.

RESULTS:

Preoperative MCS showed no significant association with outcomes VAS, ODI, or physical component summary scores. Baseline disability correlated significantly and more strongly with baseline MCS (P &lt; .001, r = −0.40) than baseline pain levels (VAS back not significant, VAS leg P = .015, r = 0.27). Outcomes disability correlated significantly and more strongly with outcome back and leg pain levels (P &lt; .001, r = 0.60 and 0.66) than outcome MCS (P = .031, r = −0.24).

CONCLUSION:

In a patient sample with mental health scores comparable to the population mean, there is no relationship between preoperative general mental health and postoperative patient-centered outcomes. Surgeons should consider the dynamic relationships between patient disability, mental health, and pain levels in assessing quality of life at different time points.

Outcome prediction in chronic unilateral lumbar radiculopathy: prospective cohort study

Background

Identification of prognostic factors for persistent pain and disability are important for better understanding of the clinical course of chronic unilateral lumbar radiculopathy and to assist clinical decision-making. There is a lack of scientific evidence concerning prognostic factors. The aim of this study was to identify clinically relevant predictors for outcome at 52 weeks.

Methods

116 patients were included in a sham controlled clinical trial on epidural injection of glucocorticoids in patients with chronic unilateral lumbar radiculopathy. Success at follow-up was ≤17.5 for visual analogue scale (VAS) leg pain, ≤22.5 for VAS back pain and ≤20 for Oswestry Disability Index (ODI). Fifteen clinically relevant variables included demographic, psychosocial, clinical and radiological data and were analysed using a logistic multivariable regression analysis.

Results

At follow-up, 75 (64.7%) patients had reached a successful outcome with an ODI score ≤20, 54 (46.6%) with a VAS leg pain score ≤17.5, and 47 (40.5%) with a VAS back pain score ≤22.5.

Lower age (OR 0.94 (CI 0.89–0.99) for each year decrease in age) and FABQ Work ≥34 (OR 0.16 (CI 0.04-0.61)) were independent variables predicting a successful outcome on the ODI.

Higher education (OR 5.77 (CI 1.46–22.87)) and working full-time (OR 2.70 (CI 1.02–7.18)) were statistically significant (P <0.05) independent predictors for successful outcome (VAS score ≤17.5) on the measure of leg pain. Lower age predicted success on ODI (OR 0.94 (95% CI 0.89 to 0.99) for each year) and less back pain (OR 0.94 (0.90 to 0.99)), while higher education (OR 5.77 (1.46 to 22.87)), working full-time (OR 2.70 (1.02 to 7.18)) and muscle weakness at baseline (OR 4.11 (1.24 to 13.61) predicted less leg pain, and reflex impairment at baseline predicted the contrary (OR 0.39 (0.15 to 0.97)).

Conclusions

Lower age, higher education, working full-time and low fear avoidance beliefs each predict a better outcome of chronic unilateral lumbar radiculopathy. Specifically, lower age and low fear avoidance predict a better functional outcome and less back pain, while higher education and working full-time predict less leg pain. These results should be validated in further studies before being used to inform patients.

Trial registration

Current Controlled Trials ISRCTN12574253. Registered 18 May 2005.

Lumbar disk herniation surgery: outcome and predictors

Study Design A retrospective cohort study. Objectives To determine the outcome and any differences in the clinical results of three different surgical methods for lumbar disk herniation and to assess the effect of factors that could predict the outcome of surgery. Methods We evaluated 148 patients who had operations for lumbar disk herniation from March 2006 to March 2011 using three different surgical techniques (laminectomy, microscopically assisted percutaneous nucleotomy, and spinous process osteotomy) by using Japanese Orthopaedic Association (JOA) Back Pain Evaluation Questionnaire, Resumption of Activities of Daily Living scale and changes of visual analog scale (VAS) for low back pain and radicular pain. Our study questionnaire addressed patient subjective satisfaction with the operation, residual complaints, and job resumption. Data were analyzed with SPSS version 16.0 (SPSS, Inc., Chicago, Illinois, United States). Statistical significance was set at 0.05. For statistical analysis, chi-square test, Mann-Whitney U test, Kruskal-Wallis test, and repeated measure analysis were performed. For determining the confounding factors, univariate analysis by chi-square test was used and followed by logistic regression analysis. Results Ninety-four percent of our patients were satisfied with the results of their surgeries. VAS documented an overall 93.3% success rate for reduction of radicular pain. Laminectomy resulted in better outcome in terms of JOA Back Pain Evaluation Questionnaire. The outcome of surgery did not significantly differ by age, sex, level of education, preoperative VAS for back, preoperative VAS for radicular pain, return to previous job, or level of herniation. Conclusion Surgery for lumbar disk herniation is effective in reducing radicular pain (93.4%). All three surgical approaches resulted in significant decrease in preoperative radicular pain and low back pain, but intergroup variation in the outcome was not achieved. As indicated by JOA Back Pain Evaluation Questionnaire-Low Back Pain (JOABPQ-LBP) and lumbar function functional scores, laminectomy achieved significantly better outcome compared with other methods. It is worth mentioning that relief of radicular pain was associated with subjective satisfaction with the surgery among our study population. Predictive factors for ineffective surgical treatment for lumbar disk herniation were female sex and negative preoperative straight leg raising. Age, level of education, and preoperative VAS for low back pain were other factors that showed prediction power.

Are psychological predictors of chronic postsurgical pain dependent on the surgical model? A comparison of total knee arthroplasty and breast surgery for cancer

Anxiety, depression, and catastrophizing are generally considered to be predictive of chronic postoperative pain, but this may not be the case after all types of surgery, raising the possibility that the results depend on the surgical model. We assessed the predictive value of these factors for chronic postsurgical pain in 2 different surgical models: total knee arthroplasty for osteoarthritis (89 patients, 65% women, age = 69 ± 9 years, baseline pain intensity = 4.7 ± 2.1) and breast surgery for cancer (100 patients, 100% women, age = 55 ± 12 years, no preoperative pain). Data were collected before surgery, then 2 days and 3 months after surgery. Anxiety, depression, and catastrophizing were measured with the Spielberger State-Trait Anxiety Inventory, Beck Depression Inventory, and Pain Catastrophizing Scale, respectively. Pain was assessed with the Brief Pain Inventory. Neuropathic pain was detected with the DN4 questionnaire. Multivariate logistic regression analyses for the total knee arthroplasty and breast surgery models considered together indicated that the presence of clinically meaningful chronic pain at 3 months (pain intensity ≥3/10) was predicted independently by age (P = .04), pain intensity on day 2 (P = .009), and state anxiety (P = .001). Linear regression models also showed that pain magnification, one of the dimensions of catastrophizing, independently predicted chronic pain intensity (P = .04). These results were not affected by the surgical model or by the neuropathic characteristics of the pain. Thus, state anxiety and pain magnification seem to constitute psychological risk factors for chronic postsurgical pain relevant in all surgical models.

PERSPECTIVE

This prospective study performed in patients with total knee arthroplasty or breast surgery for cancer shows that state anxiety, amplification of pain, and acute postoperative pain independently predict postsurgical pain at 3 months and that this does not depend on the surgical model.

Systematic review of prognostic factors predicting outcome in non-surgically treated patients with sciatica

Identification of prognostic factors for surgery in patients with sciatica is important to be able to predict surgery in an early stage. Identification of prognostic factors predicting persistent pain, disability and recovery are important for better understanding of the clinical course, to inform patient and physician and support decision making. Consequently, we aimed to systematically review prognostic factors predicting outcome in non-surgically treated patients with sciatica. A search of Medline, Embase, Web of Science and Cinahl, up to March 2012 was performed for prospective cohort studies on prognostic factors for non-surgically treated sciatica. Two reviewers independently selected studies for inclusion and assessed the risk of bias. Outcomes were pain, disability, recovery and surgery. A best evidence synthesis was carried out in order to assess and summarize the data. The initial search yielded 4392 articles of which 23 articles reporting on 14 original cohorts met the inclusion criteria. High clinical, methodological and statistical heterogeneity among studies was found. Reported evidence regarding prognostic factors predicting the outcome in sciatica is limited. The majority of factors that have been evaluated, e.g., age, body mass index, smoking and sensory disturbance, showed no association with outcome. The only positive association with strong evidence was found for leg pain intensity at baseline as prognostic factor for subsequent surgery.

A single question was as predictive of outcome as the Tampa Scale for Kinesiophobia in people with sciatica: an observational study

QUESTION

In people with sciatica in primary care, can a single question be used to predict outcome at 1 year followup as accurately as validated questionnaires on kinesiophobia, disability, and health-related quality of life?

DESIGN

Observational study within a randomised cohort.

PARTICIPANTS

135 people with sciatica in primary care.

OUTCOME MEASURES

Kinesiophobia was measured with the Tampa Scale for Kinesiophobia (TSK), disability with the Roland Morris Disability Questionnaire (RDQ), and health-related quality of life with the EQ-5D and the 36-item Short Form (SF-36) Physical Component Summary. Participants also answered a newly devised substitute question for each questionnaire on an 11-point numerical rating scale. Global perceived effect and severity of leg pain were recorded at 1 year follow-up.

RESULTS

The correlation coefficient between the TSK and its substitute question was r=0.46 (p<0.001). The substitute question was better at predicting pain severity in the leg at 1 year follow-up than the TSK (addition of explained variation of 11% versus 4% in a logistic regression analysis). The TSK and its substitute question did not significantly differ in their prediction of global perceived effect at 1 year follow-up. The other substitute questions and both the RDQ and EQ-5D did not contribute significantly to one or both of their prediction models.

CONCLUSION

It may be feasible to replace the TSK by a single substitute question for predicting outcome in people with sciatica in primary care. The other substitute questions did not consistently predict outcome at 1 year follow-up.

The effect of acupuncture on relieving pain after inguinal surgeries

BACKGROUND

Postoperative pain is one of the most prevalent and bothersome issues found in the surgical department. Nowadays, there are various methods of acupuncture used for relieving pain without the complications found in some routine postoperative analgesics. These methods could be especially useful for high risk patients prone to complications from analgesics, such as transplantation recipients. The aim of this study was to evaluate the efficacy of electro-acupuncture on postoperative pain control after inguinal surgeries.

METHODS

Ninety male patients, who were referred to our department with indications of inguinal surgery, were included in the study and randomly divided into two groups, such as acupuncture and control. We used electro-acupuncture for the acupuncture group and no actual acupuncture (but placed needle electrodes similar to the acupuncture group) for the control group. Postoperative pain was quantified by a blind observer in both groups using a visual analogue scale (VAS) standard score before being compared.

RESULTS

Pain intensity and analgesic use were significantly higher in the control group (P < 0.05). In the acupuncture group, the VAS pain scores were significantly lower than the control group at 0.5, 1 and 2 hours post operation. When the opioid related side effects were compared for each group, the results showed that the number of subjects who experienced dizziness in the acupuncture group was significantly lower than the control group (P < 0.05).

CONCLUSIONS

Acupuncture in patients, after inguinal surgery, can reduce the need of analgesics, which also directly reduces the complications that may occur when analgesics are used in relieving pain postoperatively.

The management of dental anxiety and impact of psychosomatic factors on dentistry: is recent scientific research translated into German dental practices?

This study investigated the dentists' knowledge about psychosomatic medicine. Anxiolytic techniques, considerations about psychosomatic medicine, and referrals to psychotherapists were examined by a questionnaire. Overall, 65 percent felt negatively affected by patients with dental fear. Few dentists used relaxation techniques and hypnosis. The relationship between psychosomatic factors and pain perception was well known, but not their impact on wound healing. The frequency of continuing education courses correlated with a broader range of treatment techniques and less difficulties in treatment. Research evidence about the impact of psychological factors on dental treatment has not been translated into dental practice.

Prognostic factors for non-success in patients with sciatica and disc herniation

BACKGROUND

Few studies have investigated prognostic factors for patients with sciatica, especially for patients treated without surgery. The aim of this study was to identify factors associated with non-success after 1 and 2 years of follow-up and to test the prognostic value of surgical treatment for sciatica.

METHODS

The study was a prospective multicentre observational study including 466 patients with sciatica and lumbar disc herniation. Potential prognostic factors were sociodemographic characteristics, back pain history, kinesiophobia, emotional distress, pain, comorbidity and clinical examination findings. Study participation did not alter treatment considerations for the patients in the clinics. Patients reported on the questionnaires if surgery of the disc herniation had been performed. Uni- and multivariate logistic regression analyses were used to evaluate factors associated with non-success, defined as Maine-Seattle Back Questionnaire score of ≥5 (0-12) (primary outcome) and Sciatica Bothersomeness Index ≥7 (0-24) (secondary outcome).

RESULTS

Rates of non-success were at 1 and 2 years 44% and 39% for the main outcome and 47% and 42% for the secondary outcome. Approximately 1/3 of the patients were treated surgically. For the main outcome variable, in the final multivariate model non-success at 1 year was significantly associated with being male (OR 1.70 [95% CI; 1.06 - 2.73]), smoker (2.06 [1.31 - 3.25]), more back pain (1.0 [1.01 - 1.02]), more comorbid subjective health complaints (1.09 [1.03 - 1.15]), reduced tendon reflex (1.62 [1.03 - 2.56]), and not treated surgically (2.97 [1.75 - 5.04]). Further, factors significantly associated with non-success at 2 years were duration of back problems >; 1 year (1.92 [1.11 - 3.32]), duration of sciatica >; 3 months (2.30 [1.40 - 3.80]), more comorbid subjective health complaints (1.10 [1.03 - 1.17]) and kinesiophobia (1.04 [1.00 - 1.08]). For the secondary outcome variable, in the final multivariate model, more comorbid subjective health complaints, more back pain, muscular weakness at clinical examination, and not treated surgically, were independent prognostic factors for non-success at both 1 and 2 years.

CONCLUSIONS

The results indicate that the prognosis for sciatica referred to secondary care is not that good and only slightly better after surgery and that comorbidity should be assessed in patients with sciatica. This calls for a broader assessment of patients with sciatica than the traditional clinical assessment in which mainly the physical symptoms and signs are investigated.

Cortisol awakening response and pain-related fear-avoidance versus endurance in patients six months after lumbar disc surgery

Recent research indicates that stress-induced, prolonged deviations in basal adrenocortical activity might contribute to ongoing/recurrent pain following lumbar disc surgery. Further, fear-avoidance and endurance responses to pain (FAR and ER) are regarded as important risk factors for pain after surgery. In patients with non-specific low back pain, FAR appear to possibly increase pain-related arousal, whereas ER may have an arousal-lowering effect, indicated by adrenocortical activity. The current study explores the relationship between basal adrenocortical activity and FAR and ER. Thirty-six patients 6 months after lumbar disc surgery participated. Basal adrenocortical activity was assessed through the cortisol awakening response (CAR), using salivary samples collected on two consecutive days. FAR and ER were estimated using questionnaires. While the ER variables pain-persistence behavior and positive mood despite pain showed negative associations with the CAR, the FAR variables fear-avoidance beliefs and avoidance of social activity were positively correlated with it. Additionally, higher CAR levels were found in patients with high versus patients with low fear-avoidance beliefs and, conversely, in patients with low versus high positive mood and pain persistence. These results indicate that FAR may increase the individuals' level of pain-related stress among patients after disc surgery, while ER may lower it.

Relationship of negative affect and outcome of an opioid therapy trial among low back pain patients

OBJECTIVES

Patients with chronic noncancer pain frequently report symptoms of depression and anxiety (negative affect), which are associated with higher ratings of pain intensity and a greater likelihood of being prescribed chronic opioid therapy. The purpose of this secondary analysis was to test the hypothesis that initial levels of negative affect can predict treatment-related outcomes in a double-blind, placebo-controlled study of extended-release (ER) hydromorphone among opioid-tolerant patients with chronic low back pain.

METHODS

Four hundred fifty-nine (N = 459) patients participated in the titration/conversion phase of a multicenter study, of which 268 were randomized to receive once-daily hydromorphone or placebo. All patients completed the Hospital Anxiety and Depression Scale (HADS) at baseline and were divided evenly into Low (N = 157), Moderate (N = 155), and High (N = 147) negative affect groups based on their scores. Group differences in numerical pain intensity measures at home and in the clinic, Roland-Morris Disability ratings, and measures of symptoms from the Subjective Opiate Withdrawal Scale (SOWS) throughout the trial were analyzed.

RESULTS

Two hundred sixty-eight of the initial 459 subjects who entered the 2 to 4-week titration/conversion phase (pretreatment) were successfully randomized to either placebo or ER hydromorphone; a total of 110 patients then completed this double-blind phase of the study. Those in the Moderate and High negative affect groups tended to drop out more often during the titration/conversion phase because of the adverse effects or lack of efficacy of their prescribed opioid than those in the Low negative mood group (P < 0.05). Overall, those patients in the Moderate and High groups reported significantly higher pain intensity scores in at-home and in-clinic pain intensity ratings (P < 0.05), greater disability on the Roland-Morris Scale (P < 0.01), and more withdrawal symptoms on the SOWS (P < 0.05) than those in the Low group. Higher negative affect scores also predicted less favorable ratings of the study drug during the titration phase (P < 0.05). Interestingly, the High negative affect group showed the most improvement in pain in the placebo condition (P < 0.05).

CONCLUSIONS

Negative affect is associated with diminished benefit during a trial of opioid therapy and is predictive of dropout in a controlled clinical trial.

Role of trait anxiety in persistent radicular pain after surgery for lumbar disc herniation: a 1-year longitudinal study

OBJECTIVE

To evaluate anxiety and depression as prognostic factors for radicular and back pain after surgery in patients with lumbar disc herniation in a 1-year follow-up study.

METHODS

A total of 108 patients with lumbar disc herniation were enrolled in the study. Anxiety was assessed by State and Trait Anxiety Inventory; current depression was assessed by Zung Self-Rating Depression Scale. Severity of pain was scored on the visual analog scale (VAS). The State and Trait Anxiety Inventory, Zung Self-Rating Depression Scale, and VAS were administered before surgery and 1, 3, 6, and 12 months after surgery.

RESULTS

Before surgery, 72.2% of patients showed state anxiety, 54.6% of patients showed trait anxiety, and 11.1% of patients showed current depression. During the follow-up period, there was a significant decrease in the prevalence of state anxiety (P < .0001), no variation in the prevalence of trait anxiety (P = .115), and a significant increase in the prevalence of current depression (P = .002). Linear regression analysis showed that the presence of trait anxiety before surgery was the main determinant of the presence of pain after surgery (P < .0001). VAS scores were evaluated by dividing patients into 2 groups based on the presence or absence of trait anxiety before surgery. The subgroup affected by trait anxiety before surgery had significantly higher VAS scores at each follow-up assessment compared with patients without trait anxiety (P < .0001).

CONCLUSION

The presence of trait anxiety before surgery is a prognostic factor for the persistence of pain after surgery.

Catastrophizing and depressive symptoms as prospective predictors of outcomes following total knee replacement

Several recent reports suggest that pain-related catastrophizing is a risk factor for poor acute pain outcomes following surgical interventions. However, it has been less clear whether levels of catastrophizing influence longer-term postoperative outcomes. Data were analyzed from a relatively small number (n=43) of patients who underwent total knee replacement and were followed for 12 months after their surgery. Previous research has suggested that high levels of both catastrophizing and depression are associated with elevated acute postoperative pain complaints among patients undergoing knee surgery. In this sample, catastrophizing and depression at each of the assessment points were studied as prospective predictors of pain (both global pain ratings and pain at night) at the subsequent assessment point over the course of one year. The predictive patterns differed somewhat across measures of pain reporting; depressive symptoms were unique predictors of greater global pain complaints, while catastrophizing was a specific and unique predictor of elevated nighttime pain. While surgical outcomes following total knee replacement are, on average, quite good, a significant minority of patients continue to experience long-term pain. The present findings suggest that high levels of catastrophizing and depression may promote enhanced pain levels, indicating that interventions designed to reduce catastrophizing and depressive symptoms may have the potential to further improve joint replacement outcomes.

The prediction of outcome in somatised patients undergoing elective lumbar surgery

We compared a group of 46 somatised patients with a control group of 41 non-somatised patients who had undergone elective surgery to the lumbar spine in an attempt to identify pre-operative factors which could predict the outcome. In a prospective single-centre study, the Distress and Risk Assessment method consisting of a modified somatic perception questionnaire and modified Zung depression index was used pre-operatively to identify somatised patients. The type and number of consultations were correlated with functional indicators of outcome, such as the Oswestry disability index and a visual analogue score for pain in the leg after follow-up for six and 12 months.

Similar improvements in the Oswestry disability index were found in the somatised and non-somatised groups. Somatised patients who had a good outcome on the Oswestry disability index had an increased number of orthopaedic consultations (50 of 83 patients (60%) vs 29 of 73 patients (39.7%); p = 0.16) and waited less time for their surgery (5.5 months) (sd 5.26) vs 10.1 months (sd 6.29); p = 0.026). No other identifiable factors were found. A shorter wait for surgery appeared to predict a good outcome. Early review by a spinal surgeon and a reduced waiting time to surgery appear to be of particular benefit to somatised patients.

A randomized, double-blind, placebo-controlled study of preemptively administered intravenous parecoxib: effect on anxiety levels and procedural pain during epidural catheter placement for surgical operations or for chronic pain therapy

BACKGROUND

The effect of parecoxib, when used perioperatively or during interventional techniques, is well demonstrated in the literature. Little is known about its effects on anxiety levels before the analgesic technique application. The aim of this prospective, randomized, double-blind, placebo-controlled, clinical study is to investigate whether parecoxib, preemptively administrated, has an effect on anxiety levels reported prior to an epidural puncture, and if it influences the reported pain of the interventional technique itself.

MATERIAL AND METHODS

The study protocol involved 110 patients, scheduled for epidural catheter placement for chronic pain therapy--Group I, as well as 112 patients scheduled for orthopedic operations under epidural anesthesia--Group II. Patients in each group were randomly allocated into two subgroups in relation to parecoxib/placebo administration before epidural catheter placement: Group Ia, parecoxib 40 mg i.v. (n = 54), Group Ib, placebo (n = 56), Group IIa, parecoxib 40 mg i.v. (n = 57), Group IIb, placebo (n = 55). Patients were given a self-administered inventory to measure the anxiety level of the presurgical/preprocedural state (State-Trait Spielberger Anxiety Inventory) and anxiety levels were recorded 1 hour before epidural puncture, 20 minutes postdosing, and 1 hour after epidural catheter placement. Anxiety levels were also measured and recorded using visual analog scale (VAS). One hour after epidural puncture, reported procedural pain was recorded (VAS). One hour and 6 hours postepidural, patients' satisfaction was also recorded, on a 4-point scale.

RESULTS

All four subgroups were similar regarding demographic, operative/procedural data, and coexisting diseases. Preprocedural anxiety levels were significantly decreased with parecoxib administration in comparison with placebo in both groups (P < 0.05). Reported VAS regarding pain from epidural puncture was lower in Groups IA and Ib. Patients' satisfaction was greater with parecoxib in comparison with placebo.

CONCLUSION

The levels of anxiety have been investigated in several medical procedures and early, in the study of pain. The higher the expectation of pain and the anxiety are, the higher the intensity of the pain. Parecoxib seems to exert positive influence on pain and anxiety levels of interventional procedure. Further studies are needed to elucidate the actual mechanisms that are involved.

Correlation of pain scores, analgesic use, and beck anxiety inventory scores during hospitalization in lower extremity amputees

Post amputation pain can be debilitating for patients and families. Chronic pain is a common phenomenon after lower extremity amputation, occurring in up to 80% of this population. The purpose of this pilot study was to correlate post amputation pain scores to opioid analgesic consumption and Beck Anxiety Inventory (BAI) scores. Twenty-three patients with lower extremity amputation at an 827-bed acute care inner-city hospital were surveyed pre-operatively and post-operatively to determine if there was a significant correlation between anxiety and pain. A numeric scale was utilized by patients to rate their pain level, while the BAI was utilized to measure their anxiety levels.

A significant correlation was found between the pre-operative BAI levels and the BAI levels identified at time of discharge. Patients were found to have a higher than normal level of anxiety pre-operatively. No significant correlations were found between anxiety and pain.

Predictors of low back pain hospitalization--a prospective follow-up of 57,408 adolescents

Low back pain (LBP) is common among adolescents and it has been estimated that one-fifth of adolescents suffer from recurrent severe LBP. However, longitudinal studies describing the risk factors of LBP are scarce. The purpose of this study was to investigate whether health, physical activity and other health behaviors, socio-demographic background and school success predict LBP hospitalization until early middle age. A cohort of 72,378 adolescents (57,408 respondents, response rate 79%) aged 14-18 years participating in a population survey between 1979 and 1997 was followed for an average of 11.1 years through the national hospital discharge register. We identified 810 (1.1%) persons with LBP hospitalization, 620 males (1.7% of the whole male cohort) and 190 (0.5%) females (HR 3.2; 95% CI: 2.7-3.7). In multivariate Cox's analysis, the strongest risk factors for LBP hospitalization for the whole cohort were weekly health complaints (HR 1.5; 95% CI: 1.2-1.9), daily smoking (HR 1.4; 95% CI: 1.1-1.7), and poor school success (HR 1.4; 95% CI: 1.1-1.9). Late puberty decreased the risk in males (HR 0.7; 95% CI: 0.5-0.9). Among females, participation in organized sports (HR 1.7; 95% CI: 1.1-2.5) was associated with an increased risk for LBP hospitalization. The associations between the risk factors and LBP hospitalization persisted into adulthood. Efforts to reduce adolescent smoking may decrease LBP-related morbidity in males. Coaches should pay special attention to the nature of physical training and personal exercises in females, and physiotherapists and sports physicians to the prevention of LBP hospitalization.