N. Camden Kneeland, M.D., D.A.B.A.The Montana Center for Wellness & Pain
ManagementKalispell, MT
DisclosuresResearch Stipend from St. Jude Medical
ObjectivesPresent evidence regarding the predictive
value of psychosocial evaluation in chronic pain patients undergoing interventional procedures
Define the role of diagnostic and therapeutic interventional pain management procedures in an interdisciplinary pain management paradigm
Psychosocial BackgroundBiopsychosocial complexity of chronic pain
cannot be underappreciated41% with Axis I disorder200-300% increased association with
depression and anxietyCost of chronic pain treatment annually
exceeds $600 Billion annually
Daubs, MD SPINE Volume 36, Number 21S, pp S96–S109
Fusion Versus Nonoperative Care for Chronic Low Back Pain Systematic review of randomized controlled trials18 Studies met inclusion criteria for the period 1990-
2010Beck Depression Inventory, Fear Avoidance Belief
Questionaire, Zung Depression Scale, Spielberger Trait Anxiety Inventory, and Distress and Risk Assessment Method
Patients with a personality disorder appear to respond more favorably to conservative management and those without a personality disorder more favorably to fusion
Daubs, MD SPINE Volume 36, Number 21S, pp S96–S109 2011
Can the Outcome of Spinal Cord Stimulation in Chronic Complex Regional Pain Syndrome Type I Patients BePredicted by Catastrophizing Thoughts?
32 Patients Prospective Cohort studyDutch version of the Pain Catastrophizing
ScaleEfficacy of SCS was not predicted by pain
catastrophizing
Lame´ et al, Anesthesia and Analgesia 109(2):592-9 2009
Psychological Risk Factors for Poor Outcome of SpineSurgery and Spinal Cord Stimulator Implant: A Review ofthe Literature and Their Assessment With the MMPI-2-RF
197 patientsProspective cohort studySpine surgery and spinal cord stimulationNo significant difference between groupsDepression, anxiety, pain sensitivity, and
anger were associated with poor outcomes
Block, AR. Psychological Risk Factors for Poor Outcome of Spine Surgery and Spinal Cord Stimulator Implant: A Review of the Literature and Their Assessment With the MMPI-2-RF, The Clinical Neuropsychologist, 27:1, 81-107 2013
The Impact of Psychological Factors on Outcomes for Spinal Cord Stimulation: An Analysis with Long-term Follow-upRetrospective Analysis60 patientsHospital Anxiety and Depression Test and
Pain Disability IndexNo significant difference in PDI scores with
successful and unsuccessful SCS implantsNo significant difference in HADS scores with
successful and unsuccessful SCS implants
Wolter et al, Pain Physician 16(3) 265-75 2013
Prognostic Value of Psychological Testing in Patients Undergoing
Spinal Cord Stimulation: A Prospective Study
Prospective studyMMPI58 patientsSome statistically significant association
between high indices of depression and trial period, but no association with permanent implant
North R, Neurosurgery Issue: Volume 39(2), pp 301-311 1996
Psychology and the Diagnosis of Facet Joint PainRetrospective Analysis438 patientsSurvey based on DSM IV criteria for depression,
anxiety, and somatization disorderNo statistically significant influence of depression,
anxiety, somatization disorder, or a combination of the above on the prevalence of facet joint painResponse to comparative medial branch blocks with
different anesthetics
Manchikanti et al, Pain Physician, 11(2) 145-60 2008
SummaryLimited Data for Screening outside SCSMixed ResultsCommon SenseWhen in doubt, evaluate, but don’t sacrifice
patient careComprehensive Approach
The Role of InterventionsDiagnostic Value
Physician and Patient EducationBetter Treatment Plans
Variety of Pain Generators = Variety of Interventions
Breaking the Cycle of PainImproving Function
Interventional PearlsRadicular Pain vs. Axial vs. Diffuse Pain
Shotgun ApproachSafety of Epidural Steroids
Adhesive arachnoiditis <1000 cases in 2002*
Myofascial/Musculoskeletal PainInterspinous Ligment
*Rice M, et al, BJA 92:1 109-120
Interventional PearlsFacet Pain
Second most commonsource of axial spine pain
Interventional PearlsLumbar Myofascial Pain
Iliopsoas &Quadratus Lumborum
Interventional PearlsSacroiliac Joint Pain
Lateral Branch BlocksCooled RF Ablation
SummaryUse interventional approach diagnostically
and to break pain cyclesLong term analgesia and cure is possibleInformed consent is critical