A new, 296-patient study from Tufts Medical Center and Tufts University School of Medicine has articulated the importance of psychiatric distress and its misdiagnosis in spine surgery patients. How crucial is this? It may well be the #1 co-morbidity in spine surgery!
The study, “Spine Surgeon Assessments of Patient Psychological Distress are Inaccurate and Bias Treatment Recommendations,” appears in the July 1, 2023, edition of Spine.
Co-author Andrew Moon, M.D., an orthopedic resident at Tufts Medical Center, told OTW, “Prior literature has identified the relationship between psychological factors contributing to the manifestation of back and neck pain.”
Indeed, noted Dr. Moon, the biopsychosocial model of healthcare, which is a comprehensive approach to patient care that recognizes the important interplay between the various factors that can influence a patient’s relationship with their medical condition, is a powerful influence on how patients perceive their health and, therefore, the physician’s ability to deliver healthcare services.
“Psychological distress is known to be common among patients presenting with complaints of chronic back and neck pain,” explained Dr. Moon, “with up to 77% incidence of psychiatric comorbidity in this population.”
“This is important when considering that patients with psychological distress are more likely to fail to return to work, to improve functionally, and to report improvement in pain despite treatment. Therefore, identifying these factors may be helpful in the clinic setting when considering surgical intervention in this population.”
For their study, the Tuft’s research team asked patients to complete the Modified Somatic Perception Questionnaire and Zung Depression Index. The patient’s answers then generated a Distress and Risk Assessment Method score of normal, at risk, or distressed.
The research team also gathered scores from the Oswestry Disability Index and Neck Disability Index scores. Finally, the surgeons who were treating the patients provided their own estimates of the Distress and Risk Assessment Method score after the visit and reported on their surgical recommendation.
Results and Key Findings (Not Encouraging)
Of the 296 patients who participated in the study, 40.5% reported some level of psychological distress (at risk) and 15.9% had a high level of distress.
Of the surgeons who participated in the study, all three did a poor job of accurately assessing their patient’s distress. Indeed, the research team found that the surgeons demonstrated a bias toward underestimating the patient’s true level of psychological distress.
Patients rated as normal by the surgeon were 3.78 times more likely to be recommended for surgery compared to those assessed as distressed. Patients with higher Distress and Risk Assessment Method scores had higher Oswestry Disability Index (ODI) and Neck Disability Index (NDI) scores compared to those with lower Distress and Risk Assessment Method scores.
“The key findings of this study were that psychological distress was common among patients presenting for consideration of spine surgery and spine surgeons had limited ability to detect psychological profiles in patients with a tendency to underestimate levels of distress. Moreover, these inaccurate estimations of psychological distress were found to influence surgical decision-making when recommending surgical intervention. This raises a question of whether surgeons have an implicit bias to avoid surgery in patients they perceive to have higher levels of psychological distress.”
Time to Use Validated Psychological Assessment Tools in Spine Surgery
When OTW asked what might need to happen in order for surgeons to be able to accurately assess patient distress, Dr. Moon noted, “This highlights the importance of using validated psychological assessment tools in order to accurately assess patient distress. Validated screening tools are utilized infrequently in spine clinics and psychological distress is known to be strongly correlated with increased patient reported disability scores for neck and back conditions (ODI and NDI scores).”
As for other resources that might be helpful, Dr. Moon mentioned to OTW, “Surgeons may want to consider interdisciplinary collaborations with psychiatric providers—not only to accurately assess patient levels of psychologic distress, but to provide more comprehensive care for these patients.”
“Surgeons should be aware of the high levels of psychological distress in spine patient population, as well as the poor ability of surgeons to accurately assess psychological distress. There are many factors that must be taken into consideration when evaluating candidacy for surgery. Subjective measures such as reports of pain and disability must be weighed against objective radiological imaging, lab values, range of motion, etc. This study suggests that a patient’s level of psychological distress, and the surgeon’s ability to independently measure this, may also be important components of the clinical picture and methods for evaluating this should be further studied.”
