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