Pain Sensitivity and Pain Catastrophizing Are Associated With Persistent Pain and Disability After Lumbar Spine Surgery

doi:10.1016/j.apmr.2015.06.003

Archives of Physical Medicine and Rehabilitation

Volume 96, Issue 10, October 2015, Pages 1763-1770

Presented to the American Pain Society, May 13–16, 2015, Palm Springs, CA.

https://doi.org/10.1016/j.apmr.2015.06.003 Get rights and content

Abstract

Objective

To examine whether pain sensitivity and pain catastrophizing are associated with persistent pain and disability after lumbar spine surgery.

Design

Prospective observational cohort study.

Setting

Academic medical center.

Participants

Patients (N=68; mean age, 57.9±13.1y; 40 women [58.8%]) undergoing spine surgery for a degenerative condition from March 1, 2012 to April 30, 2013 were assessed 6 weeks, 3 months, and 6 months after surgery.

Interventions

Not applicable.

Main Outcome Measures

The main outcome measures were persistent back pain intensity, pain interference, and disability. Patients with persistent back pain intensity, pain interference, or disability were identified as those patients reporting Brief Pain Inventory scores ≥4 and Oswestry Disability Index scores ≥21 at all postoperative time points.

Results

From 6 weeks to 6 months after surgery, approximately 12.9%, 24.2%, and 46.8% of patients reported persistent back pain intensity, pain interference, or disability, respectively. Increased pain sensitivity at 6 weeks was associated with having persistent back pain intensity (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.0–4.1) after surgery. Increased pain catastrophizing at 6 weeks was associated with having persistent back pain intensity (OR, 1.1; 95% CI, 1.0–1.2), pain interference (OR, 1.1; 95% CI, 1.0–1.2), and disability (OR, 1.3; 95% CI, 1.1–1.4). An interaction effect was not found between pain sensitivity and pain catastrophizing on persistent outcomes (P>.05).

Conclusions

The findings suggest the importance of early postoperative screening for pain sensitivity and pain catastrophizing to identify patients at risk for poor postoperative pain intensity, pain interference, and/or disability outcomes. Future research should consider the benefit of targeted therapeutic strategies for patients with these postoperative prognostic factors.

Section snippets

Participants

This study was a prospective observational cohort study of patients who have chronic pain and are undergoing surgery for a lumbar degenerative condition. Patients were consecutively enrolled into this study from the Department of Orthopaedic Surgery at Vanderbilt University Medical Center from March 1, 2012 to April 30, 2013. To be eligible, patients needed to be 21 years of age or older, be English speaking, have back and/or leg pain complaints for >6 months, and undergo surgical laminectomy

Patients

Tables 1 and 2 summarize sociodemographic and clinical characteristics of the sample and outcome scores across all postoperative time points. Sixty-eight patients (40 women [58.8%], 28 men [41.2%]; mean age, 57.9±13.1y) were enrolled in this study. Most patients were non-Hispanic, white, and nonsmokers with some college experience at a minimum and underwent fusion surgery. The mean PCS score and PPT score at 6 weeks after surgery were 12.6±11.1 and 4.0±2.3kg, respectively. No differences in PCS

Discussion

This study examined whether pain sensitivity and pain catastrophizing are associated with persistent pain and disability after lumbar spine surgery. After accounting for pain catastrophizing, postoperative pain sensitivity was predictive of persistent back pain intensity, but not pain interference or disability. Postoperative pain catastrophizing was a consistent predictor of all persistent pain-related outcomes. These findings suggest that pain sensitivity and pain catastrophizing may be

Conclusions

Early postoperative pain sensitivity and pain catastrophizing were associated with persistent pain-related complaints after lumbar spine surgery. Specifically, pain sensitivity predicted persistent back pain intensity whereas pain catastrophizing predicted back pain intensity, pain interference, and disability. These findings suggest the importance of early postoperative screening for pain sensitivity and pain catastrophizing to identify patients at risk for poor outcomes after lumbar spine

Suppliers

a.
Wagner Instruments.
b.
IBM Corp.

Acknowledgments

We thank Shannon Mathis, PhD, and Erin Van Hoy, BS, for assistance with data collection and Chigozie Nkemka, BA, for proofreading this article prior to submission.

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Low back pain (LBP) is a common cause of impaired quality of life and disability and studies regarding surgical management of patients with LBP show a high variation in patient-reported success rate.
To find valuable preoperative clinical risk factors and variables associated with a non-satisfactory patient-reported outcome following surgery.
The Danish surgical spine database (DaneSpine) was used to collect eight years of pre- and postoperative data on patients undergoing single-level fusions with either posterior- (PLIF) or transforaminal lumbar interbody fusions (TLIF). The primary outcome was patient nonsatisfaction. We collected data on European Quality of Life–5 Dimensions (EQ-5D), visual analogue scale (VAS), Oswestry Disability Index (ODI) score, pain intensity, duration of back pain, previous discectomy, and expectations regarding return to work after surgery at 2-year follow-up.
The cohort included 453 patients of which 19% reported treatment nonsatisfaction. The nonsatisfaction group demonstrated higher preoperative VAS scores for back pain (75 ± 19 vs. 68 ± 21, p = 0.006) and leg pain (65 ± 25 vs. 58 ± 28, p = 0.004). The preoperative EQ-5D score was significantly lower in the nonsatisfaction group (0.203 + 0.262 vs. 0.291 ± 0.312, p = 0.016). There was no statistical significance between patient nonsatisfaction and preoperative ODI score, age, body mass index, duration of back pain or expectations regarding return to work after surgery.
Low preoperative EQ-5D scores and high VAS leg and back pain scores were statistically significant with patient nonsatisfaction following surgery and may prove to be valuable tools in the preoperative screening and alignment of patient expectations.
Biomarkers and longitudinal changes in lumbar spine degeneration and low back pain: the Johnston County Osteoarthritis Project
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To determine if baseline biomarkers are associated with longitudinal changes in the worsening of disc space narrowing (DSN), vertebral osteophytes (OST), and low back pain (LBP).
Paired baseline (2003–2004) and follow-up (2006–2010) lumbar spine radiographs from the Johnston County Osteoarthritis Project were graded for severity of DSN and OST. LBP severity was self-reported. Concentrations of analytes (cytokines, proteoglycans, and neuropeptides) were quantified by immunoassay. Pressure-pain threshold (PPT), a marker of sensitivity to pressure pain, was measured with a standard dolorimeter. Binary logistic regression models were used to estimate odd ratios (OR) and 95% confidence intervals (CI) of biomarker levels with DSN, OST, or LBP. Interactions were tested between biomarker levels and the number of affected lumbar spine levels or LBP.
We included participants (n = 723) with biospecimens, PPT, and paired lumbar spine radiographic data. Baseline Lumican, a proteoglycan reflective of extracellular matrix changes, was associated with longitudinal changes in DSN worsening (OR = 3.19 [95% CI 1.22, 8.01]). Baseline brain-derived neuropathic factor, a neuropeptide, (OR = 1.80 [95% CI 1.03, 3.16]) was associated with longitudinal changes in OST worsening, which may reflect osteoclast genesis. Baseline hyaluronic acid (OR = 1.31 [95% CI 1.01, 1.71]), indicative of systemic inflammation, and PPT (OR = 1.56 [95% CI 1.02, 2.31]) were associated with longitudinal increases in LBP severity.
These findings suggest that baseline biomarkers are associated with longitudinal changes occurring in structures of the lumbar spine (DSN vs OST). Markers of inflammation and perceived pressure pain sensitivity were associated with longitudinal worsening of LBP.
The Effect of the Severity of Preoperative Leg Pain on Patient-Reported Outcomes, Minimum Clinically Important Difference Achievement, and Patient Satisfaction After Minimally Invasive Transforaminal Lumbar Interbody Fusion
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To compare patient-reported outcome measures (PROMs), satisfaction, and minimum clinically important difference (MCID) achievement after minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) in patients stratified by preoperative leg pain.
Patients undergoing MIS-TLIF were collected through retrospective review of a prospectively maintained single-surgeon database. PROMs administered preoperatively/postoperatively included Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF), visual analog scale (VAS) back/leg pain, Oswestry Disability Index (ODI), and 12-Item Short Form (SF-12) Physical/Mental Component Score (PCS/MCS). Patients were grouped based on preoperative VAS leg scores: VAS leg ≤7 or VAS leg >7. Inferential statistics were used to compare PROMs, MCID achievement rates, and postoperative satisfaction between groups.
A total of 562 patients were eligible (168 VAS leg score ≤7; 394 VAS leg score >7). Significant differences between cohorts in postoperative mean PROMs were noted for PROMIS-PF at 6 weeks/2 years, SF-12 PCS at 6 weeks/2 years, SF-12 MCS at 6 weeks/12 weeks/6 months/1 year, VAS back score at 6 weeks/12 weeks/6 months, VAS leg score at 6 weeks/12 weeks/6 months/2 years and ODI at all postoperative time points (P < 0.045, all). In the VAS leg score >7 cohort, a greater proportion achieving MCID for VAS leg score at all postoperative time points and ODI at 12 weeks (P < 0.010, all). Postoperative satisfaction was greater in VAS back score ≤7 cohort for VAS leg score at 6 weeks/12 weeks/6 months/2 years, VAS back score at 12 weeks/2 years, and ODI at 6 weeks/12 weeks/6 months/2 years (P < 0.046, all).
Patients with severe preoperative leg pain showed worse postoperative PROM scores and patient satisfaction for disability and back/leg pain. MCID achievement rates across cohorts were similar. Patients with severe leg pain may have expectations for surgical benefits incongruent with their postoperative outcomes, and physicians may seek to manage the preoperative expectations of their patients to reflect likely outcomes after MIS-TLIF.
Nonopioid Postoperative Pain Management in Neurosurgery
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Patients with preoperative pain experience more pain following craniotomy relative to those without, necessitating more intensive pain management.4 Similarly, increased pain sensitivity and pain catastrophizing are both associated with greater postoperative pain intensity in patients undergoing lumbar spine surgery.132 Preoperative depression is associated with increased cumulative opioid use, increased risk of chronic use, and decreased probability of opioid cessation after lumbar fusion.133
Perioperative Pain Management for Elective Spine Surgery: Opioid Use and Multimodal Strategies
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However, chronic pain after spine surgery is a known and distinct entity and is sometimes refractory to all interventions. This is a particularly challenging patient population and has a prevalence of 3%–40% depending on the intervention and previous pain history.9-13 This population is extremely heterogeneous and multiple factors play a critical role in their management, such as cause of back pain, spinal disease, invasiveness of surgery, and location of surgery.
In recent years, physicians and institutions have come to recognize the increasing opioid epidemic in the United States, thus prompting a dramatic shift in opioid prescribing patterns. The lack of well-studied alternative treatment regimens has led to a substantial burden of opioid addiction in the United States. These forces have led to a huge economic burden on the country. The spine surgery population is particularly high risk for uncontrolled perioperative pain, because most patients experience chronic pain preoperatively and many patients continue to experience pain postoperatively. Overall, there is a large incentive to better understand comprehensive multimodal pain management regimens, particularly in the spine surgery patient population. The goal of this review is to explore trends in pain symptoms in spine surgery patients, overview the best practices in pain medications and management, and provide a concise multimodal and behavioral treatment algorithm for pain management, which has since been adopted by a high-volume tertiary academic medical center.
The Effect of the Severity of Preoperative Disability on Patient-Reported Outcomes and Patient Satisfaction Following Minimally Invasive Transforaminal Lumbar Interbody Fusion
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These findings indicate that patients in both the mild-to-moderate and severe disability cohorts, leg and back pain significantly improved following MIS TLIF; however, the findings do not meet criteria for MCID achievement. Previous studies have reported that pain sensitivity and preoperative back pain severity may predict postoperative patient outcomes, but no studies have compared pain scores in cohorts separated by preoperative disability severity.58-61 The absence of literature assessing the effect of preoperative characteristics in postoperative outcomes requires further research to benefit future patients.
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Minimally invasive transforaminal lumbar interbody fusions were grouped by preoperative Oswestry Disability Index (ODI) score: ODI <41 or ODI ≥41. PROMs administered pre/postoperatively included Patient-Reported Outcomes Measurement Information System physical function (PROMIS-PF), visual analog scale (VAS) back/leg, ODI, and 12-Item Short-Form Physical Composite Score (SF-12 PCS)/12-Item Short-Form Mental Composite Score (SF-12 MCS). Satisfaction scores were collected for VAS back/leg and ODI. Coarsened exact match controlled for differences between cohorts. T tests compared mean PROMs and postoperative improvement/satisfaction between cohorts. Simple logistic regression compared MCID achievement.
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: Supported by the National Institute of Arthritis and Musculoskeletal Skin Diseases of the National Institutes of Health (grant no. R21AR062880) and the Magistro Family Foundation Grant through the Foundation for Physical Therapy.

: Disclosures: none.

View full text

Original researchPain Sensitivity and Pain Catastrophizing Are Associated With Persistent Pain and Disability After Lumbar Spine Surgery

Abstract

Objective

Design

Setting

Participants

Interventions

Main Outcome Measures

Results

Conclusions

Section snippets

Participants

Patients

Discussion

Conclusions

Suppliers

Acknowledgments

Spine J

Spine J

J Pain

Pain

J Pain

Lancet

Osteoarthritis Cartilage

Tech Reg Anesth Pain Manag

Am J Surg

Pain

Spine J

Pain

Pain

J Pain

Pain

Spine J

J Pain

Br J Anaesth

Nutrition

Osteoarthritis Cartilage

Pain

Pain

Pain

Degenerative lumbar spinal stenosis: evaluation and management

J Am Acad Orthop Surg

Lumbar spinal fusion: surgical rates, costs, and complications

Spine

United States trends in lumbar fusion surgery for degenerative conditions

Spine

Spinal fusion in the United States: analysis of trends from 1998 to 2008

Spine

Nationwide trends in the surgical management of lumbar spinal stenosis

Spine

Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults

JAMA

Surgery for lumbar spinal stenosis: attempted meta-analysis of the literature

Spine

Expenditures and health status among adults with back and neck problems

JAMA

Quantitative sensory testing in predicting persistent pain after joint replacement surgery: promise and challenges

Pain

Can we predict persistent postoperative pain by testing preoperative experimental pain?

Curr Opinion Anaesthesiol

Prediction of postoperative pain: a systematic review of predictive experimental pain studies

Anesthesiology

Evidence that central sensitisation is present in patients with shoulder impingement syndrome and influences the outcome after surgery

J Bone Joint Surg Br

Prediction of persistent pain after total knee replacement for osteoarthritis

J Bone Joint Surg Br

The evolution of primary hyperalgesia in orthopedic surgery: quantitative sensory testing and clinical evaluation before and after total knee arthroplasty

Anesth Analg

Presurgical assessment of temporal summation of pain predicts the development of chronic postoperative pain 12 months after total knee replacement

Pain

Original research
Pain Sensitivity and Pain Catastrophizing Are Associated With Persistent Pain and Disability After Lumbar Spine Surgery