Who needs Spine Surgery?

Selecting appropriate surgical patients poses a challenge for spine surgeons. Research has concentrated on psychological factors for outcome prediction. Initially, screening profiles were employed to identify personality traits linked to low back pain.

The Minnesota Multiphasic Personality Inventory (MMPI) revealed traits such as hypochondriasis and hysteria in patients with functional low back pain. However, this method encountered challenges in outcome prediction.

A more refined approach emerged with the biopsychosocial theory of pain, which considers factors like worker’s compensation and social support. Patient-centered outcomes encompass pain, disability, and work capacity.

Significant attempts are underway to create a screening tool that can predict the success of spine surgery, but a widely accepted measure is still lacking. Current research is focused on investigating the resilience and grit of orthopedic surgical candidates, with the potential for improvement through therapy and positive impact on surgical outcomes.

This review delves into the development of screening tools, defines psychological concepts, explores their relevance to clinical outcomes, and investigates their implications for preoperative assessments conducted by spine surgeons.

Previous Attempts In Patient Selection For Spine Surgery

The complex interplay of psychology, societal factors, and underlying pathology poses a challenge in developing a reliable tool for patient selection in spine surgery. Various presurgical psychological screening (PPS) scorecards have been tested, taking into account personality, cognitive, behavioral, and environmental factors.

However, the long-term predictive abilities and practical applicability of these scorecards in clinical practice are still uncertain. Ongoing research focuses on refining the PPS by potentially integrating parameters such as grit and resilience. Successful implementation will require further investigation and the use of objective outcome measures.

Psychosocial Metrics

The response of individuals to surgery is influenced by complex psychological concepts such as resilience, self-efficacy, and grit, which are shaped by social, cultural, and biological factors. However, there is variation in how these concepts are defined and utilized, underscoring the importance of exploring the latest understanding in this field.

Resilience

Resilience refers to the capacity to adjust and exhibit flexibility in the face of challenging life circumstances. It is connected to positive interpersonal connections, social proficiency, decreased healthcare utilization, and enhanced self-assessed health.

Resilience can be strengthened through therapeutic interventions and targeted approaches, and it has the ability to adapt in response to stress. Its definition may be impacted by its relationship with other psychological aspects, including positive mental well-being. In individuals with spinal cord injuries, high self-efficacy is associated with an increased display of resilient behaviors.

Measuring resilience is a complex task, and researchers employ a variety of scales for this purpose. Among the highly regarded scales are the Brief Resilience Scale (BRS), Connor-Davidson Resilience Scale (CD-RISC), and Resilience Scale for adults (RSA). However, these scales are considered to have a moderate level of quality.

The BRS focuses on personal agency, while the CD-RISC assesses factors such as competence and relationships. The RSA examines both interpersonal and intrapersonal factors. Some criticism has been raised regarding the overemphasis on individual factors at the expense of environmental factors in these scales. Nonetheless, these scales have been applied in studies involving orthopedic patients.

Patient Activation

In recognizing the essential role patients play in managing their health, Hibbard et al developed the concept of patient activation, closely linked to resilience.

This concept comprises four domains: understanding the significance of the patient’s role, possessing the necessary confidence and knowledge to take action, actively participating in maintaining and enhancing health, and persisting in the face of challenges.

Patient activation is widely regarded as a strong predictor of health outcomes, especially in chronic illnesses, and exhibits particular potential within the realm of spinal surgery.

The assessment of patient activation, which examines the level of patient engagement and self-assurance in healthcare, bears resemblance to the concept of resilience.

It evaluates the extent to which a patient is willing to collaborate with healthcare providers and adhere to treatment plans, even in challenging situations. The 22-item patient activation measure (PAM-22) and its subsequent version, the PAM-13, are established and trustworthy instruments for gauging this attribute.

Grit

Defined as the unwavering determination and passion to achieve long-term goals despite obstacles, grit is a personality trait. It has been linked to success among high-achieving individuals, irrespective of their talent and intelligence levels. Grit is associated with deriving happiness from engagement and meaningful pursuits, rather than pursuing instant gratification.

However, recent studies challenge the notion of grit as an entirely independent trait, suggesting that perseverance plays a more significant role in predicting success. Furthermore, there is some overlap between grit and the trait of self-control.

The measurement of grit commonly involves the use of either the 12-item Grit Scale or the revised 8-item Short Grit Scale (Grit-S), both of which exhibit satisfactory psychometric properties.

However, there is ongoing debate regarding the extent of overlap between grit and concepts such as perseverance and self-control. Recent evaluation of the Grit-S revealed a greater emphasis on consistency of interest rather than perseverance, prompting the development of a 5-item Grit Scale that specifically targets perseverance. This adapted scale demonstrates robust predictive capabilities for academic and career outcomes.

Self-Efficacy

An individual’s self-efficacy refers to their personal belief in their capacity to effectively perform in a specific situation or attain desired outcomes.

It involves the subjective perception of one’s own ability to carry out specific behaviors under particular circumstances. Self-efficacy has the potential to shape behaviors, activity levels, and achievements.

The pain self-efficacy questionnaire (PSEQ) is commonly used in the context of spinal surgery. It consists of 10 items and measures individuals’ confidence in performing activities despite ongoing pain.

Several metrics are available for assessing self-efficacy across various conditions, but a systematic review found that none of them were suitable for musculoskeletal rehabilitation.

Spine Surgery

Limited research has been conducted on resilience, patient activation, grit, and self-efficacy in the context of spinal surgery. Evidence suggests that low resilience and pain self-efficacy scores are associated with higher levels of functional disability in individuals with back and neck pain.

On the other hand, higher levels of patient activation are related to improved functional outcomes and increased participation in physical therapy. However, further research is needed to understand the role of grit in spinal surgery outcomes and the impact of self-efficacy.

The psychological factors of resilience, patient activation, grit, and self-efficacy show potential in predicting success in spine surgery. Resilience and patient activation are particularly strong metrics for assessing patients before surgery.

However, more research and standardized data collection are necessary to fully comprehend their impact on patient outcomes. Interventions targeting resilience improvement are an important area of focus. Continued study in this field has the potential to enhance preoperative risk assessment and ultimately improve patient outcomes.