1. When & How to Utilize Interventional Procedures Utility and Predictive Factors
N. Camden Kneeland, M.D., D.A.B.A.
The Montana Center for Wellness & Pain Management
Kalispell, MT

2. Disclosures
Research Stipend from St. Jude Medical

3. Objectives
Present 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

4. Psychosocial Background
Biopsychosocial complexity of chronic pain cannot be underappreciated
41% with Axis I disorder
% increased association with depression and anxiety
Cost of chronic pain treatment annually exceeds $600 Billion annually
Daubs, MD SPINE Volume 36, Number 21S, pp S96–S109

5. Fusion Versus Nonoperative Care for Chronic Low Back Pain
Systematic review of randomized controlled trials
18 Studies met inclusion criteria for the period
Beck 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–S

6. Prospective Cohort study
Can the Outcome of Spinal Cord Stimulation in Chronic Complex Regional Pain Syndrome Type I Patients Be Predicted by Catastrophizing Thoughts?
32 Patients
Prospective Cohort study
Dutch version of the Pain Catastrophizing Scale
Efficacy of SCS was not predicted by pain catastrophizing
Lame´ et al, Anesthesia and Analgesia 109(2):

7. Prospective cohort study Spine surgery and spinal cord stimulation
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
197 patients
Prospective cohort study
Spine surgery and spinal cord stimulation
No significant difference between groups
Depression, 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,

8. The Impact of Psychological Factors on Outcomes for Spinal Cord Stimulation: An Analysis with Long-term Follow-up
Retrospective Analysis
60 patients
Hospital Anxiety and Depression Test and Pain Disability Index
No significant difference in PDI scores with successful and unsuccessful SCS implants
No significant difference in HADS scores with successful and unsuccessful SCS implants
Wolter et al, Pain Physician 16(3)

9. Prognostic Value of Psychological Testing in Patients Undergoing Spinal Cord Stimulation: A Prospective Study
Prospective study
MMPI
58 patients
Some 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

10. Psychology and the Diagnosis of Facet Joint Pain
Retrospective Analysis
438 patients
Survey based on DSM IV criteria for depression, anxiety, and somatization disorder
No statistically significant influence of depression, anxiety, somatization disorder, or a combination of the above on the prevalence of facet joint pain
Response to comparative medial branch blocks with different anesthetics
Manchikanti et al, Pain Physician, 11(2)

11. Summary Limited Data for Screening outside SCS Mixed Results
Common Sense
When in doubt, evaluate, but don’t sacrifice patient care
Comprehensive Approach

12. The Role of Interventions
Diagnostic Value
Physician and Patient Education
Better Treatment Plans
Variety of Pain Generators = Variety of Interventions
Breaking the Cycle of Pain
Improving Function

13. Interventional Pearls
Radicular Pain vs. Axial vs. Diffuse Pain
Shotgun Approach
Safety of Epidural Steroids
Adhesive arachnoiditis <1000 cases
in 2002*
Myofascial/Musculoskeletal Pain
Interspinous Ligment
*Rice M, et al, BJA 92:

14. Interventional Pearls
Facet Pain
Second most common
source of axial spine
pain

15. Interventional Pearls
Lumbar Myofascial Pain
Iliopsoas &
Quadratus Lumborum

16. Interventional Pearls
Sacroiliac Joint Pain
Lateral Branch Blocks
Cooled RF Ablation

17. Summary
Use interventional approach diagnostically and to break pain cycles
Long term analgesia and cure is possible
Informed consent is critical