N. Camden Kneeland, M.D., D.A.B.A.
The Montana Center for Wellness & Pain Management
Kalispell, MT
Disclosures
 Research Stipend from St. Jude Medical
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
Psychosocial Background
 Biopsychosocial complexity of chronic pain cannot be
underappreciated
 41% with Axis I disorder
 200-300% 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
Fusion Versus Nonoperative Care for Chronic
Low Back Pain
 Systematic review of randomized controlled trials
 18 Studies met inclusion criteria for the period 1990-2010
 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–S109 2011
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):592-9 2009
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, 81-107 2013
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) 265-75 2013
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 301-311 1996
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) 145-60 2008
Summary
 Limited Data for Screening outside SCS
 Mixed Results
 Common Sense
 When in doubt, evaluate, but don’t sacrifice patient
care
 Comprehensive Approach
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
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 92:1 109-120
Interventional Pearls
 Facet Pain
 Second most common
source of axial spine
pain
Interventional Pearls
 Lumbar Myofascial Pain
 Iliopsoas &
Quadratus Lumborum
Interventional Pearls
 Sacroiliac Joint Pain
 Lateral Branch Blocks
 Cooled RF Ablation
Summary
 Use interventional approach diagnostically and to
break pain cycles
 Long term analgesia and cure is possible
 Informed consent is critical