Surgical Implants for Pain Management
Pain patients who are candidates for surgical implants—whether a spinal cord stimulator or intrathecal pump—suffer chronic moderate to severe pain and have not benefitted from conservative or less-invasive treatment methods which include, but are not limited to, oral medications including opioids, physical therapy, injections, psychological ther-apy, holistic treatments (acupuncture, massage, cranial sacral), etc. In such instances, the use of such implants may be helpful to the management and reduction of pain and is often a last resort in the spectrum of treatment options.
It is common practice for patients to have a psychological pre-implant evaluation by a qualified licensed psychologist in their home state before implantation. It is important to fully understand the significance of this psycho-educational-evaluative role as it relates to patient satisfaction and aiding in the selection of optimum preventative treatments. These assessments are not considered forensic evaluations, but ones that are both evaluative and educational in nature. The patient’s response to these interactions is important in determining their readiness for being active participants in the aspects of both pain management self-care skills and for the management of issues that may arise from their implant.
This article is a summary of the results of a follow-up study of those patients who completed a pre-implant psychological evaluation and subsequently had an implant of a pain management device.
Psychologists and Pre-implant Evaluations
Psychologists have a long history of involvement in the scientific research, assessment and treatment of various types of health care interventions. These range from assessing and improving the effectiveness of working with diabetic patients to the more present-day concern of the obesity epidemic.1 Psychology also has a history of providing scientific research within the health care arena of biological, neurological, and behavioral medicine. Additionally, psychology has focused on issues faced by medical professionals and third-party payers who are concerned with utilization and over-utilization of health care. Physicians and surgeons are commonly coordinating care with psych-ologists to offer a unique perspective to complex health care concerns and work with pain patients issues in chronic pain clinics. Psychology has a central leading role as an adjunct to medical care.2
Behavioral medicine/health psychologists who work with chronic pain patients seeking surgical implants have an obligation to assess and understand the impact of these interventions on patients to improve pre- and post-surgery outcomes. Therefore, Behavioral Health Psychologists have an obligation to understand the bio-psycho-social issues that impact the medical environment. They help to facilitate communication and education between all parties,3 in addition to providing cognitive behavioral pain management therapy to improve the patient’s ability to become active participants in active self-care techniques. Real pain management is a great deal more than just administering a particular type of medical intervention ranging from medications to surgical interventions.
Due to the gravity of surgical implantation, it is expected that the psychologist conducting a pre-implant evaluation have a Doctorate in Psychology, is licensed in his or her state, and has a background working with chronic pain patients. They would also do well to have professional affiliations with pain organizations and have a background working with neurosurgery, neurology, or other pain related specialties.4
The Goal of Pre-implant Evaluations
When a surgical implant of a pain management device—such as a spinal cord stimulator or intrathecal pump—is indicated, important questions need to be answered. Besides looking to see if alternative approaches have first been tried, it is also important to select those patients who have the best chance of successfully responding to the surgical implant. We are all aware that some patients may not have the best results from surgery, even when all the physical findings are present to suggest the need for it.
The goal of a pre-implant evaluation is to determine which patients will have the best chance of a successful outcome and follow-up rehabilitation. Some patients will be poor responders to surgical intervention regardless of how successful the procedure may be. Others may have a better outcome if they have first received appropriate behavioral medicine treatments which make them more proactive in their recovery and subsequent rehabilitation. Some patients may first need help in identifying and eliminating issues in their lives that will interfere with their recovery.
It is important to note that the pre-implant psychological evaluation is not necessarily designed to eliminate candidates from surgical implantation. Rather it is designed to assist the surgeon, the patient, and the family in making appropriate decisions and treatment choices, depending on the particular needs of the patient. It focuses on the patient, personality style response patterns, personal life issues, issues that might result in setbacks, and other factors that are important to improved outcomes. Many medical patients are exhausted, confused, over-whelmed, not coping well, and need help in emotional stabilization prior to having any chance of using the medical interventions in an appropriate cost-effective manner.
At times the evaluation may recommend surgical implantation, but with very specific recommendations for post-surgical rehabilitation and recovery interventions that will enhance the chance of the patient responding in a positive manner and quickly returning to a functional capacity. As such, the pre-implant psychological evaluation is a bio-psycho-social-educational approach to helping patients make better use of the variety of treatment choices/options available. Many patients do not feel that they have more than a brief overview of what the entire process is all about. Therefore, education and information are a key focus of these evaluations.
Implant Evaluation Issues
Implant evaluation is part of a behavioral pain management approach to care. Evaluating patients for implants considers a number of factors including the patient’s: