Cover Story

When back pain becomes unbearable, and other treatments fail, many people turn to surgery. Hundreds of thousands of spine surgeries are done each year and 99 percent of these are elective, says William Deardorff, PhD, a psychologist at two California spine surgery practices.

But surgical decision-making is not straightforward. In fact, says Deardorff, "If you take 100 people off the street who don't have back pain, up to 40 percent will show some abnormalities on an MRI." So it's his job to help surgeons determine whether surgery is the best option, prepare patients for surgery and assist with patients' pain management.

Regardless of the medical treatment plan, Deardorff sees patients for a variety of reasons and sessions, such as cognitive behavioral pain management skills, relaxation training and environmental interventions, pre-surgical assessment or even brief family psychotherapy at times.

Many patients who come to the clinic seeking an end to their pain have unrealistic expectations about surgery. Deardorff helps explain all the available treatments, including surgery, and the possible outcomes. "I help them explore their expectations about what the surgery will provide for them and their beliefs about what's wrong with them," he says. In many cases, patients are uninformed about what the postoperative recovery phase will be like--frequently it's a long road. They might be partially disabled and could still experience pain for months after surgery, or even longer. "I help them get their environments organized for the recovery," says Deardorff.

Not everyone who wants surgery gets it. Some patients just aren't good candidates. "Research really shows that psychological variables are often stronger predictors for surgical outcome than structural abnormalities," Deardorff says. He screens patients for biopsychosocial factors that can produce a poor surgical outcome, such as:

  • A history of, or ongoing, substance abuse.

  • A major psychiatric or personality disorder.

  • Amplified complaints of pain compared with objective physical findings.

  • Depression and anxiety.

  • Extended disability leave from work.

  • Litigation status. Is there a financial gain or some other "benefit" for the patient to stay in pain and disabled?

  • Poor job satisfaction.

  • Chronic pain syndrome.

  • Strained marital relationship.

After surgery, he continues behavioral coping techniques and consults with the surgeon on such things as the behavioral aspects of pain medication delivery and dosing. If the patient is over- or undermedicated, "I'm often the first to notice since I have so much contact with the patient relative to the surgeon," he says.

Sometimes patients opt for conservative treatments instead of surgery. "I teach them to ask the right questions of their surgeons." When a patient decides to forego surgery, "it's often a product of good informed consent," he says.

Some cases require other types of psychological interventions, aside from pain management. If the patient's injury is work-related, Deardorff might help him or her search for alternative employment. "Sometimes I'll refer to a vocational counselor if they're not returning to their previous job." He often works with patients on setting limits and developing assertiveness skills at work. "If a patient has medical restrictions in terms of lifting or bending but he's not very assertive, he can continually flare up his back pain," he says.

Deardorff has been in pain management since his internship in 1985 at the University of Washington with pain pioneer and psychologist William Fordyce. "It's a great area of specialization for a psychologist." But, he adds, "spine psychology practice is really an unmet need."

--J. DAW