Before treating physical pain, address the emotional one

The patient was a 78-year-old businessman who acted and looked about half his age. He was very pleasant and talked freely about his lower back pain and the pain down the side of his left leg, which had been a problem for about six months. It was consistently more severe when he stood or walked on it, and it immediately disappeared when he sat down. His MRI scan revealed that he had a bone spur pushing his fifth lumbar nerve root out to the side of his spine. Because his symptoms clearly matched the abnormal anatomy, it seemed like an easy decision to offer him a one-level fusion. He was the ideal surgical candidate, as he was so motivated and physically fit.

I rarely make a surgical decision on the first visit, but this situation seemed so straightforward that I decided to make an exception. The patient also wanted to proceed quickly, since he was frustrated by his limitations.

As I walked out the door to grab the pre-operative letter describing the details of the fusion, he quietly said, “My son just died a few months ago.” I immediately turned around and sat down with him. His son had passed away from a massive heart attack. I let him know how sorry I was about his loss, and I also told him that I was not comfortable with him making a quick decision on surgery in light of such a situation. He agreed. I gave him the pre-op letter, a book I’d written on chronic pain, and asked him to return in a couple of weeks. A week later, he called and told me that he really wasn’t interested in reading the book and just wanted to proceed with surgery. Though I asked him one more time to glance through it, I signed him up for surgery.

When the patient came in with his wife to sign the pre-operative appointment, I wanted to be sure that we were on the same page regarding his understanding of the procedure and my grasp of the severity of his pain. What he said surprised me: He told me that he was feeling better, that he had read some parts of the book, and that he had come to believe he needed to work through some feelings about his son’s death. We had a long conversation about the effect this degree of trauma can cause, and he asked me if it was okay with me if he delayed his surgery for a while.

A month later, I saw him again, and he reported having no pain in his back or down his leg. He was fully active and had just rejoined a gym. I asked him what had been the most helpful strategy in resolving his pain. He told me it was awareness. Understanding the links between anxiety, anger, trauma, and pain had helped him make sense of the different emotions he was trying to process. As a result, he had begun talking to his friends about his loss, and they were offering support. His whole demeanor had changed. In fact, he was now more concerned about how the situation was affecting his wife.

Having done spine surgery for so many years, I often convince myself that I can detect patients with anxiety and depression in my clinic. I’d say that we physicians almost uniformly feel that we can spot emotional distress in our patients. Yet research shows that no matter how long we’ve been practicing, we are correct in this regard only 25 to 43 percent of the time. The fact that my patient had to expressly tell me that he was experiencing distress reminded me that I have more blind spots than I realize.

Yet knowing what our patients are experiencing emotionally can be essential: Researchers have published hundreds of papers documenting the connection between pain and anxiety or depression. “Neurons that fire together, wire together,” the saying goes. The areas of the brain that interpret physical and emotional distress are located in close proximity to each other, and I have indeed noticed that as long as the anxiety and anger pathways are hyperactive, there is a high probability that the associated pain pathways will remain so as well.

While these factors are not routinely addressed, the contrast between the patients who have begun to deal with existing stress or grief and those who have not is frequently dramatic. When health care involves the whole person — body and mind — outcomes tend to be better and more consistent. The story I described is far from the only time I have seen a person become pain-free even in the presence of a significant structural problem. And among those patients who do require surgery, the procedures tend to result in less post-op pain, better mood, and easier rehab. Stories and outcomes like these are my motivation to continue to listen closely to every patient, at every opportunity.

David Hanscom is an orthopedic surgeon and can be reached at Back in Control.  He is the author of Back in Control: A Spine Surgeon’s Roadmap out of Chronic Pain.  He blogs at The Doctor Blog.

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