Imagine two different scenarios. Patient being prepared for lumbar discectomy and has been prepared by his physician. The patient has good family support with a satisfying occupation. He also enjoys outdoor activities but is frustrated of the pain and disability imposed by the herniated disc. Patient has not been depressed in the past and is looking forward to recover and return to a full functional life. He undergoes surgery (discectomy) and is sent home to recover. One week later he looks forward to returning to work. To begin his outdoor and sport activities, he begins a physical therapy program and within one month is able to play golf. Undoubtedly his healthy mental status contributed a great deal to his healing process. His motivation to improve leads to full participation in physical therapy. He also reached to his family for support and was looking forward for return to socializing with family and friends. The second scenario involves the same medical condition in a patient that has a history of depression and also frustrated by his condition. However, the patient works in a stressful office and is in constant battle with his employer. The patient is also overweight since he does not participate in any sport activities. His spine condition also provides him a mean to get attention from other family members and get special treatment at work. This patient too undergoes an operation to remove the herniated disc failure of conservative treatment. He wishes to stay in the hospital since he has no family support and is anxious to be home alone because he does not trust in himself. He is discharged home after two or three days. The patient requests to stay off work for a few months since his job is not satisfying secondly he is getting paid while lying at home. He does not realize that his absence from work is de-conditioning his body and lowers his endurance. He also continues down the path of depression which lowers his motivation in physical therapy. He further gains weight and gets more depressed. The cycle continues and his mental status keeps his back pain in place.
Very often we get surprised by patients that recover very quickly from very large operative procedures. We compare these patients to others and the only difference is their mental status, attitude, and motivation. Undoubtedly, metal well being contributes to faster recover with better results. The mechanism that this works is still unknown, but it is without question that worst results are seen in depressed patients, people unhappy with their work, lack of family support, sedentary life styles, and lack of motivation.
The role of education regarding the disease process and treatment options resolves a great deal of anxiety. It gives some control back to the patient elevating confidence and reducing the feelings of frustration. Realistic goal setting is of utmost importance since it places the patient on a track to improvement and eliminates guess work. Depressive episodes that may ensue from lack of hope may resolve by these realistic goal settings and may actually prove to make the difference between a motivated patient or the one that is waiting for a miracle.
Some physical phenomenon exist that may explain these differences. The effect of stress has been shown to change chemicals in our body. This is commonly seen in cardiac patients. For example, studies show a longer survival rate for patients undergoing cardiac bypass surgery if they are married with good family support. We know that stress causes the release of cortisone and epinephrine from our bodies. The release of this chemical has many effects which are actually beneficial in a fight or flight situation. Short term release of this chemical is beneficial activates our bodies with higher heart rate and other protective mechanisms. However, it also reduces the immune response, increases blood pressure, increases muscle tension, and reduces blood flow to certain internal organs. The reduction in the immune response also slows down the healing process which is of utmost importance. The lack of motivation and depression is another factor. Depression produces a great deal of anxiety in patients and may indirectly stimulate stress.
Endogenous Endorphins are also important to include in this section. Endorphins are natural chemicals released from our bodies. These chemicals are very similar to Morphine which gives us a wonderful feeling with mood elevation and reduction of perceived pain. Not all aspects of endorphins are understood, but scientists have found that its production and release can be modified by our activities. Exercise can greatly stimulate its release and is commonly refers to “runners high”. Conversely, patients with depression have decreased release of this chemical. This chemical may also expedite the healing process which may explain why some patients have faster healing than others.
The subject of pain management should be discussed since it applies to all of our patients. Evolutionary, pain is a protective mechanism to inform us of some injury or a problem. Some children are born with a congenital defect in which they do not feel pain. This is a disastrous situation since they may have many injuries without caring about them. So with that thought, pain is a protective mechanism. However when pain is not controlled it stimulates stress and slows down healing. Pain may also cause depression and the cycle starts from there. Pain control in patients after an operation is a major concern to the spine surgeon. Continued pain can be very frustrating and demoralizing. In fact, a sub-specialty in the field of anesthesiology is pain management. This subject is so important that we need specialist in this subject to control it. You spine surgeon will go through great length to ensure adequate pain control, before and after an operation. The device called Patient Controlled Anesthesia (PCA pump) pump is a great invention since it puts the patient in control of dispensing the pain medication. It is first programmed by the anesthesiologist. The pump delivers a continuous amount of medication through an IV but also allows the delivery of bolus medications when the patient pushes a button. The machine also keeps track of the usage which helps the physician to increase or decrease the deliver of medication.
Patients will be prepared psychologically for any surgical procedure. This preparation will mainly consist of information to educate the patient regarding the proposed procedure, recovery period, and realistic goals. The results will include: less distress and anxiety, decreased complications due to better compliance, expedite return to functional lifestyle, and shorter hospital stay. We encourage the patients to take responsibility for their recovery by following instructions and showing motivation. Traditionally the art of spine surgery has been looked as a mechanical event to change anatomy while ignoring the patient and its psychological needs. Hopefully, new research and the emphasis of old research will change this trend leading to happier and healthier patient with better operative outcome.
