Pain catastrophizing may predict decreased outcomes for adolescent idiopathic scoliosis
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Published results showed pain catastrophizing may predict greater self-reported pain and lower scores on other self-reported outcomes 2 years after posterior spinal fusion for adolescent idiopathic scoliosis.
“Pain catastrophizing has a reasonably high prevalence in our [adolescent idiopathic scoliosis] patient population (1:10 kids), so surgeons will undoubtedly encounter these patients, and their postoperative outcomes will be affected by it in two interesting ways,” Brandon A. Ramo, MD, of Scottish Rite for Children, told Healio. “The patients who are pain catastrophizers will continue to have lower [health-related quality of life] HRQoL scores than their peers after surgery because they started that way preoperatively, but they will have greater improvements in their scores. So, they are an interesting population: more likely to come back and complain of persistent pain or less optimal outcomes, but better than where they started.”
Ramo and colleagues compared patients with adolescent idiopathic scoliosis undergoing posterior spinal fusion who experienced clinically relevant pain catastrophizing with a group of patients with normal pain catastrophizing scale scores. Researchers defined clinically relevant pain catastrophizing as a pain catastrophizing scale for children score in the 75th percentile or higher. Researchers correlated preoperative and 2-year postoperative Scoliosis Research Society Questionnaire-30 scores with the preoperative pain catastrophizing scale score.
Among the 189 patients who underwent posterior spinal fusion for adolescent idiopathic scoliosis, researchers considered 10.6% to be experiencing pain catastrophizing. Results showed an association between pain catastrophizing and significantly lower preoperative scores in all SRS-30 domains, including pain, appearance, activity, mental health and total score, except satisfaction, compared with the normal pain catastrophizing scale score group, despite comparable demographic and radiographic variables. Researchers found patients in the pain catastrophizing group had significant improvements from preoperative scores in most SRS-30 domains at 2 years, including a large clinically relevant improvement in pain and total score. However, researchers noted patients in the pain catastrophizing group continued to have lower scores for pain and total score compared with the normal pain catastrophizing scale group. According to receiver operating characteristic curve analysis, an SRS-30 pain score of less than 3.5 had good sensitivity for predicting pain catastrophizing.
“With growing capabilities of [electronic medical records], I would love to see more of us start to use these HRQoLs not just to look backward from a research standpoint, but to look forward clinically, using them in an algorithmic way to identify these at-risk patients,” Ramo said. “We could then perhaps develop preoperative treatment algorithms to address things like pain catastrophizing (but also anxiety, depression, opiate addition, etc.) or other psychosocial variables, which we know affect our outcomes but that we have been unable to easily influence in the past, before we go down the surgical road with our patients.”
Perspective
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Using the pain catastrophizing scale, the authors objectively identify patients whose coping mechanisms may be an obstacle to the positive outcomes we want them to achieve. Other studies have examined the surgeon’s ability to identify patients who scored high on the pain catastrophizing scale and found that only about half of them were initially recognized.
This study demonstrates that the pain catastrophizing scale is an important tool that can be used to find these patients, but, perhaps more importantly, they have established a correlation between the pain catastrophizing scale and the more frequently used SRS-30. The SRS-30 pain domain can be used for screening with a score of less than 3.5 having good sensitivity to detect those at risk of pain catastrophizing. Finding this preoperatively allows for intervention and, hopefully, improvement in the perioperative and postoperative course for these patients. Fortunately, this paper also demonstrates that pain catastrophizing patients make significant functional gains with treatment of their scoliosis. Nevertheless, despite their improvement, they narrow, but do not close, the gap between the pain catastrophizing and non-pain catastrophizing groups. To try to address this, many centers (including our own) are utilizing our psychology colleagues in both the clinic and inpatient setting to help patients develop more positive coping skills. Additional study is needed to see if this does, in fact, allow patients who pain catastrophize to achieve outcomes at an equivalent level to their peers.
It is also important to remember that “idiopathic” is a diagnosis of exclusion. In scoliosis cases in which pain is severe or atypical, the first step is additional workup, typically with an MRI, to assess for other organic causes of these symptoms prior to concluding the patient is pain catastrophizing.
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