Dr. Andrew Block, a clinical psychologist at Texas Back Institute shares his commentary on the psychology of spine surgery.  This was recently featured in Spinal News International.

Spine surgery is under attack in the popular media. For example, a recent issue of Consumer Reports identified spine surgery as number 1 in their list of “overused medical tests and treatments”.  Indeed, several studies point to the limitations of spine surgery, such as that by Sherman, et al., (2010) who found unfavorable outcomes within 18 months of lumbar discectomy for 28% of patients.  However, other facts strongly contradict a pessimistic view of spine surgery.  Malter and colleagues (1996), for example, found laminectomy/discectomy patients had significantly greater quality of life at 5 years post-operation than did patients provided conservative care alone, with similar results for spinal fusion reported by Fritzell, et al., (2001). Thus, despite the negative press, it is clear that, for many patients spine surgery is an effective means of returning to a normal, healthy and happy lifestyle.

Why, then, does spine surgery go wrong?  A growing body of research suggests that one answer lies in patient selection, for psychosocial factors are increasingly being recognized as critical influences on the outcome of spine surgery.  Early work by Wiltse & Rocchio (1975), and Spengler et al. (1990), for example, demonstrated that patients who have excessive pain sensitivity, as assessed by the Minnesota Multiphasic Personality Inventory (MMPI), tend to have poorer surgical outcomes than patients whose pain perception more accurately reflects their underlying condition. Other emotional factors, such as depression, anxiety and anger can also exert strong adverse influences on surgical outcome.  Financial incentives, too, can militate against improvement, with patients receiving workers compensation or  involved in litigation tending to obtain poorer results.  Further reducing outcome can be issues such as a histories of physical or sexual abuse,  psychiatric treatment, and substance abuse.

Over twenty years of research by our group at Texas Back Institute, as well as research by others, has shown that when patients have a large number of such psychosocial risk factors, the chances of improvement from spine surgery are slim, even when there are clear clinical indications for surgery.  We have developed an algorithm as part of our process for presurgical psychological screening (PPS), which weights psychosocial risk factors and combines them to stratify patients into high, medium and low risk for reduced spine surgery results.  We find about 85% of  those in the high risk category obtain poor surgical results, whereas only about 20% of those in the low risk category are unsuccessful (Block et al, 2001; Block & Sarwer, 2013).

At Texas Back Institute, we now include PPS as part of the surgical work-up, and find that it can improve outcomes in two ways.  First, many psychosocial risk factors, such as depression, anxiety and active substance abuse, can be ameliorated prior to surgery. Thus, the patient is more emotionally stable going into surgery, and the odds of obtaining good results are increased.  Second, for those patients who have overwhelming psychopathology, or situations that would be unresponsive to psychotherapeutic intervention, surgery can be avoided in favor of more conservative treatments, such as multidisciplinary chronic pain programs.  By avoiding surgery for such psychologically recalcitrant patients, the surgeon’s overall success rate improves, and the true effectiveness of spine surgery is revealed.

The popular media attacks on spine surgery are based on research demonstrating both limitations in its effectiveness and reports that some patients go on to further surgeries or other aggressive treatments.  When surgeons recognize the value PPS brings to the diagnostic process, they can provide the most-effective, individualized treatment for the patient, and improve spine surgery outcomes.  Spine surgery, then, will again be recognized as a powerful tool for healing rather than a treatment to be avoided.


Sherman, et al., (2010). The Spine Journal 2010; 10: 108-116.

Malter et al.,  Journal of Spine 1996; 21:1048-1054.

Fritzell et al., Spine 2001; 26:2521-2532.

Wiltse & Rocchio. J Bone Joint Surg (Am) 1975;75:478–483.

Spengler et al. J Bone Joint Surg (Am) 1990;12: 230-237.

Block et al., The Spine Journal, 2001;1:274-282.

Block & Sarwer (Eds.) Presurgical Psychological Screening, 2013, APA Books

Spine Health Day

October 16, 2012

Happy Spine Health Day!

October 16th is Spine Health Day and in honor of such an important day here at Texas Back Institute here are 5 tips for maintaining a healthy spine (in no particular order) from Dr. Rey Bosita.

1. Maintain a healthy body weight.

Being overweight, especially belly fat, can put additional stress on your muscles, ligaments and tendons in your lower back.

2. Quit smoking.

Smoking can increase the risk of many life threatening illnesses. Smoking can impair blood flow to many parts of the body including the back which in turn slows down the healing process.

3. Work on your core. 

Core muscles help support the low back and pelvis.  Strengthening these muscles will help increase your spinal stability as well as reduce your risk of injury.

4. Get enough sleep. 

Sleep is essential to your overall health but it also plays an important role in maintaining a healthy spine.

5. Pay attention to any warning signs.

 It is important to listen to your body. It can be common to experience back pain once in a while, however, sometimes it can be an indication of a more serious problem. Consult with your physician to determine what is causing your pain. The best time to act is before a problem starts when there is no pain.

What are some of the things you do to maintain a healthy spine?

Congratulations to Dr. Hochschuler and Dr. Lieberman!

Becker’s Spine Review recently released the “61 Spine Surgeon Inventors to Know,” which includes Dr. Stephen Hochschuler and Dr. Isador Lieberman of Texas Back Institute.  Members of the list were selected for their research and innovation contributing to the development of spine surgical devices and techniques.

The list was created as a result of extensive research. Surgeons included on the list were trained at top medical schools and have worked with some of the biggest device companies to bring their ideas to the market. In many cases, their contributions have made a difference in the quality and cost-effectiveness of spinal procedures. Many of them are also leaders within their practices, hospital departments or professional organizations.

Here is what was written on the Becker’s website.

Stephen Hochschuler, MD (Texas Back Institute, Plano). Dr. Hochschuler is the co-founder of Texas Back Institute and chairman of Texas Back Institute Holdings. He has several patents for spinal stabilization devices and co-founder of Innovative Spinal Technologies. During his career, Dr. Hochschuler has served on the scientific advisory board of physicians for Alphatec Spine and business advisory board for DePuy Spine. He was co-founder of the Spine Arthroplasty Society, now known as the International Society for the Advancement of Spine Surgery, and has participated in several FDA trials. Dr. Hochschuler earned his medical degree at Harvard Medical School in Boston and completed his residency in orthopedic surgery at the University of Texas Southwestern Medical School in Dallas.

Isador Lieberman, MD (Texas Back Institute, Plano). Dr. Lieberman holds multiple patents for his technological innovations, including SpineAssist, a robotic tool he recently co-developed for use during minimally invasive spine surgery. He has held appointments with Cleveland Clinic as staff surgeon and professor of surgery at Cleveland Clinic Lerner College of Medicine. His developments have been recognized with awards from Cleveland Clinic and the Spine Society of Europe. He recently co-founded the Uganda Charitable Spine Surgeon Mission, with which he accompanies a team of surgeons to visit Uganda each year to treat the underprivileged with spine conditions. He earned his medical degree from the University of Toronto in Ontario, Canada, and completed his residency at Mount Sinai Hospital in Toronto. He also completed residency programs in orthopedic surgery at two Toronto hospitals along with a clinical fellowship in spine and trauma surgery at The Toronto Hospital.

Physicians do not pay and cannot pay to be selected for this list.

*Becker’s Spine Review is a Chicago-based publication focusing on spine and pain practice management. The primary contributors and audience for the publication are spine surgeons and industry experts.

Professional bass fisherman, Ryan Lovelace gets back to fishing

As a professional bass fisherman, Ryan’s pain was exacerbated by his participation in several fishing tournaments every year. In order to win or place in these professional bass fishing tournaments, the angler must catch as many bass as possible with the idea being that the final fish weight of his top 5 fish are compared to the other participants.

The fishing tournament typically lasts for two days and the more fish that are caught, the higher probability of getting 5 huge ones. This requires lots of casts. How many? “I typically cast 3,000 to 3,500 casts each day of a tournament,” Lovelace said.
Standing on his feet for about 8 hours and casting 3,000 times a day during a tournament took its toll on Ryan’s injured back. Over time, it wore down his L5 vertebra and Dr. Richard Guyer at Texas Back Institute recommended a microdiscectomy.
After this procedure was completed, Ryan spent less than 24 hours in the hospital for recovery and was sent home for rest and further rehabilitation. A short while after his operation, Ryan is getting back to his top fishing form. He hopes to be completely recovered and able to compete in the 2013 pro bass fishing season.

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