Approach to the Patient with Chronic Pain

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CHAPTER 156 Approach to the Patient with Chronic Pain

Joshua M. Rosenow

Evaluating a patient with chronic pain involves multiple considerations on the part of the physician. This chapter provides a brief overview of the initial evaluation of a patient with chronic pain in the neurosurgical clinic. This process may be time-consuming given the numerous previous medical and surgical interventions that these patients have often endured. Moreover, these previous treatment failures place a higher burden on the physician treating a patient with chronic pain. The patient has been frustrated by previous treatment failures and does not want this pattern to continue. Moreover, the expectation remains that treatment should be able to completely cure the patient’s pain. These factors should be taken into account, not just in terms of setting realistic expectations with the patient but also in determining a treatment plan.

Before Arrival

Chronic pain patients are often referred by their primary physician, another pain physician, or another neurosurgeon. To assist in establishing a focus for the referral, it is often helpful to ask the patient to obtain a referral letter from the physician. This provides a baseline from which to begin discussion of the patient’s problem. Furthermore, it also establishes a line of communication with the other physician, which is crucial for several reasons. First, the referring physician is often the primary physician and therefore needs to be informed of the results of the consultation for overall coordination of care. Moreover, because a referral for evaluation does not guarantee that the evaluating physician will accept any part of the patient’s care, the referring physician needs to understand the reasoning behind the evaluation and any steps that can be taken for further treatment of the patient. Finally, this also serves as a conduit for obtaining the patient’s medical records.

Physicians should obtain as complete a record of previous treatments and outcomes as possible, especially operative reports, psychological reports, diagnostic testing (electromyography, diskography, and so on) reports, imaging studies and reports (before and after each surgical procedure), specialist consultations, physical therapy summaries, and relevant office notes. It is also helpful to know whether there have been applications for long-term worker’s compensation disability or social security disability.

The Initial Visit

At the initial visit it is of paramount importance to establish the parameters and goals for the encounter. Included in this visit is achieving an understanding of the patient’s goals not just for the initial encounter but for the physician-patient relationship as well. Patients need to understand the capabilities and limits of the relationship (which parts of care that the evaluating physician may or may not be willing to assume) to avoid later misunderstandings that can erode the patient’s trust in the physician. In addition, some patients have expectations that are unrealistic as part of any therapeutic relationship, and it is very useful to understand this at the outset. For example, relieving a substantial portion of the patient’s pain may be deemed an adequate result by the surgeon but be viewed by the patient as a failure. Additionally, even the definition in the mind of the patient and physician of what constitutes chronic pain may be substantially different.

The evaluating physician should approach these patients with an open mind, both to their specific initial pain complaints and to their underlying diagnosis in general. Chronic pain is different from acute pain because the name implies the failure of previous medical and surgical care. The patient should be informed that the chronic pain evaluation will include examining events in the patient’s care from the beginning of the problem. Most patients with chronic pain have undergone numerous evaluations, have explained their story ad nauseam, and may become disenchanted or angry at the thought of having to go through it again. They should be reassured that this is a key part of determining both why their previous treatments have not succeeded and whether there are any further surgical treatments that may provide them with their desired outcome. In addition, patients should understand that more than a single visit may be needed to fully evaluate the situation and determine a therapeutic course of action and that further diagnostic testing or other consultative evaluations, such as psychological testing, may also be required.

It is essential to try to determine the causes of previous treatment failures so that they will not be repeated with poor clinical and psychological outcomes for the patient. The failure of previous medical or surgical attempts to relieve pain may be due to failure of the treatment itself, but it might also be related to a variety of underlying psychosocial issues. Pain relief that is judged adequate by a previous physician may not have been helpful enough for the patient. Possible reasons for previous treatment failures are listed in Table 156-1.

TABLE 156-1 Possible Reasons for Previous Treatment Failure

During this visit the evaluating physician would also be wise to pay close attention to the patient’s mannerisms during history taking and physical examination. Determining the patient’s motivations for the visit and attitudes toward past and future treatments is crucial in formulating an impression of the patient’s past care and devising an appropriate plan that moves forward. Some patients are undergoing further evaluation only because they would like a new clinician to take over opioid prescribing for them after a falling out with their previous physician. Alternatively, some may be in the clinic only because they see this as the sole way to obtain disability benefits.

Careful note should be taken of the patient’s vocal mannerisms and the amount of eye contact made with the physician. These and other similar factors provide crucial clues to the patient’s psychological state, such as motivation, depression, and anxiety.

Still other patients are in the clinic only at the urging of their spouse or child. Consequently, it is also important to observe the family members who accompany the patient. Do they constantly interrupt and speak for the patient? Do they speak about their own difficulties that are the result of the patient’s pain syndrome more than about the pain syndrome itself? Some significant others can be enabling to the patient’s pain syndrome. Others may not grasp or simply be in denial regarding the true extent of the problem. It may be necessary to redirect the interview toward the patient during the interview while acknowledging the life stressors that all those around the patient experience because of the pain syndrome.

History

General Aspects

Although a thorough history is a de facto part of any initial patient encounter, the history obtained from a chronic pain patient must be even more probing because of the many twists and turns involved in the story. In evaluating patients with chronic pain, a detailed history may be substantially more helpful than imaging or other testing in making a diagnosis and formulating a treatment plan. The history provides important information not only about the possible mechanisms and pathophysiology of the patient’s pain but also about the emotional and psychological status of the patient. The physician and patient must both be tolerant during this process because the physician may ask numerous questions (both open ended and leading) to draw out the patient’s detailed history and the patient may go on for an extended period recounting past travails. It takes a skilled physician to guide these patients and help withdrawn, depressed, or fearful patients open up while guiding and focusing overly talkative or angry patients. Keeping these sometimes complex patient histories chronologically organized is a good way to stay on track.

Many chronic pain patients are taking significant amounts of multiple medications from different classes of drugs, each of which can cause cognitive slowing and clouding of memory. If these side effects are suspected of preventing accurate history taking, gradual reduction of some of this medication may be considered before an interview in the hope of somewhat clearing the patient’s sensorium.

What are the patient’s expectations, both for the initial visit and for care in general (both with the interviewing physician and overall)? This is an important factor to glean at the initial visit. If the patient simply wants to be certified as disabled or to have narcotic prescriptions refilled, this may not be an appropriate patient to accept into the practice. If the patient has already retained legal services, what is the purpose? Again, this is important for determining the patient’s motivations for care.

In obtaining the history it is especially useful for the physician to avoid leading or closed-ended questions. Although some direction to the history is important to prevent the history from spiraling off in unproductive paths, physicians should not box the patient in by injecting their preconceptions into the patient’s story. This is not an easy task for the neurosurgeon, especially in the middle of a packed clinic schedule. However, a history thus obtained will be a more complete and revealing one.

Pain History and Onset

It is helpful to first establish the characteristics of the current pain, including standard factors such as location, quality, radiation, duration, and exacerbating and alleviating factors. This provides much information about whether the pain may be classified as neuropathic or nociceptive. Once the current baseline is established, the pain may be analyzed in relation to the past history.

The relationship of the current pain to the original pain is a key factor. Does this pain represent a continuation or progression of an original pain complaint? If so, it may indicate that previous treatments were not applied properly or to their fullest extent, that the treatments were inappropriate, or that the previously applied diagnosis was incorrect. In this case, it is extremely useful to explore which past treatments were used and to what extent they were used, along with a detailed account of their effects on the pain. This enables the physician to determine whether some of these treatments should be repeated in some form.

If the current pain is substantially different from the original pain, it may imply that a different process may be responsible for the current pain or that the current pain is the result of a treatment side effect. Patients often undergo misguided treatments of pain syndromes, and such treatments can themselves cause further pain. As stated previously, procedural complications can also result in pain that is unlike the initial pain. The physician should be cautious of patients whose pain changes significantly in location and character after each treatment. A detailed listing of previous treatments can then possibly be used to exclude them as subsequent therapeutic options.

The circumstances surrounding the initial onset of the pain are important as well. It is important to note whether there was an obvious inciting incident associated with the pain and whether this mechanism is consistent with the patient’s original complaints. The location and distribution, quality, intensity or severity, and duration of the first pain should be ascertained. Detailed information should be elicited about the exact activities that the patient was performing at the time of pain onset. Did the pain immediately become disabling or was there a gradual buildup? Did the patient report the pain to anyone at the onset? Were there any other associated neurological symptoms (weakness, numbness, paresthesias, bladder/bowel changes) at the time and did any of them develop in subacute fashion? Did the patient notice any change in color, swelling, or other anatomic alteration of the injured region, either immediately or subsequently? Was any treatment applied immediately?

Pain that is the result of an activity on the job presents a special situation because of the issues surrounding worker’s compensation claims. This history needs to be even more fastidiously documented, including the exact time and date of the injury. Other information should be also obtained, such as whether the patient continued to work after the injury, when and to whom the injury was reported, and the response of the patient’s employer to the injury regarding the patient’s work status. The history in such cases should also probe the general demands of the patient’s job and the patient’s satisfaction with the job and whether any interpersonal tension exists at work.

Neuropathic pain syndromes, such as complex regional pain syndrome types 1 and 2, most often have an antecedent injury that sets the syndrome in motion. Trigeminal neuralgia is an exception to this generalization because it frequently has a spontaneous onset. Nociceptive pain, such as degenerative spondylitic pain, may not have a single defined inciting incident but instead may be slowly progressive over time. The physician should be wary of patients whose pain syndrome does not seem compatible with the mechanism of onset. This should prompt further questions regarding other work and life events that may have contributed to the pain syndrome.

The physician should also ascertain the impact of the pain on the patient’s daily life. This is accomplished by asking the patient to provide a timeline of an average day. This portion of the history should include the times of awakening, bedtime, and any naps. General activities during the waking hours of day should be described, including how much time the patient spends at each and the effect of each (if any) on the patient’s pain level. This is intended to give the physician an impression of the tolerance of the patient for standing, sitting, and other activities. Moreover, it serves as an important window for the physician into the psychological effects of the pain on the patient’s life and the level of disability that the patient is experiencing.

Pain Characteristics

In giving a history about the current pain complaint, the patient should be asked to describe in detail the current quality, site, radiation, severity, and alleviating/exacerbating characteristics of the pain at the time of evaluation and to indicate whether any of these factors has changed since the onset or during the interval. Factors that have no effect on the pain are important as well. Such factors include stress and other emotional disturbances, movement, pressure, heat or cold, coughing, sneezing, straining, and deep breathing. Although the visual analog scale (VAS) is far from a perfect method of measuring a patient’s pain level, it is one of the most commonly accepted scales. This VAS commonly ranges from “no pain” (0) to “the worst pain imaginable” (10). Rather than asking the patient for integer ratings, it is better to provide a sheet of paper with four 10-cm lines and the ends of these lines labeled with the 0 and 10 descriptions just mentioned. The four lines are for the patient to record not just a momentary VAS rating but also an average rating over the past 30 days and the best and worst pain ratings. Physicians should be wary of patients whose pain either never varies from 10 or is rated as “11” on a scale of 0 to 10. These patients may have a nonanatomic cause of their pain.

In eliciting a description of the pain, the physician should be able to classify the pain as localized, radiating, or referred. Localized pain continues at the same location as its origination. This pain may be associated with other anatomic and sensory changes at the site of the pain, such as hyperalgesia, wind-up hyperpathia, and color and trophic changes of the skin. Pain may also be described as radiating along the distribution of a nerve root’s dermatome or the innervation of a peripheral nerve. This pain is distinct from that referred from a deep visceral structure to a separate distinct anatomic location. Classic examples are back pain or superficial abdominal pain from chronic pancreatitis and scapular pain from cholecystitis.

The quality of the pain is tied to this in that pain attributable to a superficial cause is often sharp and well localized whereas referred pain from deep somatic or visceral disease is dull, diffuse, and poorly localizable. The quality of the pain may also be assessed in terms of the length of the painful episodes, as well as factors that exacerbate and alleviate the pain. For instance, the pain of type 1 trigeminal neuralgia will often be described as brief episodes of sharp, lancinating, or electrical pain with defined triggers (i.e., talking, eating, brushing teeth), whereas trigeminal neuropathic pain may consist of constant aching, burning pain with different exacerbating factors. Some of these factors may include activity level, positioning, the time of day, weather conditions (either current or forthcoming), life stressors, and environmental factors.

Pain Treatment History

As stated previously, it is best to keep the patient’s past history organized chronologically for simplicity. Once the origin and characteristics of the pain have been fleshed out in the clinical interview, the patient can then be guided through a recounting of past medical and interventional treatments and the response to each. This is an invaluable part of the evaluation of a patient with chronic pain. Thorough analysis of this part of the history prevents the clinician from repeating past mistakes or retreading trodden ground. Which classes of medications have been tried? Were the medication trials adequate? Were interventional techniques used appropriately? Did each subsequent treatment follow logically based on past information? Moreover, this history helps ascertain patient compliance and assess for causes of past treatment failures. The clinician needs to take a very critical view of this section of the history and always ask why treatments failed and whether there is anything else for the neurosurgeon to offer the patient.

Past Medical and Surgical History

The past medical and surgical history is especially important in the evaluation of a patient with chronic pain to determine the reasons for previous treatment failures and formulate a treatment plan going forward.

The most fundamental part of this part of this history is an evaluation of the patient’s general health. Concomitant medical conditions can have an adverse impact on both medical and surgical treatments. Factors such as obesity, diabetes, hypertension, hypothyroidism, chronic obstructive pulmonary disease, and inflammatory arthritis are common, and each has the ability to complicate therapy. Patients will frequently omit conditions that they do not consider important or will omit conditions that they consider treated. For example, it is not uncommon to have patients not state that they have a history of hypertension only to have them say so on direct questioning about the disease “I don’t have that because it’s treated with medication.” For this reason it is important to inquire directly about some of these more common ailments after the patient finishes giving a list. For completeness, the inquiry should proceed through a comprehensive list of organ systems.

The patient’s surgical history (if any) surrounding the pain condition should have been covered during the general visit history. However, a comprehensive list of the patient’s other previous surgical procedures is useful as well.

One important subtext of gathering the patient’s past medical and surgical history is to assess responses to past treatments across multiple disorders and determine the patient’s compliance with physician instructions. If the patient has failed multiple surgical procedures for the pain syndrome, were there also surgical failures for other conditions as well? If so, is this due to an intrinsic patient medical factor, poor surgical techniques, unrealistic expectations, the patient seeking unnecessary surgical treatments, or just poor luck? Does the patient appear to be compliant with physician instructions for the other ailments? Answers to these questions are valuable in determining a future path for the patient.

Family History

At its most basic level, this portion of the interview entails gathering information about the health status of the patient’s first-degree relatives because important patterns may be gleaned from this history. For example, if multiple family members have required spine surgery, this could be due to many factors. Are they all employed in high-impact professions? Is there is family tendency toward spinal degeneration or stenosis? Are multiple family members receiving disability insurance? Chronic pain behavior may be a learned trait within families.¹ A history of child abuse may also increase pain behavior.¹^–⁴

Social and Psychological History

A complete psychological and psychosocial assessment is crucial for the overall management of a patient with chronic pain. This has been very well covered in other sources.⁵^–⁹ The psychological and psychosocial part of the history helps determine the contribution of affective or environmental factors to the patient’s pain syndrome. Referral to a psychologist with special expertise in the evaluation and treatment of patients with chronic pain is an essential part of the overall care of these patients.

At the minimum for the neurosurgical visit, this part of the history should include a listing of current and previous psychological and psychiatric illnesses. Special attention should be paid to depression, a common condition in patients with chronic pain. An astute neurosurgeon will delve deeper into this issue than simply inquiring about the patient’s mood. As stated earlier in this chapter, asking patients about their daily routine can provide significant information about their level of depression. Other clues are irritability, insomnia, abulia, weight gain or loss, and suicidal ideation. The patient’s family may be able to provide important perspective on this.

The neurosurgeon should also explore the patient’s vocational status and vocational stressors, including compensation-litigation issues. Such issues can affect the patient’s motivation and outcome of treatment.¹⁰^–¹³

The history of drug use is important from both a medical and psychological perspective. Although the history should include current prescription drugs, an appropriately thorough history should also include over-the-counter and alternative (e.g., herbal) medicines. Illicit pharmaceutical use (both current and past) should be elicited by direct questioning, even specifically asking about the most commonly used or abused pharmaceuticals. It may also be useful to ask whether the patient has ever used another person’s prescription medication for personal use because such a pattern may be counterproductive to treating the patient. A history of tobacco smoking and alcohol use, including the type and frequency of use of each, should be included as well. Physical and psychological dependence on drugs is relatively common in those in the chronic pain population, and alcohol dependence is a major problem.

It may be helpful to conceptualize the patient’s pain syndrome into components of pain and suffering. The pain is the purely physical and physiologic component of the patient’s syndrome, whereas suffering encompasses much more. Suffering includes the person’s individual reaction to the pain, as well the pain’s effect on the rest of the person’s psychological and emotional environment. For instance, suffering includes such considerations as depression, anxiety, loss of self-esteem, failed relationships, past emotional and physical abuses that shape the pain response, poor coping strategies, and withdrawal from friends and family. Surgical interventions may be an excellent method for dealing with the pain, but they will frequently be insufficient to remedy an overly prominent suffering component. A skilled pain psychologist may be useful to identify the balance between the pain and suffering components in the patient’s pain syndrome, as well as any maladaptive coping strategies and other pitfalls of which the surgeon should be aware before embarking on a therapeutic relationship with the patient.

It is crucial to remember the complex interplay that exists between psychological and physical factors in the patient’s overall pain syndrome. Although it is true that there is a small population of individuals entirely without a physical basis for their pain complaints,¹⁴ the majority of patients with chronic pain have both psychological and physical components in varying proportions. Among the neurosurgeon’s challenges in evaluating and managing patients with chronic pain are first determining the relative balance between these factors and then using that estimation to drive the selection of an individualized combination of medical, interventional, surgical, and psychological treatments for each patient.

Physical and Neurological Examination

Examination of a patient with chronic pain is essentially no different from that of a patient undergoing any other type of neurosurgical evaluation. However, it is important to observe for certain signs on the examination.

Most importantly, aside from any signs specifically present in chronic pain states, the neurosurgeon must still look for signs, such as weakness and exaggerated pathologic reflexes, that may indicate conditions that could warrant urgent further evaluation or treatment, such as nerve root or spinal cord compression. These findings should not be discounted or neglected just because the patient may have already seen other physicians or have had other surgical procedures.

The central sensitization that occurs in many patients with chronic pain can result in certain characteristic examination findings. Central sensitization affects the wide-dynamic-range neurons in the dorsal horn of the spinal cord that receive input from both Aβ and C fibers. In neuropathic pain states, Aβ-fiber depolarization also results in stimulation of these other fibers and gives rise to allodynia, or the perception of pain from light touch. Patients with chronic pain may also exhibit generalized hyperpathia, or exaggerated and prolonged reactions to painful stimuli. For example, a patient with generalized hyperpathia may report that a pin prick is intensely painful over the entire body. Repetitive stimulation of C fibers may result in an augmented response to each subsequent stimulus, a process known as wind-up. Repetitive light stroking of the painful area is interpreted by the patient as increasingly painful with each iteration.

Finally, red flags on examination should engender skepticism in the examiner. These may include Waddell’s signs ¹⁵^–¹⁷ for nonphysiologic back pain and other inconsistencies on physical and neurological examination. For instance, does a patient with apparent ankle dorsiflexor weakness when tested while seated have the ability to heel-walk without much difficulty? Do the findings fail to conform to a peripheral or spinal nerve distribution?

Formulating a Treatment Plan

A patient with chronic pain will require an individualized treatment plan. In formulating this plan for each patient, several considerations are worth mentioning.

First, who should be included in the patient’s treatment team? These individuals should be able to work in a cohesive manner and present a united front to the patient. Representative members of a pain team are listed in Table 156-2. The clinicians involved should have clear and open lines of communication among them. The best method for achieving this is during a regularly scheduled patient management meeting attended by the pain team. This meeting allows each patient to be discussed freely by the team. In this manner a team consensus is reached and may then be discussed with the patient and family.

TABLE 156-2 Members of a Pain Team

Next, in defining a plan with the patient it is important to outline the plan with as much specificity as possible and then stick to it. The plan should have steps included for dealing with medication-related side effects and procedural failures. In this manner the patient has a clear understanding of what steps will be undertaken and in what order. Moreover, the patient understands what the expected outcomes are for each step and what will be done if the actual outcome does not meet the expected outcome at each step. Part of outlining this plan may include signing of a treatment contract on the part of the patient and clinician.¹⁸^–²⁰ If a contract is signed, the patient should have a copy to keep, in addition to the copy maintained in the patient’s medical record. Contracts should be written in clear and concise language that denotes the obligations of both parties, as well as the consequences for violations of the contract. After the initial evaluation, referrals may be made for additional diagnostic testing or specialist evaluation.

Setting expectations of treatment is a crucial part of the treatment of a patient with chronic pain. Frequently, the patient’s expectations have not been met by past medical and surgical treatments either because the treatments have not delivered expected results or because the patient’s expectations were not realistic. Substantial time should be spent discussing realistic outcomes from each step in care, as well as from the overall plan of care. For instance, it may or may not be realistic for patients to return to the same line of work after treatment, but it is critical to understand whether patients believe that they should do so. The clinician’s and patient’s ideas of a “good” outcome may be divergent.

Goal and expectation setting should include lifestyle modification as needed. Smoking and obesity are negative determinants of outcome,²¹^–²³ and the patient’s willingness to work on resolving these problems is a good determinant of the patient’s level of motivation. Return visits may need to be scheduled to evaluate progress on certain goals or to discuss consultation or imaging results before the physician agrees to embark on a therapeutic relationship.

Some patients may not be accepted for care. A true pain team is not just a dumping ground for all patients whom other specialists do not want to manage. Patients with a significant ongoing pattern of pharmaceutical misuse, whether legal or illegal, need to first have these issues resolved. Moreover, severe overwhelming emotional and psychological problems also need to be brought under control, especially before nonurgent surgical procedures.

Suggested Readings

Burns JW, Sherman ML, Devine J, et al. Association between workers’ compensation and outcome following multidisciplinary treatment for chronic pain: roles of mediators and moderators. Clin J Pain. 1995;11:94-102.

Craig KD. Social modeling influences: pain in context. In: Sternbach RA, editor. Psychology of Pain. 2nd ed. New York: Raven; 1986:67-95.

Doleys DM. Psychological factors in spinal cord stimulation therapy: brief review and discussion. Neurosurg Focus. 2006;21(6):E1.

Doleys DM. Psychologic evaluation for patients undergoing neuroaugmentative procedures. Neurosurg Clin N Am. 2003;14:409-417.

Doleys DM, Dinoff BL. Psychological aspects of interventional therapy. Anesthesiol Clin North Am. 2003;21:767-783.

Doleys DM, Rickman L. Other benefits of an opioid “agreement.”. J Pain Symptom Manage. 2003;25:402-403.

Fishman SM, Kreis PG. The opioid contract. Clin J Pain. 2002;18:S70-S75.

Fishman SM, Mahajan G, Jung SW, et al. The trilateral opioid contract. Bridging the pain clinic and the primary care physician through the opioid contract. J Pain Symptom Manage. 2002;24:335-344.

Jamison RN, Stetson BA, Parris WC. The relationship between cigarette smoking and chronic low back pain. Addict Behav. 1991;16:103-110.

Klekamp J, McCarty E, Spengler DM. Results of elective lumbar discectomy for patients involved in the workers’ compensation system. J Spinal Disord. 1998;11:277-282.

Koss MP, Heslet L. Somatic consequences of violence against women. Arch Fam Med. 1992;1:53-59.

LaCaille RA, DeBerard MS, LaCaille LJ, et al. Obesity and litigation predict workers’ compensation costs associated with interbody cage lumbar fusion. Spine J. 2007;7:266-272.

Lampe A, Solder E, Ennemoser A, et al. Chronic pelvic pain and previous sexual abuse. Obstet Gynecol. 2000;96:929-933.

Patel N, Bagan B, Vadera S, et al. Obesity and spine surgery: relation to perioperative complications. J Neurosurg Spine. 2007;6:291-297.

Seres G, Kovacs Z, Kovacs A, et al. Different associations of health related quality of life with pain, psychological distress and coping strategies in patients with irritable bowel syndrome and inflammatory bowel disorder. J Clin Psychol Med Settings. 2008;15:287-295.

Sullivan MD, Turk DC. Psychiatric illness, depression, and psychogenic pain. In: Loeser JD, editor. Bonica’s Management of Pain. Philadelphia: Lippincott Williams & Wilkins, 2001.

Turner JA, Romano JM. Psychological and psychosocial evaluation. In: Loeser JD, editor. Bonica’s Management of Pain. Philadelphia: Lippincott Williams & Wilkins, 2001.

Vaccaro AR, Ring D, Scuderi G, et al. Predictors of outcome in patients with chronic back pain and low-grade spondylolisthesis. Spine. 1997;22:2030-2034.

Vogt MT, Hanscom B, Lauerman WC, et al. Influence of smoking on the health status of spinal patients: the National Spine Network database. Spine. 2002;27:313-319.

Waddell G, Bircher M, Finlayson D, et al. Symptoms and signs: physical disease or illness behaviour? Br Med J (Clin Res Ed). 1984;289:739-741.

Waddell G, McCulloch JA, Kummel E, et al. Nonorganic physical signs in low-back pain. Spine. 1980;5:117-125.

Waddell G, Pilowsky I, Bond MR. Clinical assessment and interpretation of abnormal illness behaviour in low back pain. Pain. 1989;39:41-53.

Walker EA, Stenchever MA. Sexual victimization and chronic pelvic pain. Obstet Gynecol Clin North Am. 1993;20:795-807.

1 Craig KD. Social modeling influences: pain in context. In: Sternbach RA, editor. Psychology of Pain. 2nd ed. New York: Raven; 1986:67-95.

2 Koss MP, Heslet L. Somatic consequences of violence against women. Arch Fam Med. 1992;1:53-59.

3 Lampe A, Solder E, Ennemoser A, et al. Chronic pelvic pain and previous sexual abuse. Obstet Gynecol. 2000;96:929-933.

4 Walker EA, Stenchever MA. Sexual victimization and chronic pelvic pain. Obstet Gynecol Clin North Am. 1993;20:795-807.

5 Doleys DM. Psychologic evaluation for patients undergoing neuroaugmentative procedures. Neurosurg Clin N Am. 2003;14:409-417.

6 Doleys DM. Psychological factors in spinal cord stimulation therapy: brief review and discussion. Neurosurg Focus. 2006;21(6):E1.

7 Doleys DM, Dinoff BL. Psychological aspects of interventional therapy. Anesthesiol Clin North Am. 2003;21:767-783.

8 Seres G, Kovacs Z, Kovacs A, et al. Different associations of health related quality of life with pain, psychological distress and coping strategies in patients with irritable bowel syndrome and inflammatory bowel disorder. J Clin Psychol Med Settings. 2008;15:287-295.

9 Turner JA, Romano JM. Psychological and psychosocial evaluation. In: Loeser JD, editor. Bonica’s Management of Pain. Philadelphia: Lippincott Williams & Wilkins, 2001.

10 Burns JW, Sherman ML, Devine J, et al. Association between workers’ compensation and outcome following multidisciplinary treatment for chronic pain: roles of mediators and moderators. Clin J Pain. 1995;11:94-102.

11 Klekamp J, McCarty E, Spengler DM. Results of elective lumbar discectomy for patients involved in the workers’ compensation system. J Spinal Disord. 1998;11:277-282.

12 LaCaille RA, DeBerard MS, LaCaille LJ, et al. Obesity and litigation predict workers’ compensation costs associated with interbody cage lumbar fusion. Spine J. 2007;7:266-272.

13 Vaccaro AR, Ring D, Scuderi G, et al. Predictors of outcome in patients with chronic back pain and low-grade spondylolisthesis. Spine. 1997;22:2030-2034.

14 Sullivan MD, Turk DC. Psychiatric illness, depression, and psychogenic pain. In: Loeser JD, editor. Bonica’s Management of Pain. Philadelphia: Lippincott Williams & Wilkins, 2001.

15 Waddell G, Bircher M, Finlayson D, et al. Symptoms and signs: physical disease or illness behaviour? Br Med J (Clin Res Ed). 1984;289:739-741.

16 Waddell G, McCulloch JA, Kummel E, et al. Nonorganic physical signs in low-back pain. Spine. 1980;5:117-125.

17 Waddell G, Pilowsky I, Bond MR. Clinical assessment and interpretation of abnormal illness behaviour in low back pain. Pain. 1989;39:41-53.

18 Doleys DM, Rickman L. Other benefits of an opioid “agreement.”. J Pain Symptom Manage. 2003;25:402-403.

19 Fishman SM, Kreis PG. The opioid contract. Clin J Pain. 2002;18:S70-S75.

20 Fishman SM, Mahajan G, Jung SW, et al. The trilateral opioid contract. Bridging the pain clinic and the primary care physician through the opioid contract. J Pain Symptom Manage. 2002;24:335-344.

21 Jamison RN, Stetson BA, Parris WC. The relationship between cigarette smoking and chronic low back pain. Addict Behav. 1991;16:103-110.

22 Patel N, Bagan B, Vadera S, et al. Obesity and spine surgery: relation to perioperative complications. J Neurosurg Spine. 2007;6:291-297.

23 Vogt MT, Hanscom B, Lauerman WC, et al. Influence of smoking on the health status of spinal patients: the National Spine Network database. Spine. 2002;27:313-319.

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