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Spine Surgery & Preoperative Psychological Assessments

Spine Surgery & Preoperative Psychological Assessments

The United States Preven-tive Services Task Force (USPSTF) recommends that pre-surgical psychological screening (PPS) be used in clinical practice to assure that a patient’s diagnosis is correct, to identify those at risk for poor outcomes, and to provide effective treatment and follow-up services. PPS involves referring patients—including those with chronic pain who are considering spine surgery—to a health psychologist for further evaluation. This usually involves a semi-structured interview and psychometric testing. Studies suggest that few adults with depression and anxiety seek care, but these conditions may play a role in disabling back pain and contribute to poor health outcomes. The USPSTF recommendations were developed in response to the realization that many psychological disorders go untreated. “These illnesses are often overlooked,” explains Richard L. Skolasky, ScD, “but they could pose serious risks to patients and may influence recovery.” Previous research has linked depression and anxiety to longer recuperation time, delayed returns to work, more postoperative complications, and failure to comply with medication schedules after discharge. Examining Use of PPS Little is known about how often PPS is used by spine surgeons or the factors that may affect its use. To address this research gap, Dr. Skolasky and colleagues conducted a study to estimate the prevalence of PPS use among spine surgeons in the U.S. The study, published in the Journal of Spinal Disorders and Techniques, also sought to identify factors associated with the use of PPS and evaluate spine surgeons’ opinions of PPS. The quality of patient care may improve by gaining a better understanding of the factors contributing to the use of PPS. For the analysis, an online survey...
A Conservative Approach to Lymph Node Removal

A Conservative Approach to Lymph Node Removal

Until recently, guidelines recommended complete axillary node dissection in women with breast cancer for whom their sentinel node biopsy was positive. However, patients who undergo this procedure routinely experience complications. The introduction of sentinel lymph node biopsy in the 1990s included the benefit of avoiding complete axillary node dissection if two or three sentinel nodes tested negative for cancer, thus reducing morbidity. However, complete axillary node dissection was still used in patients with positive sentinel nodes. The recently completed American College of Surgeons Oncology Group Z0011 (Z-11) trial indicated that women with positive sentinel nodes scheduled for lumpectomy and whole-breast radiation could safely avoid complete axillary lymph node dissection. A Need for Clarity Few studies have compared the risks and benefits of the various axillary interventions for patients with breast cancer. To address this research gap, Roshni Rao, MD, and colleagues performed a systematic review of 17 studies. The analysis, published in JAMA, reviewed studies of women with breast cancer who mostly had benign axilla and received surgical treatment that ranged from removal of one lymph node to removal of all axillary lymph nodes. Outcomes of these procedures were compared with each other as well as with nonsurgical interventions, such as radiation. Women with no suspicious, palpable axillary nodes who underwent breast-conserving therapy did not experience a benefit with complete axillary node dissection when compared with sentinel node biopsy alone. Complete axillary node dissection was associated with a 1% to 3% reduction in axillary lymph node metastases recurrence but was also associated with a 14% risk of lymphedema. Complete axillary lymph node dissection was well suited for patients with...

Drug Wars in the Exam Room

As physicians, we have all been faced with patients inappropriately looking for prescriptions for controlled substances. Some are looking to abuse them and some to divert them for profit. It is often hard to distinguish when a patient truly needs these medications or when they are just “drug-seeking.” More experienced doctors have a better sense of which patients are which. Drug-seeking patients often play on our emotions because they know we generally care about patients and may have difficulty turning down a request for opioids from someone in supposed pain. For years, patients have used many ruses to access these medications. Many of them “doctor shop,” use several pharmacies, or frequent various emergency rooms, making it difficult to track their prescriptions. And it’s much harder for a doctor to turn down a request from a new patient in acute pain than from one the doctor knows well and doubts. Having so many controlled substances available and sold on the streets has led to an increase in prescription drug dependency. These patients have a hard time breaking these addictions and often can only stop with help from special rehab programs. It has led to a further resurgence of IV heroin addiction and opioid deaths in many areas. As the states have tightened controlled substance prescriptions, they have become less available for diversion and are now a gateway drug to heroin—which is cheaper than prescribed medications. I am seeing teens in my practice addicted to IV heroin, a habit that started by raiding parents’ or relatives’ medicine cabinets. It has never been more imperative for doctors to step up and do...
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