Pain Psychology

Pain is produced by the brain in response to signals from the body, and how much pain a person feels — and how disabling it is — depends heavily on factors beyond the physical problem: stress, low mood, poor sleep, anxiety, and beliefs and fears about the pain. Two people with identical scans can have very different experiences of pain and very different levels of function. Recognising this is not to diminish anyone's pain; it is to understand it more fully and to treat it more effectively. It also explains why treatments that address these factors can help, and why ignoring them limits what any physical treatment, including surgery, can achieve.

This is the point most relevant to my work as a surgeon. Certain psychological factors — in particular pain catastrophising (fearing the worst about pain), fear-avoidance (avoiding movement for fear of harm), depression and anxiety — are consistently linked to poorer outcomes, both from non-surgical treatment and from spine surgery. This does not mean these patients should not have surgery when it is indicated; it means that recognising and addressing these factors improves the chances of a good result, and that surgery alone will not resolve pain that is being driven substantially by them. Understanding this helps me counsel people honestly about what an operation can and cannot achieve, and to involve psychology where it will help.

My role is to recognise when psychological factors are a significant part of the picture, to raise this sensitively and without judgement, and to involve clinical or health psychologists and pain services who can assess and support these factors properly. In some settings, psychological screening before major spine surgery helps identify people who would benefit from support alongside their treatment. The psychological work itself — assessment and therapy — is delivered by psychologists; I contribute the surgical picture and coordinate care. Treating the person, not just the scan, means taking this dimension seriously.

The evidence that psychological factors influence spinal pain and surgical outcomes is robust. Systematic reviews show that fear-avoidance beliefs and pain catastrophising predict poorer outcomes in non-specific low back pain, and reviews of psychosocial predictors of lumbar surgery and spinal cord stimulation outcomes find that depression, anxiety and somatisation predict worse results. Studies support presurgical psychological screening, and a large meta-analysis found that preoperative depression is associated with worse baseline and postoperative pain and disability. This evidence is why I regard the psychology of pain as an integral part of assessment and care.

Where psychological factors are significant, I will raise the matter supportively and, with the person's agreement, involve psychology and pain services who can assess and support them. This is offered as part of comprehensive care — addressing the whole experience of pain — not as a suggestion that the pain is imagined. The psychological support itself is provided by appropriately qualified psychologists over time.

• —Wertli MM, et al. Fear-avoidance beliefs as a prognostic factor in nonspecific low back pain: systematic review. Spine J 2014. (PMID 24412032)
• —Wertli MM, et al. Influence of catastrophizing on treatment outcome in nonspecific low back pain: systematic review. Spine 2014. (PMID 24253796)
• —Celestin J, et al. Pretreatment psychosocial variables as predictors of outcomes following lumbar surgery and spinal cord stimulation: systematic review. Pain Med 2009. (PMID 19638142)
• —Block AR, et al. The use of presurgical psychological screening to predict the outcome of spine surgery. Spine J 2003. (PMID 14588332)
• —Implications of preoperative depression for lumbar spine surgery outcomes: systematic review and meta-analysis. JAMA Netw Open 2024. (PMID 38277149)