By now, it is a well-known fact that low back pain is a very common condition disabling a lot of people during the span of their lives, as well as that many of these people have to undergo lumbar surgery at one point or another. However, a lesser known fact is that many of these patients continue to experience pain and disability following their surgery. Studies estimate that 10 to 40% of patients undergoing lumbar surgery report persistent pain in the months and years following the surgery (1).

Insights in patient-related factors that are related to the outcome following lumbar surgery are thus undeniably important, as they can help us to develop targeted patient-centered prevention strategies to implement in current care pathways. Earlier research studies already showed a negative influence of work-related factors, physical factors, depression, symptom duration and preoperative back pain intensity on pain and function following lumbar surgery (2-4). However, the prognostic value of fear avoidance beliefs for surgical outcome is a lot less established. The examination of fear avoidance beliefs as prognostic factors for treatment outcome is mostly conducted in non-surgical patients, as these pain-related cognitions and beliefs are considered important factors in the development of chronic musculoskeletal pain. The well-known fear avoidance model describes this development and outlines how people who experience pain as highly threatening might develop fear and avoidance behavior, which in turn, can lead to disuse and disability (5). Over the many years, the fear avoidance model has known various versions and updates. However, whichever model you take into consideration, pain catastrophizing (i.e. exaggerated negative orientation toward actual or anticipated pain experiences) (6) and pain-related fear (i.e. fear that incorporates fear of pain, fear of injury, fear of physical activity, and so forth) (7) are depicted as important components of the model. Indeed, various studies and reviews have established them, as well as the other concepts related to the fear avoidance model, as important predictors for chronic pain (8).

A recent randomized controlled trial by the same authors included 60 patients undergoing lumbar surgery and analyzed the longitudinal association between preoperative fear avoidance beliefs and postoperative pain and disability (9). The authors reported that the fear avoidance beliefs significantly predicted postoperative pain and disability 10 weeks following the surgery. However, no long term consequences were investigated. An earlier systematic review examined the prognostic value of fear avoidance beliefs for outcome following lumbar surgery and concluded that they indeed appear to negatively influence long-term surgical outcomes (10). However, the authors do remark that only a few studies were included in the review and that future research should still confirm these findings (10).

In conclusion, future studies providing more insight in the prognostic values of fear avoidance beliefs in the context of lumbar surgery are definitely still warranted. However, given the apparent short- and long-term influence of fear avoidance beliefs on surgical outcome, research trials focusing on developing perioperative therapies addressing these maladaptive cognitions (cfr. the B²aSic-trial performed by Pain in Motion members) are indeed crucial. As we still anticipate the results of these trials, we can already think ahead towards the next step: the implementation of treatment strategies targeting preoperative fear avoidance beliefs in patients undergoing lumbar surgery…

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Wouter Van Bogaert

Wouter is a doctoral researcher at the Vrije Universiteit Brussel (Brussels, Belgium). Currently, his work focusses on perioperative pain neuroscience education in patients undergoing surgery for lumbar radiculopathy. His primary research interests include persistent pain and quality of life following the surgery.

2020Pain in Motion

References and further reading:

1. Sebaaly A, Lahoud MJ, Rizkallah M, Kreichati G, Kharrat K. Etiology, Evaluation, and Treatment of Failed Back Surgery Syndrome. Asian Spine J. 2018;12(3):574-585.

2. Rushton A, Zoulas K, Powell A, Staal JB. Physical prognostic factors predicting outcome following lumbar discectomy surgery: systematic review and narrative synthesis. BMC Musculoskelet Disord. 2018;19(1):326.

3. den Boer JJ, Oostendorp RA, Beems T, Munneke M, Oerlemans M, Evers AW. A systematic review of bio-psychosocial risk factors for an unfavourable outcome after lumbar disc surgery. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society. 2006;15(5):527-536.

4. Aalto TJ, Malmivaara A, Kovacs F, et al. Preoperative predictors for postoperative clinical outcome in lumbar spinal stenosis: systematic review. Spine. 2006;31(18):E648-663.

5. Vlaeyen JW, Crombez G, Linton SJ. The fear-avoidance model of pain. Pain. 2016;157(8):1588-1589.

6. Sullivan MJL, Bishop SR, Pivik J. The Pain Catastrophizing Scale: Development and validation. Psychol Assess. 1995;7:524-532.

7. Lundberg M, Grimby-Ekman A, Verbunt J, Simmonds MJ. Pain-related fear: a critical review of the related measures. Pain Res Treat. 2011;2011:494196.

8. Hruschak V, Cochran G. Psychosocial predictors in the transition from acute to chronic pain: a systematic review. Psychol Health Med. 2018;23(10):1151-1167.

9. Alodaibi FA, Fritz JM, Thackeray A, Koppenhaver SL, Hebert JJ. The Fear Avoidance Model predicts short-term pain and disability following lumbar disc surgery. PloS one. 2018;13(3):e0193566.

10. Alodaibi FA, Minick KI, Fritz JM. Do preoperative fear avoidance model factors predict outcomes after lumbar disc herniation surgery? A systematic review. Chiropr Man Therap. 2013;21(1):40.