It Really is Upside Down

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I have a patient who is a muscular 43 y/o welder. He injured his back on the job about four years ago.  After undergoing a laminectomy for low back pain, his pain actually increased.  When I first saw him a couple of years ago, his complaint was unrelenting low back pain that was not position related.  He was disabled and could not work.

His tests and treatment were as follows:

  • His lumbar MRI showed disc degeneration at every level but no instability.
  • He had crippling anxiety including fairly frequent panic attacks.
  • He was open to psychological care.
  • I engaged him a structured rehab program, but essentially every request we made for biofeedback, psychological intervention, mindfulness/meditation, and back school was denied by Worker’s Comp—over and over again.
  • I somewhat kept him on his feet by seeing him back every couple of weeks for about six months. We kept requesting care.  Even personal phone calls to his claims examiner were of no avail.

I referred him to a pain specialist that I have teamed up with, and he continued with a similar program but again with no support from Workers’ Comp.

  • The patient still complained of severe crippling anxiety and was somewhat desperate for mental health care.
  • I am not currently his treating physician but last week my colleague emailed me and asked me to re-evaluate him.
  • It has been recommended to him that he have a two-level lumbar fusion for his degenerated discs.  My friend begged him not to pursue it.
  • The patient is anxious, frustrated, and does not want to talk to me or anyone else.  He is now intent on pursuing surgery.

So look at this situation.

  • We know that chronic pain increases anxiety and frustration, which exacerbates pain.
  • Psychosocial stress is a better predictor of outcome than the surgical pathology.
  • The return-to-work rate at one year from a lumbar fusion for low back pain in the State of WA is 15%.
  • The patient has documented severe untreated anxiety.
  • In addition to his baseline anxiety, interacting with the Worker’s Comp system has pushed him almost into a rage.
  • The state still will not pay for any mental health resources
  • They will pay for an operation that will cost them between 50-75 thousand dollars and has a re-operation rate between 15-20% within the first twelve months of the index operation.
  • If he does not undergo surgery, his claim will be closed and he does not have the emotional capacity to compete in the work force.

I have no ability to intervene, as I am no longer his treating physician.  I realize that “this is not my problem.”  That is correct.  It is not my problem; it belongs to all of us.

Does anyone have any suggestions?