Patients undergoing elective surgery often attend a pre-assessment clinic where suitability for surgery is determined. Patient Reported Outcome Measures (PROMs) are increasingly used to assess the quality of care delivered to NHS patients and to demonstrate health gains following surgical intervention.  There is a body of evidence that establishes the interaction between mental health, surgical intervention, and pain, however conditions such as depression, chronic pain and anxiety are rarely prioritised at the pre-operative assessment.  Furthermore, current PROMs do not adequately include a psychological assessment to assess their influence on the postoperative outcome.
Many patients who reach the clinic are keen for surgery, but there is a group of them who go on to suffer from significant post-operative pain. Their symptoms are not improved by surgery and conservative management is more appropriate. However, they can be difficult to identify pre-operatively. We propose a more informed decision for surgery, taking into account the patient’s pre-operative pain and potential benefit of surgery. To explore these issues we have considered foot and ankle surgery, which goes hand in hand with pain and catastrophizing.
Pain catastrophizing is the tendency to magnify the threat value of pain, fixate on pain, and feel helpless to control pain.  Higher pre-surgical levels of pain catastrophizing and anxiety have been implicated in both acute and chronic post-surgical pain. [3,4] If it is possible to predict post-operative pain through pre-operative assessment, taking into account a patient’s psychological history, these complication rates could be reduced. By pursuing conservative management in patients at greater risk of persisting or severe post-operative pain one may also reduce the number of surgical interventions needed in this population.
Additionally, pain has a significant emotional component that is not explored by currently used PROMs, despite a clear effect on the outcome from surgery. [1,3,5] One example of a PROM is the Manchester and Oxford Foot and Ankle Questionnaire (MOXFQ). This is endorsed by the British Foot and Ankle Society and is widely used in prospective research.  It is a 16-item self-assessment questionnaire consisting of three scales: walking/standing, pain, and social interaction. MOXFQ assesses how foot problems impair quality of life before and after operative intervention.  This tool may be limited by not incorporating mental health assessment.
We believe outcomes that selectively incorporate psychological assessment may help develop a more meaningful prediction of post-surgical pain. This would better inform patients prior to surgery and help manage expectations. In the United States, the Patient Reported Outcomes Measurement Information System (PROMIS) is performing this on a large scale.  It may also assist in patient selection for surgery and choice of anaesthetic technique, based on risk of chronic post-surgical pain and the concept of preventative analgesia. Munimara previously described this as personalised anaesthesia, where the chosen technique and analgesic regimen is informed by detailed consideration of baseline characteristics. 
There is a need to deepen understanding of the psychological variables on patient selection and surgical outcome. We feel that a rigorous pre-operative assessment that includes these psychological parameters may enable risk stratification at baseline, optimise patient selection, and facilitate fully informed patient consent. This, in turn, may facilitate personalised anaesthesia, fewer inappropriate surgical interventions and better outcomes. Furthermore, large registries, for example the National Hip Fracture Database, which incorporates psychological parameters, enable analysis such as logistical regression.  These powerful methods to scrutinise large data sets can further help improve our understanding on how mental health affects surgical outcome more so than small scale audits. This approach could be adopted in foot and ankle surgery by the widespread adoption of PROMs recording, with inclusion of mental health and pain catastrophizing assessment in the PROMs dataset.
Alastair Faulkner, Specialty Registrar in Trauma and Orthopaedics, Ninewells Hospital, Dundee & Honorary Clinical Lecturer, University of Dundee.
Competing interests: None declared.
- Patient Reported Outcome Measures [Online] Available at https://www.england.nhs.uk/statistics/statistical-work-areas/proms/ (accessed 14th July 2017).
- Egloff N, Wegmann B, Juon B, Stauber S, von Känel R, Vögelin E. The impact of anxiety and depressive symptoms on chronic pain in conservatively and operatively treated hand surgery patients. Journal of Pain Research. 2017:10 259-263
- Harrison T, Fawzy E, Dinah F, Palmer S. Prospective assessment of dorsal cheilectomy for hallux rigidus using a patient-reported outcome score. J Foot Ankle Surg 2010; 49:232–7.
- Theunissen M, Peters ML, Bruce J, Gramke HF, Marcus MA. Preoperative anxiety and catastrophizing: a systematic review and meta-analysis of the association with chronic postsurgical pain. Clin J Pain, 2012;28(9):819-41.
- Rosenbloom BN, Katz J, Chin KY, Haslam L, Canzian S, Kreder HJ, McCartney CJ. Predicting pain outcomes after traumatic musculoskeletal injury. Pain, 2016;157(8):1733-43.
- The Manchester-Oxford Foot Questionnaire [Online] Available at https://innovation.ox.ac.uk/outcome-measures/manchester-oxford-foot-questionnaire-moxfq/ (accessed 14th July 2017).
- Patient-reported outcomes measurement information system (PROMIS). Available at http://www.healthmeasures.net/explore-measurement-systems/promis (Accessed 21st November 2017)
- Munirama S, MacLeod G. ‘Stratified’ approach to individualized anaesthetic care. Br J Anaesth, 2015;114(4):543-45.
- National Hip Fracture Database. Available at: http://www.nhfd.co.uk/ (accessed 1st August 2017).