report

1. 1
Neuropsychological Evaluation
Comprehensive history can be found in other documents and will not be repeated here. Please
refer to XXXX Pain Center records.
Patient Name: Pain Center
Date: 8-15-13
ID and Reasonfor Referral: Mr. XXXX is xx-year-old, white, xxxx, male who is supported by
SSD and was referred by Dr. xxxx at the XXXX Pain Center. The purpose of this evaluation is to
assess his appropriateness for spinal cord stimulator implantation.
Information sources: XXXX Pain Center records
Clinical Interview and Mental Status Exam 8-15-13
Psychosocial History and Symptom Questionnaire
Neuropsychological Screening/Cognitive Testing
McGill Pain Questionnaire
Dallas Pain Questionnaire
Schalling-Sifneos Personality Scale
History of the Presenting Problem: On April 26, 2010 while he was employed as a xxxx at a
xxxx mine he “threw a heavy coil of cable and heard a pop” in his back “causing me to feel like
a knife went into my hip”. He subsequently experienced lower back pain and a radiculopathy in
both legs. On 1-24-11 he had an L4/L5 laminectomy which relived his pain for 6 months after
which the pain returned to pre-surgery levels. He had a second surgery in August of 2011 with
the same results. He now has leg “spasms” severe enough that he has to stop the car if he is
driving.
Background Information:
 He had a similar injury with the same symptoms in 2003 and back surgery on 6-17-03
which kept him out of work for 11 months.
 I did not have access to his spinal imaging or any details describing his surgeries or other
treatments for that matter and Mr. XXXX was not clear about these issues.
Pain Assessment: He has had continuous back pain and intermittent leg pain which averaged
5/10 during the past 24 hours and 7/10 during the past week. He described the lumbar back pain
as cramping and gnawing and his bilateral radicular pain as sharp, shooting and stabbing. The
areas where pain has had the greatest negative impact on his daily life include: sleeping, lifting,
sitting, standing, riding in a car, social activities and sexual relations. He has little or no trouble
with: bathing, grooming or dressing himself. Psychologically the pain has had a profoundly
negative effect on his self-esteem and caused him to feel “weak and worn out”. He previously
took great pride in being a “xxxx for 26 years”. Now he is dependent on his wife for most
things.

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Current Medications: Gabapentin 300mg tid, Tramadol 50mg qid prn, Lyrica 150mg bid,
Vitamin-B12, Cyclobenzaprine 10mg bid prn.
Medical History: Hypertension, Depressive Disorder
Mental Status Exam: He was an alert, casually dressed, well groomed, cooperative middle
aged man who was strikingly anxious; he said, “Because I have never done this before”. His
hands shook and his voice trembled. He calmed down as the interview progressed and then
seemed to tense up again as we concluded. His affect was constricted. He denied depression and
biological signs of depression such as early morning awakening, loss of appitite with weight loss,
anedonia, low energy and crying spells were absent. His speech was logical, coherent, relevant
and goal directed. There were no hallucinations or other psychotic symptoms such as delusions.
He was fully oriented. His insight and judgment were both adequate.
He said he was depressed at one point in his life. In a bland, affectless manor and without any
anger, he described how his first wife left him after 13 years of marriage; “I came home one day
and she was gone; she drained our accounts and took everything of value with her; she ran off
with a guy from work; I never suspected a thing; I felt like a fool.” He has been remarried for 13
years. He is happy in this marriage. He feels supported. He loves his 3 step-daughters and
remains close to his 2 sons. He denied any history of alcohol or drug abuse.
Neuropsychological Screening Results: On the neuropsychological screening, all areas of
cognitive and intellectual functioning were intact except for ability to abstract and attention and
concentration. He was moderately concrete on proverbs. He made numerous errors on serial 3’s
and digits forward and backward which were probably due to anxiety. His speech was fluent,
spontaneous, non-dysarthric and free of paraphasic errors. All areas of memory: registration,
repetition, recall, recent and remote were unimpaired as seen in his performance on the story for
immediate recall, as well as other tests. He was able to recall 3 items after 5 minutes. He was
fully oriented with a good fund of information. Reading, writing and naming were adequate;
there was no agnosia. He could follow three stage commands and copy figures. He did well on
tests of ideational and ideomotor apraxia. There were no problems with constructional or
visuospatial ability; no signs of neglect. Oral comprehension was 100%. There were no gross
signs of impaired executive functions, no stereotypical or perseverative behaviors.
Findings: Mr. XXXX is free of any cognitive or intellectual impairment. On the formal
cognitive testing, the only area where his performance was below normal is one which is highly
sensitive to anxiety. He is not clinically depressed. He is not psychotic nor does he suffer from a
serious mental illness of any type. He does not exhibit any of the characteristics of the types of
character pathology which would make him a poor candidate for spinal cord stimulator
implantation such as somatization disorder, histrionic personality disorder or conversion
disorder.
To address his pain he has in the past tried various medications, physical therapy, chiropractic,
multiple surgeries and presumably epidural injections all without lasting success.

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However, across the board test results and his clinical presentation point toward fairly high levels
of anxiety for Mr. XXXX. Anxiety is the second most common psychiatric comorbidity to
chronic pain with depression being the most common. The presence of comorbid anxiety may
lead to hyperarousal and increased vigilance for pain and somatic concerns which in turn could
lead to a vicious cycle of increasing pain and increasing anxiety. This should be addressed as a
component of his pain treatment. He exhibited a kind of performance anxiety in relation to this
evaluation despite the fact that few of the items presented to him had correct or incorrect
answers.
Recommendations:
1. There are no psychological contraindications for spinal cord stimulator implantation.
2. Consider treating his anxiety and there by disrupting the above described vicious-cycle
with a non-benzodiazepine medication such as: Lexapro (for its anxiolytic effect) 10mg
qd x one week then increase to 20mg qd or BuSpar 10mg tid quickly titrating up to a total
of 60mg per day. The latency period could be long for BuSpar. The problem here is Mr.
XXXX denies all psych symptoms including anxiety. Despite his health insurance status
he would be eligible for psychotherapy services a XXXX but he may not be interested.
3. I would encourage him to remain active. The more he sinks into inactivity the more his
symptoms will worsen. He has an avocation which he can pursue. He also needs to be
involved in an activity which will lift his sagging self-esteem.
4. Considering the fact that “muscle spasm” is part of the picture here think about teaching
him Jacksonian Muscle Tension Relaxation Exercises for the wide variety of benefits
it would provide.
http://emedicine.medscape.com/article/324583-overview
_________________________________
Drew Chenelly, Psy.D. Date:
Clinical Neuropsychologist