The influence of preoperative mental health on clinical outcomes after laminectomy in patients with lumbar spinal stenosis

Relating preoperative MCS-12 to microdiscectomy outcomes

PURPOSE

To determine the impact of poor mental health on patient-reported and surgical outcomes after microdiscectomy.

METHODS

Patients ≥ 18 years who underwent a single-level lumbar microdiscectomy from 2014 to 2021 at a single academic institution were retrospectively identified. Patient-reported outcomes (PROMs) were collected at preoperative, three-month, and one-year postoperative time points. PROMs included the Oswestry Disability Index (ODI), Visual Analog Scale Back and Leg (VAS Back and VAS Leg, respectively), and the mental and physical component of the short form-12 survey (MCS and PCS). The minimum clinically important differences (MCID) were employed to compare scores for each PROM. Patients were categorized as having worse mental health or better mental health based on a MCS threshold of 50.

RESULTS

Of 210 patients identified, 128 (61%) patients had a preoperative MCS score ≤ 50. There was no difference in 90-day surgical readmissions or spine reoperations within one year. At 3- and 12-month time points, both groups demonstrated improvements in all PROMs (p < 0.05). At three months postoperatively, patients with worse mental health had significantly lower PCS (42.1 vs. 46.4, p = 0.004) and higher ODI (20.5 vs. 13.3, p = 0.006) scores. Lower mental health scores were associated with lower 12-month PCS scores (43.3 vs. 48.8, p < 0.001), but greater improvements in 12-month ODI (- 28.36 vs.  - 18.55, p = 0.040).

CONCLUSION

While worse preoperative mental health was associated with lower baseline and postoperative PROMs, patients in both groups experienced similar improvements in PROMs. Rates of surgical readmissions and reoperations were similar among patients with varying preoperative mental health status.

Implications of Preoperative Depression for Lumbar Spine Surgery Outcomes: A Systematic Review and Meta-Analysis

Importance

Comorbid depression is common among patients with degenerative lumbar spine disease. Although a well-researched topic, the evidence of the role of depression in spine surgery outcomes remains inconclusive.

Objective

To investigate the association between preoperative depression and patient-reported outcome measures (PROMs) after lumbar spine surgery.

Data Sources

A systematic search of PubMed, Cochrane Database of Systematic Reviews, Embase, Scopus, PsychInfo, Web of Science, and ClinicalTrials.gov was performed from database inception to September 14, 2023.

Study Selection

Included studies involved adults undergoing lumbar spine surgery and compared PROMs in patients with vs those without depression. Studies evaluating the correlation between preoperative depression and disease severity were also included.

Data Extraction and Synthesis

All data were independently extracted by 2 authors and independently verified by a third author. Study quality was assessed using Newcastle-Ottawa Scale. Random-effects meta-analysis was used to synthesize data, and I2 was used to assess heterogeneity. Metaregression was performed to identify factors explaining the heterogeneity.

Main Outcomes and Measures

The primary outcome was the standardized mean difference (SMD) of change from preoperative baseline to postoperative follow-up in PROMs of disability, pain, and physical function for patients with vs without depression. Secondary outcomes were preoperative and postoperative differences in absolute disease severity for these 2 patient populations.

Results

Of the 8459 articles identified, 44 were included in the analysis. These studies involved 21 452 patients with a mean (SD) age of 57 (8) years and included 11 747 females (55%). Among these studies, the median (range) follow-up duration was 12 (6-120) months. The pooled estimates of disability, pain, and physical function showed that patients with depression experienced a greater magnitude of improvement compared with patients without depression, but this difference was not significant (SMD, 0.04 [95% CI, -0.02 to 0.10]; I2 = 75%; P = .21). Nonetheless, patients with depression presented with worse preoperative disease severity in disability, pain, and physical function (SMD, -0.52 [95% CI, -0.62 to -0.41]; I2 = 89%; P < .001), which remained worse postoperatively (SMD, -0.52 [95% CI, -0.75 to -0.28]; I2 = 98%; P < .001). There was no significant correlation between depression severity and the primary outcome. A multivariable metaregression analysis suggested that age, sex (male to female ratio), percentage of comorbidities, and follow-up attrition were significant sources of variance.

Conclusions and Relevance

Results of this systematic review and meta-analysis suggested that, although patients with depression had worse disease severity both before and after surgery compared with patients without depression, they had significant potential for recovery in disability, pain, and physical function. Further investigations are needed to examine the association between spine-related disability and depression as well as the role of perioperative mental health treatments.

Impact of Preoperative 12-item Short Form Mental Composite Scores on Clinical Outcomes in Cervical Disc Replacement

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

We aim to examine the effects of preoperative mental health status on demographic, perioperative characteristics, and postoperative outcomes in patients undergoing cervical disc replacement (CDR).

SUMMARY OF BACKGROUND DATA

The effect of preoperative mental health status has not been widely studied in CDR.

METHODS

Patients undergoing primary CDR were retrospectively collected and stratified into 2 cohorts by 12-item Short Form Survey Mental Composite Score (SF-12 MCS) ≥48.9. Patients without preoperative SF-12 MCS scores or diagnosis of infection, malignancy, or trauma were excluded. Demographic information, perioperative characteristic, and patient reported outcome measures (PROMs) were collected. Patient reported outcome measurement information system physical function (PROMIS-PF)/SF-12 Physical Component Score (PCS)/SF-12 MCS/visual analog scale (VAS) neck/VAS leg/neck disability index (NDI) were collected preoperatively and 6 weeks/12 weeks/6 months/1 year postoperatively.

RESULTS

Eighty-seven patients were included, (47 having SF-12 MCS≥48.9). For PROMs, both cohorts had significant improvement from preoperative baseline, besides SF-12 PCS/MCS at 1 year for the depressed cohort and SF-12 MCS at all time points. The non-depressed cohort demonstrated significantly higher PROMIS-PF preoperatively and at 12 weeks, SF-12 PCS at 12 weeks, SF-12 MCS at all time points, decreased VAS neck at 12 weeks and NDI preoperatively and at 12 weeks, overall minimal clinically important difference (MCID) in most patients in all PROMs besides SF-12 MCS, and higher MCID for PROMIS-PF at 12 weeks. The depressed cohort demonstrated overall MCID in most patients with PROMIS-PF/SF-12 MCS/VAS neck/NDI, and a higher MCID for 6 weeks/12 weeks/6 months postoperatively and overall SF-12 PCS.

CONCLUSION

Whereas both cohorts demonstrated significantly improved PROMs from baseline, the non-depressed cohort demonstrated better physical function, mental health, decreased pain, and disability at various time points, whereas the depressed cohort demonstrated higher mental health MCID achievement at every time point except 1 year. These findings may be useful in managing expectations for patients undergoing cervical surgery.

Are We Considering the Whole Patient? The Impact of Physical and Mental Health on the Outcomes of Spine Care

STUDY DESIGN

Retrospective, observational.

OBJECTIVE

To evaluate the influence of baseline health status on the physical and mental health (MH) outcomes of spine patients.

SUMMARY OF BACKGROUND DATA

Spine conditions can have a significant burden on both the physical and MH of patients. To date, few studies have evaluated the outcomes of both dimensions of health, particularly in nonoperative populations.

MATERIALS AND METHODS

At their first visit to a multidisciplinary spine clinic, 2668 nonoperative patients completed the Patient-reported Outcomes Measurement Information System-Global Health (PROMIS-GH) instrument and a questionnaire evaluating symptoms and goals of care. Patients were stratified by their baseline percentile score of the MH and physical health (PH) components of the PROMIS-GH. Four groups of patients were compared based on the presence or absence of bottom quartile PH or MH scores. The primary end point was the achievement of a minimal clinically important difference (MCID) on the MH or PH components at follow-up. Multivariate regression assessed the predictors of MCID achievement.

RESULTS

After controlling for demographics, symptoms, and goals, each 1-point increase in baseline PROMIS-GH mental score reduced the odds of achieving MH MCID by 9.0% ( P <0.001). Conversely, each 1-point increase in baseline GH-physical score increased the odds of achieving MCID by 4.5% ( P =0.005). Each 1-point increase in baseline GH-physical score reduced the odds of achieving PH MCID by 12.5% ( P <0.001), whereas each 1-point increase in baseline GH-mental score increased the odds of achieving MCID by 5.0% ( P <0.001).

CONCLUSIONS

Spine patients presenting with the lowest levels of physical or MH were most likely to experience clinically significant improvement in those domains. However, lower levels of physical or mental health made it less likely that patients would experience significant improvement in the alternative domain. Physicians should evaluate and address the complex spine population holistically to maximize improvement in both physical and mental health status.

Impact of leg numbness on patient satisfaction following decompression surgery for lumbar spinal stenosis

Decompression surgery is the most common surgical treatment for lumbar spinal stenosis (LSS). Relatively low satisfaction rate was reported. Patients often complaint of residual numbness despite significant pain relief. We hypothesized that numbness had a significant impact on patient satisfaction, but had not been evaluated, which is associated with low satisfaction rate. This study aimed to examine how much numbness is associated with patient satisfaction. We retrospectively reviewed prospectively collected data from consecutive patients who underwent decompression without fusion for LSS. We evaluated the Numeric Rating Scale (NRS) scores of low back pain (LBP), leg pain, and leg numbness preoperatively and at the final follow-up visit. Improvement was evaluated using minimum clinically important differences (MCIDs). Patient satisfaction was evaluated using the question, "How satisfied are you with the overall result of your back operation?". There are four possible answers consisting of "very satisfied (4-point)", "somewhat satisfied (3-point)", "somewhat dissatisfied (2-point)", or "very dissatisfied (1-point)". Spearman correlation was used to evaluate the association between patient satisfaction and reaching MCIDs. A total of 116 patients were included. All three components had correlation with patient satisfaction with the correlation efficient of 0.30 in LBP, 0.22 in leg pain, and 0.33 in numbness. Numbness had greatest correlation efficient value. We showed that numbness has a greater impact than leg/back pain on patient satisfaction in patients undergoing decompression for LSS. We suggest not only LBP and leg pain but also numbness should be evaluated pre- and postoperatively.

Pre-operative prognostic factors for walking capacity after surgery for lumbar spinal stenosis: a systematic review

BACKGROUND

Lumbar spinal stenosis (LSS) reduces walking and quality of life. It is the main indication for spinal surgery in older people yet 40% report walking disability post-operatively. Identifying the prognostic factors of post-operative walking capacity could aid clinical decision-making, guide rehabilitation and optimise health outcomes.

OBJECTIVE

To synthesise the evidence for pre-operative mutable and immutable prognostic factors for post-operative walking in adults with LSS.

DESIGN

Systematic review with narrative synthesis.

METHODS

Electronic databases (CENTRAL, MEDLINE, EMBASE, CINAHL, PsycINFO, Web of Science, OpenGrey) were searched for observational studies, evaluating factors associated with walking after surgery in adults receiving surgery for LSS from database inception to January 2020. Two reviewers independently evaluated studies for eligibility, extracted data and assessed risk of bias (Quality in Prognosis Studies). The Grading of Recommendations Assessment, Development and Evaluation method was used to determine level of evidence for each factor.

RESULTS

5526 studies were screened for eligibility. Thirty-four studies (20 cohorts, 9,973 participants, 26 high, 2 moderate, 6 low risk of bias) were included. Forty variables (12 mutable) were identified. There was moderate quality of evidence that pre-operative walking capacity was positively associated with post-operative walking capacity. The presence of spondylolisthesis and the severity of stenosis were not associated with post-operative walking capacity. All other factors investigated had low/very low level of evidence.

CONCLUSION

Greater pre-operative walking is associated with greater post-operative walking capacity but not spondylolisthesis or severity of stenosis. Few studies have investigated mutable prognostic factors that could be potentially targeted to optimise surgical outcomes.

Prediction of walking ability following posterior decompression for lumbar spinal stenosis

PURPOSE

Following surgery for lumbar spinal stenosis (LSS) up to 40% of people report persistent walking disability. This study aimed to identify pre-operative factors that are predictive of walking ability post-surgery for LSS.

METHODS

An observational cohort study was conducted using data from the British Spine Registry (2017-2018) of adults (≥ 50 years) with LSS, who underwent ≤ 2 level posterior lumbar decompression. Patients receiving fixation or who had previous lumbar surgery were excluded. Walking ability was assessed by a single item on the Oswestry Disability Index and dichotomised into poor/good outcome. Multivariable regression models were performed.

RESULTS

14,485 patients were identified. Pre-operatively 30% patients reported poor walking ability, this decreased to 8% at 12 months follow-up. Predictors associated with poor walking ability at 12 months were: increasing age (≥ 75 years OR 1.54, 95% CI 1.07, 2.18), BMI ≥ 35 kg/m² (OR 1.52, 95% CI 1.00, 2.30), severity of leg pain (OR 1.10, CI 95% 1.01, 1.21), disability (OR 1.01, 95% CI 1.01, 1.02) and quality of life (OR 0.72, 95% CI 0.56, 0.89). Pre-operative maximum walking distance (OR 1.10, 95% CI 1.05, 1.25) and higher education (OR 0.90, 95% CI 0.80, 0.96) were associated with reduced risk of poor walking ability at 12 months; p < 0.05. Depression, fear of movement and symptom duration were not associated with risk of poor outcome.

CONCLUSION

Older age, obesity, greater pre-operative pain and disability and lower quality of life are associated with risk of poor walking ability post-operatively. Greater pre-operative walking and higher education are associated with reduced risk of poor walking ability post-operatively. Patients should be counselled on their risk of poor outcome and considered for rehabilitation so that walking and surgical outcomes may be optimised.

Correlating Psychological Comorbidities and Outcomes After Spine Surgery

STUDY DESIGN

Literature review.

OBJECTIVE

The aim of this literature review is to examine the effects of psychological disorders on postoperative complications, surgical outcomes, and long-term narcotic use. We also hope to detail the value of preoperative identification and treatment of these pathologies.

METHODS

A series of systematic reviews of the relevant literature examining the effects of psychological disorders and spine surgery was conducted using PubMed and Cochrane databases.

RESULTS

Combined, the database queries yielded 2275 articles for consideration. After applying screening criteria, 96 articles were selected for inclusion. Patients with underlying psychological disease have higher rates of delirium, readmission, longer hospital stays, and higher rates of nonroutine discharge following spine surgery. They also have higher rates of chronic postoperative narcotic use and may experience worse surgical outcomes. Because of these defined issues, researchers have developed multiple screening tools to help identify patients with psychological disorders preoperatively for potential treatment. Treatment of these disorders prior to surgery may significantly improve surgical outcomes.

CONCLUSION

Patients with psychological disorders represent a unique population with respect to their higher rates of spinal pain complaints, postoperative complications, and worsened functional outcomes. However, proper identification and treatment of these conditions prior to surgery may significantly improve many outcome measures in this population. Future investigations in this field should attempt to develop and validate current strategies to identify and treat individuals with psychological disorders before surgery to further improve outcomes.

Minimum clinically important difference of major patient-reported outcome measures in patients undergoing decompression surgery for lumbar spinal stenosis

OBJECTIVE

A minimum clinically important difference (MCID) has been increasingly well known in the current era of patient-centered care because it reflects a smallest change that is meaningful for patients following a clinical intervention. Previous studies suggested MCID values are disease and/or procedure dependent. No MCID values have been reported on the lumbar spinal stenosis (LSS) following decompression surgery despite LSS is the most common spinal disease and the main treatment is decompression surgery. Therefore, this study aimed to determine the MCID values as major outcome measures including the Numeric Rating Scale (NRS) of back pain, leg pain and numbness, Roland-Morris Disability Questionnaire (RMDQ), and Physical Component Summary (PCS) and Mental Component Summary (MCS) of Short Form 8 (SF-8) for patients with LSS undergoing decompression surgery.

PATIENTS AND METHODS

This is a retrospective cohort study using prospectively collected data from consecutive patients who underwent lumbar decompression without fusion for LSS at a single institution between May 2014 and March 2016. Inclusion criteria were 1) minimum 1-year follow-up 2) a complete set of preoperative and final follow-up questionnaires available, including the NRS, RMDQ, and SF-8. Revision surgery or non-degenerative etiology such as infection or tumor was excluded. MCIDs of each outcome measure were determined using two major approaches, distribution- and anchor-based methods. The distribution-based method uses the distributional characteristics of the sample. This method expresses the observed degree of variation to obtain a standardized metric such as the standard deviation or standard error of measurement. The anchor-based method uses an external criterion known as anchor to determine the factors that should be considered by patients for an important improvement. Anchor-based methods assess how much changes in the measurement instrument correspond with a minimal important change defined on the anchor. We used symptom severity, physical function, and satisfaction scores from Zurich Claudication Questionnaire as anchors for NRS and RMDQ, PCS, and MCS, respectively.

RESULTS

A total of 126 patients were included. From the anchor-based method, MCIDs were determined to be 2 points for back pain, 4 points for leg pain and numbness, 5 points for RMDQ, 5 points for PCS, and 2 points for MCS. From the distribution-based method, MCIDs were determined to be 2 points for back pain, leg pain and numbness, 3-4 points for RMDQ, 6 points for PCS, and 5 points for MCS.

CONCLUSION

We first identified the MCIDs of the NRS, RMDQ, and SF-8 specific to patients undergoing decompression surgery for LSS.

Risk factors for persistent numbness following decompression surgery for lumbar spinal stenosis

OBJECTIVE

Decompression surgery is a mainstay of surgical treatment for lumbar spinal stenosis (LSS). However, up to 30% of patients have low satisfaction due to residual symptoms. In the clinical setting, improvements in leg pain are more significant than those in leg numbness. Residual numbness could be related to the relatively low satisfaction rate. However, few studies have focused on numbness; thus, elucidating the risk factors and rate of residual numbness would benefit surgeons and patients. This study aimed to clarify the risk factors for and rate of residual numbness after decompression surgery.

PATIENTS AND METHODS

We retrospectively reviewed prospectively collected data from consecutive patients who underwent lumbar decompression without fusion for LSS at a single institution between January 2014 and March 2016. Patients were included if preoperative and final follow-up questionnaires and radiographs were available. A minimum one-year follow-up was required. We evaluated the Numeric Rating Scale (NRS) scores of low back pain, leg pain, and leg numbness preoperatively and at the final follow-up visit. Residual numbness was defined as a postoperative NRS ≥ 1, whereas persistent numbness was defined as a postoperative NRS ≥ 5. We compared the clinical data of patients with or without residual numbness to those of patients with or without persistent numbness. Multivariate logistic regression analysis was performed to identify risk factors for residual and persistent numbness.

RESULTS

A total of 116 patients (73 men, 43 women) were included. Of them, 60% had residual numbness with a mean follow-up period of 25 months. Only durotomy differed significantly between patients with and those without residual numbness. However, the significance did not persist after logistic regression analysis. A total of 16% had persistent numbness. Diabetes mellitus, intraoperative durotomy, and preoperative NRS of numbness were identified as risk factors. There were no differences in smoking status, presence of spondylolisthesis or scoliosis, or severity of stenosis.

CONCLUSIONS

We found three risk factors for persistent numbness following decompression surgery for LSS; diabetes mellitus and durotomy were modifiable, whereas preoperative numbness was not. Our findings would help surgeons minimize the incidence of persistent numbness by adequately controlling diabetes and avoiding durotomy during surgery. Providing information about the potential for residual numbness during the informed consent process is important to ensuring realistic patient expectations.