Effect of mental health on postoperative infection rates following cervical spine fusion procedures

The use of the Core Yellow Flags Index for the assessment of psychosocial distress in patients undergoing surgery of the cervical spine

BACKGROUND

Psychosocial distress (the presence of yellow flags) has been linked to poor outcomes in spine surgery. The Core Yellow Flags Index (CYFI), a short instrument assessing the 4 main yellow flags, was developed for use in patients undergoing lumbar spine surgery. This study evaluated its ability to predict outcome in patients undergoing cervical spine surgery.

METHODS

Patients with degenerative spinal disorders (excluding myelopathy) operated in one centre, from 2015 to 2019, were asked to complete the CYFI at baseline and the Core Outcome Measures Index (COMI) at baseline and 3 and 12 months after surgery. The relationship between CYFI and COMI scores at baseline as well as the predictive ability of the CYFI on the COMI follow-up scores were tested using structural equation modelling.

RESULTS

From 731 eligible patients, 547 (61.0 ± 12.5 years; 57.2% female) completed forms at all three timepoints. On a cross-sectional basis, preoperative CYFI and COMI scores were highly correlated (β = 0.54, in men and 0.51 in women; each p < 0.001). CYFI added significantly and independently to the prediction of COMI at 3 months' FU in men (β = 0.36) and 12 months' FU in men and women (both β = 0.20) (all p < 0.001).

CONCLUSION

The CYFI had a low to moderate but significant and independent association with cervical spine surgery outcomes. Implementing the CYFI in the preoperative workup of these patients could help refine outcome predictions and better manage patient expectations.

The impact of pre-operative mental health on outcomes of foot and ankle surgery: A scoping review

BACKGROUND

Evidence suggests that certain groups of orthopaedic patients have an increased prevalence of mental health disorders than the general population. This scoping review aims to evaluate the effect of pre-operative mental health on outcomes of foot and ankle surgery.

METHODS

A literature search was performed in four databases. Studies investigating a relationship between preoperative mental health and postoperative patient reported outcome measures (PROMs), complications, readmissions or reoperations were included.

RESULTS

Of the 19 studies investigating the effect of preoperative mental health on PROMs, 16 (84.2%) reported a significant relationship between poorer preoperative mental health and inferior postoperative PROMs. Poorer mental health was associated with an increased rate of complications, readmissions and/or reoperations in four studies.

CONCLUSIONS

Poorer preoperative mental health is associated with significantly inferior outcomes following foot and ankle surgery. Clinicians should evaluate mental health to stratify likely outcomes and aid in the management of patient expectations.

LEVEL OF EVIDENCE

Level IV: Scoping review of Level II-IV studies.

Onset of mental disorders in patients who developed failed back surgery syndrome

PURPOSE

Failed back surgery syndrome (FBSS) is a complex and multifaceted condition associated with significant disability and morbidity. The purpose of this study was to investigate the association between FBSS with new incidences of mental health disorders.

METHODS

Our cohort included patients diagnosed with FBSS within 12 months of a posterior fusion, laminectomy, or discectomy, identified using The International Classification of Disease, both Ninth and Tenth Revisions (ICD-9 and ICD-10). In the next step, both non-FBSS and FBSS-diagnosed patients were queried for the diagnosis of first-time occurrence of mental health disorders. The incidence of new mental health disorders was determined within 12-months following FBSS diagnosis.

RESULTS

FBSS patients were significantly at greater risk than non-FBSS patients of developing all included mental health pathologies: Depression: OR 1.9, 95% CI 1.8-2.0, p < 0.0001); Anxiety: OR 1.5, 95% CI 1.4-1.6, p < 0.0001; Sleep Disorder: OR 1.9, 95% CI 1.7-2.0, p < 0.0001; Bipolar Disorder: OR 1.7, 95% CI 1.5-2.0 p < 0.0001; PTSD: OR 1.5, 95% CI 1.3-1.8, p < 0.0001; Panic Disorder: OR 1.8, 95% CI 1.5-2.1, p < 0.0001; Suicidal Disorder: OR 1.7 95% CI 1.4-2.0, p < 0.0001, ADHD: OR 1.3, 95% CI 1.0-1.5, p = 0.0367.

CONCLUSIONS

In the current study, patients diagnosed with FBSS were at a significantly greater risk of developing mental health pathologies. While other studies have suggested pre-surgical psychological support and treatment, the current results suggest that a post-operative psychologic care may also be warranted. By identifying potential psychosocial unforeseen obstacles that occur in patients diagnosed with FBSS, more precise treatment pathways can be developed leading to improved patient outcomes.

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.

Are preoperative depression and anxiety associated with patient-reported outcomes, health care payments, and opioid use after anterior discectomy and fusion?

BACKGROUND CONTEXT

Depression and anxiety are common psychiatric conditions among US adults, and anterior cervical discectomy and fusion (ACDF) is one of the most commonly performed spinal surgeries. Mental health conditions can affect physical health, and thus have the potential to contribute to adverse outcomes after spine surgery; however, a comprehensive assessment of long-term outcomes and the additive economic burden of these conditions in patients undergoing ACDF has not been well described.

PURPOSE

Our goal was to assess the associations between depression/anxiety and adverse outcomes and health-resource utilization after anterior cervical discectomy and fusion (ACDF).

STUDY DESIGN

Retrospective database study.

PATIENT SAMPLE

We retrospectively analyzed a private administrative health claims database to identify patients who underwent ACDF in the United States from 2010 to 2013. A total of 16,306 patients met our inclusion criteria. Mean (± standard deviation) patient age was 50±7.9 years. Approximately 4,800 patients (30%) had a depression diagnosis and 4,000 (25%) had a diagnosis of anxiety.

OUTCOME MEASURES

The primary outcomes of interest were intensive care unit admission, multiday hospitalization, discharge disposition, 30- and 90-day hospital readmission, 1- and 2-year rates of revision surgery, and chronic postoperative opioid use. Secondary outcomes were 1- and 2-year total cumulative health care payments and cumulative postoperative opioid consumption.

METHODS

Regression models controlled for demographic and medical covariates, alpha=0.05.

RESULTS

A preoperative diagnosis of depression was associated with higher odds of multiday hospitalization (odds ratio [OR] 1.09, 95% confidence interval [CI] 1.01-1.19), 90-day readmission (OR 1.71, 95% CI 1.46-2.02), revision surgery within 2 years (OR 1.43 95% CI 1.16-1.76), and chronic postoperative opioid use (OR 1.58, 95% CI 1.45-1.72) and an increase of $5,915 in adjusted 2-year health care payments (p<.001). Patients with a preoperative diagnosis of anxiety had higher odds of multiday hospitalization (OR 1.15, 95% CI 1.06-1.25), revision surgery within 2 years (OR 1.33, 95% CI 1.07-1.65), and chronic postoperative opioid use (OR 1.62, 95% CI 1.48-1.77) and an increase of $4,471 in adjusted 2-year health care payments (p<.001). Neither anxiety nor depression was associated with intensive care unit admission, discharge disposition, 30-day readmission, revision surgery within 1 year, 1-year cumulative health care payments, or cumulative postoperative opioid consumption.

CONCLUSIONS

Patients with preoperative diagnoses of depression or anxiety have a greater likelihood of adverse outcomes, increased opioid consumption, and increased cumulative health care payments after ACDF compared with patients without depression or anxiety.