Depressive burden is associated with a poorer surgical outcome among lumbar spinal stenosis patients: a 5-year follow-up study

Outcomes of cobalt-chrome 3D-printed total talus replacement with and without combined total ankle replacement

BACKGROUND

Collapse of the talus and peri-talar arthritis pose treatment challenges due to the anatomy and location of the talus as a keystone of the foot and ankle. Custom 3D-printed total talus replacement (TTR) and combined total ankle total talus replacement (TATTR) have emerged as treatment options for these pathologies. However, the safety and efficacy of these implants is unknown due to the limited number of cases and short follow-up durations.

METHODS

This was a retrospective study to assess surgical outcomes of patients who underwent a TTR and TATTR with or without subtalar fusion. Patient demographics, intraoperative parameters, device related surgical and non-surgical events, imaging and clinical evaluations, and patient reported outcome (PRO) measures were compiled.

RESULTS

A total of 38 patients received a custom 3D-printed implant with mean follow-up time of 22.1 (range: 12-45) months. In this cohort, 7 (18.4 %) required secondary surgery and 3 (7.9 %) required implant removal. Multivariate logistic regression revealed that patient diagnosis of depression was a significant predictor of secondary surgery with an OR 17.50 (p = 0.037). Significant postoperative improvements were observed in the talocalcaneal height (p = 0.005) and talar declination angle (p = 0.013) for the TATTR group. VAS and PROMIS pain interference (PI) scores demonstrated an initial significant improvement in pain, but this improvement did not maintain significance at most recent follow-up. However, there was a significant increase in the PROMIS physical function (PF) scores (p = 0.037) at most recent follow-up.

CONCLUSION

These results demonstrate that TTR and TATTR provide significant improvement in post-operative radiographic foot and ankle alignment and physical function at the two-year timepoint. PRO findings suggest that patients are more active after surgery. Surgeons considering proceeding with either of these procedures should counsel patients about pain and functional outcomes as well as realistic expectations in patients with depression.

LEVEL OF EVIDENCE

Level 3.

Depression as a prognostic factor for lumbar spinal stenosis outcomes: a systematic review

PURPOSE

Lumbar spinal stenosis (LSS) is associated with increased levels of psychological distress, including depression; however, the prognostic value of depression remains unclear. The purpose of this systematic review was to synthesize the evidence on the prognostic value of depression for a range of outcomes in patients with LSS.

METHODS

Inclusion criteria were prospective cohort studies that investigated depression in patients diagnosed with LSS. Searches were conducted in 7 databases. Critical appraisal, data extraction, and judgement of cumulative evidence were conducted independently by two reviewers. A meta-analysis was not conducted due to a lack of unique cohorts for each outcome, varying follow-up times, and differences in measurements for both prognostic factors and outcomes.

RESULTS

Twenty-three articles were included. There was evidence for an association between preoperative depression and postoperative disability and symptom severity outcomes for patients with LSS. Odds ratios ranged from 1.15 to 2.94 for postoperative disability and 1.16-1.20 for symptom severity at various follow-up times. Using GRADE, evidence supporting depression as a prognostic factor for these LSS outcomes was deemed to be of moderate quality. Similarly strong evidence suggested depressive symptoms are of no prognostic value for postoperative walking capacity.

CONCLUSION

Depression appears to have small to moderate prognostic value for LSS outcomes, with the strongest evidence for postoperative disability and symptom severity. The prognostic value of depression for LSS outcomes should be further explored using standardized measures in additional cohorts, including patients managing their condition conservatively, who have been neglected in related research.

Central sensitization as a predictive factor for the surgical outcome in patients with lumbar spinal stenosis: a multicenter prospective study

PURPOSE

The impact of central sensitization (CS) on neurological symptoms and surgical outcomes in patients with lumbar spinal stenosis (LSS) remains unknown. This study aimed to investigate the influence of preoperative CS on the surgical outcomes of patients with LSS.

METHODS

A total of 197 consecutive patients with LSS (mean age 69.3) who underwent posterior decompression surgery with or without fusion were included in this study. The participants completed the CS inventory (CSI) scores and the following clinical outcome assessments (COAs) preoperatively and 12 months postoperatively: the Japanese Orthopaedic Association (JOA) score for back pain, JOA back pain evaluation questionnaire, and Oswestry Disability Index (ODI). The association between preoperative CSI scores and preoperative and postoperative COAs was analyzed, and postoperative changes were statistically evaluated.

RESULTS

The preoperative CSI score significantly decreased at 12 months postoperatively and was significantly correlated with all COAs preoperatively and 12 months postoperatively. Higher preoperative CSI showed worse postoperative COAs and inferior postoperative improvement rates in the JOA score, VAS score for neurological symptoms, and ODI. Multiple regression analysis demonstrated that preoperative CSI was significantly associated with postoperative low back pain (LBP), mental health, quality of life (QOL), and neurological symptoms at 12 months postoperatively.

CONCLUSIONS

Preoperative CS evaluated by CSI had a significantly worse impact on surgical outcomes, including neurological symptoms, disability, and QOL, especially related to LBP and psychological factors. CSI can be used clinically as a patient-reported measure for predicting postoperative outcomes in patients with LSS.

Associations between future health expectations and patient satisfaction after lumbar spine surgery: a longitudinal observational study of 9929 lumbar spine surgery procedures

OBJECTIVE

This study aimed to investigate the associations between general health expectations and patient satisfaction with treatment for the two common spine surgery procedures diskectomy for lumbar disk herniation (LDH) and decompression for lumbar spinal stenosis (LSS).

DESIGN

Register study with prospectively collected preoperative and 1-year postoperative data.

SETTING

National outcome data from Swespine, the national Swedish spine register.

PARTICIPANTS

A total of 9929 patients, aged between 20 and 85 years, who were self-reported non-smokers, and were operated between 2007 and 2016 for one-level LSS without degenerative spondylolisthesis, or one-level LDH, were identified in the national Swedish spine register (Swespine). We used SF-36 items 11c and 11d to assess future health expectations and present health perceptions. Satisfaction with treatment was assessed using the Swespine satisfaction item.

INTERVENTIONS

One-level diskectomy for LDH or one-level decompression for LSS.

PRIMARY OUTCOME MEASURES

Satisfaction with treatment.

RESULTS

For LSS, the year 1 satisfaction ratio among patients with negative future health expectations preoperatively was 60% (95% CI 58% to 63%), while it was 75% (95% CI 73% to 76%) for patients with positive future health expectations preoperatively. The corresponding numbers for LDH were 73% (95% CI 71% to 75%) and 84% (95% CI 83% to 85%), respectively.

CONCLUSIONS

Patients operated for the common lumbar spine diseases LSS or LDH, with negative future general health expectations, were significantly less satisfied with treatment than patients with positive expectations with regard to future general health. These findings are important for patients, and for the surgeons who counsel them, when surgery is a treatment option for LSS or LDH.

Preoperative Depression Screening in Primary Lumbar Fusion: An Evaluation of Its Modifiability on Outcomes in Patients with Diagnosed Depressive Disorder

OBJECTIVE

Studies have reported the detrimental effects of depression following spine surgery; however, none have evaluated whether preoperative depression screening in patients with a history of depression is protective from adverse outcomes and lowers health care costs. We studied whether depression screenings/psychotherapy visits within 3 months before 1- to 2-level lumbar fusion were associated with lower medical complications, emergency department utilization, readmissions, and health care costs.

METHODS

The PearlDiver database from 2010 to 2020 was queried for depressive disorder (DD) patients undergoing primary 1- to 2-level lumbar fusion. Two cohorts were 1:5 ratio matched and included DD patients with (n = 2,622) and DD patients without (n = 13,058) a preoperative depression screen/psychotherapy visit within 3 months of lumbar fusion. A 90-day surveillance period was used to compare outcomes. Logistic regression models computed odds ratio (OR) of complications and readmissions. P value < 0.003 was significant.

RESULTS

DD patients without depression screening had significantly greater incidence and odds of experiencing medical complications (40.57% vs. 16.00%; OR 2.71, P < 0.0001). Rates of emergency department utilization were increased in patients without screening versus screening (15.78% vs. 4.23%; OR 4.25, P < 0.0001), despite no difference in readmissions (9.31% vs. 9.53%; OR 0.97, P = 0.721). Finally, 90-day reimbursements ($51,160 vs. $54,731) were significantly lower in the screened cohort (all P < 0.0001).

CONCLUSIONS

Patients who underwent a preoperative depression screening within 3 months of lumbar fusion had decreased medical complications, emergency department utilization, and health care costs. Spine surgeons may use these data to counsel their patients with depression before surgical intervention.

Influence of preoperative depression on clinical outcomes after cervical laminoplasty: A retrospective study

Background

Depression is a highly prevalent mental disorder, and we found that patients with preoperative depression had worse postoperative improvement in lumbar fusion. Are mental factors related to the prognosis of laminoplasty?

Objective

To analyze the relationship between depression and clinical outcomes after laminoplasty for the treatment of multilevel CSM.

Methods

In this retrospective study, 115 patients with multilevel cervical spondylotic myelopathy (CSM), who underwent laminoplasty and were followed up for more than 1 year, were enrolled in this study from October 2018 to October 2021. Patients with the scores of 21-item Beck Depression Inventory (BDI) ≥ 15 or Hamilton Depression Scale-24 (HAMD-24) > 20 were included in the depression group. The clinical outcomes were evaluated by the changes and recovery rate (RR) of Japanese Orthopaedic Association Scores (JOA) and Neck Disability Index (NDI) respectively. Univariate and multiple linear regression analyses were performed to reveal the relationship between preoperative depressive states and clinical outcomes.

Results

Fourteen patients were diagnosed with depression by BDI and twenty-nine by HAMD-24. Between the depression group and the non-depression group, the age, gender, smoking history, and duration of symptoms were statistically significant (P < 0.05). Multiple linear regression showed that the BDI scores had a negative relationship with the changes and RR of JOA and NDI, and the HAMD-24 scores had a negative relationship with the changes and RR of JOA.

Conclusions

Preoperative depression in patients with multilevel CSM can lead to worse prognosis. In order to improve the curative effect of the operation, we should pay attention to the psychological state monitoring and intervention of patients before they receive laminoplasty.

Japanese Orthopaedic Association (JOA) clinical practice guidelines on the management of lumbar spinal stenosis, 2021 - Secondary publication

BACKGROUND

The Japanese Orthopaedic Association (JOA) guideline for the management of lumbar spinal stenosis (LSS) was first published in 2011. Since then, the medical care system for LSS has changed and many new articles regarding the epidemiology and diagnostics of LSS, conservative treatments such as new pharmacotherapy and physical therapy, and surgical treatments including minimally invasive surgery have been published. In addition, various issues need to be examined, such as verification of patient-reported outcome measures, and the economic effect of revised medical management of patients with lumbar spinal disorders. Accordingly, in 2019 the JOA clinical guidelines committee decided to update the guideline and consequently established a formulation committee. The purpose of this study was to describe the formulation we implemented for the revision of the guideline, incorporating the recent advances of evidence-based medicine.

METHODS

The JOA LSS guideline formulation committee revised the previous guideline based on the method for preparing clinical guidelines in Japan proposed by the Medical Information Network Distribution Service in 2017. Background and clinical questions were determined followed by a literature search related to each question. Appropriate articles based on keywords were selected from all the searched literature. Using prepared structured abstracts, systematic reviews and meta-analyses were performed. The strength of evidence and recommendations for each clinical question was decided by the committee members.

RESULTS

Eight background and 15 clinical questions were determined. Answers and explanations were described for the background questions. For each clinical question, the strength of evidence and the recommendation were both decided, and an explanation was provided.

CONCLUSIONS

The 2021 clinical practice guideline for the management of LSS was completed according to the latest evidence-based medicine. We expect that this guideline will be useful for all medical providers as an index in daily medical care, as well as for patients with LSS.

Feasibility and Assessment of a Machine Learning-Based Predictive Model of Outcome After Lumbar Decompression Surgery

STUDY DESIGN

Retrospective study at a unique center.

OBJECTIVE

The aim of this study is twofold, to develop a virtual patients model for lumbar decompression surgery and to evaluate the precision of an artificial neural network (ANN) model designed to accurately predict the clinical outcomes of lumbar decompression surgery.

METHODS

We performed a retrospective study of complete Electronic Health Records (EHR) to identify potential unfavorable criteria for spine surgery (predictors). A cohort of synthetics EHR was created to classify patients by surgical success (green zone) or partial failure (orange zone) using an Artificial Neural Network which screens all the available predictors.

RESULTS

In the actual cohort, we included 60 patients, with complete EHR allowing efficient analysis, 26 patients were in the orange zone (43.4%) and 34 were in the green zone (56.6%). The average positive criteria amount for actual patients was 8.62 for the green zone (SD+/- 3.09) and 10.92 for the orange zone (SD 3.38). The classifier (a neural network) was trained using 10,000 virtual patients and 2000 virtual patients were used for test purposes. The 12,000 virtual patients were generated from the 60 EHR, of which half were in the green zone and half in the orange zone. The model showed an accuracy of 72% and a ROC score of 0.78. The sensitivity was 0.885 and the specificity 0.59.

CONCLUSION

Our method can be used to predict a favorable patient to have lumbar decompression surgery. However, there is still a need to further develop its ability to analyze patients in the "failure of treatment" zone to offer precise management of patient health before spinal surgery.

Impact of Depression on Patient Reported Outcomes Following Primary Versus Revision ACDF

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

To assess the relationship of depressive symptoms with patient reported outcome measures (PROMs) in patients undergoing either primary or revision anterior cervical discectomy and fusion (ACDF) procedures.

SUMMARY OF BACKGROUND

Depression has been associated with poorer outcomes following ACDF. However, research examining the relationship between depression and PROMs in revision ACDF procedures is limited.

METHODS

A prospective database was retrospectively reviewed for primary or revision, single- or multilevel ACDF procedures from 2016 to 2019. Patients lacking preoperative Patient Health Questionnaire-9 (PHQ-9) surveys were excluded. Demographic and perioperative characteristics were recorded and analyzed using Fisher's exact test or t test. Patient-reported outcome measures were collected preoperatively and postoperatively. Postoperative improvement from baseline scores (ΔPROM) was calculated at all postoperative timepoints. Differences in mean PROM and ΔPROM between groups and changes from baseline PROM scores within groups were assessed using Student's t test. Linear regression analyzed the impact of preoperative PHQ-9 on ΔPROM.

RESULTS

A total of 143 patients (121 primary and 22 revision) were included. Significant differences between groups were demonstrated at the preoperative timepoint for Neck Disability Index (NDI) (P = 0.022). ΔPROM values did not significantly differ between groups. Regression analysis revealed significant relationships between preoperative PHQ-9 and ΔPHQ-9 at all timepoints, ΔVAS neck at 6-weeks and 6-months, ΔVAS arm at 6-months, and ΔNDI at 6-weeks and 6-months for the primary group (all P < 0.05). Regression analysis revealed no significant associations for the revision group.

CONCLUSION

Primary or revision ACDF procedures did not significantly differ in depressive symptoms through 1-year. Primary ACDF patients significantly improved in all PROMs through all timepoints, while revision patients had limited improvement in PROMs. Preoperative depression may have a stronger association on postoperative outcomes for primary procedures.Level of Evidence: 3.

The influence of comorbidities on the treatment outcome in symptomatic lumbar spinal stenosis: A systematic review and meta-analysis

BACKGROUND

Lumbar spinal stenosis (LSS) affects mainly elderly patients. To this day, it is unclear whether comorbidities influence treatment success. The aim of this systematic review and meta-analysis was to assess the impact of comorbidities on the treatment effectiveness in symptomatic LSS.

METHODS

We conducted a systematic review and meta-analysis and reviewed prospective or retrospective studies from Medline, Embase, Cochrane Library and CINAHL from inception to May 2020, including adult patients with LSS undergoing surgical or conservative treatment. Main outcomes were satisfaction, functional and symptoms improvement, and adverse events (AE). Proportions of outcomes within two subgroups of a comorbidity were compared with risk ratio (RR) as summary measure. Availability of ≥3 studies for the same subgroup and outcome was required for meta-analysis.

RESULTS

Of 72 publications, 51 studies, mostly assessing surgery, there was no evidence reported that patients with comorbidities were less satisfied compared to patients without comorbidities (RR 1.06, 95% confidence interval (CI) 0.77 to 1.45, I 2 94%), but they had an increased risk for AE (RR 1.46, 95% CI 1.06 to 2.01, I 2 72%). A limited number of studies found no influence of comorbidities on functional and symptoms improvement. Older age did not affect satisfaction, symptoms and functional improvement, and AE (age >80 years RR 1.22, 95% CI 0.98 to 1.52, I 2 60%). Diabetes was associated with more AE (RR 1.72, 95% CI 1.19 to 2.47, I 2 58%).

CONCLUSION

In patients with LSS and comorbidities (in particular diabetes), a higher risk for AE should be considered in the treatment decision. Older age alone was not associated with an increased risk for AE, less functional and symptoms improvement, and less treatment satisfaction.

Are Patient-Reported Outcomes of Minimally Invasive Transforaminal Lumbar Interbody Fusion Influenced by Preoperative Mental Health?

STUDY DESIGN

This was a retrospective review of prospectively collected data.

OBJECTIVES

Few studies have described the relationship between mental health and patient-reported outcome measures (PROMs) after minimally invasive spine surgery. Prior studies on open surgery included small cohorts with short follow-ups.

METHODS

Patients undergoing primary minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) for degenerative pathology were retrospectively reviewed and stratified by Short Form (SF-36) Mental Component Summary (MCS): low MCS (<50, n = 436) versus high MCS (≥50, n = 363). PROMs assessed were back pain, leg pain, North American Spine Society Neurogenic Symptoms, Oswestry Disability Index, SF-36 Physical Component Summary, and MCS. Satisfaction, expectation fulfilment, and return to work (RTW) rates also were recorded at 1 month, 3 months, 6 months, and 2 years.

RESULTS

Preoperative MCS was 39.4 ± 8.6 and 58.5 ± 5.4 in the low and high MCS groups, respectively (P < .001). The low MCS group had significantly poorer preoperative PROMs and longer lengths of stay. Despite this, both groups achieved comparable PROMs from 3 months onward. The mean MCS was no longer significantly different by 3 months (P = .353). The low MCS group had poorer satisfaction (P = .022) and expectation fulfilment (P = .020) at final follow-up. RTW rates were initially lower in the low MCS group up to 3 months (P = .034), but the rates converged from 6 months onward.

CONCLUSIONS

Despite poorer PROMs preoperatively, patients with poor baseline mental health still achieved comparable results from 3 months up to 2 years after MIS-TLIF. Preoperative optimization of mental health should still be pursued to improve satisfaction and prevent delayed RTW after surgery.

Does the Preoperative Depression Affect Clinical Outcomes in Adults With Following Lumbar Fusion?: A Retrospective Cohort Study

STUDY DESIGN

This was a retrospective cohort review.

OBJECTIVE

The objective of this study was to analyze depression using Beck Depression Inventory (BDI) and Hamilton Depression Scale (HAMD-24), and to correlate with clinical outcomes and improvement in adults with following lumbar fusion.

SUMMARY OF BACKGROUND DATA

Psychological factors such as depression are found to influence outcomes and improvement following spinal surgery. It is still unclear whether there are differences during screening for depression by different implementations to predict outcomes for spine surgery.

MATERIALS AND METHODS

Between July 2016 and May 2018, patients with degenerative lumbar disease, who underwent lumbar fusion were enrolled in this study. The patient's characteristics, preoperative BDI and HAMD-24 score, and preoperative and postoperative outcomes were collected, respectively. Depressed patients were identified by a score of BDI≥15 or HAMD-24>20, respectively. Preoperative and postoperative outcome scores, absolute changes, and recovery ratios of disability and pain were compared within and between groups. Finally, univariate and multiple linear regression analyses was performed to reveal the relationship between preoperative depressive states and outcomes and improvement.

RESULTS

A total of 125 patients were eligible in the study, with 113 (90.4%) patients without depressive symptoms and 12 (9.6%) depressed patients by BDI, and 97 (77.6%) patients without depressive symptoms and 28 (22.4%) depressed patients by HAMD-24. Both higher BDI and HAMD-24 group was found to have significant worse preoperative and postoperative outcomes as well as less recovery ratios than the patients without depressive symptoms. Univariate and multiple linear regression analyses suggested that preoperative depression might be a potential predictor of worse surgical outcomes.

CONCLUSIONS

Depressive symptoms might lead to smaller magnitude of improvement. Moreover, both preoperative BDI and HAMD-24 score was a negative predictor of postoperative outcomes and can be regarded as a candidate to screen for depression preoperatively.

Patterns and Impact of Electronic Health Records-Defined Depression Phenotypes in Spine Surgery

BACKGROUND

Preoperative depression is a risk factor for poor outcomes after spine surgery.

OBJECTIVE

To understand effects of depression on spine surgery outcomes and healthcare resource utilization.

METHODS

Using IBM's MarketScan Database, we identified 52 480 patients who underwent spinal fusion. Retained patients were classified into 6 depression phenotype groups based on International Classification of Disease, 9th/10th Revision (ICD-9/10) codes and use/nonuse of antidepressant medications: major depressive disorder (MDD), other depression (OthDep), antidepressants for other psychiatric condition (PsychRx), antidepressants for physical (nonpsychiatric) condition (NoPsychRx), psychiatric condition only (PsychOnly), and no depression (NoDep). We analyzed baseline demographics, comorbidities, healthcare utilization/payments, and chronic opioid use.

RESULTS

Breakdown of groups in our cohort: MDD (15%), OthDep (12%), PsychRx (13%), NonPsychRx (15%), PsychOnly (12%), and NoDep (33%). Postsurgery: increased outpatient resource utilization, admissions, and medication refills at 1, 2, and 5 yr in the NoDep, PsychOnly, NonPsychRx, PsychRx, and OthDep groups, and highest in MDD. Postoperative opioid usage rates remained unchanged in MDD (44%) and OthDep (36%), and reduced in PsychRx (40%), NonPsychRx (31%), and PsychOnly (20%), with greatest reduction in NoDep (13%). Reoperation rates: 1 yr after index procedure, MDD, OthDep, PsychRx, NonPsychRx, and PsychOnly had more reoperations compared to NoDep, and same at 2 and 5 yr. In NoDep patients, 45% developed new depressive phenotype postsurgery.

CONCLUSION

EHR-defined classification allowed us to study in depth the effects of depression in spine surgery. This increased understanding of the interplay of mental health will help providers identify cohorts at risk for high complication rates, and health care utilization.

Depression Identified on the Mental Component Score of the Short Form-12 Affects Health Related Quality of Life After Lumbar Decompression Surgery

STUDY DESIGN

This was a retrospective comparative study.

OBJECTIVE

The goal of this study was to further elucidate the relationship between preoperative depression and patient-reported outcome measurements (PROMs) following lumbar decompression surgery.

SUMMARY OF BACKGROUND DATA

The impact of preoperative depression on PROMs after lumbar decompression surgery is not well established.

METHODS

Patients undergoing lumbar decompression between 1 and 3 levels were retrospectively identified. Patients were split into 2 groups using a preoperative Mental Component Score (MCS)-12 threshold score of 45.6 or 35.0 to identify those with and without depressive symptoms. In addition, patients were also split based on a pre-existing diagnosis of depression in the medical chart. Absolute PROM scores, the recovery ratio and the percent of patients achieving minimum clinically important difference between groups were compared, and a multiple linear regression analysis was performed.

RESULTS

A total of 184 patients were included, with 125 (67.9%) in the MCS-12 >45.6 group and 59 (32.1%) in the MCS-12 ≤45.6 group. The MCS-12 ≤45.6 and MCS<35.0 group had worse baseline Oswestry Disability Index (ODI) (P<0.001 for both) and Visual Analogue Scale Leg (P=0.018 and 0.024, respectively) scores. The MCS ≤45.6 group had greater disability postoperatively in terms of SF-12 Physical Component Score (PCS-12) (39.1 vs. 43.1, P=0.015) and ODI (26.6 vs. 17.8, P=0.006). Using regression analysis, having a baseline MCS-12 scores ≤45.6 before surgical intervention was a significant predictor of worse improvement in terms of PCS-12 [β=-4.548 (-7.567 to -1.530), P=0.003] and ODI [β=8.234 (1.433, 15.035), P=0.010] scores than the MCS-12 >45.6 group.

CONCLUSION

Although all patients showed improved in all PROMs after surgery, those with MCS-12 ≤45.6 showed less improvement in PCS-12 and ODI scores.

Are Preoperative PHQ-9 Scores Predictive of Postoperative Outcomes Following Anterior Cervical Discectomy and Fusion?

STUDY DESIGN

This is a retrospective study.

OBJECTIVE

The objective of this study was to determine if there is an association between preoperative depression, as quantified by Patient Health Questionnaire-9 (PHQ-9), and postoperative improvement in pain and disability after anterior cervical discectomy and fusion (ACDF).

SUMMARY OF BACKGROUND DATA

Few studies have quantified depression symptoms in the preoperative period using PHQ-9 and have tracked patient-reported outcomes (PROs) following ACDF.

METHODS

Patients undergoing ACDF were retrospectively reviewed and stratified by their preoperative PHQ-9 score. PROs, including Neck Disability Index (NDI), Visual Analogue Scale (VAS) neck and arm pain, and 12-Item Short Form (SF-12) Physical Component Score (PCS), were measured preoperatively and at 6-week, 3-month, 6-month, and 1-year postoperatively. PRO scores were analyzed amongst PHQ-9 cohorts using multiple linear regression. Achievement of minimum clinically important difference (MCID) was compared using χ analysis.

RESULTS

Higher PHQ-9 scores were associated with increased preoperative NDI, VAS neck, and VAS arm scores and significantly lower SF-12 PCS scores preoperatively. Cohorts experienced similar VAS pain scores up to 1-year following surgery, except for VAS neck pain at 3 months when patients with greater depression symptoms had more pain. High PHQ-9 patients had higher NDI values at 6 weeks and 3-month marks but had similar NDI scores at 6 months and 1-year. Similarly, SF-12 PCS scores were lower for patients with a higher PHQ-9 score at 3 and 6 months, however, both groups had similar scores at 1-year follow-up. A greater percentage of the high PHQ-9 cohort achieved MCID for NDI, however, there were no differences in MCID achievement for VAS neck, VAS arm, or SF-12 PCS.

CONCLUSIONS

Patients with worse preoperative mental health reported significantly greater preoperative disability and pain. However, both cohorts demonstrated similar clinical recovery at the 1-year follow-up. These findings suggest patients with worse preoperative mental health can expect significant improvements in PROs following surgery.

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.

Validity of Patient Health Questionnaire-9 in Minimally Invasive Lumbar Interbody Fusion

STUDY DESIGN

Retrospective.

OBJECTIVE

The aim of this study was to evaluate the validity of Patient Health Questionnaire-9 (PHQ-9) among patients undergoing minimally invasive (MIS) lumbar interbody fusion.

SUMMARY OF BACKGROUND DATA

Few studies have evaluated the utility and concurrent validity of the PHQ-9 survey in patients undergoing spinal procedures.

METHODS

Patients undergoing a one- or two-level MIS lumbar interbody fusion were retrospectively reviewed. Patient-reported outcome surveys were completed preoperatively and at 6-week, 12-week, 6-month, and 1-year timepoints. Postoperative survey scores were compared to preoperative values using paired t tests. PHQ-9 scores were compared with the Mental Component Summary (MCS) scores of the Short Form-12 (SF-12) and the Veterans RAND-12 (VR-12) surveys at each timepoint using the Pearson correlation coefficient.

RESULTS

A total of 215 patients were included in the analysis. The mean preoperative scores for the PHQ-9, SF-12 MCS, and VR-12 MCS were 6.78, 49.55, and 50.39, respectively. Significant improvements in each survey outcome measure were observed at all postoperative timepoints. Strong correlations with PHQ-9 scores were identified for SF-12 MCS scores and VR-12 MCS scores at preoperative and postoperative timepoints (|r| ≥ 0.5 and P < 0.05 for each).

CONCLUSION

This study demonstrated that mental health, as measured by the PHQ-9, SF-12 MCS, and VR-12 MCS surveys, improves significantly after MIS lumbar fusion. In addition, PHQ-9 scores were strongly correlated with SF-12 and VR-12 scores. These results suggest that PHQ-9 can be a valid assessment of baseline mental health and postoperative improvement after MIS lumbar fusion. Concordant results among PHQ-9, SF-12 MCS, and VR-12 indicate that the simultaneous utilization of multiple survey instruments may not be necessary. Limiting the number of questionnaires that are administered in the evaluation of mental health could also help reduce survey burden placed on patients.

LEVEL OF EVIDENCE

3.

Perioperative Considerations for Patients With Major Depressive Disorder Undergoing Surgery

In the United States, approximately 15% of adults suffer from major depressive disorder (MDD), which results in an annual cost of over $200 billion per year. In the perioperative setting, MDD is associated with increased morbidity and mortality. The exact causes of the increase in adverse outcomes are unknown. Major depression affects virtually all major systems in the human body, and most antidepressants affect dopamine, norepinephrine, and serotonin levels or alter their target receptors. Unfortunately, anesthesia and medications used in the perioperative period affect the same neurotransmitters. As a result, patients with MDD are at an increased risk for cardiovascular effects, altered thermoregulation, and postoperative cognitive dysfunction. To determine when to continue or hold antidepressants preoperatively and avoid potential drug interactions, perioperative providers must understand the pharmacological action of antidepressants. This article reviews the pathophysiology of MDD, mechanism of action of antidepressants, and perioperative considerations for patients on antidepressant medications.

Outcomes associated with behavioral evaluation and counseling for patients undergoing orthopaedic surgery - A systematic review

Osteochondral allograft transplantation can be an effective way to treat cartilage defects in the knee. The objective of this systematic review was to evaluate available research on the effects of preoperative behavioral evaluation and counseling on the outcomes for patients undergoing orthopaedic surgery with emphasis on osteochondral allograft transplantation in the knee. This systematic review of best current evidence indicates that psychological distress and untreated mental health issues are strongly associated with unfavorable outcomes after treatment of orthopaedic disorders, underscoring the need to incorporate behavioral screening and counseling into a comprehensive patient management protocol that improves outcomes for patients.

Preoperative Mental Health May Not Be Predictive of Improvements in Patient-Reported Outcomes Following a Minimally Invasive Transforaminal Lumbar Interbody Fusion

Background

Prior literature has associated poor preoperative mental health with inferior patient-reported outcomes (PROs) after spinal procedures. Therefore, the objective of this study was to test for association of preoperative Short Form 12 (SF-12) mental health composite score (MCS) with improvements in Oswestry Disability Index (ODI) and back and leg visual analogue scale (VAS) pain scores after a minimally invasive transforaminal lumbar interbody fusion (MIS TLIF).

Methods

A surgical database of patients who underwent a primary, 1 level MIS TLIF was reviewed. Preoperative SF-12 MCS was tested for association with preoperative ODI, back VAS, and leg VAS. Preoperative MCS was then tested for association with changes in ODI, back VAS, and leg VAS from preoperative to postoperative visits. These tests were conducted using multivariate regression controlling for baseline characteristics and the preoperative score of the PRO being assessed.

Results

A total of 113 patients were included in the analysis. At baseline, higher preoperative MCS was associated with lower preoperative ODI (coefficient: -0.58, P < .001), lower preoperative back VAS (-0.05, P = .003), and lower preoperative leg VAS (-0.06, P = .003). However, there was no association between preoperative MCS and improvement in PROs at any postoperative timepoint (P > .05). The percent of patients achieving a minimum clinically important difference in PROs at 6 months did not differ between the bottom and top MCS halves (P > .05).

Conclusions

The results of this study suggest that better preoperative mental health is associated with lower perceived preoperative disability and decreased severity of back and leg pain. In contrast to other studies, the present study was unable to demonstrate that preoperative mental health is predictive of improvement in PROs at any postoperative timepoint after MIS TLIF.

Level of Evidence

3.

Clinical Relevance

These results suggest that surgeons should exercise care in assuming that patients with poorer preoperative mental health are inferior surgical candidates.

Evaluation of Postoperative Mental Health Outcomes in Patients Based on Patient-Reported Outcome Measurement Information System Physical Function Following Anterior Cervical Discectomy and Fusion

OBJECTIVE

To assess the relationship of preoperative physical function, as measured by Patient-Reported Outcome Measurement Information System Physical Function (PROMIS PF), to improvement in mental health, as evaluated by Short Form-12 Mental Component Summary (SF-12 MCS) following anterior cervical discectomy and fusion (ACDF).

METHODS

Patients undergoing primary ACDF were retrospectively reviewed and stratified based on preoperative PROMIS PF scores. PROMIS PF cohorts were tested for an association with demographic characteristics and perioperative variables using chi-square analysis and multivariate linear regression. Multivariate linear regression was utilized to determine the association between PROMIS PF cohorts and improvement in SF-12 MCS.

RESULTS

A total of 129 one- to 3-level ACDF patients were included: 73 had PROMIS PF < 40 ("low PROMIS") and 56 had PROMIS PF ≥ 40 ("high PROMIS"). The low PROMIS cohort reported worse mental health preoperatively and at all postoperative timepoints except for 1 year. Both cohorts had similar changes in mental health from baseline through the 6-month follow-up. However, at 1 year. postoperatively, the low PROMIS cohort had a statistically greater change in mental health score.

CONCLUSION

Patients with worse preoperative physical function reported significantly worse preoperative and postoperative mental health. However, patients with worse preoperative physical function made significantly greater improvements in mental health from baseline. This suggests that patients with worse preoperative physical function can still expect significant improvements in mental health following surgery.

The Influence of Preoperative Mental Health on PROMIS Physical Function Outcomes Following Minimally Invasive Transforaminal Lumbar Interbody Fusion

STUDY DESIGN

Retrospective.

OBJECTIVE

To demonstrate whether preoperative mental health status can be predictive of postoperative functional outcomes as measured by Patient-Reported Outcome Measurement Information System Physical Function (PROMIS PF) following minimally invasive transforaminal lumbar interbody fusion (MIS TLIF).

SUMMARY OF BACKGROUND DATA

There is a paucity of scientific investigations into the association between preoperative mental health as evaluated by a validated questionnaire such as the Short Form-12 Mental Health Composite Score (SF-12 MCS) and postoperative outcomes following MIS TLIF.

METHODS

Patients undergoing a primary MIS TLIF were retrospectively reviewed and stratified into cohorts based on preoperative SF-12 MCS scores. The Physical Function scores of PROMIS, of which there are other domains including Pain Interference, Sexual Function, and Cognitive Function, were compared between the cohorts. In addition, the improvement in PROMIS scores based on preoperative SF-12 MCS scores following MIS TLIF was analyzed using multivariate linear regression.

RESULTS

One hundred seventy-two patients were included: 85 patients (49.4%) had a preoperative SF-12 MCS score <50 and 87 (50.6%) had a preoperative SF-12 MCS score ≥50. Patients with poorer mental health demonstrated significantly worse PROMIS PF scores preoperatively (33.8 vs. 36.5, P < 0.001), as well as at all postoperative timepoints: 6-weeks (35.1 vs. 38.4, P < 0.001), 3-months (38.9 vs. 42.9, P < 0.001), 6-months (41.4 vs. 45.5, P < 0.001), and 1-year (42.4 vs. 47.6, P < 0.001). However, at the 1-year timepoint, patients with worse mental health reported experiencing significantly less improvement from baseline (postoperative change of 8.6 vs. 11.1, P = 0.002).

CONCLUSION

Patients with worse preoperative mental health not only demonstrated worse preoperative PROMIS PF scores, but also continued to have significantly worse postoperative outcomes. However, the postoperative improvement experienced by patients was similar in the short-term following surgery regardless of preoperative mental health status. Patients with poor mental health experienced significantly less postoperative improvement only at the 1-year timepoint.

LEVEL OF EVIDENCE

3.

Impact of Expression and Genetic Variation of microRNA-34b/c on Cognitive Dysfunction in Patients with Major Depressive Disorder

BACKGROUND

Patients suffering from major depressive disorder (MDD) commonly demonstrate lower performance across multiple cognitive domains. Cognitive impairment is an intrinsic characteristic of MDD status and is often influenced by genetic factors. microRNAs (miRNAs or miRs) have been shown to have important implications in the etiology of MDD. Therefore, we aimed to identify and analyze the impact of expression and genetic variation of miR-34b/c on cognitive dysfunction in MDD.

METHODS

First, we analyzed miR-34c-5p expression in 48 cases of MDD and 54 healthy controls in a Chinese population using qRT-PCR. We assessed the relationship between the level of miR-34c-5p expression and cognitive performance by Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) and the Trail Making Test (TMT). Second, in order to characterize allelic effects of miR-34b/c on cognitive performance in MDD patients, we performed genetic association analysis of single-nucleotide polymorphism (SNP) loci of the MIR34B/C genes with cognitive function in a second group consisting of 531 MDD patients and 267 healthy controls.

RESULTS

We found a significant negative correlation between the level of miR-34c-5p expression and both the language and delayed memory index scores in patients with MDD. We also found a significant positive correlation between the level of miR-34c-5p expression and the time required to complete tests A and B of the TMT. The interaction between the rs2187473 genotype and the disease was significant for both immediate memory and delayed memory. In the patient group, the rs2187473 CC genotype was significantly associated with higher performance on immediate memory (F = 6.683, p < 0.05) and delayed memory tasks (F = 4.221, p < 0.05).

CONCLUSION

Our findings suggest that changes in miR-34c expression level have important impacts on cognitive function in patients with MDD. In particular, the polymorphism rs2187473 is a potential genetic risk factor for cognitive function in MDD, which may be of clinical use.

The mechanisms of pain tolerance and pain-related anxiety in acute pain

This study emphasizes the role of pain catastrophizing and state anxiety on pain tolerance and pain-related anxiety. Response expectancies for pain tolerance and pain intensity were tested as potential mediators. A cold-pressor task was used on a healthy sample. Measures were taken before and after cold-pressor procedure, while aversive versus neutral information regarding the cold-pressor task was given prior to the pain induction. An exploratory path model was conducted. Similar paths for pain tolerance and for pain-related anxiety were shown in aversive condition. Also, psychological measures may explain pain experience in aversive context.

Preoperative depression, lumbar fusion, and opioid use: an assessment of postoperative prescription, quality, and economic outcomes

OBJECTIVE Preoperative depression has been linked to a variety of adverse outcomes following lumbar fusion, including increased pain, disability, and 30-day readmission rates. The goal of the present study was to determine whether preoperative depression is associated with increased narcotic use following lumbar fusion. Moreover, the authors examined the association between preoperative depression and a variety of secondary quality indicator and economic outcomes, including complications, 30-day readmissions, revision surgeries, likelihood of discharge home, and 1- and 2-year costs. METHODS A retrospective analysis was conducted using a national longitudinal administrative database (MarketScan) containing diagnostic and reimbursement data on patients with a variety of private insurance providers and Medicare for the period from 2007 to 2014. Multivariable logistic and negative binomial regressions were performed to assess the relationship between preoperative depression and the primary postoperative opioid use outcomes while controlling for demographic, comorbidity, and preoperative prescription drug-use variables. Logistic and log-linear regressions were also used to evaluate the association between depression and the secondary outcomes of complications, 30-day readmissions, revisions, likelihood of discharge home, and 1- and 2-year costs. RESULTS The authors identified 60,597 patients who had undergone lumbar fusion and met the study inclusion criteria, 4985 of whom also had a preoperative diagnosis of depression and 21,905 of whom had a diagnosis of spondylolisthesis at the time of surgery. A preoperative depression diagnosis was associated with increased cumulative opioid use (β = 0.25, p < 0.001), an increased risk of chronic use (OR 1.28, 95% CI 1.17-1.40), and a decreased probability of opioid cessation (OR 0.96, 95% CI 0.95-0.98) following lumbar fusion. In terms of secondary outcomes, preoperative depression was also associated with a slightly increased risk of complications (OR 1.14, 95% CI 1.03-1.25), revision fusions (OR 1.15, 95% CI 1.05-1.26), and 30-day readmissions (OR 1.19, 95% CI 1.04-1.36), although it was not significantly associated with the probability of discharge to home (OR 0.92, 95% CI 0.84-1.01). Preoperative depression also resulted in increased costs at 1 (β = 0.06, p < 0.001) and 2 (β = 0.09, p < 0.001) years postoperatively. CONCLUSIONS Although these findings must be interpreted in the context of the limitations inherent to retrospective studies utilizing administrative data, they provide additional evidence for the link between a preoperative diagnosis of depression and adverse outcomes, particularly increased opioid use, following lumbar fusion.

Development and Validation of a Prediction Model for Pain and Functional Outcomes After Lumbar Spine Surgery

Importance

Functional impairment and pain are common indications for the initiation of lumbar spine surgery, but information about expected improvement in these patient-reported outcome (PRO) domains is not readily available to most patients and clinicians considering this type of surgery.

Objective

To assess population-level PRO response after lumbar spine surgery, and develop/validate a prediction tool for PRO improvement.

Design, Setting, and Participants

This statewide multicenter cohort was based at 15 Washington state hospitals representing approximately 75% of the state's spine fusion procedures. The Spine Surgical Care and Outcomes Assessment Program and the survey center at the Comparative Effectiveness Translational Network prospectively collected clinical and PRO data from adult candidates for lumbar surgery, preoperatively and postoperatively, between 2012 and 2016. Prediction models were derived for PRO improvement 1 year after lumbar fusion surgeries on a random sample of 85% of the data and were validated in the remaining 15%. Surgical candidates from 2012 through 2015 were included; follow-up surveying continued until December 31, 2016, and data analysis was completed from July 2016 to April 2017.

Main Outcomes and Measures

Functional improvement, defined as a reduction in Oswestry Disability Index score of 15 points or more; and back pain and leg pain improvement, defined a reduction in Numeric Rating Scale score of 2 points or more.

Results

A total of 1965 adult lumbar surgical candidates (mean [SD] age, 61.3 [12.5] years; 944 [59.6%] female) completed baseline surveys before surgery and at least 1 postoperative follow-up survey within 3 years. Of these, 1583 (80.6%) underwent elective lumbar fusion procedures; 1223 (77.3%) had stenosis, and 1033 (65.3%) had spondylolisthesis. Twelve-month follow-up participation rates for each outcome were between 66% and 70%. Improvements were reported in function, back pain, and leg pain at 12 months by 306 of 528 surgical patients (58.0%), 616 of 899 patients (68.5%), and 355 of 464 patients (76.5%), respectively, whose baseline scores indicated moderate to severe symptoms. Among nonoperative patients, 35 (43.8%), 47 (53.4%), and 53 (63.9%) reported improvements in function, back pain, and leg pain, respectively. Demographic and clinical characteristics included in the final prediction models were age, sex, race, insurance status, American Society of Anesthesiologists score, smoking status, diagnoses, prior surgery, prescription opioid use, asthma, and baseline PRO scores. The models had good predictive performance in the validation cohort (concordance statistic, 0.66-0.79) and were incorporated into a patient-facing, web-based interactive tool (https://becertain.shinyapps.io/lumbar_fusion_calculator).

Conclusions and Relevance

The PRO response prediction tool, informed by population-level data, explained most of the variability in pain reduction and functional improvement after surgery. Giving patients accurate information about their likelihood of outcomes may be a helpful component in surgery decision making.

Disability, emotional distress and well-being among patients with lumbar spondylolisthesis

AIM AND OBJECTIVE

To explore the disability, emotional distress and well-being of patients with lumbar spondylolisthesis.

BACKGROUND

Few studies have investigated the correlations between disability, emotional distress and well-being of patients with lumbar spondylolisthesis.

DESIGN

This study used a cross-sectional research design.

METHODS

Participants were 133 patients aged over 50 years who were experiencing lumbar spondylolisthesis. The research instruments included a demographic information questionnaire; the Numeric Rating Scale (NRS); the Charlson Comorbidity Index (CCI); the Chinese versions of the Oswestry Disability Index (ODI), State-Trait Anxiety Inventory-State (STAI-S) and Center for Epidemiological Study-Depression (CES-D); and the Psychological Well-being (PWB) Scale. Emotional distress was measured by the STAI-S and CES-D. Pearson's correlations coefficient, multiple linear regression and a mediating effect model were introduced to explore correlations between the variables and predictors of psychological well-being, and details of the methods are reported in coherence to STROBE criteria.

RESULTS

Eighty-six participants (64.6%) had moderate and severe anxiety, and 42 (31.6%) experienced depression. Participants reported medium to high levels of well-being; "satisfaction with interpersonal relationships" was rated the highest and "physical and mental health" the lowest. Disability, depression and anxiety had significant negative correlations with well-being. Depression and anxiety mediated the relationship between disability and well-being. Moreover, depression, family support, educational background and anxiety were predictors of well-being, accounting for 39.1% of the total variance.

CONCLUSIONS

Disability and emotional distress among patients with lumbar spondylolisthesis had a negative impact on well-being. Anxiety and depression were closely correlated with and substantially influenced well-being.

RELEVANCE TO CLINICAL PRACTICE

Health professionals will enhance the understanding of important factors influencing well-being among patients with lumbar spondylolisthesis. This study suggests the conduct of depression and anxiety evaluations at outpatient clinics and prior to surgery, so that clinicians will be aware of the emotional distress status of patients with lumbar spondylolisthesis and, therefore, enhance their well-being.

Poor Baseline Mental Health Does Not Influence Improvement in Patient-reported Outcomes, Satisfaction, and Return to Work Two Years After Single-level Anterior Cervical Discectomy and Fusion

STUDY DESIGN

Retrospective study using prospectively collected registry data.

OBJECTIVE

The authors examine the influence of preoperative mental health on outcomes after anterior cervical discectomy and fusion (ACDF) and determine the impact of ACDF on postoperative mental health.

SUMMARY OF BACKGROUND DATA

While studies have reported a negative correlation between preoperative mental health and outcomes following lumbar spine surgery, the influence on outcomes following cervical spine surgery remains relatively understudied.

METHODS

Prospectively collected registry data of 104 patients who underwent single-level ACDF for cervical spondylotic myelopathy were reviewed. Patients were dichotomized into top and bottom halves based on preoperative SF-36 MCS (Mental Component Summary) using a cutoff of 48. Outcomes assessed were visual analogue scale for neck pain, arm pain, AAOS Neck Pain and Disability, Neurogenic Symptoms, Neck Disability Index, Short-Form 36, Japanese Orthopaedic Association myelopathy score, return to work, return to function, satisfaction and expectation fulfilment up to 2 years postoperatively.

RESULTS

The preoperative MCS was 37.5 ± 8.1 and 57.4 ± 6.3 in the Low and High MCS groups respectively (P < 0.001). The Low MCS group had poorer preoperative scores (P < 0.05). There was no significant difference in length of stay or comorbidities (P > 0.05). The High MCS group had less neck pain (P = 0.002) and showed a trend towards lower Neck Disability Index (P = 0.062) at 2 years. The Low MCS group demonstrated greater improvement in Japanese Orthopaedic Association (P = 0.007) and similar improvement in other scores (P > 0.05). There was no significant difference in proportion that achieved minimal clinically important difference for each score (P > 0.05). Both groups had similar rates of return to work, return to function, expectation fulfilment, and satisfaction (P > 0.05). Lower preoperative MCS was predictive of greater improvement in MCS (r = -0.477, P < 0.001).

CONCLUSION

Despite relatively greater pain and disability at 2 years, patients with poor baseline mental health experienced similar improvement in clinical outcomes, return to work, and satisfaction rates.

LEVEL OF EVIDENCE

3.

Patient phenotypes associated with outcome following surgery for mild degenerative cervical myelopathy: a principal component regression analysis

BACKGROUND CONTEXT

Predictors of outcome after surgery for degenerative cervical myelopathy (DCM) have been determined previously through hypothesis-driven multivariate statistical models that rely on a priori knowledge of potential confounders, exclude potentially important variables because of restrictions in model building, cannot include highly collinear variables in the same model, and ignore intrinsic correlations among variables.

PURPOSE

The present study aimed to apply a data-driven approach to identify patient phenotypes that may predict outcomes after surgery for mild DCM.

STUDY DESIGN

This is a principal component analysis of data from two related prospective, multicenter cohort studies.

PATIENT SAMPLE

The study included patients with mild DCM, defined by a modified Japanese Orthopaedic Association score of 15-17, undergoing surgical decompression as part of the AOSpine CSM-NA or CSM-I trials.

OUTCOME MEASURES

Patient outcomes were evaluated preoperatively at baseline and at 6 months, 1 year, and 2 years after surgery. Quality of life (QOL) was evaluated by the Neck Disability Index (NDI) and Short Form-36 version 2 (SF-36v2). These are both patient self-reported measures that evaluate health-related QOL, with NDI being specific to neck conditions and SF-36v2 being a generic instrument.

MATERIALS AND METHODS

The analysis included 154 patients. A heterogeneous correlation matrix was created using a combination of Pearson, polyserial, and polychoric regressions among 67 variables, which then underwent eigen decomposition. Scores of significant principal components (PCs) (with eigenvalues>1) were included in multivariate logistic regression analyses for three dichotomous outcomes of interest: achievement of the minimum clinically important difference [MCID] in (1) NDI (≤-7.5), (2) SF-36v2 Physical Component Summary (PCS) score (≥5), and (3) SF-36v2 Mental Component Summary (MCS) score (≥5).

RESULTS

Twenty-four significant PCs accounting for 75% of the variance in the data were identified. Two PCs were associated with achievement of the MCID in NDI. The first (PC 1) was dominated by variables related to surgical approach and number of operated levels; the second (PC 21) consisted of variables related to patient demographics, severity and etiology of DCM, comorbid status, and surgical approach. Both PC 1 and PC 21 also correlated with SF-36v2 PCS score, in addition to PC 4, which described patients' physical profile, including gender, height, and weight, as well as comorbid renal disease; PC 6, which received large loadings from variables related to cardiac disease, impaired mobility, and length of surgery and recovery; and PC 9, which harbored large contributions from features of upper limb dysfunction, cardiorespiratory disease, surgical approach, and region. In addition to PC 21, a component profiling patients' socioeconomic status and support systems and degree of physical disability (PC 24) was associated with achievement of the MCID in SF-36 MCS score.

CONCLUSIONS

Through a data-driven approach, we identified several phenotypes associated with disability and physical and mental health-related QOL. Such data reduction methods may separate patient-, disease-, and treatment-related variables more accurately into clinically meaningful phenotypes that may inform patient care and recruitment into clinical trials.

Are Psychologic Factors Associated With Shoulder Scores After Rotator Cuff Surgery?

BACKGROUND

Psychologic factors are associated with pain and disability in patients with chronic shoulder pain. Recent research regarding the association of affective psychologic factors (emotions) with patients' pain and disability outcome after surgery disagrees; and the relationship between cognitive psychologic factors (thoughts and beliefs) and outcome after surgery is unknown.

QUESTIONS/PURPOSES

(1) Are there identifiable clusters (based on psychologic functioning measures) in patients undergoing shoulder surgery? (2) Is poorer psychologic functioning associated with worse outcome (American Shoulder and Elbow Surgeons [ASES] score) after shoulder surgery?

METHODS

This prospective cohort study investigated patients undergoing shoulder surgery for rotator cuff-related shoulder pain or rotator cuff tear by one of six surgeons between January 2014 and July 2015. Inclusion criteria were patients undergoing surgery for rotator cuff repair with or without subacromial decompression and arthroscopic subacromial decompression only. Of 153 patients who were recruited and consented to participate in the study, 16 withdrew before data collection, leaving 137 who underwent surgery and were included in analyses. Of these, 124 (46 of 124 [37%] female; median age, 54 years [range, 21-79 years]) had a complete set of four psychologic measures before surgery: Depression, Anxiety and Stress Scale; Pain Catastrophizing Scale; Pain Self-Efficacy Questionnaire; and Tampa Scale for Kinesiophobia. The existence of clusters of people with different profiles of affective and cognitive factors was investigated using latent class analysis, which grouped people according to their pattern of scores on the four psychologic measures. Resultant clusters were profiled on potential confounding variables. The ASES score was measured before surgery and 3 and 12 months after surgery. Linear mixed models assessed the association between psychologic cluster membership before surgery and trajectories of ASES score over time adjusting for potential confounding variables.

RESULTS

Two clusters were identified: one cluster (84 of 124 [68%]) had lower scores indicating better psychologic functioning and a second cluster (40 of 124 [32%]) had higher scores indicating poorer psychologic functioning. Accounting for all variables, the cluster with poorer psychologic functioning was found to be independently associated with worse ASES score at all time points (regression coefficient for ASES: before surgery -9 [95% confidence interval {CI}, -16 to -2], p = 0.011); 3 months after surgery -15 [95% CI, -23 to -8], p < 0.001); and 12 months after surgery -9 [95% CI, -17 to -1], p = 0.023). However, both clusters showed improvement in ASES score from before to 12 months after surgery, and there was no difference in the amount of improvement between clusters (regression coefficient for ASES: cluster with poorer psychologic function 31 [95% CI, 26-36], p < 0.001); cluster with better psychologic function 31 [95% CI, 23-39], p < 0.001).

CONCLUSIONS

Patients who scored poorly on a range of psychologic measures before shoulder surgery displayed worse ASES scores at 3 and 12 months after surgery. Screening of psychologic factors before surgery is recommended to identify patients with poor psychologic function. Such patients may warrant additional behavioral or psychologic management before proceeding to surgery. However, further research is needed to determine the optimal management for patients with poorer psychologic function to improve pain and disability levels before and after surgery.

LEVEL OF EVIDENCE

Level II, therapeutic study.

Impact of Psychiatric Comorbidities on Short-Term Outcomes Following Intervention for Lumbar Degenerative Disc Disease

STUDY DESIGN

Retrospective, observational cohort study.

OBJECTIVE

To investigate the impact of psychiatric diseases on short-term outcomes in patients undergoing fusion surgery for lumbar degenerative disc disease (LDDD).

SUMMARY OF BACKGROUND DATA

Limited literature exists on the prevalence and impact of psychiatric comorbidities on outcomes in patients undergoing surgery for LDDD.

METHODS

Adult patients (>18 yr) registered in the Nationwide Inpatient Sample database (2002-2011) and undergoing an elective spine fusion for LDDD that met inclusion criteria formed the study population. Defined primary outcome measures were discharge disposition, length of stay, hospitalization cost, and short-term postsurgical complications (neurological, respiratory, cardiac, gastrointestinal, wound complication and infections, venous thromboembolism, and acute renal failure). Multivariable regression techniques were used to explore the association of psychiatric comorbidities on short-term outcomes by adjusting for patient demographics, clinical, and hospital characteristics.

RESULTS

Of the 126,044 adult patients undergoing fusion surgery for LDDD (mean age: 54.91 yr, 58% female) approximately 18% had a psychiatric disease. Multivariable regression analysis revealed patients with psychiatric disease undergoing fusion surgery have higher likelihood for unfavorable discharge (odds ratio [OR] 1.41; 95% confidence interval [CI] 1.35-1.47; P < 0.001), length of stay (OR 1.03; 95% CI 1.02-1.04; P < 0001), postsurgery neurologic complications (OR 1.25; 95% CI 1.13-1.37; P < 0.001), venous thromboembolic events (OR 1.38 95% CI 1.26-1.52; P < 0.001), and acute renal failure (OR 1.17; 95% CI 1.01-1.37; P = 0.040). Patients with psychiatric disease were also associated to have higher hospitalization cost (6.3% higher; 95% CI: 5.6%-7.1%; P < 0.001) compared to those without it.

CONCLUSION

Our study quantifies the estimates for presence of concomitant psychiatric comorbid conditions on short outcomes in patients undergoing fusions for LDDD. The data provide supporting evidence for adequate preoperative planning and postsurgical care including consultation for mental health for favorable outcomes.

LEVEL OF EVIDENCE

4.

THE IMPORTANCE OF PSYCHOLOGICAL TESTING IN PREDICTING THE EFFECTIVENESS OF LUMBAR SPINE SURGERY

ABSTRACT Objective: The result of treatment of patients with degenerative disc diseases is partly determined by the psychological characteristics of the patients. The aim of this study was to examine the correlations between the psychological scales scores in patients with degenerative lumbar disc diseases and the effectiveness of surgical treatment. Methods: The efficacy of the operation and patients’ satisfaction were compared with the preoperative psychological characteristics, according to the questionnaires and scales (BBQ Symonds, Zung Scale, FABQ, PCI, BBQ Catastrophization). Results: In patients with neurogenic intermittent claudication syndrome without significant pain, the operative treatment depended significantly on the value of the BBQ Symonds scale (p = 0.016). In patients with severe radicular pain in the lower extremity, the effectiveness of the operation depended significantly on the value of the subscale “protection” of the PCI questionnaire (p = 0.04), the ODI index filled out before the operation (p = 0.0). In patients with lumbar syndrome, the effectiveness of operation depended significantly on the value of the PCI questionnaire as a whole (p = 0.042) and its subscores “rest” (p = 0.028), the index of the Oswestry filled out before the operation (p = 0.035). Conclusion: The effectiveness of the operation of degenerative lumbar disc diseases is associated with the results of preoperative psychological testing. It has been established that the BBQ Symonds scale, PCI protection and rest subscales, and the ODI questionnaire are the most significant; these psychological scales have the power to predict the effectiveness of surgical treatment. Level of Evidence II; Therapeutic Study - Investigating the Results of Treatment.

RELATIONSHIP BETWEEN PARAMETERS OF THE LUMBAR FACET JOINTS IN A LONG-TERM POSTOPERATIVE OUTCOME

ABSTRACT Objective: To analyze the impact of the relationship between tropism and angulation of the lower lumbar facet joints on a remote clinical outcome after dynamic and rigid surgical interventions. Methods: Patients with degenerative diseases of the lower lumbar spine were subdivided into three groups, according to the method of surgical treatment: 1) (n=48) the use of an artificial prosthesis intervertebral disc (IVD); 2) (n=42) the use of interbody fusion combined with transpedicular and transfacet stabilization; 3) (n=51) the use of interbody fusion and bilateral transpedicular stabilization. Analysis was performed of the remote clinical parameters and neuroimaging characteristics before the operation was performed. Results: When analyzing clinical and instrumental parameters, a significant correlation was found between the long-term outcomes of surgical treatment on the VAS and Oswestry scales and the neuroimaging data on angulation and tropism of the facet joints (FJ). Conclusions: The data obtained testify to the importance of preoperative diagnosis of tropism and angulation of the lower lumbar facet joint, which enables differentiated surgical tactics to be selected, and remote clinical outcomes to be optimized. In the presence of neuroimaging parameters of Facet Joint angulation of less than 600, regardless of the presence of tropism, it is possible to perform total arthroplasty of IVD. When neuroimaging parameters of Facet Joint angulation of more than 600 are detected, rigid stabilization of the operated segment is recommended, while in the absence of tropism of Facet Joints, a contralateral transfacetal fixation is possible; in the presence of tropism, it is expedient to perform bilateral transpedicular stabilization. Level of Evidence II; Prognostic Studies—Investigating the Effect of a Patient Characteristic on the Outcome of Disease.

Analysis of factors affecting baseline SF-36 Mental Component Summary in Adult Spinal Deformity and its impact on surgical outcomes

OBJECTIVES

To identify the factors that affect SF-36 mental component summary (MCS) in patients with adult spinal deformity (ASD) at the time of presentation, and to analyse the effect of SF-36 MCS on clinical outcomes in surgically treated patients.

METHODS

Prospectively collected data from a multicentric ASD database was analysed for baseline parameters. Then, the same database for surgically treated patients with a minimum of 1-year follow-up was analysed to see the effect of baseline SF-36 MCS on treatment results. A clinically useful SF-36 MCS was determined by ROC Curve analysis.

RESULTS

A total of 229 patients with the baseline parameters were analysed. A strong correlation between SF-36 MCS and SRS-22, ODI, gender, and diagnosis were found (p < 0.05). For the second part of the study, a total of 186 surgically treated patients were analysed. Only for SF-36 PCS, the un-improved cohort based on minimum clinically important differences had significantly lower mean baseline SF-36 MCS (p < 0.001). SF-36 MCS was found to have an odds ratio of 0.914 in improving SF-36 PCS score (unit by unit) (p < 0.001). A cut-off point of 43.97 for SF-36 MCS was found to be predictive of SF-36 PCS (AUC = 0.631; p < 0.001).

CONCLUSIONS

The factors effective on the baseline SF-36 MCS in an ASD population are other HRQOL parameters such as SRS-22 and ODI as well as the baseline thoracic kyphosis and gender. This study has also demonstrated that baseline SF-36 MCS does not necessarily have any effect on the treatment results by surgery as assessed by SRS-22 or ODI.

LEVEL OF EVIDENCE

Level III, prognostic study.

Depression is associated with the long-term outcome of lumbar spinal stenosis surgery: a 10-year follow-up study

BACKGROUND CONTEXT

Depression is associated with greater postoperative disability in patients with lumbar spinal stenosis (LSS). No previous studies have reported the association in a 10-year follow-up.

PURPOSE

To evaluate the association between preoperative and postoperative depressive symptoms and the surgical outcome among patients with LSS in a 10-year follow-up. In addition, we examined the effects of the depressive burden on the surgical outcome.

DESIGN

A prospective observational follow-up study.

PATIENT SAMPLE

A total of 102 patients with LSS underwent decompressive surgery, and 72 of the original sample participated in the 10-year follow-up study.

OUTCOME MEASURES

Self-report measures: the Oswestry Disability Index (ODI) and visual analog scale (VAS).

METHODS

Data were collected using a questionnaire that was administered seven times during the study period. Depressive symptoms were measured with the Beck Depressive Inventory (BDI). The depressive burden was calculated by summing the preoperative and all follow-up BDI scores. Statistical analysis included cross-sectional group comparisons and linear mixed models. The authors report no conflicts of interest related to this work.

RESULTS

The high depressive burden group had a poorer outcome for pain, disability, and the walking distance at the 10-year follow-up. In linear mixed models, a higher preoperative BDI score associated with higher disability. Furthermore, higher postoperative BDI scores and the depressive burden were associated with higher disability and pain in the 10-year follow-up.

CONCLUSIONS

Patients with LSS with even slightly elevated depressive symptoms have an increased risk of postoperative pain and disability in a 10-year follow-up. To improve the surgical outcome among these patients, screening for depression both preoperatively and during the rehabilitation following surgery is important.

Clinical and psychological outcome after surgery for lumbar spinal stenosis: A prospective observational study with analysis of prognostic factors

BACKGROUND

The identification of psychological risk factors is important for the selection of patients before spinal surgery. Moreover, the effect of surgical decompression in lumbar spinal stenosis (LSS) on psychological outcome is not previously well analyzed.

AIM OF PAPER

to investigate clinical and psychological outcome after surgery for LSS and the effect of depressive symptoms and anxiety on the clinical outcome.

MATERIALS AND METHODS

A total of 25 patients with symptomatic LSS underwent decompressive surgery with or without spinal stabilization were prospectively enrolled in this observational surgery. The Symptom Checklist-90-Revised (SCL-90-R) was used to assess global psychological distress with a summary score termed Global Severity Index (GSI) and single psychological disorders including depression (DEP) and anxiety (ANX). The clinical outcome of surgery was evaluated with the Oswestry Disability Index (ODI) and visual analogue scale (VAS) pain assessment.

RESULTS

Compared with baseline, there was a statistically significant improvement in VAS, ODI and GSI after surgery (p<0.05) in all patients. Univariate analysis revealed that patients with high GSI and anxiety and depression scores had significantly higher ODI and VAS scores in the follow-up with a bad outcome.

CONCLUSIONS

Surgery for spinal stenosis was effective to treat pain and disability. In this prospective study baseline global psychological distress, depression and anxiety were associated with poorer clinical outcome.

Depression and Anxiety in Traumatic Brachial Plexus Injury Patients Are Associated With Reduced Motor Outcome After Surgical Intervention for Restoration of Elbow Flexion

BACKGROUND

Depression has been associated with poor outcomes in neurosurgical patients, including increased pain, poorer functional recovery, delayed return to work, and decreased patient satisfaction. No reports exist regarding an association of psychiatric diagnoses with outcomes after brachial plexus reconstruction. As outcomes and patient satisfaction become increasingly important to payers and physician reimbursement, assessing modifiable preoperative risk factors for their association with poor outcome and patient satisfaction is imperative.

OBJECTIVE

To analyze patients undergoing brachial plexus reconstruction to assess the relationship of depression/anxiety with functional outcome.

METHODS

Data were collected retrospectively on all patients who underwent brachial plexus reconstruction to restore elbow flexion between 2005 and 2013. Elbow flexion, graded via the Medical Research Council scale, was assessed at latest follow-up. Multiple variables, including the presence of Axis I psychiatric diagnoses, were assessed for their association with the dichotomous outcome of Medical Research Council scale score ≥3 (antigravity) vs <3 elbow flexion. Standard statistical methods were used.

RESULTS

Thirty-seven patients met inclusion criteria. The median postsurgical follow-up time was 21 months. Operations included neurolysis (n = 3), nerve graft repair (n = 6), and nerve transfer (n = 28). Depression was present in 10 of 37 patients (27%). Of variables tested, only depression was associated with poor elbow flexion outcome (odds ratio: 6.038; P = .04).

CONCLUSION

Preoperative depression is common after brachial plexus injury. The presence of depression is associated with reduced elbow flexion recovery after reconstruction. Our data suggest assessment and treatment of preoperative mental health is important in designing a comprehensive postoperative management plan to optimize outcomes and patient satisfaction.

ABBREVIATIONS

MRC, Medical Research CouncilTBI, traumatic brain injury.

Does the effectiveness of core stability exercises correlate with the severity of spinal stenosis in patients with lumbar spinal stenosis?

Objective:

To determine whether the effectiveness of core stability exercises correlates with the severity of spinal stenosis in patients with degenerative lumbar spinal stenosis.

Methods:

Forty-two patients with degenerative lumbar spinal stenosis treated in the department of orthopedics of our hospital between May 2013 and January 2016 were included in the study. All the patients performed core stability exercises once daily for six weeks, and the clinical outcomes were evaluated using Japanese Orthopaedic Association (JOA) score and self-reported walking capacity. The anteroposterior osseous spinal canal diameter was measured to evaluate the severity of spinal stenosis. The correlation between the stenosis degree and the differences of Japanese Orthopaedic Association score or self-reported walking capacity at baseline and after treatment were analyzed.

Results:

The patients were divided into three groups according to the spinal stenosis degree. In the three groups, there was no significant difference in JOA or self-reported walking distance at baseline (p>0.05) and after treatment (p>0.05). The JOA scores and self-reported walking distance were significantly increased after treatment (p<0.05) in any of the three groups when compared to the baseline. Also, there was no significant correlation between the stenosis degree and the difference of JOA (p>0.05) or self-reported walking distance (p>0.05).

Conclusion:

There was no significantcorrelation between the effectiveness of core stability exercises and the severity of spinal stenosis in patients with degenerative lumbar spinal stenosis.

The association between preoperative mental distress and patient-reported outcome measures in patients treated surgically for cervical radiculopathy

BACKGROUND CONTEXT

Previous research indicates that there might exist a link between the experience of pain and mental distress. Pain can possibly trigger anxiety and chronic pain, as well as also depression. On the other hand, anxiety and depression might also be risk factors for painful conditions and more pronounced subsequent disability and thus, the pathways may be bidirectional. Expanded knowledge of how different factors affect pain and function may help surgeons in preoperative decision-making.

PURPOSE

The aim of this study was to evaluate the impact of potential preoperative risk factors with special reference to mental distress.

STUDY DESIGN/SETTING

This is a prospective outcome study in a cohort from a multicenter randomized controlled trial comparing anterior cervical decompression and fusion with disc replacement.

PATIENT SAMPLE

The sample included 151 patients with cervical radiculopathy planned for surgery.

OUTCOME MEASURES

Surgical outcome was evaluated with Neck Disability Index (NDI), health related quality-of-life with European Quality of Life-5 Dimensions, and pain with visual analogue scale for arm and neck. Mental distress was preoperatively measured with the Hospital Anxiety and Depression (HAD) scale.

METHODS

Preoperative data regarding possible risk factors for poor outcome were analyzed in multiple linear regression models with postoperative NDI and change of NDI as dependent factors. Patients with high preoperative levels of anxiety or depression (H-HAD), indicating mental distress, were compared with patients scoring low/moderate levels (L-HAD) regarding patient-reported outcome measures (PROMs) preoperatively and at 1- and 2-year follow-up.

RESULTS

Outcome data were available for 136 patients at the 2-year follow-up. No statistically significant difference in any outcome data could be demonstrated between the two surgical treatment groups. Mental distress was the variable most strongly associated with NDI at 2 years in the regression analysis. There were 42 patients classified as H-HAD and 94 as L-HAD. The average improvement in NDI was 16.9 in the H-HAD group and 26.3 in the L-HAD group, p=.02. The H-HAD patients showed a tendency for poorer baseline data and worse outcome overall in all PROMs at follow-up at both 1 and 2 years.

CONCLUSIONS

Preoperative mental distress measured with HAD was associated with worse outcome overall. More research is needed to investigate whether patients with mental distress may achieve better results if other treatments are offered, either as non-surgical treatment alone or as an adjunct to surgery.

Relationship between depression and clinical outcome following anterior cervical discectomy and fusion

BACKGROUND

Anterior cervical discectomy and fusion (ACDF) is a commonly performed procedure for patients with symptomatic degenerative conditions of the cervical spine. The objective is to assess the impact of preoperative depression and other baseline characteristics on patient reported clinical outcomes following ACDF surgery based on the experience at our institution.

METHODS

This was a retrospective cohort study of some patients undergoing ACDF at a single institution from 2012 to 2014. Ninety-three patients that underwent an ACDF procedure were included. The primary outcome measure was post-operative Nurick score.

RESULTS

Sixteen (17.2%) patients had a formal diagnosis of depression compared to 77 (82.8%) patients without depression. On univariate analysis, patients with depression had statistically significantly higher Nurick scores compared to patients without depression after surgery (coefficient =0.55, 95% CI: 0.21-0.90, P=0.002). On multivariate analysis, there was a trend toward higher postoperative Nurick scores in patients that had depression (coefficient =0.31, 95% CI: -0.01-0.63, P=0.057).

CONCLUSIONS

This small retrospective study reveals an inverse relationship between preoperative depression and functional outcome. Further research should be performed to investigate this relationship and to investigate if treating depression can improve postoperative outcomes.

An analysis from the Quality Outcomes Database, Part 1. Disability, quality of life, and pain outcomes following lumbar spine surgery: predicting likely individual patient outcomes for shared decision-making

OBJECTIVE Quality and outcomes registry platforms lie at the center of many emerging evidence-driven reform models. Specifically, clinical registry data are progressively informing health care decision-making. In this analysis, the authors used data from a national prospective outcomes registry (the Quality Outcomes Database) to develop a predictive model for 12-month postoperative pain, disability, and quality of life (QOL) in patients undergoing elective lumbar spine surgery. METHODS Included in this analysis were 7618 patients who had completed 12 months of follow-up. The authors prospectively assessed baseline and 12-month patient-reported outcomes (PROs) via telephone interviews. The PROs assessed were those ascertained using the Oswestry Disability Index (ODI), EQ-5D, and numeric rating scale (NRS) for back pain (BP) and leg pain (LP). Variables analyzed for the predictive model included age, gender, body mass index, race, education level, history of prior surgery, smoking status, comorbid conditions, American Society of Anesthesiologists (ASA) score, symptom duration, indication for surgery, number of levels surgically treated, history of fusion surgery, surgical approach, receipt of workers' compensation, liability insurance, insurance status, and ambulatory ability. To create a predictive model, each 12-month PRO was treated as an ordinal dependent variable and a separate proportional-odds ordinal logistic regression model was fitted for each PRO. RESULTS There was a significant improvement in all PROs (p < 0.0001) at 12 months following lumbar spine surgery. The most important predictors of overall disability, QOL, and pain outcomes following lumbar spine surgery were employment status, baseline NRS-BP scores, psychological distress, baseline ODI scores, level of education, workers' compensation status, symptom duration, race, baseline NRS-LP scores, ASA score, age, predominant symptom, smoking status, and insurance status. The prediction discrimination of the 4 separate novel predictive models was good, with a c-index of 0.69 for ODI, 0.69 for EQ-5D, 0.67 for NRS-BP, and 0.64 for NRS-LP (i.e., good concordance between predicted outcomes and observed outcomes). CONCLUSIONS This study found that preoperative patient-specific factors derived from a prospective national outcomes registry significantly influence PRO measures of treatment effectiveness at 12 months after lumbar surgery. Novel predictive models constructed with these data hold the potential to improve surgical effectiveness and the overall value of spine surgery by optimizing patient selection and identifying important modifiable factors before a surgery even takes place. Furthermore, these models can advance patient-focused care when used as shared decision-making tools during preoperative patient counseling.

Prognostic factors associated with the surgical indication for lumbar spinal stenosis patients less responsive to conservative treatments: An investigator-initiated observational cohort study

BACKGROUND

A few cohort studies have determined which patients with lumbar spinal stenosis are likely to need surgery because of the deterioration of symptoms. However, there are still insufficient data regarding the management of lumbar spinal stenosis due to lack of prognostic factors associated with the need for surgery. The purpose of this study was to identify the prognostic factors associated with the need for surgical treatment in patients with lumbar spinal stenosis.

METHODS

Patients with lumbar spinal stenosis from our hospital and related facilities were enrolled. Eligibility criteria were as follows: age 50-85 years and the patient's conditions met the definition of lumbar spinal stenosis; the presence of neurogenic intermittent claudication caused by numbness and/or pain in the lower limbs; and magnetic resonance imaging-confirmed symptomatic LSS. We followed 274 patients (151 men; mean age, 71 ± 7.4 years) for 3 years to identify prognostic factors. We used a multivariate logistic regression model to investigate the association between the indication for surgical treatment (within 3 years) and age, sex, complications, depression, illness duration, the presence of cauda equina symptoms, and the presence of degenerative spondylolisthesis/scoliosis.

RESULTS

In the survey conducted 3 years after treatment, 185 patients responded (follow-up rate 67.5%). In 82 patients, surgery was performed during the follow-up period. The multivariate logistic regression model showed that the presence of cauda equina symptoms and the presence of degenerative spondylolisthesis/scoliosis were significantly associated with the indication for surgical treatment within 3 years.

CONCLUSIONS

This study showed that the presence of cauda equina symptoms and degenerative spondylolisthesis/scoliosis were prognostic factors associated with the indication for surgery in patients with lumbar spinal stenosis.

Impact of Depression and Bipolar Disorders on Functional and Quality of Life Outcomes in Patients Undergoing Surgery for Degenerative Cervical Myelopathy: Analysis of a Combined Prospective Dataset

STUDY DESIGN

Analysis of a combined prospective dataset.

OBJECTIVE

To compare clinical outcomes in patients with and without preexisting depression or bipolar disorder undergoing surgery for degenerative cervical myelopathy (DCM).

SUMMARY OF BACKGROUND DATA

Psychiatric comorbidities, including depression, have been associated with worse clinical outcomes after lumbar spine surgery; however, it is unclear whether these psychiatric disorders are also predictive of outcomes in patients undergoing surgery for the treatment of DCM.

METHODS

Four hundred and one patients with symptomatic DCM were enrolled in the prospective AOSpine International or North America study at twelve North American sites. Patients were evaluated preoperatively and at 6, 12, and 24 months using the modified Japanese Orthopedic Association scale (mJOA), Nurick score, Neck Disability Index (NDI), and Short- Form 36v2 (SF-36v2) Health Survey. A mixed model analytic approach was used to evaluate differences in outcomes at 24 months among patients with and without psychiatric disorders, while controlling for relevant baseline characteristics and surgical factors.

RESULTS

Ninety-seven patients (24.19%) were diagnosed with preexisting depression or bipolar disorder. There were more females (65.98%) with these psychiatric disorders than males (34.02%) (P < 0.0001). Patients with psychiatric comorbidities were more likely to have cardiovascular (P = 0.0177), respiratory (P < 0.0001), gastrointestinal (P < 0.0001), rheumatologic (P = 0.0109), and neurologic (P = 0.0309) disorders. At 24 months after surgery, patients in both groups demonstrated significant improvements on the mJOA, Nurick, NDI, and SF-36v2 Physical Component Score (PCS). Patients with depression or bipolar disorder, however, did not exhibit a significant or clinically important change on the SF-36v2 Mental Component Score (MCS). There were no differences in mJOA and Nurick scores at 24 months among patients in each group. Improvement in NDI, SF-36v2 PCS, and MCS, however, were smaller in patients with depression or bipolar disorder than those without.

CONCLUSION

Patients with depression or bipolar disorder have smaller functional and quality of life improvements after surgery compared to patients without psychiatric comorbidities.

LEVEL OF EVIDENCE

2.

Preoperative mental health status may not be predictive of improvements in patient-reported outcomes following an anterior cervical discectomy and fusion

OBJECTIVE

Prior studies have correlated preoperative depression and poor mental health status with inferior patient-reported outcomes following lumbar spinal procedures. However, literature regarding the effect of mental health on outcomes following cervical spinal surgery is limited. As such, the purpose of this study is to test for the association of preoperative SF-12 Mental Component Summary (MCS) scores with improvements in Neck Disability Index (NDI), SF-12 Physical Component Summary (PCS), and neck and arm pain following anterior cervical discectomy and fusion (ACDF).

METHODS

A prospectively maintained surgical database of patients who underwent a primary 1- or 2-level ACDF during 2014–2015 was reviewed. Patients were excluded if they did not have complete patient-reported outcome data for the preoperative or 6-week, 12-week, or 6-month postoperative visits. At baseline, preoperative SF-12 MCS score was assessed for association with preoperative NDI, neck visual analog scale (VAS) score, arm VAS score, and SF-12 PCS score. The preoperative MCS score was then tested for association with changes in NDI, neck VAS, arm VAS, and SF-12 PCS scores from the preoperative visit to postoperative visits. These tests were conducted using multivariate regression controlling for baseline characteristics as well as for the preoperative score for the patient-reported outcome being assessed.

RESULTS

A total of 52 patients were included in the analysis. At baseline, a higher preoperative MCS score was negatively associated with a lower preoperative NDI (coefficient: −0.74, p < 0.001) and preoperative arm VAS score (−0.06, p = 0.026), but not preoperative neck VAS score (−0.03, p = 0.325) or SF-12 PCS score (0.04, p = 0.664). Additionally, there was no association between preoperative MCS score and improvement in NDI, neck VAS, arm VAS, or SF-12 PCS score at any of the postoperative time points (6 weeks, 12 weeks, and 6 months, p > 0.05 for each). The percentage of patients achieving a minimum clinically important difference at 6 months did not differ between the bottom and top MCS score halves (p > 0.05 for each).

CONCLUSIONS

The results of this study suggest that better preoperative mental health status is associated with lower perceived preoperative disability but is not associated with severity of preoperative neck or arm pain. In contrast to other studies, the present study was unable to demonstrate that preoperative mental health is predictive of improvement in patient-reported outcomes at any postoperative time point following an ACDF.