Anxiety and depression in spine surgery-a systematic integrative review

The Impact of the Preoperative Mental Health Component Summary (MCS) Score on Short-Term Outcomes After Lumbar Fusion

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The purpose of this study is to characterize the relationship between preoperative MCS and surgical outcomes after lumbar spine surgery including inpatient complications, length of stay, readmissions, and reoperations.

SUMMARY OF BACKGROUND DATA

As the prevalence of mental health disorders in the United States increases, it is important to identify risks associated with poor mental health status in the surgical spine patient. The mental health component summary (MCS) of the Short Form-12 has been used extensively as an indication of a patient's mental health status and psychological well-being.

PATIENTS AND METHODS

Adult patients older than or equal to 18 years who underwent primary one to three level lumbar fusion surgery at our academic medical institution from 2017 to 2021 were retrospectively identified. Preoperative MCS score was used to analyze outcomes in patients based on a cutoff (<45.6). A score >45.6 indicated better preoperative mental health and a score ≤45.6 indicated worse preoperative mental health.

RESULTS

Patients with lower preoperative MCS scores had longer hospital stays (3.86±2.16 vs. 3.55±1.42 d, P =0.010) and were more likely to have inpatient renal complications (3.09% vs. 7.19%, P =0.006). Patients with lower preoperative MCS scores also had lower activity measure for post-acute care (AM-PAC) scores (17.1±2.85 vs. 17.6±2.49, P =0.030). Ninety-day surgical readmissions, medical readmissions, and reoperations were not significantly different between groups ( P >0.05).

CONCLUSION

Our study suggests that patients with lower preoperative mental health scores (MCS ≤45.6) were independently more likely to experience more renal complications and longer length of stay after primary lumbar fusion. In addition, higher MCS scores may correlate with better postoperative mobility and daily activity scores. Nevertheless, long-term outcomes are not significantly different between patients of better or worse preoperative mental health.

LEVEL OF EVIDENCE

Level IV.

Preoperative Optimization Strategies in Elective Spine Surgery

» Although spine surgery is effective in reducing pain and improving functional status, it is associated with unacceptably high rates of complications, thus necessitating comprehensive preoperative patient optimization.» Numerous risk factors that can impact long-term surgical outcomes have been identified, including malnutrition, cardiovascular disease, osteoporosis, substance use, and more.» Preoperative screening and personalized, evidence-based interventions to manage medical comorbidities and optimize medications can enhance clinical outcomes and improve patient satisfaction following spine surgery.» Multidisciplinary team-based approaches, such as enhanced recovery after surgery protocols and multidisciplinary conferences, can further facilitate coordinated care from across specialties and reduce overall hospital length of stay.

Effects of volatile anaesthetics on incidence of postoperative depression and anxiety symptoms in elderly patients: A retrospective analysis of a prospective cohort study

Studies have suggested volatile anaesthetics may alleviate depression and anxiety symptoms in patients. However, there is a paucity of research in this area. We wanted to determine the association between volatile anaesthetics and depression/anxiety symptoms in elderly patients within 7 days after surgery. This study retrospectively analysed data from a prospective database of patients aged 65 and above who underwent non-cardiac, non-neurosurgical elective surgery in 19 tertiary hospitals across 10 provinces in China. The study period spanned from April 1, 2020 to April 30, 2022. Patients receiving volatile anaesthetics received at least one volatile anaesthetic (sevoflurane, isoflurane, desflurane), and those who received non-volatile anaesthetics did not receive any volatile anaesthetic. Binary logistic regression analyses were conducted, and propensity score-matching (PSM) and subgroup analyses were also applied. A total of 7165 patients were included in the analysis. Among them, 4957 (69.18%) cases received volatile anaesthetics. The administration of volatile anaesthetics was associated with a lower rate of postoperative depression [22.76% vs. 27.26%, odds ratio (OR): 0.75, P < 0.001], and reduced the incidence of postoperative anxiety (19.59% vs. 24.68%, OR: 0.78, P < 0.001). The risk of postoperative depression (24.78% vs.27.93%, OR: 0.85, P = 0.035), and anxiety (21.45% vs. 25.92%, OR: 0.81, P = 0.006) were both significantly decreased in the volatile anaesthetics group in the PSM cohort. The results suggest that using volatile anaesthetics maybe associated with a reduction in the incidence of depression and anxiety in elderly patients during the early postoperative period.

Patients' experience on waiting for spinal arthrodesis: a qualitative study

PURPOSE

A number of studies have explored patients' subjective experience of waiting for spinal surgery, however, they did so through an investigation conducted post-operatively. Thus, the aim of this study was to explore the experience of patients while still on the waitlist for lumbar spinal arthrodesis.

METHODS

This qualitative study of semi-structured interviews was conducted at an orthopedic research institute in Italy. The interview track was developed by a team of professionals (physiotherapists, orthopedic surgeon, psychologist) and consisted of 40 questions. Fifteen patients, 10 females and 5 males aged between 23 and 80 years, waiting for spinal arthrodesis were interviewed. The interviews were performed, transcribed and analyzed by the multiprofessional team through thematic analysis using a reflexive approach.

RESULTS

Five main themes were generated: (1) Impact of persistent pain on patients' physical and psychological functioning; (2) Fear of the unknown and uncertainties; (3) Hope and regaining normality; (4) The impact of the unpredictability of the waiting time; (5) Need for better communication and information on the care pathway. Two minor themes were also produced.

CONCLUSIONS

These findings highlighted that patients on the waiting list for spinal arthrodesis need more certainty about waiting times, better communication with hospital staff, more thorough information about their care pathway. This could help patients feel more confident and may lead to more adequate expectations before surgery.

TRIAL REGISTRATION

The study protocol was registered on ClinicalTrials.gov database on 14/03/2022 with ID number NCT06323694.

The impact of compassion-based interventions on perioperative anxiety and depression: A systematic review and meta-analysis

BACKGROUND

The perioperative period can be a stressful time for many patients. Concerns for the procedure or fearing potential complications contribute to perioperative anxiety and depression, which significantly impact patient wellbeing and recovery. Understanding the psychological impact of the perioperative period can inform individualized care focused on each patient's unique stressors. Compassion-based interventions are limited but have shown benefits in non-surgical healthcare settings, and can provide support by prioritizing empathy and understanding in the perioperative period. This review evaluates the impact of compassion-based interventions on anxiety and depression among adult surgical patients.

METHODS

A systematic review of 25 randomized controlled trials was conducted with a meta-analysis of 14 studies for anxiety and 9 studies for depression that provided sufficient information.

RESULTS

The included studies tested compassion-based interventions that focused on enhanced communication, emotional support, and individualized attention from healthcare professionals. In 72 % of the studies, the interventions decreased anxiety and depression, compared to control groups. These interventions improved health-related outcomes such patient satisfaction and postoperative complications. The meta-analysis indicated a large effect of the compassion-based interventions for anxiety (g = -0.95) and depressive symptoms (g = -0.82). The findings were consistent among various surgeries and patient populations.

LIMITATIONS

Many of the included studies lacked clarity in their methods and only 14 studies provided sufficient information for the meta-analysis.

CONCLUSIONS

Given the growing evidence suggesting that compassion-based psychological interventions are feasible and applicable in the perioperative setting, their inclusion in routine care could reduce depression and anxiety around surgery and improve patient outcomes and experiences.

Evaluating the prevalence of psychiatric comorbidities associated with pediatric scoliosis utilizing ResearchMatch

PURPOSE

The goal of this study is to characterize the self-reported prevalence of psychiatric comorbidities among patients with adolescent scoliosis.

METHODS

Eligible patients across the US were surveyed using ResearchMatch, a validated online platform. The survey collected patient demographics, type of scoliosis, scoliosis treatment received, and the mental health diagnoses and interventions.

RESULTS

Nearly all (98%) of the 162 respondents were patients themselves, the remainder of which were parents. The majority of whom were female (93%), Caucasian (85%), and diagnosed with idiopathic scoliosis (63%). The median age of diagnosis was 13 (IQR 11-18). Most respondents had mild to moderate scoliosis (65%), and 17% received surgical treatment. 76 of 158 (48%) responded that scoliosis affected their overall mental health, and 92 (58%) had received a mental health diagnosis-76% were diagnosed after their scoliosis diagnosis. Of the 92 with mental health diagnoses, the most common diagnoses were clinical depression (83%), anxiety (71%), negative body image (62%). Over 80% of patients received medical treatment or therapy. Of those with depression, 38.4% received counseling and 45.2% received medication. 52% of the respondents also had immediate family members with mental health diagnoses, with siblings (48%) having the highest proportion.

CONCLUSION

According to the CDC, the prevalence of US teenagers with diagnosed depression was found to be 3.9% and anxiety disorder to be 4.7%, notably higher among adolescent girls. In this national sample, over half of adolescent scoliosis patients report psychiatric comorbidity, often diagnosed years later. The most prevalent psychiatric condition is depression, anxiety, and body-image disturbances. These findings highlight the importance of awareness of the psychiatric impact of adolescent scoliosis, and importance of screening and treatment of comorbid mental health conditions.

LEVEL OF EVIDENCE

IV.

Does Epidural Corticosteroid Application During Spinal Surgery Reduce Postoperative Pain?: An Adjunct to Multimodal Analgesia

STUDY DESIGN

A prospective, randomized, placebo-controlled, double-blinded study.

OBJECTIVE

To examine the effect of intraoperative epidural administration of Depo-Medrol on postoperative back pain and radiculitis symptoms in patients undergoing Transforaminal Lumbar Interbody Fusion (TLIF).

SUMMARY OF BACKGROUND DATA

Postoperative pain is commonly experienced by patients undergoing spinal fusion surgery. Adequate management of intense pain is necessary to encourage early ambulation, increase patient satisfaction, and limit opioid consumption. Intraoperative steroid application has been shown to improve postoperative pain in patients undergoing lumbar decompression surgeries. There have been no studies examining the effect of epidural steroids on both back pain and radicular pain in patients undergoing TLIF.

METHOD

In all, 151 patients underwent TLIF surgery using rh-BMP2 with 3 surgeons at a single institution. Of those, 116 remained in the study and were included in the final analysis. Based on a 1:1 randomization, a collagen sponge saturated with either Saline (1 cc) or Depo-Medrol (40 mg/1 cc) was placed at the annulotomy site on the TLIF level. Follow-up occurred on postoperative days 1, 2, 3, 7, and postoperative months 1, 2, and 3. Lumbar radiculopathy was measured by a modified symptom- and laterality-specific Visual Analog Scale (VAS) regarding the severity of back pain and common radiculopathy symptoms.

RESULTS

The patients who received Depo-Medrol, compared with those who received saline, experienced significantly less back pain on postoperative days 1, 2, 3, and 7 ( P <0.05). There was no significant difference in back pain beyond day 7. Radiculopathy-related symptoms such as leg pain, numbness, tingling, stiffness, and weakness tended to be reduced in the steroid group at most time points.

CONCLUSION

This study provides Level 1 evidence that intraoperative application of Depo-Medrol during a TLIF surgery with rh-BMP2 significantly reduces back pain for the first week after TLIF surgery. The use of epidural Depo-Medrol may be a useful adjunct to multimodal analgesia for pain relief in the postoperative period.

Correlation between anxiety, sleep disturbance and clinical outcomes in a lumbar decompression cohort

BACKGROUND

Patients with lumbar spinal pathology often suffer from anxiety and sleep disturbance, but correlations between anxiety and sleep disturbance and other patient-reported outcome measures (PROMs) before and after surgical intervention have not been explored. The purpose of this study is to analyze the correlations between patient-reported anxiety, sleep disturbance, and PROMs before and after lumbar decompression.

METHODS

All patients undergoing elective, primary, lumbar decompression were retrospectively queried from a prospectively-maintained single spine surgeon database. Demographic and perioperative data and pre- and postoperative PROMs were extracted. Patient-Reported Outcome Measure Information System (PROMIS)-Anxiety, PROMIS-Sleep Disturbance (SD), PROMIS-Physical Function (PF), 9-Item Patient Health Questionnaire (PHQ-9), Visual Analog Scale (VAS)-Back, VAS-Leg, Oswestry Disability Index (ODI) were obtained preoperatively and through two years postoperatively. Pearson's correlation coefficients were calculated between PROMIS-Anxiety, PROMIS-SD, and the other PROMs of interest.

RESULTS

PROMIS-Anxiety was positively correlated with PROMIS-SD (range: r = 0.473-0.828, p ≤ 0.006, all), PHQ-9 (range: r = 0.613--0.890, p ≤ 0.006, all), VAS-Back (range: r = -0.410-0.798, p ≤ 0.039, all), and ODI (range: r = 0.503-0.732, p ≤ 0.033, all) at all timepoints. PROMIS-Anxiety was negatively correlated with PROMIS-PF through 1 year postoperatively (range: r = -0.323- -0.729p ≤ 0.033, all). PROMIS-Anxiety was positively correlated to VAS-Leg at preoperative, 6-week, 12-week, and 2-year postoperative timepoints (range: r = 0.333--0.707, p ≤ 0.022, all). PROMIS-SD was positively correlated with PHQ-9 (range: r = 0.600-0.836), VASBack (range: r = 0.383-0.734), VAS-Leg (range: r = 0.399-0.811), and ODI (range: r = 0.404-0.812) at all timepoints (p ≤ 0.031, all). PROMIS-SD was negatively correlated with PROMIS-PF at all timepoints (range: r = -0.339-0.665, p ≤ 0.035, all).

CONCLUSION

Patient-reported anxiety and sleep disturbance are significantly correlated with depressive burden, back pain, disability, and physical function, before and after lumbar decompression. Future studies should aim to determine the directionality of the associations and test interventions to improve health-related quality of life following lumbar decompression.

Artificial neural network analysis of factors affecting functional independence recovery in patients with lumbar stenosis after neurosurgery treatment: An observational cohort study

Background and aim

Lumbar spinal stenosis (LSS) is a leading cause of low back pain and lower limbs pain often associated with functional impairment which entails the loss or the impairment of independence in older adults. Conservative treatment is effective in a small percentage of patients, while a significant percentage undergo surgery, even if often without a complete resolution of clinical symptoms and motor deficits. The aim of the study is to identify clinical and demographic prognostic factors characterising the patients who would benefit most from surgical treatment in relation to the functional independence recovery using an innovative approach based on an artificial neural network.

Methods

Adult patients with LSS and indication of neurosurgical treatment were enrolled in the study. Clinical evaluation was performed in the preoperative-phase (into the 48 h before surgery) and after two months. Clinical battery investigated the motor, functional, cognitive, behavioural, and pain status. Demographics and clinical characteristics were analysed via Artificial Neural Network (ANN) using 24 input variables, 2 hidden layers and a single final output layer to predict the outcome. ANN results were compared with those of a multiple linear regression.

Results

108 patients were included in the study and 90 of them [66.5 ± 12.8 years; 27.8 % F] were submitted to surgery treatment and completed longitudinal evaluation. Statistically significant improvement was recorded in all clinical scales comparing pre- and post-surgery. The ANN results showed a prediction ability up to 81 %. Disability, functional limitations, and pain concerning clinical assessment and stature, onset and age about demographic characteristics are the main variables impacting on surgical outcome.

Conclusions

ANN can support clinical decision making, using clinical and demographic characteristics of patients with LSS identifying the characteristics of those who might benefit more from the surgical treatment in terms of global functional recovery.

The Effect of Patient Resilience on Postoperative Scores After One- and Two-Level Anterior Cervical Discectomy and Fusion

OBJECTIVE

To investigate the association between resilience and outcomes of pain and neck-related disability after single- and double-level anterior cervical discectomy and fusion (ACDF).

METHODS

Patients who underwent single- or double-level ACDF were sent a survey between 6 months and 2 years after surgery. The survey included the Brief Resilience Scale (BRS), visual analogue scale (VAS) for pain, Neck Disability Index (NDI), and Pain Self-Efficacy Questionnaire (PSEQ-2). Patients completed the VAS and NDI twice, once describing preoperative pain and disability and once describing current pain and disability. Respondents were classified as high resilience (HR), medium resilience (MR), or low resilience (LR). Demographics, PSEQ-2 scores, pre- and postoperative VAS and NDI scores, and change in VAS (ΔVAS) and NDI (ΔNDI) scores were compared between groups.

RESULTS

Thirty-three patients comprised the HR group, 273 patients comprised the MR group, and 47 patients comprised the LR group. All groups demonstrated postoperative improvement in VAS and NDI scores that exceeded previously established MCID values. The HR group demonstrated greater improvement in pain compared with the LR group (ΔVAS: -5.8 for HR vs. -4.4 for LR, P = 0.05). Compared with the MR group, the LR group demonstrated greater postoperative pain (VAS: 3.2 for LR vs. 2.5 for MR, P = 0.02) and disability (NDI: 11.9 for LR vs. 8.6 for MR, P = 0.02).

CONCLUSIONS

Patients demonstrated improvement in pain and neck-related disability after single- and double-level ACDF, regardless of resilience score. Patients with greater resilience may be expected to demonstrate more improvement in pain after ACDF.

Anxiety and depression as risk factors for postoperative complications and pain in lumbar spine surgery: A national database study

Objective: To investigate the potential association between anxiety and depression and surgical outcomes in patients undergoing LSS. By analyzing data from the Nationwide Inpatient Sample (NIS) database, we aim to identify whether anxiety and depression serve as predictors for postoperative complications and pain-related symptoms. Methods: A retrospective analysis was conducted via the NIS database. Those undergoing LSS from 2010 to 2019 were divided into four groups: those with a diagnosis of anxiety, depression, both depression and anxiety, and neither depression nor anxiety. The chi-squared test, rank sum test, the Student-Newman-Keuls, least significant difference, and Bonferroni tests were used to identify differences between these groups. Logistic regression analysis was utilized to determine if anxiety and depression were predictors for postoperative complications and pain-related symptoms. Results: From 2010 to 2019, 832,099 patients undergoing LSS were identified. Patients with either anxiety or depression were associated with heavier economic burdens ($85,375, $76,840, $88,542 in the anxiety, depression, and comorbid group, respectively, p < 0.001) and prolonged hospital stay (p < 0.001). They were identified to experience higher risks of various complications especially thrombophilia (OR = 1.82, and 1.55 in the anxiety and the depression group, respectively, p < 0.01). Multiple pain-related symptoms, but face reduced risks of inpatient mortality (OR = 0.71, 0.75, and 0.63 in the anxiety, depression, and comorbid group, respectively, p < 0.01). Conclusions: The overall morbidities of depression and anxiety were relatively high. Psychiatric comorbidities were closely correlated with the negative outcomes after LSS. The psychological health of patients receiving LSS requires necessary attention to ensure pain control and prevent complications postoperatively.

Association between opioid utilization and patient-reported outcome measures following lumbar spine surgery

BACKGROUND CONTEXT

The patient-reported outcomes measurement information system (PROMIS), created by the National institute of Health, is a reliable and valid survey for patients with lumbar spine pathology. Preoperative opioid use has been shown to be an important predictor variable of self-reported health status in legacy patient-reported outcome measures.

PURPOSE

To investigate the impact of chronic preoperative opiate use on PROMIS survey scores.

STUDY DESIGN

Retrospective database analysis.

PATIENT SAMPLE

Between March 2019 and November 2021, 227 patients underwent lumbar decompression ± ≤ 2 level fusion. Fifty-seven patients (25.11%) had chronic preoperative opioid use.

OUTCOME MEASURES

Oswestry disability index (ODI) and PROMIS survey scores.

METHODS

A retrospective analysis of a prospectively maintained single center patient-reported outcome database was performed with a minimum of 2 year follow-up. PROMIS Anxiety, Depression, Fatigue, Pain Interference (PI), Physical Function (PF), Sleep disturbance (SD), and Social Roles (SR) surveys were recorded at preoperative intake with subsequent follow-up at 6, 12, and 24 months postoperatively. Patients were grouped into chronic opioid users as defined by >6-month duration of use. Differences in mean survey scores were evaluated using Welch t-tests.

RESULTS

Two hundred and twenty-seven patients met our inclusion criteria of completed PROMIS surveys at the designated timepoints. A total of 57 (25.11%) were chronic opioid users (COU) prior to surgery. Analysis of patient-reported health outcomes shows that long term opioid use correlated with worse ODI and PROMIS scores at baseline compared to nonchronic users (NOU). At 1 and 2 year follow-up, the COU cohort continued to have significantly worse ODI, PROMIS Fatigue, PF, PI, SD, and SR scores. There is a statistical difference in the magnitude of change in health status between the 2 cohorts at 1 year follow-up in PROMIS Depression (-5.04±7.88 vs -2.49±8.73, p=.042), PF (6.25±7.11 vs 9.03±9.04, p=.019), and PI (-7.40±7.37 vs -10.58±9.87, p=.011) and 2 year follow-up in PROMIS PF (5.58±6.84 vs 7.99±9.64, p=.041) and PI (-6.71±8.32 vs -9.62±10.06, p=.032). Mean improvement in PROMIS scores for the COU cohort at 2 year follow-up exceeded minimal clinically important difference (MCID) in all domains except PROMIS Depression, SR and SD.

CONCLUSION

Patients with chronic opioid use status have worse baseline PROMIS scores compared with patients who had nonchronic use. However, patients in the COU cohort displayed clinically significant postoperative improvement in multiple PROMIS domains. These results show that patients with chronic opioid use can benefit greatly from surgical intervention and will allow physicians to better set expectations with their patients.

Impact of preoperative mental health diagnosis on postoperative opioid use patterns in spine fusion surgery: A systematic literature review

Opioids are frequently prescribed for patients undergoing procedures such as spinal fusion surgery for the management of chronic back pain. However, the association between a preoperative mental health illness, such as depression or anxiety, and opioid use patterns after spinal fusion surgery remain unclear. Therefore, we performed a systematic literature review in accordance with PRISMA guidelines to identify articles from the PubMed Database that analyzed the relationship between preoperative mental health illness and postoperative opioid usage after spinal fusion surgery on June 1, 2023. The Methodological Index for Nonrandomized Studies (MINORS) was utilized to evaluate the quality of included articles. Seven studies with 139,580 patients and a mean MINORS score of 18 ± 0.5 were included in qualitative synthesis. The most common spine surgery performed was lumbar fusion (59 %) and the mean age across studies ranged from 50 to 62 years. The range of postoperative opioid usage patterns analyzed ranged from 1 to 24 months. The majority of studies (6/7; 86 %) reported that a preoperative diagnosis of mental health illness was associated with increased opioid dependence after spinal fusion surgery. Preoperative use of opioids for protracted periods was shown to be associated with postoperative chronic opioid dependence. Consensus findings suggest that having a preoperative diagnosis of a mental health illness such as depression or anxiety is associated with increased postoperative opioid use after spinal fusion surgery. Patient comorbidities, including diagnoses of mental health illness, must be considered by the spine surgeon in order to reduce rates of postoperative opioid dependence.

Mental health after lumbar spine surgery: cognitive appraisal processes and outcome in a longitudinal cohort study

BACKGROUND CONTEXT

A not uncommon finding following spine surgery is that many patients do not achieve mental health improvement up to population norms for their age cohort, despite improvement in pain and functioning.

PURPOSE

This study examined how patients who were categorized as depressed versus not depressed think about health-related quality of life as assessed by cognitive-appraisal processes. It examined cross-sectional and longitudinal differences over 12 months postsurgery.

DESIGN

Prospective longitudinal cohort study with data collected at presurgery and at ∼3- and ∼12-months postsurgery from August 2013 to August 2023.

PATIENT SAMPLE

We included 173 adults undergoing lumbar spine surgery for degenerative spinal conditions at an academic medical center. The study sample was 47% female, with a mean age of 61 (SD=15.0), and a median level of education of college graduate.

OUTCOME MEASURES

Depression was defined as a Mental Component Score (MCS)≤38 on the Rand-36, building on studies that equated MCS scores with significant depression as assessed by clinically validated depression scales. The Quality-of-Life Appraisal Profile assessed the cognitive-appraisal domains of Experience Sampling and Standards of Comparison.

METHODS

The analysis focused on two comparisons: cross-sectionally comparing those who were not depressed (n=82) to those who were depressed (n=77) at baseline; and comparing longitudinal trajectories among those depressed before surgery and improved (n=54) versus did not improve (n=23). T-tests characterized group differences in appraisal endorsement; analysis of variance evaluated appraisal items in terms of explained variance; and Pearson correlation coefficients assessed direction of association in predicting mental health.

RESULTS

There were presurgical and longitudinal differences in both cognitive appraisal domains. Before surgery, depressed patients were less likely than nondepressed patients to endorse emphasizing the positive; more likely to focus on worst moments, recent flare-ups, their spinal condition, and the future; and more likely to compare themselves to high aspirations (eg, perfect health). Over time, among those who were depressed before surgery, those who improved focused decreasingly on worst moments and on the time before their spinal condition, and increasingly on emphasizing the positive and balancing the positives/negatives. Appraisal explained more variance in mental health among those who did not improve as compared to those who did, at all timepoints. All appraisal items were more highly correlated with mental health among those who remained depressed as compared to those who improved, particularly over time.

CONCLUSIONS

Endorsement of cognitive appraisal processes was different for depressed versus nondepressed spine-surgery patients before surgery and distinguished those who were depressed before surgery and improved versus those who did not improve. These findings suggest that targeted interventions could be beneficial for addressing mental health concerns during the spine surgery recovery trajectory. These interventions might use appraisal measures to identify patients likely to remain depressed after surgery, and then focus on helping these patients shift their focus and standards of comparison.

The impact of instrumented lumbar fusion surgery on psychiatric problems in elderly patients with degenerative spinal stenosis: The observational study

This is a prospective cohort study to investigate the effects of instrumented lumbar fusion surgery on psychiatric problems, including anxiety, insomnia, and depression, in patients with degenerative spinal stenosis, as well as on pain and the activities of daily living. Surgery was performed in the patients with Schizas grade C or D spinal stenosis with; if a patient's quality of life was impaired for at least 3 months or if patient had neurologic deficits. Finally, 69 patients were reviewed. Beck anxiety inventory, insomnia severity index, geriatric depression scale short form-Korean, visual analog scale for back pain, visual analog scale for leg pain, and Oswestry disability index was measured on the day surgery was decided on (T1), the day before surgery (T2), the day before discharge (T3), and 6 months after surgery (T4). The patients had mild degrees of anxiety, insomnia, and depression at T1, and Beck anxiety inventory, insomnia severity index, visual analog scale for back pain, visual analog scale for leg pain, and Oswestry disability index improved significantly by T4. In elderly patients with degenerative spinal stenosis, instrumented lumbar fusion surgery improves not only pain and activities of daily living, but also anxiety and insomnia. However, there was no improvement in depression over the 6-month follow-up period.

Impact of Early Depressive Burden on Patient-Reported Outcomes Following Minimally Invasive Transforaminal Lumbar Interbody Fusion

STUDY DESIGN

Retrospective review.

OBJECTIVE

To evaluate mental health influence on minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) patients.

SUMMARY OF BACKGROUND DATA

Poor mental health has been postulated to indicate inferior patient perceptions of surgical outcomes in spine literature. Few studies have assessed mental health as a dynamic metric throughout the perioperative period.

METHODS

A single-surgeon database was retrospectively searched for patients who underwent primary, elective MIS-TLIF for degenerative or isthmic spondylolisthesis. Summative depressive burden (SDB) was defined by the sum of preoperative and 6-week postoperative 9-item Patient Health Questionnaire (PHQ-9), with Lesser Burden (LB, SDB<10) and Greater Burden (GB, SDB≥10) cohorts. Patient-reported outcomes measures (PROMs) were compared preoperatively, at 6 weeks, and at final postoperative follow-up (11.4±10.9 mo), using Patient-Reported Outcomes Measurement Information System-Physical Function (PROMIS-PF), Oswestry disability index (ODI), visual analog scale-back (VAS-B), VAS-leg (VAS-L), and PHQ-9. Improvements at 6-week (∆PROM-6W), final follow-up (∆PROM-FF), and minimum clinically important difference (MCID) achievement were compared.

RESULTS

The GB cohort consisted of 44 of 105 patients. Demographic variations included older age, higher Charlson comorbidity index, increased hypertension prevalence, and private insurance in the LB cohort (P≤0.018). The LB cohort demonstrated better baseline and 6-week PROMIS-PF/ODI/VAS-L (P≤0.032) and better final PROMIS-PF/ODI/VAS-L/PHQ-9 (P≤0.031). Both cohorts improved in all PROMs at 6 weeks and final follow-up (P≤0.029), except for PROMIS-PF at 6 weeks in the GB cohort. ∆PROM-6W, ∆PROM-FF, and MCID achievement rate for PHQ-9 were greater in the GB cohort (P≤0.001).

CONCLUSION

On average, patients undergoing MIS-TLIF for degenerative or isthmic spondylolisthesis improved in all PROMs by final follow-up. Patients with GB suffered inferior perceptions of physical function, disability, and leg pain. MCID rates in mental health were higher for GB cohort. Surgeons are encouraged to adopt a compassionate understanding of depressive burden and educate the patient on possible consequential postoperative outcomes.

Impact of Spinal CSF Leaks on Quality of Life and Mental Health and Long-Term Reversal by Surgical Closure

Background and Objectives

Spontaneous intracranial hypotension (SIH) caused by a spinal CSF leak is a multisymptom syndrome, which can dramatically affect physical and mental health. However, systematic data on health-related quality of life (HRQoL) and mental health are scarce. We hypothesized that surgical treatment leads to significant and sustained improvements in HRQoL and mental health in patients with SIH.

Methods

In this single-center cohort study, we prospectively collected HRQoL and mental health data in patients undergoing surgical closure of a spinal CSF leak from September 2020 to November 2022. EuroQoL (EQ-5D-5L), including the health state index (EQ-Index) and the visual analog scale (EQ-VAS), measured HRQoL. The 21-item version of the Depression Anxiety Stress Scales (DASS-21) measured symptoms of mental health. Follow-ups were performed 3 and 6 months postoperatively. Primary outcome was the change in EQ-Index, EQ-VAS, and DASS-21 subscales. Secondary outcome was the impact of baseline depression symptoms on HRQoL outcomes following surgery.

Results

Seventy-four patients were included. EQ-VAS improved from 40 (interquartile range [IQR] 30-60) preoperatively to 70 (IQR 55-85) at 3 months and to 72 (IQR 60-88) at 6 months postoperatively (p < 0.001, respectively). EQ-Index increased from 0.683 (IQR 0.374-0.799) to 0.877 (0.740-0.943) at 3 months and to 0.907 (0.780-0.956) at 6 months postoperatively (p < 0.001, respectively). Depression, anxiety, and stress significantly improved after surgery. Preoperative depressive symptoms did not affect the HRQoL outcome.

Discussion

The severe impact of a spinal CSF leak on HRQoL and mental health significantly improved after closure of the leak. Higher levels of depressive symptoms do not predict worse outcomes and should not discourage invasive treatment. Further systematic evaluation of outcomes, with special regard to quality of life, is needed, as it allows a comparison of symptom burden between SIH and more familiar diseases as well as a comparison of different treatment modalities in future studies.

HADS and SOMS-2 brief score evaluation can prevent unnecessary minimal invasive spine interventions - a prospective blinded observational clinical trial

INTRODUCTION

To test the hypothesis, whether HADS/SOMS is practical in a spine surgery consultation setting and that patients with CLBP, but a high-risk of psychic comorbidities using above screenings will not improve after minimal-invasive spine interventions (MIS).

METHODS

n = 150 completed HADS and SOMS prior to the acquisition of history and examination. Primary outcome was improvement by numeric rating scale (NRS), Pain disability index (PDI) and oswestry disability index (ODI) at baseline and 6 months after intervention. In case of sciatica due to disc herniation epidural neurolysis, for facet or SI-joint-syndrome, radiofrequency and for discogenic pain intradiscal electrothermal therapy (IDET) was performed.

RESULTS

6 months after interventions, pat. with a high-risk of anxiety or depression showed no clinically important improvements in NRS, PDI and ODI, whereas in the low-risk group all 3 parameters were significantly reduced. We found a statistically significant difference in the improvement of NRS (p < 0·05), PDI (p < 0·001), ODI (p < 0·001) between high- and low-risk HADS-anxiety and depression groups and in the improvement of NRS and PDI (p < 0·05) between high- and low-risk SOMS-2-subgroups.

CONCLUSIONS

In this group of CLBP patients, the easy-to-administer HADS/SOMS reliably predicted outcome after MIS due to the detection of somatoform comorbidities. Thus, 30 out of 150 patients were invasively treated without improvement. This is alarming not only because of unnecessary MIS being performed on these individuals, but also because it represents an inefficient allocation of increasingly limited healthcare funds.

LEVEL OF EVIDENCE

II.

Effects of nurses-led multidisciplinary-based psychological management in spinal surgery: a retrospective, propensity-score-matching comparative study

BACKGROUND

Patients in spine surgery often have emotional disorders which is caused by multi-factors. Therefore, a multidisciplinary and multimodal intervention program is required to improve emotional disorders during the perioperative period. However, related studies were rare. This study aimed to confirm that the multidisciplinary-based psychological management leading by nurses was effective in treating emotional disorders and show the assignments of the members of the multidisciplinary team with the orientations of nurses.

DESIGN

A retrospective, comparative study.

METHOD

This study was a retrospective cohort research and compared the results between the intervention group and control group using the Huaxi Emotional Distress Index (HEI) which was used to evaluate emotional disorders. The intervention group consisted of patients who underwent surgery between January 2018 and December 2020 after psychological management was implemented. The control group consisted of patients with regular care who underwent surgery between January 2015 and December 2017. To improve comparability between the two groups, baseline data from the recruited patients were analyzed using propensity-score-matching (PSM) based on age, sex, marital status, education, and disease region.

RESULTS

A total of 539 (11.5%) people developed emotional disorders, of which 319 (6.8%), 151 (3.2%) and 69 (1.5%) had mild, moderate mood and severe emotional disorders, respectively. 2107 pairs of patients were matched after PSM. Scores of HEI in the intervention group were heightened compared with those in the control group (P<0.001) after matching. Moreover, the incidence of emotional disorders in patients decreased after implementing psychological management (P = 0.001). The severity of emotional disorders was alleviated with statistical significance as well (P = 0.010).

CONCLUSIONS

Nurses-led Multidisciplinary-Based psychological management was able to reduce the incidence of emotional disorders and improve the severity of these in spine surgery patients.

Influence of Anxiety and Depression on Opioid Use After Cervical Spine Fusion: An Analysis of a National Claims Database

Patients with spine pathology demonstrate an above average rate of active psychiatric disorders, which can influence their recovery. This study was designed to understand how mental health diagnoses (ie, anxiety and depression) influence a patient's postoperative need for opioids after a single level cervical spine fusion. The PearlDiver database was used to identify patients. Patients were placed into one of four groups: those with a diagnosis of depression, those with a diagnosis of anxiety, those with a diagnosis of both anxiety and depression, and a control group. Chi-square tests were used to assess differences in the number of patients filling initial and additional opioid prescriptions for up to 90 days after their fusion. A total of 168,967 patients who underwent an elective cervical spine fusion in the United States between 2010 and 2021 were included in this study. The control group filled significantly more opioid prescriptions within the first 90 days after their cervical fusion (P<.001). There was no difference among the study groups regarding the need to fill additional opioid prescriptions. Patients with a diagnosis of depression and/or anxiety may present as complex patients; however, results suggest they do not need additional opioids for pain control after a single level cervical spine fusion. [Orthopedics. 2024;47(2):89-94.].

Psychological Distress After Inpatient Noncardiac Surgery: A Secondary Analysis of the Measurement of Exercise Tolerance Before Surgery Prospective Cohort Study

OBJECTIVE

To describe the incidence and natural progression of psychological distress after major surgery.

BACKGROUND

The recovery process after surgery imposes physical and mental burdens that put patients at risk of psychological distress. Understanding the natural course of psychological distress after surgery is critical to supporting the timely and tailored management of high-risk individuals.

METHODS

We conducted a secondary analysis of the "Measurement of Exercise Tolerance before Surgery" multicentre cohort study (Canada, Australia, New Zealand, and the UK). Measurement of Exercise Tolerance before Surgery recruited adult participants (≥40 years) undergoing elective inpatient noncardiac surgery and followed them for 1 year. The primary outcome was the severity of psychological distress measured using the anxiety-depression item of EQ-5D-3L. We used cumulative link mixed models to characterize the time trajectory of psychological distress among relevant patient subgroups. We also explored potential predictors of severe and/or worsened psychological distress at 1 year using multivariable logistic regression models.

RESULTS

Of 1546 participants, moderate-to-severe psychological distress was reported by 32.6% of participants before surgery, 27.3% at 30 days after surgery, and 26.2% at 1 year after surgery. Psychological distress appeared to improve over time among females [odds ratio (OR): 0.80, 95% CI: 0.65-0.95] and patients undergoing orthopedic procedures (OR: 0.73, 95% CI: 0.55-0.91), but not among males (OR: 0.87, 95% CI: 0.87-1.07) or patients undergoing nonorthopedic procedures (OR: 0.95, 95% CI: 0.87-1.04). Among the average middle-aged adult, there were no time-related changes (OR: 0.94, 97% CI: 0.75-1.13), whereas the young-old (OR: 0.89, 95% CI: 0.79-0.99) and middle-old (OR: 0.87, 95% CI: 0.73-1.01) had small improvements. Predictors of severe and/or worsened psychological distress at 1 year were younger age, poor self-reported functional capacity, smoking history, and undergoing open surgery.

CONCLUSIONS

One-third of adults experience moderate to severe psychological distress before major elective noncardiac surgery. This distress tends to persist or worsen over time among select patient subgroups.

Influence of Anxiety and Depression on Opioid Use Following Lumbar Spine Fusion: A Large Database Study

STUDY DESIGN

Retrospective database.

OBJECTIVE

The purpose of this study was to understand how a mental health disorder, specifically anxiety and depression, influences a patient's postoperative opioid needs following single-level lumbar spine fusion.

SUMMARY OF BACKGROUND DATA

Patients with spine pathology commonly demonstrate symptoms of an active psychiatric disorder. Mental health significantly influences how a patient perceives pain and a patient's opioid pain control needs after surgery.

MATERIALS AND METHODS

The Pearldiver Patient Claims Database was used to identify patients undergoing single-level posterior spine fusion within the United States between 2010 and 2020. Patients were placed into 1 of 4 groups: those with a diagnosis of depression, those with a diagnosis of anxiety, those with a diagnosis of both anxiety and depression, and a control group. χ 2 tests were used to assess differences in the number of patients filling initial and additional opioid prescriptions for up to 90 days following their fusion.

RESULTS

The control group filled significantly more initial opioid prescriptions within the first 90 days following their spine fusion ( P <0.001). However, there was no difference among the study groups in regard to the additional need for prescriptions.

CONCLUSION

Patients with mental health diagnoses may present as complex patients to spine surgeons; however, this study suggests they do not require additional opioid pain control following a single-level lumbar fusion.

A Perioperative Mental Health Intervention for Depressed and Anxious Older Surgical Patients: Results From a Feasibility Study

OBJECTIVES

The perioperative period is challenging and stressful for older adults. Those with depression and/or anxiety have an increased risk of adverse surgical outcomes. We assessed the feasibility of a perioperative mental health intervention composed of medication optimization and a wellness program following principles of behavioral activation and care coordination for older surgical patients.

METHODS

We included orthopedic, oncologic, and cardiac surgical patients aged 60 and older. Feasibility outcomes included study reach, the number of patients who agreed to participate out of the total eligible; and intervention reach, the number of patients who completed the intervention out of patients who agreed to participate. Intervention efficacy was assessed using the Patient Health Questionnaire for Anxiety and Depression (PHQ-ADS). Implementation potential and experiences were collected using patient surveys and qualitative interviews. Complementary caregiver feedback was also collected.

RESULTS

Twenty-three out of 28 eligible older adults participated in this study (mean age 68.0 years, 65% women), achieving study reach of 82% and intervention reach of 83%. In qualitative interviews, patients (n = 15) and caregivers (complementary data, n = 5) described overwhelmingly positive experiences with both the intervention components and the interventionist, and reported improvement in managing depression and/or anxiety. Preliminary efficacy analysis indicated improvement in PHQ-ADS scores (F = 12.13, p <0.001).

CONCLUSIONS

The study procedures were reported by participants as feasible and the perioperative mental health intervention to reduce anxiety and depression in older surgical patients showed strong implementation potential. Preliminary data suggest its efficacy for improving depression and/or anxiety symptoms. A randomized controlled trial assessing the intervention and implementation effectiveness is currently ongoing.

Hip Preservation Surgery in Patients With Femoroacetabular Impingement Syndrome and Acetabular Dysplasia Improves Functional Measures and Pain Catastrophizing

Background Chronic hip pain is a debilitating condition that severely reduces one's quality of life. Prior studies uncovered a link between hip pathologies and pain catastrophizing, anxiety, and depression. The purpose of this study was to investigate whether hip preservation surgery in patients with femoroacetabular impingement syndrome (FAIS) and acetabular dysplasia (AD) improves functional outcomes and pain catastrophizing. Methods Patients with FAIS and AD were requested to complete a hip questionnaire both preoperatively and postoperatively at a single academic center (University of Texas Southwestern Medical Center, Dallas, Texas, USA). Pain catastrophizing was evaluated using the pain catastrophizing scale, and pain level was assessed using the visual analog scale. Assessments of hip functional outcomes included the hip outcome score (HOS) and the hip disability and osteoarthritis outcome score (HOOS). Outcome measures before and after treatment were compared using the dependent samples t-test. A correlation analysis, using the Spearman partial correlation coefficient (rs), was conducted to evaluate the relationship between variables. Results The results indicated a clinically significant improvement in functional measures and pain catastrophizing in patients who underwent hip preservation surgery. The most significant discovery was an inverse relationship between both HOOS quality of life (rs=-0.293, p=0.0065, false discovery rate (FDR)=0.0210) and HOS activities of daily living (rs=-0.242, p=0.0254, FDR=0.0423) and pain catastrophizing; however, similar improvements were seen in pain catastrophizing with improvements in other functional outcomes. Conclusion Undergoing hip preservation surgery for patients with AD or FAIS improved their hip functional measures and decreased pain catastrophizing postoperatively. The improvement of hip function, quality of life, and pain catastrophizing reveals an intricate link between the functional outcomes of hip preservation surgery and pain catastrophizing.

Psychological Screening, Standards and Spinal Cord Injury: Introducing Change in NHS England Commissioned Services

Psychologist resourcing across the United Kingdom (UK) spinal cord injury centres (SCICs) varies considerably, which has detrimentally impacted standardising service provision for people with spinal cord injuries/disorders (PwSCI/D) compared with other nations. This paper presents the outcome of a project involving the Spinal Cord Injury Psychology Advisory Group (SCIPAG) and NHS England Clinical Reference Group/SCI transformation groups to agree upon screening and standards and shares data from the National Spinal Injuries Centre (NSIC) and the Yorkshire and Midlands Regional SCICs. Inpatients completed the GAD-7, the PHQ-9, and the short form of the Appraisals of DisAbility: Primary and Secondary Scale (ADAPSSsf), assessing adjustment. A total of 646 participants were included, with 43% scoring above the clinical threshold on at least one of the measures on admission. A subset of 272 participants also completed discharge measures and 42% remained above the threshold on discharge, demonstrating sustained psychological need. This paper provides support for services to move to a screen-and-assessment model supplemented by referral options for those with changing needs or who present with difficulties outside the remit of screening. The findings also support the efficacy of universal screening across the system and consideration of screening and standards for psychological care by the wider psychology community.

Psychometric Evaluation of the Farsi Version of the Surgical Anxiety Questionnaire

PURPOSE

The aim of this study was to evaluate the psychometric properties of the Farsi version of the Surgical Anxiety Questionnaire.

DESIGN

Cross-sectional study.

METHODS

This study was performed on 402 patients who were candidates for elective surgery in Mashhad [East Iran) hospitals in winter 2021. After forward-backward translation, face and content validity checks were performed qualitatively. The construct validity was assessed by exploratory and confirmatory factor analysis. Data analysis was performed with SPSS 16 and AMOS 26.

FINDINGS

In exploratory factor analysis, two factors were extracted: concerns about surgery and anesthesia; and postdischarge concerns, which explained 52% of the total variance. The Cronbach's alpha for the entire questionnaire was 0.91 and for the subscales ranged from 0.80 to 0.87. The final model had a good fit as determined by confirmatory factor analysis.

CONCLUSIONS

The Farsi version of the surgical anxiety questionnaire has acceptable validity and reliability. The existence of this scale measuring domain-specific anxiety allows for further research in this area.

Risk factors for failure to achieve minimal clinically important difference following cervical disc replacement

BACKGROUND CONTEXT

While cervical disc replacement (CDR) has been emerging as a reliable and efficacious treatment option for degenerative cervical spine pathology, not all patients undergoing CDR will achieve minimal clinically important difference (MCID) in patient-reported outcome measures (PROMs) postoperatively-risk factors for failure to achieve MCID in PROMs following CDR have not been established.

PURPOSE

To identify risk factors for failure to achieve MCID in Neck Disability Index (NDI, Visual Analog Scale (VAS) neck and arm following primary 1- or 2-level CDRs in the early and late postoperative periods.

STUDY DESIGN

Retrospective review of prospectively collected data.

PATIENT SAMPLE

Patients who had undergone primary 1- or 2-level CDR for the treatment of degenerative cervical pathology at a single institution with a minimum follow-up of 6 weeks between 2017 and 2022.

OUTCOME MEASURES

Patient-reported outcomes: Neck disability index (NDI), Visual analog scale (VAS) neck and arm, MCID.

METHODS

Minimal clinically important difference achievement rates for NDI, VAS-Neck, and VAS-Arm within early (within 3 months) and late (6 months to 2 years) postoperative periods were assessed based on previously established thresholds. Multivariate logistic regressions were performed for each PROM and evaluation period, with failure to achieve MCID assigned as the outcome variable, to establish models to identify risk factors for failure to achieve MCID and predictors for achievement of MCID. Predictor variables included in the analyses featured demographics, comorbidities, diagnoses/symptoms, and perioperative characteristics.

RESULTS

A total of 154 patients met the inclusion criteria. The majority of patients achieved MCID for NDI, VAS-Neck, and VAS-Arm for both early and late postoperative periods-79% achieved MCID for at least one of the PROMs in the early postoperative period, while 80% achieved MCID for at least one of the PROMs in the late postoperative period. Predominant neck pain was identified as a risk factor for failure to achieve MCID for NDI in the early (OR: 3.13 [1.10-8.87], p-value: .032) and late (OR: 5.01 [1.31-19.12], p-value: .018) postoperative periods, and VAS-Arm for the late postoperative period (OR: 36.63 [3.78-354.56], p-value: .002). Myelopathy was identified as a risk factor for failure to achieve MCID for VAS-Neck in the early postoperative period (OR: 3.40 [1.08-10.66], p-value: .036). Anxiety was identified as a risk factor for failure to achieve MCID for VAS-Neck in the late postoperative period (OR: 6.51 [1.91-22.18], p-value: .003). CDR at levels C5C7 was identified as a risk factor for failure to achieve MCID in NDI for the late postoperative period (OR: 9.74 [1.43-66.34], p-value: .020).

CONCLUSIONS

Our study identified several risk factors for failure to achieve MCID in common PROMs following CDR including predominant neck pain, myelopathy, anxiety, and CDR at levels C5-C7. These findings may help inform the approach to counseling patients on outcomes of CDR as the evidence suggests that those with the risk factors above may not improve as reliably after CDR.

The Current Status of Awake Endoscopic Surgery: A Systematic Review and Meta-Analysis

OBJECTIVE

To examine the use of local anesthesia and/or conscious sedation in endoscopic spine procedures within the past decade.

METHODS

This systematic review abided by PRISMA guidelines. Embase, PubMed, Google Scholar, and Cochrane databases were searched for post-2011 articles with patients >18 years old, lumbar/cervical percutaneous endoscopic spine procedures using local/awake anesthesia, and patient/surgical outcomes. Reviews, book chapters, single case reports, or small case series (n ≤15 patients) were excluded. Scoring systems of the National Institutes of Health quality assessment tool, Newcastle-Ottawa Scale, and Cochrane Risk of Bias evaluated interventional case series, comparative studies, and randomized control trials, respectively.

RESULTS

Twenty-six articles were included, with 4 studies comparing general and local anesthesia. Of 2113 total patients, 1873 patients received local anesthesia. Significant improvements were seen in pain and disability scores. Studies that included MacNab scores showed that 96% of patients rated their postoperative satisfaction as excellent to good. Subanalysis of comparative studies showed a reduced risk of surgical/major medical complications and a slight increased risk for minor medical complications among awake spine patients. Length of stay was shorter for patients receiving local anesthesia.

CONCLUSIONS

The current systematic review and meta-analysis shows that use of local anesthesia is a safe and effective alternative to general anesthesia among different endoscopic spinal procedures. Although awake spine surgery is associated with a decreased risk of severe complications, lower revision rates, and higher postoperative satisfaction, more robust studies involving larger cohorts of patients are needed to evaluate the true impact of awake spine surgery on outcomes.

The Reoperation, Readmission, and Complication Rates at 30 Days Following Lumbar Decompression for Cauda Equina Syndrome

Background and objective Cauda equina syndrome (CES) is considered a surgical emergency, and its primary treatment involves decompression of the nerve roots, typically in the form of discectomy or laminectomy. The primary aim of this study was to determine the complication, reoperation, and readmission rates within 30 days of surgical treatment of CES secondary to disc herniation by using the PearlDiver database (PearlDiver Technologies, Colorado Springs, CO). The secondary aim was to assess preoperative risk factors for a higher likelihood of complication occurrence within 30 days of surgery for CES. Methods A total of 524 patients who had undergone lumbar discectomy or laminectomy for CES were identified. The outcome measures were 30-day reoperation rate for revision decompression or lumbar fusion, and 30-day readmissions related to surgery. The patient data collected included medical history and surgical data including the number of levels of discectomy and laminectomy. Results Based on our findings, intraoperative dural tears, valvular heart disease, and fluid and electrolyte abnormalities were significant risk factors for readmission to the hospital within 30 days following surgery for CES. The most common postoperative complications were as follows: visits to the emergency department (63 patients, 12%), surgical site infection (21 patients, 4%), urinary tract infection (14 patients, 3%), and postoperative anemia (11 patients, 2%). Conclusions In the 30-day period following lumbar decompression for cauda equina syndrome, our findings demonstrated an 8% reoperation rate and 17% readmission rate. Although CES is considered an indication for urgent surgery, gaining awareness about reoperation, readmission, and complication rates in the immediate postoperative period may help calibrate expectations and inform medical decision-making.

A multi- and mixed-method adaptation study of a patient-centered perioperative mental health intervention bundle

BACKGROUND

Anxiety and depression are common among older adults and can intensify during perioperative periods, but few mental health interventions are designed for older surgical patients' unique needs. As part of the feasibility trial, we developed and adapted a perioperative mental health (PMH) bundle for older patients comprised of behavioral activation (BA) and medication optimization (MO) to ameliorate anxiety and depressive symptoms before, during, and after cardiac, orthopedic, and oncologic surgery.

METHODS

We used mixed-methods including workshop studios with patients, caregivers, clinicians, researchers, and interventionists; intervention refinement and reflection meetings; patient case review meetings; intervention session audio-recordings and documentation forms; and patient and caregiver semi-structured interviews. We used the results to refine our PMH bundle. We used multiple analytical approaches to report the nature of adaptations, including hybrid thematic analysis and content analysis informed by the Framework for Reporting Adaptations and Modifications - Expanded.

RESULTS

Adaptations were categorized by content (intervention components), context (how the intervention is delivered, based on the study, target population, intervention format, intervention delivery mode, study setting, study personnel), training, and evaluation. Of 51 adaptations, 43.1% involved content, 41.2% involved context, and 15.7% involved training and evaluation. Several key adaptations were noted: (1) Intervention content was tailored to patient preferences and needs (e.g., rewording elements to prevent stigmatization of mental health needs; adjusting BA techniques and documentation forms to improve patient buy-in and motivation). (2) Cohort-specific adaptations were recommended based on differing patient needs. (3) Compassion was identified by patients as the most important element.

CONCLUSIONS

We identified evidence-based mental health intervention components from other settings and adapted them to the perioperative setting for older adults. Informed by mixed-methods, we created an innovative and pragmatic patient-centered intervention bundle that is acceptable, feasible, and responsive to the needs of older surgical populations. This approach allowed us to identify implementation strategies to improve the reach, scalability, and sustainability of our bundle, and can guide future patient-centered intervention adaptations.

CLINICAL TRIALS REGISTRATION

NCT05110690 (11/08/2021).

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.

Failed Back Surgery Syndrome: No Longer a Surgeon's Defeat-A Narrative Review

The introduction of the term Persistent Spinal Pain Syndrome (PSPS-T1/2), replacing the older term Failed Back Surgery Syndrome (FBSS), has significantly influenced our approach to diagnosing and treating post-surgical spinal pain. This comprehensive review discusses this change and its effects on patient care. Various diagnostic methods are employed to elucidate the underlying causes of back pain, and this information is critical in guiding treatment decisions. The management of PSPS-T1/2 involves both causative treatments, which directly address the root cause of pain, and symptomatic treatments, which focus on managing the symptoms of pain and improving overall function. The importance of a multidisciplinary and holistic approach is emphasized in the treatment of PSPS-T1/2. This approach is patient-centered and treatment plans are customized to individual patient needs and circumstances. The review concludes with a reflection on the impact of the new PSPS nomenclature on the perception and management of post-surgical spinal pain.

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

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

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

SUMMARY OF BACKGROUND DATA

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

METHODS

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

RESULTS

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

CONCLUSION

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

Using Sentiment Analysis to Understand What Patients Are Saying About Hand Surgeons Online

BACKGROUND

Physician review websites have influence on a patient's selection of a provider. Written reviews are subjective and difficult to quantitatively analyze. Sentiment analysis of writing can quantitatively assess surgeon reviews to provide actionable feedback for surgeons to improve practice. The objective of this study is to quantitatively analyze large subset of written reviews of hand surgeons using sentiment analysis and report unbiased trends in words used to describe the reviewed surgeons and biases associated with surgeon demographic factors.

METHODS

Online written and star-rating reviews of hand surgeons were obtained from healthgrades.com and webmd.com. A sentiment analysis package was used to calculate compound scores of all reviews. Mann-Whitney U tests were performed to determine the relationship between demographic variables and average sentiment score of written reviews. Positive and negative word and word-pair frequency analysis was also performed.

RESULTS

A total of 786 hand surgeons' reviews were analyzed. Analysis showed a significant relationship between the sentiment scores and overall average star-rated reviews (r2 = 0.604, P ≤ .01). There was no significant difference in review sentiment by provider sex; however, surgeons aged 50 years and younger had more positive reviews than older (P < .01). The most frequently used bigrams used to describe top-rated surgeons were associated with good bedside manner and efficient pain management, whereas those with the worst reviews are often characterized as rude and unable to relieve pain.

CONCLUSIONS

This study provides insight into both demographic and behavioral factors contributing to positive reviews and reinforces the importance of pain expectation management.

The role of catastrophizing and basic psychological needs satisfaction on health-related quality of life and pain in patients with lumbar disc herniation

Introduction

Lumbar disc herniation (LDH) is one of the most common conditions associated with functional disability, affecting patients' quality of life (QOL). Disability can be affected by cognitive factors, such as pain catastrophizing. Similarly, unfulfilled basic psychological needs (i.e., autonomy, competence, relatedness) are associated with biases in pain perception and QOL. Using the fear-avoidance model and the self-determination theory, this study investigates: (1) the separate contribution of pain-related variables and basic psychological needs satisfaction in predicting QOL in patients proposed for LDH surgery; (2) pre- and post-surgical differences in pain catastrophizing and basic psychological needs satisfaction.

Methods

First, we used hierarchical regression on 193 patients (M_age = 46.10, SD_age = 11.40) to identify predictors of QOL. Second, we performed paired t-tests on 55 patients to investigate pre- and post-surgical differences in pain catastrophizing and basic psychological needs satisfaction.

Results

Hierarchical regression showed that the model predicts 27% of the variance in QOL; medium pain level, age, pain catastrophizing, and basic psychological needs satisfaction were significant predictors. Also, pain catastrophizing significantly decreased after surgery [t (54) = 6.07, p < 0.001, Cohen's d = 0.81], but basic psychological needs satisfaction did not modify significantly.

Discussion

This research confirms the importance of pain perception and pain catastrophizing for LDH patients' QOL and broadens the applicability of the self-determination theory for spinal patients.

Presence and Severity of Mental Illness Is Associated With Increased Risk of Postoperative Emergency Visits, Readmission, and Reoperation Following Outpatient ACDF: A National Database Analysis

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The purpose was to compare rates of postoperative ED visits, readmission, and reoperation between patients with and without preexisting mental illness undergoing outpatient anterior cervical discectomy and fusion (ACDF).

METHODS

A retrospective review of the Mariner Database was conducted on patients who underwent ACDF between 2010 and 2017. Exclusion criteria included same day revision surgery and patients with a history of spine infection, trauma, or neoplasm. Patients were grouped into 3 categories: those with existing history of anxiety and/or depression, those with severe mental illness, and those without any history of mental illness. Severe mental illness was defined as a combination of diagnosis including schizophrenia, bipolar disorder, and/or psychotic disorder. Outcome measures were analyzed by comparing groups using multivariate logistic regression. Significance was set at P < 0.05.

RESULTS

Patients with anxiety/depression and patients with severe mental illness both had significantly increased risk of ED visits and readmission at 30-day and 90-day intervals. Compared to patients without mental illness, patients with severe mental illness (OR 1.93, P < 0.001) had significantly increased rates of reoperation at 90-days and 1-years postoperatively. Patients with anxiety/depression did not have increased rates of reoperation relative to patients without anxiety/depression at any time interval (P > 0.05).

CONCLUSION

Anxiety/depression as well as more severe psychiatric disease such as Schizophrenia and Bipolar disorder were significantly associated with increased healthcare utilization following outpatient ACDF. Patients with preexisting mental illness undergoing outpatient ACDF should be carefully evaluated preoperatively and closely followed postoperatively to reduce risk of adverse events.

Indicators and predictors modifiable by the nursing department during the preoperative period: A scoping review

AIM AND OBJECTIVES

The aim of this study is to identify preoperative indicators and/or predictors of complications or inefficiencies in the surgical process that can be modified within nursing practice.

BACKGROUND

Due to rapid sociodemographic and technological change, the global demand for surgical attention is rising exponentially, requiring new strategies for optimisation and sustainability in perioperative care.

DESIGN

We conduced the scoping review using the methodology recommended by the Joanna Briggs Institute supported with The PAGER framework and guided by the PRISMA-ScR Checklist.

METHODS

Four databases (CINAHL, MEDLINE, SCOPUS and PUBMED) were examined to extract relevant published results for elective surgery on adult patients during the period 2011-2021. This process identified 609 records. Exclusion criteria were applied, and the sample was then evaluated with the Quality Assessment Tool for Studies with Diverse Designs (QATSDD), after which 15 studies remained.

RESULTS

The following preoperative indicators and/or predictors were considered: (1) Anxiety; (2) Pain; (3) Health education, knowledge and training; (4) Satisfaction; (5) Management/organisation (including costs, resources used/available, organisational issues, hospital stay (preoperative), standardisation and protocolisation.

CONCLUSION

The identification of five indicators and/or predictors of complications or inefficiencies in the surgical process, which can be modified by nursing, allows the effective application of interventions in the preoperative phase, optimising care and improving health outcomes.

RELEVANCE TO CLINICAL PRACTICE

The development and implementation of specific nursing skills in the preoperative phase are essential to optimise the surgical process.

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

STUDY DESIGN

Retrospective, observational.

OBJECTIVE

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

SUMMARY OF BACKGROUND DATA

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Poor mental health scores correlate with inferior outcomes following minimally invasive transforaminal lumbar interbody fusion

BACKGROUND

Limited spine literature has studied the strength of association of mental health with other outcomes at time of survey collection. We aim to evaluate the degree to which mental health correlates with outcomes in patients undergoing minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) at several postoperative periods.

METHODS

Patients having undergone elective MIS-TLIF were searched within a retrospective single-surgeon database. Five hundred eighty-five patients were included. Patient-reported outcomes (PROs) including Patient-Reported Outcome Measurement Information System Physical Function (PROMIS PF), 12-item Short Form Physical Component Score (SF-12 PCS) and Mental Component Score (SF-12 MCS), Patient Health Questionnaire-9 (PHQ-9), Visual Analog Scale (VAS) back and leg pain, and Oswestry Disability Index (ODI) scores were collected preoperatively and at 6-week, 12-week, 6-month, 1-year, and 2-year periods. Pearson's correlation tests were used to evaluate the association between both SF-12 MCS and PHQ-9 scores to other PROs at each period.

RESULTS

SF-12 MCS correlated with PROMIS PF (|r|= 0.308-0.531), SF-12 PCS (|r|= 0.207-0.328), VAS back (|r|= 0.279-0.474), VAS leg (|r|= 0.178-0.395), and ODI (|r|= 0.450-0.538) at all time points (P ≤ 0.021, all) except for preoperative SF-12 PCS and 1-year VAS leg. PHQ-9 correlated with PROMIS PF (|r|= 0.366-0.701), SF-12 PCS (|r|= 0.305-0.568), VAS back (|r|= 0.362-0.714), VAS leg (|r|= 0.319-0.694), and ODI (|r|= 0.613-0.784) at all periods (P < 0.001, all).

CONCLUSION

Poor mental health scores were correlated with lower physical function, elevated pain scores, and higher disability. PHQ-9 scores demonstrated stronger correlation in all relationships compared to SF-12 MCS. Optimization of patient mental health may lead to improved patient perception regarding function, pain, and disability following MIS-TLIF.

Psychedelic-Assisted Therapy and Psychedelic Science: A Review and Perspective on Opportunities in Neurosurgery and Neuro-Oncology

After a decades-long pause, psychedelics are again being intensely investigated for treating a wide range of neuropsychiatric ailments including depression, anxiety, addiction, post-traumatic stress disorder, anorexia, and chronic pain syndromes. The classic serotonergic psychedelics psilocybin and lysergic acid diethylamide and nonclassic psychedelics 3,4-methylenedioxymethamphetamine and ketamine are increasingly appreciated as neuroplastogens given their potential to fundamentally alter mood and behavior well beyond the time window of measurable exposure. Imaging studies with psychedelics are also helping advance our understanding of neural networks and connectomics. This resurgence in psychedelic science and psychedelic-assisted therapy has potential significance for the fields of neurosurgery and neuro-oncology and their diverse and challenging patients, many of whom continue to have mental health issues and poor quality of life despite receiving state-of-the-art care. In this study, we review recent and ongoing clinical trials, the set and setting model of psychedelic-assisted therapy, potential risks and adverse events, proposed mechanisms of action, and provide a perspective on how the safe and evidence-based use of psychedelics could potentially benefit many patients, including those with brain tumors, pain syndromes, ruminative disorders, stroke, SAH, TBI, and movement disorders. By leveraging psychedelics' neuroplastic potential to rehabilitate the mind and brain, novel treatments may be possible for many of these patient populations, in some instances working synergistically with current treatments and in some using subpsychedelic doses that do not require mind-altering effects for efficacy. This review aims to encourage broader multidisciplinary collaboration across the neurosciences to explore and help realize the transdiagnostic healing potential of psychedelics.

Enhanced recovery after surgery (ERAS) relieves psychological stress in patients with osteoporotic vertebral compression fracture undergoing percutaneous kyphoplasty: an observational retrospective cohort study

STUDY DESIGN

This is an observational retrospective cohort study.

OBJECTIVE

The purpose of this study is to investigate the incidence rate of depression and anxiety and the changes in patients treated with percutaneous kyphoplasty (PKP) following ERAS protocol. The incidence of depression and anxiety is not uncommon in patients with osteoporotic vertebral compression fracture (OVCF), which affects the prognosis of surgery. Enhanced recovery after surgery (ERAS) protocols can improve the perioperative stress response of patients.

MATERIALS AND METHODS

Patients were treated conventionally in 2019 as the control group (CG) (n = 281), and patients were treated according to the ERAS protocol in 2020 as the intervention group (IG) (n = 251). All patients were evaluated for depression and anxiety using Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 at admission, postoperative 1 week, 1 month and 3, 6, 12 months.

RESULTS

The degree of depression statistically decreased in the IG at follow-up periods (p < 0.001), and the degree of anxiety statistically decreased at 1 week (p < 0.001), 1 month (p < 0.001), 3 months (p = 0.017). Patients in the IG could soothe depression and anxiety disorders faster than patients in the CG and maintain psychological stability at the follow-up periods. The percentage of moderate or above depression in the IG was statistically fewer than in the CG at follow-up periods (p < 0.01). The odds ratio (OR) was respectively 0.410, 0.357, 0.294, 0.333, 0.327 from 1 week to 12 months. While the percentage of patients with moderate or above anxiety significantly decreased in the IG at 1 week (p < 0.001), OR = 0.528, 1 month (p = 0.037), OR = 0.309 and 12 months (p = 0.040), OR = 0.554, no differences between 3 months (p = 0.187) and 6 months (p = 0.133).

CONCLUSION

PKP following ERAS protocol to treat patients with OVCF had a better effect on relieving postoperative anxiety and depression than following conventional protocol.

Patient-level payment patterns prior to single level lumbar decompression are associated with resource utilization, postoperative payments, and adverse events

BACKGROUND

Understanding patient-specific trends in costs and healthcare resource utilization (HCRU) surrounding lumbar spine surgery is critically needed to better inform surgical decision making and the development of targeted interventions.

PURPOSE

1) Identify subgroups of patients following distinct patterns in direct healthcare payments pre- and postoperatively, 2) determine whether these patterns are associated with patient and surgical factors, and 3) examine whether preoperative payment patterns are related to postoperative payments, healthcare resource utilization (HCRU), and adverse events.

STUDY DESIGN/SETTING

Retrospective analysis of an administrative claims database (IBM Marketscan Research Databases 2007-2015).

PATIENT SAMPLE

Adults undergoing primary single-level decompression surgery for lumbar stenosis (n=12,394).

OUTCOME MEASURES

Direct healthcare payments, HCRU payments (15 categories), 90-day complications and all-cause readmission, 2-year reoperation METHODS: Group-based trajectory modeling is an application of finite mixture modeling that is able to identify meaningful subgroups within a population that follow distinct developmental trajectories over time. We used this technique to identify subgroups of patients following distinct profiles in preoperative direct healthcare payments. A separate analysis was performed to identify distinct profiles in payments postoperatively. Patient and surgical factors associated with these payment profiles were assessed with multinomial logistic regression, and associations with adverse events were assessed with risk-adjusted multivariable logistic regression.

RESULTS

We identified 4 preoperative patient payment subgroups following distinct profiles in payments: Pre-Low (5.8% of patients), Pre-Early-Rising (4.8%), Pre-Medium (26.1%), and Pre-High (63.3%). Postoperatively, 3 patient subgroups were identified: Post-Low (8.9%), Post-Medium (29.6%), and Post-High (61.4%). Patients following the higher-cost pre- and postoperative payment profiles were older, more likely female, and had a greater physical and mental comorbidity burden. With each successively higher preoperative payment profile, patients were increasingly likely to have high postoperative payments, use more HCRU (particularly high-cost services such as inpatient admissions, ER, and SNF/IRF care), and experience postoperative adverse events. Following risk adjustment for patient and surgical factors, patients following the Pre-High payment profile had 209.5 (95% CI: 144.2, 309.7; p<.001) fold greater odds for following the Post-High payment profile, 1.8 (1.3, 2.5; p=.003) fold greater odds for 90-day complications, and 1.7 (1.2, 2.6; p=.035) fold greater odds for 2-year reoperation relative to patients following the Pre-Low payment profile.

CONCLUSIONS

There are identifiable subgroups of patients who follow distinct profiles in direct healthcare payments surrounding lumbar decompression surgery. These payment profiles are related to patient age, sex, and physical and mental comorbidities. Notably, preoperative payment profiles may provide prognostic value, as they are associated with postoperative costs, HCRU, and adverse events.

LEVEL OF EVIDENCE

III.

Nurse-led web-based patient education reduces anxiety in thyroidectomy patients: A randomized controlled study

AIM

The aim of this study was to determine the effect of web-based patient education on anxiety in patients scheduled for thyroid surgery. A secondary aim was to evaluate the patients' postoperative recovery outcomes.

DESIGN

This study is a randomized controlled trial.

METHOD

The study was conducted at a university hospital in Turkey between September 2018 and May 2019 with 76 patients scheduled for thyroidectomy surgery and randomly assigned into two groups. Patients in the intervention group received web-based education, while those in the control group were given only routine care. Measurements were performed before surgery, on the day of surgery, and 1 week after discharge.

RESULTS

On the day of surgery, intervention group anxiety levels were lower than those of the control group, and the majority of early recovery parameters were significantly better in the intervention group than in the control group. One week after discharge, the intervention group patients' anxiety levels were significantly lower. Web-based education had no impact on pain, time in the operating room, readmission to the hospital after discharge, or length of hospitalization.

CONCLUSIONS

Nurse-led web-based education reduced patients' anxiety regarding surgery. The results also show that it may improve postoperative early recovery.

A Patient-Centered Perioperative Mental Health Intervention Bundle: A Multi- and Mixed-Method Adaptation Study

Background

Anxiety and depression are common among older adults and can intensify during perioperative periods, but few mental health interventions are designed for older surgical patients' unique needs. We developed and adapted a perioperative mental health (PMH) bundle for older patients comprised of behavioral activation (BA) and medication optimization (MO) to ameliorate anxiety and depressive symptoms before, during, and after cardiac, orthopedic, and oncologic surgery.

Methods

We used mixed-methods including workshop studios with patients, caregivers, clinicians, researchers, and interventionists; intervention refinement and reflection meetings; patient case review meetings; intervention session audio-recordings and documentation forms; and patient and caregiver semi-structured interviews. We used the results to refine our PMH bundle. We used multiple analytical approaches to report the nature of adaptations, including hybrid thematic analysis and content analysis informed by the Framework for Reporting Adaptations and Modifications - Expanded.

Results

Adaptations were categorized by content (intervention components), context (how the intervention is delivered, based on the study, target population, intervention format, intervention delivery mode, study setting, study personnel), training, and evaluation. Of 51 adaptations, 43.1% involved content, 41.2% involved context, and 15.7% involved training and evaluation. Several key adaptations were noted: 1) Intervention content was tailored to patient preferences and needs (e.g., rewording elements to prevent stigmatization of mental health needs; adjusting BA techniques and documentation forms to improve patient buy-in and motivation). 2) Cohort-specific adaptations were recommended based on differing patient needs. 3) Compassion was identified by patients as the most important element.

Conclusions

We identified evidence-based mental health intervention components from other settings and adapted them to the perioperative setting for older adults. Informed by mixed-methods, we created an innovative and pragmatic patient-centered intervention bundle that is acceptable, feasible, and responsive to the needs of older surgical populations. This approach allowed us to identify implementation strategies to improve the reach, scalability, and sustainability of our bundle, and can guide future patient-centered intervention adaptations.

Depression and anxiety in cervical degenerative disc disease: Who are susceptible?

Background

Pre-operative depression and anxiety are associated with poorer patient-reported outcomes following cervical spine surgery. Identification of and interventions for these disorders are key to preventing related negative effects. However, most spine surgeons do not routinely evaluate mental health disorders. Few studies have investigated which patients with cervical degenerative disc diseases (CDDD) are susceptible to depression and anxiety.

Objective

To determine the factors associated with depression and anxiety in patients with CDDD.

Methods

Three hundred twelve patients with CDDD were recruited in this cross-sectional case-control study. Patients underwent a structured interview to acquire demographic and clinical characteristic information, which included the Neck Disability Index (NDI), modified Japanese Orthopedic Association (mJOA), and Visual Analog Scale (VAS) for neck/arm pain. Depression and anxiety were evaluated using the Zung Self-Rating Depression and Anxiety Scales. Univariate and multivariate logistic regression analyses were used to identify factors associated with depression and anxiety.

Results

Of all patients, 102 (32.7%) had depression and 92 (29.5%) had anxiety. Two hundred six (66.0%) patients with neither depression nor anxiety were defined as the control group. Univariate analysis indicated that gender, educational level, occupation type, Charlson comorbidity index, symptom duration, symptomatology, surgery history, NDI, mJOA, VAS-neck, and VAS-arm scores were associated with depression and anxiety (except for symptom duration for anxiety). Multivariate logistic regression analysis indicated that females [odds ratio (OR) 1.81, 95% confidence interval (CI) 1.01-3.23], physical work (OR 2.06, 95% CI 1.16-3.65), poor mJOA score (ORmoderate 2.67, 95% CI 1.40-5.07; ORsevere 7.63, 95% CI 3.85-15.11), and high VAS-neck score (OR 1.24, 95% CI 1.11-1.39) were independent risk factors for depression. Physical work (OR 1.84, 95% CI 1.01-3.35), poor mJOA score (ORmoderate 2.66, 95% CI 1.33-5.33; ORsevere 9.26, 95% CI 4.52-18.99), and high VAS-neck score (OR 1.34, 95% CI 1.19-1.51) were independent risk factors for anxiety.

Conclusion

Approximately one-third of patients with CDDD had depression or anxiety. Patients who engaged in heavy work and had severe symptoms (poor mJOA and high VAS-neck scores) are susceptible to depression and anxiety. Additionally, female patients are susceptible to depression. Our findings may help identify CDDD patients with depression and anxiety in clinical practice.

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.

The role of psychopathological symptoms in lumbar stenosis: A prediction model of disability after lumbar decompression and fusion

Introduction

Pre-operative psychological factors may influence outcome after spine surgery. The identification of patients at risk of persisting disability may be useful for patient selection and possibly to improve treatment outcome.

Methods

Patients with neurogenic claudication associated with degenerative lumbar spinal stenosis (DLSS) performed a psychological assessment before lumbar decompression and fusion (LDF) surgery. The following tests were administrated: Visual Analogic Scale; Symptom Checklist-90 (SCL-90-R), Short Form-36 and Oswestry Disability Index (ODI). The primary outcome was ODI score lower than 20. A cross correlation matrix (CCM) was carried out with significant variables after univariate analysis and a linear logistic regression model was calculated considering the most significant variable.

Results

125 patient (61 men and 64 women) were included in the study. Seven parameters of the SCL-90-R scale showed statistical significance at the univariate analysis: obsessivity (p < 0.001), Current Symptom Index (p = 0.001), Global Severity Index (p < 0.001), depression (p < 0.001), positive Symptom Total (p = 0.002), somatization (p = 0.001) and anxiety (p = 0.036). Obsessivity was correlated with other significant parameters, except GSI (Pearson's correlation coefficient = 0.11).The ROC curve for the logistic model considering obsessivity as risk factor, has an area under the curve of 0.75.

Conclusion

Pre-operative psychopathological symptoms can predict persistence of disability after LDF for DLSS. Future studies will evaluate the possibility of modifying post operative outcome through targeted treatment for psychological features emerged during pre-operative assessment.

Minimally Invasive Transforaminal versus Anterior Lumbar Interbody Fusion in Patients Undergoing Revision Fusion: Clinical Outcome Comparison

OBJECTIVE

We aim to compare perioperative/postoperative clinical outcomes between minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) and anterior lumbar interbody fusion (ALIF) in patients presenting for revision surgery.

METHODS

A retrospective database was reviewed for procedures between November 2005 and December 2021. Revision MIS-TLIF/ALIFs were included, whereas primary fusions or diagnosis of infection/malignancy/trauma were excluded. Patients were grouped into MIS-TLIF/ALIF cohorts. Preoperatively/postoperatively collected patient-reported outcome measures (PROMs) included visual analog scale back/leg score, Oswestry Disability Index, Patient-Reported Outcome Measurement Information System-Physical Function (PROMIS-PF), and Short-Form 12-Item Survey Mental/Physical Composite Scores.

RESULTS

A total of 164 patients were eligible, with 84 patients in the MIS-TLIF cohort. The presence of degenerative spondylolisthesis and central stenosis, narcotic consumption on postoperative day 0/1, and postoperative urinary retention rates was greater in the MIS-TLIF cohort (P ≤ 0.036, all). Preoperative PROMs between cohorts did not significantly differ. Significantly favorable postoperative PROM scores were shown in the MIS-TLIF cohort with PROMIS-PF at 12 weeks/6 months (P ≤ 0.033, all). Most patients in both cohorts achieved overall minimum clinically important difference for visual analog scale back/leg score, Oswestry Disability Index, Short-Form 12-Item Survey Physical Composite Score, and PROMIS-PF. No differences were noted between cohorts within rates of MCID achievement.

CONCLUSIONS

Patients undergoing revision fusion via MIS-TLIF or ALIF reported similar 1-year postoperative mean outcomes and rates of meaningful clinical achievement for physical function, mental health, disability, and back/leg pain. However, patients undergoing revision MIS-TLIF reported improved physical function at 12 weeks and 6 months. Perioperatively, patients undergoing revision MIS-TLIF were noted to consume significantly greater quantities of narcotics.