PHQ-9 Score Predicts Postoperative Outcomes Following Minimally Invasive Transforaminal Lumbar Interbody Fusion

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

Importance

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

Objective

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

Data Sources

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

Study Selection

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

Data Extraction and Synthesis

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

Main Outcomes and Measures

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

Results

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

Conclusions and Relevance

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

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.

Workers compensation patients experiencing depression report meaningful improvement in mental health scores after anterior cervical discectomy and fusion

Background

Mental health has been demonstrated to affect postoperative outcomes. No prior literature has reported the relationship between preoperative mental health on outcomes following anterior cervical discectomy and fusion (ACDF) in the Workers Compensation (WC) population.

Methods

WC claimants who underwent primary ACDF were identified from a single-surgeon retrospective database. Patients were separated by SF-12 MCS score into Depressed (<45.6) or Not Depressed (ND) (≥45.6) cohorts. Patient-reported Outcome Measurement Information System Physical Function (PROMIS PF), SF-12 Physical Component Score (SF-12 PCS), SF-12 MCS, visual analog scale (VAS) neck/arm pain, and Neck Disability Index (NDI) were collected and compared within and between groups. Minimum clinically important difference (MCID) achievement rates were compared between groups.

Results

Depressed patients had greater length of stay (p = 0.007) and postoperative narcotic consumption (p = 0.026). Depressed patients improved at 12-week to 2-year PROMIS PF, 6-month SF-12 PCS, 6-week to 6-month SF-12 MCS, 6-week to 6-month and 2-year VAS neck, all VAS arm, and 6-month NDI (p ≤ 0.045, all). ND patients improved at 12-week to 1-year PROMIS PF, 6-month to 2-year SF-12 PCS, 12-week to 1-year VAS neck, 6-week to 1-year VAS arm, and 12-week to 1-year NDI (p ≤ 0.044, all). Between groups, ND patients reported superior PROMIS PF, SF-12 MCS, VAS neck, VAS arm, and NDI scores at two or more periods (p ≤ 0.045, all). MCID achievement rate regarding SF-12 MCS was greater in the Depressed cohort at all postoperative points up to 1 year (p ≤ 0.020, all).

Conclusion

Depressed patients tended to have a greater length of stay and postoperative narcotic consumption immediately after surgery. Not depressed patients reported more favorable physical and mental function, pain, and disability scores preoperatively and postoperatively. Depressed patients reported greater MCID achievement in mental function following surgery. Depressed patients with WC have a greater likelihood of reporting tangible improvement in mental health scores following ACDF.

Two-year validation and minimal clinically important difference of the Veterans RAND 12 Item Health Survey Physical Component Score in patients undergoing minimally invasive transforaminal lumbar interbody fusion

OBJECTIVE

The Physical Component Score of the Veterans RAND 12 Item Health Survey (VR-12 PCS) has been assessed for use at short-term and intermediate-term time points for lumbar fusion populations. This study assesses the long-term validity and establishes minimal clinically important difference (MCID) values of VR-12 PCS in patients undergoing minimally invasive transforaminal lumbar interbody fusion (MIS TLIF).

METHODS

A surgical registry was retrospectively reviewed for primary, elective, single-level MIS TLIF procedures with posterior instrumentation. Patients missing preoperative and 2-year postoperative VR-12 PCS survey data were excluded. VR-12 PCS, SF-12 Health Survey Physical Component Summary (SF-12 PCS), Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS PF), and Oswestry Disability Index (ODI) patient-reported outcome measures (PROMs) were recorded preoperatively and postoperatively. Responsiveness of the VR-12 measure was assessed in two ways. First, the mean postoperative PROM scores were compared with preoperative baseline values using a paired Student t-test. Second, MCID values were calculated using both distribution-based and anchor-based methods and used to assess improvement in VR-12 score at the 2-year time point. Discriminant validity of the VR-12 was assessed using cross-sectional and longitudinal anchors. Convergent validity of the VR-12 measure was assessed using Pearson's correlation coefficient and partial time-independent correlation. Floor and ceiling effects were assessed.

RESULTS

A total of 74 patients who underwent MIS TLIF were included. The VR-12 PCS demonstrated significant improvements at all time points from 12 weeks to 2 years (p < 0.001 for all). VR-12 PCSs were significantly different for patients classified using cross-sectional anchors (p < 0.001) and longitudinal anchors (p ≤ 0.005). Calculated MCID values ranged from 4.1 to 8.5, and 4.1 was selected as the optimal MCID, which 87.8% of patients achieved. Strong, significant correlations of the VR-12 PCS with SF-12 PCS and PROMIS PF were demonstrated at all time points (p < 0.001 for all). No significant floor or ceiling effects were detected.

CONCLUSIONS

The VR-12 PCS demonstrated excellent responsiveness, discriminant and convergent validity, and no significant floor or ceiling effects up to 2 years after MIS TLIF. Therefore, VR-12 PCS may serve as a valid measure of long-term physical function.

Epidemiological Relevance of Elevated Preoperative Patient Health Questionnaire-9 Scores on Clinical Improvement Following Lumbar Decompression

BACKGROUND

Limited research exists regarding the influence of preoperative depression on postoperative mental health, physical function, and pain in lumbar decompression (LD) patients. This study aims to evaluate the association of depressive symptoms as measured by the Patient Health Questionnaire-9 (PHQ-9) with other mental health and physical function clinical outcomes among patients undergoing LD.

METHODS

A prospectively maintained surgical registry was reviewed for primary LD from March 2016 to May 2019. Patients were stratified into 3 preoperative PHQ-9 score subgroups. Higher PHQ-9 scores indicated greater depressive symptoms. We assessed demographic and perioperative characteristics among subgroups with appropriate statistical testing. We also evaluated outcome instruments and postoperative improvement for the following outcomes: PHQ-9, Short Form 12 (SF-12), Veterans RAND 12-Item (VR-12), Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF), visual analog scale (VAS) leg, and VAS back.

RESULTS

The 351-subject cohort was 70.4% men with an average age of 47 years; 186 subjects had minimal preoperative depressive symptoms (PHQ-9 <5), 94 had moderate (5≤ PHQ-9 ≤10), and 71 had severe (PHQ-9 >10). Subgroups with more severe symptoms of depression had worse mental health outcome scores (PHQ-9, 12-Mental Health Composite Score [12-MCS], and VR-12-MCS) and a positive linear association with greater pre- to postoperative mental health improvements at all timepoints. Subgroups with more severe symptoms of depression had worse PROMIS-PF scores at all timepoints, though VAS pain scores had no depression symptom association by 1 year.

CONCLUSION

Patients with more severe preoperative depressive symptoms, as evaluated by PHQ-9, have a greater improvement in PHQ-9, SF-12, and VR-12 scores, but more severe PHQ-9 scores are associated with worse overall physical function scores. This study demonstrates the relevance of preoperative depressive symptoms and their necessity in future risk factor models.

CLINICAL RELEVANCE

Severity of preoperative PHQ-9 acts as a significant risk factor to postoperative pain and mental and physical health improvement.

What Can Legacy Patient-Reported Outcome Measures Tell Us About Participation Bias in Patient-Reported Outcomes Measurement Information System Scores Among Lumbar Spine Patients?

Objective

Patient-Reported Outcomes Measurement Information System (PROMIS) is a validated tool for assessing patient reported outcomes in spine surgery. However, PROMIS is vulnerable to non-response bias. The purpose of this study is to characterize differences in patient reported outcome measure (PROM) scores between patients who do and do not complete PROMIS physical function (PF) surveys following lumbar spine surgery.

Methods

A prospectively maintained database was retrospectively reviewed for primary, elective lumbar spine procedures from 2015 to 2019. Outcome measures for Patient Health Questionnaire (PHQ-9), Visual Analogue Score (VAS) back & leg, Oswestry Disability Index (ODI), and 12-Item Short Form Physical Composite Summary (SF-12 PCS) were recorded at both preoperative and postoperative (6-week, 12-week, 6-month, 1-year, 2-year) timepoints. Completion rates for PROMIS PF surveys were recorded and patients were categorized into groups based on completion. Differences in mean scores at each timepoint between groups was determined.

Results

809 patients were included with an average age of 48.1 years. No significant differences were observed for all outcome measures between PROMIS completion groups preoperatively. Postoperative PHQ-9, VAS back, VAS leg, and ODI scores differed significantly between groups through 1-year (all p<0.05). SF-12 PCS differed significantly only at 6-weeks (p=0.003).

Conclusion

Patients who did not complete PROMIS PF surveys had significantly poorer outcomes than those that did in terms of postoperative depressive symptoms, pain, and disability. This suggests that patients completing PROMIS questionnaires may represent a healthier cohort than the overall lumbar spine population.

Preoperative Physical Function Association With Mental Health Improvement After Anterior Cervical Discectomy and Fusion

STUDY DESIGN

This was a retrospective study.

OBJECTIVE

This study investigates the influence of physical function and their influence on postoperative depressive symptom scores as measured by Patient Health Questionnaire-9 (PHQ-9) among anterior cervical decompression and fusion (ACDF) patients.

BACKGROUND

While ACDF is one of the most commonly performed ambulatory surgeries, research is limited on the predictive value of Patient-Reported Outcomes Measurement Information System (PROMIS) scores and their influence on depressive symptoms as measured by the PHQ-9.

METHODS

A prospectively maintained surgical registry was retrospectively reviewed from March 2016 to January 2019. Inclusion criteria were primary or revision ACDF procedures. Patients were grouped by preoperative PROMIS score (≥35.0, <35.0), with higher scores indicating greater physical function. The χ2 and Student t tests assessed categorical and continuous variables (eg, demographics, perioperative, and postoperative values). A t test evaluated postoperative improvement in PROMIS Physical Function (PF) scores between subgroups among PROMIS PF scores and PHQ-9 score improvement at 6, 12 weeks, 6 months, and 1 year. Linear regression assessed preoperative PROMIS scores influence on PHQ-9 score improvement.

RESULTS

The 121 subject cohort was 61.2% male with an average age of 49.6±9.8 years. Compared with the PROMIS ≥35.0 group, the PROMIS <35.0 group also had larger improvement of PROMIS scores at 6 weeks. No significant difference in postoperative PHQ-9 improvement was observed between subgroups. There was a negative association between preoperative PROMIS scores and improvement in PROMIS scores at 6, 12 weeks, 6 months, and 1 year. There was a positive association between preoperative PROMIS scores and magnitude of 1-year PHQ-9 change.

CONCLUSIONS

Individuals with lower preoperative PROMIS PF scores had significantly higher PHQ-9 scores at 1 year. Patients with lower preoperative physical function, as evaluated by PROMIS PF scoring, had greater improvement of mental health at 1 year postoperatively. This suggests that many patients experience multidimensional health benefits after ACDF procedures.

Time to Complete Legacy Patient-Reported Outcome Measures in Patients with Lumbar Decompression

INTRODUCTION

Patient-reported outcome measures (PROMs) are used to capture the true extent of postoperative improvement. Use of lengthier and repetitive PROMs can increase question burden on patients. This study aims to determine whether the length of time to complete (TTC) legacy PROMs has an impact on scores after lumbar decompression.

METHODS

A surgical database was retrospectively reviewed for patients who underwent primary, single-level lumbar decompression from 2013 to 2020. Demographic and perioperative characteristics were collected. Physical function (PF) was measured by 12-Item Short Form (SF-12), 12-Item Veterans RAND (VR-12), and Patient-Reported Outcomes Measurement Information System (PROMIS) and was collected preoperatively and postoperatively. TTC was calculated as the difference between start and ending times for each instance of survey completion. Improvements for PROMs and comparison of TTC between SF-12/VR-12 and PROMIS PF were evaluated using a t-test. Correlation between TTC and PROM scores was evaluated using the Pearson correlation. Impact of TTC on postoperative PROM scores was evaluated using linear regression.

RESULTS

A total of 216 patients, of which 68.1% were men, were included with a mean age of 45.8 years. Mean postoperative TTC for SF-12 and VR-12 was significantly longer than preoperative values (all P < 0.05). No notable difference in TTC was demonstrated for PROMIS PF. TTC PROMIS PF was significantly shorter than SF-12 and VR-12 from 12 weeks through 1 year (all P < 0.050). A low-strength negative correlation of TTC with SF-12 and VR-12 was observed at the preoperative, 6-week and 1-year timepoint whereas PROMIS PF had a low-strength positive correlation with TTC preoperatively and at 6 months (all P > 0.05).

CONCLUSION

Time spent completing PROMIS PF did not markedly differ postoperatively, but SF-12 and VR-12 required a longer TTC than PROMIS PF. Although insightful to patient improvement, SF-12 and VR-12 may increase the question burden placed on patients to complete surveys in a timely manner.

The Effect of the Severity of Preoperative Back Pain on Patient-Reported Outcomes, Recovery Ratios, and Patient Satisfaction Following Minimally Invasive Transforaminal Lumbar Interbody Fusion (MIS-TLIF)

BACKGROUND

Limited literature has addressed impact of preoperative back pain severity on patient-reported outcome measures (PROMs), recovery ratios (RRs), and patient satisfaction following minimally invasive transforaminal lumbar interbody fusion (MIS TLIF).

METHODS

MIS TLIFs were retrospectively identified and grouped: preoperative visual analog scale (VAS) back ≤7 or VAS back >7. PROMs, including PROMIS-PF, VAS back and leg, Oswestry Disability Index (ODI), and SF-12 Physical Composite Score and Mental Composite Score (MCS), were collected pre- and postoperatively. A PROM's RR was calculated as proportion of postoperative improvement to overall potential improvement.

RESULTS

In total, 740 patients were included: 359 patients with VAS back ≤7 and 381 patients with VAS back >7. The VAS back >7 cohort reported significantly greater postoperative inpatient pain (P ≤ .003, both). All preoperative and the following postoperative PROMs favored the VAS back ≤7 cohort: PROMIS-PF 2-years, VAS back overall, SF-12 Physical Composite Score 12 weeks and 1 year, SF-12 MCS 6 weeks/12 weeks, VAS leg 6 weeks, 12 weeks, 6 months, and 2 years, and ODI overall (P ≤ 0.048, all). The VAS back >7 cohort demonstrated greater delta PROMs for all VAS back and ODI except 2 years (P ≤ 0.021, all). A greater proportion of patients in the VAS back >7 group achieved minimal clinically important difference for VAS back overall, ODI 6 weeks/12 weeks, PROMIS-PF 6 weeks, and SF-12 MCS 6 weeks/6 months (P ≤ 0.044, all). The VAS back>7 cohort RR was significantly greater for VAS back 6 months and VAS leg 6 months/2 years (P ≤ 0.034, all). The VAS back ≤7 cohort's postoperative satisfaction was significantly greater for VAS back 12 weeks, VAS leg 12 weeks, and ODI 6 weeks/12 weeks (P ≤ 0.046, all).

CONCLUSIONS

Patients with greater preoperative back pain demonstrated significantly worse postoperative scores for most PROMs at most time points and significantly worse patient satisfaction for disability, back and leg pain at multiple time points.

Validation of VR-12 Physical Function in Minimally Invasive Lumbar Discectomy

BACKGROUND

Although the Veterans RAND 12-item Physical Component Survey (VR-12 PCS) has been broadly used to evaluate patient-reported outcome measures (PROMs) in spine surgery, its feasibility for use in patients undergoing minimally invasive lumbar discectomy (MIS LD) has not been well studied. This study aimed to assess the feasibility of VR-12 PCS for use up to 2 years postoperatively for MIS LD by correlation with PROMs for physical function.

METHODS

Patients undergoing primary single-level MIS LD procedures were reviewed retrospectively. Results on the VR-12 PCS, 12-Item Short Form (SF-12) PCS, and Patient-Reported Outcomes Measurement Information System (PROMIS PF) were recorded preoperatively and up to 2 years postoperatively. Improvements in postoperative PROMs were calculated and assessed for significant differences from baseline values. Correlation significance and strength were evaluated between VR-12 PCS and SF-12 PCS or PROMIS PF. Scatterplots were constructed to demonstrate relationships of VR-12 PCS with SF-12 PCS and PROMIS PF at each time point.

RESULTS

Our cohort comprised 402 patients. Patients improved significantly from preoperative baseline for all 3 PROMs at all postoperative time points. Both Pearson's correlation and time-independent partial correlation revealed statistically significant strong correlations of VR-12 PCS with SF-12 PCS and PROMIS PF through 2-years.

DISCUSSION

Physical function scores for VR-12, SF-12, and PROMIS PF all demonstrated significant improvements following MIS LD. Strongly statistically significant correlations of VR-12 PCS with SF-12 PCS and PROMIS PF from preoperative measures through 2 years demonstrate the feasibility of VR-12 for assessing patient-reported physical function in MIS LD patients.

Patient Health Questionnaire-9 Is a Valid Assessment for Depression in Minimally Invasive Lumbar Discectomy

Objective

The Patient Health Questionnaire-9 (PHQ-9) is a screening tool for evaluating depressive symptoms. Research is scarce regarding the validity and correlation of PHQ-9 scores with other patient-reported outcomes of mental health after minimally invasive lumbar discectomy (MIS LD). We aim to validate PHQ-9 as a metric for assessing mental health in MIS LD patients.

Methods

A database was retrospectively reviewed for patients who underwent elective, single-level MIS LD. Patients were excluded if they had incomplete preoperative PHQ-9, 12-item Short Form Health Survey (SF-12), or Veterans RAND 12-item health survey (VR-12). Survey scores were collected preoperatively and postoperatively through 1 year. Mean scores were used to calculate postoperative improvement from preoperative scores. Correlation of PHQ-9 with SF-12 mental composite score (MCS) and VR-12 MCS scores was also calculated. Correlation strength was assessed by the following categories: 0.1 ≤ |r| < 0.3 = low; 0.3 ≤ |r| < 0.5 = moderate; |r| ≥ 0.5 = strong.

Results

A total of 239 patients underwent single-level MIS LD. PHQ-9, VR-12 MCS, and SF-12 MCS all demonstrated statistically significant increases from preoperative scores at all postoperative timepoints (p ≤ 0.001). SF-12 MCS and VR-12 MCS were each observed to have strong and significant correlations with PHQ-9 at all timepoints when evaluated with both Pearson correlation coefficients and partial correlation coefficients.

Conclusion

We observed that PHQ-9, SF-12 MCS and VR-12 MCS all significantly improve following lumbar discectomy and that PHQ-9 scores strongly correlated with these previously established measures. Our results substantiate evidence from other surgical fields that PHQ-9 scores are a valid tool to evaluate pre- and postsurgical depressive symptoms.

The Minimum Clinically Important Difference for Patient Health Questionnaire-9 in Minimally Invasive Transforaminal Interbody Fusion

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

To investigate and establish minimum clinically important differences (MCID) for Patient Health Questionnaire-9 (PHQ-9) among patients undergoing minimally invasive transforaminal lumbar interbody fusion (MIS TLIF).

SUMMARY OF BACKGROUND

Spine surgery is linked to postoperative improvements in anxiety, depression, and mental health. These improvements have been documented using patient-reported outcome measures such as PHQ-9. Few studies evaluated the clinical significance of PHQ-9 for lumbar spine surgery.

METHODS

Patients who underwent single-level, primary MIS TLIF from 2015 to 2017 were retrospectively reviewed in a prospective database. Patients with incomplete preoperative and 2-year postoperative PHQ-9 surveys were excluded. Demographic and perioperative characteristics were recorded. PHQ-9, 12-Item Short Form (SF-12), and Veterans RAND 12-Item Health Survey (VR-12) Mental Component Summary (MCS) were collected at preoperative, 6-week, 12-week, 6-month, 1-year, and 2-year intervals. MCID was calculated using anchor and distribution-based methods. SF-12 served as an anchor. MCID was assessed using mean change methodology, four receiver operating characteristic curve assessments, and standard error measurement. Cutoff values were selected from receiver operating characteristic curve analysis. MCID achievement rates for all patient-reported outcome measures were calculated.

RESULTS

A total of 139 patients met inclusion criteria, with a mean age of 55 years and 39% females. The most common spinal pathology was radiculopathy (92%). MCID analysis revealed the following ranges of values: 2.0 to 4.8 (PHQ-9), 6.7 to 12.1 (SF-12 MCS), and 7.5 to 15.9 (VR-12 MCS). Final MCID thresholds were 3.0 (PHQ-9), 9.1 (SF-12 MCS), and 8.1 (VR-12 MCS). MCID achievement at 2-years for PHQ-9, SF-12 MCS, and VR-12 MCS was 89.2%, 85.6%, and 84.9% respectively.

CONCLUSION

Our 2-year postoperative MCID analysis is the first mental health calculation from an MIS TLIF cohort. We report a 2-year MCID value for PHQ-9 of 3.0 (2.0-4.8). MCID values for mental health instruments are important for determining overall success of lumbar spine surgery.Level of Evidence: 3.

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

STUDY DESIGN

This was a retrospective review of prospectively collected data.

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Impact of Psychiatric Diagnoses and Treatment on Postoperative Outcomes Among Patients Undergoing Surgery for Colorectal Cancer

OBJECTIVE

Psychiatric diagnoses may be a risk factor for poor colorectal cancer (CRC) surgery outcomes. The authors investigated the risk of psychiatric diagnoses and benefit of mental health treatment for surgery outcomes among CRC patients.

METHODS

This retrospective cohort study of patients undergoing CRC surgery in the 2000-2014 period identified documentation of psychiatric diagnosis and mental health treatment (no treatment, medication only, psychotherapy only, or both medication and psychotherapy) 30 days before surgery. Associations between psychiatric diagnoses, mental health treatment, and postoperative outcomes (postoperative complications, length of stay [LOS], and 90-day readmission rate) were evaluated with multivariable generalized estimating equations.

RESULTS

Among 58,961 patients undergoing CRC surgery, 9,029 (15.3%) had psychiatric diagnoses, 4,601 (51.0%) of whom received preoperative mental health treatment (90.0% psychiatric medication, 6.7% psychotherapy, and 3.0% medication and psychotherapy). Patients with psychiatric diagnoses had an increased risk for postoperative complications (odds ratio [OR]=1.09, 95% confidence interval [CI]=1.03-1.15) and 90-day readmission (OR=1.11, 95% CI=1.06-1.17) compared with patients without psychiatric diagnoses. Patients with psychiatric diagnoses who received no mental health treatment or only medication had a 7%-17% increased risk for postoperative complications and 90-day readmission compared with patients without psychiatric diagnoses. Patients who received medication only also had a 4% increase in LOS relative to patients without psychiatric diagnoses. Patients with psychiatric diagnoses receiving only psychotherapy and patients without psychiatric diagnoses had similar postoperative outcomes.

CONCLUSIONS

Preoperative psychiatric diagnoses were associated with worse postoperative outcomes. Surgical quality-improvement efforts should focus on identifying patients with preoperative psychiatric diagnoses and addressing these conditions presurgery.

Role of Gender in Improvement of Depressive Symptoms Among Patients Undergoing Cervical Spine Procedures

OBJECTIVE

There is a scarcity of research evaluating gender differences in depressive symptoms among patients undergoing cervical surgery. This study investigated gender differences with regard to depressive symptom severity, measured by Patient Health Questionnaire-9 (PHQ-9), in patients following anterior cervical discectomy and fusion (ACDF) or artificial disc replacement (ADR).

METHODS

A prospectively maintained surgical registry was retrospectively reviewed for eligible spine surgeries. Depressive symptom severity was evaluated by PHQ-9 at both preand postoperative timepoints (e.g. , 6 weeks, 12 weeks, 6 months, 1 year, and 2 years). A chi-square test and Student t-test evaluated differences between the gender for demographic and operative variables where appropriate. Differences between the gender subgroup mean PHQ-9 scores were assessed using a t-test pre- and postoperatively (e.g. , 6 weeks, 12 weeks, 6 months, and 1 year) and a paired t-test was used to assess differences from preoperative scores at each postoperative time point.

RESULTS

A total of 170 subjects underwent 125 ACDFs and 45 ADRs. Both pre- and postoperative timepoints demonstrated no significant differences between mean PHQ-9 scores by gender. Female patients demonstrated statistically significant improvement in PHQ-9 scores at 6 weeks, and 12 weeks, but not through 2 years. Male patients demonstrated statistically significant improvement in PHQ-9 scores at 6 weeks, 12 weeks, 6 months, 1 year, and 2 years.

CONCLUSION

Although there were no significant differences between mean PHQ-9 score between the genders, there was a difference in magnitude of improvement. Females had a significant improvement in depressive symptom severity over baseline at the 6- and 12-week timepoints only, whereas males had significant improvement through 2 years postoperatively.

The Perioperative Symptom Severity of Higher Patient Health Questionnaire-9 Scores Between Genders in Single-Level Lumbar Fusion

BACKGROUND

Preoperative depression is associated with increased perioperative pain, worse physical function, reduced quality of life, and inferior outcomes. Few studies have evaluated depressive symptoms between genders for individuals undergoing minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). The purpose of this investigation was to assess the severity of Patient Health Questionnaire-9 (PHQ-9) scores among patients with depressive symptoms before and after single-level MIS TLIF.

METHODS

A prospective surgical registry was retrospectively reviewed for spine surgeries between March 2016 and December 2018. We included patients with at least mild depressive symptoms (PHQ-9 scores ≥ 5) who underwent primary, single-level MIS TLIF and compared genders using χ2 tests and t tests. Genders were stratified by depressive symptom severity: mild (5-9), moderate (10-14), and moderately severe (≥15) and then analyzed at preoperative and postoperative intervals: 6 weeks, 12 weeks, 6 months, and 1 year. Finally, PHQ-9 scores were validated with a Pearson correlation test against the 12-item Short Form (SF-12) Mental Composite Score (MCS) and the Veterans RAND (VR-12) MCS.

RESULTS

Of 75 subjects, 44.0% were women and the mean age was 49.9 years. The preoperative distribution among PHQ-9 subgroups was 38.7%, 26.6%, and 34.7% for mild, moderate, and moderately severe depressive symptoms, respectively. Among PHQ-9 stratifications both genders demonstrated intermittent statistically significant improvements in PHQ-9 scores. The moderately severe PHQ-9 subgroup had improvement at all postoperative time points. The PHQ-9 scores demonstrated a strong correlation with the SF-12 MCS and VR-12 MCS at all postoperative evaluations.

CONCLUSION

At baseline and by the final 1-year follow-up there were no statistically significant PHQ-9 score differences between genders within any depressive symptom stratifications. Whereas some contend that men and women have substantial mental health differences, this study is aligned with growing evidence that demonstrates similar depressive symptoms between genders.

LEVEL OF EVIDENCE

3.

CLINICAL RELEVANCE

Men and women may be at an equivalent risk for perioperative depressive symptoms.

Correlating Psychological Comorbidities and Outcomes After Spine Surgery

STUDY DESIGN

Literature review.

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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