A national snapshot of the impact of clinical depression on post-surgical pain and adverse outcomes after anterior cervical discectomy and fusion for cervical myelopathy and radiculopathy: 10-year results from the US Nationwide Inpatient Sample

Prior Antidepressant Prescription is Associated with Greater Opioid Prescriptions and Complications in Cervical Spine Surgery: A Propensity Matched Cohort Study

STUDY DESIGN

Retrospective cohort study of national database.

OBJECTIVE

This study evaluates the impact of antidepressant prescriptions on postoperative outcomes and complications in cervical spine surgery.

SUMMARY OF BACKGROUND DATA

Patients who underwent cervical spine surgery often receive antidepressant prescriptions (ADP) to address concurrent mental health issues such as depression and anxiety. However, the use of antidepressants can affect bone metabolism. Yet, there is an opacity in the literature regarding the effects of ADP on outcomes of cervical spine surgery.

METHODS

Utilizing the TriNetX database, ACDF and Cervical Arthroplasty patients were matched on a 1:1 basis according to ADP status. Outcome variables such as emergency department visits, hospital readmissions, opioid prescription, and misuse, pseudoarthrosis, adjacent segment disease, and hardware failure were evaluated over follow-up periods ranging from 2 to 24 months.

RESULTS

In a matched sample of 12,838 patients, those with ADP exhibited significantly higher rates of opioid prescriptions at 2 weeks (OR 1.34, P<0.0001), 6 months (OR 1.36, P<0.0001), 12 months (OR 1.36, P<0.0001), and 24 months (OR 1.33, P<0.0001). Emergency Department visits were significantly higher at 6 months (OR 1.11, P=0.0082) and 24 months (OR 1.083, P=0.014). Opioid abuse is notably higher by 24 months (OR 1.37, P=0.0033). Hospitalization rates were significantly increased at 12 months (OR 1.16, P=0.0013) and 24 months (OR 1.18, P<0.0001). Adjacent segment disease (OR 1.54, P<0.0001 at 24 mo), hardware failure (OR 1.42, P=0.013 at 24 mo), and pseudarthrosis (OR 1.48, P<0.0001 at 24 mo) were also significantly higher in the ADP group.

CONCLUSIONS

Patients with ADP undergoing cervical spine surgery experience higher risks of opioid use and abuse, increased hospital readmissions, emergency department visits, and a higher rate of mechanical complications.

LEVEL OF EVIDENCE

III.

Association of Untreated Pre-surgical Depression With Pain and Outcomes After Spinal Surgery

STUDY DESIGN

Prospective Cohort Study.

OBJECTIVE

Untreated pre-surgical depression may prolong post-surgical pain and hinder recovery. However, research on the impact of untreated pre-surgical depression on post-spinal surgery pain is lacking. Therefore, this study aimed to assess pre-surgical depression in patients and analyze its relationship with post-surgical pain and overall post-surgical outcomes.

METHODS

We recruited 100 patients scheduled for lumbar spine surgery due to spondylolisthesis, degenerative lumbar disc diseases, and herniated lumbar disc diseases. Psychiatrists evaluated them for the final selection. We assessed the Beck Depression Inventory (BDI), Japanese Orthopaedic Association (JOA), Oswestry Disability Index (ODI), and EuroQoL 5 Dimensions (EQ-5D) scores, numerical back and leg pain scales, and medication dosage data collected before and at 6 weeks, 3 months, and 6 months after surgery.

RESULTS

Ninety-one patients were included in this study; 40 and 51 were allocated to the control and depression groups, respectively. The pre- and post-surgical leg pain, back pain, and functional scores were not different. However, the depression group showed higher ODI and EQ-5D and lower JOA scores than the control group 3 months post-surgery. Partial correlation analysis revealed an inverse correlation between the JOA and BDI scores and a positive correlation between the EQ-5D and BDI scores at 3 months postoperatively.

CONCLUSION

Untreated depression can prolong postoperative pain and hinder recovery. Detecting and treating depression in patients before spine surgery may improve their overall quality of life and functional recovery.

The impact of pre-operative depression on pain outcomes after major surgery: a systematic review and meta-analysis

Symptoms of depression are common among patients before surgery. Depression may be associated with worse postoperative pain and other pain-related outcomes. This review aimed to characterise the impact of pre-operative depression on postoperative pain outcomes. We conducted a systematic review of observational studies that reported an association between pre-operative depression and pain outcomes after major surgery. Multilevel random effects meta-analyses were conducted to pool standardised mean differences and 95%CI for postoperative pain scores in patients with depression compared with those without depression, at different time intervals. A meta-analysis was performed for studies reporting change in pain scores from the pre-operative period to any time-point after surgery. Sixty studies (n = 501,962) were included in the overall review, of which 18 were eligible for meta-analysis. Pre-operative depression was associated with greater pain scores at < 72 h (standardised mean difference 0.97 (95%CI 0.37-1.56), p = 0.009, I2  = 41%; moderate certainty) and > 6 months (standardised mean difference 0.45 (95%CI 0.23-0.68), p < 0.001, I2  = 78%; low certainty) after surgery, but not at 3-6 months after surgery (standardised mean difference 0.54 (95%CI -0.06-1.15), p = 0.07, I2  = 83%; very low certainty). The change in pain scores from pre-operative baseline to 1-2 years after surgery was similar between patients with and without pre-operative depression (standardised mean difference 0.13 (95%CI -0.06-0.32), p = 0.15, I2  = 54%; very low certainty). Overall, pre-existing depression before surgery was associated with worse pain severity postoperatively. Our findings highlight the importance of incorporating psychological care into current postoperative pain management approaches in patients with depression.

Prevalence of unpaid caregiving, pain, and depression in older seriously ill patients undergoing elective surgery

INTRODUCTION

Serious illness is a life-limiting condition negatively impacting daily function, quality of life, or excessively straining caregivers. Over 1 million older seriously ill adults undergo major surgery annually, and national guidelines recommend that palliative care be available to all seriously ill patients. However, the palliative care needs of elective surgical patients are incompletely described. Understanding baseline caregiving needs and symptom burden among seriously ill older surgical patients could inform interventions to improve outcomes.

METHODS

Using Health and Retirement Study data (2008-2018) linked to Medicare claims, we identified patients ≥66 years who met an established serious illness definition from administrative data and underwent major elective surgery using Agency for Healthcare Research and Quality (AHRQ) criteria. Descriptive analyses were performed for preoperative patient characteristics, including: unpaid caregiving (no or yes); pain (none/mild or moderate/severe); and depression (no, CES-D < 3, or yes, CES-D ≥ 3). Multivariable regression was performed to examine the association between unpaid caregiving, pain, depression, and in-hospital outcomes, including hospital days (days admitted between discharge date and one-year post-discharge), in-hospital complications (no or yes), and discharge destination (home or non-home).

RESULTS

Of the 1343 patients, 55.0% were female and 81.6% were non-Hispanic White. Mean age was 78.0 (SD 6.8); 86.9% had ≥2 comorbidities. Before admission, 27.3% of patients received unpaid caregiving. Pre-admission pain and depression were 42.6% and 32.8%, respectively. Baseline depression was significantly associated with non-home discharge (OR 1.6, 95% CI 1.2-2.1, p = 0.003), while baseline pain and unpaid caregiving needs were not associated with in-hospital or post-acute outcomes in multivariable analysis.

CONCLUSIONS

Prior to elective surgery, older adults with serious illnesses have high unpaid caregiving needs and a prevalence of pain and depression. Baseline depression alone was associated with discharge destinations. These findings highlight opportunities for targeted palliative care interventions throughout the surgical encounter.

Correlation of mental health with physical function, pain, and disability following anterior lumbar interbody fusion

BACKGROUND

Studies have demonstrated the influence of preoperative mental health on outcomes following spine surgery, but prior literature has not assessed the influence of mental health at time of outcome survey collection.

METHODS

Patients who underwent elective anterior lumbar interbody fusion (ALIF) were identified from a prospective registry. Patient-reported outcomes (PROs) were collected preoperatively and up to 1 year postoperatively. Mental health measures studied included 12-item Short Form (SF-12) Mental Component Score (MCS) and Patient Health Questionnaire-9 (PHQ-9). Patient-Reported Outcome Measurement Information System-Physical Function (PROMIS-PF), SF-12 Physical Component Score (PCS), visual analog scale (VAS) back and leg pain, and Oswestry Disability Index (ODI) were compared to the mental health measures by Pearson's correlation tests.

RESULTS

A total of 166 patients were included. SF-12 MCS demonstrated positive correlation to PROMIS-PF preoperatively (|r|= 0.379) and at 6 weeks (|r|= 0.387) (p ≤ 0.016, all). SF-12 MCS demonstrated negative correlation to VAS back at 6 months (|r|= 0.359), VAS leg at 6 weeks (|r|= 0.475) and 12 weeks (|r|= 0.422), and ODI up to 6 months postoperatively (|r|= 0.417-0.526) (p ≤ 0.037, all). PHQ-9 negatively correlated with PROMIS-PF at all periods studied (|r|= 0.425-0.587) and SF-12 PCS up to 6 months postoperatively (|r|= 0.367-0.642) (p ≤ 0.016, all). PHQ-9 positively correlated to VAS back at 6 weeks (|r|= 0.408) and 6 months (|r|= 0.411), VAS leg at 6 weeks (|r|= 0.344), and ODI up to 6 months postoperatively (|r|= 0.321-0.669) (p ≤ 0.034, all).

CONCLUSION

Inferior mental health correlated with inferior pain, function, and disability scores at one or more periods postoperatively. This finding was most consistent for correlation between mental health scores and disability. Optimization of mental health may positively influence outcomes, especially regarding disability, following ALIF.

Clinical outcomes after surgery for cervical radiculopathy performed in public and private hospitals : a nationwide relative effectiveness study

AIMS

The number of patients undergoing surgery for degenerative cervical radiculopathy has increased. In many countries, public hospitals have limited capacity. This has resulted in long waiting times for elective treatment and a need for supplementary private healthcare. It is uncertain whether the management of patients and the outcome of treatment are equivalent in public and private hospitals. The aim of this study was to compare the management and patient-reported outcomes among patients who underwent surgery for degenerative cervical radiculopathy in public and private hospitals in Norway, and to assess whether the effectiveness of the treatment was equivalent.

METHODS

This was a comparative study using prospectively collected data from the Norwegian Registry for Spine Surgery. A total of 4,750 consecutive patients who underwent surgery for degenerative cervical radiculopathy and were followed for 12 months were included. Case-mix adjustment between those managed in public and private hospitals was performed using propensity score matching. The primary outcome measure was the change in the Neck Disability Index (NDI) between baseline and 12 months postoperatively. A mean difference in improvement of the NDI score between public and private hospitals of ≤ 15 points was considered equivalent. Secondary outcome measures were a numerical rating scale for neck and arm pain and the EuroQol five-dimension three-level health questionnaire. The duration of surgery, length of hospital stay, and complications were also recorded.

RESULTS

The mean improvement from baseline to 12 months postoperatively of patients who underwent surgery in public and private hospitals was equivalent, both in the unmatched cohort (mean NDI difference between groups 3.9 points (95% confidence interval (CI) 2.2 to 5.6); p < 0.001) and in the matched cohort (4.0 points (95% CI 2.3 to 5.7); p < 0.001). Secondary outcomes showed similar results. The duration of surgery and length of hospital stay were significantly longer in public hospitals. Those treated in private hospitals reported significantly fewer complications in the unmatched cohort, but not in the matched cohort.

CONCLUSION

The clinical effectiveness of surgery for degenerative cervical radiculopathy performed in public and private hospitals was equivalent 12 months after surgery.Cite this article: Bone Joint J 2023;105-B(1):64-71.

Prognostic Factors Impacting Surgical Outcomes in Patients With Cervical Spondylotic Myelopathy

The purpose of surgical decompression in patients who have CSM is to stop the progression of symptoms and hopefully improve function. It is critical to understand prognostic factors that affect the outcome. Factors intrinsic to the patient that can adversely affect outcomes include diabetes, older age, tobacco use, the presence of mental health disease, and obesity. MRI imaging findings of T2 hyperintensity and clinical duration and severity of symptoms is also associated with poorer outcomes. Patients should be counseled regarding the efficacy of decompressive procedures for CSM and given realistic expectations based on their unique biophysical profiles.

Brain connectivity markers in degenerative cervical myelopathy patients with depression for predicting the prognosis following decompression surgery

OBJECTIVE

To determine if brain functional connectivity (FC) is associated with the prognosis in depressed degenerative cervical myelopathy patients (DCM) and to investigate the possible brain functional mechanism.

METHODS

Resting-state fMRI scans and peripheral blood cell counts from 33 depressed DCM patients, 33 age and gender-matched DCM patients without depression were analyzed. All patients were evaluated using Japanese Orthopedic Association score before and 6 weeks after decompression surgery. JOA recovery rate was calculated to assess the functional recovery for DCM patients. For each participant, seed-based functional connectivity maps based on sub-regions centered on the striatum were computed and compared between groups. Pearson correlations were performed to explore the relationships between clinical measures and brain alterations in depressed DCM patients. To further investigate the relationships between brain alterations and clinical measures in depressed DCM patients, mediation analyses were performed. Flow cytometry was also performed on the three of the 33 depressed DCM patients, and the results were analyzed.

RESULTS

In comparison to patients without depression, DCM patients exhibited lower FC between the dorsal caudate (dC) and the inferior frontal operculum, which is located in the dorsal lateral prefrontal cortex (dlPFC). In depressed DCM patients, the altered dC-dlPFC FC was associated with inflammation as determined by the neutrophils/lymphocyte's ratio and prognosis. Furthermore, the mediation analysis demonstrated that the dC-dlPFC FC mediated the effect of inflammation on prognosis. The outcomes of our three cases followed a similar pattern to these findings.

CONCLUSION

In conclusion, our findings imply that inflammation slowed the functional recovery in depressed DCM patients through the striatal-frontal FC pathway.

Effects of Preexisting Depression and Anxiety on Postoperative Outcomes following Arthroscopic Rotator Cuff Repair

Background

Rotator cuff repairs (RCRs) are one of the most commonly performed shoulder surgeries in the United States. Psychological health has been shown to influence postoperative outcomes in orthopedic procedures. The purpose of this study is to evaluate the relationship between depression and anxiety (DA) and psychotropic medication and postoperative outcomes following RCR.

Methods

A single institution retrospective observational cohort study of 816 patients undergoing arthroscopic RCR from January 2014 to October 2020 was conducted. Univariate statistics were used to assess differences in demographics, operative characteristics, and postoperative outcomes; multivariate analysis was used to evaluate risk factors for postoperative complications.

Results

Patients with DA were more likely to have a higher first (3.60 vs. 3.00, P = .004) and last (1.23 vs. 0.96, P = .042) postoperative pain scores, lower first (18.67 vs. 21.85, P = .008) and last (61.87 vs. 64.71, P = .014) Upper Extremity Functional Score (UEFS), more likely to experience an emergency department visit postoperatively (9.1 vs. 5.0%, P = .028), have a symptomatic recurrent tear (8.2 vs. 3.3%, P = .003), and persistent pain (4.3 vs. 1.2%, P = .011). After controlling for age, sex, body mass index, American Society of Anesthesiologists score, diabetes, smoking, coronary artery disease, asthma, hypertension, psychotropic medication and DA, having DA at the time of surgery was independently predictive of any complication (odds ratio, 2.033; P = .028) and persistent pain (odds ratio, 8.232; P ≤ .001). Patients with and without DA showed significant improvement in postoperative pain and UEFS from the first to the last measurement (P < .001).

Conclusion

DA is not a deterrent for RCR but targeted interventions may be needed to decrease the occurrence of complications.

Is depression the contraindication of anterior cervical decompression and fusion for cervical spondylosis?

OBJECTIVE

To evaluate whether depression is the contraindication of anterior cervical decompression and fusion (ACDF) for cervical spondylosis.

MATERIAL AND METHODS

Patients with single-segment cervical spondylosis who underwent ACDF from January 2015 to December 2018 in our department were retrospectively included in this study and divided into two groups. Patients who were diagnosed of depression and prescribed with antidepressant drugs for at least 6 months before surgery were included in the intervention group. Patients without depression were included in the control group. The Beck Depression Inventory (BDI) score was used to evaluate the severity of depression. Visual Analogue Scale (VAS) score, Japanese Orthopeadic Association (JOA) score, Neck Disability Index (NDI), and the 36-Item Short-Form Health Survey (SF-36) were recorded as indexes to assess the pain, cervical spine function, degree of cervical spine injury, and life quality, respectively. The operative time, operative blood loss, hospital stay and complications were also recorded and compared.

RESULTS

A total of 117 patients were included in this study, involving 32 patients in the intervention group and 85 patients in the control group. No significant differences were found in operative time, operative blood loss, hospital stay and complications between the two groups (P>0.05). The BDI score, VAS score, JOA score, NDI, SF-36 physical component score (SF-36 PCS) and SF-36 mental component score (SF-36 MCS) were all significantly improved at last follow-up in both the two groups. The intervention group showed higher BDI score and SF-36 MCS than the control group at both preoperative and the last follow-up (P<0.05), and the improvements of BDI score and SF-36 MCS were also higher in the intervention group (P<0.05). Although the intervention group showed higher VAS score, NDI, SF-36 PCS and lower JOA score at preoperative and last follow-up, respectively (P<0.05), there were no significant differences in the improvements of these indexes between the two group (P>0.05).

CONCLUSIONS

Depression is not the contraindication of ACDF for cervical spondylosis. Depression patients who received preoperative antidepressants can achieve similar improvement of clinical symptoms from ACDF with non-depression patients.