Preoperative Depression Is a Factor in Postoperative Improvement for Lumbar Spine Surgery
Higher levels of preoperative depression and pain are associated with significantly less improvement in a patient’s quality of life after lumbar decompression or fusion. This finding comes from a retrospective study of 919 surgical patients who were followed for at least 6 months after surgery.
This study found that the odds ratio for a higher measure of preoperative depression would be associated with poorer postoperative improvement was 0.93. The odds ratio that a higher amount of preoperative pain would be associated with poorer postoperative improvement was 0.99. Both were statistically significant. Baseline pain, depression, and quality of life scores independent of each other were all clinically and statistically significant predictors of whether there would be improvement in health after lumbar surgery.
Previous studies have shown there is a strong correlation between psychological issues such as depression and poor clinical outcomes after lumbar spine surgery. However, this is a large study and it is the first to use the Patient Health Questionnaire (PHQ-9) and the Pain Disability Questionnaire (PDQ) to evaluate depression and pain before and after lumbar surgery. The PHQ-9 asks nine questions with each question scored zero to three for a total score between 0 and 27. The PDQ measures functional and psychosocial components of pain, with a total score between 0 and 150.
The EuroQol five dimension (EQ-5D) questionnaire was used to measure postoperative quality of life. This test asks questions about five dimensions of health status: mobility, self-care, usual activities, pain or discomfort, and anxiety or depression. Each dimension is scored from 0 to 3. The EQ-5D index score is then calculated from the dimension subscores and the index score represents the patient’s quality-adjusted life-years ranging from 0 to 1.
About the Study
The study was conducted at the Cleveland Center for Spine Health; part of the Cleveland Clinic in Ohio. The researchers performed a retrospective review of all patients who underwent elective lumbar decompression or fusion there between 2008 and 2012 and who were followed for a minimum of 6 months. The clinic had prospectively collected patient-reported health status measures, including the PHQ-9, PDQ, and EQ-5D before surgery and at follow-up visits.
The patients enrolled in the study were diagnosed with lumbosacral spondylosis, degenerative disc disease, lumbar spinal stenosis, lumbar disc displacement, lumbar kyphosis, or lumbar scoliosis. Patients under age 18 were excluded from the study, as were any who were missing any quality of life information. At the last follow-up visits, there was statistically significant improvement in quality of life scores in all questionnaires.
Preop Depression and Poor Outcomes
Surgeons should recognize that patients who are depressed before surgery are more likely to have poorer results afterward, the authors said. Using simple questionnaires can help diagnose depression or other psychological problems before surgery. “A trained multidisciplinary team may then address and treat depression before progressing to surgical intervention in an effort to maximize the benefit of surgery,” the authors stated.
“This study contributes to the body of evidence that demonstrates the negative impact of preoperative depression on postoperative [quality of life] outcomes. Furthermore, the model is generalizable to surgeries with and without fusion,” the authors said.
The limitations of this study include that it is a retrospective review, and that it was conducted at only one site. Another factor is that there is still a social stigma to admitting to being depressed, which means that patients may not be completely honest about reporting their depression. The PHQ-9 has been shown to be highly sensitive and specific in assessing self-reported depression.
In a note accompanying the report, the editors of The Spine Journal said, “This study is remarkable due to the amount of data collected on participating patients and the number of individuals included.”