Do You Screen Your Surgical Patients for Psychological Comorbidities?

Mental health comorbidities are a predictor of readmission and revision after spine surgery, but few surgeons perform psychological screenings for prospective patients.

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When a patient gets spine surgery, often there’s more at play than the spinal condition that needs treatment. Most patients who need surgery on their spines carry psychological comorbidities into the operating room­—and the recovery room.  

Spine surgery psychological screeningPsychological comorbidities are predictors of outcome and recovery, yet most spine surgeons do not screen their patients.

More than half of patients with adult spinal deformities (ASDs) have at least one psychological diagnosis, and about half of those have two or more. Research suggests that psychological comorbidities are linked to poorer outcomes from spinal surgery.

A large-scale (n=6,020) 2018 study published in SPINE found that psychological comorbidities were a significant predictor of hospital readmission, postop complications and revision surgery after thoracolumbar fusion. A smaller, earlier study, also published in SPINE, suggests that higher scores on mental health screening predicted less back pain and better function after fusion surgery.

You want your patients to have realistic, healthy expectations as well as surgeries that help them function better and with less pain. Mental health is a big component in both, but few spine surgeons aside from the most experienced providers implement presurgical mental health screening. In fact, only a little more than a third of spine surgeon participants in a 2014 study published in Journal of Spinal Disorders and Technique used one.

Furthermore, there is no standardized presurgical psychological screening process or test for spine surgery. One institution has attempted to develop one. Its results have been published in February 2020 in Spine Deformity, the Scoliosis Research Society’s journal.

Color Codes

Researchers from the Neuroscience Institute at the Virginia Mason Medical Center in Seattle have developed a color-coded psychological health chart for preoperative spine surgery mental health screening. The chart goes, in order of most psychological wellness to least:

  • Green
  • Green-minus
  • Yellow
  • Yellow-minus
  • Orange
  • Red

It assesses 18 criteria, including:

  • Depression
  • Anxiety
  • Alcohol, opioid or other substance abuse
  • Emotional and social support
  • Physical or architectural barriers
  • Expectations for surgery
  • Results from other cognitive screening assessments

…and more. The Red code is reserved for patients exhibiting psychosis or homicidal or suicidal ideation.

Is Presurgical Mental Health Screening Viable?

This study included 129 patients of the Virginia Mason Medical Center. In this study population, more than four out of five patients had at least one psychological comorbidity. Only 17% had a support plan in place, realistic expectations about their surgery and no history of mental illness.

A color-coded mental health assessment such as that which appears in the Spine Deformity article can be a convenient shorthand for spine surgeons to assess their patients’ mental state. Patients scoring low on the assessment can be referred out to psychological treatment pre-surgery, or extra steps can be taken to ensure positive recovery outcomes.

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Updated on: 03/16/20
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Which Patients Undergo Pre-Surgical Psychological Evaluation Before Spine Surgery?
Steven Richeimer, MD
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