General Session: Value and Outcomes in Spine Surgery - Hall F

Presented by: R. Knight


A. Tuck(1), M. Scribani(2), S. Grainger(3), C. Johns(4), R. Knight(5)

(1) Columbia/Bassett School of Medicine, Cooperstown, NY, United States
(2) Bassett Research Institute Center for Biostatistics, Cooperstown, NY, United States
(3) Bassett Spine Care Institute, Cooperstown, NY, United States
(4) Bassett Healthcare Network Department of Psychiatry, Cooperstown, NY, United States
(5) Bassett Spine Care Institute, Orthopedics, Oneonta, NY, United States


Introduction: Psychosocial factors have received increasing attention as predictors of clinical outcomes of spinal surgery. Pre-operative depression has been shown to predict a variety of outcomes, including postoperative disability, pain, patient satisfaction; and general quality of life. There have been calls for implementation of preoperative screening for depression as a means of patient selection for spinal surgery. One possible measure is the Patient Health Questionnaire 9-item (PHQ-9) depression scale. The PHQ-9 is a self-administered survey that consists of nine questions, each based on a criterion from Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) used to establish a major depressive episode. In the present study, we examined the relationship of preoperative depression as measured by the PHQ-9 and patient-reported functional outcomes after surgery.

Methods: A patient centered surgical registry of elective spine surgery patients, between January 2010 to present was established. Demographics collected included age, sex, smoking history, chronic daily narcotic use, prior surgery at the index level, and insurance carrier. Patient-reported functional outcomes (PRFO) addressed were depression, pain, and disability. Postoperative depression was measured by the PHQ-9. Pain was measured with visual analog scales (VAS). Disability was measured by the Oswestry Disability Index (ODI). Patients were stratified based on age, smoking history, history of prior spinal surgery at the index level, chronic daily narcotic use, PHQ-9 score (mild depression 0-7, moderate 8-14, moderate severe/severe ≥15) and insurance provider (Medicare, Medicaid, Private, Worker's Compensation). Functional improvement (ODI, VAS) over time and between groups was compared using two-way Analysis of Variance (ANOVA). Associations between PHQ-9 and PRFO for disability and pain were tested using Pearson's Correlation at each time point separately. 3,219 PHQ-9 forms from 1000 patients were used as data sets.

Results: Study cohort was 52.8% male and 47.2% female patients with mean age 58.7 years (range 22-91). The cohort demonstrated significant improvement in PRFO. PHQ-9 data demonstrated reduction from mean preoperative value (8.03) to 24 month postoperative (5.37; p< 0.0001). Significant differences in reported PHQ-9 at each reported time point (preoperative, 1, 4, 10, and 24 months postoperative) were noted based on age, smoking history, narcotic use, and insurance provider. Younger patients, age 22-44 years, demonstrated significantly higher PHQ-9 scores compared to patients 65 years or older. Smokers compared to nonsmokers, chronic daily narcotic users versus non-chronic narcotic users and Medicaid or Worker's Compensation patients versus Medicare or Private insured patients, demonstrate significantly elevated PHQ-9 scores. While PRFO significantly improved across time and stratification, level of PRFO improvement within stratification was significantly different. Significant positive correlation was noted between PHQ-9 and PRFO. Patients with moderate severe/severe depression (PHQ-9 ≥ 15) showed a significant decline in mean PHQ-9 immediately following surgery (one month follow-up) compared to those with mild or moderate depression (p interaction < 0.0001).

Conclusion: Depressive symptoms were found to be a significant predictor of patient-reported functional outcomes. Patients with higher preoperative depression experienced smaller gains in PRFO after surgery (although all patient groups experienced improvement regardless of preoperative depressive status). Depressed patients experienced significant improvement of depressive symptoms that was sustained even 24 months post-operatively. PHQ-9 demonstrated utility as a screening instrument in outcomes research.