General Session: Thoraco-Lumbar Degenerative
Presented by: R. Duculan - View Audio/Video Presentation (Members Only)
C.A. Mancuso(1,2), R. Duculan(3), F.P. Cammisa(3), A.A. Sama(3), A.P. Hughes(3), D.R. Lebl(3), F.P. Girardi(3)
(1) Hospital for Special Surgery, Research, New York, NY, United States
(2) Weill Cornell Medical College, Medicine, New York, NY, United States
(3) Hospital for Special Surgery, Orthopedics, New York, NY, United States
Purpose: Patients undergoing lumbar surgery often have a high prevalence of depressive and anxiety symptoms. Long-term effects of surgery on these psychological symptoms have not been rigorously evaluated. This longitudinal study compared pre- and 2-year postoperative psychological symptoms in 276 lumbar surgery patients and assessed whether change in symptoms was associated with success of surgery.
Methods: Several days before surgery patients completed two psychological surveys, the Geriatric Depression Scale (GDS) (possible score 0-30, ≥11 is a positive screen for depression) and the Spielberg State Anxiety Inventory (STAI) (possible score 20-80, population norms are used for comparison). Patients also completed the Oswestry Disability Index (ODI) measuring disability due to low back pain (possible score 0-100) and a validated Lumbar Spine Surgery Expectations Survey measuring expected amount of improvement for symptoms, function, and mental health (possible score 0-100). Medical comorbidity was obtained according to a standard index. Two years postop patients again completed the GDS, STAI, and ODI from the perspective of their current condition, and pre- to postop change in scores were calculated. Patients also reported new or worse comorbidity since surgery, and amount of improvement obtained for each expectation from which an overall proportion of expectations fulfilled was calculated (range 0-1, higher is greater fulfillment). Improvement in GDS and STAI was defined as better psychological well-being. Success of surgery was defined as greater proportion of expectations fulfilled and improvement in ODI scores.
Results: Mean age was 55 years, 56% were men, 78% had chronic spine conditions, 28% had major comorbidity preop, and 19% reported new or worsening comorbidity postop. Mean GDS scores were 9.8 (preop), 5.1 (postop), and 4.8 (within-patient change, p< .0001). More improvement in GDS scores was associated with a greater proportion of expectations fulfilled (p< .0001) and greater improvement in ODI scores (p< .0001). 41% preop screened positive for depression versus 16% postop (p< .0001). Compared to those who screened positive, those who screened negative postop had a greater proportion of expectations fulfilled (.33 vs .75, p< .0001), and a greater change in ODI scores (13 vs 34, p< .0001). Mean STAI scores were 40 (preop), 31 (postop), and 9 (within-patient change, p< .0001). More improvement in STAI scores was associated with a greater proportion of expectations fulfilled (p< .0001) and greater improvement in ODI scores (p< .0001). 59% preop had anxiety symptoms above population norms versus 26% postop (p=.002). Compared to those who were above population norms, those who were below population norms postop had a greater proportion of expectations fulfilled (.40 vs .79, p< .0001) and a greater change in ODI scores (15 vs 36, p< .0001). All associations persisted when controlled for pre- and postop comorbidity.
Conclusions: Traditionally, preoperative psychological symptoms have been assessed as predictors of outcomes of lumbar surgery. Our study demonstrated that outcomes of lumbar surgery, in turn, predict postoperative psychological well-being. The strengths of this study are its longitudinal design, use of within-patient change in scores for all measurements, use of patient-centered measurements, and control for pre- and postoperative comorbidity. This study provides evidence that successful lumbar surgery not only improves physical symptoms and function, but also improves psychological well-being.