Evidence & Methods
Preoperative clinical depression has been suspected to negatively impact surgical outcomes following revision lumbar spinal surgery. This study aims to examine this hypothesis.
Preoperative depression, as assessed by a self-reported Zung Depression Scale, was found to be an independent predictor of poorer functional outcomes at 2 years following commonly performed revision surgeries.
This information is important for clinical research in that it suggests that depression can be a primary confounder in outcome studies. Thus, the relative proportion of patients with preoperative clinical depression in different groups in comparative studies (ie, RCTs or matched-cohorts) is vital for comparing interventions or other outcome predictors. The findings are also helpful at the individual patient level, improving informed consent and gaining better insight into how non-spinal health problems affect spine surgical outcomes.
—The Editors
Low back pain is a leading cause of disability in Western societies. In the United States, approximately 80% of people experience an episode of back pain at some point in their life [1], [2], [3], [4], [5], [6], and 3% of patients with back pain will require surgical intervention [7], [8], [9], [10], [11]. Although spine surgery has been shown to be clinically effective, outcomes are not universally successful [12], [13]. Turner et al. [14] reported successful outcomes in 65% to 75% of spinal fusions, with a mean reoperation rate of 23%. Similarly, Hoffman et al. [15] observed a mean success rate of 65% with a reoperation rate of 10%. These inconsistencies in satisfactory outcomes have led health care researchers and policymakers to examine preoperative factors that may independently predict outcome.
Growing evidence suggests that the variability observed in outcomes after spine surgery may be partially attributed to preoperative psychological predispositions. In the 1970s, Spengler et al. [10], [16], using the Minnesota Multiphasic Personality Inventory, demonstrated a strong correlation between psychological factors and clinical outcomes in patients undergoing lumbar discectomy. Similarly, Junge et al. [12], [17], in a study of patients undergoing lumbar discectomy, demonstrated that baseline psychological predispositions were useful in predicting poor clinical outcomes after surgery. Several other studies have corroborated these findings [8], [18], [19], [20], [21], [22]. However, most published studies have been retrospective case series with varying definitions of a “successful outcome,” using provider-defined outcomes rather than validated patient-reported outcome metrics.
Patients requiring revision decompression and fusion for same-level recurrent stenosis, pseudarthrosis, or adjacent segment disease (ASD) are a particularly challenging cohort to treat. Revision surgery can be technically challenging, and patients often present with long durations of symptoms coupled with anxiety regarding the surgeries they feel that they have already failed. Hence, outcomes after revision neural decompression and fusion have been reported to vary widely. Patients requiring revision lumbar surgery represent a unique group where their psychological factors, such as anxiety, depression, and somatic perception, may play a particularly increased role in their perceived outcome. To date, no studies have used validated patient-reported outcomes to assess the value of preoperative depression assessment in predicting outcome after revision lumbar decompression and fusion.
Given the paucity of data assessing the effect of preoperative depression on surgical outcomes in patients failing their index lumbar surgery, we set out to evaluate, using validated patient-reported outcome instruments, the predictive value of preoperative depression on improvement in disability after revision lumbar surgery for ASD, pseudarthrosis, and recurrent stenosis.