Elsevier

The Spine Journal

Volume 12, Issue 3, March 2012, Pages 179-185
The Spine Journal

Clinical Study
Preoperative Zung Depression Scale predicts outcome after revision lumbar surgery for adjacent segment disease, recurrent stenosis, and pseudarthrosis

https://doi.org/10.1016/j.spinee.2011.08.014Get rights and content

Abstract

Background context

Persistent back pain and leg pain after index surgery is distressing to patients and spinal surgeons. Revision surgical treatment is technically challenging and has been reported to yield unpredictable outcomes. Recently, affective disorders, such as depression and anxiety, have been considered potential predictors of surgical outcomes across many disease states of chronic pain. There remains a paucity of studies assessing the predictive value of baseline depression on outcomes in the setting of revision spine surgery.

Purpose

To assess the predictive value of preoperative depression on 2-year postoperative outcome after revision lumbar surgery for symptomatic pseudarthrosis, adjacent segment disease (ASD), and same-level recurrent stenosis.

Patient sample

One hundred fifty patients undergoing revision surgery for symptomatic ASD, pseudarthrosis, and same-level recurrent stenosis.

Outcome measures

Patient-reported outcome measures were assessed using an outcomes questionnaire that included questions on health-state values (EQ-5D), disability (Oswestry Disability Index [ODI]), pain (visual analog scale), depression (Zung Self-Rating Depression Scale), and 12-Item Short Form Health Survey physical and mental component scores.

Methods

One hundred fifty patients undergoing revision neural decompression and instrumented fusion for ASD (n=50), pseudarthrosis (n=47), or same-level recurrent stenosis (n=53) were included in this study. Preoperative Zung Self-Reported Depression Scale score was assessed for all patients. Preoperative and 2-year postoperative visual analog scale for back pain and leg pain scores and ODI were assessed. The association between preoperative Zung Depression Scale score and 2-year improvement in disability was assessed via multivariate regression analysis.

Results

Compared to preoperative status, VAS-BP was significantly improved 2 years after surgery for ASD (8.72±1.85 vs. 3.92±2.84, p=.001), pseudoarthrosis (7.31±0.81 vs. 5.06±2.64, p=.001), and same-level recurrent stenosis (9.28±1.00 vs. 5.00±2.94, p=.001). Two-year ODI was also significantly improved after surgery for ASD (28.72±9.64 vs. 18.48±11.31, p=.001), pseudoarthrosis (29.74±5.35 vs. 25.42±6.00, p=.001), and same-level recurrent stenosis (36.01±6.00 vs. 21.75±12.07, p=.001). Independent of age, BMI, symptom duration, smoking, comorbidities, and level of preoperative pain and disability, increasing preoperative Zung depression score was significantly associated with less 2-year improvement in disability (ODI) after revision surgery for ASD, pseudoarthrosis, and recurrent stenosis.

Conclusions

Our study suggests that the extent of preoperative depression is an independent predictor of functional outcome after revision lumbar surgery for ASD, pseudoarthrosis, and recurrent stenosis. Future comparative effectiveness studies assessing outcomes after revision lumbar surgery should account for depression as a potential confounder. The Zung depression questionnaire may help risk stratify patients presenting for revision lumbar surgery.

Introduction

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.

Section snippets

Patient selection

One hundred fifty consecutive patients undergoing revision lumbar decompression and instrumented fusion for symptomatic back pain and leg pain from ASD (n=50), pseudarthrosis (n=47), or same-level recurrent stenosis (n=53) were included. Pseudarthrosis was defined as dynamic X-ray and computed tomography evidence of pseudarthrosis (lack of bridging bone across motion segments or pedicle screw halos and motion on dynamic X-rays); corresponding mechanical low back pain; and prior attempted

Results

Forty-seven patients underwent revision-instrumented arthrodesis for pseudarthrosis, 50 underwent decompression and extension of fusion for ASD, and 53 underwent revision neural decompression and instrumented fusion for same-level recurrent stenosis. The baseline characteristics are given in Table 1. Overall, mean±SD age was 57±11 years (94 women and 56 men). Twenty-two (15%) patients had diabetes, and 16 (11%) were smokers. Mean body mass index (BMI) was 29.78±5.92. Mean±SD duration of time

Discussion

In a 2-year longitudinal cohort study, we set out to assess the predictive value of preoperative depression on improvement in disability in patients undergoing revision surgery for symptomatic pseudarthrosis, ASD, and same-level recurrent stenosis. In all three disease states, the presence and magnitude of preoperative depression were significantly and independently associated with poor response to surgery. As expected, extent of preoperative disability was also associated with postoperative

Conclusions

Our study suggests that the extent of preoperative depression is an independent predictor of functional outcome after revision lumbar surgery for ASD, pseudarthrosis, and recurrent stenosis. Future comparative effectiveness studies assessing the outcomes after revision lumbar surgery should account for depression as a potential confounder. The Zung Depression questionnaire may help in risk stratification of patients presenting for revision lumbar surgery.

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    Author disclosures: OA: Nothing to disclose. SLP: Nothing to disclose. DNS: Nothing to disclose. SKM: Nothing to disclose. OSA: Nothing to disclose. JSC: Speaking/Teaching Arrangements: Synthes (B). CJD: Research Support (Staff/Materials): DePuy (C, Paid directly to institution/employer). MJM: Research Support (Staff/Materials): Globus (E), DePuy (E).

    The disclosure key can be found on the Table of Contents and at www.TheSpineJournalOnline.com.

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