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Studies show depressed, anxious patients may not have worse surgical outcomes
Surgeons should not be reluctant to perform spine procedures on anxious patients, based on two studies.
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Depressed and anxious patients who undergo surgery for cervical myelopathy or receive a lumbar epidural steroid injection for degenerative spine disease may experience benefits from these treatments that are similar to those seen in patients who undergo the same procedures but are not depressed, according to investigators.
Harrison F. Kay, and Silky Chotai, MD, presented two separate studies at the North American Spine Society Annual Meeting that evaluated outcomes of spine procedures in depressed vs. non-depressed patients.
In Kay’s study, the investigators compared outcomes for depressed or anxiety-ridden patients with those of non-depressed patients who underwent surgery for cervical myelopathy.
Harrison F. Kay
“Patients with depression and anxiety have worse absolute pain and disability at 12 months, but similar 12-month change scores and satisfaction following cervical spinal surgery. Patients with psychiatric comorbidities should not be dismissed as potential surgical candidates because they do experience similar benefit from these surgeries,” Kay said.
Kay and colleagues evaluated consecutive patients with cervical myelopathy undergoing operative management. The prospective, registry data-based study included 262 patients who underwent surgery for cervical myelopathy and were followed-up for at least 12 months. Researchers collected baseline and 12-month patient-reported outcome measures (PROMs), Zung Depression Scale (ZDS) and Modified Somatic Perception Questionnaire (MSPQ) scores.
Patients with ZDS scores greater than 33 points were defined as depressed, and patients with MSPQ scores greater than 12 points were defined as anxious.
Kay and colleagues noted that mean 12-month absolute scores for all outcomes were significantly worse in patients who were classified as depressed and/or anxious.
However, the 12-month change scores for Neck Disability Index (NDI) percentage and SF-6D scores for the depressed patients were significantly better than for the non-depressed patients. There were no significant differences in VAS neck and arm pain scores evident between the two groups of patients, according to Kay.
No difference in anxious patients
Kay noted in his presentation that 12-month change scores for NDI percentage were significantly better in anxious patients than non-anxious patients. Also, the differences in VAS neck and arm pain scores between the anxious and non-anxious patients were not significant.
Silky Chotai
The one measure that was significantly different between depressed and non-depressed patients in Kay’s study was satisfaction with surgery. Patients with myelopathy who were depressed had less satisfaction with their surgery compared with non-depressed patients, Kay said.
Similar outcomes for epidurals
Chotai and colleagues evaluated PROMs after lumbar epidural steroid injections for degenerative spine disease in depressed and non-depressed patients.
In findings that were similar to those of Kay and colleagues, the change scores at follow-up were similar between depressed and non-depressed patients, Chotai said in her presentation.
“This suggests patients with underlying depression can expect to receive similar benefits compared to patients who are not depressed. In addition, depressed patients had a significantly higher change or improvement in general health score mental components (SF-12 MCS). Therefore, the studies reporting depression as an indicator for worse outcomes should consider that these patients can achieve as much improvement as non-depressed patients following injection therapy,” she said.
Depression had limited effect
Chotai and colleagues included 161 patients in their study of prospective, longitudinal, registry-based data from a single institution. They included 71 depressed patients and 90 non-depressed patients.
Patients were classified as depressed or non-depressed based on previously validated values for the ZDS. Patients with ZDS scores of less than 33 points were classified as non-depressed, and patients with ZDS scores greater than 33 points were classified as depressed.
The mean absolute patient-reported scores were worse in depressed patients at the 12-month follow-up for Oswestry Disability Index (ODI) percentage scores, EQ-5D scores, SF-12 scores, and back and leg pain scores, according to the investigators.
No effect on change scores
However, there was no statistically significant difference in mean change scores at 12-month follow-up for EQ-5D, SF-12 PCS, ODI percentage, and back and leg pain scores between depressed and non-depressed patients, according to Chotai.
“Although depressed patients had worse baseline and 12-month PROMs, interestingly, the change scores between depressed and non-depressed patients were similar,” she said. – by Robert Linnehan
- References:
- Chotai S, et al. Paper #18. Presented at: North American Spine Society Annual Meeting; Oct. 14-17, 2015; Chicago.
- Kay HF, et al. Paper #16. Presented at: North American Spine Society Annual Meeting; Oct. 14-17, 2015; Chicago.
- For more information:
- Silky Chotai, MD, can be reached at Vanderbilt University Medical Center, 1211 Medical Center Dr., Nashville, TN 37232; email: silky.chotai@vanderbilt.edu.
- Harrison F. Kay, can be reached at Vanderbilt Orthopaedic Institute, Medical Center East, South Tower, Suite 4200, Nashville, TN 37232; email: harrison.f.kay@vanderbilt.edu.
Disclosures: Chotai and Kay report no relevant financial disclosures.
Perspective
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Heidi Prather, DO
I thought the studies from Vanderbilt were particularly important for health care providers to hear. The groups looked at two different types of patient populations. One was a surgical population, and one was a population undergoing an epidural. What they found was when they stratified patients from the beginning and stratified them as having a history of scores that put them in a group of having anxiety or depression, and compared them to people without anxiety or depression, they found what we have known from the past. Those with anxiety or depression, their scores may not be as high as those without that disorder after a spine treatment, whether it was a surgical treatment or injection. What they did point out that was so important, is that folks with anxiety or depression did improve. In fact, they improved at the same rate as those without. This means, patients with biopsychosocial factors, when identified from the beginning, still have a chance to seek improvement after an intervention. What we do not know from the abstract, and I look forward to seeing possibly in the paper, is if any of those patients had been treated to address their biopsychosocial factors. If not, or if that had not been done consecutively with patients, that is a big opportunity for improvement. If we can stratify patients who have risk factors related to their biopsychosocial situation prior to an intervention and address that issue, we may see even improved outcomes with spine care.
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