by Elizabeth Hofheinz, M.P.H., M.Ed., November 21, 2019
Pain, even the emotional kind, can be felt deep down in the bones. But how does such pain—depression and anxiety—factor into spine surgery? Recent work has tackled this issue, looking specifically at the role of preoperative mental health in postoperative outcomes in patients undergoing anterior cervical discectomy and fusion (ACDF).
Andrew Harris, a research fellow at the Johns
Hopkins Hospital Department of Orthopaedic Spine Surgery, worked alongside Richard L. Skolasky,
Jr., M.A., Sc.D., director of the Spine Outcomes Research Center at Johns
Hopkins and employed a retrospective analysis of the Truven Health
Marketscan© insurance claims data to examine postoperative outcomes, increased
health-resource utilization and any rise in chronic postoperative opioid use. 
Harris notes, “Prior work has demonstrated that in the U.S., there is a lifetime prevalence of 21% for depression and 30% for anxiety. While a number of studies have examined the relationship between psychiatric comorbidities and outcomes after ACDF, these previous studies have been in small cohorts and have had mixed results. And what really makes our work stand out is that we were able to capture data on over 16,000 individuals.”
The team hypothesized that anxious and depressed patients would have worse outcomes, increased health-resource utilization and would be more likely to use opioids chronically postoperatively. They also surmised that the increase in resource utilization would be reflected by an increase in postoperative healthcare payments.
Andrew Harris: “We identified patient comorbidities, opioid use, postoperative outcomes, and total payments for healthcare services from discharge through the 2-year postoperative period. Patients were included who underwent surgery from 2010-2013.”
There are innumerable things that can affect outcomes following spine surgery. But this research, the largest of its kind to date, clearly shows that mental health cannot be overlooked in patients undergoing ACDF.
“Our study found that 30% of patients had a diagnosis of depression and 25% had a diagnosis of anxiety,” says Andrew Harris. Both depression and anxiety were both independently associated with a 1.5x greater odds of chronic opioid use following ACDF. Both psychological conditions were independently associated with higher odds of having a multi-day hospitalization; depressed patients had decreased odds of being discharged home.”
“Alarmingly,” says Harris, “patients with depression had 1.5 and 1.7 times greater odds of 30 and 90-day hospital readmission, 1.6 times greater odds of having revision surgery at 1-year and 1.4 times greater odds of having revision surgery by 2-years even after controlling for patient comorbidities and demographics. Anxiety was less strongly associated with these adverse outcomes, with only 1.3 times greater odds of revision surgery by 2-years.”
On the financial front, depressed patients had significantly increased 1 and 2-year total healthcare payments, and almost twice the cumulative total opioid consumption at 1-year postop compared with patients without depression.
Andrew Harris: “Opioid use, anxiety, pain, and depression are potentially related to each other. Spine surgeons are not expected to treat these conditions, of course, but the very least we can do is screen for them.”
Prior research by the same authors found that use of presurgical psychological screening (PPS) prior to spine surgery is uncommon. Harris states, “That work showed that surgeons were less likely to use PPS if they had completed residency or begun practicing within 14 years, had fewer than 200 cases annually, or were university affiliated.”
“Going forward,” says Harris, “ it will be important to determine if treating a patient for depression or anxiety pre- or postoperatively leads to a reduction in the disparity in adverse outcomes. We are not suggesting that patients with anxiety and/or depression should not be undergoing surgery, but perhaps patients who have treated anxiety and/or depression would not have the same degree of adverse outcomes as those who have untreated anxiety and/or depression. We think this is an important area for future studies to investigate.”
“And,” says Harris, “at some point we should examine whether patients with mental health disorders are more or less satisfied with their postoperative outcome. Although hospital admission rates and cost are important, we were not able to quantify the degree to which patients were satisfied with their outcome using administrative claims data.”