Does the Predominant Pain Location Influence Functional Outcomes, Satisfaction and Return to Work After Anterior Cervical Discectomy and Fusion for Cervical Radiculopathy?

STUDY DESIGN: Retrospective review of prospectively-collected registry data. OBJECTIVES: The aim of this study was to determine how different combinations of preoperative neck pain (NP) and arm pain (AP) influence functional outcomes, patient satisfaction, and return-to-work in patients undergoing anterior cervical discectomy and fusion (ACDF) for degenerative cervical radiculopathy (DCR). SUMMARY OF BACKGROUND DATA: Surgeons often base decisions on the traditional belief that the predominance of radicular upper extremity symptoms is a stronger indication for cervical spine surgery than axial pain. However, there is a paucity of literature supporting this notion. METHODS: A prospectively maintained registry was reviewed for all patients who underwent primary ACDF for DCR. Patients were categorized into three groups depending on predominant pain location: AP predominant ([APP]; AP > NP), NP predominant ([NPP]; NP > AP), and equal pain predominance ([EPP]; NP = AP). Patients were prospectively followed for at least 2 years. RESULTS: In total, 303 patients were included: 27.4% APP, 38.9% NPP, and 33.7% EPP cases. The APP group was significantly older (P = 0.030), although there were no other preoperative differences among the three groups. After adjusting for baseline differences, the SF-36 Physical Component Summary was significantly better in the APP group at 6 months (P = 0.048) and 2 years (P = 0.039). In addition, they showed a trend towards better 6-month Neck Disability Index (P = 0.077) and 2-year SF-36 Mental Component Summary (P = 0.059). However, an equal proportion of patients in each group achieved the Minimal Clinically Important Difference for each outcome, were satisfied, and returned to work 2 years after surgery. CONCLUSION: Although patients with NPP had slightly poorer function and quality of life, all patients experienced a clinically meaningful improvement in patient-reported outcomes, regardless of the predominant pain location. High rates of satisfaction and return-to-work were also achieved. In the context of proper indications, these findings suggest that ACDF can be equally effective for DCR patients with varying combinations of NP or AP.Level of Evidence: 3.

A Validation of Patient Health Questionnaire-9 for Cervical Spine Surgery.

STUDY DESIGN: Retrospective. OBJECTIVE: The purpose of this study is to evaluate depressive symptoms as measured by the PHQ-9 survey and correlated them with scores from the SF-12 and VR-12 Mental Component Summary (MCS). SUMMARY OF BACKGROUND DATA: With the rising incidence of depression and the need to identify modifiable risk factors before surgery, it is increasingly important to screen for preoperative depressive symptoms in spine surgery. Although the Patient Health Questionnaire-9 (PHQ-9) has favorable characteristics as a depressive symptom screening instrument, it has not been evaluated within cervical spine surgery. METHODS: A prospectively maintained surgical registry was reviewed for patients undergoing single or multilevel anterior cervical discectomy and fusion (ACDF) or cervical disc replacement (CDR) from March 2016 until May 2019. Included patients underwent a procedure for degenerative spinal pathology. We collected demographic, baseline, and perioperative variables. The mean scores for postoperative PHQ-9, Short Form-12 (SF-12), and Veterans RAND-12 (VR-12) surveys were calculated, and an average change between preoperative and postoperative scores. Scatterplots depicted the association of SF-12 MCS and VR-12 MCS with PHQ-9. We evaluated the relationship of PHQ-9 with SF-12 MCS and VR-12 MCS scores by calculating a Pearson correlation coefficient and time-independent partial correlation coefficient. RESULTS: One hundred fifty-two patients underwent single or multilevel level cervical spine surgery (ACDF: 73% and CDR: 27%). The average age was 42.4 and 39% were female. Compared to preoperative scores, significant increases were observed among postoperative PHQ-9, SF-12, and VR-12 MCS surveys (P ≤ 0.001). We observed strong correlations between SF-12 and VR-12 MCS with PHQ-9 scores for both assessed correlations. CONCLUSION: Patients undergoing ACDF or CDR demonstrated significant improvement with PHQ-9, SF-12 MCS, and VR-12 MCS instruments. PHQ-9 scores strongly correlated with SF-12 MCS and VR-12 MCS. Our findings indicate PHQ-9 is a valid tool to evaluate pre and postsurgical depressive symptoms. LEVEL OF EVIDENCE: 4.

Psychological predictors of quality of life after anterior cervical discectomy and fusion for degenerative cervical spine disease.

We aimed to identify independent psychological predictors of quality of life (QOL) and functional outcome after anterior cervical discectomy and fusion (ACDF) for degenerative cervical spine disease. We prospectively included patients undergoing ACDF for degenerative cervical disc herniation and stenosis. Patients completed a structured psychological assessment including the Center for Epidemiological Studies Depression Scale (ADS-K), Post-Traumatic Stress Scale-10 (PTSS-10), State Trait Anxiety Inventory-State Anxiety and - Trait Anxiety (STAI-S and STAI-T) and Anxiety Sensitivity Index-3 (ASI-3) before surgery, after 3 and 12 months. Outcome measures included EuroQol-5D (EQ), Short Form-36 (SF-36) and Oswestry Disability Index (ODI) scores. Of 104 included patients who underwent ACDF between March 2013 and November 2017, 92 completed follow-up after 3 and 12 months. The mean Visual Analogue Scale (VAS) scores for neck pain (- 1.4; p < .001) and arm pain (- 1.8; p = .031) significantly decreased by 12 months. QOL scores significantly increased by 3 months (EQ: + 0.2; p < .001; SF-36 PCS: + 6.2; p < .001; SF-36 MCS: + 2.5; p = .044), a benefit which was retained at 12 months. Linear regression analyses identified statistically significant predictors in preoperative ASI-3, SF-36 MCS and STAI-S for postoperative QOL and ODI scores. There is a benefit for patients in terms of quality of life and function after undergoing surgery for degenerative cervical spine disease. With the ASI-3, SF-36 MCS and STAI-S there exist some predictors for postoperative QOL and ODI scores.

Evaluation of Health-related Quality of Life Improvement in Patients Undergoing Spine Versus Adult Reconstructive Surgery.

STUDY DESIGN: Retrospective analysis of outcomes in single-level spine and primary hip and knee arthroplasty patients. OBJECTIVE: The aim of this study was to compare baseline and postoperative outcomes in patients undergoing spine surgery procedures with total hip arthroplasty (THA) and total knee arthroplasty (TKA) to further define outcomes in orthopedic surgery. SUMMARY OF BACKGROUND DATA: Computer-adaptive Patient Reported Outcome Information System (PROMIS) allows for standardized assessment of the health-related quality of life across different disease states. METHODS: Patients who underwent spine surgery (anterior cervical discectomy and fusion, cervical disc replacement, lumbar laminectomy, microscopic lumbar discectomy, transforaminal lumbar interbody fusion or adult reconstruction surgery [THA, TKA]) were grouped. Mean Charlson Comorbidity Index (CCI), Baseline (BL), and 6-month PROMIS scores of physical function, pain interference, and pain intensity were determined. Paired t tests compared differences in CCI, BL, 6 months, and change in PROMIS scores for spine and adult reconstruction procedures. RESULTS: A total of 304 spine surgery patients (age = 58.1 ±â€Š15.6; 42.9% female) and 347 adult reconstruction patients (age = 62.9 ±â€Š11.8; 54.1% Female) were compared. Spine surgery groups had more disability and pain at baseline than adult reconstruction patients according to physical function ([21.0, 22.2, 9.07, 12.6, 10.4] vs. [35.8, 35.0], respectively, P < 0.01), pain interference ([80.1, 74.1, 89.6, 92.5, 90.6] vs. [64.0, 63.9], respectively, P < 0.01), and pain intensity ([53.0, 53.1, 58.3, 58.5, 56.1] vs. [53.4, 53.8], respectively, P < 0.01). At 6 months, spine surgery patients remained more disabled and had more pain compared to adult reconstruction patients. Over the 6-month timespan, spine patients experienced greater improvements than adult reconstruction patients in terms of physical function ([+8.7, +22.2, +9.7, +12.9, +12.1] vs. [+5.3, +3.9], respectively, P < 0.01) and pain interference scores ([-15.4,-28.1, -14.7, -13.1, -12.3] vs. [-8.3, -6.0], respectively, P < 0.01). CONCLUSION: Spinal surgery patients had lower BL and 6-month PROMIS scores, but greater relative improvement in PROMIS scores compared to adult reconstruction patients. LEVEL OF EVIDENCE: 3.

New Onset Depression and Anxiety After Spinal Fusion Surgery: Incidence and Risk Factors.

STUDY DESIGN: Retrospective database study. OBJECTIVE: We sought to investigate trends and risk factors for new-onset anxiety and/or depression within 6 months after elective spine surgery. SUMMARY OF BACKGROUND DATA: Surgery represents a stressful experience associated with a number of physiological and psychological consequences. A subset of patients develop clinically significant symptoms of new-onset anxiety or depression. However, the incidence of and risk factors for these adverse outcomes after spine surgery remain ill-defined. METHODS: We performed a retrospective analysis including anterior cervical discectomy and fusion and posterior lumbar fusion cases from 2012 to 2015, utilizing the Truven MarketScan database. Primary outcomes were new-onset depression, new-onset anxiety, and new-onset depression and/or anxiety after surgery. Potential risk factors included patient demographics, comorbidities, hospital and procedural characteristics as well as perioperative opioid regimens. Multivariable logistic regression models measured associations between risk factors and outcomes. Odds ratios (OR) were reported and results with P < 0.0167 were considered statistically significant. RESULTS: Among 39,495 unique patients, overall incidence of new-onset depression and anxiety was 6% and 11.2%, respectively. In adjusted analyses, significant risk factors across all three outcomes included chronic opioid use (ORs ranging from 1.31 to 2.93; P < 0.01), female sex (ORs ranging from 1.25 to 1.67; P < 0.01), longer length of stay (ORs ranging from 1.05 to 1.08; P < 0.01), and readmission within 6 months of surgery (OR ranging from 1.31 to 1.68; P < 0.01). CONCLUSION: We identified several risk factors contributing to increased odds of new-onset depression and/or anxiety after spine fusion surgery. These data may aid the implementation of preventative measures among identified high-risk patients. LEVEL OF EVIDENCE: 3.

Severity of Preoperative Myelopathy Symptoms Affects Patient-reported Outcomes, Satisfaction, and Return to Work After Anterior Cervical Discectomy and Fusion for Degenerative Cervical Myelopathy.

STUDY DESIGN: Retrospective review of prospectively-collected registry data. OBJECTIVE: To compare the patient-reported outcomes, satisfaction, and return to work among a large cohort of patients stratified by preoperative myelopathy severity undergoing Anterior Cervical Discectomy and Fusion (ACDF) for Degenerative Cervical Myelopathy. SUMMARY OF BACKGROUND DATA: Recent clinical practice guidelines noted a lack of studies stratifying their sample based on preoperative disease severity. The benefits of early surgical intervention for patients with mild myelopathy remain uncertain. METHODS: A prospectively-maintained registry was retrospectively reviewed for all patients who underwent primary ACDF for Degenerative Cervical Myelopathy. Patients were stratified based on severity of preoperative myelopathy symptoms according to the Japanese Orthopaedic Association (JOA) scale: mild (>13), moderate (9-13), or severe (<9). Patients were prospectively followed for at least 2 years. RESULTS: In total, 219 patients were included: 74 mild, 94 moderate, and 51 severe cases. The mild group had significantly better Neurogenic Symptoms (NS), Neck Disability Index (NDI), SF-36 Physical (PCS), and Mental Component Summary at baseline (P < 0.05). Neck and arm pain scores were similar at all time points. At 2 years, the severe group still had significantly worse patient-reported outcomes and lower rates of satisfaction, expectation fulfilment and return to work. However, they had significantly greater improvement in JOA, Neurogenic Symptoms, NDI, PCS, and Mental Component Summary, and a larger proportion attained minimal clinically important difference (MCID) for NDI and PCS. All three groups had similar proportions attaining MCID for JOA. CONCLUSION: Patients with severe myelopathy experienced a greater improvement after ACDF. Although fewer patients attained MCID, early surgical intervention for patients with mild myelopathy should also be considered, as this may allow patients to maintain their higher functional status. They also had high rates of postoperative satisfaction and return to work. The clinical trajectory outlined in this study may provide valuable prognostic information for patients. LEVEL OF EVIDENCE: 3.

Clinical performance of a bone-anchored annular closure device in older adults.

Background: Lumbar discectomy is a common surgical procedure in middle-aged adults. However, outcomes of lumbar discectomy among older adults are unclear. Methods: Lumbar discectomy patients with an annular defect ≥6 mm width were randomized to receive additional implantation with a bone-anchored annular closure device (ACD, n=272) or no additional implantation (controls, n=278). Over 3 years follow-up, main outcomes were symptomatic reherniation, reoperation, and the percentage of patients who achieved the minimum clinically important difference (MCID) without a reoperation for leg pain, Oswestry Disability Index (ODI), SF-36 Physical Component Summary (PCS) score, and SF-36 Mental Component Summary (MCS) score. Results were compared between older (≥60 years) and younger (<60 years) patients. We additionally analyzed data from two postmarket ACD registries to determine consistency of outcomes between the randomized trial and postmarket, real-world results. Results: Among all patients, older patients suffered from crippling or bed-bound preoperative disability more frequently than younger patients (57.9% vs 39.1%, p=0.03). Among controls, female sex, higher preoperative ODI, and current smoking status, but not age, were associated with greater risk of reherniation and reoperation. Compared to controls, the ACD group had lower risk of symptomatic reherniation (HR=0.45, p<0.001) and reoperation (HR=0.54, p=0.008), with risk reductions comparable in older vs younger patients. The percentage of patients achieving the MCID without a reoperation was higher in the ACD group for leg pain (81% vs 72%, p=0.04), ODI (82% vs 73%, p=0.03), PCS (85% vs 75%, p=0.01), and MCS (59% vs 46%, p=0.007), and this benefit was comparable in older versus younger patients. Comparable benefits in older patients were observed in the postmarket ACD registries. Conclusion: Outcomes with lumbar discectomy and additional bone-anchored ACD are superior to lumbar discectomy alone. Older patients derived similar benefits with additional bone-anchored ACD implantation as younger patients.

Psychosocial Stress Reactivity as Predictor of Operative Outcome in Lumbar Disc Surgery.

BACKGROUND: A large proportion of the population suffers from chronic back pain. For optimal treatment, the question arises which patients would benefit from conservative therapy and for whom lumbar disc surgery is most appropriate. It seems reasonable to analyze the impact of paraclinical parameters on the operation outcome to identify patients who would benefit less from surgery or need special pre-/postoperative medical care. MATERIALS AND METHODS: From March 2012 to July 2014, 32 patients were treated via microscopically supported interlaminar fenestration and discectomy at the Department of Neurosurgery, University Hospital Carl Gustav Carus Dresden. One day before the operation, a cortisol survey was made during the stress response of the Trier Social Stress Test. At the same time, a survey of relevant questionnaires was conducted by which the postoperative symptom experience was made operational and comparable with the evaluation of the same information thirty days afterwards. RESULTS: It could be shown that there is a connection between cortisol reactivity and the pain burden following operations. Patients with a greater cortisol reaction under stress exposition partially experienced more intense postoperative pain than the patients with a lower cortisol reaction. However, this relationship could only be explained by single significant results, whereas further calculations could not produce any significance. CONCLUSIONS: Cortisol reactivity seems to be associated with pain development. The inconsistent findings in empiricism as well as in this investigation are indicative of a complex association of postoperative pain and cortisol reactivity, which needs to be examined further.

Poor Baseline Mental Health Does Not Influence Improvement in Patient-reported Outcomes, Satisfaction, and Return to Work Two Years After Single-level Anterior Cervical Discectomy and Fusion.

STUDY DESIGN: Retrospective study using prospectively collected registry data. OBJECTIVE: The authors examine the influence of preoperative mental health on outcomes after anterior cervical discectomy and fusion (ACDF) and determine the impact of ACDF on postoperative mental health. SUMMARY OF BACKGROUND DATA: While studies have reported a negative correlation between preoperative mental health and outcomes following lumbar spine surgery, the influence on outcomes following cervical spine surgery remains relatively understudied. METHODS: Prospectively collected registry data of 104 patients who underwent single-level ACDF for cervical spondylotic myelopathy were reviewed. Patients were dichotomized into top and bottom halves based on preoperative SF-36 MCS (Mental Component Summary) using a cutoff of 48. Outcomes assessed were visual analogue scale for neck pain, arm pain, AAOS Neck Pain and Disability, Neurogenic Symptoms, Neck Disability Index, Short-Form 36, Japanese Orthopaedic Association myelopathy score, return to work, return to function, satisfaction and expectation fulfilment up to 2 years postoperatively. RESULTS: The preoperative MCS was 37.5 ±â€Š8.1 and 57.4 ±â€Š6.3 in the Low and High MCS groups respectively (P < 0.001). The Low MCS group had poorer preoperative scores (P < 0.05). There was no significant difference in length of stay or comorbidities (P > 0.05). The High MCS group had less neck pain (P = 0.002) and showed a trend towards lower Neck Disability Index (P = 0.062) at 2 years. The Low MCS group demonstrated greater improvement in Japanese Orthopaedic Association (P = 0.007) and similar improvement in other scores (P > 0.05). There was no significant difference in proportion that achieved minimal clinically important difference for each score (P > 0.05). Both groups had similar rates of return to work, return to function, expectation fulfilment, and satisfaction (P > 0.05). Lower preoperative MCS was predictive of greater improvement in MCS (r = -0.477, P < 0.001). CONCLUSION: Despite relatively greater pain and disability at 2 years, patients with poor baseline mental health experienced similar improvement in clinical outcomes, return to work, and satisfaction rates. LEVEL OF EVIDENCE: 3.

Comparing Health-Related Quality of Life Outcomes in Patients Undergoing Either Primary or Revision Anterior Cervical Discectomy and Fusion.

STUDY DESIGN: A retrospective review of prospectively collected data. OBJECTIVE: Compare health-related quality of life (HRQOL) outcome metrics in patients undergoing primary and revision anterior cervical discectomy and fusion (ACDF). SUMMARY OF BACKGROUND DATA: ACDF is associated with significant improvements in HRQOL outcome metrics. However, 2.9% of patients per year will develop symptomatic adjacent segment disease and there is a paucity of literature on HRQOL outcomes after revision ACDF. METHODS: Patients were identified who underwent either a primary or revision ACDF, and who had both preoperative and a minimum of 1-year postoperative HRQOL outcome data. Pre- and postoperative Short Form 12 Physical Component Score (SF12 PCS), Short Form 12 Mental Component Score (SF12 MCS) Visual Analog Scale for neck pain (VAS-Neck), VAS-Arm, and Neck Disability Index (NDI) scores were compared. RESULTS: A total of 360 patients (299 primary, 61 revision) were identified. Significant improvement in SF12 PCS, NDI, VAS-Neck, and VAS-Arm was seen in both groups; however, only a significant improvement in SF12 MCS was seen in the primary group. When comparing the results of a primary versus a revision surgery, the SF12 PCS score was the only outcome with a significantly different net improvement in the primary group (7.23 ±â€Š9.72) compared to the revision group (2.9 ±â€Š11.07; P = 0.006) despite similar baseline SF12 PCS scores. The improvement in each of the other reported HRQOL outcomes did not significantly vary between surgical groups. CONCLUSION: A revision ACDF for cervical radiculopathy or myelopathy leads to a significant improvement in the HRQOL outcome, and with the exception of the SF12 PCS, these results are similar to those of patients undergoing a primary ACDF. LEVEL OF EVIDENCE: 2.

Pre-operative obesity does not predict poorer symptom control and quality of life after lumbar disc surgery.

PURPOSE: We aimed to determine whether there was a difference in post-operative symptomatic control and quality of life (QoL) between patients who were obese (BMI >30) and non-obese (BMI <30) pre-operatively. This information may inform the decision making of Physicians and patients whether to proceed to surgery for management of symptomatic lumbar disc prolapse. METHODS: We conducted a prospective questionnaire-based study of QoL and symptom control in 120 patients with postal follow-up at 3 and 12 months after lumbar disc surgery. This study was conducted in two United Kingdom regional neurosurgical units, with ethical approval from the North of Scotland Research Ethics Service (09/S0801/7). RESULTS: 120 patients were recruited; 37 (34.5%) were obese. Follow up was 71% at 3 months and 57% at 12 months. At recruitment, both obese and non-obese patient groups had similar functional status and pain scores. At 3 and 12 months, non-obese and obese patients reported similar and significant benefits from surgery (e.g. 12 month SF-36 80.5 vs. 68.8, respectively). In non-obese and obese patients, time to return to work was 47.5 days and 53.8 days, respectively, (p = .345). After 12 months all QoL scores were significantly improved from pre-operative levels in both groups. CONCLUSIONS: Obese patients derive significant benefit from lumbar discectomy that it is similar to the benefit experienced by non-obese patients. Obese individuals may achieve excellent results from discectomy and these patients should not be refused surgery on the basis of BMI alone.

Patient and physiotherapist perceptions of rehabilitation following primary lumbar discectomy: a qualitative focus group study embedded within an external pilot and feasibility trial.

OBJECTIVE: To evaluate patients' and physiotherapists' perceptions, preferences and feelings about rehabilitation following lumbar discectomy surgery. DESIGN: A qualitative focus group study, informed from the theoretical perspective of phenomenology, of patients' and physiotherapists' experiences of rehabilitation following lumbar discectomy was conducted. The focus groups were used to explore patients' and physiotherapists' perceptions and their preferences and feelings about different approaches to rehabilitation. The focus groups were facilitated and observed by experienced researchers and were informed by a topic guide that had been piloted previously. SETTING: The study was embedded within an external pilot and feasibility trial that randomised patients across two secondary care spinal surgery sites in the UK to receive either 1:1 physiotherapy and leaflet or leaflet-only interventions. PARTICIPANTS: Five focus groups took place between April and July 2014. A framework analysis of thematic coding (deductive and inductive components) by two researchers captured identified themes common to both patients and physiotherapists. Data from three focus groups with patients and carers (n=11) and two with physiotherapists (n=15) contributed to the analytic framework. RESULTS: Emerging themes included: the value of patient leaflets with or without physiotherapy interventions; the importance of self-motivation in the recovery pathway; benefits of group physiotherapy for some patient groups and patient preference influencing rehabilitation. CONCLUSION: Patients and physiotherapists perceived the study patient leaflet and 1:1 physiotherapy interventions as high quality and valuable. Patients' personal priorities, for example, their need to return to work, influenced their preferences for rehabilitation interventions following surgery.

An evidence-based information booklet helps reduce fear-avoidance beliefs after first-time discectomy for disc prolapse.

OBJECTIVE: We aimed to assess the impact of a booklet integrating the biopsychosocial model of chronic pain management on reducing disability among patients undergoing lumbar discetomy. METHODS: In a prospective, controlled, time-series study with an alternate-month design, we enrolled 129 patients from a tertiary care university hospital after they underwent uncomplicated lumbar discectomy for the first time. The intervention group received the biopsychosocial evidence-based booklet and the control group a biomedical-based booklet; the booklets differed only in information content. Patients were blinded to treatment group. The main outcome was disability at 2 months (measured by the Quebec back-pain disability scale [QBPDS]). Secondary outcomes were fear and avoidance beliefs measured by the Fear-Avoidance Beliefs Questionnaire (FABQ). All data were collected by self-reporting questionnaires. RESULTS: At 2 months, disability did not differ between the 2 groups (QBPDS score 32.4±22.8 vs 36.1±18.7, P=0.36). FABQ physical activity score was lower with the evidenced-based booklet as compared with controls (8.0±7.14 vs 11.2±6.3, P=0.008). CONCLUSIONS: Providing an evidence-based booklet had no effect at 2 months after surgery on disability but reduced fear-avoidance beliefs about physical activity. This booklet could be an effective tool for health care professionals in helping with patient education. CLINICALTRIALS. GOV IDENTIFIER: NCT00761111.

Pretreatment of Anxiety Before Cervical Spine Surgery Improves Clinical Outcomes: A Prospective, Single-Institution Experience.

BACKGROUND: Affective disorders such as depression and anxiety have been shown to contribute to inferior outcomes after spine surgery. A high baseline level of anxiety is associated with refractory postoperative pain and patient dissatisfaction with surgery. The aim of this prospective study is to assess whether the pretreatment of anxiety before spine surgery improves patient reported outcomes 1-year after an anterior cervical discectomy and fusion (ACDF) procedure. METHODS: A total of 27 adult patients with a known history of anxiety disorder (pretreated cohort: 11 patients, control cohort: 16 patients) undergoing ACDF at Duke University Medical Center were included in this study. All patients were diagnosed with an anxiety disorder at least 6 months before surgery by a board-certified psychiatrist. Enrollment criteria included available demographic, surgical, and clinical outcomes data. All patients had prospectively collected patient reported outcomes measures and a minimum 1-year follow-up. Patients completed the Neck Disability Index (NDI), Short-Form 12 (SF-12), and visual analog scale (VAS) before surgery then at 6 weeks, and 3, 6, and 12 months after surgery. Clinical outcomes and complication rates were compared between both patient cohorts. RESULTS: Baseline characteristics were similar between both cohorts. At baseline, there were no significant differences between cohorts in NDI (P = 0.11), SF-12 PCS (P = 0.63), SF-12 MCS (P = 0.90), and VAS neck pain (P = 0.80). There was no nerve root injury or incidental durotomy in either cohort. At 6 months after surgery, patients in the pretreated cohort reported significantly lower postoperative pain compared to the control cohort (P = 0.01). These results were durable through 1 year (P = 0.02). At 1 year, patients who were pretreated for anxiety before surgery reported significantly lower postoperative neck pain scores compared with the control cohort (P = 0.02). CONCLUSION: Our study demonstrates that pretreatment of anxiety before cervical spine surgery results in a significant reduction in postoperative neck pain scores and may be a viable management strategy for patients with coexisting affective disorders and cervical spine pathology. Patients awaiting spine surgery should routinely be assessed for anxiety before surgery, and interventions to reduce and treat anxiety should be provided.

Pretreatment of Depression Before Cervical Spine Surgery Improves Patients' Perception of Postoperative Health Status: A Retrospective, Single Institutional Experience.

BACKGROUND: Previous research has indicated that postoperative pain and functional outcomes are influenced by affective disorders, especially depression. The aim of this retrospective analysis is to assess whether pretreatment of depression before surgery improved patient-reported outcomes measures and overall satisfaction with care. METHODS: A total of 140 adult patients (pretreated patients: 25; control patients: 115) underwent anterior cervical discectomy and fusion at Duke University Medical Center were included in this study. Of the 140 patients, 25 patients had a known history of depression diagnosed and treated by a board-certified psychiatrist with an antidepressant at least 6 months before surgery. Enrollment criteria included available demographic, surgical, medication, and clinical outcome data. Patients completed the Neck Disability Index (NDI), Short Form-12 (SF-12), and visual analog scale (VAS) before surgery, then at 3, 6, 12, and 24 months after surgery. Clinical outcomes were compared between both patient cohorts. RESULTS: Baseline characteristics were similar between both cohorts. At baseline there were no significant differences in NDI (P = 0.11), SF-12 physical component score (PCS; P = 0.63), and neck pain VAS (P = 0.80). There were no significant differences in the incidence of nerve root injury (P = 0.00) or durotomy (P = 0.31) between the treatment and control cohorts. At 1 year postoperatively, both cohorts demonstrated similar improvement in neck pain VAS (P = 0.92), NDI (P = 0.32), SF-12 PCS (P = 0.15), and SF-12 mental component score (P = 0.38). These results were durable through 2 years. At 2 years, both the demonstrated similar improvement from baseline in neck pain VAS (P = 0.88), NDI (P = 0.43), SF-12 PCS (P = 0.28), and SF-12 mental component score (P = 0.40). CONCLUSION: Our study suggests that in patients with depression, pretreatment with antidepressants before surgery significantly improves their perception and pain and functional disability.

Preoperative anxiety about spinal surgery under general anesthesia.

PURPOSE: No study has investigated preoperative anxiety about spinal surgery under general anesthesia. The purposes of this study were (1) to determine how many patients have preoperative anxiety about spinal surgery and general anesthesia, (2) to evaluate the level of anxiety, (3) to identify patient factors potentially associated with the level of anxiety, and (4) to describe the characteristics of the anxiety that patients experience during the perioperative period. METHODS: This study was performed in 175 consecutive patients undergoing laminectomy for lumbar stenosis or discectomy for herniated nucleus pulposus under general anesthesia. Demographic data, information related to surgery, and characteristics of anxiety were obtained using a questionnaire. The level of anxiety was assessed using a visual analog scale of anxiety (VAS-anxiety). Patient factors potentially associated with the level of anxiety were investigated using multiple stepwise regression analysis. RESULTS: Of 157 patients finally included in this study, 137 (87%) had preoperative anxiety (VAS-anxiety > 0). The mean VAS-anxiety score for spinal surgery was significantly higher than that for general anesthesia (4.6 ± 3.0 vs. 3.2 ± 2.7; P < 0.001). Sex and age were significant patient factors related to the level of anxiety about spinal surgery (P = 0.009) and general anesthesia (P = 0.018); female patients had a higher level of anxiety about spinal surgery, and elderly patients had a higher level of anxiety about general anesthesia. The most helpful factors in overcoming anxiety before surgery and in reducing anxiety after surgery were faith in the medical staff (48.9 %) and surgeon's explanation of the surgery performed (72.3%), respectively. CONCLUSIONS: Patients awaiting laminectomy or discectomy feared spinal surgery more than general anesthesia. This study also found that medical staff and surgeons play important roles in overcoming and reducing patient anxiety during the perioperative period.

Associations among pain, disability and psychosocial factors and the predictive value of expectations on returning to work in patients who undergo lumbar disc surgery.

PURPOSE: The aim of this study was to describe the associations among pain, disability and psychosocial factors preoperatively as well as 3 and 24 months later for patients who undergo first time discectomy and to analyse the predictive value of psychosocial factors on the outcome 24 months after surgery. METHODS: Fifty-nine patients, 41 % women, with a mean age of 40 years and without comorbidities were included, of whom 56 responded to the 24-month follow-up; at that point, they were divided into patients with complaints (C, n = 36) and patients without complaints (NC, n = 20). Correlations among the pain intensity, disability and psychosocial factors were analysed preoperatively, 3 and 24 months after discectomy, and regression analyses of psychosocial factors on the outcome at 24 months were performed. RESULTS: Psychosocial variables were weakly correlated with the pain intensity and disability preoperatively. High expectations on the return to work were predictive of both pain intensity (ß = 8.0, p = 0.03) and disability (ß = 9.1, p < 0.001) at 24 months. Associations between psychosocial variables and outcome variables were strengthened at the 3-month follow-up in the C group, and this association remained 24 months after surgery. Fear of movement was most strongly correlated with leg pain intensity (r (s) 0.64, p < 0.001) and the ability to decrease pain was the most correlated with disability (r (s) 0.78, p < 0.001). CONCLUSION: Having high expectations on the return to work after surgery was the strongest predictor for a favourable outcome. Therefore, low preoperative expectations on return to work convey an important prognostic signal.

Change in quality of life, disability, and well-being after decompressive surgery: results from a longitudinal study.

The aim of this study is to evaluate quality of life (QoL), disability, and psychological well-being (PWB) in patients with disc herniation and stenosis before and after decompressive surgery and to investigate factors associated with an improvement in the postoperative disability level. An observational longitudinal study was carried out to collect preoperative and postoperative data on QoL, disability, and PWB using European Health Interview Survey-Quality of Life (EUROHIS-QoL), WHO Disability Assessment Schedule, second version (WHODAS-II), and Psychological General Well-Being Index-Short (PGWB-S) questionnaires. Friedman's analysis of variance was performed to compare preoperative and postoperative test scores, whereas a one-sample t-test was calculated to compare the mean test scores with the general population. A hierarchical logistic regression was developed to investigate the association between the change in the disability level after surgery, sociodemographic and clinical characteristics, and preoperative test scores. Complete data were available for 55 patients. PGWB-S and WHODAS-II scores improved significantly (P=0.004 and 0.003), even if the disability level remained high after surgery. The logistic regression showed that patients with worse preoperative WHODAS-II scores had higher odds achieving improvement in their disability level after surgery. This study showed that disability and PWB improve significantly after surgery, but further treatment and a healthy lifestyle are expected and recommended as the disability level remains high. In addition, more severe preoperative disability was a predictor of better clinical outcome.

Effects of dynamic lumbar stabilization exercises following lumbar microdiscectomy on pain, mobility and return to work. Randomized controlled trial.

BACKGROUND: Various lumbar exercise programs are prescribed for rehabilitation purposes following microdiscectomy applied for the treatment of lumbar disk herniation. The literature contains several studies on this subject. However, there are no studies investigating the effects of supervised dynamic lumbar stabilization exercises on fear and fear/regression attitudes of patients and on their return to work. AIM: This study investigates the effects of supervised dynamic lumbar stabilization exercises during postoperative rehabilitation on spinal mobility, pain, functional status, return to work, quality of life, and fear/regression attitude of patients who underwent lumbar microdiscectomy for the first time. SETTING: The study was conducted at physical therapy and rehabilitation clinics. STUDY DESIGN: A randomized clinical trial comparing exercise programs after lumbar microdiscectomy. PATIENTS SAMPLE: Forty-four lumbar microdiscectomy patients were randomized into two groups. OUTCOME MEASURES: Each group was assessed in terms of low back pain, leg pain, spinal mobility, Oswestry Disability Index (ODI), and Nottingham Health Profile (NHP), at the postoperative first, second, and sixth months. Fear/regression beliefs and level of pain were evaluated through the Fear Avoidance Belief Questionnaire (FABQ). METHODS: Forty-four patients were randomly divided into two equal groups of 22 subjects, respectively, as a study group with Dynamic Lumbar Stabilization (DLS) exercises and home exercises, and a control group with only home exercises for a period of four weeks. RESULTS: Leg pain decreased more in the study group compared with the control group (P=0.004). Spinal mobility scores demonstrated greater increases in the study group (P<0.001). Statistically greater reductions were observed in the study group regarding ODI and FABQ scores (P<0.017). CONCLUSION: DLS exercises may be recommended to patients following spinal surgery due to their benefits in reducing pain, increasing spinal mobility, and ensuring faster return to work periods.

Comparison of patient satisfaction and cost in spinal and general anesthesia for lumbar disc surgery.

AIM: The aim of this study was to evaluate patient satisfaction and cost in spinal and general anesthesia for lumbar disc surgery. MATERIAL AND METHODS: The study was performed on 66 ASA class I-II patients with one level lumbar disc herniation (LDH). In this prospective study, patients were assigned randomly to either spinal anesthesia or general anesthesia groups. Hemodynamic variables, intraoperative opioid requirements, postoperative pain scores and analgesic requirements and complications were recorded. Patients were handed a questionnaire about the procedure they underwent to determine patient satisfaction. The costs of preoperative and postoperative anesthesia procedures, medications, and hospitalization were calculated individually. RESULTS: Spinal anesthesia and general anesthesia were similar concerning hemodynamic stability, first urination time, first mobilization time, postoperative analgesic requirement, and pain. Patients in group S needed less additional dose of fentanyl intraoperatively than the patients in group G. Patient satisfaction was significantly higher in Group S when compared to Group G. Total cost was higher in Group G compared to Group S. CONCLUSION: We conclude that successful LDH surgery can be performed using either anesthesia type. As long as patients are selected carefully, spinal anesthesia is a safe, comfortable, and a more economical alternative.