The 9-Item Patient Health Questionnaire (PHQ-9): an aid to assessment of patient-reported functional outcomes after spinal surgery

Impact of Early Depressive Burden on Patient-Reported Outcomes Following Minimally Invasive Transforaminal Lumbar Interbody Fusion

STUDY DESIGN

Retrospective review.

OBJECTIVE

To evaluate mental health influence on minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) patients.

SUMMARY OF BACKGROUND DATA

Poor mental health has been postulated to indicate inferior patient perceptions of surgical outcomes in spine literature. Few studies have assessed mental health as a dynamic metric throughout the perioperative period.

METHODS

A single-surgeon database was retrospectively searched for patients who underwent primary, elective MIS-TLIF for degenerative or isthmic spondylolisthesis. Summative depressive burden (SDB) was defined by the sum of preoperative and 6-week postoperative 9-item Patient Health Questionnaire (PHQ-9), with Lesser Burden (LB, SDB<10) and Greater Burden (GB, SDB≥10) cohorts. Patient-reported outcomes measures (PROMs) were compared preoperatively, at 6 weeks, and at final postoperative follow-up (11.4±10.9 mo), using Patient-Reported Outcomes Measurement Information System-Physical Function (PROMIS-PF), Oswestry disability index (ODI), visual analog scale-back (VAS-B), VAS-leg (VAS-L), and PHQ-9. Improvements at 6-week (∆PROM-6W), final follow-up (∆PROM-FF), and minimum clinically important difference (MCID) achievement were compared.

RESULTS

The GB cohort consisted of 44 of 105 patients. Demographic variations included older age, higher Charlson comorbidity index, increased hypertension prevalence, and private insurance in the LB cohort ( P ≤0.018). The LB cohort demonstrated better baseline and 6-week PROMIS-PF/ODI/VAS-L ( P ≤0.032) and better final PROMIS-PF/ODI/VAS-L/PHQ-9 ( P ≤0.031). Both cohorts improved in all PROMs at 6 weeks and final follow-up ( P ≤0.029), except for PROMIS-PF at 6 weeks in the GB cohort. ∆PROM-6W, ∆PROM-FF, and MCID achievement rate for PHQ-9 were greater in the GB cohort ( P ≤0.001).

CONCLUSION

On average, patients undergoing MIS-TLIF for degenerative or isthmic spondylolisthesis improved in all PROMs by final follow-up. Patients with GB suffered inferior perceptions of physical function, disability, and leg pain. MCID rates in mental health were higher for GB cohort. Surgeons are encouraged to adopt a compassionate understanding of depressive burden and educate the patient on possible consequential postoperative outcomes.

Preoperative determinants of postoperative expectation fulfillment following elective lumbar spine surgery: an observational study from the Canadian Spine Outcome Research Network (CSORN)

BACKGROUND CONTEXT

Preoperative patient factors determining expectation fulfillment from elective lumbar surgeries are poorly defined.

PURPOSE

To identify preoperative factors associated with the levels of expectation fulfillment following elective lumbar spine surgery.

STUDY DESIGN/ SETTING

This retrospective cohort study used the Canadian Spine Outcome Research Network (CSORN) registry data with participants enrolled between January 2015 and December 2020. The registry prospectively enrolled surgical patients to treat spinal disorders from twenty-three sites. Participating patients completed preoperative and follow-up questionnaires, including information on surgery expectations. Patients recorded their levels of expectation fulfillment on a Likert scale of 1 to 5, with responses ranging from Completely met (5) to Not applicable (1) in 7 expectation dimensions.

PATIENT SAMPLE

Consecutive patients with 4 lumbar conditions (spinal stenosis, disc herniation, degenerative disc disease, or degenerative spondylolisthesis) and those with complete 1-year follow-up questionnaires were included. Patients treated for thoracic or cervical pathologies and nonelective lumbar conditions were excluded. A total of 5389 patients who underwent surgery and completed 1-year follow-up questionnaires out of 6971 eligible patients were included. Patients' socio-demographics, lifestyle, health status, and clinical factors were examined.

OUTCOME MEASURES

The primary outcome was the association between expectation fulfillment and preoperative patient factors.

METHODS

Patient factors were described for the expectation fulfillment categories using descriptive statistics. Bivariable and multivariable associations between patient factors and expectation fulfillment were estimated with ordinal logistic regression models. Point estimates represented as odd ratios, and 95% CIs were reported.

RESULTS

The mean age of the participants was 59.5 years, with 49.8% (2683) of them being women. Unmet expectations ranged from 6.7% to 25.7%, with improvement in general physical capacity being the most important expectation fulfilled from surgery for 20% of patients. Factors such as longer symptom duration (OR: 0.74; 95% CI: 0.63-0.86), previous lumbar spine surgery (OR: 0.63; 95% CI: 0.46, 0.89), and reoperations (OR: 0.36; 95% CI: 0.2, 0.63) were associated with higher unmet expectations in the leg pain reduction dimension. Similar results were noted across all other expectation dimensions.

CONCLUSION

Utilizing information on the preoperative factors in presurgical consultations can improve patient satisfaction and expectations from surgery.

Association of Preoperative High C-Reactive Protein to Albumin Ratio with Adverse Outcomes After Elective Non-Cardiac Surgery in Older Patients: A Multicenter Prospective Study

Purpose

Although preoperative C-Reactive Protein to Albumin Ratio(CAR) is one of the important indicators for surgical risk assessment, the relationship between preoperative CAR and postoperative outcomes in older patients undergoing non-cardiac surgery is still unclear. Therefore, the purpose of this study is to explore the relationship between preoperative CAR and adverse postoperative outcomes in older patients undergoing non-cardiac surgery.

Patients and Methods

We conducted a secondary analysis of data from the multicenter, prospective, longitudinal study called Early-Warning model of Perioperative Adverse Events for Elderly Patients (EPAE). A total of 2511 individuals from seven centers in Guangdong province were included in this study. The CAR was the latest blood counts measured within 3 days prior to surgery. The primary outcome of interest in this study was Clavien-Dindo grade III (CD3) complications. Secondary outcomes included: overall morbidity, reoperation and readmission. This cohort compared baseline characteristics and clinical data between different groups based on the quartile of CAR. Multivariate logistic regression and restricted cubic spline analysis (RCS) were used to explore the relationship between CAR and adverse postoperative outcomes. Further, the subgroup analyses were also conducted.

Results

Among the 2511 older patients enrolled in the study, 1524 individuals (60.7%) were females and the median age at admission was 69.0 years (65.0, 73.0). Multivariate logistic regression analysis and sensitivity analysis both revealed that high CAR is associated with a high incidence of CD3 complications, overall morbidity, and reoperation (P < 0.05). Furthermore, the restricted cubic spline analysis shows a non-linear relationship between CAR and overall morbidity (cut-off value = 0.034, P for nonlinear < 0.001). No significant interaction was found in the subgroup analyses (P for interaction >0.05).

Conclusion

In older patients with non-cardiac surgery, high CAR was significantly associated with adverse postoperative outcomes, including CD3 complications, overall morbidity and reoperation.

Association of preoperative cognitive frailty with postoperative complications in older patients under general anesthesia: a prospective cohort study

BACKGROUND

Cognitive frailty (CF) is characterized by the coexistence of physical frailty and cognitive impairment, and it is associated with adverse health outcomes. Older adults are particularly vulnerable to CF due to factors such as age-related brain changes and the presence of comorbidities.

OBJECTIVE

To investigate the effect of preoperative CF on postoperative complications in older patients.

METHODS

This prospective cohort study was conducted among 253 patients aged 60-85 years, who underwent elective orthopedic and abdominal surgery (with a postoperative hospital stay of ≥ 3 days) at the Second Affiliated Hospital of Guangzhou University of Chinese Medicine from May 2023 to November 2023. CF was assessed using the Montreal Cognitive Assessment (MoCA) for the cognitive status and the Fried criteria for five frailty scales. Participants were split into four groups: Group A (neither frailty nor cognitive impairment), Group B (frailty without cognitive impairment), Group C (cognitive impairment without frailty), and Group D (cognitive frailty). The primary outcome was postoperative complications, while secondary outcomes included mobility disability, prolonged hospital stay (PLOS), re-operation and 90-day readmission.

RESULTS

The median age (interquartile range) of participants was 69 (65-73) years, of which 40.3% were male. The prevalence of CF was 17.8%. The incidence of postoperative complications was 18.2% in Group A, 50.0% in Group B, 37.4% in Group C, and 75.6% in Group D. Multivariate analysis revealed that, compared to the control group (without cognitive impairment or frailty), patients with CF had a significantly higher risk of postoperative complications (OR, 12.86; 95%CI, 4.23-39.08). "Patients with frailty without cognitive impairment" had an increased risk (OR, 6.53; 95%CI, 2.04-20.9), while "those with cognitive impairment without frailty" also showed a higher risk (OR, 3.46; 95%CI, 1.57-7.64).

CONCLUSIONS

Cognitive frailty is significantly associated with an increased risk of postoperative adverse outcomes in older patients undergoing orthopedic and abdominal surgeries with general anesthesia. It indicates that clinicians should pay much attention to these older adults with CF.

Do Six-Week Postoperative Patient-Reported Outcomes Predict Long-Term Clinical Outcomes Following Lumbar Decompression?

BACKGROUND

Little research has been done to evaluate the prognostic value of short-term postoperative patient-reported outcomes (PROs) on long-term PROs following lumbar decompression (LD). We evaluated the prognostic value of short-term PROs on long-term PROs through 2 years after LD.

METHODS

A single spine surgeon database was retrospectively queried for patients undergoing primary LD with 6-week postoperative PROs reported. The demographics, perioperative traits, and preoperative, 6-month, 1-year, and 2-year PROs were recorded. The PROs included the visual analog scale (VAS) for back pain, VAS for leg pain, PRO measure information system for physical function (PROMIS-PF), and Oswestry disability index. Two-step multivariate linear regression was performed to determine the predictive value of 6-week PROs for the 6-month, 1-year, and 2-year PROs.

RESULTS

A total of 277 patients were included. The 6-week Oswestry disability index, VAS for leg pain, and 9-item patient health questionnaire (PHQ-9) are all positive predictors for their respective outcomes at 6 months. Additionally, the 6-week PROMIS-PF was a negative predictor of the 6-month PHQ-9. The 6-week PROMIS-PF positively predicted the PROMIS-PF through 1 year, and the PHQ-9 was a positive predictor of the PHQ-9 at 1 and 2 years postoperatively.

CONCLUSIONS

The 6-week postoperative PROs are predictive of the same outcomes at 6 months, the PROMIS-PF is predictive through 1 year, and the PHQ-9 is predictive through 2 years. Determining the predictive value of early postoperative PROs can be helpful in understanding the likely postoperative trajectory following LD and informing patient expectations.

Construct validity of the Hungarian Version of the Patient-Reported Outcomes Measurement Information System-29 Profile Among Patients with Low Back Pain

OBJECTIVE

We aim to evaluate the psychometric properties of the Hungarian version of the patient-reported outcomes measurement information system (PROMIS)-29 profile domains among patients with chronic low back pain.

METHODS

We used a convenience, cross-sectional sampling of patients recruited at our neurosurgical institution. The participants completed paper-pencil version of the PROMIS-29 profile in addition to validated legacy questionnaires, including the Oswestry disability index, Research and Development Corporation 36-item short-form survey, 7-item general anxiety disorder scale, 9-item patient health questionnaire. Reliability was evaluated by calculating the internal consistency (Cronbach's α). Test-retest reliability was assessed using the intraclass correlation coefficient. The structural validity of PROMIS-29 was assessed using a confirmatory factor analysis. Construct validity was assessed by evaluating convergent and discriminant validity using Spearman's rank correlation. To further corroborate the construct validity, we also performed known-group comparisons.

RESULTS

The mean age of the 131 participants was 54 ± 16 years. Of the 131 patients, 62% were women. The internal consistency of each PROMIS domain was high (Cronbach's α >0.89 for all). The test-retest reliability was excellent (intraclass correlation >0.97). The confirmatory factor analysis showed good structural validity (comparative fit index >0.96; standardized root mean square residual <0.026 for all domains). All measured PROMIS scores correlated strongly with the scores obtained using the corresponding primary legacy instrument, indicating excellent convergent validity. The known-group comparisons demonstrated differences as hypothesized.

CONCLUSIONS

We present data supporting the validity and reliability of the Hungarian PROMIS-29 profile short forms for patients with low back pain. This instrument will be useful for research and clinical applications in spine care.

Enhanced recovery after surgery (ERAS) relieves psychological stress in patients with osteoporotic vertebral compression fracture undergoing percutaneous kyphoplasty: an observational retrospective cohort study

STUDY DESIGN

This is an observational retrospective cohort study.

OBJECTIVE

The purpose of this study is to investigate the incidence rate of depression and anxiety and the changes in patients treated with percutaneous kyphoplasty (PKP) following ERAS protocol. The incidence of depression and anxiety is not uncommon in patients with osteoporotic vertebral compression fracture (OVCF), which affects the prognosis of surgery. Enhanced recovery after surgery (ERAS) protocols can improve the perioperative stress response of patients.

MATERIALS AND METHODS

Patients were treated conventionally in 2019 as the control group (CG) (n = 281), and patients were treated according to the ERAS protocol in 2020 as the intervention group (IG) (n = 251). All patients were evaluated for depression and anxiety using Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 at admission, postoperative 1 week, 1 month and 3, 6, 12 months.

RESULTS

The degree of depression statistically decreased in the IG at follow-up periods (p < 0.001), and the degree of anxiety statistically decreased at 1 week (p < 0.001), 1 month (p < 0.001), 3 months (p = 0.017). Patients in the IG could soothe depression and anxiety disorders faster than patients in the CG and maintain psychological stability at the follow-up periods. The percentage of moderate or above depression in the IG was statistically fewer than in the CG at follow-up periods (p < 0.01). The odds ratio (OR) was respectively 0.410, 0.357, 0.294, 0.333, 0.327 from 1 week to 12 months. While the percentage of patients with moderate or above anxiety significantly decreased in the IG at 1 week (p < 0.001), OR = 0.528, 1 month (p = 0.037), OR = 0.309 and 12 months (p = 0.040), OR = 0.554, no differences between 3 months (p = 0.187) and 6 months (p = 0.133).

CONCLUSION

PKP following ERAS protocol to treat patients with OVCF had a better effect on relieving postoperative anxiety and depression than following conventional protocol.

Influence of preoperative depression on clinical outcomes after cervical laminoplasty: A retrospective study

Background

Depression is a highly prevalent mental disorder, and we found that patients with preoperative depression had worse postoperative improvement in lumbar fusion. Are mental factors related to the prognosis of laminoplasty?

Objective

To analyze the relationship between depression and clinical outcomes after laminoplasty for the treatment of multilevel CSM.

Methods

In this retrospective study, 115 patients with multilevel cervical spondylotic myelopathy (CSM), who underwent laminoplasty and were followed up for more than 1 year, were enrolled in this study from October 2018 to October 2021. Patients with the scores of 21-item Beck Depression Inventory (BDI) ≥ 15 or Hamilton Depression Scale-24 (HAMD-24) > 20 were included in the depression group. The clinical outcomes were evaluated by the changes and recovery rate (RR) of Japanese Orthopaedic Association Scores (JOA) and Neck Disability Index (NDI) respectively. Univariate and multiple linear regression analyses were performed to reveal the relationship between preoperative depressive states and clinical outcomes.

Results

Fourteen patients were diagnosed with depression by BDI and twenty-nine by HAMD-24. Between the depression group and the non-depression group, the age, gender, smoking history, and duration of symptoms were statistically significant (P < 0.05). Multiple linear regression showed that the BDI scores had a negative relationship with the changes and RR of JOA and NDI, and the HAMD-24 scores had a negative relationship with the changes and RR of JOA.

Conclusions

Preoperative depression in patients with multilevel CSM can lead to worse prognosis. In order to improve the curative effect of the operation, we should pay attention to the psychological state monitoring and intervention of patients before they receive laminoplasty.

Lumbar Fusion Surgery for Patients With Back Pain and Degenerative Disc Disease: An Observational Study From the Canadian Spine Outcomes and Research Network

STUDY DESIGN

Uncontrolled retrospective observational study.

OBJECTIVES

Surgery for patients with back pain and degenerative disc disease is controversial, and studies to date have yielded conflicting results. We evaluated the effects of lumbar fusion surgery for patients with this indication in the Canadian Spine Outcomes and Research Network (CSORN).

METHODS

We analyzed data that were prospectively collected from consecutive patients at 11 centers between 2015 and 2019. Our primary outcome was change in patient-reported back pain at 12 months of follow-up, and our secondary outcomes were satisfaction, disability, health-related quality of life, and rates of adverse events.

RESULTS

Among 84 patients, we observed a statistically significant improvement of back pain at 12 months that exceeded the threshold of Minimum Clinically Important Difference (MCID) (mean change -3.7 points, SD 2.6, p < 0.001, MCID = 1.2; 77% achieved MCID), and 81% reported being "somewhat" or "extremely" satisfied. We also observed improvements of Oswestry Disability Index (-17.3, SD 16.6), Short Form-12 Physical Component Summary (10.3, SD 9.6) and Short Form-12 Mental Component Summary (3.1, SD 8.3); all p < 0.001). The overall rate of adverse events was 19%.

CONCLUSIONS

Among a highly selective group of patients undergoing lumbar fusion surgery for degenerative disc disease, most experienced a clinically significant improvement of back pain as well as significant improvements of disability and health-related quality of life, with high satisfaction at 1 year of follow-up. These findings suggest that surgery for this indication may provide some benefit, and that further research is warranted.

What Can Legacy Patient-Reported Outcome Measures Tell Us About Participation Bias in Patient-Reported Outcomes Measurement Information System Scores Among Lumbar Spine Patients?

Objective

Patient-Reported Outcomes Measurement Information System (PROMIS) is a validated tool for assessing patient reported outcomes in spine surgery. However, PROMIS is vulnerable to non-response bias. The purpose of this study is to characterize differences in patient reported outcome measure (PROM) scores between patients who do and do not complete PROMIS physical function (PF) surveys following lumbar spine surgery.

Methods

A prospectively maintained database was retrospectively reviewed for primary, elective lumbar spine procedures from 2015 to 2019. Outcome measures for Patient Health Questionnaire (PHQ-9), Visual Analogue Score (VAS) back & leg, Oswestry Disability Index (ODI), and 12-Item Short Form Physical Composite Summary (SF-12 PCS) were recorded at both preoperative and postoperative (6-week, 12-week, 6-month, 1-year, 2-year) timepoints. Completion rates for PROMIS PF surveys were recorded and patients were categorized into groups based on completion. Differences in mean scores at each timepoint between groups was determined.

Results

809 patients were included with an average age of 48.1 years. No significant differences were observed for all outcome measures between PROMIS completion groups preoperatively. Postoperative PHQ-9, VAS back, VAS leg, and ODI scores differed significantly between groups through 1-year (all p<0.05). SF-12 PCS differed significantly only at 6-weeks (p=0.003).

Conclusion

Patients who did not complete PROMIS PF surveys had significantly poorer outcomes than those that did in terms of postoperative depressive symptoms, pain, and disability. This suggests that patients completing PROMIS questionnaires may represent a healthier cohort than the overall lumbar spine population.

Virtual Mind-Body Program for Obese Knee Osteoarthritis Patients with Comorbid Depression: Development and Feasibility Pilot (Preprint)

Background

Knee osteoarthritis (KOA) is the most common joint disorder in the United States and a leading cause of disability. Depression and obesity are highly comorbid with KOA and accelerate knee degeneration and disability through biopsychosocial mechanisms. Mind-body physical activity programs can engage biological, mechanical, and psychological mechanisms to improve outcomes in KOA, but such programs are not currently available.

Objective

This mixed methods study aims to adapt a mind-body activity program for the unique needs of patients with KOA, depression, and obesity (GetActive-OA) delivered via live video.

Methods

Participants were adults (aged ≥45 years) from rural Kentucky with obesity (BMI≥30 kg/m²), idiopathic KOA with mild to moderate radiographic changes, and elevated depressive symptoms (9-item Patient Health Questionnaire ≥10) recruited from 2 orthopedic centers. In phase 1, we developed GetActive-OA and the study protocol using qualitative focus group feedback from the study population (N=9; 2 focus groups, 90 minutes) and multidisciplinary expertise from clinical psychologists and orthopedic researchers. In phase 2, we explored the initial feasibility, credibility, and acceptability of GetActive-OA, live video delivery, and study procedures via an open pilot with exit interviews (N=5; 1 group). This research was guided by National Institutes of Health (NIH) model stage IA.

Results

Phase 1 qualitative analyses revealed nuanced information about challenges with coping and increasing activity, high interest in a mind-body activity program, program participation facilitators (flexibility with technology) and barriers (amotivation and forgetfulness), and perceived challenges with data collection procedures (blood and urine samples and homework). Phase 2 quantitative analyses showed that GetActive-OA met most a priori feasibility markers: acceptability (80%), expectancy (100%), credibility (100%), clinician adherence (90%), homework adherence (80%), questionnaire data collection (100%), program satisfaction (100%), and safety (100%). Adherence to ActiGraph wear (80% baseline, 20% posttest) and collection of blood samples (60%) were low. Participation in GetActive-OA was associated with signals of improvements in general coping (Cohen d=2.41), pain catastrophizing (Cohen d=1.24), depression (Cohen d=0.88), anxiety (Cohen d=0.78), self-efficacy (Cohen d=0.73), pain (Cohen d=0.39), and KOA symptoms (Cohen d=0.36). Qualitative exit interviews confirmed quantitative findings and provided valuable information to optimize the program and protocol.

Conclusions

Patients with KOA, depression, and obesity from rural Kentucky were interested in a live video mind-body activity program. GetActive-OA shows promise; however, the program and protocol require further NIH stage I refinement before formal efficacy testing (NIH model stage II).

International Registered Report Identifier (IRRID)

RR2-10.1016/j.conctc.2021.100720

Impact of Depression on Patient Reported Outcomes Following Primary Versus Revision ACDF

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

To assess the relationship of depressive symptoms with patient reported outcome measures (PROMs) in patients undergoing either primary or revision anterior cervical discectomy and fusion (ACDF) procedures.

SUMMARY OF BACKGROUND

Depression has been associated with poorer outcomes following ACDF. However, research examining the relationship between depression and PROMs in revision ACDF procedures is limited.

METHODS

A prospective database was retrospectively reviewed for primary or revision, single- or multilevel ACDF procedures from 2016 to 2019. Patients lacking preoperative Patient Health Questionnaire-9 (PHQ-9) surveys were excluded. Demographic and perioperative characteristics were recorded and analyzed using Fisher's exact test or t test. Patient-reported outcome measures were collected preoperatively and postoperatively. Postoperative improvement from baseline scores (ΔPROM) was calculated at all postoperative timepoints. Differences in mean PROM and ΔPROM between groups and changes from baseline PROM scores within groups were assessed using Student's t test. Linear regression analyzed the impact of preoperative PHQ-9 on ΔPROM.

RESULTS

A total of 143 patients (121 primary and 22 revision) were included. Significant differences between groups were demonstrated at the preoperative timepoint for Neck Disability Index (NDI) (P = 0.022). ΔPROM values did not significantly differ between groups. Regression analysis revealed significant relationships between preoperative PHQ-9 and ΔPHQ-9 at all timepoints, ΔVAS neck at 6-weeks and 6-months, ΔVAS arm at 6-months, and ΔNDI at 6-weeks and 6-months for the primary group (all P < 0.05). Regression analysis revealed no significant associations for the revision group.

CONCLUSION

Primary or revision ACDF procedures did not significantly differ in depressive symptoms through 1-year. Primary ACDF patients significantly improved in all PROMs through all timepoints, while revision patients had limited improvement in PROMs. Preoperative depression may have a stronger association on postoperative outcomes for primary procedures.Level of Evidence: 3.

Patient Health Questionnaire-9 Is a Valid Assessment for Depression in Minimally Invasive Lumbar Discectomy

Objective

The Patient Health Questionnaire-9 (PHQ-9) is a screening tool for evaluating depressive symptoms. Research is scarce regarding the validity and correlation of PHQ-9 scores with other patient-reported outcomes of mental health after minimally invasive lumbar discectomy (MIS LD). We aim to validate PHQ-9 as a metric for assessing mental health in MIS LD patients.

Methods

A database was retrospectively reviewed for patients who underwent elective, single-level MIS LD. Patients were excluded if they had incomplete preoperative PHQ-9, 12-item Short Form Health Survey (SF-12), or Veterans RAND 12-item health survey (VR-12). Survey scores were collected preoperatively and postoperatively through 1 year. Mean scores were used to calculate postoperative improvement from preoperative scores. Correlation of PHQ-9 with SF-12 mental composite score (MCS) and VR-12 MCS scores was also calculated. Correlation strength was assessed by the following categories: 0.1 ≤ |r| < 0.3 = low; 0.3 ≤ |r| < 0.5 = moderate; |r| ≥ 0.5 = strong.

Results

A total of 239 patients underwent single-level MIS LD. PHQ-9, VR-12 MCS, and SF-12 MCS all demonstrated statistically significant increases from preoperative scores at all postoperative timepoints (p ≤ 0.001). SF-12 MCS and VR-12 MCS were each observed to have strong and significant correlations with PHQ-9 at all timepoints when evaluated with both Pearson correlation coefficients and partial correlation coefficients.

Conclusion

We observed that PHQ-9, SF-12 MCS and VR-12 MCS all significantly improve following lumbar discectomy and that PHQ-9 scores strongly correlated with these previously established measures. Our results substantiate evidence from other surgical fields that PHQ-9 scores are a valid tool to evaluate pre- and postsurgical depressive symptoms.

The Minimum Clinically Important Difference for Patient Health Questionnaire-9 in Minimally Invasive Transforaminal Interbody Fusion

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

To investigate and establish minimum clinically important differences (MCID) for Patient Health Questionnaire-9 (PHQ-9) among patients undergoing minimally invasive transforaminal lumbar interbody fusion (MIS TLIF).

SUMMARY OF BACKGROUND

Spine surgery is linked to postoperative improvements in anxiety, depression, and mental health. These improvements have been documented using patient-reported outcome measures such as PHQ-9. Few studies evaluated the clinical significance of PHQ-9 for lumbar spine surgery.

METHODS

Patients who underwent single-level, primary MIS TLIF from 2015 to 2017 were retrospectively reviewed in a prospective database. Patients with incomplete preoperative and 2-year postoperative PHQ-9 surveys were excluded. Demographic and perioperative characteristics were recorded. PHQ-9, 12-Item Short Form (SF-12), and Veterans RAND 12-Item Health Survey (VR-12) Mental Component Summary (MCS) were collected at preoperative, 6-week, 12-week, 6-month, 1-year, and 2-year intervals. MCID was calculated using anchor and distribution-based methods. SF-12 served as an anchor. MCID was assessed using mean change methodology, four receiver operating characteristic curve assessments, and standard error measurement. Cutoff values were selected from receiver operating characteristic curve analysis. MCID achievement rates for all patient-reported outcome measures were calculated.

RESULTS

A total of 139 patients met inclusion criteria, with a mean age of 55 years and 39% females. The most common spinal pathology was radiculopathy (92%). MCID analysis revealed the following ranges of values: 2.0 to 4.8 (PHQ-9), 6.7 to 12.1 (SF-12 MCS), and 7.5 to 15.9 (VR-12 MCS). Final MCID thresholds were 3.0 (PHQ-9), 9.1 (SF-12 MCS), and 8.1 (VR-12 MCS). MCID achievement at 2-years for PHQ-9, SF-12 MCS, and VR-12 MCS was 89.2%, 85.6%, and 84.9% respectively.

CONCLUSION

Our 2-year postoperative MCID analysis is the first mental health calculation from an MIS TLIF cohort. We report a 2-year MCID value for PHQ-9 of 3.0 (2.0-4.8). MCID values for mental health instruments are important for determining overall success of lumbar spine surgery.Level of Evidence: 3.

Does the Preoperative Depression Affect Clinical Outcomes in Adults With Following Lumbar Fusion?: A Retrospective Cohort Study

STUDY DESIGN

This was a retrospective cohort review.

OBJECTIVE

The objective of this study was to analyze depression using Beck Depression Inventory (BDI) and Hamilton Depression Scale (HAMD-24), and to correlate with clinical outcomes and improvement in adults with following lumbar fusion.

SUMMARY OF BACKGROUND DATA

Psychological factors such as depression are found to influence outcomes and improvement following spinal surgery. It is still unclear whether there are differences during screening for depression by different implementations to predict outcomes for spine surgery.

MATERIALS AND METHODS

Between July 2016 and May 2018, patients with degenerative lumbar disease, who underwent lumbar fusion were enrolled in this study. The patient's characteristics, preoperative BDI and HAMD-24 score, and preoperative and postoperative outcomes were collected, respectively. Depressed patients were identified by a score of BDI≥15 or HAMD-24>20, respectively. Preoperative and postoperative outcome scores, absolute changes, and recovery ratios of disability and pain were compared within and between groups. Finally, univariate and multiple linear regression analyses was performed to reveal the relationship between preoperative depressive states and outcomes and improvement.

RESULTS

A total of 125 patients were eligible in the study, with 113 (90.4%) patients without depressive symptoms and 12 (9.6%) depressed patients by BDI, and 97 (77.6%) patients without depressive symptoms and 28 (22.4%) depressed patients by HAMD-24. Both higher BDI and HAMD-24 group was found to have significant worse preoperative and postoperative outcomes as well as less recovery ratios than the patients without depressive symptoms. Univariate and multiple linear regression analyses suggested that preoperative depression might be a potential predictor of worse surgical outcomes.

CONCLUSIONS

Depressive symptoms might lead to smaller magnitude of improvement. Moreover, both preoperative BDI and HAMD-24 score was a negative predictor of postoperative outcomes and can be regarded as a candidate to screen for depression preoperatively.

The Perioperative Symptom Severity of Higher Patient Health Questionnaire-9 Scores Between Genders in Single-Level Lumbar Fusion

BACKGROUND

Preoperative depression is associated with increased perioperative pain, worse physical function, reduced quality of life, and inferior outcomes. Few studies have evaluated depressive symptoms between genders for individuals undergoing minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). The purpose of this investigation was to assess the severity of Patient Health Questionnaire-9 (PHQ-9) scores among patients with depressive symptoms before and after single-level MIS TLIF.

METHODS

A prospective surgical registry was retrospectively reviewed for spine surgeries between March 2016 and December 2018. We included patients with at least mild depressive symptoms (PHQ-9 scores ≥ 5) who underwent primary, single-level MIS TLIF and compared genders using χ2 tests and t tests. Genders were stratified by depressive symptom severity: mild (5-9), moderate (10-14), and moderately severe (≥15) and then analyzed at preoperative and postoperative intervals: 6 weeks, 12 weeks, 6 months, and 1 year. Finally, PHQ-9 scores were validated with a Pearson correlation test against the 12-item Short Form (SF-12) Mental Composite Score (MCS) and the Veterans RAND (VR-12) MCS.

RESULTS

Of 75 subjects, 44.0% were women and the mean age was 49.9 years. The preoperative distribution among PHQ-9 subgroups was 38.7%, 26.6%, and 34.7% for mild, moderate, and moderately severe depressive symptoms, respectively. Among PHQ-9 stratifications both genders demonstrated intermittent statistically significant improvements in PHQ-9 scores. The moderately severe PHQ-9 subgroup had improvement at all postoperative time points. The PHQ-9 scores demonstrated a strong correlation with the SF-12 MCS and VR-12 MCS at all postoperative evaluations.

CONCLUSION

At baseline and by the final 1-year follow-up there were no statistically significant PHQ-9 score differences between genders within any depressive symptom stratifications. Whereas some contend that men and women have substantial mental health differences, this study is aligned with growing evidence that demonstrates similar depressive symptoms between genders.

LEVEL OF EVIDENCE

3.

CLINICAL RELEVANCE

Men and women may be at an equivalent risk for perioperative depressive symptoms.

Are Preoperative PHQ-9 Scores Predictive of Postoperative Outcomes Following Anterior Cervical Discectomy and Fusion?

STUDY DESIGN

This is a retrospective study.

OBJECTIVE

The objective of this study was to determine if there is an association between preoperative depression, as quantified by Patient Health Questionnaire-9 (PHQ-9), and postoperative improvement in pain and disability after anterior cervical discectomy and fusion (ACDF).

SUMMARY OF BACKGROUND DATA

Few studies have quantified depression symptoms in the preoperative period using PHQ-9 and have tracked patient-reported outcomes (PROs) following ACDF.

METHODS

Patients undergoing ACDF were retrospectively reviewed and stratified by their preoperative PHQ-9 score. PROs, including Neck Disability Index (NDI), Visual Analogue Scale (VAS) neck and arm pain, and 12-Item Short Form (SF-12) Physical Component Score (PCS), were measured preoperatively and at 6-week, 3-month, 6-month, and 1-year postoperatively. PRO scores were analyzed amongst PHQ-9 cohorts using multiple linear regression. Achievement of minimum clinically important difference (MCID) was compared using χ analysis.

RESULTS

Higher PHQ-9 scores were associated with increased preoperative NDI, VAS neck, and VAS arm scores and significantly lower SF-12 PCS scores preoperatively. Cohorts experienced similar VAS pain scores up to 1-year following surgery, except for VAS neck pain at 3 months when patients with greater depression symptoms had more pain. High PHQ-9 patients had higher NDI values at 6 weeks and 3-month marks but had similar NDI scores at 6 months and 1-year. Similarly, SF-12 PCS scores were lower for patients with a higher PHQ-9 score at 3 and 6 months, however, both groups had similar scores at 1-year follow-up. A greater percentage of the high PHQ-9 cohort achieved MCID for NDI, however, there were no differences in MCID achievement for VAS neck, VAS arm, or SF-12 PCS.

CONCLUSIONS

Patients with worse preoperative mental health reported significantly greater preoperative disability and pain. However, both cohorts demonstrated similar clinical recovery at the 1-year follow-up. These findings suggest patients with worse preoperative mental health can expect significant improvements in PROs following surgery.

The Psychological Impact of COVID-19 Disease is more Severe on Intensive Care Unit Healthcare Providers: A Cross-sectional Study

OBJECTIVE

: Fear, anxiety, depression and sleep deprivation are common mental health disorders in COVID-19 disease. We aimed to analyse the risk for healthcare providers during COVID-19 pandemic in a university hospital.

METHODS

Anesthesiologists, nurses and nurse anesthetists were invited to fill out the survey. The survey was consist of questions from ''The Fear of COVID-19 Scale'', ''Patient Health Questionnaire'' and ''Pittsburgh Sleep Quality Index'' (PSQI). Each question was worth a point.

RESULTS

The data of 208 participants were analyzed. Mean age was 29 ± 7.748 years, 72.1% were male, 67.3% were nurses, 62% were working in intensive care units, 38% were in hospital wards, 62% of all participants were living alone. Moderate depression was the most frequently detected outcome (n = 90, 43.3%). Mean The Fear of COVID-19 Scale for all participants was 18.56 ± 7.731. The mean PSQI of patients was 6.18 ± 4.356 with a 45.7% rate of poor sleep quality. PSQI was found significantly higher in nurses (7.1 ± 4.7, p = 0.000). Nurses were the group with the highest deterioration in sleep quality (53.6%, p = 0.003). The rate of moderate-to-severe depressive symptoms was significantly higher in intensive care unit nurses and physicians (p = 0.018). PSQI score was found significantly higher in intensive care unit nurses and physicians than hospital ward co-workers (7.02 ± 4.59 vs. 4.81 ± 3.57 respectively, p = 0.001). A significant positive correlation was observed between PSQI and The Fear of COVID-19 Scale total score in all patients (p < 0.005).

CONCLUSION

Depression, anxiety, fear and sleep disorders may occur in healthcare workers during COVID-19 outbreak. Intensive care unit nurses were at highest risk.

Validity of Patient Health Questionnaire-9 in Minimally Invasive Lumbar Interbody Fusion

STUDY DESIGN

Retrospective.

OBJECTIVE

The aim of this study was to evaluate the validity of Patient Health Questionnaire-9 (PHQ-9) among patients undergoing minimally invasive (MIS) lumbar interbody fusion.

SUMMARY OF BACKGROUND DATA

Few studies have evaluated the utility and concurrent validity of the PHQ-9 survey in patients undergoing spinal procedures.

METHODS

Patients undergoing a one- or two-level MIS lumbar interbody fusion were retrospectively reviewed. Patient-reported outcome surveys were completed preoperatively and at 6-week, 12-week, 6-month, and 1-year timepoints. Postoperative survey scores were compared to preoperative values using paired t tests. PHQ-9 scores were compared with the Mental Component Summary (MCS) scores of the Short Form-12 (SF-12) and the Veterans RAND-12 (VR-12) surveys at each timepoint using the Pearson correlation coefficient.

RESULTS

A total of 215 patients were included in the analysis. The mean preoperative scores for the PHQ-9, SF-12 MCS, and VR-12 MCS were 6.78, 49.55, and 50.39, respectively. Significant improvements in each survey outcome measure were observed at all postoperative timepoints. Strong correlations with PHQ-9 scores were identified for SF-12 MCS scores and VR-12 MCS scores at preoperative and postoperative timepoints (|r| ≥ 0.5 and P < 0.05 for each).

CONCLUSION

This study demonstrated that mental health, as measured by the PHQ-9, SF-12 MCS, and VR-12 MCS surveys, improves significantly after MIS lumbar fusion. In addition, PHQ-9 scores were strongly correlated with SF-12 and VR-12 scores. These results suggest that PHQ-9 can be a valid assessment of baseline mental health and postoperative improvement after MIS lumbar fusion. Concordant results among PHQ-9, SF-12 MCS, and VR-12 indicate that the simultaneous utilization of multiple survey instruments may not be necessary. Limiting the number of questionnaires that are administered in the evaluation of mental health could also help reduce survey burden placed on patients.

LEVEL OF EVIDENCE

3.

Correlation between patient health questionnaire-2 and postoperative pain in laparoscopic cholecystectomy

Background

Postoperative pain is affected by preoperative depression. If the risk of postoperative pain associated with depression can be predicted preoperatively, anesthesiologists and/or surgeons can better manage it with personalized care. The objective of this study was to determine the efficacy of Patient Health Questionnaire-2 (PHQ-2) depression screening tool as a predictor of postoperative pain.

Methods

A total of 50 patients scheduled for elective laparoscopic cholecystectomy with an American Society of Anesthesiologists physical status 1 or 2 were enrolled. They answered the PHQ-2, which consists of two questions, under the supervision of a researcher on the day before the surgery. The numerical rating scale (NRS) scores were assessed at post-anesthesia care unit (PACU), at 24, and 48 postoperative hours, and the amount of intravenous patient-controlled analgesia (IV-PCA) administered was documented at 24, 48, and 72 postoperative hours. At 72 h, the IV-PCA device was removed and the final dosage was recorded.

Results

The NRS score in PACU was not significantly associated with the PHQ-2 score (correlation coefficients: 0.13 [P = 0.367]). However, the use of analgesics after surgery was higher in patients with PHQ-2 score of 3 or more (correlation coefficients: 0.33 [P = 0.018]).

Conclusions

We observed a correlation between the PHQ-2 score and postoperative pain. Therefore, PHQ-2 could be useful as a screening test for preoperative depression. Particularly, when 3 points were used as the cut-off score, the PHQ-2 score was associated with the dosage of analgesics, and the analgesic demand could be expected to be high with higher PHQ-2 scores.

Evaluation of Postoperative Mental Health Outcomes in Patients Based on Patient-Reported Outcome Measurement Information System Physical Function Following Anterior Cervical Discectomy and Fusion

OBJECTIVE

To assess the relationship of preoperative physical function, as measured by Patient-Reported Outcome Measurement Information System Physical Function (PROMIS PF), to improvement in mental health, as evaluated by Short Form-12 Mental Component Summary (SF-12 MCS) following anterior cervical discectomy and fusion (ACDF).

METHODS

Patients undergoing primary ACDF were retrospectively reviewed and stratified based on preoperative PROMIS PF scores. PROMIS PF cohorts were tested for an association with demographic characteristics and perioperative variables using chi-square analysis and multivariate linear regression. Multivariate linear regression was utilized to determine the association between PROMIS PF cohorts and improvement in SF-12 MCS.

RESULTS

A total of 129 one- to 3-level ACDF patients were included: 73 had PROMIS PF < 40 ("low PROMIS") and 56 had PROMIS PF ≥ 40 ("high PROMIS"). The low PROMIS cohort reported worse mental health preoperatively and at all postoperative timepoints except for 1 year. Both cohorts had similar changes in mental health from baseline through the 6-month follow-up. However, at 1 year. postoperatively, the low PROMIS cohort had a statistically greater change in mental health score.

CONCLUSION

Patients with worse preoperative physical function reported significantly worse preoperative and postoperative mental health. However, patients with worse preoperative physical function made significantly greater improvements in mental health from baseline. This suggests that patients with worse preoperative physical function can still expect significant improvements in mental health following surgery.

The Influence of Preoperative Mental Health on PROMIS Physical Function Outcomes Following Minimally Invasive Transforaminal Lumbar Interbody Fusion

STUDY DESIGN

Retrospective.

OBJECTIVE

To demonstrate whether preoperative mental health status can be predictive of postoperative functional outcomes as measured by Patient-Reported Outcome Measurement Information System Physical Function (PROMIS PF) following minimally invasive transforaminal lumbar interbody fusion (MIS TLIF).

SUMMARY OF BACKGROUND DATA

There is a paucity of scientific investigations into the association between preoperative mental health as evaluated by a validated questionnaire such as the Short Form-12 Mental Health Composite Score (SF-12 MCS) and postoperative outcomes following MIS TLIF.

METHODS

Patients undergoing a primary MIS TLIF were retrospectively reviewed and stratified into cohorts based on preoperative SF-12 MCS scores. The Physical Function scores of PROMIS, of which there are other domains including Pain Interference, Sexual Function, and Cognitive Function, were compared between the cohorts. In addition, the improvement in PROMIS scores based on preoperative SF-12 MCS scores following MIS TLIF was analyzed using multivariate linear regression.

RESULTS

One hundred seventy-two patients were included: 85 patients (49.4%) had a preoperative SF-12 MCS score <50 and 87 (50.6%) had a preoperative SF-12 MCS score ≥50. Patients with poorer mental health demonstrated significantly worse PROMIS PF scores preoperatively (33.8 vs. 36.5, P < 0.001), as well as at all postoperative timepoints: 6-weeks (35.1 vs. 38.4, P < 0.001), 3-months (38.9 vs. 42.9, P < 0.001), 6-months (41.4 vs. 45.5, P < 0.001), and 1-year (42.4 vs. 47.6, P < 0.001). However, at the 1-year timepoint, patients with worse mental health reported experiencing significantly less improvement from baseline (postoperative change of 8.6 vs. 11.1, P = 0.002).

CONCLUSION

Patients with worse preoperative mental health not only demonstrated worse preoperative PROMIS PF scores, but also continued to have significantly worse postoperative outcomes. However, the postoperative improvement experienced by patients was similar in the short-term following surgery regardless of preoperative mental health status. Patients with poor mental health experienced significantly less postoperative improvement only at the 1-year timepoint.

LEVEL OF EVIDENCE

3.

Are Outcomes of Anterior Cervical Discectomy and Fusion Influenced by Presurgical Depression Symptoms on the Mental Component Score of the Short Form-12 Survey?

STUDY DESIGN

Retrospective comparative study.

OBJECTIVE

The purpose of this study was to investigate whether preoperative depressive symptoms, measured by mental component score of the Short Form-12 survey (MCS-12), influence patient-reported outcome measurements (PROMs) following an anterior cervical discectomy and fusion (ACDF) surgery for cervical degeneration.

SUMMARY OF BACKGROUND DATA

There is a paucity of literature regarding preoperative depression and PROMs following ACDF surgery for cervical degenerative disease.

METHODS

Patients who underwent an ACDF for degenerative cervical pathology were identified. A score of 45.6 on the MCS-12 was used as the threshold for depression symptoms, and patients were divided into two groups based on this value: depression (MCS-12 ≤45.6) and nondepression (MCS-12 >45.6) groups. Outcomes including Neck Disability Index (NDI), physical component score of the Short Form-12 survey (PCS-12), and Visual Analogue Scale Neck (VAS Neck), and Arm (VAS Arm) pain scores were evaluated using independent sample t test, recovery ratios, percentage of patients reaching the minimum clinically important difference, and multiple linear regression - controlling for factors such as age, sex, and BMI.

RESULTS

The depression group was found to have significantly worse baseline pain and disability than the nondepression group in NDI (P < 0.001), VAS Neck pain (P < 0.001), and VAS Arm pain (P < 0.001) scores. Postoperatively, both groups improved to a similar amount with surgery based on the recovery ratio analysis. The depression group continued to have worse scores than the nondepression group in NDI (P = 0.010), PCS-12 (P = 0.026), and VAS Arm pain (P = 0.001) scores. Depression was not a significant predictor of change in any PROMs based on regression analysis.

CONCLUSION

Patients who presented with preoperative depression reported more pain and disability symptoms preoperatively and postoperatively; however, both groups achieved similar degrees of improvement.

LEVEL OF EVIDENCE

3.

PHQ-9 Score Predicts Postoperative Outcomes Following Minimally Invasive Transforaminal Lumbar Interbody Fusion

STUDY DESIGN

This was a retrospective cohort study.

OBJECTIVE

This study evaluates if an association exists between preoperative depression and postoperative outcomes following minimally invasive transforaminal lumbar interbody fusion (MIS TLIF).

SUMMARY OF BACKGROUND DATA

Few studies have quantified preoperative depression symptoms using Patient Health Questionnaire-9 (PHQ-9) to predict postoperative outcomes after lumbar fusion, especially MIS TLIF.

METHODS

A surgical database of patients undergoing primary, single-level MIS TLIF was retrospectively reviewed. Patients were stratified by predefined preoperative PHQ-9 scores: no depression (<5), mild depression (5-9), and moderate to severe depression (≥10). Inpatient pain scores and narcotics use were recorded. Oswestry Disability Index, Veterans RAND-12 Mental Component Score and Physical Component Score, and Visual Analog Scale (VAS) back and leg pain scores were collected preoperatively and at 6-week, 12-week, and 6-month follow-up. One-way analysis of variance and χ analysis determined if an association existed between PHQ-9 subgroups and baseline characteristics or perioperative outcomes. Multivariate linear regression assessed for an association between PHQ-9 and postoperative patient-reported outcomes.

RESULTS

In total, 94 patients were included. Patients with higher PHQ-9 scores were younger, obese, and carried workers' compensation insurance. Higher PHQ-9 scores were associated with worse preoperative Oswestry Disability Index, Veterans RAND-12 Mental Component Score and Physical Component Score, and VAS back and leg pain scores. Patients with higher PHQ-9 reported greater inpatient VAS pain scores on postoperative day 0 and 1 and demonstrated greater hourly narcotics consumption on postoperative day 0. Furthermore, higher PHQ-9 scores exhibited less improvement in all patient-reported outcomes.

CONCLUSIONS

Patients with severe depression symptoms reported greater pain, increased narcotics consumption, and less clinical improvement after MIS TLIF. Therefore, patients with greater PHQ-9 scores should be monitored more closely and may benefit from additional counseling with regard to postoperative outcomes to better manage pain control and expectations of recovery.

The association between depressive symptoms or depression and health outcomes in adults with low back pain with or without radiculopathy: protocol of a systematic review

BACKGROUND

A considerable proportion of adults with low back pain (LBP) suffer from depressive symptoms or depression. Those with depressive symptoms or depression may be at risk of poorer LBP recovery and require more health care. Understanding the role of prognostic factors for LBP is critically important to guide management and health services delivery. Our objective is to conduct a systematic review to assess the association between depressive symptoms or depression and health outcomes in adults with LBP with or without radiculopathy.

METHODS

Electronic databases including MEDLINE, Embase, CINAHL, and PsycINFO will be searched from inception to April 2019 to identify relevant studies. Additional citations will be identified by searching reference lists of included studies and related systematic reviews. Cohort and case-control studies assessing the association between depressive symptoms/depression and health outcomes in adults aged 16 years and older with LBP with or without radiculopathy will be included. The following will be included: depressive symptoms as measured on standardized questionnaires (e.g., Center for Epidemiologic Studies Depression Scale, Beck Depression Index), and depression as standardized diagnoses (e.g., International Classification of Diseases codes) or self-reported depression diagnosis on standardized questionnaires. Outcomes of interest are standardized measures for pain, disability, overall health status, satisfaction with care, and health care utilization. These are informed by core outcome domains that international expert panels consider important for LBP research. Pairs of reviewers will screen articles retrieved from the search, extract data, and assess risk of bias using the Risk Of Bias In Non-randomized Studies-of Exposures (ROBINS-E) tool. Reviewers will use these criteria to inform their judgment on the internal validity of studies (e.g., low, moderate, or high risk of bias). If studies are deemed homogeneous, a random effects meta-analysis on the association between depressive symptoms and health outcomes will be performed. The results of the included studies will be descriptively outlined if studies are deemed heterogeneous.

DISCUSSION

The impact of depressive symptoms and depression on health- and health care-related outcomes for LBP with or without radiculopathy will be assessed and quantified. Findings of this systematic review will advance our understanding of LBP prognosis, and guide decision-making and improve quality of care for adults with LBP.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019130047.