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Post-traumatic Stress Symptoms After Elective Lumbar Arthrodesis are Associated With Reduced Clinical Benefit

Hart, Robert, MD*; Perry, Elizabeth, MD; Hiratzka, Shannon, MPH*; Kane, Marie, MS*; Deisseroth, Kate, MD

doi: 10.1097/BRS.0b013e318285f05a
Health Services Research

Study Design. Prospective cohort study.

Objective. To assess the impact of postoperative post-traumatic stress disorder (PTSD) symptoms on clinical outcomes after lumbar arthrodesis.

Summary of Background Data. Postoperative PTSD symptoms occur among many patients who underwent elective lumbar fusion. Although adverse impact of preoperative depression and psychiatric distress has been described, no reports have assessed the impact of postoperative PTSD symptoms on clinical outcomes after lumbar arthrodesis.

Methods. Seventy-three patients undergoing elective lumbar spinal arthrodesis completed the PTSD Checklist-Civilian Version (PCL-C) at 3, 6, 9, and 12 months postoperatively. Short-Form 36 and the Oswestry Disability Index (ODI) were completed preoperatively and at 1 year postoperatively. Impact of postoperative PTSD symptoms, preoperative psychiatric diagnoses, and mental composite scores on clinical outcome scores and likelihood of reaching minimal clinically important difference for ODI and physical composite score (PCS) was evaluated.

Results. PTSD symptoms were reported in 22% of the cohort, with significantly reduced surgical benefit as measured by final (P < 0.0001 and P = 0.003) and total change (P = 0.013 and P = 0.032) in ODI and PCS scores, respectively. Likelihood of reaching minimal clinically important difference for both ODI and PCS was also reduced for patients reporting PTSD symptoms (P = 0.009 and P = 0.001, respectively). A preoperative psychiatric diagnosis correlated only with final ODI score (P = 0.008). Preoperative mental composite scores were significantly correlated with final ODI and PCS scores, as well as final change from preoperative and likelihood of reaching minimal clinically important difference for PCS, but not for ODI scores.

Conclusion. Postoperative psychological distress was strongly correlated with reduced clinical benefit among patients who underwent elective lumbar arthrodesis, and seemed to be a stronger predictor of reduced clinical benefit than either major psychiatric diagnosis or preoperative mental composite scores. Efforts to reduce postoperative psychological distress may offer an opportunity to enhance patient reported clinical outcomes from elective spine surgery.

Level of Evidence: 2

A total of 22% of patients demonstrated symptoms of post-traumatic stress disorder (PTSD) after elective lumbar arthrodesis. Patients with PTSD symptoms experienced significantly reduced clinical benefit and likelihood of reaching minimal clinically important difference for both Oswestry Disability Index and physical composite score. Postoperative PTSD symptoms were a stronger predictor of reduced clinical benefit than a major psychiatric diagnosis or preoperative mental composite scores.

*Department of Orthopedics and Rehabilitation, Oregon Health and Science University, Portland, OR

Department of Emergency Medicine, Lincoln Medical and Mental Health Center;

Malcom Grow Medical Clinic, Andrews AFB, MD.

Address correspondence and reprint requests to Robert Hart, MD, Department of Orthopedics and Rehabilitation, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239; E-mail: hartro@ohsu.edu

Acknowledgment date: October 19, 2012. Revision date: December 20, 2012. Acceptance date: December 21, 2012.

The manuscript submitted does not contain information about medical device(s)/drug(s).

No funds were received in support of this work.

Relevant financial activities outside the submitted work: consultancy, expert testimony, grants, royalties, payment for lecture, stocks.

© 2013 by Lippincott Williams & Wilkins