Rinnakkaistallenteet Terveystieteiden tiedekunta
2018
Depression is associated with the long-term outcome of lumbar spinal
stenosis surgery: a 10-year follow-up study
Tuomainen, I
Elsevier BV
Tieteelliset aikakauslehtiartikkelit
© Elsevier Inc
CC BY-NC-ND https://creativecommons.org/licenses/by-nc-nd/4.0/
http://dx.doi.org/10.1016/j.spinee.2017.08.228
https://erepo.uef.fi/handle/123456789/6287
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Title: Depression is associated with the long-term outcome of lumbar spinal stenosis surgery: a 10-year follow-up study
Author: Iina Tuomainen, Maarit Pakarinen, Timo Aalto, Sanna Sinikallio, Heikki Kröger, Heimo Viinamäki, Olavi Airaksinen
PII: S1529-9430(17)30902-6
DOI: http://dx.doi.org/doi: 10.1016/j.spinee.2017.08.228 Reference: SPINEE 57457
To appear in: The Spine Journal
Received date: 8-6-2017 Revised date: 13-7-2017 Accepted date: 9-8-2017
Please cite this article as: Iina Tuomainen, Maarit Pakarinen, Timo Aalto, Sanna Sinikallio, Heikki Kröger, Heimo Viinamäki, Olavi Airaksinen, Depression is associated with the long-term outcome of lumbar spinal stenosis surgery: a 10-year follow-up study, The Spine Journal (2017), http://dx.doi.org/doi: 10.1016/j.spinee.2017.08.228.
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Depression is associated with the long-term outcome of lumbar
1
spinal stenosis surgery: a 10-year follow-up study
2
3
Tuomainen Iina BM*1, Pakarinen Maarit MD, PhD*2, Aalto Timo MD, PhD 3, Sinikallio Sanna 4
PhD4, Kröger Heikki MD, PhD5, Viinamäki Heimo MD, PhD², Airaksinen Olavi MD, PhD 1 5
6
1. Department of Rehabilitation, Kuopio University Hospital, Finland 7
2. Department of Psychiatry, Kuopio University Hospital and University of Eastern Finland 8
3. Medical Center Ikioma, Mikkeli, Finland 9
4. School of Educational Sciences and Psychology, University of Eastern Finland, Joensuu, 10
Finland 11
12
5. Department of Orthopaedics and Traumatology, Kuopio University Hospital and 13
Kuopio Musculoskeletal Research Unit, University of Eastern Finland 14
* Equal Contribution 15
16
Corresponding author: Iina Tuomainen, Department of Rehabilitation Medicine, Kuopio 17
University Hospital, PL 100, FI-70029 KYS, Finland, Tel +358443438562, e-mail:
18
iinatuo@student.uef.fi, 19
20
Abstract
21
Background Context Depression is associated with greater postoperative
22
disability in lumbar spinal stenosis (LSS) patients. No previous studies have
23
reported the association in a 10-year follow-up.
24 25
Purpose To evaluate the association between preoperative and postoperative
1
depressive symptoms and the surgical outcome among LSS patients in a 10-
2
year follow-up. In addition, we examined the effects of the depressive burden
3
on the surgical outcome.
4 5
Design A prospective observational follow-up study.
6 7
Patient Sample 102 LSS patients underwent decompressive surgery and 72 of
8
the original sample participated in the 10-year follow-up study.
9 10
Outcome measures Self-report measures: the Oswestry Disability Index (ODI)
11
and Visual Analogue Scale (VAS).
12 13
Methods Data were collected using a questionnaire that was administered
14
seven times during the study period. Depressive symptoms were measured
15
with the Beck Depressive Inventory (BDI). The depressive burden was
16
calculated by summing the preoperative and all follow-up BDI scores.
17
Statistical analysis included cross-sectional group comparisons and linear
18
mixed models. The authors report no conflicts of interest related to this work.
19 20
Results The high depressive burden group had a poorer outcome for pain,
21
disability and the walking distance at the 10-year follow-up. In linear mixed
22
models, a higher preoperative BDI score associated with higher disability.
23
Furthermore, higher postoperative BDI scores and the depressive burden were
24
associated with higher disability and pain in the 10-year follow-up.
25 26
Conclusions LSS patients with even slightly elevated depressive symptoms
1
have an increased risk of postoperative pain and disability in a 10-year follow-
2
up. In order to improve the surgical outcome among these patients, screening
3
for depression both preoperatively and during the rehabilitation following
4
surgery is important.
5
Keywords: Depression; Subthreshold depression; Lumbar spinal stenosis;
6
Surgery; Long-term; Disability
7 8
Introduction
9 10
Lumbar spinal stenosis (LSS) is a common clinical syndrome among adults older
11
than 65 years, with an increasing prevalence due to the aging of the
12
population. [1, 2] LSS often results from degenerative changes and can lead to
13
a debilitating condition. [3] Neurogenic claudication, radicular pain that
14
worsens while standing or walking, pain relief when seated, and symptoms
15
easing when bending forwards, as well as wide-based gait, are the most
16
common symptoms of LSS. [3-5]
17 18
Conservative treatment, including medication and physical therapy, is usually
19
the first line choice especially in mild to moderate cases. [6, 7] If the
20
conservative treatment fails to lead to an improvement in symptoms after
21
three to six months, surgical treatment is suggested to be more beneficial than
22
continuous conservative treatment. [8] The benefits of surgery appear to
23
decline with time when compared to conservative treatment; however,
24
operative treatment is considered more beneficial for at least up to 4 years. [8-
25
12] According to a recent meta-analysis by Fritsch et al., [13] LSS patients
26
experience a significant decrease in pain and disability in the first three months
27
after surgery, and at least in the following 5 years, some further improvement
1
can occur.
2 3
Preoperative psychological distress is associated with an increased risk of a
4
poorer outcome following lumbar surgery. [14, 15] Depression, as a prognostic
5
factor, has been associated with greater postoperative symptom severity and
6
disability in LSS patients in a two-year follow-up. [16, 17] However, the
7
association between preoperative depression and postoperative pain is less
8
clear. [17]
9 10
In addition, subclinical depression or depressive symptoms without diagnosis
11
have an influence on functional disability and other health conditions.
12
Moreover, these patients have a higher risk of progressing to major
13
depression. [18, 19] The depressive burden, also estimating the subclinical
14
depressive mood over time, has been demonstrated to be associated with
15
poorer surgical outcome in LSS patients from one to five years postoperatively.
16
[16, 20, 21] The depressive burden also allows an assessment of the effects of
17
the long-term cumulative mental burden. [20-24] On the other hand,
18
depression and psychological well-being can improve after decompressive
19
surgery, and those who have experienced psychological distress also gain
20
benefits from surgery. [16, 25, 26]
21 22
So far, the longest follow-up period in which the association between
23
depressive symptoms and the surgical outcome has been evaluated in LSS
24
patients has been five years. [21] The effects of depressive symptoms on the
25
surgical outcome in LSS patients has not studied in a 10-year follow-up. The
26
objective of this prospective observational study was not only to determine
27
the prognostic value of preoperative depression in the 10-year follow-up, but
1
also to examine the effects of depressive symptoms at the postoperative
2
follow-up points and during the entire study period.
3 4
Material and methods
5 6
Study settings and participants
7 8
At baseline, the study population included 102 patients who underwent
9
decompressive surgery due to LSS. The LSS was defined both radiologically and
10
clinically by an orthopaedist or a neurosurgeon. Selection for surgery was
11
carried out at XXXXX, XXXX, between October 2001 and October 2004. The 10-
12
year follow-up data were collected in 2013.
13 14
Inclusion criteria for the study population were the presence of severe pain in
15
the back, buttocks, and/or lower extremities. Furthermore, the compression of
16
the cauda equine or exiting nerve roots due to degenerative changes had to
17
have radiographic evidence. Moreover, patients needed the surgeon’s clinical
18
evaluation of degenerative LSS requiring operative treatment. All the patients
19
also had a history of insufficiently responding to conservative treatment for
20
several months.
21 22
An urgent or emergency spinal operation preventing recruitment and other
23
protocol investigations was an exclusion criterion. Moreover, the presence of
24
metallic particles in the body precluding magnetic resonance imaging (MRI)
25
was an exclusion criterion. Patients with cognitive impairment preventing the
26
completion of the questionnaires or with other failures in co-operation were
1
also excluded. The Ethics Committee of XXXXXXX approved the study design.
2 3
Questionnaires
4 5
The data were collected using questionnaires that patients completed
6
preoperatively and 3 months, 6 months, 1 year, 2 years, 5 years and 10 years
7
postoperatively. The questionnaires included the followings:
8 9
1. The self-reported overall satisfaction with the surgery on a 7-point scale
10
from -3 to 3 (-3 = “the surgery was a total failure”; 3 = “the condition has
11
been completely cured”; 0 = “no difference after the operation
12
compared to before”);
13 14
2. The self-reported walking capacity in metres;
15 16
3. Subjective disability was measured using the validated Finnish version of
17
the Oswestry Disability Index (ODI). The scale ranges from 0–100%,
18
where 0% indicates no disability and 100% indicates extreme disability;
19
[27, 28]
20 21
4. Current overall pain was evaluated using a visual analogue scale (VAS),
22
from 0–100 mm; [29]
23 24
5. Assessment of depressive symptoms with the Finnish version of the 21-
25
item Beck Depression Inventory (BDI), whit a scale from 0–63; [30, 31]
26 27
6. Comorbidities were evaluated using the Work Ability Index (WAI), where
1
the number of current diseases or injuries diagnosed by a physician was
2
recorded. Mental health comorbidities were excluded from the analyses.
3
[32]
4 5
Statistical analysis
6 7
Statistical analysis was performed using SPSS/PC (version 23.0; SPSS, Inc.,
8
Chicago, IL, USA). The participants were divided into two groups according to
9
the preoperative BDI score. The cut-off point was determined to be 15 for
10
clinically significant depressive symptoms. [33] Preoperatively, 57 patients had
11
BDI scores less than 15 and 13 patients had BDI scores of 15 or more. The
12
depressive burden, indicating long-term depressive symptoms, was calculated
13
by summing the individual BDI scores from all observation points. The study
14
patients were divided into two groups according to the depressive burden, the
15
high depressive burden group (n = 24) and the low depressive burden group (n
16
= 22). The cut-off point was determined to be the median of the depressive
17
burden in the study group (median 44; range 5–139).
18 19
The independent samples t-test and Mann-Whitney U-test were used to
20
compare the means. The distribution of the data was determined using the
21
Shapiro-Wilk test. To compare the means between preoperative and 10-year
22
postoperative variables, the Wilcoxon signed ranks test was used due to the
23
non-parametric distribution. ODI and VAS scores were separately analyzed
24
using a linear mixed model, where the BDI and depressive burden were factors
25
in model 1 and 2, respectively. The mixed models were adjusted for time,
26
gender, preoperative age, comorbidities and marital status. Moreover, the
27
interaction of the BDI score and time was included in the first model to
1
examine whether the BDI score at different time points had a statistical
2
association with the outcome measures. Factors in the model were selected as
3
fixed factors and unstructured covariance was used for repeated measures.
4
The assumption of a normal distribution was visually checked from the
5
residuals. The data included some missing values, but these were assumed to
6
occur completely at random.
7 8
Results
9 10
After 10 years of follow-up, 17 patients had died and 13 patients were not
11
available for the evaluation. Thus, 72 of the original participants responded at
12
the 10-year follow-up. Preoperative the study drop-outs were older compared
13
to patients who responded to the follow-up questionnaire (mean age 71 years
14
vs 58 years, p < 0.001). Moreover, they had more comorbidities preoperatively
15
than patients who responded at the follow-up (mean 7.5 vs 4.9, p < 0.001).
16
However, the other baseline characteristics (ODI, VAS, BDI, walking distance
17
and gender) were similar between the groups. In the preoperative
18
questionnaires, two patients had unrecorded BDI data, and 63 patients
19
completed the BDI at the 10-year follow-up.
20 21
The mean age of the study population at the 10-year follow-up was 69 years
22
(SD 9.6), 37.5% were male and 65% were married or living with a partner. A
23
total of 19% (n = 12) of the patients had elevated depressive symptoms (BDI ≥
24
15) at the 10-year follow-up. BDI scores had decreased below 15 at the 10-year
25
follow-up in 5 (8%) patients who had elevated depressive symptoms in the
26
preoperative phase. Conversely, BDI scores had increased above 15 at the 10-
27
year follow-up in 5 patients (8%) who had BDI scores below 15 in the
1
preoperative phase. The mean ODI and VAS scores at the 10-year follow-up
2
were 29.4 (SD 20.9) and 32.8 (SD 28.2), respectively.
3 4
At the 10-year follow-up, the group with higher BDI scores preoperatively had
5
higher BDI, ODI and VAS scores in the cross-sectional analysis. Furthermore,
6
they had a shorter walking distance and more comorbidities at the 10-year
7
follow-up. In addition, patients the group with lower BDI scores preoperatively
8
were more satisfied with the surgical outcome at the 10-year follow-up (Table
9
1).
10 11
Table 1 about here.
12 13
The patients with a higher depressive burden had higher BDI scores
14
preoperatively and at the 3-month and 10-year follow-up points. At the 3-
15
month and the 10-year follow-up points, they had higher ODI and VAS scores
16
and their walking distance was shorter (Table 2).
17 18
Table 2 about here.
19 20
Within the low depressive burden group, there was a significant decrease in
21
the ODI (p < 0.005), VAS (p < 0.005) and BDI scores (p < 0.05) between the
22
preoperative phase and the 10-year follow-up. Likewise, the walking distance
23
improved significantly from the preoperative phase to the 10-year follow-up (p
24
< 0.005). Within the high depressive burden group, a significant improvement
25
at the 10-year follow-up compared to the preoperative phase was only seen in
26
the ODI scores (p < 0.01), while no statistically significant differences were
1
observed for the walking distance or VAS or BDI scores.
2 3
In the linear mixed models, higher BDI scores in the preoperative phase and at
4
all follow-up points were significantly associated with a greater ODI score.
5
Furthermore, higher BDI scores at all follow-up points were significantly
6
associated with a greater VAS score. The depressive burden was also
7
significantly associated with the ODI and VAS score at the 10-year follow-up
8
(Table 3).
9 10
Table 3 about here.
11 12
Discussion
13 14
This study demonstrated an association between depressive symptoms and
15
the surgical outcome in terms of pain and disability among LSS patients in
16
extended follow-up time. Preoperative depression was associated with greater
17
disability even in the 10-year follow-up. Previous studies have suggested
18
preoperative screening for depression in spinal conditions due to its adverse
19
effect on the surgical outcome. [15, 17] Our study further confirmed the
20
importance of screening, as patients with elevated preoperative depressive
21
symptoms had a poorer outcome even 10 years after the original surgery. In
22
addition to current depression, previously depressed individuals are at
23
increased risk of unhealthy behaviours, such as functional inactivity, [34] which
24
might lead to greater disability over time. Moreover, the association between
25
immune function and depressive symptoms may have an impact on recovery
26
from surgery. [35-37]
27
1
In this study population, almost one-fifth had clinically significant elevated
2
depressive symptoms at the 10-year follow-up. This is clearly higher than the
3
prevalence of depression among the Finnish general population aged over 65
4
years (2.6%). [38] This finding highlights the importance of also screening for
5
depression after surgery, since the prevalence of depression is higher among
6
LSS patients than in the general population.
7 8
Moreover, elevated depressive symptoms at different postoperative time
9
points associated with greater disability and pain in the longitudinal analysis.
10
One earlier study focusing on conservatively treated LSS patients revealed that
11
the number of comorbid diseases, which included psychiatric disorders, had a
12
negative effect on the subjective outcome during a follow-up period of up to
13
12 years. [39] There is a lack of studies focusing on surgically treated LSS
14
patients, especially with longer follow-ups than 5 years. A one-year follow-up
15
study by Falavigna et al. [25] suggested that since depression in the
16
postoperative period might have worse effects on the clinical outcome than in
17
the preoperative period, the assessment of depressive symptoms during the
18
postoperative period is more important. These findings underline the need to
19
evaluate depressive symptoms and other possible psychological distress also
20
during postoperative rehabilitation.
21 22
In the present study, patients with a higher depressive burden had a poorer
23
outcome following LSS surgery compared to the low depressive burden group.
24
In addition, a higher depressive burden was associated with greater disability
25
and pain in the 10-year follow-up period. The depressive burden provides an
26
assessment of the effects of the long-term cumulative mental burden and
27
enables to study subclinical depression and its effects on the surgical outcome.
1
[20-24]
2 3
Similarly to this study, patients without depression reported a greater
4
improvement after surgery than patients with continuous depression, and the
5
same association was seen in follow-up periods lasting from one to five years.
6
[16, 20, 21] However, a significant postoperative improvement in functional
7
ability also occurred in patients with a high depressive burden in the present
8
10-year follow-up. Thus, LSS patients with depressive symptoms can benefit
9
from surgery in terms of functional ability measured with the ODI.
10 11
Our previous study found a cross-sectional association between life
12
dissatisfaction and poorer surgical outcome in a 10-year follow-up. [23]
13
Nevertheless, the association between depressive symptoms and surgical
14
outcome has not yet been studied in a 10-year follow-up. In addition, it is
15
important to investigate if patients’ supporting and negative psychological
16
factors can be recognized, and how they are separately associated with a
17
surgical outcome in a greater follow-up time among LSS patients.
18 19
A meta-analysis by McGregor et al. [40] revealed the positive effect of
20
postoperative rehabilitation in LSS surgery. Furthermore, in their review,
21
Marchand et al. [41] suggested that multimodal rehabilitation protocols
22
following lumbar surgery might improve the outcome when the rehabilitation
23
programs include muscle strengthening, aerobic conditioning, or stretching
24
and different educational means. Moreover, rehabilitation combined with
25
psychosocial support might improve the postoperative outcome even further.
26
[16, 25, 26] Nevertheless, further randomized controlled trials are needed to
27
conclude whether the management of depressive symptoms can improve the
1
surgical outcome in LSS.
2 3
There were some limitations in this study. The small study sample size could
4
have biased the results. The study setting was naturalistic and directly
5
applicable to clinical settings, and the follow-up time was extensive, providing
6
important information on the long-term outcomes. Although we observed an
7
association between depressive symptoms and a poorer outcome of surgery in
8
our longitudinal assessment, we could not completely exclude the possibility
9
that our results were due to an initially poor surgical outcome or other factors
10
not evaluated in this study.
11 12
In conclusion, preoperative depression can predict greater postoperative
13
disability among lumbar spinal stenosis patients during a 10-year follow-up.
14
Moreover, the results demonstrated an association between the depressive
15
symptoms at all follow-up points and postoperative pain and disability. Based
16
on the study results, we recommend considering rehabilitation, including
17
psychosocial support, in LSS patients with depressive symptoms. However,
18
further studies are needed to assess whether the management of depression
19
can improve the long-term surgical outcome.
20 21 22
References 23
[1]Kalichman L, Cole R, Kim DH, Li L, Suri P, Guermazi A, et al. Spinal stenosis prevalence and 24
association with symptoms: The framingham study. Spine J. 2009 Jul;9(7):545-50.
25
[2]Deyo RA. Treatment of lumbar spinal stenosis: A balancing act. Spine J. 2010 26
Jul;10(7):625-7.
27
[3]Lurie J, Tomkins-Lane C. Management of lumbar spinal stenosis. BMJ. 2016 Jan 1
4;352:h6234.
2
[4]de Schepper EI, Overdevest GM, Suri P, Peul WC, Oei EH, Koes BW, et al. Diagnosis of 3
lumbar spinal stenosis: An updated systematic review of the accuracy of diagnostic tests.
4
Spine (Phila Pa 1976). 2013 Apr 15;38(8):E469-81.
5
[5]Tomkins-Lane C, Melloh M, Lurie J, Smuck M, Battie MC, Freeman B, et al. ISSLS prize 6
winner: Consensus on the clinical diagnosis of lumbar spinal stenosis: Results of an 7
international delphi study. Spine (Phila Pa 1976). 2016 Aug 1;41(15):1239-46.
8
[6]Benoist M. The natural history of lumbar degenerative spinal stenosis. Joint Bone Spine.
9
2002 Oct;69(5):450-7.
10
[7]Genevay S, Atlas SJ. Lumbar spinal stenosis. Best Pract Res Clin Rheumatol. 2010 11
Apr;24(2):253-65.
12
[8]Kovacs FM, Urrutia G, Alarcon JD. Surgery versus conservative treatment for symptomatic 13
lumbar spinal stenosis: A systematic review of randomized controlled trials. Spine (Phila Pa 14
1976). 2011 Sep 15;36(20):E1335-51.
15
[9]Weinstein JN, Tosteson TD, Lurie JD, Tosteson A, Blood E, Herkowitz H, et al. Surgical 16
versus nonoperative treatment for lumbar spinal stenosis four-year results of the spine 17
patient outcomes research trial. Spine (Phila Pa 1976). 2010 Jun 15;35(14):1329-38.
18
[10]Chang Y, Singer DE, Wu YA, Keller RB, Atlas SJ. The effect of surgical and nonsurgical 19
treatment on longitudinal outcomes of lumbar spinal stenosis over 10 years. J Am Geriatr 20
Soc. 2005 May;53(5):785-92.
21
[11]Atlas SJ, Keller RB, Wu YA, Deyo RA, Singer DE. Long-term outcomes of surgical and 22
nonsurgical management of lumbar spinal stenosis: 8 to 10 year results from the maine 23
lumbar spine study. Spine (Phila Pa 1976). 2005 Apr 15;30(8):936-43.
24
[12]Lurie JD, Tosteson TD, Tosteson A, Abdu WA, Zhao W, Morgan TS, et al. Long-term 25
outcomes of lumbar spinal stenosis: Eight-year results of the spine patient outcomes 26
research trial (SPORT). Spine (Phila Pa 1976). 2015 Jan 15;40(2):63-76.
27
[13]Fritsch CG, Ferreira ML, Maher CG, Herbert RD, Pinto RZ, Koes B, et al. The clinical 28
course of pain and disability following surgery for spinal stenosis: A systematic review and 29
meta-analysis of cohort studies. Eur Spine J. 2017 Feb;26(2):324-35.
30
[14]Celestin J, Edwards RR, Jamison RN. Pretreatment psychosocial variables as predictors of 31
outcomes following lumbar surgery and spinal cord stimulation: A systematic review and 32
literature synthesis. Pain Med. 2009 May-Jun;10(4):639-53.
33
[15]Trief PM, Grant W, Fredrickson B. A prospective study of psychological predictors of 34
lumbar surgery outcome. Spine (Phila Pa 1976). 2000 Oct 15;25(20):2616-21.
35
[16]Sinikallio S, Aalto T, Airaksinen O, Lehto SM, Kroger H, Viinamaki H. Depression is 1
associated with a poorer outcome of lumbar spinal stenosis surgery: A two-year prospective 2
follow-up study. Spine (Phila Pa 1976). 2011 Apr 15;36(8):677-82.
3
[17]McKillop AB, Carroll LJ, Battie MC. Depression as a prognostic factor of lumbar spinal 4
stenosis: A systematic review. Spine J. 2014 May 1;14(5):837-46.
5
[18]Rucci P, Gherardi S, Tansella M, Piccinelli M, Berardi D, Bisoffi G, et al. Subthreshold 6
psychiatric disorders in primary care: Prevalence and associated characteristics. J Affect 7
Disord. 2003 Sep;76(1-3):171-81.
8
[19]Cuijpers P, de Graaf R, van Dorsselaer S. Minor depression: Risk profiles, functional 9
disability, health care use and risk of developing major depression. J Affect Disord. 2004 10
Apr;79(1-3):71-9.
11
[20]Sinikallio S, Aalto T, Airaksinen O, Herno A, Kroger H, Viinamaki H. Depressive burden in 12
the preoperative and early recovery phase predicts poorer surgery outcome among lumbar 13
spinal stenosis patients: A one-year prospective follow-up study. Spine (Phila Pa 1976). 2009 14
Nov 1;34(23):2573-8.
15
[21]Pakarinen M, Vanhanen S, Sinikallio S, Aalto T, Lehto SM, Airaksinen O, et al. Depressive 16
burden is associated with a poorer surgical outcome among lumbar spinal stenosis patients:
17
A 5-year follow-up study. Spine J. 2014 Oct 1;14(10):2392-6.
18
[22]Rissanen T, Viinamaki H, Honkalampi K, Lehto SM, Hintikka J, Saharinen T, et al. Long 19
term life dissatisfaction and subsequent major depressive disorder and poor mental health.
20
BMC Psychiatry. 2011 Aug 23;11:140,244X-11-140.
21
[23]Pakarinen M, Tuomainen I, Koivumaa-Honkanen H, Sinikallio S, Lehto SM, Airaksinen O, 22
et al. Life dissatisfaction is associated with depression and poorer surgical outcomes among 23
lumbar spinal stenosis patients: A 10-year follow-up study. Int J Rehabil Res. 2016 24
Dec;39(4):291-5.
25
[24]Pakarinen M, Koivumaa-Honkanen H, Sinikallio S, Lehto SM, Aalto T, Airaksinen O, et al.
26
Life dissatisfaction burden is associated with a poor surgical outcome among lumbar spinal 27
stenosis patients: A 5-year follow-up study. Int J Rehabil Res. 2014 Mar;37(1):80-5.
28
[25]Falavigna A, Righesso O, Teles AR, Conzati LP, Bossardi JB, da Silva PG, et al.
29
Responsiveness of depression and its influence on surgical outcomes of lumbar 30
degenerative diseases. Eur J Orthop Surg Traumatol. 2015 Jul;25 Suppl 1:S35-41.
31
[26]Schiavolin S, Broggi M, Visintini S, Schiariti M, Leonardi M, Ferroli P. Change in quality of 32
life, disability, and well-being after decompressive surgery: Results from a longitudinal 33
study. Int J Rehabil Res. 2015 Dec;38(4):357-63.
34
[27]Fairbank JC, Pynsent PB. The oswestry disability index. Spine (Phila Pa 1976). 2000 Nov 35
15;25(22):2940,52; discussion 2952.
36
[28]Fairbank JC, Couper J, Davies JB, O'Brien JP. The oswestry low back pain disability 1
questionnaire. Physiotherapy. 1980 Aug;66(8):271-3.
2
[29]Price DD, McGrath PA, Rafii A, Buckingham B. The validation of visual analogue scales as 3
ratio scale measures for chronic and experimental pain. Pain. 1983 Sep;17(1):45-56.
4
[30]BECK AT, WARD CH, MENDELSON M, MOCK J, ERBAUGH J. An inventory for measuring 5
depression. Arch Gen Psychiatry. 1961 Jun;4:561-71.
6
[31]Raitasalo R. Depression and its connections with the need for psychotherapy. Social 7
Insurance Institute, Helsinki. 1977.
8
[32]Tuomi K, Tuomi K, Oja G. Work ability index. 2. rev. ed ed. Helsinki: Finnish Institute of 9
Occupational Health; 1998.
10
[33]Viinamaki H, Tanskanen A, Honkalampi K, Koivumaa-Honkanen H, Haatainen K, Kaustio 11
O, et al. Is the beck depression inventory suitable for screening major depression in different 12
phases of the disease? Nord J Psychiatry. 2004;58(1):49-53.
13
[34]Strine TW, Mokdad AH, Dube SR, Balluz LS, Gonzalez O, Berry JT, et al. The association of 14
depression and anxiety with obesity and unhealthy behaviors among community-dwelling 15
US adults. Gen Hosp Psychiatry. 2008 Mar-Apr;30(2):127-37.
16
[35]Raison CL, Miller AH. Is depression an inflammatory disorder? Curr Psychiatry Rep. 2011 17
Dec;13(6):467-75.
18
[36]Kudoh A, Katagai H, Takazawa T. Plasma inflammatory cytokine response to surgical 19
trauma in chronic depressed patients. Cytokine. 2001 Jan 21;13(2):104-8.
20
[37]Starkweather AR, Witek-Janusek L, Nockels RP, Peterson J, Mathews HL. Immune 21
function, pain, and psychological stress in patients undergoing spinal surgery. Spine (Phila Pa 22
1976). 2006 Aug 15;31(18):E641-7.
23
[38]Pirkola SP, Isometsa E, Suvisaari J, Aro H, Joukamaa M, Poikolainen K, et al. DSM-IV 24
mood-, anxiety- and alcohol use disorders and their comorbidity in the finnish general 25
population--results from the health 2000 study. Soc Psychiatry Psychiatr Epidemiol. 2005 26
Jan;40(1):1-10.
27
[39]Adamova B, Vohanka S, Dusek L, Jarkovsky J, Chaloupka R, Bednarik J. Outcomes and 28
their predictors in lumbar spinal stenosis: A 12-year follow-up. Eur Spine J. 2015 29
Feb;24(2):369-80.
30
[40]McGregor AH, Probyn K, Cro S, Dore CJ, Burton AK, Balague F, et al. Rehabilitation 31
following surgery for lumbar spinal stenosis. A cochrane review. Spine (Phila Pa 1976). 2014 32
Jun 1;39(13):1044-54.
33
[41]Marchand AA, O'Shaughnessy J, Chatillon CE, Sorra K, Descarreaux M. Current practices 1
in lumbar surgery perioperative rehabilitation: A scoping review. J Manipulative Physiol 2
Ther. 2016 Nov - Dec;39(9):668-92.
3 4 5 6 7
Table 1. Comparison of the study group characteristic at the 10-year follow-up point according to 1
preoperative depressive symptoms 2
Characteristic BDI ≤ 14
(n = 57)
BDI ≥ 15 (n = 13)
p-value
Age, mean (SD) 68.7 (9.1) 68.3 (12.7) NS
Gender, male/female 19/38 8/5 NS
BDI score, mean (SD) 6.4 (5.0) 18.3 (7.7) < 0.001
ODI, mean (SD) 26.1 (19.3) 47.3 (18.6) < 0.005
VAS, mean (SD) 28.4 (26.5) 53.1 (26.8) < 0.01
Walking distance, mean (SD) 3,160.4 (3,206.6) 670.8 (630.9) < 0.005
Smoking, yeas/no 6/46 4/9 NS
Comorbidity, median (min, max) 4 (0,7) 7 (0,7) < 0.05
Satisfaction, median (min, max) 2.0 (-3,3) 1.0 (-2,3) < 0.05 ODI=Oswestry Disability Index; VAS=Visual Analogue Scale; BDI=Beck Depressive Index; SD=Standard 3
Deviation; NS=not significant 4
5 6 7 8
Table 2. Comparison of clinical characteristics at different follow-up points according to the 1
depressive burden status at the 10-year follow-up 2
Characteristics Low depressive burden (n = 22)
High depressive burden (n = 23)
p-value
BDI-score, mean (SD)
Preoperatively 5.45 (2.4) 12.79 (6.0) < 0.001
On 3-month follow-up 3.41 (2.8) 9.75 (5.4) < 0.001
On 10-year follow-up 4.36 (4.4)* 11.79 (7.4) < 0.001
ODI, mean (SD)
Preoperatively 35.64 (13.8) 45.13 (14.9) NS
On 3-month follow-up 15.28 (12.3) 27.29 (18.8) < 0.05
On 10-year follow-up 16.90 (16.7)* 34.46 (19.29)* < 0.005 VAS, mean (SD)
Preoperatively 51.45 (25.0) 53.71 (26.3) NS
On 3-month follow-up 13.50 (13.9) 29.29 (25.1) < 0.05
On 10-year follow-up 14.9 (17.3)* 44.24 (26.7) < 0.005
Walking distance, mean (SD)
Preoperatively 2,068 (2,191.8) 1,805 (2.351,4) NS
On 3-month follow-up 4,795 (4,363.4) 2,670 (2,605.3) < 0.05 On 10-year follow-up 4,285 (3,426.1)* 2,549 (3,298.0) < 0.05 ODI=Oswestry Disability Index; VAS=Visual Analogue Scale; BDI=Beck Depressive Index; SD=Standard 3
Deviation; NS=not significant 4
*=significant difference between preoperative and 10-year follow-up 5
6 7 8
Table 3. Mixed Model for longitudinal ODI-score and VAS-score 1
ODI VAS
Parameter Model 1
Estimate (SD) P-value 95% CI Estimate
(SD) P-value 95% CI preoperative * BDI 0.80 (0.18) < 0.001 0.44–1.16 0.41 (0.39) NS -0.36–1.18 3-month follow-up* BDI 1.06 (0.18) < 0.001 0.70–1.42 1.69 (0.29) < 0.001 1.12–2.27 6-month follow-up * BDI 0.98 (0.14) < 0.001 0.72–1.25 1.61 (0.26) < 0.001 1.08–2.13 1-year follow-up * BDI 0.78 (0.14) < 0.001 0.51–1.05 0.97 (0.21) < 0.001 0.55–1.40 2-year follow-up * BDI 1.39 (0.16) < 0.001 1.08–1.70 1.14 (0.21) < 0.001 0.72–1.55 5-year follow-up * BDI 1.16 (0.19) < 0.001 0.77–1.55 1.69 (0.37) < 0.001 0.94–2.45 10-year follow-up * BDI 1.74 (0.22) < 0.001 1.30–2.18 2.34 (0.34) < 0.001 1.67–3.01 Model 2
Depressive burden 0.25 (0.04) < 0.001 0.18–0.33 0.19 (0.06) < 0.005 0.07–0.31 ODI=Oswestry Disability Index; VAS=Visual Analogue Scale; BDI=Beck Depressive Index; SD=Standard 2
Deviation; NS=not significant 3
4 5
