Commentary Sheds Light on Potential ASD Misdiagnosis

(Burr Ridge, IL)—What if a spine surgeon could predict patient outcomes by doing a simple, pre-op psychological test? A longitudinal study published in the March 2012 issue of The Spine Journal has put that theory to the test.

In “Preoperative Zung Depression Scale Predicts Outcome After Revision Lumbar Surgery for Adjacent Segment Disease, Recurrent Stenosis and Pseudoarthrosis,” the authors conclude that the extent of preoperative depression is an independent predictor of functional outcome after revision lumbar surgery for pseudarthrosis, recurrent stenosis and adjacent segment disease (ASD).

One hundred fifty patients undergoing revision neural decompression and instrumented fusion for ASD (n550), pseudarthrosis (n547), or same-level recurrent stenosis (n553) were included in this study. A Preoperative Zung Self-Reported Depression Scale score was assessed for all patients. Preoperative and 2-year postoperative visual analog scale for back pain and leg pain scores and Oswestry Disability Index (ODI) were assessed. The association between preoperative Zung Depression Scale score and 2-year improvement in disability was assessed via multivariate regression analysis.

Compared to preoperative status, a score on the visual analog scale for back pain (VAS-BP) was significantly improved two years after surgery for ASD (8.7261.85 vs. 3.9262.84, p5.001), pseudoarthrosis (7.3160.81 vs. 5.0662.64, p5.001), and same-level recurrent stenosis (9.2861.00 vs. 5.0062.94, p5.001). Two-year ODI was also significantly improved after surgery for ASD (28.7269.64 vs. 18.48611.31, p5.001), pseudoarthrosis (29.7465.35 vs. 25.4266.00, p5.001), and same-level recurrent stenosis (36.0166.00 vs. 21.75612.07, p5.001). Independent of age, BMI, symptom duration, smoking, comorbidities and level of preoperative pain and disability, increasing preoperative Zung depression score was significantly associated with less two-year improvement in disability (ODI) after revision surgery for ASD, pseudoarthrosis and recurrent stenosis.

Based on their results, the authors suggest that future comparative effectiveness studies assessing outcomes after revision lumbar surgery should account for depression as a potential confounder. Also, the Zung depression questionnaire may help risk-stratify patients presenting for revision lumbar surgery.

In an accompanying commentary, “Revision lumbar surgery and revisiting the role of
preoperative depression screening,” Eugene J. Carragee, MD and Connor J. Telles, MD applaud the “illuminating” and thorough study. They go on to suggest that some patients identified as having ASD actually may be misunderstood or misdiagnosed because psychosocial issues, such as depression or drug use, may have been present all along.
 
“It is unlikely that depression has some unique or mysterious effect on patients with major mechanical failure of adjacent discs that precludes our making them better with fusion,” said Carragee, of the Stanford University School of Medicine, Redwood City, CA and the editor in chief of The Spine Journal.  “What’s more likely is that a distinct subgroup of patients with psychosocial issues, such as depression or drug use, end up with the vague “ASD” label. Therefore, it’s little wonder that a revision surgery does not help their pain.”

Drs. Carragee and Telles indicate that they would like to see additional research into whether patients who have depression would benefit from preoperative and postoperative psychological interventions, including social, pharmacological or psychological treatment.

“This more holistic approach as shown by Dr Adogwa et al, in both practice and research, has the potential to lead to not only the greater satisfaction of the patient but less disappointment for the surgeon frustrated in proper patient selection,” said Dr. Carragee. 

The following study authors are from the Department of Neurosurgery, The Spinal Column Surgical Quality and Outcomes Research Laboratory, Vanderbilt University Medical Center in Nashville, TN:

Owoicho Adogwa, MPH; Scott L. Parker, MD; David N. Shau, BS; Stephen K. Mendenhall, BS; Oran S. Aaronson, MD; Joseph S. Cheng, MD; and Matthew J. McGirt, MD.

Clinton J. Devin, MD is from the Department of Orthopedic Surgery and Rehabilitation, The Spinal Column Surgical Quality and Outcomes Research Laboratory, Vanderbilt University Medical Center in Nashville, TN.

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The Spine Journal is an international, multidisciplinary journal that publishes original, peer-reviewed articles on research and treatment related to the spine and spine care, including basic science and clinical investigations. Published online continuously and printed monthly by Elsevier, Inc, The Spine Journal is the scientific publication of the North American Spine Society (NASS). NASS adheres to a policy of editorial independence for the journal’s editorial board, which follows guidelines of the International Committee of Medical Journal Editors, Committee on Publication Ethics and other best editorial practices. The Spine Journal recently earned an Impact Factor of 3.024, making it the top-rated spine publication in the world. 

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