Anxiety, Depression Contribute to Higher LOS After Posterior Spinal Fusion in AIS Patients

by Elizabeth Hofheinz, M.P.H., M.Ed.

A multidisciplinary team from Duke University Medical Center in Durham, North Carolina and Emory University in Atlanta, Georgia has found that an increased length of stay (LOS) of adolescent idiopathic scoliosis (AIS) patients with anxiety or depression who have posterior spinal fusion (PSF).

Their work, “Depression and anxiety as emerging contributors to increased hospital length of stay after posterior spinal fusion in patients with adolescent idiopathic scoliosis,” appears in the June 14, 2020 edition of the North American Spine Society Journal.

Co-author Albert Thomas Anastasio, M.D. is a PGY-2 orthopedic surgery resident at Duke University Medical Center in Durham, North Carolina. He commented to OSN, “Through collaboration on patient care with my colleagues in psychiatry as well as through my own direct interactions with adolescent patients, I have been made aware of the rising incidence of depression and anxiety in these cohorts. The mechanisms behind this appear multifactorial, but they are at least in part impacted by pressures induced by social media usage at an age when peer-to-peer interactions are particularly impactful. As orthopedic surgeons, our team felt that this recent trend may be adversely affecting our patients, and we wanted to explore this topic.”

Utilizing the Nationwide Inpatient Sample (maintained by the Agency for Healthcare Research and Quality), the researchers studied a sample of 564 patients in the depression and anxiety cohort and 5,185 patients in the cohort without concomitant diagnosis of depression and anxiety.

Of the total, 85.5% of the sample were female, most procedures were done in an urban, teaching hospital (97.3%) and 84.2% of the sample was 11–16 years of age.

Dr. Anastasio told OSN, “Substantial work exists documenting the rise of adolescent anxiety and depression (typically conditions that were more commonly diagnosed in adult cohorts). There is a paucity of literature evaluating the contribution of these comorbid conditions to outcomes following common orthopedic surgeries, and we hope our manuscript helps to shed light on an area of future research by identify increased length of stay as being associated with these conditions after posterior spinal fusion.”

The team found that out of 5,749 patients undergoing PSF for AIS, 564 patients had a coexisting diagnosis of either depression or anxiety (10.9%). They state that this is the first study to show that major depressive disorder and generalized anxiety disorder adversely impact the inpatient stay.

Dr. Anastasio told OSN, “As described above, we noted an increased length of stay of inpatients with anxiety or depression undergoing posterior spinal fusion. While this may not seem particularly impactful, in reality, this finding can have profound implications, not only as far as patient outcomes are concerned, but also with regard to hospital resource utilization, especially in the COVID-19 era when ICU bed space may be limited.”

“We hope practitioners will continue to consider depression and anxiety as being potential comorbid conditions in not only adult patients, but adolescent patients as well. Additionally, we hope providers will recognize the potential impact that these conditions can have not just on long term outcomes, but on the initial hospital stay for the procedure. These findings hold true for spine surgery, but also for other surgical procedures as demonstrated across the literature.”

Asked what future work should be done on this, Dr. Anastasio told OSN, “Future work should aim to expand upon complications associated with depression and anxiety in the adolescent cohort across surgical fields. Currently, evidence suggests these diagnoses are under recognized in younger cohorts, and thus it is likely patients suffering from these conditions may not have actually received the diagnosis of anxiety or depression. This makes performing research difficult, as the patient sample may include misdiagnoses. Thus, heightened awareness of proper diagnosis of these conditions will lead to be better research, and vice versa.”