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Preoperative psychological factors affecting surgical satisfaction of elderly patients with lumbar spinal stenosis
Journal of Orthopaedic Science xxx (xxxx) xxx
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Original Article
Preoperative psychological factors affecting surgical satisfaction of elderly patients with lumbar spinal stenosis Tomoko Kitano CP a, *, Mamoru Kawakami a, Daisuke Fukui b, Yuyu Ishimoto b, Keiji Nagata b, Hiroshi Yamada b, Yukihiro Nakagawa a a b
Spine Care Center, Wakayama Medical University Kihoku Hospital, Japan Department of Orthopaedic Surgery, Wakayama Medical University, Japan
a r t i c l e i n f o
a b s t r a c t
Article history: Received 18 December 2018 Received in revised form 5 September 2019 Accepted 1 October 2019 Available online xxx
Objective: The objective of this observational study was to investigate the effects of preoperative psychological factors on short-term patient satisfaction with surgery in elderly patients with lumbar spinal stenosis (LSS). Methods: Surgery was performed on 90 elderly patients with clinically and radiologically defined LSS: mean age at surgery, 73 years; 46 men and 44 women. Patients completed questionnaires before surgery and 1 year postoperatively. They used a self-administered the Roland Morris Disability Questionnaire (RDQ), the Japanese Orthopaedic Association Back Pain Questionnaire (JOABPEQ), MOS 36-Item ShortForm Health Survey (SF-36), and satisfaction for surgery (VAS) were completed. At baseline, psychological factors were assessed using the Self-Rating Questionnaire for Depression (SRQ-D), Hospital Anxiety and Depression scale (HADS), Pain Catastrophizing Scale (PCS), Pain Anxiety Symptoms Scale-20, and Brief Scale for Psychiatric Problems in Orthopaedic Patients (BS-POP). At follow-up, patient satisfaction was evaluated using 2 items: (1) satisfaction with surgery and (2) Would you undergo the same surgery again?. Results: Satisfaction item 1 correlated negatively with the VAS for low back pain, leg pain, numbness, JOABPEQ social life disturbance score, SF-36 physical function score, and HADS anxiety score (p < 0.05). Satisfaction 2 correlated negatively with age at surgery, VAS of leg pain, PCS magnification score, and BSPOP score (p < 0.05). Multiple regression analysis showed significant associations between satisfaction 1 and SF-36 physical function and HADS anxiety scores, and between satisfaction 2 and PCS magnification score (p < 0.05). Statistical analysis: The preoperative factors independently associated with surgical satisfaction were analyzed utilizing Speaman’s rank correlation coefficient and multiple regression analysis. Conclusion: Physical function and anxiety were identified as preoperative factors that affected patient satisfaction with surgery. Preoperative assessment of psychological factors and interventions for anxiety may help improve patient satisfaction after surgery for LSS. © 2019 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.
1. Introduction Patient-reported outcomes are used for assessing the clinical outcomes of spinal disorders. Patient satisfaction with a treatment is an important outcome measure and is associated with increased adherence to that treatment. As the proportion of elderly people to
* Corresponding author. 219 Myoji, Katsuragi-cho, Ito-gun, Wakayama, 649-7113, Japan. Fax: þ81 736 22 8223. E-mail address: [email protected] (T. Kitano CP).
the general population increases, spine surgeons have more opportunities to treat patients with lumbar spinal stenosis (LSS). It is important to improve patient satisfaction with surgery as well as the physical function and quality of life in elderly patients with LSS. Previous publications have reported that satisfaction with surgery in patients with LSS is related to age at the time of surgery, severity of symptoms, obesity, history of lumbar surgery, patient expectations for surgery, and depression [1e6]. It is possible that psychological factors such as the patient's anxiety level and catastrophic thinking which negatively captures pain experience in addition to depression may also be affect the
https://doi.org/10.1016/j.jos.2019.10.005 0949-2658/© 2019 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.
Please cite this article as: Kitano CP T et al., Preoperative psychological factors affecting surgical satisfaction of elderly patients with lumbar spinal stenosis, Journal of Orthopaedic Science, https://doi.org/10.1016/j.jos.2019.10.005
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surgical outcomes of patients with LSS. However, few reports have identified the specific psychological factors that affect patient satisfaction with surgery in patients with LSS. The objective of this retrospective observational cohort study was to investigate whether preoperative psychological factors are related to the satisfaction with surgery of elderly LSS patients.
2. Materials and methods Patients aged more than 65 years who underwent surgery for clinically and radiologically defined LSS at our spine care center between October 2012 and March 2015 were included. Patients with previous spine surgery, other spinal disorders, osteoarthrosis of the lower extremities, peripheral artery disease, peripheral neuropathy, patients with psychiatric consultation or disease which cannot obtain answer in questionnaire that could compromise outcomes assessment, or who were lost to follow-up at 1 year were excluded. Ninety patients were included in this study. Their mean age at the time of surgery was 73.0 ± 6.4 years (mean ± standard deviation). There were 46 men and 44 women. Follow-up rate in the present study was 80.3%. In this retrospective cohort study, prospectively collected data for these patients were reviewed 1 year postoperatively. At the baseline and follow-up, patients were asked about their demographic background and duration of symptoms before surgery. Demographic data recorded age, gender, and whether the patient had a live-in relative. A self-administered visual analog scale (VAS) was used to assess the patients’ expectations of surgery (Please let us know how much you are expecting symptoms to be taken in order to do your daily life and work without problems.) and the intensity of low back pain, leg pain, and leg numbness. The Roland Morris Disability Questionnaire (RDQ), five subdomains of the Japanese Orthopaedic Association Back Pain Questionnaire (JOABPEQ), and the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) were completed. At the baseline, psychological factors were assessed using the Self-Rating Questionnaire for Depression (SRQ-D), Pain Catastrophizing Scale (PCS), which includes rumination, magnification, and helplessness, Pain Anxiety Symptoms Scale-20 (PASS20), Hospital Anxiety and Depression scale (HADS), and Brief Scale for Psychiatric Problems in Orthopaedic Patients (BS-POP). The VAS ranges from 0 to 100 mm, with higher scores indicating more severe symptoms. This has proved to be a valid index of experimental, clinical, and chronic pain [7,19]. The RDQ score ranges from 0 to 24 and asks about the degree of disability experienced during daily activities such as standing, walking, sitting, getting dressed, and working [8]. The JOABPEQ includes five factors: pain-related disorders, lumbar dysfunction, gait disturbance, social life dysfunction, and psychological disorders. The range of the score for each domain is 0e100 points, with lower scores indicating more severe symptoms. The JOABPEQ has been shown to have good reliability and validity, and is used in the evaluation of lumbar disease [9,10]. The SF-36 comprises eight factors: vitality, physical functioning, bodily pain, general health perceptions, physical role functioning, emotional role functioning, social role functioning, and mental health. The range of scores for each domain is 0e100 points, with lower scores indicating greater disability [11,21,22]. The SRQ-D includes many questions about depression-related physical symptoms and is suitable for evaluating masked depression. The SRQ-D score ranges from 0 to 36, with higher scores indicating greater severity. A score of 10 points or less is regarded as being in the normal range, a score of 10e15 is suggestive of depression, and a score of 16 points or more indicates
the probable presence of mild depression [12,24]. The SRQ-D has been found to have good reliability and validity. The HADS is anxiety and depression evaluation of patients with physical symptoms. The HADS anxiety and depression subscales range from 0 to 21, with higher scores indicating greater severity. A score of 0e7 for either subscale is regarded as being in the normal range, a score of 8e10 is suggestive of the presence of anxiety or depression, and a score of 11 or higher indicates the probable presence of a mood disorder. The HADS has been found to have good reliability and validity [13,20]. The PCS score ranges from 0 to 52, with higher scores indicating more frequent catastrophizing when experiencing pain. The PCS has been shown to have sufficient internal reliability, including the Japanese version [14,25]. The PASS-20 score ranges from 0 to 100, with higher scores indicating greater pain, anxiety, or fear of pain. The Japanese version of the PASS-20 has been shown to be internally reliable [15,26]. The BS-POP is used to evaluate psychiatric problems more simply than instruments such as the Minnesota Multiphasic Personality Inventory. The BS-POP comprises two parts: a questionnaire for patient evaluation completed by the doctor and a questionnaire about emotions completed by the patient. The range of the score for doctor domain is 8e24 points and for patient domain is 10e30 points. The cutoff values over the 11 points by doctor or over the 10 points by doctor and over 15 points by patient. The BS-POP has been found to have good reliability and validity [16]. At the follow-up, patient satisfaction was evaluated using two ratings. One is satisfaction with surgery received because it carries out daily life and work without problems. Second, if you have similar symptoms, will you receive the same operation again? These were scored using a VAS (range 0e100 mm), with higher scores indicating greater satisfaction [23]. This research has been approved by the IRB of the authors’ affiliated institutions.
2.1. Statistical analysis Comparisons of parametric variables between preoperative and postoperative measures were compared using Student's t test for parametric variables and the ManneWhitney U test for nonparametric variables. The data obtained from the JOABPEQ are presented as effective rates for each domain according to the instructions for the use of the JOABPEQ. Preoperative factors affecting surgical satisfaction were examined using Spearman's rank correlation coefficient and the stepwise method of multiple regression analysis. All statistical tests were two-tailed, and the significance level was fixed at 0.05. All computations were performed using IBM SPSS Statistics (version 23, IBM Corp., Armonk, NY, USA).
3. Results In the preoperative psychological evaluation, the average total PCS and PASS-20 scores were higher in patients than in healthy people [17] (Table 1). Preoperatively, patients in this cohort showed evidence of high pain catastrophizing, anxiety, and fear. The expectation VAS was average of patients planning to receive an operation: 92.0 ± 12.7 mm (mean ± standard deviation). The preoperative RDQ score was 14.1 ± 7.8 and improved to 8.3 ± 6.4 at 1 year postoperatively. The VAS for low back pain, leg
Please cite this article as: Kitano CP T et al., Preoperative psychological factors affecting surgical satisfaction of elderly patients with lumbar spinal stenosis, Journal of Orthopaedic Science, https://doi.org/10.1016/j.jos.2019.10.005
T. Kitano CP et al. / Journal of Orthopaedic Science xxx (xxxx) xxx
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Table 1 Average/standard divided of psychological evaluation in preoperation.
SRQ-D PCS
total rumination helplessness magnification total cognitive anxiety escape/avoidance fear physiological anxiety anxiety depression patient doctor
PASS-20
HADS BS-POP
Patient (point)
abnormal (%)
Healthy person (average)
Cut off point
9.5 ± 4.9 34.6 ± 10.6 16.3 ± 3.7 11.4 ± 4.9 6.9 ± 3.1 47.6 ± 18 14.3 ± 5.8 13.2 ± 5 13 ± 5.8 7 ± 4.8 5.9 ± 3.7 5.9 ± 3.9 9.7 ± 1.8 16.4 ± 3.3
35.6 55.6
8.6 20.1
&10 &31
37.8 64.4 33.3 40 10 10 10 42.2
Males 4.4 Females 5.0 Males 4.8 Females 4.7 16.53 11.19
&14 &14 &14 &14 &7 &7 310 315
SRQ-D:Self Rating Questionnaire of Depression、PCS:Pain Catastrophyzing Scale、PASS-20:Pain Anxiety Symptoms Scale-20、HADS:Hospital Anxiety Depression Scale、BSPOP:Brief Scale for Psychiatric Problems in Orthopaedic Patients. Average ± standard deviation.
preopelaƟon VAS
investgated VAS
100 90 80 70
73 66.6
64.1
60 50 37.1
40
35.9
39.4
30
20 10 0 low back pain
Lower limb pain
Lower limb numbness
Fig. 1. Preoperative and postoperative VAS value (mm) at the preoperative of low back pain/lower limb pain/lower limb numbness.
pain, and leg numbness also improved significantly after surgery (Fig. 1). The effective rates of JOABPEQ domains were 70%, 39%, 57%, 43%, and 33% for pain-related disorder, lumbar spine dysfunction, gait dysfunction, social life dysfunction, and psychological disorder, respectively. The SF-36 showed improvements in all domains at the follow-up, but only the improvements in physical function and
Table 2 Each of subdomain points of SF-36 preoperative and investigation. Pre Operation PF RE MH VT RP SF BP GH
38.9 41.7 53.7 45.5 36.6 56.4 29.2 46.8
± ± ± ± ± ± ± ±
21.8 30.2 22.6 22.2 26.6 26.4 15.2 15.2
Investigation 59.5 57.4 67.9 58.8 49.4 71.7 54.9 55.9
± ± ± ± ± ± ± ±
26.4 * 30.8 21.3 21.1 29.2 26.6 24.2 * 16.6 p < 0.05
PF: Physical Functioning、RE: Role Emotional、MH: Mental Health、VT: Vitality、 RP: Role Physical、SF:Social Functioning、BP: Bodily Pan、GH: General Health. Average ± standard deviation.
body pain were significant (Table 2): P < 0.001 and P < 0.001, respectively. The VAS scores for the questions about the patient's satisfaction with surgery and whether the patient would undertake the same surgery again were 73.4 ± 23.6 mm, and 55.2 ± 39.1 mm, respectively (Fig. 2). Spearman's rank correlation analysis was used to analyze the relationships between the VAS scores for the patient's satisfaction with surgery and whether the patient would undergo the same surgery again with preoperative psychological evaluation items. Satisfaction with surgery correlated weakly and negatively with the VAS for leg numbness, JOABPEQ social life disturbance score, SF-36 physical function score, and HADS anxiety score, and positively with SF-36 mental health score (P < 0.05) (Table 3). A positive response to whether the patient would undertake the same surgery again correlated negatively with age at the time of surgery, RDQ score, PCS total and magnification scores, HADS anxiety score, and BS-POP patient's score (P < 0.05) (Table 3). Multiple regression analysis was used with inclusion of the VAS scores for the two satisfaction items as the dependent variables and the evaluation of preoperative patients including psychological measures as the independent variables. Significant models for each satisfaction item were obtained. The equation for the first
Please cite this article as: Kitano CP T et al., Preoperative psychological factors affecting surgical satisfaction of elderly patients with lumbar spinal stenosis, Journal of Orthopaedic Science, https://doi.org/10.1016/j.jos.2019.10.005
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100 90 80 70 60 73.4 50 55.2
40 30 20 10 0
Fig. 2. Patient's satisfaction with surgery, Would you undergo the same surgery ? Each mean value (mm) of VAS.
Table 3 Correlation with each VAS and preoperative survey items. satisfaction surgery VAS
age gender
Would you undergo the same surgery again? VAS
correlation coefficient
P score
correlation coefficient
P score
0.028 0.081
0.405 0.243
0.210 0.223
0.034* 0.026*
0.009 0.108 0.072 0.206
0.470 0.177 0.267 0.037 *
0.027 0.095 0.179 0.069
0.410 0.208 0.061 0.276
VAS
expectation low back pain leg pain leg numbness RDQ
0.056
0.315
0.197
0.044*
JOABPEQ
low back pain Lumbar function Walking ability Social life function Mental health
0.053 0.087 0.060 0.191 0.023
0.323 0.227 0.305 0.049 * 0.422
0.161 0.050 0.146 0.134 0.136
0.083 0.335 0.104 0.125 0.121
SF-36
PF RE VT RP SF BP GH severity of symptoms physical function
0.229 0.041 0.208 0.097 0.116 0.034 0.067 0.078 0.030 0.063
0.024* 0.364 0.036* 0.203 0.159 0.3 86 0.283 0.251 0.399 0.294
0.031 0.185 0.082 0.055 0.138 0.163 0.032 0.178 0.070 0.223
0.396 0.054 0.240 0.319 0.117 0.080 0.392 0.062 0.275 0.027
SRQ-D
0.138
0.118
0.013
0.455
PCS
total rumination helplessness magnification
0.105 0.118 0.029 0.168
0.182 0.155 0.400 0.074
0.195 0.132 0.156 0.259
0.045* 0.128 0.089 0.012*
PASS-20
total cognitive anxiety escape/avoidance fear physiologic al anxiety
0.047 0.018 0.005 0.052 0.143
0.343 0.440 0.484 0.328 0.109
0.077 0.046 0.129 0.047 0.051
0.253 0.348 0.134 0.344 0.331
HADS
anxiety depression
0.275 0.131
0.008** 0.131
0.217 0.140
0.030* 0.113
BS-POP
physician version Patient version
0.033 0.009
0.390 0.470
0.127 0.203
0.137 0.040*
MH
ZCQ
*p < 0.05, **:p < 0.01 VAS:Visual Analog Scale, JOABPEQ:Japanese Orthopaedic Association Back Pain Evaluation, SF-36:MOS short form 36 health survey, ZCQ:The Zurich claudication questionnaire, PCS:Pain Catastrophizing Scale, PASS-20:Pain Anxiety Symptoms Scale, HADS: Hospital Anxiety Depression Scale, BS-POP:Brief Scale for Psychiatric Problem in Orthopaedic Patients.
Please cite this article as: Kitano CP T et al., Preoperative psychological factors affecting surgical satisfaction of elderly patients with lumbar spinal stenosis, Journal of Orthopaedic Science, https://doi.org/10.1016/j.jos.2019.10.005
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satisfaction item (patient's satisfaction) was VAS ¼ 100.1e2.24 x HADS anxiety score e 0.36 x preoperative SF-36 physical function score (R ¼ 0.42, R2 ¼ 0.17, P ¼ 0.001). The equation for the second satisfaction item (Would you undergo the same surgery again?) was VAS ¼ 76.54e3.22 PCS magnified view (R ¼ 0.26, R2 ¼ 0.07, P ¼ 0.02). 4. Discussion In this retrospective cohort study, various patient-reported outcomes improved after surgery even in patients with LSS who were older than 65 years. However, patient satisfaction with surgery, which was evaluated using two-dimensional measures (patient satisfaction and would you undergo the same surgery again?) was not high. In the present study, we focused on the preoperative psychological aspects and evaluated the relationships between patient demographic data, patient-reported outcomes, and patient satisfaction. Psychological factors are involved in the initiation, maintenance, and deterioration of symptoms in patients with low back pain [17]. Therefore, evaluation of psychological factors may be helpful in the diagnosis and treatment of patients with low back pain. In the present study, we used the PCS, which was developed as a comprehensive evaluation instrument that encompassed different perspectives on catastrophizing and is currently one of the most widely used measures of catastrophic thinking related to pain, and the PASS-20, which measures fear, anxiety, and avoidance behavior responses specific to pain. As noted above, the relationship between low back pain and depression has been reported. In the present study, we used the HADS, which was developed to detect anxiety and depression in people with physical health problems to avoid reliance on aspects of these conditions that are also common somatic symptoms of other conditions such as fatigue and insomnia. We used the SRQ-D, which contains many questions about depression-related physical symptoms and is suitable for evaluating masked depression. To evaluate any psychiatric problems in the orthopedic patients, we also used the BS-POP, which comprises two separate instruments for the patients' selfevaluation and the doctor's evaluation of the patient. We found no relationships between patient satisfaction, as measured by the two questions about their satisfaction and whether they would undertake the surgery again, and depressive status, as evaluated by the HADS and SRQ-D. Patients with LSS with indications of severe depression were excluded in this series, and there may have been a selection bias. The preoperative factors affecting patient satisfaction were identified as physical function on the SF-36, anxiety on the HADS, and magnification of pain on the PCS. We found that the higher the physical function score before surgery, the lower the satisfaction with surgery. This suggests that physical function of LSS patients might be affected by not only dysfunction of the lumbar spine and lower extremities secondary to LSS itself, but also by the functional disability associated with the aging process. This may mean that, in elderly patients with LSS with mild physical dysfunction, agingrelated dysfunction is not expected to improve even after surgery. Surgery can improve LSS dysfunction but not age-related decline. As such, this may have resulted in the lower patient satisfaction observed in our study. We also found that both the VAS scores for the questions about the patient's satisfaction with surgery and whether the patient would undertake the same surgery again were influenced by preoperative anxiety. People who are strong anxiety were reluctant to undergo the same surgery again and led to a decrease in satisfaction. Severe anxiety might decrease patient satisfaction with surgery. This suggests that acknowledging the patient's anxiety and
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about pain, and possibly modifying the pain before surgery, may help the patient to feel more secure about the surgery. It was found that there is a tendency to be reluctant to undergo the same operation again if the tendency to catastrophizing for pain or magnification the pain (Overreact to pain) is high. In the case of chronic pain where the cause of the pain is obvious, physical treatment and psychological intervention (thinking how to manage pain together, understanding the progression of the disease, and preparing a postoperative support system) to deepen understanding of the medical condition and facilitate treatment. These preoperative psychological approaches may reduce preoperative anxiety and increase patient satisfaction with the treatment [18]. Our study has some limitations. The number of patients was small, and the study design was not prospective. Differences in surgical procedures and measurements from the imaging studies were not examined. It is possible that there was selection bias in the inclusion of the target patients. Although psychological disorders improved, as measured using the JOABPEQ, the psychological state at the follow-up might have affected patient satisfaction with surgery. Psychological evaluation at the follow-up is needed in future studies. Finally, although statistically significant, the correlation coefficients and contribution rates were low in the present study. 5. Conclusion In this retrospective cohort study, 90 patients aged more than 65 years who were surgically treated for LSS were recruited and followed for 1 year postoperatively. We evaluated the relationships between patient-reported outcomes, including patient's satisfaction after surgery, and preoperative psychological factors. Satisfaction with surgery was closely associated with physical function and anxiety before surgery. These findings suggest that clinicians should consider both the patient's physical function and their preoperative psychological state when treating elderly patients with LSS and that such consideration may lead to improved patient satisfaction with surgery. Declaration of Competing Interest None declared. Sources of funding None declared. Appendix A. Supplementary data Supplementary data related to this article can be found at https://doi.org/10.1016/j.jos.2019.10.005. References [1] Sinikallio S, Aalt T, Airaksinen O, Herno A, Kroger H, Savolainen S, Turunen V, Viinamaki H. Depression is associated with poorer outcome of lumbar spinal stenosis surgery. Eur Spine J 2007 Jul;16(7):905e12. [2] Knutsson B, Michaelsson K, Sanden B. Obesity is associated with inferior results after surgery for spinal stenosis. Spine 2013 Mar 1;38(5):435e41. [3] Sinikallio S, Aalto T, Airaksinen O, Airaksinen O, Herno A, Kroger H, Savolainen S, Turunen V, Viinamaki H. Lumbar spinal stenosis patients are satisfied with short-term results of surgery-younger age, symptom severity, disability and depression decrease satisfaction. Disabil Rehabil 2007 Apr 15;29(7):537e44. [4] Gepstein R, Arinzon Z, Adunsky A, Folman Y. Decompression surgery for lumbar spinal stenosis in the elderly: preoperative expectations and postoperative satisfaction. Spinal Cord 2006 Jul;44(7):427e31. [5] Iversen MD, Daltroy LH, Fossel AH, Katz JN. The prognostic importance of patient pre-operative expectations of surgery for lumbar spinal stenosis. Patient Educ Couns 1998 Jun;34(2):169e78.
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Please cite this article as: Kitano CP T et al., Preoperative psychological factors affecting surgical satisfaction of elderly patients with lumbar spinal stenosis, Journal of Orthopaedic Science, https://doi.org/10.1016/j.jos.2019.10.005
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Original Article
Preoperative psychological factors affecting surgical satisfaction of elderly patients with lumbar spinal stenosis Tomoko Kitano CP a, *, Mamoru Kawakami a, Daisuke Fukui b, Yuyu Ishimoto b, Keiji Nagata b, Hiroshi Yamada b, Yukihiro Nakagawa a a b
Spine Care Center, Wakayama Medical University Kihoku Hospital, Japan Department of Orthopaedic Surgery, Wakayama Medical University, Japan
a r t i c l e i n f o
a b s t r a c t
Article history: Received 18 December 2018 Received in revised form 5 September 2019 Accepted 1 October 2019 Available online xxx
Objective: The objective of this observational study was to investigate the effects of preoperative psychological factors on short-term patient satisfaction with surgery in elderly patients with lumbar spinal stenosis (LSS). Methods: Surgery was performed on 90 elderly patients with clinically and radiologically defined LSS: mean age at surgery, 73 years; 46 men and 44 women. Patients completed questionnaires before surgery and 1 year postoperatively. They used a self-administered the Roland Morris Disability Questionnaire (RDQ), the Japanese Orthopaedic Association Back Pain Questionnaire (JOABPEQ), MOS 36-Item ShortForm Health Survey (SF-36), and satisfaction for surgery (VAS) were completed. At baseline, psychological factors were assessed using the Self-Rating Questionnaire for Depression (SRQ-D), Hospital Anxiety and Depression scale (HADS), Pain Catastrophizing Scale (PCS), Pain Anxiety Symptoms Scale-20, and Brief Scale for Psychiatric Problems in Orthopaedic Patients (BS-POP). At follow-up, patient satisfaction was evaluated using 2 items: (1) satisfaction with surgery and (2) Would you undergo the same surgery again?. Results: Satisfaction item 1 correlated negatively with the VAS for low back pain, leg pain, numbness, JOABPEQ social life disturbance score, SF-36 physical function score, and HADS anxiety score (p < 0.05). Satisfaction 2 correlated negatively with age at surgery, VAS of leg pain, PCS magnification score, and BSPOP score (p < 0.05). Multiple regression analysis showed significant associations between satisfaction 1 and SF-36 physical function and HADS anxiety scores, and between satisfaction 2 and PCS magnification score (p < 0.05). Statistical analysis: The preoperative factors independently associated with surgical satisfaction were analyzed utilizing Speaman’s rank correlation coefficient and multiple regression analysis. Conclusion: Physical function and anxiety were identified as preoperative factors that affected patient satisfaction with surgery. Preoperative assessment of psychological factors and interventions for anxiety may help improve patient satisfaction after surgery for LSS. © 2019 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.
1. Introduction Patient-reported outcomes are used for assessing the clinical outcomes of spinal disorders. Patient satisfaction with a treatment is an important outcome measure and is associated with increased adherence to that treatment. As the proportion of elderly people to
* Corresponding author. 219 Myoji, Katsuragi-cho, Ito-gun, Wakayama, 649-7113, Japan. Fax: þ81 736 22 8223. E-mail address: [email protected] (T. Kitano CP).
the general population increases, spine surgeons have more opportunities to treat patients with lumbar spinal stenosis (LSS). It is important to improve patient satisfaction with surgery as well as the physical function and quality of life in elderly patients with LSS. Previous publications have reported that satisfaction with surgery in patients with LSS is related to age at the time of surgery, severity of symptoms, obesity, history of lumbar surgery, patient expectations for surgery, and depression [1e6]. It is possible that psychological factors such as the patient's anxiety level and catastrophic thinking which negatively captures pain experience in addition to depression may also be affect the
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Please cite this article as: Kitano CP T et al., Preoperative psychological factors affecting surgical satisfaction of elderly patients with lumbar spinal stenosis, Journal of Orthopaedic Science, https://doi.org/10.1016/j.jos.2019.10.005
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surgical outcomes of patients with LSS. However, few reports have identified the specific psychological factors that affect patient satisfaction with surgery in patients with LSS. The objective of this retrospective observational cohort study was to investigate whether preoperative psychological factors are related to the satisfaction with surgery of elderly LSS patients.
2. Materials and methods Patients aged more than 65 years who underwent surgery for clinically and radiologically defined LSS at our spine care center between October 2012 and March 2015 were included. Patients with previous spine surgery, other spinal disorders, osteoarthrosis of the lower extremities, peripheral artery disease, peripheral neuropathy, patients with psychiatric consultation or disease which cannot obtain answer in questionnaire that could compromise outcomes assessment, or who were lost to follow-up at 1 year were excluded. Ninety patients were included in this study. Their mean age at the time of surgery was 73.0 ± 6.4 years (mean ± standard deviation). There were 46 men and 44 women. Follow-up rate in the present study was 80.3%. In this retrospective cohort study, prospectively collected data for these patients were reviewed 1 year postoperatively. At the baseline and follow-up, patients were asked about their demographic background and duration of symptoms before surgery. Demographic data recorded age, gender, and whether the patient had a live-in relative. A self-administered visual analog scale (VAS) was used to assess the patients’ expectations of surgery (Please let us know how much you are expecting symptoms to be taken in order to do your daily life and work without problems.) and the intensity of low back pain, leg pain, and leg numbness. The Roland Morris Disability Questionnaire (RDQ), five subdomains of the Japanese Orthopaedic Association Back Pain Questionnaire (JOABPEQ), and the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) were completed. At the baseline, psychological factors were assessed using the Self-Rating Questionnaire for Depression (SRQ-D), Pain Catastrophizing Scale (PCS), which includes rumination, magnification, and helplessness, Pain Anxiety Symptoms Scale-20 (PASS20), Hospital Anxiety and Depression scale (HADS), and Brief Scale for Psychiatric Problems in Orthopaedic Patients (BS-POP). The VAS ranges from 0 to 100 mm, with higher scores indicating more severe symptoms. This has proved to be a valid index of experimental, clinical, and chronic pain [7,19]. The RDQ score ranges from 0 to 24 and asks about the degree of disability experienced during daily activities such as standing, walking, sitting, getting dressed, and working [8]. The JOABPEQ includes five factors: pain-related disorders, lumbar dysfunction, gait disturbance, social life dysfunction, and psychological disorders. The range of the score for each domain is 0e100 points, with lower scores indicating more severe symptoms. The JOABPEQ has been shown to have good reliability and validity, and is used in the evaluation of lumbar disease [9,10]. The SF-36 comprises eight factors: vitality, physical functioning, bodily pain, general health perceptions, physical role functioning, emotional role functioning, social role functioning, and mental health. The range of scores for each domain is 0e100 points, with lower scores indicating greater disability [11,21,22]. The SRQ-D includes many questions about depression-related physical symptoms and is suitable for evaluating masked depression. The SRQ-D score ranges from 0 to 36, with higher scores indicating greater severity. A score of 10 points or less is regarded as being in the normal range, a score of 10e15 is suggestive of depression, and a score of 16 points or more indicates
the probable presence of mild depression [12,24]. The SRQ-D has been found to have good reliability and validity. The HADS is anxiety and depression evaluation of patients with physical symptoms. The HADS anxiety and depression subscales range from 0 to 21, with higher scores indicating greater severity. A score of 0e7 for either subscale is regarded as being in the normal range, a score of 8e10 is suggestive of the presence of anxiety or depression, and a score of 11 or higher indicates the probable presence of a mood disorder. The HADS has been found to have good reliability and validity [13,20]. The PCS score ranges from 0 to 52, with higher scores indicating more frequent catastrophizing when experiencing pain. The PCS has been shown to have sufficient internal reliability, including the Japanese version [14,25]. The PASS-20 score ranges from 0 to 100, with higher scores indicating greater pain, anxiety, or fear of pain. The Japanese version of the PASS-20 has been shown to be internally reliable [15,26]. The BS-POP is used to evaluate psychiatric problems more simply than instruments such as the Minnesota Multiphasic Personality Inventory. The BS-POP comprises two parts: a questionnaire for patient evaluation completed by the doctor and a questionnaire about emotions completed by the patient. The range of the score for doctor domain is 8e24 points and for patient domain is 10e30 points. The cutoff values over the 11 points by doctor or over the 10 points by doctor and over 15 points by patient. The BS-POP has been found to have good reliability and validity [16]. At the follow-up, patient satisfaction was evaluated using two ratings. One is satisfaction with surgery received because it carries out daily life and work without problems. Second, if you have similar symptoms, will you receive the same operation again? These were scored using a VAS (range 0e100 mm), with higher scores indicating greater satisfaction [23]. This research has been approved by the IRB of the authors’ affiliated institutions.
2.1. Statistical analysis Comparisons of parametric variables between preoperative and postoperative measures were compared using Student's t test for parametric variables and the ManneWhitney U test for nonparametric variables. The data obtained from the JOABPEQ are presented as effective rates for each domain according to the instructions for the use of the JOABPEQ. Preoperative factors affecting surgical satisfaction were examined using Spearman's rank correlation coefficient and the stepwise method of multiple regression analysis. All statistical tests were two-tailed, and the significance level was fixed at 0.05. All computations were performed using IBM SPSS Statistics (version 23, IBM Corp., Armonk, NY, USA).
3. Results In the preoperative psychological evaluation, the average total PCS and PASS-20 scores were higher in patients than in healthy people [17] (Table 1). Preoperatively, patients in this cohort showed evidence of high pain catastrophizing, anxiety, and fear. The expectation VAS was average of patients planning to receive an operation: 92.0 ± 12.7 mm (mean ± standard deviation). The preoperative RDQ score was 14.1 ± 7.8 and improved to 8.3 ± 6.4 at 1 year postoperatively. The VAS for low back pain, leg
Please cite this article as: Kitano CP T et al., Preoperative psychological factors affecting surgical satisfaction of elderly patients with lumbar spinal stenosis, Journal of Orthopaedic Science, https://doi.org/10.1016/j.jos.2019.10.005
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Table 1 Average/standard divided of psychological evaluation in preoperation.
SRQ-D PCS
total rumination helplessness magnification total cognitive anxiety escape/avoidance fear physiological anxiety anxiety depression patient doctor
PASS-20
HADS BS-POP
Patient (point)
abnormal (%)
Healthy person (average)
Cut off point
9.5 ± 4.9 34.6 ± 10.6 16.3 ± 3.7 11.4 ± 4.9 6.9 ± 3.1 47.6 ± 18 14.3 ± 5.8 13.2 ± 5 13 ± 5.8 7 ± 4.8 5.9 ± 3.7 5.9 ± 3.9 9.7 ± 1.8 16.4 ± 3.3
35.6 55.6
8.6 20.1
&10 &31
37.8 64.4 33.3 40 10 10 10 42.2
Males 4.4 Females 5.0 Males 4.8 Females 4.7 16.53 11.19
&14 &14 &14 &14 &7 &7 310 315
SRQ-D:Self Rating Questionnaire of Depression、PCS:Pain Catastrophyzing Scale、PASS-20:Pain Anxiety Symptoms Scale-20、HADS:Hospital Anxiety Depression Scale、BSPOP:Brief Scale for Psychiatric Problems in Orthopaedic Patients. Average ± standard deviation.
preopelaƟon VAS
investgated VAS
100 90 80 70
73 66.6
64.1
60 50 37.1
40
35.9
39.4
30
20 10 0 low back pain
Lower limb pain
Lower limb numbness
Fig. 1. Preoperative and postoperative VAS value (mm) at the preoperative of low back pain/lower limb pain/lower limb numbness.
pain, and leg numbness also improved significantly after surgery (Fig. 1). The effective rates of JOABPEQ domains were 70%, 39%, 57%, 43%, and 33% for pain-related disorder, lumbar spine dysfunction, gait dysfunction, social life dysfunction, and psychological disorder, respectively. The SF-36 showed improvements in all domains at the follow-up, but only the improvements in physical function and
Table 2 Each of subdomain points of SF-36 preoperative and investigation. Pre Operation PF RE MH VT RP SF BP GH
38.9 41.7 53.7 45.5 36.6 56.4 29.2 46.8
± ± ± ± ± ± ± ±
21.8 30.2 22.6 22.2 26.6 26.4 15.2 15.2
Investigation 59.5 57.4 67.9 58.8 49.4 71.7 54.9 55.9
± ± ± ± ± ± ± ±
26.4 * 30.8 21.3 21.1 29.2 26.6 24.2 * 16.6 p < 0.05
PF: Physical Functioning、RE: Role Emotional、MH: Mental Health、VT: Vitality、 RP: Role Physical、SF:Social Functioning、BP: Bodily Pan、GH: General Health. Average ± standard deviation.
body pain were significant (Table 2): P < 0.001 and P < 0.001, respectively. The VAS scores for the questions about the patient's satisfaction with surgery and whether the patient would undertake the same surgery again were 73.4 ± 23.6 mm, and 55.2 ± 39.1 mm, respectively (Fig. 2). Spearman's rank correlation analysis was used to analyze the relationships between the VAS scores for the patient's satisfaction with surgery and whether the patient would undergo the same surgery again with preoperative psychological evaluation items. Satisfaction with surgery correlated weakly and negatively with the VAS for leg numbness, JOABPEQ social life disturbance score, SF-36 physical function score, and HADS anxiety score, and positively with SF-36 mental health score (P < 0.05) (Table 3). A positive response to whether the patient would undertake the same surgery again correlated negatively with age at the time of surgery, RDQ score, PCS total and magnification scores, HADS anxiety score, and BS-POP patient's score (P < 0.05) (Table 3). Multiple regression analysis was used with inclusion of the VAS scores for the two satisfaction items as the dependent variables and the evaluation of preoperative patients including psychological measures as the independent variables. Significant models for each satisfaction item were obtained. The equation for the first
Please cite this article as: Kitano CP T et al., Preoperative psychological factors affecting surgical satisfaction of elderly patients with lumbar spinal stenosis, Journal of Orthopaedic Science, https://doi.org/10.1016/j.jos.2019.10.005
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100 90 80 70 60 73.4 50 55.2
40 30 20 10 0
Fig. 2. Patient's satisfaction with surgery, Would you undergo the same surgery ? Each mean value (mm) of VAS.
Table 3 Correlation with each VAS and preoperative survey items. satisfaction surgery VAS
age gender
Would you undergo the same surgery again? VAS
correlation coefficient
P score
correlation coefficient
P score
0.028 0.081
0.405 0.243
0.210 0.223
0.034* 0.026*
0.009 0.108 0.072 0.206
0.470 0.177 0.267 0.037 *
0.027 0.095 0.179 0.069
0.410 0.208 0.061 0.276
VAS
expectation low back pain leg pain leg numbness RDQ
0.056
0.315
0.197
0.044*
JOABPEQ
low back pain Lumbar function Walking ability Social life function Mental health
0.053 0.087 0.060 0.191 0.023
0.323 0.227 0.305 0.049 * 0.422
0.161 0.050 0.146 0.134 0.136
0.083 0.335 0.104 0.125 0.121
SF-36
PF RE VT RP SF BP GH severity of symptoms physical function
0.229 0.041 0.208 0.097 0.116 0.034 0.067 0.078 0.030 0.063
0.024* 0.364 0.036* 0.203 0.159 0.3 86 0.283 0.251 0.399 0.294
0.031 0.185 0.082 0.055 0.138 0.163 0.032 0.178 0.070 0.223
0.396 0.054 0.240 0.319 0.117 0.080 0.392 0.062 0.275 0.027
SRQ-D
0.138
0.118
0.013
0.455
PCS
total rumination helplessness magnification
0.105 0.118 0.029 0.168
0.182 0.155 0.400 0.074
0.195 0.132 0.156 0.259
0.045* 0.128 0.089 0.012*
PASS-20
total cognitive anxiety escape/avoidance fear physiologic al anxiety
0.047 0.018 0.005 0.052 0.143
0.343 0.440 0.484 0.328 0.109
0.077 0.046 0.129 0.047 0.051
0.253 0.348 0.134 0.344 0.331
HADS
anxiety depression
0.275 0.131
0.008** 0.131
0.217 0.140
0.030* 0.113
BS-POP
physician version Patient version
0.033 0.009
0.390 0.470
0.127 0.203
0.137 0.040*
MH
ZCQ
*p < 0.05, **:p < 0.01 VAS:Visual Analog Scale, JOABPEQ:Japanese Orthopaedic Association Back Pain Evaluation, SF-36:MOS short form 36 health survey, ZCQ:The Zurich claudication questionnaire, PCS:Pain Catastrophizing Scale, PASS-20:Pain Anxiety Symptoms Scale, HADS: Hospital Anxiety Depression Scale, BS-POP:Brief Scale for Psychiatric Problem in Orthopaedic Patients.
Please cite this article as: Kitano CP T et al., Preoperative psychological factors affecting surgical satisfaction of elderly patients with lumbar spinal stenosis, Journal of Orthopaedic Science, https://doi.org/10.1016/j.jos.2019.10.005
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satisfaction item (patient's satisfaction) was VAS ¼ 100.1e2.24 x HADS anxiety score e 0.36 x preoperative SF-36 physical function score (R ¼ 0.42, R2 ¼ 0.17, P ¼ 0.001). The equation for the second satisfaction item (Would you undergo the same surgery again?) was VAS ¼ 76.54e3.22 PCS magnified view (R ¼ 0.26, R2 ¼ 0.07, P ¼ 0.02). 4. Discussion In this retrospective cohort study, various patient-reported outcomes improved after surgery even in patients with LSS who were older than 65 years. However, patient satisfaction with surgery, which was evaluated using two-dimensional measures (patient satisfaction and would you undergo the same surgery again?) was not high. In the present study, we focused on the preoperative psychological aspects and evaluated the relationships between patient demographic data, patient-reported outcomes, and patient satisfaction. Psychological factors are involved in the initiation, maintenance, and deterioration of symptoms in patients with low back pain [17]. Therefore, evaluation of psychological factors may be helpful in the diagnosis and treatment of patients with low back pain. In the present study, we used the PCS, which was developed as a comprehensive evaluation instrument that encompassed different perspectives on catastrophizing and is currently one of the most widely used measures of catastrophic thinking related to pain, and the PASS-20, which measures fear, anxiety, and avoidance behavior responses specific to pain. As noted above, the relationship between low back pain and depression has been reported. In the present study, we used the HADS, which was developed to detect anxiety and depression in people with physical health problems to avoid reliance on aspects of these conditions that are also common somatic symptoms of other conditions such as fatigue and insomnia. We used the SRQ-D, which contains many questions about depression-related physical symptoms and is suitable for evaluating masked depression. To evaluate any psychiatric problems in the orthopedic patients, we also used the BS-POP, which comprises two separate instruments for the patients' selfevaluation and the doctor's evaluation of the patient. We found no relationships between patient satisfaction, as measured by the two questions about their satisfaction and whether they would undertake the surgery again, and depressive status, as evaluated by the HADS and SRQ-D. Patients with LSS with indications of severe depression were excluded in this series, and there may have been a selection bias. The preoperative factors affecting patient satisfaction were identified as physical function on the SF-36, anxiety on the HADS, and magnification of pain on the PCS. We found that the higher the physical function score before surgery, the lower the satisfaction with surgery. This suggests that physical function of LSS patients might be affected by not only dysfunction of the lumbar spine and lower extremities secondary to LSS itself, but also by the functional disability associated with the aging process. This may mean that, in elderly patients with LSS with mild physical dysfunction, agingrelated dysfunction is not expected to improve even after surgery. Surgery can improve LSS dysfunction but not age-related decline. As such, this may have resulted in the lower patient satisfaction observed in our study. We also found that both the VAS scores for the questions about the patient's satisfaction with surgery and whether the patient would undertake the same surgery again were influenced by preoperative anxiety. People who are strong anxiety were reluctant to undergo the same surgery again and led to a decrease in satisfaction. Severe anxiety might decrease patient satisfaction with surgery. This suggests that acknowledging the patient's anxiety and
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about pain, and possibly modifying the pain before surgery, may help the patient to feel more secure about the surgery. It was found that there is a tendency to be reluctant to undergo the same operation again if the tendency to catastrophizing for pain or magnification the pain (Overreact to pain) is high. In the case of chronic pain where the cause of the pain is obvious, physical treatment and psychological intervention (thinking how to manage pain together, understanding the progression of the disease, and preparing a postoperative support system) to deepen understanding of the medical condition and facilitate treatment. These preoperative psychological approaches may reduce preoperative anxiety and increase patient satisfaction with the treatment [18]. Our study has some limitations. The number of patients was small, and the study design was not prospective. Differences in surgical procedures and measurements from the imaging studies were not examined. It is possible that there was selection bias in the inclusion of the target patients. Although psychological disorders improved, as measured using the JOABPEQ, the psychological state at the follow-up might have affected patient satisfaction with surgery. Psychological evaluation at the follow-up is needed in future studies. Finally, although statistically significant, the correlation coefficients and contribution rates were low in the present study. 5. Conclusion In this retrospective cohort study, 90 patients aged more than 65 years who were surgically treated for LSS were recruited and followed for 1 year postoperatively. We evaluated the relationships between patient-reported outcomes, including patient's satisfaction after surgery, and preoperative psychological factors. Satisfaction with surgery was closely associated with physical function and anxiety before surgery. These findings suggest that clinicians should consider both the patient's physical function and their preoperative psychological state when treating elderly patients with LSS and that such consideration may lead to improved patient satisfaction with surgery. Declaration of Competing Interest None declared. Sources of funding None declared. Appendix A. Supplementary data Supplementary data related to this article can be found at https://doi.org/10.1016/j.jos.2019.10.005. References [1] Sinikallio S, Aalt T, Airaksinen O, Herno A, Kroger H, Savolainen S, Turunen V, Viinamaki H. Depression is associated with poorer outcome of lumbar spinal stenosis surgery. Eur Spine J 2007 Jul;16(7):905e12. [2] Knutsson B, Michaelsson K, Sanden B. Obesity is associated with inferior results after surgery for spinal stenosis. Spine 2013 Mar 1;38(5):435e41. [3] Sinikallio S, Aalto T, Airaksinen O, Airaksinen O, Herno A, Kroger H, Savolainen S, Turunen V, Viinamaki H. Lumbar spinal stenosis patients are satisfied with short-term results of surgery-younger age, symptom severity, disability and depression decrease satisfaction. Disabil Rehabil 2007 Apr 15;29(7):537e44. [4] Gepstein R, Arinzon Z, Adunsky A, Folman Y. Decompression surgery for lumbar spinal stenosis in the elderly: preoperative expectations and postoperative satisfaction. Spinal Cord 2006 Jul;44(7):427e31. [5] Iversen MD, Daltroy LH, Fossel AH, Katz JN. The prognostic importance of patient pre-operative expectations of surgery for lumbar spinal stenosis. Patient Educ Couns 1998 Jun;34(2):169e78.
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Please cite this article as: Kitano CP T et al., Preoperative psychological factors affecting surgical satisfaction of elderly patients with lumbar spinal stenosis, Journal of Orthopaedic Science, https://doi.org/10.1016/j.jos.2019.10.005