# Valuable Prognostic Role of Disability, Pain, Anxiety, and Depression Scales in Instrumented Lumbar Spine Surgery for Degenerative Pathology: The SAP-LD Study

## TL;DR

This study shows that preoperative psychological factors like anxiety and depression can predict recovery outcomes after lumbar spine surgery, suggesting the need for psychological screening in surgical planning.

## Contribution

The SAP-LD study introduces a new scale to assess the prognostic role of psychological and physical factors in lumbar spine surgery outcomes.

## Key findings

- Higher preoperative anxiety and depression scores correlate with worse postoperative outcomes, including increased pain and disability.
- Psychological interventions could improve long-term recovery and quality of life for patients undergoing lumbar spine surgery.
- Initial postoperative improvements in disability and pain often regress by 6 months, especially in patients with high preoperative psychological distress.

## Abstract

Background: Degenerative lumbar spine disease is a prevalent cause of chronic low back pain that significantly impairs daily function and quality of life. While conservative management is the first line of treatment, many patients ultimately require instrumented lumbar spine surgery. However, postoperative outcomes vary considerably, with emerging evidence suggesting that preoperative psychological factors such as anxiety, depression, and pain catastrophizing may influence recovery. The SAP-LD (Scale for Anxiety and Pain in Lumbar Degeneration) study was designed to assess the prognostic role of these psychological and physical parameters in surgical outcomes. Methods: This prospective observational study enrolled 70 adult patients with degenerative lumbar spine pathology scheduled for instrumented surgical treatment at the University of Brescia and ASST Spedali Civili di Brescia between March and December 2024. Preoperative assessments included demographic, clinical, and radiologic data along with validated scales: the Oswestry Disability Index (ODI), 36-Item Short Form Health Survey (SF-36), Visual Analogue Scale (VAS), Pain Catastrophizing Scale (PCS), and Hospital Anxiety and Depression Scale (HADS). Follow-up evaluations were performed at 45 days and at 6 months, and statistical analyses were conducted using correlation tests, ANOVA, and regression modeling. Results: The demographic analysis of the 70 enrolled patients shows a balanced gender distribution (38 females, 34 males) with a mean age of 61 years (range 23–81). The educational level distribution indicates that the majority of patients (44.29%) have a secondary education level, while 35.71% have a tertiary education level. Regarding employment status, 50% of the patients are retired or not working. Patients with clinically significant anxiety and/or depression showed higher levels of perceived pain, pain catastrophizing, and disability at baseline. These patients reported significantly worse scores on the Visual Analogue Scale (VAS), Pain Catastrophizing Scale (PCS), and Oswestry Disability Index (ODI). The Oswestry Disability Index (ODI) demonstrates a clinically significant improvement (reduction) in disability between the preoperative period (t0) and the 45-day follow-up (t2), with the median decreasing from 39.00 to 13.00. However, there is a partial regression at the 6-month follow-up (t3), with the median increasing to 27.00. For the SF-36 Health Survey, the General Health subscale shows an improvement between t0 and t2 (median increasing from 55.00 to 60.00), followed by a slight decrease at t3 (median 55.00). Similar patterns are observed in most other subscales, with initial improvement followed by partial regression. The Pain Catastrophizing Scale (PCS) shows a substantial reduction in catastrophizing between t0 and t2 (median decreasing from 16.00 to 3.00), followed by an increase at t3 (median 11.00), though still below baseline levels. Pain intensity as measured by the Visual Analogue Scale (VAS) shows a significant reduction at t2 (median decreasing from 5.00 to 3.00), but increases again at t3 (median 6.00), even exceeding the preoperative level. For the Hospital Anxiety and Depression Scale (HADS), no significant differences were observed across time points, with values indicating mild symptoms throughout the study period. Correlation analyses confirmed that higher preoperative anxiety and depression scores were predictive of poorer postoperative outcomes. Specifically, higher HADS scores at baseline are associated with higher ODI scores (increased disability) at all time points (p = 0.002), higher VAS scores (increased pain) at all time points (p = 0.015), and lower scores on SF-36 subscales, particularly Emotional Well-being (p = 0.00023) and Social Functioning (p = 0.002). Higher PCS scores at baseline are associated with higher ODI scores at all time points (p = 0.001), higher VAS scores at all time points (p = 0.008), and lower scores on SF-36 subscales, particularly Pain (p = 0.00023) and Physical Functioning (p = 0.04254). The mixed linear models analysis confirms these findings, showing that the ODI score decreases significantly between t0 and t2 (p = 0.00023) and increases between t2 and t3, though this increase is not statistically significant (p = 0.079). For VAS scores, there is a significant decrease between t0 and t2 (p = 0.00023) and a significant increase between t2 and t3 (p = 0.04254). Patients with elevated preoperative HADS scores tended to have slower recovery trajectories and reported lower satisfaction levels. These findings reinforce the prognostic value of psychological assessments in spine surgery and suggest that targeted psychological interventions could improve patient outcomes. Conclusions: By identifying psychological predictors of postoperative recovery, this study underscores the importance of integrating preoperative psychological screening into routine clinical practice. The results suggest that a multidisciplinary approach, including both surgical and psychological care, could enhance long-term functional outcomes and quality of life for patients undergoing instrumented lumbar spine surgery.