Psychological predictors of quality of life and functional outcome in patients undergoing elective surgery for degenerative lumbar spine disease



To quantify the correlation between patients’ psychopathological predisposition, disability and health-related quality of life (QOL) after surgery for degenerative lumbar spine disease.


We prospectively included patients undergoing decompression for degenerative lumbar spinal stenosis, spondylolisthesis or disc herniation with additional fusion of up to two segments. Patients completed a structured psychological assessment including the Center for Epidemiological Studies Depression Scale (ADS-K), Post-Traumatic Stress Scale–10 (PTSS-10), State Trait Anxiety Inventory–State Anxiety and State Trait Anxiety Inventory–Trait Anxiety (STAI-S and STAI-T) and Anxiety Sensitivity Index–3 (ASI-3) before surgery, after 3 and 12 months. Outcome measures included EuroQol 5D (EQ), Short Form-36 (SF-36) and Oswestry Disability Index (ODI) scores.


In total, 245 patients between March 2013 and November 2017 received surgery, of which 180 (73.5%) fully completed follow-up after 3 months and 12 months. QOL scores significantly increased by 3 months (EQ: +0.2; p < 0.001; SF-36 PCS: +7.0; p < 0.001; SF-36 MCS: +3.3; p = 0.018), a benefit which was retained at 12 months, without statistically significant difference between fused and non-fused patients. Depressed patients exhibited impaired mean scores of EQ (0.58 vs. 0.36; p < 0.001) and ODI mean scores (35.5 vs. 51.9; p < 0.001) at baseline, which significantly improved and converged with scores of non-depressed patients after 12 months. Linear regression analysis identified statistically significant predictors in age, STAI-T and SF-36 MCS for post-operative QOL and disability.


Despite exhibiting pronounced psychological distress preoperatively, patients may significantly benefit from surgery with an outcome equal to psychologically healthy patients after 12 months.

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  1. 1.

    Weinstein JN, Lurie JD, Tosteson TD, Tosteson ANA, Blood EA, Abdu WA, Herkowitz H, Hilibrand A, Albert T, Fischgrund J (2008) Surgical versus nonoperative treatment for lumbar disc herniation: four-year results for the Spine Patient Outcomes Research Trial (SPORT). Spine 33:2789–2800.

    Article  PubMed  PubMed Central  Google Scholar 

  2. 2.

    Weinstein JN, Tosteson TD, Lurie JD, Tosteson A, Blood E, Herkowitz H, Cammisa F, Albert T, Boden SD, Hilibrand A, Goldberg H, Berven S, An H (2010) Surgical versus nonoperative treatment for lumbar spinal stenosis four-year results of the Spine Patient Outcomes Research Trial. Spine 35:1329–1338.

    Article  PubMed  PubMed Central  Google Scholar 

  3. 3.

    Martin B, Mirza SK, Spina N, Spiker WR, Lawrence B, Brodke DS (2019) Trends in lumbar fusion procedure rates and associated hospital costs for degenerative spinal diseases in the United States, 2004–2015. Spine Publish Ahead of Print.

  4. 4.

    Eck JC, Sharan A, Ghogawala Z, Resnick DK, Watters WC 3rd, Mummaneni PV, Dailey AT, Choudhri TF, Groff MW, Wang JC, Dhall SS, Kaiser MG (2014) Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 7: lumbar fusion for intractable low-back pain without stenosis or spondylolisthesis. J Neurosurg Spine 21:42–47.

    Article  PubMed  Google Scholar 

  5. 5.

    Trief PM, Ploutz-Snyder R, Fredrickson BE (2006) Emotional health predicts pain and function after fusion: a prospective multicenter study. Spine 31:823–830.

    Article  PubMed  Google Scholar 

  6. 6.

    Daubs MD, Norvell DC, McGuire R, Molinari R, Hermsmeyer JT, Fourney DR, Wolinsky JP, Brodke D (2011) Fusion versus nonoperative care for chronic low back pain: Do psychological factors affect outcomes? Spine 36:S96–S109.

    Article  PubMed  Google Scholar 

  7. 7.

    Cobo Soriano J, Sendino Revuelta M, Fabregate Fuente M, Cimarra Díaz I, Martínez Ureña P, Deglané Meneses R (2010) Predictors of outcome after decompressive lumbar surgery and instrumented posterolateral fusion. Eur Spine J 19:1841–1848.

    Article  PubMed  PubMed Central  Google Scholar 

  8. 8.

    Chaichana KL, Mukherjee D, Adogwa O, Cheng JS, McGirt MJ (2011) Correlation of preoperative depression and somatic perception scales with postoperative disability and quality of life after lumbar discectomy. J Neurosurg Spine 14:261–267.

    Article  PubMed  Google Scholar 

  9. 9.

    Lebow R, Parker SL, Adogwa O, Reig A, Cheng J, Bydon A, McGirt MJ (2012) Microdiscectomy improves pain-associated depression, somatic anxiety, and mental well-being in patients with herniated lumbar disc. Neurosurgery 70:306–311; discussion 311.

  10. 10.

    Kemper CJ, Lutz J, Bähr T, Rüddel H, Hock M (2012) Construct validity of the Anxiety Sensitivity Index-3 in clinical samples. Assessment 19:89–100.

    Article  PubMed  Google Scholar 

  11. 11.

    Maercker A (2003) Posttraumatische-stress-Skala-10 (PTSS-10). In: Hoyer J, Margraf J (eds) Angstdiagnostik - Grundlagen und Testverfahren. Springer, Berlin, pp 401–403

    Google Scholar 

  12. 12.

    Auerbach SM (1973) Trait-state anxiety and adjustment of surgery. J Consult Clin Psychol 40:264–271.

    CAS  Article  PubMed  Google Scholar 

  13. 13.

    Hautzinger M, Bailer M (1993) Allgemeine Depressions Skala (ADS). Beltz Test, Weinheim

    Google Scholar 

  14. 14.

    Monticone M, Ambrosini E, Rocca B, Foti C, Ferrante S (2017) Responsiveness and minimal clinically important changes for the Tampa Scale of Kinesiophobia after lumbar fusion during cognitive behavioral rehabilitation. Eur J Phys Rehabil Med 53:351–358.

    Article  PubMed  Google Scholar 

  15. 15.

    Monticone M, Ferrante S, Teli M, Rocca B, Foti C, Lovi A, Brayda Bruno M (2014) Management of catastrophising and kinesiophobia improves rehabilitation after fusion for lumbar spondylolisthesis and stenosis. A randomised controlled trial. Eur Spine J 23:87–95.

    Article  PubMed  Google Scholar 

  16. 16.

    Donnarumma P, Presaghi F, Tarantino R, Fragale M, Rullo M, Delfini R (2017) The impact of pelvic balance, physical activity, and fear-avoidance on the outcome after decompression and instrumented fusion for degenerative lumbar stenosis. Eur Spine J 26:428–433.

    CAS  Article  PubMed  Google Scholar 

  17. 17.

    Abbey G, Thompson SBN, Hickish T, Heathcote D (2015) A meta-analysis of prevalence rates and moderating factors for cancer-related post-traumatic stress disorder. Psycho-oncology 24:371–381.

    Article  PubMed  Google Scholar 

  18. 18.

    Haddad M, Walters P, Phillips R, Tsakok J, Williams P, Mann A, Tylee A (2013) Detecting depression in patients with coronary heart disease: a diagnostic evaluation of the PHQ-9 and HADS-D in primary care, findings from the UPBEAT-UK study. PLoS ONE 8:e78493.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  19. 19.

    Lehr D, Hillert A, Schmitz E, Sosnowsky N (2008) Screening depressiver Störungen mittels Allgemeiner Depressions-Skala (ADS-K) und State-Trait Depressions Scales (STDS-T): Eine vergleichende Evaluation von Cut-Off-Werten. Diagnostica 54:61–70

    Article  Google Scholar 

  20. 20.

    Mannion AF, Junge A, Grob D, Dvorak J, Fairbank JCT (2006) Development of a German version of the Oswestry Disability Index. Part 2: sensitivity to change after spinal surgery. Eur Spine J 15:66–73.

    CAS  Article  PubMed  Google Scholar 

  21. 21.

    Chotai S, Khan I, Nian H, Archer KR, Harrell FE, Weisenthal BM, Bydon M, Asher AL, Devin CJ (2019) Utility of anxiety/depression domain of EQ-5D to define psychological distress in spine surgery. World Neurosurg.

    Article  PubMed  Google Scholar 

  22. 22.

    Parker SL, Mendenhall SK, Shau DN, Adogwa O, Anderson WN, Devin CJ, McGirt MJ (2012) Minimum clinically important difference in pain, disability, and quality of life after neural decompression and fusion for same-level recurrent lumbar stenosis: understanding clinical versus statistical significance. J Neurosurg Spine 16:471–478.

    Article  PubMed  Google Scholar 

  23. 23.

    Hagg O, Fritzell P, Nordwall A (2003) The clinical importance of changes in outcome scores after treatment for chronic low back pain. Eur Spine J 12:12–20.

    CAS  Article  PubMed  Google Scholar 

  24. 24.

    Graver V, Haaland AK, Magnaes B, Loeb M (1999) Seven-year clinical follow-up after lumbar disc surgery: results and predictors of outcome. Br J Neurosurg 13:178–184

    CAS  Article  Google Scholar 

  25. 25.

    DeVine J, Norvell DC, Ecker E, Fourney DR, Vaccaro A, Wang J, Andersson G (2011) Evaluating the correlation and responsiveness of patient-reported pain with function and quality-of-life outcomes after spine surgery. Spine 36:S69–S74.

    Article  PubMed  Google Scholar 

  26. 26.

    Carreon LY, Glassman SD, Howard J (2008) Fusion and nonsurgical treatment for symptomatic lumbar degenerative disease: a systematic review of Oswestry Disability Index and MOS Short Form-36 outcomes. Spine J 8:747–755.

    Article  PubMed  Google Scholar 

  27. 27.

    Cheng T, Gerdhem P (2018) Outcome of surgery for degenerative lumbar scoliosis: an observational study using the Swedish Spine register. Eur Spine J 27:622–629.

    Article  PubMed  Google Scholar 

  28. 28.

    Gautschi OP, Smoll NR, Joswig H, Corniola MV, Schaller K, Hildebrandt G, Stienen MN (2016) Influence of age on pain intensity, functional impairment and health-related quality of life before and after surgery for lumbar degenerative disc disease. Clin Neurol Neurosurg 150:33–39.

    Article  PubMed  Google Scholar 

  29. 29.

    Sinikallio S, Aalto T, Koivumaa-Honkanen H, Airaksinen O, Herno A, Kroger H, Viinamaki H (2009) Life dissatisfaction is associated with a poorer surgery outcome and depression among lumbar spinal stenosis patients: a 2-year prospective study. Eur Spine J 18:1187–1193.

    Article  PubMed  PubMed Central  Google Scholar 

  30. 30.

    Wilhelm M, Reiman M, Goode A, Richardson W, Brown C, Vaughn D, Cook C (2017) Psychological predictors of outcomes with lumbar spinal fusion: a systematic literature review. Physiother Res Int.

    Article  PubMed  Google Scholar 

  31. 31.

    Lee J, Kim HS, Shim KD, Park YS (2017) The effect of anxiety, depression, and optimism on postoperative satisfaction and clinical outcomes in lumbar spinal stenosis and degenerative spondylolisthesis patients: cohort study. Clin Orthop Surg 9:177–183.

    Article  PubMed  PubMed Central  Google Scholar 

  32. 32.

    Netto MB, Barranco ABS, Oliveira KWK, Petronilho F (2018) Influence of anxiety and depression symptoms on the quality of life in patients undergoing lumbar spine surgery. Revista brasileira de ortopedia 53:38–44.

    Article  PubMed  Google Scholar 

  33. 33.

    Wahlman M, Hakkinen A, Dekker J, Marttinen I, Vihtonen K, Neva MH (2014) The prevalence of depressive symptoms before and after surgery and its association with disability in patients undergoing lumbar spinal fusion. Eur Spine J 23:129–134.

    Article  PubMed  Google Scholar 

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Correspondence to Arthur Wagner.

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Conflict of interest

ES received research grants and is a consultant for Nevro (Redwood City, California, USA) and Icotec (Alstätten, Switzerland). BM received research grants and is a consultant for Brainlab AG (Munich, Germany). BM received honoraria, consulting fees, and research grants from Medtronic (Meerbusch, Germany), Icotec ag (Altstätten, Switzerland), and Relievant Medsystems Inc., (Sunnyvale, CA, USA), honoraria, and research grants from Ulrich Medical (Ulm, Germany), honoraria and consulting fees from Spineart Deutschland GmbH (Frankfurt, Germany) and DePuy Synthes (West Chester, PA, USA), and royalties from Spineart Deutschland GmbH (Frankfurt, Germany). However, all authors declare that they have no conflict of interest regarding the materials used or the results presented in this study.

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Wagner, A., Shiban, Y., Wagner, C. et al. Psychological predictors of quality of life and functional outcome in patients undergoing elective surgery for degenerative lumbar spine disease. Eur Spine J 29, 349–359 (2020).

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  • Degenerative spine disease
  • Depression
  • Anxiety
  • Quality of life