The Impact of High Depressive Burden on Outcomes after Anterior Cervical Discectomy and Fusion

Study Design. Retrospective chart review of a single institution’s ACDF patients. Objective. To evaluate how depressive burden impacts outcomes after anterior cervical discectomy and fusion (ACDF). Summary of Background Data. Poor mental health is associated with worse outcomes after spine surgery. However, these findings are typically based on preoperative, short-form psychometric assessments. “Depressive burden” has been proposed as a more robust evaluation of mental health, which includes both pre- and postoperative mental health patient-reported outcome-measure (PROM). Methods. Patients who underwent primary, elective ACDF (2014-2020) were retrospectively identified—demographic/surgical variables were evaluated via chart review. PROMs were evaluated preoperatively and at 3/6/12-months, including Visual-Analog-Scale (VAS) Neck/Arm, SF-12-Mental (MCS) and Physical-Component-Scores (PCS), Neck-Disability-Index (NDI), and Modified-Japanese-Orthopaedic-Association (mJOA). Patients were excluded if they underwent ACDF for trauma/tumor/infection/revision or had inadequate PROMs. High depressive burden was defined as average pre- and 3-month postoperative MCS scores ≤45, consistent with literature regarding clinically relevant depression. Achievement of Minimum-Clinically-Important-Difference (MCID) was evaluated at 1-year postoperatively. Results. 311 patients were included (93 with high depressive burden). Patients with high depressive burden were younger (55 vs. 58.6; P <0.001) and had better Charlson Comorbidity Index (CCI) (1.35 vs. 1.68; P =0.046), but were otherwise demographically/surgically like patients without high depressive burden. Despite having similar postoperative outcomes, patients with high depressive burden had worse PROM scores at all timepoints. Patients with high depressive burden experienced greater MCS improvement (4.6 vs. 0.48; P =0.003), but worse PCS improvement (3.22 vs. 7.13; P <0.001) at one-year. Multivariable regression identified high depressive burden as predictive of not achieving MCID for PCS (OR: 0.34; P <0.001) and mJOA (OR: 0.42; P <0.001), when controlling for age, CCI, number of levels fused, socioeconomic status, and preoperative PROM. Conclusions. ACDF patients with high depressive burden had worse one-year PROMs across all metrics. Despite similar surgical outcomes, multivariable regression showed high depressive burden was independently predictive of not achieving MCID for PCS and mJOA.