Preoperative Depression, Lumbar Fusion, and Opioid Use

An Assessment of Postoperative Prescription, Quality, and Economic Outcomes

Chloe O'Connell, BS; Tej Deepak Azad, MS; Vaishali Mittal, BS; Daniel Vail, BA; Eli Johnson, BS; Atman Desai, MD; Eric Sun, MD, PhD; John K. Ratliff, MD; Anand Veeravagu, MD


Neurosurg Focus. 2018;44(1):e5 

In This Article

Abstract and Introduction


Objective Preoperative depression has been linked to a variety of adverse outcomes following lumbar fusion, including increased pain, disability, and 30-day readmission rates. The goal of the present study was to determine whether preoperative depression is associated with increased narcotic use following lumbar fusion. Moreover, the authors examined the association between preoperative depression and a variety of secondary quality indicator and economic outcomes, including complications, 30-day readmissions, revision surgeries, likelihood of discharge home, and 1- and 2-year costs.

Methods A retrospective analysis was conducted using a national longitudinal administrative database (MarketScan) containing diagnostic and reimbursement data on patients with a variety of private insurance providers and Medicare for the period from 2007 to 2014. Multivariable logistic and negative binomial regressions were performed to assess the relationship between preoperative depression and the primary postoperative opioid use outcomes while controlling for demographic, comorbidity, and preoperative prescription drug–use variables. Logistic and log-linear regressions were also used to evaluate the association between depression and the secondary outcomes of complications, 30-day readmissions, revisions, likelihood of discharge home, and 1- and 2-year costs.

Results The authors identified 60,597 patients who had undergone lumbar fusion and met the study inclusion criteria, 4985 of whom also had a preoperative diagnosis of depression and 21,905 of whom had a diagnosis of spondylolisthesis at the time of surgery. A preoperative depression diagnosis was associated with increased cumulative opioid use (β = 0.25, p < 0.001), an increased risk of chronic use (OR 1.28, 95% CI 1.17–1.40), and a decreased probability of opioid cessation (OR 0.96, 95% CI 0.95–0.98) following lumbar fusion. In terms of secondary outcomes, preoperative depression was also associated with a slightly increased risk of complications (OR 1.14, 95% CI 1.03–1.25), revision fusions (OR 1.15, 95% CI 1.05–1.26), and 30-day readmissions (OR 1.19, 95% CI 1.04–1.36), although it was not significantly associated with the probability of discharge to home (OR 0.92, 95% CI 0.84–1.01). Preoperative depression also resulted in increased costs at 1 (β = 0.06, p < 0.001) and 2 (β = 0.09, p < 0.001) years postoperatively.

Conclusions Although these findings must be interpreted in the context of the limitations inherent to retrospective studies utilizing administrative data, they provide additional evidence for the link between a preoperative diagnosis of depression and adverse outcomes, particularly increased opioid use, following lumbar fusion.


Major depressive disorder is the leading cause of disability among people between the ages of 15 and 44 years, with a 12-month prevalence of 6.6% and a lifetime prevalence of 16.2%.[7,16] The relationship between depression and low-back pain is well established,[7] with depressive symptomatology linked to a more than 2-fold increase in the odds of low-back pain in 1 study.[25] Despite this association, as well as the link between depression and adverse outcomes after many types of surgery,[5,21] the impact of depression on outcomes following lumbar fusion has yet to be fully characterized.

Previous studies have described associations between preoperative depression and various outcomes of spinal surgery, including postoperative disability, patient satisfaction, and 30-day readmission rates.[1–3,23,29] Notably, the depressed population is particularly vulnerable to substance abuse and dependence issues,[7,17] but the link between depression and opioid use and abuse following lumbar fusion has remained largely unexplored. The only study reporting a link between depression and greater opioid use after lumbar fusion was performed in a workers' compensation setting, which has been associated with poorer overall outcomes than those of the general population, limiting the external validity and applicability of these findings.[6,14,22] The association between depression and opioid use following fusion is increasingly relevant given the epidemic of opioid abuse sweeping the country in recent years.[15,30,34,35]

In the present study, we used data from the MarketScan national administrative database (Truven Health Analytics) to examine the effects of preoperative depression on opioid use following lumbar fusion, controlling for different levels of preoperative opioid use and other confounding variables. Secondarily, we examined whether patients with a preexisting diagnosis of depression have poorer overall lumbar fusion outcomes than the patients without depression. A variety of different quality indicator and economic outcomes were considered, including complications, 30-day all-cause readmissions, revision surgeries, discharge home, and 1- and 2-year costs.