Worsening pain and quality of life for spine surgery patients during the COVID-19 pandemic: roles of psychological distress and patient activation

ABSTRACT

BACKGROUND CONTEXT The consequences of public health protection measures may include loss of income, lack of access to basic resources (including health care), and increased psychological burdens. This has led to cancellation of elective surgical cases and greater reliance on telemedicine to conduct consultations and maintain patient access to orthopedic providers. Little is currently known regarding the effects that this has on spine surgery patients and their recovery. The effects of the COVID-19 pandemic may affect individuals differently according to their access to socioeconomic resources, preexisting burden of psychological distress, and knowledge, skills, and confidence to manage their health care. Evidence suggests that the presence of psychological distress, defined as a high burden of symptoms of anxiety and/or depression, is associated with poorer postoperative outcomes than those for patients without psychological distress. Because of the effects of the pandemic, patients may need to rely more than ever on their internal strengths as they recover from spine surgery. One measure of internal strength is “patient activation,” which is a hierarchical construct that encompasses the knowledge, skills, and confidence to manage one's health care. Patient activation may mitigate the negative effects of psychological stress in patients undergoing spine surgery. PURPOSE We tested the hypotheses that patients with greater socioeconomic resources would experience less disruption of access to basic resources;those with psychological distress would experience worsening pain and HRQOL;and those with high patient activation would experience less worsening of pain and HRQOL. STUDY DESIGN/SETTING This was a prospective survey of patients presenting to an academic medical center. PATIENT SAMPLE We selected adults who had undergone or were scheduled to undergo spine surgery for cervical or lumbar spine degeneration or deformity correction at our academic center. Between May 1, 2020 and July 31, 2020, patients were asked to complete a survey regarding the effects of COVID-19 on their health, well-being, and personal life. Surveys were sent to 1,506 patients, 431 of whom (29%) completed and returned them. The mean (± standard deviation [SD]) age of the 431 respondents was 61 ± 15 years. Fifty-five percent of respondents identified as female, and most respondents were non-Hispanic (92%) and white (81%). Most reported living with a partner (71%) and were not currently employed (68%). Approximately one-fifth of respondents reported an annual household income of ≤$50,000, and 120 reported having less than a college education. Two hundred twenty-nine patients were being treated for a degenerative lumbar condition, 118 for a degenerative cervical condition, and 84 for spinal deformity. We found no significant differences between groups in terms of demographic characteristics. OUTCOME MEASURES Respondents reported on their access to basic resources and health care and on their health and wellness. Patients scored their worst back, leg, neck and arm pain during the previous week on a numeric rating scale, with 0 representing no pain and 10 representing the worst imaginable pain. Patients completed the Patient-Reported Outcome Measurement Information System 29-Item profile (PROMIS-29), version 2, which assesses HRQOL using the following domains pain interference, Physical Function, Fatigue, Anxiety, Depression, Sleep Disturbance, and Satisfaction with Participation in Social Roles. At their preoperative visit, patients provided information on their annual income and highest level of education attained and completed assessments of psychological distress (anxiety and depression) and patient activation. Patient activation was assessed using the Patient Activation Measure. Psychological distress was assessed from PROMIS-29 domains. Methods We surveyed 431 patients who had undergone or were scheduled for surgical treatment of lumbar or cervical spine degeneration or deformity at 1 institution. The survey inquired about the effec s of COVID-19 on patients’ access to basic resources and health care and assessed pain (numeric rating scale) and HRQOL (PROMIS-29). We compared the proportions of patients who reported worsening pain and HRQOL between groups defined by presence of psychological distress and high patient activation measured before the pandemic. Alpha = 0.05. Results Respondents reported only minor disruptions in access to basic resources but significant worsening of pain and HRQOL during COVID-19. Health care access was interrupted, with 117 respondents (43%) reporting a canceled health care appointment. Respondents who had undergone spine surgery before the pandemic (N = 296) reported significantly worse outcomes between the most recent pre-pandemic and COVID-19. assessments. During COVID-19, respondents reported worsening of the following back pain (mean increase, 0.57 ± 3.0 points;p=.027), leg pain (mean increase, 0.74 ± 3.4 points;p=.013), physical function (mean decrease, 2.4 ± 7.5 points;p<.001), fatigue (mean increase, 3.8 ± 9.6 points;p<.001) and satisfaction with participation in social roles (mean decrease, 1.9 ± 11 points;p=.048). Those with psychological distress were more likely to experience clinically relevant worsening of back pain, leg pain and physical function than those without distress (p<.01 for all outcomes). High patient activation (measured before the pandemic) was associated with less worsening of physical function (p = 0.031). Conclusions Spine surgery patients reported little disruption in access to basic resources during COVID-19. Psychological distress was associated with worsening of pain and HRQOL. High patient activation appeared to mitigate the worsening of physical function during COVID-19. Health care systems should screen for psychological distress and patient activation and, during times of disruption, enhance supports to manage pain and maintain HRQOL. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.