Correlation between anxiety, depression, and social stress in young patients with thoracolumbar spine fractures

Abstract

BACKGROUND

Traumatic injuries, such as falling, car accidents, and crushing mostly cause spinal fractures in young and middle-aged people, and > 50% of them are thoracolumbar fractures. This kind of fracture is easily combined with serious injuries to peripheral nerves and soft tissues, which causes paralysis of the lower limbs if there is no timely rehabilitation treatment. Young patients with thoracolumbar fractures find it difficult to recover after the operation, and they are prone to depression, low self-esteem, and other negative emotions.

AIM

To investigate the association between anxiety, depression, and social stress in young patients with thoracolumbar spine fractures and the effect on rehabilitation outcomes.

METHODS

This study retrospectively analyzed 100 patients admitted to the orthopedic department of Honghui Hospital, Xi’an Jiaotong University who underwent thoracolumbar spine fracture surgery from January 2022 to June 2023. The general data of the patients were assessed with the Hamilton anxiety scale (HAMA), Hamilton depression scale (HAMD), life events scale, and social support rating scale (SSRS) to identify the correlation between anxiety, depression scores, and social stress and social support. The Japanese Orthopedic Association (JOA) was utilized to evaluate the rehabilitation outcomes of the patients and to analyze the effects of anxiety and depression scores on rehabilitation.

RESULTS

According to the scores of HAMD and HAMA in all patients, the prevalence of depression in patients was 39% (39/100), and the prevalence of anxiety was 49% (49/100). Patients were categorized into non-depression (n = 61) and depression (n = 39), non-anxiety (n = 51), and anxiety (n = 49) groups. Statistically significant differences in gender, occupation, Pittsburgh Sleep Quality Index (PSQI) score, and monthly family income were observed between the non-depression and depression groups (P < 0.05). A significant difference in occupation and PSQI score was found between the non-anxiety and anxiety groups. Both depression (r = 0.207, P = 0.038) and anxiety scores (r = 0.473, P < 0.001) were significantly and positively correlated with negative life events. The difference in negative life event scores as well as SSRS total and item scores was statistically significant between patients in the non-depression and depression groups (P < 0.05). The difference between the non-anxiety and anxiety groups was statistically significant (P < 0.05) in the negative life event scores as well as the total SSRS scores. Additionally, JOA scores were significantly lower in both anxious and depressed patients.

CONCLUSION

Young patients with thoracolumbar fractures are prone to anxiety and depression. Patients’ anxiety and depression are closely associated with social pressure, which reduces the life pressure of young patients with thoracolumbar fractures, enhances social support, and improves the psychology of anxiety and depression., which affects patients’ recovery.

Key Words: Patients with thoracolumbar fractures; Anxiety; Depression; Social pressure; Social support

Core Tip: Thoracolumbar fracture is a type of continuous injury of the thoracolumbar bone caused by an external force, which easily damages the peripheral nerve tissue of the body and causes lower limb paralysis. This study adopts a comprehensive approach, evaluating the interplay between psychological states (anxiety and depression) and social factors (stress and support), which provides a nuanced understanding of patient recovery dynamics.

INTRODUCTION

Thoracolumbar fracture is a type of continuous injury of the thoracolumbar bone caused by an external force. It occurs frequently in the spine, accounting for approximately 5%-6% of all fractures and 79% of spinal fractures[1,2]. Additionally, 50% of patients with thoracolumbar fractures occur in the thoracolumbar region, which easily damages the peripheral nerve tissue of the body and causes lower limb paralysis[3]. The factors causing injury include car accidents, falling, etc. Concurrently, the incidence of high-energy trauma is increasing with modern industry, transportation, and tourism development, among which young patients are the majority. Thoracolumbar fractures in young and middle-aged patients are prevalently unstable fractures[4]. Unstable fractures as well as thoracolumbar fractures with neurologic symptoms are generally accepted in clinical practice to be operated promptly, whereas stable fractures without neurologic symptoms are treated conservatively[5,6]. Most scholars consider an unstable fracture if the loss of vertebral height is > 50%, the localized posterior convexity deformity is greater than 20°-30°, and the area of canal encroachment is over 30%-50%[7]. The main clinical manifestations of thoracolumbar spine fractures include neurological injuries, such as limb numbness, incontinence, etc.; localized cut-like severe pain, sometimes accompanied by localized injuries with pressure pain at the site of the injury, etc[8]. All of these symptoms will seriously affect patients’ labor and activities of daily living.

Surgery is the most effective way to treat thoracolumbar spine fractures, regardless of traditional open surgery or the current popular minimally invasive surgery, the purpose of which is to correct local deformity, rebuild vertebral body height, release spinal cord or nerve compression, and restore spinal stability[9,10]. Patients inevitably bear pain, physiological decline, etc., due to the complexity of surgical treatment of thoracolumbar fractures and the effects of the disease, which seriously affect the quality of life[11]. Orthopedic surgeons appear to focus on physical and technical factors when treating these musculoskeletal injuries despite significant advances in the treatment of patients with orthopedic trauma. Dramatic physical changes, unfamiliar hospital environments, and the uncertainty of post-injury recovery influence patients psychologically. The process of postoperative recovery is long, and patients will inevitably experience negative emotions, such as depression and anxiety, during the recovery process. Anxiety and depression have a great effect on patient prognosis[12]. Anxiety and depression incidence rates were 5%-35% and 13%-56% in patients with orthopedic trauma, respectively[13,14]. The effects of anxiety and depression almost completely prevent patients from returning to their familiar daily lives in some cases, even after a successful initial treatment. Several studies have revealed that mood disorders (anxiety or depression) are associated with factors, including pain, nuclear family, female gender, injury severity, younger age, and lack of social support[15,16]. Several studies have revealed that these psychological factors adversely affect outcomes[17,18]. Previous studies have emphasized the importance of recognizing deficits in coping strategies as well as anxiety and depressive tendencies in early disease stages[19]. Concurrently, compared to elderly patients, young and middle-aged patients will face greater social pressure in the face of fracture, as the fracture will cause a certain amount of transient loss of labor force, and thus the pressure on work and life ensues, and to some extent exacerbates the patient’s anxiety or depression. To date, research on the correlation between anxiety, depression, and social stress in young patients with thoracolumbar fractures and its impact on rehabilitation remains insufficient, although psychosocial care for each patient is considered an essential treatment form. Therefore, this study mainly investigates the correlation between anxiety, depression, and social stress in patients with annual thoracolumbar fractures and its effect on the rehabilitation effect, to provide reference for improving the quality of life of young patients with thoracolumbar fractures.

MATERIALS AND METHODS

Research objects

This study retrospectively analyzes patients admitted to the Orthopedic Department of Honghui Hospital, Xi’an Jiaotong University who underwent thoracolumbar spine fracture surgery from January 2022 to June 2023. Inclusion criteria: (1) Thoracolumbar fractures diagnosed by imaging examination, with an intervertebral disk injury, compression, or burst fracture; (2) > 50% vertebral body compression and > 30% canal encroachment; (3) All completed the operation successfully and recovered more than 4 weeks postoperatively, receiving routine postoperative rehabilitation nursing; and (4) Complete clinical data and follow-up data. Exclusion criteria: (1) Compression fractures caused by vertebral burst fractures, vertebral tumors, or acute or chronic infectious diseases of the vertebral body; (2) History of traffic accidents; (3) Conscious disorders or a history of mental illness; (4) Old thoracolumbar compression fracture; and (5) Incomplete clinical and follow-up data. This study included 100 patients based on inclusion and exclusion criteria. The Ethics Committee of Honghui Hospital, Xi’an Jiaotong University approved this study.

Research methods

General data collection: Basic data were collected from the patients, and a self-designed questionnaire was administered, including age, gender, body mass index (BMI), occupation (yes or no), education, family financial status, way of medical payment, sleep [assessed using the Pittsburgh Sleep Quality Index (PSQI)], and level of pain (assessed using a visual analog rating scale), in patients with thoracic and lumbar vertebral fractures.

Anxiety and depression: The Hamilton anxiety scale (HAMA) was used to evaluate the anxiety of patients. HAMA consisted of 14 items, with a 5-grade score of 0-4. The criteria of all levels were 0: Asymptomatic, 1: Mild, 2: Moderate, 3: Severe, and 4: Extremely severe. The total score of ≥ 29 indicates severe anxiety; ≥ 21 denotes obvious anxiety; ≥ 14, represents anxiety; ≥ 7 demonstrates the possibility of anxiety; < 7 exhibits no anxiety symptoms. The Hamilton 17-item depression scale was used to evaluate depression in patients. The scale included 17 items. The 1-9 items were scored as 0: None, 1: Mild, 2: Moderate, 3: Severe, and 4: Extremely severe. The 10-17 scoring criteria were 0: None, 1: Mild-moderate, 2: Severe. Overall evaluation: < 7 points: Normal, 7-17 points: Possible depression, 17-24 points: Mild to moderate depression, and > 24 points: Severe depression. All patients were categorized into anxiety, non-anxiety, depression, and non-depression groups following anxiety and depression scores.

Social stress assessment: Social stress came from different life events and was scored by the life events scale (LES). The amount of stimulation of negative events and the total stimulation of life events in statistical study subjects, self-rating scale, including 48 common life events in China, are mainly associated with three aspects, life and family, study and work, social and other aspects. Additionally, two blank items are provided where the subjects fill in the events they have experienced but are not listed in the table. The scale calculates the stimulation amount of the event to the patient by calculating the effect, duration, and occurrence times of the event within one year. The patients evaluate the event as positive or negative. The sum of all negative stimuli is considered the total amount of negative events. Higher scores indicated the more effects of negative life events within a year. In this study, the total stimulus of negative events in the LES was utilized as the score of negative life events to assess the level of negative self-cognition of the subjects. The quantitative study of life events recognized the life change unit (LCU) index of Holmes[20] globally. The correlation between LES and the corresponding items of LCU was 0.8 (P < 0.01).

Social support: The social support rating scale (SSRS) was used to assess 14 items, including objective support (3 items, 1-16 points), subjective support (4 items, 4-16 points) and utilization of support (3 items, 3-12 points). SSRS consisted of 10 items with a total score of 8-44. The higher the score, the higher the degree of social support. Among them, a score of < 20 indicates less social support, 20-30 denotes general social support, and 31-40 demonstrates satisfaction with social support and utilization.

Rehabilitation effect evaluation: The Japanese Orthopedic Association (JOA) was utilized to assess the treatment score, including three aspects (limitation of daily activity, clinical signs, and subjective symptoms). The total score was 0-29. The higher the score, the better the lumbar function.

Statistical analysis

Statistical Package for the Social Sciences version 25.0 statistical software was used for data analyses. The measurement data, expressed as average ± SD, were assessed by t-test. The counting data were marked by rate and investigated by the χ² test. Spearman correlation was used for correlation analysis, and P values of < 0.05 indicated a statistically significant difference.

RESULTS

Depression and anxiety in all patients

HAMD and HAMA scores in those with thoracolumbar fractures indicated a certain number of patients with depression and anxiety. The patients were categorized into the non-depression (n = 61) and depression groups (n = 39) based on the HAMD score. The comparison of HAMD and HAMA scores revealed higher HAMD scores in the patients of the depression group than those of the non-depression group (P < 0.05), whereas no remarkable difference was observed in HAMA scores (P > 0.05). The patients were categorized into the non-anxiety (n = 51) and anxiety groups (n = 49) based on the HAMA score. The comparison of HAMD and HAMA scores of patients demonstrated higher HAMA scores in the patients of the anxiety group than those of the non-anxiety group (P < 0.05), where no marked difference was observed in HAMD scores (P > 0.05; Table 1).

Table 1 Depression and anxiety of patients.

	Total score of HAMD	Total score of HAMA
Non-depression group (n = 61)	4.00 ± 1.60	8.41 ± 4.91
Depression group (n = 39)	14.62 ± 4.69a	7.56 ± 4.10
Non-anxiety group (n = 51)	7.43 ± 5.94	4.61 ± 1.13
Anxiety group (n = 49)	8.88 ± 6.22	11.69 ± 4.04a
Total (n = 100)	8.14 ± 6.09	8.08 ± 4.61

^aP < 0.05 compared with non-depression/anxiety group.

HAMA: Hamilton anxiety scale; HAMD: Hamilton depression scale.

General data on patients with different depression levels

No significant difference in terms of age, BMI, fracture site, cause of injury, visual analogue scale (VAS) score, education, and way of medical payment was observed between the non-depression and depression groups. However, a statistically significant difference was found in gender, occupation, PSQI score, and monthly family income (P < 0.05; Table 2).

Table 2 Comparison of clinical characteristics of patients with different depressive conditions.

	Non-depression group (n = 61)	Depression group (n = 39)	χ2	P value
Age (year)	24.13 ± 1.52	23.95 ± 1.59	0.569	0.572
Gender			10.721	0.001
Male	45	16
Female	16	23
BMI	23.40 ± 1.54	23.49 ± 1.32	0.301	0.764
Fracture site			1.787	0.181
L1-2	48	26
T11-12	13	13
Cause of injury			1.446	0.485
Traffic accidents	44	24
Falling	10	10
Crushing injuries	7	5
Occupation			12.301	0.000
Yes	50	19
No	11	20
VAS score	3.80 ± 0.51	3.82 ± 0.39	0.209	0.835
PSQI score	6.77 ± 1.77	8.97 ± 4.31	3.553	0.000
Educational			0.018	0.892
Bachelor degree or above	29	18
Junior college/high school or below	32	21
Monthly family income			4.333	0.037
> 5000	38	16
≤ 5000	23	23
Way of medical payment			1.376	0.241
Medical insurance	37	19
Self-funded	24	20

BMI: Body mass index; VAS: Visual analogue scale; PSQI: Pittsburgh Sleep Quality Index.

Grouping with different anxiety levels

No significant difference in terms of age, gender, BMI, fracture site, cause of injury, VAS score, educational level, monthly family income, and way of medical payment was observed between the non-depression and depression groups. However, a statistically significant difference was found regarding occupation and PSQI score (P < 0.05; Table 3).

Table 3 Comparison of clinical characteristics of patients with different anxiety conditions.

	Non-anxiety group (n = 51)	Anxiety group (n = 49)	χ2	P value
Age (year)	24.10 ± 1.70	24.01 ± 1.38	0.289	0.772
Gender			2.401	0.121
Male	40	44
Female	11	5
BMI	23.52 ± 1.48	23.34 ± 1.43	0.618	0.538
Fracture site			0.000	0.978
L1-2	42	45
T11-12	9	4
Cause of injury			0.211	0.899
Traffic accidents	43	40
Falling	5	5
Crushing injuries	3	4
Occupation			4.697	0.030
Yes	42	47
No	9	2
VAS score	3.76 ± 0.47	3.86 ± 0.46	1.075	0.285
PSQI score	6.96 ± 3.21	8.33 ± 3.05	2.186	0.031
Educational			0.008	0.926
Bachelor degree or above	15	14
Junior college/senior high school or below	36	35
Monthly family income			0.364	0.546
> 5000	38	39
≤ 5000	13	10
Way of medical payment			1.149	0.284
Medical insurance	42	36
Self-funded	9	13

BMI: Body mass index; VAS: Visual analogue scale; PSQI: Pittsburgh Sleep Quality Index.

Depression, anxiety, and social stress and support score

The scores of social stress and social support of patients with different depression and anxiety were compared. It revealed statistically significant differences (P < 0.05) in negative life event scores, total SSRS scores, and various item scores between the non-depression and depression groups. The difference in negative life event scores and total SSRS scores between the non-anxiety and anxiety groups was statistically significant (P < 0.05), whereas no statistically significant difference was found in objective support scores (P > 0.05; Table 4).

Table 4 Comparison of depression and anxiety with social stress and support scores.

	Non-depression group (n = 61)	Depression group (n = 39)	χ2	P value	Non-anxiety group (n = 51)	Anxiety group (n = 49)	χ2	P value
Negative life event scores	28.26 ± 9.85	34.33 ± 10.91	2.882	0.005	26.20 ± 8.12	38.27 ± 10.05	6.618	< 0.0001
Total SSRS scores	32.85 ± 4.45	26.23 ± 5.68	6.506	< 0.0001	32.45 ± 5.68	27.00 ± 4.13	5.469	< 0.0001
Subjective support	11.54 ± 2.67	9.15 ± 3.22	4.026	0.0001	11.84 ± 2.98	8.71 ± 2.05	6.095	< 0.0001
Objective support	12.36 ± 2.15	8.92 ± 3.58	6.008	< 0.0001	11.39 ± 3.69	10.33 ± 2.41	1.693	0.094
Support utilization	8.82 ± 1.41	8.15 ± 1.81	2.072	0.041	9.22 ± 1.15	7.96 ± 1.78	4.221	< 0.0001

SSRS: Social support rating scale.

Correlation between patient anxiety and depression scores and social stress and support

The results revealed that anxiety was positively correlated with negative life events (r = 0.473, P < 0.001), depression was positively correlated with negative life events (r = 0.207, P = 0.038), and anxiety was significantly negatively correlated with subjective support, support utilization, and SSRS score (P < 0.05). Meanwhile, no significant correlation was found with objective support (P > 0.05). Depression is significantly negatively correlated with objective support, support utilization, and SSRS score, whereas no significant correlation was found with subjective support (P > 0.05; Figure 1).

Figure 1 Correlation between anxiety, depression and social stress and support. A: Correlation between patient Hamilton anxiety scale score and social stress and support score; B: Correlation between patient Hamilton depression scale score and social stress and support score. HAMA: Hamilton anxiety scale; HAMD: Hamilton depression scale.

Rehabilitation effects on patients with different depression and anxiety levels

The JOA scores of lumbar spine function in patients with different depression and anxiety levels were compared, revealing significant differences in the JOA scores of all groups. The JOA scores of patients with anxiety and depression were lower than those with no anxiety and depression (Figure 2).

Figure 2 Comparison of rehabilitation effects for patients. A: Comparison of Japanese Orthopedic Association (JOA) scores between non-anxiety group and anxiety group patients; B: Comparison of JOA scores between non-depression group and depression group patients. ^aP < 0.01; ^bP < 0.001. JOA: Japanese Orthopedic Association.

DISCUSSION

Currently, surgery is the main treatment method for thoracolumbar vertebral fractures in clinical practice. The advantages of percutaneous minimally invasive pedicle screw fixation over traditional open surgery involved low risk, minimal trauma, and high safety, which have been widely accepted in clinical practice and patients[21]. Recent studies have revealed that patients with thoracolumbar vertebral fractures require prolonged bed rest, coupled with the risk of postoperative complications, such as deep vein thrombosis, pulmonary infections, and pressure ulcers[22,23], which not only reduces the treatment effectiveness but also exacerbates the psychological health problems of patients. Young patients with thoracolumbar vertebral fractures demonstrate slow recovery from physical diseases postoperatively, and they are unable to take care of themselves, causing psychological changes.

This study analyzed the HAMD and HAMA scores collected from patients with thoracolumbar vertebral fractures and revealed the presence of a certain number of patients with depression and anxiety. Reportedly, anxiety and depression incidence rates in patients with orthopedic trauma were 5%-35% and 13%-56%, respectively[24,25]. Meanwhile, statistically significant differences between the non-depression and depression groups were observed in terms of gender, occupation, PSQI score, and monthly family income. However, statistically significant differences were found in negative life event scores, total SSRS scores, and various item scores, whereas the non-anxiety and anxiety groups demonstrated only statistically significant differences in occupation and PSQI scores. Similar to some studies, the majority of patients with depression are female. Some studies demonstrated that emotional disorders (anxiety or depression) are related to women[26]. Previous studies that investigated anxiety and depression levels in patients with orthopedic disorders reported female sex, long hospital stays, lack of social support, unemployment, and youth were important determinants in this regard[27,28]. We revealed that unemployment and sleep quality are predominant differences between patients with depression and anxiety. Employment plays a crucial role as a healthy social determinant from a sociological perspective[29,30]. Unemployment and youth rates are factors associated with increased levels of negative mental health outcomes, including depression and anxiety, in the general population[31]. Patients who underwent fracture surgery exhibited limited physical function and activities, causing greater economic pressure for unemployed patients. Therefore, relatively more patients have depression and anxiety. Numerous studies have revealed that poor sleep quality is related to an increased risk of anxiety or depression symptoms[32,33]. Some evidence demonstrates that anxiety or depression symptoms reverse predict poor sleep quality[34], indicating the complex and bidirectional association between poor sleep quality and anxiety or depression symptoms.

Furthermore, we revealed a significant positive correlation between depression and anxiety scores and social stress. A statistically significant difference in negative life event scores, total social support scores, and various item scores was observed between the non-depression and depression groups, whereas no statistically significant difference in objective support scores was found between the non-anxiety and anxiety groups. Cohen defined social support as “a social network that provides psychological and material resources aimed at improving an individual’s ability to cope with stress”[35]. Perceived social support refers to the subjective accessibility of care and assistance from social relationships, characterized by emotional support (including emotional expression), instrumental support (including household assistance), and informational support (including financial advice), as provided from various sources (friends or family)[36]. Previous studies have revealed a negative correlation between social support and psychological symptoms (anxiety and depression)[37]. The results of systematic review and meta-analysis indicate that individuals who experience more social support demonstrate fewer depressive symptoms[38,39]. People generally believe that positive social support is a crucial aspect of psychological adjustment, which helps alleviate the pathogenic effects of stress[40]. Hence, patients with no depression and anxiety received higher social support scores. Meanwhile, the state of anxiety or depression influences the rehabilitation effect of patients. Anxiety and depression result from multiple factors, which cause patients to worry about treatment effectiveness and condition worsening, and some of them may exhibit poor compliance due to the need for long-term rehabilitation exercise postoperatively. It easily causes resistance and aversion, thereby exacerbating anxiety and depression, which affect rehabilitation exercise effectiveness and increase the risk of poor postoperative functional recovery.

Our study focuses on young and middle-aged patients who frequently face significant social and emotional challenges post-injury and touches upon a crucial demographic that may benefit most from targeted interventions. The study linked emotional and social factors with rehabilitation outcomes to provide actionable information for clinicians to improve patient care through holistic treatment approaches. The study distinguishes itself by using a holistic assessment of mental health, social stress, and support systems in conjunction with traditional physical rehabilitation outcomes. This multidimensional analysis is crucial in understanding the full effect of spine fractures on patients, moving beyond purely clinical measures. Targeting young and middle-aged adults confirms the demographic that may face distinct challenges post-injury, including career disruption, financial strain, and social isolation. This focus is essential as this age group may be overlooked in conventional research, which frequently centers on older adults with similar injuries.

CONCLUSION

In summary, patients undergoing thoracolumbar spine fracture surgery demonstrate a higher proportion of anxiety and depression, and negative emotions affect their rehabilitation outcomes. Thus, as healthcare workers, we need to improve our medical level as much as possible to enhance the prognosis of patients postoperatively. Additionally, we need to care about the emotions of patients and encourage them to have confidence and hope in life, improve social support, and enhance their anxiety and depression. The study emphasizes the role of social support as a buffer against stress and its beneficial effect on mental health, advocating for the establishment of stronger support systems around patients. This information inspires new models of care that incorporate family and community support services of patient rehabilitation protocols.