Letter to the editor: Integrating psychological care into postoperative spinal cord injury rehabilitation: An imperative based on recent evidence

Abstract

A spinal cord injury (SCI), as a severe form of central nervous system trauma, results in permanent or temporary impairment of motor, sensory, and autonomic functions. SCIs pose a profound threat to patient psychological well-being. Although previous studies have investigated the epidemiologic characteristics, pathologic mechanisms, and surgical intervention strategies of patients with SCI, a systematic evaluation of postoperative psychological status - especially anxiety and depression - and its relationship with injury severity and sleep quality has received insufficient attention. The study entitled “Postoperative anxiety-depression in patients with SCI: Correlations with injury severity and sleep quality” conducted by Tian et al and published in the World Journal of Psychiatry, provides a systematic response to this clinical gap. Importantly, this study strongly argues that we must reconceptualize postoperative follow-up to include routine, mandatory psychological screening.

Key Words: Spinal cord injury; Anxiety; Depression; Sleep quality; Clinical dimension; Stratified intervention

Core Tip: (1) Highlight the clinical significance of the study’s findings within the broader context of spinal cord injury rehabilitation; (2) Emphasize the importance of integrating psychological assessment into routine postoperative care; (3) Discuss the potential of sleep quality as a modifiable therapeutic target; (4) Propose stratified intervention strategies based on the identified risk factors; and (5) Offer perspectives on future research directions, including mechanistic studies and longitudinal designs.

TO THE EDITOR

A spinal cord injury (SCI), as a severe form of central nervous system trauma, results in permanent or temporary impairment of motor, sensory, and autonomic functions. SCIs pose a profound threat to patient psychological well-being. Although previous studies have investigated the epidemiologic characteristics, pathologic mechanisms, and surgical intervention strategies of patients with SCI, a systematic evaluation of postoperative psychological status - especially anxiety and depression - and its relationship with injury severity and sleep quality has received insufficient attention[1]. The study conducted by Tian et al[2] and published in the World Journal of Psychiatry, provides a systematic response to this clinical gap. Importantly, this study strongly argues that we must reconceptualize postoperative follow-up to include routine, mandatory psychological screening.

The authors evaluated 149 patients surgically treated for SCI, conducting multidimensional assessments three months postoperatively using the Hamilton Anxiety Scale, Hamilton Depression Scale, American Spinal Injury Association (ASIA) Impairment Scale, and Pittsburgh Sleep Quality Index (PSQI). The detection rates for postoperative anxiety and depression were 34.90% and 24.83%, respectively. More than half of the patients (51.68%) experienced at least one type of emotional disorder, and 8.05% presented with co-morbid anxiety and depression. Notably, anxiety and depression scores exhibited a significant positive correlation with the ASIA grade, suggesting that the severity of neurologic deficits is directly associated with a more pronounced psychological burden. Furthermore, overall sleep quality was generally poor, with a median PSQI score of 12.00 (11.00, 14.00). Reduced sleep duration, decreased sleep efficiency, and prolonged sleep latency were the most prominently affected dimensions. Multivariate regression analysis identified six independent risk factors: Age ≥ 60 years, male sex, disease duration ≥ 12 months, education level below senior high school, ASIA grades A-B (complete or severe incomplete injury), and a PSQI score ≥ 13.

The clinical implications of this study are manifested in several key dimensions. First, the findings provide empirical support for integrating the “bio-psycho-social” medical model into postoperative SCI management. The positive correlation between injury severity and psychological status suggests that the ASIA grade should serve not only as a predictor of neurologic prognosis but also as a risk stratification tool for psychological screening. Incorporating psychological assessment into routine postoperative follow-up protocols will facilitate the early identification of high-risk populations and enable targeted interventions.

Second, the study highlights the importance of sleep quality as a potentially modifiable therapeutic target. Patients with PSQI scores ≥ 13 had a 3.36-fold increased risk of developing anxiety and depression, indicating that sleep disturbance may function both as a clinical manifestation of psychological disorders and as a precipitating factor. Therefore, clinicians must prioritize postoperative sleep management - including optimizing the ward environment, ensuring effective pain control, and standardizing nighttime care procedures - as an indirect pathway to alleviate psychological distress.

Third, identifying high-risk population characteristics provides an evidence-based foundation for stratified intervention. For elderly patients, adaptive psychological counseling and linkage to social support resources are recommended. Interestingly, the study identifies male sex as an independent risk factor. While general epidemiological studies often report higher depression rates in females, the profound physical impact of SCI on traditional masculine roles (e.g., physical independence and occupational status) likely exacerbates psychological distress in this specific population. Because these traditional gender roles can inhibit emotional expression, male-friendly intervention models - such as activity-based peer support or integrating psychological discussions into physical therapy - are crucial for facilitating psychological adjustment[3]. For patients with prolonged disease duration, establishing long-term support networks is necessary to address the chronic psychological burden. For those with lower educational levels, easily accessible health education materials should be utilized to enhance disease comprehension and perceived control. Furthermore, for patients with ASIA grades A-B, functional loss often causes severe frustration; integrating psychological techniques like mindfulness-based stress reduction can help alleviate this burden. Ultimately, for patients with poor sleep quality, optimizing sleep management must be prioritized as the primary entry point for psychological intervention (Table 1).

Table 1 Risk factors for postoperative anxiety/depression in patients with spinal cord injury and proposed stratified intervention strategies.

Independent risk factor	Stratified intervention strategy	Evidence/remarks
Male sex	Male-friendly intervention models (e.g., activity-based peer support, integrating psychological discussions into physical therapy)	Overcomes inhibition of emotional expression by traditional gender roles
PSQI score ≥ 13 (sleep disturbance)	Optimize sleep management: Introduce evidence-based protocols such as CBT-I	Modifiable therapeutic target; improving sleep indirectly alleviates psychological distress
ASIA grades A-B	Integrate psychological techniques, e.g., mindfulness-based stress reduction	Targets frustration from severe functional loss
Age ≥ 60 years	Adaptive psychological counseling, linkage to social support resources	Addresses specific psychological challenges of aging
Disease duration ≥ 12 months	Establish long-term support networks, focus on chronic psychological burden	Transition from acute management to longterm rehabilitation support
Education below senior high school	Use easy-to-understand health education materials	Enhances disease understanding and perceived control

PSQI: Pittsburgh Sleep Quality Index; CBT-I: Cognitive behavioral therapy for insomnia; ASIA: American Spinal Injury Association.

While this study offers important clinical insights, several limitations must be acknowledged. First, the single-center design and relatively limited sample size (especially the uneven distribution across ASIA grades) restrict the generalizability of the findings. Second, the cross-sectional design precludes causal inference and limits the ability to track the dynamic evolution of psychological status over time. Third, the absence of long-term follow-up data restricts the assessment of the prognostic value of the identified risk factors. Fourth, the potential mediating role of inflammatory pathways in the relationship between injury severity, sleep disturbance, and psychological status has not been thoroughly investigated. Recent basic research reveals that neuroinflammation after SCI directly contributes to depressive-like behaviors by affecting emotion-regulating brain regions, such as the hippocampus[4]. Exploring these neuroinflammatory mechanisms represents a crucial direction for future studies. Finally, variables such as etiological characteristics, rehabilitation pathways, family support, and economic status were not incorporated into the analysis. Subsequent studies should construct more comprehensive predictive models to enhance precision.

In summary, postoperative anxiety and depression demonstrate relatively high detection rates in patients with SCI and are closely associated with injury severity and sleep quality[5]. This study not only systematically delineates the epidemiologic landscape of this clinical issue but also provides evidence-based tools for high-risk population identification and stratified intervention. Future research is warranted to further elucidate the underlying biological mechanisms, validate the clinical effectiveness of multidimensional intervention strategies, and promote the normalization of psychological assessment and intervention in clinical practice[6]. Drawing on successful experiences from other chronic disease rehabilitations (e.g., cardiovascular disease and cancer) where psychological support is a core component, establishing a new multidisciplinary SCI psychological rehabilitation model should be a definitive future direction. Only through such comprehensive efforts can we truly achieve holistic care for patients with SCI - focusing not merely on the restoration of neurologic function, but on the complete return of psychological well-being.