Perioperative anxiety/depression in patients with lumbar degenerative disease undergoing endoscopic spine surgery and their correlation with resilience

Abstract

BACKGROUND

Anxiety and depression are common perioperative emotional disorders in patients undergoing endoscopic spine surgery for lumbar degenerative diseases (LDDs) and may hinder optimal clinical recovery.

AIM

To examine perioperative anxiety and depression in endoscopic spine surgery-managed LDD patients and explored how these emotional disturbances relate to resilience.

METHODS

A total of 167 patients with LDD treated surgically between February 2021 and February 2024 were enrolled. Anxiety and depression were evaluated using the Zung Self-Rating Anxiety Scale (SAS) and Self-Rating Depression Scale (SDS), respectively, on the preoperative day (day 1), postoperative day 7, and 6 months post-surgery. Resilience was assessed preoperatively with the Connor-Davidson Resilience Scale (CD-RISC). Associations between preoperative emotional distress and resilience were analyzed, and determinants of resilience among clinically anxious or depressive patients were identified using univariate and multivariate regression.

RESULTS

SAS and SDS scores decreased significantly after surgery. The mean preoperative CD-RISC score was 64.26 ± 8.16, with 27.54% classified as having low resilience. Preoperative SAS and SDS values showed significant inverse correlations with CD-RISC. Patients with anxiety or depression had markedly lower CD-RISC scores at baseline, and those with depression exhibited persistently reduced resilience at day 7 and 6 months. Social support, household monthly income per capita, and preoperative SAS/SDS scores independently predicted resilience.

CONCLUSION

Perioperative anxiety and depression are prevalent in LDD patients, peak preoperatively, and improve by postoperative day 7 and at 6 months. Resilience appears protective, given its inverse association with emotional distress. Social support, family income, and preoperative anxiety/depression severity serve as key resilience predictors.

Key Words: Lumbar degenerative diseases; Endoscopic spine surgery; Perioperative; Anxiety/depression; Resilience

Core Tip: This study shows that perioperative endoscopic spine surgery patients with lumbar degenerative diseases commonly experience anxiety and depression, with the greatest severity occurring preoperatively and improving after surgery. Preoperative anxiety and depression were closely linked to resilience, although these associations weakened postoperatively over time. Higher levels of preoperative emotional distress also limited social support, and lower family income increased the likelihood of reduced resilience. These findings support incorporating resilience assessment and targeted social support interventions into routine perioperative management to promote simultaneous physical and psychological recovery in patients with lumbar degenerative disease.

INTRODUCTION

Lumbar degenerative diseases (LDDs) - including spinal stenosis, disc herniation, and degenerative spondylolisthesis - poses a growing global health burden. They impair functional capacity across age groups, diminishing quality of life and occupational or academic performance[1,2]. Patients typically present with low back pain, lower extremity numbness or pain, limping, and in severe cases disability, all of which all increase in frequency with age[3]. LDDs account for approximately 40% of all low back pain diagnoses and generate nearly 100 billion dollars in direct annual healthcare costs in the United States[4,5]. Their pathophysiology is multifaceted; oxidative stress is a well-documented driver that disrupts redox homeostasis, induces reactive oxygen species-mediated tissue injury, and destabilizes the inflammatory microenvironment[6]. Endoscopic spine surgery (ESS) is an effective option for LDD cases unresponsive to conservative treatment, offering minimal invasiveness, reduced pain, rapid recovery, and favorable safety profiles[7]. However, affective disturbances - particularly anxiety and depression - can negatively affect surgical outcomes, increasing risks of infection, reoperation, and persistent back or leg pain[8]. Wei et al[9] reported that preoperative anxiety or depression affects nearly half (47%) of the patients undergoing percutaneous endoscopic discectomy. Perioperative anxiety/depression in LDD patients arises from disease-induced discomfort, anxiety over treatment or complications, and limitations in daily or occupational activities, all of which contribute to varying degrees of psychological burden[10]. Resilience, a malleable form of psychological adaptability, helps individuals withstand adversity by promoting flexible, proactive coping. Higher resilience has been shown to reduce anxiety and depression risks across diverse populations[11,12], whereas diminished preoperative resilience predicts poorer one-year outcomes after lumbar spinal fusion[13]. However, limited evidence exists regarding perioperative anxiety/depression in ESS-managed LDD patients and its relationship with resilience. This study addresses these gaps through targeted analyses described below.

MATERIALS AND METHODS

Patient information

Eligibility criteria were as follows: (1) LDDs (e.g., lumbar degenerative spondylolisthesis, spinal stenosis, herniated disc) confirmed pathologically[14]; (2) Concordant clinical symptoms (lumbocrural pain, intermittent claudication) and radiographic findings; (3) A single-level symptomatic lesion; (4) Treatment-naive status with no prior ESS; and (5) Complete clinical records. Exclusion criteria included the following: (1) Congenital spinal deformities, lumbar instability, infection, tumor, or fractures; (2) A history of lumbar surgery; (3) Pregnancy or breastfeeding; (4) Current use of antipsychotic or previous psychiatric illness; (5) Bleeding disorders or coagulation dysfunction; (6) Contraindications to ESS; and (7) Major stressful or catastrophic events unrelated to the disease within three months preoperatively. Following ethics committee approval, 167 patients with LDDs treated at Nanjing Lishui People’s Hospital between February 2021 and February 2024 were enrolled. Strict eligibility screening yielded two groups comparable in baseline demographic and clinical characteristics (P > 0.05), supporting the validity of subsequent comparisons. The patient screening flowchart is shown in Figure 1.

Figure 1  Flowchart of patient selection.

Evaluation indexes

Anxiety and depression were evaluated using the Zung Self-Rating Anxiety Scale (SAS) and Self-Rating Depression Scale (SDS) preoperatively (on day 1), postoperatively (day 7), and at 6 months. Psychological resilience was also measured on day 1 using the Connor-Davidson Resilience Scale (CD-RISC).

The SAS, which also contains 20 items, measures the core emotional, psychological, and physiological features of depression[15]. For both scales, item scores were summed into raw totals and converted to standardized scores, with higher values indicating more severe symptoms. CD-RISC quantifies resilience - defined as an individual’s ability to effectively cope with adversity, trauma, and stress - across three dimensions: Strength (8 items), optimism (4 items), and tenacity (13 items), totaling 25 items[16]. Each item is scored 0-4, generating a total score of 0-100. Scores ≥ 60 indicated high resilience, whereas scores < 60 reflects poor resilience[17]. All scales were completed independently by patients after standardized instruction on item interpretation and scoring procedures.

Statistical analysis

Statistical analyses were performed using SPSS version 25.0, and figures were generated using GraphPad Prism 7.0. Measurement data, expressed as the mean ± SD of the mean or the median (interquartile range), were compared using independent-samples t-tests or Mann-Whitney U tests. Categorical variables, expressed as n (%), were compared using χ² tests. Associations between perioperative anxiety/depression and resilience were examined using Pearson’s or Spearman’s correlation coefficients. Determinants of resilience were assessed using univariate and multivariate logistic regression. Statistical significance was defined as P < 0.05.

RESULTS

Anxiety and depression variations in perioperative patients

Perioperative fluctuations in anxiety and depression are summarized in Figure 2 and Table 1. Among the 167 ESS-managed LDD patients, SAS scores averaged 49.04 ± 5.57 preoperatively, decreased to 45.22 ± 6.63 at 7 days postoperatively, and slightly increased to 46.37 ± 6.55 at 6 months postoperatively. SDS scores averaged 51.22 ± 7.42 preoperatively, 49.62 ± 6.23 at 7 days postoperatively, and 49.72 ± 6.69 at 6 months postoperatively. Postoperative SAS scores were significantly lower than preoperative values at both 7 days (P < 0.01) and 6 months (P < 0.05); however, the 6-month values differed insignificantly from those at 1 week (P > 0.05). SDS scores decreased after surgery but did not differ significantly among time points (P > 0.05). Perioperative rates of anxiety, depression, anxiety or depression, and comorbid anxiety-depression were as follows: Day 1: 39.52%, 44.91%, 63.47%, and 20.96%; day 7: 19.16%, 28.14%, 42.51%, and 4.79%; 6 months: 26.35%, 34.73%, 52.10%, and 8.98%. Anxiety rates decreased significantly at day 7 (P < 0.001) and at 6 months (P < 0.05) relative to day 1. Similar reductions were observed for “anxiety or depression” and comorbidity rates (P < 0.05). Depression rates were significantly reduced only at day 7 compared with day 1 (P < 0.01).

Figure 2 Perioperative changes in patient anxiety and depression levels. A: Fluctuations in Self-Rating Anxiety Scale scores; B: Self-Rating Depression Scale score changes over time. ^aP < 0.05 vs preoperative assessment; ^bP < 0.01 vs preoperative assessment. SAS: Self-Rating Anxiety Scale; SDS: Self-Rating Depression Scale.

Table 1 Dynamics of anxiety and depression in patients across the perioperative period, n (%).

Indicators	1 day before surgery	7 days postoperatively	6 months postoperatively
SAS > 50 points	66 (39.52)	32 (19.16)c	44 (26.35)a
SDS > 52 points	75 (44.91)	47 (28.14)b	58 (34.73)
SAS > 50 or SDS > 52 points	106 (63.47)	71 (42.51)c	87 (52.10)a
SAS > 50 and SDS > 52 points	35 (20.96)	8 (4.79)c	15 (8.98)b

^aP < 0.05 vs preoperative assessment.

^bP < 0.01 vs preoperative assessment.

^cP < 0.001 vs preoperative assessment.

SAS: Self-Rating Anxiety Scale; SDS: Self-Rating Depression Scale.

Assessment of patient resilience on the preoperative day

Preoperative resilience, measured using CD-RISC on day 1, averaged 64.26 ± 8.16. Domain scores were tenacity (29.08 ± 6.02), optimism 25.00 (21.00-27.00), and strength 11.00 (9.00-13.00) (Table 2).

Table 2 Resilience in patients one day prior to surgical procedures.

Indicators	mean ± SD/median (interquartile rage)
Tenacity (points)	29.08 ± 6.02
Optimism (points)	25.00 (21.00-27.00)
Strength (points)	11.00 (9.00-13.00)
CD-RISC (points)	64.26 ± 8.16

CD-RISC: Connor-Davidson Resilience Scale.

Relationship between perioperative anxiety/depression and resilience

Pearson/Spearman correlation analyses (Table 3) revealed significant negative correlations between day 1 CD-RISC scores and both SAS and SDS scores at all assessment points (preoperative: r = -0.481, r = -0.439; 7 days postoperative: r = -0.258, r = -0.356; and 6 months postoperative: r = -0.209, r = -0.250; all P < 0.01). These inverse correlations were strongest preoperatively and gradually weakened over time.

Table 3 Correlates of anxiety and depression with resilience in surgical patients.

Indicators	r	P value
Preoperative SAS and CD-RISC scores (points)	-0.481	< 0.001
Preoperative SDS and CD-RISC scores (points)	-0.439	< 0.001
Postoperative day-7 SAS and CD-RISC scores (points)	-0.258	< 0.001
Postoperative day-7 SDS and CD-RISC scores (points)	-0.356	< 0.001
6-month postoperative SAS and CD-RISC scores (points)	-0.209	0.007
6-month postoperative SDS and CD-RISC scores (points)	-0.250	0.001

SAS: Self-Rating Anxiety Scale; CD-RISC: Connor-Davidson Resilience Scale; SDS: Self-Rating Depression Scale.

CD-RISC scores in patients with anxiety or depression

Anxiety was defined as SAS > 50 and depression as SDS > 52. Patients not meeting these thresholds formed the corresponding nonanxiety or non-depression groups. As shown in Figure 3, preoperative CD-RISC scores were significantly lower in patients with anxiety or depression than in those without (P < 0.01). At 7 days and 6 months postoperatively, resilience did not differ significantly between anxiety and nonanxiety groups (P > 0.05). However, depressed patients scored significantly lower on the CD-RISC than nondepressed patients at both time points (P < 0.01).

Figure 3 Connor-Davidson Resilience Scale levels in patients with anxiety or depression. A: Preoperative Connor-Davidson Resilience Scale (CD-RISC) levels in patients with vs without anxiety; B: Preoperative CD-RISC levels in patients with vs without depression; C: CD-RISC levels at 7 days postoperatively in patients with vs without anxiety; D: 7-day postoperative CD-RISC levels in in depressed and depression-free patients; E: CD-RISC levels at 6 months postoperatively in patients with vs without anxiety; F: 6-month postoperative CD-RISC levels in depressed and depression-free patients. ^bP < 0.01 vs non-anxious/non-depressed patients. CD-RISC: Connor-Davidson Resilience Scale.

Univariate and multivariate analysis of factors influencing patients’ resilience

Patients scoring ≥ 60 on CD-RISC were classified as high-resilience group (n = 121), and those scoring < 60 as the low-resilience group (n = 46). Univariate and multivariate findings (Tables 4 and 5) indicated no significant associations with gender, age, illness duration, or marital status (P > 0.05). In contrast, social support, monthly per-capita household income, and preoperative SAS/SDS scores significantly predicted resilience (P < 0.05).

Table 4 Determinants of patient resilience (univariate analysis), n (%).

Variable	Poor resilience (n = 46)	High resilience (n = 121)	χ2	P value
Sex			0.026	0.872
Male	18 (39.13)	49 (40.50)
Female	28 (60.87)	72 (59.50)
Age (years)			2.580	0.108
< 60	23 (50.00)	44 (36.36)
≥ 60	23 (50.00)	77 (63.64)
Disease duration (months)			0.372	0.542
< 6	17 (36.96)	51 (42.15)
≥ 6	29 (63.04)	70 (57.85)
Marital status			1.340	0.247
Married	28 (60.87)	85 (70.25)
Other	18 (39.13)	36 (29.75)
Social support			5.839	0.016
No	25 (54.35)	41 (33.88)
Yes	21 (45.65)	80 (66.12)
Monthly household income per capita, (yuan)			4.341	0.037
< 4000	37 (80.43)	77 (63.64)
≥ 4000	9 (19.57)	44 (36.36)
Preoperative SAS (points)			9.766	0.002
≤ 50	19 (41.30)	82 (67.77)
> 50	27 (58.70)	39 (32.23)
Preoperative SDS (points)			10.582	0.001
≤ 52	16 (34.78)	76 (62.81)
> 52	30 (65.22)	45 (37.19)

SAS: Self-Rating Anxiety Scale; SDS: Self-Rating Depression Scale.

Table 5 Predictors of resilience based on multivariate analysis.

Variable	B	SE	Wald	P value	OR	95%CI
Social support	1.255	0.412	9.296	0.002	3.510	1.566-7.866
Monthly household income per capita (yuan)	0.897	0.452	3.948	0.047	2.453	1.012-5.946
Preoperative SAS (points)	1.261	0.396	10.162	0.001	3.529	1.625-7.664
Preoperative SDS (points)	1.396	0.409	11.649	0.001	4.039	1.812-9.004

SAS: Self-Rating Anxiety Scale; SDS: Self-Rating Depression Scale; OR: Odds ratio; CI: Confidence interval.

Multivariate results identified four independent predictors of low resilience: Lack of social support [odds ratio (OR) = 3.510, 95% confidence interval (CI): 1.566-7.866; P < 0.05], monthly household income < 4000 yuan (OR = 2.453, 95%CI: 1.012-5.946; P < 0.05), elevated preoperative SAS score (> 50; OR = 3.529, 95%CI: 1.625-7.664; P < 0.05), and elevated preoperative SDS score (> 52; OR = 4.039, 95%CI: 1.812-9.004; P < 0.05).

DISCUSSION

Anxiety and depression can worsen clinical outcomes in ESS-treated LDD patients, and low resilience may further delay recovery[18,19]. This study examined perioperative anxiety and depressive symptoms and their association with resilience to inform improved patient management.

We observed significant reductions in SAS scores at 7 days and 6 months postoperatively compared with preoperative values. SDS scores showed a downward trend, though without statistical significance. Postoperative reductions in anxiety and depression rates likely reflect effective pain relief, restoration of lumbar function, and improvements in limb function and self-care capacity following ESS. These gains may strengthen patients’ sense of self-efficacy regarding their physical being and brighter expectations for their future lives, thereby easing psychological distress. Our preoperative anxiety rate (39.52%) aligns with Laufenberg-Feldmann et al[20], who reported 42.50% in patients with lumbar disc herniation. Similarly, Jabłońska et al[21] documented a 47.30% preoperative depression rate among single-level microdiscectomy candidates, which decreased to 25.10% at 7 days but increased slightly to 31.10% at 6 months postoperatively - patterns consistent with our findings.

Preoperative resilience averaged 64.26 ± 8.16, with tenacity scoring highest 29.08 ± 6.02, followed by optimism 25.00 (21.00-27.00), and strength lowest 11.00 (9.00-13.00). A clear inverse correlation emerged between preoperative CD-RISC scores and both anxiety and depression scores at all postoperative time points, although the correlation weakened over time. Patients with preoperative anxiety or depression had marked reduced resilience, and depressed patients continued to show reduced resilience during follow-up. Highly resilient individuals may approach disease- and procedure-induced stressors with greater optimism, which can buffer psychological strain and reduce susceptibility to anxiety and depression. Zhang et al[22] similarly reported an inverse correlation and significant linear trend between resilience and anxiety in patients with lumbar disc herniation. Prior research has also indicated that higher preoperative resilience levels in patients with lumbar fusion is linked to reduced short-term postoperative pain and improved mental and physical health outcomes, supporting a robust negative correlation between resilience and psychological distress symptoms in endoscopic spinal procedures for degenerative disease[23].

Univariate and multivariate analyses identified limited social support, low household income, and elevated preoperative anxiety and depression as independent predictors of reduced resilience. Social support - whether emotional or informational - can help rebuild patient confidence in combating illnesses and enhance psychological adaptability[24]. A stable family financial situation may also facilitate better adjustment by allowing access to higher-quality medical resources[25]. Conversely, significant preoperative anxiety and depression may reflect maladaptive cognitive and behavioral styles inadequate social support networks, jointly undermining resilience[26]. Zhang et al[27] similarly reported that resilience in Chinese patients on maintenance hemodialysis was influenced by age, religious beliefs, family income, and baseline family resilience. Despite differing populations, our findings align with this literature.

CONCLUSION

High preoperative anxiety and depression levels, insufficient social support, and low family income are key predictors of poor psychological resilience after surgery. Resilience shows an inverse association with anxiety and depressive symptoms and may play a modulatory role in postoperative emotional recovery.