Tian ZS, Yan MJ, Wang H, Zhang YK, Song XJ, Zhao KC. Postoperative anxiety-depression in patients with spinal cord injury: Correlations with injury severity and sleep quality. World J Psychiatry 2026; 16(6): 113881 [DOI: 10.5498/wjp.v16.i6.113881]
Corresponding Author of This Article
Kun-Chi Zhao, Department of Spinal Surgery, China-Japan Union Hospital of Jilin University, No. 126 Xiantai Street, Changchun 130033, Jilin Province, China. zhaokunchi@jlu.edu.cn
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Psychology
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Tian ZS, Yan MJ, Wang H, Zhang YK, Song XJ, Zhao KC. Postoperative anxiety-depression in patients with spinal cord injury: Correlations with injury severity and sleep quality. World J Psychiatry 2026; 16(6): 113881 [DOI: 10.5498/wjp.v16.i6.113881]
Zhi-Sen Tian, Hang Wang, Yi-Ke Zhang, Xian-Ji Song, Kun-Chi Zhao, Department of Spinal Surgery, China-Japan Union Hospital of Jilin University, Changchun 130033, Jilin Province, China
Meng-Jie Yan, Department of Cardiovascular Medicine, China-Japan Union Hospital of Jilin University, Changchun 130033, Jilin Province, China
Co-corresponding authors: Xian-Ji Song and Kun-Chi Zhao.
Author contributions: Tian ZS and Yan MJ designed the research and wrote the first manuscript, conducted the analysis and provided guidance for the research, and they contributed equally to this manuscript as co-first authors; Tian ZS, Yan MJ, Wang H, Zhang YK, Song XJ, and Zhao KC contributed to conceiving the research and analyzing data; Song XJ and Zhao KC contributed equally to this manuscript as co-corresponding authors. All authors reviewed and approved the final manuscript.
AI contribution statement: No AI tools (including ChatGPT, Grammarly, DeepL, etc.) were used for manuscript writing, language polishing, data analysis, study design, result interpretation, or image generation. All content is human-created.
Supported by Department of Science and Technology of Jilin Province, No. YDZJ202201ZYTS094.
Institutional review board statement: This study was approved by the Ethic Committee of China-Japan Union Hospital of Jilin University (approval No. 2025092902).
Informed consent statement: Patients were not required to give informed consent to the study because the analysis used anonymous clinical data that were obtained after each patient agreed to treatment by written consent.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
Data sharing statement: No additional data are available.
Corresponding author: Kun-Chi Zhao, Department of Spinal Surgery, China-Japan Union Hospital of Jilin University, No. 126 Xiantai Street, Changchun 130033, Jilin Province, China. zhaokunchi@jlu.edu.cn
Received: November 4, 2025 Revised: December 21, 2025 Accepted: February 13, 2026 Published online: June 19, 2026 Processing time: 205 Days and 0.5 Hours
Abstract
BACKGROUND
Patients with spinal cord injury (SCI) commonly experience varying degrees of anxiety, depression, and sleep disturbances, which may hinder postoperative recovery.
AIM
To examine the association between postoperative anxiety-depression symptoms, injury severity, and sleep quality in patients with SCI.
METHODS
A total of 149 patients who underwent surgical treatment for SCI from December 2021 to December 2024 were enrolled. At three months postoperatively, all participants were assessed using the Hamilton Anxiety Scale (HAMA) and Hamilton Depression Scale (HAMD) for psychological status, the American Spinal Injury Association (ASIA) Impairment Scale for injury severity, and the Pittsburgh Sleep Quality Index (PSQI) for sleep quality. Correlation analyses were conducted to evaluate relationships among postoperative anxiety, depression, SCI severity, and sleep disturbances, and regression analyses were used to identify predictors of psychological symptoms.
RESULTS
Mean HAMA and HAMD scores were 12.00 (9.00, 14.00) and 14.00 (10.00, 16.50), respectively, indicating mild anxiety (34.90%) and probable depression (24.83%). Higher ASIA grades were associated with elevated HAMA and HAMD scores. The mean global PSQI score was 12.00 (11.00, 14.00), with sleep duration, sleep efficiency, and sleep latency being the most affected domains (scores > 1). HAMA and HAMD scores showed significant positive correlations with ASIA grades and PSQI scores. Multivariate analysis identified age ≥ 60 years, male sex, disease duration ≥ 12 months, educational level below high school, ASIA grades A-B, and PSQI score ≥ 13 as independent risk factors for postoperative anxiety and depression.
CONCLUSION
Postoperative anxiety and depression are positively associated with SCI severity and impaired sleep quality management in patients with SCI.
Core Tip: In these cohort of 149 patients with spinal cord injury (SCI), anxiety, depression, injury severity, and sleep quality were evaluated three months after surgery. A substantial proportion of the patients exhibited postoperative anxiety and depression, which were significantly and positively correlated with SCI severity and sleep disorders. Advanced age (≥ 60 years), male sex, disease duration ≥ 12 months, educational level of under senior high school, American Spinal Injury Association grades A-B, and Pittsburgh Sleep Quality Index score ≥ 13 were associated with an increased risk of postoperative anxiety and depression in patients with SCI.
Citation: Tian ZS, Yan MJ, Wang H, Zhang YK, Song XJ, Zhao KC. Postoperative anxiety-depression in patients with spinal cord injury: Correlations with injury severity and sleep quality. World J Psychiatry 2026; 16(6): 113881
Spinal cord injury (SCI) involves damage to spinal structures, including bones, ligaments, the spinal cord, intervertebral discs, blood vessels, or nerve roots. Such injuries may result in permanent or temporary impairment of spinal cord function, leading to deficits in nervous, motor, sensory, and autonomic functions[1]. Globally, SCI incidence is estimated at 105 cases per million people annually, with higher rates reported in developing countries, where traffic accidents and falls are the primary causes[2]. SCI is characterized by high destructiveness and catastrophic consequences, with elevated mortality, disability, and healthcare costs. It often deprives patients of their ability to work and perform activities of daily living, resulting in significant physical and psychological distress and increasing the burden on families and society[3-5]. Consequently, many individuals with SCI develop anxiety and depression to varying degrees. Some adopt maladaptive coping behaviors, such as alcohol consumption or smoking, which may further exacerbate health risks and complications[6]. Emerging evidence suggests an association between anxiety and depression in patients with SCI and activation of the NOD-like receptor thermal protein domain-associated protein 3 inflammasome pathway, which may contribute to mood disorder development by regulating the release of pro-inflammatory cytokines[7]. Sleep disturbances, including difficulty initiating sleep and fragmented sleep, are also common in this population and are associated with poorer recovery and reduced quality of life[8]. These disturbances are often driven by disease-related spasticity, neuropathic pain, and sensory abnormalities, and are further compounded by psychological distress[9].
Although previous studies have extensively explored the epidemiology, mechanisms, and interventions related to SCI, limited attention has been paid to the interrelationships among injury severity, sleep quality, and postoperative anxiety and depression. The present study aims to address this gap by examining these associations in a cohort of surgically treated SCI patients.
MATERIALS AND METHODS
Case selection
A total of 149 patients with SCI who underwent surgical treatment at China-Japan Union Hospital of Jilin University from December 2021 to December 2024 were included in this study. The flowchart for patient selection is shown in Figure 1. Inclusion criteria: A confirmed diagnosis of SCI, regardless of etiology or severity[10]; age ≥ 18 years; willingness to complete all psychometric assessments and questionnaires; intact cognitive function with normal communication and comprehension abilities; first-time treatment seekers; clinical eligibility for surgical intervention; and complete clinical data.
Exclusion criteria: A personal or family history of psychiatric disorders; previous major psychological trauma; coexisting intellectual disability or organic brain disease; medical conditions associated with psychiatric symptoms (e.g., diabetes, hepatic encephalopathy, and pulmonary encephalopathy); other serious comorbidities (e.g., malignant tumors and coronary heart disease); and recent (within 3 months) use of medications that could interfere with study outcomes (e.g., anxiolytics, antidepressants, sedative hypnotics, glucocorticoids, and analgesics).
Data collection and outcome measurement
Assessment of anxiety and depression[11]. Anxiety and depressive symptoms were evaluated three months postoperatively using the Hamilton Anxiety Scale (HAMA) and Hamilton Depression Scale (HAMD). The HAMA comprises 14 items scored on a 4-point scale, yielding a maximum score of 56, with higher scores indicating greater anxiety severity. The HAMD consists of 17 items of which the first nine are scored 0-4, and the remaining eight 0-2, resulting in a maximum total score of 52; higher scores reflect more severe depressive symptoms.
SCI severity classification[12]. Injury severity was assessed three months after surgery using the American Spinal Injury Association (ASIA) Impairment Scale. Grade A indicates complete injury with no preservation of motor or sensory function in sacral segments; grade B indicates incomplete injury with preserved sensory - but not motor - function below the lesion; grade C indicates incomplete injury with preserved sensory function and residual motor function below the injury level, with more than half of key muscles graded < 3; grade D indicates incomplete injury with functional motor strength (≥ 3) in at least half of key muscles and below the injury level; and grade E indicates normal sensory and motor function.
Sleep quality assessment[13]. Sleep quality was evaluated three months postoperatively using the Pittsburgh Sleep Quality Index Scale (PSQI). The scale assesses seven components - subjective sleep quality, sleep latency, sleep duration, sleep efficiency, sleep disturbances, use of sleep medication, and daytime dysfunction - each scored 0-3, with a total possible score of 21. Higher scores indicate poorer sleep quality. In addition, the proportion of patients scoring > 1 in each component was calculated, with such scores indicative of clinically meaningful sleep impairment.
Statistical analysis
Statistical analyses were performed using SPSS statistics version 25.0 and GraphPad Prism version 7.0. A two-sided P < 0.05 was considered statistically significant. Normality was assessed using the Shapiro-Wilk test. Normally distributed data are presented as mean ± SD, and differences among multiple groups were analyzed using one-way analysis of variance. When analysis of variance assumptions were met, post hoc comparisons were conducted using Tukey’s honestly significant difference test. For data not meeting assumptions of normality or homogeneity of variance, results are expressed as median (interquartile range), and group comparisons were performed using the Kruskal-Wallis H test. The association of negative emotional states with injury severity and sleep quality was analyzed using Spearman’s rank correlation. Potential predictors of postoperative anxiety and depression were identified using univariate analyses followed by multivariate logistic modeling.
RESULTS
Anxiety and depression status among the 149 patients with SCI
Table 1 presents the anxiety and depression assessment results for the 149 patients with SCI, evaluated using HAMA and HAMD, respectively. The mean HAMA score was 12.00 (9.00, 14.00). By severity category, mild anxiety was observed in 51.68% of patients, obvious anxiety in 34.90%, and no patient (0.00%) had severe anxiety. The mean HAMD score was 14.00 (10.00, 16.50), with 22.82% of patients classified as having mild-to-moderate depression and 2.01% having severe depression. As shown in Table 2, the prevalence rates of anxiety and depression were 34.90% and 24.83% respectively. Overall, 51.68% experienced at least one of the two conditions, while 8.05% exhibited comorbid anxiety and depression.
Table 1 Assessment results of anxiety and depressive symptoms in 149 study participants.
ASIA grade distribution among the 149 patients with SCI
ASIA Impairment Scale distribution and the corresponding HAMA and HAMD scores are presented in Table 3. As neurological impairment progressed from grade D-A, anxiety and depression scores increased in a consistent and statistically significant manner (P < 0.05).
Table 3 American Spinal Injury Association grading in 149 spinal cord injury patients, mean ± SD/median (interquartile range).
Sleep quality evaluation among the 149 patients with SCI
Sleep quality assessment result based on the PSQI are summarized in Table 4. The mean global PSQI score was 12.00 (11.00, 14.00). The most prevalent issue was reduced sleep duration, affecting 81.88% of the patients (component score > 1), followed by impaired sleep efficiency (71.81%) and prolonged sleep latency (71.14%).
Table 4 Sleep quality profile in 149 spinal cord injury patients, median (interquartile range)/n (%).
Correlation analysis of negative emotions with SCI severity and sleep quality
As illustrated in Figure 2, the correlations of negative emotional states with SCI severity and PSQI were analyzed using Spearman’s rank correlation, with ASIA grades numerically coded from A to D as 4-1. Both HAMA and HAMD scores showed significant positive correlations with ASIA grades and global PSQI scores (P < 0.01).
Figure 2 Associations of negative emotions with spinal cord injury grade and sleep quality.
A: There was a significant positive correlation between Hamilton Anxiety Scale (HAMA) and American Spinal Injury Association Impairment Scale grade (r = 0.288, P < 0.001); B: Hamilton Depression Scale demonstrated a significant positive correlation with American Spinal Injury Association grades (r = 0.316, P < 0.001); C: HAMA was positively correlated with the global Pittsburgh Sleep Quality Index score (r = 0.289, P < 0.001); D: A positive association was observed between HAMA and global Pittsburgh Sleep Quality Index scores (r = 0.241, P = 0.003). HAMA: Hamilton Anxiety Scale; HAMD: Hamilton Depression Scale; ASIA: American Spinal Injury Association; PSQI: Pittsburgh Sleep Quality Index.
Predictors of postoperative anxiety and depression in the patients with SCI
Univariate and multivariate analyses (Tables 5 and 6) were used to identify factors associated with postoperative anxiety and depression. Age, sex, disease duration, educational background, ASIA grade, and PSQI score were significantly associated with psychological outcomes (P < 0.05). In contrast, injury level and etiology were not significantly associated with postoperative anxiety or depression (P > 0.05).
Table 5 Univariate predictors of postoperative anxiety and depression in the spinal cord injury cohort, n (%).
Multivariate logistic regression analysis demonstrated that age [odds ratio (OR) = 2.673, 95% confidence interval (CI): 1.178-6.064], sex (OR = 3.994, 95%CI: 1.684-9.474), disease duration (OR = 3.261, 95%CI: 1.474-7.214), educational background (OR = 3.947, 95%CI: 1.720-9.056), ASIA classification (OR = 0.429, 95%CI: 0.194-0.947), and PSQI score (OR = 3.361, 95%CI: 1.519-7.440) independently influenced the risk of developing anxiety and depression after SCI surgery (P < 0.05).
DISCUSSION
SCI results from trauma or disease leading to spinal cord compression, scarring, or transection. Affected individuals frequently experience chronic pain, persistent inflammation, and reduced muscle strength, which markedly impair quality of life and social functioning[14]. This population also exhibits an increased susceptibility to psychological disorders[15]. In the present study, 34.90% of surgically treated SCI patients experienced postoperative anxiety, while 24.83% exhibited depressive symptoms. Anxiety was predominantly mild, and suspected depression constituted the most common depressive subtype. The findings were consistent with those of Strøm et al[16], who reported that approximately one-third of adults undergoing spinal surgery experienced anxiety or depression, with factors such as pain, inadequate information and guidance, functional limitations, return-to-work challenges, and psychological status. Previous reports have estimated depression prevalence in patients with SCI at up to 26.00%, closely aligning with the rates observed in the present cohort[15]. Experimental studies have linked depressive-like behaviors following traumatic SCI in animal models to the dysregulation of systemic pro-inflammatory cytokines[17], implying that an imbalance between pro- and anti-inflammatory processes may contribute to neuropsychiatric symptoms. Li et al[18] further demonstrated that the nuclear factor erythroid 2-related factor 2 (Nrf2)/glutathione peroxidase 4 (GPX4) Nrf2/GPX4 signaling pathway may play a role in depressive phenotypes and cognitive impairment in SCI animal models. Activation of the Nrf2/GPX4 pathway may mitigate ferroptosis and subsequently improve behavioral outcomes, providing a potential mechanistic link between SCI pathology and psychological dysfunction.
A second key finding was that patients with more severe SCI on the ASIA Impairment Scale demonstrated elevated anxiety and depression levels. This finding is consistent with the report by Huang et al[19], who observed that individuals with greater neurological deficits experienced more pronounced depressive symptoms during rehabilitation and were more likely to develop severe disability. One possible explanation is that greater impairments in motor and sensory function heighten feelings of helplessness and loss of autonomy, thereby exacerbating emotional distress. Additionally, the mean global PSQI score in this cohort was 12.00 (11.00, 14.00), indicating generally poor sleep quality. The most affected components were sleep duration, sleep efficiency, and sleep latency. Existing evidence suggests that insomnia in SCI is multifactorial and is aggravated not only by the injury itself but also by comorbid anxiety and depression[20]. A randomized trial further reported that alterations in gut microbiota composition and disruptions in fecal metabolism may partly explain the overlap between affective symptoms and sleep disturbances[21]. Previous studies have also indicated that SCI may disrupt sleep architecture by activating systemic inflammatory responses, which may, in turn, aggravate emotional disturbances[22,23]. Interventions such as mindfulness-based stress reduction have shown potential benefits in improving sleep quality and alleviating psychological distress in this population[24]. Correlation analyses in the present study confirmed significant positive associations between anxiety and depression scores and both ASIA grade and sleep disturbance severity. However, whether the inflammatory pathway mediates the effects of SCI severity and sleep quality on psychological status remains unclear and warrants further investigation. Hsu et al[25] reported that greater disease severity in patients with atopic dermatitis was associated with higher anxiety and depression levels, suggesting a potential dose-response relationship between disease burden and psychological morbidity. Multivariate regression analysis identified multiple independent predictors of postoperative anxiety and depression, including age ≥ 60 years, male sex, disease duration ≥ 12 months, educational attainment below high school level, ASIA grades A-B, and PSQI score ≥ 13. Based on these findings, targeted psychological interventions may be considered. For patients aged ≥ 60 years, adaptive psychological counseling may help facilitate acceptance of age-related functional changes, alongside linkage to community-based elderly care resources, such as day care services and home medical visits, to reduce caregiver burden and alleviate negative emotions. Male patients often experience a shift in social roles, transitioning from primary family providers to care recipients. Their rehabilitation expectations tend to emphasize functional independence and social reintegration; however, traditional gender norms may discourage proactive help-seeking for emotional distress. Group-based support programs or peer education tailored to male psychological characteristics may therefore encourage emotional expression. For patients with a disease duration ≥ 12 months, establishing long-term support networks may promote sustainable social participation, counteracting disease-related social isolation and reducing psychological burden. For patients with educational attainment below senior high school, targeted health education delivered through intuitive and accessible formats, such as visual materials and plain-language explanations, may enhance disease understanding, improve perceived control, and reduce psychological stress. In patients with ASIA grades C-D, mindfulness-based stress reduction techniques may be integrated into rehabilitation programs to mitigate frustration associated with functional impairment. For those with PSQI score of ≥ 13, postoperative sleep management should be prioritized as a core component of psychological intervention, including optimization of the sleep environment in hospital and home settings and provision of nighttime caregiving guidance, to minimize anxiety and depression related to sleep disturbances. These findings are supported by Lim et al[26], who identified male sex, lower income, and greater injury severity as predictors of poorer mental health following SCI. Likewise, Tang and Yu[27] noted that male sex, prolonged disease duration, lower educational level, higher pain intensity, and poor family economic status were associated with major depressive disorder in this population. Notably, male sex emerged as an independent risk factor for postoperative anxiety and depression in the present study, which contrasts with the findings of Widuch-Spodyniuk et al[28], who reported no significant sex differences in psychological distress among comparable patients. This discrepancy may reflect differences in sample composition assessment instruments, or sociocultural factors, particularly the social role pressure and emotional expression constraints faced by men after injury. Further qualitative research is needed to clarify these mechanisms.
There are several limitations in this study. First, the sample size was limited to 149 patients from a single center, with an uneven distribution of ASIA grades. Future studies should expand the sample size and incorporate multicenter cohorts to improve statistical power. Second, the cross-sectional design permits assessment of intervariable associations but does not allow casual inference. Longitudinal studies with data collection at multiple time points are needed to clarify causal relationships. Third, the absence of long-term follow-up data precludes the evaluation of temporal changes in anxiety and depressive symptoms and limits assessment of the impact of identified predictors on long-term outcomes, such as rehabilitation compliance and quality of life. Prospective cohort studies are therefore warranted to elucidate psychological trajectories and their prognostic significance. Fourth, the potential role of inflammatory pathways in simultaneously mediating the effects of SCI severity and sleep disturbances on psychological status was not examined; addressing this gap may help clarify the underlying mechanistic pathways. Finally, information on injury etiology, rehabilitation pathways, family support, economic status, and rehabilitation compliance was not included. Incorporating these variables in future analysis may enhance the accuracy and generalizability of predictive models.
CONCLUSION
In summary, postoperative anxiety and depression are common among patients with SCI and are significantly and positively associated with injury severity and sleep disturbances. Advanced age, male sex, longer disease duration (≥ 12 months), lower educational attainment (< senior high school), more severe ASIA grades (A-B), and poor sleep quality (PSQI ≥ 13 score) may increase the risk of these psychological complications.
Fehlings MG, Alvi MA, Evaniew N, Tetreault LA, Martin AR, McKenna SL, Rahimi-Movaghar V, Ha Y, Kirshblum S, Hejrati N, Srikandarajah N, Quddusi A, Moghaddamjou A, Malvea A, Pinto RR, Marco RAW, Newcombe VFJ, Basu S, Strantzas S, Zipser CM, Douglas S, Laufer I, Chou D, Saigal R, Arnold PM, Hawryluk GWJ, Skelly AC, Kwon BK. A Clinical Practice Guideline for Prevention, Diagnosis and Management of Intraoperative Spinal Cord Injury: Recommendations for Use of Intraoperative Neuromonitoring and for the Use of Preoperative and Intraoperative Protocols for Patients Undergoing Spine Surgery.Global Spine J. 2024;14:212S-222S.
[RCA] [PubMed] [DOI] [Full Text][Cited by in Crossref: 2][Cited by in RCA: 19][Article Influence: 9.5][Reference Citation Analysis (0)]
Huang H, Chen M, Ding P, Xia X, Dai Q, Feng L, Xu L, Shu J, Li L. Disability trajectories individuals with spinal cord injury in mainland China: do psychosocial resources and diseases factors predict trajectories?Spinal Cord. 2025;63:1-8.
[RCA] [PubMed] [DOI] [Full Text][Cited by in RCA: 2][Reference Citation Analysis (0)]
Kelly MR, Zeineddine S, Mitchell MN, Sankari A, Pandya N, Carroll S, Shamim-Uzzaman QA, Salloum A, Badr MS, Martin JL. Insomnia severity predicts depression, anxiety, and posttraumatic stress disorder in veterans with spinal cord injury or disease: a cross-sectional observational study.J Clin Sleep Med. 2023;19:695-701.
[RCA] [PubMed] [DOI] [Full Text][Cited by in RCA: 9][Reference Citation Analysis (0)]
Furlan JC, Loh E, Boulos MI. The potential effects of untreated sleep-related breathing disorders on neuropathic pain, spasticity, and cardiovascular dysfunction following spinal cord injury: A cross-sectional prospective study protocol.PLoS One. 2023;18:e0282860.
[RCA] [PubMed] [DOI] [Full Text][Cited by in RCA: 2][Reference Citation Analysis (0)]
Widuch-Spodyniuk A, Tarnacka B, Korczyński B, Wiśniowska J. Impact of Robotic-Assisted Gait Therapy on Depression and Anxiety Symptoms in Patients with Subacute Spinal Cord Injuries (SCIs)-A Prospective Clinical Study.J Clin Med. 2023;12:7153.
[RCA] [PubMed] [DOI] [Full Text][Cited by in RCA: 3][Reference Citation Analysis (0)]
Footnotes
Peer review: Externally peer reviewed.
Peer-review model: Single blind
Specialty type: Psychology
Country of origin: China
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P-Reviewer: Milosevic L, PhD, United States; Wilkens J, Assistant Professor, Germany S-Editor: Hu XY L-Editor: A P-Editor: Yu HG
