Does preoperative depression predict return to sport and exercise after degenerative spine surgery?

Predicting postoperative return to sport (RTS)/return to exercise (RTE) is challenging, particularly given the unclear impact of preexisting mood conditions. In sport/exercise participants who underwent spine surgery, the authors sought to evaluate the relationship between preoperative depression and postoperative sport/exercise participation and establish a threshold depression score predictive of RTS/RTE.

A retrospective cohort study (2011-2022) was conducted of sport/exercise participants who underwent degenerative spine surgery. Moderate/severe depression was defined as a score ≥ 10 on the Patient Health Questionnaire-9 (PHQ-9). Primary outcomes were 1) RTS/RTE (yes/no), time to return (months), frequency of participation (hours and days per week); and 2) optimal PHQ-9 score predicting RTS/RTE. Secondary outcomes were patient-reported outcome measures (PROMs), including the Oswestry Disability Index (ODI) and Neck Disability Index (NDI). Multivariable regression controlled for age, sex, BMI, use of narcotics, surgical procedure, and preoperative PROM scores.

Of 737 patients surveyed on sports/exercise participation, 150 (20.4%) reported preoperative sport/exercise. The mean patient age was 56.3 ± 13.8 years, and the mean follow-up was 6.0 ± 2.1 years. Thirty-four (22.7%) patients had moderate/severe depression. Common sports/exercises were hiking (55.3%), weight lifting (46.0%), and running/jogging (40.7%). Of the 150 patients, 127 (84.7%; 64.7% depressed vs 90.5% nondepressed, p < 0.001) returned to sport/exercise within 8.9 ± 3.7 months (13.0 ± 19.3 vs 8.1 ± 12.2 months, p = 0.147) postoperatively. Compared with their presymptom baseline, depressed patients engaged in fewer days (2.5 ± 1.9 vs 4.2 ± 1.4 days, p = 0.011) and hours (5.1 ± 4.8 vs 10.1 ± 7.3 hours, p = 0.047) of sport/exercise weekly, compared with their presymptom baseline. Preoperative depression predicted longer time to RTS/RTE (HR 0.6, 95% CI 0.4-1.0; p = 0.043). A PHQ-9 score of 7.2 (AUC 0.71, p = 0.001) predicted failure to RTS/RTE. Preoperative depression predicted worse long-term ODI (β 15.0, 95% CI 4.2-25.8; p = 0.007) and NDI (β 17.3, 95% CI 0.94-33.7; p = 0.039) scores.

Sport/exercise participants undergoing degenerative spine surgery with moderate/severe depression were less likely to return to sport/return to exercise, returned later, and failed to regain presymptom levels of participation. Even mild depression (PHQ-9 score 7-9) predicted failure to return to sport/return to exercise. To facilitate successful return to sport/return to exercise, surgeons should screen all patients for depression and consider referring those with even mild depression for preoperative psychiatric optimization.