Article Review: Symptoms of post-traumatic stress following elective lumbar spinal arthrodesis
By: Brendan Remus
Psychological constructs have been used to assess medical outcomes for some time. The relationship between psychological distress, in the form of depression and anxiety, has been studied and found to reduce the patients’ perceived efficacy of treatments and to reduce adherence. Psychological distress which originates from medical procedures has rarely been examined. One article that did examine psychological distress due to a medical intervention was Deisseroth and Hart (2012). They noted that nearly 20% of patients receiving spinal athrodesis (spinal fusions) experienced PTSD in the following year.
Deisseroth and Hart (2012) begin their article with a review of DSM-IV PTSD and known risk factors for developing PTSD in medical settings. Their definition of PTSD will be familiar to most readers: re-experiencing a traumatic event, symptoms of physiological arousal, and avoidance of stimuli related to the trauma. This is a disorder which is well studied in the context of combat veterans, sexual assault victims, and survivors of natural disasters. The researchers noted previously identified risk factors for developing PTSD such as lack of social support, previous psychiatric illness, and being female. The stated purpose for this study was to assess the prevalence and time course for PTSD in spinal fusion patients. In examining the prevalence of PTSD following spinal fusions, the researchers also sought to evaluate the impact of variables related to surgery as risk factors for developing the disorder.
This study utilized a repeated measures cohort design which also included demographic and perioperative data. Basic demographic information was obtained from patients’ medical records; additionally, perioperative records were examined for data related to their actual surgery such as blood loss, need for intubation, and complications. The PTSD checklist civilian version (PCL-C) was used as the sole indicator of PTSD symptoms in patients following surgery. The PCL-C was given at 6 weeks and 3, 6, 9, and 12 months with verbal instructions for patients to relate their answers to their surgery. Completion rates of the PCL-C at each time point ranged from 82.2% to 100% and every participant completed the measure at least 3 times. A PCL-C cutoff score of 50 was used to identify patients with significant PTSD symptoms; this cutoff resulted in 19.2% of participants being identified as having significant PTSD at one or more times during the study (Deisseroth & Hart, 2012). Factors which significantly predicted the development of PTSD symptoms were previous diagnoses of psychiatric illness and surgical complications such as pulmonary hypo-oxygenation or tachycardia.
Some weaknesses in methodology were noted by Deisseroth and Hart (2012) which include an inability to actually diagnose PTSD in participants and diversity of participants. The PCL-C cutoff score of 50 is an accepted cutoff for identifying PTSD symptoms, but the measure does not allow for an actual PTSD diagnosis because the symptoms must remain for at least 4 weeks with significant impairment for that time. The PCL-C does not record impairment or duration of symptoms though consecutive scores over 50 on the measure give some indication of duration of symptoms for some participants. Diversity in participant spinal diagnosis is a threat to internal validity but given that this variability is fairly representative of the patients seen by orthopedic and neurosurgical spine surgeons it may make this study more generalizable.
The study does not mention some other weaknesses in methodology such as having one PTSD measure, little screening of participants, and not being able to identify which specific stressor contributed to the development of PTSD symptoms. The PCL-C has been used extensively in PTSD research and is viewed favorable as a measure of PTSD symptoms though the use of an additional measure of PTSD would have allowed for more confident assertions of PTSD symptomology when reporting results. One additional consideration when it come to the PCL-C is the existence of the PTSD checklist specific version (PCL-S) which attempts to identify PTSD symptoms related to a specific trauma; the PCL-S may have been a more appropriate PTSD measure for this study. The clinician administered PTSD scale (CAPS) would also have allowed for a more confident assertion of PTSD symptomology and in some instances an actual diagnosis of PTSD. The CAPS would also allow researchers to determine the origin of the PTSD symptoms and exclude patients whose PTSD resulted from something other than the medical procedure. Deisseroth and Hart (2012) likely chose their measures to balance ease of administration and validity though I would argue for the use of different or more measures of the primary construct of interest. The final weakness in the article was a failure to screen for PTSD or other psychological disorder symptoms prior to surgery. This oversight may have led to higher rates of PTSD symptoms at follow-up due to existing characteristics.
Things that the article did well include exclusion criteria, not overstating findings, and reporting non-significant findings. Deisseroth and Hart (2012) excluded patients who received spine surgery due to a traumatic event which likely excluded patients whose injury produced PTSD symptoms regardless of surgery. Instead, they used people with chronic or degenerative conditions. The authors’ reporting of non-significant findings provides useful information about the impact of intubation, ICU stay, level of surgery, and demographic data. Future readers can look at the non-significant findings to influence their study designs. The final thing that the authors did well was to not overstate their findings; they recognized that one measure does not definitively indicate PTSD.
Overall, this article provided a needed exploration of PTSD development following spine surgery. Filling a research gap like this is crucial for identifying the relationship between PTSD, invasive surgery, and demographic data.
Deisseroth, K., & Hart, R. A. (2012). Symptoms of post-traumatic stress following elective lumbar spinal arthrodesis. Spine, 37(18), 1628-1633.