The United States Preven-tive Services Task Force (USPSTF) recommends that pre-surgical psychological screening (PPS) be used in clinical practice to assure that a patient’s diagnosis is correct, to identify those at risk for poor outcomes, and to provide effective treatment and follow-up services. PPS involves referring patients—including those with chronic pain who are considering spine surgery—to a health psychologist for further evaluation. This usually involves a semi-structured interview and psychometric testing.

Studies suggest that few adults with depression and anxiety seek care, but these conditions may play a role in disabling back pain and contribute to poor health outcomes. The USPSTF recommendations were developed in response to the realization that many psychological disorders go untreated. “These illnesses are often overlooked,” explains Richard L. Skolasky, ScD, “but they could pose serious risks to patients and may influence recovery.” Previous research has linked depression and anxiety to longer recuperation time, delayed returns to work, more postoperative complications, and failure to comply with medication schedules after discharge.

Examining Use of PPS

Little is known about how often PPS is used by spine surgeons or the factors that may affect its use. To address this research gap, Dr. Skolasky and colleagues conducted a study to estimate the prevalence of PPS use among spine surgeons in the U.S. The study, published in the Journal of Spinal Disorders and Techniques, also sought to identify factors associated with the use of PPS and evaluate spine surgeons’ opinions of PPS. The quality of patient care may improve by gaining a better understanding of the factors contributing to the use of PPS.


For the analysis, an online survey invitation was emailed to 340 spine surgeons, with 110 completing the survey. Participants were asked about their own characteristics and those of their practice, whether or not their practices included rehabilitation and psychological services, and if PPS was used. “A key finding was that only about 10% of spine surgeons reported adhering to formal PPS structure,” says Dr. Skolasky. Of the 110 responders, just 37% reported that they used some form of mental health screening (Table 1). Of these respondents, 100% routinely screened for depression, 85% routinely screened for anxiety, and more than half referred patients for PPS.

Significant relationships were also observed between PPS use and education background (Table 2). PPS use was highest among spine surgeons with more experience, higher annual volume, and no university affiliation. Spine surgeons who had completed their residency or had been in practice within the last 14 years were less likely to use PPS than others with more experience. In addition, those who had fewer than 200 surgical cases annually or were university affiliated also had a greater tendency to not use PPS. The finding that surgeons in private practice or community hospitals were more likely to use PPS than those from larger, university-affiliated hospitals was somewhat surprising, Dr. Skolasky says. It is counterintuitive because academic medical centers usually have better access to psychologists as well as other testing resources that private practices and community hospitals often lack.

Important Implications

“Our results indicate that surgeons and patients must better recognize and appreciate how much psychological factors and mental health can impact the success of their surgeries,” says Dr. Skolasky. He says that PPS may also be viewed in the context of spine surgery being elective or emergent. Some surgeons may view PPS as an unnecessary surgical delay, thinking that taking time to treat depression or anxiety before surgery may allow for a patient’s condition to deteriorate while mental health is being addressed. “If the surgery is elective and patients have experienced back pain for a long time, clinicians should take the extra time to treat mental health before surgery,” Dr. Skolasky says.

Dr. Skolasky notes that his study team’s results should serve as an important reminder to all clinicians to follow the USPSTF recommendations for PPS and develop protocols to ensure that they are followed. He adds that a better understanding of the barriers to PPS use is still needed. “Use of PPS should be emphasized during surgical education so that it is better adopted into clinical practice,” he says. “The benefits of PPS to both patients and surgeons should be better explained during the training of clinicians.” Dr. Skolasky notes that he and his colleagues are planning to conduct more research to better assess how screening and treatment for anxiety and depression before spine surgery affect patient recovery. This information may further educate clinicians on the benefits of PPS and drive home the need for using these screenings more frequently.