Letter to the editor on “anxiety and depression as risk factors for postoperative complications and pain in lumbar spine surgery”

Dear Editor,

We have thoroughly read the article by Wu et al., which explores the association between anxiety, depression, and postoperative outcomes in lumbar spine surgery. The study gives valuable insight into the increasing recognition of mental health comorbidities as contributors to surgical outcomes.

To expand on these findings, We observed that there’s a critical need for engaging mental health professionals in the postoperative management of lumbar spine surgery (LSS) patients. As the article correctly notes, anxiety and depression are major predictors of increased postoperative complications, pain, and functional impairment. Primarily, over half of patients undergoing spine surgery report preoperative anxiety or depression, highlighting the psychological burden associated with these procedures. ¹

Multiple studies confirm that these mental health conditions not only affect pain perception but also elevate the risk of complications such as delirium, deep vein thrombosis, surgical site infections, urinary retention, and longer hospital stays. ² These effects are often compounded by comorbidities like osteoporosis and inflammatory conditions, which are more prevalent among patients with depression. ² Furthermore, mental health disorders have been shown to reduce patients’ motivation and adherence to postoperative rehabilitation programs, impeding optimal recovery.^2,3

In addition to the physiological complications, depression and anxiety deeply influence subjective outcomes such as satisfaction, pain severity, and return to function. One study noted that untreated depression led to greater postoperative symptom severity, while patients whose depressive symptoms resolved reported better outcomes even at 2- and 5-year follow-up points. ⁴

Given the multifactorial nature of pain and recovery, a biopsychosocial and interdisciplinary approach involving surgeons, pain specialists, psychologists, and rehabilitation experts is essential. Informants in interdisciplinary pain centers have highlighted how collaborative approaches foster new insights, tailor treatment goals, and avoid redundant care across systems. ⁵ Such collaboration enables a unified framework to understand pain from both biological and psychosocial perspectives, something a single-discipline model often fails to achieve.^1,5

Moreover, the failure of many orthopedic practices to routinely screen for psychological distress—missing diagnoses in up to 21% of cases—points to a critical gap in preoperative preparation. ³ Brief, validated tools like the STarT Back Screening Tool (SBT), PHQ-9, or HADS can be administered quickly and integrated into routine care, flagging high-risk patients for early intervention. ³

It is also vital to recognize that the psychological burden may persist or even worsen postoperatively if left unaddressed. Some patients develop new depressive phenotypes after surgery, further delaying recovery and complicating long-term outcomes. ¹ Psychological disorders have also been linked to increased opioid use, higher healthcare costs, and prolonged functional limitations. ³

Wu et al.’s findings serve as an important reminder that surgical excellence alone is not enough; psychological optimization must become a standard component of spine surgery protocols. The integration of mental health care can facilitate not just better outcomes, but more humane, holistic, and cost-effective care.