Perception and severity of perioperative pain are

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1 CLINICAL ARTICLE J Neurosurg Sine 28: , 2018 Influence of catastrohizing, anxiety, and deression on in-hosital oioid consumtion, ain, and quality of recovery after adult sine surgery Lauren K. Dunn, MD, PhD, 1 Marcel E. Durieux, MD, PhD, 1,2 Lucas G. Fernández, MD, DSc, 1 Siny Tsang, PhD, 3 Emily E. Smith-Straesser, MD, 1 Hasan F. Jhaveri, 1 Shauna P. Sanos, MD, 1 Matthew R. Thames, MD, MBA, 1 Christoher D. Sencer, MD, MSc, 1 Aaron Lloyd, MD, 1 Russell Stuart, MD, 1 Fan Ye, MD, MPH, 1 Jacob P. Bray, MD, 1 Edward C. Nemergut, MD, 1,2 and Bhiken I. Naik, MBBCh 1,2 Deartments of 1 Anesthesiology and 2 Neurosurgery, University of Virginia, Charlottesville, Virginia; and 3 Deartment of Eidemiology, Columbia University, New York, New York OBJECTIVE Percetion of erioerative ain is influenced by various sychological factors. The aim of this study was to determine the imact of catastrohizing, anxiety, and deression on in-hosital oioid consumtion, ain s, and quality of recovery in adults who underwent sine surgery. METHODS Patients undergoing sine surgery were enrolled in this study, and the reoeratively comleted questionnaires included the verbal rating scale (VRS), Pain Catastrohizing Scale (PCS), Hosital Anxiety and Deression Scale (HADS), and Oswestry Disability Index (ODI). Quality of recovery was assessed using the 40-item Quality of Recovery questionnaire (QoR40). Oioid consumtion and ain s according to the VRS were recorded daily until discharge. RESULTS One hundred thirty-nine atients were recruited for the study, and 101 comleted the QoR40 assessment ostoeratively. Patients with higher catastrohizing s were more likely to have higher maximum ain s ostoeratively (estimate: 0.03, SE: 0.01, = 0.02), without increased oioid use (estimate: 0.44, SE: 0.27, = 0.11). Preoerative anxiety (estimate: 1.18, SE: 0.65, = 0.07) and deression s (estimate: 1.06, SE: 0.71, = 0.14) did not correlate with increased ostoerative oioid use; however, atients with higher reoerative deression s had lower quality of recovery after surgery (estimate: -1.9, SE: 0.56, < 0.001). CONCLUSIONS Catastrohizing, anxiety, and deression lay imortant roles in modulating ostoerative ain. Preoerative evaluation of these factors, utilizing a validated tool, hels to identify atients at risk. This might allow for earlier sychological intervention that could reduce ain severity and imrove the quality of recovery. htts://thejns.org/doi/abs/ / spine1734 KEY WORDS ain catastrohizing; anxiety; deression; sine surgery Percetion and severity of erioerative ain are influenced by various biological, cultural, and sychological factors. 31 The sychological factors that imact ostoerative recovery include catastrohizing, anxiety, and deression. 4 Catastrohizing is an exaggerated behavioral resonse to anticiated or actual ain and influences the ercetion of ain. 10,33 It can account for between 7% and 13% of variation in ain s. 31 Catastrohizing includes 3 comonents: magnification, rumination, and hellessness. 11 High levels of catastrohizing are correlated with increased reorted ain intensity and a greater incidence of chronic ain and are an indeendent determinant of disability in atients with chronic ain syndromes. 1,8,14,20,22,32,35 Subsets of atients who tend to dislay higher levels of catastrohizing include women and younger atients. 9,10,12,34 Patients with sine disease have a high incidence of chronic ain, increased disability, and oor quality of life. 21 ABBREVIATIONS ASA = American Society of Anesthesiologists; CBT = cognitive behavioral theray; HADS = Hosital Anxiety and Deression Scale; ICU = intensive care unit; LMM = linear mixed effects model; ODI = Oswestry Disability Index; PACU = ost-anesthesia care unit; PCA = atient-controlled analgesia; PCS = Pain Catastrohizing Scale; QoR40 = 40-item quality of recovery questionnaire; VRS = verbal rating scale. SUBMITTED January 7, ACCEPTED May 22, INCLUDE WHEN CITING Published online November 10, 2017; DOI: / SPINE1734. AANS 2018, excet where rohibited by US coyright law J Neurosurg Sine Volume 28 January

2 L. K. Dunn et al. Interestingly, erceived back and leg ain and the level of disability are not correlated with objective markers of the severity of sinal disease. 16,27 Psychological factors may lay an imortant role in ain ercetion and the management of atients with sine-related chronic ain. 1,12,13 The aim of this study was to determine the imact of catastrohizing, anxiety, and deression on in-hosital oioid consumtion, ain s, and quality of recovery in adults who underwent sine surgery. Methods This rosective single-center observational study of adults undergoing sine surgery was aroved by the University of Virginia Institutional Review Board for Health Science Research, and the need for written consent was waived. We enrolled atients between 18 and 80 years of age who were scheduled for cervical, thoracic, and/or lumbar sine surgery and could read and seak English. We excluded atients undergoing emergency surgery, regnant females, and risoners. Subjects were enrolled from Aril 2015 to Aril Study Protocol After verbal consent was obtained, demograhic data were collected (atient sex, age, and American Society of Anesthesiologists [ASA] hysical status classification [Arabic numbers were used for the classification to erform statistical analysis]). The reoerative use of oioid and nonoioid medications, including nonsteroidal antiinflammatory drugs, gabaentinoids, benzodiazeines, and muscle relaxants was recorded. All oioids used during the erioerative eriod were converted to morhine equivalents to facilitate analysis (htt:// com/contents/cancerain-management-with-oioidsotimizing-analgesia). An 11-oint verbal rating scale (VRS) was used to quantify re- and ostoerative ain. Questionnaires In addition to the VRS, other questionnaires comleted rior to surgery included the 1) Pain Catastrohizing Scale (PCS), a 13-item scale that evaluates rumination, magnification, and hellessness associated with ain, with each item rated on a 5-oint scale: 0 (not at all) to 4 (all the time); 2) Hosital Anxiety and Deression Scale (HADS), a 14-item scale (7 items each for anxiety and deression), with each item d from 0 to 3; and 3) Oswestry Disability Index (ODI). 6,11,27 Quality of recovery after surgery was assessed using the 40-item quality of recovery questionnaire (QoR40), which measures 5 asects (dimensions) of recovery: emotional state (9 items), hysical comfort (12 items), sychological suort (7 items), hysical indeendence (5 items), and ain (7 items). A comosite for the QoR40 was used for analysis in this study. 17 Intraoerative and Postoerative Data Collected intraoerative data included duration of rocedure, time to extubation, and total administration of intraoerative oioid and nonoioid analgesics (lidocaine, ketamine, dexmedetomidine, intravenous acetaminohen). Surgery-secific data included rimary versus reeat surgery, site of surgery (cervical, thoracic, or lumbar), anterior versus osterior aroach, number of intervertebral rocedures (transforaminal lumbar interbody fusions), and number of osteotomies erformed. Collected ostoerative data included total daily oioid consumtion, nonoioid medications (including lidocaine, ketamine, dexmedetomidine, and acetaminohen), daily VRS (including the highest, lowest, and median s), time to first ambulation, intensive care unit (ICU) length of stay, and hosital length of stay. Perioerative Analgesia Postoeratively, all study articiants were admitted to either the ost-anesthesia care unit (PACU) or the ICU based on the extent of surgery and consistent with our institutional ractice. Postoerative oioid analgesia was administered according to a standardized rotocol. This included the use of a hydromorhone atient-controlled analgesia (PCA) um with a atient-controlled bolus dose of 0.1 mg with a lockout eriod of 8 minutes. If ain control was inadequate, the PCA um could be adjusted according to standardized institutional ractice. In addition to the intravenous oioid regimen, oral oxycodone was initiated when oral intake was commenced and was increased if ain control remained inadequate. Statistical Analysis Continuous variables are resented as the mean and standard deviation. Dichotomous variables are resented as ercentages, whereas count variables are resented as the median and range. Linear regression models were used to examine the associations between reoerative and ostoerative characteristics. The effects of reoerative characteristics (catastrohizing, anxiety, and deression) on reeatedly measured ostoerative characteristics were examined using mixed effects models, controlling for atient demograhic characteristics, reoerative morhine use, surgical rocedures, and intraoerative characteristics. Linear mixed effects models (LMMs) were used for continuous ostoerative characteristics (oioid use and ain s). The LMMs are adoted to take into account the correlated observations within subjects. For each observation j in atient i, the general form of the LMM is written as follows: y ij = β 0 + β 1 x 1ij + β 2 x 2ij... β n x nij + b i0 + b i1 z 1ij +... b in z nij + ε ij, where y ij is the outcome variable, β n are the fixed effect coefficients associated with the fixed effect redictors x nij, b in are the random effect coefficients associated with the random effect redictors z nij, and ε ij is the random error. In this study, the reoerative characteristic of interest (catastrohizing [PCS ], anxiety [HADS ], or deression [HADS ]) and time (that is, number of days ostoeratively) were modeled as fixed effects x 1ij and x 2ij, resectively. To take into account atient demograhic characteristics, reoerative morhine use, surgical rocedures, and intraoerative characteristics, these variables were each modeled as fixed effects (x nij,..., x nij ). Two random effects were included: the random intercet (b i0 ) 120 J Neurosurg Sine Volume 28 January 2018

3 Psychological factors in major sine surgery TABLE 1. Demograhics and reoerative analgesic use in 138 atients undergoing sine surgery Parameter All Men Women Value No. of atients Mean age in yrs 61 (11) 61 (10) 61 (12) 0.86 Mean BMI in kg/m 2 32 (7) 32 (6) 31 (9) 0.88 Mean ASA hysical status* 2.5 (0.6) 2.5 (0.6) 2.5 (0.5) 0.53 Mean VRS 6 (3) 6 (3) 6 (3) 0.66 Mean PCS 20 (11) 21 (11) 19 (10) 0.29 Mean ODI 47 (17) 46 (18) 48 (15) 0.51 Mean anxiety HADS 8 (5) 8 (4) 8 (5) 0.71 Mean deression HADS 7 (4) 7 (4) 7 (4) 0.72 Mean reo oioid: morhine 11 (14) 10 (14) 11 (14) 0.63 equivalent dose in mg % taking NSAID % taking benzodiazeine % taking muscle relaxant % taking tramadol BMI = body mass index; NSAID = nonsteroidal antiinflammatory drug. Data resented as the mean (standard deviation) or ercentage. Sex differences were examined using linear regression models (for continuous variables), and chi-square statistics (for dichotomous variables). * Arabic numerals were used for the classification to erform statistical analysis. and the random sloe (b i1 ) of time (that is, number of days ostoeratively) for atient i. Strength of correlation was interreted as follows: , very weak; , weak; , moderate; , strong; and , very strong. All statistical analyses were conducted using the statistical rogram R (R Foundation). Linear mixed effects models were erformed using the lme4 ackage in R. 3 Results A total of 139 atients were recruited, and 1 of these atients was excluded because of significant daily oioid use from an oioid intrathecal um. One hundred one atients comleted the QoR40 assessment ostoeratively. Demograhic and reoerative sychosocial characteristics are resented in Table 1. No significant differences were noted between men and women with regard to demograhics or reoerative oioid and nonoioid medication use. Patients with PCS s 30 were classified as having ain catastrohizing. 30 Most atients (107 [79.2%]) had a PCS < 30, whereas 28 (20.7%) had a PCS 30; 3 atients did not comlete the PCS questionnaire. Patient s on the HADS can be categorized as normal (0 7), borderline case (8 10), and abnormal case (11 21) for deression and anxiety. Eighty-four atients (61.3%) were normal, 27 (19.7%) were borderline cases, and 26 (19.0%) were abnormal cases for deression (1 atient did not comlete the HADS). Seventy-one atients (51.8%) were normal, 27 (19.7%) were borderline cases, and 39 (28.5%) were abnormal cases for anxiety. Oioid and nonoioid use and other surgical data are listed in Table 2. Of note, male atients had longer oerations (male: 316 ± 126 minutes vs female: 248 ± 97 minutes, < 0.05) and a higher total intraoerative ket- TABLE 2. Intraoerative and ostoerative data Parameter All Men Women Value Intrao Mean total oioid dose in mg 20 (26) 22 (33) 16 (10) 0.15 Mean lidocaine dose in mg 790 (631) 844 (487) 712 (791) 0.23 Mean Dex dose in μg 9 (41) 9 (40) 9 (40) 0.98 Mean ketamine dose in mg 71 (83) 85 (96) 51 (56) 0.02 Mean acetaminohen dose in mg 359 (508) 321 (520) 412 (490) 0.3 Mean oeration time in mins 288 (119) 316 (126) 248 (97) <0.01 % undergoing redo surgery % undergoing st aroach % undergoing lumbar surgery Median no. of osteotomies (range) 0 (0 8) 0 (0 8) 0 (0 6) 0.07 Median no. of TLIFs (range) 1 (0 3) 1 (0 3) 0 (0 3) 0.42 Posto Mean QoR (21) 151 (22) 154 (20) 0.60 Mean time to ambulation in days 2 (1) 2 (2) 2 (1) 0.89 Mean ICU LOS in hrs 22 (26) 21 (23) 25 (30) 0.37 Mean hosital LOS in days 5 (3) 5 (3) 5 (3) 0.79 Dex = dexmedetomidine; LOS = length of stay; st = osterior; TLIF = transforaminal lumbar interbody fusion. Data resented as the mean (standard deviation), ercentage, or median (range), as aroriate. Sex differences were examined using linear regression models (for continuous variables), chi-square statistics (for dichotomous variables), and generalized linear regression models (for count variables). J Neurosurg Sine Volume 28 January

4 L. K. Dunn et al. TABLE 3. Linear mixed effects models estimating the effect of reoerative ain catastrohizing, deression, and anxiety on ostoerative oioid use* Catastrohizing Model Estimate SE Value Deression Model Estimate SE Value Anxiety Model Estimate SE Fixed effect Intercet Intercet Intercet PCS Deression HADS Anxiety HADS Time (days) <0.001 Time (days) <0.001 Time (days) <0.001 Age Age Age Sex (female) Sex (female) Sex (female) log(bmi) log(bmi) log(bmi) Preo morhine use <0.001 Preo morhine use <0.001 Preo morhine use <0.001 Procedure (redo) Procedure (redo) Procedure (redo) Aroach (st) Aroach (st) Aroach (st) No. of osteotomies No. of osteotomies No. of osteotomies TLIF TLIF TLIF Surgical site Surgical site Surgical site (lumbar) (lumbar) (lumbar) Intrao oioids Intrao oioids Intrao oioids Lidocaine Lidocaine Lidocaine Dex Dex Dex Ketamine Ketamine Ketamine Acetaminohen Acetaminohen Acetaminohen Oeration length Oeration length Oeration length Extubation in OR Extubation in OR Extubation in OR Random effect Intercet Time (days) OR = oerating room; SE = standard error; Time (days) = number of days ostoeratively. * Controlling for atient demograhics, reoerative morhine use, surgical rocedures, and intraoerative variables. Value amine dose (male: 85 ± 96 mg vs female: 51 ± 56 mg, = 0.02). Postoerative ICU time, hosital length of stay, and QoR40 s were not significantly different between men and women. Oioid Consumtion The effects of reoerative catastrohizing, deression, and anxiety on in-hosital ostoerative oioid consumtion were examined using LMMs, after taking into account atient age, sex, reoerative oioid consumtion, and characteristics of surgical rocedures. Preoerative catastrohizing (estimate: 0.44, SE: 0.27, = 0.11), deression (estimate: 1.06, SE: 0.71, = 0.14), and anxiety (estimate: 1.18, SE: 0.65, = 0.07) were not associated with increased ostoerative oioid use (Table 3). After controlling for demograhic, surgical, and sychological factors, we found that reoerative oioid use was associated with increased ostoerative oioid consumtion. Pain Scores The effects of reoerative catastrohizing on ostoerative ain s were examined using LMMs, after taking into account atient age, sex, reoerative oioid consumtion, and characteristics of surgical rocedures. Preoerative catastrohizing was associated with the maximum (estimate: 0.03, SE: 0.01, = 0.02) and median (estimate: 0.03, SE: 0.02, = 0.03) VRS s, suggesting that atients with increased catastrohizing were more likely to have higher ostoerative maximum and median VRS s than those with lower catastrohizing s (Table 4). The effect can be interreted, holding other variables constant, as follows: a 1-unit increase in the PCS is associated with a 0.03-unit increase in the maximum ostoerative VRS. In contrast, catastrohizing was not associated with ostoerative minimum VRS s (estimate: 0.0, SE: 0.02, = 0.89). Of note, the maximum, minimum, and median VRS s were significantly correlated with age, with older atients reorting lower VRS s than the younger atients. Postoerative Quality of Recovery There was a statistically significant negative effect of intraoerative oiates on QoR40, indicating that atients who had received more intraoerative oiates reorted lower QoR40 s ostoeratively than those who had received less intraoerative oiates (Table 5). The effect of 122 J Neurosurg Sine Volume 28 January 2018

5 Psychological factors in major sine surgery TABLE 4. Linear mixed effects model estimating the effect of reoerative ain catastrohizing on ostoerative median, maximum, and minimum VRS s* Model Median VRS Maximum VRS Minimum VRS Estimate SE Value Estimate SE Value Estimate SE Value Fixed effect Intercet < < <0.001 PCS Time (days) < < Age < <0.001 Sex (female) log(bmi) Preo morhine <0.001 Procedure (redo) Aroach (st) No. of osteotomies TLIF Surgical site (lumbar) Total oiates Lidocaine Dex Ketamine Acetaminohen Oeration length Extubation in OR Random effect Intercet Time (days) * Controlling for atient demograhics, reoerative morhine use, surgical rocedures, and intraoerative variables. reoerative catastrohizing, deression, and anxiety on quality of recovery was examined using multile regression models, controlling for atient age, sex, reoerative oioid use, and characteristics of surgical rocedures. Results showed no statistically significant effects of catastrohizing (estimate: -0.13, SE: 0.23, = 0.56) or anxiety (estimate: -0.56, SE: 0.55, = 0.31) on QoR40 s; however, deression was found to be negatively associated with QoR40 s (estimate: -1.9, SE: 0.56, < 0.001). The effect of deression on the QoR40 can be interreted, holding other variables constant, as follows: a 1-unit increase in the HADS deression is associated with 1.9-unit decrease in the QoR40. This suggests that atients who are more deressed reoeratively are more likely to reort lower quality of recovery s after surgery. Correlations We examined correlations between atient age and reoerative characteristics including the ain, PCS, ODI, HADS deression, HADS anxiety, and the amount of reoerative oioid use (morhineequivalent dose; Table 6). Patient age was very weakly correlated with ODI (r = -0.19, = 0.02); weakly correlated with reoerative VRS (r = -0.2, = 0.02), PCS (r = -0.3, < 0.001), reoerative oioid use (r = -0.23, = 0.007), and deression (r = -0.29, < 0.001); and moderately correlated with anxiety (r = -0.51, < 0.001). Age was weakly correlated with ASA status (r = 0.22, = 0.01), reflective of increasing comorbidity with age. Preoerative VRS was weakly correlated with PCS (r = 0.39, < 0.001), deression (r = 0.30, < 0.001), and anxiety (r = 0.33, < 0.001) and moderately correlated with ODI (r = 0.51, < 0.001). Preoerative oioid consumtion was very weakly correlated with reoerative VRS (r = 0.19, = 0.03) and deression (r = 0.18, = 0.04) but not with PCS (r = 0.16, = 0.07) or anxiety (r = 0.16, = 0.07). Finally, reoerative variables that were correlated with ostoerative variables included time to ambulation, hosital and ICU length of stay, and the QoR40 (Table 7). Age was weakly correlated with ICU stay (r = 0.24, < 0.01) and hosital stay (r = 0.21, < 0.05) but no correlation was found between age and QoR40 ostoeratively (r = 0.02). Discussion This study demonstrated that after controlling for age, sex, reoerative oioid use, and characteristics of surgical rocedures, there was no correlation between higher catastrohizing s and increased in-hosital oioid use or a oorer quality of recovery. However, atients with higher catastrohizing s were more likely to have higher maximum ain s ostoeratively. In contrast to revi- J Neurosurg Sine Volume 28 January

6 L. K. Dunn et al. TABLE 5. Multile regression models estimating the effect of ain catastrohizing, deression, and anxiety on ostoerative QoR40 * Fixed Effect Estimate SE Value Fixed Effect Estimate SE Value Fixed Effect Estimate SE Intercet Intercet <0.001 Intercet PCS Deression HADS <0.001 Anxiety HADS Age Age Age Sex (female) Sex (female) Sex (female) log(bmi) log(bmi) log(bmi) Preo morhine Preo morhine Preo morhine Procedure (redo) Procedure (redo) Procedure (redo) Aroach (st) Aroach (st) Aroach (st) No. of osteotomies No. of osteotomies No. of osteotomies TLIF TLIF TLIF Surgical site (lumbar) Surgical site (lumbar) Surgical site (lumbar) Intrao oioids Intrao oioids Intrao oioids Lidocaine Lidocaine Lidocaine Dex Dex Dex Ketamine Ketamine Ketamine Acetaminohen Acetaminohen Acetaminohen Oeration length Oeration length Oeration length Extubation in OR Extubation in OR Extubation in OR * Controlling for atient demograhics, reoerative morhine use, surgical rocedures, and intraoerative variables. Value ously ublished results, we found that reoerative anxiety and deression s were not correlated with increased in-hosital oioid use; however, atients with higher reoerative deression s were more likely to reort a oorer quality of recovery. Finally, we demonstrated that reoerative ain s, catastrohizing, deression, anxiety, and disability were all ositively correlated with one another. Our results are consistent with reviously ublished studies in both Southern 19 and Northern 2 Euroean atients. In 61 Greek atients undergoing 1-level osterior lumbar sine fusion, Paaioannou et al. reorted that catastrohizing redicted ostoerative ain intensity and analgesic use. 19 A limitation of their study was that reoerative analgesic use and ain s were not reorted. Among Swedish atients undergoing lumbar sine fusion, Abbott et al. found that reoerative catastrohizing redicted back ain intensity and functional disability u to TABLE 6. Correlation coefficients of reoerative variables Preo Variable Preo Variable Age BMI ASA Status VRS Score PCS Score ODI Deression HADS Score Anxiety HADS Score Age BMI 0.05 ASA status 0.22* 0.22* VRS 0.20* PCS ODI 0.19* Deression HADS Anxiety HADS Morhine use * * 0.18* 0.16 * < < < J Neurosurg Sine Volume 28 January 2018

7 Psychological factors in major sine surgery TABLE 7. Correlation coefficients of ostoerative variables Parameter Preo Age Preo BMI Preo ASA Status Posto Ambulation Posto ICU LOS Posto Hosital LOS Preo age Preo BMI 0.05 Preo ASA status 0.22* 0.22* Posto ambulation Posto ICU LOS Posto hosital LOS 0.21* * Posto QoR * < < < years after surgery. 2 However, cultural influences lay an imortant role in ain ercetion, 23,24 and these findings may not be alicable to a North American oulation. Aroximately 68% 71% of atients resenting for sine surgery use oioids reoeratively, which reflects the high revalence of chronic ain in this oulation. 16,18,27 Identification and treatment of high-risk atients via sychological screening rior to surgery may rovide benefit for ostoerative recovery. Recently, Caumo et al. develoed a brief measure of emotional reoerative stress (B- MEPS) to aid clinicians in identifying atients at risk for develoing moderate to severe ain ostoeratively. 5 The B-MEPS index, which was develoed utilizing reviously validated measures to assess sychological factors reoeratively, is simlified to 15 questions. Although not validated in atients with sine disease, the B-MEPS offers a simle, integrated tool that identifies atients at risk for moderate to severe ain ostoeratively. Interventions that can be initiated reoeratively might include cognitive behavioral theray (CBT) and distraction techniques. The two comonents of CBT aim to modify dysfunctional thought and change behavior. In nonoerative chronic low-back ain atients, van Tulder et al. reorted that behavioral theray had a moderate ositive effect on ain intensity, as well as small ositive effects on generic functional status and behavioral outcomes. 36 The distraction technique, whereby atients focus on toics unrelated to their ain, is another tool available for the high-risk atient. Schreiber et al. reorted that distraction techniques aear to be most beneficial in atients with chronic ain who are high catastrohizers, similar to the oulation described in our study. 26 A customized enhanced recovery athway for high-risk atients can include reoerative CBT, distraction, education, and the increased use of nonoioid adjuncts (ketamine and lidocaine) to reduce the risk of severe ostoerative ain. 7,15 According to our study, an enhanced recovery rogram for sine surgery should be customized based on age as older atients reort lower catastrohizing s. The influence of age on catastrohizing is similar to that observed for other surgical rocedures such as head and neck and breast surgery. 9,29 An imortant difference is that catastrohizing in younger atients is associated with emotional resonses, while in older atients it is associated with ain intensity scale and thus requires different behavioral modification interventions. 25 This is relevant for sine surgery as adolescent idioathic scoliosis and degenerative sine disease have a tyical bimodal age distribution. There are several limitations to our study. First, it was a single-center study in a North American oulation undergoing sine surgery. As mentioned above, our findings must be interreted with caution in other cultural grous and in atients undergoing nonsine surgery. Second, only 73% of atients comleted the QoR40 rior to discharge. This may have affected our findings about the reoerative sychological influences on ostoerative quality of recovery. Third, long-term clinical outcomes related to catastrohizing, anxiety, or deression were not assessed in our study. Future studies with 1- and 2-year follow-us will be imortant to determine long-term recovery and the risk of develoing chronic ain related to reoerative sychological factors. A final limitation of our study was that QoR40 s were not adjusted for erioerative clinical events and outcomes. Conclusions Pain catastrohizing and deression lay imortant roles in both the ercetion of ostoerative ain and the subjective assessment of the quality of ostoerative recovery, resectively. Identifying these factors reoeratively, utilizing a validated tool, allows for earlier sychological intervention that could reduce ain severity and imrove the quality of recovery. References 1. Abbott AD, Tyni-Lenné R, Hedlund R: The influence of sychological factors on re-oerative levels of ain intensity, disability and health-related quality of life in lumbar sinal fusion surgery atients. Physiotheray 96: , Abbott AD, Tyni-Lenné R, Hedlund R: Leg ain and sychological variables redict outcome 2 3 years after lumbar fusion surgery. Eur Sine J 20: , Bates D, Mächler M, Bolker B, Walker S: Fitting linear mixed-effects models using lme4. J Stat Softw 67:i01, Boutin RD, Williamson MR: Magnetic resonance imaging of musculoskeletal tumors. West J Med 156:295, Caumo W, Nazare Furtado da Cunha M, Camey S, Maris de Jezus Castro S, Torres IL, Cadore Stefani L: Develoment, sychometric evaluation and validation of a brief measure of emotional reoerative stress (B-MEPS) to redict moderate to intense ostoerative acute ain. Br J Anaesth 117: , 2016 J Neurosurg Sine Volume 28 January

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Author Contributions Concetion and design: Naik, Dunn, Durieux, Nemurgut. Acquisition of data: Naik, Fernández, Smith-Straesser, Jhaveri, Sanos, Thames, Sencer, Lloyd, Stuart, Ye, Bray. Analysis and interretation of data: Naik, Durieux. Drafting the article: Naik, Dunn, Durieux. Critically revising the article: Nemurgut. Reviewed submitted version of manuscrit: Naik, Dunn, Durieux, Fernández, Tsang, Smith-Straesser, Jhaveri, Sanos, Thames, Sencer, Lloyd, Stuart, Ye, Bray. Aroved the final version of the manuscrit on behalf of all authors: Naik. Statistical analysis: Naik, Tsang. Study suervision: Naik. Corresondence Bhiken I. Naik, Deartment of Anesthesiology, University of Virginia, Box , Charlottesville, VA bin4n@ virginia.edu. 126 J Neurosurg Sine Volume 28 January 2018