Serotonin Reuptake Inhibitor Increases Pseudarthrosis Rates in Anterior Cervical Discectomy and Fusions

Abstract

To determine (1) the effects of serotonin reuptake inhibitors in pseudarthrosis rates after anterior cervical decompression and fusion (ACDF) and ( 2) to identify patient-reported outcome measures in patients taking serotonin reuptake inhibitors. Overview of Literature: Recent literature suggests that selective serotonin reuptake inhibitors (SSRIs) may inhibit fracture healing via downregulation of osteoblast differentiation. Spinal fusion supplementation with osteoblast-rich substances enhances spinal fusion, thus SSRIs may be detrimental. Methods: Patients with 1-year postoperative dynamic cervical spine radiographs following ACDF were grouped into serotonin reuptake inhibitor prescriptions (SSRI, serotonin-norepinephrine reuptake inhibitor [SNRI], or tricyclic antidepressant [TCA]) and no prescription (atypical antidepressant or no antidepressant). Pseudarthrosis was defined as ≥1 mm interspinous process motion on dynamic radiographs. Logistic regression models were controlled for confounding to analyze pseudarthrosis rates. Alpha was set at pvalues of <0.05. Results: Of the 523 patients who meet the inclusion criteria, 137 (26.2%) were prescribed an SSRI, SNRI, or TCA. Patients with these prescriptions were more likely to have pseudarthrosis (p=0.008) but not a revision surgery due to pseudarthrosis (p=0.219). Additionally, these patients had worse 1-year postoperative mental component summary (MCS)-12 (p=0.015) and Neck Disability Index (NDI) (p=0.006). The multivariate logistic regression analysis identified SSRI/SNRI/TCA use (odds ratio [OR], 1.82; 95% confidence interval [CI], 1.11-2.99; p=0.018) and construct length (OR, 1.91; 95% CI, 1.50-2.44; p<0.001) as pseudarthrosis predictors. A SSRI/SNRI/TCA prescription was a revision surgery predictor due to adjacent segment disease on univariate analysis (OR, 2.51; p=0.035) but not on multivariate logistic regression analysis (OR, 2.24; p=0.10). Conclusions: Patients taking serotonin reuptake-inhibiting antidepressants are at increased risk of worse postoperative outcome scores, including NDI and MCS-12, likely due to their underlying depression. This may contribute to their greater likelihood of having adjacent segment surgery. Additionally, preoperative use of serotonin reuptake inhibitors in patients undergoing an ACDF is a predictor of radiographic pseudarthrosis but not pseudarthrosis revision.

Effect of Osteoporosis on Clinical and Radiological Outcomes Following One-Level Anterior Cervical Discectomy and Fusion

“…Various factors affect cage subsidence, including overdistraction, endplate preparation, and appropriate cage size. However, information concerning the factors affecting subsidence following ACDF is limited [ 3 , 5 – 7 , 14 , 16 , 17 ]. Lee et al [ 3 ] analyzed the risk factors for subsidence following ACDF.…”

Poor Mental Health Negatively Impacts Outcomes After Spinal Surgery: A Narrative Review

“…In retrospective cohort studies, Adogwa et al36,37 found that preoperative depression, measured by the Zung Depression Scale, was associated with increased rates of symptomatic pseudarthrosis after lumbar spinal fusion surgery. In contrast, Lambrechts et al38 demonstrated that a diagnosis of depression was not independently predictive of radiographic pseudarthrosis in ACDF. Although the literature on other mental health disorders is sparse, further research is needed to determine whether optimization of a person's mental health before spinal fusion surgery can reduce their risk of developing pseudarthrosis.…”

“…More specifically, these medications seem to stimulate osteoclasts while inhibiting bone mineralization and differentiation of osteoblasts 41,42. Several clinical studies have demonstrated the negative effects of antidepressants on bone healing and fracture risk 34,38,43,44. In particular, Lambrechts et al38 demonstrated that antidepressants (SSRIs, selective serotonin-norepinephrine reuptake inhibitors, and tricyclic antidepressants) were independently associated with radiographic pseudarthrosis after ACDF.…”

“…41,42 Several clinical studies have demonstrated the negative effects of antidepressants on bone healing and fracture risk. 34,38,43,44 In particular, Lambrechts et al 38 demonstrated that antidepressants (SSRIs, selective serotonin-norepinephrine reuptake inhibitors, and tricyclic antidepressants) were independently associated with radiographic pseudarthrosis after ACDF. This body of research warrants further investigation regarding risk factors for pseudarthrosis, but should not preclude patients from spinal fusion surgery based on medications being taken.…”