The Impact of Preoperative Depressive Symptoms on Acute and Chronic Postoperative Pain Trajectories After Orthopedic Surgery for Adolescent Idiopathic Scoliosis: a Prospective Cohort Study

The Impact of Preoperative Depressive Symptoms on Acute and Chronic Postoperative Pain Trajectories After Orthopedic Surgery for Adolescent Idiopathic Scoliosis: a Prospective Cohort Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Impact of Preoperative Depressive Symptoms on Acute and Chronic Postoperative Pain Trajectories After Orthopedic Surgery for Adolescent Idiopathic Scoliosis: a Prospective Cohort Study Sijia Ma, Zhen Wang, Jiacheng Yu, Yu Zhang, Jinhua Bo, Yu’e Sun This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9030306/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background: Patients with adolescent idiopathic scoliosis (AIS) frequentlyexperience depressive symptoms, and their functional rehabilitation can be greatly influenced by postoperative acute and chronic pain. This study aims to explore the association ofpreoperative depressive symptoms in AIS patients with postoperative acute and chronic pain. Methods: This was a prospective study involving AIS patients aged 10-17 years who were surgically managed by scoliosis correction under general anesthesia. Depressive symptoms, pain, functional activity, sleep quality, and quality of life were preoperatively assessed using scales. Dynamic trajectories in the acute postsurgical pain (APSP) and chronic postsurgical pain (CPSP) were evaluated during a 90-day follow-up. The primary outcomes were the incidence of APSP and CPSP. Secondary outcomes consisted of early postoperative oral morphine milligram equivalents (MME), early complications, postoperative length of stay, and long-term rehabilitation status. Results: Multivariate analysis identified that female sex (odds ratio [OR]=6.36, P <0.05), number of surgical segments (OR=1.31, P <0.01), and preoperative depressive symptoms (OR=41.06, P <0.001) wereindependent risk factors for CPSP. A risk prediction model (nomogram)constructed by incorporating the above variables effectively distinguished CPSP in postoperative AIS patients, with an area under the curve (AUC) of 0.852 (95% confidence intervals [CI]: 0.786–0.918, P <0.01). The incidence of CPSP was significantly higher in postoperative AIS patients with persistent depressive symptoms than those with relieved or cured depressive symptoms (100% vs. 67.86% vs. 10.40%, χ²=50.46, P <0.001). Conclusions: Preoperative depressive symptoms are risk factors for both APSP and CPSP in postoperative AIS patients, showing a gradient association with the incidence of CPSP. A nomogram incorporating female sex, number of surgical segments, and preoperative depressive symptoms effectively predicts CPSP in this population. An integrative psychological and analgesic intervention centered on preoperative depressive symptoms is expected to benefit high-risk AIS patients. Trial registration: According to the Helsinki Declaration,the research protocol has been registered with the Chinese Clinical Trial Registry (ChiCTR; https://www.chictr.org.cn/) (Registration No: ChiCTR2300077637). AIS Depressive Symptoms Postoperative Pain Pain Trajectories Risk Prediction Model Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Background Adolescent idiopathic scoliosis (AIS) is the most common three-dimensional structural deformity of the spine during the peak growth in 10-18 years of age [1]. The global prevalence of AIS ranges from 2% to 4%, which is more frequent in children aged 10–16 years (1%-3%) [2–4]. Large-scale screening data in China indicate a female preference of AIS, with a male-to-female ratio of approximately 1:1.5 [5]. Posterior spinal corrective fusion surgery is preferred for AIS patients with progressive worsening of the Cobb angle (usually ≥45°-50°) or significant cardiopulmonary dysfunction [6–8]. While being recognized for the high efficacy in correcting deformities and improving trunk balance and cardiopulmonary function, surgical procedures frequently bring postsurgical pain affecting the rehabilitation. A majority of AIS patients (>80%) experience moderate-to-severe acute pain postoperatively, and nearly half of them finally develop chronic postsurgical pain (CPSP) [9]. Depressive symptoms, as manifested as persistent low mood, loss of interest, decreased energy, and sleep disturbances [10], are seen in 34% of adolescents [11]. The overall prevalence of depressive symptoms can be even elevated in AIS patients due to body dysmorphic disorders, social avoidance, and treatment-related stress. Existing evidence indicates that preoperative depressive symptoms are closely related to the exacerbation of acute postsurgical pain (APSP), prolonged hospital stay, and increased fees in surgically treated people [12–14]. However, high-quality prospective evidence is scant on the influence of preoperative depressive symptoms on the trajectories of postoperative pain in AIS patients, as well as the risk factors. In the present study, we screened risk factors for APSP and CPSP in postoperative AIS patients, and illustrated the role of preoperative depressive symptoms in altering postoperative pain trajectories. Moreover, a nomogram was constructed to predict the risk of CPSP in AIS patients. Our findings are expected to emphasize the standardized depression screening (e.g., the Children's Depression Inventory [CDI]) in routine perioperative assessment of AIS, and the importance of an integrative psychological and analgesic intervention for high-risk AIS patients. Following the Revised Strengthening the Reporting of Cohort, Cross-Sectional and Case-Control Studies in Surgery (STROCSS) Guideline [15]. Methods Study design This was a single-center, prospective cohort study involving AIS patients treated with elective spinal deformity surgeries in Hospital between November 2023 and December 2024. Briefly, AIS patients aged 10-17 years, with the American Society of Anesthesiologists (ASA) physical status classification of Ⅰ-Ⅲ, and managed by elective spinal fusion surgeries were included. Informed consent was signed by their patients or guardians. Exclusion criteria were as follows: 1) refusal to participate in this study; 2) a long-term preoperative use of analgesics over 7 days or a history of opioid abuse; 3) severe hepatic insufficiency (advanced liver disease in the Child-Pugh classification of Class C), renal failure with the necessity of dialysis, or expected survival≤24 h; 4) schizophrenia, bipolar disorder, epilepsy, or myasthenia gravis; 5) inability to complete scale assessments; 6) presence of uncontrolled severe hypertension preoperatively (systolic blood pressure>180 mmHg), significant sinus tachycardia (heart rate>120 bpm), acute coronary syndrome, or severe intracranial hypertension occurring within the past week; and 7) a history of perioperative use of ketamine or esketamine. Sample size estimation and participant grouping The sample size of the present study was estimated based on the primary outcome of the incidence of APSP. A previous article reports that moderate-to-severe pain during patient-controlled intravenous analgesia (PCIA) affects 70% of people treated with scoliosis orthopedic surgeries [16]. A preliminary pre-experiment survey shows that 94% and 20% of AIS patients suffer from moderate-to-severe postoperative pain and depressive symptoms, respectively. Based on a test power of 80%, a two-sided significance of 0.05, and a dropout rate of 15%, a sample size of 155 was necessary, involving 31 participants in the depression group and 124 in the non-depression group. In our study, 200 AIS patients were initially allocated, and 157 who completed all follow-ups were included in the final analysis. They were divided into the depression group (n=32, CDI≥19 points) and the non-depression group (n=125, CDI<19 points) based on the preoperative CDI scores. Additionally, AIS patients were assigned into persistent depression group (preoperative CDI≥19, and postoperative CDI≥19), depression relief group (preoperative CDI≥19, and postoperative CDI<19) and cured depression group (preoperative CDI<19, postoperative CDI<19) based on dynamic changes in CDI scores on POD-1 and POD90. Data collection and scale assessments Baseline data of AIS patients were collected on admission, including sex, age, body mass index (BMI), education level, surgical history, medication history, ASA physical status classification, laboratory testing results (complete blood count, liver and kidney function, electrolytes), and auxiliary examinations (electrocardiography, echocardiography, etc.). Perioperative indicators, including operation time (min), anesthesia time (min), total fluid volume (mL), intraoperative urine volume (mL), blood loss (mL), and transfusion status, were recorded as well. A series of scales were used to assess pain, depressive symptoms, sleep quality, and quality of life. Briefly, pain assessment, as twice daily (8:00-10:00 and 18:00-20:00), was conducted one day before surgery (POD-1) and 1–5 days postoperatively (POD1-5), and recorded by pretrained investigators face-to-face in the ward. Additional assessments were performed on POD30 and POD90. The intensity of pain at rest (lying quietly) and during movement (immediately after standardized actions like turning over or sitting up) was assessed using the Numerical Rating Scale (NRS), ranging from 0 (no pain) to 10 (the most severe pain imaginable) [17]. APSP was determined by an NRS score of 4 or higher, indicating clinically significant moderate-to-severe pain. According to the International Classification of Diseases, 11 th Revision (ICD-11) [18], CPSP was defined as persistent pain or newly appeared pain at the original surgical site for at least three months after tissue healing. In this study, CPSP was recorded positive in AIS patients reporting persistent pain at the incision site with an NRS ≥ 4 on POD90. Follow-up data were obtained on POD30 and POD90 through structured telephonic interviews. Depressive symptoms were assessed using the CDI on POD-1, POD30 and POD90. The CDI consists of 27 items covering dimensions of negative mood, loss of pleasure, feelings of worthlessness, interpersonal distress, and somatic symptoms, ranging from 0 (no depressive symptoms) to 54 (all depressive symptoms are present) [19]. Based on previous findings, clinically significant depressive symptoms were determined by a total CDI score of ≥19[20]. The patient's cognitive function was assessed using the Mini-Mental State Examination (MMSE) scale on POD-1.Sleep quality and delirium was assessed using the Pittsburgh Sleep Quality Index (PSQI) and 3-Minute Diagnostic Confusion Assessment Method (3D-CAM) on POD-1 and POD1-5, once daily between 8:00 and 10:00. Impaired sleep quality was determined by a PSQI exceeding 5 [21,22]. The Scoliosis Research Society 22-Item (SRS-22) and the 36-Item Short Form Survey (SF-36) were used to assess the spinal function and health-related quality of life on POD-1, POD30 and POD90, respectively [23-25]. All questionnaires were completed independently by patients themselves in a quiet environment, and neutral explanations of the item meanings without influencing responses were provided by pretrained investigators, if necessary. All data were independently imported into an electronic database by two pretrained investigators, and cross-verified to ensure data integrity and accuracy. Surgical and anesthetic management Following an 8-hour fasting, patients were sent to the operation room, where electrocardiogram (ECG), oxygen saturation (SpO 2 ), non-invasive blood pressure (NIBP), and bispectral index (BIS) were routinely monitored. Anesthesia induction was performed by intravenous injections of midazolam (0.1 mg/kg), sufentanil (0.05 µg/kg), propofol (2 mg/kg), and vecuronium (0.1 mg/kg). Mechanical ventilation after intubation was applied with the following parameters: inspired fraction of oxygen (FiO 2 ) 60%-80%, tidal volume (VT) 8-10 ml/kg, respiratory rate (RR) 12-15 breaths/min, and inspiration-to-expiration ratio (I/E) 1:2. During the procedure, arterial blood pressure (ABP), central venous pressure (CVP), and BIS were continuously monitored. Propofol (4–10 mg·kg⁻¹·h⁻¹), remifentanil (0.5–1.0 μg·kg⁻¹·min⁻¹), cisatracurium (0.2 mg·kg⁻¹·h⁻¹), and dexmedetomidine (0.2 μg·kg⁻¹·h⁻¹) were continuously infused for anesthesia maintenance. Medications were timely adjusted based on the BIS values (target 40-60) and hemodynamic responses. Muscle relaxants were discontinued 30 min before the end of the procedure. Weaning from mechanical ventilation was conducted until patients regained spontaneous breathing and consciousness, followed by the initiation of PCIA. An NRS score of 4 and above was a sign of rescue analgesia. All opioids used on POD1-5, including those used for PCIA and rescue anesthesia, were converted into oral morphine milligram equivalents (MME) using internationally accepted conversion factors (Appendix 1 for details). Outcomes The primary outcomes of this study were the incidences of APSP and CPSP. Secondary outcomes included early postoperative MME, early complications (e.g., delirium), postoperative length of stay, and long-term rehabilitation status. Statistical analysis All data analyses were performed by SPSS software (version 26.0; IBM Corp., Armonk, NY, USA) and R software (version 4.4.0, http://www.R-project.org). Continuous variables within a normal distribution were described as mean ± standard deviation (mean ± SD) and compared between groups using the independent samples t-test; otherwise, they were expressed as median (interquartile range, IQR) and compared using the Mann-Whitney U test. Categorical variables were expressed as frequency and percentage (n [%]) and compared by the Chi-square test. Shapiro-Wilk test examined data normality. Repeated Measures ANCOVA was used to assess the effect of preoperative depressive symptoms on the dynamic trajectories in APSP. In this model, "time" (POD 1-5) was treated as a within-subject factor, and "severity of depressive symptoms" was the between-subject factor. The preoperative NRS score, PSQI, total score of SRS-22, and scores on the mental health dimension in SF-36 were covariates to be controlled as confounders. Potential influences of age, sex, BMI, preoperative depressive symptoms, number of surgical fusion segments, preoperative pain intensity, sleep quality, and scores on the quality of life on CPSP (a binary outcome variable: yes/no) were examined using univariate logistic regression. Variables with P <0.1 were included in the multivariate logistic regression model for identifying independent risk factors for CPSP using the backward stepwise method. Results were reported as odds ratios (OR) with 95% confidence intervals (95% CI). The performance of the created nomogram in predicting CPSP was verified via plotting the receiver operative characteristic (ROC) curves, calibration curves, and the decision curve analysis (DCA). Two-tailed p <0.05 was considered as statistically significant. Results Baseline characteristics A total of 200 AIS patients were initially allocated, and 157 who completed all follow-ups were included in the final analysis (Figure 1). Stratified by the cut-off CDI of 19, AIS patients were divided into the depression group (n=32, CDI≥19 points) and the non-depression group (n=125, CDI<19 points). Demographic characteristics and preoperative indicators, including age, sex, BMI, education level, the New York Heart Association Functional Classification (NYHA), ASA physical status classification, the Mini-Mental State Examination (MMSE) score, albumin (Alb), number of surgical fusion segments, Cobb angle, anesthesia time, operation time, intraoperative blood loss, urine output, total fluid volume, transfusion rate, and uses of vasopressors and antihypertensive drugs, were comparable between groups ( P >0.05, Table 1). However, AIS patients in the depression group graded significantly higher preoperative NRS scores at rest and during activity, as well as PSQI scores than those in the non-depression group ( P < 0.05), indicating severer pain and worse sleep quality in AIS patients with depressive symptoms. Moreover, significantly lower SRS-22 and SF-36 scores in the depression group than the non-depression group indicated that depressive symptoms were associated with worse spine-related function and health-related quality of life before the surgery ( P <0.05). Outcome indicators There were no significant differences between the two groups in the APSP incidence, MME within 5 days postoperatively, length of hospital stay, incidence of delirium within 5 days postoperatively, all-cause mortality within 30 days postoperatively, and SRS-22 scores on POD90 ( P >0.05, Table 2). In comparison to the non-depression group, the incidence of CPSP in the depression group was significantly higher ( P <0.001). Significantly lower SRS-22 scores on POD30 and SF-36 scores on POD90 in the depression group than the non-depression group indicated worse postoperative functional recovery and quality of life in AIS patients with preoperative depressive symptoms ( P <0.05). The impact of preoperative depressive symptoms on APSP The impact of preoperative depressive symptoms on APSP was analyzed using repeated-measures ANCOVA with Greenhouse-Geisser correction (Mauchly’s Test of Sphericity ,W=0.088, P<0.001). Baseline covariates included preoperative NRS, PSQI, SRS-22, and SF-36 scores. For pain at rest, the main effect of grouping of depressive symptoms was significant (F=7.144, P <0.05, partial η 2 =0.045, Figure 2a). This indicated that, after controlling for baseline differences, postoperative pain levels at rest were significantly higher in the depression group than those in the non-depression group. However, the main effect of time (F=1.597, P =0.150, partial η 2 = 0.011) and the interaction effect between the group and time (F=1.26, P =0.276, partial η 2 = 0.008) were not statistically significant. For pain during movement, a significant main effect of time on the pain during movement (F=2.176, P <0.05, partial η 2 = 0.014, Figure 2b). The main effect was also statistically significant in the depression group (F=10.960, P <0.05, partial η 2 =0.068). However, no significant difference was detected in the interaction effect between the group and time (F=9.209, P =0.061, partial η 2 =0.013). The impact of preoperative depressive symptoms on CPSP A total of 36 (22.93%) AIS patients suffered from CPSP on POD90. Factors potentially influencing CPSP were first identified by the univariate logistic regression analysis. It is shown that preoperative depressive symptoms, sex, preoperative hematocrit (HCT), number of surgical fusion segments, pain scores at rest, pain scores during movement, SRS-22 score, SF-36 score, and PSQI score were significantly associated with CPSP ( P <0.10, Appendix Table 2). These variables were included in the multivariate logistic regression model using a backward stepwise method. The final model identified that female sex (OR=6.36, 95% CI: 1.02-39.57, P <0.05), number of surgical fusion segments (OR=1.31, 95% CI: 1.07-1.60, P <0.01), and preoperative depressive symptoms (OR=41.06, 95% CI: 8.68-194.19, P <0.001) were independent risk factors for CPSP (Table 3). Correspondingly, a nomogram was created to predict the risk of CPSP in AIS patients (Figure 3a), displaying an area under the curve (AUC) of 0.852 (95% CI: 0.773-0.932, P <0.01; sensitivity=0.750, specificity=0.868; Figure 3b). The calibration curve showed that the predicted probabilities were highly consistent with the actual observed probabilities (slope close to 1, intercept close to 0) (Figure 3c). The Hosmer-Lemeshow test further proved the goodness-of-fit of the nomogram (χ²=13.132, P =0.107). DCA showed that the nomogram achieved a significant net clinical benefit within the threshold probability range of 10% to 70% (Figure 3d). The AUC of the multi-predictor model was 0.852 (95% CI: 0.773-0.932, P <0.01), which was significantly larger than that of the single-predictor model (AUC=0.782, 95% CI: 0.683-0.882, P <0.01), and the difference in AUC was statistically significant (P<0.05). (Figure 4). Dynamic changes in depressive symptoms and their impact on CPSP AIS patients were assigned into persistent depression group (n=4), depression relief group (n=28) and cured depression group (n=125) based on dynamic changes in CDI scores on POD-1 and POD90. The incidence of CPSP was 100% (4/4) in the persistent depression group, 67.86% (19/28) in the depression relief group, and 10.4% (13/125) in the cured depression group, showing a significant difference among the three groups (χ²=50.46, P <0.001, Figure 5). Further pairwise comparisons showed that the risk of CPSP was significantly higher in the persistent depression group than the depression relief and cured depression groups ( P <0.05). It was significantly higher in the depression relief group than the cured depression groups, but lower than the persistent depression group ( P <0.05). Discussion This prospective cohort study systematically revealed the impact of preoperative depressive symptoms on postoperative pain trajectories in AIS patients. Although depressive symptoms did not pose a direct effect on APSP, they significantly worsened pain intensities at rest and during movement, showing a unique pain trajectory of high baseline and steady relief. We further proved that preoperative depressive symptoms were the strongest independent predictor of CPSP, with an effect size far greater than that of traditional clinical variables. Superior to the analgesia-centered approach to control postoperative pain, an integrative psychological and analgesic intervention centered on preoperative depressive symptoms greatly benefited AIS patients. While the incidence of APSP was comparable in AIS patients either with preoperative depressive symptoms or not, those in the depression group suffered more from pain at rest and during movement. Compared to the persistent postoperative pain at rest following the surgical procedures for AIS, the pain during movement relieved over time, showing a similar pain trajectory between groups. We considered that spinal orthopedic surgery triggered APSP, and depressive symptoms acted as a pain modulator to influence how the body perceived and managed pain, known as pain experience. At the macro level, depressive symptoms often relate to functional abnormalities in brain regions dominating pain management, including the anterior cingulate cortex (ACC) and prefrontal cortex (PFC) [26–28]. They are also intertwined with cognitive factors like catastrophization of pain and fear-avoidance beliefs, altogether amplifying the subjective pain perception [29,30]. At the micro-level of neurobiology, preoperative depressive symptoms exacerbate central sensitization and prolong pain signal transmission by multiple mechanisms, such as activating the hypothalamic-pituitary-adrenal axis (HPA), promoting the release of inflammatory factors, impairing hippocampal neurons, and mediating synaptic plasticity changes by targeting CREB/BDNF [25,31]. Current neurobiological evidence indicates that depressive symptoms affect endogenous pain modulation via the descending pain inhibitory pathways, manifesting as decreases in the endogenous analgesic capacity and pain threshold [32]. This consequently induces an intrinsic hypervigilant status or central sensitization even without exogenous stimuli [33,34]. Our findings consistently supported this conclusion that preoperative depressive symptoms significantly increased baseline pain level, rather than hindering the postoperative pain relief naturally accompanied with wound healing. Although being recognized as a positive clinical sign of normal physiological recovery, an increased pain intensity during postoperative rehabilitation of AIS called for a more effective and individualized analgesic management. A previous study illustrated a correlation between preoperative depressive symptoms and increased postoperative opioid consumption [35]. Inconsistently, we did not see a significant difference in the MME during the first five days postoperatively between groups. The increased pain perception associated with depressive symptoms was probably attributed to alterations in pain processing, rather than the product of insufficient analgesia. A monotherapy of pharmacological analgesics was insufficient to fully control postoperative pain in AIS patients with preoperative depressive symptoms, necessitating a shift towards a multidimensional, integrated perioperative pain management model. CPSP is strongly associated with preoperative depressive symptoms in individuals managed by colorectal cancer surgery, thoracic surgery, and hip arthroplasty [36–38]. In our cohort, CPSP was more frequently detected in AIS patients with clinically significant depressive symptoms (CDI≥19) than those without (71.88% vs. 10.4%, P <0.001). Multivariate logistic regression analysis revealed that preoperative depressive symptoms, female sex, and the number of fused surgical segments were independent risk factors for CPSP. A meta-analysis demonstrated that preoperative depression not only increases the risk of CPSP following various types of surgeries, but is also linked with the duration and severity [39]. The present study only focused on a single surgical procedure of spinal deformity correction, effectively enhancing the internal validity of the causal inference by controlling for confounders arising from the heterogeneity of surgery types. Additionally, the number of fused surgical segments (OR=1.31/segment), as an independent risk factor, supports the dose-response relationship of trauma load-central sensitization [40]. Our findings showed that physiological trauma and psychological factors should be considered as influencing factors for CPSP. Correspondingly, a nomogram involving preoperative depressive symptoms, female sex, and the number of fused surgical segments was created to predict the risk of CPSP in AIS patients, showing acceptable discrimination, calibration, and clinical net benefit. This could be a useful tool to assist the screening of high-risk individuals with CPSP and the application of multimodal interventions (e.g., analgesia, psychological counselling, acupuncture, etc.) as early as possible. The grouping based on longitudinal changes in CDI scores showed that the highest incidence of CPSP (100%) was detected in AIS patients with persistent depressive symptoms, followed by those with relieved (67.9%) and cured depression (10.4%). This gradient association strongly indicated the critical value of an early management of preoperative depressive symptoms in surgically treated people. Interestingly, this reversible effect has been rarely reported in adults, potentially due to a weaker neural plasticity and less sensitive psychological intervention windows in adulthood than the adolescent period. Overall, a dynamic psychological monitoring system covering preoperative, early postoperative, and rehabilitation periods is recommended to screen high-risk populations of postoperative pain. In addition, multimodal psychological interventions can be applied to AIS patients, including cognitive behavioral therapy (CBT), mindfulness-based stress reduction (MBSR), and structured preoperative psychological education. These measures help soothe negative emotions and block the pain-depression vicious cycle [41, 42]. Currently, a multimodal analgesia program has been recommended by the Scoliosis Research Society (SRS) and Enhanced Recovery After Surgery (ERAS) [43,44]. Guidelines for psychological interventions against postoperative pain, however, are scant. Our findings provided solid foundations for the importance of standardized depression screening as a key link involved in the risk stratification and individualized intervention for surgically treated patients. Strengths and limitations This study held several strengths. We painted a holistic view of pain trajectories in postoperative AIS patients, showing that preoperative depressive symptoms were an independent risk factor for CPSP. Moreover, dynamic changes in depressive symptoms were closely associated with the prognosis of postoperative pain in AIS patients. Limitations should be noted. First of all, depressive symptoms were solely assessed by the CDI, and the self-rating reports could potentially be influenced by recall biases or emotional interference. Second, we failed to analyze confounders like perioperative functional indicators (e.g., gait analysis) and pain catastrophizing due to insufficient data. Third, we did not balance baseline characteristics between groups because of a large proportion of sample loss (>40%) after propensity score matching (PSM). Multivariate regression, as a widely accepted statistical method with good robustness in prospective cohort studies, was used to adjust covariates [45]. Finally, this was a single-center study with a limited sample size, and the external validity of our nomogram should be further investigated through large-scale, multi-center studies. Machine learning was also an option to enhance the predictive performance of the nomogram. Conclusions Preoperative depressive symptoms are risk factors for both APSP and CPSP in postoperative AIS patients, showing a gradient association with the risk of CPSP. A nomogram incorporating female sex, number of surgical segments, and preoperative depressive symptoms effectively predicts CPSP in this population. An integrative psychological and analgesic intervention centered on preoperative depressive symptoms is expected to benefit high-risk AIS patients. Abbreviations AIS - adolescent idiopathic scoliosis APSP - acute postsurgical pain CPSP - chronic postsurgical pain MME - morphine milligram equivalents OR - odds ratio AUC - area under the curve 95% CI - 95% confidence intervals CDI - the Children's Depression Inventory ASA - the American Society of Anesthesiologists PCIA - patient-controlled intravenous analgesia BMI -body mass index POD-1 - one day before surgery POD - postoperative day NRS - Numerical Rating Scale ICD-11 - International Classification of Diseases, 11 th Revision MMSE - Mini-Mental State Examination PSQI - Pittsburgh Sleep Quality Index 3D-CAM - 3-Minute Diagnostic Confusion Assessment Method SRS-22 - Scoliosis Research Society 22-Item SF-36 - 36-Item Short Form Survey ECG - electrocardiogram SpO 2 - oxygen saturation NIBP - non-invasive blood pressure BIS- bispectral index FiO 2 - inspired fraction of oxygen VT - tidal volume RR - respiratory rate I/E - inspiration-to-expiration ratio ABP - arterial blood pressure CVP - central venous pressure SD - standard deviation IQR - interquartile range n [%] - frequency and percentage ROC - receiver operative characteristic DCA - decision curve analysis NYHA - New York Heart Association Functional Classification Alb - albumin HCT - hematocrit ACC - anterior cingulate cortex PFC - prefrontal cortex HPA - hypothalamic-pituitary-adrenal axis CBT - cognitive behavioral therapy MBSR - mindfulness-based stress reduction SRS - Scoliosis Research Society ERAS - Enhanced Recovery After Surgery PSM - propensity score matching Declarations Ethical approval All methods were carried out in accordance with the rules approved by the Institutional Review Board of Nanjing Drum Tower Hospital (Nanjing, China; No. 2023-458-02). Registration According to the Helsinki Declaration,the research protocol has been registered with the Chinese Clinical Trial Registry (ChiCTR; https://www.chictr.org.cn/) (Registration No: ChiCTR2300077637). Reg Date:2023-11-14. Consent Informed Consent was obtained from all participants Data availability The datasets generated and analyzed during the current study are available from the corresponding author on reasonable request. Conflict of interests The authors declare that they have no competing interests. Funding The author(s) declare that financial support was received for the research, authorship, and/or publication of this article. This work was supported by the National Natural Science Foundation of China (82571402, 82071229); Nanjing Health Science and Technology Development Special Fund (YKK22089); Nanjing Drum Tower Hospital 2023 Clinical Research Special Fund (2023-LCYJ-PY-07). Author contributions SM: Writing–original draft, Writing–review & editing, Data curation, Formal analysis, Project administration, Software, Validation, Visualization. ZW: Data curation, Investigation, Validation, Writing–review & editing. JY: Writing–review & editing, Data curation, Formal analysis, Investigation. YZ: Data curation, Investigation, Resources, Writing–review & editing. JB: Conceptualization, Funding acquisition, Methodology, Resources, Software, Supervision, Visualization, Writing-review & editing. YS: Conceptualization, Funding acquisition, Methodology, Resources, Software, Supervision, Visualization, Writing–review & editing. References Yan B, Lu X, Qiu Q, Nie G, Huang Y. Predicting Adolescent Idiopathic Scoliosis among Chinese Children and Adolescents. BioMed Res Int 2020;2020:1784360. https://doi.org/10.1155/2020/1784360. Chen H, Yang KG, Zhang J, Cheuk K-Y, Nepotchatykh E, Wang Y, et al. Upregulation of microRNA-96-5p is associated with adolescent idiopathic scoliosis and low bone mass phenotype. Sci Rep 2022;12:9705. https://doi.org/10.1038/s41598-022-12938-3. An S, Hyun S-J, Ahn J-M, Park B-J, Wui S-H, Kim K-J. Efficacy Comparison of Multiplanar Deformity Reducer System and Direct Vertebral Rotation in Adolescent Idiopathic Scoliosis Corrective Surgery. J Korean Neurosurg Soc 2025;68:436–45. https://doi.org/10.3340/jkns.2024.0076. Luo Y-Y, Hung T-M, Zheng Q, Wu H-D, Wong M-S, Bai Z-Q, et al. Predicting Surgical and Non-surgical Curvature Correction by Radiographic Spinal Flexibility Assessments for Patients With Adolescent Idiopathic Scoliosis: A Systematic Review and Meta-Analysis. Glob Spine J 2025;15:2822–38. https://doi.org/10.1177/21925682251319543. Chinese Orthopedic Association, Zhao Y, Zhao Y, Lu S, Yang Q, Chen L, et al. Guideline for adolescent scoliosis screening in China (public version 2024). J Orthop Transl 2025;50:364–72. https://doi.org/10.1016/j.jot.2024.09.006. Hammad AM, Balsano M, Ahmad AA. Vertebral body tethering: An alternative to posterior spinal fusion in idiopathic scoliosis? Front Pediatr 2023;11:1133049. https://doi.org/10.3389/fped.2023.1133049. Landauer F, Trieb K. Scoliosis: Brace treatment - from the past 50 years to the future. Medicine (Baltimore) 2022;101:e30556. https://doi.org/10.1097/MD.0000000000030556. Jiang C-H, Shi Y, Sun Y-M, Cai M-J, Wu H-L, Hu L-S, et al. Using a 3D Navigation Template to Increase the Accuracy of Thoracic Pedicle Screws in Patients with Scoliosis. Bioeng Basel Switz 2023;10:756. https://doi.org/10.3390/bioengineering10070756. Rabbitts JA, Zhou C, de la Vega R, Aalfs H, Murray CB, Palermo TM. Correction to: A digital health peri-operative cognitive-behavioral intervention to prevent transition from acute to chronic postsurgical pain in adolescents undergoing spinal fusion (SurgeryPalTM): study protocol for a multisite randomized controlled trial. Trials 2021;22:646. https://doi.org/10.1186/s13063-021-05596-9. Zhu L, Wang Y, Li J, Zhou H, Li N, Wang Y. Depressive symptoms and all-cause mortality among middle-aged and older people in China and associations with chronic diseases. Front Public Health 2024;12:1381273. https://doi.org/10.3389/fpubh.2024.1381273. Shorey S, Ng ED, Wong CHJ. Global prevalence of depression and elevated depressive symptoms among adolescents: A systematic review and meta-analysis. Br J Clin Psychol 2022;61:287–305. https://doi.org/10.1111/bjc.12333. Kremic L, Jaffer A, Patel K, Lee S, Xue Y, Daza JF, et al. Association between Preoperative Depression and Length of Stay after Major Surgery: A Systematic Review and Meta-analysis. Anesthesiology 2025;143:929–43. https://doi.org/10.1097/ALN.0000000000005626. Liu Q-R, Dai Y-C, Ji M-H, Liu P-M, Dong Y-Y, Yang J-J. Risk Factors for Acute Postsurgical Pain: A Narrative Review. J Pain Res 2024;17:1793–804. https://doi.org/10.2147/JPR.S462112. Wilson JM, Farley KX, Erens GA, Bradbury TL, Guild GN. Preoperative Depression Is Associated With Increased Risk Following Revision Total Joint Arthroplasty. J Arthroplasty 2020;35:1048–53. https://doi.org/10.1016/j.arth.2019.11.025. Schulz KF, Altman DG, Moher D, CONSORT Group. CONSORT 2010 statement: updated guidelines for reporting parallel group randomised trials. BMJ 2010;340:c332. https://doi.org/10.1136/bmj.c332. Zhang Y, Cui F, Ma J-H, Wang D-X. Mini-dose esketamine–dexmedetomidine combination to supplement analgesia for patients after scoliosis correction surgery: a double-blind randomised trial. Br J Anaesth 2023;131:385–96. https://doi.org/10.1016/j.bja.2023.05.001. López-Martínez AE, Sainero-Tirado G, Esteve R, Reyes-Pérez Á, Ruiz-Párraga GT, de la Vega R, et al. Does pain catastrophizing and distress intolerance mediate the relationship between PTSD and prescribed opioid misuse in people with chronic noncancer pain? Psychol Trauma Theory Res Pract Policy 2023;15:394–403. https://doi.org/10.1037/tra0001269. Widder A, Reese L, Lock JF, Wiegering A, Germer C-T, Rittner HL, et al. Chronic postsurgical pain (CPSP): an underestimated problem after incisional hernia treatment. Hernia J Hernias Abdom Wall Surg 2024;28:1697–707. https://doi.org/10.1007/s10029-024-03027-7. Hawes MT, Szenczy AK, Klein DN, Hajcak G, Nelson BD. Increases in depression and anxiety symptoms in adolescents and young adults during the COVID-19 pandemic. Psychol Med 2022;52:3222–30. https://doi.org/10.1017/S0033291720005358. Lv W, Li B, Feng J, Chen L, Qiu X, Liu S. Depression, anxiety and health-related quality of life in paediatric intracranial germ cell tumor survivors. Health Qual Life Outcomes 2022;20:9. https://doi.org/10.1186/s12955-021-01911-9. Sunhary de Verville PL, Etchecopar-Etchart D, Richieri R, Godin O, Schürhoff F, Berna F, et al. Recommendations of the schizophrenia expert center network for the screening prevention and treatment of sleep disorders based on the results from the real-world schizophrenia FACE-SZ national cohort. Prog Neuropsychopharmacol Biol Psychiatry 2021;110:110275. https://doi.org/10.1016/j.pnpbp.2021.110275. Scialpi A, Mignolli E, De Vito C, Berardi A, Tofani M, Valente D, et al. Italian Validation of the Pittsburgh Sleep Quality Index (PSQI) in a Population of Healthy Children: A Cross Sectional Study. Int J Environ Res Public Health 2022;19:9132. https://doi.org/10.3390/ijerph19159132. Clement ND, Weir D, Deehan D. Meaningful values in the Short Form Health Survey-36 after total knee arthroplasty - an alternative to the EuroQol five-dimension index as a measure for health-related quality of life : minimal clinically important difference, minimal important change, patient-acceptable symptom state thresholds, and responsiveness. Bone Jt Res 2022;11:477–83. https://doi.org/10.1302/2046-3758.117.BJR-2021-0493.R1. Gao A, Li J-Y, Shao R, Wu T-X, Wang Y-Q, Liu X-G, et al. Schroth exercises improve health-related quality of life and radiographic parameters in adolescent idiopathic scoliosis patients. Chin Med J (Engl) 2021;134:2589–96. https://doi.org/10.1097/CM9.0000000000001799. Jamjoom AB, Gahtani AY, Alzahrani MT, Albeshri AS, Sharab MA. Review of the Most Cited Patient-Reported Outcome Measure (PROM) Studies Published in the Neurospine Surgical Literature. Cureus 2023;15:e44262. https://doi.org/10.7759/cureus.44262. Feng Y, Zeng W, Xie Y, Chen H, Wang L, Wang Y, et al. Neural Modulation Alteration to Positive and Negative Emotions in Depressed Patients: Insights from fMRI Using Positive/Negative Emotion Atlas. Tomogr Ann Arbor Mich 2024;10:2014–37. https://doi.org/10.3390/tomography10120144. Jiang S, Shen Z, Xu W. Electroacupuncture Reverses CUMS-Induced Depression-Like Behaviors and LTP Impairment in Hippocampus by Downregulating NR2B and CaMK II Expression. Evid-Based Complement Altern Med ECAM 2021;2021:9639131. https://doi.org/10.1155/2021/9639131. Wen J, Xu Y, Yu Z, Zhou Y, Wang W, Yang J, et al. The cAMP Response Element- Binding Protein/Brain-Derived Neurotrophic Factor Pathway in Anterior Cingulate Cortex Regulates Neuropathic Pain and Anxiodepression Like Behaviors in Rats. Front Mol Neurosci 2022;15:831151. https://doi.org/10.3389/fnmol.2022.831151. Simic K, Savic B, Knezevic NN. Pain Catastrophizing: How Far Have We Come. Neurol Int 2024;16:483–501. https://doi.org/10.3390/neurolint16030036. Rogers AH, Farris SG. A meta-analysis of the associations of elements of the fear-avoidance model of chronic pain with negative affect, depression, anxiety, pain-related disability and pain intensity. Eur J Pain Lond Engl 2022;26:1611–35. https://doi.org/10.1002/ejp.1994. Eller-Smith OC, Nicol AL, Christianson JA. Potential Mechanisms Underlying Centralized Pain and Emerging Therapeutic Interventions. Front Cell Neurosci 2018;12:35. https://doi.org/10.3389/fncel.2018.00035. Johnsen K, Owen PJ, Tagliaferri SD, Van Oosterwijck J, Fitzgibbon BM, Ford JJ, et al. The Interaction Between Psychosocial Factors and Exercise-Induced Hypoalgesia in Pain-Free Nurses. J Pain Res 2023;16:529–41. https://doi.org/10.2147/JPR.S386440. Satyanarayanan SK, Shih Y-H, Wen Y-R, Palani M, Lin Y-W, Su H, et al. miR-200a-3p modulates gene expression in comorbid pain and depression: Molecular implication for central sensitization.. Brain Behav Immun 2019;82:230–8. https://doi.org/10.1016/j.bbi.2019.08.190. Sannes A-C, Ghani U, Niazi IK, Moberget T, Jonassen R, Haavik H, et al. Investigating Whether a Combination of Electro-Encephalography and Gene Expression Profiling Can Predict the Risk of Chronic Pain: A Protocol for an Observational Prospective Cohort Study. Brain Sci 2024;14:641. https://doi.org/10.3390/brainsci14070641. Kurkis G, Wilson JM, Anastasio AT, Farley KX, Bradbury TL. Preoperative Diagnosis of Depression Leads to Increased Opioid Tablets Taken After Total Hip Arthroplasty: A Prospective Study. J Surg Orthop Adv 2021;30:144–9. Jin J, Chen Q, Min S, Du X, Zhang D, Qin P. Prevalence and predictors of chronic postsurgical pain after colorectal surgery: A prospective study. Colorectal Dis Off J Assoc Coloproctology G B Irel 2021;23:1878–89. https://doi.org/10.1111/codi.15640. Khan JS, Dana E, Xiao MZX, Rao V, Djaiani G, Seltzer Z, et al. Prevalence and Risk Factors for Chronic Postsurgical Pain After Thoracic Surgery: A Prospective Cohort Study. J Cardiothorac Vasc Anesth 2024;38:490–8. https://doi.org/10.1053/j.jvca.2023.09.042. Lu Y, Hu B, Dai H, Wang B, Yao J, Yao X. Predictors of Chronic Postsurgical Pain in Elderly Patients Undergoing Hip Arthroplasty: A Multi-Center Retrospective Cohort Study. Int J Gen Med 2021;14:7885–94. https://doi.org/10.2147/IJGM.S337170. Lee S, Xue Y, Petricca J, Kremic L, Xiao MZX, Pivetta B, et al. The impact of pre-operative depression on pain outcomes after major surgery: a systematic review and meta-analysis. Anaesthesia 2024;79:423–34. https://doi.org/10.1111/anae.16188. Tassou A, Richebé P, Rivat C. Mechanisms of chronic postsurgical pain. Reg Anesth Pain Med 2025. https://doi.org/10.1136/rapm-2024-105964. Chen JA, Anderson ML, Cherkin DC, Balderson BH, Cook AJ, Sherman KJ, et al. Moderators and Nonspecific Predictors of Treatment Benefits in a Randomized Trial of Mindfulness-Based Stress Reduction vs Cognitive-Behavioral Therapy vs Usual Care for Chronic Low Back Pain. J Pain 2023;24:282–303. https://doi.org/10.1016/j.jpain.2022.09.014. Petrucci G, Papalia GF, Russo F, Vadalà G, Piredda M, De Marinis MG, et al. Psychological Approaches for the Integrative Care of Chronic Low Back Pain: A Systematic Review and Metanalysis. Int J Environ Res Public Health 2021;19:60. https://doi.org/10.3390/ijerph19010060. Debono B, Wainwright TW, Wang MY, Sigmundsson FG, Yang MMH, Smid-Nanninga H, et al. Consensus statement for perioperative care in lumbar spinal fusion: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Spine J Off J North Am Spine Soc 2021;21:729–52. https://doi.org/10.1016/j.spinee.2021.01.001. Turtle JD, Mehta JS, Parent S, Xiong GX, Cheung JP, Welborn MC, et al. Guidelines for returning to activity after spinal deformity surgery. Spine Deform 2025;13:383–90. https://doi.org/10.1007/s43390-024-01010-x. Elze MC, Gregson J, Baber U, Williamson E, Sartori S, Mehran R, et al. Comparison of Propensity Score Methods and Covariate Adjustment: Evaluation in 4 Cardiovascular Studies. J Am Coll Cardiol 2017;69:345–57. https://doi.org/10.1016/j.jacc.2016.10.060. Tables Table 1 Demographic and baseline characteristics of adolescent idiopathic scoliosis patients with preoperative depressive symptoms or not. Variable Depression group (n=32) Non-depression group (n=125) P -value Age (years) 14 (13,16.8) 13 (12,15) 0.118 Sex (n, %) 0.057 Males 5 (15.6) 41 (32.8) Females 27 (84.4) 84 (67.2) BMI (kg/m 2 ) 18.3 (17.3,21.7) 19.1 (16.8,21.9) 0.984 Education level 0.063 Primary school 20 (62.5) 98 (78.4) Middle school or above 12 (37.5) 27 (21.6) NYHA (n, %) >0.999 I 31 (96.9) 121 (96.8) II 1 (3.1) 2 (3.2) ASA (n, %) >0.999 I-II 32 (100) 123 (98.4) III 0 (0) 2 (1.6) Preoperative pain (points) NRS during movement 1.5 (0,3) 0 (0,2) 0.006 NRS at rest 0 (0,2) 0 (0,0) 0.049 PSQI (points) 3.5 (2.3,5) 2 (1,3) <0.001 MMSE (points) 29 (27,30) 29 (28,30) 0.062 SF-36 (points) 61.7 (50,71.7) 80 (69.6,86.4) <0.001 SRS-22 (points) 77.3±10.6 91.9±8.5 <0.001 Alb (g/L) 41.8±2.3 42±2.6 0.680 Surgical fusion segments 10.5 (6.3,12) 10 (7,12) 0.502 Cobb angle (°) 47.5 (42,62.3) 51 (44.5,64.5) 0.456 Operation time (min) 225.2±60.8 232±57.7 0.553 Anesthesia time (min) 258.8±605.5 264.8±60.3 0.620 Blood loss (mL) 750 (425, 1 200) 725 (500, 1 000) 0.897 Urine output (mL) 800 (700, 1 200) 950 (600, 1 400) 0.683 Infusion volume (mL) 3 547.5 (2 939, 4 431) 3 470 (2 908.8, 4 236.3) 0.722 Blood transfusion (n, %) 29 (90.6) 122 (97.6) 0.187 Vasopressor (n, %) 16 (50) 65 (52) 0.840 Antihypertensive drugs (n, %) 2 (6.25) 10 (8) >0.999 Note: BMI, body mass index; NYHA, New York Heart Association Functional Classification; ASA, American Society of Anesthesiologists; NRS, Numerical Rating Scale; PSQI, Pittsburgh Sleep Quality Index; MMSE, Mini-Mental State Examination; SF-36, 36-Item Short Form Survey; SRS-22, Scoliosis Research Society 22-Item; Alb, albumin. The bolded P -value indicates statistical significance. Table 2 Outcome comparisons in adolescent idiopathic scoliosis patients with preoperative depressive symptoms or not. Variable Depression group (n=32) Non-depression group (n=125) P -value Primary outcomes Incidence of moderate APSP (n, %) 18 (56.25) 61 (48.8) 0.452 Incidence of severe APSP (n, %) 12 (37.5) 54 (43.2) 0.560 Incidence of CPSP (n, %) 23 (71.88) 13 (10.4) 0.999 Length of stay (days) 7 (7, 8) 7 (7, 8) 0.961 All-cause mortality on POD30 (%) 0 (0) 0 (0) >0.999 SRS-22 on POD30 (points) 81.38 (74, 85.75) 87.80 (81, 96) <0.001 SF-36 on POD30 (points) 63.59 (61.19, 68.77) 75.09 (68.77, 80.18) <0.001 SRS-22 on POD90 (points) 89.17 (84, 96) 91.95 (85, 98) 0.089 SF-36 on POD90 (points) 75.80 (68.77, 79.80) 80.60 (75.83, 87.37) <0.01 Note: APSP, acute postsurgical pain; CPSP, chronic postsurgical pain; POD, postoperative day; MME, morphine milligram equivalent; SRS-22, Scoliosis Research Society 22-Item; SF-36, 36-Item Short Form Survey. The bolded P -value indicates statistical significance. Table 3 Univariate and multivariate logistic regression analyses on illustrating risk factors for chronic postsurgical pain in adolescent idiopathic scoliosis patients. Variable Univariate logistic regression Multivariate logistic regression OR (95% CI) P -value OR (95% CI) P -value Depressive symptoms Absence Reference Reference Presence 22.02 (8.42, 57.56) <0.001 41.06 (8.68, 194.19) <0.001 Sex Male Reference Reference Female 6.06 (1.76, 20.94) 0.004 6.36 (1.02, 39.57) 0.047 Surgical fusion segments 1.17 (1.02, 1.34) 0.024 1.31 (1.07, 1.60) 0.008 Preoperative pain NRS at rest 1.46 (1.08, 1.98) 0.014 1.08 (0.67, 1.76) 0.750 NRS during movement 1.41 (1.10, 1.79) 0.006 1.21 (0.81, 1.81) 0.344 SRS-22 0.92 (0.89, 0.96) <0.001 0.98 (0.90, 1.07) 0.640 PSQI 1.31 (1.08, 1.59) 0.006 0.90 (0.68, 1.19) 0.454 SF-36 0.96 (0.93, 0.98) 0.001 1.02 (0.97, 1.09) 0.428 HCT 0.89 (0.80, 0.99) 0.028 1.02 (0.87, 1.21) 0.783 Note: OR, odds ratio; CI, confidence interval; NRS, Numerical Rating Scale; SRS-22, Scoliosis Research Society 22-Item; PSQI, Pittsburgh Sleep Quality Index; SF-36, 36-Item Short Form Survey; HCT, hematocrit.The bolded P -value indicates statistical significance. Additional Declarations No competing interests reported. Supplementary Files SupplementaryTable.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 25 Mar, 2026 Reviews received at journal 15 Mar, 2026 Reviewers agreed at journal 14 Mar, 2026 Reviews received at journal 13 Mar, 2026 Reviewers agreed at journal 13 Mar, 2026 Reviewers agreed at journal 13 Mar, 2026 Reviewers invited by journal 12 Mar, 2026 Editor assigned by journal 05 Mar, 2026 Submission checks completed at journal 05 Mar, 2026 First submitted to journal 04 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9030306","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":606434455,"identity":"22c94209-17e8-4af0-a1df-b93dff1c5deb","order_by":0,"name":"Sijia Ma","email":"","orcid":"","institution":"Nanjing Drum Tower Hospital Clinical College of Jiangsu University","correspondingAuthor":false,"prefix":"","firstName":"Sijia","middleName":"","lastName":"Ma","suffix":""},{"id":606434456,"identity":"e6be0b34-4012-4d72-80a7-136780af3f1f","order_by":1,"name":"Zhen Wang","email":"","orcid":"","institution":"The Affiliated Stomatological Hospital of Nanjing Medical University","correspondingAuthor":false,"prefix":"","firstName":"Zhen","middleName":"","lastName":"Wang","suffix":""},{"id":606434458,"identity":"ff2ddb4e-3ac9-4c0c-b04b-b5a6c0f231e3","order_by":2,"name":"Jiacheng Yu","email":"","orcid":"","institution":"Nanjing Drum Tower Hospital, Nanjing University","correspondingAuthor":false,"prefix":"","firstName":"Jiacheng","middleName":"","lastName":"Yu","suffix":""},{"id":606434460,"identity":"240acd30-ca19-4dbb-b9ea-415dd9686e35","order_by":3,"name":"Yu Zhang","email":"","orcid":"","institution":"The Affiliated Stomatological Hospital of Nanjing Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yu","middleName":"","lastName":"Zhang","suffix":""},{"id":606434464,"identity":"e8bd6382-8c81-44cb-ba7c-3154cff13964","order_by":4,"name":"Jinhua Bo","email":"","orcid":"","institution":"Nanjing Drum Tower Hospital, Nanjing University","correspondingAuthor":false,"prefix":"","firstName":"Jinhua","middleName":"","lastName":"Bo","suffix":""},{"id":606434466,"identity":"90e33ff7-7946-40d1-a5f0-f7ce7b08f324","order_by":5,"name":"Yu’e Sun","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAwklEQVRIiWNgGAWjYPACGwbGBiDFQ4KWNNK1HIZQRGmRn5F7TJqn4nwe84wExgdv2xjkzQlpMbiRlybNc+Z2MeOMBGbDuW0MhjsbCGmRyDGT5m27ndg4I4ENyGBIMDhA0GEgLf/OgbSw/yZKC8MNkJaGA2BbmInSYnDmjbHlnGPJiY09D5sl55yTMNxA0GHtOYY33tTYJW5sTz744U2ZjTxhhzEwsEiASMMGcGRKEFYPBMwfwNYRpXYUjIJRMApGJAAAPyI9jfE/bWEAAAAASUVORK5CYII=","orcid":"","institution":"Nanjing Drum Tower Hospital Clinical College of Jiangsu University","correspondingAuthor":true,"prefix":"","firstName":"Yu’e","middleName":"","lastName":"Sun","suffix":""}],"badges":[],"createdAt":"2026-03-04 12:38:31","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9030306/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9030306/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104874150,"identity":"3bc15740-b61d-48fd-9c44-4fed295a8824","added_by":"auto","created_at":"2026-03-18 08:29:15","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":326444,"visible":true,"origin":"","legend":"\u003cp\u003eA flowchart of participant allocation and grouping.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-9030306/v1/c8d55effebffa750dfa6b126.png"},{"id":104874018,"identity":"f314025c-e47b-4896-9004-4321c5320c5b","added_by":"auto","created_at":"2026-03-18 08:28:49","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":127125,"visible":true,"origin":"","legend":"\u003cp\u003eThe trajectories of acute postoperative pain changes in the two groups under different conditions (a) Assessment of pain at rest. Group main effect: P\u0026lt;0.05. (b) Assessment of pain during movement. Main effects: Time P\u0026lt;0.05, Group P\u0026lt;0.05\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-9030306/v1/ba1667be481da661d04a3bc4.png"},{"id":104874017,"identity":"a49e92bb-f7a7-48ba-a20a-c8f869cf16a6","added_by":"auto","created_at":"2026-03-18 08:28:48","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":228454,"visible":true,"origin":"","legend":"\u003cp\u003eA nomogram to predict the risk of CPSP and its performance validation. (a) A nomogram visualized to predict the risk of CPSP in postoperative AIS patients, involving variables of female sex, number of surgical segments, and preoperative depressive symptoms. For continuous variables, the distribution is represented by a frequency distribution curve. For categorical variables, the distribution is indicated by green squares, with larger squares corresponding to a higher proportion of individuals at that category level. For the categorical variables, Depression=0 indicates the absence of depressive symptoms, and Gender=1 indicates male.The profile of the first patient in the dataset is highlighted with red dots on the scale lines, and their corresponding points are also marked in red. (b-c) ROC curves (b), calibration curves (c) and DCA (d) verified the discriminative ability, calibration, and goodness-of-fit of the nomogram.\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-9030306/v1/355d7ea8ad743e1f361abbce.png"},{"id":104874162,"identity":"a381bb4e-6a61-4c59-bfd9-99facc9d64c2","added_by":"auto","created_at":"2026-03-18 08:29:18","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":568152,"visible":true,"origin":"","legend":"\u003cp\u003eROC curves of a multi-predictor model and a single-predictor model solely involving one variable of preoperative depression symptoms.\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-9030306/v1/d843cfd1e0decfc35ce2cd2b.png"},{"id":104874081,"identity":"70c791bd-a282-439e-a155-794f33ca60d8","added_by":"auto","created_at":"2026-03-18 08:28:56","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":786998,"visible":true,"origin":"","legend":"\u003cp\u003eThe incidence of CPSP in AIS patients with persistent, relieved and cured depressive symptoms.\u003c/p\u003e\n\u003cp\u003eNote:*\u003cem\u003eP \u003c/em\u003e\u0026lt; 0.05 ,***\u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001\u003c/p\u003e","description":"","filename":"Figure5.png","url":"https://assets-eu.researchsquare.com/files/rs-9030306/v1/533bc2abbd813baa9a15027e.png"},{"id":104874262,"identity":"fabd9063-78f3-48c1-bc02-5b622c03a630","added_by":"auto","created_at":"2026-03-18 08:29:40","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2860269,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9030306/v1/7a365dd1-c28f-47b9-a559-120d488c232a.pdf"},{"id":104874115,"identity":"ad6c84da-dc0f-4e87-9e53-1bf330d7ad36","added_by":"auto","created_at":"2026-03-18 08:29:06","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":21060,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryTable.docx","url":"https://assets-eu.researchsquare.com/files/rs-9030306/v1/c08cbea10d909a9f5f88c0f9.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Impact of Preoperative Depressive Symptoms on Acute and Chronic Postoperative Pain Trajectories After Orthopedic Surgery for Adolescent Idiopathic Scoliosis: a Prospective Cohort Study","fulltext":[{"header":"Background","content":"\u003cp\u003eAdolescent idiopathic scoliosis (AIS) is the most common three-dimensional structural deformity of the spine during the peak growth in 10-18 years of age [1]. The global prevalence of AIS ranges from 2% to 4%, which is more frequent in children aged 10\u0026ndash;16 years (1%-3%) [2\u0026ndash;4]. Large-scale screening data in China indicate a female preference of AIS, with a male-to-female ratio of approximately 1:1.5 [5]. Posterior spinal corrective fusion surgery is preferred for AIS patients with progressive worsening of the Cobb angle (usually \u0026ge;45\u0026deg;-50\u0026deg;) or significant cardiopulmonary dysfunction [6\u0026ndash;8]. While being recognized for the high efficacy in correcting deformities and improving trunk balance and cardiopulmonary function, surgical procedures frequently bring postsurgical pain affecting the rehabilitation. A majority of AIS patients (\u0026gt;80%) experience moderate-to-severe acute pain postoperatively, and nearly half of them finally develop chronic postsurgical pain (CPSP) [9].\u003c/p\u003e\n\u003cp\u003eDepressive symptoms, as manifested as persistent low mood, loss of interest, decreased energy, and sleep disturbances [10], are seen in 34% of adolescents [11]. The overall prevalence of depressive symptoms can be even elevated in AIS patients due to body dysmorphic disorders, social avoidance, and treatment-related stress. Existing evidence indicates that preoperative depressive symptoms are closely related to the exacerbation of acute postsurgical pain (APSP), prolonged hospital stay, and increased fees in surgically treated people [12\u0026ndash;14]. However, high-quality prospective evidence is scant on the influence of preoperative depressive symptoms on the trajectories of postoperative pain in AIS patients, as well as the risk factors.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the present study, we screened risk factors for APSP and CPSP in postoperative AIS patients, and illustrated the role of preoperative depressive symptoms in altering postoperative pain trajectories. Moreover, a nomogram was constructed to predict the risk of CPSP in AIS patients. Our findings are expected to emphasize the standardized depression screening (e.g., the Children\u0026apos;s Depression Inventory [CDI]) in routine perioperative assessment of AIS, and the importance of an integrative psychological and analgesic intervention for high-risk AIS patients. Following the Revised Strengthening the Reporting of Cohort, Cross-Sectional and Case-Control Studies in Surgery (STROCSS) Guideline [15].\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis was a single-center, prospective cohort study involving AIS patients treated with elective spinal deformity surgeries in Hospital between November 2023 and December 2024. Briefly, AIS patients aged 10-17 years, with the American Society of Anesthesiologists (ASA) physical status classification of Ⅰ-Ⅲ, and managed by elective spinal fusion surgeries were included. Informed consent was signed by their patients or guardians. Exclusion criteria were as follows: 1) refusal to participate in this study; 2) a long-term preoperative use of analgesics over 7 days or a history of opioid abuse; 3) severe hepatic insufficiency (advanced liver disease in the Child-Pugh classification of Class C), renal failure with the necessity of dialysis, or expected survival≤24 h; 4) schizophrenia, bipolar disorder, epilepsy, or myasthenia gravis; 5) inability to complete scale assessments; 6) presence of uncontrolled severe hypertension preoperatively (systolic blood pressure\u0026gt;180 mmHg), significant sinus tachycardia (heart rate\u0026gt;120 bpm), acute coronary syndrome, or severe intracranial hypertension occurring within the past week; and 7) a history of perioperative use of ketamine or esketamine.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSample size estimation and participant grouping\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe sample size of the present study was estimated based on the primary outcome of the incidence of APSP. A previous article reports that moderate-to-severe pain during patient-controlled intravenous analgesia (PCIA) affects 70% of people treated with scoliosis orthopedic surgeries [16]. A preliminary pre-experiment survey shows that 94% and 20% of AIS patients suffer from moderate-to-severe postoperative pain and depressive symptoms, respectively. Based on a test power of 80%, a two-sided significance of 0.05, and a dropout rate of 15%, a sample size of 155 was necessary, involving 31 participants in the depression group and 124 in the non-depression group. In our study, 200 AIS patients were initially allocated, and 157 who completed all follow-ups were included in the final analysis. They were divided into the depression group (n=32, CDI≥19 points) and the non-depression group (n=125, CDI\u0026lt;19 points) based on the preoperative CDI scores. Additionally, AIS patients were assigned into persistent depression group (preoperative CDI≥19, and postoperative CDI≥19), depression relief group (preoperative CDI≥19, and postoperative CDI\u0026lt;19) and cured depression group (preoperative CDI\u0026lt;19, postoperative CDI\u0026lt;19) based on dynamic changes in CDI scores on POD-1 and POD90.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection and scale assessments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBaseline data of AIS patients were collected on admission, including sex, age, body mass index (BMI), education level, surgical history, medication history, ASA physical status classification, laboratory testing results (complete blood count, liver and kidney function, electrolytes), and auxiliary examinations (electrocardiography, echocardiography, etc.). Perioperative indicators, including operation time (min), anesthesia time (min), total fluid volume (mL), intraoperative urine volume (mL), blood loss (mL), and transfusion status, were recorded as well.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA series of scales were used to assess pain, depressive symptoms, sleep quality, and quality of life. Briefly, pain assessment, as twice daily (8:00-10:00 and 18:00-20:00), was conducted one day before surgery (POD-1) and 1–5 days postoperatively (POD1-5), and recorded by pretrained investigators face-to-face in the ward. Additional assessments were performed on POD30 and POD90. The intensity of pain at rest (lying quietly) and during movement (immediately after standardized actions like turning over or sitting up) was assessed using the Numerical Rating Scale (NRS), ranging from 0 (no pain) to 10 (the most severe pain imaginable) [17]. APSP was determined by an NRS score of 4 or higher, indicating clinically significant moderate-to-severe pain. According to the International Classification of Diseases, 11\u003csup\u003eth\u003c/sup\u003e Revision (ICD-11) [18], CPSP was defined as persistent pain or newly appeared pain at the original surgical site for at least three months after tissue healing. In this study, CPSP was recorded positive in AIS patients reporting persistent pain at the incision site with an NRS ≥ 4 on POD90. Follow-up data were obtained on POD30 and POD90 through structured telephonic interviews.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDepressive symptoms were assessed using the CDI on POD-1, POD30 and POD90. The CDI consists of 27 items covering dimensions of negative mood, loss of pleasure, feelings of worthlessness, interpersonal distress, and somatic symptoms, ranging from 0 (no depressive symptoms) to 54 (all depressive symptoms are present) [19]. Based on previous findings, clinically significant depressive symptoms were determined by a total CDI score of ≥19[20].\u003c/p\u003e\n\u003cp\u003eThe patient's cognitive function was assessed using the Mini-Mental State Examination (MMSE) scale on POD-1.Sleep quality and delirium was assessed using the Pittsburgh Sleep Quality Index (PSQI) and\u0026nbsp;3-Minute Diagnostic Confusion Assessment Method (3D-CAM) on POD-1 and POD1-5,\u0026nbsp;once daily\u0026nbsp;between 8:00 and 10:00.\u0026nbsp;Impaired sleep quality\u0026nbsp;was determined by a PSQI exceeding 5\u0026nbsp;[21,22]. The Scoliosis Research Society\u0026nbsp;22-Item\u0026nbsp;(SRS-22) and\u0026nbsp;the 36-Item\u0026nbsp;Short Form Survey (SF-36) were used to assess the spinal function and health-related quality of life on\u0026nbsp;POD-1, POD30 and POD90, respectively\u0026nbsp;[23-25].\u0026nbsp;All\u0026nbsp;questionnaires were completed independently by patients\u0026nbsp;themselves\u0026nbsp;in a quiet environment, and\u0026nbsp;neutral explanations of the item meanings without influencing\u0026nbsp;responses\u0026nbsp;were provided by pretrained investigators, if necessary.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll data were independently imported into an electronic database by two pretrained investigators, and cross-verified to ensure data integrity and accuracy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical and anesthetic management\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFollowing an 8-hour fasting, patients were sent to the operation room, where electrocardiogram (ECG), oxygen saturation (SpO\u003csub\u003e2\u003c/sub\u003e), non-invasive blood pressure (NIBP), and bispectral index (BIS) were routinely monitored. Anesthesia induction was performed by intravenous injections of midazolam (0.1 mg/kg), sufentanil (0.05 µg/kg), propofol (2 mg/kg), and vecuronium (0.1 mg/kg). Mechanical ventilation after intubation was applied with the following parameters: inspired fraction of oxygen (FiO\u003csub\u003e2\u003c/sub\u003e) 60%-80%, tidal volume (VT) 8-10 ml/kg, respiratory rate (RR) 12-15 breaths/min, and inspiration-to-expiration ratio (I/E) 1:2. During the procedure, arterial blood pressure (ABP), central venous pressure (CVP), and BIS were continuously monitored. Propofol (4–10 mg·kg⁻¹·h⁻¹), remifentanil (0.5–1.0 μg·kg⁻¹·min⁻¹), cisatracurium (0.2 mg·kg⁻¹·h⁻¹), and dexmedetomidine (0.2 μg·kg⁻¹·h⁻¹) were continuously infused for anesthesia maintenance. Medications were timely adjusted based on the BIS values (target 40-60) and hemodynamic responses. Muscle relaxants were discontinued 30 min before the end of the procedure. Weaning from mechanical ventilation was conducted until patients regained spontaneous breathing and consciousness, followed by the initiation of PCIA. An NRS score of 4 and above was a sign of rescue analgesia. All opioids used on POD1-5, including those used for PCIA and rescue anesthesia, were\u0026nbsp;converted into oral morphine milligram equivalents (MME) using internationally accepted conversion factors (Appendix 1 for details).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOutcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe primary outcomes of this study were the incidences of APSP and CPSP. Secondary outcomes included early postoperative MME, early complications (e.g., delirium), postoperative length of stay, and long-term rehabilitation status.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data analyses were performed by SPSS software (version 26.0; IBM Corp., Armonk, NY, USA) and R software (version 4.4.0, http://www.R-project.org). Continuous variables within a normal distribution were described as mean ± standard deviation (mean ± SD) and compared between groups using the independent samples t-test; otherwise, they were expressed as median (interquartile range, IQR) and compared using the Mann-Whitney U test. Categorical variables were expressed as frequency and percentage (n [%]) and compared by the Chi-square test. Shapiro-Wilk test examined data normality. Repeated Measures ANCOVA was used to assess the effect of preoperative depressive symptoms on the dynamic trajectories in APSP. \u0026nbsp;In this model, \"time\" (POD 1-5) was treated as a within-subject factor, and \"severity of depressive symptoms\" was the between-subject factor. The preoperative NRS score, PSQI, total score of SRS-22, and scores on the mental health dimension in SF-36 were covariates to be controlled as confounders. Potential influences of age, sex, BMI, preoperative depressive symptoms, number of surgical fusion segments, preoperative pain intensity, sleep quality, and scores on the quality of life on CPSP (a binary outcome variable: yes/no) were examined using univariate logistic regression. Variables with \u003cem\u003eP\u003c/em\u003e\u0026lt;0.1 were included in the multivariate logistic regression model for identifying independent risk factors for CPSP using the backward stepwise method. Results were reported as odds ratios (OR) with 95% confidence intervals (95% CI). The performance of the created nomogram in predicting CPSP was verified via plotting the receiver operative characteristic (ROC) curves, calibration curves, and the decision curve analysis (DCA). Two-tailed \u003cem\u003ep\u003c/em\u003e\u0026lt;0.05 was considered as statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eBaseline characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 200 AIS patients were initially allocated, and 157 who completed all follow-ups were included in the final analysis (Figure 1). Stratified by the cut-off CDI of 19, AIS patients were divided into the depression group (n=32, CDI\u0026ge;19 points) and the non-depression group (n=125, CDI\u0026lt;19 points).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDemographic characteristics and preoperative indicators, including age, sex, BMI, education level, the New York Heart Association Functional Classification (NYHA), ASA physical status classification, the Mini-Mental State Examination (MMSE) score, albumin (Alb), number of surgical fusion segments, Cobb angle, anesthesia time, operation time, intraoperative blood loss, urine output, total fluid volume, transfusion rate, and uses of vasopressors and antihypertensive drugs, were comparable between groups (\u003cem\u003eP\u003c/em\u003e\u0026gt;0.05, Table 1). However, AIS patients in the depression group graded significantly higher preoperative NRS scores at rest and during activity, as well as PSQI scores than those in the non-depression group (\u003cem\u003eP\u003c/em\u003e \u0026lt; 0.05), indicating severer pain and worse sleep quality in AIS patients with depressive symptoms. Moreover, significantly lower SRS-22 and SF-36 scores in the depression group than the non-depression group indicated that depressive symptoms were associated with worse spine-related function and health-related quality of life before the surgery (\u003cem\u003eP\u003c/em\u003e\u0026lt;0.05).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOutcome indicators\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere were no significant differences between the two groups in the APSP incidence, MME within 5 days postoperatively, length of hospital stay, incidence of delirium within 5 days postoperatively, all-cause mortality within 30 days postoperatively, and SRS-22 scores on POD90 (\u003cem\u003eP\u003c/em\u003e\u0026gt;0.05, Table 2).\u0026nbsp;In comparison to the non-depression group, the incidence of CPSP in the depression group was significantly higher (\u003cem\u003eP\u003c/em\u003e\u0026lt;0.001).\u0026nbsp;Significantly lower\u0026nbsp;SRS-22 scores\u0026nbsp;on POD30\u0026nbsp;and SF-36 scores\u0026nbsp;on POD90 in the depression group than the non-depression group indicated worse\u0026nbsp;postoperative functional recovery and quality of life\u0026nbsp;in AIS patients with preoperative depressive symptoms\u0026nbsp;(\u003cem\u003eP\u003c/em\u003e\u0026lt;0.05).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe impact of preoperative depressive symptoms on APSP\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe impact of preoperative depressive symptoms on APSP was analyzed using repeated-measures ANCOVA with Greenhouse-Geisser correction (Mauchly\u0026rsquo;s Test of Sphericity ,W=0.088, P\u0026lt;0.001). Baseline covariates included preoperative NRS, PSQI, SRS-22, and SF-36 scores.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor pain at rest, the main effect of grouping of depressive symptoms was significant (F=7.144,\u003cem\u003e\u0026nbsp;P\u003c/em\u003e\u0026lt;0.05, partial \u0026eta;\u003csup\u003e2\u003c/sup\u003e=0.045, Figure 2a). This indicated that, after controlling for baseline differences, postoperative pain levels at rest were significantly higher in the depression group than those in the non-depression group. However, the main effect of time (F=1.597, \u003cem\u003eP\u003c/em\u003e=0.150, partial \u0026eta;\u003csup\u003e2\u003c/sup\u003e = 0.011) and the interaction effect between the group and time (F=1.26, \u003cem\u003eP\u003c/em\u003e=0.276, partial \u0026eta;\u003csup\u003e2\u003c/sup\u003e = 0.008) were not statistically significant.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor pain during movement, a significant main effect of time on the pain during movement (F=2.176, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.05, partial \u0026eta;\u003csup\u003e2\u003c/sup\u003e = 0.014, Figure 2b). The main effect was also statistically significant in the depression group (F=10.960, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.05, partial \u0026eta;\u003csup\u003e2\u003c/sup\u003e=0.068). However, no significant difference was detected in the interaction effect between the group and time (F=9.209,\u003cem\u003e\u0026nbsp;P\u003c/em\u003e=0.061, partial \u0026eta;\u003csup\u003e2\u003c/sup\u003e=0.013).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe impact of preoperative depressive symptoms on CPSP\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 36 (22.93%) AIS patients suffered from CPSP on POD90. Factors potentially influencing CPSP were first identified by the univariate logistic regression analysis. It is shown that preoperative depressive symptoms, sex, preoperative hematocrit (HCT), number of surgical fusion segments, pain scores at rest, pain scores during movement, SRS-22 score, SF-36 score, and PSQI score were significantly associated with CPSP (\u003cem\u003eP\u003c/em\u003e\u0026lt;0.10, Appendix Table 2). These variables were included in the multivariate logistic regression model using a backward stepwise method. The final model identified that female sex (OR=6.36, 95% CI: 1.02-39.57, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.05), number of surgical fusion segments (OR=1.31, 95% CI: 1.07-1.60,\u003cem\u003e\u0026nbsp;P\u003c/em\u003e\u0026lt;0.01), and preoperative depressive symptoms (OR=41.06, 95% CI: 8.68-194.19,\u003cem\u003e\u0026nbsp;P\u003c/em\u003e\u0026lt;0.001) were independent risk factors for CPSP (Table 3).\u003c/p\u003e\n\u003cp\u003eCorrespondingly, a nomogram was created to predict the risk of CPSP in AIS patients (Figure 3a), displaying an area under the curve (AUC) of 0.852 (95% CI: 0.773-0.932,\u003cem\u003e\u0026nbsp;P\u003c/em\u003e\u0026lt;0.01; sensitivity=0.750, specificity=0.868; Figure 3b). The calibration curve showed that the predicted probabilities were highly consistent with the actual observed probabilities (slope close to 1, intercept close to 0) (Figure 3c). The Hosmer-Lemeshow test further proved the goodness-of-fit of the nomogram (\u0026chi;\u0026sup2;=13.132, \u003cem\u003eP\u003c/em\u003e=0.107). DCA showed that the nomogram achieved a significant net clinical benefit within the threshold probability range of 10% to 70% (Figure 3d).\u003c/p\u003e\n\u003cp\u003eThe AUC of the multi-predictor model was 0.852 (95% CI: 0.773-0.932,\u003cem\u003e\u0026nbsp;P\u003c/em\u003e\u0026lt;0.01), which was significantly larger than that of the single-predictor model (AUC=0.782, 95% CI: 0.683-0.882,\u003cem\u003e\u0026nbsp;P\u003c/em\u003e\u0026lt;0.01), and the difference in AUC was statistically significant (P\u0026lt;0.05).\u0026nbsp;(Figure\u0026nbsp;4).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDynamic changes in depressive symptoms and their impact on CPSP\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAIS patients were assigned into persistent depression group (n=4), depression relief group (n=28) and cured depression group (n=125) based on dynamic changes in CDI scores on POD-1 and POD90. The incidence of CPSP was 100% (4/4) in the persistent depression group, 67.86% (19/28) in the depression relief group, and 10.4% (13/125) in the cured depression group, showing a significant difference among the three groups (\u0026chi;\u0026sup2;=50.46, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.001, Figure 5).\u003c/p\u003e\n\u003cp\u003eFurther pairwise comparisons showed that the risk of CPSP was significantly higher in the persistent depression group than the depression relief and cured depression groups (\u003cem\u003eP\u003c/em\u003e\u0026lt;0.05). It was significantly higher in the depression relief group than the cured depression groups, but lower than the persistent depression group (\u003cem\u003eP\u003c/em\u003e\u0026lt;0.05).\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis prospective cohort study systematically revealed the impact of preoperative depressive symptoms on postoperative pain trajectories in AIS patients. Although depressive symptoms did not pose a direct effect on APSP, they significantly worsened pain intensities at rest and during movement, showing a unique pain trajectory of high baseline and steady relief. We further proved that preoperative depressive symptoms were the strongest independent predictor of CPSP, with an effect size far greater than that of traditional clinical variables. Superior to the analgesia-centered approach to control postoperative pain, an integrative psychological and analgesic intervention centered on preoperative depressive symptoms greatly benefited AIS patients.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWhile the incidence of APSP was comparable in AIS patients either with preoperative depressive symptoms or not, those in the depression group suffered more from pain at rest and during movement. Compared to the persistent postoperative pain at rest following the surgical procedures for AIS, the pain during movement relieved over time, showing a similar pain trajectory between groups.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe considered that spinal orthopedic surgery triggered APSP, and depressive symptoms acted as a pain modulator to influence how the body perceived and managed pain, known as pain experience. At the macro level, depressive symptoms often relate to functional abnormalities in brain regions dominating pain management, including the anterior cingulate cortex (ACC) and prefrontal cortex (PFC) [26–28]. They are also intertwined with cognitive factors like catastrophization of pain and fear-avoidance beliefs, altogether amplifying the subjective pain perception [29,30]. At the micro-level of neurobiology, preoperative depressive symptoms exacerbate central sensitization and prolong pain signal transmission by multiple mechanisms, such as activating the hypothalamic-pituitary-adrenal axis (HPA), promoting the release of inflammatory factors, impairing hippocampal neurons, and mediating synaptic plasticity changes by targeting CREB/BDNF [25,31]. Current neurobiological evidence indicates that depressive symptoms affect endogenous pain modulation via the descending pain inhibitory pathways, manifesting as decreases in the endogenous analgesic capacity and pain threshold [32]. This consequently induces an intrinsic hypervigilant status or central sensitization even without exogenous stimuli [33,34]. Our findings consistently supported this conclusion that preoperative depressive symptoms significantly increased baseline pain level, rather than hindering the postoperative pain relief naturally accompanied with wound healing. Although being recognized as a positive clinical sign of normal physiological recovery, an increased pain intensity during postoperative rehabilitation of AIS called for a more effective and individualized analgesic management.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA previous study illustrated a correlation between preoperative depressive symptoms and increased postoperative opioid consumption [35]. Inconsistently, we did not see a significant difference in the MME during the first five days postoperatively between groups. The increased pain perception associated with depressive symptoms was probably attributed to alterations in pain processing, rather than the product of insufficient analgesia. A monotherapy of pharmacological analgesics was insufficient to fully control postoperative pain in AIS patients with preoperative depressive symptoms, necessitating a shift towards a multidimensional, integrated perioperative pain management model.\u003c/p\u003e\n\u003cp\u003eCPSP is strongly associated with\u0026nbsp;preoperative depressive symptoms in individuals managed by colorectal cancer surgery, thoracic surgery, and hip arthroplasty [36–38]. In our cohort, CPSP was more frequently detected in AIS patients with clinically significant depressive symptoms (CDI≥19) than those without (71.88% vs. 10.4%, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.001). Multivariate logistic regression analysis revealed that preoperative depressive symptoms, female sex, and the number of fused surgical segments were independent risk factors for CPSP. A meta-analysis demonstrated that preoperative depression not only increases the risk of CPSP following various types of surgeries, but is also linked with the duration and severity [39]. The present study only focused on a single surgical procedure of spinal deformity correction, effectively enhancing the internal validity of the causal inference by controlling for confounders arising from the heterogeneity of surgery types. Additionally, the number of fused surgical segments (OR=1.31/segment), as an independent risk factor, supports the dose-response relationship of trauma load-central sensitization [40].\u003c/p\u003e\n\u003cp\u003eOur findings showed that physiological trauma and psychological factors should be considered as influencing factors for CPSP. Correspondingly, a nomogram involving preoperative depressive symptoms, female sex, and the number of fused surgical segments was created to predict the risk of CPSP in AIS patients, showing acceptable discrimination, calibration, and clinical net benefit. This could be a useful tool to assist the screening of high-risk individuals with CPSP and the application of multimodal interventions (e.g., analgesia, psychological counselling, acupuncture, etc.) as early as possible.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe grouping based on longitudinal changes in CDI scores showed that the highest incidence of CPSP (100%) was detected in AIS patients with persistent depressive symptoms, followed by those with relieved (67.9%) and cured depression (10.4%). This gradient association strongly indicated the critical value of an early management of preoperative depressive symptoms in surgically treated people. Interestingly, this reversible effect has been rarely reported in adults, potentially due to a weaker neural plasticity and less sensitive psychological intervention windows in adulthood than the adolescent period.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOverall, a dynamic psychological monitoring system covering preoperative, early postoperative, and rehabilitation periods is recommended to screen high-risk populations of postoperative pain. In addition, multimodal psychological interventions can be applied to AIS patients, including cognitive behavioral therapy (CBT), mindfulness-based stress reduction (MBSR), and structured preoperative psychological education. These measures help soothe negative emotions and block the pain-depression vicious cycle [41, 42]. Currently, a multimodal analgesia program has been recommended by the Scoliosis Research Society (SRS) and Enhanced Recovery After Surgery (ERAS) [43,44]. Guidelines for psychological interventions against postoperative pain, however, are scant. Our findings provided solid foundations for the importance of standardized depression screening as a key link involved in the risk stratification and individualized intervention for surgically treated patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStrengths and limitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study held several strengths. We painted a holistic view of pain trajectories in postoperative AIS patients, showing that preoperative depressive symptoms were an independent risk factor for CPSP. Moreover, dynamic changes in depressive symptoms were closely associated with the prognosis of postoperative pain in AIS patients.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLimitations should be noted. First of all, depressive symptoms were solely assessed by the CDI, and the self-rating reports could potentially be influenced by recall biases or emotional interference. Second, we failed to analyze confounders like perioperative functional indicators (e.g., gait analysis) and pain catastrophizing due to insufficient data. Third, we did not balance baseline characteristics between groups because of a large proportion of sample loss (\u0026gt;40%) after propensity score matching (PSM). Multivariate regression, as a widely accepted statistical method with good robustness in prospective cohort studies, was used to adjust covariates [45]. Finally, this was a single-center study with a limited sample size, and the external validity of our nomogram should be further investigated through large-scale, multi-center studies. Machine learning was also an option to enhance the predictive performance of the nomogram.\u0026nbsp;\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003ePreoperative depressive symptoms are risk factors for both APSP and CPSP in postoperative AIS patients, showing a gradient association with the risk of CPSP. A nomogram incorporating female sex, number of surgical segments, and preoperative depressive symptoms effectively predicts CPSP in this population. An integrative psychological and analgesic intervention centered on preoperative depressive symptoms is expected to benefit high-risk AIS patients.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAIS - adolescent idiopathic scoliosis\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAPSP - acute postsurgical pain\u003c/p\u003e\n\u003cp\u003eCPSP - chronic postsurgical pain\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMME - morphine milligram equivalents\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOR - odds ratio\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAUC - area under the curve\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e95% CI - 95% confidence intervals\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCDI - the Children\u0026apos;s Depression Inventory\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eASA - the American Society of Anesthesiologists\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePCIA - patient-controlled intravenous analgesia\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBMI -body mass index\u003c/p\u003e\n\u003cp\u003ePOD-1 - one day before surgery \u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePOD - postoperative day\u003c/p\u003e\n\u003cp\u003eNRS - Numerical Rating Scale\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eICD-11 - International Classification of Diseases, 11\u003csup\u003eth\u003c/sup\u003e Revision \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMMSE - Mini-Mental State Examination\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePSQI - Pittsburgh Sleep Quality Index\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e3D-CAM - 3-Minute Diagnostic Confusion Assessment Method\u003c/p\u003e\n\u003cp\u003eSRS-22 - Scoliosis Research Society 22-Item\u003c/p\u003e\n\u003cp\u003eSF-36 - 36-Item Short Form Survey\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eECG - electrocardiogram\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSpO\u003csub\u003e2\u0026nbsp;\u003c/sub\u003e-\u003csub\u003e\u0026nbsp;\u003c/sub\u003eoxygen saturation\u003c/p\u003e\n\u003cp\u003eNIBP - non-invasive blood pressure\u003c/p\u003e\n\u003cp\u003eBIS- bispectral index\u003c/p\u003e\n\u003cp\u003eFiO\u003csub\u003e2\u0026nbsp;\u003c/sub\u003e- inspired fraction of oxygen\u003c/p\u003e\n\u003cp\u003eVT - tidal volume\u003c/p\u003e\n\u003cp\u003eRR - respiratory rate\u003c/p\u003e\n\u003cp\u003eI/E - inspiration-to-expiration ratio\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eABP - arterial blood pressure\u003c/p\u003e\n\u003cp\u003eCVP - central venous pressure\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSD - standard deviation\u003c/p\u003e\n\u003cp\u003eIQR - interquartile range\u003c/p\u003e\n\u003cp\u003en [%] - frequency and percentage\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eROC - receiver operative characteristic\u003c/p\u003e\n\u003cp\u003eDCA - decision curve analysis\u003c/p\u003e\n\u003cp\u003eNYHA - New York Heart Association Functional Classification\u003c/p\u003e\n\u003cp\u003eAlb - albumin\u003c/p\u003e\n\u003cp\u003eHCT - hematocrit\u003c/p\u003e\n\u003cp\u003eACC - anterior cingulate cortex\u003c/p\u003e\n\u003cp\u003ePFC - prefrontal cortex\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHPA - hypothalamic-pituitary-adrenal axis\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCBT - cognitive behavioral therapy\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMBSR - mindfulness-based stress reduction\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSRS - Scoliosis Research Society\u003c/p\u003e\n\u003cp\u003eERAS - Enhanced Recovery After Surgery\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePSM - propensity score matching\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e All methods were carried out in accordance with the rules approved by the Institutional Review Board of Nanjing Drum Tower Hospital (Nanjing, China; No. 2023-458-02).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRegistration\u003c/strong\u003e According to the Helsinki Declaration,the research protocol has been registered with the Chinese Clinical Trial Registry (ChiCTR; https://www.chictr.org.cn/) (Registration No: ChiCTR2300077637). Reg Date:2023-11-14.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent Informed\u003c/strong\u003e Consent was obtained from all participants\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u0026nbsp;\u003c/strong\u003eThe datasets generated and analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interests\u0026nbsp;\u003c/strong\u003eThe authors declare that they have no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e The author(s) declare that financial support was received for the research, authorship, and/or publication of this article. This work was supported by the National Natural Science Foundation of China (82571402, 82071229); Nanjing Health Science and Technology Development Special Fund (YKK22089); Nanjing Drum Tower Hospital 2023 Clinical Research Special Fund (2023-LCYJ-PY-07).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u0026nbsp;\u003c/strong\u003eSM:\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eWriting\u0026ndash;original draft, Writing\u0026ndash;review \u0026amp; editing, Data curation, Formal analysis, Project administration, Software, Validation, Visualization. ZW: Data curation, Investigation, Validation, Writing\u0026ndash;review \u0026amp; editing. JY: Writing\u0026ndash;review \u0026amp; editing, Data curation, Formal analysis, Investigation. YZ: Data curation, Investigation, Resources, Writing\u0026ndash;review \u0026amp; editing. JB: Conceptualization, Funding acquisition, Methodology, Resources, Software, Supervision, Visualization, Writing-review \u0026amp; editing. YS: Conceptualization, Funding acquisition, Methodology, Resources, Software, Supervision, Visualization, Writing\u0026ndash;review \u0026amp; editing.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eYan B, Lu X, Qiu Q, Nie G, Huang Y. Predicting Adolescent Idiopathic Scoliosis among Chinese Children and Adolescents. BioMed Res Int 2020;2020:1784360. https://doi.org/10.1155/2020/1784360.\u003c/li\u003e\n\u003cli\u003eChen H, Yang KG, Zhang J, Cheuk K-Y, Nepotchatykh E, Wang Y, et al. Upregulation of microRNA-96-5p is associated with adolescent idiopathic scoliosis and low bone mass phenotype. Sci Rep 2022;12:9705. https://doi.org/10.1038/s41598-022-12938-3.\u003c/li\u003e\n\u003cli\u003eAn S, Hyun S-J, Ahn J-M, Park B-J, Wui S-H, Kim K-J. Efficacy Comparison of Multiplanar Deformity Reducer System and Direct Vertebral Rotation in Adolescent Idiopathic Scoliosis Corrective Surgery. J Korean Neurosurg Soc 2025;68:436\u0026ndash;45. https://doi.org/10.3340/jkns.2024.0076.\u003c/li\u003e\n\u003cli\u003eLuo Y-Y, Hung T-M, Zheng Q, Wu H-D, Wong M-S, Bai Z-Q, et al. Predicting Surgical and Non-surgical Curvature Correction by Radiographic Spinal Flexibility Assessments for Patients With Adolescent Idiopathic Scoliosis: A Systematic Review and Meta-Analysis. Glob Spine J 2025;15:2822\u0026ndash;38. https://doi.org/10.1177/21925682251319543.\u003c/li\u003e\n\u003cli\u003eChinese Orthopedic Association, Zhao Y, Zhao Y, Lu S, Yang Q, Chen L, et al. Guideline for adolescent scoliosis screening in China (public version 2024). J Orthop Transl 2025;50:364\u0026ndash;72. https://doi.org/10.1016/j.jot.2024.09.006.\u003c/li\u003e\n\u003cli\u003eHammad AM, Balsano M, Ahmad AA. Vertebral body tethering: An alternative to posterior spinal fusion in idiopathic scoliosis? Front Pediatr 2023;11:1133049. https://doi.org/10.3389/fped.2023.1133049.\u003c/li\u003e\n\u003cli\u003eLandauer F, Trieb K. Scoliosis: Brace treatment - from the past 50 years to the future. Medicine (Baltimore) 2022;101:e30556. https://doi.org/10.1097/MD.0000000000030556.\u003c/li\u003e\n\u003cli\u003eJiang C-H, Shi Y, Sun Y-M, Cai M-J, Wu H-L, Hu L-S, et al. Using a 3D Navigation Template to Increase the Accuracy of Thoracic Pedicle Screws in Patients with Scoliosis. Bioeng Basel Switz 2023;10:756. https://doi.org/10.3390/bioengineering10070756.\u003c/li\u003e\n\u003cli\u003eRabbitts JA, Zhou C, de la Vega R, Aalfs H, Murray CB, Palermo TM. Correction to: A digital health peri-operative cognitive-behavioral intervention to prevent transition from acute to chronic postsurgical pain in adolescents undergoing spinal fusion (SurgeryPalTM): study protocol for a multisite randomized controlled trial. Trials 2021;22:646. https://doi.org/10.1186/s13063-021-05596-9.\u003c/li\u003e\n\u003cli\u003eZhu L, Wang Y, Li J, Zhou H, Li N, Wang Y. Depressive symptoms and all-cause mortality among middle-aged and older people in China and associations with chronic diseases. Front Public Health 2024;12:1381273. https://doi.org/10.3389/fpubh.2024.1381273.\u003c/li\u003e\n\u003cli\u003eShorey S, Ng ED, Wong CHJ. Global prevalence of depression and elevated depressive symptoms among adolescents: A systematic review and meta-analysis. Br J Clin Psychol 2022;61:287\u0026ndash;305. https://doi.org/10.1111/bjc.12333.\u003c/li\u003e\n\u003cli\u003eKremic L, Jaffer A, Patel K, Lee S, Xue Y, Daza JF, et al. Association between Preoperative Depression and Length of Stay after Major Surgery: A Systematic Review and Meta-analysis. Anesthesiology 2025;143:929\u0026ndash;43. https://doi.org/10.1097/ALN.0000000000005626.\u003c/li\u003e\n\u003cli\u003eLiu Q-R, Dai Y-C, Ji M-H, Liu P-M, Dong Y-Y, Yang J-J. Risk Factors for Acute Postsurgical Pain: A Narrative Review. J Pain Res 2024;17:1793\u0026ndash;804. https://doi.org/10.2147/JPR.S462112.\u003c/li\u003e\n\u003cli\u003eWilson JM, Farley KX, Erens GA, Bradbury TL, Guild GN. Preoperative Depression Is Associated With Increased Risk Following Revision Total Joint Arthroplasty. J Arthroplasty 2020;35:1048\u0026ndash;53. https://doi.org/10.1016/j.arth.2019.11.025.\u003c/li\u003e\n\u003cli\u003eSchulz KF, Altman DG, Moher D, CONSORT Group. CONSORT 2010 statement: updated guidelines for reporting parallel group randomised trials. BMJ 2010;340:c332. https://doi.org/10.1136/bmj.c332.\u003c/li\u003e\n\u003cli\u003eZhang Y, Cui F, Ma J-H, Wang D-X. Mini-dose esketamine\u0026ndash;dexmedetomidine combination to supplement analgesia for patients after scoliosis correction surgery: a double-blind randomised trial. Br J Anaesth 2023;131:385\u0026ndash;96. https://doi.org/10.1016/j.bja.2023.05.001.\u003c/li\u003e\n\u003cli\u003eL\u0026oacute;pez-Mart\u0026iacute;nez AE, Sainero-Tirado G, Esteve R, Reyes-P\u0026eacute;rez \u0026Aacute;, Ruiz-P\u0026aacute;rraga GT, de la Vega R, et al. Does pain catastrophizing and distress intolerance mediate the relationship between PTSD and prescribed opioid misuse in people with chronic noncancer pain? Psychol Trauma Theory Res Pract Policy 2023;15:394\u0026ndash;403. https://doi.org/10.1037/tra0001269.\u003c/li\u003e\n\u003cli\u003eWidder A, Reese L, Lock JF, Wiegering A, Germer C-T, Rittner HL, et al. Chronic postsurgical pain (CPSP): an underestimated problem after incisional hernia treatment. Hernia J Hernias Abdom Wall Surg 2024;28:1697\u0026ndash;707. https://doi.org/10.1007/s10029-024-03027-7.\u003c/li\u003e\n\u003cli\u003eHawes MT, Szenczy AK, Klein DN, Hajcak G, Nelson BD. Increases in depression and anxiety symptoms in adolescents and young adults during the COVID-19 pandemic. Psychol Med 2022;52:3222\u0026ndash;30. https://doi.org/10.1017/S0033291720005358.\u003c/li\u003e\n\u003cli\u003eLv W, Li B, Feng J, Chen L, Qiu X, Liu S. Depression, anxiety and health-related quality of life in paediatric intracranial germ cell tumor survivors. Health Qual Life Outcomes 2022;20:9. https://doi.org/10.1186/s12955-021-01911-9.\u003c/li\u003e\n\u003cli\u003eSunhary de Verville PL, Etchecopar-Etchart D, Richieri R, Godin O, Sch\u0026uuml;rhoff F, Berna F, et al. Recommendations of the schizophrenia expert center network for the screening prevention and treatment of sleep disorders based on the results from the real-world schizophrenia FACE-SZ national cohort. Prog Neuropsychopharmacol Biol Psychiatry 2021;110:110275. https://doi.org/10.1016/j.pnpbp.2021.110275.\u003c/li\u003e\n\u003cli\u003eScialpi A, Mignolli E, De Vito C, Berardi A, Tofani M, Valente D, et al. Italian Validation of the Pittsburgh Sleep Quality Index (PSQI) in a Population of Healthy Children: A Cross Sectional Study. Int J Environ Res Public Health 2022;19:9132. https://doi.org/10.3390/ijerph19159132.\u003c/li\u003e\n\u003cli\u003eClement ND, Weir D, Deehan D. Meaningful values in the Short Form Health Survey-36 after total knee arthroplasty - an alternative to the EuroQol five-dimension index as a measure for health-related quality of life : minimal clinically important difference, minimal important change, patient-acceptable symptom state thresholds, and responsiveness. Bone Jt Res 2022;11:477\u0026ndash;83. https://doi.org/10.1302/2046-3758.117.BJR-2021-0493.R1.\u003c/li\u003e\n\u003cli\u003eGao A, Li J-Y, Shao R, Wu T-X, Wang Y-Q, Liu X-G, et al. Schroth exercises improve health-related quality of life and radiographic parameters in adolescent idiopathic scoliosis patients. Chin Med J (Engl) 2021;134:2589\u0026ndash;96. https://doi.org/10.1097/CM9.0000000000001799.\u003c/li\u003e\n\u003cli\u003eJamjoom AB, Gahtani AY, Alzahrani MT, Albeshri AS, Sharab MA. Review of the Most Cited Patient-Reported Outcome Measure (PROM) Studies Published in the Neurospine Surgical Literature. Cureus 2023;15:e44262. https://doi.org/10.7759/cureus.44262.\u003c/li\u003e\n\u003cli\u003eFeng Y, Zeng W, Xie Y, Chen H, Wang L, Wang Y, et al. Neural Modulation Alteration to Positive and Negative Emotions in Depressed Patients: Insights from fMRI Using Positive/Negative Emotion Atlas. Tomogr Ann Arbor Mich 2024;10:2014\u0026ndash;37. https://doi.org/10.3390/tomography10120144.\u003c/li\u003e\n\u003cli\u003eJiang S, Shen Z, Xu W. Electroacupuncture Reverses CUMS-Induced Depression-Like Behaviors and LTP Impairment in Hippocampus by Downregulating NR2B and CaMK II Expression. Evid-Based Complement Altern Med ECAM 2021;2021:9639131. https://doi.org/10.1155/2021/9639131.\u003c/li\u003e\n\u003cli\u003eWen J, Xu Y, Yu Z, Zhou Y, Wang W, Yang J, et al. The cAMP Response Element- Binding Protein/Brain-Derived Neurotrophic Factor Pathway in Anterior Cingulate Cortex Regulates Neuropathic Pain and Anxiodepression Like Behaviors in Rats. Front Mol Neurosci 2022;15:831151. https://doi.org/10.3389/fnmol.2022.831151.\u003c/li\u003e\n\u003cli\u003eSimic K, Savic B, Knezevic NN. Pain Catastrophizing: How Far Have We Come. Neurol Int 2024;16:483\u0026ndash;501. https://doi.org/10.3390/neurolint16030036.\u003c/li\u003e\n\u003cli\u003eRogers AH, Farris SG. A meta-analysis of the associations of elements of the fear-avoidance model of chronic pain with negative affect, depression, anxiety, pain-related disability and pain intensity. Eur J Pain Lond Engl 2022;26:1611\u0026ndash;35. https://doi.org/10.1002/ejp.1994.\u003c/li\u003e\n\u003cli\u003eEller-Smith OC, Nicol AL, Christianson JA. Potential Mechanisms Underlying Centralized Pain and Emerging Therapeutic Interventions. Front Cell Neurosci 2018;12:35. https://doi.org/10.3389/fncel.2018.00035.\u003c/li\u003e\n\u003cli\u003eJohnsen K, Owen PJ, Tagliaferri SD, Van Oosterwijck J, Fitzgibbon BM, Ford JJ, et al. The Interaction Between Psychosocial Factors and Exercise-Induced Hypoalgesia in Pain-Free Nurses. J Pain Res 2023;16:529\u0026ndash;41. https://doi.org/10.2147/JPR.S386440.\u003c/li\u003e\n\u003cli\u003eSatyanarayanan SK, Shih Y-H, Wen Y-R, Palani M, Lin Y-W, Su H, et al. miR-200a-3p modulates gene expression in comorbid pain and depression: Molecular implication for central sensitization.. Brain Behav Immun 2019;82:230\u0026ndash;8. https://doi.org/10.1016/j.bbi.2019.08.190.\u003c/li\u003e\n\u003cli\u003eSannes A-C, Ghani U, Niazi IK, Moberget T, Jonassen R, Haavik H, et al. Investigating Whether a Combination of Electro-Encephalography and Gene Expression Profiling Can Predict the Risk of Chronic Pain: A Protocol for an Observational Prospective Cohort Study. Brain Sci 2024;14:641. https://doi.org/10.3390/brainsci14070641.\u003c/li\u003e\n\u003cli\u003eKurkis G, Wilson JM, Anastasio AT, Farley KX, Bradbury TL. Preoperative Diagnosis of Depression Leads to Increased Opioid Tablets Taken After Total Hip Arthroplasty: A Prospective Study. J Surg Orthop Adv 2021;30:144\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eJin J, Chen Q, Min S, Du X, Zhang D, Qin P. Prevalence and predictors of chronic postsurgical pain after colorectal surgery: A prospective study. Colorectal Dis Off J Assoc Coloproctology G B Irel 2021;23:1878\u0026ndash;89. https://doi.org/10.1111/codi.15640.\u003c/li\u003e\n\u003cli\u003eKhan JS, Dana E, Xiao MZX, Rao V, Djaiani G, Seltzer Z, et al. Prevalence and Risk Factors for Chronic Postsurgical Pain After Thoracic Surgery: A Prospective Cohort Study. J Cardiothorac Vasc Anesth 2024;38:490\u0026ndash;8. https://doi.org/10.1053/j.jvca.2023.09.042.\u003c/li\u003e\n\u003cli\u003eLu Y, Hu B, Dai H, Wang B, Yao J, Yao X. Predictors of Chronic Postsurgical Pain in Elderly Patients Undergoing Hip Arthroplasty: A Multi-Center Retrospective Cohort Study. Int J Gen Med 2021;14:7885\u0026ndash;94. https://doi.org/10.2147/IJGM.S337170.\u003c/li\u003e\n\u003cli\u003eLee S, Xue Y, Petricca J, Kremic L, Xiao MZX, Pivetta B, et al. The impact of pre-operative depression on pain outcomes after major surgery: a systematic review and meta-analysis. Anaesthesia 2024;79:423\u0026ndash;34. https://doi.org/10.1111/anae.16188.\u003c/li\u003e\n\u003cli\u003eTassou A, Richeb\u0026eacute; P, Rivat C. Mechanisms of chronic postsurgical pain. Reg Anesth Pain Med 2025. https://doi.org/10.1136/rapm-2024-105964.\u003c/li\u003e\n\u003cli\u003eChen JA, Anderson ML, Cherkin DC, Balderson BH, Cook AJ, Sherman KJ, et al. Moderators and Nonspecific Predictors of Treatment Benefits in a Randomized Trial of Mindfulness-Based Stress Reduction vs Cognitive-Behavioral Therapy vs Usual Care for Chronic Low Back Pain. J Pain 2023;24:282\u0026ndash;303. https://doi.org/10.1016/j.jpain.2022.09.014.\u003c/li\u003e\n\u003cli\u003ePetrucci G, Papalia GF, Russo F, Vadal\u0026agrave; G, Piredda M, De Marinis MG, et al. Psychological Approaches for the Integrative Care of Chronic Low Back Pain: A Systematic Review and Metanalysis. Int J Environ Res Public Health 2021;19:60. https://doi.org/10.3390/ijerph19010060.\u003c/li\u003e\n\u003cli\u003eDebono B, Wainwright TW, Wang MY, Sigmundsson FG, Yang MMH, Smid-Nanninga H, et al. Consensus statement for perioperative care in lumbar spinal fusion: Enhanced Recovery After Surgery (ERAS\u0026reg;) Society recommendations. Spine J Off J North Am Spine Soc 2021;21:729\u0026ndash;52. https://doi.org/10.1016/j.spinee.2021.01.001.\u003c/li\u003e\n\u003cli\u003eTurtle JD, Mehta JS, Parent S, Xiong GX, Cheung JP, Welborn MC, et al. Guidelines for returning to activity after spinal deformity surgery. Spine Deform 2025;13:383\u0026ndash;90. https://doi.org/10.1007/s43390-024-01010-x.\u003c/li\u003e\n\u003cli\u003eElze MC, Gregson J, Baber U, Williamson E, Sartori S, Mehran R, et al. Comparison of Propensity Score Methods and Covariate Adjustment: Evaluation in 4 Cardiovascular Studies. J Am Coll Cardiol 2017;69:345\u0026ndash;57. https://doi.org/10.1016/j.jacc.2016.10.060.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 Demographic and baseline characteristics of adolescent idiopathic scoliosis patients with preoperative depressive symptoms or not.\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 139px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDepression group\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=32)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNon-depression group\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=125)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e-value\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 139px;\"\u003e\n \u003cp\u003e14 (13,16.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003e13 (12,15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e0.118\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eSex (n, %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 139px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e0.057\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eMales\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 139px;\"\u003e\n \u003cp\u003e5 (15.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003e41 (32.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eFemales\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 139px;\"\u003e\n \u003cp\u003e27 (84.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003e84 (67.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 139px;\"\u003e\n \u003cp\u003e18.3 (17.3,21.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003e19.1 (16.8,21.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e0.984\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eEducation level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 139px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e0.063\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003ePrimary school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 139px;\"\u003e\n \u003cp\u003e20 (62.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003e98 (78.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eMiddle school or above\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 139px;\"\u003e\n \u003cp\u003e12 (37.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003e27 (21.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eNYHA (n, %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 139px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u0026gt;0.999\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 139px;\"\u003e\n \u003cp\u003e31 (96.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003e121 (96.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 139px;\"\u003e\n \u003cp\u003e1 (3.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003e2 (3.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eASA (n, %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 139px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u0026gt;0.999\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eI-II\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 139px;\"\u003e\n \u003cp\u003e32 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003e123 (98.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eIII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 139px;\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003e2 (1.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003ePreoperative pain (points)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 139px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eNRS during movement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 139px;\"\u003e\n \u003cp\u003e1.5 (0,3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003e0 (0,2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.006\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eNRS at rest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 139px;\"\u003e\n \u003cp\u003e0 (0,2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003e0 (0,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.049\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003ePSQI (points)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 139px;\"\u003e\n \u003cp\u003e3.5 (2.3,5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003e2 (1,3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eMMSE (points)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 139px;\"\u003e\n \u003cp\u003e29 (27,30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003e29 (28,30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e0.062\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eSF-36 (points)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 139px;\"\u003e\n \u003cp\u003e61.7 (50,71.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003e80 (69.6,86.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eSRS-22 (points)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 139px;\"\u003e\n \u003cp\u003e77.3\u0026plusmn;10.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003e91.9\u0026plusmn;8.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eAlb (g/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 139px;\"\u003e\n \u003cp\u003e41.8\u0026plusmn;2.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003e42\u0026plusmn;2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e0.680\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eSurgical fusion segments\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 139px;\"\u003e\n \u003cp\u003e10.5 (6.3,12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003e10 (7,12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e0.502\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eCobb angle (\u0026deg;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 139px;\"\u003e\n \u003cp\u003e47.5 (42,62.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003e51 (44.5,64.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e0.456\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eOperation time (min)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 139px;\"\u003e\n \u003cp\u003e225.2\u0026plusmn;60.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003e232\u0026plusmn;57.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e0.553\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eAnesthesia time (min)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 139px;\"\u003e\n \u003cp\u003e258.8\u0026plusmn;605.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003e264.8\u0026plusmn;60.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e0.620\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eBlood loss (mL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 139px;\"\u003e\n \u003cp\u003e750 (425, 1 200)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003e725 (500, 1 000)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e0.897\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eUrine output (mL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 139px;\"\u003e\n \u003cp\u003e800 (700, 1 200)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003e950 (600, 1 400)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e0.683\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eInfusion volume (mL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 139px;\"\u003e\n \u003cp\u003e3 547.5 (2 939, 4 431)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003e3 470 (2 908.8, 4 236.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e0.722\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eBlood transfusion (n, %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 139px;\"\u003e\n \u003cp\u003e29 (90.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003e122 (97.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e0.187\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eVasopressor (n, %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 139px;\"\u003e\n \u003cp\u003e16 (50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003e65 (52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e0.840\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eAntihypertensive drugs (n, %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 139px;\"\u003e\n \u003cp\u003e2 (6.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003e10 (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u0026gt;0.999\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote: BMI, body mass index; NYHA, New York Heart Association Functional Classification; ASA, American Society of Anesthesiologists; NRS, Numerical Rating Scale; PSQI, Pittsburgh Sleep Quality Index; MMSE, Mini-Mental State Examination; SF-36,\u0026nbsp;36-Item Short Form Survey; SRS-22,\u0026nbsp;Scoliosis Research Society 22-Item; Alb, albumin. The bolded\u003cem\u003e\u0026nbsp;P\u003c/em\u003e-value indicates statistical significance.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 2 Outcome comparisons in adolescent idiopathic scoliosis patients with preoperative depressive symptoms or not.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 214px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDepression group\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=32)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNon-depression group\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=125)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e-value\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 214px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrimary outcomes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 214px;\"\u003e\n \u003cp\u003eIncidence of moderate APSP (n, %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003e18 (56.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e61 (48.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e0.452\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 214px;\"\u003e\n \u003cp\u003eIncidence of severe APSP (n, %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003e12 (37.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e54 (43.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e0.560\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 214px;\"\u003e\n \u003cp\u003eIncidence of CPSP (n, %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003e23 (71.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e13 (10.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 214px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSecondary outcomes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 214px;\"\u003e\n \u003cp\u003eSupplemental opioid use on POD1-3 (n, %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003e3 (9.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e6 (4.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e0.571\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 214px;\"\u003e\n \u003cp\u003eMME\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003e100 (100, 100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e100 (100, 102.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e0.542\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 214px;\"\u003e\n \u003cp\u003eIncidence of delirium on POD1-5 (n, %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e\u0026gt;0.999\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 214px;\"\u003e\n \u003cp\u003eLength of stay (days)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003e7 (7, 8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e7 (7, 8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e0.961\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 214px;\"\u003e\n \u003cp\u003eAll-cause mortality on POD30 (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e\u0026gt;0.999\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 214px;\"\u003e\n \u003cp\u003eSRS-22 on POD30 (points)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003e81.38 (74, 85.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e87.80 (81, 96)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 214px;\"\u003e\n \u003cp\u003eSF-36 on POD30 (points)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003e63.59 (61.19, 68.77)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e75.09 (68.77, 80.18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 214px;\"\u003e\n \u003cp\u003eSRS-22 on POD90 (points)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003e89.17 (84, 96)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e91.95 (85, 98)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e0.089\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 214px;\"\u003e\n \u003cp\u003eSF-36 on POD90 (points)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003e75.80 (68.77, 79.80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e80.60 (75.83, 87.37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote: APSP, acute postsurgical pain; CPSP, chronic postsurgical pain; POD, postoperative day; MME, morphine milligram equivalent; SRS-22, Scoliosis Research Society 22-Item; SF-36, 36-Item Short Form Survey. The bolded \u003cem\u003eP\u003c/em\u003e-value indicates statistical significance.\u003c/p\u003e\n\u003cp\u003eTable 3 Univariate and multivariate logistic regression analyses on illustrating risk factors for chronic postsurgical pain in adolescent idiopathic scoliosis patients.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 356px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUnivariate logistic regression\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 356px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMultivariate logistic regression\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eDepressive symptoms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eAbsence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003ePresence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e22.02 (8.42, 57.56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e41.06 (8.68, 194.19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e6.06 (1.76, 20.94)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.004\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e6.36 (1.02, 39.57)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.047\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eSurgical fusion segments\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e1.17 (1.02, 1.34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.024\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e1.31 (1.07, 1.60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.008\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003ePreoperative pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eNRS at rest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e1.46 (1.08, 1.98)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.014\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e1.08 (0.67, 1.76)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e0.750\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eNRS during movement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e1.41 (1.10, 1.79)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.006\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e1.21 (0.81, 1.81)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e0.344\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eSRS-22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e0.92 (0.89, 0.96)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e0.98 (0.90, 1.07)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e0.640\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003ePSQI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e1.31 (1.08, 1.59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.006\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e0.90 (0.68, 1.19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e0.454\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eSF-36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e0.96 (0.93, 0.98)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e1.02 (0.97, 1.09)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e0.428\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eHCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e0.89 (0.80, 0.99)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.028\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e1.02 (0.87, 1.21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e0.783\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote: OR, odds ratio; CI, confidence interval; NRS, Numerical Rating Scale; SRS-22,\u0026nbsp;Scoliosis Research Society 22-Item; PSQI, Pittsburgh Sleep Quality Index; SF-36, 36-Item Short Form Survey; HCT, hematocrit.The bolded \u003cem\u003eP\u003c/em\u003e-value indicates statistical significance.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-orthopaedic-surgery-and-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"josr","sideBox":"Learn more about [Journal of Orthopaedic Surgery and Research](http://josr-online.biomedcentral.com)","snPcode":"13018","submissionUrl":"https://submission.nature.com/new-submission/13018/3","title":"Journal of Orthopaedic Surgery and Research","twitterHandle":"@MSKmedBMC","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"AIS, Depressive Symptoms, Postoperative Pain, Pain Trajectories, Risk Prediction Model","lastPublishedDoi":"10.21203/rs.3.rs-9030306/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9030306/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Patients with adolescent idiopathic scoliosis (AIS) frequentlyexperience depressive symptoms, and their functional rehabilitation can be greatly influenced by postoperative acute and chronic pain. This study aims to explore the association ofpreoperative depressive symptoms in AIS patients with postoperative acute and chronic pain.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eThis was a prospective study involving AIS patients aged 10-17 years who were surgically managed by scoliosis correction under general anesthesia. Depressive symptoms, pain, functional activity, sleep quality, and quality of life were preoperatively assessed using scales. Dynamic trajectories in the acute postsurgical pain (APSP) and chronic postsurgical pain (CPSP) were evaluated during a 90-day follow-up. The primary outcomes were the incidence of APSP and CPSP. Secondary outcomes consisted of early postoperative oral morphine milligram equivalents (MME), early complications, postoperative length of stay, and long-term rehabilitation status.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eMultivariate analysis identified that female sex (odds ratio [OR]=6.36, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.05), number of surgical segments (OR=1.31, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.01), and preoperative depressive symptoms (OR=41.06,\u003cem\u003eP\u003c/em\u003e\u0026lt;0.001) wereindependent risk factors for CPSP. A risk prediction model (nomogram)constructed by incorporating the above variables effectively distinguished CPSP in postoperative AIS patients, with an area under the curve (AUC) of 0.852 (95% confidence intervals [CI]: 0.786–0.918, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.01). The incidence of CPSP was significantly higher in postoperative AIS patients with persistent depressive symptoms than those with relieved or cured depressive symptoms (100% vs. 67.86% vs. 10.40%, χ²=50.46, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e Preoperative depressive symptoms are risk factors for both APSP and CPSP in postoperative AIS patients, showing a gradient association with the incidence of CPSP. A nomogram incorporating female sex, number of surgical segments, and preoperative depressive symptoms effectively predicts CPSP in this population. An integrative psychological and analgesic intervention centered on preoperative depressive symptoms is expected to benefit high-risk AIS patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration:\u003c/strong\u003e According to the Helsinki Declaration,the research protocol has been registered with the Chinese Clinical Trial Registry (ChiCTR; https://www.chictr.org.cn/) (Registration No: ChiCTR2300077637).\u003c/p\u003e","manuscriptTitle":"The Impact of Preoperative Depressive Symptoms on Acute and Chronic Postoperative Pain Trajectories After Orthopedic Surgery for Adolescent Idiopathic Scoliosis: a Prospective Cohort Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-18 08:26:34","doi":"10.21203/rs.3.rs-9030306/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-26T03:49:33+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-15T07:58:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"65556587924470281591962320195870700496","date":"2026-03-14T14:52:55+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-13T12:28:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"1931068926747906794074981336149315240","date":"2026-03-13T10:53:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"9841239337868298548809000205984115135","date":"2026-03-13T05:28:47+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-12T15:51:05+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-06T02:56:14+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-06T02:55:11+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Orthopaedic Surgery and Research","date":"2026-03-04T12:28:22+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-orthopaedic-surgery-and-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"josr","sideBox":"Learn more about [Journal of Orthopaedic Surgery and Research](http://josr-online.biomedcentral.com)","snPcode":"13018","submissionUrl":"https://submission.nature.com/new-submission/13018/3","title":"Journal of Orthopaedic Surgery and Research","twitterHandle":"@MSKmedBMC","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"88d615ef-3f4d-4934-9881-c47ec53bad80","owner":[],"postedDate":"March 18th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-04T23:53:50+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-18 08:26:34","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9030306","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9030306","identity":"rs-9030306","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}