Effectiveness of preoperative cognitive behavioral therapy for patients undergoing lumbar spine fusion surgery: A systematic review focusing on patient-reported outcomes

To examine implementation approaches and effectiveness of preoperative cognitive behavioral therapy (CBT) on patient-reported outcomes following lumbar fusion. We systematically searched PubMed/Medline, Cochrane Database of Systematic Reviews, and Epistemonikos (inception to December 15, 2024) for studies investigating preoperative CBT in patients scheduled for lumbar fusion. Primary and secondary outcomes were postoperative disability (Oswestry Disability Index, ODI) and health-related quality of life (EQ-5D), respectively, at 3 and 6 months. Meta-analysis employed Inverse Variance Random Effects Standardized Mean Difference models to compare the change from baseline. From a total of 182 studies, three RCTs comprising 307 patients (mean age: 50 years; 58% female) met the inclusion criteria. Meta-analysis revealed no statistically significant differences between CBT and control groups in ODI change from baseline at 3 months (SMD 0.04 [95% CI: -0.81 to 0.88]; p = 0.93; I² = 92%) or 6 months (SMD - 0.17 [95% CI: -0.53 to 0.19]; p = 0.36; I² = 58%). Similarly, no significant differences emerged for EQ-5D at 3 months (SMD 0.09 [95% CI: -0.27 to 0.46]; p = 0.62; I² = 59%) or 6 months (SMD - 0.56 [95% CI: -1.49 to 0.36]; p = 0.23; I² = 93%). Current evidence does not support preoperative CBT as broadly effective for unselected lumbar fusion candidates. However, substantial heterogeneity tempers the validity of conclusions across surgical settings. Targeted psychological interventions for high-risk patients (catastrophizing, anxiety, depression) within comprehensive prehabilitation programs warrant consideration.