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Development of the "Core Yellow Flags Index" (CYFI) as a brief instrument for the assessment of key psychological factors in patients undergoing spine surgery

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Abstract

Background

Depression, anxiety, catastrophising, and fear-avoidance beliefs are key "yellow flags" (YFs) that predict a poor outcome in back patients. Most surgeons acknowledge the importance of YFs but have difficulty assessing them due to the complexity of the instruments used for their measurement and time constraints during consultations. We performed a secondary analysis of existing questionnaire data to develop a brief tool to enable the systematic evaluation of YFs and then tested it in clinical practice.

Methods

The following questionnaire datasets were available from a total of 932 secondary/tertiary care patients (61 ± 16 years; 51% female): pain catastrophising (N = 347); ZUNG depression (N = 453); Hospital Anxiety and Depression Scale (anxiety subscale) (N = 308); fear-avoidance beliefs (N = 761). The single item that best represented the full-scale score was identified, to form the 4-item "Core Yellow Flags Index" (CYFI). 2422 patients (64 ± 16 years; 54% female) completed CYFI and a Core Outcome Measures Index (COMI) before lumbar spine surgery, and a COMI 3 and 12 months later (FU).

Results

The item–total correlation for each item with its full-length questionnaire was: 0.77 (catastrophising), 0.67 (depression), 0.69 (anxiety), 0.68 (fear-avoidance beliefs). Cronbach's α for the CYFI was 0.79. Structural equation modelling showed CYFI uniquely explained variance (p < 0.001) in COMI at both the 3- and 12-month FUs (β = 0.11 (women), 0.24 (men); and β = 0.13 (women), β = 0.14 (men), respectively).

Conclusion

The 4-item CYFI proved to be a simple, practicable tool for routinely assessing key psychological attributes in spine surgery patients and made a relevant contribution in predicting postoperative outcome. CYFI's items were similar to those in the "STarT Back screening tool" used in primary care to triage patients into treatment pathways, further substantiating its validity. Wider use of CYFI may help improve the accuracy of predictive models derived using spine registry data.

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Acknowledgements

We thank all the patients of the Schulthess Klinik who contributed their data. We thank Dave O’Riordan, Gordana Balaban, Stéphanie Dosch, and Selina Nauer for their administration of the Spine Tango surgery forms and patient-rated outcome measures. We thank Astrid Junge for her help and advice in finalising the wording of the introductory text and response options for the German version of the CYFI and Melissa Wilhelmi for her English translations of the same. We thank the authors of the original studies from which data were derived to develop the new CYFI.

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Authors and Affiliations

  1. Spine Center Division, Department of Teaching, Research and Development, Schulthess Klinik, Lengghalde 2, 8008, Zurich, Switzerland

    Anne F. Mannion & Francine Mariaux

  2. Spine Center, Schulthess Klinik, Lengghalde 2, 8008, Zurich, Switzerland

    Raluca Reitmeir, Tamas F. Fekete, Daniel Haschtmann, Markus Loibl, Dezsö Jeszenszky, Frank S. Kleinstück & François Porchet

  3. Institute for Psychology, University of Bern, Fabrikstrasse 8, 3012, Bern, Switzerland

    Achim Elfering

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  1. Anne F. Mannion
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Mannion, A.F., Mariaux, F., Reitmeir, R. et al. Development of the "Core Yellow Flags Index" (CYFI) as a brief instrument for the assessment of key psychological factors in patients undergoing spine surgery. Eur Spine J 29, 1935–1952 (2020). https://doi.org/10.1007/s00586-020-06462-z

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