Aims. The purpose of this study was to assess the prevalence of depression and anxiety symptoms in patients undergoing shoulder surgery using the National Institutes of Health (NIH) Patient-Reported Outcomes Measurement Information System (PROMIS) Depression and Anxiety computer adaptive tests, and to determine the factors associated with more severe symptoms. Additionally, we sought to determine whether PROMIS Depression and Anxiety were associated with functional outcomes after shoulder surgery. Methods. This was a retrospective analysis of 293 patients from an urban population who underwent elective shoulder surgery from 2015 to 2018. Survey questionnaires included preoperative and two-year postoperative data. Bivariate analysis was used to identify associations and multivariable analysis was used to control for confounding variables. Results. Mean two-year PROMIS Depression and Anxiety scores significantly improved from preoperative scores, with a greater improvement observed in PROMIS Anxiety. Worse PROMIS Depression and Anxiety scores were also significantly correlated with worse PROMIS Physical Function (PF) and American Shoulder and Elbow Surgeons scores (ASES). After controlling for confounding variables, worse PROMIS Depression was an independent predictor of worse PROMIS PF, while worse PROMIS Anxiety was an independent predictor of worse PROMIS PF and ASES scores. Conclusion. Mean two-year PROMIS Depression and Anxiety scores improved after elective shoulder surgery and several patient characteristics were associated with these scores. Worse functional outcomes were associated with worse PROMIS Depression and Anxiety; however, more severe two-year PROMIS Anxiety was the strongest predictor of worse functional outcomes. Cite this article: Bone Joint J 2022;104-B(4):479–485

Aims. Fracture-related infections (FRIs) are a devastating complication of fracture management. However, the impact of FRIs on mental health remains understudied. The aim of this study was a longitudinal evaluation of patients’ psychological state, and expectations for recovery comparing patients with recurrent FRI to those with primary FRI. Methods. A prospective longitudinal study was conducted at a level 1 trauma centre from January 2020 to December 2022. In total, 56 patients treated for FRI were enrolled. The ICD-10 symptom rating (ISR) and an expectation questionnaire were assessed at five timepoints: preoperatively, one month postoperatively, and at three, six, and 12 months. Results. Recurrent FRI cases consistently exceeded the symptom burden threshold (0.60) in ISR scores at all assessment points. The difference between preoperative-assessed total ISR scores and the 12-month follow-up was not significant in either group, with 0.04 for primary FRI (p = 0.807) and 0.01 for recurrent FRI (p = 0.768). While primary FRI patients showed decreased depression scores post surgery, recurrent FRI cases experienced an increase, reaching a peak at 12 months (1.92 vs 0.94; p < 0.001). Anxiety scores rose for both groups after surgery, notably higher in recurrent FRI cases (1.39 vs 1.02; p < 0.001). Moreover, patients with primary FRI reported lower expectations of returning to normal health at three (1.99 vs 1.11; p < 0.001) and 12 months (2.01 vs 1.33; p = 0.006). Conclusion. The findings demonstrate the significant psychological burden experienced by individuals undergoing treatment for FRI, which is more severe in recurrent FRI. Understanding the psychological dimensions of recurrent FRIs is crucial for comprehensive patient care, and underscores the importance of integrating psychological support into the treatment paradigm for such cases. Cite this article: Bone Jt Open 2024;5(7):621–627

Introduction. Previous studies have shown the potential for virtual reality (VR) immersion as a promising technique for pain and anxiety management. The aim of our study was to evaluate the feasibility of VR in the management of pain and anxiety during post-op external fixator care procedures. Method. This study involved patients aged 5-21 years following limb lengthening/reconstruction surgery with an external fixator. Aqua VR application from the KindVR® was utilized for this study. Subjects were seen during the first four postoperative visits and assigned to a ‘VR-first’ or ‘no-VR-first’ group. Visits alternated between VR immersion and no VR immersion during care procedures. The study endpoints (pain and anxiety levels) were assessed before, during, and after procedures using the Wong-Baker Faces (FACES) and Children's Fear Scale, respectively. Proxy scores for pain and anxiety were also obtained from parents or legal guardians and providers. Result. A total of 29 patients (16 male and 13 female) were evaluated. The mean age at enrollment was 14.4 ± 2.2 years for group 1 and 14.7 ± 4.0 years for group 2. The median number of pin sites was 7. Anxiety scores were consistently higher during the non-VR immersion experience compared to the VR immersion visits. The pain and anxiety scores were significantly lower in the ‘VR-first’ group during the non-VR immersion study visits compared to patients in the ‘no-VR-first’ group. This observation was also consistent with survey findings among the parent proxies and providers. Conclusion. VR immersion is associated with lower anxiety scores for pin-site care procedures. VR immersion at the first post-operative visit following limb reconstruction surgery was also associated with lower pain and anxiety scores during subsequent non-VR immersion visits

Periacetabular Osteotomy (PAO) has become the most important surgical procedure for patients with hip dysplasia, offering significant pain relief and improved joint function. This study focuses on recovery after PAO, specifically the return to sports (RTS) timeline, with the objective of identifying preoperative predictors to optimize patient outcomes. Our prospective, monocentric study from 2019 to 2023 included 698 hips from 606 patients undergoing PAO. Comprehensive preoperative data were collected, including demographic information, clinical assessments (Modified Harris Hip Score (mHHS), International Hip Outcome Tool-12 (iHot-12), Hip Disability and Osteoarthritis Outcome Score (HOOS), UCLA Activity Score) and psychological evaluations (Brief Symptom Inventory (BSI) and SF-36 Health Survey). Advanced logistic regression and machine learning techniques (R Core Team. (2016)) were employed to develop a predictive model. Multivariate regression analysis revealed that several preoperative factors significantly influenced the RTS timeline. These included gender, invasiveness of the surgical approach, preoperative UCLA Score, preoperative sports activity level, mHHS, and various HOOS subscales (Sport/Recreation, Symptoms, Pain) as well as psychological factors (BSI and SF-36). The subsequent model, using a decision tree approach, showed that the combination of a UCLA score greater than 3 (p<0.001), non-female gender (p=0.003), preoperative sports frequency not less than twice per week (p<0.001), participation in high-impact sports preoperatively (p=0.008), and a BSI anxiety score less than 2 (p<0.001) had the highest likelihood of early RTS with a probability of 71.4% at three months. Using a decision tree approach, this model provides a nuanced prediction of RTS after PAO, highlighting the synergy of physical, psychological, and lifestyle influences. By quantifying the impact of these variables, it provides clinicians with a valuable tool for predicting individual patient recovery trajectories, aiding in tailored rehabilitation planning and predicting postoperative satisfaction

Aims. COVID-19 has compounded a growing waiting list problem, with over 4.5 million patients now waiting for planned elective care in the UK. Views of patients on waiting lists are rarely considered in prioritization. Our primary aim was to understand how to support patients on waiting lists by hearing their experiences, concerns, and expectations. The secondary aim was to capture objective change in disability and coping mechanisms. Methods. A minimum representative sample of 824 patients was required for quantitative analysis to provide a 3% margin of error. Sampling was stratified by body region (upper/lower limb, spine) and duration on the waiting list. Questionnaires were sent to a random sample of elective orthopaedic waiting list patients with their planned intervention paused due to COVID-19. Analyzed parameters included baseline health, change in physical/mental health status, challenges and coping strategies, preferences/concerns regarding treatment, and objective quality of life (EuroQol five-dimension questionnaire (EQ-5D), Generalized Anxiety Disorder 2-item scale (GAD-2)). Qualitative analysis was performed via the Normalization Process Theory. Results. A total of 888 patients responded. Better health, pain, and mood scores were reported by upper limb patients. The longest waiters reported better health but poorer mood and anxiety scores. Overall, 82% had tried self-help measures to ease symptoms; 94% wished to proceed with their intervention; and 21% were prepared to tolerate deferral. Qualitative analysis highlighted the overall patient mood to be represented by the terms ‘understandable’, ‘frustrated’, ‘pain’, ‘disappointed’, and ‘not happy/depressed’. COVID-19-mandated health and safety measures and technology solutions were felt to be implemented well. However, patients struggled with access to doctors and pain management, quality of life (physical and psychosocial) deterioration, and delay updates. Conclusion. This is the largest study to hear the views of this ‘hidden’ cohort. Our findings are widely relevant to ensure provision of better ongoing support and communication, mostly within the constraints of current resources. In response, we developed a reproducible local action plan to address highlighted issues. Cite this article: Bone Jt Open 2021;2(8):583–593

Purpose: To determine if oral midazolam reduces the anxiety of children undergoing removal of percutaneous Kirschner wires (K-wires) from the distal humerus in the Orthopaedic Outpatient Department. Methods: This was a prospective double blind, randomised controlled trial. 46 children aged between 3 and 12 years who had supracondylar fractures of the distal humerus internally fixed with K-wires were randomised into 2 groups. 0.2mg/kg oral midazolam (active group) or the same volume of an oral placebo (control group) was administered 30 minutes prior to removal of K-wires. Venham Situational Anxiety Score was performed before and immediately after removal of K-wires. University College London Hospital sedation score was recorded every 20 minutes. Results: 42 children with an average age of 7.1 years (range 3.6–12.3 years) had complete documentation for analysis. The two groups had similar demographics. All wires were removed in the clinic with or without midazolam. There was no significant difference in anxiety scores between the groups either before or after wire removal. The change in scores was not significantly different between the 2 groups. However, 45% of children in the active group had reduced anxiety levels in the active group compared to 18% of children given placebo but this difference was not significant (p=0.102). No child was excessively sedated but one in the active group became agitated and restless. Conclusions: The anxiety scores before and after wire removal in the active group were not significantly different from the placebo group scores. We do not recommend the routine administration of midazolam (0.2 mg/kg) to all children requiring k-wire removal in the outpatient department

Our purpose wasto determine if oral midazolam reduces the anxiety of children undergoing removal of percutaneous Kirschner wires (K-wires) from the distal humerus in the Orthopaedic Outpatient Department. This was a prospective double blind, randomised controlled trial. 46 children aged between 3 and 12 years who had supracondylar fractures of the distal humerus internally fixed with K-wires were randomised into 2 groups. 0.2mg/kg oral midazolam (active group) or the same volume of an oral placebo (control group) was administered 30 minutes prior to removal of K-wires. Venham Situational Anxiety Score was performed before and immediately after removal of K-wires. University College London Hospital sedation score was recorded every 20 minutes. 42 children with an average age of 7.1 years (range 3.6–12.3 years) had complete documentation for analysis. The two groups had similar demographics. All wires were removed in the clinic with or without midazolam. There was no significant difference in anxiety scores between the groups either before or after wire removal. The change in scores was not significantly different between the 2 groups. However, 45% of children in the active group had reduced anxiety levels in the active group compared to 18% of children given placebo but this difference was not significant (p=0.102). No child was excessively sedated but one in the active group became agitated and restless. The anxiety scores before and after wire removal in the active group were not significantly different from the placebo group scores. We do not recommend the routine administration of midazolam (0.2 mg/kg) to all children requiring k-wire removal in the outpatient department

Depression and anxiety are widely prevalent amongst patients suffering from chronic diseases including osteoarthritis. National Institute for Clinical Excellence (NICE) guidelines recommend vigilance and routine screening in such chronic disease patients, and a recent King's Fund report found depression causes considerable expense to the NHS, with £1 for every £8 spent on chronic disease spent on patients mental health, costing between £8-13 billion annually. Depression increases length of hospital stay, and poorer clinical outcomes: depressed patients are 3.5 x as likely to die after suffering from myocardial infarction. Despite this, depression screening is not performed widely pre operatively. To see if there is a basis to recommend routine pre operative depression screening in hip and knee arthroplasty patients, we asked all patients attending Joint School to complete a Hospital Anxiety and Depression Scale (HADS). This is a well-validated tool for assessing the presence and degree (either mild, moderate or severe if present) of anxiety and depression, using fourteen questions, and providing a score out of 21 for each. We then correlated these results to pre operative Oxford Knee and Oxford Hip Scores to see if there was any relationship between the extent of impact of disease and any mood disorder present. 190 patients completed the questionnaire pre operatively. Of those, 82 (43%) scored as anxious. 73 (38%) scored as depressed. 47 (25%) scored as both. Overall 107 (56%) were either anxious, depressed or both. The median anxiety score was 7, with 44 (54%) scoring 8–10 (mild), 35 (43%) 11–15 (moderate) and 3 (4%) 16+ (severe). The median depression score was 6, with 53 (73%) scoring 8–10 (mild), 19 (26%) 11–15 (moderate) and 1 (1%) 16+ (severe). In order to look for an association between the severity of depression or anxiety and Oxford Scores, we grouped the Oxford Scores according to the patient's score on the HADS, and performed analysis of variance (ANOVA) to look for a significant difference between the Oxford Scores in the groups. There was no significant link between increase in Oxford Score and anxiety score (p=0.173314) but there was between Oxford Score and depression score (p=0.001377). There was equally no correlation between scores in patients classified simply as anxious or not anxious (p=0.14918) but a significant difference in Oxford Score was present between patients designated as depressed or not depressed (p=0.000297). We thus conclude depression and anxiety are very common amongst pre operative arthroplasty patients and thus assessment for this should be considered routinely preoperatively. In addition, there is a link between severity of osteoarthritis and severity of depression with increasing depression score associated with increasing Oxford Score. This makes further work to assess the reasons for this link imperative: does increasing severity of osteoarthritis result in increasing severity of depression, or does depression cause patients to feel the effects of their disease more keenly, and thus score higher on Oxford Scores? If this is the case, would patients treated for depression find the effect of their joint problems severe enough to warrant undertaking arthroplasty surgery?

Aims

Paediatric fractures are highly prevalent and are most often treated with plaster. The application and removal of plaster is often an anxiety-inducing experience for children. Decreasing the anxiety level may improve the patients’ satisfaction and the quality of healthcare. Virtual reality (VR) has proven to effectively distract children and reduce their anxiety in other clinical settings, and it seems to have a similar effect during plaster treatment. This study aims to further investigate the effect of VR on the anxiety level of children with fractures who undergo plaster removal or replacement in the plaster room.

The October 2024 Children’s orthopaedics Roundup³⁶⁰ looks at: Cost-effectiveness analysis of soft bandage and immediate discharge versus rigid immobilization in children with distal radius torus fractures: the FORCE trial; Percutaneous Achilles tendon tenotomy in clubfoot with a blade or a needle: a single-centre randomized controlled noninferiority trial; Treatment of hip displacement in children with cerebral palsy: a five-year comparison of proximal femoral osteotomy and combined femoral-pelvic osteotomy in 163 children; The Core outcome Clubfoot (CoCo) study: relapse, with poorer clinical and quality of life outcomes, affects 37% of idiopathic clubfoot patients; Retention versus removal of epiphyseal screws in paediatric distal tibial fractures: no significant impact on outcomes; Predicting the resolution of residual acetabular dysplasia after brace treatment in infant DDH; Low prevalence of acetabular dysplasia following treatment for neonatal hip instability: a long-term study; How best to distract the patient?.

Aims

Pain is the most frequent complaint associated with osteonecrosis of the femoral head (ONFH), but the factors contributing to such pain are poorly understood. This study explored diverse demographic, clinical, radiological, psychological, and neurophysiological factors for their potential contribution to pain in patients with ONFH.

Chronic pain and psychosocial distress are generally thought to be associated in chronic musculoskeletal disorders such as non-specific neck pain. However, it is unclear whether a raised level of anxiety is necessarily a feature of longstanding, intense pain amongst patient and general population sub-groups. Post-hoc analysis. In a cohort of 70 self-selected female, non-specific neck pain sufferers, we observed relatively high levels of self-reported pain of 4.46 (measured on the 11 point numerical pain rating scale (NRS-101)) and a longstanding duration of symptoms (156 days/year). However, the mean anxiety scores observed (5.49), fell well below the clinically relevant threshold of 21 required by the Beck Anxiety Inventory. The cohort was stratified to further distinguish individuals with higher pain intensity (NRS>6) and longer symptom duration (>90 days). Although a highly statistically significant difference (p=0.000) was subsequently observed with respect to pain intensity, in the resulting sub-groups, none such a difference was noted with respect to anxiety levels. Our results indicate that chronic, intense pain and anxiety do not always appear to be related. Explanations for these findings may include that anxiety is not triggered in socially functional individuals, that individual coping strategies have come into play or in some instances that a psychological disorder like alexithymia could be a confounder. More studies are needed to clarify the specific role of anxiety in chronic non-specific musculoskeletal pain before general evidence-driven clinical extrapolations can be made

Aims

Psychological status may be an important predictor of outcome after periacetabular osteotomy (PAO). The aim of this study was to investigate the influence of psychological distress on postoperative health-related quality of life, joint function, self-assessed pain, and sports ability in patients undergoing PAO.

Background: It has been demonstrated that a relationship exists between pro-inflammatory cytokine levels and psychological distress. Psychological distress commonly co-exists with back pain and may be detrimental to rehabilitation in such patients undergoing surgery. We aim to establish whether a link exists between psychological distress and increased levels of Interleukin- 6 (IL-6) and it’s soluble receptor (sIL-6r) in patients undergoing surgery for low back pain. Methods: All individuals selected for spinal fusion or stabilisation surgery, in whom low back pain was the predominant feature, were eligible for inclusion. Participants completed both the Distress and Risk Assessment Method (DRAM) and Hospital Anxiety and Depression Score (HADS) questionnaires pre-operatively. Blood samples for serum IL-6, sIL-6r and high sensitivity C-Reactive Protein (CRP) levels were extracted at recruitment and results were compared with questionnaire findings. Results: 63 patients were recruited of whom 90.5% had some degree of measurable psychological distress. Patients were divided into two groups based upon the degree of their distress. Mean IL-6 levels were higher in groups of patients with more distress measured by the DRAM and HADS depression component but were lower in patients with more anxiety. IL-6 receptor levels were higher in patients with raised DRAM and HADS anxiety scores. No significant correlation between questionnaire responses and cytokine levels was found. A correlation exists between IL-6 and CRP levels even at normal levels of CRP. Conclusion: There does not appear to be a significant relationship between IL-6 and sIL-6r levels and psychological distress in back pain patients

The study aims to determine the effects of obesity on the patients’ symptoms and their knee function before knee arthroplasty, as well as their states of anxiety and depression. Ethical approval was obtained before the start of the study. Weights and heights of all patients were measured and BMI calculated on admission. Anxiety and depression states were recorded using the Hospital Anxiety and Depression Scale (HADS). The severity of pain and loss of function of the knees undergoing arthroplasty was measured using the Oxford Knee Score and the American Knee Society Score. All scores were measured per-op and again at 6 weeks post-op. To date, 28 patients were included. The mean body mass index was 28.9. Only six patients had a BMI of < 25. Patients with normal BMI (< 25) had mean anxiety and depression scores of 6.8 and 5.67 respectively. Overweight patients (BMI > 25) had scores of 5.59 and 4.9 respectively. Patients with BMI > 30 had scores of 6.71 (p= 0.22) and 7.0 (p= 0.04) respectively. Patients with BMI > 30 had an improvement in anxiety scores of 1.33 points compared with 0.55 for patients with BMI < 30 (p= 0.3). Depression scores improved by 4 points in the BMI > 30 group compared with 0.67 in the BMI < 30 group (p= 0.03). Improvements in the knee scores were comparable in both groups. Obese patients with BMI of > 30 have higher rates of anxiety and depression pre-operatively. At 6 weeks follow up, there is an improvement in both measures of psychological distress but this is more pronounced for depressive symptoms

Nowadays more attention is paid to the quality of life during and after cancer treatment, and fatigue is an important factor influencing this. Still little is known about the development of fatigue before, during and after cancer treatment and its contributing factors. We analyzed the level of fatigue, pain, anxiety and activity before and after the treatment of benign or low-grade malignant bone and soft tissue tumours in 43 patients. All patients were treated with surgery only. The mean age of the patients was 40 years (range 20 to 67 years). Fatigue severity was measured with the CIS-fatigue questionnaire, where a score of 35 or higher reflects severe fatigue. The VAS score was used to measure pain (0=no pain, 10=severe pain), and the Dutch version of the Spielberger State-Trait Anxiety Inventory to measure state anxiety. Physical activity was measured with an actometer, worn at the ankle for two weeks. All measurements were done before the tumor surgery and twelve months later. Severe fatigue was seen in 35% of the patients before they had tumor surgery. After 12 months 32% of the patients still was severely fatigued. The mean VAS pain score was 2,3 before treatment and 2,2 after 12 months. The anxiety score lowered from 38,1 before treatment to 33,2 one year later. Actometer scores increased from 57,7 before treatment to 69,9 after 12 months. Fatigue severity correlated with pain and anxiety both before and 12 months after treatment, but not with actometer scores. In this study we see that severe fatigue is present in 35% of tumor patients before they are treated, and this percentage remains high (32%) until one year after surgery. Since severe fatigue correlated with more anxiety and pain, these symptoms can help us understand and treat severe fatigue in tumor patients better

Patients overestimate pain following hip and knee replacement. Ninety two patients awaiting hip or knee replacement were asked at their pre-operative assessment to estimate the level of pain they expected following their surgery on a 10cm visual analogue scale. Note was made of their age, gender, previous surgeries, Amsterdam anxiety score as regards the anaesthetic and surgery and an information score relating to their anaesthetic and surgery. Seventy nine patients had pain scores collected on a daily basis post surgery. Mean (std dev) age of the group was 68 (11) years and with a female to male ratio of 1.57. Females were significantly more anxious about the surgery than males (t-test, p< 0.007). Patients were more anxious about the anaesthetic and the surgery with hip replacement compared to knee replacement although this did not reach significance (t-test p=0.07). The mean (std dev) pain score pre-operatively was 7.5 (1.6). The mean (std dev) pain score expected was 7.0 (2.2) on the first post operative day and 4.3 (2.2) on the sixth post operative day. Forty four per cent of patients expected to have pain greater than their arthritis pain on the day following surgery. The level of pain experienced post-operatively was significantly lower than expected. Mean (std dev) pain score was 5.1 (2.7) on day 1 post op and 3.3 (2.4) on day 6 (t-test, p< 0.05 for both). There was no correlation between age, gender, number of previous surgeries, anxiety or information scores and the expected level of pain. The majority of patients, whatever their age, gender or level of anxiety over estimate their level of post-operative pain after joint replacement. Studies are needed to assess whether educating patients about pain post surgery will be of benefit, particularly in their early rehabilitation

Assessment and referral of spinal disease in a primary care setting is a challenge for the general practitioner. This has led to establishment of spinal assessment clinic to insure prompt access to the patient who requires treatment by a spinal surgeon. These clinics are run by a trained physiotherapist who liaises with a member of the spinal team and decides the need for referral to the spinal clinic on the bases of the patient’s history and clinical examination. In our clinic each patient is also assessed with Oswestry disability index, Short form-36, visual analogue score and hospital anxiety score (HADS), although these scores do not contribute to the clinical decision-making. The aim of this study is to assess the screening value of Oswestry disability score, Short form-36 scores in diagnosing acute spinal pathology. Sixty-nine patients who were referred to the spine clinic from the assessment clinic between March and December 2001 were recruited. Sixty-nine age and sex-matched patients were randomly chosen from five hundred and twelve patients who were seen in the spinal assessment clinic and did not need referral to the specialised spine clinic. The Oswestry disability score, Short form-36 scores and pain visual analogue scores between the two groups were statistically compared. The correlation between the level of psychological morbidity, length of symptoms and presence of past history of symptoms against the level of disability was statistically assessed. Although there was a significant increase in the level of disability in the referred group with each score (Oswestry Disability Score P< 0.001, SF-36 physical component score P=0.014, Visual analogue pain score P< 0.001). The variation in the scores makes the scoring system unspecific for use as a screening tool. We also found strong relationship between psychological disability and length of symptoms indicating the need for prompt treatment for back pain

Introduction: Cervical disc replacement has emerged as an alternative to the gold standard ACDF in ordered to preserve the motion of the cervical spine, and reduce the risk of adjacent degenerative changes. However, little data actually exists to support or refute the effect of symptoms chronicity on TDA for the treatment of degenerative cervical spine. Material and Methods: We prospectively investigated 130 consecutive patients who have undergone a Prestige LP cervical disc replacement for degenerative disease causing chronic neck pain and radiculopathy. The pre and post-operative NDI, SF-36, Visual Analogue Score (VAS), HDS and HAS were recorded. Results: There were 130 patients in total. There were 66 males and 64 females, with an mean age at surgery was 51.12 +/− 0.84. Seventy five patients had one level disc replacement, and 56 had 2 levels. The mean follow up was 28+/−0.35 months, and the mean duration of symptoms was 34.46 +/−3.8 months. Mean length of stay 1.75+/−0.11 (1–4). There was no correlation between the DOS and any of the functional outcome:. Improvement Neck disability index (r=−0.181, p=0.134). Improvement in HDS (r=−0.126, p=0.296). Improvement in HAS (r=0.00, p=0.99). Improvement in SF-36 bodily pain (r=−0.011, p=0.925). Improvement in SF-26 mental health (r=0.042, p=0.324). Improvement in VAS neck pain (r=−0.0120, p=0.324). Improvement in VAS arm pain (r=0.0178, p=0.141). Dividing the DOS into more or less than 12 months shows significant improvement only in the NDI: less than 12 months DOS (31.85±3.209) and in patients with more than 12 months DOS (19.71±2.164), p=0.002. While there was no statistical difference in the other outcomes. Dividing the DOS into more or less than 24 months showed significant improvement the out come in patients with less than 24 months in the following outcomes:. Improvement in NDI: less than 24 months (27.35±2.714), more thank 24 months (19.72+2.435), p=0.04. Improvement in VAS arm pain: less than 24 months (4.6000±0.34446), more than 24 months (2.7414±3.7236), p=0.001. Improvement in hospital depression score: less than 24 months (5.37±0.589), more than 24 months (3.60±0.47), p-0.023. Improvement in hospital anxiety score: less than 24 months (4.28±0.49), more than 24 months (2.45±0.48), p=0.009. While there was no significant difference in the other outcomes. Dividing the DOS into less or more than 36 months showed no statistical difference in any of the outcome,. That was also the case when the DOS was divided into more or less than 48 months. Conclusion: Duration of symptoms of more that 24 months was associated with less favorable outcome, that was evident in improvement in NDI, HDS, HAS and VAS arm pain. Patients should be counseled when they present with DOS more than 24 months