Impact of serotonergic modulators on short- and long-term outcomes after transforaminal lumbar interbody fusion: a national propensity-matched cohort study.

Abstract

PURPOSE: Selective serotonin reuptake inhibitors (SSRIs) and serotonin–norepinephrine reuptake inhibitors (SNRIs) are widely prescribed and may influence perioperative bleeding risk and fusion biology. This study evaluated the association between preoperative SSRI/SNRI use and postoperative outcomes following transforaminal lumbar interbody fusion (TLIF). METHODS: A retrospective propensity score–matched cohort study was conducted using a multi-institutional electronic medical record database. Adult patients undergoing single- or multi-level TLIF between 2004 and 2024 were identified using CPT codes 22,633 and 22,634. The exposure group included patients prescribed SSRIs/SNRIs within two years before surgery. Exclusion criteria included infection, malignancy, inflammatory bone disease, prior lumbar fusion, and documented pseudoarthrosis. Matching (1:1) was performed across demographics and > 300 comorbidities. Outcomes were assessed at 30, 90 days, and 2-, and 5-year intervals using chi-squared tests and t-tests. RESULTS: After propensity matching, 14,536 patients undergoing single-level TLIF and 4,386 patients undergoing multi-level TLIF were included. At 30 days, SSRI/SNRI use was associated with significantly higher rates of infection and opioid utilization in both cohorts. At 90 days, SSRI/SNRI use was associated with higher rates of pneumonia, incision and drainage, and opioid utilization in single-level TLIF. Among multi-level TLIF, SSRI/SNRI use was associated with increased opioid and emergency department utilization. At two years, SSRI/SNRI use was associated with higher rates of pseudoarthrosis and adjacent segment disease following single-level TLIF. Among multi-level TLIF, SSRI/SNRI use was associated with higher rates of reoperation at five years. CONCLUSION: Preoperative SSRI/SNRI use was independently associated with increased short- and long-term complications following TLIF, underscoring the importance of incorporating antidepressant exposure into perioperative risk assessment.