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STUDY DESIGN Prospective cohort study. OBJECTIVE This study determined (1) the surgeon accuracy of psychological assessment in patients in spine clinic, (2) the impact of psychological distress on surgical recommendation, and (3) the correlation between patient-reported disability and psychological distress. SUMMARY OF BACKGROUND DATA Psychological distress is common among patients presenting for spine surgery. Surgeon estimations of patients' distress may influence treatment recommendations, but little is known as to whether these assessments accurately mirror patient-perceived psychological distress. METHODS A sample of new patients was recruited from an academic spine center. Prior to their initial consultation, patients completed the Modified Somatic Perception Questionnaire and Zung Depression Index to assess mental and physical manifestations of distress, which generated a Distress and Risk Assessment Method (DRAM) score of N (normal), R (at risk), or D (distressed). The Oswestry Disability Index (ODI) and Neck Disability Index (NDI) scores were also collected. Surgeons provided their estimates of the DRAM score after the visit and indicated their surgery recommendation. RESULTS Of 296 patients, 40.5% reported some level of psychological distress (DRAM=R) and 15.9% had a high level of distress (DRAM=D). All three surgeons' ability to accurately assess the participant DRAM score was poor, with an overall kappa of 0.13 (0.08-0.18), biased towards underestimating the patient's true level of psychological distress. Patients rated as normal (N) by the surgeon were 3.78 times more likely to be recommended for surgery compared to those assessed as distressed (D) (P=0.007). Patients with higher DRAM scores had higher ODI (P=0.008) and NDI (P=0.005) scores compared to those with lower DRAM scores. CONCLUSIONS Spine surgeons have limited ability to detect psychological profiles in patients, with a tendency to underestimate levels of distress. The finding that these inaccurate assessments influence surgical recommendations underscores the importance of limiting surgeon bias in the decision-making process. LEVEL OF EVIDENCE Diagnostic Level II.