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• Steps/d at 6 weeks was associated with decreased disability and pain at 1 year. • Steps/d at 6 weeks was associated with no opioid use at 1 year after spine surgery. • Threshold of 3500 steps/d may serve as initial early postoperative recommendation after lumbar spine surgery. To investigate whether early postoperative walking is associated with "best outcome" and no opioid use at 1 year after lumbar spine surgery and establish a threshold for steps/day to inform clinical practice. Secondary analysis from randomized controlled trial. Two academic medical centers in the United States. We enrolled 248 participants undergoing surgery for a degenerative lumbar spine condition (N=248). A total of 212 participants (mean age, 62.8±11.4y, 53.3% female) had valid walking data at baseline. Not applicable. Disability (Oswestry Disability Index), back and leg pain (Brief Pain Inventory), and opioid use (yes vs no) were assessed at baseline and 1 year after surgery. "Best outcome" was defined as Oswestry Disability Index ≤20, back pain ≤2, and leg pain ≤2. Steps/day (walking) was assessed with an accelerometer worn for at least 3 days and 10 h/d at 6 weeks after spine surgery, which was considered as study baseline. Separate multivariable logistic regression analyses were conducted to determine the association between steps/day at 6 weeks and "best outcome" and no opioid use at 1-year. Receiver operating characteristic curves identified a steps/day threshold for achieving outcomes. Each additional 1000 steps/d at 6 weeks after spine surgery was associated with 41% higher odds of achieving "best outcome" (95% confidence interval [CI], 1.15-1.74) and 38% higher odds of no opioid use (95% CI, 1.09-1.76) at 1 year. Walking ≥3500 steps/d was associated with 3.75 times the odds (95% CI, 1.56-9.02) of achieving "best outcome" and 2.37 times the odds (95% CI, 1.07-5.24) of not using opioids. Walking early after surgery may optimize patient-reported outcomes after lumbar spine surgery. A 3500 steps/d threshold may serve as an initial recommendation during early postoperative counseling. [ABSTRACT FROM AUTHOR]

Background Context: Effective alternatives to lumbar fusion for degenerative conditions have remained elusive. Anterior total disc replacement does not address facet pathology or central/recess stenosis, resulting in limited indications. A posterior-based motion-preserving option that allows for neural decompression, facetectomy, and reconstruction of the disc and facets may have a role.Purpose: The purpose was to compare one-year patient-reported outcomes for a novel, all-posterior, lumbar total joint replacement (LTJR - replacing both the disc and facet joints) against transforaminal lumbar interbody fusion (TLIF) for degenerative lumbar conditions warranting fusion (degenerative spondylolisthesis, recurrent disc herniation, severe foraminal stenosis requiring facet removal, and adjacent segment degeneration).Study Design/setting: A retrospective analysis of prospectively collected data comparing outcomes for LTJR patients to TLIF patients at an academic teaching hospital.Patient Sample: Analysis was conducted on 156 adult TLIF patients who were propensity matched to the 52 LTJR patients for a total sample of 208.Outcome Measures: Self-reported Oswestry Disability Index (ODI) and Numeric Rating Scale (NRS) for back and leg pain were compared preoperatively, 3 months and 1 year after surgery.Methods: The implant is a motion-preserving lumbar reconstruction that replaces the function of both the disc and facets and is implanted using a bilateral transforaminal approach with complete facetectomies. Adult patients with degenerative lumbar pathology undergoing either LTJR or open TLIF were analyzed. These degenerative conditions included: grade 1 degenerative spondylolisthesis, recurrent disc herniation, adjacent segment disease, disc degeneration with severe foraminal stenosis). Trauma, tumor, grade 2 or higher spondylolisthesis, spinal deformity, and infection cases were excluded. Propensity score matching was performed to ensure parity between the cohorts. Multivariable regression analyses were done to compare the 1-year results as measured by 3 different standards to assess procedure success.Results: At 3 months, both the LTJR and TLIF cohorts showed significant and similar improvements in ODI and NRS back and leg pain. At 1 year, the LTJR cohort showed continued improvement in ODI and NRS back pain, while the TLIF group showed a plateau for ODI, back and leg pain. In a series of three multivariable logistic regressions, LTJR was shown to provide 3.3 times greater odds of achieving the minimal clinical symptom state in disability and pain (ODI <20%, NRS back and leg pain <2) and 2.4 and 4.1 times greater odds of achieving substantial clinical benefit (18% reduction in ODI) and minimal clinically important difference (30% reduction in ODI) as compared to TLIF.Conclusions: Here we present a comparative analysis for the first 52 patients undergoing a novel, posterior-based LTJR for the lumbar spine versus TLIF for degenerative pathology. The approach for the LTJR allows for wide neural decompression, facetectomy, and complete discectomy, with the implant working to replace the function of the disc and facets to preserve motion. At 1 year, the LTJR cohort showed significant improvement in ODI and NRS back and leg pain as compared to TLIF. These results suggest that wide neural decompression combined with motion preservation using this novel LTJR may represent a viable alternative to TLIF for treating certain degenerative conditions. A prospective controlled trial is under development to further evaluate the efficacy, safety, and durability of this procedure. [ABSTRACT FROM AUTHOR]

• Patient population selected from inpatient or outpatient hospital setting. • 2.83% had complications while 0.48% had potentially catastrophic complications. • Prior cardiac intervention was sole, independent predictor of complications. • Need to validate these findings in patient population treated at ambulatory centers. To minimize healthcare related costs, ambulatory surgery centers (ASCs) have become increasingly favored venues for outpatient spine surgery. Using a national cohort of patients undergoing elective lumbar decompression (LD) in an inpatient or outpatient hospital setting, the current objectives were to: 1) outline specific factors that were associated with complications, and 2) describe potentially catastrophic complications. Adults who underwent LD between 2008 and 2014 were identified in the National Surgical Quality Improvement Program (NSQIP) database. Inclusion criteria were: principal procedure LD (CPT 63030), elective, neurologic/orthopaedic surgeons, length of stay (LOS) of 0/1 days, and discharged home. The primary outcome was presence of any complication. The secondary outcome was occurrence of potentially catastrophic complications. Univariate/multivariable logistic regression was performed. A total of 19,908 patients met the inclusion criteria. 564 (2.83%) patients experienced a complication. Cardiac intervention remained the only independent predictor of complications after multivariate testing (OR: 2.02, 95% CI: 1.00, 4.07, p = 0.049). Approximate comorbidity score cut-offs associated with <2% risk of complication were: ASA ≤ 3, CCI ≤ 5, mFI ≤ 0.182. A total of 96 (0.48%) patients experienced potentially catastrophic complications. We utilized a national cohort of patients undergoing elective inpatient and outpatient LD in a hospital setting to identify preoperative risk factors for postoperative complications. Previous cardiac intervention was the sole independent predictor of complications. Although no patients treated at ASCs were studied, we believe these factors can aid in selecting patients most appropriate for ASCs and begin the process of selecting the best patients for an ambulatory setting. [ABSTRACT FROM AUTHOR]

The incidence of spine surgeries performed annually continues to rise and despite advances in instrumentation and surgical techniques, reoperation rates are still high. Common reasons for revision surgery include an incorrect preoperative diagnosis, technical error, complications of procedure or implants, or a poor surgical candidate for the index procedure. Identifying the source of symptoms can present a diagnostic challenge and requires a careful and strategic approach. Given that outcomes lessen with each subsequent spine surgery, spine surgeons must be cautious and meticulous when considering a revision spine surgery. This article will review a general diagnostic approach when evaluating a patient with persistent symptoms, along with a review of the more common indications for revision spine surgery. [ABSTRACT FROM AUTHOR]

Abstract Spine pathology is among the most common, most disabling, and costliest disorders in the US health care system. Traditional reimbursement models in which volume of service rather than quality is incentivized has resulted in an unsustainable rise in cost. The focus for all stakeholders is now on value-based health care. Value is determined by the outcomes achieved per dollar spent to achieve those outcomes. Clinical registries and validated outcome tools are now making it possible for all spine practitioners to define and develop value-based care. Accurate measurement of outcomes and cost and identifying outliers are essential to improving the value in spine surgery. [ABSTRACT FROM AUTHOR]

Treatment of spinal pathology is a significant contributor to the current rise in health care spending in the United States. To maximize value, the cost of spine care must be analyzed to assess for any inefficiencies. In parallel, outcomes must be tracked to ensure that any potential cost reductions do not have a negative impact on the efficacy of treatments. This article focuses on three primary topics in spinal care. We will begin with a general review of cost analysis methods, highlight specific drivers of cost, and finally offer broad solutions to help improve the value of spine care. [ABSTRACT FROM AUTHOR]

Osteoporosis is responsible for a global medical and economic burden that will grow as the elderly population doubles over the next 20 years. Measuring the cost of the effects of osteoporosis on treatment of spinal disorders is important as we prioritize distribution of resources in the healthcare community. This article examines the monetary cost of osteoporotic disorders associated with spinal care, specifically compression fractures, complications of spinal fusions, and medical treatment of osteoporosis. Examining these costs will allow us to focus further research into the primary cost drivers associated with osteoporosis. [ABSTRACT FROM AUTHOR]

Background: Comprehensive assessment of quality of care includes patient-reported outcomes, safety of care delivered, and patient satisfaction. The impact of the patient-reported Oswestry Disability Index (ODI) scores at baseline and 12 months on satisfaction with outcomes following spine surgery is not well documented.Purpose: This study aimed to determine the impact of patient disability (ODI) scores at baseline and 12 months on satisfaction with outcomes following surgery.Study Design: Analysis of prospectively collected longitudinal web-based multicenter data.Patient Sample: Patients undergoing elective surgery for degenerative lumbar disease were entered into a prospective multicenter registry.Outcome Measures: Primary outcome measures were ODI, North American Spine Society satisfaction (NASS) questionnaire.Methods: Baseline and 12-month ODI scores were recorded. Satisfaction at 12 months after surgery was measured using NASS questionnaire. Multivariable proportional odds logistic regression analysis was conducted to determine the impact of baseline and 12-month ODI on satisfaction with outcomes.Results: Of the total 5,443 patients, 64% (n=3,460) were satisfied at a level where surgery met their expectations (NASS level 1) at 12 months after surgery. After adjusting for all baseline and surgery-specific variables, the 12-month ODI score had the highest impact (Wald χ2=1,555, 86% of the total χ2) on achieving satisfaction with outcomes compared with baseline ODI scores (Wald χ2=93, 5% of the total χ2). The level of satisfaction decreases with increasing 12-month ODI score. Greater change in ODI is required to achieve a better satisfaction level when the patient starts with a higher baseline ODI score.Conclusion: Absolute 12-month ODI following surgery had a significant association on satisfaction with outcomes 12 months after surgery. Patients with higher baseline ODI required a larger change in ODI score to achieve satisfaction. No single measure can be used as a sole yardstick to measure quality of care after spine surgery. Satisfaction may be used in conjunction with baseline and 12-month ODI scores to provide an assessment of the quality of spine surgery provided in a patient centric fashion. [ABSTRACT FROM AUTHOR]

Health care costs are on an unsustainable upward trajectory and spine disorders are one of the most costly disease states worldwide. Value-based care is being implemented across all medical specialties. However, the true meaning of value and how to accurately and precisely measure value poses a significant challenge. The keys to identifying and optimizing value in spine care lies at the individual patient level. Analyzing drivers of cost from all perspectives and identifying patient factors, surgeon factors, and others that lead to increased cost and cost variation is critical to make improvements in value. Equally important, is the ability to accurately measure patient outcomes. Innovative methods are being developed for measuring patient outcomes and developing evidence to guide clinical decision-making. It can no longer be acceptable to only look at population based outcomes when evaluating the value of a spine intervention, rather the factors that drive variation in outcomes in the outliers must be identified and modified. Understanding what drives cost in spine surgery, the ability to accurately measure outcomes following spine intervention, and identifying factors that drive variation in cost and outcomes is critical to improving the value of health care. These concepts are essential in order to strive toward individualized care, which will not only lead to improved benefit to the patient, but also benefit to the surgeon, the hospital, the payer, and society as a whole. [ABSTRACT FROM AUTHOR]

Unlabelled: The purpose of this study was to determine the efficacy of a cognitive-behavioral-based physical therapy (CBPT) program for improving outcomes in patients after lumbar spine surgery. A randomized controlled trial was conducted on 86 adults undergoing a laminectomy with or without arthrodesis for a lumbar degenerative condition. Patients were screened preoperatively for high fear of movement using the Tampa Scale for Kinesiophobia. Randomization to either CBPT or an education program occurred at 6 weeks after surgery. Assessments were completed pretreatment, posttreatment and at 3-month follow-up. The primary outcomes were pain and disability measured by the Brief Pain Inventory and Oswestry Disability Index. Secondary outcomes included general health (SF-12) and performance-based tests (5-Chair Stand, Timed Up and Go, 10-Meter Walk). Multivariable linear regression analyses found that CBPT participants had significantly greater decreases in pain and disability and increases in general health and physical performance compared with the education group at the 3-month follow-up. Results suggest a targeted CBPT program may result in significant and clinically meaningful improvement in postoperative outcomes. CBPT has the potential to be an evidence-based program that clinicians can recommend for patients at risk for poor recovery after spine surgery.Perspective: This study investigated a targeted cognitive-behavioral-based physical therapy program for patients after lumbar spine surgery. Findings lend support to the hypothesis that incorporating cognitive-behavioral strategies into postoperative physical therapy may address psychosocial risk factors and improve pain, disability, general health, and physical performance outcomes. [ABSTRACT FROM AUTHOR]

Objective: To examine whether pain sensitivity and pain catastrophizing are associated with persistent pain and disability after lumbar spine surgery. Design: Prospective observational cohort study. Setting: Academic medical center. Participants: Patients (N = 68; mean age, 57.9±13.1y; 40 women [58.8%]) undergoing spine surgery for a degenerative condition from March I, 2012 to April 30, 2013 were assessed 6 weeks, 3 months, and 6 months after surgery. Interventions: Not applicable. Main Outcome Measures: The main outcome measures were persistent back pain intensity, pain interference, and disability. Patients with persistent back pain intensity, pain interference, or disability were identified as those patients reporting Brief Pain Inventory scores >4 and Oswestry Disability Index scores ≥21 at all postoperative time points. Results: From 6 weeks to 6 months after surgery, approximately 12.9%, 24.2%, and 46.8% of patients reported persistent back pain intensity, pain interference, or disability, respectively. Increased pain sensitivity at 6 weeks was associated with having persistent back pain intensity (odds ratio [OR], 2.0; 95% confidence interval [O], 1.0-4.1) after surgery. Increased pain catastrophizing at 6 weeks was associated with having persistent back pain intensity (OR. 1.1; 95% CI, 1.0-1.2), pain interference (OR, 1.1; 95% CI, 1.0-1.2), and disability (OR, 1.3; 95% CI, 1.1 -1.4). An interaction effect was not found between pain sensitivity and pain catastrophizing on persistent outcomes (P>.05). Conclusions: The findings suggest the importance of early postoperative screening for pain sensitivity and pain catastrophizing to identify patients at risk for poor postoperative pain intensity, pain interference, and/or disability outcomes. Future research should consider the benefit of targeted therapeutic strategies for patients with these postoperative prognostic factors. [ABSTRACT FROM AUTHOR]

Multimodal approaches to pain management have arisen with the goal of improving postoperative pain and reducing opioid analgesic use. We performed a comprehensive literature review to determine grades of recommendation for commonly used agents in multimodal pain management and provide a best practice guideline. To evaluate common drugs used in multimodal treatment of pain, a search was performed on English language publications on Medline (PubMed; National Library of Medicine, Bethesda, MD, USA). Manuscripts were rated as Level I–V according to the North American Spine Society’s (NASS) standardized levels of evidence tables. Grades of recommendation were assigned for each drug based on the NASS Clinical Guidelines for Multidisciplinary Spine Care. There is good (Grade A) evidence gabapentinoids, acetaminophen, neuraxial blockade and extended-release local anesthetics reduce postoperative pain and narcotic requirements. There is fair (Grade B) evidence that preemptive analgesia and nonsteroidal anti-inflammatory drugs (NSAID) result in reduced postoperative pain. There is insufficient and/or conflicting (Grade I) evidence that muscle relaxants and ketamine provide a significant reduction in postoperative pain or narcotic usage. There is fair (Grade B) evidence that short-term use of NSAID result in no long-term reduction in bone healing or fusion rates. Comprehensive assessment of the effectiveness of perioperative pain control can be accomplished through the use of validated measures. Multimodal pain management protocols have consistently been demonstrated to allow for improved pain control with less reliance on opioids. There is good quality evidence that supports many of the common agents utilized in multimodal therapy, however, there is a lack of evidence regarding optimal postoperative protocols or pathways. [ABSTRACT FROM AUTHOR]

In the current era of value-based health care reform, engaging patients in shared decision-making for treatment planning is imperative. Predictive models capable of providing individualized predictions of patient-reported outcomes (PROs) following cervical spine surgery have the potential to be valuable tools for a shared decision-making process. The aim of the study is to develop and validate predictive models for 12-month postoperative disability, pain, and myelopathy outcomes in patients undergoing elective spine surgery for degenerative cervical diseases (radiculopathy and myelopathy). This study is a retrospective analysis of prospectively collected data from the cervical module of a national spine registry, the Quality Outcomes Database (QOD). Patients undergoing cervical spine surgery for the diagnosis of radiculopathy or myelopathy with degenerative etiologies are eligible for inclusion in the QOD registry. The outcomes of interest in this study were neck related disability (NDI), pain [NRS- neck pain (NP) and arm pain (AP)] and modified Japanese Orthopedic Association score for myelopathy (mJOA). Two distinct sets of multivariable proportional odds ordinal regression models were developed with the outcomes of interest of disability (NDI), pain (NRS-NP and NRS-AP) and myelopathy (mJOA) score in the myelopathy cohort and disability (NDI) and pain (NRS-NP and NRS-AP) in the radiculopathy cohort. Patient characteristics of age, gender, BMI, race, education level, smoking status, history of diabetes, anxiety and depression, symptom duration, motor deficit or numbness at presentation, preoperative imaging finding of listhesis, employment status, workers' compensation, insurance status, and ambulatory ability, baseline PROs as well as surgery-specific variables of number of levels, arthrodesis, and surgical approach were included in the models. The models were internally validated using bootstrap resampling. A total of 5,076 patients who underwent surgery for cervical radiculopathy and 2717 patients who underwent surgery for cervical myelopathy were included in fitting the models for the distinct set of outcomes. There was a significant improvement in all PROs at 12 months after surgery (P<0.001). The most important predictors of the outcomes in both the models set were the respective baseline PROs scores. In addition, symptom duration, preoperative ambulatory status, patients' employment status, patients' education status, race and age of the patients had a statistically significant impact on the outcomes (p <0.001). Among the surgery-specific variables, surgical approach was the most important predictor for all outcomes across the models for radiculopathy and myelopathy (p<0.001). The models' discriminative performance (measured by overfitting-corrected c-index) were: NDI=0.688, NRS-NP=0.668, NRS-AP=0.645 for the radiculopathy and NDI=0.696, NRS-NP=0.682, NRS-AP=0.670, mJOA=0.717 for the myelopathy patients. These predictive models can provide individualized risk-adjusted estimates of 12-month disability, pain, and myelopathy outcomes for patients undergoing spine surgery for degenerative cervical diseases. Novel predictive models constructed with these data hold the potential to guide individualized patient discussions on postsurgical outcomes and expectations. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Background Context: Diabetes mellitus (DM) is a well-established risk factor for suboptimal outcomes following cervical spine surgery. Hemoglobin A1C (HbA1c), a surrogate for long-term glycemic control, is a valuable assessment tool in diabetic patients.Purpose: In patients undergoing elective cervical spine surgery, we sought to identify optimal HbA1c levels to: (1) maximize 1-year postoperative patient-reported outcomes (PROs), and (2) predict the occurrence of medical and surgical complications.Study Design/setting: A retrospective cohort study using prospectively collected data was performed in a single academic center.Patient Sample: Diabetic patients undergoing elective anterior cervical fusion and posterior cervical laminectomy and fusion (PCLF) between October 2010-March 2021 were included.Outcome Measures: Primary outcomes included Numeric Rating Scale (NRS)-Neck pain, NRS-Arm pain, and Neck Disability Index (NDI). Secondary outcomes included surgical site infection (SSI), complications, readmissions, and reoperations within 90-days postoperatively.Methods: HbA1c, demographic, comorbidity, and perioperative variables were gathered in diabetic patients only. PROs were analyzed as continuous variables and minimum clinically difference (MCID) was set at 30% improvement from baseline.Results: Of 1992 registry patients undergoing cervical surgery, 408 diabetic patients underwent cervical fusion surgery. Anterior: A total of 259 diabetic patients underwent anterior cervical fusion, 141 of which had an available HbA1c level within one year prior to surgery. Mean age was 55.8±10.1, and mean HbA1c value was 7.2±1.4. HbA1c levels above 6.1 were associated with failure to achieve MCID for NDI (AUC=0.77, 95%CI 0.70-0.84, p<.001), and HbA1c levels above 6.8 may be associated with increased odds of reoperation (AUC=0.61, 95%CI 0.52-0.69, p=.078). Posterior: A total of 149 diabetic patients underwent PCLF, 65 of which had an available HbA1c level within 1 year. Mean age was 63.6±9.2, and mean HbA1c value was 7.2±1.5. Despite a low AUC for NRS-Arm pain and readmission, HbA1c levels above 6.8 may be associated with failure to achieve MCID for NRS-Arm pain (AUC=0.61, 95%CI 0.49-0.73, p=.094), and HbA1c levels above 7.6 may be associated with higher readmission rate (AUC=0.63, 95%CI 0.50-0.75, p=.185).Conclusions: In a cohort of diabetic patients undergoing elective cervical spine surgery, HbA1c levels above 6.1 were associated with decreased odds of achieving MCID for NDI in anterior cervical fusion surgery. Though only moderate associations were seen for the select outcomes of reoperation (6.8), readmission (7.6), and MCID for NRS-Arm pain (6.8), preoperative optimization of HbA1c using these levels as benchmarks should be considered to reduce the risk of complications and maximize PROs for patients undergoing elective cervical spine surgery. [ABSTRACT FROM AUTHOR]

Opioid use prior to spine surgery has been associated with worse patient-reported outcomes, complications, and sustained postoperative opioid use. However, studies thus far have not assessed the relationship between opioid use in the initial postoperative period with long-term clinical outcomes and chronic postoperative opioid use. Determine if longer duration and higher opioid dosage in the months following spine surgery is associated with 1-year patient-reported outcomes and chronic opioid use at 1 year. Using data from our prospective clinical spine registry linked with opioid prescription data from our state's prescription drug monitoring program, we conducted a longitudinal cohort study. Patients undergoing elective lumbar or cervical spine surgery at a single academic center from January 2011 to February 2017, and living in the surgical institution's state. Primary outcomes were meaningful improvements at 1 year (>30% from baseline) in axial and extremity pain (Numeric Rating Scale [NRS]), disability (Oswestry Disability Index [ODI] & Neck Disability Index [NDI]), quality of life (Euro-Qol 5D [EQ-5D]), satisfaction (North American Spine Society Satisfaction); and chronic opioid use at 1 year after surgery. The state database was queried to record the dosage (morphine milligram equivalents [MME]) and duration of every opioid prescription filled in the year before and after surgery to calculate the daily MME. The main exposure variables for this study were postoperative opioid use duration (classified as brief [<30 days], intermediate [active prescription until 30-59 days], or sustained [beyond 60 days]); and high- (>60 MME/day) or low dosage. Multivariable logistic regression was used to identify associations between postoperative duration, and high-postoperative dosage with each outcome. Covariates were chosen a priori and included age, sex, race, smoking history, arthritis, anxiety, depression, insurance, symptom duration, ASA class, procedure, revision surgery, number of levels, preoperative pain and disability scores, and preoperative chronic opioid use. Adjusted odds ratios (aOR) with 95% confidence intervals (95% CI) were computed for the odds of a poor outcome associated with intermediate postoperative opioid use duration; and high-postoperative dosage. P-value < 0.05 indicated significance. A total 2128 patients were included, with an overall 1-year satisfaction rate of 82%. Compared to patients with <30 days, patients with intermediate postoperative duration (30-59 days) were significantly less likely to be satisfied at 1 year (aOR:1.9 [1.4-2.6]), have meaningful improvements in extremity pain (aOR:1.8 [1.3-2.4]), axial pain (aOR:2.3 [1.7-2.9]), or disability (aOR:1.8 [1.4-2.3]); and significantly more likely to be on chronic opioids at 1 year (aOR:4.6 [2.9-7.3]). High postoperative dosage was not significantly associated with outcomes. A subgroup analysis of preoperative opioid naïve patients showed intermediate duration (30-59 days) was associated with significant risk of chronic opioids at 1 year (aOR: 6.3 [3.3-12]). In a risk-adjusted analysis of patients undergoing elective spine surgery, an active opioid prescription beyond 30 days was associated with significantly worse 1-year clinical outcomes and chronic opioid use. When considered in conjunction with the known dangers of opioids, our results can be used to develop postoperative opioid protocols to improve outcomes and minimize opioid dependence after spine surgery. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Background Context: Positive psychosocial factors early after surgery, such as resilience and self-efficacy, may be important characteristics for informing individualized postoperative care.Purpose: To examine the association of early postoperative resilience and self-efficacy on 12-month physical function, pain interference, social participation, disability, pain intensity, and physical activity after lumbar spine surgery.Study Design/setting: Pooled secondary analysis of prospectively collected trial data from two academic medical centers.Patient Sample: Two hundred and forty-eight patients who underwent laminectomy with or without fusion for a degenerative lumbar condition.Outcome Measures: Physical function, pain inference, and social participation (ability to participate in social roles and activities) were measured using the Patient Reported Outcomes Measurement Information System. The Oswestry Disability Index, Numeric Rating Scale, and accelerometer activity counts were used to measure disability, pain intensity, and physical activity, respectively.Methods: Participants completed validated outcome questionnaires at 6 weeks (baseline) and 12 months after surgery. Baseline positive psychosocial factors included resilience (Brief Resilience Scale) and self-efficacy (Pain Self-Efficacy Questionnaire). Multivariable linear regression analyses were used to assess the associations between early postoperative psychosocial factors and 12-month outcomes adjusting for age, sex, study site, randomized group, fusion status, fear of movement (Tampa Scale for Kinesiophobia), and outcome score at baseline. This study was funded by Patient-Centered Outcomes Research Institute and Foundation for Physical Therapy Research. There are no conflicts of interest.Results: Resilience at 6 weeks after surgery was associated with 12-month physical function (unstandardized beta=1.85 [95% confidence interval [CI]: 0.29; 3.40]), pain interference (unstandardized beta=-1.80 [95% CI: -3.48; -0.12]), social participation (unstandardized beta=2.69 [95% CI: 0.97; 4.41]), and disability (unstandardized beta=-3.03 [95% CI: -6.04; -0.02]). Self-efficacy was associated with 12-month disability (unstandardized beta=-0.21 [95% CI: -0.37; -0.04].Conclusions: Postoperative resilience and pain self-efficacy were associated with improved 12-month patient-reported outcomes after spine surgery. Future work should consider how early postoperative screening for positive psychosocial characteristics can enhance risk stratification and targeted rehabilitation management in patients undergoing spine surgery. [ABSTRACT FROM AUTHOR]

Background Context: Studies have found that most patients are satisfied after spine surgery, with rates ranging from 53% to 90%. Patient satisfaction appears to be closely related to achieving clinical improvement in pain and disability after surgery. While the majority of the literature has focused on patients who report both satisfaction and clinical improvement in disability and pain, there remains an important subpopulation of patients who have clinically relevant improvement but report being dissatisfied with surgery.Purpose: To examine why patients who achieve clinical improvement in disability or pain also report dissatisfaction at 1-year after spinal surgery.Study Design: Retrospective analysis of prospective data from a national spine registry, the Quality Outcomes Database.Patient Sample: There were 34,076 participants undergoing elective surgery for degenerative spine pathology who had clinical improvement in disability or pain.Outcome Measures: Satisfaction with surgery was assessed with 1-item from the North American Spine Society lumbar spine outcome assessment. Participants with answer choices other than "treatment met my expectations" were classified as dissatisfied.Methods: Patients completed a baseline and 12-month postoperative assessment to evaluate disability, pain, and satisfaction. Clinical improvement was defined as patients who achieved a 30% or greater improvement in spine-related disability (Oswestry/Neck Disability Index) or extremity pain (11-point Numeric Rating Scale) from baseline to 12-month after surgery. A generalized linear mixed model was used to predict the odds of the patient being dissatisfied 1-year after surgery from demographic, clinical and surgical characteristics, postoperative complications and revision, and return to work and previous physical activity. Random effects were included to model the effect of both site and surgeon on dissatisfaction. Sensitivity analyses were conducted on samples who achieved 30% or greater improvement in (1) disability only, (2) axial (back/neck) pain only, (3) extremity (leg/arm)pain only, (4) both disability and axial pain, and (5) both disability and extremity pain. Results showed the same pattern of findings across all samples.Results: Twenty-eight percent of patients were classified as dissatisfied with their spine surgery and 72% classified as satisfied. For patients with clinical improvement in disability or extremity pain at 1-year, significant predictors of higher odds of dissatisfaction included baseline psychological distress, current smoking status, workers compensation claim, lower education, higher ASA grade, lumbar versus cervical procedure, and increased axial pain, major complication within 30 days, and revision surgery within 12-months. The most important contributors to dissatisfaction were return to work and return to previous physical activity, with the odds of dissatisfaction being over 2 times and 4 times higher for these variables. Site and surgeon explained 3.8% of the variance in dissatisfaction, with more of the variance attributed to site than to surgeon.Conclusions: Several modifiable factors, including psychological distress, current smoking status, and failure to return to work and physical activity, helped explain why patients report being dissatisfied with surgery despite clinical improvement in disability or pain. The findings of this study have the potential to help providers identify at-risk patients, set realistic expectations during preoperative counseling, and implement postoperative management strategies. A multidisciplinary approach to rehabilitation that includes functional goal setting or restoration may help to improve patients psychological distress as well as return to work and previous physical activity after spine surgery. [ABSTRACT FROM AUTHOR]

Background Context: Patient reported outcome measures (PROMs) are valuable tools for evaluating the success of spine surgery, with the Neck Disability Index (NDI) commonly used to assess pain-related disability. Recently, patient-reported outcomes measurement information system (PROMIS) has gained attention in its ability to measure PROs across general patient populations. However, PROMIS is not condition-specific so spine researchers are reluctant to incorporate it in place of common legacy measures.Purpose: To compare the PROMIS-29 (v2.0) to the NDI and compute a conversion equation.Study Design: This study retrospectively analyzes prospectively collected data from the cervical module of national spine registry, the Quality Outcomes Database (QOD).Patient Sample: The QOD was queried for cervical spine surgery patients with PROMIS-29 and NDI scores. The cervical module of QOD includes patients undergoing primary or revision surgery for cervical degenerative spine diseases. Exclusion criteria included age under 18 years and diagnoses of infection, tumor, or trauma as the cause of cervical-related pain.Outcome Measures: The outcome of interest for this study was a conversion equation from PROMIS-29 to NDI.Methods: The PROMIS-29 includes seven 4-item domains each rated on a 5-point scale: Physical function, depression, anxiety, fatigue, sleep disturbance, ability to participate in social roles and activities (social roles), and pain interference plus one stand-alone pain intensity item. The NDI contains 10 pain-related questions scored from 0 (no pain) to 5 (most severe pain). Outcomes were collected prior to surgery and at 3- and 12-month post surgery. Patients were included in the current analysis if they had outcome data available at one or more time points. Multivariable mixed effects regression models predicting NDI scores from PROMIS-29 domains were conducted in a development data set and validated in a separate data set. Predicted NDI scores were plotted against NDI scores to determine how well PROMIS-29 domains predicted NDI. Conversion equations were created from the PROMIS-29 regression coefficients.Results: 2,018 patients from 18 US hospitals were included (mean age=57 years (SD=12)) with 48% female, 87% Caucasian, and 11% had revision surgery. Strong correlations were found between NDI and pain interference (r=0.79), pain intensity (r=0.74), social roles (r=-0.71), physical function (r=-0.69), sleep disturbance (r=0.63), fatigue (r=0.63), and anxiety (r=0.54). Correlation between NDI and depression (r=0.49) was slightly weaker. The pattern of correlations was consistent across timepoints. Four conversion equations were created for NDI using (1) only pain interference, (2) only physical function, (3) pain interference and physical function, and (4) the five statistically significant domains of pain interference, physical function, social roles, sleep disturbance, and anxiety, plus the pain intensity item. Equations 1, 3, and 4 were the best predictors of NDI, predicting approximately 80% of NDI scores within 15 points in the validation data set. Equation 4 (NDI%=18.897+0.855*[pain interferenceraw]-0.694*[physical functionraw]+2.010*[pain intensityraw]-0.663*[social rolesraw]+0.732*[sleep disturbanceraw]+0.426*[anxietyraw]) predicted NDI most accurately with an R2 between the predicted and actual NDI scores of 0.72. Model 1 (R2 = 0.62; NDI%=-4.055+3.164*[pain interferenceraw])) and Model 3 (R2=0.65; NDI%=17.321+2.543*[pain interferenceraw]-1.012*[physical functionraw]) also had good accuracy.Conclusions: Findings suggest accurate NDI scores can be derived from PROMIS-29 domains. Clinicians who want to move from NDI to PROMIS-29 can use this equation to obtain estimated NDI scores when only collecting PROMIS-29. These results support the use of PROMIS-29 in cervical surgery populations and underscore the idea that PROMIS-29 domains have the potential to replace disease-specific traditional PROMs. [ABSTRACT FROM AUTHOR]

Background Context: Prognostic models including early postoperative variables may provide optimal estimates of long-term outcomes and help direct postoperative care.Purpose: To develop and validate prognostic models for 12-month disability, back pain, leg pain, and satisfaction among patients undergoing microdiscectomy, laminectomy, and laminectomy with fusion for degenerative lumbar conditions.Study Design/setting: Retrospective cohort study using the Quality Outcomes Database.Patient Sample: Patients receiving elective lumbar spine surgery due to degenerative spine conditions.Outcome Measures: Oswestry Disability Index, pain numerical rating scale, and NASS Patient Satisfaction Index.Methods: Prognostic models were developed using proportional odds ordinal logistic regression using patient characteristics and baseline and 3-month patient-reported outcome scores. Models were fit for each outcome stratified by type of surgical procedure. Adjusted odds ratio and 95% confidence intervals were reported for all predictors by procedure. Models were internally validated using bootstrap resampling. Discrimination was reported as the c-index and calibration was presented using the calibration slope. We compared the performance of models with and without 3-month patient-reported variables. This research was supported by the Foundation for Physical Therapy's Center of Excellence in Physical Therapy Health Services, and Health Policy Research and Training grant.Results: The sample consisted of 5,840 patients receiving a microdiscectomy (n=2,085), laminectomy (n=1,837), or laminectomy with fusion (n=1,918). The 3-month Oswestry score was the strongest and most consistent predictor associated with 12-month outcomes. All prognostic models performed well with overfitting-corrected c-index values ranging from 0.718 to 0.795 and all optimism corrected calibration slopes over 0.92. The increase in c-index values ranged from 0.09 to 0.21 when adding 3-month patient-reported outcome scores.Conclusions: Models had good discrimination and were well calibrated for estimating 12-month disability, back pain, leg pain, and satisfaction. Patient-reported outcomes at 3 months after surgery, especially 3-month Oswestry scores, improved the 12-month performance of all prognostic models beyond using only baseline variables. [ABSTRACT FROM AUTHOR]

Background Context: Low back pain has an immense impact on the US economy. A significant number of patients undergo surgical management in order to regain meaningful functionality in daily life and in the workplace. Return to work (RTW) is a key metric in surgical outcomes, as it has profound implications for both individual patients and the economy at large.Purpose: In this study, we investigated the factors associated with RTW in patients who achieved otherwise favorable outcomes after lumbar spine surgery.Study Design/setting: This study retrospectively analyzes prospectively collected data from the lumbar module of national spine registry, the Quality Outcomes Database (QOD).Patient Sample: The lumbar module of QOD includes patients undergoing lumbar surgery for primary stenosis, disc herniation, spondylolisthesis (Grade I) and symptomatic mechanical disc collapse or revision surgery for recurrent same-level disc herniation, pseudarthrosis, and adjacent segment disease. Exclusion criteria included age under 18 years and diagnoses of infection, tumor, or trauma as the cause of lumbar-related pain.Outcome Measures: The outcome of interest for this study was the return to work 12-month after surgery.Methods: The lumbar module of QOD was queried for patients who were employed at the time of surgery. Good outcomes were defined as patients who had no adverse events (readmissions/complications), had achieved 30% improvement in Oswestry disability index (ODI) and were satisfied (NASS satisfaction) at 3-month post-surgery. Distinct multivariable logistic regression models were fitted with 12-month RTW as outcome for a. overall population and b. the patients with good outcomes. The variables included in the models were age, gender, race, insurance type, education level, occupation type, currently working/on-leave status, workers' compensation, ambulatory status, smoking status, anxiety, depression, symptom duration, number of spinal levels, diabetes, motor deficit, and preoperative back-pain, leg-pain and ODI score.Results: Of the total 12,435 patients, 10,604 (85.3%) had successful RTW at 1-year postsurgery. Among patients who achieved good surgical outcomes, 605 (7%) failed to RTW. For both the overall and subgroup analysis, older patients had lower odds of RTW. Females had lower odds of RTW compared with males and patients with higher back pain and baseline ODI had lower odds of RTW. Patients with longer duration of symptoms, more physically demanding occupations, worker's compensation claim and those who had short-term disability leave at the time of surgery had lower odds of RTW independent of their good surgical outcomes.Conclusions: This study identifies certain risk factors for failure to RTW independent of surgical outcomes. Most of these risk factors are occupational; hence, involving the patient's employer in treatment process and setting realistic expectations may help improve the patients' work-related functionality. [ABSTRACT FROM AUTHOR]

Prospective patient-reported outcomes (PROs) registries are central to emerging evidence-driven reform models. These registries entail significant operator and responder burden to capture PROs data. It is important to limit the number of PROs administered. We sought to determine whether the anxiety/depression domain of EQ-5D could be used to define preoperative psychological distress in patients undergoing elective spine surgery. Patients undergoing elective spine surgery and enrolled into a prospective registry were analyzed. The 12-Item Short-Form Health Survey Mental Component Summary, Zung depression scale, Modified Somatic Perception Questionnaire, and EQ-5D were completed. The anxiety/depression domain of EQ-5D was used to define psychological distress; responses were captured as 1) not anxious or depressed, 2) moderately anxious or depressed, or 3) extremely anxious or depressed. Univariate correlation and proportional odds logistic regression analyses were conducted. Of 2470 included patients undergoing elective spine surgery, 45% (n = 1109) reported no psychological distress, 47% (n = 1168) reported moderate psychological distress, and 8% (n = 193) reported extreme psychological distress on EQ-5D. Psychological distress on EQ-5D had positive correlation with Zung depression scale (P < 0.0001, r = 0.620) and Modified Somatic Perception Questionnaire (P < 0.0001, r = 0.450) and negative correlation with 12-Item Short-Form Health Survey Mental Component Summary (P < 0.0001, r = −0.662). In proportional odds logistic regression models, EQ-5D psychological distress had significant correlations with 12-Item Short-Form Health Survey Mental Component Summary (P < 0.0001, C-index = 0.831), Zung depression scale (P < 0.0001, C-index = 0.802), and Modified Somatic Perception Questionnaire (P < 0.0001, C-index = 0.711). The anxiety/depression domain of EQ-5D could be used to categorize preoperative psychological distress. Spine registries could use this information to potentially limit the number of validated PROs administered. [ABSTRACT FROM AUTHOR]

Background Context: No consensus exists for defining chronic preoperative opioid use. Most spine studies rely solely on opioid duration to stratify patients into preoperative risk categories.Purpose: The purpose of this study is to compare established opioid definitions that contain both duration and dosage to opioid models that rely solely on duration, including the CDC Guideline for Prescribing Opioids for Chronic Pain, in patients undergoing spine surgery.Study Design: This was a retrospective cohort study that used opioid data from the Tennessee Controlled Substance Monitoring Database and prospective clinical data from a single-center academic spine registry.Patient Sample: The study cohort consisted of 2,373 patients who underwent elective spine surgery for degenerative conditions between January 2011 and February 2017 and who completed a follow-up assessment at 12 months after surgery.Outcome Measures: Postoperative opioid use and patient-reported satisfaction (NASS Satisfaction Scale), disability (Oswestry/Neck Disability Index), and pain (Numeric Rating Scale) at 12 month follow-up.Methods: Six different chronic preoperative opioid use variables were created based on the number of times a prescription was filled and/or daily morphine milligram equivalent for the one year before surgery. These variables defined chronic opioid use as 1) most days for > 3 months (CDC), 2) continuous use for ≥ 6 months (Schoenfeld), 3) >4,500 mg for at least 9 months (Svendsen wide), 4) >9,000 mg for 12 months (Svendsen intermediary), 5) >18,000 mg for 12 months (Svendsen strict), 6) low-dose chronic (1-36 mg for >91 days), medium-dose chronic (36-120 mg for >91 days), and high-dose chronic (>120 mg for >91 days) (Edlund). Multivariable regression models yielding C-index and R2 values were used to compare chronic preoperative opioid use definitions by postoperative outcomes, adjusting for type of surgery.Results: Chronic preoperative opioid use was reported in 470 to 725 (19.8% to 30.6%) patients, depending on definition. The Edlund definition, accounting for duration and dosage, had the highest predictive ability for postoperative opioid use (77.5%), followed by Schoenfeld (75.7%), CDC (72.6%), and Svendsen (59.9% to 72.5%) definitions. A combined Edlund and Schoenfeld duration and dosage definition in post-hoc analysis, that included 3 and 6 month duration cut-offs, performed the best overall with a C-index of 78.4%. Both Edlund and Schoenfeld definitions explained similar amounts of variance in satisfaction, disability, and pain (4.2% to 8.5%). Svendsen and CDC definitions demonstrated poorer performance for patient-reported outcomes (1.4% to 7.2%).Conclusions: The Edlund definition is recommended for identifying patients at highest risk for postoperative opioid use. When opioid dosage is unavailable, the Schoenfeld definition is a reasonable choice with similar predictive ability. For patient-reported outcomes, either the Edlund or Schoenfeld definition is recommended. Future work should consider combing dosage and duration, with 3 and 6 month cutoffs, into chronic opioid use definitions. [ABSTRACT FROM AUTHOR]

Background Adult spinal deformity (ASD) operations are complex and often require a multisurgeon team. Simultaneously, it is the responsibility of academic spine surgeons to train future complex spine surgeons. Our objective was to assess the effect of resident and fellow involvement (RFI) on ASD surgery in 4 areas: 1) perioperative outcomes, 2) length of stay (LOS), 3) discharge status, and 4) complications. Methods Adults undergoing thoracolumbar spinal deformity correction from 2008 to 2014 were identified in the National Surgical Quality Improvement Program database. Cases were divided into those with RFI and those with attendings only. Outcomes were operative time, transfusions, LOS, discharge status, and complications. Univariate and multivariable regression modeling was used. Covariates included preoperative comorbidities, specialty, and levels undergoing instrumentation. Results A total of 1471 patients underwent ASD surgery with RFI in 784 operations (53%). After multivariable regression modeling, RFI was independently associated with longer operations (β = 66.01 minutes; 95% confidence interval [CI], 35.82–96.19; P < 0.001), increased odds of transfusion (odds ratio, 2.80; 95% CI, 1.81–4.32; P < 0.001), longer hospital stay (β = 1.76 days; 95% CI, 0.18–3.34; P = 0.030), and discharge to an inpatient rehabilitation or a skilled nursing facility (odds ratio, 2.02; 95% CI, 1.34–3.05; P < 0.001). However, RFI was not associated with any increase in major or minor complications. Conclusion RFI in ASD surgery was associated with increased operative time, the need for additional transfusions, longer LOS, and nonhome discharge. However, no increase in major, minor, or severe complications occurred. These data support the continued training of future deformity and complex spine surgeons without fear of worsening complications; however, areas of improvement exist. [ABSTRACT FROM AUTHOR]

Background In an era of rising health care costs, it is prudent to consider effective use of resources. Given the rapidly expanding elderly population with an anticipated increase in adult spinal deformity, identifying the significant cost drivers for the surgical management is an important step in the process of increasing sustainability and cost-effectiveness of adult spinal deformity surgery. Methods A total of 129 patients undergoing elective spine surgery for thoraco-lumbar deformity were enrolled in a prospective longitudinal registry. Patient-reported resource use during the 3-month postoperative period, including outpatient visits, spine-related diagnostic tests, injections, emergency department room visits, rehabilitation/skilled nursing facility utilization, and use of all medications, was collected in a single-center prospective registry. Multiple linear regression analysis was conducted to find the significant patient coefficient for the cost variability. Results The study population showed significant improvement (P < 0.001) in all patient-reported outcomes including disability (Oswestry Disability Index), pain (Numeric Rating Scale for Back Pain and Numeric Rating Scale for Leg Pain), and quality of life (Euro-Qol-5D). In risk-adjusted multiple patient comorbidities including chronic obstructive pulmonary disease and diabetes, preoperative deformity diagnosis, number of levels involved, length of surgery and hospital stay, 90-day readmission and use of inpatient rehabilitation were the significant drivers of the cost. Conclusions Our study demonstrates that several patient-specific, surgery-related factors, 90-day readmission and postdischarge inpatient rehabilitation use, were associated with increased cost associated with the adult deformity spine surgery. Highlights • In an era of rising healthcare costs, it is prudent to consider effective use of resources. • We report prospective data identifying the significant cost drivers in corrective procedures for adult spine deformity. • This study is an important step for enhancing sustainability and cost-effectiveness of adult spinal deformity surgery. [ABSTRACT FROM AUTHOR]

Background Context: Chronic opioid therapy is associated with worse patient-reported outcomes (PROs) following spine surgery. However, little literature exists on the relationship between opioid use and PROs following epidural steroid injections for radicular pain.Purpose: We evaluated the association between pre-injection opioid use and PROs following spine epidural steroid injection.Study Design: This study is a retrospective analysis of a prospective longitudinal registry database.Patient Sample: A total of 392 patients within our database who were undergoing epidural steroid injections (ESIs) at our institution for degenerative structural spine diagnoses and met our inclusion criteria were included in this study.Outcome Measures: Patient-reported outcomes for disability (Oswestry Disability Index/Neck Disability Index [ODI/NDI)]), quality of life (EuroQol-5D [EQ-5D]), and pain (Numerical Rating Scale scores for back pain, neck pain, leg pain, and arm pain [NRS-BP/NP/LP/AP]) were assessed at baseline and at 3 and 12 months post-injection.Methods: Multivariable proportional odds logistic regression models were created to examine the relationship between pre-injection opioid use and post-injection PROs. A logistic regression with Bayesian Markov chain Monte Carlo parameter estimation was used to investigate a possible cutoff value of pre-injection opioid use above which the effectiveness of ESI (as measured by minimum clinically important difference [MCID] for ODI/NDI) decreases.Results: A total of 276 patients with complete 12-month follow-up following ESI were analyzed. The mean pre-injection daily morphine equivalent amount (MEA) was 14.7 mg (95% confidence interval [CI] 12.4 mg-19.1 mg) for the cohort. Pre-injection opioid use was associated with slightly higher odds of worse disability (odds ratio [OR] 1.03, p=.03) and leg/arm pain (OR 1.01, p=.04) scores at 3 months post-injection only. No significant association between pre-injection opioid use and MCID for ODI/NDI was found, although a cutoff of 55.5 mg/day might serve as a significant threshold.Conclusion: Increased pre-injection opioid use does not impact long-term outcomes after ESIs for degenerative spine diseases. A pre-injection MEA around 50 mg/day may represent a threshold above which the 3-month effectiveness of ESI for back- and neck-related disability decreases. Epidural steroid injection is an effective treatment modality for pain in patients using opioids, and can be part of a multimodal strategy for opioid independence. [ABSTRACT FROM AUTHOR]

Background: Obese patients have greater comorbidities along with higher risk of complications and greater costs after spine surgery, which may result in increased cost and lower quality of life compared with their non-obese counterparts.Purpose: The aim of the present study was to determine cost-utility following anterior cervical discectomy and fusion (ACDF) in obese patients.Study Design: This study analyzed prospectively collected data.Patient Sample: Patients undergoing elective ACDF for degenerative cervical pathology at a single academic institution were included in the study.Outcome Measures: Cost and quality-adjusted life years (QALYs) were the outcome measures.Methods: One- and two-year medical resource utilization, missed work, and health state values (QALYs) were assessed. Two-year resource use was multiplied by unit costs based on Medicare national payment amounts (direct cost). Patient and caregiver workday losses were multiplied by the self-reported gross-of-tax wage rate (indirect cost). Total cost (direct+indirect) was used to compute cost per QALY gained. Patients were defined as obese for body mass index (BMI) ≥35 based on the WHO definition of class II obesity. A subgroup analysis was conducted in morbidly obese patients (BMI≥40).Results: There were significant improvements in pain (neck pain or arm pain), disability (Neck Disability Index), and quality of life (EuroQol-5D and Short Form-12) at 2 years after surgery (p<.001). There was no significant difference in post-discharge health-care resource utilization, direct cost, indirect cost, and total cost between obese and non-obese patients at postoperative 1-year and 2-year follow-up. Mean 2-year direct cost for obese patients was $19,225±$8,065 and $17,635±$6,413 for non-obese patients (p=.14). There was no significant difference in the mean total 2-year cost between obese ($23,144±$9,216) and non-obese ($22,183±$10,564) patients (p=.48). Obese patients had a lower mean cumulative gain in QALYs versus non-obese patients at 2-years (0.34 vs. 0.42, p=.32). Two-year cost-utility in obese ($68,070/QALY) versus non-obese patients ($52,816/QALY) was not significantly different (p=.11). Morbidly obese patients had lower QALYs gained (0.17) and higher cost per QALYs gained ($138,094/QALY) at 2 years.Conclusions: Anterior cervical discectomy and fusion provided a significant gain in health state utility in obese patients, with a mean 2-year cost-utility of $68,070 per QALYs gained, which can be considered moderately cost-effective. Morbidly obese patients had lower cost-effectiveness; however, surgery does provide a significant improvement in outcomes. Obesity, and specifically morbid obesity, should to be taken into consideration as physician and hospital reimbursements move toward a bundled model. [ABSTRACT FROM AUTHOR]

Background Context: In cervical spondylotic myelopathy (CSM), cervical sagittal alignment (CSA) is associated with disease severity. Increased kyphosis and C2-C7 sagittal vertical axis (SVA) correlate with worse myelopathy and poor outcomes. However, when alignment is lordotic, it is unknown whether these associations persist.Purpose: The study aimed to investigate the associations between CSA parameters and patient-reported outcomes (PROs) following posterior decompression and fusion for CSM when baseline lordosis is maintained.Study Design/setting: This is an analysis of a prospective surgical cohort at a single academic institution.Patient Sample: The sample includes adult patients undergoing primary cervical laminectomy and fusion for CSM over a 3-year period.Outcome Measures: The PROs included EuroQol-5D, Short-Form-12 (SF-12) physical composite (PCS) and mental composite scales (MCS), Neck Disability Index, and the modified Japanese Orthopaedic Association scores. Radiographic CSA parameters measured included C1-C2 Cobb, C2-C7 Cobb, C1-C7 Cobb, C2-C7 SVA, C1-C7 SVA, and T1 slope.Methods: The PROs were recorded at baseline and at 3 and 12 months postoperatively. The CSA parameters were measured on standing radiographs in the neutral position at baseline and 3 months. Wilcoxon rank test was used to test for changes in PROs and CSA parameters, and Pearson correlation coefficients were calculated for CSA parameters and PROs preoperatively and at 12 months. No external sources of funding were used for this work.Results: There were 45 patients included with an average age of 63 years who underwent posterior decompression and fusion of 3.7±1.3 levels. Significant improvements were found in all PROs except SF-12 MCS (p=.06). Small but statistically significant changes were found in C2-C7 Cobb (mean change: +3.6°; p=.03) and C2-C7 SVA (mean change: +3 mm; p=.01). At baseline, only C2-C7 SVA associated with worse SF-12 PCS scores (r=-0.34, p=.02). Postoperatively, there were no associations found between PROs and any CSA parameters. Similarly, no CSA parameters were associated with changes in PROs.Conclusions: Although creating more lordosis and decreasing SVA are associated with improved myelopathy and outcomes in patients with kyphosis, our study did not find such associationsin patients with lordosis undergoing posterior laminectomy and fusion for CSM. This suggests that any amount of lordosis may be sufficient. [ABSTRACT FROM AUTHOR]

Background: Lumbar epidural steroid injection (LESI) is a valuable therapeutic option when administered to the appropriate patient, for the appropriate disease process, at the appropriate time. There is considerable variability in patient-reported outcomes (PROs) after LESI, creating uncertainty as to who will benefit from the therapy and who will not.Purpose: We set out to identify patient attributes, which are important predictors for the achievement of a minimum clinically important difference (MCID) in the Oswestry Disability Index (ODI) after LESI.Study Design: A prospective cohort study was carried out.Patient Sample: A total of 239 consecutive patients undergoing LESI for back-related disability, back pain (BP), and leg pain (LP) associated with degenerative pathology comprised the patient sample.Outcome Measures: Baseline and 3-month patient self-reported ODI, numeric rating scale-BP and LP, Euro-Qol-5D, and Short Form (SF)-12 scores were recorded.Methods: A total of 239 consecutive patients undergoing LESI for degenerative pathology over a period of 2 years who were enrolled into a prospective web-based registry were included in the study. Using the previously reported anchor-based approach, an MCID threshold of 7.1% was established for ODI after LESI. Each enrolled patient was then dichotomized as a "responder" (achieving MCID) or a "non-responder." Multiple logistic regression analysis was then performed, with the achievement of MCID serving as the outcome of interest. Candidate variables included in the regression analyses were age, gender, employment, insurance type, smoking status, preoperative ambulation, preinjection narcotic use, comorbidities, predominant LP or BP symptoms, symptom duration, diagnosis, number of levels, prior surgery, baseline PROs, type of stenosis (central, lateral recesses, or foraminal), injection route (transforaminal, interlaminar, or caudal), and number of injections. Subsequently, we also randomly selected 80% of the patients to serve as the training data for a multiple logistic regression model. Once this predictive model was built, it was validated using the remaining 20% of patients.Results: There were 124 (62%) patients who achieved MCID for ODI. The existence of central stenosis (p=.006), TF or IL injection route (p=.02) compared with caudal epidural steroid injection, higher baseline ODI (p=.00001), and a diagnosis of disc herniation (p=.02) increase the odds of achieving MCID for ODI at 3 months. Symptom duration for over a year (p=.006), prior surgery (p=.08), and preinjection anxiety (p=.001) decrease the odds of achieving MCID. The area under the curve (AUC) for our predictive model's receiver-operator characteristic was 0.81 when using the 80% training data set, and the AUC was 0.72 when using the 20% validation data.Conclusion: We have identified patient attributes that are important predictors for the achievement of MCID in ODI 3 months after LESI. The use of these attributes, in the form of a predictive model for LESI efficacy, has the potential to improve decision making around LESI. Spine care providers can use the information to gain insight into the likelihood that a particular patient will experience a meaningful benefit from LESI. [ABSTRACT FROM AUTHOR]

Background Context: Pelvic fixation improves fusion and stability for thoracolumbar constructs that extend across the L5-S1 junction. No patient-reported outcomes have been published to evaluate patients' functional outcomes following these procedures compared with pelvis-sparing procedures.Purpose: The goal of this study is to identify the effect of pelvic fixation on both objective and patient-reported outcomes.Study Design/setting: This was a retrospective, matched cohort study.Patient Sample: The sample comprised adult patients undergoing spine surgery at our institution who had complete 1-year postoperative follow-up.Outcome Measures: Patient-reported outcome instruments (Oswestry Disability Index [ODI], Short-Form 12-item survey, and EuroQol-5D) and objective measures (length of hospital stay, discharge disposition, postoperative complications, and readmission rates) were considered.Methods: We identified patients in our outcomes registry undergoing instrumented spinal fusion involving the pelvis between October 2010 and May 2014 who had 1-year follow-up data. Nearest-neighbor 1:1 matched controls were identified using propensity scoring from the cohort of patients undergoing any spinal procedure which extended caudally to the lumbar spine or sacrum. Objective and patient-reported outcomes were compared between cases and controls.Results: There were 44 patients who underwent spinal procedures involving the pelvis and had 1-year follow-up data. An equal number of controls were identified and had similar baseline demographic and clinical characteristics. No significant differences were found among operative variables or objective complication rates. Patients undergoing pelvic fixation had moderately greater improvement at 3 months as measured by ODI, but this difference was not present at 1 year. Other patient-reported outcome measures were equivocal between groups.Conclusions: This matched cohort study demonstrates that inclusion of the pelvis in spinal hardware constructs is not associated with increased complications and may slightly improve patient disability at 1 year. Given that pelvic fixation may reduce L5-S1 breakdown and improve biomechanics, surgeons should more readily include the pelvis in instrumented fusion procedures. [ABSTRACT FROM AUTHOR]

Background Context: Only Level 3 evidence exists for the diagnosis and treatment of atlantooccipital dislocation (AOD) with few studies examining mortality, neurologic improvement, and patient-reported outcomes (PROs).Purpose: First, the aim was to determine: the incidence of AOD, 90-day surgical morbidity and mortality after AOD, patient factors that may be associated with delayed or missed diagnosis, and factors that were associated with mortality and neurologic improvement after AOD. Secondly, the aim was to quantify the pain, disability, and quality of life experienced by patients surviving AOD.Study Design/setting: This was a retrospective cohort study.Patient Sample: A total of 5,337 consecutive spine computed tomography traumagrams from 1997 to 2012 were included.Outcome Measures: Mortality, neurologic improvement, complications, EuroQol five dimensions (EQ-5D), Neck Disability Index (NDI), Numeric Rating Scale (NRS)-neck, NRS-arm, and return-to-work were the outcome measures.Methods: Patients were considered to have AOD if they met one of the following radiographic criteria: basion-dens interval greater than 10 mm; basion-axial interval: anterior displacement greater than 12 mm or posterior displacement greater than 4 mm between the basion and posterior C2 line; and condyle to C1 interval greater than 1.4 mm. Linear regression analysis was performed to identify factors associated with 90-day mortality, neurologic improvement, and missed diagnosis. Patient-reported outcomes were assessed via phone interview.Results: Thirty-one patients met radiographic criteria for AOD; an incidence of 0.6% over 15 years. Twenty-one (68%) patients were treated with occipital cervical fusion. At 90 days postoperatively, there were no new neurologic deficits or reoperations. Eight (26%) patients died within 90 days. All patients who died had no documented AOD diagnosis and were not treated surgically. Missed AOD diagnosis was the strongest predictor of mortality. Younger age, lower Glasgow Coma Score, lower Injury Severity Score (ISS) score, and worse initial American Spinal Injury Association (ASIA) score were significantly associated with greater neurologic improvement. Higher ISS score and better ASIA score were significantly associated with missed AOD diagnosis. The average PROs metrics at time of telephone follow-up were as follows: EQ-5D=0.73±0.19, NDI=30.89±18.57, NRS-neck=2.33±2.21, NRS-arm=2.00±2.54. Of the patients with follow-up data, four were employed full-time, and five were receiving disability.Conclusions: Our work suggests that failure to diagnose AOD is a powerful predictor of mortality. Higher ISS scores and better neurologic presentation were significantly associated with missed diagnosis. Craniocervical arthrodesis preserved neurologic function with low complication rate and unexpectedly high PROs and return-to-work. These results must be carefully interpreted because it is unclear whether missed AOD diagnosis accompanies another death-causing injury (eg, traumatic brain injury) or if failure to treat AOD contributes to mortality in a multifactorial manner. [ABSTRACT FROM AUTHOR]

Background The ability to understand factors associated with an increased duration of missed work postoperatively could be used to more effectively select patients with the greatest opportunity for a successful outcome. We set out to determine the effect of preoperative depression on postoperative return to work in patients undergoing transforaminal lumbar interbody fusion (TLIF) for degenerative spondylolisthesis. Methods Fifty-eight patients undergoing TLIF for symptomatic grade I degenerative lumbar spondylolisthesis were included in this analysis. Patient demographics, clinical presentation, indications for surgery, radiologic studies, and operative variables were assessed for each case. Patient-assessed outcome measures were obtained prospectively at baseline and 2 years postoperatively. To understand the factors associated with prolonged return to work, univariate linear regression analysis and stepwise multivariate Cox proportional hazards model was used. Results All patient-reported outcomes assessed were significantly improved 2 years after TLIF ( P < 0.001). Of the 32 patients working preoperatively, 26 (81%) returned to work postoperatively. Median time to return to work was 56 days (range, 10–150 days). Independent of patient age; preoperative pain, disability, and quality of life; and extent of postoperative improvement, increased preoperative Zung depression score remained associated with prolonged return to work ( P = 0.02). Conclusions Independent of postoperative improvement in pain, disability, and quality of life, the extent of preoperative depression was an independent predictor of time to return to work in patients undergoing TLIF for spondylolisthesis, suggesting that regardless of how successful TLIF surgery may be at improving a patient's pain, disability, or quality of life, greater depression will delay or prohibit their ability to return to work postoperatively. [ABSTRACT FROM AUTHOR]

Longstanding and progressive compression of the cervical spinal cord can lead to irreversible loss of neurologic function due to demyelination and apoptosis of oligodendrocytes. A commonly used metric to quantify the severity of cervical myelopathy is the modified Japanese Orthopedic Association (mJOA) score. The mJOA score comprises six items to assess the impact of spinal cord compression on: (1) ability to feed oneself, (2) ability to walk, (3) loss of feeling or numbness in arms, (4) loss of feeling or numbness in legs, (5) loss of feeling or numbness in body and (6) ability to urinate. In the present study, the primary objective was to construct a clinical prediction model for improvement of mJOA subdomains at 12 months following surgery utilizing data from a longitudinal, multicenter clinical spine registry. This study was conducted using data from the cervical module of the Quality Outcomes Database (QOD), a longitudinal, multicenter, prospective spine outcomes registry. A total of 5,000 patients who underwent elective surgery for cervical myelopathy were enrolled into the registry and had complete 12-month follow-up. mJOA subdomain scores. This study was conducted using data from the cervical module of the Quality Outcomes Database (QOD). The outcomes of interest were the subdomains or items of the mJOA at 12 months following surgery. A multivariate multivariable proportional odds ordinal regression model was developed for patients with cervical myelopathy using a latent variable approach. The latent variables were assumed to follow a multivariate logistic distribution which was constructed by univariate logistic margins and a t copula. Patient demographic, clinical, and surgery covariates as well as baseline subdomain scores were included as the independent variables. The model was internally validated using bootstrap resampling to estimate the likely performance on a new sample of patients. A total of 5,000 patients who underwent elective surgery for cervical myelopathy were enrolled into the registry and had complete 12-month follow-up. The mean age for the patients was 60.9 (±11.4) years and comprised of 47% (n=2,339) females. Patients had statistically significant improvement from baseline to 12-months postsurgery on all the mJOA subdomains(p<0.001). The multivariable analysis identified that the baseline subdomains of the mJOA were the strongest predictors of 12-month scores, with numbness in legs and ability to walk predicting 5 of the 6 mJOA items. Additional covariates that significantly predicted 3 or more of the subdomain mJOA scores at 12 months included age, preoperative anxiety or depression, gender, race, employment status, duration of symptoms, smoking status, and presence of listhesis on radiology. Surgical approach, the presence of motor deficits, number of surgical levels involved, history of diabetes mellitus, worker's compensation claim and a patient's insurance had no impact on the 12-month scores of the mJOA. The discriminative ability of the model regarding joint probabilities measured by unweighted generalized C-index was 0.753. In conclusion, our study has developed and validated a clinical prediction model for improvement in mJOA scores at 12-months following surgery. Results highlight the importance of assessing preoperative numbness symptoms and walking ability as well as the modifiable variables of anxiety/depression and smoking status prior to surgery. Additional patient demographic variables to consider are age, gender, race, employment status, duration of symptoms, and presence of listhesis when counseling patients prior to surgery. This prediction model has the potential to assist surgeons, patients and families when considering surgery for cervical myelopathy and provides clinically useful information in the preoperative setting. Future steps include prospective, external validation of the predictive model in order to assess the reproducibility and clinical utility of this work. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Engaging in physical activity early after lumbar spine surgery has promising effects on long-term postoperative recovery, including improved physical function. However, whether this effect is mediated through improvement in psychosocial factors is yet to be established. The purpose of this study was to investigate the longitudinal postoperative relationship between physical activity, psychosocial factors, and physical function in patients undergoing lumbar spine surgery. Secondary analysis from randomized controlled trial. This study included 248 participants (mean ± SD; age=62.2±11.9 years; BMI=32.4±6.6 kg/m2 and 51% females) who underwent surgery for a degenerative lumbar spine condition. Physical activity, defined as steps per day, was measured using a triaxial accelerometer (Actigraph GT3X) worn for >10 hours for >1 day(s) at 6 weeks (6wk), 6 months (6M), 12 months (12M) and 24 months (24M) following spine surgery. Physical function, measured with Patient-Reported Outcomes Measurement Information System, and psychosocial factors pain self-efficacy [Pain Self-Efficacy Questionnare], depression [Patient Health Questionnaire-9] and fear of movement [Tampa Scale for Kinesiophobia]) were assessed at preoperative visit and 6wk, 6M, 12M and 24M after surgery. Structural equation modeling (SEM) was used to analyze data and compute standardized coefficients to determine the effects of physical activity, function and psychosocial factors. Multiple imputation accounted for missing data and pooled coefficients and p-values were calculated using Rubin's approach. The mediation effect of each psychosocial factor on the effect of physical activity on physical function were computed by dividing the direct effects with the indirect effects. All SEM models controlled for age, employment, comorbidities, prior spine surgery, and preoperative pain self-efficacy, depression, fear of movement, physical function, and back and leg pain. Each SEM models was tested for model fit by assessing the established fit indexes. The overall standardized direct effect of physical activity (ie, steps per day) on physical function ranged from 0.08 to 0.19 (p<0.05), while the overall effect of physical function on physical activity ranged from non-existent to 0.14 (p<0.01 to 0.3). The effect of physical activity on physical function remained consistent after accounting for psychosocial factors in each of the mediation models. Pain self-efficacy did not mediate but depression and fear of movement at 6M mediated 3.4% and 5.4% of the effect of physical actvity at 6Wk on physical function at 12M, respectively. The findings of this study support the use of early postoperative strategies to address physical activity in order to improve long-term physical function. Pain self-efficacy did not have a mediating effect while depression and fear of movement had a very small mediating effect; therefore, additional work is needed to investigate other potential mediating factors such as pain catastrophizing, resilience and exercise self-efficacy. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]