The clinical course of symptoms during wait time for lumbar spinal stenosis surgery and its effect on postoperative outcome: a retrospective cohort study.

BACKGROUND CONTEXT: Wait time for surgeries can be lengthy and its effect on postoperative outcome remains largely unknown. PURPOSE: We evaluated the effect of wait time on postoperative outcome and on clinical course while awaiting surgery for lumbar spinal stenosis. STUDY DESIGN/SETTING: This was a retrospective cohort study. PATIENT SAMPLE: A convenience sample (n=134) from prospective longitudinal studies that provided preoperative Oswestry Disability Index (ODI) data at two different time points and follow-up of ≥12 months. METHODS: Wait time was the period between the initial consultation and immediately preoperatively. OUTCOME MEASURES: The primary outcome was the ODI minimal clinically important difference (MCID) (<30% vs ≥30% improvement) at 1 year. RESULTS: The median wait time was 5.9 (interquartile range (IQR) 8.2) months and postoperative follow-up was 19.2 (IQR 8.1) months. Wait time was not associated with absolute postoperative change in ODI scores, but patients with wait times <12 months were significantly more likely to reach the ODI MCID at last follow-up (66 (73.3%) for <12 months versus 13 (46.4%) for ≥12 months, p=.008; odds ratio=0.29 (95% confidence interval 0.12-0.75), p=.011). During wait time, there was no difference in patients deteriorating above the MCID for each time point (10 [9.7%] versus 5 [16.1%], p=.320). CONCLUSIONS: Longer wait times did not negatively influence postoperative outcome in patients with lumbar spinal stenosis using absolute values, but may impact individual patients' ability to achieve MCID. Patient-reported pain-related disability from the initial surgical consultation to surgery is relatively stable in most patients for at least 6 to 12 months.

Hospital spending and length of stay attributable to perioperative adverse events for inpatient hip, knee, and spine surgery: a retrospective cohort study.

BACKGROUND: The incremental hospital cost and length of stay (LOS) associated with adverse events (AEs) has not been well characterized for planned and unplanned inpatient spine, hip, and knee surgeries. METHODS: Retrospective cohort study of hip, knee, and spine surgeries at an academic hospital in 2011-2012. Adverse events were prospectively collected for 3,063 inpatient cases using the Orthopaedic Surgical AdVerse Event Severity (OrthoSAVES) reporting tool. Case costs were retrospectively obtained and inflated to equivalent 2021 CAD values. Propensity score methodology was used to assess the cost and LOS attributable to AEs, controlling for a variety of patient and procedure factors. RESULTS: The sample was 55% female and average age was 64; 79% of admissions were planned. 30% of cases had one or more AEs (82% had low-severity AEs at worst). The incremental cost and LOS attributable to AEs were $8,500 (95% confidence interval [CI]: 5100-11,800) and 4.7 days (95% CI: 3.4-5.9) per admission. This corresponded to a cumulative $7.8 M (14% of total cohort cost) and 4,290 bed-days (19% of cohort bed-days) attributable to AEs. Incremental estimates varied substantially by (1) admission type (planned: $4,700/2.4 days; unplanned: $20,700/11.5 days), (2) AE severity (low: $4,000/3.1 days; high: $29,500/11.9 days), and (3) anatomical region (spine: $19,800/9 days; hip: $4,900/3.8 days; knee: $1,900/1.5 days). Despite only 21% of admissions being unplanned, adverse events in these admissions cumulatively accounted for 59% of costs and 62% of bed-days attributable to AEs. CONCLUSIONS: This study comprehensively demonstrates the considerable cost and LOS attributable to AEs in orthopaedic and spine admissions. In particular, the incremental cost and LOS attributable to AEs per admission were almost five times as high among unplanned admissions compared to planned admissions. Mitigation strategies focused on unplanned surgeries may result in significant quality improvement and cost savings in the healthcare system.

Association of presurgical circulating MicroRNAs with 1-year postsurgical pain reduction in spine facet osteoarthritis patients with lumbar spinal stenosis.

Purpose: Up to 30% of spine facet osteoarthritis patients with lumbar spinal stenosis (SF-OA â€‹+ â€‹LSS) have little to no improvement in their pain after surgery. Lack of meaningful improvement in pain following surgery provides a unique opportunity to identify specific predictive biomarker signatures that might be associated with the outcomes of surgical treatment. The objective of the present study was to determine whether a microRNA (miRNA) biomarker signature could be identified in presurgical blood plasma that corresponded with levels of SF-OA â€‹+ â€‹LSS patient post-surgical pain intensity one year later. Methods: RNA was extracted from baseline plasma of SF-OA â€‹+ â€‹LSS patients and prepared for miRNA sequencing. Statistical approaches were performed to identify differentially expressed miRNAs associated with reduced 1-year postsurgical pain (n â€‹= â€‹56). Using an integrated computational approach, we further created predicted gene and pathway networks for each identified miRNA. Results: We identified a panel of 4 circulating candidate miRNAs (hsa-miR-155-5p, hsa-let-7e-5p, hsa-miR-125a-5p, hsa-miR-99b-5p) with higher levels at presurgical baseline that were associated with greater changes in % NPRS20Δ, reflecting reduced pain intensity levels at one year. Genes encoding hsa-let-7e-5p, hsa-miR-125a-5p, and hsa-miR-99b-5p are part of an evolutionarily conserved miRNA cluster. Using integrated computational analyses, we showed that mammalian target of rapamycin, transforming growth factor-ß1 receptor, Wnt signaling, epithelial-mesenchymal transition regulators, and cholecystokinin signaling were enriched pathways of predicted gene targets. Conclusions: Taken together, our findings suggest that 4 presurgical baseline circulating miRNAs correlate with 1-year postsurgical SF-OA â€‹+ â€‹LSS patient pain intensity and represent possible candidate biomarker signature of surgical pain response.

Bridging the Gap Between Symptom Onset and Diagnosis in Axial Spondyloarthritis.

OBJECTIVE: To evaluate a stratified screening process for the early identification of axial spondyloarthritis (SpA) with consideration of the following: 1) wait times from primary care to rheumatology screen, 2) incremental precision and accuracy from primary care to rheumatology screening, and 3) diagnostic delay. METHODS: Adults with low back pain attending primary care at low back pain clinics prospectively underwent a primary standardized clinical screening. Patients with low back pain of >3 months who experienced symptom onset at age <50 years were referred for a comprehensive secondary screening by a physical therapist with advanced rheumatology training. At secondary screening, patients with features of inflammation were classified as being at a low, medium, or high risk for axial SpA versus no risk for axial SpA. Precision and accuracy of this screening strata were measured against a rheumatologist with expertise in axial SpA. RESULTS: Overall, 405 patients underwent primary and secondary screening in the present study. The study cohort had a mean ± SD age of 36.9 ± 9.9 years, and 55% were women. HLA-B27 was present in 14.4% of patients. Median wait time from primary screening to secondary screening was 15 days. Axial SpA risk assignment by rheumatologist was 64.9% for no risk or low risk for axial SpA and 35.1% for medium risk or high risk for axial SpA. The best combination of sensitivity (68%), specificity (90%), positive predictive values (80%), and negative predictive values (84%) was evident in the secondary screening. In this cohort, 15.6% of patients received a final diagnosis of axial SpA. Median low back pain duration from symptom onset to diagnosis was 2 years for nonradiographic axial SpA and 7 years for ankylosing spondylitis. CONCLUSION: A stratified interprofessional screening process can facilitate rapid diagnosis of persistent low back pain with high precision and accuracy in patients who have axial SpA.

The potential for diversion of prescribed opioids among orthopaedic patients: Results of an anonymous patient survey.

INTRODUCTION: Diversion of prescription opioid medication is a contributor to the opioid epidemic. Safe handling practices can reduce the risk of diversion. We aimed to understand: 1) if orthopaedic patients received instructions on how to safely handle opioids, 2) their typical storage/disposal practices, and 3) their willingness to participate in an opioid disposal program (ODP). METHODS: Cross-sectional study of adult orthopaedic patients who completed an anonymous survey on current or past prescription opioid use, instruction on handling, storage and disposal practices, presence of children in the household, and willingness to participate in an ODP. Frequencies and percentages of responses were computed, both overall and stratified by possession of unused opioids. RESULTS: 569 respondents who reported either current or past prescription opioid use were analyzed. 44% reported receiving storage instructions and 56% reported receiving disposal instructions from a health care provider. Many respondents indicated unsafe handling practices: possessing unused opioids (34%), using unsafe storage methods (90%), and using unsafe disposal methods (34%). Respondents with unused opioids were less likely to report receiving handling instructions or using safe handling methods, and 47% of this group reported having minors or young adults in the household. Respondents who received storage and disposal instructions were more likely to report safe storage and disposal methods. Seventy-four percent of respondents reported that they would participate in an ODP. CONCLUSION: While many orthopaedic patients report inadequate education on safe opioid handling and using unsafe handling practices, findings suggest targeted education is associated with better behaviours. However, patients are willing to safely dispose of unused medication if provided a convenient option. These findings suggest a need to address patient knowledge and behavior regarding opioid handling to reduce the risk of opioid diversion.

What Goes Bump in the Night: An Evaluation of Emergency Department Visits Following Total Joint Arthroplasty.

BACKGROUND: Interest in postoperative healthcare utilization has increased following the implementation of episode-of-care funding for elective orthopedic surgery. Most efforts have focused on readmission; however, little has been reported on emergency department (ED) presentation. We analyzed elective, primary total hip or knee arthroplasty (THA and TKA) cases to determine the rate, reasons, risk factors, timing, and hospital cost associated with 30-day ED presentations. METHODS: An observational study of patients who underwent primary, elective TKA and THA between January 1, 2016, and December 31, 2017, was performed. The primary outcome was an ED visit within 30-days of the index operation. Secondary outcomes included reasons, risk factors, timing, and hospital cost of ED visits. A multivariable logistic regression was undertaken to determine patient factors associated with ED presentation. RESULTS: Overall, 1690 patients were included, of which 9.2% presented to the ED within 30-days of surgery. Approximately two-thirds of the visits were after-hours, and most were discharged home without readmission (81.4%). The most commonly reported reasons were wound concerns (30.1%) and pain (20.5%). Older age (OR 1.1, P = .03) and preoperative dyspnea (OR 2.1, P < .001) increased the odds of ED visits. The mean cost of an ED visit was significantly greater after-hours (P = .015). CONCLUSION: Overall, 1 in 10 patients undergoing TKA/THA presented to the ED within 30-days of surgery, of which over 80% were not readmitted, and most occurred after-hours where cost is greatest. Our observations suggest ED visits following TKA/THA are common, and most are likely preventable. Future efforts should focus on developing interventions to reduce these visits.

Patterns of Depressive Symptoms Before and After Surgery for Osteoarthritis: A Descriptive Study.

OBJECTIVE: To examine patterns of depressive symptoms before and over the year following osteoarthritis (OA) surgery, stratified by joint and postsurgical outcome. METHODS: Participants were hip (n = 287), knee (n = 360), and lumbar spine (n = 100) OA patients scheduled for joint replacement or decompression surgery with or without fusion. One pre- and 4 postsurgery questionnaires were completed. Depressive symptoms were quantified using the Hospital Anxiety and Depression Scale (HADS). One-year outcomes were based on Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain scores for hip and knee patients and Oswestry Disability Index (ODI) scores for spine patients and were categorized as "worse" (top score tertile) vs. "better" outcomes (first, second tertiles). Plots over time were generated by joint and outcome: 1) mean pain/disability and depression scores and 2) percentage of patients meeting HADS cut-off for depression "caseness," reporting depression diagnosis and treatment. RESULTS: There were notable decreases in depression scores for patients with better outcomes. For those with worse outcomes, decreases were smaller for hip patients and were not significant for knee and spine patients. Among those with poorer outcomes, 25% of spine and knee patients were depression "cases" pre- and postsurgery; an additional 16% of spine and 10% of knee patients developed new "caseness" postsurgery. The proportion of these patients deemed depression cases by score was much higher than the proportion reporting diagnosis/treatment. CONCLUSION: Although depressive symptoms decrease overall in OA patients postsurgery, degrees of change vary by joint and surgical outcome. Greater attention to mental health postsurgery is warranted and may lead to improved surgical outcomes, particularly among knee and spine patients.

A classification modeling approach for determining metabolite signatures in osteoarthritis.

Multiple factors can help predict knee osteoarthritis (OA) patients from healthy individuals, including age, sex, and BMI, and possibly metabolite levels. Using plasma from individuals with primary OA undergoing total knee replacement and healthy volunteers, we measured lysophosphatidylcholine (lysoPC) and phosphatidylcholine (PC) analogues by metabolomics. Populations were stratified on demographic factors and lysoPC and PC analogue signatures were determined by univariate receiver-operator curve (AUC) analysis. Using signatures, multivariate classification modeling was performed using various algorithms to select the most consistent method as measured by AUC differences between resampled training and test sets. Lists of metabolites indicative of OA [AUC > 0.5] were identified for each stratum. The signature from males age > 50 years old encompassed the majority of identified metabolites, suggesting lysoPCs and PCs are dominant indicators of OA in older males. Principal component regression with logistic regression was the most consistent multivariate classification algorithm tested. Using this algorithm, classification of older males had fair power to classify OA patients from healthy individuals. Thus, individual levels of lysoPC and PC analogues may be indicative of individuals with OA in older populations, particularly males. Our metabolite signature modeling method is likely to increase classification power in validation cohorts.

Identification of microRNA-181a-5p and microRNA-4454 as mediators of facet cartilage degeneration.

Osteoarthritis (OA) of spine (facet joints [FJs]) is one of the major causes of severe low back pain and disability worldwide. The degeneration of facet cartilage is a hallmark of FJ OA. However, endogenous mechanisms that initiate degeneration of facet cartilage are unknown, and there are no disease-modifying therapies to stop FJ OA. In this study, we have identified microRNAs (small noncoding RNAs) as mediators of FJ cartilage degeneration. We first established a cohort of patients with varying degrees of facet cartilage degeneration (control group: normal or mild facet cartilage degeneration; FJ OA group: moderate to severe facet cartilage degeneration) and then screened 2,100 miRNAs and identified 2 miRNAs (miR-181a-5p and miR-4454) that were significantly elevated in FJ OA cartilage compared with control facet cartilage. We further explored their role, function, and signaling mechanisms using computational, in vitro functional, and in vivo studies. We specifically indicate that miR-181a-5p and miR-4454 are involved in promoting inflammatory, catabolic, and cell death activity in FJ chondrocytes. This is the first report to our knowledge that identifies miR-181a-5p and miR-4454 as mediators of cartilage degeneration in FJs and potential therapeutic targets for stopping cartilage degeneration.

Racial Differences in Serum Adipokine and Insulin Levels in a Matched Osteoarthritis Sample: A Pilot Study.

BACKGROUND: In an attempt to correlate biomarkers with disease, serum-based biomarkers often are compared between individuals with osteoarthritis (OA) and control subjects. However, variable results have been reported. Some studies have suggested an association between certain adipokines and insulin and OA. We know that there are racial differences in OA prevalence and incidence, and from general population-based studies, those of Asian race consistently demonstrate a unique adipokine/insulin serum concentration profile as compared to Caucasians. Whether similar racial differences exist within OA samples is unknown and may have implications for selecting appropriate controls in comparative studies. METHODS: Serum levels of adipokines, leptin, and adiponectin, along with insulin, were determined by ELISA in patients scheduled for total hip or knee replacement surgery for OA. Fifteen Asian patients were matched 1 : 1 on age (±2 years), gender, body mass index (±1.5 kg/m(2)), and surgical joint with Caucasian patients. Differences in serum concentrations were tested using paired t-tests. RESULTS: Serum leptin and insulin levels were significantly higher in Asians compared to Caucasians (p < 0.05). While serum adiponectin levels were lower among Asians, the difference did not reach statistical significance (p = 0.12). CONCLUSION: Findings from this work suggest that when studying serum biomarker concentrations in OA versus controls, race may be an important factor to consider. Our findings warrant confirmation in larger studies.

Perioperative outcomes and adverse events of minimally invasive versus open posterior lumbar fusion: meta-analysis and systematic review.

OBJECT: The objective of this study was to determine the clinical comparative effectiveness and adverse event rates of posterior minimally invasive surgery (MIS) compared with open transforaminal or posterior lumbar interbody fusion (TLIF/PLIF). METHODS: A systematic review of the Medline, EMBASE, PubMed, Web of Science, and Cochrane databases was performed. A hand search of reference lists was conducted. Studies were reviewed by 2 independent assessors to identify randomized controlled trials (RCTs) or comparative cohort studies including at least 10 patients undergoing MIS or open TLIF/PLIF for degenerative lumbar spinal disorders and reporting at least 1 of the following: clinical outcome measure, perioperative clinical or process measure, radiographic outcome, or adverse events. Study quality was assessed using the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) protocol. When appropriate, a meta-analysis of outcomes data was conducted. RESULTS: The systematic review and reference list search identified 3301 articles, with 26 meeting study inclusion criteria. All studies, including 1 RCT, were of low or very low quality. No significant difference regarding age, sex, surgical levels, or diagnosis was identified between the 2 cohorts (856 patients in the MIS cohort, 806 patients in the open cohort). The meta-analysis revealed changes in the perioperative outcomes of mean estimated blood loss, time to ambulation, and length of stay favoring an MIS approach by 260 ml (p < 0.00001), 3.5 days (p = 0.0006), and 2.9 days (p < 0.00001), respectively. Operative time was not significantly different between the surgical techniques (p = 0.78). There was no significant difference in surgical adverse events (p = 0.97), but MIS cases were significantly less likely to experience medical adverse events (risk ratio [MIS vs open] = 0.39, 95% confidence interval 0.23-0.69, p = 0.001). No difference in nonunion (p = 0.97) or reoperation rates (p = 0.97) was observed. Mean Oswestry Disability Index scores were slightly better in the patients undergoing MIS (n = 346) versus open TLIF/PLIF (n = 346) at a median follow-up time of 24 months (mean difference [MIS - open] = 3.32, p = 0.001). CONCLUSIONS: The result of this quantitative systematic review of clinical comparative effectiveness research examining MIS versus open TLIF/PLIF for degenerative lumbar pathology suggests equipoise in patient-reported clinical outcomes. Furthermore, a meta-analysis of adverse event data suggests equivalent rates of surgical complications with lower rates of medical complications in patients undergoing minimally invasive TLIF/PLIF compared with open surgery. The quality of the current comparative evidence is low to very low, with significant inherent bias.

The relationship between diet quality and adult obesity: evidence from Canada.

OBJECTIVE: To assess the relationship between diet quality and body mass index (BMI) in Canadian adults. METHODS: We used confidential, individual-level data on 6325 adult men and 7211 nonpregnant adult women from the 2004 Canadian Community Health Survey to construct 2 diet quality indices (the Diet Quality Index [DQI] and and the Healthy Eating Index [HEI]) and BMI. After adjusting for known observable confounders, a latent class modeling analysis was conducted to account for unobservable confounders. RESULTS: We found that there were 2 latent classes (low-BMI and high-BMI components), and that DQI and HEI indices were negatively associated with BMI in the high-BMI component. In the high-BMI component, a one-unit increase in DQI score is associated with a 0.053 kg/m(2) decrease in BMI, whereas a one-unit increase in HEI score is associated with a 0.095 kg/m(2) decrease in BMI. Subgroup analyses revealed that the association between diet quality and obesity was stronger in women. CONCLUSIONS: Diet quality is associated with lower BMI in high-BMI individuals in Canada. Diet quality exhibits a distinct association in each latent class; this association is stronger in women. Latent class analysis offers a superior methodological framework in understanding the modifiable risk factors for obesity.

Comparative outcomes of minimally invasive surgery for posterior lumbar fusion: a systematic review.

BACKGROUND: Although minimally invasive surgical (MIS) approaches to the lumbar spine for posterior fusion are increasingly being utilized, the comparative outcomes of MIS and open posterior lumbar fusion remain unclear. QUESTIONS/PURPOSES: In this systematic review, we compared MIS and open transforaminal or posterior lumbar interbody fusion (TLIF/PLIF), specifically with respect to (1) surgical end points (including blood loss, surgical time, and fluoroscopy time), (2) clinical outcomes (Oswestry Disability Index [ODI] and VAS pain scores), and (3) adverse events. METHODS: We performed a systematic review of MEDLINE(®), Embase, Web of Science, and Cochrane Library. Reference lists were manually searched. We included studies with 10 or more patients undergoing MIS compared to open TLIF/PLIF for degenerative lumbar disorders and reporting on surgical end points, clinical outcomes, or adverse events. Twenty-six studies of low- or very low-quality (GRADE protocol) met our inclusion criteria. No significant differences in patient demographics were identified between the cohorts (MIS: n = 856; open: n = 806). RESULTS: Equivalent operative times were observed between the cohorts, although patients undergoing MIS fusion tended to lose less blood, be exposed to more fluoroscopy, and leave the hospital sooner than their open counterparts. Patient-reported outcomes, including VAS pain scores and ODI values, were clinically equivalent between the MIS and open cohorts at 12 to 36 months postoperatively. Trends toward lower rates of surgical and medical adverse events were also identified in patients undergoing MIS procedures. However, in the absence of randomization, selection bias may have influenced these results in favor of MIS fusion. CONCLUSIONS: Current evidence examining MIS versus open TLIF/PLIF is of low to very low quality and therefore highly biased. Results of this systematic review suggest equipoise in surgical and clinical outcomes with equivalent rates of intraoperative surgical complications and perhaps a slight decrease in perioperative medical complications. However, the quality of the current literature precludes firm conclusions regarding the comparative effectiveness of MIS versus open posterior lumbar fusion from being drawn and further higher-quality studies are critically required.