The influence of cognitive behavioral therapy on lumbar spine surgery outcomes: a systematic review and meta-analysis.

PURPOSE: As more patients undergo lumbar spine surgery, novel interventions may improve physical and mental health outcomes. Few studies summarize the benefit of cognitive behavioral therapy (CBT) among lumbar spine surgery patients. This study collects randomized control trial data to investigate the influence of CBT on patient reported outcomes among lumbar spine surgery patients. METHODS: Our study used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and a medical library expert assisted in searching PubMed/MEDLINE, Scopus, CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, PsycINFO, and Google Scholar. We calculated standardized mean differences (SMD) to evaluate the effect size of CBT versus control groups with a sensitivity analysis. RESULTS: Our meta-analysis included seven studies with a total of 531 patients. The majority of included studies evaluated lumbar fusion, with preoperative CBT performed by physiotherapists. The largest effects were observed for overall quality of life (SMD = 0.55 [95% CI 0.05, 1.05], p < 0.001, I2 = 86.7%) and psychological outcomes (SMD = 0.61 [95% CI 0.28, 0.94], p < 0.001, I2 = 89.7%) though disability and pain outcomes also favored CBT intervention. Included studies demonstrated low overall bias but large heterogeneity. Sensitivity analysis demonstrated negligible study design differences and revealed moderators including CBT session frequency and final follow-up duration (p < 0.001). CONCLUSION: Compared to usual care or alternative therapy control arms, CBT delivered the most improvement with overall quality of life and psychological outcomes. Among appropriately selected patients, CBT could improve perioperative disability, pain, quality of life, and psychological health following lumbar spine surgery.

Preoperative patient activation is predictive of improvements in patient-reported outcomes following minimally invasive lumbar decompression.

PURPOSE: To determine whether there is an association between preoperative 10-Item Patient Activation Measure (PAM-10) scores and clinical outcomes following MIS LD. METHODS: Patients undergoing a primary MIS LD were retrospectively reviewed and stratified according to their preoperative PAM-10 scores: "low PAM," "moderate PAM," and "high PAM." Preoperative PAM score cohorts were tested for improvements in Oswestry Disability Index (ODI), 12-Item Short-Form Physical Component Score (SF-12 PCS), and Visual Analog Scale (VAS) back and leg pain using multivariate linear regression. RESULTS: Eighty-nine patients were included: 29 had a low PAM score, 32 had a moderate PAM score, and 28 had a high PAM score. Cohorts experienced similar preoperative VAS back pain, VAS leg pain, ODI, and SF-12 PCS. Patients with low PAM scores experienced a trend of higher pain scores throughout 6 months with VAS back pain being significant at 3 months and VAS leg pain being significant at 6-week and 3-month follow-up. Patients with lower PAM scores experienced a worse improvement in ODI at 6-week, 3-month, and 6-month timepoints. Lastly, patients with lower PAM scores demonstrated less improvement in SF-12 PCS at 3-month and 6-month follow-up. CONCLUSIONS: Lower preoperative PAM scores were associated with worse improvement in clinical outcomes following MIS LD. Patients with lower PAM scores had diminished improvement in long-term patient-reported outcomes including ODI, SF-12, and VAS back and leg pain. Our investigation suggests that preoperative PAM assessments may be an effective tool to predict postoperative outcomes following MIS LD.

The Current Status of Awake Endoscopic Surgery: A Systematic Review and Meta-Analysis.

OBJECTIVE: To examine the use of local anesthesia and/or conscious sedation in endoscopic spine procedures within the past decade. METHODS: This systematic review abided by PRISMA guidelines. Embase, PubMed, Google Scholar, and Cochrane databases were searched for post-2011 articles with patients >18 years old, lumbar/cervical percutaneous endoscopic spine procedures using local/awake anesthesia, and patient/surgical outcomes. Reviews, book chapters, single case reports, or small case series (n ≤15 patients) were excluded. Scoring systems of the National Institutes of Health quality assessment tool, Newcastle-Ottawa Scale, and Cochrane Risk of Bias evaluated interventional case series, comparative studies, and randomized control trials, respectively. RESULTS: Twenty-six articles were included, with 4 studies comparing general and local anesthesia. Of 2113 total patients, 1873 patients received local anesthesia. Significant improvements were seen in pain and disability scores. Studies that included MacNab scores showed that 96% of patients rated their postoperative satisfaction as excellent to good. Subanalysis of comparative studies showed a reduced risk of surgical/major medical complications and a slight increased risk for minor medical complications among awake spine patients. Length of stay was shorter for patients receiving local anesthesia. CONCLUSIONS: The current systematic review and meta-analysis shows that use of local anesthesia is a safe and effective alternative to general anesthesia among different endoscopic spinal procedures. Although awake spine surgery is associated with a decreased risk of severe complications, lower revision rates, and higher postoperative satisfaction, more robust studies involving larger cohorts of patients are needed to evaluate the true impact of awake spine surgery on outcomes.

Effects of Anterior Plating on Achieving Clinically Meaningful Improvement Following Single-Level Anterior Cervical Discectomy and Fusion.

OBJECTIVE: The clinical utility of anterior cervical plating for anterior cervical discectomy and fusion (ACDF) procedures remains controversial. This study aims to compare the impact of cervical plating on achievement of minimum clinically important difference (MCID) up to 2 years following ACDF. METHODS: Patients undergoing primary, single-level ACDF procedures were grouped based on whether their procedure included application of an anterior cervical plate. Demographics, preoperative spinal diagnoses, operative characteristics, and patient-reported outcome measures (PROMs) were compared between plating groups. Achievement of an MCID was assessed using the following previously established thresholds: 12-item Short Form health survey physical component summary (SF-12 PCS) 8.1, visual analogue scale (VAS) neck 2.6, VAS arm 4.1, Neck Disability Index (NDI) 8.5. Rates of MCID achievement were compared between groups. RESULTS: The cohort included 192 patients of whom 102 received plating and 90 received no plating. Plating status was significantly associated with Charlson Comorbidity Index and insurance status. Operative duration and estimated blood loss were significantly greater for the plating group. Both groups demonstrated significant improvements at the majority of postoperative timepoints. Significant intergroup differences in PROM improvement were demonstrated for VAS neck and NDI at 6 weeks. Rates of MCID achievement differed significantly between groups for NDI at 6 weeks, and 12 weeks, and SF-12 PCS overall. CONCLUSION: Patients improved significantly in terms of pain, disability and physical function, regardless of plating status, and with the exception of early neck pain and disability, these improvements were similar between groups. Patients that underwent plating as part of their ACDF procedure achieved an MCID for physical function at lower rates overall.

Higher American Society of Anesthesiologists Classification Does Not Limit Safety or Improvement Following Minimally Invasive Transforaminal Lumbar Interbody Fusion.

OBJECTIVE: The American Society of Anesthesiologists (ASA) physical status classification has been used to risk stratify surgical candidates. Our study compares outcomes of minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) procedures based on preoperative ASA physical status classification. METHODS: A surgical registry was reviewed for primary, single-level MIS TLIF patients. Patients were categorized by preoperative ASA physical status classification: ASA I, ASA II, ASA III+. Perioperative complications were compared among groups. Patient-reported outcome measures (PROMs) for back pain, leg pain, physical function, and disability were recorded preoperatively and at 6-week, 12-week, 6-month, 1-year, and 2-year postoperative timepoints. PROM improvement from baseline (ΔPROM) and minimum clinically important difference (MCID) achievement was calculated for each timepoint and compared among groups. MCID achievement was determined as ΔPROMs that surpassed previously established MCID values. RESULTS: Of the 487 patients, 64 had an ASA classification of I, whereas 336 had an ASA of II, and 87 had an ASA of III or greater. Rates of complications were not associated with ASA classification (all p > 0.050). Neither mean PROM scores nor ΔPROM scores were significantly associated with ASA classification at any timepoint (all p > 0.050). MCID achievement was significantly associated with ASA classification for back pain at 1 year only (p = 0.041). Overall MCID achievement was not significantly associated with ASA classification for any PROM (p > 0.050). CONCLUSION: While ASA classification has been commonly used to risk stratify surgical candidates for spinal procedures, patients with an ASA of III or greater may be able to achieve similar long-term outcomes following MIS TLIF given proper selection criteria.

What Can Legacy Patient-Reported Outcome Measures Tell Us About Participation Bias in Patient-Reported Outcomes Measurement Information System Scores Among Lumbar Spine Patients?

OBJECTIVE: Patient-Reported Outcomes Measurement Information System (PROMIS) is a validated tool for assessing patient-reported outcomes in spine surgery. However, PROMIS is vulnerable to nonresponse bias. The purpose of this study is to characterize differences in patient-reported outcome measure scores between patients who do and do not complete PROMIS physical function (PF) surveys following lumbar spine surgery. METHODS: A prospectively maintained database was retrospectively reviewed for primary, elective lumbar spine procedures from 2015 to 2019. Outcome measures for Patient Health Questionnaire-9 (PHQ-9), visual analogue scale (VAS) back & leg, Oswestry Disability Index (ODI), and 12-item Short Form health survey physical composite summary (SF-12 PCS) were recorded at both preoperative and postoperative (6 weeks, 12 weeks, 6 months, 1 year, 2 years) timepoints. Completion rates for PROMIS PF surveys were recorded and patients were categorized into groups based on completion. Differences in mean scores at each timepoint between groups was determined. RESULTS: Eight hundred nine patients were included with an average age of 48.1 years. No significant differences were observed for all outcome measures between PROMIS completion groups preoperatively. Postoperative PHQ-9, VAS back, VAS leg, and ODI scores differed significantly between groups through 1 year (all p < 0.05). SF-12 PCS differed significantly only at 6 weeks (p = 0.003). CONCLUSION: Patients who did not complete PROMIS PF surveys had significantly poorer outcomes than those that did in terms of postoperative depressive symptoms, pain, and disability. This suggests that patients completing PROMIS questionnaires may represent a healthier cohort than the overall lumbar spine population.

Preoperative Duration of Symptoms Does Not Affect Outcomes of Anterior Lumbar Interbody Fusion.

BACKGROUND: Previous studies have examined the impact of preoperative duration of symptoms (DOS) on lumbar spinal surgery outcomes although this has not been explored for anterior lumbar interbody fusion (ALIF). OBJECTIVE: To assess the impact of preoperative DOS on patient-reported outcome measures (PROMs) of ALIF with posterior instrumentation. METHODS: A database was retrospectively reviewed for ALIFs with posterior instrumentation. PROMs recorded at preoperative, 6-wk, 12-wk, 6-mo, and 1-yr postoperative timepoints included Visual Analog Scale back and leg, Oswestry Disability Index, 12-Item Short-Form Physical Component Score (SF-12 PCS), and PROM Information System physical function. Achievement of minimum clinically important difference (MCID) was determined by comparing differences in postoperative PROMs from baseline to established values. Patients were grouped based on preoperative DOS into <1-yr and ≥1-yr groups. Differences in PROMs were compared using a t-test, whereas MCID achievement used a χ2 test. RESULTS: Fifty-three patients were included, with 20 in the <1-yr group and 33 in the ≥1-yr group. The most common diagnosis was isthmic spondylolisthesis. No significant preoperative differences were observed in any PROM. DOS groups demonstrated significantly different scores for SF-12 PCS at 6 wk (P = .049). No significant differences in MCID achievement were observed between groups for any PROM. CONCLUSION: ALIF patients demonstrated similar levels of pain, disability, and physical function regardless of preoperative DOS, except for back pain and physical function at intermittent timepoints. MCID achievement did not differ based on DOS for all outcome measures.

Risk Factors for Failing to Reach a Minimal Clinically Important Difference Following Minimally Invasive Lumbar Decompression.

BACKGROUND: Clinically important postoperative changes can be best evaluated through the minimal clinically important difference (MCID). Our study aims to evaluate risk factors associated with failure to achieve MCID following lumbar decompression (LD). METHODS: Demographics, perioperative characteristics, and patient-reported outcome measures (PROM) for pain, disability, and physical function were retrospectively reviewed and collected for patients undergoing LD. MCID achievement was calculated using established values. Relative risk of demographic and perioperative characteristics with failure to meet MCID for all PROMs was calculated. Least absolute shrinkage and selection operator (LASSO) was used to estimate individual risk factors, and postestimation logistic regression was performed. RESULTS: The study cohort included 811 patients. Comorbidity burden was associated with failed MCID for visual analog scale (VAS) back and leg pain and Oswestry Disability Index (ODI). Operative levels or duration was associated with failed MCID for VAS leg pain, 12-item short form physical component summary (SF-12 PCS), and the patient-reported outcomes measurement information system physical function (PROMIS PF). Preoperative spinal pathology was associated with failed MCID for VAS leg pain, ODI, SF-12 PCS, and PROMIS PF. Additional risk factors included the type of operation, insurance, age, and body mass index. LASSO selected insurance, age, comorbidity burden, blood loss, operative duration, and type of spinal pathology as significant risk factors for failure to reach MCID. CONCLUSION: Failure to reach MCID was greatest for VAS back. Age, comorbidity burden, and prolonged procedures were significantly associated with risk for failure to reach MCID for a majority of PROMs. Comorbidity burden combined with operative outcomes may place patients at increased risk for failure to reach MCID for pain, disability, and physical function following LD. CLINICAL RELEVANCE: Establishes risk factors for failing to reach the threshold of meaningful difference in symptoms after LD surgery.

Differences in Clinically Important Physical Function Improvement in Workers' Compensation Population.

BACKGROUND: Patients receiving workers' compensation demonstrate a propensity for poorer postoperative outcomes. This study aims to determine rates of minimum clinically important difference (MCID) achievement in patients receiving workers' compensation following transforaminal lumbar interbody fusion (TLIF). METHODS: We retrospectively reviewed a prospective surgical database from 2015 to 2020 for primary, single-level TLIFs with posterior instrumentation for degenerative spinal pathologies. Visual analog scale (VAS) for back and leg, Oswestry Disability Index (ODI), 12-Item Short Form Physical Component Summary (SF-12 PCS), and Patient-Reported Outcome Measurement Information System physical function (PROMIS-PF) were collected pre- and postoperatively. Patients were separated by workers' compensation (WC) status. Propensity score matching was performed to account for differences in demographic characteristics. Postoperative improvements in patient-reported outcome measures (PROMs) were calculated using paired Student's t test, and intergroup differences were determined by Mann-Whitney U test. Achievement of MCID was determined using established values, and intergroup differences were assessed using χ 2 analysis. RESULTS: A total of 121 patients were included in this study with 29 WC and 92 non-WC patients. The mean age was 53.5 years with the majority being men (63.6%) and nonobese (54.5%). WC patients demonstrated significantly poorer PROM values at all timepoints except for preoperative VAS back (P = 0.297) and leg (P = 0.475). Overall achievement of MCID was significantly lower for WC patients for VAS back (P = 0.040), ODI (P = 0.001), SF-12 PCS (P = 0.010), and PROMIS-PF (P = 0.039). CONCLUSION: WC patients demonstrated poorer postoperative outcomes at multiple timepoints. Additionally, a significantly lower rate of MCID achievement for back pain, disability, and physical function was observed for WC patients. CLINICAL RELEVANCE: These results suggest that WC patients may require alternative preoperative counseling about realistic expectations for improvement following lumbar fusion.

Impact of Depression Severity on Patient-Reported Outcome Measures Following Multilevel Anterior Cervical Discectomy and Fusion.

BACKGROUND: Few studies have investigated the effects of preoperative depression and multilevel procedures on patient-reported outcomes (PROs) following anterior cervical discectomy and fusion (ACDF). This study aims to determine the impact of preoperative depression on PROs in single vs multilevel ACDF procedures. METHODS: Eligible primary single or multilevel ACDF procedures were retrospectively reviewed from 2015 to 2020 using a surgical database. PROs included visual analog scale (VAS), Neck Disability Index (NDI), 12-Item Short Form Physical Composite Summary and Mental Composite Summary (SF-12 PCS and MCS), and Patient-Reported Outcomes Measurement Information System physical function (PROMIS PF). PROs were collected preoperatively and at 6 weeks, 12 weeks, 6 months, and 1 year postoperatively. Patients were stratified into 3 groups based on Patient Health Questionnaire-9 (PHQ-9) score. Differences in PROs were assessed based on preoperative depression severity or both preoperative depression severity and number of operative levels. RESULTS: Our patient cohort included 42 individuals with minimal preoperative depressive symptoms, 32 having mild and 27 having moderate to severe. Baseline PRO values were significantly different between groups (all P < 0.01). Improvement significantly differed between groups at 6 weeks for VAS arm, NDI, and SF-12 MCS (all P < 0.05), and at 12 wweeks for VAS neck, NDI, SF-12 PCS and MCS, and PROMIS PF (all P < 0.05). SF-12 PCS and MCS at 6 months and VAS arm and SF-12 MCS at 1 year demonstrated significant intergroup differences (all P < 0.05). VAS arm at 1 year (P = 0.029), NDI at 12 weeks (P = 0.034), PROMIS PF at 6 weeks (P = 0.038), and SF-MCS at all postoperative time points were impacted by both preoperative depression severity and number of levels fused. CONCLUSION: Depression severity impacted recovery of pain, disability, and physical function preoperatively and at intermittent postoperative time points. Both severity and multilevel procedures impacted pain and mental health at intermittent postoperative time points. In addition to depression, multilevel ACDF procedures are an additional factor that must be considered in expected improvement of postoperative outcomes. CLINICAL RELEVANCE: Multilevel ACDF procedures and preoperative depression severity both impact postoperative pain, disability, and physical function.

Two-year validation and minimal clinically important difference of the Veterans RAND 12 Item Health Survey Physical Component Score in patients undergoing minimally invasive transforaminal lumbar interbody fusion.

OBJECTIVE: The Physical Component Score of the Veterans RAND 12 Item Health Survey (VR-12 PCS) has been assessed for use at short-term and intermediate-term time points for lumbar fusion populations. This study assesses the long-term validity and establishes minimal clinically important difference (MCID) values of VR-12 PCS in patients undergoing minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). METHODS: A surgical registry was retrospectively reviewed for primary, elective, single-level MIS TLIF procedures with posterior instrumentation. Patients missing preoperative and 2-year postoperative VR-12 PCS survey data were excluded. VR-12 PCS, SF-12 Health Survey Physical Component Summary (SF-12 PCS), Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS PF), and Oswestry Disability Index (ODI) patient-reported outcome measures (PROMs) were recorded preoperatively and postoperatively. Responsiveness of the VR-12 measure was assessed in two ways. First, the mean postoperative PROM scores were compared with preoperative baseline values using a paired Student t-test. Second, MCID values were calculated using both distribution-based and anchor-based methods and used to assess improvement in VR-12 score at the 2-year time point. Discriminant validity of the VR-12 was assessed using cross-sectional and longitudinal anchors. Convergent validity of the VR-12 measure was assessed using Pearson's correlation coefficient and partial time-independent correlation. Floor and ceiling effects were assessed. RESULTS: A total of 74 patients who underwent MIS TLIF were included. The VR-12 PCS demonstrated significant improvements at all time points from 12 weeks to 2 years (p < 0.001 for all). VR-12 PCSs were significantly different for patients classified using cross-sectional anchors (p < 0.001) and longitudinal anchors (p ≤ 0.005). Calculated MCID values ranged from 4.1 to 8.5, and 4.1 was selected as the optimal MCID, which 87.8% of patients achieved. Strong, significant correlations of the VR-12 PCS with SF-12 PCS and PROMIS PF were demonstrated at all time points (p < 0.001 for all). No significant floor or ceiling effects were detected. CONCLUSIONS: The VR-12 PCS demonstrated excellent responsiveness, discriminant and convergent validity, and no significant floor or ceiling effects up to 2 years after MIS TLIF. Therefore, VR-12 PCS may serve as a valid measure of long-term physical function.

Predicting Acute Changes in Depressive Symptoms Following Lumbar Decompression.

BACKGROUND: While depressive symptoms improve for most patients following minimally invasive lumbar decompression (MIS LD), for some, symptoms may worsen. This study aimed to investigate predictors of change in depressive symptoms in the short-term postoperative period following MIS LD. METHODS: We retrospectively analyzed a prospective surgical database for patients undergoing primary MIS LD procedures from 2016 to 2020. Preoperative pain (visual analog scale back and leg) scores were recorded, and the 9-Item Patient Health Questionnaire (PHQ-9) was administered at the preoperative and postoperative (6 weeks, 12 weeks, 6 months, and 1 year) timepoints. Patients were grouped into 1 of 3 categories of depression severity based on preoperative PHQ-9 scores: minimal (0-4), mild (5-9), and moderate to severe (10-27). Postoperative change in depressive symptoms was calculated by determining differences from baseline scores to scores at 6 weeks, 12 weeks, and 6 months. Analysis of demographics, perioperative characteristics, and spinal pathologies was conducted using χ 2 test. Significant factors contributing to postoperative changes in depression were analyzed using multiple linear regression analysis. Significance was set at P = 0.05. RESULTS: The 216 patients included had a mean age of 48 years, and a majority were men (70.4%). Most patients had a preoperative diagnosis of spinal stenosis (90.3%) or herniated nucleus pulposus (69.9%). Univariate analysis identified age, ethnicity, insurance, and diabetes as significant variables among depression severity groups. Patients demonstrated significant improvements in depressive symptoms at all postoperative timepoints (P < 0.001). Multivariate analysis identified several significant predictors of postoperative change in PHQ-9, which included moderate to severe preoperative depression for all postoperative timepoints (all P ≤ 0.038), mild preoperative depression for 6 weeks and 12 weeks (both P ≤ 0.029), and private insurance (P = 0.002) and smoking status (P = 0.047) at 12 weeks. CONCLUSION: Depression improved at all postoperative timepoints following LD. Insurance type, smoking status, and preoperative depression severity were all identified as significant predictors of postoperative changes in depressive symptoms. CLINICAL RELEVANCE: This study explores predictors of changes in depressive symptoms following LD.

Impact of Lower Extremity Arthroplasty on Improvement of Quality-of-Life Outcomes Following Lumbar Fusion.

BACKGROUND: Both hip-spine and knee-spine syndromes can significantly impact a patient's quality of life; however, few studies have investigated their effect on postoperative outcomes following lumbar fusion. OBJECTIVE: Our study aimed to evaluate the impact of a prior lower extremity arthroplasty on the improvement of patient-reported outcome measures (PROMs) following lumbar fusion surgery. METHODS: Patients undergoing primary, single, or multilevel lumbar interbody fusion were retrospectively reviewed. Patients missing preoperative PROMs were excluded. PROMs were collected preoperatively and postoperatively and included the Oswestry Disability Index (ODI), 12-Item Short Form Physical Component Summary, Patient-Reported Outcomes Measurement Information System Physical Function, and visual analog scale (VAS). A minimum clinically important difference (MCID) was calculated. Patients were categorized based on a history of hip/knee arthroplasty and propensity score matched. Intragroup improvement of PROM scores and intergroup differences in mean scores were evaluated using a paired t test and linear regression. MCID achievement differences were evaluated using logistic regression. RESULTS: A total of 335 patients were included, with 25 having a history of hip/knee arthroplasty. Arthroplasty patients were significantly older (P = 0.001) and typically had a higher Charlson Comorbidity Index (P ≤ 0.003, both). Patients differed in spinal pathology of degenerative spondylolisthesis (P = 0.049). Nonarthroplasty patients demonstrated significant improvements in all PROMs by 2 years (P < 0.001, all). The arthroplasty group demonstrated significant improvements in all PROMs by 1 year (P < 0.031, all). Preoperative VAS back was significantly worse for nonarthroplasty patients (P = 0.035). MCID achievement did not significantly differ between groups except at 6 months for ODI (P = 0.035). CONCLUSION: Following lumbar fusion, patients with a past surgical history did not demonstrate differences in outcome measures or MCID from those without. These results suggest that comorbid orthopedic conditions requiring surgery do not negatively impact the ability of patients to improve following lumbar fusion. CLINICAL RELEVANCE: Prior surgical history of lower extremity arthroplasty should not discourage the use of lumbar fusion when properly indicated, as patients reported clinical improvement regardless of history of hip or knee arthroplasty.

History of Prior Lumbar Surgery Does Not Impact Mental Health Outcomes Following Anterior Cervical Discectomy and Fusion.

STUDY DESIGN: This was a retrospective cohort study. OBJECTIVE: The objective of this study was to evaluate the impact of undergoing a prior lumbar procedure on mental health outcomes following anterior cervical discectomy and fusion. SUMMARY OF BACKGROUND DATA: Revision and reoperations are perceived as risk factors for worse mental health outcomes. METHODS: A retrospective review of a surgical database was performed for cervical and lumbar procedures. The mental health measures used were: Short Form 12-Item Mental Composite Score (SF-12 MCS) and Patient Health Questionnaire 9 (PHQ-9). Secondary outcomes of interest were Visual Analogue Scale for neck and arm pain, Neck Disability Index, and Short Form 12-Item Physical Composite Score (SF-12 PCS). All outcomes were collected preoperatively and at 6 weeks, 12 weeks, 6 months, and 1 year postoperatively. Minimum clinically important difference (MCID) was calculated using established values. Patients were grouped based on the surgical history of an elective lumbar spine procedure and propensity-matched. Differences in postoperative outcome scores and MCID achievement were evaluated using linear and logistic regression respectively. RESULTS: A total of 74 patients were included in this study. Mental health outcomes did not demonstrate significant differences between groups for SF-12 MCS and PHQ-9 for all time points except at 6 weeks for PHQ-9 ( P =0.038). MCID achievement was not significantly impacted by surgical history for all outcome measures at all postoperative time points (all P >0.050). The majority of patients achieved an MCID by the 1-year time point for all outcomes for patients without a prior lumbar surgery except for Visual Analogue Scale arm and SF-12 PCS, while those with a surgical history achieved an MCID for all outcomes except SF-12 PCS and PHQ-9. CONCLUSIONS: Anterior cervical discectomy and fusion patients with a past history of lumbar surgery demonstrated significant improvements in depression, neck and arm pain, disability, and physical function as those without a past lumbar surgical history. Prior surgery also did not impact MCID achievement for all outcomes.

Anterior Cervical Discectomy and Fusion Results in Clinically Significant Improvements in Patients With Preoperative Sleep Difficulties.

BACKGROUND: Individual items within the Patient Health Questionnaire-9 (PHQ-9) have not been assessed as predictors of postoperative outcomes. Our objective is to study the relationship between responses to individual PHQ-9 items and achievement of a minimum clinically important difference (MCID) following anterior cervical discectomy and fusion (ACDF). METHODS: A prospective surgical database was reviewed for primary, single-level ACDF procedures performed for degenerative spinal pathology. Patient demographics, preoperative spinal pathology, and perioperative characteristics were recorded. Patient-reported outcome measures (PROMs) including PHQ-9, visual analog scale (VAS) neck and arm, Neck Disability Index, 12-item Short Form physical component score (SF-12 PCS), and Patient-Reported Outcomes Measurement Information System Physical Function were administered at preoperative and 6-week, 12-week, 6-month, 1-year, and 2-year postoperative timepoints. MCID achievement was determined by comparing postoperative PROM improvement from baseline to previously established values. Logistic regression assessed responses to each individual question of the preoperative PHQ-9 as predictors of MCID achievement in each other PROMs. RESULTS: Sixty-six ACDF patients were included with a mean age of 47.2 years. Herniated nucleus pulposus was the most common preoperative spinal diagnosis (95.6%). The mean operative duration was 50.3 minutes, the mean estimated blood loss was 27.5 mL, and most patients were discharged on postoperative day 0 (81.8%). A majority of patients achieved MCID for all measures except SF-12 PCS. PHQ-9 question 3 significantly predicted MCID achievement for VAS neck (P = 0.045), VAS arm (P = 0.049), and SF-12 PCS (P = 0.037). No other PHQ-9 items or overall PHQ-9 scores significantly predicted MCID achievement. CONCLUSION: Question 3 of the PHQ-9 regarding "trouble falling asleep, staying asleep, or sleeping too much" significantly predicted clinically meaningful improvement in neck pain, arm pain, and physical function following ACDF, although overall PHQ-9 scores did not. Providers should inform patients experiencing significant sleep-related difficulties that they may be especially likely to benefit from ACDF surgery. CLINICAL RELEVANCE: Evaluation of sleep from the PHQ-9 predicts clinically relevant improvement in neck pain, arm pain, and physical function in patients undergoing ACDF.

Epidemiological Relevance of Elevated Preoperative Patient Health Questionnaire-9 Scores on Clinical Improvement Following Lumbar Decompression.

BACKGROUND: Limited research exists regarding the influence of preoperative depression on postoperative mental health, physical function, and pain in lumbar decompression (LD) patients. This study aims to evaluate the association of depressive symptoms as measured by the Patient Health Questionnaire-9 (PHQ-9) with other mental health and physical function clinical outcomes among patients undergoing LD. METHODS: A prospectively maintained surgical registry was reviewed for primary LD from March 2016 to May 2019. Patients were stratified into 3 preoperative PHQ-9 score subgroups. Higher PHQ-9 scores indicated greater depressive symptoms. We assessed demographic and perioperative characteristics among subgroups with appropriate statistical testing. We also evaluated outcome instruments and postoperative improvement for the following outcomes: PHQ-9, Short Form 12 (SF-12), Veterans RAND 12-Item (VR-12), Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF), visual analog scale (VAS) leg, and VAS back. RESULTS: The 351-subject cohort was 70.4% men with an average age of 47 years; 186 subjects had minimal preoperative depressive symptoms (PHQ-9 <5), 94 had moderate (5≤ PHQ-9 ≤10), and 71 had severe (PHQ-9 >10). Subgroups with more severe symptoms of depression had worse mental health outcome scores (PHQ-9, 12-Mental Health Composite Score [12-MCS], and VR-12-MCS) and a positive linear association with greater pre- to postoperative mental health improvements at all timepoints. Subgroups with more severe symptoms of depression had worse PROMIS-PF scores at all timepoints, though VAS pain scores had no depression symptom association by 1 year. CONCLUSION: Patients with more severe preoperative depressive symptoms, as evaluated by PHQ-9, have a greater improvement in PHQ-9, SF-12, and VR-12 scores, but more severe PHQ-9 scores are associated with worse overall physical function scores. This study demonstrates the relevance of preoperative depressive symptoms and their necessity in future risk factor models. CLINICAL RELEVANCE: Severity of preoperative PHQ-9 acts as a significant risk factor to postoperative pain and mental and physical health improvement.

Impact of Prolonged Duration of Symptoms on Mental Health in Anterior Cervical Disectomy and Fusion Patients.

INTRODUCTION: Prolonged duration of symptoms is associated with worse pain and disability in patients undergoing anterior cervical discectomy and fusion (ACDF). Our study aims to determine the effect of symptom duration on severity of depression among ACDF patients. METHODS: We retrospectively reviewed a prospective surgical database from 2006 to 2019 for primary, single, or multilevel ACDF. Patients missing the duration of symptom information or patient-reported outcome measures (PROMs) were excluded. PROMs included Patient Health Questionnaire-9, 12-Item Short Form Mental Component Score, and 12-Item Veterans RAND Mental Component Score and were collected at preoperative, 6-week, 12-week, 6-month, 1-year, and 2-year timepoints. The minimum clinically important difference (MCID) was calculated using the established values. Patients were categorized based on preoperative duration of symptoms as follows: <6 months, ≥6 months and <1 year, 1 to 2 years, and >2 years. Univariate analysis was done to determine differences in demographics and perioperative characteristics. Intergroup differences in PROMs and MCID achievement were evaluated using linear regression and logistic regression, respectively. RESULTS: Two hundred thirty-one ACDF patients included had a mean age of 49.6 years and most were male (61.0%) and nonobese (<30 kg/m2; 55.0%). The groups differed by their American Society of Anesthesiologists classification (P = 0.029), workers' compensation status (P = 0.022), and diagnosis of herniated nucleus pulposus (P = 0.010). Postoperative mental health outcomes did not significantly differ between duration groups except for Veterans Rand-12 Mental Component Score at 12 weeks (P = 0.044). MCID achievement rates did not significantly differ. CONCLUSION: Patients undergoing ACDF largely did not demonstrate differences in mental health scores or achievement of MCID based on the duration of symptoms.

Impact of Obesity Severity on Achieving a Minimum Clinically Important Difference Following Minimally Invasive Transforaminal Lumbar Interbody Fusion.

STUDY DESIGN: This was a retrospective cohort study. OBJECTIVE: The objective of this study was to determine the impact of obesity on postoperative outcomes and minimum clinically important difference (MCID) achievement following minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). SUMMARY OF BACKGROUND DATA: Obesity is a proven risk factor for poorer outcomes in MIS TLIF patients. However, few studies have investigated the impact of body mass index (BMI) on achievement of a MCID for Patient-Reported Outcome Measurement Information System Physical Function (PROMIS PF). METHODS: A prospective surgical database was retrospectively reviewed for primary, elective, single level MIS TLIF patients. Patients were categorized into BMI groups: nonobese (<30 kg/m2); obese I (≥30 and <35 kg/m2); severe (≥35 and <40 kg/m2); and morbid (≥40 kg/m2). Demographic, perioperative information, and complication rates were compared between groups. Visual Analog Scale (VAS) back and leg, Oswestry Disability Index (ODI), 12-Item Short Form-12 Physical Composite Score (SF-12 PCS), and PROMIS PF were collected preoperatively and up to 2-year postoperatively. Impact of BMI on outcome measures and MCID achievement at all timepoints was evaluated. RESULTS: A total of 162 patients were included with 88 patients categorized as normal weight, 37 obese I, 25 severe, and 12 morbid. SF-12 PCS, and PROMIS PF significantly differed by BMI at all timepoints, but only at 6- and 12-week for VAS back, preoperatively and 12 weeks for VAS leg, and preoperatively to 1-year for ODI. MCID achievement only differed for PROMIS PF and VAS back at 2 years, but did not for overall MCID achievement. CONCLUSIONS: BMI is a significant predictor of ODI, SF-12 PCS, and PROMIS PF preoperatively to 1-year postoperatively, but only through 12-week for VAS scores. MCID achievement varied for PROMIS PF and VAS back, suggesting that though BMI may affect postoperative outcome values, obesity may impact a patient's perception of meaningful improvements in pain and physical function.

The Influence of Preoperative Narcotic Consumption on Patient-Reported Outcomes of Lumbar Decompression.

STUDY DESIGN: Retrospective cohort. PURPOSE: This study aimed to assess the relationship between preoperative narcotic consumption and patient-reported outcomes (PRO) in patients undergoing minimally invasive (MIS) lumbar decompression (LD). OVERVIEW OF LITERATURE: Previous studies report negative effects of narcotic consumption on perioperative outcomes and recovery; however, its impact on quality of life and surgical outcomes is not fully understood. METHODS: A surgical database was retrospectively reviewed for patients undergoing primary, single-level MIS LD from 2013 to 2020. Patients lacking preoperative narcotic consumption data were excluded. Demographics, spinal pathologies, and operative characteristics were collected. Patients were grouped based on preoperative narcotic consumption. Patient Health Questionnaire-9 (PHQ-9), Visual Analog Scale (VAS) for back and leg, Oswestry Disability Index (ODI), 12-item Short Form Physical Component Summary, and Patient-Reported Outcomes Measurement Information System physical function (PROMIS-PF) were collected preoperatively and postoperatively. Preestablished values were used to calculate achievement of minimum clinically important difference (MCID). Differences in mean PROs and MCID achievement between groups were evaluated. RESULTS: The cohort was 453 patients; 184 used preoperative narcotics and 269 did not. Significant differences were found in American Society of Anesthesiologists classification, ethnicity, insurance type, and estimated blood loss between groups. Significant differences were also found in preoperative PHQ-9, VAS leg, ODI, and PROMIS-PF between groups (all p<0.05). Mean postoperative PROs did not differ by group (p>0.05). A higher rate of MCID achievement was associated with the narcotic group for PHQ-9 and PROMIS-PF at 6 weeks (both p≤0.050), VAS leg at 1 year (p=0.009), and overall for ODI and PHQ-9 (both p≤0.050). CONCLUSIONS: Preoperative narcotic consumption was associated with worse preoperative depression, leg pain, disability, and physical function. In patients consuming preoperative narcotics, a higher proportion achieved an overall MCID for disability and depressive symptoms. Patients taking preoperative narcotic medications may report significantly worse preoperative PROs but demonstrate greater improvements in postoperative disability and mental health.

Meeting Patient Expectations or Achieving a Minimum Clinically Important Difference: Predictors of Satisfaction among Lumbar Fusion Patients.

STUDY DESIGN: Retrospective cohort. PURPOSE: To investigate the impact of meeting a patient's preoperative expectations for back or leg pain or the achievement of minimum clinically important difference (MCID) on patient satisfaction following lumbar fusion. OVERVIEW OF LITERATURE: Few studies have compared if MCID achievement or meeting preoperative expectations for pain reduction affects patient satisfaction. METHODS: A surgical database was reviewed for eligible patients who underwent lumbar fusion. Patient satisfaction and Visual Analog Scale (VAS) for back and leg pain were the outcomes of interest. Meeting expectations was calculated as a difference of ≤0 between preoperative expectations and postoperative VAS scores. MCID achievement was calculated by comparing changes in VAS scores with established values. Meeting preoperative expectations or MCID achievement as predictors of patient satisfaction was evaluated using regression analysis. RESULTS: A total of 134 patients were included in this study. Patients demonstrated significant improvements in VAS back and VAS leg (p<0.001). At 1 year, 56.4% of patients had their VAS back expectations met compared with 59.5% for VAS leg. Similarly, at 1 year, 77.3% and 71.3% of patients achieved MCID for VAS back and leg, respectively. Meeting expectations for VAS back was significantly associated with patient satisfaction at all postoperative timepoints; however, MCID achievement only demonstrated a significant association with patient satisfaction at 6 and 12 weeks (all, p≤0.024). Meeting VAS leg expectations and MCID achievement both demonstrated a significant association with patient satisfaction at all postoperative timepoints (all, p≤0.02). No differences between MCID achievement and meeting expectations as predictors of satisfaction were noted. CONCLUSIONS: The majority of patients achieved MCID and had their back and leg pain expectations met by 1 year. Both measures were significant predictors of patient satisfaction and suggest that MCID achievement may act as a suitable substitute for patient satisfaction.