Preoperative Physical Function Association With Mental Health Improvement After Anterior Cervical Discectomy and Fusion.

STUDY DESIGN: This was a retrospective study. OBJECTIVE: This study investigates the influence of physical function and their influence on postoperative depressive symptom scores as measured by Patient Health Questionnaire-9 (PHQ-9) among anterior cervical decompression and fusion (ACDF) patients. BACKGROUND: While ACDF is one of the most commonly performed ambulatory surgeries, research is limited on the predictive value of Patient-Reported Outcomes Measurement Information System (PROMIS) scores and their influence on depressive symptoms as measured by the PHQ-9. METHODS: A prospectively maintained surgical registry was retrospectively reviewed from March 2016 to January 2019. Inclusion criteria were primary or revision ACDF procedures. Patients were grouped by preoperative PROMIS score (≥35.0, <35.0), with higher scores indicating greater physical function. The χ2 and Student t tests assessed categorical and continuous variables (eg, demographics, perioperative, and postoperative values). A t test evaluated postoperative improvement in PROMIS Physical Function (PF) scores between subgroups among PROMIS PF scores and PHQ-9 score improvement at 6, 12 weeks, 6 months, and 1 year. Linear regression assessed preoperative PROMIS scores influence on PHQ-9 score improvement. RESULTS: The 121 subject cohort was 61.2% male with an average age of 49.6±9.8 years. Compared with the PROMIS ≥35.0 group, the PROMIS <35.0 group also had larger improvement of PROMIS scores at 6 weeks. No significant difference in postoperative PHQ-9 improvement was observed between subgroups. There was a negative association between preoperative PROMIS scores and improvement in PROMIS scores at 6, 12 weeks, 6 months, and 1 year. There was a positive association between preoperative PROMIS scores and magnitude of 1-year PHQ-9 change. CONCLUSIONS: Individuals with lower preoperative PROMIS PF scores had significantly higher PHQ-9 scores at 1 year. Patients with lower preoperative physical function, as evaluated by PROMIS PF scoring, had greater improvement of mental health at 1 year postoperatively. This suggests that many patients experience multidimensional health benefits after ACDF procedures.

The Perioperative Symptom Severity of Higher Patient Health Questionnaire-9 Scores Between Genders in Single-Level Lumbar Fusion.

BACKGROUND: Preoperative depression is associated with increased perioperative pain, worse physical function, reduced quality of life, and inferior outcomes. Few studies have evaluated depressive symptoms between genders for individuals undergoing minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). The purpose of this investigation was to assess the severity of Patient Health Questionnaire-9 (PHQ-9) scores among patients with depressive symptoms before and after single-level MIS TLIF. METHODS: A prospective surgical registry was retrospectively reviewed for spine surgeries between March 2016 and December 2018. We included patients with at least mild depressive symptoms (PHQ-9 scores ≥ 5) who underwent primary, single-level MIS TLIF and compared genders using χ2 tests and t tests. Genders were stratified by depressive symptom severity: mild (5-9), moderate (10-14), and moderately severe (≥15) and then analyzed at preoperative and postoperative intervals: 6 weeks, 12 weeks, 6 months, and 1 year. Finally, PHQ-9 scores were validated with a Pearson correlation test against the 12-item Short Form (SF-12) Mental Composite Score (MCS) and the Veterans RAND (VR-12) MCS. RESULTS: Of 75 subjects, 44.0% were women and the mean age was 49.9 years. The preoperative distribution among PHQ-9 subgroups was 38.7%, 26.6%, and 34.7% for mild, moderate, and moderately severe depressive symptoms, respectively. Among PHQ-9 stratifications both genders demonstrated intermittent statistically significant improvements in PHQ-9 scores. The moderately severe PHQ-9 subgroup had improvement at all postoperative time points. The PHQ-9 scores demonstrated a strong correlation with the SF-12 MCS and VR-12 MCS at all postoperative evaluations. CONCLUSION: At baseline and by the final 1-year follow-up there were no statistically significant PHQ-9 score differences between genders within any depressive symptom stratifications. Whereas some contend that men and women have substantial mental health differences, this study is aligned with growing evidence that demonstrates similar depressive symptoms between genders. LEVEL OF EVIDENCE: 3. CLINICAL RELEVANCE: Men and women may be at an equivalent risk for perioperative depressive symptoms.

Validating the VR-12 Physical Function Instrument After Anterior Cervical Discectomy and Fusion with SF-12, PROMIS, and NDI.

BACKGROUND: Development and validation of Veterans RAND 12-item (VR-12) physical component survey (PCS) has been established among civilian and veteran populations but it has not been examined among anterior cervical discectomy and fusion (ACDF) patients. PURPOSES/QUESTIONS: We sought to validate legacy patient-reported outcome measures (PROMs) with VR-12 PCS among patients undergoing ACDF procedures. METHODS: A prospectively collected surgical registry was retrospectively evaluated for elective single or multi-level ACDFs performed for degenerative spinal pathologies from January 2014 to August 2019. Exclusion criteria included missing pre-operative surveys and surgery for trauma, metastasis, or infection. Demographic variables, baseline pathologies, and peri-operative variables were collected. A paired t test evaluated the change from the pre-operative score to each post-operative timepoint for VR-12 PCS, the 12-item Short-Form Survey (SF-12) PCS, Patient-Reported Outcomes Measurement Information System physical function (PROMIS-PF), and Neck Disability Index (NDI). Minimal clinically important difference (MCID) achievement was calculated at each timepoint. Correlation was evaluated with a Pearson's correlation coefficient and time-independent partial correlation. RESULTS: Of the 202 patients who underwent ACDF, 41.1% were female and the average age was 49.5 years. All PROMs had statistically significantly increased from baseline when compared with post-operative timepoints (12 weeks, 6 months, 1 year, and 2 years). MCID achievement rates increased through 2 years. All timepoints revealed strong VR-12 PCS correlations with SF-12 PCS, PROMIS-PF, and NDI scores. CONCLUSION: VR-12 PCS was strongly correlated with the well-validated SF-12 PCS and NDI metrics as well as with the more recent PROMIS-PF. All PROMs demonstrated statistically significant improvement in patients post-operatively. VR-12 PCS is a valid measure of physical function among patients undergoing ACDF.

Postoperative Pain, Narcotics Consumption, and Patient-Reported Outcomes Based on PROMIS Physical Function Following a Single-Level Anterior Cervical Discectomy and Fusion.

STUDY DESIGN: Retrospective. OBJECTIVE: To determine the association between preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) scores with postoperative pain, narcotics use, and patient-reported outcomes (PRO) following a single-level anterior cervical discectomy and fusion (ACDF) procedure. SUMMARY OF BACKGROUND DATA: There is a scarcity of prior literature on the ability of baseline PROMIS scores to predict clinical outcomes for patients undergoing ACDF procedures. METHODS: Patients who underwent a primary ACDF were retrospectively reviewed and stratified into low and high disability cohorts. Preoperative PROMIS PF cohorts were tested for association with demographic and perioperative characteristics using chi-square analysis and one-way analysis of variance. Cohorts were tested for association with inpatient pain scores and narcotics consumption, as well as postoperative improvements in PROMIS PF, neck disability index (NDI), and visual analog scale (VAS) neck and arm pain using linear regression. RESULTS: Ninety one patients were included: 39 low disability and 52 high disability. Inpatient postoperative VAS pain scores and narcotic consumption are also compared between cohorts. Patients with greater disability reported higher VAS pain scores (P = 0.003). However, patients in both cohorts consumed comparable amounts of narcotics (P = 0.926). Patients with greater preoperative disability demonstrated lower PROMIS PF scores, greater NDI scores, and greater VAS Neck scores at the preoperative baseline. However, patients demonstrated similar improvement of VAS neck and arm pain, as well as NDI at all postoperative timepoints. Patients with low disability reported worsened physical function at the 6 weeks timepoint. CONCLUSION: Patients with worse preoperative disability as measured by PROMIS PF reported increased pain but comparable narcotics consumption in the immediate postoperative period following a single-level ACDF procedure. Furthermore, patients experienced similar long-term postoperative improvement of PROs regardless of preoperative physical function. PROMIS PF can efficiently quantify physical function before and after the ACDF procedure as self-evaluated by patients. LEVEL OF EVIDENCE: 3.

The influence of gender on postoperative PROMIS physical function outcomes following minimally invasive transforaminal lumbar interbody fusion.

PURPOSE: Our aim is to examine the gender performance of Patient-Reported Outcome Measurement Information System Physical Function (PROMIS-PF) scores among patients undergoing minimally invasive transforaminal lumbar fusion (MIS TLIF). METHODS: A prospectively collected surgical dataset was retrospectively assessed for eligible patients from March 2015-June 2019. We included patients if they underwent primary MIS TLIF procedures on one or two vertebral levels. We collected baseline demographics, perioperative characteristics, and PROMIS-PF scores for each subject at pre and postoperative timepoints (e.g., 6-weeks, 3-months, 6-months, and 1-year). Chi-squared analyses were utilized to assess categorical variables and a Student's t-tests analyzed continuous variables. A linear regression was used to analyze PROMIS-PF scores from baseline through all postoperative time points. Finally, we evaluated the PROMIS PF achievement of minimal clinically important difference (MCID) among gender. RESULTS: 192 patients were included: 77 were females and 115 were males. No significant differences were observed among gender subgroups for PROMIS-PF scores at pre- or postoperative evaluations. Compared to males, females experienced significantly greater postoperative improvement with PROMIS-PF scores at the 3-month assessments, though no significant gender differences were observed during later follow-up evaluations at 6-months or one year. Females were observed to have significant PROMIS-PF score improvement from their preoperative evaluation to each postoperative score. Males were assessed to have statistically significant postoperative (e.g., at 3-months, 6-months, and 1-year) PROMIS-PF score improvement from their preoperative PROMIS-PF scores. There were no significant differences among gender in achieving MCID at any postoperative time interval. CONCLUSION: Among gender, we observed no statistically significant difference in PROMIS-PF scores during the pre- or postoperative evaluations. Additionally, with no difference in the rate of achieving PROMIS-PF MCID postoperatively, this study established that both genders should experience similar functional outcomes following MIS TLIF.

A Validation of Patient Health Questionnaire-9 for Cervical Spine Surgery.

STUDY DESIGN: Retrospective. OBJECTIVE: The purpose of this study is to evaluate depressive symptoms as measured by the PHQ-9 survey and correlated them with scores from the SF-12 and VR-12 Mental Component Summary (MCS). SUMMARY OF BACKGROUND DATA: With the rising incidence of depression and the need to identify modifiable risk factors before surgery, it is increasingly important to screen for preoperative depressive symptoms in spine surgery. Although the Patient Health Questionnaire-9 (PHQ-9) has favorable characteristics as a depressive symptom screening instrument, it has not been evaluated within cervical spine surgery. METHODS: A prospectively maintained surgical registry was reviewed for patients undergoing single or multilevel anterior cervical discectomy and fusion (ACDF) or cervical disc replacement (CDR) from March 2016 until May 2019. Included patients underwent a procedure for degenerative spinal pathology. We collected demographic, baseline, and perioperative variables. The mean scores for postoperative PHQ-9, Short Form-12 (SF-12), and Veterans RAND-12 (VR-12) surveys were calculated, and an average change between preoperative and postoperative scores. Scatterplots depicted the association of SF-12 MCS and VR-12 MCS with PHQ-9. We evaluated the relationship of PHQ-9 with SF-12 MCS and VR-12 MCS scores by calculating a Pearson correlation coefficient and time-independent partial correlation coefficient. RESULTS: One hundred fifty-two patients underwent single or multilevel level cervical spine surgery (ACDF: 73% and CDR: 27%). The average age was 42.4 and 39% were female. Compared to preoperative scores, significant increases were observed among postoperative PHQ-9, SF-12, and VR-12 MCS surveys (P ≤ 0.001). We observed strong correlations between SF-12 and VR-12 MCS with PHQ-9 scores for both assessed correlations. CONCLUSION: Patients undergoing ACDF or CDR demonstrated significant improvement with PHQ-9, SF-12 MCS, and VR-12 MCS instruments. PHQ-9 scores strongly correlated with SF-12 MCS and VR-12 MCS. Our findings indicate PHQ-9 is a valid tool to evaluate pre and postsurgical depressive symptoms. LEVEL OF EVIDENCE: 4.

A Review of Vitamin D in Spinal Surgery: Deficiency Screening, Treatment, and Outcomes.

In this review, we discuss the demonstrated value of vitamin D in bone maintenance, fracture resistance, spinal health, and spine surgery outcomes. Despite this, the effect of vitamin D levels in spine surgery has not been well described. Through this review of literature, several conclusions were drawn. First, despite the fact that a high number of spine surgery patients are vitamin D deficient, screening is not commonly performed. Second, adequate vitamin D levels will not be achieved in a majority of these patients without supplementation. Last, inadequate vitamin D levels may increase the risk of pseudarthrosis. Given these findings, we suggest that many patients undergoing spinal surgery could be treated with vitamin D supplementation prior to surgery without the need for confirmatory testing for vitamin D deficiency. This is a more cost-effective method than screening all patients. However, future randomized trials and cost-effectiveness analyses are needed to determine the ultimate effects of vitamin D supplementation on clinical morbidity and surgical outcomes.

Association of Preoperative PROMIS Scores With Short-term Postoperative Improvements in Physical Function After Minimally Invasive Transforaminal Lumbar Interbody Fusion.

OBJECTIVE: This study examines the associations between preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) score, measured by PROMIS-PF and the change between pre- and postoperative PROMIS-PF scores. METHODS: A prospectively maintained surgical registry was retrospectively reviewed for spine surgeries between May 2015-June 2019. Inclusion criteria were primary, single-level minimally invasive transforaminal lumbar interbody fusions. Revisions, multilevel procedures, and patients missing preoperative surveys were excluded. Patients were grouped by preoperative PROMIS-PF scores of ≥ 35 and < 35, with higher scores indicating greater PF. A chi-squared and Student t-test were used to analyze categorical and continuous variables respectively. Linear regression evaluated the relationship of PROMIS-PF score improvement. RESULTS: Of the 180 subjects, 84 were in the PROMIS-PF < 35 group which had more obese patients (p < 0.001) and more males (p = 0.001). Length of stay was greater for the PROMIS-PF < 35 group (36.2 hours vs. 28.7 hours, p = 0.014). PROMIS-PF and Oswestry Disability Index scores were significantly different between subgroups at all timepoints. PROMIS-PF < 35 cohort had larger postoperative PROMIS-PF improvements at 6 weeks (p = 0.008) and 12 weeks (p = 0.003). Linear regression demonstrated a negative association between preoperative PROMIS-PF scores and improvement at 6 weeks, 12 weeks, 6 months, and 2 years (p < 0.001). PROMIS-PF < 35 demonstrated significantly lower rate of achieving minimum clinically important difference at 6 months, otherwise no difference observed throughout the 2-year follow-up. CONCLUSION: Up to 6 months postoperatively, lower preoperative PROMIS-PF scores were associated with larger PROMIS-PF improvements. Understanding the relationship preoperative PROMIS-PF scores have with postoperative improvement may enable better patient counseling.

The Top 100 Spine Surgery Articles on Social Media: An Altmetric Study.

STUDY DESIGN: Literature review. OBJECTIVE: To discern which social media outlets contribute most to spine surgery literature dissemination and to investigate how popular articles compare to articles with most citations. SUMMARY OF BACKGROUND DATA: Scientific literature is increasingly disseminated through social media. The Altmetric Attention Score (AAS) is defined as an automated, weighted score calculation from counts of all online attention received by various research outputs. Increasing AAS values indicate more online attention. For example, the overall top 100 Altmetric spine surgery peer-reviewed articles since 2010 had an AAS range from 78 to 1537. Among all spine surgery literature reviewed since 2010, the mean AAS was 5.3 with a median of 1.0. METHODS: We performed an Altmetric database search of nine spine surgery journals from January 2010 to October 2019. Mean AAS was summarized alongside metrics including citation count and impact factor. We assessed correlations between AAS and online sources, readers, and citations. Journals were grouped by impact factor, and analysis-of-variance compared mean AAS. The 100 highest AAS articles were compared to the most cited. RESULTS: 13,601 articles were included. The mean AAS was 5.3, with Twitter contributing the most. The three highest associations were news (P < 0.001), Twitter (P < 0.001), and Facebook (P < 0.001). There was no significant association between impact factor and AAS. Compared with the most cited articles, the top 100 AAS articles had significantly more article types, more prospective studies, fewer retrospective studies, fewer reviews, and fewer systematic reviews (P < 0.001 for all). Spine contributed the most articles in both top 100 sets. CONCLUSION: Our evaluation revealed Twitter, newsfeeds, and Facebook were the most significant social media outlets. Compared to articles with the most citations, the most popular articles are prospective and encompass broader study designs. Social media plays an integral role in dissemination, both within spine literature and the public sphere. LEVEL OF EVIDENCE: 3.

Predictors of inpatient admission in the setting of anterior lumbar interbody fusion: a Minimally Invasive Spine Study Group (MISSG) investigation.

OBJECTIVE: While the anterior lumbar interbody fusion (ALIF) procedure may be amenable to ambulatory surgery, it has been hypothesized that limitations such as the risk of postoperative ileus and vascular complications have hindered transition of this procedure to the outpatient setting. Identification of independent risk factors predisposing patients to inpatient stays of ≥ 24 hours after ALIF may facilitate better postsurgical outcomes, target modifiable risk factors, and assist in the development of screening tools to transition appropriate patients to the ambulatory surgery center (ASC) setting for this procedure. The purpose of this study was to identify the most relevant risk factors that predispose patients to ≥ 24-hour admission following ALIF. METHODS: A prospectively maintained surgical registry was reviewed for patients undergoing single ALIF between May 2006 and December 2019. Demographics, preoperative diagnosis, perioperative variables, and postoperative complications were evaluated according to their relative risk (RR) elevation for an inpatient stay of ≥ 24 hours. A Poisson regression model was used to evaluate predictors of inpatient stays of ≥ 24 hours. Risk factors for inpatient admission of ≥ 24 hours were identified with a stepwise backward regression model. RESULTS: A total of 111 patients underwent single-level ALIF (50.9% female and 52.6% male, ≤ 50 years old). Eleven (9.5%) patients were discharged in < 24 hours and 116 remained admitted for ≥ 24 hours. The average inpatient stay was > 2 days (53.7 hours). The most common postoperative complications were fever (body temperature ≥ 100.4°F; n = 4, 3.5%) and blood transfusions (n = 4, 3.5%). Bivariate analysis revealed a preoperative diagnosis of retrolisthesis or lateral listhesis to elevate the RR for an inpatient stay of ≥ 24 hours (RR 1.11, p = 0.001, both diagnoses). Stepwise multivariate analysis demonstrated significant predictors for inpatient stays of ≥ 24 hours to be an operation on L4-5, coexisting degenerative disc disease (DDD) with foraminal stenosis, and herniated nucleus pulposus (RR 1.11, 95% CI 1.03-1.20, p = 0.009, all covariates). CONCLUSIONS: This study provides data regarding the incidence of demographic and perioperative characteristics and postoperative complications as they pertain to patients undergoing single-level ALIF. This preliminary investigation identified the most relevant risk factors to be considered before appropriately transitioning ALIF procedures to the ASC. Further studies of preoperative characteristics are needed to elucidate ideal ASC ALIF patients.

Are Preoperative PHQ-9 Scores Predictive of Postoperative Outcomes Following Anterior Cervical Discectomy and Fusion?

STUDY DESIGN: This is a retrospective study. OBJECTIVE: The objective of this study was to determine if there is an association between preoperative depression, as quantified by Patient Health Questionnaire-9 (PHQ-9), and postoperative improvement in pain and disability after anterior cervical discectomy and fusion (ACDF). SUMMARY OF BACKGROUND DATA: Few studies have quantified depression symptoms in the preoperative period using PHQ-9 and have tracked patient-reported outcomes (PROs) following ACDF. METHODS: Patients undergoing ACDF were retrospectively reviewed and stratified by their preoperative PHQ-9 score. PROs, including Neck Disability Index (NDI), Visual Analogue Scale (VAS) neck and arm pain, and 12-Item Short Form (SF-12) Physical Component Score (PCS), were measured preoperatively and at 6-week, 3-month, 6-month, and 1-year postoperatively. PRO scores were analyzed amongst PHQ-9 cohorts using multiple linear regression. Achievement of minimum clinically important difference (MCID) was compared using χ analysis. RESULTS: Higher PHQ-9 scores were associated with increased preoperative NDI, VAS neck, and VAS arm scores and significantly lower SF-12 PCS scores preoperatively. Cohorts experienced similar VAS pain scores up to 1-year following surgery, except for VAS neck pain at 3 months when patients with greater depression symptoms had more pain. High PHQ-9 patients had higher NDI values at 6 weeks and 3-month marks but had similar NDI scores at 6 months and 1-year. Similarly, SF-12 PCS scores were lower for patients with a higher PHQ-9 score at 3 and 6 months, however, both groups had similar scores at 1-year follow-up. A greater percentage of the high PHQ-9 cohort achieved MCID for NDI, however, there were no differences in MCID achievement for VAS neck, VAS arm, or SF-12 PCS. CONCLUSIONS: Patients with worse preoperative mental health reported significantly greater preoperative disability and pain. However, both cohorts demonstrated similar clinical recovery at the 1-year follow-up. These findings suggest patients with worse preoperative mental health can expect significant improvements in PROs following surgery.

PROMIS Physical Function Predicts Postoperative Pain and Disability Following Anterior Cervical Discectomy and Fusion.

STUDY DESIGN: This was a retrospective study. OBJECTIVE: The objective of this study was to determine if preoperative Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS PF) score is predictive of improvement in pain and physical function following anterior cervical discectomy and fusion (ACDF). SUMMARY OF BACKGROUND DATA: Few studies have investigated the predictive nature of PROMIS PF of patients undergoing spine surgery, such as ACDF. METHODS: Patients undergoing a primary, 1-3-level ACDF were retrospectively reviewed and were stratified into 3 cohorts according to preoperative PROMIS PF scores: minimal disability (score 50-60), mild disability (score 40-50), moderate disability (score 30-40), and severe disability (score 20-30). Preoperative PROMIS PF cohorts were tested for an association with demographics, perioperative characteristics, and improvement in Neck Disability Index (NDI), 12-Item Short-Form Physical Component Score (SF-12 PCS), and Visual Analog Scale (VAS) neck and arm pain using χ analysis and multivariate linear regression. RESULTS: A total of 126 patients were included: 11 had a minimal disability, 44 had mild disability, 54 had moderate disability, and 17 had severe disability. Patients with a severe disability experienced no statistically significant increase in their length of stay. Greater preoperative disability demonstrated lower NDI and SF-12 PCS scores preoperatively and at each postoperative timepoint. Greater preoperative disability had worse VAS neck and arm pain preoperatively and 6-week and 3-month postoperatively. Although patients with severe disability trended worse VAS neck and arm pain at the 6-month follow-up, this did not reach statistical significance. CONCLUSIONS: In this investigation, patients with worse PROMIS PF scores reported greater pain and disability in the preoperative period and experienced less improvement in NDI, SF-12 PCS, and VAS back and leg following ACDF. PROMIS PF is an efficient and accurate instrument that can effectively evaluate strength, mobility, and coordination in the preoperative period and may be used to predict clinical outcomes following ACDF.

Evaluation of Postoperative Mental Health Outcomes in Patients Based on Patient-Reported Outcome Measurement Information System Physical Function Following Anterior Cervical Discectomy and Fusion.

OBJECTIVE: To assess the relationship of preoperative physical function, as measured by Patient-Reported Outcome Measurement Information System Physical Function (PROMIS PF), to improvement in mental health, as evaluated by Short Form-12 Mental Component Summary (SF-12 MCS) following anterior cervical discectomy and fusion (ACDF). METHODS: Patients undergoing primary ACDF were retrospectively reviewed and stratified based on preoperative PROMIS PF scores. PROMIS PF cohorts were tested for an association with demographic characteristics and perioperative variables using chi-square analysis and multivariate linear regression. Multivariate linear regression was utilized to determine the association between PROMIS PF cohorts and improvement in SF-12 MCS. RESULTS: A total of 129 one- to 3-level ACDF patients were included: 73 had PROMIS PF < 40 ("low PROMIS") and 56 had PROMIS PF ≥ 40 ("high PROMIS"). The low PROMIS cohort reported worse mental health preoperatively and at all postoperative timepoints except for 1 year. Both cohorts had similar changes in mental health from baseline through the 6-month follow-up. However, at 1 year. postoperatively, the low PROMIS cohort had a statistically greater change in mental health score. CONCLUSION: Patients with worse preoperative physical function reported significantly worse preoperative and postoperative mental health. However, patients with worse preoperative physical function made significantly greater improvements in mental health from baseline. This suggests that patients with worse preoperative physical function can still expect significant improvements in mental health following surgery.

The Relationship Between Preoperative PROMIS Scores With Postoperative Improvements in Physical Function After Anterior Cervical Discectomy and Fusion.

OBJECTIVE: Assess preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) scores and differences between preoperative and postoperative PROMIS-PF scores for patients undergoing anterior cervical discectomy and fusion (ACDF). METHODS: After Institutional Review Board approval, a prospectively maintained surgical registry was retrospectively reviewed for elective spine surgeries of nontraumatic, degenerative pathology between 2015-2018. Inclusion criteria were primary or revision, single-level ACDF procedures. Multilevel procedures and patients without preoperative surveys were excluded. A preoperative PROMIS score cutoff of 35 divided patients into PROMIS-PF score categories (e.g. , ≥ 35.0, < 35.0). Categorical and continuous variables were evaluated with chi-square tests and t-tests. Linear regression analyzed PROMIS-PF score improvement. RESULTS: Eighty-six patients were selected, the high and low PROMIS-PF subgroups only differed in mean age (49.1 vs. 41.3, p = 0.002). Significant differences in PROMIS-PF scores were observed among high and low preoperative PROMIS-PF score subgroups at 6 weeks (p = 0.006), 12 weeks (p = 0.006), and 6 months (p = 0.014). Mean differences between preoperative and postoperative PROMIS-PF scores were significantly different between the high and low PROMIS-PF subgroups at 6 weeks (p = 0.041) and 1 year (p = 0.038). A significant negative association was observed between preoperative PROMIS scores and magnitude of improvement at the 6-week postoperative time point (slope = -0.6291, p < 0.001). CONCLUSION: Patients with low preoperative PROMIS-PF scores demonstrated greater improvements at 6 weeks and 1 year. Clinicians should consider patients with low preoperative PROMIS-PF scores to be in the unique position to potentially experience larger postoperative improvement magnitudes than patients with higher preoperative PROMIS-PF scores.

The identification of risk factors for increased postoperative pain following minimally invasive transforaminal lumbar interbody fusion.

PURPOSE: To evaluate specific demographic and perioperative variables associated with higher inpatient pain scores following minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). METHODS: Patients who underwent a single-level, primary MIS TLIF were retrospectively reviewed. Perioperative outcomes were collected, and postoperative inpatient VAS pain scores were measured. Both bivariate and stepwise multivariate Poisson regressions with robust error variance were used to assess risk factors for average inpatient pain score ≥ 5.0. A final backward stepwise regression model was created using age, gender, smoking status, diabetes status, insurance status, BMI, comorbidity burden, pedicle screw laterality, operative time, and estimated blood loss. RESULTS: A total of 255 patients undergoing primary, single-level MIS TLIF were included. Age less than 50 years, workers' compensation insurance, preoperative VAS pain score ≥ 7, and operative duration ≥ 110 min were associated with greater postoperative pain. However, other variables such as gender, BMI, smoking status, comorbidity burden, diabetes status, and pedicle screw laterality were not associated with increased postoperative pain. CONCLUSION: The results of this study suggest that younger age, workers' compensation, elevated preoperative pain scores, and longer operative times are independently associated with greater inpatient pain following TLIF. Surgeons can use this information to better assess which patients may require additional pain control following TLIF. Patient expectations of postoperative outcomes in regard to pain and recovery may also be better managed. These slides can be retrieved under Electronic Supplementary Material. (paragraph). Then process the ppt slide as graphical image.

Postoperative Outcomes Based on American Society of Anesthesiologists Score After Minimally Invasive Transforaminal Lumbar Interbody Fusion.

STUDY DESIGN: A retrospective cohort study. OBJECTIVE: To examine the association between the American Society of Anesthesiologists (ASA) score and patient-reported outcomes (PROs) after minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). SUMMARY OF BACKGROUND DATA: Few studies have investigated the correlation between ASA score and PROs after MIS TLIF. METHODS: Patients undergoing primary, single-level MIS TLIF were retrospectively reviewed and placed into 3 cohorts: ASA score ≤2 and outpatient status, ASA score ≤2 and inpatient status, and ASA score >2. Oswestry Disability Index (ODI), visual analog scale (VAS) back and leg pain, and Short Form-12 Physical Component Score (SF-12 PCS) were administered preoperatively and at 6-week, 12-week, and 6-month time points. ASA scores were tested for association with improvements in PROs using linear regression. RESULTS: A total of 187 patients had an ASA score ≤2 and 41 patients had an ASA score >2. Higher ASA scores were associated with older age, obesity, higher comorbidity burden, and an increased length of stay. ASA subgroups demonstrated a significant difference in preoperative ODI and VAS back pain scores and improvement in VAS back pain scores at the 12-week and 6-month time points; however, there was no discernible pattern of improvement amongst cohorts. No statistically significant differences were observed with improvements in PROs. CONCLUSIONS: The study suggests ASA scores are not associated with postoperative recovery in pain and disability after MIS TLIF. Our results indicate that regardless of the preoperative ASA score, patients are likely to achieve similar improvements in PROs through 6 months follow-up. Although using ASA as a risk stratification tool to predict perioperative complications, its utility in predicting improvement in PROs is still uncertain at this time.

Predictors of Citation Rate in the Spine Literature.

The number of citations a publication receives has been regarded as one measure of its importance and clinical impact. However, studies have yet to investigate which characteristics are predictors of citation rates within the spine subspecialty literature. To explore this topic, all articles published in 2010 in Spine and from 2010 to 2011 in The Spine Journal and the Journal of Neurosurgery: Spine were reviewed. The Web of Science search engine was used to determine the number of times each article was cited in the 5 years following its publication. Sample characteristics were collected and were compared with a χ test for differences Multivariate logistic regression was utilized to determine if collected study characteristics were associated with achievement of citation frequency higher than the median for the entire study sample. Among the 927 articles analyzed, the 5-year citation number ranged from 0 to 125, with a median of 8 (interquartile range: 4-16). Upon multivariate analysis, the following were identified as predictors of citation number higher than the median: North American origin (P=0.014), sample size >30 (P<0.001), study topic (P<0.050), and publication in the Journal of Neurosurgery: Spine (P<0.001). Practitioners and research personnel can use these findings to help elucidate which factors might affect the potential impact and overall reach of their work in the spine literature.

Complications Following Minimally Invasive Transforaminal Lumbar Interbody Fusion: Incidence, Independent Risk Factors, and Clinical Impact.

STUDY DESIGN: This was a retrospective study. OBJECTIVE: The objective of this study was to determine the incidence and risk factors for postoperative complications following minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). SUMMARY OF BACKGROUND DATA: The identification of independent risk factors that predispose patients to postoperative complications following MIS TLIF may allow for improved outcomes and the optimization of modifiable conditions before surgical intervention. MATERIALS AND METHODS: Patients undergoing a single-level MIS TLIF were retrospectively reviewed. Demographic information and the presence of baseline medical conditions was recorded for all patients. Postsurgical complications that arose following the MIS TLIF procedure were recorded. The incidence of postoperative complications was tested for association with patient and surgical characteristics using bivariate Poisson regression. Independent risk factors for complications were identified through a backward stepwise regression model. RESULTS: A total of 421 patients who underwent a primary, single-level MIS TLIF procedure were included in our analysis. The most common complication was urinary retention requiring catheterization (n=43, 10.2%), followed by pseudarthrosis (n=37, 8.8%), and then altered mental status (n=11, 2.6%). Multivariate analysis was conducted to determine the independent risk factors predictive of complications. The significant factors were obesity status (relative risk=2.2, P=0.001), the presence of diabetes (relative risk=2.6, P=0.002), and operative duration >105 minutes (relative risk=2.5, P=0.008). CONCLUSIONS: The present study provides the incidence of complications following MIS TLIF, as well as risk factors that are predictive of complications that may arise following the procedure. Independent variables for increased complication rates included extended operative duration, obesity, and diabetes status. The identification of these factors may be clinically useful to spine surgeons in terms of preoperative discussion and planning.

The Impact of Comorbidity Burden on Postoperative PROMIS Physical Function Following Minimally Invasive Transforaminal Lumbar Interbody Fusion.

STUDY DESIGN: This was a retrospective cohort study. OBJECTIVE: To assess the utility of Patient-Reported Outcome Measurement Information System Physical Function (PROMIS PF) in assessing postoperative recovery on the basis of the comorbidity burden after minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). SUMMARY OF BACKGROUND DATA: Few studies have evaluated the effect of comorbidity burden in long-term clinical recovery after MIS TLIF. METHODS: Patients undergoing primary, 1-level to 2-level MIS TLIF were retrospectively reviewed and stratified on the basis of Charlson Comorbidity Index (CCI) score: 0 points (no comorbidities), 1-2 points (low CCI), ≥3 points (high CCI). CCI was tested for an association with demographic characteristics and perioperative variables using χ analysis and multivariate linear regression. Multivariate linear regression was utilized to determine the association between CCI cohorts and PROMIS PF. RESULTS: A total of 187 1-level and 2-level MIS TLIF patients were included: 53 had no comorbidities, 78 had a low CCI, and 56 a high CCI. One patient in the high CCI group experienced nonunion. Patients reported similar PROMIS PF scores preoperatively and up to 1-year postoperatively. Each cohort experienced a similar improvement in PROMIS PF scores from baseline at each postoperative time point. For patients without comorbidities, the change in the postoperative PROMIS PF score from baseline was significant at every postoperative time point. However, for the patients with ≥1 comorbidities, the change in the postoperative PROMIS PF score from baseline was significant at the 3-month, 6-month, and 1-year time points, however, the change from baseline to 6 weeks was not significant. CONCLUSIONS: In this investigation, the authors compared the clinical recovery of patients with varying comorbidities undergoing an MIS TLIF using PROMIS PF. Regardless of comorbidity, patients reported similar preoperative PROMIS PF scores and had similar improvements throughout the 1-year follow-up. This study established that PROMIS PF is an effective tool to evaluate the recovery of patients with differing comorbidities after MIS TLIF.

PROMIS PF in the Evaluation of Postoperative Outcomes in Workers' Compensation Patients Following Anterior Cervical Discectomy and Fusion.

STUDY DESIGN: This was a retrospective cohort study. OBJECTIVE: To determine the improvement of clinical outcomes in Workers' Compensation (WC) patients compared with non-WC patients utilizing Patient-reported Outcome Measurement Information System Physical Function (PROMIS PF) following anterior cervical discectomy and fusion (ACDF). SUMMARY OF BACKGROUND DATA: To our knowledge, there has not been a study to evaluate clinical outcomes of WC patients utilizing the PROMIS PF survey. METHODS AND MATERIALS: Patients undergoing a primary, 1 to 3-level ACDF were retrospectively reviewed and stratified according to insurance (WC and non-WC). Demographic and perioperative characteristics were compared using χ test and independent t tests. Change in PROMIS PF scores was calculated using paired t tests. Differences in postoperative PROMIS PF scores and changes in PROMIS PF from baseline were compared using linear regression. RESULTS: In total, 124 1 to 3-level ACDF patients were included: 36 had WC insurance and 88 had non-WC insurance. WC patients were younger and more likely to be obese. WC patients reported significantly lower PROMIS PF scores preoperatively and at 6 weeks, 12 weeks, and 6 months timepoints. However, both cohorts reported comparable PROMIS PF scores at the 1-year timepoint. WC patients demonstrated similar improvements from baseline through 1-year postoperatively compared with non-WC patients. For both non-WC and WC cohort, the change in the postoperative PROMIS PF score from baseline was significant at 3 months, 6 months, and 1 year. However, in both cohorts, the change in the postoperative PROMIS PF score from baseline was not significantly different at 6 weeks. CONCLUSIONS: In our study, WC patients had worse baseline physical function as indicated by lower preoperative PROMIS PF scores and reported lower PROMIS PF scores postoperatively. However, there were no significant differences when comparing the postoperative change from baseline between the cohorts. Both cohorts experienced significant postoperative improvements from baseline. This study established that PROMIS PF is an effective tool to evaluate recovery of WC patients following ACDF.