Effect of Preoperative Motor Weakness on Postoperative Clinical Outcomes in Patients Undergoing Cervical Disk Replacement.

STUDY DESIGN: This is a retrospective review. OBJECTIVE: To examine the effect of preoperative motor weakness on clinical outcomes in patients undergoing cervical disk replacement (CDR). SUMMARY OF BACKGROUND DATA: Studies examining the effect of preoperative motor weakness on postoperative clinical outcomes in CDR are limited. METHODS: Patient cohorts were based on documented upper-extremity motor weakness on physical exam versus no motor weakness. Demographics, perioperative characteristics, and preoperative patient-reported outcome measures (PROMs) were compared using univariate inferential statistics. PROMs consisted of Visual Analog Pain Scale-Neck (VAS-N), Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF), VAS-Arm (VAS-A), 12-Item Short Form (SF-12) Physical Component Score (PCS), Oswestry Neck Disability Index (NDI), and SF-12 Mental Component Score (MCS). Postoperative PROMs were collected at the 6-week, 12-week, 6-month, and final follow-up up to 1-yeartime points, and intercohort minimum clinically important difference (MCID) achievement was compared through multivariable linear logistic regression adjusting for significant differences in preoperative characteristics. RESULTS: A total of 118 patients formed cohorts based on documented upper-extremity weakness (n=73) versus no weakness (n=45). The average time to postoperative follow-up was 9.7±7.0 mo. The differences in insurance type between the 2 cohorts were significant (P<0.042). Perioperative diagnosis of foraminal stenosis was significantly more common in the motor weakness cohort (P<0.013). There were no differences in reported PROMs between cohorts. Patients with motor weakness reported significant MCID achievement for PROMIS-PF at 6-/12-weeks (P<0.012, P<0.041 respectively), SF-12 PCS at 6-months (P<0.042), VAS-N at final follow-up (P<0.021), and NDI at final follow-up (P<0.013). CONCLUSIONS: CDR patients with preoperative muscle weakness achieved MCID across several PROMs compared with patients without muscle weakness. Patients with motor weakness reported greater improvement in mental health, pain, and disability as early as 6 weeks and up to 1 year after CDR. This information serves to inform physicians that motor weakness may not indicate a negative overall outcome.

Worse Pain and Disability at Presentation Predicts Greater Improvement in Pain, Disability, and Mental Health in Patients Undergoing Minimally Invasive Transforaminal Lumbar Interbody Fusion for Degenerative Spondylolisthesis.

STUDY DESIGN: Retrospective Review. OBJECTIVE: To assess the impact of preoperative pain and disability on patient-reported outcome measures (PROMs) following minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) for degenerative spondylolisthesis. SUMMARY OF BACKGROUND DATA: Varying preoperative symptom severity in lumbar fusion patients alters perceptions of surgical success. METHODS: Degenerative spondylolisthesis patients undergoing elective, primary, single-level MI-TLIF were stratified by preoperative symptom severity: Mild (VAS-B<7/ODI<50), Moderate (VAS-B≥7/ODI<50 or VAS-B<7/ODI≥50), and Severe (VAS-B≥7/ODI≥50). PROMs, Patient-reported Outcomes Measurement Information System-Physical Function (PROMIS-PF), ODI, VAS-B, VAS-Leg (VAS-L), and 9-item Patient Health Questionnaire (PHQ-9) were compared at baseline, 6 weeks, and final follow-up (µ=16.3±8.8 mo). Postoperative PROMs, magnitudes of improvement, and minimal clinically important difference (MCID) achievement rates were compared between cohorts through multivariable regression. RESULTS: A total of 177 patients were included. Acute postoperative pain and narcotic consumption were highest in the severe cohort (P≤0.003). All preoperative PROMs worsened from mild to severe cohorts (P<0.001). All PROMs continued to be significantly different between cohorts at 6 weeks and final follow-up, with the worst scores in the Severe cohort (P≤0.003). At 6 weeks, all cohorts improved in ODI, VAS-B, VAS-L, and PHQ-9 (P≤0.003), with the Moderate cohort also improving in PROMIS-PF (P=0.017). All Cohorts improved across PROMs at the final follow-up (P≤0.044). Magnitudes of improvement in ODI, VAS-B, and PHQ-9 increased with worsening preoperative symptom severity (P≤0.042). The Moderate and Severe cohorts demonstrated higher MCID achievement in ODI, VAS-B, and PHQ-9 rates than the Mild cohort. CONCLUSIONS: Despite preoperative pain and disability severity, patients undergoing MI-TLIF for degenerative spondylolisthesis report significant improvement in physical function, pain, disability, and mental health postoperatively. Patients with increasing symptom severity continued to report worse severity postoperatively compared with those with milder symptoms preoperatively but were more likely to report larger improvements and achieve clinically meaningful improvement in disability, pain, and mental health.

Impact of Early Depressive Burden on Patient-Reported Outcomes Following Minimally Invasive Transforaminal Lumbar Interbody Fusion.

STUDY DESIGN: Retrospective review. OBJECTIVE: To evaluate mental health influence on minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) patients. SUMMARY OF BACKGROUND DATA: Poor mental health has been postulated to indicate inferior patient perceptions of surgical outcomes in spine literature. Few studies have assessed mental health as a dynamic metric throughout the perioperative period. METHODS: A single-surgeon database was retrospectively searched for patients who underwent primary, elective MIS-TLIF for degenerative or isthmic spondylolisthesis. Summative depressive burden (SDB) was defined by the sum of preoperative and 6-week postoperative 9-item Patient Health Questionnaire (PHQ-9), with Lesser Burden (LB, SDB<10) and Greater Burden (GB, SDB≥10) cohorts. Patient-reported outcomes measures (PROMs) were compared preoperatively, at 6 weeks, and at final postoperative follow-up (11.4±10.9 mo), using Patient-Reported Outcomes Measurement Information System-Physical Function (PROMIS-PF), Oswestry disability index (ODI), visual analog scale-back (VAS-B), VAS-leg (VAS-L), and PHQ-9. Improvements at 6-week (∆PROM-6W), final follow-up (∆PROM-FF), and minimum clinically important difference (MCID) achievement were compared. RESULTS: The GB cohort consisted of 44 of 105 patients. Demographic variations included older age, higher Charlson comorbidity index, increased hypertension prevalence, and private insurance in the LB cohort (P≤0.018). The LB cohort demonstrated better baseline and 6-week PROMIS-PF/ODI/VAS-L (P≤0.032) and better final PROMIS-PF/ODI/VAS-L/PHQ-9 (P≤0.031). Both cohorts improved in all PROMs at 6 weeks and final follow-up (P≤0.029), except for PROMIS-PF at 6 weeks in the GB cohort. ∆PROM-6W, ∆PROM-FF, and MCID achievement rate for PHQ-9 were greater in the GB cohort (P≤0.001). CONCLUSION: On average, patients undergoing MIS-TLIF for degenerative or isthmic spondylolisthesis improved in all PROMs by final follow-up. Patients with GB suffered inferior perceptions of physical function, disability, and leg pain. MCID rates in mental health were higher for GB cohort. Surgeons are encouraged to adopt a compassionate understanding of depressive burden and educate the patient on possible consequential postoperative outcomes.

Worse Preoperative 12-Item Veterans Rand Physical Component Scores Prognosticate Inferior Outcomes Following Outpatient Lumbar Decompression.

STUDY DESIGN: Retrospective Review. OBJECTIVE: Evaluate the influence of the 12-Item veterans Rand (VR-12) physical component score (PCS) on patient-reported outcome measures (PROMs) in an outpatient lumbar decompression (LD) cohort. SUMMARY OF BACKGROUND DATA: The influence of baseline VR-12 PCS on postoperative clinical outcomes has not been evaluated in patients undergoing outpatient LD. METHODS: Patients undergoing primary, elective, 1/2-level outpatient LD with baseline VR-12 PCS scores were retrospectively identified from a prospectively maintained single-surgeon database. Cohorts were preoperative VR-12 PCS<30 and VR-12 PCS≥30. Patient/perioperative characteristics and preoperative/postoperative 6-week/final follow-up (FF) PROMs were collected. Physical health PROMs included the VR-12 PCS, 12-Item Short Form (SF-12) PCS, patient-reported outcome measure information system-physical function (PROMIS-PF), visual analog scale (VAS)-back/leg, and Oswestry disability index (ODI). Mental health PROMs included the VR-12/SF-12 mental component score (MCS) and the patient-health questionnaire-9 (PHQ-9). Average FF was 13.8±8.9 months postoperatively. PROM improvements at 6 weeks/FF and minimal clinically important difference (MCID) achievement rates were determined. χ 2 analysis and the Student's t tests compared demographics, perioperative data, and preoperative PROMs. Multivariate linear/logistic regression compared postoperative PROMs, PROM improvements, and MCID achievement rates. RESULTS: Six weeks postoperatively, VR-12 PCS<30 reported worse baseline PROMs ( P ≤0.042, all) and worse scores except VR-12/SF-12 MCS ( P ≤0.043, all). Compared with VR-12 PCS≥30, VR-12 PCS<30 had worse FF VR-12 PCS, SF-12 PCS/MCS, PROMIS-PF, PHQ-9, and VAS-Back ( P ≤0.033, all). VR-12 PCS<30 experienced greater 6-week improvements in VR-12/SF-12 PCS, PHQ-9, VAS-Back, and ODI ( P ≤0.039, all). VR-12 PCS<30 had greater FF improvements in VR-12/SF-12 PCS, PHQ-9, and ODI ( P ≤0.001, all) and greater overall MCID achievement in VR-12 PCS/MCS, SF-12 PCS, PHQ-9, and ODI ( P ≤0.033, all). CONCLUSIONS: VR-12 PCS<30 patients-reported worse baseline/postoperative mental/physical health scores. However, they reported greater improvements in physical function, depressive burden, back pain, and disability by 6 weeks and FF and experienced greater MCID achievement for physical functioning, mental health, and disability scores.

Prognostic value in preoperative Veterans RAND-12 mental Component score on clinical outcomes for patients undergoing minimally invasive transforaminal lumbar interbody fusion.

No study has examined the prognostic value of the Veterans RAND-12 (VR-12) Mental Component Score (MCS) on postoperative outcomes in minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) patients. This study examines the effect of preoperative VR-12 MCS on postoperative patient-reported outcome measures (PROMs) in MIS-TLIF patients. Patients were separated into 2 cohorts: VR-12 MCS < 50 and VR-12 MCS ≥ 50. PROMs of VR-12 MCS/Physical Component Score (PCS), Short Form-12 (SF-12) MCS/PCS, Patient-Reported Outcomes Measurement Information System-Physical Function (PROMIS-PF), Patient Health Questionnaire-9 (PHQ-9), Visual Analog Scale (VAS) Back/Leg Pain (VAS-BP/LP), and Oswestry Disability Index (ODI) were collected.Of 329 patients, 151 were in the VR-12 MCS < 50 cohort. The VR-12 MCS < 50 cohort reported significantly inferior scores in all PROMs preoperatively, significantly inferior VR-12 MCS, SF-12 MCS, PROMIS-PF, PHQ-9, and ODI scores at 6-weeks postoperatively, and significantly inferior scores in all PROMs, except for VAS-BP at final follow-up. Magnitude of 6-week postoperative improvement was significantly greater in the VR-12 MCS < 50 cohort for VR-12 MCS, SF-12 MCS, and PHQ-9. Magnitude of final postoperative improvement was significantly greater in the VR-12 MCS < 50 cohort for VR-12 MCS, SF-12 MCS/PCS, and PHQ-9. MCID achievement rates were significantly greater in the VR-12 MCS < 50 cohort for VR-12 MCS, SF-12 MCS, and PHQ-9. MIS-TLIF patients with lesser preoperative VR-12 MCS reported inferior postoperative outcomes in mental health, physical function, pain, and disability. However, patients with inferior preoperative mental health reported greater rates of clinically meaningful improvement in mental health. Inferior preoperative mental health does not limit postoperative improvement in patients undergoing MIS-TLIF.

Preoperative motor weakness and the impact on patient reported outcomes in lateral lumbar interbody fusion.

This study measures the impact of preoperative motor weakness (MW) on Patient-Reported Outcome Measures (PROMs) in lateral lumbar interbody fusion (LLIF) patients. Retrospectively-sourced data from a prospectively-maintained, single-surgeon database created two cohorts of LLIF patients: patients with/without documented MW. Demographics/perioperative characteristics/PROMs were collected preoperatively and at six-weeks/final follow-up (FF). Studied outcomes were Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF), 12-Item Short Form (SF-12) Physical/Mental Component Score (PCS/MCS), Patient Health Questionnaire (PHQ-9), Visual Analog Scale Back/Leg Pain (VAS-BP/LP), and Oswestry Disability Index (ODI). Multivariable linear/logistic regression calculated/compared intercohort minimum clinically important difference (MCID). Mean postoperative follow-up time was 11.5 ± 7.52 months. In total, 214 LLIF patients from December 2010 to May 2023 were included, with 149 having documented MW. In Table 1, self-reported gender was significant between cohorts (p < 0.025). Other significant demographic characteristics were smoker status (p < 0.002), diabetes (p < 0.016), and CCI score (p < 0.011). Table 2 shows notably significant perioperative characteristics: spinal pathology (degenerative spondylolisthesis/foraminal stenosis/herniated nucleus pulposus) (p < 0.005, all), estimated blood loss/length of stay/postoperative day (POD)-zero narcotic consumption (p < 0.001, all). Table 3 outcomes/MCID achievement percentages demonstrated insignificant intercohort differences besides a weakly significant FF ODI score (p < 0.036). MW, a frequently reported symptom in spine surgery, is poorly studied in LLIF patients. Thus, this study evaluates MW impact on PROMs and notes no significant differences. However, one exception regarding FF disability scores was recorded. MW did not affect MCID achievement for our patient population. Therefore, the preliminary findings suggest preoperative MW imparts minimal influence on PROMs/MCID in LLIF patients.

Risk of Subsequent Fusion After Isolated Decompression of Lumbar Facet Cysts.

INTRODUCTION: Lumbar facet cysts represent a potential source of nerve root compression in elderly patients. Isolated decompression without fusion has proven to be a reasonable treatment option in properly indicated patients. However, the risk of lumbar fusion after isolated decompression and facet cyst excision has yet to be elucidated. METHODS: The PearlDiver database was reviewed for patients undergoing isolated laminectomy for lumbar facet cyst from January 2015 to December 2018 using Current Procedural Terminology coding. Patients undergoing concomitant fusion or additional decompression, as well as those diagnosed with preexisting spondylolisthesis or without a minimum of 5-year follow-up, were excluded. Rates of subsequent lumbar fusion and potential risk factors for subsequent fusion were identified. Statistical analysis included descriptive statistics, chi square test, and multivariate logistic regression. Results were considered significant at P < 0.05. RESULTS: In total, 10,707 patients were ultimately included for analysis. At 5-year follow-up, 727 (6.79%) of patients underwent subsequent lumbar fusion after initial isolated decompression. Of these, 301 (2.81% of total patients, 41.4% of fusion patients) underwent fusion within the first year after decompression. Multivariate analysis identified chronic kidney disease, hypertension, and osteoarthritis as risk factors for requiring subsequent lumbar fusion at 5 years following the index decompression procedure ( P < 0.033; all). CONCLUSION: Patients undergoing isolated decompression for lumbar facet cysts undergo subsequent lumbar fusion at a 5-year rate of 6.79%. Risk factors for subsequent decompression include chronic kidney disease, hypertension, and osteoarthritis. This study will assist spine surgeons in appropriately counseling patients on expected postoperative course and potential risks of isolated decompression.

Severe Preoperative Disability Is Associated With Greater Mental Health Improvements Following Surgery for Degenerative Spondylolisthesis: A Cohort Matched Analysis.

OBJECTIVE: To evaluate preoperative disability's influence on patient-reported outcomes (PROs) following surgery for degenerative spondylolisthesis (DS). METHODS: DS patients who underwent surgical intervention were retrospectively identified from a single-surgeon spine registry. Cohorts based on Oswestry Disability Index (ODI) < 41 (milder disability) and ≥ 41 (severe disability) were created. Demographic differences were accounted for with 1:1 propensity score matching. For the matched sample, perioperative and PRO data were additionally collected. PROs assessed included mental health, physical function, pain, and disability. Pre- and up to 2-year postoperative PROs were utilized. Average time to final follow-up was 15.7 ± 8.8 months. Improvements in PROs and minimal clinically important difference (MCID) rates were calculated. Continuous variables were compared through Student t-test and categorical variables were compared through chi-square tests. RESULTS: Altogether, 214 patients were included with 77 in the milder disability group. The severe disability group had worse postoperative day (POD) 1 pain scores and longer hospital stays (p ≤ 0.038, both). The severe disability group reported worse outcomes pre- and postoperatively (p < 0.011, all), but had greater average improvement in 12-item Short Form health survey mental composite score (SF-12 MCS), 9-Item Patient Health Questionnaire (PHQ-9), visual analogue scale (VAS)-back, and ODI by 6 weeks (p ≤ 0.037, all) and PHQ-9, VAS-back and ODI by final follow-up (p ≤ 0.015, all). The severe disability cohort was more likely to achieve MCID for SF-12 MCS, PHQ-9, and ODI (p ≤ 0.003, all). CONCLUSION: Patients with greater baseline disability report higher POD 1 pain and discharge later than patients with milder disability. While these patients report inferior physical/mental health before and after surgery, they report greater improvements in mental health and disability postoperatively.

Utility of preoperative comorbidity burden on PROMIS outcomes after lumbar decompression: Cohort matched analysis.

The influence of Charlson Comorbidity Index (CCI) burden on Patient-Reported Outcomes Measurement Information System (PROMIS) outcomes following lumbar decompression (LD) is limited. The objective of this study is to evaluate CCI burden impact on PROMIS outcomes. Retrospective review of elective LD excluding revision or surgeries for infectious, malignant, or traumatic reasons. Demographics and PROMIS scores collected preoperatively and postoperatively up to 2 years included: PROMIS-Physical Function (PF)/Sleep Disturbance (SD)/Pain Interference (PI)/Anxiety (A), VR-12 Physical/Mental Health Composite scores (VR-12 PCS/MCS)/Oswestry Disability Index (ODI). Patients were divided into two groups based on their preoperative CCI score <3 (mild) or ≥4 (moderate to severe). Descriptive statistical analysis and MCID achievement rate calculations were conducted. A total of 182 patients were included: 93 CCI < 3 and 88 CCI ≥ 4. No significant differences were reported across preoperative PROMIS/legacy PROMs or final follow-up (p > 0.05, all). At 6-weeks, VR-12 PCS and ΔPROM scores indicated improved physician function in the CCI < 3 group (p = 0.020 and p = 0.040, respectively). Significant PROMIS-A ΔPROM score at final post-op was noted for CCI < 3 group (p = 0.026). MCID achievement demonstrated no significant differences for PROMIS outcomes and legacy PROMs. Results demonstrated that PROMIS outcomes were not impacted by a greater baseline comorbidity burden. At 6-weeks, the physical function scores were improved for the lower CCI group, and at final reported less anxiety. Our data suggests that comorbidity burden has a limited effect on PROMIS and legacy outcomes in patients undergoing LD.

Effect of Baseline Veterans RAND-12 Mental Composite Score on Postoperative Patient-Reported Outcome Measures for Cervical Disk Replacement.

STUDY DESIGN: Retrospective review. OBJECTIVE: To examine the effect of baseline Veterans RAND-12 (VR-12) Mental Composite Score (MCS) on clinical outcomes in patients undergoing cervical disk replacement (CDR) for herniated disk. BACKGROUND: Few studies in spine surgery have evaluated the impact of preoperative VR-12 MCS on postoperative outcomes in patients undergoing CDR. METHODS: Patients undergoing CDR for herniated disk were separated into 2 cohorts based on the VR-12 MCS standardized mean: VR-12 MCS<50 (worse mental health) and VR-12 MCS≥50 (better mental health). Patient-reported outcome measures of VR-12 MCS, VR-12 Physical Composite Score, Short Form-12 (SF-12) MCS, SF-12 Physical Composite Score, Patient-Reported Outcomes Measurement Information System Physical Function, Patient Health Questionnaire-9 (PHQ-9), Visual Analog Scale (VAS) Neck Pain, VAS Arm Pain, and Neck Disability Index were collected at preoperative and up to 2-year postoperative time points. RESULTS: In all, 109 patients were identified, with 50 patients in the worse mental health cohort. The worse mental health cohort reported inferior patient-reported outcome measures in all domains at preoperative, 6-week postoperative, and final postoperative time points. For 6-week postoperative improvement, the worse mental health cohort reported greater improvement for VR-12 MCS, SF-12 MCS, and PHQ-9. For final postoperative improvement, the worse mental health cohort reported greater improvement in VR-12 MCS and SF-12 MCS. Minimum clinically important difference achievement rates were higher in the worse mental health cohort for VR-12 MCS, SF-12 MCS, and PHQ-9. CONCLUSION: Patients undergoing cervical disk replacement for herniated disk with worse baseline mental health reported inferior clinical outcomes in mental health, physical function, pain, and disability outcomes throughout the postoperative period. Patients with worse baseline mental health demonstrated greater clinically meaningful improvement in mental health. In cervical disk replacement patients, those with worse baseline mental health may report inferior postoperative clinical outcomes but experience greater rates of tangible improvement in mental health.

Impact of Preoperative Symptom Duration on Patient-reported Outcomes After Minimally Invasive Transforaminal Interbody Fusion for Degenerative Spondylolisthesis.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To assess the impact of preoperative symptom duration (PSD) on patient-reported outcome measures (PROMs) after minimally invasive (MIS) transforaminal lumbar interbody fusion (TLIF) for degenerative spondylolisthesis (DSpond). BACKGROUND: A prolonged duration of preoperative symptoms may implicate inferior long-term outcomes postsurgery. Prior studies of lumbar fusion recipients are limited by the inclusion of heterogeneous populations. METHODS: A single-surgeon registry was retrospectively queried for privately insured patients who had undergone primary, elective, single-level MIS-TLIF for DSpond with a recorded symptom start date. Cohorts were formed by PSD: shorter duration (PSD <1 y) or greater duration (GD; PSD ≥1 y). PROMs evaluated included Patient-reported Outcomes Measurement Information System-Physical Function, Oswestry Disability Index, Visual Analog Scale-Back, Visual Analog Scale-Leg, and 9-item Patient Health Questionnaire. The magnitude of PROM (∆PROM) improvement from preoperative baseline to 6 weeks and final follow-up (∆PROM-FF) were compared between cohorts. Intercohort achievement rates of a minimum clinically important difference in each PROM were compared. RESULTS: A total of 133 patients included 85 patients with GD cohort. There were no significant differences in pre hoc demographics and perioperative characteristics between cohorts, as well as preoperative, 6-week, or final follow-up PROMs between cohorts. Both cohorts demonstrated significant improvement in all PROMs at 6 weeks and final follow-up ( P ≤ 0.049, all). There were no significant intercohort differences demonstrated in minimum clinically important difference achievement rates, ∆PROM-6W, or ∆PROM-FF in any PROM. CONCLUSIONS: Regardless of the symptom duration before MIS-TLIF for DSpond, patients demonstrate significant improvement in physical function, pain, disability, and mental health. Patients with a GD of preoperative symptoms did not report inferior scores in any PROM domain. Patients with a GD of preoperative symptoms did not suffer inferior rates of clinically meaningful improvement after surgical intervention. These findings should be considered when counseling patients before surgical intervention for DSpond.

Obesity Does Not Negatively Affect Patient-perceived Outcomes After Cervical Disc Replacement for Disc Herniation.

STUDY DESIGN: Retrospective review. OBJECTIVE: To assess the impact of Body Mass Index (BMI) on patient-reported outcome measures (PROMs) after cervical disc replacement (CDR). BACKGROUND: BMI may affect PROMs after spine surgery. METHODS: Primary CDR recipients for herniated disc(s) with BMI <40 were retrospectively selected from a single-surgeon registry. Cohorts were divided into non-obese (BMI <30) and obese (BMI ≥30). Intercohort in-hospital complication rates were compared through independent samples t tests. Pre/postoperative PROMs were compared between cohorts through multivariable regression accounting for demographic differences. Final follow-up dates between patients averaged 11.8 ± 9.3 months. PROMs assessed included Patient-reported Outcomes Measurement Information System-Physical Function, Neck Disability Index, Visual Analog Scale-Neck, Visual Analog Scale-Arm, and the 9-item Patient Health Questionnaire. Improvements in PROMs were evaluated and compared at each follow-up within cohorts through paired t tests. The magnitude of improvement in PROMs from preoperative baseline at 6-week follow-up (∆PROM-6W) and final follow-up (∆PROM-FF) along with achievement rates of minimum clinically important differences were compared between cohorts through multivariable regression accounting for demographic differences. RESULTS: Of 153 patients, 53 patients were noted as obese. Demographic differences included age, prevalence of hypertension and diabetes, and comorbidity burden scores ( P ≤ 0.011, all). No significant variations in in-hospital complications were found. The non-obese cohort demonstrated improvements in all PROMs at 6 weeks and final follow-up periods ( P ≤ 0.005, all). The obese cohort demonstrated improvements in all postoperative PROMs besides 9-item Patient Health Questionnaire at 6 weeks ( P ≤ 0.015, all). After accounting for age and comorbidity variations, there were no significant intercohort differences in raw PROM scores, ∆PROM-6W, ∆PROM-FF, or minimum clinically important difference achievement rates. CONCLUSIONS: Regardless of BMI, patients experience significant improvements in physical function, disability, pain, and mental health after CDR for disc herniation. Patients with obesity do not suffer inferior patient-perceived outcomes after CDR. These findings may help surgeons counsel patients in the preoperative period.

Medicare procedural costs in ambulatory surgery centers versus hospital outpatient departments for spine surgeries.

OBJECTIVE: Multiple studies have demonstrated the safety of outpatient spine surgery, with reports of equivalent to improved patient outcomes compared with inpatient procedures. This has resulted in the increased use of outpatient surgery over time. However, there remains a paucity of literature evaluating the difference in costs between ambulatory surgery center (ASC)- and hospital outpatient department (HOPD)-based procedures for Medicare beneficiaries. METHODS: Publicly available data from Centers for Medicare & Medicaid Services were accessed via the Medicare Procedure Price Lookup tool. Current Procedural Terminology (CPT) codes were used to identify spine-specific procedures approved for the outpatient setting by CMS. Procedures were grouped into decompression (cervical, thoracic, and lumbar), fusion/instrumentation (cervical, lumbar, and sacroiliac), and kyphoplasty/vertebroplasty cohorts, as well as an overall cohort. Data regarding total costs, facility fees, surgeon reimbursement, Medicare payments, and patient copayments were extracted for each procedure. Descriptive statistics were used to calculate means and standard deviations. Differences between ASC- and HOPD-associated costs were analyzed using the Mann-Whitney U-test. RESULTS: Twenty-one individual CPT codes approved by Medicare for the ASC and/or HOPD setting were identified. Decompression procedures were associated with a significantly lower total cost ($4183 ± $411.07 vs $7583.67 ± $410.89, p < 0.001), facility fees ($2998 ± $0 vs $6397 ± $0, p < 0.001), Medicare payments ($3345.75 ± $328.80 vs $6064.75 ± $328.80, p < 0.001), and patient payments ($835.58 ± $82.13 vs $1515.58 ± $82.13, p < 0.001) in ASCs compared with HOPDs. Fusion/instrumentation procedures had significantly lower facility fees ($10,436.6 ± $2347.51 vs $14,161 ± $2147.07, p = 0.044) and Medicare payments ($9501.2 ± $1732.42 vs $13,757 ± $2037.58, p = 0.009) in ASCs, as well as a trend toward lower total costs ($11,876.8 ± $2165.22 vs $15,601.2 ± $2016.06, p = 0.076). Patient payments in the HOPD setting were significantly lower in the fusion/instrumentation cohort ($1843.6 ± $73.42 vs $2374.4 ± $433.48, p = 0.009). In the kyphoplasty/vertebroplasty cohort, there was no statistically significant difference between ASCs and HOPDs, despite lower overall costs in the ASC for all variables. Surgeon fees were the same regardless of setting for all procedures (p > 0.99). When combining decompression, fusion/instrumentation, and kyphoplasty/vertebroplasty CPT codes into a single cohort, ASC setting was associated with significant cost savings in total cost, facility fees, Medicare payments, and patient payments. CONCLUSIONS: In general, performing spine surgeries in ASCs is associated with cost savings compared with HOPDs. This was demonstrated for decompression and fusion/instrumentation, and kyphoplasty/vertebroplasty Medicare-approved outpatient procedures.

Antibiotic use in spine surgery: A narrative review based in principles of antibiotic stewardship.

Background: A growing emphasis on antibiotic stewardship has led to extensive literature regarding antibiotic use in spine surgery for surgical prophylaxis and the treatment of spinal infections. Purpose: This article aims to review principles of antibiotic stewardship, evidence-based guidelines for surgical prophylaxis and ways to optimize antibiotics use in the treatment of spinal infections. Methods: A narrative review of several society guidelines and spine surgery literature was conducted. Results: Antibiotic stewardship in spine surgery requires multidisciplinary investment and consistent evaluation of antibiotic use for drug selection, dose, duration, drug-route, and de-escalation. Developing effective surgical prophylaxis regimens is a key strategy in reducing the burden of antibiotic resistance. For treatment of primary spinal infection, the diagnostic work-up is vital in tailoring effective antibiotic therapy. The future of antibiotics in spine surgery will be highly influenced by improving surgical technique and evidence regarding the role of bacteria in the pathogenesis of degenerative spinal pathology. Conclusions: Incorporating evidence-based guidelines into regular practice will serve to limit the development of resistance while preventing morbidity from spinal infection. Further research should be conducted to provide more evidence for surgical site infection prevention and treatment of spinal infections.

Effect of baseline veterans RAND-12 physical composite score on postoperative patient-reported outcome measures following lateral lumbar interbody fusion.

PURPOSE: To determine the prognostic value of preoperative Veterans RAND-12 (VR-12) Physical Composite Score (PCS) scores on postoperative clinical outcomes in patients undergoing lateral lumbar interbody fusion (LLIF). METHODS: LLIF patients were separated into 2 cohorts based on preoperative VR-12 PCS scores: VR-12 PCS < 30 (lesser physical function) and VR-12 PCS ≥ 30 (greater physical function). Patient-reported outcome measures (PROMs) of VR-12 PCS, VR-12 Mental Composite Score (MCS), Short Form-12 (SF-12) PCS, SF-12 MCS, Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF), Patient Health Questionnaire-9 (PHQ-9), Visual Analog Scale (VAS) Back Pain (VAS-BP), VAS Leg Pain (VAS-LP), and Oswestry Disability Index (ODI) were collected at preoperative and up to 2-year postoperative time points. Mean postoperative follow-up time was 16.69 ± 8.53 months. Minimum clinically important difference (MCID) achievement was determined by comparing ∆PROM to previously established thresholds. RESULTS: Seventy-eight patients were included, with 38 patients with lesser preoperative physical function scores. Patients with lesser physical function reported significantly inferior preoperative PROM scores in all domains, except for SF-12 MCS and VAS-LP. At the 6-week postoperative time point, patients with lesser physical function reported significantly inferior VR-12 PCS, VR-12 MCS, SF-12 PCS, PROMIS-PF, and PHQ-9. At the final postoperative time point, patients with lesser physical function reported significantly inferior VR-12 PCS, VR-12 MCS, PROMIS-PF, PHQ-9, and ODI. Magnitude of 6-week postoperative improvement was significantly higher in the lesser physical function cohort for VR-12 PCS. CONCLUSION: Patients undergoing LLIF with worse baseline VR-12 PCS scores reported inferior postoperative physical function, mental health, and disability outcomes. At the final postoperative follow-up, magnitude of postoperative improvement and MCID achievement did not significantly differ. Baseline VR-12 PCS scores may indicate inferior postoperative clinical outcomes in physical function, mental health, and disability in patients undergoing LLIF; however, baseline VR-12 PCS does not limit the magnitude of postoperative improvement.

Medicare Reimbursement Rates and Utilization Trends in Sacroiliac Joint Fusion.

INTRODUCTION: Sacroiliac joint (SIJ) fusion is a surgical treatment option for SIJ pathology in select patients who have failed conservative management. More recently, minimally invasive surgical (MIS) techniques have been developed. This study aimed to determine the trends in procedure volume and reimbursement rates for SIJ fusion. METHODS: Publicly available Medicare databases were assessed using the National Summary Data Files for 2010 to 2020. Files were organized according to current procedural terminology (CPT) codes. CPT codes specific to open and MIS SI joint fusion (27279 and 27280) were identified and tracked. To track surgeon reimbursements, the CMS Medicare Physician Fee Schedule Look-Up Tool was used to extract facility prices. Descriptive statistics and linear regression were used to evaluate trends in procedure volume, utilization, and reimbursement rates. Compound annual growth rates were calculated, and discrepancies in inflation were corrected for using the Consumer Price Index. RESULTS: A total of 33,963 SIJ fusions were conducted in the Medicare population between 2010 and 2020, with an overall increase in procedure volume of 2,350.9% from 318 cases in 2010 to 7,794 in 2020. Since the introduction of the 27279 CPT code in 2015, 8,806 cases (31.5%) have been open and 19,120 (68.5%) have been MIS. Surgeon reimbursement for open fusions increased nominally by 42.8% (inflation-adjusted increase of 20%) from $998 in 2010 to $1,425 in 2020. Meanwhile, reimbursement for MIS fusion experienced a nominal increase of 58.4% (inflation-adjusted increase of 44.9%) from $582 in 2015 to $922 in 2020. CONCLUSION: SIJ fusion volume in the Medicare population has increased substantially in the past 10 years, with MIS SIJ fusion accounting for most of the procedures since the introduction of the 27279 CPT code in 2015. Reimbursement rates for surgeons have also increased for both open and MIS procedures, even after adjusting for inflation.

Success of Surgical Simulation in Orthopedic Training and Applications in Spine Surgery.

STUDY DESIGN: This was a narrative review. OBJECTIVE: This study aimed to review the current literature on surgical simulation in orthopedics and its application to spine surgery. SUMMARY OF BACKGROUND DATA: As orthopedic surgery increases in complexity, training becomes more relevant. There have been mandates in the United States for training orthopedic residents the fundamentals of surgical skills; however, few studies have examined the various training options available. Lack of funding, availability, and time are major constraints to surgical simulation options. METHODS: A PubMed review of the current literature was performed on all relevant articles that examined orthopedic trainees using surgical simulation options. Studies were examined for their thoroughness and application of simulation options to orthopedic surgery. RESULTS: Twenty-three studies have explored orthopedic surgical simulation in a setting that objectively assessed trainee performance, most in the field of trauma and arthroscopy. However, there was a lack of consistency in measurements made and skills tested by these simulators. There has only been one study exploring surgical simulation in spine surgery. CONCLUSIONS: While there has been a growing number of surgical simulators to train orthopedic residents the fundamentals of surgical skills, most of these simulators are not feasible, reproducible, or available to the majority of training centers. Furthermore, the lack of consistency in the objective measurements of these studies makes interpretation of their results difficult. There is a need for more simulation in spine surgery, and future simulators and their respective studies should be reproducible, affordable, applicable to the surgical setting, and easily assembled by various programs across the world.

Minimally Invasive Transforaminal Lumbar Interbody Fusion: Comparison of Grade I Versus Grade II Isthmic Spondylolisthesis.

BACKGROUND: Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) is often used to treat low-grade isthmic spondylolisthesis (IS). No studies have compared surgical outcomes for grade I and II IS following MIS-TLIF. Therefore, the objective of the current study was to compare outcomes between patients with grade I and II IS following MIS-TLIF. METHODS: A retrospective cohort analysis was performed on a prospectively maintained database of patients who underwent a primary 1-level MIS-TLIF for treatment of IS between 2007 and 2015. Grade I patients underwent a unilateral tubular approach with a single interbody cage and bilateral pedicle screw instrumentation. Grade II patients underwent a bilateral tubular approach with bilateral interbody cage and pedicle screw placement. Baseline patient demographics and characteristics were compared using Student t test and χ2 analysis. Differences in peri- and postoperative outcomes were assessed using Poisson regression with robust error variance or linear regression adjusted for perioperative variables. RESULTS: A total of 58 patients with IS underwent MIS-TLIF; 21 (36.2%) were grade I and 37 (63.8%) were grade II. The grade I cohort was younger (42.2 versus 50.6 years, P = .029); no other differences in preoperative variables were observed. No significant differences in operative time, estimated blood loss, length of hospital stay, postoperative visual analogue scale scores, or complication and revision rates were demonstrated between cohorts. Arthrodesis rate was lower in the grade I cohort, though not statistically significant. CONCLUSIONS: Despite the grade I cohort being younger with less-severe diagnoses, the grade II cohort experienced similar outcomes. This finding may be due to the grade II cohort receiving bilateral cages, potentially providing a better fusion environment. CLINICAL RELEVANCE: These results suggest that MIS-TLIF provides sufficient stabilization and fusion for treatment of grade II IS despite increased vertebral body displacement. In addition, MIS-TLIF with bilateral approach and interbody cage placement should be examined for treatment of high-grade IS cases.

Improvements in Back and Leg Pain After Minimally Invasive Lumbar Decompression.

BACKGROUND: Few studies have quantified clinical improvement following minimally invasive lumbar decompression based on predominant back pain or leg pain. PURPOSE: To quantify improvement in patient-reported outcomes following minimally invasive lumbar decompression and determine the degree of improvement in back pain, leg pain, and disability in patients who present with predominant back pain or predominant leg pain. METHODS: Patients who underwent primary, one-level minimally invasive lumbar decompression for degenerative pathology were retrospectively reviewed. Comparisons of visual analog scale (VAS) back and leg pain scores, Oswestry Disability Index (ODI) scores, and Short Form-12 (SF-12) mental and physical component scores from pre-operative to 6-week, 12-week, 6-month, and 1-year follow-up. Subgroup analyses were performed for patients with predominant back pain or predominant leg pain. RESULTS: A total of 102 patients were identified. Scores on VAS back and leg pain, ODI, and SF-12 physical component improved from pre-operative to all post-operative time points. After 1 year, patients reported a 2.8-point (47%) reduction in back pain and a 4-point (61.1%) reduction in leg pain scores; 52 patients with predominant back pain and 50 patients with predominant leg pain reported reductions in pain throughout the year following surgery. In both the back and leg pain cohorts, patients experienced reductions in ODI during the first 6 months and throughout 1-year follow-up, respectively. The majority of patients achieved minimum clinically important difference, regardless of predominant symptom. CONCLUSIONS: Patients reported improvements in back and leg pain following minimally invasive lumbar decompression regardless of predominant presenting symptom; however, patients with predominant leg pain may experience greater improvement than those with predominant back pain.

Comparison of Stand-alone Lateral Lumbar Interbody Fusion Versus Open Laminectomy and Posterolateral Instrumented Fusion in the Treatment of Adjacent Segment Disease Following Previous Lumbar Fusion Surgery.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The aim of this study was to compare clinical and radiographic outcomes of patients who underwent stand-alone lateral lumbar interbody fusion (LLIF) to those who underwent posterolateral fusion (PLF) for symptomatic adjacent segment disease (ASD). SUMMARY OF BACKGROUND DATA: Recent studies have suggested that LLIF can successfully treat ASD; however, there are no studies to date that compare LLIF with the traditional open PLF in this cohort. METHODS: A total of 47 consecutive patients who underwent LLIF or PLF for symptomatic ASD between January 2007 and August 2016 after failure of conservative management were reviewed for this study. Patient-reported outcomes (PROs) were collected on all patients at preoperative, postoperative, and most recent post-operative visit using the Oswestry Disability Index, Visual Analog Scale (VAS)-Back, and VAS-Leg surveys. Preoperative, immediate postoperative, and most recent postoperative radiographs were assessed for pelvic incidence, fusion, intervertebral disc height, segmental and overall lumbar lordosis (LL). Symptomatic ASD was diagnosed if back pain, neurogenic claudication, or lower extremity radiculopathy presented following a previous lumbar fusion. Preoperative plain radiographs were evaluated for evidence of adjacent segment degeneration. RESULTS: A total of 47 patients (23 LLIF, 24 PLF) met inclusion criteria. Operative times (P < 0.001) and intraoperative blood loss (P < 0.001) were significantly higher in the PLF group. Patients who underwent PLF were discharged approximately 3 days after the LLIF patients (P < 0.001). PROs in the PLF and LLIF cohorts showed significant and equivalent improvement, with equivalent radiographic fusion rates. LLIF significantly improve segmental lordosis (P < 0.001), total LL (P = 0.003), and disc height (P < 0.001) from preoperative to immediate postoperative and final follow-up (P = 0.004, P = 0.019, P ≤ 0.001, respectively). CONCLUSION: Although LLIF may provide less perioperative morbidity and shorter length of hospitalization, both techniques are safe and effective approaches to restore radiographic alignment and provide successful clinical outcomes in patients with adjacent segment degeneration following previous lumbar fusion surgery. LEVEL OF EVIDENCE: 3.