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.

Does Preoperative Back Pain Impact Patient-reported Outcomes in Patients Undergoing Minimally Invasive Transforaminal Lumbar Interbody Fusion for Isthmic Spondylolisthesis?

STUDY DESIGN: Retrospective review. OBJECTIVE: To determine postoperative clinical outcomes in patients undergoing minimally invasive (MIS) transforaminal lumbar interbody fusion (TLIF) for isthmic spondylolisthesis (IS). BACKGROUND: Few studies have examined the postoperative clinical trajectory in patients undergoing MIS-TLIF specifically for IS. METHODS: Patients were separated into two cohorts based on the previously defined Visual Analog Scale (VAS) back pain (BP) for severe pain: VAS-BP <7 and VAS-BP ≥7. Patient-reported outcome measures (PROMs) of Patient-Reported Outcomes Measurement Information System-physical function (PF), 12-item Short Form (SF-12) Physical/Mental Component Score, Patient Health Questionnaire-9, VAS-BP, VAS leg pain, and Oswestry Disability Index were collected preoperatively and up to 2-year postoperatively. Minimum clinically important difference (MCID) was calculated through previously defined thresholds. RESULTS: A total of 160 patients were recorded, with 58 patients in the VAS-BP <7 cohort. The VAS-BP <7 cohort demonstrated significant improvement in all PROMs at one or more postoperative time points. The VAS-BP ≥7 demonstrated significant improvement at 3 or more postoperative time points in all PROMs except for SF-12 Mental Component Score. The VAS-BP <7 cohort reported significantly superior preoperative and postoperative PROMs in all domains, except for SF-12 Physical Component Score. The VAS-BP ≥7 cohort had higher MCID achievement rates at one or more time points in multiple PROMs. CONCLUSION: Patients undergoing MIS-TLIF for IS demonstrated significant postoperative improvement in PF, mental function, pain, and disability outcomes independent of preoperative severity of BP. Patients with lower preoperative BP demonstrated superior outcomes in PF, mental function, pain, and disability. However, patients with greater preoperative BP achieved higher rates of MCID in mental function, BP, and disability outcomes. Patients with greater severity of preoperative BP undergoing MIS-TLIF for IS may experience greater rates of clinically relevant improvement in mental function, BP, and disability outcomes.

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.

The Surgical Learning Curve for Cervical Disk Replacement.

STUDY DESIGN: Retrospective study. OBJECTIVE: To characterize an experienced single surgeon learning curve for cervical disk replacement (CDR). SUMMARY OF BACKGROUND DATA: A single surgeon learning curve has not been established for CDR. METHODS: Patients undergoing CDR were included. The cumulative sum of operative time was utilized to separate cases into 3 phases: learning, practicing, and mastery. Demographics, perioperative characteristics, complications, patient-reported outcomes (PROs), and radiographic outcomes were collected preoperatively and up to 1 year postoperatively. PROs included Patient-reported Outcomes Measurement Information System Physical Function, 12-item Short Form-12 Physical Component Score, 12-item Short Form-12 Mental Component Score, visual analog scale (VAS) arm, VAS neck, Neck Disability Index. Radiographic outcomes included segmental angle/segmental range of motion/C2-C7 range of motion. Minimum clinically important difference achievement was determined through a comparison of previously established values. RESULTS: A total of 173 patients were identified, with 14 patients in the learning phase, 42 patients in the practicing phase, and 117 patients in the mastery phase. Mean operative time and mean postoperative day 0 narcotic consumption were significantly higher in the learning phase. The preoperative segmental angle was significantly lower for the learning phase, though these differences were eliminated at the final postoperative time point. Patients in the learning phase reported worse improvement to 6-week postoperative, final postoperative, and worse overall final postoperative VAS Arm scores compared with practicing and mastery phases. CONCLUSIONS: For an experienced spine surgeon, the learning phase for CDR was estimated to span 14 patients. During this phase, patients demonstrated longer operative times, higher postoperative narcotic consumption, and worse postoperative VAS Arm scores. Radiographically, no postoperative differences were noted between different phases of mastery. This single surgeon learning curve demonstrates that CDR may be performed safely and with comparable outcomes by experienced spine surgeons despite decreased operative efficiency in the learning phase.

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.

Poor patient-reported mental health correlates with inferior patient-reported outcome measures following cervical disc replacement.

PURPOSE: This study aims to assess the correlation between the patient-reported mental health and the self-reported outcome measures (PROMs) physical function, pain, and disability at different time points following disc replacement (CDR). METHODS: A single-surgeon registry was searched for patients who had undergone CDR, excluding those with indication for infection, cancer, or trauma. One hundred fifty-one patients were included. PROMs were collected preoperatively as well as 6 weeks, 3 months, 6 months, and 1 year postoperatively. Mental health measures evaluated included 12-Item Short Form (SF-12), Mental Component Score (MCS), and Patient Health Questionnaire-9 (PHQ-9) which were individually assessed via Pearson's correlation tests in relation to Patient-Reported Outcome Measurement Information System Physical Function (PROMIS-PF), SF-12 Physical Component Score (PCS), visual analog scale (VAS) neck and arm pain, and Neck Disability Index (NDI). RESULTS: SF-12 MCS positively correlated with PROMIS-PF (range: r = 0.369-0.614) and SF-12 PCS (range: r = 0.208-0.585) with significance found at two or more time points for each (p ≤ 0.009, all). SF-12 MCS negatively correlated with VAS neck (range: r = - 0.259 to - 0.464), VAS arm (range: r = - 0.281 to - 0.567), and NDI (range: r = - 0.474 to - 831) with significance found at three or more time points (p ≤ 0.028, all). PHQ-9 significantly negatively correlated with PROMIS-PF (range: r = - 0.457 to - 0.732) and SF-12 PCS (range: r = - 0.332 to - 0.629) at all time points (p ≤ 0.013, all). PHQ-9 positively correlated with VAS neck (range: r = 0.351-0.711), VAS arm (range: r = 0.239-0.572), and NDI (range: r = 0.602-0.837) at four or more periods (p ≤ 0.032, all). CONCLUSION: Patients undergoing CDR who reported lower mental health scores via either SF-12 MCS or PHQ-9 were associated with increased perception of pain and disability. Disability level correlated with mental health at all time periods. Patients with optimized mental health may report higher outcome scores following CDR.

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.

Does Surgeon Level of Expertise Correlate with Patient Outcomes?

Background It is difficult to evaluate the results of surgical techniques as there is inherent variability between surgeons in regard to experience, skill level, and knowledge. Tang suggested a classification system in 2009 in an attempt to standardize surgeon level of expertise, with categories ranging from nonspecialist (Level I) to expert (Level V). This epidemiological analysis of all articles citing Tang's original paper examines if a surgeon's self-reported level of expertise correlates with outcomes and evaluates whether the current definition of Tang level is sufficient to account for expertise bias. Methods In May 2021, all articles citing Tang level of expertise were identified ( N = 222). Articles were included if they described a novel technique and provided author(s)' levels ( n = 205). Statistical analysis was conducted, and p -values less than 0.05 were considered significant. Results The most common specialties reporting Tang level of expertise were orthopaedic surgery (82.9%) and plastic surgery (15.5%). The most common subspecialty was hand surgery. 2020 was the year with the most studies reporting level of expertise (31.7%), followed by 2021 (20.0%) and 2019 (17.1%). The majority of studies (80.5%) reported positive results with their technique, and of these, 63.3% were statistically significant. Level of expertise was not significantly associated with a doctoral degree, type of residency completed, fellowship completion, hand fellowship, author sex, study type, or result significance. Discussion The current Tang classification is both underreported and incomplete in its present state. To account for expertise bias, we recommend all authors report Tang level when describing surgical techniques. Studies with multiple authors should explicitly state the level of each author, as well as a weighted average accounting for the total contribution of each individual.

Time to achievement of minimum clinically important difference after lumbar decompression.

OBJECTIVE: The objective of this study is to examine factors associated with delayed time to achieve minimum clinically important difference (MCID) in patients undergoing lumbar decompression (LD) for the Patient-Reported Outcomes (PROs) of Oswestry Disability Index (ODI), Visual Analog Scale (VAS) back, and VAS leg pain. METHODS: Patients undergoing LD with preoperative and postoperative ODI, VAS back, and VAS leg scores were retrospectively reviewed from April 2016 to January 2021. MCID values from previously established studies were utilized to determine MCID achievement. Kaplan-Meier survival analysis determined the time to achieve MCID. Hazard ratios from multivariable Cox regression were utilized to determine the preoperative factors predictive of MCID achievement. RESULTS: Three-hundred and forty-three patients were identified undergoing LD. Overall MCID achievement rates were 67.4% for ODI, 67.1% for VAS back, and 65.0% for VAS leg. The mean time in weeks for MCID achievement was 22.52 ± 30.48 for ODI, 18.90 ± 27.43 for VAS back, and 20.96 ± 29.81 for VAS leg. Multivariable Cox regression revealed active smoker status, preoperative Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF), ODI, VAS Back, and VAS Leg (HR 1.03-2.14) as predictors of early MCID achievement, whereas an American Society of Anesthesiologist (ASA) classification of 2, Black ethnicity, workers' compensation, private insurance, and diagnosis of foraminal stenosis were predictors of late MCID achievement (HR 0.34-0.58). CONCLUSION: Most patients undergoing LD achieved MCID within 6 months of surgery. Significant factors for early MCID achievement were active smoking status and baseline PROs. Significant factors for late MCID achievement were ASA = 2, Black ethnicity, type of insurance, and foraminal stenosis diagnosis. These factors may be considered by surgeons in setting patient expectations.

Preoperative predictors of prolonged hospitalization in patients undergoing lateral lumbar interbody fusion.

PURPOSE: We aim to examine the preoperative factors associated with increased postoperative length of stay in patients undergoing LLIF in the hospital setting. METHODS: Patient demographics, perioperative characteristics, and patient-reported outcome measures (PROMs) were collected from a single-surgeon database. Patients undergoing LLIF in the hospital setting were separated into postoperative LOS <48 h (H) and LOS ≥ 48H. Univariate analysis for preoperative characteristics was utilized to determine covariates for multivariable logistic regression. Multivariable logistic regression was then utilized to determine significant predictors of extended postoperative length of stay. Secondary univariate analysis of inpatient complications, operative, and postoperative characteristics were calculated to determine postoperative factors associated with prolonged hospitalization. RESULTS: Two-hundred and forty patients were identified with 115 patients' LOS ≥ 48H. Univariate analysis identified age/Charlson Comorbidity Index (CCI) score/gender/insurance type/number of contiguous fused levels/preoperative PROMs of Visual Analog Scale (VAS) back/VAS leg/Patient-Reported Outcomes Measurement Information System (PROMIS-PF)/Oswestry Disability Index (ODI)/degenerative spondylolisthesis diagnoses/foraminal stenosis/central stenosis for multivariable logistic regression. Multivariable logistic regression calculated significant positive predictors of LOS ≥ 48H to be age/3-level fusion/preoperative ODI scores. Negative predictors of LOS ≥ 48H were the diagnosis of foraminal stenosis/preoperative PROMIS-PF/male gender. The secondary analysis determined that patients with longer operative time/estimated blood loss/transfusion/postoperative day 0 and 1 pain and narcotic consumption/complications of altered mental status/postoperative anemia/fever/ileus/urinary retention were associated with prolonged hospitalization. CONCLUSION: Older patients undergoing LLIF with greater preoperative disability and 3-level fusion were more likely to require prolonged hospitalization. Male patients with higher preoperative physical function and who were diagnosed with foraminal stenosis were less likely to require prolonged hospitalization.

Postoperative clinical outcomes in patients undergoing MIS-TLIF versus LLIF for adjacent segment disease.

PURPOSE: Few studies examine the clinical outcomes in patients undergoing minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) versus lateral lumbar interbody fusion (LLIF) for adjacent segment disease (ASD). We aim to compare the postoperative clinical trajectory through patient-reported outcome measures (PROMs) and minimum clinically important difference (MCID) in patients undergoing MIS-TLIF versus LLIF for ASD. METHODS: Patients were stratified into two cohorts based on surgical technique for ASD: MIS-TLIF versus LLIF. PROMs of 12-Item Short Form Physical Component Score (SF-12 PCS), visual analog scale (VAS) back, VAS leg, and Oswestry Disability Index (ODI) were collected at preoperative and postoperative 6-week/12-week/6-month/1-year time points. MCID attainment was calculated through comparison to established thresholds. Cohorts were compared through nonparametric inferential statistics. RESULTS: Fifty-four patients were identified, with 22 patients undergoing MIS-TLIF after propensity score matching. Patients undergoing MIS-TLIF for ASD demonstrated significant postoperative improvement up to 1-year VAS back, up to 1-year VAS leg, and 6-month through 1-year ODI (p ≤ 0.035, all). Patients undergoing LLIF demonstrated significant postoperative improvement in 6-month SF-12 PCS, 6-month through 1-year VAS back, 12-week through 6-month VAS leg, and 6-month to 1-year ODI (p ≤ 0.035, all). No significant differences were calculated between surgical techniques for PROMs or MCID achievement rates. CONCLUSION: Patients undergoing either MIS-TLIF or LLIF for adjacent segment disease demonstrated significant postoperative improvement in pain and disability outcomes. Additionally, patients undergoing LLIF reported significant improvement in physical function. Both MIS-TLIF and LLIF are effective for the treatment of adjacent segment disease.

Differences in Time to Achieve Minimum Clinically Important Difference Between Patients Undergoing Anterior Cervical Discectomy and Fusion and Cervical Disc Replacement.

OBJECTIVE: To compare patients undergoing anterior cervical discectomy and fusion (ACDF) versus cervical disc replacement (CDR) for time to minimum clinically important difference (MCID) achievement and predictors of delayed MCID achievement for the patient-reported outcomes (PROs), Patient-Reported Outcomes Measurement Information System Physical Function, Neck Disability Index, Visual Analog Scale (VAS) neck, and VAS arm. METHODS: PROs of patients undergoing ACDF or CDR were collected preoperatively and postoperatively at 6-week/12-week/6-month/1-year/2-year periods. MCID achievement was calculated through comparison of changes in Patient-Reported Outcomes Measurement to previously established values in literature. Time to MCID achievement and predictors for delayed MCID achievement were determined through Kaplan-Meier survival analysis and multivariable Cox regression, respectively. RESULTS: One hundred ninety-seven patients were identified, with 118 and 79 undergoing ACDF and CDR, respectively. Kaplan-Meier survival analysis demonstrated faster time to achieve MCID for CDR patients in Patient-Reported Outcomes Measurement Information System Physical Function (P = 0.006). Early predictors of MCID achievement through Cox regression were CDR procedure, Asian ethnicity, elevated preoperative PROs of VAS neck and VAS arm (hazard ratio, 1.16-7.28). Workers' compensation was a late predictor of MCID achievement (hazard ratio, 0.15). CONCLUSIONS: Most patients achieved MCID in physical function, disability, and back pain outcomes within 2 years of surgery. Patients undergoing CDR achieved MCID faster in physical function. Early predictors of MCID achievement were CDR procedure, Asian ethnicity, and elevated preoperative PROs of pain outcomes. Workers' compensation was a late predictor. These findings may be helpful in managing patient expectations.

Depressed patients with greater symptom duration before MIS-TLIF do not report inferior outcomes.

PURPOSE: Patients with preoperative depressive symptoms may demonstrate inferior patient-reported outcomes (PROs). The effect of preoperative symptom duration (SD) on PROs in this population has not been well-studied. We aim to assess the influence of preoperative SD on PROs in patients with low mental health scores prior to minimally invasive transforaminal interbody fusion (MIS-TLIF). METHODS: Patients who had undergone elective, primary MIS-TLIF with preoperative SF-12 MCS score below 45.6, a previously established threshold for depression, were selected. Patients were divided into matched lesser duration (LD; SD<365 days) and greater duration (GD; SD≥365 days) cohorts. PROs were collected preoperatively and at 6-week/12-week/6-month/1-year postoperative periods. PROs included PROMIS-PF/ODI/VAS back/VAS leg/SF-12 MCS. PROs were compared within and between groups. Rates of achievement of minimal clinically important difference (MCID) were compared between groups. RESULTS: One hundred twenty-two patients were included after matching cohorts. Patients in the LD cohort demonstrated improvement in PROMIS-PF at 12-weeks/6-month/1-year, and ODI/VAS back/VAS leg/SF-12 MCS at all postoperative periods (p≤0.024, all). Patients in the GD cohort demonstrated improvement in PROMIS-PF at 12-weeks/6-month/1-year, and ODI/VAS back/VAS leg/SF-12 MCS at all postoperative periods (p≤0.013, all). There were no differences in PROs or MCID achievement between cohorts at any period. CONCLUSION: Patients with preoperative depressive symptoms undergoing MIS-TLIF, regardless of duration of preoperative symptoms, demonstrated improvements in physical function, disability, pain, and mental health domains. Patients with greater duration of preoperative symptoms did not report inferior outcomes at any period. Rates of clinically important improvements in all domains were favorable and similar between cohorts.

Influence of Prolonged Duration of Symptoms Before MIS-TLIF in a Workers' Compensation Population.

OBJECTIVE: We assessed the potential effect of the preoperative symptom duration on patient-reported outcomes (PROs) for workers' compensation (WC) patients undergoing minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF). METHODS: WC patients who had undergone primary, elective MIS-TLIF with recorded symptoms duration data available were included. Two cohorts were generated: those with a shorter (lesser) duration (LD; symptom duration <1 year) and those with a prolonged duration (PD; symptom duration >1 year). PROs were collected preoperatively and at several follow-up points for ≤1 year postoperatively. The PROs were compared within and between the 2 cohorts. The achievement rates of minimum clinically important differences were also compared between the 2 cohorts. RESULTS: A total of 145 patients were included, with 76 in the PD cohort and 69 in the LD cohort. The LD cohort demonstrated improvement in the patient-reported outcomes measurement information system for physical function (PROMIS-PF) at 6 months and 1 year postoperatively, Oswestry disability index (ODI) at 12 weeks and 6 months postoperatively, visual analog scale (VAS) score for back pain at 6 weeks, 12 weeks, and 6 months postoperatively, and VAS score for leg pain at all postoperative points (P ≤ 0.015 for all). The PD cohort demonstrated improvement in the PROMIS-PF at 12 weeks and 6 months postoperatively, ODI at 6 weeks, 12 weeks, and 6 months postoperatively, and VAS score for back pain and leg pain at all postoperative periods (P ≤ 0.007 for all). All the preoperative PROs were superior for the LD cohort (P < 0.001 for all). The LD cohort reported better PROMIS-PF at 6 months and 1 year and ODI at 1 year postoperatively (P ≤ 0.037 for all). The PD cohort was more likely to achieve a minimum clinically important difference in ODI at 6 and 12 weeks postoperatively, VAS score for back pain at 6 weeks postoperatively, and VAS score for leg pain at 6 weeks and 1 year postoperatively and overall (P ≤ 0.036 for all). CONCLUSIONS: Independently of the preoperative symptom duration, WC patients demonstrated improvement in physical function and pain after MIS-TLIF. Patients with a longer symptom duration reported inferior function and pain preoperatively and were more likely to demonstrate clinically significant improvements in disability and pain postoperatively.

The impact of the Florida law HB21 on opioid prescribing patterns after spine surgery.

Background: The opioid epidemic represents a major public health issue in the United States and has led to significant morbidity and mortality. On July 1 2018, Florida implemented state-law House Bill 21 (HB21), limiting opioid prescriptions to a 3-day supply for acute pain or 7 days if an exception is documented. The purpose of this study is to evaluate the effects of HB21 on opioid prescribing patterns after spine surgery. Methods: Patients 18 years and older who underwent spine surgery between January 2017 and January 2021 were eligible for inclusion. Information including demographics, pills, days, and morphine milligram equivalents (MMEs) was obtained via retrospective chart review using the Florida Prescription Drug Monitoring Program and Epic Chart Review. Student's t tests and Fisher's exact tests were used for comparison of continuous variables. Multiple logistic regression was utilized to determine which variables were associated with postoperative opioid prescriptions. p<.05 was considered significant. Results: We reviewed 114 patients who underwent spine surgery from January 2017 to July 2018 and 264 patients from July 2018 to January 21. There were no significant differences between the groups in age, sex, ethnicity, body mass index, number of levels fused, or preoperative opioid use. The average number of MMEs, pills prescribed and days in the first postoperative prescription decreased significantly after HB21. Multiple logistic regression revealed that the variable most predictive of MMEs and number of pills in the first postoperative prescription was postlaw status (p=.002, p=.50). Conclusions: Florida law HB21 was successful in decreasing postoperative opioid prescriptions after spine surgery, however, the need for additional progress remains. Legislation should be combined with multimodal pain regimens, as well as patient and provider education in order to further decrease postoperative opioid requirements. Future studies should include a larger number of patients treated by multiple spine surgeons across multiple institutions in order to further evaluate the effects of HB21 on postoperative opioid prescriptions.

Impact of body mass index on PROMIS outcomes following lumbar decompression.

BACKGROUND: No studies have examined the impact of body mass index (BMI) on newer Patient-Reported Outcomes Measurement Information System (PROMIS) outcomes in patients undergoing lumbar decompression (LD). METHODS: Patients undergoing LD with preoperative PROMIS measures were stratified into four cohorts: normal (18.5 ≤ BMI < 25 kg/m2), overweight (25 ≤ BMI < 30 kg/m2), obese I (30 ≤ BMI < 35 kg/m2), and obese II-III (BMI ≥ 35 kg/m2). Demographics, perioperative characteristics, and patient-reported outcomes (PROs) were obtained. PROs of PROMIS Physical Function (PROMIS-PF), PROMIS Anxiety (PROMIS-A), PROMIS Pain Interference (PROMIS-PI), PROMIS Sleep Disturbance (PROMIS-SD), 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. Minimum clinically important difference (MCID) achievement was determined through comparison of previously established values. Comparison between cohorts were determined through inferential statistics. RESULTS: A total of 473 patients were identified, with stratification of 125 patients in the normal cohort, 161 in the overweight cohort, 101 in the obese I cohort, and 87 in the obese II-III cohort. Mean postoperative follow-up time was 13.51 ± 8.72 months. Higher BMI patients had higher operative times, longer postoperative length of stay, and greater narcotic consumption (p ≤ 0.001, all). Patients with higher BMI (obese I, obese II-III) reported inferior preoperative PROMIS-PF, VAS-BP, and ODI scores (p ≤ 0.003, all). Postoperatively, obese I-III cohorts demonstrated inferior PROMIS-PF, PHQ-9, VAS-BP, and ODI scores at final follow-up (p ≤ 0.016, all). However, patients demonstrated similar postoperative changes and MCID achievement regardless of preoperative BMI. CONCLUSION: Patients undergoing lumbar decompression demonstrated similar postoperative improvement in physical function, anxiety, pain interference, sleep disturbance, mental health, pain, and disability outcomes independent of preoperative BMI. However, obese patients reported worse physical function, mental health, back pain, and disability outcomes at final postoperative follow-up. Patients with greater BMI undergoing lumbar decompression demonstrate inferior postoperative clinical outcomes.

Recovery ratios and minimum clinically important difference for clinical outcomes in workers' compensation recipients undergoing MIS-TLIF versus ALIF.

BACKGROUND: There is a scarcity of literature that examines clinical outcomes through patient-reported outcomes (PROs), minimum clinically important difference (MCID), and recovery ratios (RR) for workers' compensation (WC) recipients undergoing minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) versus anterior lumbar interbody fusion (ALIF). METHODS: WC claimants undergoing MIS-TLIF versus ALIF were propensity score matched to account for demographic differences. Demographics, perioperative characteristics, and PROs were collected. PROs of Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF), 12-Item Short Form Physical Composite Score (SF-12 PCS), Visual Analog Scale (VAS) back, VAS leg, and Oswestry Disability Index (ODI) were collected at preoperative and postoperative time points. MCID achievement was determined through comparison to values in literature. RR was calculated as the difference between postoperative and preoperative PROs over potential improvement. Comparison between surgical techniques was through non-parametric inferential statistics. RESULTS: Eighty-four WC claimants, with 50 patients undergoing MIS-TLIF, were identified after propensity score matching. ALIF patients had higher estimated blood loss. MIS-TLIF patients had higher postoperative day (POD) 0 VAS pain and POD 0 + 1 narcotic consumption. Patients undergoing either MIS-TLIF or ALIF reported significant improvement in pain and disability. ALIF patients reported significant improvement in physical function. ALIF patients reported superior 1-year PROMIS-PF, 6-week SF-12 PCS, 6-month VAS back, and 12-week VAS leg. No significant differences in MCID achievement rates were noted between cohorts. ALIF patients had higher RR in 6-week and 1-year PROMIS-PF and 6-week SF-12 PCS. CONCLUSION: Workers' compensation claimants undergoing either MIS-TLIF or ALIF reported significant improvement in pain and disability. ALIF patients reported superior postoperative physical function and pain. ALIF patients had higher recovery ratios in physical function. Workers' compensation claimants undergoing ALIF may experience greater physical function recovery and superior clinical outcomes in physical function and pain.

Impact of preoperative symptom duration in patients undergoing lateral lumbar interbody fusion.

BACKGROUND: Few studies have examined the influence of preoperative symptom duration on clinical outcomes in patients undergoing lateral lumbar interbody fusion (LLIF) for degenerative conditions. METHODS: Patients undergoing LLIF presenting with radiculopathy and/or neurogenic claudication were separated into two groups: preoperative symptom duration < 1-year (shorter duration) versus duration ≥ 1-year (longer duration). Patients undergoing surgery for trauma/malignancy/infection were excluded. Patient-reported outcome measures (PROMs) of Patient-Reported Outcomes Measurement Information System-Physical Function (PROMIS-PF), 12-Item Short Form Physical/Mental Component Score (SF-12 PCS/MCS), Patient Health Questionnaire-9 (PHQ-9), visual analog scale (VAS) back/leg, and Oswestry Disability Index (ODI) were collected at preoperative and postoperative time points. RESULTS: Eighty-two total patients, with 34 shorter-duration patients, were identified after propensity score matching for demographics. Longer-duration patients had higher estimated blood loss. All patients reported significant improvement in physical function, mental function, pain, and disability in at least one postoperative time point, except for SF-12 MCS in the shorter duration cohort. The longer duration cohort had higher MCID achievement in 12-week VAS back. CONCLUSION: Patients undergoing LLIF demonstrated significant postoperative improvement in physical function, mental function, pain, and disability outcomes independent of preoperative symptom duration. Both cohorts, when compared by preoperative symptom duration, demonstrated similar postoperative PROM scores. Patients with longer preoperative symptom duration had higher 12-week leg pain MCID achievement. These findings suggest that delayed time to surgery may not lead to inferior clinical outcomes in patients undergoing LLIF for degenerative conditions.

Influence of Preoperative Disability on Clinical Outcomes in Patients Undergoing Anterior Lumbar Interbody Fusion.

BACKGROUND: Few studies have examined the influence of preoperative disability through the Oswestry Disability Index (ODI) on clinical outcomes in patients undergoing anterior lumbar interbody fusion (ALIF). METHODS: Patients undergoing ALIF were separated into 2 groups based on ODI<41 (lower disability) versus ODI≥41% (higher disability). Patient-reported outcomes (PROs) were collected at preoperative and postoperative 6-week/12-week/6-month/1-year/2-year time points. Physical function PROs were Patient-Reported Outcomes Measurement Information System Physical Function and 12-item Short Form Physical Component Score. Mental function PROs were 12-item Short Form Mental Component Score and Patient Health Questionnaire-9. Pain PROs were visual analog scale back and visual analog scale leg. ODI was the disability PRO. RESULTS: A total of 148 patients were identified, with 52 patients with lower disability. Higher disability patients demonstrated significant improvement in mental function (P ≤ 0.010, all). Lower disability patients demonstrated superior postoperative PROs in physical function, mental function, back pain, and disability outcomes (P ≤ 0.034, all). Minimum clinically important difference achievement rates for lower disability patients were higher for back pain and lower for mental function and disability outcomes (P ≤ 0.041, all). CONCLUSIONS: Independent of preoperative disability, patients undergoing ALIF reported significant postoperative improvement in physical function, pain, and disability outcomes. Patients with lower preoperative disability continued to report superior PROs in mental function, back pain, and disability postoperatively. Minimum clinically important difference achievement rates for lower disability patients were higher for back pain and lower in mental function and disability outcomes. Patients undergoing ALIF with higher preoperative disability may experience greater clinically meaningful improvement in mental function and disability.