Cervical Disk Replacement Versus Anterior Cervical Diskectomy and Fusion: Effect of Procedural Variant on Patients With a Prolonged Preoperative Duration of Symptoms From Disk Herniation.

INTRODUCTION: Patients with a prolonged preoperative symptom duration (PSD) in the setting of cervical disk herniation (DH) may suffer inferior outcomes after surgical intervention. Comparison between anterior cervical diskectomy and fusion (ACDF) versus cervical disk arthroplasty (CDA) in this at-risk population has not yet been conducted. METHODS: Patients undergoing ACDF or CDA for DH with a PSD > 180 days were selected. Six-week (6W) and final follow-up (FF) patient-reported outcome measures (PROMs) as well as magnitude of postoperative improvements (∆PROM) were compared between cohorts using multivariable linear regression. Intercohort achievement rates of minimal clinically important difference (MCID) in each PROM were compared. RESULTS: Seventy-seven of 190 patients were in the CDA cohort. 6W Patient-Reported Outcomes Measurement Information System-Physical Function (PROMIS-PF) was superior in the CDA cohort. The ACDF cohort demonstrated notable improvements in the 6W Neck Disability Index (NDI), visual analog scale-neck pain (VAS-N), visual analog scale-arm pain (VAS-A), and 9-item Patient Health Questionnaire (PHQ-9). The CDA cohort demonstrated notable improvements in 6W PROMIS-PF, NDI, VAS-N, and VAS-A. FF VAS-A was better in the CDA cohort. The ACDF cohort demonstrated notable improvements in FF PROMIS-PF, NDI, VAS-N, and VAS-A. The CDA cohort demonstrated notable improvements in all FF PROMs. ∆PROM-6W in PROMIS-PF was greater in the CDA cohort. CONCLUSION: Patients with prolonged PSD due to cervical DH demonstrated notable improvements in physical function, disability, pain, and mental health regardless of fusion versus arthroplasty techniques. Accounting for demographic variations, patients undergoing CDA demonstrated a greater magnitude of improvement and superior scores in physical function at the first postoperative follow-up. Rates of clinically tangible improvements in PROMs did not markedly vary by surgical procedure. Patients undergoing CDA may perceive greater early improvements to physical function compared with patients undergoing ACDF for prolonged PSD due to DH.

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.

The influence of preoperative Veterans RAND-12 physical composite score in patients undergoing anterior lumbar interbody fusion [Retrospective Review].

No study has evaluated the preoperative impact of Veterans RAND-12 Physical Composite Score (VR-12 PCS) on anterior lumbar interbody fusion (ALIF) patients. This study examines its influence on physical function, mental health, pain, and disability outcomes. Two cohorts of ALIF patients with preoperative VR-12 PCS scores were formed using a single-surgeon registry: VR-12 PCS < 30 and VR-12 PCS ≥ 30. Demographics, perioperative characteristics, and patient-reported outcome measures (PROMs) were collected. PROMs of VR-12 PCS/Mental Composite Score (MCS), Short Form-12 (SF-12) PCS/MCS, Patient-Reported Outcomes Measurement Information System-Physical Function (PROMIS-PF), Patient Health Questionnaire-9 (PHQ-9), Visual Analog Scale-Back/Leg Pain (VAS-BP/LP), and Oswestry Disability Index (ODI) were collected pre/postoperatively up to 2-years. Demographics, perioperative characteristics, and preoperative PROMs were compared. Intercohort postoperative 6-week/final PROMs and improvements were compared. Of 80 patients, there were 41 in the VR-12 PCS < 30 cohort. Besides VR-12 PCS, VR-12 PCS < 30 patients reported inferior preoperative VR-12 MCS/SF-12 PCS/PROMIS-PF/PHQ-9/ODI scores (p ≤ 0.003, all). At 6-weeks postoperatively, VR-12 PCS < 30 reported inferior VR-12 PCS/SF-12 PCS/PROMIS-PF/PHQ-9 (p ≤ 0.030, all). There was greater improvement up to 6-weeks postoperatively in VR-12 PCS < 30 for VR-12 PCS/MCS and SF-12 PCS (p ≤ 0.020, all). VR-12 PCS < 30 reported superior improvement by final follow-up in VR-12 PCS/SF-12 PCS/PHQ-9 (p ≤ 0.006, all). MCID achievement rates were higher in VR-12 PCS < 30 for PHQ-9 and ODI (p ≤ 0.013, both). VR-12 PCS < 30 patients reported inferior postoperative physical function, mental health, and disability, yet superior magnitude of improvement in physical function and mental health. Rates of clinically meaningful improvement for VR-12 PCS < 30 were greater in mental health and disability.

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.

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.

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.

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.

Impact of American Society of Anesthesiologists' Classification on Postoperative Satisfaction and Clinical Outcomes Following Lumbar Decompression: Cohort-Matched Analysis.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: The aim was to compare patient-reported outcomes (PROMs), minimum clinically important difference (MCID) achievement, and postoperative satisfaction following minimally invasive lumbar decompression in patients stratified by American Society of Anesthesiologists (ASA) classification. SUMMARY OF BACKGROUND DATA: Some guidelines recommend against performing elective procedures for patients with an ASA score of 3 or greater; however, long-term postoperative outcomes are not well described. METHODS: Primary, single-level, minimally invasive lumbar decompression procedures were identified. PROMs were administered at preoperative, 6-week, 12-week, 6-month, 1-year, 2-year timepoints and included Patient-Reported Outcomes Measurement Information System-Physical Function, visual analog scale (VAS) back/leg, Oswestry disability index (ODI), and 12-item short form physical component score. Satisfaction scores were collected postoperatively for VAS back/leg, ODI, and individual ODI subcategories. Patients were grouped (ASA<3, ASA≥3), and propensity scores were matched to control for significant differences. Demographic and perioperative characteristics were compared using χ 2 and the Student's t test. Mean PROMs and postoperative satisfaction were compared at each time point by a 2-sample t test. Postoperative PROM improvement from the preoperative baseline within each cohort was calculated with a paired t test. MCID achievement was determined by comparing ΔPROMs to established thresholds and comparing between groups using simple logistic regression. RESULTS: One hundred and twenty-nine propensity-matched patients were included: 99 ASA<3 and 30 ASA≥3. No significant demographic differences were observed between groups. ASA≥3 patients experienced significantly increased length of stay and postoperative narcotic consumption on surgery day ( P <0.048, all). Mean PROMs and MCID achievement did not differ. The ASA<3 cohort significantly improved from the preoperative baseline for all PROMs at all postoperative time points. ASA<3 patients demonstrated higher levels of postoperative satisfaction at 6 weeks for VAS leg, VAS back, ODI, sleeping, lifting, walking, standing, sex, travel, and at 6 months for VAS back ( P <0.045, all). CONCLUSION: ASA≥3 patients may achieve similar long-term clinical outcomes to ASA<3 patients, though they may show poorer short-term satisfaction for disability, leg pain, and back pain, which could be related to differing preoperative expectations.

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.

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.

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.

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

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

Coronavirus Disease 2019 Shutdown Did Not Affect Mental Health Scores in Lumbar Decompression Patients in a Large Metropolitan Region.

STUDY DESIGN: Retrospective study. OBJECTIVE: To evaluate the effect of the coronavirus disease 2019 (COVID-19) shutdown in a large metropolitan area on mental health scores of spine patients undergoing lumbar decompression in the preoperative and early postoperative phases. SUMMARY OF BACKGROUND DATA: Global mental health has been demonstrated to be negatively affected by COVID-19 shutdowns. Preoperative mental health affects outcomes in spine patients, and the effect of COVID-19 shutdowns on mental health in this population is unclear. PATIENTS AND METHODS: Patients were retrospectively identified from a single orthopedic spine surgeon registry. Patients were divided into 2 cohorts, separated by the date of surgery on or after March 20, 2020, the date of local shutdown due to COVID-19. After division, patients were propensity score matched for age, sex, ethnicity, common comorbidities, body mass index, preoperative visual analog scale back and leg pain scores, and preoperative Oswestry Disability Index. Perioperative characteristics were observed and recorded. Mental health scores, 12-item Short Form Mental Component Score, and 9-item Patient Health Questionnaire 9 were collected preoperatively, at 6 weeks, and at 12 weeks and compared between cohorts through Student t tests. RESULTS: Three hundred thirty-four patients were identified, with 184 patients remaining after propensity score matching. Of the remaining 184 patients, 119 patients were identified as having surgery within the 2 years before the shutdown ("Pre-Shutdown"), whereas 65 patients had surgery within the 2 years after shutdown ("Post-Shutdown"). There were no significant differences between Pre-Shutdown and Post-Shutdown cohorts with regard to either Short Form Mental Component Score or Patient Health Questionnaire-9 at any time period evaluated ( P > 0.050, all). CONCLUSION: The COVID-19 shutdown in a large metropolitan area did not affect preoperative or early postoperative mental health in patients undergoing lumbar decompression. However, each cohort was matched for preoperative pain and disability scores, which may have adversely been affected by the shutdown.

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.

Correlation Between Mental Health and Patient-Reported Outcomes After Lateral Lumbar Interbody Fusion.

OBJECTIVE: We sought to assess correlational relationship between mental health and outcomes following lateral lumbar interbody fusion (LLIF). METHODS: Patients who had undergone LLIF were identified. Patients with indications for surgery including infection, trauma, or malignancy were excluded. Patient-reported outcomes (PROs) included short-form (SF)-12 Mental Component Score (MCS)/Patient Health Questionnaire (PHQ)-9/Patient-Reported Outcomes Measurement Information System-Physical Function (PROMIS-PF)/12-Item Short-Form Physical Component Score (SF-12 PCS)/Visual Analog Scale (VAS) back and leg pain/Oswestry Disability Index (ODI) and were collected preoperatively and at several postoperative time points extending to 1 year. Pearson correlation tests were used to compare the 12-item Short Form Mental Component Score (SF-12 MCS) and PHQ-9 with the other PROs. RESULTS: We included 124 patients. SF-12 MCS positively correlated with PROMIS-PF at 6 months (r = 0.466) and SF-12 PCS preoperatively (r = 0.287) and at 6 months (r = 0.419) (P ≤ 0.041, all). SF-12 MCS negatively correlated with VAS back preoperatively (r = -0.315), at 12 weeks (r = -0.414), and at 6 months (r = -0.746); VAS leg at 12 weeks (r = -0.378); and ODI preoperatively (r = -0.580) (P ≤ 0.023, all). PHQ-9 negatively correlated with PROMIS-PF at all periods except 12 weeks (range: r = -0.357 to -0.566, P ≤ 0.017, all) and SF-12 PCS preoperatively, at 6 weeks, and at 6 months (range: r = -0.363 to -0.562, P ≤ 0.022, all). PHQ-9 positively correlated with VAS back at all periods before 1-year (range: r = 0.415-0.690, P ≤ 0.001, all), VAS leg at 12-weeks (r = 0.467) and 6-months (r = 0.402) (P ≤ 0.028, both), and ODI at all periods except 6-months (range: r = 0.413-0.637, P ≤ 0.008, all). CONCLUSIONS: Better mental health scores correlated with superior physical function, pain, and disability scores when measured by both SF-12 MCS and PHQ-9. PHQ-9 more consistently reported significant correlation to all outcomes measured when compared to SF-12 MCS.

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.

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.