Evaluating Instability in Degenerative Lumbar Spondylolisthesis: Objective Variables Versus Surgeon Impressions.

The subjective degenerative spondylolisthesis instability classification (S-DSIC) system attempts to define preoperative instability associated with degenerative lumbar spondylolisthesis (DLS). The system guides surgical decision-making based on numerous indicators of instability that surgeons subjectively assess and incorporate. A more objective classification is warranted in order to decrease variation among surgeons. In this study, our objectives included (1) proposing an objective version of the DSIC system (O-DSIC) based on the best available clinical and biomechanical data and (2) comparing subjective surgeon perceptions (S-DSIC) with an objective measure (O-DSIC) of instability related to DLS. Methods: In this multicenter cohort study, we prospectively enrolled 408 consecutive adult patients who received surgery for symptomatic DLS. Surgeons prospectively categorized preoperative instability using the existing S-DSIC system. Subsequently, an O-DSIC system was created. Variables selected for inclusion were assigned point values based on previously determined evidence quality. DSIC types were derived by point summation: 0 to 2 points was considered stable, Type I); 3 points, potentially unstable, Type II; and 4 to 5 points, unstable, Type III. Surgeons' subjective perceptions of instability (S-DSIC) were retrospectively compared with O-DSIC types. Results: The O-DSIC system includes 5 variables: presence of facet effusion, disc height preservation (≥6.5 mm), translation (≥4 mm), a kyphotic or neutral disc angle in flexion, and low back pain (≥5 of 10 intensity). Type I (n = 176, 57.0%) and Type II (n = 164, 53.0%) were the most common DSIC types according to the O-DSIC and S-DSIC systems, respectively. Surgeons categorized higher degrees of instability with the S-DSIC than the O-DSIC system in 130 patients (42%) (p < 0.001). The assignment of DSIC types was not influenced by demographic variables with either system. Conclusions: The O-DSIC system facilitates objective assessment of preoperative instability related to DLS. Surgeons assigned higher degrees of instability with the S-DSIC than the O-DSIC system in 42% of cases. Level of Evidence: Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Fulfillment of Patient Expectations After Spine Surgery is Critical to Patient Satisfaction: A Cohort Study of Spine Surgery Patients.

BACKGROUND: Patient satisfaction is an important indicator used to monitor quality of care and outcomes after spine surgery. OBJECTIVE: To examine the complex relationship between preoperative expectations, fulfillment of expectations, postsurgical outcomes, and satisfaction after spine surgery. METHODS: In this national study of patients undergoing elective surgery for degenerative spinal conditions from the Canadian Spine Outcomes and Research Network Registry, we used logistic regression to examine the relationships between patient satisfaction with surgery (1-5 scale), preoperative expectation score (0 = none to 100 = highest), fulfillment of expectations, and disability and pain improvement. RESULTS: Fifty-eight percent of patients were extremely satisfied, and 3% were extremely dissatisfied. Expectations were variable and generally high (mean 79.5 of 100) while 17.3% reported that none of their expectations were met, 49.8% reported that their most important expectation was met, and 32.9% reported that their most important expectation was not met but others were. The results from the fully adjusted ordinal logistic model for satisfaction indicate that satisfaction was higher among patients with higher preoperative expectations (odds ratio [OR] [95% CI]: 1.11, [1.04-1.19]), reporting important improvements in disability (OR [95% CI]: 2.52 [1.96-3.25]) and pain (OR [95% CI]: 1.64 [1.25-2.15]) and reporting that expectations were fulfilled (OR = 80.15, for all expectations were met). The results were similar for lumbar and cervical patients. CONCLUSION: Given the dominant impact of expectation fulfillment on satisfaction level, there is an opportunity for improving overall patient satisfaction by specifically assessing and mitigating the potential discrepancies between patients' preoperative expectations and likely surgical outcomes. The findings are likely relevant across elective surgical populations.

Back pain in surgically treated degenerative lumbar spondylolisthesis: what can we tell our patients?

OF BACKGROUND DATA: Surgery for degenerative lumbar spondylolisthesis (DLS) has traditionally been indicated for patients with neurogenic claudication. Surgery improves patients' disability and lower extremity symptoms, but less is known about the impact on back pain. OBJECTIVE: To evaluate changes in back pain after surgery and identify factors associated with these changes in surgically-treated DLS. STUDY DESIGN: Retrospective review of prospectively collected data. METHODS: There were 486 consecutive patients with surgically-treated DLS who were enrolled in the Canadian Spine Outcomes Research Network prospective registry and identified for this study. Patients had demographic data, clinical information, disability (Oswestry Disability Index), and back pain rating scores collected prospectively at baseline, and 12 months follow-up RESULTS: Of the 486 DLS patients, 376 (77.3%) were successfully followed at 12 months. Mean age at baseline was 66.7 (standard deviation [SD] 9.2) years old, and 63% were female. Back pain improved significantly at 12 months, compared with baseline (p<.001). Improvement in Numeric Rating Scale (NRS)-back pain ratings was on average 2.97 (SD 2.5) points at one year and clinically significant improvement in back pain was observed in 75% of patients (minimal clinically important difference (MCID) NRS-Pain 1.2 points). Multivariable logistic regression revealed five factors associated with meeting MCID NRS-back pain at 12 month follow up: higher baseline back pain, better baseline physical function (higher SF-12 Physical Component Score), symptoms duration less than 1 to 2 years, and having no intraoperative adverse events. CONCLUSIONS: Back pain improved significantly for patients treated surgically for DLS at 1-year follow-up.