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.

Anterior Cervical Discectomy and Fusion Versus Cervical Disc Replacement for a Workers' Compensation Population in an Ambulatory Surgical Center.

STUDY DESIGN: Retrospective Cohort. OBJECTIVE: To evaluate patient-reported outcome measures (PROM) and minimal clinically important difference (MCID) achievement outcomes between anterior cervical discectomy and fusion (ACDF) and cervical disk replacement (CDR) in the Workers' Compensation (WC) population. SUMMARY OF BACKGROUND DATA: No studies to our knowledge have compared PROMs and MCID attainment between ACDF and CDR among patients with WC insurance undergoing surgery in an outpatient ambulatory surgical center (ASC). METHODS: WC insurance patients undergoing primary, single/double-level ACDF/CDR in an ASC were identified. Patients were divided into ACDF versus CDR. PROMs were collected at preoperative/6-week/12-week/6-month/1-year timepoints, including PROMIS-PF, SF-12 PCS/MCS, VAS neck/arm, and NDI. RESULTS: Seventy-nine patients were included, 51 ACDF/28 CDR. While operative time (56.4 vs. 54.4 min), estimated blood loss (29.2 vs. 25.9 mL), POD0 pain (4.9 vs. 3.8), and POD0 narcotic consumption (21.2 vs. 14.5 oral morphine equivalents) were higher in ACDF patients, none reached statistical significance ( P >0.050, all). One-year arthrodesis rate was 100.0% among ACDF recipients with available imaging (n=36). ACDF cohort improved from preoperative for PROMIS-PF from 12 weeks to 1 year, SF-12 PCS at 6 months, all timepoints for VAS neck/arm, and 12 weeks/6 months for NDI ( P ≤0.044, all). CDR cohort improved from preoperative for PROMIS-PF at 6 months, VAS neck/arm from 12 weeks to 1 year, and NDI at 12 weeks/6 months ( P ≤0.049, all). CDR cohort reported significantly lower VAS neck at 12 weeks/1 year and VAS arm at 12 weeks ( P ≤0.039, all). MCID achievement rates did not differ. CONCLUSION: While operative duration/estimated blood loss/acute postoperative pain/narcotic consumption were, on average, higher among ACDF recipients, these were not statistically significant, possibly due to the limited sample size. ACDF and CDR ASC patients generally demonstrated comparable arm pain/disability/physical function/mental health, though neck pain was significantly lower at multiple timepoints among CDR patients. Clinically meaningful PROM improvements were comparable. Larger, multicentered studies are required to confirm our results.

Does Baseline Severity of Arm Pain Influence Outcomes Following Single-Level Anterior Cervical Discectomy and Fusion?

STUDY DESIGN: Retrospective cohort. PURPOSE: To assess preoperative arm pain severity influence on postoperative patient-reported outcomes measures (PROMs) and minimal clinically important difference (MCID) achievement following single-level anterior cervical discectomy and fusion (ACDF). OVERVIEW OF LITERATURE: There is evidence that preoperative symptom severity can affect postoperative outcomes. Few have evaluated this association between preoperative arm pain severity and postoperative PROMs and MCID achievement following ACDF. METHODS: Individuals undergoing single-level ACDF were identified. Patients were grouped by preoperative Visual Analog Scale (VAS) arm ≤8 vs. >8. PROMs collected preoperatively and postoperatively included VAS-arm/VAS-neck/Neck Disability Index (NDI)/12-item Short Form (SF-12) Physical Composite Score (PCS)/SF-12 mental composite score (MCS)/Patient-Reported Outcomes Measurement Information System physical function (PROMIS-PF). Demographics, PROMs, and MCID rates were compared between cohorts. RESULTS: A total of 128 patients were included. The VAS arm ≤8 cohort significantly improved for all PROMs excepting VAS arm at 1-year/2-years, SF-12 MCS at 12-weeks/1-year/2-years, and SF-12 PCS/PROMIS-PF at 6-weeks, only (p ≤0.021, all). The VAS arm >8 cohort significantly improved for VAS neck at all timepoints, VAS arm from 6-weeks to 1-year, NDI from 6-weeks to 6-months, and SF-12 MCS/PROMIS-PF at 6-months (p ≤0.038, all). Postoperatively, the VAS arm >8 cohort had higher VAS-neck (6 weeks/6 months), VAS-arm (12 weeks/6 months), NDI (6 weeks/6 months), lower SF-12 MCS (6 weeks/6 months), SF-12 PCS (6 months), and PROMISPF (12 weeks/6 months) (p ≤0.038, all). MCID achievement rates were higher among the VAS arm >8 cohort for the VAS-arm at 6-weeks/12-weeks/1-year/overall and NDI at 2 years (p ≤0.038, all). CONCLUSIONS: Significance in PROM score differences between VAS arm ≤8 vs. >8 generally dissipated at the 1-year and 2-year timepoint, although higher preoperative arm pain patients suffered from worse pain, disability, and mental/physical function scores. Furthermore, clinically meaningful rates of improvement were similar throughout the vast majority of timepoints for all PROMs studied.

Impact of Postoperative Length of Stay on Patient-Reported and Clinical Outcomes After Anterior Lumbar Interbody Fusion.

BACKGROUND: Existing literature has not yet evaluated the impact of postoperative length of stay (LOS) on patient-reported outcome measures (PROMs) and minimum clinically important difference (MCID) in patients undergoing anterior lumbar interbody fusion (ALIF). The authors investigates the influence of postoperative LOS following ALIF on PROMs and MCID achievement rates. METHODS: A single-surgeon database was retrospectively reviewed for patients undergoing single-level ALIF. The following 2 cohorts were studied: patients with LOS <45 hours and patients with LOS ≥45 hours. The following PROMs were recorded at preoperative and 6-week, 12-week, 6-month, 1-year, and 2-year postoperative timepoints: visual analog scale (VAS) back and leg, Oswestry Disability Index (ODI), 12-item short form (SF-12) physical composite score (PCS), and patient-reported outcome measurement information system physical function. MCID achievement was compared by LOS grouping using χ 2 analysis. The rates of complications by LOS grouping and the relative risk among demographic and perioperative characteristics for a longer hospital stay of ≥45 hours were calculated. RESULTS: A total of 52 subjects were included in each cohort. LOS ≥45 hours demonstrated worse ODI at 6 weeks and SF-12 PCS preoperative and at 12 weeks (P ≤ 0.026, all). LOS <45 hours demonstrated greater MCID rates for all PROMs except VAS back (P ≤ 0.004, all). Postoperative urinary retention (POUR), fever, and total complications (P ≤ 0.003, all) were associated with increased LOS. Diabetes (P = 0.037), preoperative VAS neck ≥7 (P = 0.012), and American Society of Anesthesiologists classification ≥2 (P = 0.003) served as preoperative risk factors for postoperative stay ≥45 hours. CONCLUSION: Following single-level ALIF, patients with shorter LOS demonstrated significantly greater overall MCID achievement for most PROMs. POUR, fever, and total complications were associated with longer LOS and greater blood loss. Diabetes and higher preoperative leg pain were identified as risk factors for longer LOS. CLINICAL RELEVANCE: Patients undergoing ALIF with shorter LOS had greater MCID achievement for disability, physical function, and leg pain outcomes. Patients with greater preoperative leg pain and diabetes may be at risk for longer LOS.

The Influence of Presenting Physical Function on Postoperative Patient Satisfaction and Clinical Outcomes Following Minimally Invasive Lumbar Decompression.

STUDY DESIGN: The study of retrospective cohort. OBJECTIVE: The aim was to compare patient-reported outcome measures (PROMs), satisfaction, and minimum clinically important difference (MCID) achievement following minimally invasive lumbar decompression (MIS-LD) in patients stratified by the preoperative patient-reported outcomes measurement information system physical function (PROMIS-PF) score. SUMMARY OF BACKGROUND DATA: Although prior studies have assessed the predictive utility of preoperative PROMIS-PF scores on patient outcomes in spinal fusion, its utility has not been studied for patients undergoing MIS-LD. METHODS: Primary, single/multilevel MIS-LD procedures were identified. PROMs were administered at preoperative/6-week/12-week/6-month/1-year/2-year time points and included PROMIS-PF/visual analog scale (VAS) back and leg/Oswestry Disability Index (ODI). Satisfaction scores were collected postoperatively. The patients were grouped by preoperative PROMIS-PF score (≤35, >35), with higher scores indicating improved physical function. Demographic/perioperative characteristics were compared using χ 2 /Student t test. Mean PROMs/postoperative satisfaction was compared utilizing 2-sample t test. Postoperative PROM improvement from preoperative was calculated with paired t tests. MCID achievement rates were compared using simple logistic regression. RESULTS: Two hundred and sixteen patients were included, 58 PROMIS-PF≤35 and 158 PROMIS-PF>35. Ethnicity/insurance differed ( P ≤0.004, all). Hospital length of stay was greater for PROMIS-PF>35 ( P =0.042). All preoperative mean PROMs significantly differed except for VAS Back. Several postoperative mean PROMs differed: PROMIS-PF at 6 weeks/12 weeks/6 months/1 year, SF-12 PCS at 6 weeks/12 weeks/1 year, VAS Back at 6 weeks/12 weeks, VAS leg at 6 weeks/12 weeks, and ODI at 6 weeks/12 weeks ( P <0.050, all). All PROMs significantly improved from preoperative at all postoperative time points ( P <0.003, all). The MCID achievement rates differed only for VAS back for 6 weeks, favoring PROMIS-PF>35 cohort ( P =0.001). Postoperative satisfaction was greater in PROMIS-PF>35 cohort for VAS leg at 6 weeks/12 weeks/6 months/2 years, VAS back at 6-weeks/12-weeks, and ODI at all time points ( P <0.037, all). Postoperative satisfaction was greater in PROMIS-PF>35 cohort for individual ODI categories: sleep at 6-weeks/12-weeks/1-year/2-years, lifting, walking, standing, and travel at all time points, and sexual at 6-weeks/12-weeks/1-year/2-years ( P <0.030, all). CONCLUSION: Poorer preoperative PROMIS-PF scores were associated with worse postoperative clinical outcomes and satisfaction. By stratifying patients with preoperative PROMIS-PF scores, surgeons may better predict postoperative clinical improvement and seek to manage patient expectations.

Validation of Neck Disability Index Severity among Patients Receiving One or Two-Level Anterior Cervical Surgery.

STUDY DESIGN: Retrospective cohort. PURPOSE: To evaluate the validity of established severity thresholds for Neck Disability Index (NDI) among patients undergoing anterior cervical discectomy and fusion (ACDF) or cervical disc arthroplasty (CDA). OVERVIEW OF LITERATURE: Few studies have examined the validity of established NDI threshold values among patients undergoing ACDF or CDA. METHODS: A surgical database was reviewed to identify patients undergoing cervical spine procedures. Demographics, operative characteristics, comorbidities, NDI, Visual Analog Scale (VAS), and 12-item Short Form (SF-12) physical and mental composite scores (PCS and MCS) were recorded. NDI severity was categorized using previously established threshold values. Improvement from preoperative scores at each postoperative timepoint and convergent validity of NDI was evaluated. Discriminant validity of NDI was evaluated against VAS neck and arm and SF-12 PCS and MCS. RESULTS: All 290 patients included in the study demonstrated significant improvements from baseline values for all patient-reported outcome measures (PROMs) at all postoperative timepoints (p<0.001) except SF-12 MCS at 2 years (p =0.393). NDI showed a moderate- to-strong correlation (r≥0.419) at most timepoints for VAS neck, VAS arm, SF-12 PCS, and SF-12 MCS (p<0.001, all). NDI severity categories demonstrated significant differences in mean VAS neck, VAS arm, SF-12 PCS, and SF-12 MCS at all timepoints (p<0.001, all). Differences between NDI severity groups were not uniform for all PROMs. VAS neck values demonstrated significant intergroup differences at most timepoints, whereas SF-12 MCS showed significantly different values between most severity groups. CONCLUSIONS: Neck disability is strongly correlated with neck and arm pain, physical function, and mental health and demonstrates worse outcomes with increasing severity. Previously established severity categories may be more applicable to pain than physical function or mental health and may be more uniformly applied preoperatively for cervical spine patients.

Impact of Gender on Postsurgical Outcomes in Patients Undergoing Anterior Cervical Discectomy and Fusion.

BACKGROUND: Prior studies associate male gender with higher complication rates following anterior cervical discectomy and fusion (ACDF), but none has investigated gender influence on patient-reported outcome measures (PROMs) and minimal clinically important difference (MCID) following single-level ACDF. METHODS: Patients undergoing primary, single-level ACDF were divided into female and male groups. Visual analog scale (VAS) neck/arm, Neck Disability Index (NDI), 12-item short form (SF-12) physical composite score (PCS), PROM information system physical function (PROMIS-PF), and veterans RAND 12-item (VR-12) health survey PCS were collected preoperatively and postoperatively. Simple linear regression analysis evaluated the predictive capability of gender on PROMs. Multiple regression analysis was performed to determine the effects of gender on mean PROMs while accounting for insurance type. Established MCID values determined achievement rates across PROMs. χ 2 analysis compared MCID achievement by gender. RESULTS: A total of 179 women and 134 men were included. Cohorts differed in insurance type, length of stay, and discharge day (P ≤ 0.017, all). Women improved in PROMs at all timepoints (P ≤ 0.049, all) except SF-12 PCS 6 weeks and PROMIS-PF 6 weeks. Men improved in PROMs at all timepoints (P ≤ 0.042) except VAS arm 2 years, SF-12 PCS 6 weeks and 2 years, PROMIS-PF 6 weeks, and VR-12 PCS 6 weeks. Women demonstrated higher SF-12 PCS (P = 0.043) and VR-12 PCS (P = 0.035) 2 years. Multiple regression determined that VAS neck and arm from 6 weeks to 6 months, NDI from preoperative to 6 months, SF-12 PCS and VR-12 PCS from preoperative to 12 weeks, and PROMIS-PF preoperative, 6 weeks, and 6 months were significantly affected by gender and insurance status (P ≤ 0.031, all). MCID achievement rate did not differ for any PROM between genders. CONCLUSION: Women reported significantly higher long-term physical function health (SF-12 PCS and VR-12 PCS) compared with men, while disability and pain did not differ. Nevertheless, no significant differences in MCID achievement were observed for any PROM studied. Gender does not appear to play a significant role in clinically meaningful recovery following single-level ACDF. CLINICAL RELEVANCE: Gender has little value in prognostication for determining clinically meaningful recovery after single-level ACDF.

Multimodal analgesic protocol for cervical disc replacement in the ambulatory setting: Clinical case series.

Background: Effective pain management is paramount for outpatient surgical success. This study aims to report a case series of patients undergoing cervical disc replacement (CDR) in an ambulatory surgery center (ASC) with the use of an enhanced multimodal analgesic (MMA) protocol. Methods: Primary, single-/2-level CDR procedures at an ASC with an enhanced MMA protocol were included. ASC patients were discharged day of surgery. Patient-reported outcome measures (PROMs) were administered at preoperative/6-week/12-week/6-month/1-year/2-year timepoints and included Visual Analogue Scale (VAS) neck, VAS arm, Neck Disability Index (NDI), Patient-Reported Outcomes Measurement Information System-Physical Function (PROMIS-PF), and 12-Item Short-Form Physical and Mental Composite Score (SF-12 PCS/SF-12 MCS). A t-test assessed postoperative PROM improvement from baseline. MCID achievement was determined by comparing ΔPROM scores to previously established thresholds. Results: 106 patients were included, 76 single-level and 30 2-level. Most single-levels occurred at C5-C6, most 2-levels at C5-C7. One 2-level patient developed a hematoma 5 days postoperatively and underwent revision for evacuation. Five patients reported postoperative dysphagia; all were quickly resolved. One patient had an episode of seizure secondary to serotonin syndrome from concealed drug use. Patient was reintubated, transferred, and treated for serotonin syndrome. Two patients experienced postoperative nausea/vomiting. Cohort significantly improved from baseline for all PROMS at all timepoints except SF-12 MCS at 1-year/2-years and SF-12 PCS at 2 years (p < 0.047, all). Overall MCID achievement rates were: VAS arm (48.7%), VAS neck (69.1%), NDI (98.9%), SF-12 MCS (50.0%), SF-12 PCS (54.6%), and PROMIS-PF (73.4%). Conclusion: Outpatient CDR, incorporating an enhanced MMA protocol, can be safely and effectively performed with proper patient selection and surgical technique. Patients saw timely discharge, well-controlled postoperative pain, and favorable long-term outcomes.

History and Evolution of the Minimally Invasive Transforaminal Lumbar Interbody Fusion.

The minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) is a popular surgical technique for lumbar arthrodesis, widely considered to hold great efficacy while conferring an impressive safety profile through the minimization of soft tissue damage. This elegant approach to lumbar stabilization is the byproduct of several innovations throughout the past century. In 1934, Mixter and Barr's paper in the New England Journal of Medicine elucidated the role of disc herniation in spinal instability and radiculopathy, prompting surgeons to explore new approaches and instruments to access the disc space. In 1944, Briggs and Milligan published their novel technique, the posterior lumbar interbody fusion (PLIF), involving continuous removal of vertebral bone chips and replacement of the disc with a round bone peg. The following decades witnessed several PLIF modifications, including the addition of long pedicle screws. In 1982, Harms and Rolinger sought to redefine the posterior corridor by approaching the disc space through the intervertebral foramen, establishing the transforaminal lumbar interbody fusion (TLIF). In the 1990s, lumbar spine surgery experienced a paradigm shift, with surgeons placing increased emphasis on tissuesparing minimally invasive techniques. Spurred by this revolution, Foley and Lefkowitz published the novel MIS-TLIF technique in 2002. The MIS-TLIF has demonstrated comparable surgical outcomes to the TLIF, with an improved safety profile. Here, we present a view into the history of the posterior-approach treatment of the discogenic radiculopathy, culminating in the MIS-TLIF. Additionally, we evaluate the hallmark characteristics, technical variability, and reported outcomes of the modern MIS-TLIF and take a brief look at technologies that may define the future MIS-TLIF.

Single-level Minimally Invasive Transforaminal Lumbar Interbody Fusion Versus Anterior Lumbar Interbody Fusion for the Surgical Treatment of Isthmic Spondylolisthesis.

INTRODUCTION: Limited studies have compared minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) with anterior lumbar interbody fusion (ALIF) for the treatment of isthmic spondylolisthesis. This study aims to compare perioperative variables, patient-reported outcome measures (PROMs), and minimal clinically important difference (MCID) achievement rates between these surgical approaches. METHODS: Patients with isthmic spondylolisthesis undergoing primary, single-level MIS TLIF or ALIF were identified in a surgical database. Patients were divided into MIS TLIF and ALIF cohorts. Demographics and perioperative characteristics were collected and compared between groups using the chi square test or Student t-test. PROMs including the Patient-Reported Outcomes Measurement Information System Physical Function, 12-Item Short Form Physical Composite Score, visual analog scale (VAS) back, VAS leg, and Oswestry Disability Index were collected at preoperative, 6-, 12-week, 6-month, 1-, and 2-year time points. Mean PROMs were compared using the Student t-test for independent samples. MCID attainment was determined using established values in the literature; achievement rates by grouping were compared using chi square analysis. RESULTS: One hundred seventy-one patients were included, 121 MIS TLIF and 50 ALIF. No demographic differences were observed. Mean surgical times were 139.7 minutes (MIS TLIF) and 165.5 minutes (ALIF) (P < 0.001). No other perioperative differences were observed. Mean estimated blood loss values were 63.8 mL (MIS TLIF) and 73.7 mL (ALIF). Mean postoperative lengths of stay were 43.9 hours (MIS TLIF) and 42.5 hours (ALIF). Mean PROMs did not markedly differ among groups at any time point. MCID attainment was markedly higher among MIS TLIF patients for the Oswestry Disability Index at 6 weeks (P = 0.046) and 12 weeks (P = 0.007), Patient-Reported Outcomes Measurement Information System Physical Function at 12 weeks (P = 0.015), and VAS leg at 6 weeks (P = 0.031) and 12 weeks (P = 0.045). No other notable differences were observed among MCID achievement by grouping. DISCUSSION: While single-level ALIF demonstrated markedly higher surgical times, other perioperative characteristics and PROMs were comparable among ALIF and MIS TLIF patients. Although MCID achievement rates were generally lower for disability and leg pain among ALIF patients, significance was not reached at 6 months, 1 year, or during the overall postoperative period after fusion.

Management of lymphocele following anterior lumbar interbody fusion, case report and review of literature.

While anterior lumbar interbody fusion (ALIF) is known as an established and safe procedure for treatment of degenerative disc disease, albeit rare, the development of postoperative intra-abdominal or retroperitoneal collection of lymph warrants timely diagnosis and management. This study presents the case of a 62-year-old male who underwent L4-L5 and L5-S1 ALIF and developed a persistent left-sided fluid collection, resulting in a symptomatic retroperitoneal lymphocele confirmed by computed tomography (CT). After percutaneous drainage by interventional radiology (IR), output remained high at 1 liter (L) per day, necessitating sclerotherapy with doxycycline and ethanol. In the absence of improvement, a lymphangiogram demonstrating a persistent lymph leak and glue embolization was performed. Due to refractory symptoms, retroperitoneal exploration with methylene blue dye was utilized for lymphatic mapping, and a lymphatic capillary leak in proximity to the left iliac artery was identified and successfully ligated with resolution of symptoms. With suspected fluid collections following ALIF, confirmation with CT or ultrasound (US) imaging followed by percutaneous drainage and testing of fluid is necessary. In mild cases, drainage alone or nonsurgical chemical sclerotherapy may suffice. In symptomatic refractory cases, localization of the site with lymphangiogram or US-guided injection of methylene blue dye allows for easier identification and definitive management with either transabdominal laparoscopic fenestration or retroperitoneal surgical exploration and ligation.

Minimally Invasive Transforaminal versus Anterior Lumbar Interbody Fusion in Patients Undergoing Revision Fusion: Clinical Outcome Comparison.

OBJECTIVE: We aim to compare perioperative/postoperative clinical outcomes between minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) and anterior lumbar interbody fusion (ALIF) in patients presenting for revision surgery. METHODS: A retrospective database was reviewed for procedures between November 2005 and December 2021. Revision MIS-TLIF/ALIFs were included, whereas primary fusions or diagnosis of infection/malignancy/trauma were excluded. Patients were grouped into MIS-TLIF/ALIF cohorts. Preoperatively/postoperatively collected patient-reported outcome measures (PROMs) included visual analog scale back/leg score, Oswestry Disability Index, Patient-Reported Outcome Measurement Information System-Physical Function (PROMIS-PF), and Short-Form 12-Item Survey Mental/Physical Composite Scores. RESULTS: A total of 164 patients were eligible, with 84 patients in the MIS-TLIF cohort. The presence of degenerative spondylolisthesis and central stenosis, narcotic consumption on postoperative day 0/1, and postoperative urinary retention rates was greater in the MIS-TLIF cohort (P ≤ 0.036, all). Preoperative PROMs between cohorts did not significantly differ. Significantly favorable postoperative PROM scores were shown in the MIS-TLIF cohort with PROMIS-PF at 12 weeks/6 months (P ≤ 0.033, all). Most patients in both cohorts achieved overall minimum clinically important difference for visual analog scale back/leg score, Oswestry Disability Index, Short-Form 12-Item Survey Physical Composite Score, and PROMIS-PF. No differences were noted between cohorts within rates of MCID achievement. CONCLUSIONS: Patients undergoing revision fusion via MIS-TLIF or ALIF reported similar 1-year postoperative mean outcomes and rates of meaningful clinical achievement for physical function, mental health, disability, and back/leg pain. However, patients undergoing revision MIS-TLIF reported improved physical function at 12 weeks and 6 months. Perioperatively, patients undergoing revision MIS-TLIF were noted to consume significantly greater quantities of narcotics.

The Effect of the Severity of Preoperative Leg Pain on Patient-Reported Outcomes, Minimum Clinically Important Difference Achievement, and Patient Satisfaction After Minimally Invasive Transforaminal Lumbar Interbody Fusion.

OBJECTIVE: To compare patient-reported outcome measures (PROMs), satisfaction, and minimum clinically important difference (MCID) achievement after minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) in patients stratified by preoperative leg pain. METHODS: Patients undergoing MIS-TLIF were collected through retrospective review of a prospectively maintained single-surgeon database. PROMs administered preoperatively/postoperatively included Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF), visual analog scale (VAS) back/leg pain, Oswestry Disability Index (ODI), and 12-Item Short Form (SF-12) Physical/Mental Component Score (PCS/MCS). Patients were grouped based on preoperative VAS leg scores: VAS leg ≤7 or VAS leg >7. Inferential statistics were used to compare PROMs, MCID achievement rates, and postoperative satisfaction between groups. RESULTS: A total of 562 patients were eligible (168 VAS leg score ≤7; 394 VAS leg score >7). Significant differences between cohorts in postoperative mean PROMs were noted for PROMIS-PF at 6 weeks/2 years, SF-12 PCS at 6 weeks/2 years, SF-12 MCS at 6 weeks/12 weeks/6 months/1 year, VAS back score at 6 weeks/12 weeks/6 months, VAS leg score at 6 weeks/12 weeks/6 months/2 years and ODI at all postoperative time points (P < 0.045, all). In the VAS leg score >7 cohort, a greater proportion achieving MCID for VAS leg score at all postoperative time points and ODI at 12 weeks (P < 0.010, all). Postoperative satisfaction was greater in VAS back score ≤7 cohort for VAS leg score at 6 weeks/12 weeks/6 months/2 years, VAS back score at 12 weeks/2 years, and ODI at 6 weeks/12 weeks/6 months/2 years (P < 0.046, all). CONCLUSIONS: Patients with severe preoperative leg pain showed worse postoperative PROM scores and patient satisfaction for disability and back/leg pain. MCID achievement rates across cohorts were similar. Patients with severe leg pain may have expectations for surgical benefits incongruent with their postoperative outcomes, and physicians may seek to manage the preoperative expectations of their patients to reflect likely outcomes after MIS-TLIF.

Level-specific Perioperative and Clinical Outcome Comparison: Cervical Disk Replacement Versus Anterior Cervical Diskectomy and Fusion at C5-C6 in Patients With Myeloradiculopathy.

INTRODUCTION: This study compares perioperative and postoperative clinical outcomes in patients undergoing anterior cervical diskectomy and fusion (ACDF) or cervical disk replacement (CDR) at C5-C6 in patients with myeloradiculopathy. METHODS: Primary, elective, single-level CDR or ACDF procedures at C5-C6 for patients with myeloradiculopathy were included. Patient-reported outcome measures (PROMs) included visual analog scale (VAS) neck, VAS arm, Neck Disability Index (NDI), Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF), and Short-Form 12-Item Physical Composite Score (SF-12 PCS) collected at preoperative/6-week/12-week/6-month/1-year time points. Surgical cohorts were assessed for differences in demographics/perioperative characteristics using the chi square test and unpaired Student t-test for categorical and continuous variables, respectively. Achievement of minimum clinically important difference (MCID) was determined by comparing ΔPROMs with established thresholds. Outcome measures were compared at postoperative time points with the Student t-test, and improvement from preoperative baseline was assessed with a paired sample t-test. RESULTS: One hundred thirty-seven patients were included, 43 CDR and 94 ACDF. CDR patients demonstrated significantly reduced surgical times (46.3 versus 55.1 minutes), estimated blood loss (24.4 versus 43.6 mL), revision surgery rates (0.0% versus 5.3%), postoperative length of stay (8.9 versus 23.0 hours), and postoperative narcotic consumption (P < 0.017, all). Complication rates and mean PROMs did not differ between cohorts. The CDR cohort markedly improved from baseline for all PROMs postoperatively except SF-12 PCS/PROMIS-PF at 6 weeks. The ACDF cohort markedly improved at each time point except VAS arm at 1 year, NDI at 6 weeks/1 year, and SF-12 PCS/PROMIS-PF at 6 weeks. A majority of both cohorts achieved overall MCID for VAS neck/NDI/PROMIS-PF. MCID achievement rates did not differ except NDI at 12 weeks/1 year and SF-12 PCS at 6 months, both favoring CDR. DISCUSSION: Both procedural cohorts demonstrated similar long-term clinical outcomes for arm/neck pain and physical function; however, patients undergoing CDR at C5-C6 demonstrated an improved ability to maintain 1-year postoperative progress for neck disability with improved 1-year NDI MCID achievement. The CDR cohort, in addition, demonstrated an improved perioperative profile and reduced rate of revision surgery.

Comparing Patient-Reported Outcomes in Patients Undergoing Lumbar Fusion for Isthmic Spondylolisthesis with Predominant Back Pain versus Predominant Leg Pain Symptoms.

OBJECTIVE: To compare patient-reported outcome measures (PROMs) and minimum clinically important difference (MCID) achievement following anterior or transforaminal lumbar interbody fusion for isthmic spondylolisthesis in patients presenting with predominant back pain versus predominant leg pain symptoms. METHODS: A single-surgeon database was reviewed for anterior or transforaminal lumbar interbody fusion procedures for isthmic spondylolisthesis. Patient demographics, perioperative characteristics, postoperative complications, and PROMs were collected. Demographic/perioperative characteristics were compared among groups using χ2 and Student t tests for categorical and continuous variables, respectively. Mean PROM scores were compared using an unpaired Student t test. Postoperative improvement from preoperative baseline within each cohort was assessed with paired-samples t test. MCID achievement rates were compared with χ2 analysis. RESULTS: In total, 143 patients were included with 65 patients in the predominant back pain and 78 patients in the predominant leg pain cohort. Preoperative visual analog scale (VAS) leg was noted to be significantly greater in predominant leg pain cohort (P < 0.001). Cohorts demonstrated significant mean postoperative differences for the following PROMs at the following postoperative time points: significant differences were noted between cohorts for rate of achievement of MCID for the following PROMs at the following time points: VAS back at 2 years and VAS leg at 6 weeks/12 weeks/6 months/overall (P < 0.036, all). CONCLUSIONS: Compared with patients presenting for surgery with predominant leg pain symptoms, patients undergoing lumbar fusion at L4-L5 and L5-S1 for isthmic spondylolisthesis with predominant back pain symptoms may demonstrate improved long-term clinical outcomes for reported back pain, leg pain, and disability and reduced postoperative length of stay and narcotic consumption.

Predicting Acute Changes in Depressive Symptoms Following Lumbar Decompression.

BACKGROUND: While depressive symptoms improve for most patients following minimally invasive lumbar decompression (MIS LD), for some, symptoms may worsen. This study aimed to investigate predictors of change in depressive symptoms in the short-term postoperative period following MIS LD. METHODS: We retrospectively analyzed a prospective surgical database for patients undergoing primary MIS LD procedures from 2016 to 2020. Preoperative pain (visual analog scale back and leg) scores were recorded, and the 9-Item Patient Health Questionnaire (PHQ-9) was administered at the preoperative and postoperative (6 weeks, 12 weeks, 6 months, and 1 year) timepoints. Patients were grouped into 1 of 3 categories of depression severity based on preoperative PHQ-9 scores: minimal (0-4), mild (5-9), and moderate to severe (10-27). Postoperative change in depressive symptoms was calculated by determining differences from baseline scores to scores at 6 weeks, 12 weeks, and 6 months. Analysis of demographics, perioperative characteristics, and spinal pathologies was conducted using χ 2 test. Significant factors contributing to postoperative changes in depression were analyzed using multiple linear regression analysis. Significance was set at P = 0.05. RESULTS: The 216 patients included had a mean age of 48 years, and a majority were men (70.4%). Most patients had a preoperative diagnosis of spinal stenosis (90.3%) or herniated nucleus pulposus (69.9%). Univariate analysis identified age, ethnicity, insurance, and diabetes as significant variables among depression severity groups. Patients demonstrated significant improvements in depressive symptoms at all postoperative timepoints (P < 0.001). Multivariate analysis identified several significant predictors of postoperative change in PHQ-9, which included moderate to severe preoperative depression for all postoperative timepoints (all P ≤ 0.038), mild preoperative depression for 6 weeks and 12 weeks (both P ≤ 0.029), and private insurance (P = 0.002) and smoking status (P = 0.047) at 12 weeks. CONCLUSION: Depression improved at all postoperative timepoints following LD. Insurance type, smoking status, and preoperative depression severity were all identified as significant predictors of postoperative changes in depressive symptoms. CLINICAL RELEVANCE: This study explores predictors of changes in depressive symptoms following LD.

Dysphagia May Attenuate Improvements in Postoperative Outcomes Following Anterior Cervical Discectomy and Fusion.

BACKGROUND: Past studies outline potential risk factors for dysphagia following anterior cervical discectomy and fusion (ACDF). Few studies explored the impact of dysphagia, as measured by the swallowing quality of life (SWAL-QOL), on postoperative patient-reported outcome measure (PROM) improvement. This study aimed to determine the relationship between dysphagia and improvement in pain, disability, physical function, and mental health following ACDF. METHODS: A retrospective review of patients undergoing primary 1- or 2-level ACDF was performed. Individuals without a completed preoperative SWAL-QOL were excluded. Outcomes were collected for visual analog scale (VAS) neck and arm pain, Neck Disability Index (NDI), Patient-Reported Outcome Measurement Information System Physical Function (PROMIS-PF), 12-Item Short Form Physical Component Score (SF-12 PCS), 9-Item Patient Health Questionnaire (PHQ-9), and SWAL-QOL. Postoperative improvement from preoperative values was evaluated using a paired t test. The impact of SWAL-QOL on each PROM was assessed using linear regression. RESULTS: A total of 91 patients were included. Mean preoperative SWAL-QoL was 90.4, which worsened at 6 weeks and resolved by 6 months (P ≤ 0.007, both). VAS neck and arm scores significantly improved postoperatively (P < 0.001), as did the NDI score (P < 0.001). Physical function significantly improved at 12 weeks and 6 months (P ≤ 0.021, both). Depressive symptoms improved at 6 weeks and 12 weeks (P ≤ 0.007, both). Preoperatively, SWAL-QOL demonstrated significant relationships with all PROMs (P ≤ 0.005, all). At 6 weeks, 12 weeks, and 6 months (P ≤ 0.048, all), SWAL-QoL again demonstrated a similar significant association with all PROMs. Multiple regression did not demonstrate common demographic or operative variables that were significant predictors of PROMs. CONCLUSION: Following ACDF, patients experienced a worsening of dysphagia but resolved by 12 weeks. All PROMs demonstrated significant improvements by the 6-month timepoint, except for PHQ-9. SWAL-QoL demonstrated a significant effect on all postoperative outcomes, which may suggest that this questionnaire could effectively evaluate dysphagia and predict positive or negative outcomes following ACDF. LEVEL OF EVIDENCE: 3 CLINICAL RELEVANCE: The severity of dysphagia has a significant association with pain, disability, mental health, and physical function patient-reported outcome measures in patients undergoing ACDF.

Anterior Cervical Discectomy and Fusion Results in Clinically Significant Improvements in Patients With Preoperative Sleep Difficulties.

BACKGROUND: Individual items within the Patient Health Questionnaire-9 (PHQ-9) have not been assessed as predictors of postoperative outcomes. Our objective is to study the relationship between responses to individual PHQ-9 items and achievement of a minimum clinically important difference (MCID) following anterior cervical discectomy and fusion (ACDF). METHODS: A prospective surgical database was reviewed for primary, single-level ACDF procedures performed for degenerative spinal pathology. Patient demographics, preoperative spinal pathology, and perioperative characteristics were recorded. Patient-reported outcome measures (PROMs) including PHQ-9, visual analog scale (VAS) neck and arm, Neck Disability Index, 12-item Short Form physical component score (SF-12 PCS), and Patient-Reported Outcomes Measurement Information System Physical Function were administered at preoperative and 6-week, 12-week, 6-month, 1-year, and 2-year postoperative timepoints. MCID achievement was determined by comparing postoperative PROM improvement from baseline to previously established values. Logistic regression assessed responses to each individual question of the preoperative PHQ-9 as predictors of MCID achievement in each other PROMs. RESULTS: Sixty-six ACDF patients were included with a mean age of 47.2 years. Herniated nucleus pulposus was the most common preoperative spinal diagnosis (95.6%). The mean operative duration was 50.3 minutes, the mean estimated blood loss was 27.5 mL, and most patients were discharged on postoperative day 0 (81.8%). A majority of patients achieved MCID for all measures except SF-12 PCS. PHQ-9 question 3 significantly predicted MCID achievement for VAS neck (P = 0.045), VAS arm (P = 0.049), and SF-12 PCS (P = 0.037). No other PHQ-9 items or overall PHQ-9 scores significantly predicted MCID achievement. CONCLUSION: Question 3 of the PHQ-9 regarding "trouble falling asleep, staying asleep, or sleeping too much" significantly predicted clinically meaningful improvement in neck pain, arm pain, and physical function following ACDF, although overall PHQ-9 scores did not. Providers should inform patients experiencing significant sleep-related difficulties that they may be especially likely to benefit from ACDF surgery. CLINICAL RELEVANCE: Evaluation of sleep from the PHQ-9 predicts clinically relevant improvement in neck pain, arm pain, and physical function in patients undergoing ACDF.

The Effect of the Preoperative Severity of Neck Pain on Patient-Reported Outcome Measures and Minimum Clinically Important Difference Achievement After Anterior Cervical Discectomy and Fusion.

OBJECTIVE: To compare patient-reported outcome measure (PROM) scores and minimum clinically important difference (MCID) achievement rates among patients undergoing single-level anterior cervical discectomy and fusion (ACDF) in patients with varying severity of preoperative visual analog scale (VAS) neck score. METHODS: Patients with ACDF were grouped: severity of preoperative VAS neck score ≤8 or >8. Demographic/perioperative variables and PROMs (Patient-Reported Outcomes Measurement Information System Physical Function [PROMIS PF] score, 12-Item Short Form [SF-12] Mental Component Score [MCS], VAS neck/arm score, and Neck Disability Index [NDI]) were collected preoperatively/postoperatively. MCID attainment comparison by grouping was evaluated using χ2 analysis. RESULTS: A total of 137 patients were included (103 VAS neck preoperative score ≤8; 34 VAS neck preoperative score >8). The VAS neck preoperative score ≤8 cohort did not improve: 6 weeks PROMIS-PF score, 6 weeks SF-12 Physical Component Score [PCS], 12 weeks/1 year/2 years SF-12 MCS, 2 years VAS neck score, and 1 years/2 years VAS arm score (P ≤ 0.015, all). VAS neck preoperative score >8 did not improve: 6 weeks/12 weeks/2 years PROMIS-PF score, all time points SF-12 PCS, 6 weeks/12 weeks/1 year/2 years SF-12 MCS, and 2 years VAS arm score (P ≤ 0.013, all). VAS neck preoperative score >8 had inferior PROMIS-PF scores all time points except 1 year (P ≤ 0.036, all), lower SF-12 PCS 6 weeks/6 months (P ≤ 0.043, both), inferior SF-12 MCS at preoperative to 6 months (P ≤ 006, all), higher VAS neck score from preoperative to 6 months (P ≤ 0.018), higher VAS arm score preoperative/12 weeks/6 months (P ≤ 0.020, all), and higher NDI at preoperative/12 weeks/6 months (P ≤ 0.030, all). MCID attainment rates for VAS neck preoperative score >8 were greater for NDI 2 years (P = 0.040), lower for PROMIS-PF score 2 years, and overall (P = 0.018), lower for SF-12 MCS 12 weeks (P = 0.046), lower for VAS neck score 12 weeks to 1 year and overall (P ≤ 0.032, all), and lower for VAS arm score 6 weeks/1 year (P ≤ 0.030, both). CONCLUSIONS: Patients with single-level ACDF presenting with greater baseline neck pain showed poorer physical function/pain/disability/mental health at preoperative/intermediate postoperative time points, but had comparable long-term PROMs by 2 years. MCID attainment was lower among patients with greater preoperative neck pain; MCID among the VAS neck score >8 cohort were only significantly inferior for neck pain.