YouTube as an Information Source for Lumbar Disc Herniations: A Systematic Review.

OBJECTIVE: The Internet is a source of health information for patients. Quality of information available to patients is varied and uncontrolled. Physicians should be familiar with the overall quality of the information. This review provides an evaluation of YouTube's current patient accessible health information on the topic of lumbar disc herniation (LDH). METHODS: YouTube was queried using 3 different search strings: (1) "disc herniation", (2) "lumbar disc herniation", or (3) "lower back disc herniation". Video duplicates, non-English, or those that contained no audio or were not relevant to LDH were excluded. The first 50 videos per search string were evaluated. Two reviewers independently assessed videos. Parameters included duration, upload date, number of views, number of likes, views per day, and likes per day. A scoring system was used to grade the videos for their performance on diagnosis and treatment of LDH. RESULTS: The first 50 videos produced a total number of hits of 50,500, 29,100, and 22,100, respectively. Strong agreement, assessed using intraclass correlation coefficient (ICC), was demonstrated between readers for both diagnostic scores (ICC 0.921, 95% CI 0.866-0.953) and treatment scores (ICC 0.916, 95% CI 0.855-0.951). Educational Physician videos had significantly greater diagnostic and treatment scores compared to non-physician videos (9.54 vs. 7.05, P = 0.048, and 6.53 vs. 5.3, P = 0.004). CONCLUSIONS: YouTube videos pertaining to LDH were found to have low overall quality. Physicians should be cognizant about information sources readily available to patients as they may influence patient expectations and preconceptions.

Validation of Veterans RAND 12-Item Physical Function Survey in Minimally Invasive Transforaminal Lumbar Interbody Fusion.

BACKGROUND: Veterans RAND 12-item (VR-12) physical component score (PCS) has been validated in both veteran and US citizen populations; however, its use for spine surgery populations has not been evaluated. This study aims to correlate the VR-12 PCS survey with legacy patient-reported outcome measures (PROMs) in patients undergoing minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). METHODS: A prospective surgical database was retrospectively assessed for MIS TLIFs performed at 1 level from March 2015 to June 2019. Inclusion criteria were elective procedures for degenerative spinal pathology. Patients were excluded if they had surgery for metastatic, traumatic, or infectious etiologies or had incomplete preoperative 12-item Short Form (SF-12) PCS or Patient-Reported Outcomes Measurement Information System physical function (PROMIS-PF) survey. Additionally, patients with any incomplete VR-12 PCS surveys through 1 year were excluded. Demographics and perioperative characteristics were recorded. Mean postoperative PROM scores and score difference from preoperative baseline were calculated at each postoperative timepoint through 1 year. The relationship of VR-12-PCS with SF-12-PCS and PROMIS PF was evaluated with a Pearson's correlation coefficient and time-independent partial correlation. RESULTS: A total of 59 patients underwent single-level MIS TLIFs. The cohort was 44.1% women with an average age of 53.8 years, and 52.5% were obese (body mass index ≥30 kg/m2). The VR-12 PCS, SF-12 PCS, and PROMIS PF surveys had significant improvements from baseline to the 6 month through 1 year postoperative timepoints (P ≤ 0.001, all). All timepoints revealed strong VR-12-PCS correlations with SF-12-PCS and PROMIS PF (all P ≤ 0.001). CONCLUSION: VR-12 PCS, SF-12 PCS, and PROMIS PF scores all indicate statistically significant improvements in physical function for patients following MIS TLIF. VR-12 PCS was strongly correlated with the historically validated SF-12 PCS system as well as with the more recent PROMIS PF survey. Our observations give weight to utilizing the VR-12 PCS survey as a valid measure of physical function among patients undergoing MIS TLIF. CLINICAL RELEVANCE: This study validates VR-12 PCS to measure physical function for TLIF patients.

Influence of Preoperative Depressive Burden on Achieving a Minimal Clinically Important Difference Following Lumbar Decompression.

STUDY DESIGN: This was a retrospective cohort study. OBJECTIVE: This study evaluates the association of preoperative mental health with the rate of achieving minimal clinically important difference (MCID) in patient-reported outcomes following lumbar decompression (LD). SUMMARY OF BACKGROUND DATA: Research is scarce regarding the influence of preoperative depression on the rate of achieving MCID for mental health, physical function, and pain among LD patients. METHODS: A surgical registry was retrospectively reviewed for primary LD surgeries. Patients were grouped by depressive symptom severity according to the preoperative Patient Health Questionnaire 9 score. The association of Patient Health Questionnaire 9 subgroups with demographic and surgical variables was analyzed, and differences among subgroups were assessed. Achievement rates of MCID for physical function, pain, disability, and mental health were compared among groups at each time point using previously established MCID thresholds. RESULTS: Of the 321 subjects, 69.8% were male, and 170 subjects had minimal preoperative depressive symptoms, 86 had moderate, and 65 had severe. Patients in moderate and severe groups demonstrated a significantly greater rate of MCID achievement for disability at 6 weeks and 3 months postoperatively. The severe group demonstrated a significantly higher rate of achieving MCID for mental health at the 1-year time point. CONCLUSIONS: Patients with any range of preoperative depressive symptom severity had a similar rate of achieving MCID for pain and physical function throughout 1 year following LD. The severe depressive symptom group had a higher rate of MCID achievement with disability at 6 weeks and with mental health at 1 year. This study demonstrates that patients with any preoperative depressive symptom severity have an indistinguishable ability to attain MCID by 1 year following LD. LEVEL OF EVIDENCE: Level III.

The Worldwide Influence of Social Media on Cervical Spine Literature.

BACKGROUND: The Altmetric (Digital Science, Holtzbrinck Publishing) Attention Score (AAS) is an automatically calculated score that accounts for other literary influences, which include academic sources as well as nonacademically focused social media outlets such as Twitter, Facebook, and news articles. This study compares the most popular cervical surgery articles on social media to the most cited articles within peer-reviewed literature and identifies journals that contribute the most articles and geographic trends. METHODS: We searched the Altmetric database for cervical spine surgery articles since inception using the search phrase "cervical" and "spine." We ranked journals that contributed the most articles and calculated their AAS, contributing social media outlets (eg, Twitter, Facebook, News, etc) and citation counts. We also ranked the top 100 most popular cervical spine articles on social media and compared them to the most cited articles. Countries were assessed based on their mentions through the most contributing social media platform. RESULTS: Of the 527 total journals identified in our search, the top 10 journals were responsible for contributing 60.2% of the total articles. The 3 journals that contributed the most articles were Spine (18.9%), European Spine Journal (11.8%), and The Spine Journal (10.3%). The journals with the highest AAS scores included Journal of Neurosurgery: Spine (11.3), Spine (8.8), and Journal of Manipulative & Physiological Therapeutics (5.8). Social media outlets that contributed the most mentions per article were Twitter (4.4), Facebook (0.5), and news sources (0.3). Among all countries contributing Twitter mentions, the 3 countries with the most cervical spine posts included the United States (23.3%), the United Kingdom (10.3%), and Spain (5.5%). CONCLUSION: Our evaluation of cervical spine literature revealed Twitter, Facebook, and news sources are the most common social media outlets influencing title dissemination. Journals contributing the most articles did not necessarily have the highest average AAS. CLINICAL RELEVANCE: Spinal surgeons should consider utilization of social media outlets, such as Twitter, Facebook, and news sources, to potentially increase the dissemination of their articles.

Risk Assessment of Anterior Lumbar Interbody Fusion Access in Degenerative Spinal Conditions.

STUDY DESIGN: This was a retrospective cohort study. OBJECTIVE: Develop an evidence-based preoperative risk assessment scoring system for patients undergoing anterior lumbar interbody fusion (ALIF). SUMMARY OF BACKGROUND DATA: ALIF may hold advantages over other fusion techniques in sagittal restoration and fusion rates, though it introduces unique risks to vascular and abdominal structures and thus possibly increased risk of operative morbidity. METHODS: Primary, 1 or 2-level ALIFs were identified in a surgical registry. Baseline characteristics were recorded. Axial magnetic resonance imagings at L4-L5 and L5-S1 were reviewed for vascular confluence/bifurcation or anomalous structures, and measured for operative window size/slope. To assess favorable outcomes, a clinical grade was calculated: (clinical grade=blood loss×operative duration), higher value indicating poorer outcome. To establish a risk scoring system, a base risk score algorithm was established and stratified into 5 categories: high, high to intermediate, intermediate, intermediate to low, and low. Modifiers to base risk score included age, body mass index, operative level, history of bone morphogenic protein use, calcified vasculature, spondylolisthesis grade, working window size and slope, and abnormal vasculature. Modifiers were weighted for contribution to surgical risk. A total risk score was calculated and evaluated for strength of association with clinical outcome grades by Pearson correlation coefficient. RESULTS: A total of 65 patients were included. Mean clinical outcome grade was 5.6, mean total risk score 21.3±21.5. Multilevel procedures (L4-S1) mean total risk score was 57.3±7.8. L4-L5 mean total risk score was 23.6±5.2; L5-S1 mean total risk score 8.3±6.6. Correlation analysis demonstrated a significant and strong relationship (| r |=0.753; P <0.001) between total risk scores and clinical outcome grades. CONCLUSION: Calculated ALIF risk scores significantly correlated with operative duration and blood loss. This scoring system represents a potential framework to facilitate clinical decision-making and risk assessment for potential ALIF candidates with degenerative spinal pathologies.

Epidemiological Relevance of Elevated Preoperative Patient Health Questionnaire-9 Scores on Clinical Improvement Following Lumbar Decompression.

BACKGROUND: Limited research exists regarding the influence of preoperative depression on postoperative mental health, physical function, and pain in lumbar decompression (LD) patients. This study aims to evaluate the association of depressive symptoms as measured by the Patient Health Questionnaire-9 (PHQ-9) with other mental health and physical function clinical outcomes among patients undergoing LD. METHODS: A prospectively maintained surgical registry was reviewed for primary LD from March 2016 to May 2019. Patients were stratified into 3 preoperative PHQ-9 score subgroups. Higher PHQ-9 scores indicated greater depressive symptoms. We assessed demographic and perioperative characteristics among subgroups with appropriate statistical testing. We also evaluated outcome instruments and postoperative improvement for the following outcomes: PHQ-9, Short Form 12 (SF-12), Veterans RAND 12-Item (VR-12), Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF), visual analog scale (VAS) leg, and VAS back. RESULTS: The 351-subject cohort was 70.4% men with an average age of 47 years; 186 subjects had minimal preoperative depressive symptoms (PHQ-9 <5), 94 had moderate (5≤ PHQ-9 ≤10), and 71 had severe (PHQ-9 >10). Subgroups with more severe symptoms of depression had worse mental health outcome scores (PHQ-9, 12-Mental Health Composite Score [12-MCS], and VR-12-MCS) and a positive linear association with greater pre- to postoperative mental health improvements at all timepoints. Subgroups with more severe symptoms of depression had worse PROMIS-PF scores at all timepoints, though VAS pain scores had no depression symptom association by 1 year. CONCLUSION: Patients with more severe preoperative depressive symptoms, as evaluated by PHQ-9, have a greater improvement in PHQ-9, SF-12, and VR-12 scores, but more severe PHQ-9 scores are associated with worse overall physical function scores. This study demonstrates the relevance of preoperative depressive symptoms and their necessity in future risk factor models. CLINICAL RELEVANCE: Severity of preoperative PHQ-9 acts as a significant risk factor to postoperative pain and mental and physical health improvement.

Workers' Compensation Association With Clinical Outcomes After Anterior Cervical Diskectomy and Fusion.

BACKGROUND: Research has suggested that workers' compensation (WC) status can result in poor outcomes after anterior cervical diskectomy and fusion (ACDF). OBJECTIVE: To determine the influence WC status has on postoperative clinical outcomes after ACDF. METHODS: A surgical database was reviewed for patients undergoing primary or revision single-level ACDF. Patients were grouped into WC vs Non-WC, and differences in baseline characteristics were assessed. Postoperative improvement was assessed for differences in mean scores between WC subgroups for visual analog scale (VAS) arm, VAS neck, 12-item Short Form Physical Composite Score, Patient-Reported Outcomes Measurement Information System physical function (PF), and Neck Disability Index (NDI) at preoperative and postoperative time points. Minimum clinically important difference (MCID) achievement was compared between groups. RESULTS: The patient cohort included 44 with WC and 95 without. The cohort was 40% female with an average age of 48 years and mean body mass index of 30. Mean VAS arm, VAS neck, NDI, 12-item Short-Form Physical Composite Score, and Patient-Reported Outcomes Measurement Information System PF scores differed between groups; however, the difference was not sustained at the 1-yr time point. MCID achievement among WC subgroups was different for VAS arm (6 wk through 6 mo, P = .005), VAS neck (3 and 6 mo, P < .01), and NDI (3 and 6 mo, P < .05). No statistically significant difference was noted between cohorts for overall rates of MCID achievement for all patient-reported outcome measures collected. CONCLUSION: WC patients reported similar preoperative and 1-yr postoperative neck and arm pain compared with non-WC patients after ACDF. One-yr MCID achievement rates were similar between cohorts for disability and PF scores.

Patients With Opioid Use Disorder Have Increased Readmission Rates, Emergency Room Visits, and Costs Following a Hallux Valgus Procedure.

BACKGROUND: Patients with a history of opioid use disorder (OUD) tend to have more complications, higher readmission rates, and increased costs following orthopaedic procedures. This study evaluated patients undergoing hallux valgus correction for their odds of increased (1) readmission rates, (2) emergency room (ER) visits, and (3) costs. METHODS: Patients undergoing hallux valgus corrections with OUD history were identified using a national Medicare administrative claims database of approximately 24 million orthopaedic surgery patients. OUD patients were matched to non-opioid use disorder (NUD) patients in a 1:4 ratio by age, sex, Elixhauser-Comorbidity Index (ECI), diabetes mellitus, hyperlipidemia, hypertension, and tobacco use. The query yielded 6318 patients (OUD = 1276; NUD = 5042) who underwent a hallux valgus correction. Primary outcomes analyzed included odds of 90-day readmission rates, 30-day ER visits, and 90-day episode-of-care costs. Demographics, odds ratios (ORs), ECI, and cost were assessed as appropriate using a Pearson χ2 test, logistic regression, and a t test. A P value <.05 was considered statistically significant. RESULTS: There were no significant differences in demographics between OUD and NUD patients. OUD patients had higher incidence and odds of 90-day readmission (9.56% vs 6.04%; OR = 1.55; P < .001) and 30-day ER visits (0.86% vs 0.35%; OR = 2.42; P = .021) and incurred greater 90-day episode-of-care costs ($7208.28 vs $6134.75; P < .001) compared with NUD patient controls. CONCLUSION: The study demonstrates the possible influence of OUD on higher odds of readmission, ER visits, and costs following a hallux valgus correction. LEVELS OF EVIDENCE: Level III: Retrospective cohort study.

Spine Surgery Complications in the Ambulatory Surgical Center Setting: Systematic Review.

STUDY DESIGN: This was a systematic review study. PURPOSE: This study aims to review current literature to determine the rates of complications in relation to spine surgery in ambulatory surgery centers (ASC). BACKGROUND: Recent improvements in anesthesia, surgical techniques, and technological advances have facilitated a rise in the use of ASC. Despite the benefits and lower costs associated with ASCs, there is inconsistent reporting of complication rates. METHODS: This systematic review was completed utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Pertinent studies were identified through Embase and PubMed databases using the search string ((("ambulatory surgery center") AND "spine surgery") AND "complications"). Articles were excluded if they did not report outpatient surgery in an ASC, did not define complications, were in a language other than English, were non-human studies, or if the articles were classified as reviews, book chapters, single case reports, or small case series (≤10 patients). The primary outcome was the frequency of complications with respect to various categories. RESULTS: Our query identified 150 articles. After filtering relevance by title, abstract, and full text, 22 articles were included. After accounting for 2 studies that were conducted on the same study sample, a total of 11,245 patients were analyzed in this study. The most recent study reported results from May 2019. While 5 studies did not list their surgical technique, studies reported techniques including open (6), minimally invasive surgery (2), endoscopic (4), microsurgery (1), and combined techniques (4). The following rates of complications were determined: cardiac 0.29% (3/1027), vascular 0.25% (18/7116), pulmonary 0.60% (11/1839), gastrointestinal 1.12% (2/179), musculoskeletal/spine/operative 0.59% (24/4053), urologic 0.80% (2/250), transient neurological 0.67% (31/4616), persistent neurological 0.61% (9/1479), pain related 0.57% (20/3479), and wound site 0.68% (28/4092). CONCLUSIONS: After literature review, this is the first study to comprehensively analyze the current state of literature reporting on the complication profile of all ASC spine surgery procedures. The most common complications were gastrointestinal (1.12%) and the most infrequent were vascular (0.25%). Case reports varied significantly with regard to the type and rate of complications reported. This study provides complication profiles to assist surgeons in counseling patients on the most realistic expectations.

Preliminary Evaluation of Standing Full-Length Plain Radiographs Utility in an Adult Degenerative Spine Practice.

INTRODUCTION: The role of weight-bearing full-length standing radiographs (FLSRs) of the spine in the preoperative workup of adult degenerative disease of the lumbar spine is a subject of increasing research. This investigation aims to determine whether FLSR influences preoperative planning decisions. METHODS: In this prospective study, eight spine surgeons reviewed two 30-patient case series. The first set (set A) contained a patient history, physical examination data, and preoperative images. The second set (set B) contained all information in set A in addition to preoperative FLSR AP and lateral radiographs. Within 2 weeks of evaluating set A, reviewers assessed set B. Case sets were randomized. After reviewing each set, reviewers gave surgical plans and whether they believed an FLSR was important in planning. Decisions were evaluated by subspecialty, years of practice, and postfellowship years. A McNemar test assessed differences between set viewings. A chi-square test assessed differences of preoperative decision changes between different specialties and levels of experience. A Poisson regression assessed characteristics associated with changing preoperative plans. We analyzed patients by the number of unique reviewer procedures, surgical levels, and associated pathology. RESULTS: After viewing an FLSR, 44.7% of reviewers changed procedure. Reviewer opinion of FLSR importance differed between sets (27.1% versus 35.7%, P = 0.047). Among all reviewers, FLSR presentation was associated with aligning the number of proposed procedures in 15 patients. Scoliosis and sacral dysplasia were associated with negative deltas. FLSR viewing reduced the span of operational levels considered. Along the most divided patients, those with a high magnitude (≥6 choices) of initial procedures had more negative deltas than did those with a high number (≥5 choices) of surgical level choices. CONCLUSION: FLSR remains a critical aspect of presurgical planning. Even when reviewers initially believed patients would not benefit from FLSR, we observed changes in preoperative planning after FLSR viewing.

Readability Analysis of Patient-Accessible Information Regarding Ambulatory Surgical Center Procedures.

BACKGROUND: As spine surgery in the ambulatory setting becomes more frequent, patients should comprehend the difference from traditional hospital-based, outpatient settings. Limited research exists on the readability of online articles surrounding spine surgery in the ambulatory surgery center (ASC). In this study, we intend to evaluate the readability of online articles pertaining to spine surgery in the outpatient and ambulatory surgical settings. METHODS: Three search engines were queried, and the first 100 articles pertaining to each outpatient spine surgery search term were collected. Advertisements, videos, and peer-reviewed scientific articles were excluded. Articles were categorized by publishing source as follows: hospital or institution, general medical Websites, private practice, or surgery center. Flesch-Kincaid (FK) grade level, Flesch Reading Ease (FRE) score, word count, sentences per paragraph, words per sentence, and characters per word were evaluated for each article. Student's t tests compared readability metrics between groups based on setting and procedure region. RESULTS: A total of 342 articles was analyzed; 279 articles were outpatient hospital related, and 63 ASC related. Flesch-Kincaid grade levels or FRE scores were not significantly different between outpatient hospital and ambulatory center. Comparison of ASC to outpatient articles from a hospital or institution source significantly differed in FRE score (40.7 versus 32.4) and FK grade level (12.3 versus 13.9; all P < .05). Articles addressing procedure type were significantly different in FRE score (36.2 versus 30.0) and FK grade level (13.0 ± 2.1 versus 14.3 ± 1.8). CONCLUSIONS: Hospital, private practice, and medical journalists should be aware of significant differences in readability of patient-accessible ASC articles. These articles may be more difficult to read than outpatient hospital articles, and production of more reading-level-appropriate online literature is required. LEVEL OF EVIDENCE: 3 CLINICAL RELEVANCE: There is a significant difference in the readability of patient-accessible ASC articles.

Validation of VR-12 Physical Function in Minimally Invasive Lumbar Discectomy.

BACKGROUND: Although the Veterans RAND 12-item Physical Component Survey (VR-12 PCS) has been broadly used to evaluate patient-reported outcome measures (PROMs) in spine surgery, its feasibility for use in patients undergoing minimally invasive lumbar discectomy (MIS LD) has not been well studied. This study aimed to assess the feasibility of VR-12 PCS for use up to 2 years postoperatively for MIS LD by correlation with PROMs for physical function. METHODS: Patients undergoing primary single-level MIS LD procedures were reviewed retrospectively. Results on the VR-12 PCS, 12-Item Short Form (SF-12) PCS, and Patient-Reported Outcomes Measurement Information System (PROMIS PF) were recorded preoperatively and up to 2 years postoperatively. Improvements in postoperative PROMs were calculated and assessed for significant differences from baseline values. Correlation significance and strength were evaluated between VR-12 PCS and SF-12 PCS or PROMIS PF. Scatterplots were constructed to demonstrate relationships of VR-12 PCS with SF-12 PCS and PROMIS PF at each time point. RESULTS: Our cohort comprised 402 patients. Patients improved significantly from preoperative baseline for all 3 PROMs at all postoperative time points. Both Pearson's correlation and time-independent partial correlation revealed statistically significant strong correlations of VR-12 PCS with SF-12 PCS and PROMIS PF through 2-years. DISCUSSION: Physical function scores for VR-12, SF-12, and PROMIS PF all demonstrated significant improvements following MIS LD. Strongly statistically significant correlations of VR-12 PCS with SF-12 PCS and PROMIS PF from preoperative measures through 2 years demonstrate the feasibility of VR-12 for assessing patient-reported physical function in MIS LD patients.

Multimodal Analgesic Management for Lumbar Decompression Surgery in the Ambulatory Setting: Clinical Case Series and Review of the Literature.

BACKGROUND: Effective pain control is vital for successful surgery in the ambulatory setting. Our study aims to characterize a case series of patients who underwent lumbar decompression (LD) in the ambulatory surgical center (ASC) with the use of a multimodal analgesic (MMA) protocol. METHODS: A prospective surgical registry was retrospectively assessed for patients who underwent single or multilevel LD in an ASC using MMA from 2013 to 2019. Observation in excess of 23 hours was not permitted at the ASC, and patients were required to be discharged the same day. Length of stay, patient-reported visual analog scale pain scores before discharge, and the quantity of narcotic medications administered to patients before discharge were recorded. Quantity of narcotic medications were converted into units of oral morphine equivalents and summed across all types of narcotic medications prescribed. RESULTS: A total of 499 patients were included. In total, 86.0% (429) of the patients underwent a single-level decompression procedure, 13.8% (69) of patients underwent a 2-level, and 0.2% (1) of the patients underwent a 3-level procedure; 83.6% (417) of the patients in this study underwent a primary LD, and 14.0% (70) underwent a revision decompression. CONCLUSIONS: This is the largest clinical case series focused on LD procedures within an ASC requiring no planned 23-hour observation. This study demonstrates the feasibility of performing LD surgery in an ASC with proper patient selection, surgical technique, and MMA protocol. All patients were discharged from the surgical center on the same day of surgery.

Charlson Comorbidity Index: An Inaccurate Predictor of Minimally Invasive Lumbar Spinal Fusion Outcomes.

BACKGROUND: There is a scarcity of research on the Charlson Comorbidity Index (CCI) and its influence on minimum clinically important difference (MCID) achievement after minimally invasive (MIS) transforaminal lumbar interbody fusion (TLIF). The objective of this study is to detail the association between the CCI and attaining MCID after MIS TLIF. METHODS: A prospective surgical registry was retrospectively reviewed for spine surgeries between May 2015 and February 2019. Inclusion criteria were primary or revision, 1- or 2-level MIS TLIF procedures. Patients were stratified based on CCI score: 0 points (no comorbidities), 1-2 points (mild CCI), ≥3 points (moderate CCI). Preoperative, intraoperative, and postoperative variables were assessed by subgroup using appropriate statistical analysis. Subgroups were analyzed with linear regression or χ2 tests for continuous or categorical variables, respectively. Subgroup scores, improvement, and MCID achievement were assessed at postoperative timepoints (eg, 6 weeks, 12 weeks, 6 months, and 1 year) for back and leg pain, Oswestry Disability Index (ODI), SF-12 Physical Composite Score (PCS), and Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS PF). RESULTS: A total of 171 patients were included (n = 51 [no comorbidities], n = 73 [mild CCI], and n = 47 [moderate CCI]). Higher CCI patients were older and more likely to be smokers, diabetic, arthritic, hypertensive, or have a malignancy history (P < 0.003). Preoperatively, ODI and PROMIS PF were the only patient-reported outcomes with a significant association by CCI group (P = 0.015 and 0.014). Back pain was the only measure that had a significant association with the CCI subgroup at 1 year for score (P = 0.002) or MCID (P = 0.028). CONCLUSIONS: By 1 year, regardless of the number of comorbidities, a similar proportion of patients undergoing MIS TLIF were able to achieve MCID for visual analog scale leg, SF-12 PCS, and PROMIS PF. Patients with higher comorbidities are not likely to experience a significant difference in symptom improvement. Regardless of CCI score, MIS TLIF can have a significant benefit for patients. LEVEL OF EVIDENCE: 4. CLINICAL RELEVANCE: Text.

Preoperative Physical Function Association With Mental Health Improvement After Anterior Cervical Discectomy and Fusion.

STUDY DESIGN: This was a retrospective study. OBJECTIVE: This study investigates the influence of physical function and their influence on postoperative depressive symptom scores as measured by Patient Health Questionnaire-9 (PHQ-9) among anterior cervical decompression and fusion (ACDF) patients. BACKGROUND: While ACDF is one of the most commonly performed ambulatory surgeries, research is limited on the predictive value of Patient-Reported Outcomes Measurement Information System (PROMIS) scores and their influence on depressive symptoms as measured by the PHQ-9. METHODS: A prospectively maintained surgical registry was retrospectively reviewed from March 2016 to January 2019. Inclusion criteria were primary or revision ACDF procedures. Patients were grouped by preoperative PROMIS score (≥35.0, <35.0), with higher scores indicating greater physical function. The χ2 and Student t tests assessed categorical and continuous variables (eg, demographics, perioperative, and postoperative values). A t test evaluated postoperative improvement in PROMIS Physical Function (PF) scores between subgroups among PROMIS PF scores and PHQ-9 score improvement at 6, 12 weeks, 6 months, and 1 year. Linear regression assessed preoperative PROMIS scores influence on PHQ-9 score improvement. RESULTS: The 121 subject cohort was 61.2% male with an average age of 49.6±9.8 years. Compared with the PROMIS ≥35.0 group, the PROMIS <35.0 group also had larger improvement of PROMIS scores at 6 weeks. No significant difference in postoperative PHQ-9 improvement was observed between subgroups. There was a negative association between preoperative PROMIS scores and improvement in PROMIS scores at 6, 12 weeks, 6 months, and 1 year. There was a positive association between preoperative PROMIS scores and magnitude of 1-year PHQ-9 change. CONCLUSIONS: Individuals with lower preoperative PROMIS PF scores had significantly higher PHQ-9 scores at 1 year. Patients with lower preoperative physical function, as evaluated by PROMIS PF scoring, had greater improvement of mental health at 1 year postoperatively. This suggests that many patients experience multidimensional health benefits after ACDF procedures.

Patient Health Questionnaire-9 Is a Valid Assessment for Depression in Minimally Invasive Lumbar Discectomy.

OBJECTIVE: The Patient Health Questionnaire-9 (PHQ-9) is a screening tool for evaluating depressive symptoms. Research is scarce regarding the validity and correlation of PHQ-9 scores with other patient-reported outcomes of mental health after minimally invasive lumbar discectomy (MIS LD). We aim to validate PHQ-9 as a metric for assessing mental health in MIS LD patients. METHODS: A database was retrospectively reviewed for patients who underwent elective, single-level MIS LD. Patients were excluded if they had incomplete preoperative PHQ-9, 12-item Short Form Health Survey (SF-12), or Veterans RAND 12-item health survey (VR12). Survey scores were collected preoperatively and postoperatively through 1 year. Mean scores were used to calculate postoperative improvement from preoperative scores. Correlation of PHQ-9 with SF-12 mental composite score (MCS) and VR-12 MCS scores was also calculated. Correlation strength was assessed by the following categories: 0.1 ≤ |r| < 0.3 = low; 0.3 ≤ |r| < 0.5 = moderate; |r| ≥ 0.5 = strong. RESULTS: A total of 239 patients underwent single-level MIS LD. PHQ-9, VR-12 MCS, and SF-12 MCS all demonstrated statistically significant increases from preoperative scores at all postoperative timepoints (p ≤ 0.001). SF-12 MCS and VR-12 MCS were each observed to have strong and significant correlations with PHQ-9 at all timepoints when evaluated with both Pearson correlation coefficients and partial correlation coefficients. CONCLUSION: We observed that PHQ-9, SF-12 MCS and VR-12 MCS all significantly improve following lumbar discectomy and that PHQ-9 scores strongly correlated with these previously established measures. Our results substantiate evidence from other surgical fields that PHQ-9 scores are a valid tool to evaluate pre- and postsurgical depressive symptoms.

The Influence of Sex on Clinical Outcomes in Minimally Invasive Lumbar Decompression.

BACKGROUND: Research focused on postoperative outcomes among men and women undergoing minimally invasive lumbar decompression (MIS LD) spine surgery is sparse. This study aims to assess the influence of sex on postoperative patient-reported outcome measure (PROM) evaluations and achievement of a minimum clinically important difference (MCID). METHODS: A prospectively maintained surgical database was retrospectively queried for patients undergoing primary or revision, single or multilevel LD procedures from 2011 to 2019. Patients with incomplete visual analog scale (VAS) leg or back surveys were excluded. Demographic and operative variables were recorded, and a chi-squared analysis or t tests were used to compare by sex. PROMs were evaluated from preoperative to postoperative time points. PROM score differences and postoperative improvement were evaluated between sexes by a t test. Achievement of MCID by sex was compared using chi-squared analysis. RESULTS: The study cohort (n = 572) was 70% male (n = 398), had an average age of 47 years, and 42% were obese. Sexes differed in preoperative VAS leg, Oswestry Disability Index (ODI), and 12-item short form (SF-12)-physical composite score (PCS) scores (all P < .05) and in ODI at 6 and 12 weeks (P = .048; P = .001) and VAS back and leg scores at 6 months (P = .039; P = .019). Both sexes significantly improved (P < .050) all PROMs at all time points except for VAS back at 1 year for women and ODI at 6 weeks and 6 months for men. The only significant difference in achievement of MCID was for ODI at 6 months (P = .008). CONCLUSIONS: Significant preoperative differences were observed among sexes with ODI, SF-12-PCS, and VAS leg scores. By 1 year, there were no significant sex differences for any PROM or for achievement of MCID. MIS LD has an equivalent role for both sexes in achieving MCID. LEVEL OF EVIDENCE: 3. CLINICAL RELEVANCE: Results demonstrate no sex difference in PROMs following LD.

Two-Year Postoperative Validation of Patient-Reported Outcomes Measurement Information System Physical Function After Lumbar Decompression.

INTRODUCTION: Physical function evaluated by Patient-Reported Outcomes Measurement Information System (PROMIS PF) instrument has been validated through the short-term postsurgical period in spine surgery patients. Evidence for long-term efficacy of PROMIS PF is lacking in lumbar decompression (LD) patients. The objective of this study was to evaluate correlations between PROMIS PF and legacy patient-reported outcome measures for patients undergoing LD. METHODS: Consecutive primary or revision, single-level or multilevel LD surgeries were retrospectively reviewed from May 2015 to September 2017. Patients lacking preoperative or 2-year PROMIS PF scores were excluded. Demographics, baseline pathology, and perioperative characteristics were collected, and descriptive statistics performed. Visual Analogue Scale (VAS) back and leg, Oswestry Disability Index (ODI), 12-Item Short Form (SF-12) Physical Composite Score (PCS), and PROMIS PF were collected at preoperative and postoperative timepoints and evaluated for improvement from baseline values. Correlations between PROMIS PF and VAS back, VAS leg, SF-12 PCS, and ODI were calculated and categorized according to the strength of relationship. RESULTS: Ninety-two patients were included in this study with 58.7% of LDs performed at the single level. All patient-reported outcome measures demonstrated significant improvement from baseline values at all assessment timepoints (all P < 0.001). Apart from preoperative VAS back and VAS leg, PROMIS PF demonstrated a significant and strong correlation with VAS back, VAS leg, ODI, and SF-12 PCS at all timepoints (all P < 0.001). CONCLUSION: PROMIS PF demonstrated a strong correlation with pain, disability, and PF outcome measures throughout the postoperative period out to 2 years after LD. Our study provides longitudinal evidence that the PROMIS PF instrument is a valid measure for PF for patients undergoing LD.