Early Opioid Consumption Patterns After Anterior Cervical Spine Surgery.

STUDY DESIGN: This is a prospective observational study. OBJECTIVE: The aim was to record daily opioid use and pain levels after 1-level or 2-level anterior cervical discectomy and fusion (ACDF) or cervical disc arthroplasty (CDA). SUMMARY OF BACKGROUND DATA: Data to inform opioid prescription guidelines following ACDF or CDA is lacking. Understanding postoperative opioid consumption behaviors is critical to provide appropriate postdischarge prescriptions. METHODS: Patients undergoing 1-level or 2-level primary ACDF or CDA were consecutively enrolled at 2 participating institutions between March 2018 and March 2019. Patients with opioid dependence (defined as daily use ≥6 mo before surgery) were excluded. Starting postoperative day 1, daily opioid use and numeric pain rating scale pain levels were collected through a Health Insurance Portability and Accountability Act-compliant, automated text-messaging system. To facilitate clinical applications, opioid use was converted from oral morphine equivalents into "pills" (oxycodone 5 mg equivalents). After 6 weeks or upon patient-reported cessation of opioid use, final survey questions were asked. Refill data were verified from the state prescription registry. Risk factors for patients in top quartile of consumption were analyzed. RESULTS: Of 57 patients, 48 completed the daily queries (84.2%). Mean age of the patient sample was 50.2±10.9 years. Thirty-two patients (66.7%) underwent ACDF and 16 CDA (33.3%); 64.6% one level; 35.4% two levels. Median postdischarge use was 6.7 pills (range: 0-160). Cumulative opioid use did not vary between the 1-level and 2-level groups (median pill consumption, 10 interquartile range: 1.3-31.3 vs. 4 interquartile range: 0-18, respectively, P=0.085). Thirteen patients (27.1%) did not use any opioids after discharge. Of those patients that took opioids after discharge, half ceased opioids by postoperative day 8. Preoperative intermittent opioid use was associated with the top quartile of opioid consumption (9.1% vs. 50%, P=0.006). CONCLUSION: Given that most patients use few opioids, patients could be offered the option of a 12 oxycodone 5 mg (90 oral morphine equivalents) discharge prescription, accompanied by education on appropriate opioid use and disposal.

Are Preoperative PHQ-9 Scores Predictive of Postoperative Outcomes Following Anterior Cervical Discectomy and Fusion?

STUDY DESIGN: This is a retrospective study. OBJECTIVE: The objective of this study was to determine if there is an association between preoperative depression, as quantified by Patient Health Questionnaire-9 (PHQ-9), and postoperative improvement in pain and disability after anterior cervical discectomy and fusion (ACDF). SUMMARY OF BACKGROUND DATA: Few studies have quantified depression symptoms in the preoperative period using PHQ-9 and have tracked patient-reported outcomes (PROs) following ACDF. METHODS: Patients undergoing ACDF were retrospectively reviewed and stratified by their preoperative PHQ-9 score. PROs, including Neck Disability Index (NDI), Visual Analogue Scale (VAS) neck and arm pain, and 12-Item Short Form (SF-12) Physical Component Score (PCS), were measured preoperatively and at 6-week, 3-month, 6-month, and 1-year postoperatively. PRO scores were analyzed amongst PHQ-9 cohorts using multiple linear regression. Achievement of minimum clinically important difference (MCID) was compared using χ analysis. RESULTS: Higher PHQ-9 scores were associated with increased preoperative NDI, VAS neck, and VAS arm scores and significantly lower SF-12 PCS scores preoperatively. Cohorts experienced similar VAS pain scores up to 1-year following surgery, except for VAS neck pain at 3 months when patients with greater depression symptoms had more pain. High PHQ-9 patients had higher NDI values at 6 weeks and 3-month marks but had similar NDI scores at 6 months and 1-year. Similarly, SF-12 PCS scores were lower for patients with a higher PHQ-9 score at 3 and 6 months, however, both groups had similar scores at 1-year follow-up. A greater percentage of the high PHQ-9 cohort achieved MCID for NDI, however, there were no differences in MCID achievement for VAS neck, VAS arm, or SF-12 PCS. CONCLUSIONS: Patients with worse preoperative mental health reported significantly greater preoperative disability and pain. However, both cohorts demonstrated similar clinical recovery at the 1-year follow-up. These findings suggest patients with worse preoperative mental health can expect significant improvements in PROs following surgery.

Demographic and Perioperative Factors Associated With Patient-reported Outcomes Measurement Information System (PROMIS) Survey Completion.

STUDY DESIGN: This was a retrospective study. OBJECTIVE: To evaluate independent demographic and perioperative factors associated with lower Patient-reported Outcome Measurement Information System Physical Function (PROMIS PF) survey completion rates after spine surgery. SUMMARY OF BACKGROUND DATA: There has not been a study evaluating factors related to PROMIS PF survey completion following spine surgery. METHODS: Patients undergoing spine procedures were retrospectively reviewed. The number of PROMIS PF surveys that were completed at each time period and the number of surveys that were completed in succession starting with the first survey were tabulated and reported using descriptive statistics. Independent preoperative and perioperative factors associated with full survey completion up to the 12-month period were identified using χ analysis and Poisson regression with robust error variance. A final multivariate model was created using a backward, stepwise multivariate regression. RESULTS: A total of 713 patients were included. Variables positively associated with PROMIS survey completion were aged above 60 years and Patient Health Questionnaire (PHQ)-9≥10. African Americans and Hispanics were negatively associated with survey completion. Postoperative day 0 narcotic use ≥50 oral morphine equivalents was positively associated with survey completion, while outpatient surgical setting and high preoperative radicular arm/leg pain were negatively associated with survey completion. In the final multivariate model, depression was the only variable that was positively associated, while both outpatient surgical setting and high preoperative radicular arm/leg pain were negatively associated with survey completion. CONCLUSION: This study identified demographic and perioperative variables associated with PROMIS survey completion and response rates. Patients who underwent surgery in the outpatient setting and those with high preoperative radicular limb pain were less likely to complete surveys. Interestingly, patients with clinical signs of depression were more likely to fill out surveys. Understanding variables associated with survey completion may provide the clinician with insight into which demographic groups are the most at-risk for not responding to surveys.

Patient Perceptions of Physician Ownership in Spine Care.

STUDY DESIGN: This was a prospective study. OBJECTIVE: This study aims to determine the perspectives of patients seeking spine care in regard to physician ownership of surgical facilities and to understand the importance of disclosing financial conflicts. SUMMARY OF BACKGROUND DATA: There has been limited investigation regarding patient perceptions of the proprietary structure of surgical facilities. METHODS: Patients seeking treatment for spine pathology completed an 8-item survey. The questions assessed if patients acknowledged the owners of surgical facilities, if the patient thought knowledge of ownership is important, who they perceived as most qualified to own surgical facilities, preference of communication of ownership, and impact of facility ownership on care. RESULTS: A total of 200 patients completed the survey. When patients were asked whom they thought owned the hospital, most reported private hospital corporations followed by universities/medical schools and insurance companies. With regard to whom patients thought owned an ambulatory surgical center, most reported physicians, followed by private hospital corporations and individual investors. When asked how important it is to know the financial stakeholders of a surgical facility, 73.5% of patients stated "very important" or "somewhat important." Most patients reported they were not aware of who owned the facility. Regarding how facility owners should be communicated, 31.0% answered "written document," whereas 25.0% preferred verbal communication with the staff/surgeon. When asked how much impact the owner of a surgical facility has on their care, 38.0% of patients responded, "strong impact," followed by "moderate impact," (43.0%), and "little or no impact" (19.0%). Patients thought that physicians were the most qualified to own an ambulatory surgical center, followed by universities/medical schools and private hospital corporations. CONCLUSIONS: The pretreatment perception of patients referred to a spine clinic favored the opinion that physicians were the most qualified to own and manage surgical facilities. Therefore, physicians should be encouraged to share disclosures with patients as their ownership of surgical facilities is viewed favorably.

PROMIS Physical Function Predicts Postoperative Pain and Disability Following Anterior Cervical Discectomy and Fusion.

STUDY DESIGN: This was a retrospective study. OBJECTIVE: The objective of this study was to determine if preoperative Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS PF) score is predictive of improvement in pain and physical function following anterior cervical discectomy and fusion (ACDF). SUMMARY OF BACKGROUND DATA: Few studies have investigated the predictive nature of PROMIS PF of patients undergoing spine surgery, such as ACDF. METHODS: Patients undergoing a primary, 1-3-level ACDF were retrospectively reviewed and were stratified into 3 cohorts according to preoperative PROMIS PF scores: minimal disability (score 50-60), mild disability (score 40-50), moderate disability (score 30-40), and severe disability (score 20-30). Preoperative PROMIS PF cohorts were tested for an association with demographics, perioperative characteristics, and improvement in Neck Disability Index (NDI), 12-Item Short-Form Physical Component Score (SF-12 PCS), and Visual Analog Scale (VAS) neck and arm pain using χ analysis and multivariate linear regression. RESULTS: A total of 126 patients were included: 11 had a minimal disability, 44 had mild disability, 54 had moderate disability, and 17 had severe disability. Patients with a severe disability experienced no statistically significant increase in their length of stay. Greater preoperative disability demonstrated lower NDI and SF-12 PCS scores preoperatively and at each postoperative timepoint. Greater preoperative disability had worse VAS neck and arm pain preoperatively and 6-week and 3-month postoperatively. Although patients with severe disability trended worse VAS neck and arm pain at the 6-month follow-up, this did not reach statistical significance. CONCLUSIONS: In this investigation, patients with worse PROMIS PF scores reported greater pain and disability in the preoperative period and experienced less improvement in NDI, SF-12 PCS, and VAS back and leg following ACDF. PROMIS PF is an efficient and accurate instrument that can effectively evaluate strength, mobility, and coordination in the preoperative period and may be used to predict clinical outcomes following ACDF.

Static Versus Expandable Devices Provide Similar Clinical Outcomes Following Minimally Invasive Transforaminal Lumbar Interbody Fusion.

BACKGROUND: Few studies have analyzed differences in radiographic parameters and patient-reported outcomes (PROs) between expandable and static interbody devices in patients undergoing minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). QUESTIONS/PURPOSES: To evaluate differences in radiographic parameters and PROs following MIS TLIF between static and expandable interbody devices. METHODS: Patients undergoing primary, single-level MIS TLIF between 2014 and 2017 were retrospectively identified. Radiographic measurements including lumbar lordosis (LL), segmental lordosis (SL), disc height (DH), and foraminal height (FH) were performed on lateral radiographs before and after MIS TLIF with a static or expandable articulating interbody device. Radiographic outcomes and PROs were compared using paired and unpaired Student's t test. RESULTS: Thirty patients received expandable interbody devices and 30 patients received static interbody devices. The expandable device cohort exhibited significantly greater improvement in DH and FH at final follow-up compared with those receiving a static device. Both device cohorts experienced significant improvements in PROs at 6 months post-operatively. CONCLUSION: MIS TLIF with an expandable interbody device led to a greater increase of DH and FH than with a static interbody device. Patients undergoing MIS TLIF can expect similar improvements in PROs whether receiving a static or an expandable interbody device. Further studies are required to better understand improvements in clinical outcomes afforded by expandable interbody devices.

Evaluation of Postoperative Mental Health Outcomes in Patients Based on Patient-Reported Outcome Measurement Information System Physical Function Following Anterior Cervical Discectomy and Fusion.

OBJECTIVE: To assess the relationship of preoperative physical function, as measured by Patient-Reported Outcome Measurement Information System Physical Function (PROMIS PF), to improvement in mental health, as evaluated by Short Form-12 Mental Component Summary (SF-12 MCS) following anterior cervical discectomy and fusion (ACDF). METHODS: Patients undergoing primary ACDF were retrospectively reviewed and stratified based on preoperative PROMIS PF scores. PROMIS PF cohorts were tested for an association with demographic characteristics and perioperative variables using chi-square analysis and multivariate linear regression. Multivariate linear regression was utilized to determine the association between PROMIS PF cohorts and improvement in SF-12 MCS. RESULTS: A total of 129 one- to 3-level ACDF patients were included: 73 had PROMIS PF < 40 ("low PROMIS") and 56 had PROMIS PF ≥ 40 ("high PROMIS"). The low PROMIS cohort reported worse mental health preoperatively and at all postoperative timepoints except for 1 year. Both cohorts had similar changes in mental health from baseline through the 6-month follow-up. However, at 1 year. postoperatively, the low PROMIS cohort had a statistically greater change in mental health score. CONCLUSION: Patients with worse preoperative physical function reported significantly worse preoperative and postoperative mental health. However, patients with worse preoperative physical function made significantly greater improvements in mental health from baseline. This suggests that patients with worse preoperative physical function can still expect significant improvements in mental health following surgery.

The identification of risk factors for increased postoperative pain following minimally invasive transforaminal lumbar interbody fusion.

PURPOSE: To evaluate specific demographic and perioperative variables associated with higher inpatient pain scores following minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). METHODS: Patients who underwent a single-level, primary MIS TLIF were retrospectively reviewed. Perioperative outcomes were collected, and postoperative inpatient VAS pain scores were measured. Both bivariate and stepwise multivariate Poisson regressions with robust error variance were used to assess risk factors for average inpatient pain score ≥ 5.0. A final backward stepwise regression model was created using age, gender, smoking status, diabetes status, insurance status, BMI, comorbidity burden, pedicle screw laterality, operative time, and estimated blood loss. RESULTS: A total of 255 patients undergoing primary, single-level MIS TLIF were included. Age less than 50 years, workers' compensation insurance, preoperative VAS pain score ≥ 7, and operative duration ≥ 110 min were associated with greater postoperative pain. However, other variables such as gender, BMI, smoking status, comorbidity burden, diabetes status, and pedicle screw laterality were not associated with increased postoperative pain. CONCLUSION: The results of this study suggest that younger age, workers' compensation, elevated preoperative pain scores, and longer operative times are independently associated with greater inpatient pain following TLIF. Surgeons can use this information to better assess which patients may require additional pain control following TLIF. Patient expectations of postoperative outcomes in regard to pain and recovery may also be better managed. These slides can be retrieved under Electronic Supplementary Material. (paragraph). Then process the ppt slide as graphical image.

Postoperative Outcomes Based on American Society of Anesthesiologists Score After Minimally Invasive Transforaminal Lumbar Interbody Fusion.

STUDY DESIGN: A retrospective cohort study. OBJECTIVE: To examine the association between the American Society of Anesthesiologists (ASA) score and patient-reported outcomes (PROs) after minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). SUMMARY OF BACKGROUND DATA: Few studies have investigated the correlation between ASA score and PROs after MIS TLIF. METHODS: Patients undergoing primary, single-level MIS TLIF were retrospectively reviewed and placed into 3 cohorts: ASA score ≤2 and outpatient status, ASA score ≤2 and inpatient status, and ASA score >2. Oswestry Disability Index (ODI), visual analog scale (VAS) back and leg pain, and Short Form-12 Physical Component Score (SF-12 PCS) were administered preoperatively and at 6-week, 12-week, and 6-month time points. ASA scores were tested for association with improvements in PROs using linear regression. RESULTS: A total of 187 patients had an ASA score ≤2 and 41 patients had an ASA score >2. Higher ASA scores were associated with older age, obesity, higher comorbidity burden, and an increased length of stay. ASA subgroups demonstrated a significant difference in preoperative ODI and VAS back pain scores and improvement in VAS back pain scores at the 12-week and 6-month time points; however, there was no discernible pattern of improvement amongst cohorts. No statistically significant differences were observed with improvements in PROs. CONCLUSIONS: The study suggests ASA scores are not associated with postoperative recovery in pain and disability after MIS TLIF. Our results indicate that regardless of the preoperative ASA score, patients are likely to achieve similar improvements in PROs through 6 months follow-up. Although using ASA as a risk stratification tool to predict perioperative complications, its utility in predicting improvement in PROs is still uncertain at this time.

The Impact of Comorbidity Burden on Postoperative PROMIS Physical Function Following Minimally Invasive Transforaminal Lumbar Interbody Fusion.

STUDY DESIGN: This was a retrospective cohort study. OBJECTIVE: To assess the utility of Patient-Reported Outcome Measurement Information System Physical Function (PROMIS PF) in assessing postoperative recovery on the basis of the comorbidity burden after minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). SUMMARY OF BACKGROUND DATA: Few studies have evaluated the effect of comorbidity burden in long-term clinical recovery after MIS TLIF. METHODS: Patients undergoing primary, 1-level to 2-level MIS TLIF were retrospectively reviewed and stratified on the basis of Charlson Comorbidity Index (CCI) score: 0 points (no comorbidities), 1-2 points (low CCI), ≥3 points (high CCI). CCI was tested for an association with demographic characteristics and perioperative variables using χ analysis and multivariate linear regression. Multivariate linear regression was utilized to determine the association between CCI cohorts and PROMIS PF. RESULTS: A total of 187 1-level and 2-level MIS TLIF patients were included: 53 had no comorbidities, 78 had a low CCI, and 56 a high CCI. One patient in the high CCI group experienced nonunion. Patients reported similar PROMIS PF scores preoperatively and up to 1-year postoperatively. Each cohort experienced a similar improvement in PROMIS PF scores from baseline at each postoperative time point. For patients without comorbidities, the change in the postoperative PROMIS PF score from baseline was significant at every postoperative time point. However, for the patients with ≥1 comorbidities, the change in the postoperative PROMIS PF score from baseline was significant at the 3-month, 6-month, and 1-year time points, however, the change from baseline to 6 weeks was not significant. CONCLUSIONS: In this investigation, the authors compared the clinical recovery of patients with varying comorbidities undergoing an MIS TLIF using PROMIS PF. Regardless of comorbidity, patients reported similar preoperative PROMIS PF scores and had similar improvements throughout the 1-year follow-up. This study established that PROMIS PF is an effective tool to evaluate the recovery of patients with differing comorbidities after MIS TLIF.

PROMIS PF in the Evaluation of Postoperative Outcomes in Workers' Compensation Patients Following Anterior Cervical Discectomy and Fusion.

STUDY DESIGN: This was a retrospective cohort study. OBJECTIVE: To determine the improvement of clinical outcomes in Workers' Compensation (WC) patients compared with non-WC patients utilizing Patient-reported Outcome Measurement Information System Physical Function (PROMIS PF) following anterior cervical discectomy and fusion (ACDF). SUMMARY OF BACKGROUND DATA: To our knowledge, there has not been a study to evaluate clinical outcomes of WC patients utilizing the PROMIS PF survey. METHODS AND MATERIALS: Patients undergoing a primary, 1 to 3-level ACDF were retrospectively reviewed and stratified according to insurance (WC and non-WC). Demographic and perioperative characteristics were compared using χ test and independent t tests. Change in PROMIS PF scores was calculated using paired t tests. Differences in postoperative PROMIS PF scores and changes in PROMIS PF from baseline were compared using linear regression. RESULTS: In total, 124 1 to 3-level ACDF patients were included: 36 had WC insurance and 88 had non-WC insurance. WC patients were younger and more likely to be obese. WC patients reported significantly lower PROMIS PF scores preoperatively and at 6 weeks, 12 weeks, and 6 months timepoints. However, both cohorts reported comparable PROMIS PF scores at the 1-year timepoint. WC patients demonstrated similar improvements from baseline through 1-year postoperatively compared with non-WC patients. For both non-WC and WC cohort, the change in the postoperative PROMIS PF score from baseline was significant at 3 months, 6 months, and 1 year. However, in both cohorts, the change in the postoperative PROMIS PF score from baseline was not significantly different at 6 weeks. CONCLUSIONS: In our study, WC patients had worse baseline physical function as indicated by lower preoperative PROMIS PF scores and reported lower PROMIS PF scores postoperatively. However, there were no significant differences when comparing the postoperative change from baseline between the cohorts. Both cohorts experienced significant postoperative improvements from baseline. This study established that PROMIS PF is an effective tool to evaluate recovery of WC patients following ACDF.

The Effect of Preoperative Symptom Duration on Postoperative Outcomes After Minimally Invasive Transforaminal Lumbar Interbody Fusion.

STUDY DESIGN: Retrospective. OBJECT: This study aims to examine whether the time spanning from symptom onset to surgical intervention has an effect on postoperative clinical improvement in patients undergoing minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). SUMMARY OF BACKGROUND DATA: Evidence is limited regarding the influence of preoperative symptom duration on patient-reported outcomes (PROs). METHODS: Patients undergoing a primary, single-level minimally invasive transforaminal lumbar interbody fusion were retrospectively reviewed and stratified according to preoperative symptom duration (<12 mo and ≥12 mo). Differences in PROs, including Oswestry Disability Index (ODI), 12-Item Short-Form Physical Component Score (SF-12 PCS), Visual Analogue Scale (VAS) back pain, and VAS leg pain, at each postoperative timepoint and were compared between duration of symptoms (DOS) cohorts using linear regression. Achievement of minimal clinically important difference (MCID) for PROs was compared using χ analysis. RESULTS: A total of 248 patients were included: 96 had a DOS <12 months and 152 had a DOS >12 months. When comparing PROs preoperatively, the shorter DOS cohort had significantly worse ODI, VAS leg pain, and SF-12 PCS compared with patients with longer DOS. However, there was no preoperative difference in VAS back pain between cohorts. Postoperatively, there were no significant differences in improvement of PROs throughout the 12-month timepoint. The shorter DOS cohort had a comparable number of patients achieving MCID for ODI, VAS back pain, VAS leg pain, and SF-12 PCS relative to the longer DOS cohort. CONCLUSIONS: In our study, patients with DOS <12 months exhibited significantly worse ODI and VAS leg pain scores at the time of surgery compared with patients with longer DOS. However, these patients demonstrated similar clinical improvement postoperatively regardless of preoperative symptom duration. These findings suggest that delayed surgical intervention may not lead to impaired functional recovery in patients with degenerative lumbar disease.

All Disclosure is Good Disclosure: Patient Awareness of the Sunshine Act and Perceptions of Surgeon-Industry Relationships.

STUDY DESIGN: This was a prospective study. OBJECTIVE: To determine patient awareness of surgeon-industry relationships, how these relationships affect patient perceptions of surgeons, and which relationships cause the greatest concern to patients. SUMMARY OF BACKGROUND DATA: The prevalence of orthopedic surgeon-industry relationships led to the establishment of a national database of physician-industry interaction [Open Payments Database (OPD)] as part of the Physician Payments Sunshine Act (PPSA). MATERIALS AND METHODS: A 10-item questionnaire was administered to patients before their first evaluation. Two questions asked about awareness of the surgeon's industry relationships and of the OPD. One question evaluated the importance of surgeon-industry relationships of patients when choosing a provider. Six questions assessed patient perception of specific types of surgeon-industry relationships. Lastly, each patient ranked specific types of surgeon-industry relationships (1-most concerning to 6-least/not concerning). The distribution of patient-perceptions was compared using a Friedman 2-way analysis of variance by Ranks test. Distributions across awareness were compared using a Kruskal-Wallis test. RESULTS: A total of 205 patients completed the survey. A majority of patients were unaware of their surgeons' relationships with industry and the existence of the OPD. However, most patients considered surgeon-industry relationships an important, very important or most important part of choosing their physician. There were significant differences in how industry relationships affected patient perceptions. Research funding had the most positive impact on perception. Financial ownership was reported to be the most concerning relationship followed by royalty payments and consulting. CONCLUSIONS: Our results suggest that despite a lack of awareness, most patients consider surgeon-industry relationships an important factor in choosing their doctor. Patients generally report a more positive view of surgeons that have active relationships with industry. These results emphasize the value of disclosure for surgeons; it provides transparency and improves their standing amongst a majority of their patients.

Validity of Patient Health Questionnaire-9 in Minimally Invasive Lumbar Interbody Fusion.

STUDY DESIGN: Retrospective. OBJECTIVE: The aim of this study was to evaluate the validity of Patient Health Questionnaire-9 (PHQ-9) among patients undergoing minimally invasive (MIS) lumbar interbody fusion. SUMMARY OF BACKGROUND DATA: Few studies have evaluated the utility and concurrent validity of the PHQ-9 survey in patients undergoing spinal procedures. METHODS: Patients undergoing a one- or two-level MIS lumbar interbody fusion were retrospectively reviewed. Patient-reported outcome surveys were completed preoperatively and at 6-week, 12-week, 6-month, and 1-year timepoints. Postoperative survey scores were compared to preoperative values using paired t tests. PHQ-9 scores were compared with the Mental Component Summary (MCS) scores of the Short Form-12 (SF-12) and the Veterans RAND-12 (VR-12) surveys at each timepoint using the Pearson correlation coefficient. RESULTS: A total of 215 patients were included in the analysis. The mean preoperative scores for the PHQ-9, SF-12 MCS, and VR-12 MCS were 6.78, 49.55, and 50.39, respectively. Significant improvements in each survey outcome measure were observed at all postoperative timepoints. Strong correlations with PHQ-9 scores were identified for SF-12 MCS scores and VR-12 MCS scores at preoperative and postoperative timepoints (|r| ≥ 0.5 and P < 0.05 for each). CONCLUSION: This study demonstrated that mental health, as measured by the PHQ-9, SF-12 MCS, and VR-12 MCS surveys, improves significantly after MIS lumbar fusion. In addition, PHQ-9 scores were strongly correlated with SF-12 and VR-12 scores. These results suggest that PHQ-9 can be a valid assessment of baseline mental health and postoperative improvement after MIS lumbar fusion. Concordant results among PHQ-9, SF-12 MCS, and VR-12 indicate that the simultaneous utilization of multiple survey instruments may not be necessary. Limiting the number of questionnaires that are administered in the evaluation of mental health could also help reduce survey burden placed on patients. LEVEL OF EVIDENCE: 3.

The Influence of Preoperative Mental Health on PROMIS Physical Function Outcomes Following Minimally Invasive Transforaminal Lumbar Interbody Fusion.

STUDY DESIGN: Retrospective. OBJECTIVE: To demonstrate whether preoperative mental health status can be predictive of postoperative functional outcomes as measured by Patient-Reported Outcome Measurement Information System Physical Function (PROMIS PF) following minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). SUMMARY OF BACKGROUND DATA: There is a paucity of scientific investigations into the association between preoperative mental health as evaluated by a validated questionnaire such as the Short Form-12 Mental Health Composite Score (SF-12 MCS) and postoperative outcomes following MIS TLIF. METHODS: Patients undergoing a primary MIS TLIF were retrospectively reviewed and stratified into cohorts based on preoperative SF-12 MCS scores. The Physical Function scores of PROMIS, of which there are other domains including Pain Interference, Sexual Function, and Cognitive Function, were compared between the cohorts. In addition, the improvement in PROMIS scores based on preoperative SF-12 MCS scores following MIS TLIF was analyzed using multivariate linear regression. RESULTS: One hundred seventy-two patients were included: 85 patients (49.4%) had a preoperative SF-12 MCS score <50 and 87 (50.6%) had a preoperative SF-12 MCS score ≥50. Patients with poorer mental health demonstrated significantly worse PROMIS PF scores preoperatively (33.8 vs. 36.5, P < 0.001), as well as at all postoperative timepoints: 6-weeks (35.1 vs. 38.4, P < 0.001), 3-months (38.9 vs. 42.9, P < 0.001), 6-months (41.4 vs. 45.5, P < 0.001), and 1-year (42.4 vs. 47.6, P < 0.001). However, at the 1-year timepoint, patients with worse mental health reported experiencing significantly less improvement from baseline (postoperative change of 8.6 vs. 11.1, P = 0.002). CONCLUSION: Patients with worse preoperative mental health not only demonstrated worse preoperative PROMIS PF scores, but also continued to have significantly worse postoperative outcomes. However, the postoperative improvement experienced by patients was similar in the short-term following surgery regardless of preoperative mental health status. Patients with poor mental health experienced significantly less postoperative improvement only at the 1-year timepoint. LEVEL OF EVIDENCE: 3.

Inpatient Pain Scores and Narcotic Utilization Based on American Society of Anesthesiologists Score Following Anterior Cervical Discectomy and Fusion.

STUDY DESIGN: Retrospective. OBJECTIVE: To examine the relationship between American Society of Anesthesiologists (ASA) score and inpatient pain and narcotics consumption following anterior cervical discectomy and fusion (ACDF). SUMMARY OF BACKGROUND DATA: Higher ASA scores have been previously linked to increased postoperative complication rates, healthcare costs, length of stay, and hospital readmissions. However, to our knowledge, there have not been previous investigations into the association between ASA scores and postoperative inpatient pain and narcotics utilization following ACDF. METHODS: Patients who underwent a single-level, primary ACDF were retrospectively reviewed and stratified into two cohorts based on ASA score less than or equal to 2 or ASA score more than 2. ASA score was tested for association with demographic variables and perioperative characteristics using student's t test, chi-squared analysis, and Fisher exact test. Inpatient pain scores and narcotics consumption on each postoperative day were then compared between cohorts using bivariate linear regression. RESULTS: Two hundred eleven patients who underwent ACDF were included: 184 had an ASA score less than or equal to 2 and 27 had an ASA score more than 2. Higher ASA score was associated with older age, higher comorbidity burden as measured by the modified Charlson Comorbidity Index (CCI), and lower prevalence of obesity. Higher ASA scores were associated with longer duration of hospital stay, while other perioperative characteristics were similar between ASA score cohorts. There were no differences in inpatient Visual Analog Scale (VAS) pain scores, or hourly, daily, and cumulative inpatient narcotic consumption between cohorts on any postoperative day. CONCLUSION: This retrospective investigation demonstrated that a higher ASA score is associated with increased operative time following ACDF. However, ASA score was determined not to be an independent risk factor that can predict postoperative pain or narcotics consumption among patients who undergo ACDF. Therefore, postoperative pain in the inpatient setting can be managed with similar modalities regardless of ASA score for patients undergoing ACDF. LEVEL OF EVIDENCE: 3.

The Use of Patient-Reported Outcome Measurement Information System Physical Function to Predict Outcomes Based on Body Mass Index Following Minimally Invasive Transforaminal Lumbar Interbody Fusion.

STUDY DESIGN: Retrospective. OBJECTIVE: To determine clinical outcomes in obese patients compared with non-obese patients utilizing Patient-Reported Outcome Measurement Information System Physical Function (PROMIS PF) following minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). SUMMARY OF BACKGROUND DATA: Although obesity is a risk factor for poor outcomes after spinal fusion, there has not been a study to evaluate clinical outcomes of obese patients utilizing the PROMIS PF survey. METHODS: Patients undergoing MIS TLIF were stratified into three cohorts: non-obese (body mass index [BMI] ≤ 29.9 kg/m), obese I (BMI = 30.0-34.9 kg/m), and obese II-III (BMI ≥ 35.0 kg/m). Demographic and perioperative characteristics were compared using chi-squared analysis and linear regression. Change in PROMIS PF scores was calculated using paired t tests. Differences in PROMIS PF scores at each postoperative timepoint and changes in PROMIS PF from baseline were compared using linear regression. RESULTS: One hundred eighty-six patients were included: 101 were non-obese, 41 were classified as obese I, and 44 were classified as obese II-III. Obese patients were more likely to be diabetic. Otherwise, no significant differences in demographic and perioperative characteristics were identified. Patients with higher BMIs reported significantly lower PROMIS PF scores at preoperative and all postoperative timepoints. However, patients experienced similar improvements through 6-month follow-up in PROMIS PF scores regardless of BMI. For the non-obese cohort, the change in the postoperative PROMIS PF score from baseline was significant at every postoperative timepoint. However, for the obese I and obese II-III cohorts, the change in the PROMIS PF score from baseline was significant at the 3-month and 6-month timepoints, but not at the 6-week timepoint. CONCLUSION: Patients with higher BMI had lower preoperative PROMIS PF scores and experienced similar improvement in PROMIS PF scores in the postoperative period. This study established that PROMIS PF may be utilized to evaluate the recovery of obese patients following MIS TLIF. LEVEL OF EVIDENCE: 3.

An evaluation of biomaterials and osteobiologics for arthrodesis achievement in spine surgery.

An increasing variety of orthobiologic materials, including autologous and allogeneic bone graft, bone marrow aspirate, demineralized bone matrix, ceramics, and growth factors are available to the spine surgeon. Although autologous bone graft remains the gold standard material, concerns for failure in achieving fusion have prompted evaluation of current and new biologic materials. As such, this review attempts to summarize the available biologic materials with their pertinent characteristics, advantages, disadvantages, and primary uses.

The utility of virtual reality and augmented reality in spine surgery.

As the number of advances in surgical techniques increases, it becomes increasingly important to assess and research the technology regarding spine surgery techniques in order to increase surgical accuracy, decrease overall length of surgery, and minimize overall radiation exposure. Currently, augmented reality and virtual reality have shown promising results in regard to their applicability beyond their current functions. At present, VR has been generally applied to a teaching and preparatory role, while AR has been utilized in surgical settings. As such, the following review attempts to provide an overview of both virtual reality and augmented reality, followed by a discussion of their current applications and future direction.