The use of the Core Yellow Flags Index for the assessment of psychosocial distress in patients undergoing surgery of the cervical spine.

BACKGROUND: Psychosocial distress (the presence of yellow flags) has been linked to poor outcomes in spine surgery. The Core Yellow Flags Index (CYFI), a short instrument assessing the 4 main yellow flags, was developed for use in patients undergoing lumbar spine surgery. This study evaluated its ability to predict outcome in patients undergoing cervical spine surgery. METHODS: Patients with degenerative spinal disorders (excluding myelopathy) operated in one centre, from 2015 to 2019, were asked to complete the CYFI at baseline and the Core Outcome Measures Index (COMI) at baseline and 3 and 12 months after surgery. The relationship between CYFI and COMI scores at baseline as well as the predictive ability of the CYFI on the COMI follow-up scores were tested using structural equation modelling. RESULTS: From 731 eligible patients, 547 (61.0 ± 12.5 years; 57.2% female) completed forms at all three timepoints. On a cross-sectional basis, preoperative CYFI and COMI scores were highly correlated (ß = 0.54, in men and 0.51 in women; each p < 0.001). CYFI added significantly and independently to the prediction of COMI at 3 months' FU in men (ß = 0.36) and 12 months' FU in men and women (both ß = 0.20) (all p < 0.001). CONCLUSION: The CYFI had a low to moderate but significant and independent association with cervical spine surgery outcomes. Implementing the CYFI in the preoperative workup of these patients could help refine outcome predictions and better manage patient expectations.

Validation of the arabic version of the EuroQol-5-dimension 5-level (EQ-5D-5 L) in patients with spinal degenerative diseases.

OBJECTIVE: This study aims to test the reliability and validity of the translated Arabic version of EQ-5D-5 L. METHODS: The study was conducted on 100 patients operated upon for degenerative spine diseases coming for follow up in the outpatient clinic of a Tertiary care hospital. Test-retest reliability was assessed by completing the self-administered tool in two follow up visits, one week apart, by 50 patients. Internal consistency was evaluated by Cronbach's alpha. Intra-class correlation coefficients and kappa statistics were performed to test for the agreement between the two ratings. Criterion validity was assessed by comparing the responses of 100 patients to the EQ-5D-5 L with scores of two validated questionnaires; the Arabic version of the Oswestry disability index and the Arabic version of short-form health survey-36. The construct validity was assessed using known-groups comparison to test for hypothesized differences concerning demographic and clinical variables. RESULTS: The Arabic version of EQ-5D-5 L questionnaire had a high reliability with high observed internal consistency (Cronbach's alpha = 0.816, CI: 0.719-0.886). It showed strong temporal stability, with ICCs of the EQ-5D-5 L score, index and EQ-visual analog scale (EQ-VAS) of 0.852, 0.801, and 0.839 respectively. Agreement by kappa was moderate; above 0.4, for all domains, except for the "Usual activities" domain. EQ-5D-5 L domains, VAS and index had moderate to strong significant correlations with SF-36 and ODI subscales and total scores in the correct direction indicating a good criterion validity of the instrument. CONCLUSION: The Arabic version of EQ-5D-5 L is reliable and valid for assessment of HRQoL of Arabic speaking patients.

Spine Surgeon Assessments of Patient Psychological Distress are Inaccurate and Bias Treatment Recommendations.

STUDY DESIGN: Prospective cohort study. OBJECTIVE: This study determined (1) the surgeon accuracy of psychological assessment in patients in spine clinic, (2) the impact of psychological distress on surgical recommendation, and (3) the correlation between patient-reported disability and psychological distress. SUMMARY OF BACKGROUND DATA: Psychological distress is common among patients presenting for spine surgery. Surgeon estimations of patients' distress may influence treatment recommendations, but little is known as to whether these assessments accurately mirror patient-perceived psychological distress. MATERIALS AND METHODS: A sample of new patients was recruited from an academic spine center. Prior to their initial consultation, patients completed the Modified Somatic Perception Questionnaire and Zung Depression Index to assess mental and physical manifestations of distress, which generated a Distress and Risk Assessment Method (DRAM) score of N (normal), R (at risk), or D (distressed). The Oswestry Disability Index and Neck Disability Index scores were also collected. Surgeons provided their estimates of the DRAM score after the visit and indicated their surgery recommendation. RESULTS: Of 296 patients, 40.5% reported some level of psychological distress (DRAM=R) and 15.9% had a high level of distress (DRAM=D). All three surgeons' ability to accurately assess the participant DRAM score was poor, with an overall kappa of 0.13 (0.08-0.18), biased toward underestimating the patient's true level of psychological distress. Patients rated as normal (N) by the surgeon were 3.78 times more likely to be recommended for surgery compared to those assessed as distressed (D) ( P =0.007). Patients with higher DRAM scores had higher Oswestry Disability Index ( P =0.008) and Neck Disability Index ( P =0.005) scores compared to those with lower DRAM scores. CONCLUSIONS: Spine surgeons have limited ability to detect psychological profiles in patients, with a tendency to underestimate levels of distress. The finding that these inaccurate assessments influence surgical recommendations underscores the importance of limiting surgeon bias in the decision-making process. LEVEL OF EVIDENCE: Diagnostic Level 2.

Effect of a Biopsychosocial Intervention or Postural Therapy on Disability and Health Care Spending Among Patients With Acute and Subacute Spine Pain: The SPINE CARE Randomized Clinical Trial.

Importance: Low back and neck pain are often self-limited, but health care spending remains high. Objective: To evaluate the effects of 2 interventions that emphasize noninvasive care for spine pain. Design, Setting, and Participants: Pragmatic, cluster, randomized clinical trial conducted at 33 centers in the US that enrolled 2971 participants with neck or back pain of 3 months' duration or less (enrollment, June 2017 to March 2020; final follow-up, March 2021). Interventions: Participants were randomized at the clinic-level to (1) usual care (n = 992); (2) a risk-stratified, multidisciplinary intervention (the identify, coordinate, and enhance [ICE] care model that combines physical therapy, health coach counseling, and consultation from a specialist in pain medicine or rehabilitation) (n = 829); or (3) individualized postural therapy (IPT), a postural therapy approach that combines physical therapy with building self-efficacy and self-management (n = 1150). Main Outcomes and Measures: The primary outcomes were change in Oswestry Disability Index (ODI) score at 3 months (range, 0 [best] to 100 [worst]; minimal clinically important difference, 6) and spine-related health care spending at 1 year. A 2-sided significance threshold of .025 was used to define statistical significance. Results: Among 2971 participants randomized (mean age, 51.7 years; 1792 women [60.3%]), 2733 (92%) finished the trial. Between baseline and 3-month follow-up, mean ODI scores changed from 31.2 to 15.4 for ICE, from 29.3 to 15.4 for IPT, and from 28.9 to 19.5 for usual care. At 3-month follow-up, absolute differences compared with usual care were -5.8 (95% CI, -7.7 to -3.9; P < .001) for ICE and -4.3 (95% CI, -5.9 to -2.6; P < .001) for IPT. Mean 12-month spending was $1448, $2528, and $1587 in the ICE, IPT, and usual care groups, respectively. Differences in spending compared with usual care were -$139 (risk ratio, 0.93 [95% CI, 0.87 to 0.997]; P = .04) for ICE and $941 (risk ratio, 1.40 [95% CI, 1.35 to 1.45]; P < .001) for IPT. Conclusions and Relevance: Among patients with acute or subacute spine pain, a multidisciplinary biopsychosocial intervention or an individualized postural therapy intervention, each compared with usual care, resulted in small but statistically significant reductions in pain-related disability at 3 months. However, compared with usual care, the biopsychosocial intervention resulted in no significant difference in spine-related health care spending and the postural therapy intervention resulted in significantly greater spine-related health care spending at 1 year. Trial Registration: ClinicalTrials.gov Identifier: NCT03083886.

Patient Satisfaction Following Minimally Invasive and Open Surgeries for Adult Spinal Deformity.

BACKGROUND: Patient satisfaction has become an important variable in assessing outcomes after spine surgery. Although minimally invasive surgery (MIS) techniques have become popular owing to reduced perioperative complications compared with open deformity surgery, whether patient-reported postoperative satisfaction differ between the 2 surgical approaches is unclear. The aim of this study was to characterize postoperative patient-reported outcomes (PRO) in patients who underwent open surgery or MIS for adult spinal deformity (ASD). METHODS: PRO scores were prospectively collected for patients undergoing deformity correction surgery between 2016 and 2018. Inclusion criteria were age >18 years, ASD, and completed PRO surveys. Patient demographic, clinical, and radiographic data and PRO survey responses were analyzed. A post hoc analysis comparing patients who were satisfied with their outcome and those who were unsatisfied was performed. RESULTS: Forty patients who underwent operative management of ASD (19 in the open surgery group and 21 in the MIS group) met the criteria for inclusion in this study. Patients in the MIS group reported higher mental health and self-image scores at 6 months; however, at the 12-month follow-up, both the open surgery and MIS groups reported minimal clinically important differences in back pain, leg pain, and functional status. Patient satisfaction scores did not differ based on surgical approach or intraoperative complications. CONCLUSIONS: PRO after open surgery and after MIS for ASD reflected successful outcomes with significant improvements in PRO survey scores but with subtle differences in the postoperative recovery process. The MIS group reported faster recovery with earlier improvement in self-image and mental health scores, which may stem from correction of smaller deformities. At the 12-month follow-up, postoperative satisfaction was high for the majority of patients in both groups.

Functional Ability Classification Based on Moderate and Severe Kinesophobia and Demoralization Scores in Degenerative Spine Patients.

STUDY DESIGN: A prospective cohort study. OBJECTIVE: To assess the relationship of fear avoidance and demoralization on gait and balance and determine a threshold score for the Tampa Scale for Kinesophobia (TSK) and the Demoralization Scale (DS) that identifies spine patients with gait and balance dysfunction amplified by underlying psychological factors. SUMMARY OF BACKGROUND DATA: Fear avoidance and demoralization are crucial components of mental health that impact the outcomes in spine surgery. However, interpreting their effect on patient function remains challenging. Further establishing this correlation and identifying a threshold of severity can aid in identifying patients in whom a portion of their altered gait and balance may be amplified by underlying psychologic distress. METHODS: Four hundred five symptomatic spine patients were given the TSK and DS questionnaires. Patient's gait and balance were tested with a human motion capture system. A TSK score of 41 and a DS score of 30 were chosen as thresholds to classify moderate versus severe dysfunction based on literature and statistical analysis. RESULTS: Higher TSK and DS scores were correlated with worse walking speed (P < 0.001), longer stride time (P = 0.001), decreased stride length (P < 0.048), and wider step width (<0.001) during gait as well as increased sway across planes (P = 0.001) during standing balance. When classified by TSK scores >41, patients with more severe fear avoidance had slower walking speed (P < 0.001), longer stride time (P = 0.001), shorter stride length (P = 0.004), increased step width (P < 0.001), and increased sway (P = 0.001) compared with their lower scoring counterparts. Similarly, patients with DS > 30 had slower walking speed (P = 0.012), longer stride time (P = 0.022), and increased sway (P = 0.003) compared with their lower scoring counterparts. CONCLUSION: This study demonstrates that fear avoidance and demoralization directly correlate with worsening gait and balance. Furthermore, patients with TSK > 41 and DS > 30 have more underlying psychological factors that contribute to significantly worse function compared with lower scoring peers. Understanding this relationship and using these guidelines can help identify and treat patients whose gait dysfunction may be amplified by psychologic distress.Level of Evidence: 3.

Qualitative Analysis of Illness Representations and Coping Perceptions Among Older Adults With Chronic Spinal Disability: "A Thought in the Back of My Mind".

OBJECTIVE: The purpose of this study was to explore older adults' illness representations, their beliefs about health, and their coping perceptions of chronic spinal disability. METHODS: This qualitative descriptive study used structured interviews that were completed during a randomized trial of non-pharmacological management of spine-related disability with chiropractic spinal manipulative therapy and exercise. Dual coders conducted a descriptive thematic analysis of 50 randomly selected transcripts supported by qualitative data management software. The Common-Sense Model provided an organizing framework for coding and interpretation. RESULTS: Fifty participants (34 women, median age: 68 years) described 4 illness representations, 4 coping styles, and 6 coping strategies for their management of spinal disability. Illness representations formed a continuum of little-to-no health impact to bothersome symptoms to heightened symptom intensity to unmanaged pain and/or disability. Most participants adopted either self-care or self-management coping styles, but some used healthcare-seeking or fear avoidance with worsening symptoms or interference with employment or preferred activities. Participants mentioned 6 coping strategies for spinal disability. Distraction included position changes, hobbies, and supportive relationships. Limitation focused on rest and/or relaxation, restricted movements, and activity modifications. Prevention enhanced self-care knowledge, posture and/or ergonomics, nutrition, and stress management. Movement emphasized stretching, home exercise and/or walking, and exercise therapy. Palliation augmented patient comfort through the use of heat and/or ice, over-the-counter medicine, and spinal manipulation. Avoidance strategies included missing employment, stopping house and/or yard work, and prescription medication. CONCLUSION: The community-dwelling older adults in this study offered varied illness representations of their chronic spinal disability. Most participants combined and personalized coping strategies to minimize pain and symptom impact; thus, representations may influence the coping styles adopted by older persons to manage their spinal conditions. A quote from a participant that pain was "a thought in the back of my mind" suggests the presence of cognitive and emotional processes that may influence individual perceptions and feelings about their spinal symptoms or conditions. These findings suggest that there may be a broader role for spine care clinicians to include teaching older people about self-management strategies to better cope with spinal disabilities.

Impact of New Motor Deficit on HRQOL After Adult Spinal Deformity Surgery: Subanalysis From Scoli Risk 1 Prospective Study.

STUDY DESIGN: International, multicenter, prospective, longitudinal observational cohort. OBJECTIVE: To assess how new motor deficits affect patient reported quality of life scores after adult deformity surgery. SUMMARY OF BACKGROUND DATA: Adult spinal deformity surgery is associated with high morbidity, including risk of new postoperative motor deficit. It is unclear what effect new motor deficit has on Health-related Quality of Life scores (HRQOL) scores. METHODS: Adult spinal deformity patients were enrolled prospectively at 15 sites worldwide. Other inclusion criteria included major Cobb more than 80°, C7-L2 curve apex, and any patient undergoing three column osteotomy. American Spinal Injury Association (ASIA) scores and standard HRQOL scores were recorded pre-op, 6 weeks, 6 months, and 2 years. RESULTS: Two hundred seventy two complex adult spinal deformity (ASD) patients enrolled. HRQOL scores were worse for patients with lower extremity motor score (LEMS). Mean HRQOL changes at 6 weeks and 2 years compared with pre-op for patients with motor worsening were: ODI (+12.4 at 6 weeks and -4.7 at 2 years), SF-36v2 physical (-4.5 at 6 weeks and +2.3 at 2 years), SRS-22r (0.0 at 6 weeks and +0.4 at 2 years). Mean HRQOL changes for motor-neutral patients were: ODI (+0.6 at 6 weeks and -12.1 at 2 years), SF-36v2 physical (-1.6 at 6 weeks and +5.9 at 2 years), and SRS-22r (+0.4 at 6 weeks and +0.7 at 2 years). For patients with LEMS improvement, mean HRQOL changes were: ODI (-0.6 at 6 weeks and -16.3 at 2 years), SF-36v2 physical (+1.0 at 6 weeks and +7.0 at 2 years), and SRS-22r (+0.5 at 6 weeks and +0.9 at 2 years). CONCLUSION: In the subgroup of deformity patients who developed a new motor deficit, total HRQOLs and HRQOL changes were negatively impacted. Patients with more than 2 points of LEMS worsening had the worst changes, but still showed overall HRQOL improvement at 6 months and 2 years compared with pre-op baseline.Level of Evidence: 3.

Concordance Between Patients' and Surgeons' Expectations of Lumbar Surgery.

STUDY DESIGN: Longitudinal cohort. OBJECTIVE: The aims of this study were to measure concordance between patients' and surgeons' preoperative expectations of lumbar surgery, and determine which member of the dyad more closely predicted fulfillment of expectations, defined as patient-reported status postoperatively. SUMMARY OF BACKGROUND DATA: Concordant patient-surgeon expectations reflect effective communication and should foster better outcomes. METHODS: Preoperatively patients and surgeons completed identical surveys measuring expectations for improvement in symptoms and physical/psychosocial function. Responses ranged from "complete improvement" to "do not have this expectation"; scores for each survey ranged from 0 to 100 (greatest expectations). Concordance between pairs of patient-surgeon scores was measured with the intraclass correlation coefficient (ICC). Postoperatively, fulfillment of expectations was measured from patient-reported amount of improvement received and was calculated as the proportion of patient-reported postoperative score relative to patient-reported preoperative score, and surgeon-reported preoperative score (range 0 [no expectations fulfilled] to >1.2 [expectations surpassed]). Clinical measures included patient-reported spine-related disability. RESULTS: For 402 patient-surgeon pairs, mean survey scores were 73 ±â€Š19 (patients) and 57 ±â€Š16 (surgeons); 84% of patients had higher scores than surgeons, mainly due to expecting complete improvement, whereas surgeons expected a lot/moderate/little improvement. The ICC for the entire sample was .31 (fair agreement); for subgroups, the greatest difference in ICC was for patients with more spine-related disability (ICC = .10, 95% confidence interval [CI]:0.00-0.23) versus less disability (ICC = .46, 95% CI: 0.34-0.56). 96% of patients were contacted ≥2.0 years postoperatively. Proportions of expectations fulfilled were 0.79 (0-3.00) (patients) and 1.01 (0-2.29) (surgeons). Thus patients were less likely to anticipate subsequent postoperative status (odds ratio [OR] 0.34, 95% CI 0.25-0.45) versus surgeons who were more likely to anticipate patient-reported postoperative status (OR 2.98, 95% CI: 2.22-4.00). CONCLUSION: Concordance between patients' and surgeons' expectations was fair; due mostly to patients expecting complete improvement whereas surgeons expected a lot/moderate/little improvement. Compared to patients' expectations, surgeons' expectations more closely coincided with patient-reported fulfillment of expectations 2 years postoperatively.Level of Evidence: 1.

Lumbar Muscle Fat Content Has More Correlations with Living Quality than Sagittal Vertical Axis in Elderly Patients with Degenerative Lumbar Disorders.

PURPOSE: As the most poorly tolerated and debilitating form of spinal malalignment, sagittal imbalance is becoming an increasingly recognized cause of pain and disability in adults. However, there is evidence showing that sagittal imbalance has a weak or no correlation with health-related quality-of-life (HRQoL) outcomes. The objective of this study was to describe the direct factor associated with HRQoL in terms of Oswestry Disability Index (ODI) assessment. PATIENTS AND METHODS: This study retrospectively evaluated the clinical and radiographic information of 179 elderly patients with degenerative lumbar disorders and suboptimal sagittal standing posture (sagittal vertical axis>50 mm). Patient-reported outcomes were assessed using ODI. Patients with ODI≥40% were assigned to Group D (disability), while those with ODI<40% were assigned to Group ND (non-disability). RESULTS: Compared with Group ND (n=104), patients in Group D (n=75) had greater thoracolumbar kyphosis, pelvic incidence-lumbar lordosis (PI-LL), sagittal vertical axis (SVA), T1 pelvic angle, and fat infiltration, and smaller LL and muscle mass ratio. Pearson analysis revealed a high correlation between the percentage of fat infiltrated and ODI (r=768, P<0.01) and moderate correlation between SVA and ODI (r=0.408, P<0.001). Linear regression results indicated that fat infiltration was an independent factor associated with ODI. ODI significantly correlated with SVA in patients with major fat infiltration (r=0.328, P=0.001), while having no correlation with SVA in those with moderate or minor fat infiltration (r=0.083, P=0.464). CONCLUSION: Lumbar muscle fat infiltration is an independent factor associated with the living quality in terms of ODI assessment in the elderly population with degenerative lumbar disorders, which has more correlations with ODI scores than the sagittal imbalance. The relationship between HRQoL outcomes and sagittal imbalance depends on the quality of lumbar muscle.

Psychological predictors of quality of life after anterior cervical discectomy and fusion for degenerative cervical spine disease.

We aimed to identify independent psychological predictors of quality of life (QOL) and functional outcome after anterior cervical discectomy and fusion (ACDF) for degenerative cervical spine disease. We prospectively included patients undergoing ACDF for degenerative cervical disc herniation and stenosis. Patients completed a structured psychological assessment including the Center for Epidemiological Studies Depression Scale (ADS-K), Post-Traumatic Stress Scale-10 (PTSS-10), State Trait Anxiety Inventory-State Anxiety and - Trait Anxiety (STAI-S and STAI-T) and Anxiety Sensitivity Index-3 (ASI-3) before surgery, after 3 and 12 months. Outcome measures included EuroQol-5D (EQ), Short Form-36 (SF-36) and Oswestry Disability Index (ODI) scores. Of 104 included patients who underwent ACDF between March 2013 and November 2017, 92 completed follow-up after 3 and 12 months. The mean Visual Analogue Scale (VAS) scores for neck pain (- 1.4; p < .001) and arm pain (- 1.8; p = .031) significantly decreased by 12 months. QOL scores significantly increased by 3 months (EQ: + 0.2; p < .001; SF-36 PCS: + 6.2; p < .001; SF-36 MCS: + 2.5; p = .044), a benefit which was retained at 12 months. Linear regression analyses identified statistically significant predictors in preoperative ASI-3, SF-36 MCS and STAI-S for postoperative QOL and ODI scores. There is a benefit for patients in terms of quality of life and function after undergoing surgery for degenerative cervical spine disease. With the ASI-3, SF-36 MCS and STAI-S there exist some predictors for postoperative QOL and ODI scores.

Influence of Hand Grip Strength on Surgical Outcomes After Surgery for Adult Spinal Deformity.

STUDY DESIGN: A prospective observational study. OBJECTIVE: This study was done to examine the influence of hand grip strength (HGS) on surgical outcomes of adult spinal deformity (ASD) patients. SUMMARY OF BACKGROUND DATA: No study has investigated the relation between hand grip strength and treatment outcome of adult spinal deformity correction surgery. METHODS: A total of 78 consecutive patients who underwent adult spinal deformity correction surgery were included in this study. Patients were assigned to either the high HGS (≥ 26 kg for men and ≥ 18 kg for women, n = 26) or the low HGS (< 26 kg for men and < 18 kg for women, n = 52) based on their preoperative measurements. The Oswestry disability index (ODI), EQ-5D, and visual analog scale (VAS) for back pain were assessed preoperatively, and 3 months, 6 months, and 12 months postoperatively. The primary outcome measure was ODI scores 12 months after surgery. The secondary outcome measures included the overall ODI scores, EQ-5D, and VAS for back pain, assessed at each time point during the 12-months follow-up. RESULTS: The ODI score at 12 months after surgery was significantly lower in the high HGS group than the low HGS group (P < 0.001), which was best predicted by a multivariate regression model including age, gender, BMI, HGS, and preoperative ODI scores. The overall ODI score, EQ-5D, and VAS for back pain had better outcomes in the high HGS group across each follow-up assessment (P < 0.001 for all follow-ups), while they improved significantly with time after surgery in both groups. CONCLUSIONS: Patients with higher preoperative HGS displayed better surgical outcomes, in terms of disability and health-related quality of life at 12 months after reconstructive spinal surgery for ASD. LEVEL OF EVIDENCE: 2.

Feasibility and Acceptability of Telemedicine to Substitute Outpatient Rehabilitation Services in the COVID-19 Emergency in Italy: An Observational Everyday Clinical-Life Study.

OBJECTIVES: To investigate the feasibility and acceptability of telemedicine as a substitute for outpatient services in emergency situations such as the sudden surge of the COVID-19 pandemic in Italy. DESIGN: Observational cohort study with historical control. SETTING: Tertiary referral outpatient institute. PARTICIPANTS: Consecutive services provided to patients with spinal disorders (N=1207). INTERVENTIONS: Telemedicine services included teleconsultations and telephysiotherapy, and lasted as long as usual interventions. They were delivered using free teleconference apps, caregivers were actively involved, and interviews and counseling were performed as usual. Teleconsultations included standard, but adapted, measurements and evaluations by video and from photographs and videos sent in advance according to specific tutorials. During telephysiotherapy, new sets of exercises were defined and recorded as usual. MAIN OUTCOME MEASURES: We compared the number of services provided in 3 phases, including corresponding periods in 2018 and 2019. During the control (30 working d) and COVID-19 surge (13d) only usual consultations and physiotherapy were provided; during the telemed phase (15d), only teleconsultations and telephysiotherapy were provided. If a reliable medical decision was not possible during teleconsultations, usual face-to-face interventions were prescribed. Continuous quality improvement questionnaires were also evaluated. RESULTS: During telemed, 325 teleconsulations and 882 telephysiotherapy sessions were provided in 15 days. We found a rapid decrease (-39%) of outpatient services from the control to the COVID-19 phase (R2=0.85), which partially recovered in the telemed phase for telephysiotherapy (from -37% to -21%; P<.05) and stabilized for teleconsultation (from -55% to -60%) interventions. Usual face-to-face interventions were required for 0.5% of patients. Patients' satisfaction with telemedicine was very high (2.8 out of 3). CONCLUSIONS: Telemedicine is feasible and allows medical professionals to continue providing outpatient services with a high level of patient satisfaction. During the current pandemic, this experience can provide a viable alternative for many outpatient services while reducing the need for travel and face-to-face contact to a minimum.

The Association Between Physicians' Communication and Patient-Reported Outcomes in Spine Surgery.

STUDY DESIGN: Retrospective cohort study using prospectively collected data. OBJECTIVE: Determine the association between satisfaction with physician communication and patient-reported outcomes in the inpatient spine surgery setting. SUMMARY OF BACKGROUND DATA: Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys measure the patient experience of care and influence reimbursement for hospital systems and providers in the United States. It is not known whether patient satisfaction with physician communication is associated with better outcomes after spine surgery. Therefore, we evaluated the association between patient satisfaction with physician communication on the HCAHPS survey and improvements in validated patient-reported outcomes measures in a spine surgery population. METHODS: HCAHPS responses were obtained for patients undergoing elective cervical or lumbar spine surgery from 2013 to 2015. Patient-reported health status measures were the primary outcomes, including EuroQol Five Dimensions (EQ-5D), Pain Disability Questionnaire (PDQ), and Visual Analog Scores for Back and Neck Pain (VAS-BP/NP). The association between satisfaction with communication and preoperative to 1 year postoperative changes in each health status measure was evaluated utilizing multivariable linear regression models. RESULTS: Our study included 648 patients, of which, 479 (74.4%) created our satisfied cohort. Demographically, our two cohorts were similar with regards to preoperative clinical measures; however, the satisfied cohort had a higher self-rating of their mental health (P < 0.01), and overall health (P < 0.01). After adjusting for clinically relevant confounders, our results demonstrated no significant association between satisfaction with physician communication and improvement in EQ-5D (P = 0.312), PDQ (P = 0.498), or VAS pain scores (P = 0.592). CONCLUSION: Patient satisfaction with physician communication was not associated with 1-year postoperative improvement in EQ-5D, PDQ, and VAS-Pain after spine surgery. These findings do not diminish the importance of effective communication between doctor and patient, but instead suggest that within the spine surgery setting, using only patient experience data may not accurately reflect the true quality of care received during their inpatient stay. LEVEL OF EVIDENCE: 3.

Evaluation of Health-related Quality of Life Improvement in Patients Undergoing Spine Versus Adult Reconstructive Surgery.

STUDY DESIGN: Retrospective analysis of outcomes in single-level spine and primary hip and knee arthroplasty patients. OBJECTIVE: The aim of this study was to compare baseline and postoperative outcomes in patients undergoing spine surgery procedures with total hip arthroplasty (THA) and total knee arthroplasty (TKA) to further define outcomes in orthopedic surgery. SUMMARY OF BACKGROUND DATA: Computer-adaptive Patient Reported Outcome Information System (PROMIS) allows for standardized assessment of the health-related quality of life across different disease states. METHODS: Patients who underwent spine surgery (anterior cervical discectomy and fusion, cervical disc replacement, lumbar laminectomy, microscopic lumbar discectomy, transforaminal lumbar interbody fusion or adult reconstruction surgery [THA, TKA]) were grouped. Mean Charlson Comorbidity Index (CCI), Baseline (BL), and 6-month PROMIS scores of physical function, pain interference, and pain intensity were determined. Paired t tests compared differences in CCI, BL, 6 months, and change in PROMIS scores for spine and adult reconstruction procedures. RESULTS: A total of 304 spine surgery patients (age = 58.1 ±â€Š15.6; 42.9% female) and 347 adult reconstruction patients (age = 62.9 ±â€Š11.8; 54.1% Female) were compared. Spine surgery groups had more disability and pain at baseline than adult reconstruction patients according to physical function ([21.0, 22.2, 9.07, 12.6, 10.4] vs. [35.8, 35.0], respectively, P < 0.01), pain interference ([80.1, 74.1, 89.6, 92.5, 90.6] vs. [64.0, 63.9], respectively, P < 0.01), and pain intensity ([53.0, 53.1, 58.3, 58.5, 56.1] vs. [53.4, 53.8], respectively, P < 0.01). At 6 months, spine surgery patients remained more disabled and had more pain compared to adult reconstruction patients. Over the 6-month timespan, spine patients experienced greater improvements than adult reconstruction patients in terms of physical function ([+8.7, +22.2, +9.7, +12.9, +12.1] vs. [+5.3, +3.9], respectively, P < 0.01) and pain interference scores ([-15.4,-28.1, -14.7, -13.1, -12.3] vs. [-8.3, -6.0], respectively, P < 0.01). CONCLUSION: Spinal surgery patients had lower BL and 6-month PROMIS scores, but greater relative improvement in PROMIS scores compared to adult reconstruction patients. LEVEL OF EVIDENCE: 3.

Electronic Communication Patterns Could Reflect Preoperative Anxiety and Serve as an Early Complication Warning in Elective Spine Surgery Patients with Affective Disorders: A Retrospective Analysis of a Cohort of 1199 Elective Spine Patients.

OBJECTIVE: The analysis of perioperative electronic patient portal (EPP) communication may provide risk stratification and insight for complication prevention in patients with affective disorders (ADs). We aimed to understand how patterns of EPP communication in patients with AD relate to preoperative narcotic use, surgical outcomes, and readmission rates. METHODS: The records of adult patients who underwent elective spinal surgery between January 2010 and August 2017 at a single institution were retrospectively reviewed for analysis. Primary outcomes included preoperative narcotic use, the number of perioperative EPP messages sent, rates of perioperative complications, hospital length of stay, emergency department (ED) visits within 6 weeks, and readmissions within 30 days after surgery. RESULTS: A total of 1199 patients were included in the analysis. Patients with an AD were more likely to take narcotics before surgery (51.69% vs. 41%, P < 0.001) and to have active EPP accounts (75.36% vs. 69.75%, P = 0.014) compared with controls. They were also more likely to send postoperative messages (38.89% vs. 32.75%, P = 0.030) and tended to send more messages (0.67 vs. 0.48, P = 0.034). The AD group had higher rates of postoperative complications (8.21% vs. 3.98%, P = 0.001), ED visits (4.99% vs. 2.43%, P = 0.009), and readmissions postoperatively (2.49% vs. 1.38%, P = 0.049). CONCLUSIONS: AD patients have specific patterns of perioperative EPP communication. They are at a higher risk of postoperative complications. Addressing these concerns early may prevent more serious morbidity and avoid unnecessary ED visits and readmissions, thus reducing costs and improving patient care.

Psychosocial Mechanisms of Cognitive-Behavioral-Based Physical Therapy Outcomes After Spine Surgery: Preliminary Findings From Mediation Analyses.

OBJECTIVE: Changing Behavior through Physical Therapy (CBPT), a cognitive-behavioral-based program, has been shown to improve outcomes after lumbar spine surgery in patients with a high psychosocial risk profile; however, little is known about potential mechanisms associated with CBPT treatment effects. The purpose of this study was to explore potential mediators underlying CBPT efficacy after spine surgery. METHODS: In this secondary analysis, 86 participants were enrolled in a randomized trial comparing a postoperative CBPT (n = 43) and education program (n = 43). Participants completed validated questionnaires at 6 weeks (baseline) and 3 and 6 months following surgery for back pain (Brief Pain Inventory), disability (Oswestry Disability Index), physical health (12-Item Short-Form Health Survey), fear of movement (Tampa Scale for Kinesiophobia), pain catastrophizing (Pain Catastrophizing Scale), and pain self-efficacy (Pain Self-Efficacy Questionnaire). Parallel multiple mediation analyses using Statistical Package for the Social Sciences (SPSS) were conducted to examine whether 3- and 6-month changes in fear of movement, pain catastrophizing, and pain self-efficacy mediate treatment outcome effects at 6 months. RESULTS: Six-month changes, but not 3-month changes, in fear of movement and pain self-efficacy mediated postoperative outcomes at 6 months. Specifically, changes in fear of movement mediated the effects of CBPT treatment on disability (indirect effect = -2.0 [95% CI = -4.3 to 0.3]), whereas changes in pain self-efficacy mediated the effects of CBPT treatment on physical health (indirect effect = 3.5 [95% CI = 1.2 to 6.1]). CONCLUSIONS: This study advances evidence on potential mechanisms underlying cognitive-behavioral strategies. Future work with larger samples is needed to establish whether these factors are a definitive causal mechanism. IMPACT: Fear of movement and pain self-efficacy may be important mechanisms to consider when developing and testing psychologically informed physical therapy programs.

Sex-Specific Impact of Pain Severity, Insomnia, and Psychosocial Factors on Disability due to Spinal Degenerative Disease.

Purpose: Pain experience due to spinal degenerative disease decreases activity of daily living and quality of life. The present cross-sectional study was aimed at examining the sex-specific impact of pain severity, psychosocial factors, and insomnia on the disability due to chronic pain arising from spinal degenerative disease. Methods: In total, 111 outpatients with chronic spinal degenerative on initial diagnosis were analyzed. The definition of chronic spinal degenerative disease was (1) pain duration ≥3 months, (2) findings of nerve root compression on neurological examination and imaging, and (3) localized neck or lower back pain (not widespread, upper or lower limb pain). We used Numerical Rating Scale (NRS), Pain Disability Assessment Scale (PDAS), Hospital Anxiety and Depression Scale (HADS), Pain Catastrophizing Scale (PCS), and Athens Insomnia Scale (AIS) to assess patients. Univariate regression analysis was performed to investigate whether sex influences the PDAS score, and sex-stratified multivariate regression analysis was conducted to identify the variables associated with the PDAS score. Results: Sex was identified as a predictor of the PDAS score (standardized coefficient (ß) = 0.28; 95% confidence interval (CI), 0.10-0.46; p=0.003). In men, the AIS score was associated with PDAS (ß = 0.36, 95% CI 0.09-0.63). Age (ß = 0.31, 95% CI 0.06-0.55) and NRS (ß = 0.40, 95% CI 0.14-0.67) were associated with PDAS in women. HADS-A, HADS-D, and PCS were not associated with PDAS in both sexes. Conclusion: Insomnia was associated with disability in men, whereas aging and pain severity were associated with disability in women. Catastrophic thinking was not associated with disability in both sexes.

Prevalence and risk factors of postoperative delirium after spinal surgery: a meta-analysis.

OBJECTIVE: Postoperative delirium (POD) was common after spinal surgery, but the main findings in previous studies remained conflicting. This current meta-analysis was aimed at exploring the prevalence and risk factors of POD after spinal surgery. METHODS: PubMed and Embase were searched from inception to June 2019. Studies which reported the prevalence and risk factors of POD after spinal surgery were included. STATA version 12.0 was employed to analyze the pooled data. Statistical heterogeneity across included studies was identified using the I2 statistics. RESULTS: A total of 28 studies with 588,732 patients were included in the meta-analysis. The pooled prevalence of POD after spinal surgery was 0.85% (95%CI, 0.83-0.88%) with substantial heterogeneity (I2 = 97.3%). The central nervous system disorder (OR 4.73; 95%CI, 4.30-5.19) was a strong predictor for POD, whereas age (OR 1.16; 95%CI, 1.05-2.47; I2 = 99.2%) and blood loss (OR 1.10; 95%CI, 1.01-1.20; I2 = 93.3%) were weaker predictors. The funnel plot and statistical tests suggested that there existed potential publication bias, but the trim and fill method indicated that the pooled prevalence basically kept stable after adding two "missing" studies. CONCLUSIONS: The pooled POD after spinal surgery ranges from 0.83 to 0.88%. The central nervous system disorder, age, and blood loss were potential risk factors for POD.

Cervico-thoracic vertebral subluxation in sheep: Awareness among veterinarians of a rare syndrome.

Cervico-thoracic vertebral subluxation (CTVS) in sheep is a collective term that is used to describe various conditions that concomitantly affect the cervical and thoracic vertebrae, leading to their collapse. The aetiology and pathophysiology of CTVS remain unknown. The objective of this study was to conduct an epidemiological farm investigation and describe the clinicopathological findings of CTVS cases occurring in a flock of sheep; as well as to determine awareness of CTVS among sheep producers and ruminant veterinarians in Australia. Diagnostic imaging revealed severe deformities in the vertebrae between C6-C7 and T1-T3. Sheep affected with CTVS were at a four times higher risk of having low body condition scores (< 2 based on a 5-point scale) compared with non-affected sheep, OR = 3.98, 95% CI (1.20-12.65), p = .02. Survey results revealed that only 34% (15/44) of respondents were aware of CTVS. There is a need to further explore the aetiology and pathophysiology of CTVS, and the impact it has on sheep breeding and production.