Patient Predictors of Surgical Candidacy in Elective Spine Disorders.

BACKGROUND: The expansion of age-related degenerative spine pathologies has led to increased referrals to spine surgeons. However, the majority of patients referred for surgical consultation do not need surgery, leading to inefficient use of healthcare resources. This study aims to elucidate preoperative patient variables that are predictive of patients being offered spine surgery. METHODS: We conducted an observational cohort study on patients referred to our institution between May 2013 and January 2015. Patients completed a detailed preclinic questionnaire on items such as history of presenting illness, quality-of-life questionnaires, and past medical history. The primary end point was whether surgery was offered. A multivariable logistical regression using the random forest method was used to determine the odds of being offered surgery based on preoperative patient variables. RESULTS: An analysis of 1194 patients found that preoperative patient variables that reduced the odds of surgery being offered include mild pain (odds ratio [OR] 0.37, p=0.008), normal walking distance (OR 0.51, p=0.007), and normal sitting tolerance (OR 0.58, p=0.01). Factors that increased the odds of surgery include radiculopathy (OR 2.0, p=0.001), patient's belief that they should have surgery (OR 1.9, p=0.003), walking distance <50 ft (OR 1.9, p=0.01), relief of symptoms when bending forward (OR 1.7, p=0.008) and sitting (OR 1.6, p=0.009), works more slowly (OR 1.6 p=0.01), aggravation of symptoms by Valsalva (OR 1.4, p=0.03), and pain affecting sitting/standing (OR 1.1, p=0.001). CONCLUSIONS: We identified 11 preoperative variables that were predictive of whether patients were offered surgery, which are important factors to consider when screening outpatient spine referrals.

CONTEXTE: L'augmentation des pathologies de la colonne vertébrale liées au vieillissement de la population a entraîné un accroissement des cas de patients adressés à des chirurgiens spécialistes de la colonne vertébrale. Cela dit, la majorité de ces patients n'ont pas besoin d'une telle intervention chirurgicale, ce qui entraîne une utilisation inefficace des ressources prévues pour les soins de santé. Cette étude vise donc, en regard de ces patients, à déterminer les variables préopératoires susceptibles de prédire ceux à qui l'on offrira finalement une chirurgie de la colonne vertébrale. MÉTHODES: Nous avons réalisé une étude de cohorte observationnelle portant sur des patients ayant été acheminés vers notre établissement entre mai 2013 et janvier 2015. Ces patients ont tout d'abord complété un questionnaire préclinique détaillé abordant notamment les aspects suivants : les antécédents d'apparition de leur maladie, le fait d'avoir rempli auparavant des questionnaires portant sur leur qualité de vie et leurs antécédents médicaux. Le principal indicateur ici évalué a été dans quelle mesure une intervention chirurgicale fut offerte. À l'aide la méthode dite de « forêts des arbres décisionnels ¼ (random forest method), nous avons effectué une régression logistique à variables multiples afin de déterminer la probabilité qu'un patient se voit offrir une intervention chirurgicale. Pour ce faire, nous avons utilisé les variables préopératoires évoquées ci-dessus. RÉSULTATS: Parmi les 1194 patients analysés, nous avons déterminé qu'une douleur modérée (RC 0,37 ; p = 0,008), la capacité de parcourir à pied une distance normale (RC 0,51 ; p = 0,007) et la capacité normale de tolérer une position assise (RC 0,58 ; p = 0,01) étaient les variables préopératoires qui réduisaient la probabilité de se voir offrir une chirurgie. Parmi les variables augmentant au contraire la probabilité d'être acheminé vers un service de chirurgie, mentionnons les suivantes : être atteint de radiculopathie (RC 2,0 ; p = 0,001) ; le fait qu'un patient estime qu'il devrait bénéficier d'une opération chirurgicale (RC 1,9 ; p = 0,003) ; une capacité de marche inférieure à plus ou moins 15 mètres (50 pieds) (RC 1,9 ; p = 0,01) ; le soulagement des symptômes en se penchant vers l'avant (RC 1,7 ; p = 0,008) ou en s'asseyant (RC 1,6 ; p = 0,009) ; le fait de travailler plus lentement (RC 1,6 ; p = 0,01) ; l'aggravation des symptômes en lien avec la manœuvre de Valsalva (RC 1,4 ; p = 0,03) ; et des douleurs associées au fait de s'asseoir et de se lever (RC 1,1 ; p = 0,001). CONCLUSIONS: Au total, nous avons identifié 11 variables préopératoires qui peuvent nous aider à prédire dans quelle mesure des patients sont susceptibles de se voir offrir une intervention chirurgicale. Il est donc important d'en tenir compte au moment de sélectionner des patients externes ayant été acheminés vers un service de chirurgie en raison de troubles de la colonne vertébrale.

Performance Indicators in Spine Surgery.

STUDY DESIGN: Systematic review. OBJECTIVE: To elucidate how performance indicators are currently used in spine surgery. SUMMARY OF BACKGROUND DATA: The Patient Protection and Affordable Care Act has given significant traction to the idea that healthcare must provide value to the patient through the introduction of hospital value-based purchasing. The key to implementing this new paradigm is to measure this value notably through performance indicators. METHODS: MEDLINE, CINAHL Plus, EMBASE, and Google Scholar were searched for studies reporting the use of performance indicators specific to spine surgery. We followed the Prisma-P methodology for a systematic review for entries from January 1980 to July 2016. All full text articles were then reviewed to identify any measure of performance published within the article. This measure was then examined as per the three criteria of established standard, exclusion/risk adjustment, and benchmarking to determine if it constituted a performance indicator. RESULTS: The initial search yielded 85 results among which two relevant studies were identified. The extended search gave a total of 865 citations across databases among which 15 new articles were identified. The grey literature search provided five additional reports which in turn led to six additional articles. A total of 27 full text articles and reports were retrieved and reviewed. We were unable to identify performance indicators. The articles presenting a measure of performance were organized based on how many criteria they lacked. We further examined the next steps to be taken to craft the first performance indicator in spine surgery. CONCLUSION: The science of performance measurement applied to spine surgery is still in its infancy. Current outcome metrics used in clinical settings require refinement to become performance indicators. Current registry work is providing the necessary foundation, but requires benchmarking to truly measure performance. LEVEL OF EVIDENCE: 1.

Video Diversion Improves Success Rate of Fundoscopic Examination in Children: A Prospective Randomized Controlled Trial.

BACKGROUND: Fundoscopy is an important component of the neurological examination as it can detect pathologies such as high intracranial pressure. However, the examination can be challenging in young children. This study evaluated whether playing a video during eye examination improves the success, duration, and ease of pediatric fundoscopy. MATERIALS AND METHODS: This was a prospective, multipractitioner, multiclinic, randomized controlled trial. Patients aged one to four years were recruited in the emergency department, neurology clinic, spinal cord clinic, and general pediatric clinic. Eye examination was randomized to video or non-video-assisted fundoscopy. Successful examinations were defined as visualizing the fundus within 60 seconds. Time to visualize optic disc was recorded and difficulty of examination was assessed using a 10-point Likert scale. RESULTS: We recruited 101 subjects with a mean age of 2.8 years. Overall, there was a 20% absolute improvement in the success rate of visualizing the optic disc in the video versus non-video group (P < 0.001, 95%CI: 7.8% to 31%). Time to visualize optic disc was also improved (Δ5.3 seconds, P < 0.01, 95%CI: 1.4 to 9.1 seconds). Practitioners and caregivers noticed a 33% (P < 0.01, 95%CI: 21% to 44%) and 42% (P < 0.01, 95%CI: 30% to 56%) relative improvement in the ease of examination with video, respectively. CONCLUSIONS: The use of videos improved the ease, duration, and, most importantly, the success of fundoscopy in younger children. This simple, inexpensive adjunct has great potential to improve the ease and efficacy of this aspect of the neurological examination and allow fundoscopic examination to be effectively performed earlier in the age-appropriate vision screening protocols.

Validation of the Calgary Spine Severity Score.

BACKGROUND CONTEXT: The Calgary Spine Severity Score (CSSS) is a published triage score reported in the Spine Journal in 2010. It separates spine referrals into four time categories of urgency. It stratifies patients according to clinical, radiologic, and pathologic findings. The CSSS however still requires external validation at another institution and in an unselected sample of patients. PURPOSE: The aim was to validate the CSSS. STUDY DESIGN/SETTING: This was a validation study. PATIENT SAMPLE: The sample included a total of 316 consecutive patients undergoing spinal surgery between April 2014 and September 2014 at a tertiary care hospital in Canada. OUTCOME MEASURES: The outcome was validity of the CSSS via its predicted time to operating room (OR) to predict actual time to OR. METHODS: We applied the CSSS to an unselected sample of consecutive patients from a tertiary care hospital between April 2014 and September 2014. Demographic and clinical data were collected. The CSSS was determined. We compared the time with OR predicted by the CSSS in one of four categories (routine>6 months=CSSS 3-5, priority<6 months=CSSS 6-8, urgent<1 month=CSSS 9-11, and emergent<1 week=CSSS 12-15) with the actual time to OR. We used Kaplan-Meier survival analysis to assess the CSSS predictive ability. Cox proportional hazard models were built and compared via analysis of variance to determine whether the models differed in their ability to fit the data. RESULTS: Three hundred sixteen patients were eligible. Two hundred eighty-nine had sufficient data. One hundred eighteen were a mismatch with the actual time to OR yielding an accuracy of 63%. The CSSS overestimated the urgency in 68 cases and underestimated it in 50 cases. Notably, seven cauda equina syndrome cases were classified as priority (<6 months) instead of emergent. The concordance was 0.70 and the R-square 0.33. We proposed several adjustments to the CSSS to increase its accuracy. The modified CSSS had an accuracy of 96%, overestimating nine cases and underestimating one case. The concordance was 0.77, and the R-square 0.70. CONCLUSIONS: The modified CSSS is an easy-to-use triage score, which represents a substantial improvement as compared with the original CSSS. It now requires further external validation.