Objective
The objective of this study is to examine factors associated with delayed time to achieve minimum clinically important difference (MCID) in patients undergoing lumbar decompression (LD) for ...the Patient-Reported Outcomes (PROs) of Oswestry Disability Index (ODI), Visual Analog Scale (VAS) back, and VAS leg pain.
Methods
Patients undergoing LD with preoperative and postoperative ODI, VAS back, and VAS leg scores were retrospectively reviewed from April 2016 to January 2021. MCID values from previously established studies were utilized to determine MCID achievement. Kaplan–Meier survival analysis determined the time to achieve MCID. Hazard ratios from multivariable Cox regression were utilized to determine the preoperative factors predictive of MCID achievement.
Results
Three-hundred and forty-three patients were identified undergoing LD. Overall MCID achievement rates were 67.4% for ODI, 67.1% for VAS back, and 65.0% for VAS leg. The mean time in weeks for MCID achievement was 22.52 ± 30.48 for ODI, 18.90 ± 27.43 for VAS back, and 20.96 ± 29.81 for VAS leg. Multivariable Cox regression revealed active smoker status, preoperative Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF), ODI, VAS Back, and VAS Leg (HR 1.03–2.14) as predictors of early MCID achievement, whereas an American Society of Anesthesiologist (ASA) classification of 2, Black ethnicity, workers’ compensation, private insurance, and diagnosis of foraminal stenosis were predictors of late MCID achievement (HR 0.34–0.58).
Conclusion
Most patients undergoing LD achieved MCID within 6 months of surgery. Significant factors for early MCID achievement were active smoking status and baseline PROs. Significant factors for late MCID achievement were ASA = 2, Black ethnicity, type of insurance, and foraminal stenosis diagnosis. These factors may be considered by surgeons in setting patient expectations.
Patients with a prolonged preoperative symptom duration (PSD) in the setting of cervical disk herniation (DH) may suffer inferior outcomes after surgical intervention. Comparison between anterior ...cervical diskectomy and fusion (ACDF) versus cervical disk arthroplasty (CDA) in this at-risk population has not yet been conducted.
Patients undergoing ACDF or CDA for DH with a PSD > 180 days were selected. Six-week (6W) and final follow-up (FF) patient-reported outcome measures (PROMs) as well as magnitude of postoperative improvements (∆PROM) were compared between cohorts using multivariable linear regression. Intercohort achievement rates of minimal clinically important difference (MCID) in each PROM were compared.
Seventy-seven of 190 patients were in the CDA cohort. 6W Patient-Reported Outcomes Measurement Information System-Physical Function (PROMIS-PF) was superior in the CDA cohort. The ACDF cohort demonstrated notable improvements in the 6W Neck Disability Index (NDI), visual analog scale-neck pain (VAS-N), visual analog scale-arm pain (VAS-A), and 9-item Patient Health Questionnaire (PHQ-9). The CDA cohort demonstrated notable improvements in 6W PROMIS-PF, NDI, VAS-N, and VAS-A. FF VAS-A was better in the CDA cohort. The ACDF cohort demonstrated notable improvements in FF PROMIS-PF, NDI, VAS-N, and VAS-A. The CDA cohort demonstrated notable improvements in all FF PROMs. ∆PROM-6W in PROMIS-PF was greater in the CDA cohort.
Patients with prolonged PSD due to cervical DH demonstrated notable improvements in physical function, disability, pain, and mental health regardless of fusion versus arthroplasty techniques. Accounting for demographic variations, patients undergoing CDA demonstrated a greater magnitude of improvement and superior scores in physical function at the first postoperative follow-up. Rates of clinically tangible improvements in PROMs did not markedly vary by surgical procedure. Patients undergoing CDA may perceive greater early improvements to physical function compared with patients undergoing ACDF for prolonged PSD due to DH.
Purpose
To determine the prognostic value of preoperative Veterans RAND-12 (VR-12) Physical Composite Score (PCS) scores on postoperative clinical outcomes in patients undergoing lateral lumbar ...interbody fusion (LLIF).
Methods
LLIF patients were separated into 2 cohorts based on preoperative VR-12 PCS scores: VR-12 PCS < 30 (lesser physical function) and VR-12 PCS ≥ 30 (greater physical function). Patient-reported outcome measures (PROMs) of VR-12 PCS, VR-12 Mental Composite Score (MCS), Short Form-12 (SF-12) PCS, SF-12 MCS, Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF), Patient Health Questionnaire-9 (PHQ-9), Visual Analog Scale (VAS) Back Pain (VAS-BP), VAS Leg Pain (VAS-LP), and Oswestry Disability Index (ODI) were collected at preoperative and up to 2-year postoperative time points. Mean postoperative follow-up time was 16.69 ± 8.53 months. Minimum clinically important difference (MCID) achievement was determined by comparing ∆PROM to previously established thresholds.
Results
Seventy-eight patients were included, with 38 patients with lesser preoperative physical function scores. Patients with lesser physical function reported significantly inferior preoperative PROM scores in all domains, except for SF-12 MCS and VAS-LP. At the 6-week postoperative time point, patients with lesser physical function reported significantly inferior VR-12 PCS, VR-12 MCS, SF-12 PCS, PROMIS-PF, and PHQ-9. At the final postoperative time point, patients with lesser physical function reported significantly inferior VR-12 PCS, VR-12 MCS, PROMIS-PF, PHQ-9, and ODI. Magnitude of 6-week postoperative improvement was significantly higher in the lesser physical function cohort for VR-12 PCS.
Conclusion
Patients undergoing LLIF with worse baseline VR-12 PCS scores reported inferior postoperative physical function, mental health, and disability outcomes. At the final postoperative follow-up, magnitude of postoperative improvement and MCID achievement did not significantly differ. Baseline VR-12 PCS scores may indicate inferior postoperative clinical outcomes in physical function, mental health, and disability in patients undergoing LLIF; however, baseline VR-12 PCS does not limit the magnitude of postoperative improvement.
To compare patients undergoing anterior cervical discectomy and fusion (ACDF) versus cervical disc replacement (CDR) for time to minimum clinically important difference (MCID) achievement and ...predictors of delayed MCID achievement for the patient-reported outcomes (PROs), Patient-Reported Outcomes Measurement Information System Physical Function, Neck Disability Index, Visual Analog Scale (VAS) neck, and VAS arm.
PROs of patients undergoing ACDF or CDR were collected preoperatively and postoperatively at 6-week/12-week/6-month/1-year/2-year periods. MCID achievement was calculated through comparison of changes in Patient-Reported Outcomes Measurement to previously established values in literature. Time to MCID achievement and predictors for delayed MCID achievement were determined through Kaplan-Meier survival analysis and multivariable Cox regression, respectively.
One hundred ninety-seven patients were identified, with 118 and 79 undergoing ACDF and CDR, respectively. Kaplan-Meier survival analysis demonstrated faster time to achieve MCID for CDR patients in Patient-Reported Outcomes Measurement Information System Physical Function (P = 0.006). Early predictors of MCID achievement through Cox regression were CDR procedure, Asian ethnicity, elevated preoperative PROs of VAS neck and VAS arm (hazard ratio, 1.16–7.28). Workers' compensation was a late predictor of MCID achievement (hazard ratio, 0.15).
Most patients achieved MCID in physical function, disability, and back pain outcomes within 2 years of surgery. Patients undergoing CDR achieved MCID faster in physical function. Early predictors of MCID achievement were CDR procedure, Asian ethnicity, and elevated preoperative PROs of pain outcomes. Workers' compensation was a late predictor. These findings may be helpful in managing patient expectations.
To evaluate the effect of early depressive burden on PROMs in the setting of cervical disc replacement (CDR).
Patients who had undergone primary elective CDR with recorded preoperative and 6-week ...postoperative 9-item Patient Health Questionnaire (PHQ-9) scores were identified. Early depressive burden was calculated via addition of the preoperative and 6-week PHQ-9 scores. Patients were divided into 2 cohorts, those with summative PHQ-9 scores beneath one-half standard deviation less than the mean (Lesser Burden; LB) and those with summative PHQ-9 scores above one-half standard deviation greater than the mean (Greater Burden; GB). Magnitude of improvement in PROMs (ΔPROM) was compared within and between cohorts at 6-weeks (ΔPROM-6W) and final follow-up (ΔPROM-FF). PROMs evaluated included PROMIS-PF/NDI/VAS-Neck (VAS-N)/VAS-Arm (VAS-A)/PHQ-9.
Fifty-five patients were included with 34 in the LB cohort. The LB cohort demonstrated improvements from the preoperative baseline in 6-week PROMIS-PF/NDI/VAS-N/VAS-A (P ≤ 0.012, all). The GB cohort demonstrated improvements from the preoperative baseline in 6-week NDI/VAS-N/VAS-A/PHQ-9 (P ≤ 0.038, all). The GB cohort demonstrated greater ΔPROM-6W and ΔPROM-FF in PHQ-9 (P ≤ 0.047, both). The LB cohort demonstrated a greater ΔPROM-FF in PROMIS-PF (P = 0.023).
Patients with a greater depressive burden were more likely to experience greater magnitudes of improvements in PHQ-9 at both 6-week and final follow-up and experience clinically meaningful improvement in depressive symptoms. Patients with a lesser depressive burden were more likely to experience a greater magnitude of improvement in PROMIS-PF at final follow-up and experience clinically meaningful improvement in physical function.
Purpose
Patients with preoperative depressive symptoms may demonstrate inferior patient-reported outcomes (PROs). The effect of preoperative symptom duration (SD) on PROs in this population has not ...been well-studied. We aim to assess the influence of preoperative SD on PROs in patients with low mental health scores prior to minimally invasive transforaminal interbody fusion (MIS-TLIF).
Methods
Patients who had undergone elective, primary MIS-TLIF with preoperative SF-12 MCS score below 45.6, a previously established threshold for depression, were selected. Patients were divided into matched lesser duration (LD; SD<365 days) and greater duration (GD; SD≥365 days) cohorts. PROs were collected preoperatively and at 6-week/12-week/6-month/1-year postoperative periods. PROs included PROMIS-PF/ODI/VAS back/VAS leg/SF-12 MCS. PROs were compared within and between groups. Rates of achievement of minimal clinically important difference (MCID) were compared between groups.
Results
One hundred twenty-two patients were included after matching cohorts. Patients in the LD cohort demonstrated improvement in PROMIS-PF at 12-weeks/6-month/1-year, and ODI/VAS back/VAS leg/SF-12 MCS at all postoperative periods (
p
≤0.024, all). Patients in the GD cohort demonstrated improvement in PROMIS-PF at 12-weeks/6-month/1-year, and ODI/VAS back/VAS leg/SF-12 MCS at all postoperative periods (
p
≤0.013, all). There were no differences in PROs or MCID achievement between cohorts at any period.
Conclusion
Patients with preoperative depressive symptoms undergoing MIS-TLIF, regardless of duration of preoperative symptoms, demonstrated improvements in physical function, disability, pain, and mental health domains. Patients with greater duration of preoperative symptoms did not report inferior outcomes at any period. Rates of clinically important improvements in all domains were favorable and similar between cohorts.
To establish minimum clinically important difference (MCID) in anterior lumbar interbody fusion (ALIF) for the physical function patient-reported outcome measures, Patient-Reported Outcomes ...Measurement Information System Physical Function (PROMIS-PF), 12-Item Short Form (SF-12) physical component score (PCS), Veterans RAND 12 (VR-12) PCS, and pain patient-reported outcome measures visual analog scale (VAS) back and VAS leg through anchor- and distribution-based calculations.
Patients undergoing ALIF with preoperative and 6-month Oswestry Disability Index were included. Using Oswestry Disability Index as the anchor, anchor-based calculation methods were the average change, minimum detectable change, and receiver operating characteristic curve methods. Distribution-based methods were the standard error of measurement, reliable change index, effect size, and half of the standard deviation (0.5ΔSD).
Fifty-one patients were identified. Anchor-based methods ranged from 2.9 to 11.5 for PROMIS-PF, 8.2–13.6 for SF-12 PCS, 7.8–16.8 for VR-12 PCS, 0.5–3.9 for VAS back, and 1.0–3.4 for VAS leg. The area under curve ranged from 0.59 (VAS back) to 0.78 (VR-12 PCS). Distribution-based methods ranged from 1.0 to 4.2 for PROMIS-PF, 1.8–12.2 for SF-12 PCS, 1.9–6.2 for VR-12 PCS, 0.4–1.6 for VAS back, and 0.5–1.7 for VAS leg.
The MCID values greatly relied on the calculation method. The minimum detectable change method was selected as the most appropriate MCID calculation method. The MCID values that may be utilized for ALIF patients are 7.3 for PROMIS-PF, 8.2 for SF-12 PCS, 7.8 for VR-12 PCS, 3.2 for VAS back, and 2.2 for VAS leg.
We assessed the potential effect of the preoperative symptom duration on patient-reported outcomes (PROs) for workers’ compensation (WC) patients undergoing minimally invasive transforaminal lumbar ...interbody fusion (MIS-TLIF).
WC patients who had undergone primary, elective MIS-TLIF with recorded symptoms duration data available were included. Two cohorts were generated: those with a shorter (lesser) duration (LD; symptom duration <1 year) and those with a prolonged duration (PD; symptom duration >1 year). PROs were collected preoperatively and at several follow-up points for ≤1 year postoperatively. The PROs were compared within and between the 2 cohorts. The achievement rates of minimum clinically important differences were also compared between the 2 cohorts.
A total of 145 patients were included, with 76 in the PD cohort and 69 in the LD cohort. The LD cohort demonstrated improvement in the patient-reported outcomes measurement information system for physical function (PROMIS-PF) at 6 months and 1 year postoperatively, Oswestry disability index (ODI) at 12 weeks and 6 months postoperatively, visual analog scale (VAS) score for back pain at 6 weeks, 12 weeks, and 6 months postoperatively, and VAS score for leg pain at all postoperative points (P ≤ 0.015 for all). The PD cohort demonstrated improvement in the PROMIS-PF at 12 weeks and 6 months postoperatively, ODI at 6 weeks, 12 weeks, and 6 months postoperatively, and VAS score for back pain and leg pain at all postoperative periods (P ≤ 0.007 for all). All the preoperative PROs were superior for the LD cohort (P < 0.001 for all). The LD cohort reported better PROMIS-PF at 6 months and 1 year and ODI at 1 year postoperatively (P ≤ 0.037 for all). The PD cohort was more likely to achieve a minimum clinically important difference in ODI at 6 and 12 weeks postoperatively, VAS score for back pain at 6 weeks postoperatively, and VAS score for leg pain at 6 weeks and 1 year postoperatively and overall (P ≤ 0.036 for all).
Independently of the preoperative symptom duration, WC patients demonstrated improvement in physical function and pain after MIS-TLIF. Patients with a longer symptom duration reported inferior function and pain preoperatively and were more likely to demonstrate clinically significant improvements in disability and pain postoperatively.
Purpose
Few studies examine the clinical outcomes in patients undergoing minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) versus lateral lumbar interbody fusion (LLIF) for ...adjacent segment disease (ASD). We aim to compare the postoperative clinical trajectory through patient-reported outcome measures (PROMs) and minimum clinically important difference (MCID) in patients undergoing MIS-TLIF versus LLIF for ASD.
Methods
Patients were stratified into two cohorts based on surgical technique for ASD: MIS-TLIF versus LLIF. PROMs of 12-Item Short Form Physical Component Score (SF-12 PCS), visual analog scale (VAS) back, VAS leg, and Oswestry Disability Index (ODI) were collected at preoperative and postoperative 6-week/12-week/6-month/1-year time points. MCID attainment was calculated through comparison to established thresholds. Cohorts were compared through nonparametric inferential statistics.
Results
Fifty-four patients were identified, with 22 patients undergoing MIS-TLIF after propensity score matching. Patients undergoing MIS-TLIF for ASD demonstrated significant postoperative improvement up to 1-year VAS back, up to 1-year VAS leg, and 6-month through 1-year ODI (
p
≤ 0.035, all). Patients undergoing LLIF demonstrated significant postoperative improvement in 6-month SF-12 PCS, 6-month through 1-year VAS back, 12-week through 6-month VAS leg, and 6-month to 1-year ODI (
p
≤ 0.035, all). No significant differences were calculated between surgical techniques for PROMs or MCID achievement rates.
Conclusion
Patients undergoing either MIS-TLIF or LLIF for adjacent segment disease demonstrated significant postoperative improvement in pain and disability outcomes. Additionally, patients undergoing LLIF reported significant improvement in physical function. Both MIS-TLIF and LLIF are effective for the treatment of adjacent segment disease.
To identify perioperative predictors of minimum clinically important difference (MCID) for patients undergoing lateral lumbar interbody fusion (LLIF) for the patient-reported outcome measures (PROMs) ...of Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF), visual analog scale (VAS) back, VAS leg, Oswestry Disability Index (ODI), and Patient Health Questionnaire-9 (PHQ-9).
Patients undergoing LLIF were identified through retrospective review of a single-surgeon database. Overall MCID achievement was determined as the number of unique patients achieving ΔPROM thresholds of PROMIS-PF = 4.5, VAS back = 2.1, VAS leg = 2.8, ODI = 14.9, and PHQ-9 = 3.0 over a 2-year postoperative period. Univariate and multivariable logistic regression were used to determine perioperative predictors for MCID achievement.
Two-hundred and ninety patients were identified. For PROMIS-PF MCID achievement, increased preoperative PROMIS-PF and postoperative day (POD) 1 VAS pain were significant negative predictors. For VAS back, primary fusion with revision decompression was a negative predictor, whereas increased preoperative VAS back score was a positive predictor of MCID achievement. For VAS leg, increased preoperative VAS leg score was a positive predictor. For ODI, increased POD 0 VAS pain score was a negative predictor, whereas increased preoperative ODI was a positive predictor. For PHQ-9, increased preoperative PHQ-9 score was a positive predictor.
In patients undergoing LLIF, perioperative predictors for MCID achievement were highly dependent on PROM. Preoperative PROM was the most consistent perioperative predictor for achieving MCID. Increased acute postoperative pain and primary fusion after failed index decompression were significant predictors of failing to achieve MCID. Surgeons may use these findings in prognostication and management of postoperative expectations.
