1
|
Grob A, Rohr J, Stumpo V, Vieli M, Ciobanu-Caraus O, Ricciardi L, Maldaner N, Raco A, Miscusi M, Perna A, Proietti L, Lofrese G, Dughiero M, Cultrera F, D'Andrea M, An SB, Ha Y, Amelot A, Bedia Cadelo J, Viñuela-Prieto JM, Gandía-González ML, Girod PP, Lener S, Kögl N, Abramovic A, Laux CJ, Farshad M, O'Riordan D, Loibl M, Galbusera F, Mannion AF, Scerrati A, De Bonis P, Molliqaj G, Tessitore E, Schröder ML, Stienen MN, Regli L, Serra C, Staartjes VE. Multicenter external validation of prediction models for clinical outcomes after spinal fusion for lumbar degenerative disease. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024:10.1007/s00586-024-08395-3. [PMID: 38987513 DOI: 10.1007/s00586-024-08395-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 06/18/2024] [Accepted: 06/30/2024] [Indexed: 07/12/2024]
Abstract
BACKGROUND Clinical prediction models (CPM), such as the SCOAP-CERTAIN tool, can be utilized to enhance decision-making for lumbar spinal fusion surgery by providing quantitative estimates of outcomes, aiding surgeons in assessing potential benefits and risks for each individual patient. External validation is crucial in CPM to assess generalizability beyond the initial dataset. This ensures performance in diverse populations, reliability and real-world applicability of the results. Therefore, we externally validated the tool for predictability of improvement in oswestry disability index (ODI), back and leg pain (BP, LP). METHODS Prospective and retrospective data from multicenter registry was obtained. As outcome measure minimum clinically important change was chosen for ODI with ≥ 15-point and ≥ 2-point reduction for numeric rating scales (NRS) for BP and LP 12 months after lumbar fusion for degenerative disease. We externally validate this tool by calculating discrimination and calibration metrics such as intercept, slope, Brier Score, expected/observed ratio, Hosmer-Lemeshow (HL), AUC, sensitivity and specificity. RESULTS We included 1115 patients, average age 60.8 ± 12.5 years. For 12-month ODI, area-under-the-curve (AUC) was 0.70, the calibration intercept and slope were 1.01 and 0.84, respectively. For NRS BP, AUC was 0.72, with calibration intercept of 0.97 and slope of 0.87. For NRS LP, AUC was 0.70, with calibration intercept of 0.04 and slope of 0.72. Sensitivity ranged from 0.63 to 0.96, while specificity ranged from 0.15 to 0.68. Lack of fit was found for all three models based on HL testing. CONCLUSIONS Utilizing data from a multinational registry, we externally validate the SCOAP-CERTAIN prediction tool. The model demonstrated fair discrimination and calibration of predicted probabilities, necessitating caution in applying it in clinical practice. We suggest that future CPMs focus on predicting longer-term prognosis for this patient population, emphasizing the significance of robust calibration and thorough reporting.
Collapse
Affiliation(s)
- Alexandra Grob
- Machine Intelligence in Clinical Neuroscience and Microsurgical Neuroanatomy (MICN) Laboratory, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Jonas Rohr
- Machine Intelligence in Clinical Neuroscience and Microsurgical Neuroanatomy (MICN) Laboratory, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Vittorio Stumpo
- Machine Intelligence in Clinical Neuroscience and Microsurgical Neuroanatomy (MICN) Laboratory, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Moira Vieli
- Machine Intelligence in Clinical Neuroscience and Microsurgical Neuroanatomy (MICN) Laboratory, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Olga Ciobanu-Caraus
- Machine Intelligence in Clinical Neuroscience and Microsurgical Neuroanatomy (MICN) Laboratory, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Luca Ricciardi
- Department of NESMOS, Azienda Ospedaliera Universitaria Sant'Andrea, Sapienza University, Rome, Italy
| | - Nicolai Maldaner
- Machine Intelligence in Clinical Neuroscience and Microsurgical Neuroanatomy (MICN) Laboratory, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Antonino Raco
- Department of NESMOS, Azienda Ospedaliera Universitaria Sant'Andrea, Sapienza University, Rome, Italy
| | - Massimo Miscusi
- Department of NESMOS, Azienda Ospedaliera Universitaria Sant'Andrea, Sapienza University, Rome, Italy
| | - Andrea Perna
- Department of Orthopedics, Foundation Casa Sollievo Della Sofferenza IRCCS, San Giovanni Rotondo, Italy
| | - Luca Proietti
- Department of Aging, Neurological, Orthopedic and Head-Neck Sciences, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
- Department of Geriatrics and Orthopedics, Sacred Heart Catholic University, Rome, Italy
| | - Giorgio Lofrese
- Neurosurgery Division, Department of Neurosciences, "M.Bufalini" Hospital, Cesena, Italy
| | - Michele Dughiero
- Neurosurgery Division, Department of Neurosciences, "M.Bufalini" Hospital, Cesena, Italy
| | - Francesco Cultrera
- Neurosurgery Division, Department of Neurosciences, "M.Bufalini" Hospital, Cesena, Italy
| | - Marcello D'Andrea
- Neurosurgery Division, Department of Neurosciences, "M.Bufalini" Hospital, Cesena, Italy
| | - Seong Bae An
- Department of Neurosurgery, Spine and Spinal Cord Institute, College of Medicine, Severance Hospital, Yonsei University, Seoul, Korea
| | - Yoon Ha
- Department of Neurosurgery, Spine and Spinal Cord Institute, College of Medicine, Severance Hospital, Yonsei University, Seoul, Korea
| | - Aymeric Amelot
- Department of Neurosurgery, La Pitié Salpétrière Hospital, Paris, France
- Neurosurgical Spine Department, University Hospital of Tours, Tours, France
| | - Jorge Bedia Cadelo
- Department of Neurosurgery, Hospital Universitario La Paz, Madrid, Spain
| | | | | | - Pierre-Pascal Girod
- Department of Neurosurgery, Vienna Healthcare Network/ Municipial Hospital, Vienna, Austria
| | - Sara Lener
- Department of Neurosurgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Nikolaus Kögl
- Department of Neurosurgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Anto Abramovic
- Department of Neurosurgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Christoph J Laux
- University Spine Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Mazda Farshad
- University Spine Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Dave O'Riordan
- Spine Center Division, Department of Teaching, Research and Development, Schulthess Klinik, Zurich, Switzerland
| | - Markus Loibl
- Department of Spine Surgery, Schulthess Klinik, Zurich, Switzerland
| | - Fabio Galbusera
- Spine Center Division, Department of Teaching, Research and Development, Schulthess Klinik, Zurich, Switzerland
| | - Anne F Mannion
- Spine Center Division, Department of Teaching, Research and Development, Schulthess Klinik, Zurich, Switzerland
| | - Alba Scerrati
- Department of Neurosurgery, University Hospital Sant'Anna, Ferrara, Italy
| | - Pasquale De Bonis
- Department of Neurosurgery, University Hospital Sant'Anna, Ferrara, Italy
| | - Granit Molliqaj
- Department of Neurosurgery, HUG Geneva University Hospital, Geneva, Switzerland
| | - Enrico Tessitore
- Department of Neurosurgery, HUG Geneva University Hospital, Geneva, Switzerland
| | - Marc L Schröder
- Department of Neurosurgery, Bergman Clinics Amsterdam, Amsterdam, The Netherlands
| | - Martin N Stienen
- Department of Neurosurgery and Spine Center of Eastern Switzerland, Cantonal Hospital St. Gallen and Medical School of St.Gallen, St. Gallen, Switzerland
| | - Luca Regli
- Machine Intelligence in Clinical Neuroscience and Microsurgical Neuroanatomy (MICN) Laboratory, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Carlo Serra
- Machine Intelligence in Clinical Neuroscience and Microsurgical Neuroanatomy (MICN) Laboratory, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Victor E Staartjes
- Machine Intelligence in Clinical Neuroscience and Microsurgical Neuroanatomy (MICN) Laboratory, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland.
| |
Collapse
|
2
|
Anwar FN, Roca AM, Hartman TJ, Nie JW, Medakkar SS, Loya AC, MacGregor KR, Oyetayo OO, Zheng E, Federico VP, Sayari AJ, Lopez GD, Singh K. Worse Pain and Disability at Presentation Predicts Greater Improvement in Pain, Disability, and Mental Health in Patients Undergoing Minimally Invasive Transforaminal Lumbar Interbody Fusion for Degenerative Spondylolisthesis. Clin Spine Surg 2024:01933606-990000000-00330. [PMID: 38940454 DOI: 10.1097/bsd.0000000000001650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 04/29/2024] [Indexed: 06/29/2024]
Abstract
STUDY DESIGN Retrospective Review. OBJECTIVE To assess the impact of preoperative pain and disability on patient-reported outcome measures (PROMs) following minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) for degenerative spondylolisthesis. SUMMARY OF BACKGROUND DATA Varying preoperative symptom severity in lumbar fusion patients alters perceptions of surgical success. METHODS Degenerative spondylolisthesis patients undergoing elective, primary, single-level MI-TLIF were stratified by preoperative symptom severity: Mild (VAS-B<7/ODI<50), Moderate (VAS-B≥7/ODI<50 or VAS-B<7/ODI≥50), and Severe (VAS-B≥7/ODI≥50). PROMs, Patient-reported Outcomes Measurement Information System-Physical Function (PROMIS-PF), ODI, VAS-B, VAS-Leg (VAS-L), and 9-item Patient Health Questionnaire (PHQ-9) were compared at baseline, 6 weeks, and final follow-up (μ=16.3±8.8 mo). Postoperative PROMs, magnitudes of improvement, and minimal clinically important difference (MCID) achievement rates were compared between cohorts through multivariable regression. RESULTS A total of 177 patients were included. Acute postoperative pain and narcotic consumption were highest in the severe cohort (P≤0.003). All preoperative PROMs worsened from mild to severe cohorts (P<0.001). All PROMs continued to be significantly different between cohorts at 6 weeks and final follow-up, with the worst scores in the Severe cohort (P≤0.003). At 6 weeks, all cohorts improved in ODI, VAS-B, VAS-L, and PHQ-9 (P≤0.003), with the Moderate cohort also improving in PROMIS-PF (P=0.017). All Cohorts improved across PROMs at the final follow-up (P≤0.044). Magnitudes of improvement in ODI, VAS-B, and PHQ-9 increased with worsening preoperative symptom severity (P≤0.042). The Moderate and Severe cohorts demonstrated higher MCID achievement in ODI, VAS-B, and PHQ-9 rates than the Mild cohort. CONCLUSIONS Despite preoperative pain and disability severity, patients undergoing MI-TLIF for degenerative spondylolisthesis report significant improvement in physical function, pain, disability, and mental health postoperatively. Patients with increasing symptom severity continued to report worse severity postoperatively compared with those with milder symptoms preoperatively but were more likely to report larger improvements and achieve clinically meaningful improvement in disability, pain, and mental health.
Collapse
Affiliation(s)
- Fatima N Anwar
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
3
|
Yuan L, Liu Y, Zeng Y, Chen Z, Li W. Impact of preoperative clinical state on 2-year clinical outcomes following degenerative lumbar scoliosis surgery. J Orthop Res 2024; 42:1335-1342. [PMID: 38151818 DOI: 10.1002/jor.25780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 12/10/2023] [Accepted: 12/18/2023] [Indexed: 12/29/2023]
Abstract
To assess the preoperative clinical state's impact on clinical outcomes after surgery for degenerative lumbar scoliosis (DLS) based on the minimal clinically important difference (MCID). Preoperative and follow-up (FU) scores in each Scoliosis Research Society-22 (SRS-22) domain were compared with age- and sex-matched normative references. At baseline, patients were classified by differences from normative values in four groups: Worst, Severe, Poor, and Moderate. At 2 years postoperative FU, patients were divided into four groups (Worst Severe Poor Asymptomatic) based on the difference in MCID between postoperative and normal values. The changes in MCID were considered as the criterion for surgical efficacy. In addition, we calculated the classification of preoperative and FU clinical symptom severity in each domain in same patient. The distinction among curve types was also performed based on the SRS-Schwab classification. A total of 123 patients were included. During FU, patients with more severe preoperative clinical symptoms were more likely to achieve clinical changes (>1 MCID, p < 0.05), but the rate of reaching "asymptomatic" was lower (p < 0.05). Kendall's tau-b correlation analysis found that preoperative clinical severity was correlated with clinical changes category in Activity (Tau-b = 0.252; p = 0.002), Pain (Tau-b = 0.230; p = 0.005), Appearance (Tau-b = 0.307; p < 0.001), and Mental (Tau-b = 0.199; p = 0.016), and it also was correlated with FU clinical severity in Activity (Tau-b = 0.173; p = 0.023), Pain (Tau-b = 0.280; p < 0.001), and Mental (Tau-b = 0.349; p < 0.001). There was a correlation between preoperative clinical severity and FU SRS-22 score outcomes. Patients with severe preoperative clinical symptoms can experience better treatment outcomes during FU, but it is also more difficult to recover to the normal reference.
Collapse
Affiliation(s)
- Lei Yuan
- Department of Orthopedics, Peking University Third Hospital, Beijing, China
- Beijing Key Laboratory of Spinal Disease Research, Peking University Third Hospital, Beijing, China
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Peking University Third Hospital, Beijing, China
| | - Yinhao Liu
- Department of Orthopedics, Peking University Third Hospital, Beijing, China
- Beijing Key Laboratory of Spinal Disease Research, Peking University Third Hospital, Beijing, China
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Peking University Third Hospital, Beijing, China
- Peking University Health Science Center, Beijing, China
| | - Yan Zeng
- Department of Orthopedics, Peking University Third Hospital, Beijing, China
- Beijing Key Laboratory of Spinal Disease Research, Peking University Third Hospital, Beijing, China
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Peking University Third Hospital, Beijing, China
| | - Zhongqiang Chen
- Department of Orthopedics, Peking University Third Hospital, Beijing, China
- Beijing Key Laboratory of Spinal Disease Research, Peking University Third Hospital, Beijing, China
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Peking University Third Hospital, Beijing, China
| | - Weishi Li
- Department of Orthopedics, Peking University Third Hospital, Beijing, China
- Beijing Key Laboratory of Spinal Disease Research, Peking University Third Hospital, Beijing, China
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Peking University Third Hospital, Beijing, China
| |
Collapse
|
4
|
Nie JW, Hartman TJ, Zheng E, Oyetayo OO, MacGregor KR, Federico VP, Massel DH, Sayari AJ, Singh K. Does Preoperative Back Pain Impact Patient-reported Outcomes in Patients Undergoing Minimally Invasive Transforaminal Lumbar Interbody Fusion for Isthmic Spondylolisthesis? Clin Spine Surg 2024; 37:E179-E184. [PMID: 38178316 DOI: 10.1097/bsd.0000000000001568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 11/29/2023] [Indexed: 01/06/2024]
Abstract
STUDY DESIGN Retrospective review. OBJECTIVE To determine postoperative clinical outcomes in patients undergoing minimally invasive (MIS) transforaminal lumbar interbody fusion (TLIF) for isthmic spondylolisthesis (IS). BACKGROUND Few studies have examined the postoperative clinical trajectory in patients undergoing MIS-TLIF specifically for IS. METHODS Patients were separated into two cohorts based on the previously defined Visual Analog Scale (VAS) back pain (BP) for severe pain: VAS-BP <7 and VAS-BP ≥7. Patient-reported outcome measures (PROMs) of Patient-Reported Outcomes Measurement Information System-physical function (PF), 12-item Short Form (SF-12) Physical/Mental Component Score, Patient Health Questionnaire-9, VAS-BP, VAS leg pain, and Oswestry Disability Index were collected preoperatively and up to 2-year postoperatively. Minimum clinically important difference (MCID) was calculated through previously defined thresholds. RESULTS A total of 160 patients were recorded, with 58 patients in the VAS-BP <7 cohort. The VAS-BP <7 cohort demonstrated significant improvement in all PROMs at one or more postoperative time points. The VAS-BP ≥7 demonstrated significant improvement at 3 or more postoperative time points in all PROMs except for SF-12 Mental Component Score. The VAS-BP <7 cohort reported significantly superior preoperative and postoperative PROMs in all domains, except for SF-12 Physical Component Score. The VAS-BP ≥7 cohort had higher MCID achievement rates at one or more time points in multiple PROMs. CONCLUSION Patients undergoing MIS-TLIF for IS demonstrated significant postoperative improvement in PF, mental function, pain, and disability outcomes independent of preoperative severity of BP. Patients with lower preoperative BP demonstrated superior outcomes in PF, mental function, pain, and disability. However, patients with greater preoperative BP achieved higher rates of MCID in mental function, BP, and disability outcomes. Patients with greater severity of preoperative BP undergoing MIS-TLIF for IS may experience greater rates of clinically relevant improvement in mental function, BP, and disability outcomes.
Collapse
Affiliation(s)
- James W Nie
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL
| | | | | | | | | | | | | | | | | |
Collapse
|
5
|
El-Abtah ME, Makineni PS, El-Abtah M, Roach MJ, Kelly ML. Impact of preoperative mental health diagnosis on postoperative opioid use patterns in spine fusion surgery: A systematic literature review. J Clin Neurosci 2024; 125:17-23. [PMID: 38733899 DOI: 10.1016/j.jocn.2024.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 04/30/2024] [Accepted: 05/05/2024] [Indexed: 05/13/2024]
Abstract
Opioids are frequently prescribed for patients undergoing procedures such as spinal fusion surgery for the management of chronic back pain. However, the association between a preoperative mental health illness, such as depression or anxiety, and opioid use patterns after spinal fusion surgery remain unclear. Therefore, we performed a systematic literature review in accordance with PRISMA guidelines to identify articles from the PubMed Database that analyzed the relationship between preoperative mental health illness and postoperative opioid usage after spinal fusion surgery on June 1, 2023. The Methodological Index for Nonrandomized Studies (MINORS) was utilized to evaluate the quality of included articles. Seven studies with 139,580 patients and a mean MINORS score of 18 ± 0.5 were included in qualitative synthesis. The most common spine surgery performed was lumbar fusion (59 %) and the mean age across studies ranged from 50 to 62 years. The range of postoperative opioid usage patterns analyzed ranged from 1 to 24 months. The majority of studies (6/7; 86 %) reported that a preoperative diagnosis of mental health illness was associated with increased opioid dependence after spinal fusion surgery. Preoperative use of opioids for protracted periods was shown to be associated with postoperative chronic opioid dependence. Consensus findings suggest that having a preoperative diagnosis of a mental health illness such as depression or anxiety is associated with increased postoperative opioid use after spinal fusion surgery. Patient comorbidities, including diagnoses of mental health illness, must be considered by the spine surgeon in order to reduce rates of postoperative opioid dependence.
Collapse
Affiliation(s)
| | | | - Malk El-Abtah
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Mary J Roach
- Department of Physical Medicine and Rehabilitation, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Michael L Kelly
- Case Western Reserve University School of Medicine, Cleveland, OH, USA; Department of Neurological Surgery, Case Western Reserve University School of Medicine MetroHealth Medical Center, Cleveland, OH, USA.
| |
Collapse
|
6
|
Wolf JC, Kaul A, Anwar FN, Roca AM, Khosla I, Loya AC, Medakkar SS, Federico VP, Sayari AJ, Lopez GD, Singh K. Do Six-Week Postoperative Patient-Reported Outcomes Predict Long-Term Clinical Outcomes Following Lumbar Decompression? World Neurosurg 2024; 185:e900-e906. [PMID: 38458252 DOI: 10.1016/j.wneu.2024.02.149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 02/27/2024] [Accepted: 02/28/2024] [Indexed: 03/10/2024]
Abstract
BACKGROUND Little research has been done to evaluate the prognostic value of short-term postoperative patient-reported outcomes (PROs) on long-term PROs following lumbar decompression (LD). We evaluated the prognostic value of short-term PROs on long-term PROs through 2 years after LD. METHODS A single spine surgeon database was retrospectively queried for patients undergoing primary LD with 6-week postoperative PROs reported. The demographics, perioperative traits, and preoperative, 6-month, 1-year, and 2-year PROs were recorded. The PROs included the visual analog scale (VAS) for back pain, VAS for leg pain, PRO measure information system for physical function (PROMIS-PF), and Oswestry disability index. Two-step multivariate linear regression was performed to determine the predictive value of 6-week PROs for the 6-month, 1-year, and 2-year PROs. RESULTS A total of 277 patients were included. The 6-week Oswestry disability index, VAS for leg pain, and 9-item patient health questionnaire (PHQ-9) are all positive predictors for their respective outcomes at 6 months. Additionally, the 6-week PROMIS-PF was a negative predictor of the 6-month PHQ-9. The 6-week PROMIS-PF positively predicted the PROMIS-PF through 1 year, and the PHQ-9 was a positive predictor of the PHQ-9 at 1 and 2 years postoperatively. CONCLUSIONS The 6-week postoperative PROs are predictive of the same outcomes at 6 months, the PROMIS-PF is predictive through 1 year, and the PHQ-9 is predictive through 2 years. Determining the predictive value of early postoperative PROs can be helpful in understanding the likely postoperative trajectory following LD and informing patient expectations.
Collapse
Affiliation(s)
- Jacob C Wolf
- Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois
| | - Aayush Kaul
- Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois
| | - Fatima N Anwar
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Andrea M Roca
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Ishan Khosla
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Alexandra C Loya
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Srinath S Medakkar
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Vincent P Federico
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Arash J Sayari
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Gregory D Lopez
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Kern Singh
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois.
| |
Collapse
|
7
|
Carreon LY, Glassman SD, Mummaneni P, Bydon M, Chan AK, Asher A. Assessment of the External Validity of Dialogue Support for Predicting Lumbar Spine Surgery Outcomes in a US Cohort. Spine (Phila Pa 1976) 2024; 49:E107-E113. [PMID: 37235812 DOI: 10.1097/brs.0000000000004728] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 05/05/2023] [Indexed: 05/28/2023]
Abstract
STUDY DESIGN External validation using prospectively collected data. OBJECTIVES To determine the model performance of "Dialogue Support" (DS) in predicting outcomes after lumbar spine surgery. SUMMARY OF BACKGROUND DATA To help clinicians discuss risk versus benefit with patients considering lumbar fusion surgery, DS has been made available online. As DS was created using a Swedish sample, there is a need to study how well DS performs in alternative populations. PATIENTS AND METHODS Preoperative data from patients enrolled in the Quality Outcomes Database were entered into DS. The probability for each patient to report satisfaction, achieve success (leg pain improvement ≥3), or have no leg pain 12 months after surgery was extracted and compared with their actual 12-month postoperative data. The ability of DS to identify patients in the Quality Outcomes Database who report satisfaction, achieve success, or have no leg pain 12 months after surgery was determined using Receiver operating characteristic curve analysis, goodness-of-fit tests, and calibration plots. RESULTS There was a significant improvement in all outcomes in 23,928 cases included in the analysis from baseline to 12 months postoperative. Most (84%) reported satisfaction, 67% achieved success, and 44% were pain-free 12 months postoperative. Receiver operating characteristic analysis showed that DS had a low ability to predict satisfaction [area under the curve (AUC) = 0.606], success (AUC = 0.546), and being pain-free (AUC = 0.578) at 12 months postoperative; poor fit for satisfaction (<0.001) and being pain-free ( P = 0.004), but acceptable fit for success ( P = 0.052). Calibration plots showed underestimation for satisfaction and success, but acceptable estimates for being pain-free. CONCLUSION DS is not directly transferable to predict satisfaction and success after lumbar surgery in a US population. This may be due to differences in patient characteristics, weights of the variables included, or the exclusion of unknown variables associated with outcomes. Future studies to better understand and improve the transferability of these models are needed.
Collapse
Affiliation(s)
| | | | - Praveen Mummaneni
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA
| | - Mohamad Bydon
- Department of Neurosurgery, Mayo Clinic, Rochester; Rochester, MN
| | - Andrew K Chan
- The Neurological Institute of New York, New York, NY
| | - Anthony Asher
- Carolina Neurosurgery and Spine Associates, Charlotte, NC
| |
Collapse
|
8
|
Carreon LY, Nian H, Archer KR, Andersen MØ, Hansen KH, Glassman SD. Performance of the streamlined quality outcomes database web-based calculator: internal and external validation. Spine J 2024; 24:662-669. [PMID: 38081465 DOI: 10.1016/j.spinee.2023.11.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 11/15/2023] [Accepted: 11/27/2023] [Indexed: 12/25/2023]
Abstract
BACKGROUND CONTEXT With an increasing number of web-based calculators designed to provide the probabilities of an individual achieving improvement after lumbar spine surgery, there is a need to determine the accuracy of these models. PURPOSE To perform an internal and external validation study of the reduced Quality Outcomes Database web-based Calculator (QOD-Calc). STUDY DESIGN Observational longitudinal cohort. PATIENT SAMPLE Patients enrolled study-wide in Quality Outcomes Database (QOD) and patients enrolled in DaneSpine at a single institution who had elective lumbar spine surgery with baseline data to complete QOD-Calc and 12-month postoperative data. OUTCOME MEASURES Oswestry Disability Index (ODI), Numeric Rating Scales (NRS) for back and leg pain, EuroQOL-5D (EQ-5D). METHODS Baseline data elements were entered into QOD-Calc to determine the probability for each patient having Any Improvement and 30% Improvement in NRS leg pain, back pain, EQ-5D and ODI. These probabilities were compared with the actual 12-month postop data for each of the QOD and DaneSpine cases. Receiver-operating characteristics analyses were performed and calibration plots created to assess model performance. RESULTS 24,755 QOD cases and 8,105 DaneSpine lumbar cases were included in the analysis. QOD-Calc had acceptable to outstanding ability (AUC: 0.694-0.874) to predict Any Improvement in the QOD cohort and moderate to acceptable ability (AUC: 0.658-0.747) to predict 30% Improvement. QOD-Calc had acceptable to exceptional ability (AUC: 0.669-0.734) to predict Any improvement and moderate to exceptional ability (AUC: 0.619-0.862) to predict 30% Improvement in the DaneSpine cohort. AUCs for the DaneSpine cohort was consistently lower that the AUCs for the QOD validation cohort. CONCLUSION QOD-Calc performs well in predicting outcomes in a patient population that is similar to the patients that was used to develop it. Although still acceptable, model performance was slightly worse in a distinct population, despite the fact that the sample was more homogenous. Model performance may also be attributed to the low discrimination threshold, with close to 90% of cases reporting Any Improvement in outcome. Prediction models may need to be developed that are highly specific to the characteristics of the population.
Collapse
Affiliation(s)
- Leah Y Carreon
- Norton Leatherman Spine Center, 210 East Gray St, Suite 900, Louisville, KY, USA; Center for Spine Surgery and Research, Region of Southern Denmark, Østre Hougvej 55, DK-5500, Middelfart, Denmark; Institute of Regional Health Research, University of Southern Denmark, Winsløwparken 19, 3, DK-5000, Odense, Denmark.
| | - Hui Nian
- Department of Biostatistics, Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN, 37232, USA
| | - Kristin R Archer
- Center for Musculoskeletal Research, Vanderbilt Orthopaedic Institute, Vanderbilt University Medical Center, Nashville, TN, 37232 USA; Department of Physical Medicine and Rehabilitation, Osher Center for Integrative Health, Vanderbilt University Medical Center, 2201 Children's Way, Suite 1318, Nashville, TN, 37212, USA
| | - Mikkel Ø Andersen
- Center for Spine Surgery and Research, Region of Southern Denmark, Østre Hougvej 55, DK-5500, Middelfart, Denmark; Institute of Regional Health Research, University of Southern Denmark, Winsløwparken 19, 3, DK-5000, Odense, Denmark
| | - Karen Højmark Hansen
- Center for Spine Surgery and Research, Region of Southern Denmark, Østre Hougvej 55, DK-5500, Middelfart, Denmark
| | - Steven D Glassman
- Norton Leatherman Spine Center, 210 East Gray St, Suite 900, Louisville, KY, USA
| |
Collapse
|
9
|
Toh ZA, Berg B, Han QYC, Hey HWD, Pikkarainen M, Grotle M, He HG. Clinical Decision Support System Used in Spinal Disorders: Scoping Review. J Med Internet Res 2024; 26:e53951. [PMID: 38502157 PMCID: PMC10988379 DOI: 10.2196/53951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 01/29/2024] [Accepted: 02/10/2024] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND Spinal disorders are highly prevalent worldwide with high socioeconomic costs. This cost is associated with the demand for treatment and productivity loss, prompting the exploration of technologies to improve patient outcomes. Clinical decision support systems (CDSSs) are computerized systems that are increasingly used to facilitate safe and efficient health care. Their applications range in depth and can be found across health care specialties. OBJECTIVE This scoping review aims to explore the use of CDSSs in patients with spinal disorders. METHODS We used the Joanna Briggs Institute methodological guidance for this scoping review and reported according to the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) statement. Databases, including PubMed, Embase, Cochrane, CINAHL, Web of Science, Scopus, ProQuest, and PsycINFO, were searched from inception until October 11, 2022. The included studies examined the use of digitalized CDSSs in patients with spinal disorders. RESULTS A total of 4 major CDSS functions were identified from 31 studies: preventing unnecessary imaging (n=8, 26%), aiding diagnosis (n=6, 19%), aiding prognosis (n=11, 35%), and recommending treatment options (n=6, 20%). Most studies used the knowledge-based system. Logistic regression was the most commonly used method, followed by decision tree algorithms. The use of CDSSs to aid in the management of spinal disorders was generally accepted over the threat to physicians' clinical decision-making autonomy. CONCLUSIONS Although the effectiveness was frequently evaluated by examining the agreement between the decisions made by the CDSSs and the health care providers, comparing the CDSS recommendations with actual clinical outcomes would be preferable. In addition, future studies on CDSS development should focus on system integration, considering end user's needs and preferences, and external validation and impact studies to assess effectiveness and generalizability. TRIAL REGISTRATION OSF Registries osf.io/dyz3f; https://osf.io/dyz3f.
Collapse
Affiliation(s)
- Zheng An Toh
- National University Hospital, National University Health System, Singapore, Singapore
| | - Bjørnar Berg
- Centre for Intelligent Musculoskeletal Health, Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
| | | | - Hwee Weng Dennis Hey
- Division of Orthopaedic Surgery, National University Hospital, National University Health System, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Minna Pikkarainen
- Department of Rehabilitation and Health Technology, Oslo Metropolitan University, Oslo, Norway
- Martti Ahtisaari Institute, Oulu Business School, Oulu University, Oulu, Finland
- Department of Product Design, Oslo Metropolitan University, Oslo, Norway
| | - Margreth Grotle
- Centre for Intelligent Musculoskeletal Health, Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
- Department of Research and Innovation, Division of Clinical Neuroscience, Oslo University Hospital, Oslo, Norway
| | - Hong-Gu He
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| |
Collapse
|
10
|
Wang J, Liu M, Tian C, Gu J, Chen S, Huang Q, Lv P, Zhang Y, Li W. Elaboration and validation of a novelty nomogram for the prognostication of anxiety susceptibility in individuals suffering from low back pain. J Clin Neurosci 2024; 122:35-43. [PMID: 38461740 DOI: 10.1016/j.jocn.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 02/22/2024] [Accepted: 03/06/2024] [Indexed: 03/12/2024]
Abstract
Low back pain (LBP) constitutes a distressing emotional ordeal and serves as a potent catalyst for adverse emotional states, notably anxiety. We dedicated to discerning methodologies for identifying patients who are predisposed to heightened levels of anxiety and pain. A self-assessment questionnaire was administered to patients afflicted with LBP. The pain scores were subjected to analysis in conjunction with anxiety scores, and a clustering procedure was executed using the scientific k-means methodology. Subsequently, six machine learning algorithms, including Logistics Regression (LR), K-Nearest Neighbor (KNN), Decision Tree (DT), Support Vector Machine (SVM), Random Forest (RF), and Extreme Gradient Boosting (XGB), were employed. Next, five pertinent variables were identified, namely Age, Course, Body Mass Index (BMI), Education, and Marital status. Furthermore, a LR model was utilized to construct a nomogram, which was subsequently subjected to assessment for discrimination, calibration, and evaluation of its clinical utility. As a result, 599 questionnaires were valid (effective rate: 99 %). The correlation analysis revealed a significant association between anxiety and pain scores (r = 0.31, P < 0.001). LBP patients could be divided into two clusters, Cluster1 had higher pain scores (P < 0.05) and SAS scores (P < 0.001). The proposed nomogram demonstrated an area under the receiver operating characteristics curve (ROC) of 0.841 (95 %CI: 0.804-0.878) and 0.800 (95 %CI: 0.733-0.867) in the training and test groups, respectively. Briefly, the established nomogram has demonstrated remarkable proficiency in discerning individuals afflicted with LBP who are at a heightened risk of experiencing anxiety.
Collapse
Affiliation(s)
- Jian Wang
- Department of Neurosurgery, Tangdu Hospital, Affiliated Hospital of the Air Force Medical University, Xi'an, China
| | - Miaomiao Liu
- Department of Respiratory and Critical Care Medicine, Tangdu Hospital, Affiliated Hospital of the Air Force Medical University, Xi'an, China
| | - Chao Tian
- Department of Rehabilitation, Southeast Hospital, Affiliated Hospital of Xiamen University, Xiamen, China
| | - Junxiang Gu
- Department of Neurosurgery, the Second Affiliated Hospital of the Xi'an Jiaotong University, Xi'an, China
| | - Sihai Chen
- Department of Psychiatry, Xiaogan Mental Health Center, Xiaogan, China
| | - Qiujuan Huang
- Department of Rehabilitation, Southeast Hospital, Affiliated Hospital of Xiamen University, Xiamen, China
| | - Peiyuan Lv
- Department of Neurosurgery, Tangdu Hospital, Affiliated Hospital of the Air Force Medical University, Xi'an, China
| | - Yuhai Zhang
- Department of Health Statistics and Ministry of Education Key Lab of Hazard Assessment and Control in Special Operational, China.
| | - Weixin Li
- Department of Neurosurgery, Tangdu Hospital, Affiliated Hospital of the Air Force Medical University, Xi'an, China.
| |
Collapse
|
11
|
Licciardone JC, Miller CL, Nazzal AJ, Hernandez CT, Nguyen LH, Aryal S. Racial Disparities in Opioid Use and Lumbar Spine Surgery for Chronic Pain and in Pain and Function Over 3 Years: A Retrospective Cohort Study. THE JOURNAL OF PAIN 2024; 25:659-671. [PMID: 37777036 DOI: 10.1016/j.jpain.2023.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 09/13/2023] [Accepted: 09/26/2023] [Indexed: 10/02/2023]
Abstract
This study aims to compare treatments and outcomes among Black and White patients with chronic low back pain in the United States. A retrospective cohort study was conducted within a pain research registry, including 1,443 participants with up to 3 years of follow-up. Pain treatments were measured at quarterly research encounters using reported current opioid use and prior lumbar spine surgery. Pain intensity and functional disability were also measured quarterly with a numerical rating scale and the Roland-Morris Disability Questionnaire, respectively. Longitudinal data were analyzed with generalized estimating equations, including multivariable models to measure temporal trends and adjust for potential confounders. The mean baseline age of participants was 53.5 years (SD, 13.1 years); 1,074 (74.4%) were female, and 260 (18.0%) were Black. In longitudinal multivariable analyses, Black participants reported more frequent current opioid use (odds ratio, 1.40; 95% confidence interval [CI], 1.03-1.91; P = .03) and less frequent lumbar spine surgery (odds ratio, .45; 95% CI, .28-.72; P < .001). Black participants also reported greater pain intensity (mean, 6.6; 95% CI, 6.3-6.9 vs mean, 5.6; 95% CI, 5.4-5.8; P < .001) and functional disability (mean, 15.3; 95% CI, 14.6-16.0 vs mean, 13.8; 95% CI, 13.2-14.3; P = .002). Racial disparities were clinically important (risk ratio = 1.28 and risk ratio = .49, respectively, for opioid use and surgery; and d = .46 and d = .24, respectively, for pain and function). Racial disparities in pain and function also widened over time. Thus, barriers to guideline-adherent and specialized pain care among Black patients may affect pain and function outcomes. Greater efforts are needed to address the observed racial disparities. PERSPECTIVE: Widening racial disparities in pain and function over time indicate that new approaches to chronic pain management are needed in the United States. Considering race as a social framework represents an emerging strategy for planning and improving pain treatment services for Black patients.
Collapse
Affiliation(s)
- John C Licciardone
- Texas College of Osteopathic Medicine, University of North Texas Health Science Center, Fort Worth, Texas
| | - Chase L Miller
- Texas College of Osteopathic Medicine, University of North Texas Health Science Center, Fort Worth, Texas
| | - Alex J Nazzal
- Texas College of Osteopathic Medicine, University of North Texas Health Science Center, Fort Worth, Texas
| | - Christian T Hernandez
- Texas College of Osteopathic Medicine, University of North Texas Health Science Center, Fort Worth, Texas
| | - Linh H Nguyen
- Texas College of Osteopathic Medicine, University of North Texas Health Science Center, Fort Worth, Texas
| | - Subhash Aryal
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
12
|
Roca AM, Anwar FN, Khosla I, Medakkar SS, Loya AC, Sayari AJ, Lopez GD, Singh K. Utility of preoperative comorbidity burden on PROMIS outcomes after lumbar decompression: Cohort matched analysis. J Clin Neurosci 2024; 121:23-27. [PMID: 38335824 DOI: 10.1016/j.jocn.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 02/01/2024] [Indexed: 02/12/2024]
Abstract
The influence of Charlson Comorbidity Index (CCI) burden on Patient-Reported Outcomes Measurement Information System (PROMIS) outcomes following lumbar decompression (LD) is limited. The objective of this study is to evaluate CCI burden impact on PROMIS outcomes. Retrospective review of elective LD excluding revision or surgeries for infectious, malignant, or traumatic reasons. Demographics and PROMIS scores collected preoperatively and postoperatively up to 2 years included: PROMIS-Physical Function (PF)/Sleep Disturbance (SD)/Pain Interference (PI)/Anxiety (A), VR-12 Physical/Mental Health Composite scores (VR-12 PCS/MCS)/Oswestry Disability Index (ODI). Patients were divided into two groups based on their preoperative CCI score <3 (mild) or ≥4 (moderate to severe). Descriptive statistical analysis and MCID achievement rate calculations were conducted. A total of 182 patients were included: 93 CCI < 3 and 88 CCI ≥ 4. No significant differences were reported across preoperative PROMIS/legacy PROMs or final follow-up (p > 0.05, all). At 6-weeks, VR-12 PCS and ΔPROM scores indicated improved physician function in the CCI < 3 group (p = 0.020 and p = 0.040, respectively). Significant PROMIS-A ΔPROM score at final post-op was noted for CCI < 3 group (p = 0.026). MCID achievement demonstrated no significant differences for PROMIS outcomes and legacy PROMs. Results demonstrated that PROMIS outcomes were not impacted by a greater baseline comorbidity burden. At 6-weeks, the physical function scores were improved for the lower CCI group, and at final reported less anxiety. Our data suggests that comorbidity burden has a limited effect on PROMIS and legacy outcomes in patients undergoing LD.
Collapse
Affiliation(s)
- Andrea M Roca
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St. Suite #300, Chicago, IL 60612, United States
| | - Fatima N Anwar
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St. Suite #300, Chicago, IL 60612, United States
| | - Ishan Khosla
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St. Suite #300, Chicago, IL 60612, United States
| | - Srinath S Medakkar
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St. Suite #300, Chicago, IL 60612, United States
| | - Alexandra C Loya
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St. Suite #300, Chicago, IL 60612, United States
| | - Arash J Sayari
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St. Suite #300, Chicago, IL 60612, United States
| | - Gregory D Lopez
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St. Suite #300, Chicago, IL 60612, United States
| | - Kern Singh
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St. Suite #300, Chicago, IL 60612, United States.
| |
Collapse
|
13
|
Javeed S, Benedict B, Yakdan S, Saleem S, Zhang JK, Botterbush K, Frumkin MR, Hardi A, Neuman B, Kelly MP, Steinmetz MP, Piccirillo JF, Goodin BR, Rodebaugh TL, Ray WZ, Greenberg JK. Implications of Preoperative Depression for Lumbar Spine Surgery Outcomes: A Systematic Review and Meta-Analysis. JAMA Netw Open 2024; 7:e2348565. [PMID: 38277149 PMCID: PMC10818221 DOI: 10.1001/jamanetworkopen.2023.48565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 11/07/2023] [Indexed: 01/27/2024] Open
Abstract
Importance Comorbid depression is common among patients with degenerative lumbar spine disease. Although a well-researched topic, the evidence of the role of depression in spine surgery outcomes remains inconclusive. Objective To investigate the association between preoperative depression and patient-reported outcome measures (PROMs) after lumbar spine surgery. Data Sources A systematic search of PubMed, Cochrane Database of Systematic Reviews, Embase, Scopus, PsychInfo, Web of Science, and ClinicalTrials.gov was performed from database inception to September 14, 2023. Study Selection Included studies involved adults undergoing lumbar spine surgery and compared PROMs in patients with vs those without depression. Studies evaluating the correlation between preoperative depression and disease severity were also included. Data Extraction and Synthesis All data were independently extracted by 2 authors and independently verified by a third author. Study quality was assessed using Newcastle-Ottawa Scale. Random-effects meta-analysis was used to synthesize data, and I2 was used to assess heterogeneity. Metaregression was performed to identify factors explaining the heterogeneity. Main Outcomes and Measures The primary outcome was the standardized mean difference (SMD) of change from preoperative baseline to postoperative follow-up in PROMs of disability, pain, and physical function for patients with vs without depression. Secondary outcomes were preoperative and postoperative differences in absolute disease severity for these 2 patient populations. Results Of the 8459 articles identified, 44 were included in the analysis. These studies involved 21 452 patients with a mean (SD) age of 57 (8) years and included 11 747 females (55%). Among these studies, the median (range) follow-up duration was 12 (6-120) months. The pooled estimates of disability, pain, and physical function showed that patients with depression experienced a greater magnitude of improvement compared with patients without depression, but this difference was not significant (SMD, 0.04 [95% CI, -0.02 to 0.10]; I2 = 75%; P = .21). Nonetheless, patients with depression presented with worse preoperative disease severity in disability, pain, and physical function (SMD, -0.52 [95% CI, -0.62 to -0.41]; I2 = 89%; P < .001), which remained worse postoperatively (SMD, -0.52 [95% CI, -0.75 to -0.28]; I2 = 98%; P < .001). There was no significant correlation between depression severity and the primary outcome. A multivariable metaregression analysis suggested that age, sex (male to female ratio), percentage of comorbidities, and follow-up attrition were significant sources of variance. Conclusions and Relevance Results of this systematic review and meta-analysis suggested that, although patients with depression had worse disease severity both before and after surgery compared with patients without depression, they had significant potential for recovery in disability, pain, and physical function. Further investigations are needed to examine the association between spine-related disability and depression as well as the role of perioperative mental health treatments.
Collapse
Affiliation(s)
- Saad Javeed
- Department of Neurological Surgery, Washington University, St Louis, Missouri
| | - Braeden Benedict
- Department of Neurological Surgery, Washington University, St Louis, Missouri
| | - Salim Yakdan
- Department of Neurological Surgery, Washington University, St Louis, Missouri
| | - Samia Saleem
- Department of Musculoskeletal Research, Washington University, St Louis, Missouri
| | - Justin K. Zhang
- Department of Neurological Surgery, Washington University, St Louis, Missouri
| | - Kathleen Botterbush
- Department of Neurological Surgery, Washington University, St Louis, Missouri
| | - Madelyn R. Frumkin
- Department of Psychology and Brain Sciences, Washington University, St Louis, Missouri
| | - Angela Hardi
- Becker Medical Library, Washington University, St Louis, Missouri
| | - Brian Neuman
- Department of Orthopedic Surgery, Washington University, St Louis, Missouri
| | - Michael P. Kelly
- Department of Orthopedic Surgery, Rady Children’s Hospital, University of California, San Diego, San Diego
| | | | - Jay F. Piccirillo
- Department of Otolaryngology, Washington University, St Louis, Missouri
| | - Burel R. Goodin
- Department of Anesthesiology, Washington University, St Louis, Missouri
| | - Thomas L. Rodebaugh
- Department of Psychology and Brain Sciences, Washington University, St Louis, Missouri
| | - Wilson Z. Ray
- Department of Neurological Surgery, Washington University, St Louis, Missouri
| | - Jacob K. Greenberg
- Department of Neurological Surgery, Washington University, St Louis, Missouri
- Department of Neurological Surgery, Cleveland Clinic, Cleveland, Ohio
| |
Collapse
|
14
|
Bovonratwet P, Vaishnav AS, Mok JK, Urakawa H, Dupont M, Melissaridou D, Shahi P, Song J, Shinn DJ, Dalal SS, Araghi K, Sheha ED, Gang CH, Qureshi SA. Association Between Patient Reported Outcomes Measurement Information System Physical Function With Postoperative Pain, Narcotics Consumption, and Patient-Reported Outcome Measures Following Lumbar Microdiscectomy. Global Spine J 2024; 14:225-234. [PMID: 35623628 PMCID: PMC10676173 DOI: 10.1177/21925682221103497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE To determine association between preoperative Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF) scores with postoperative pain, narcotics consumption, and patient-reported outcome measures (PROMs) following single-level lumbar microdiscectomy. METHODS Consecutive patients who underwent single-level lumbar microdiscectomy were identified from May 2017-May 2020. Patients were grouped by their preoperative PROMIS-PF scores: mild disability (score≥40), moderate disability (score 30-39.9), and severe disability (score<30). Preoperative PROMIS-PF subgroups were tested for association with inpatient postoperative pain, total inpatient narcotics consumption, time to narcotic use cessation as well as improvements in postoperative PROMIS-PF, ODI, VAS-Leg Pain, VAS-Back Pain, SF-12 Physical Component Score (PCS), SF-12 Mental Component Score (MCS) at 2-, 6-, 12-weeks, 6-month, 1-year, 2-year follow-up. RESULTS A total of 127 patients were included. Patients with greater disability reported higher inpatient maximum Visual Analog Scale (VAS) pain scores (P = .023) and total inpatient narcotics consumption (P = .008) but no difference in time to narcotic cessation after surgery (P = .373). However, patients with greater preoperative disability also demonstrated greater improvement from baseline in PROMIS-PF, ODI, SF-12 PCS, and SF-12 MCS at 2-week follow-up (P < .05). These higher improvements from baseline for patients with greater preoperative disability were sustained for PROMIS-PF, ODI, and VAS-Leg Pain at 2-year follow-up (P < .05). CONCLUSIONS Patients with greater preoperative disability, as measured by PROMIS-PF, had increased inpatient postoperative pain and narcotics consumption, but also higher improvement from baseline in long-term PROMs. This data can be utilized for patient counseling and setting expectations.
Collapse
Affiliation(s)
- Patawut Bovonratwet
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Avani S. Vaishnav
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Jung K. Mok
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Hikari Urakawa
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Marcel Dupont
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY, USA
| | | | - Pratyush Shahi
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Junho Song
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Daniel J. Shinn
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Sidhant S. Dalal
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Kasra Araghi
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Evan D. Sheha
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Catherine H. Gang
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Sheeraz A. Qureshi
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY, USA
| |
Collapse
|
15
|
Geere JH, Hunter PR, Swamy GN, Cook AJ, Rai AS. Development and temporal validation of clinical prediction models for 1-year disability and pain after lumbar decompressive surgery. The Norwich Lumbar Surgery Predictor (development version). EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:4210-4219. [PMID: 37740114 DOI: 10.1007/s00586-023-07931-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 08/21/2023] [Accepted: 08/28/2023] [Indexed: 09/24/2023]
Abstract
PURPOSE To identify clinical predictors and build prediction models for 1-year patient-reported outcomes measures (PROMs) after lumbar decompressive surgery for disc herniation or spinal stenosis. METHODS The study included 1835 cases, with or without additional single-level fusion, from a single centre from 2008 through 2020. General linear models imputed with 37 clinical variables identified 18 significant 1-year PROM predictors for retention in development models. Interaction of surgical indication with each predictor was tested. Temporal validation was conducted at the same centre on cases through 2021. R2 was used to measure goodness-of-fit, and area under curve (AUC) used to measure classification to a satisfactory symptom state (Oswestry Disability Index (ODI) ≤ 22; back or leg pain ≤ 30 out of 100). RESULTS A total 1228 (67%) had complete data for inclusion in model development. Predictors of ODI were baseline PROMs (ODI, back pain, leg pain), work status, condition duration, previous lumbar operation, multiple-joint osteoarthritis, female, diabetes, current smoker, rheumatic disorder, lower limb arthroplasty, mobility aided, provider status, facet cyst, scoliosis, and age, with BMI significantly associated with stenosis. Temporal validation (n = 188) found the ODI model R2 was 0.29 (95% confidence intervals (CI) 0.18-0.40) and AUC was 0.74 (95% CI 0.67-0.81). Back and leg pain models had lower R2 (0.12-0.14) and AUC (0.68-0.69) values. CONCLUSION Important PROM predictors are baseline PROMs, specific co-morbidities, work status, condition duration, previous lumbar operation, female, and smoking status. The ODI model predicted the likelihood of achieving a satisfactory state of both disability and pain.
Collapse
Affiliation(s)
- Jonathan H Geere
- Physiotherapy Department, Spire Norwich Hospital, Old Watton Road, Colney, Norwich, NR4 7TD, UK.
| | - Paul R Hunter
- Norwich Medical School, University of East Anglia, Norwich, UK
| | | | | | | |
Collapse
|
16
|
Wathen CA, Gallagher RS, Borja AJ, Malhotra EG, Collier T, Na J, McClintock SD, Yoon JW, Ozturk AK, Schuster JM, Welch WC, Marcotte PJ, Malhotra NR. Relationship Between Comorbidity Burden and Short-Term Outcomes Across 4680 Consecutive Spinal Fusions. World Neurosurg 2023; 180:e84-e90. [PMID: 37597658 DOI: 10.1016/j.wneu.2023.08.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 08/09/2023] [Accepted: 08/10/2023] [Indexed: 08/21/2023]
Abstract
OBJECTIVE Preoperative management requires the identification and optimization of modifiable medical comorbidities, though few studies isolate comorbid status from related patient-level variables. This study evaluates Charlson Comorbidity Index (CCI)-an easily derived measure of aggregate medical comorbidity-to predict outcomes from spinal fusion surgery. Coarsened exact matching is employed to control for key patient characteristics and isolate CCI. METHODS We retrospectively assessed 4680 consecutive patients undergoing single-level, posterior-only lumbar fusion at a single academic center. Logistic regression evaluated the univariate relationship between CCI and patient outcomes. Coarsened exact matching generated exact demographic matches between patients with high comorbid status (CCI >6) or no medical comorbidities (matched n = 524). Patients were matched 1:1 on factors associated with surgical outcomes, and outcomes were compared between matched cohorts. Primary outcomes included surgical complications, discharge status, 30- and 90-day risk of readmission, emergency department (ED) visits, reoperation, and mortality. RESULTS Univariate regression of increasing CCI was significantly associated with non-home discharge, as well as 30- and 90-day readmission, ED visits, and mortality (all P < 0.05). Subsequent isolation of comorbidity between otherwise exact-matched cohorts found comorbid status did not affect readmissions, reoperations, or mortality; high CCI score was significantly associated with non-home discharge (OR = 2.50, P < 0.001) and 30-day (OR = 2.44, P = 0.02) and 90-day (OR = 2.29, P = 0.008) ED evaluation. CONCLUSIONS Comorbidity, measured by CCI, did not increase the risk of readmission, reoperation, or mortality. Single-level, posterior lumbar fusions may be safe in appropriately selected patients regardless of comorbid status. Future studies should determine whether CCI can guide discharge planning and postoperative optimization.
Collapse
Affiliation(s)
- Connor A Wathen
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Ryan S Gallagher
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Austin J Borja
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Emelia G Malhotra
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Tara Collier
- McKenna EpiLog Fellowship in Population Health, at the University of Pennsylvania, Philadelphia, USA
| | - Jianbo Na
- McKenna EpiLog Fellowship in Population Health, at the University of Pennsylvania, Philadelphia, USA
| | - Scott D McClintock
- West Chester University, The West Chester Statistical Institute and Department of Mathematics, West Chester, Pennsylvania, USA
| | - Jang W Yoon
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Ali K Ozturk
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - James M Schuster
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - William C Welch
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Paul J Marcotte
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Neil R Malhotra
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA.
| |
Collapse
|
17
|
Saravi B, Zink A, Ülkümen S, Couillard-Despres S, Wollborn J, Lang G, Hassel F. Clinical and radiomics feature-based outcome analysis in lumbar disc herniation surgery. BMC Musculoskelet Disord 2023; 24:791. [PMID: 37803313 PMCID: PMC10557221 DOI: 10.1186/s12891-023-06911-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 09/24/2023] [Indexed: 10/08/2023] Open
Abstract
BACKGROUND Low back pain is a widely prevalent symptom and the foremost cause of disability on a global scale. Although various degenerative imaging findings observed on magnetic resonance imaging (MRI) have been linked to low back pain and disc herniation, none of them can be considered pathognomonic for this condition, given the high prevalence of abnormal findings in asymptomatic individuals. Nevertheless, there is a lack of knowledge regarding whether radiomics features in MRI images combined with clinical features can be useful for prediction modeling of treatment success. The objective of this study was to explore the potential of radiomics feature analysis combined with clinical features and artificial intelligence-based techniques (machine learning/deep learning) in identifying MRI predictors for the prediction of outcomes after lumbar disc herniation surgery. METHODS We included n = 172 patients who underwent discectomy due to disc herniation with preoperative T2-weighted MRI examinations. Extracted clinical features included sex, age, alcohol and nicotine consumption, insurance type, hospital length of stay (LOS), complications, operation time, ASA score, preoperative CRP, surgical technique (microsurgical versus full-endoscopic), and information regarding the experience of the performing surgeon (years of experience with the surgical technique and the number of surgeries performed at the time of surgery). The present study employed a semiautomatic region-growing volumetric segmentation algorithm to segment herniated discs. In addition, 3D-radiomics features, which characterize phenotypic differences based on intensity, shape, and texture, were extracted from the computed magnetic resonance imaging (MRI) images. Selected features identified by feature importance analyses were utilized for both machine learning and deep learning models (n = 17 models). RESULTS The mean accuracy over all models for training and testing in the combined feature set was 93.31 ± 4.96 and 88.17 ± 2.58. The mean accuracy for training and testing in the clinical feature set was 91.28 ± 4.56 and 87.69 ± 3.62. CONCLUSIONS Our results suggest a minimal but detectable improvement in predictive tasks when radiomics features are included. However, the extent of this advantage should be considered with caution, emphasizing the potential of exploring multimodal data inputs in future predictive modeling.
Collapse
Affiliation(s)
- Babak Saravi
- Department of Orthopedics and Trauma Surgery, Faculty of Medicine, Medical Center - University of Freiburg, University of Freiburg, Freiburg, Germany.
- Department of Spine Surgery, Loretto Hospital, Freiburg, Germany.
- Institute of Experimental Neuroregeneration, Spinal Cord Injury and Tissue Regeneration Center Salzburg (SCI-TReCS), Paracelsus Medical University, Salzburg, 5020, Austria.
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, USA.
| | - Alisia Zink
- Department of Spine Surgery, Loretto Hospital, Freiburg, Germany
| | - Sara Ülkümen
- Department of Orthopedics and Trauma Surgery, Faculty of Medicine, Medical Center - University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Sebastien Couillard-Despres
- Institute of Experimental Neuroregeneration, Spinal Cord Injury and Tissue Regeneration Center Salzburg (SCI-TReCS), Paracelsus Medical University, Salzburg, 5020, Austria
- Austrian Cluster for Tissue Regeneration, Vienna, Austria
| | - Jakob Wollborn
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Gernot Lang
- Department of Orthopedics and Trauma Surgery, Faculty of Medicine, Medical Center - University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Frank Hassel
- Department of Spine Surgery, Loretto Hospital, Freiburg, Germany
| |
Collapse
|
18
|
Tragaris T, Benetos IS, Vlamis J, Pneumaticos S. Machine Learning Applications in Spine Surgery. Cureus 2023; 15:e48078. [PMID: 38046496 PMCID: PMC10689893 DOI: 10.7759/cureus.48078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2023] [Indexed: 12/05/2023] Open
Abstract
This literature review sought to identify and evaluate the current applications of artificial intelligence (AI)/machine learning (ML) in spine surgery that can effectively guide clinical decision-making and surgical planning. By using specific keywords to maximize search sensitivity, a thorough literature research was conducted in several online databases: Scopus, PubMed, and Google Scholar, and the findings were filtered according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A total of 46 studies met the requirements and were included in this review. According to this study, AI/ML models were sufficiently accurate with a mean overall value of 74.9%, and performed best at preoperative patient selection, cost prediction, and length of stay. Performance was also good at predicting functional outcomes and postoperative mortality. Regression analysis was the most frequently utilized application whereas deep learning/artificial neural networks had the highest sensitivity score (81.5%). Despite the relatively brief history of engagement with AI/ML, as evidenced by the fact that 77.5% of studies were published after 2018, the outcomes have been promising. In light of the Big Data era, the increasing prevalence of National Registries, and the wide-ranging applications of AI, such as exemplified by ChatGPT (OpenAI, San Francisco, California), it is highly likely that the field of spine surgery will gradually adopt and integrate AI/ML into its clinical practices. Consequently, it is of great significance for spine surgeons to acquaint themselves with the fundamental principles of AI/ML, as these technologies hold the potential for substantial improvements in overall patient care.
Collapse
Affiliation(s)
- Themistoklis Tragaris
- 1st Department of Orthopaedic Surgery, National and Kapodistrian University of Athens School of Medicine, KAT Hospital, Athens, GRC
| | - Ioannis S Benetos
- 3rd Department of Orthopaedic Surgery, National and Kapodistrian University of Athens School of Medicine, KAT Hospital, Athens, GRC
| | - John Vlamis
- 3rd Department of Orthopaedic Surgery, National and Kapodistrian University of Athens School of Medicine, KAT Hospital, Athens, GRC
| | - Spyridon Pneumaticos
- 3rd Department of Orthopaedic Surgery, National and Kapodistrian University of Athens School of Medicine, KAT Hospital, Athens, GRC
| |
Collapse
|
19
|
Fritz JM, Rhon DI, Garland EL, Hanley AW, Greenlee T, Fino N, Martin B, Highland KB, Greene T. The Effectiveness of a Mindfulness-Based Intervention Integrated with Physical Therapy (MIND-PT) for Postsurgical Rehabilitation After Lumbar Surgery: A Protocol for a Randomized Controlled Trial as Part of the Back Pain Consortium (BACPAC) Research Program. PAIN MEDICINE (MALDEN, MASS.) 2023; 24:S115-S125. [PMID: 36069630 PMCID: PMC10403309 DOI: 10.1093/pm/pnac138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 08/23/2022] [Accepted: 08/30/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND Improving pain management for persons with chronic low back pain (LBP) undergoing surgery is an important consideration in improving patient-centered outcomes and reducing the risk of persistent opioid use after surgery. Nonpharmacological treatments, including physical therapy and mindfulness, are beneficial for nonsurgical LBP through complementary biopsychosocial mechanisms, but their integration and application for persons undergoing surgery for LBP have not been examined. This study (MIND-PT) is a multisite randomized trial that compares an enriched pain management (EPM) pathway that integrates physical therapy and mindfulness vs usual-care pain management (UC) for persons undergoing surgery for LBP. DESIGN Participants from military treatment facilities will be enrolled before surgery and individually randomized to the EPM or UC pain management pathways. Participants assigned to EPM will receive presurgical biopsychosocial education and mindfulness instruction. After surgery, the EPM group will receive 10 sessions of physical therapy with integrated mindfulness techniques. Participants assigned to the UC group will receive usual pain management care after surgery. The primary outcome will be the pain impact, assessed with the Pain, Enjoyment, and General Activity (PEG) scale. Time to opioid discontinuation is the main secondary outcome. SUMMARY This trial is part of the National Institutes of Health Helping to End Addiction Long-term (HEAL) initiative, which is focused on providing scientific solutions to the opioid crisis. The MIND-PT study will examine an innovative program combining nonpharmacological treatments designed to improve outcomes and reduce opioid overreliance in persons undergoing lumbar surgery.
Collapse
Affiliation(s)
- Julie M Fritz
- Department of Physical Therapy & Athletic Training, The University of Utah, Salt Lake City, Utah
| | - Daniel I Rhon
- Department of Rehabilitation Medicine, Brooke Army Medical Center, San Antonio, Texas
- Department of Rehabilitation Medicine, Uniformed Services University of Health Sciences, Bethesda, Maryland
| | - Eric L Garland
- College of Social Work, The University of Utah, Salt Lake City, Utah
| | - Adam W Hanley
- College of Social Work, The University of Utah, Salt Lake City, Utah
| | - Tina Greenlee
- Department of Rehabilitation Medicine, Brooke Army Medical Center, San Antonio, Texas
| | - Nora Fino
- Department of Population Health Sciences, The University of Utah, Salt Lake City, Utah
| | - Brook Martin
- Department of Orthopedics, School of Medicine, The University of Utah, Salt Lake City, Utah
| | - Krista B Highland
- Department of Orthopedics, School of Medicine, The University of Utah, Salt Lake City, Utah
- Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, Uniformed Services University, Bethesda, Maryland
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Rockville, Maryland, USA
| | - Tom Greene
- Department of Population Health Sciences, The University of Utah, Salt Lake City, Utah
| |
Collapse
|
20
|
Iroz CB, Johnson JK, Ager MS, Joung RHS, Brajcich BC, Cella D, Franklin PD, Holl JL, Bilimoria KY, Merkow RP. Barriers and Facilitators to Implementing Patient-Reported Outcome Monitoring in Gastrointestinal Surgery. J Surg Res 2023; 288:341-349. [PMID: 37060860 PMCID: PMC11187775 DOI: 10.1016/j.jss.2023.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 02/13/2023] [Accepted: 03/09/2023] [Indexed: 04/17/2023]
Abstract
INTRODUCTION More than 30% of patients experience complications after major gastrointestinal (GI) surgery, many of which occur after discharge when patients and families must assume responsibility for monitoring. Patient-reported outcomes (PROs) have been proposed as a tool for remote monitoring to identify deviations in recovery, and recognize and manage complications earlier. This study's objective was to characterize barriers and facilitators to the use of PROs as a patient monitoring tool following GI surgery. METHODS We conducted semistructured interviews with GI surgery patients and clinicians (surgeons, nurses, and advanced practitioners). Patients and clinicians were asked to describe their experience using a PRO monitoring system in three surgical oncology clinics. Using a phenomenological approach, research team dyads independently coded the transcripts using an inductively developed codebook and the constant comparative approach with differences reconciled by consensus. RESULTS Ten patients and five clinicians participated in the interviews. We identified four overarching themes related to functionality, workflow, meaningfulness, and actionability. Functionality refers to barriers faced by clinicians and patients in using the PRO technology. Workflow represents problematic integration of PROs into the clinical workflow and need for setting expectations with patients. Meaningfulness refers to lack of patient and clinician understanding of the impact of PROs on patient care. Finally, actionability reflects barriers to follow-up and practical use of PRO data. CONCLUSIONS While use of PRO systems for postoperative patient monitoring have expanded, significant barriers persist for both patients and clinicians. Implementation enhancements are needed to optimize functionality, workflow, meaningfulness, and actionability.
Collapse
Affiliation(s)
- Cassandra B Iroz
- Department of Surgery, Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Julie K Johnson
- Department of Surgery, Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Rachel Hae-Soo Joung
- Department of Surgery, Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Brian C Brajcich
- Department of Surgery, Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - David Cella
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Patricia D Franklin
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jane L Holl
- Biological Sciences Division, The University of Chicago, Chicago, Illinois
| | - Karl Y Bilimoria
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Ryan P Merkow
- Department of Surgery, Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Northwestern University Feinberg School of Medicine, Chicago, Illinois; Biological Sciences Division, The University of Chicago, Chicago, Illinois; Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, Illinois.
| |
Collapse
|
21
|
Nie JW, Hartman TJ, Oyetayo OO, MacGregor KR, Zheng E, Federico VP, Massel DH, Sayari AJ, Singh K. Perioperative Predictors in Patients Undergoing Lateral Lumbar Interbody Fusion for Minimum Clinically Important Difference Achievement. World Neurosurg 2023; 175:e914-e924. [PMID: 37080454 DOI: 10.1016/j.wneu.2023.04.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 04/10/2023] [Accepted: 04/11/2023] [Indexed: 04/22/2023]
Abstract
OBJECTIVE 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). METHODS 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. RESULTS 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. CONCLUSIONS 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.
Collapse
Affiliation(s)
- James W Nie
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Timothy J Hartman
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Omolabake O Oyetayo
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Keith R MacGregor
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Eileen Zheng
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Vincent P Federico
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Dustin H Massel
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Arash J Sayari
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Kern Singh
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA.
| |
Collapse
|
22
|
Rushton AB, Jadhakhan F, Verra ML, Emms A, Heneghan NR, Falla D, Reddington M, Cole AA, Willems PC, Benneker L, Selvey D, Hutton M, Heymans MW, Staal JB. Predictors of poor outcome following lumbar spinal fusion surgery: a prospective observational study to derive two clinical prediction rules using British Spine Registry data. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:2303-2318. [PMID: 37237240 DOI: 10.1007/s00586-023-07754-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 01/14/2023] [Accepted: 05/01/2023] [Indexed: 05/28/2023]
Abstract
PURPOSE Lumbar spinal fusion surgery (LSFS) is common for lumbar degenerative disorders. The objective was to develop clinical prediction rules to identify which patients are likely to have a favourable outcome to inform decisions regarding surgery and rehabilitation. METHODS A prospective observational study recruited 600 (derivation) and 600 (internal validation) consecutive adult patients undergoing LSFS for degenerative lumbar disorder through the British Spine Registry. Definition of good outcome (6 weeks, 12 months) was reduction in pain intensity (Numerical Rating Scale, 0-10) and disability (Oswestry Disability Index, ODI 0-50) > 1.7 and 14.3, respectively. Linear and logistic regression models were fitted and regression coefficients, Odds ratios and 95% CIs reported. RESULTS Lower BMI, higher ODI and higher leg pain pre-operatively were predictive of good disability outcome, higher back pain was predictive of good back pain outcome, and no previous surgery and higher leg pain were predictive of good leg pain outcome; all at 6 weeks. Working and higher leg pain were predictive of good ODI and leg pain outcomes, higher back pain was predictive of good back pain outcome, and higher leg pain was predictive of good leg pain outcome at 12 months. Model performance demonstrated reasonable to good calibration and adequate/very good discrimination. CONCLUSIONS BMI, ODI, leg and back pain and previous surgery are important considerations pre-operatively to inform decisions for surgery. Pre-operative leg and back pain and work status are important considerations to inform decisions for management following surgery. Findings may inform clinical decision making regarding LSFS and associated rehabilitation.
Collapse
Affiliation(s)
- Alison B Rushton
- School of Physical Therapy, Faculty of Health Sciences, Western University, London, ON, Canada.
- Centre of Precision Rehabilitation for Spinal Pain (CPR Spine), School of Sport Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK.
| | - Feroz Jadhakhan
- Centre of Precision Rehabilitation for Spinal Pain (CPR Spine), School of Sport Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| | - Martin L Verra
- Department of Physiotherapy, Berne University Hospital, Bern, Switzerland
| | - Andrew Emms
- Department of Physiotherapy, The Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK
| | - Nicola R Heneghan
- Centre of Precision Rehabilitation for Spinal Pain (CPR Spine), School of Sport Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| | - Deborah Falla
- Centre of Precision Rehabilitation for Spinal Pain (CPR Spine), School of Sport Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| | - Michael Reddington
- Physiotherapy Department, Sheffield Teaching Hospitals NHS Trust, Northern General Hospital, Sheffield, UK
| | - Ashley A Cole
- Department of Orthopaedics and Trauma, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Paul C Willems
- Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Lorin Benneker
- Department of Orthopaedic Surgery Inselspital, University of Bern, Bern, Switzerland
| | - David Selvey
- Amplitude Clinical, Host of the British Spine Registry, Droitwich, UK
| | - Michael Hutton
- Princess Elizabeth Orthopaedic Centre (PEOC), Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Martijn W Heymans
- Department of Epidemiology and Biostatistics, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - J Bart Staal
- Radboud Institute for Health Sciences, IQ Healthcare, Radboud University Medical Centre, Nijmegen, The Netherlands
| |
Collapse
|
23
|
Jiang X, Gu L, Xu G, Cao X, Jiang J, Zhang D, Xu M, Yan Y. Nomogram for predicting the unfavourable outcomes of percutaneous endoscopic transforaminal discectomy for lumbar disc herniation: a retrospective study. Front Surg 2023; 10:1188517. [PMID: 37334203 PMCID: PMC10272560 DOI: 10.3389/fsurg.2023.1188517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 05/19/2023] [Indexed: 06/20/2023] Open
Abstract
Objective To investigate and integrate multiple independent risk factors to establish a nomogram for predicting the unfavourable outcomes of percutaneous endoscopic transforaminal discectomy (PETD) for lumbar disc herniation (LDH). Methods From January 2018 to December 2019, a total of 425 patients with LDH undergoing PETD were included in this retrospective study. All patients were divided into the development and validation cohort at a ratio of 4:1. Univariate and multivariate logistic regression analyses were used to investigate the independent risk factors associated with the clinical outcomes of PETD for LDH in the development cohort, and a prediction model (nomogram) was established to predict the unfavourable outcomes of PETD for LDH. In the validation cohort, the nomogram was validated by the concordance index (C-index), calibration curve, and decision curve analysis (DCA). Results 29 of 340 patients showed unfavourable outcomes in the development cohort, and 7 of 85 patients showed unfavourable outcomes in the validation cohort. Body mass index (BMI), course of disease (COD), protrusion calcification (PC), and preoperative lumbar epidural steroid injection (LI) were independent risk factors associated with the unfavourable outcomes of PETD for LDH and were identified as predictors for the nomogram. The nomogram was validated by the validation cohort and showed high consistency (C-index = 0.674), good calibration and high clinical value. Conclusions The nomogram based on patients' preoperative clinical characteristics, including BMI, COD, LI and PC, can be used to accurately predict the unfavourable outcomes of PETD for LDH.
Collapse
Affiliation(s)
- Xiaofeng Jiang
- Department of Radiology, The First Affiliated Hospital of Nanchang University, Nanchang, China
- Institute of Pain Medicine, Jiangxi Academy of Clinical and Medical Sciences, Nanchang, China
| | - Lili Gu
- Institute of Pain Medicine, Jiangxi Academy of Clinical and Medical Sciences, Nanchang, China
- Department of Pain Medicine, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Gang Xu
- Institute of Pain Medicine, Jiangxi Academy of Clinical and Medical Sciences, Nanchang, China
- Department of Pain Medicine, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Xuezhong Cao
- Institute of Pain Medicine, Jiangxi Academy of Clinical and Medical Sciences, Nanchang, China
- Department of Pain Medicine, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Jian Jiang
- Department of Radiology, The First Affiliated Hospital of Nanchang University, Nanchang, China
- Institute of Pain Medicine, Jiangxi Academy of Clinical and Medical Sciences, Nanchang, China
| | - Daying Zhang
- Institute of Pain Medicine, Jiangxi Academy of Clinical and Medical Sciences, Nanchang, China
- Department of Pain Medicine, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Mu Xu
- Institute of Pain Medicine, Jiangxi Academy of Clinical and Medical Sciences, Nanchang, China
- Department of Pain Medicine, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yi Yan
- Institute of Pain Medicine, Jiangxi Academy of Clinical and Medical Sciences, Nanchang, China
- Department of Pain Medicine, The First Affiliated Hospital of Nanchang University, Nanchang, China
| |
Collapse
|
24
|
Chiu PF, Chang RCH, Lai YC, Wu KC, Wang KP, Chiu YP, Ji HR, Kao CH, Chiu CD. Machine Learning Assisting the Prediction of Clinical Outcomes following Nucleoplasty for Lumbar Degenerative Disc Disease. Diagnostics (Basel) 2023; 13:diagnostics13111863. [PMID: 37296715 DOI: 10.3390/diagnostics13111863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 05/23/2023] [Accepted: 05/23/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND Lumbar degenerative disc disease (LDDD) is a leading cause of chronic lower back pain; however, a lack of clear diagnostic criteria and solid LDDD interventional therapies have made predicting the benefits of therapeutic strategies challenging. Our goal is to develop machine learning (ML)-based radiomic models based on pre-treatment imaging for predicting the outcomes of lumbar nucleoplasty (LNP), which is one of the interventional therapies for LDDD. METHODS The input data included general patient characteristics, perioperative medical and surgical details, and pre-operative magnetic resonance imaging (MRI) results from 181 LDDD patients receiving lumbar nucleoplasty. Post-treatment pain improvements were categorized as clinically significant (defined as a ≥80% decrease in the visual analog scale) or non-significant. To develop the ML models, T2-weighted MRI images were subjected to radiomic feature extraction, which was combined with physiological clinical parameters. After data processing, we developed five ML models: support vector machine, light gradient boosting machine, extreme gradient boosting, extreme gradient boosting random forest, and improved random forest. Model performance was measured by evaluating indicators, such as the confusion matrix, accuracy, sensitivity, specificity, F1 score, and area under the receiver operating characteristic curve (AUC), which were acquired using an 8:2 allocation of training to testing sequences. RESULTS Among the five ML models, the improved random forest algorithm had the best performance, with an accuracy of 0.76, a sensitivity of 0.69, a specificity of 0.83, an F1 score of 0.73, and an AUC of 0.77. The most influential clinical features included in the ML models were pre-operative VAS and age. In contrast, the most influential radiomic features had the correlation coefficient and gray-scale co-occurrence matrix. CONCLUSIONS We developed an ML-based model for predicting pain improvement after LNP for patients with LDDD. We hope this tool will provide both doctors and patients with better information for therapeutic planning and decision-making.
Collapse
Affiliation(s)
- Po-Fan Chiu
- Spine Center, China Medical University Hospital, Taichung 404327, Taiwan
- Department of Neurosurgery, China Medical University Hospital, Taichung 404327, Taiwan
| | - Robert Chen-Hao Chang
- Department of Electrical Engineering, National Chung Hsing University, Taichung 40227, Taiwan
| | - Yung-Chi Lai
- Department of Nuclear Medicine and PET Center, China Medical University Hospital, Taichung 404327, Taiwan
| | - Kuo-Chen Wu
- Center of Artificial Intelligence, China Medical University Hospital, Taichung 404327, Taiwan
- Graduate Institute of Biomedical Electronics and Bioinformatics, National Taiwan University, Taipei 10617, Taiwan
| | - Kuan-Pin Wang
- Center of Artificial Intelligence, China Medical University Hospital, Taichung 404327, Taiwan
- Department of Computer Science and Engineering, National Chung Hsing University, Taichung 40227, Taiwan
| | - You-Pen Chiu
- Spine Center, China Medical University Hospital, Taichung 404327, Taiwan
- School of Medicine, China Medical University, Taichung 404327, Taiwan
- Graduate Institute of Biomedical Science, China Medical University, Taichung 404327, Taiwan
| | - Hui-Ru Ji
- Spine Center, China Medical University Hospital, Taichung 404327, Taiwan
- School of Medicine, China Medical University, Taichung 404327, Taiwan
- Graduate Institute of Biomedical Science, China Medical University, Taichung 404327, Taiwan
| | - Chia-Hung Kao
- Department of Nuclear Medicine and PET Center, China Medical University Hospital, Taichung 404327, Taiwan
- Center of Artificial Intelligence, China Medical University Hospital, Taichung 404327, Taiwan
- Graduate Institute of Biomedical Science, China Medical University, Taichung 404327, Taiwan
- Department of Bioinformatics and Medical Engineering, Asia University, Taichung 41354, Taiwan
| | - Cheng-Di Chiu
- Spine Center, China Medical University Hospital, Taichung 404327, Taiwan
- Department of Neurosurgery, China Medical University Hospital, Taichung 404327, Taiwan
- School of Medicine, China Medical University, Taichung 404327, Taiwan
- Graduate Institute of Biomedical Science, China Medical University, Taichung 404327, Taiwan
- Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei 11490, Taiwan
| |
Collapse
|
25
|
Halicka M, Wilby M, Duarte R, Brown C. Predicting patient-reported outcomes following lumbar spine surgery: development and external validation of multivariable prediction models. BMC Musculoskelet Disord 2023; 24:333. [PMID: 37106435 PMCID: PMC10134672 DOI: 10.1186/s12891-023-06446-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 04/19/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND This study aimed to develop and externally validate prediction models of spinal surgery outcomes based on a retrospective review of a prospective clinical database, uniquely comparing multivariate regression and random forest (machine learning) approaches, and identifying the most important predictors. METHODS Outcomes were change in back and leg pain intensity and Core Outcome Measures Index (COMI) from baseline to the last available postoperative follow-up (3-24 months), defined as minimal clinically important change (MCID) and continuous change score. Eligible patients underwent lumbar spine surgery for degenerative pathology between 2011 and 2021. Data were split by surgery date into development (N = 2691) and validation (N = 1616) sets for temporal external validation. Multivariate logistic and linear regression, and random forest classification and regression models, were fit to the development data and validated on the external data. RESULTS All models demonstrated good calibration in the validation data. Discrimination ability (area under the curve) for MCID ranged from 0.63 (COMI) to 0.72 (back pain) in regression, and from 0.62 (COMI) to 0.68 (back pain) in random forests. The explained variation in continuous change scores spanned 16%-28% in linear, and 15%-25% in random forests regression. The most important predictors included age, baseline scores on the respective outcome measures, type of degenerative pathology, previous spinal surgeries, smoking status, morbidity, and duration of hospital stay. CONCLUSIONS The developed models appear robust and generalisable across different outcomes and modelling approaches but produced only borderline acceptable discrimination ability, suggesting the need to assess further prognostic factors. External validation showed no advantage of the random forest approach.
Collapse
Affiliation(s)
- Monika Halicka
- Department of Psychology, University of Liverpool, Liverpool, UK
| | - Martin Wilby
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Rui Duarte
- Liverpool Reviews & Implementation Group (LRiG), University of Liverpool, Liverpool, UK
- Saluda Medical Pty Ltd., NSW, Artarmon, Australia
| | | |
Collapse
|
26
|
North K, Simpson GM, Stuart AR, Kubiak EN, Petelenz TJ, Hitchcock RW, Rothberg DL, Cizik AM. Early postoperative step count and walking time have greater impact on lower limb fracture outcomes than load-bearing metrics. Injury 2023:S0020-1383(23)00388-1. [PMID: 37202224 DOI: 10.1016/j.injury.2023.04.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 04/11/2023] [Accepted: 04/23/2023] [Indexed: 05/20/2023]
Abstract
INTRODUCTION Weight-bearing protocols for rehabilitation of lower extremity fractures are the gold standard despite not being data-driven. Additionally, current protocols are focused on the amount of weight placed on the limb, negating other patient rehabilitation behaviors that may contribute to outcomes. Wearable sensors can provide insight into multiple aspects of patient behavior through longitudinal monitoring. This study aimed to understand the relationship between patient behavior and rehabilitation outcomes using wearable sensors to identify the metrics of patient rehabilitation behavior that have a positive effect on 1-year rehabilitation outcomes. METHODS Prospective observational study on 42 closed ankle and tibial fracture patients. Rehabilitation behavior was monitored continuously between 2 and 6 weeks post-operative using a gait monitoring insole. Metrics describing patient rehabilitation behavior, including step count, walking time, cadence, and body weight per step, were compared between patient groups of excellent and average rehabilitation outcomes, as defined by the 1-year Patient Reported Outcome Measure Physical Function t-score (PROMIS PF). A Fuzzy Inference System (FIS) was used to rank metrics based on their impact on patient outcomes. Additionally, correlation coefficients were calculated between patient characteristics and principal components of the behavior metrics. RESULTS Twenty-two patients had complete insole data sets, and 17 of which had 1-year PROMIS PF scores (33.7 ± 14.5 years of age, 13 female, 9 in Excellent group, 8 in Average group). Step count had the highest impact ranking (0.817), while body weight per step had a low impact ranking (0.309). No significant correlation coefficients were found between patient or injury characteristics and behavior principal components. General patient rehabilitation behavior was described through cadence (mean of 71.0 steps/min) and step count (logarithmic distribution with only ten days exceeding 5,000 steps/day). CONCLUSION Step count and walking time had a greater impact on 1-year outcomes than body weight per step or cadence. The results suggest that increased activity may improve 1-year outcomes for patients with lower extremity fractures. The use of more accessible devices, such as smart watches with step counters combined with patient reported outcome measures may provide more valuable insights into patient rehabilitation behaviors and their effect on rehabilitation outcomes.
Collapse
Affiliation(s)
- Kylee North
- University of Utah Department of Biomedical Engineering, 36 S Wasatch Dr, Salt Lake City, UT 84112, United States
| | - Grange M Simpson
- University of Utah Department of Biomedical Engineering, 36 S Wasatch Dr, Salt Lake City, UT 84112, United States
| | - Ami R Stuart
- Medtronic, 710 Medtronic Parkway, Minneapolis, MN 55432-5604 USA
| | - Erik N Kubiak
- University of Nevada Las Vegas Department of Orthopaedics, University of Nevada, Las Vegas, 4505 S. Maryland Pkwy, Las Vegas, NV 89154
| | - Tomasz J Petelenz
- University of Utah Department of Biomedical Engineering, 36 S Wasatch Dr, Salt Lake City, UT 84112, United States
| | - Robert W Hitchcock
- University of Utah Department of Biomedical Engineering, 36 S Wasatch Dr, Salt Lake City, UT 84112, United States
| | - David L Rothberg
- University of Utah Department of Orthopaedics, 590 Wakara Way, Salt Lake City, Utah 84108
| | - Amy M Cizik
- University of Utah Department of Orthopaedics, 590 Wakara Way, Salt Lake City, Utah 84108.
| |
Collapse
|
27
|
Gornet MF, Eastlack RK, Peacock J, Schranck FW, Lotz JC. Magnetic resonance spectroscopy (MRS) identification of chemically painful lumbar discs leads to improved 6-, 12-, and 24-month outcomes for discogenic low back pain surgeries. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023:10.1007/s00586-023-07665-w. [PMID: 37014434 DOI: 10.1007/s00586-023-07665-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 03/07/2023] [Accepted: 03/18/2023] [Indexed: 04/05/2023]
Abstract
PURPOSE MRS was shown to reliably quantify relative levels of degenerative pain biomarkers, differentiating painful versus non-painful discs in patients with chronic discogenic low back pain (DLBP), and this correlates with surgical success rates. We now report results based on more patients and longer follow-up. METHODS Disc MRS was performed in DLBP patients who subsequently received lumbar surgery. Custom post-processing (NOCISCAN-LS®; Aclarion Inc.) calculated disc-specific NOCISCORES® that reflect relative differences in degenerative pain biomarkers for diagnosing chemically painful discs. Outcomes in 78 patients were evaluated using Oswestry Disability Index (ODI) scores. Surgical success (≥ 15-point ODI improvement) was compared between surgeries that were "Concordant" (Group C) versus "Discordant" (Group D) with NOCISCORE-based diagnosis for painful discs. RESULTS Success rates were higher for Group C versus Group D: 6 months (88% vs. 62%; p = 0.01), 12 months (91% vs. 56%; p < 0.001), and 24 months (85% vs. 63%; p = 0.07). Success rates for Group C surgeries were also higher than Group D surgeries in a variety of sub-group comparisons. Group C had a greater reduction in ODI from pre-operative to follow-up than Group D [absolute change (% change), (p)]: 6 months: - 35 (- 61%) versus - 23 (- 39%), (p < 0.05); 12 months: - 39 (- 69%) versus - 22 (- 39%), (p < 0.01); and 24 months: - 38 (- 66%) versus - 26 (- 48%), (p < 0.05). CONCLUSION More successful, sustained outcomes were obtained when surgically treating chemically painful discs identified by NOCISCAN-LS post-processed disc MRS exams. Results suggest that NOCISCAN-LS provides a valuable new diagnostic tool to help clinicians better select treatment levels.
Collapse
Affiliation(s)
- Matthew F Gornet
- The Orthopedic Center of St. Louis, 14825 N. Outer Forty Road, Suite 200, St Louis, MO, 63017, USA.
| | - Robert K Eastlack
- Department of Orthopedic Surgery, Scripps Clinic, San Diego, CA, USA
| | | | | | - Jeffrey C Lotz
- University of California at San Francisco, San Francisco, CA, USA
| |
Collapse
|
28
|
Demetriades AK, Chowdhury SM, Mavrovounis G. Patient-reported outcomes after posterior surgical stabilization for thoracolumbar junction fractures: A pilot study with combined patient-reported outcome measure methodology. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2023; 14:149-158. [PMID: 37448500 PMCID: PMC10336904 DOI: 10.4103/jcvjs.jcvjs_38_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Accepted: 04/09/2023] [Indexed: 07/15/2023] Open
Abstract
Background Thoracolumbar junction fractures (TLJFs) attract controversy for several parameters, including surgery versus conservative treatment, fusion versus stabilization, open versus percutaneous surgery, construct length, and downstream metalwork extraction. Aims and Objectives The aim of this pilot study was to assess the effectiveness of surgical treatment in patients with burst (AO Classification Type A4) TLJFs using patient-reported outcome measures (PROMs) and evaluate and compare different PROMs in this clinical scenario. Materials and Methods Patient records of consecutive patients who underwent posterior stabilization surgery for TLJFs were retrospectively reviewed. Data were collected on demographics, medical and social history, neurological examination, and postoperative complications. Telephone interviews and a combined PROM methodology (Numerical Rating Scale [NRS], EuroQol [EQ]-5D-5L, and Oswestry Disability Index [ODI]) were utilized to assess the effectiveness of intervention. Descriptive statistics were used to analyze exposure variables and outcome measures. Spearman's rank correlation was used for the outcome measures. Results Thirteen patients were included. The mean age was 42 ± 16 years; the male: female ratio was 8:5; the mean follow-up was 18.9 ± 6.4 months. The mean NRS score was 3.3 ± 2.5, in line with a median score of 2 (2) on EQ-5D-5L pain/discomfort scale. Statistically significant correlations were found between several PROMs: pain-EQ-5D-5L and NRS (rs = 0.8, P = 0.002), pain-EQ-5D-5L and ODI (rs = 0.8, P = 0.001), usual anxiety/depression-EQ-5D-5L, and ODI (rs = 0.7, P = 0.008). Conclusion A combined PROM methodology showed supportive evidence for safety and efficacy in the surgical stabilization of burst TLJFs. This alleviated significant pain and prevented neurological deficit and major disability. The preliminary widespread correlation between these PROMs supports further larger studies of their combined use in clinical practice, to measure the outcomes of spine trauma patients.
Collapse
Affiliation(s)
- Andreas K. Demetriades
- Department of Neurosurgery, New Royal Infirmary, Little France Crescent, Edinburgh, Scotland, UK
| | - Sirajam Munira Chowdhury
- Department of Neurosurgery, New Royal Infirmary, Little France Crescent, Edinburgh, Scotland, UK
| | - Georgios Mavrovounis
- Department of Neurosurgery, Faculty of Medicine, University of Thessaly, Larissa, Greece
| |
Collapse
|
29
|
Pester BD, Yoon J, Yamin JB, Papianou L, Edwards RR, Meints SM. Let’s Get Physical! A Comprehensive Review of Pre- and Post-Surgical Interventions Targeting Physical Activity to Improve Pain and Functional Outcomes in Spine Surgery Patients. J Clin Med 2023; 12:jcm12072608. [PMID: 37048691 PMCID: PMC10095133 DOI: 10.3390/jcm12072608] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 03/20/2023] [Accepted: 03/27/2023] [Indexed: 04/03/2023] Open
Abstract
The goal of this comprehensive review was to synthesize the recent literature on the efficacy of perioperative interventions targeting physical activity to improve pain and functional outcomes in spine surgery patients. Overall, research in this area does not yet permit definitive conclusions. Some evidence suggests that post-surgical interventions may yield more robust long-term outcomes than preoperative interventions, including large effect sizes for disability reduction, although there are no studies directly comparing these surgical approaches. Integrated treatment approaches that include psychosocial intervention components may supplement exercise programs by addressing fear avoidance behaviors that interfere with engagement in activity, thereby maximizing the short- and long-term benefits of exercise. Efforts should be made to test brief, efficient programs that maximize accessibility for surgical patients. Future work in this area should include both subjective and objective indices of physical activity as well as investigating both acute postoperative outcomes and long-term outcomes.
Collapse
Affiliation(s)
- Bethany D. Pester
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Chestnut Hill, MA 02467, USA
- Harvard Medical School, Boston, MA 02115, USA
- Correspondence: ; Tel.: +1-973-464-6386
| | - Jihee Yoon
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Chestnut Hill, MA 02467, USA
- Harvard Medical School, Boston, MA 02115, USA
| | - Jolin B. Yamin
- Harvard Medical School, Boston, MA 02115, USA
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
| | - Lauren Papianou
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Chestnut Hill, MA 02467, USA
- Harvard Medical School, Boston, MA 02115, USA
| | - Robert R. Edwards
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Chestnut Hill, MA 02467, USA
- Harvard Medical School, Boston, MA 02115, USA
| | - Samantha M. Meints
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Chestnut Hill, MA 02467, USA
- Harvard Medical School, Boston, MA 02115, USA
| |
Collapse
|
30
|
Dandurand C, Mashayekhi MS, McIntosh G, Singh S, Paquet J, Chaudhry H, Abraham E, Bailey CS, Weber MH, Johnson MG, Nataraj A, Attabib N, Kelly A, Hall H, Rampersaud YR, Manson N, Phan P, Thomas K, Fisher C, Charest-Morin R, Soroceanu A, LaRue B, Dea N. Cost consequence analysis of waiting for lumbar disc herniation surgery. Sci Rep 2023; 13:4519. [PMID: 36934112 PMCID: PMC10024748 DOI: 10.1038/s41598-023-31029-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Accepted: 03/06/2023] [Indexed: 03/20/2023] Open
Abstract
The economic repercussions of waiting for lumbar disc surgery have not been well studied. The primary goal of this study was to perform a cost-consequence analysis of patients receiving early vs late surgery for symptomatic disc herniation from a societal perspective. Secondarily, we compared patient factors and patient-reported outcomes. This is a retrospective analysis of prospectively collected data from the CSORN registry. A cost-consequence analysis was performed where direct and indirect costs were compared, and different outcomes were listed separately. Comparisons were made on an observational cohort of patients receiving surgery less than 60 days after consent (short wait) or 60 days or more after consent (long wait). This study included 493 patients with surgery between January 2015 and October 2021 with 272 patients (55.2%) in the short wait group and 221 patients (44.8%) classified as long wait. There was no difference in proportions of patients who returned to work at 3 and 12-months. Time from surgery to return to work was similar between both groups (34.0 vs 34.9 days, p = 0.804). Time from consent to return to work was longer in the longer wait group corresponding to an additional $11,753.10 mean indirect cost per patient. The short wait group showed increased healthcare usage at 3 months with more emergency department visits (52.6% vs 25.0%, p < 0.032), more physiotherapy (84.6% vs 72.0%, p < 0.001) and more MRI (65.2% vs 41.4%, p < 0.043). This corresponded to an additional direct cost of $518.21 per patient. Secondarily, the short wait group had higher baseline NRS leg, ODI, and lower EQ5D and PCS. The long wait group had more patients with symptoms over 2 years duration (57.6% vs 34.1%, p < 0.001). A higher proportion of patients reached MCID in terms of NRS leg pain at 3-month follow up in the short wait group (84.0% vs 75.9%, p < 0.040). This cost-consequence analysis of an observational cohort showed decreased costs associated with early surgery of $11,234.89 per patient when compared to late surgery for lumbar disc herniation. The early surgery group had more severe symptoms with higher healthcare utilization. This is counterbalanced by the additional productivity loss in the long wait group, which likely have a more chronic disease. From a societal economic perspective, early surgery seems beneficial and should be promoted.
Collapse
Affiliation(s)
- Charlotte Dandurand
- Combined Neurosurgical and Orthopedic Spine Program, Department of Orthopedics Surgery, University of British Columbia, Blusson Spinal Cord Center, 6th Floor, 818 West 10th Avenue, Vancouver, BC, V5Z 1M9, Canada.
| | - Mohammad Sadegh Mashayekhi
- Combined Neurosurgical and Orthopedic Spine Program, Department of Orthopedics Surgery, University of British Columbia, Blusson Spinal Cord Center, 6th Floor, 818 West 10th Avenue, Vancouver, BC, V5Z 1M9, Canada
| | - Greg McIntosh
- Canadian Spine Outcomes and Research Network, Markdale, ON, Canada
| | - Supriya Singh
- London Health Science Centre Combined Neurosurgical and Orthopaedic Spine Program, Schulich School of Medicine, Western University, London, ON, Canada
| | - Jerome Paquet
- Centre de Recherche CHU de Quebec, CHU de Quebec-Universite Laval, Quebec City, QC, Canada
| | - Hasaan Chaudhry
- Sunnybrook Hospital, University of Toronto, Toronto, ON, Canada
| | - Edward Abraham
- Division of Orthopaedic Surgery, Zone 2, Horizon Health Network, Canada East Spine Centre, Saint John, NB, Canada
| | - Christopher S Bailey
- London Health Science Centre Combined Neurosurgical and Orthopaedic Spine Program, Schulich School of Medicine, Western University, London, ON, Canada
| | - Michael H Weber
- Department of Surgery, Division of Orthopaedics, Montreal General Hospital, McGill University, Montreal, QC, Canada
| | - Michael G Johnson
- Department of Surgery, Section of Orthopedics and Neurosurgery, University of Manitoba, Winnipeg, MB, Canada
| | - Andrew Nataraj
- Division of Neurosurgery, University of Alberta, Edmonton, AB, Canada
| | - Najmedden Attabib
- Division of Neurosurgery, Zone 2, Horizon Health Network, Canada East Spine Centre, Saint John, NB, Canada
| | - Adrienne Kelly
- Sault Area Hospital, Northern Ontario School of Medicine, Sault Ste Marie, ON, Canada
| | - Hamilton Hall
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Y Raja Rampersaud
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Orthopaedics, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Neil Manson
- Division of Orthopaedic Surgery, Zone 2, Horizon Health Network, Canada East Spine Centre, Saint John, NB, Canada
| | - Philippe Phan
- Division of Orthopaedic Surgery, University of Ottawa, Ottawa Hospital, Ottawa, ON, Canada
| | - Ken Thomas
- University of Calgary Spine Program, University of Calgary, Calgary, AB, Canada
| | - Charles Fisher
- Combined Neurosurgical and Orthopedic Spine Program, Department of Orthopedics Surgery, University of British Columbia, Blusson Spinal Cord Center, 6th Floor, 818 West 10th Avenue, Vancouver, BC, V5Z 1M9, Canada
| | - Raphaele Charest-Morin
- Combined Neurosurgical and Orthopedic Spine Program, Department of Orthopedics Surgery, University of British Columbia, Blusson Spinal Cord Center, 6th Floor, 818 West 10th Avenue, Vancouver, BC, V5Z 1M9, Canada
| | - Alex Soroceanu
- Division of Orthopaedic Surgery, University of Ottawa, Ottawa Hospital, Ottawa, ON, Canada
| | - Bernard LaRue
- Départment de chirurgie, Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Nicolas Dea
- Combined Neurosurgical and Orthopedic Spine Program, Department of Orthopedics Surgery, University of British Columbia, Blusson Spinal Cord Center, 6th Floor, 818 West 10th Avenue, Vancouver, BC, V5Z 1M9, Canada
| |
Collapse
|
31
|
Badin D, Ortiz-Babilonia C, Musharbash FN, Jain A. Disparities in Elective Spine Surgery for Medicaid Beneficiaries: A Systematic Review. Global Spine J 2023; 13:534-546. [PMID: 35658589 PMCID: PMC9972279 DOI: 10.1177/21925682221103530] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Systematic review. OBJECTIVES We sought to synthesize the literature investigating the disparities that Medicaid patients sustain with regards to 2 types of elective spine surgery, lumbar fusion (LF) and anterior cervical discectomy and fusion (ACDF). METHODS Our review was constructed in accordance with Preferred Reporting Items and Meta-analyses (PRISMA) guidelines and protocol. We systematically searched PubMed, Embase, Scopus, CINAHL, and Web of Science databases. We included studies comparing Medicaid beneficiaries to other payer categories with regards to rates of LF and ACDF, costs/reimbursement, and health outcomes. RESULTS A total of 573 articles were assessed. Twenty-five articles were included in the analysis. We found that the literature is consistent with regards to Medicaid disparities. Medicaid was strongly associated with decreased access to LF and ACDF, lower reimbursement rates, and worse health outcomes (such as higher rates of readmission and emergency department utilization) compared to other insurance categories. CONCLUSIONS In adult patients undergoing elective spine surgery, Medicaid insurance is associated with wide disparities with regards to access to care and health outcomes. Efforts should focus on identifying causes and interventions for such disparities in this vulnerable population.
Collapse
Affiliation(s)
- Daniel Badin
- Department of Orthopaedic Surgery, Johns Hopkins
University, Baltimore, MD, USA
| | | | - Farah N. Musharbash
- Department of Orthopaedic Surgery, Johns Hopkins
University, Baltimore, MD, USA
| | - Amit Jain
- Department of Orthopaedic Surgery, Johns Hopkins
University, Baltimore, MD, USA,Amit Jain, MD, Department of Orthopaedic
Surgery, Johns Hopkins University, 601 N Caroline St, JHOC 5230 Baltimore, MD
21287, USA.
| |
Collapse
|
32
|
Krebs B, Nataraj A, McCabe E, Clark S, Sufiyan Z, Yamamoto SS, Zaïane O, Gross DP. Developing a triage predictive model for access to a spinal surgeon using clinical variables and natural language processing of radiology reports. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023:10.1007/s00586-023-07552-4. [PMID: 36740609 DOI: 10.1007/s00586-023-07552-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 01/17/2023] [Accepted: 01/22/2023] [Indexed: 02/07/2023]
Abstract
PURPOSE To utilize natural language processing (NLP) of MRI reports and various clinical variables to develop a preliminary model predictive of the need for surgery in patients with low back and neck pain. Such a model would be beneficial for informing clinical practice decisions and help reduce the number of unnecessary surgical referrals, streamlining the surgical process. METHODS A historical cohort study was conducted using de-identified data from patients referred to a spine assessment clinic. Various demographic, clinical, and radiological variables were included as potential predictors. Full-text radiology reports of patients' MRI findings were vectorized using NLP before applying machine learning algorithms to develop models predicting who underwent surgery. Outputs from these models were then entered into a logistic regression model with clinical variables to develop a preliminary model predictive of surgical recommendations. RESULTS Of the 398 patients assessed, 71 underwent spine surgery. NLP variables were significant predictors in univariate analysis but did not remain in the final logistic regression model. An outcome of receiving surgery was predicted by a primary symptom of low back and leg pain (adjusted odds ratio 2.81), distal pain indicated by a pain diagram (adjusted odds ratio 2.49) and self-reported difficulties walking (adjusted odds ratio 2.73). CONCLUSION A logistic regression model was created to predict which patients may require spine surgery. Simple clinical variables appeared more predictive than variables created using NLP. However, additional research with more data samples is needed to validate this model and fully evaluate the usefulness of NLP for this task.
Collapse
Affiliation(s)
- Brandon Krebs
- Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Canada
| | - Andrew Nataraj
- Department of Surgery, University of Alberta, Edmonton, Canada
| | - Erin McCabe
- Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Canada
| | - Shannon Clark
- Department of Computing Science, University of Alberta, Edmonton, Canada
| | - Zahin Sufiyan
- Department of Computing Science, University of Alberta, Edmonton, Canada
| | | | - Osmar Zaïane
- Department of Computing Science, University of Alberta, Edmonton, Canada
| | - Douglas P Gross
- Department of Physical Therapy, University of Alberta, 2-50 Corbett Hall, Alberta, Edmonton, T6G 2G4, Canada.
| |
Collapse
|
33
|
Development and Validation of a Risk-Prediction Nomogram for Chronic Low Back Pain Using a National Health Examination Survey: A Cross-Sectional Study. Healthcare (Basel) 2023; 11:healthcare11040468. [PMID: 36833002 PMCID: PMC9957065 DOI: 10.3390/healthcare11040468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 01/26/2023] [Accepted: 02/03/2023] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Several prognostic factors have been reported for chronic low back pain (CLBP). However, there are no studies on the prediction of CLBP development in the general population using a risk prediction model. This cross-sectional study aimed to develop and validate a risk prediction model for CLBP development in the general population, and to create a nomogram that can help a person at risk of developing CLBP to receive appropriate counseling on risk modification. METHODS Data on CLBP development, demographics, socioeconomic history, and comorbid health conditions of the participants were obtained through a nationally representative health examination and survey from 2007 to 2009. Prediction models for CLBP development were derived from a health survey on a random sample of 80% of the data and validated in the remaining 20%. After developing the risk prediction model for CLBP, the model was incorporated into a nomogram. RESULTS Data for 17,038 participants were analyzed, including 2693 with CLBP and 14,345 without CLBP. The selected risk factors included age, sex, occupation, education level, mid-intensity physical activity, depressive symptoms, and comorbidities. This model had good predictive performance in the validation dataset (concordance statistic = 0.7569, Hosmer-Lemeshow chi-square statistic = 12.10, p = 0.278). Based on our model, the findings indicated no significant differences between the observed and predicted probabilities. CONCLUSIONS The risk prediction model presented by a nomogram, which is a score-based prediction system, can be incorporated into the clinical setting. Thus, our prediction model can help individuals at risk of developing CLBP to receive appropriate counseling on risk modification from primary physicians.
Collapse
|
34
|
Ochuba AJ, Mallela DP, Feghali J, Lubelski D, Belzberg AJ, Hicks CW, Abularrage CJ, Lum YW. Development and validation of a prediction model for outcomes after transaxillary first rib resection for neurogenic thoracic outlet syndrome following strict Society for Vascular Surgery diagnostic criteria. J Vasc Surg 2023; 77:606-615. [PMID: 36273663 PMCID: PMC9868109 DOI: 10.1016/j.jvs.2022.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 10/11/2022] [Accepted: 10/12/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Neurogenic thoracic outlet syndrome (NTOS) is the most common form of thoracic outlet syndrome. However, NTOS has remained difficult to diagnose and treat successfully. The purpose of the present study was to generate a predictive clinical calculator for postoperative outcomes after first rib resection (FRR) for NTOS. METHODS We performed a retrospective review of patients who had undergone FRR for NTOS at a single tertiary care institution between 2016 and 2020. A multivariate stepwise logistic regression analysis was performed to assess the association of the percentage of improvement after FRR with the patient baseline characteristics, pertinent clinical characteristics, and diagnostic criteria set by the Society for Vascular Surgery. The primary outcome was subjective patient improvement after FRR. A prediction risk calculator was developed using backward stepwise multivariate logistic regression coefficients. Bootstrapping was used for internal validation. RESULTS A total of 208 patients (22.2% male; mean age, 35.8 ± 12.8 years; median follow-up, 44.9 months) had undergone 243 FRRs. Of the 208 patients, 94.7% had had symptoms localized to the supraclavicular area, and 97.6% had had symptoms in the hand. All the patients had had positive symptoms reproduced by the elevated arm stress test and upper limb tension test. Another reasonably likely diagnosis was absent for all the patients. Of the 196 patients who had received a lidocaine injection, 180 (93.3%) had experienced improvement of NTOS symptoms. Of the 95 patients who had received a Botox injection, 82 (74.6%) had experienced improvement of NTOS symptoms. Receiver operating characteristic curve analysis was used to assess the model. The area under the curve for the backward stepwise multivariate logistic regression model was 0.8. The multivariate logistic regression analyses revealed that the significant predictors of worsened clinical outcomes included hand weakness (adjusted odds ratio [aOR], 4.28; 95% confidence interval [CI], 1.04-17.74), increasing age (aOR, 0.93; 95% CI, 0.88-0.99), workers' compensation or litigation case (aOR, 0.09; 95% CI, 0.01-0.82), and symptoms in the dominant hand (aOR, 0.20; 95% CI, 0.05-0.88). CONCLUSIONS Using retrospective data from a single-institution database, we have developed a prediction calculator with moderate to high predictive ability, as demonstrated by an area under the curve of 0.8. The tool (available at: https://jhhntosriskcalculator.shinyapps.io/NTOS_calc/) is an important adjunct to clinical decision-making that can offer patients and providers realistic and personalized expectations of the postoperative outcome after FRR for NTOS. The findings from the present study have reinforced the diagnostic criteria set by the Society for Vascular Surgery. The calculator could aid physicians in surgical planning, referrals, and counseling patients on whether to proceed with surgery.
Collapse
Affiliation(s)
- Arinze J Ochuba
- The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Deepthi P Mallela
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH; The Center for Microbiome and Human Health, Cleveland Clinic, Cleveland, OH
| | - James Feghali
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Daniel Lubelski
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Allan J Belzberg
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Caitlin W Hicks
- Division of Vascular Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Ying Wei Lum
- Division of Vascular Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD.
| |
Collapse
|
35
|
Teimouri M, Sadat Lalehzar S, Habibpor N, Andalib A. The quality of life of 50-70 years old patients with orthopedic spinal stenosis surgery. A follow-up study (descriptive study). CASPIAN JOURNAL OF INTERNAL MEDICINE 2023; 14:703-709. [PMID: 38024168 PMCID: PMC10646352 DOI: 10.22088/cjim.14.4.703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 07/23/2022] [Accepted: 10/29/2022] [Indexed: 12/01/2023]
Abstract
Background Background: Nowadays, surgical procedures are assessed based on the state of an individual. This study aimed to investigate the effect of lumbar spinal stenosis surgery on the patient's quality of life and motor functions in Kashani and Alzahra Hospital in Esfahan. Methods In the present cross-sectional study, 40 patients aged between 50-70 were respectively evaluated who underwent lumbar spine stenosis surgery in Al Zahra and Kashani Hospitals in Esfahan University of Medical Sciences, Esfahan, Iran, during 2020-2021. The SF-36 questionnaire was used as a research tool. The visual analog scale (VAS), and spine functional index (SFI), were measured initially before surgery and 6 months and 9 months after surgery. Results The mean scores of the SF-36, SFI, and VAS scores questionnaire were 87.95±4.94, 21.38±1.24, 6.07±0.69 (p<0.001) before surgery, 89.77±5.25, 19.73±1.40, 5.37±1.56 (p<0.001) six months after surgery, and 94.70±5.34, 18.63±1.56, 4.57±0.81 (p<0.001) nine months after surgery, and all were significant. Improvement in the domains of general health, role-physical, role disorder due to impaired physical health, social function, emotional role, and bodily pain was evident. Also, the overall quality of life was enhanced but energy levels and role disorder due to impaired mental health showed no improvement. Conclusion Not only does lumbar spinal stenosis surgery significantly improve the general health, role-physical, and the social function of the patients but also enhances their quality of life.
Collapse
Affiliation(s)
- Mehdi Teimouri
- Department of Orthopedic Surgery, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Sahar Sadat Lalehzar
- Department of Orthopedic Surgery, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Niloofar Habibpor
- Department of Orthopedic Surgery, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Ali Andalib
- Department of Orthopedic Surgery, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| |
Collapse
|
36
|
Wondra JP, Kelly MP, Greenberg J, Yanik EL, Ames C, Pellise F, Vila-Casademunt A, Smith JS, Bess S, Shaffrey C, Lenke LG, Serra-Burriel M, Bridwell K. Validation of Adult Spinal Deformity Surgical Outcome Prediction Tools in Adult Symptomatic Lumbar Scoliosis. Spine (Phila Pa 1976) 2023; 48:21-28. [PMID: 35797629 PMCID: PMC9771887 DOI: 10.1097/brs.0000000000004416] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 06/03/2022] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A post hoc analysis. OBJECTIVE Advances in machine learning (ML) have led to tools offering individualized outcome predictions for adult spinal deformity (ASD). Our objective is to examine the properties of these ASD models in a cohort of adult symptomatic lumbar scoliosis (ASLS) patients. SUMMARY OF BACKGROUND DATA ML algorithms produce patient-specific probabilities of outcomes, including major complication (MC), reoperation (RO), and readmission (RA) in ASD. External validation of these models is needed. METHODS Thirty-nine predictive factors (12 demographic, 9 radiographic, 4 health-related quality of life, 14 surgical) were retrieved and entered into web-based prediction models for MC, unplanned RO, and hospital RA. Calculated probabilities were compared with actual event rates. Discrimination and calibration were analyzed using receiver operative characteristic area under the curve (where 0.5=chance, 1=perfect) and calibration curves (Brier scores, where 0.25=chance, 0=perfect). Ninety-five percent confidence intervals are reported. RESULTS A total of 169 of 187 (90%) surgical patients completed 2-year follow up. The observed rate of MCs was 41.4% with model predictions ranging from 13% to 68% (mean: 38.7%). RO was 20.7% with model predictions ranging from 9% to 54% (mean: 30.1%). Hospital RA was 17.2% with model predictions ranging from 13% to 50% (mean: 28.5%). Model classification for all three outcome measures was better than chance for all [area under the curve=MC 0.6 (0.5-0.7), RA 0.6 (0.5-0.7), RO 0.6 (0.5-0.7)]. Calibration was better than chance for all, though best for RA and RO (Brier Score=MC 0.22, RA 0.16, RO 0.17). CONCLUSIONS ASD prediction models for MC, RA, and RO performed better than chance in a cohort of adult lumbar scoliosis patients, though the homogeneity of ASLS affected calibration and accuracy. Optimization of models require samples with the breadth of outcomes (0%-100%), supporting the need for continued data collection as personalized prediction models may improve decision-making for the patient and surgeon alike.
Collapse
Affiliation(s)
- James P. Wondra
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Michael P. Kelly
- Department of Orthopaedic Surgery, Rady Children’s Hospital, University of California, San Diego, San Diego, CA
| | - Jacob Greenberg
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Elizabeth L. Yanik
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Christopher Ames
- Department of Neurosurgery, University of California, San Francisco, California. Etc
| | | | | | - Justin S. Smith
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA
| | - Shay Bess
- Denver International Spine Center, Denver, Colorado
| | | | - Lawrence G. Lenke
- Och Spine Hospital, Columbia University College of Physicians and Surgeons, New York, NY
| | - Miquel Serra-Burriel
- Center for Research in Health and Economics, Universitat Pompeu Fabra, Barcelona, Spain
| | - Keith Bridwell
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri
| |
Collapse
|
37
|
Chen X, Lin F, Xu X, Chen C, Wang R. Development, validation, and visualization of a web-based nomogram to predict the effect of tubular microdiscectomy for lumbar disc herniation. Front Surg 2023; 10:1024302. [PMID: 37021092 PMCID: PMC10069648 DOI: 10.3389/fsurg.2023.1024302] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 01/27/2023] [Indexed: 04/07/2023] Open
Abstract
Objective The purpose of this study was to retrospectively collect the relevant clinical data of lumbar disc herniation (LDH) patients treated with the tubular microdiscectomy (TMD) technique, and to develop and validate a prediction model for predicting the treatment improvement rate of TMD in LDH patients at 1 year after surgery. Methods Relevant clinical data of LDH patients treated with the TMD technology were retrospectively collected. The follow-up period was 1 year after surgery. A total of 43 possible predictors were included, and the treatment improvement rate of the Japanese Orthopedic Association (JOA) score of the lumbar spine at 1 year after TMD was used as an outcome measure. The least absolute shrinkage and selection operator (LASSO) method was used to screen out the most important predictors affecting the outcome indicators. In addition, logistic regression was used to construct the model, and a nomogram of the prediction model was drawn. Results A total of 273 patients with LDH were included in this study. Age, occupational factors, osteoporosis, Pfirrmann classification of intervertebral disc degeneration, and preoperative Oswestry Disability Index (ODI) were screened out from the 43 possible predictors based on LASSO regression. A total of 5 predictors were included while drawing a nomogram of the model. The area under the ROC curve (AUC) value of the model was 0.795. Conclusions In this study, we successfully developed a good clinical prediction model that can predict the effect of TMD for LDH. A web calculator was designed on the basis of the model (https://fabinlin.shinyapps.io/DynNomapp/).
Collapse
Affiliation(s)
| | | | | | | | - Rui Wang
- Correspondence: Chunmei Chen Rui Wang
| |
Collapse
|
38
|
Lu VM, Brusko GD, Levi DJ, Borowsky P, Wang MY. Associations With Daily Opioid Use During Hospitalization Following Lumbar Fusion: A Contemporary Cohort Study. Clin Neurol Neurosurg 2022; 224:107555. [DOI: 10.1016/j.clineuro.2022.107555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 11/27/2022] [Accepted: 12/03/2022] [Indexed: 12/12/2022]
|
39
|
Karamian BA, Toci GR, Lambrechts MJ, Canseco JA, Basques B, Tran K, Alfonsi S, Rihn J, Kurd MF, Woods BI, Hilibrand AS, Kepler CK, Vaccaro AR, Schroeder GD, Kaye ID. Does Age Younger Than 65 Affect Clinical Outcomes in Medicare Patients Undergoing Lumbar Fusion? Clin Spine Surg 2022; 35:E714-E719. [PMID: 35700082 DOI: 10.1097/bsd.0000000000001347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 04/09/2022] [Indexed: 01/25/2023]
Abstract
STUDY DESIGN This was a retrospective cohort study. OBJECTIVE To determine if age (younger than 65) and Medicare status affect patient outcomes following lumbar fusion. SUMMARY OF BACKGROUND DATA Medicare is a common spine surgery insurance provider, but most qualifying patients are older than age 65. There is a paucity of literature investigating clinical outcomes for Medicare patients under the age of 65. MATERIALS AND METHODS Patients 40 years and older who underwent lumbar fusion surgery between 2014 and 2019 were queried from electronic medical records. Patients with >2 levels fused, >3 levels decompressed, incomplete patient-reported outcome measures (PROMs), revision procedures, and tumor/infection diagnosis were excluded. Patients were placed into 4 groups based on Medicare status and age: no Medicare under 65 years (NM<65), no Medicare 65 years or older (NM≥65), yes Medicare under 65 (YM<65), and yes Medicare 65 years or older (YM≥65). T tests and χ 2 tests analyzed univariate comparisons depending on continuous or categorical type. Multivariate regression for ∆PROMs controlled for confounders. Alpha was set at 0.05. RESULTS Of the 1097 patients, 567 were NM<65 (51.7%), 133 were NM≥65 (12.1%), 42 were YM<65 (3.8%), and 355 were YM≥65 (32.4%). The YM<65 group had significantly worse preoperative Visual Analog Scale back ( P =0.01) and preoperative and postoperative Oswestry Disability Index (ODI), Short-Form 12 Mental Component Score (MCS-12), and Physical Component Score (PCS-12). However, on regression analysis, there were no significant differences in ∆PROMs for YM <65 compared with YM≥65, and NM<65. NM<65 (compared with YM<65) was an independent predictor of decreased improvement in ∆ODI following surgery (β=12.61, P =0.007); however, overall the ODI was still lower in the NM<65 compared with the YM<65. CONCLUSION Medicare patients younger than 65 years undergoing lumbar fusion had significantly worse preoperative and postoperative PROMs. The perioperative improvement in outcomes was similar between groups with the exception of ∆ODI, which demonstrated greater improvement in Medicare patients younger than 65 compared with non-Medicare patients younger than 65. LEVEL OF EVIDENCE Level III (treatment).
Collapse
Affiliation(s)
- Brian A Karamian
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
40
|
Streamlining the QOD Web-based Calculator for Clinical Integration: Development and Validation of a Reduced Prediction Model for Lumbar Spine Surgery. Spine (Phila Pa 1976) 2022; 47:E587-E590. [PMID: 35905327 DOI: 10.1097/brs.0000000000004358] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 03/11/2022] [Indexed: 02/01/2023]
|
41
|
Greenberg JK, Kelly MP, Landman JM, Zhang JK, Bess S, Smith JS, Lenke LG, Shaffrey CI, Bridwell KH. Individual differences in postoperative recovery trajectories for adult symptomatic lumbar scoliosis. J Neurosurg Spine 2022; 37:429-438. [PMID: 35334466 DOI: 10.3171/2022.2.spine211233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 02/02/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The Adult Symptomatic Lumbar Scoliosis-1 (ASLS-1) trial demonstrated the benefit of adult symptomatic lumbar scoliosis (ASLS) surgery. However, the extent to which individuals differ in their postoperative recovery trajectories is unknown. This study's objective was to evaluate variability in and factors moderating recovery trajectories after ASLS surgery. METHODS The authors used longitudinal, multilevel models to analyze postoperative recovery trajectories following ASLS surgery. Study outcomes included the Oswestry Disability Index (ODI) score and Scoliosis Research Society-22 (SRS-22) subscore, which were measured every 3 months until 2 years postoperatively. The authors evaluated the influence of preoperative disability level, along with other potential trajectory moderators, including radiographic, comorbidity, pain/function, demographic, and surgical factors. The impact of different parameters was measured using the R2, which represented the amount of variability in ODI/SRS-22 explained by each model. The R2 ranged from 0 (no variability explained) to 1 (100% of variability explained). RESULTS Among 178 patients, there was substantial variability in recovery trajectories. Applying the average trajectory to each patient explained only 15% of the variability in ODI and 21% of the variability in SRS-22 subscore. Differences in preoperative disability (ODI/SRS-22) had the strongest influence on recovery trajectories, with patients having moderate disability experiencing the greatest and most rapid improvement after surgery. Reflecting this impact, accounting for the preoperative ODI/SRS-22 level explained an additional 56%-57% of variability in recovery trajectory, while differences in the rate of postoperative change explained another 7%-9%. Among the effect moderators tested, pain/function variables-such as visual analog scale back pain score-had the biggest impact, explaining 21%-25% of variability in trajectories. Radiographic parameters were the least influential, explaining only 3%-6% more variance than models with time alone. The authors identified several significant trajectory moderators in the final model, such as significant adverse events and the number of levels fused. CONCLUSIONS ASLS patients have highly variable postoperative recovery trajectories, although most reach steady state at 12 months. Preoperative disability was the most important influence, although other factors, such as number of levels fused, also impacted recovery.
Collapse
Affiliation(s)
| | | | - Joshua M Landman
- 3Center for Population Health Informatics, Institute for Informatics
- 4Division of Computational and Data Sciences, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | | | - Shay Bess
- 5Paediatric and Adult Spine Surgery, Rocky Mountain Hospital for Children, Presbyterian St. Luke's Medical Center, Denver, Colorado
| | - Justin S Smith
- 6Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Lawrence G Lenke
- 7Department of Orthopedic Surgery, Columbia University, New York, New York; and
| | - Christopher I Shaffrey
- 8Department of Neurosurgery and Orthopaedic Surgery, Duke University, Durham, North Carolina
| | | |
Collapse
|
42
|
Ayling OGS, Rampersaud YR, Dandurand C, Yuan PHS, Ailon T, Dea N, McIntosh G, Christie SD, Abraham E, Bailey CS, Johnson MG, Bouchard J, Weber MH, Paquet J, Finkelstein J, Stratton A, Hall H, Manson N, Thomas K, Fisher CG. Surgical outcomes of patients who fail to reach minimal clinically important differences: comparison of minimally invasive versus open transforaminal lumbar interbody fusion. J Neurosurg Spine 2022; 37:376-383. [PMID: 35426818 DOI: 10.3171/2022.2.spine211210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 02/02/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Treatment of degenerative lumbar diseases has been shown to be clinically effective with open transforaminal lumbar interbody fusion (O-TLIF) or minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF). Despite this, a substantial proportion of patients do not meet minimal clinically important differences (MCIDs) in patient-reported outcomes (PROs). The objectives of this study were to compare the proportions of patients who did not meet MCIDs after O-TLIF and MIS-TLIF and to determine potential clinical factors associated with failure to achieve MCID. METHODS The authors performed a retrospective analysis of consecutive patients who underwent O-TLIF or MIS-TLIF for lumbar degenerative disorders and had been prospectively enrolled in the Canadian Spine Outcomes and Research Network. The authors analyzed the Oswestry Disability Index (ODI) scores, physical and mental component summary scores of SF-12, numeric rating scale (NRS) scores for leg and back pain, and EQ-5D scores of the patients in each group who did not meet the MCID of ODI at 2 years postoperatively. RESULTS In this study, 38.8% (137 of 353) of patients in the O-TLIF cohort and 41.8% (51 of 122) of patients in the MIS-TLIF cohort did not meet the MCID of ODI at 2 years postoperatively (p = 0.59). Demographic variables and baseline PROs were similar between groups. There were improvements across the PROs of both groups through 2 years, and there were no differences in any PROs between the O-TLIF and MIS-TLIF cohorts. Multivariable logistic regression analysis demonstrated that higher baseline leg pain score (p = 0.017) and a diagnosis of spondylolisthesis (p = 0.0053) or degenerative disc disease (p = 0.022) were associated with achieving the MCID at 2 years after O-TLIF, whereas higher baseline leg pain score was associated with reaching the MCID after MIS-TLIF (p = 0.038). CONCLUSIONS Similar proportions of patients failed to reach the MCID of ODI at 2 years after O-TLIF or MIS-TLIF. Higher baseline leg pain score was predictive of achieving the MCID in both cohorts, whereas a diagnosis of spondylolisthesis or degenerative disc disease was predictive of reaching the MCID after O-TLIF. These data provide novel insights for patient counseling and suggest that either MIS-TLIF or O-TLIF does not overcome specific patient factors to mitigate clinical success or failure in terms of the intermediate-term PROs associated with 1- to 2-level lumbar fusion surgical procedures for degenerative pathologies.
Collapse
Affiliation(s)
- Oliver G S Ayling
- 1Department of Surgery, Vancouver General Hospital/University of British Columbia, Vancouver, British Columbia
| | | | - Charlotte Dandurand
- 1Department of Surgery, Vancouver General Hospital/University of British Columbia, Vancouver, British Columbia
| | - Po Hsiang Shawn Yuan
- 1Department of Surgery, Vancouver General Hospital/University of British Columbia, Vancouver, British Columbia
| | - Tamir Ailon
- 1Department of Surgery, Vancouver General Hospital/University of British Columbia, Vancouver, British Columbia
| | - Nicolas Dea
- 1Department of Surgery, Vancouver General Hospital/University of British Columbia, Vancouver, British Columbia
| | | | - Sean D Christie
- 4Department of Surgery, Dalhousie University, Halifax, Nova Scotia
| | - Edward Abraham
- 5Department of Surgery, Canada East Spine Centre, Saint John, New Brunswick
| | | | - Michael G Johnson
- 7Departments of Orthopedics and Neurosurgery, University of Manitoba, Winnipeg, Manitoba
| | | | | | - Jerome Paquet
- 10Department of Surgery, Laval University, Quebec City, Quebec; and
| | | | | | - Hamilton Hall
- 2Department of Surgery, University of Toronto, Ontario
| | - Neil Manson
- 5Department of Surgery, Canada East Spine Centre, Saint John, New Brunswick
| | - Kenneth Thomas
- 7Departments of Orthopedics and Neurosurgery, University of Manitoba, Winnipeg, Manitoba
| | - Charles G Fisher
- 1Department of Surgery, Vancouver General Hospital/University of British Columbia, Vancouver, British Columbia
| |
Collapse
|
43
|
Lopez CD, Boddapati V, Lombardi JM, Lee NJ, Mathew J, Danford NC, Iyer RR, Dyrszka MD, Sardar ZM, Lenke LG, Lehman RA. Artificial Learning and Machine Learning Applications in Spine Surgery: A Systematic Review. Global Spine J 2022; 12:1561-1572. [PMID: 35227128 PMCID: PMC9393994 DOI: 10.1177/21925682211049164] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVES This current systematic review sought to identify and evaluate all current research-based spine surgery applications of AI/ML in optimizing preoperative patient selection, as well as predicting and managing postoperative outcomes and complications. METHODS A comprehensive search of publications was conducted through the EMBASE, Medline, and PubMed databases using relevant keywords to maximize the sensitivity of the search. No limits were placed on level of evidence or timing of the study. Findings were reported according to the PRISMA guidelines. RESULTS After application of inclusion and exclusion criteria, 41 studies were included in this review. Bayesian networks had the highest average AUC (.80), and neural networks had the best accuracy (83.0%), sensitivity (81.5%), and specificity (71.8%). Preoperative planning/cost prediction models (.89,82.2%) and discharge/length of stay models (.80,78.0%) each reported significantly higher average AUC and accuracy compared to readmissions/reoperation prediction models (.67,70.2%) (P < .001, P = .005, respectively). Model performance also significantly varied across postoperative management applications for average AUC and accuracy values (P < .001, P < .027, respectively). CONCLUSIONS Generally, authors of the reviewed studies concluded that AI/ML offers a potentially beneficial tool for providers to optimize patient care and improve cost-efficiency. More specifically, AI/ML models performed best, on average, when optimizing preoperative patient selection and planning and predicting costs, hospital discharge, and length of stay. However, models were not as accurate in predicting postoperative complications, adverse events, and readmissions and reoperations. An understanding of AI/ML-based applications is becoming increasingly important, particularly in spine surgery, as the volume of reported literature, technology accessibility, and clinical applications continue to rapidly expand.
Collapse
Affiliation(s)
- Cesar D. Lopez
- Department of Orthopaedic Surgery, The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
| | - Venkat Boddapati
- Department of Orthopaedic Surgery, The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA,Venkat Boddapati, MD, Columbia University Irving Medical Center, 622 W. 168th St., PH-11, New York, NY 10032, USA.
| | - Joseph M. Lombardi
- Department of Orthopaedic Surgery, The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
| | - Nathan J. Lee
- Department of Orthopaedic Surgery, The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
| | - Justin Mathew
- Department of Orthopaedic Surgery, The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
| | - Nicholas C. Danford
- Department of Orthopaedic Surgery, The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
| | - Rajiv R. Iyer
- Department of Orthopaedic Surgery, The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
| | - Marc D. Dyrszka
- Department of Orthopaedic Surgery, The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
| | - Zeeshan M. Sardar
- Department of Orthopaedic Surgery, The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
| | - Lawrence G. Lenke
- Department of Orthopaedic Surgery, The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
| | - Ronald A. Lehman
- Department of Orthopaedic Surgery, The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
| |
Collapse
|
44
|
Müller D, Haschtmann D, Fekete TF, Kleinstück F, Reitmeir R, Loibl M, O'Riordan D, Porchet F, Jeszenszky D, Mannion AF. Development of a machine-learning based model for predicting multidimensional outcome after surgery for degenerative disorders of the spine. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2022; 31:2125-2136. [PMID: 35834012 DOI: 10.1007/s00586-022-07306-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 05/04/2022] [Accepted: 06/24/2022] [Indexed: 01/20/2023]
Abstract
BACKGROUND It is clear that individual outcomes of spine surgery can be quite heterogeneous. When consenting a patient for surgery, it is important to be able to offer an individualized prediction regarding the likely outcome. This study used a comprehensive set of data collected over 12 years in an in-house registry to develop a parsimonious model to predict the multidimensional outcome of patients undergoing surgery for degenerative pathologies of the thoracic, lumbar or cervical spine. METHODS Data from 8374 patients (mean age 63.9 (14.9-96.3) y, 53.4% female) were used to develop a model to predict the 12-month scores for the Core Outcome Measures Index (COMI) and its subdomain scores. The data were split 80:20 into a training and test set. The top predictors were selected by applying recursive feature elimination based on LASSO cross validation models. Based on the 111 top predictors (contained within 20 variables), Ridge cross validation models were trained, validated, and tested for each of 9 outcome domains, for patients with either "Back" (thoracic/lumbar spine) or "Neck" (cervical spine) problems (total 18 models). RESULTS Among the strongest outcome predictors in most models were: preoperative scores for almost all COMI items (especially axial pain (back or neck) and peripheral pain (leg/buttock or arm/shoulder)), catastrophizing, fear avoidance beliefs, comorbidity, age, BMI, nationality, previous spine surgery, type and spinal level of intervention, number of affected levels, and surgeon seniority. The R2 of the models on the validation/test sets averaged 0.16/0.13. A preliminary online tool was programmed to present the predicted outcomes for individual patients, based on their presenting characteristics. https://linkup.kws.ch/prognostictool . CONCLUSION The models provided estimates to enable a bespoke prediction of the outcome of surgery for individual patients with varying degenerative pathologies and baseline characteristics. The models form the basis of a simple, freely-available online prognostic tool developed to improve access to and usability of prognostic information in clinical practice. It is hoped that, following confirmation of its validity and practical utility, the tool will ultimately serve to facilitate decision-making and the management of patients' expectations.
Collapse
Affiliation(s)
- D Müller
- Medcontrol AG, Liestal, Switzerland.,Spine Center Division, Department of Teaching, Research and Development, Schulthess Klinik, Lengghalde 2, 8008, Zurich, Switzerland
| | - D Haschtmann
- Department Spine Surgery and Neurosurgery, Schulthess Klinik, Zurich, Switzerland
| | - T F Fekete
- Department Spine Surgery and Neurosurgery, Schulthess Klinik, Zurich, Switzerland
| | - F Kleinstück
- Department Spine Surgery and Neurosurgery, Schulthess Klinik, Zurich, Switzerland
| | - R Reitmeir
- Department Spine Surgery and Neurosurgery, Schulthess Klinik, Zurich, Switzerland
| | - M Loibl
- Department Spine Surgery and Neurosurgery, Schulthess Klinik, Zurich, Switzerland
| | - D O'Riordan
- Spine Center Division, Department of Teaching, Research and Development, Schulthess Klinik, Lengghalde 2, 8008, Zurich, Switzerland
| | - F Porchet
- Department Spine Surgery and Neurosurgery, Schulthess Klinik, Zurich, Switzerland
| | - D Jeszenszky
- Department Spine Surgery and Neurosurgery, Schulthess Klinik, Zurich, Switzerland
| | - A F Mannion
- Spine Center Division, Department of Teaching, Research and Development, Schulthess Klinik, Lengghalde 2, 8008, Zurich, Switzerland.
| |
Collapse
|
45
|
Performance of hybrid artificial intelligence in determining candidacy for lumbar stenosis surgery. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2022; 31:2149-2155. [PMID: 35802195 DOI: 10.1007/s00586-022-07307-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 05/16/2022] [Accepted: 06/24/2022] [Indexed: 01/20/2023]
Abstract
PURPOSE Lumbar spinal stenosis (LSS) is a condition affecting several hundreds of thousands of adults in the United States each year and is associated with significant economic burden. The current decision-making practice to determine surgical candidacy for LSS is often subjective and clinician specific. In this study, we hypothesize that the performance of artificial intelligence (AI) methods could prove comparable in terms of prediction accuracy to that of a panel of spine experts. METHODS We propose a novel hybrid AI model which computes the probability of spinal surgical recommendations for LSS, based on patient demographic factors, clinical symptom manifestations, and MRI findings. The hybrid model combines a random forest model trained from medical vignette data reviewed by surgeons, with an expert Bayesian network model built from peer-reviewed literature and the expert opinions of a multidisciplinary team in spinal surgery, rehabilitation medicine, interventional and diagnostic radiology. Sets of 400 and 100 medical vignettes reviewed by surgeons were used for training and testing. RESULTS The model demonstrated high predictive accuracy, with a root mean square error (RMSE) between model predictions and ground truth of 0.0964, while the average RMSE between individual doctor's recommendations and ground truth was 0.1940. For dichotomous classification, the AUROC and Cohen's kappa were 0.9266 and 0.6298, while the corresponding average metrics based on individual doctor's recommendations were 0.8412 and 0.5659, respectively. CONCLUSIONS Our results suggest that AI can be used to automate the evaluation of surgical candidacy for LSS with performance comparable to a multidisciplinary panel of physicians.
Collapse
|
46
|
Korhonen T, Pesälä J, Järvinen J, Haapea M, Niinimäki J. Correlation between the degree of pain relief following discoblock and short-term surgical disability outcome among patients with suspected discogenic low back pain. Scand J Pain 2022; 22:526-532. [PMID: 35355491 DOI: 10.1515/sjpain-2021-0160] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 02/07/2022] [Indexed: 12/25/2022]
Abstract
OBJECTIVES To evaluate how well the degree of pain relief after discoblock predicts the disability outcome of subsequent fusion or total disc replacement (TDR) surgery, based on short-term Oswestry Disability Index (ODI) scores. METHODS We retrospectively analyzed a set of patients who had undergone discoblock and subsequent fusion or TDR surgery of the same lumbar intervertebral disc due to suspected discogenic chronic LBP between 2011 and 2018. We calculated the degree of pain relief following discoblock (ΔNRS) and the changes in both absolute and percentual ODI scores (ΔODI and ΔODI%, respectively) following fusion or TDR surgery. We analyzed the statistical significance of ΔNRS and ΔODI and the correlation (Spearman's rho) between ΔNRS and ΔODI%. The fusion and TDR group were analyzed both in combination and separately. RESULTS Fifteen patients were eligible for the current study (fusion n=9, TDR n=6). ΔNRS was statistically significant in all groups, and ΔODI was statistically significant in the combined group and in the fusion group alone. The parameters of both decreased. We found a Spearman's rho of 0.57 (p=0.026) between ΔNRS and ΔODI% for the combined group. The individual Spearman's rho values were 0.85 (p=0.004) for the fusion group and 0.62 (p=0.191) for the TDR group. CONCLUSIONS We suggest that discoblock is a useful predictive criterion for disability outcome prior to surgery for discogenic LBP, especially when stabilizing spine surgery is under consideration. ETHICAL COMMITTEE NUMBER 174/2019 (Oulu University Hospital Ethics Committee).
Collapse
Affiliation(s)
- Tero Korhonen
- Research Unit of Medical Imaging, Physics and Technology, Faculty of Medicine, University of Oulu, Oulu, Finland
- Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
- Department of Orthopaedic and Traumatology, Oulu University Hospital, Oulu, Finland
| | - Juha Pesälä
- Department of Orthopaedic and Traumatology, Oulu University Hospital, Oulu, Finland
| | - Jyri Järvinen
- Research Unit of Medical Imaging, Physics and Technology, Faculty of Medicine, University of Oulu, Oulu, Finland
- Department of Orthopaedic and Traumatology, Oulu University Hospital, Oulu, Finland
- Department of Diagnostic Radiology, Oulu University Hospital, Oulu, Finland
| | - Marianne Haapea
- Department of Diagnostic Radiology, Oulu University Hospital, Oulu, Finland
| | - Jaakko Niinimäki
- Research Unit of Medical Imaging, Physics and Technology, Faculty of Medicine, University of Oulu, Oulu, Finland
- Department of Orthopaedic and Traumatology, Oulu University Hospital, Oulu, Finland
- Department of Diagnostic Radiology, Oulu University Hospital, Oulu, Finland
| |
Collapse
|
47
|
Chao YL, Rau YA, Shiue HS, Yan JL, Tang YY, Yu SW, Yeh BY, Chen YL, Yang TH, Cheng SC, Hsieh YW, Huang HC, Tsai FK, Chen YS, Liu GH. Using a consensus acupoints regimen to explore the relationship between acupuncture sensation and lumbar spinal postoperative analgesia: A retrospective analysis of prospective clinical cooperation. JOURNAL OF INTEGRATIVE MEDICINE 2022; 20:329-337. [PMID: 35487866 DOI: 10.1016/j.joim.2022.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 01/31/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVE This study evaluated the effectiveness of acupuncture treatment on postoperative pain in patients with degenerative lumbar spine disease, and explored the relationship between the postoperative analgesic effect of acupuncture and the sensation of acupuncture experienced by the patients. METHODS This retrospective study analyzed the medical records of 97 patients who had undergone an operation by the same surgeon due to degenerative lumbar disease. These patients were divided into acupuncture group (n = 32), patient-controlled analgesia (PCA) group (n = 27), and oral analgesia group (n = 38) according to the different postoperative analgesic methods. During their hospitalization, patients completed daily evaluations of their pain using a visual analogue scale (VAS), and injection times of supplemental meperidine were recorded. Also, the Chinese version of the Massachusetts General Hospital Acupuncture Sensation Scale (C-MASS) was used in the acupuncture group. RESULTS Each of the three treatment groups showed significant reductions in postoperative pain, as shown by reduced VAS scores. The acupuncture group, however, had less rebound pain (P < 0.05) than the other two groups. Both the acupuncture and PCA groups experienced acute analgesic effects that were superior to those in the oral analgesia group. In addition, the higher the C-MASS index on the second day after surgery, the lower the VAS score on the fourth day after surgery. There was also a significant difference in the "dull pain" in the acupuncture sensation. CONCLUSION The results demonstrated that acupuncture was beneficial for postoperative pain and discomfort after simple surgery for degenerative spinal disease. It is worth noting that there was a disproportionate relevance between the patient's acupuncture sensation and the improvement of pain VAS score.
Collapse
Affiliation(s)
- Yen-Lin Chao
- Division of Acupuncture and Moxibustion, Department of Traditional Chinese Medicine, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan, China
| | - Yi-Ai Rau
- Division of Acupuncture and Moxibustion, Department of Traditional Chinese Medicine, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan, China
| | - Hong-Sheng Shiue
- School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan, China
| | - Jiun-Lin Yan
- School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan, China; Department of Neurosurgery, Keelung Chang Gung Memorial Hospital, Keelung 204, Taiwan, China
| | - Yuan-Yun Tang
- Department of Traditional Chinese Medicine, New Taipei Municipal TuCheng Hospital, Chang Gung Memorial Hospital, New Taipei 236, Taiwan, China
| | - Shao-Wen Yu
- Division of Acupuncture and Moxibustion, Department of Traditional Chinese Medicine, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan, China
| | - Bo-Yan Yeh
- Division of Acupuncture and Moxibustion, Department of Traditional Chinese Medicine, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan, China
| | - Yen-Lung Chen
- Division of Acupuncture and Moxibustion, Department of Traditional Chinese Medicine, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan, China
| | - Tsung-Hsien Yang
- Department of Traditional Chinese Medicine, New Taipei Municipal TuCheng Hospital, Chang Gung Memorial Hospital, New Taipei 236, Taiwan, China
| | - Shu-Chen Cheng
- Division of Acupuncture and Moxibustion, Department of Traditional Chinese Medicine, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan, China
| | - Yi-Wen Hsieh
- Division of Acupuncture and Moxibustion, Department of Traditional Chinese Medicine, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan, China
| | - Hsin-Chia Huang
- Division of Acupuncture and Moxibustion, Department of Traditional Chinese Medicine, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan, China
| | - Fu-Kuang Tsai
- Division of Acupuncture and Moxibustion, Department of Traditional Chinese Medicine, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan, China
| | - Yu-Sheng Chen
- Division of Acupuncture and Moxibustion, Department of Traditional Chinese Medicine, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan, China; School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan, China
| | - Geng-Hao Liu
- Division of Acupuncture and Moxibustion, Department of Traditional Chinese Medicine, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan, China; School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan, China; Sleep Center, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan, China.
| |
Collapse
|
48
|
Chan AK, Shahrestani S, Ballatori AM, Orrico KO, Manley GT, Tarapore PE, Huang M, Dhall SS, Chou D, Mummaneni PV, DiGiorgio AM. Is the Centers for Medicare and Medicaid Services Hierarchical Condition Category Risk Adjustment Model Satisfactory for Quantifying Risk After Spine Surgery? Neurosurgery 2022; 91:123-131. [PMID: 35550453 PMCID: PMC9514755 DOI: 10.1227/neu.0000000000001980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 01/12/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The Centers for Medicare and Medicaid Services (CMS) hierarchical condition category (HCC) coding is a risk adjustment model that allows for the estimation of risk-and cost-associated with health care provision. Current models may not include key factors that fully delineate the risk associated with spine surgery. OBJECTIVE To augment CMS HCC risk adjustment methodology with socioeconomic data to improve its predictive capabilities for spine surgery. METHODS The National Inpatient Sample was queried for spinal fusion, and the data was merged with county-level coverage and socioeconomic status variables obtained from the Brookings Institute. We predicted outcomes (death, nonroutine discharge, length of stay [LOS], total charges, and perioperative complication) with pairs of hierarchical, mixed effects logistic regression models-one using CMS HCC score alone and another augmenting CMS HCC scores with demographic and socioeconomic status variables. Models were compared using receiver operating characteristic curves. Variable importance was assessed in conjunction with Wald testing for model optimization. RESULTS We analyzed 653 815 patients. Expanded models outperformed models using CMS HCC score alone for mortality, nonroutine discharge, LOS, total charges, and complications. For expanded models, variable importance analyses demonstrated that CMS HCC score was of chief importance for models of mortality, LOS, total charges, and complications. For the model of nonroutine discharge, age was the most important variable. For the model of total charges, unemployment rate was nearly as important as CMS HCC score. CONCLUSION The addition of key demographic and socioeconomic characteristics substantially improves the CMS HCC risk-adjustment models when modeling spinal fusion outcomes. This finding may have important implications for payers, hospitals, and policymakers.
Collapse
Affiliation(s)
- Andrew K. Chan
- Department of Neurological Surgery, University of California, San Francisco, California, USA
- Department of Neurosurgery, Duke University, Durham, North Carolina, USA
| | - Shane Shahrestani
- Department of Medical Engineering, California Institute of Technology, Pasadena, California, USA
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Alexander M. Ballatori
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Katie O. Orrico
- American Association of Neurological Surgeons/Congress of Neurological Surgeons Washington Office, Washington, District of Columbia, USA
| | - Geoffrey T. Manley
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Phiroz E. Tarapore
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Michael Huang
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Sanjay S. Dhall
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Dean Chou
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Praveen V. Mummaneni
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Anthony M. DiGiorgio
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| |
Collapse
|
49
|
Wondra JP, Kelly MP, Yanik EL, Greenberg JK, Smith JS, Bess S, Shaffrey CI, Lenke LG, Bridwell K. Patient-reported outcome measure clustering after surgery for adult symptomatic lumbar scoliosis. J Neurosurg Spine 2022; 37:80-91. [PMID: 35171837 PMCID: PMC10193483 DOI: 10.3171/2021.11.spine21949] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 11/09/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Adult symptomatic lumbar scoliosis (ASLS) is a widespread and debilitating subset of adult spinal deformity. Although many patients benefit from operative treatment, surgery entails substantial cost and risk for adverse events. Patient-reported outcome measures (PROMs) are patient-centered tools used to evaluate the appropriateness of surgery and to assist in the shared decision-making process. Framing realistic patient expectations should include the possible functional limitation to improvement inherent in surgical intervention, such as multilevel fusion to the sacrum. The authors' objective was to predict postoperative ASLS PROMs by using clustering analysis, generalized longitudinal regression models, percentile analysis, and clinical improvement analysis of preoperative health-related quality-of-life scores for use in surgical counseling. METHODS Operative results from the combined ASLS cohorts were examined. PROM score clustering after surgery investigated limits of surgical improvement. Patients were categorized by baseline disability (mild, moderate, moderate to severe, or severe) according to preoperative Scoliosis Research Society (SRS)-22 and Oswestry Disability Index (ODI) scores. Responder analysis for patients achieving improvement meeting the minimum clinically important difference (MCID) and substantial clinical benefit (SCB) standards was performed using both fixed-threshold and patient-specific values (MCID = 30% of remaining scale, SCB = 50%). Best (top 5%), worst (bottom 5%), and median scores were calculated across disability categories. RESULTS A total of 171/187 (91%) of patients with ASLS achieved 2-year follow-up. Patients rarely achieved a PROM ceiling for any measure, with 33%-43% of individuals clustering near 4.0 for SRS domains. Patients with severe baseline disability (< 2.0) SRS-pain and SRS-function scores were often left with moderate to severe disability (2.0-2.9), unlike patients with higher (≥ 3.0) initial PROM values. Patients with mild disability according to baseline SRS-function score were unlikely to improve. Crippling baseline ODI disability (> 60) commonly left patients with moderate disability (median ODI = 32). As baseline ODI disability increased, patients were more likely to achieve MCID and SCB (p < 0.001). Compared to fixed threshold values for MCID and SCB, patient-specific values were more sensitive to change for patients with minimal ODI baseline disability (p = 0.008) and less sensitive to change for patients with moderate to severe SRS subscore disability (p = 0.01). CONCLUSIONS These findings suggest that ASLS surgeries have a limit to possible improvement, probably due to both baseline disability and the effects of surgery. The most disabled patients often had moderate to severe disability (SRS < 3, ODI > 30) at 2 years, emphasizing the importance of patient counseling and expectation management.
Collapse
Affiliation(s)
- James P. Wondra
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Michael P. Kelly
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Elizabeth L. Yanik
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Jacob K. Greenberg
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Justin S. Smith
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Shay Bess
- Denver International Spine Center, Denver, Colorado
| | | | - Lawrence G. Lenke
- Och Spine Hospital, Columbia University College of Physicians and Surgeons, New York, New York
| | - Keith Bridwell
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri
| |
Collapse
|
50
|
Machine Learning Algorithms Predict Achievement of Clinically Significant Outcomes After Orthopaedic Surgery: A Systematic Review. Arthroscopy 2022; 38:2090-2105. [PMID: 34968653 DOI: 10.1016/j.arthro.2021.12.030] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 11/15/2021] [Accepted: 12/20/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine what subspecialties have applied machine learning (ML) to predict clinically significant outcomes (CSOs) within orthopaedic surgery and to determine whether the performance of these models was acceptable through assessing discrimination and other ML metrics where reported. METHODS The PubMed, EMBASE, and Cochrane Central Register of Controlled Trials databases were queried for articles that used ML to predict achievement of the minimal clinically important difference (MCID), patient acceptable symptomatic state (PASS), or substantial clinical benefit (SCB) after orthopaedic surgical procedures. Data pertaining to demographic characteristics, subspecialty, specific ML algorithms, and algorithm performance were analyzed. RESULTS Eighteen articles met the inclusion criteria. Seventeen studies developed novel algorithms, whereas one study externally validated an established algorithm. All studies used ML to predict MCID achievement, whereas 3 (16.7%) predicted SCB achievement and none predicted PASS achievement. Of the studies, 7 (38.9%) concerned outcomes after spine surgery; 6 (33.3%), after sports medicine surgery; 3 (16.7%), after total joint arthroplasty (TJA); and 2 (11.1%), after shoulder arthroplasty. No studies were found regarding trauma, hand, elbow, pediatric, or foot and ankle surgery. In spine surgery, concordance statistics (C-statistics) ranged from 0.65 to 0.92; in hip arthroscopy, 0.51 to 0.94; in TJA, 0.63 to 0.89; and in shoulder arthroplasty, 0.70 to 0.95. Most studies reported C-statistics at the upper end of these ranges, although populations were heterogeneous. CONCLUSIONS Currently available ML algorithms can discriminate the propensity to achieve CSOs using the MCID after spine, TJA, sports medicine, and shoulder surgery with a fair to good performance as evidenced by C-statistics ranging from 0.6 to 0.95 in most analyses. Less evidence is available on the ability of ML to predict achievement of SCB, and no evidence is available for achievement of the PASS. Such algorithms may augment shared decision-making practices and allow clinicians to provide more appropriate patient expectations using individualized risk assessments. However, these studies remain limited by variable reporting of performance metrics, CSO quantification methods, and adherence to predictive modeling guidelines, as well as limited external validation. LEVEL OF EVIDENCE Level III, systematic review of Level III studies.
Collapse
|