Psychological Predictors of Outcomes with Lumbar Spinal Fusion: A Systematic Literature Review

The Effect of Graded Activity and Pain Education After Lumbar Spinal Fusion on Sedentary Behavior 3 and 12 Months Postsurgery: A Randomized Controlled Trial

OBJECTIVES

To examine the effect of an early postsurgical intervention consisting of graded activity and pain education (GAPE) in patients with chronic low back pain (CLBP) undergoing lumbar spinal fusion (LSF) on sedentary behavior, disability, pain, fear of movement, self-efficacy for exercise and health-related quality of life (HRQoL) at 3-, 6-, and 12 months follow-up.

DESIGN

A parallel-group, observer-blinded randomized controlled trial.

SETTING

Department of Occupational- and Physiotherapy and the Centre for Rheumatology and Spine Diseases, Rigshospitalet, Denmark.

PARTICIPANTS

In total, 144 participants undergoing an LSF for CLBP were randomly assigned to an intervention or a control group.

INTERVENTIONS

The intervention group received 9 sessions of GAPE, based on principles of operant conditioning.

MAIN OUTCOME MEASURES

The primary outcome was reduction in time spent in sedentary behavior, measured by an accelerometer at 3 months. The secondary outcomes were reduction in time spent in sedentary behavior at 12 months and changes from baseline to 3-, 6-, and 12 months on disability, pain, fear of movement, self-efficacy for exercise, and HRQoL.

RESULTS

No difference in changes in sedentary behavior between groups was found 3 months after surgery. At 12 months after surgery, there was a significant difference between groups (mean difference: -25.4 min/d (95% confidence interval -49.1 to -1.7)) in favor of the intervention group.

CONCLUSIONS

Compared with usual care, GAPE had no effect on short-term changes in sedentary behavior but GAPE had a statistical, but possibly not clinical significant effect on sedentary behavior 12 months after LSF. Further, the behavioral intervention was safe to perform.

The impact of instrumented lumbar fusion surgery on psychiatric problems in elderly patients with degenerative spinal stenosis: The observational study

This is a prospective cohort study to investigate the effects of instrumented lumbar fusion surgery on psychiatric problems, including anxiety, insomnia, and depression, in patients with degenerative spinal stenosis, as well as on pain and the activities of daily living. Surgery was performed in the patients with Schizas grade C or D spinal stenosis with; if a patient's quality of life was impaired for at least 3 months or if patient had neurologic deficits. Finally, 69 patients were reviewed. Beck anxiety inventory, insomnia severity index, geriatric depression scale short form-Korean, visual analog scale for back pain, visual analog scale for leg pain, and Oswestry disability index was measured on the day surgery was decided on (T1), the day before surgery (T2), the day before discharge (T3), and 6 months after surgery (T4). The patients had mild degrees of anxiety, insomnia, and depression at T1, and Beck anxiety inventory, insomnia severity index, visual analog scale for back pain, visual analog scale for leg pain, and Oswestry disability index improved significantly by T4. In elderly patients with degenerative spinal stenosis, instrumented lumbar fusion surgery improves not only pain and activities of daily living, but also anxiety and insomnia. However, there was no improvement in depression over the 6-month follow-up period.

Fear of movement was associated with sedentary behaviour 12 months after lumbar fusion surgery in patients with low back pain and degenerative disc disorder

BACKGROUND

Movement behaviours, such as sedentary behaviour (SB) and moderate to vigorous physical activity (MVPA), are linked with multiple aspects of health and can be influenced by various pain-related psychological factors, such as fear of movement, pain catastrophising and self-efficacy for exercise. However, the relationships between these factors and postoperative SB and MVPA remain unclear in patients undergoing surgery for lumbar degenerative conditions. This study aimed to investigate the association between preoperative pain-related psychological factors and postoperative SB and MVPA in patients with low back pain (LBP) and degenerative disc disorder at 6 and 12 months after lumbar fusion surgery.

METHODS

Secondary data were collected from 118 patients (63 women and 55 men; mean age 46 years) who underwent lumbar fusion surgery in a randomised controlled trial. SB and MVPA were measured using the triaxial accelerometer ActiGraph GT3X+. Fear of movement, pain catastrophising and self-efficacy for exercise served as predictors. The association between these factors and the relative time spent in SB and MVPA 6 and 12 months after surgery was analysed via linear regression models, adjusting for potential confounders.

RESULTS

Preoperative fear of movement was significantly associated with relative time spent in SB at 6 and 12 months after surgery (β = 0.013, 95% confidence interval = 0.004 to 0.022, p = 0.007). Neither pain catastrophising nor self-efficacy for exercise showed significant associations with relative time spent in SB and MVPA at these time points.

CONCLUSIONS

Our study demonstrated that preoperative fear of movement was significantly associated with postoperative SB in patients with LBP and degenerative disc disorder. This finding underscores the potential benefits of preoperative screening for pain-related psychological factors, including fear of movement, preoperatively. Such screenings could aid in identifying patients who might benefit from targeted interventions to promote healthier postoperative movement behaviour and improved health outcomes.

How Does Anxiety and Depression Affect the Outcome after Periradicular Infiltration Therapy?-A Retrospective Analysis of Patients Undergoing CT-Guided Single-Level Nerve Root Infiltration Due to Chronic Monoradicular Pain

The aim of this study was to research the influence of psychological confounders on patient-reported outcomes (PROs) after lumbar infiltration therapies of periradicular infiltrations (PRI). Patients who underwent PRI in a single center between June 2018 and December 2019 were included. PRI was performed in patients with predominantly unilateral lumbar radiculopathy which existed for at least 6 weeks based on single-level nerve root compression (caused by a herniated disc, stenosis of the lateral recess, or neuroforamen), confirmed by morphological imaging. The numeric pain rating scale (NRS) for back pain (BP) and leg pain (LP) and the Oswestry Disability Index (ODI) were assessed preinterventionally, on the first day (only NRS) and at 6 weeks, and then 3, 6, and 12 months postinterventionally. The minimally clinically important difference (MCID) served as the threshold for the therapeutic effectiveness evaluation. The health-related quality of life (SF-36) was recorded preinterventionally and after 12 months. Based on the Hospital Anxiety and Depression Scale, the patients were dichotomized into depressed or nondepressed and anxious or nonanxious. Categorical data were evaluated using Fisher's exact test, and continuous data were evaluated using Student's t test. Separate linear mixed models were built to estimate the effect of anxiety or depression on repeatedly measured PROs following PRI. Data were analyzed using SPSS software. The analysis included 102 patients. Most mean baseline PROs were significantly worse in anxious or depressed patients than in nonanxious or nondepressed patients: Anxiety NRS-BP (p = 0.007), ODI (p < 0.001); Depression NRS-BP (p = 0.026), NRS-LP (p < 0.001), ODI (p < 0.001). All patients showed a clinically meaningful reduction in pain and functional improvement over a 12-month follow-up. There was no significant difference in the estimated overall mean PRO between all patients (p > 0.05). In conclusion, anxiety and depression are associated with worse PROs before and after PRI. However, patients with underlying depression or anxiety can expect a similar gain in PRO compared to patients without depressive or anxious symptoms.

Understanding the Impact of Early Depressive Burden on Patient Perceptions of Outcomes Following Cervical Disc Replacement

OBJECTIVE

To evaluate the effect of early depressive burden on PROMs in the setting of cervical disc replacement (CDR).

METHODS

Patients who had undergone primary elective CDR with recorded preoperative and 6-week postoperative 9-item Patient Health Questionnaire (PHQ-9) scores were identified. Early depressive burden was calculated via addition of the preoperative and 6-week PHQ-9 scores. Patients were divided into 2 cohorts, those with summative PHQ-9 scores beneath one-half standard deviation less than the mean (Lesser Burden; LB) and those with summative PHQ-9 scores above one-half standard deviation greater than the mean (Greater Burden; GB). Magnitude of improvement in PROMs (ΔPROM) was compared within and between cohorts at 6-weeks (ΔPROM-6W) and final follow-up (ΔPROM-FF). PROMs evaluated included PROMIS-PF/NDI/VAS-Neck (VAS-N)/VAS-Arm (VAS-A)/PHQ-9.

RESULTS

Fifty-five patients were included with 34 in the LB cohort. The LB cohort demonstrated improvements from the preoperative baseline in 6-week PROMIS-PF/NDI/VAS-N/VAS-A (P ≤ 0.012, all). The GB cohort demonstrated improvements from the preoperative baseline in 6-week NDI/VAS-N/VAS-A/PHQ-9 (P ≤ 0.038, all). The GB cohort demonstrated greater ΔPROM-6W and ΔPROM-FF in PHQ-9 (P ≤ 0.047, both). The LB cohort demonstrated a greater ΔPROM-FF in PROMIS-PF (P = 0.023).

CONCLUSIONS

Patients with a greater depressive burden were more likely to experience greater magnitudes of improvements in PHQ-9 at both 6-week and final follow-up and experience clinically meaningful improvement in depressive symptoms. Patients with a lesser depressive burden were more likely to experience a greater magnitude of improvement in PROMIS-PF at final follow-up and experience clinically meaningful improvement in physical function.

Depressed patients with greater symptom duration before MIS-TLIF do not report inferior outcomes

PURPOSE

Patients with preoperative depressive symptoms may demonstrate inferior patient-reported outcomes (PROs). The effect of preoperative symptom duration (SD) on PROs in this population has not been well-studied. We aim to assess the influence of preoperative SD on PROs in patients with low mental health scores prior to minimally invasive transforaminal interbody fusion (MIS-TLIF).

METHODS

Patients who had undergone elective, primary MIS-TLIF with preoperative SF-12 MCS score below 45.6, a previously established threshold for depression, were selected. Patients were divided into matched lesser duration (LD; SD<365 days) and greater duration (GD; SD≥365 days) cohorts. PROs were collected preoperatively and at 6-week/12-week/6-month/1-year postoperative periods. PROs included PROMIS-PF/ODI/VAS back/VAS leg/SF-12 MCS. PROs were compared within and between groups. Rates of achievement of minimal clinically important difference (MCID) were compared between groups.

RESULTS

One hundred twenty-two patients were included after matching cohorts. Patients in the LD cohort demonstrated improvement in PROMIS-PF at 12-weeks/6-month/1-year, and ODI/VAS back/VAS leg/SF-12 MCS at all postoperative periods (p≤0.024, all). Patients in the GD cohort demonstrated improvement in PROMIS-PF at 12-weeks/6-month/1-year, and ODI/VAS back/VAS leg/SF-12 MCS at all postoperative periods (p≤0.013, all). There were no differences in PROs or MCID achievement between cohorts at any period.

CONCLUSION

Patients with preoperative depressive symptoms undergoing MIS-TLIF, regardless of duration of preoperative symptoms, demonstrated improvements in physical function, disability, pain, and mental health domains. Patients with greater duration of preoperative symptoms did not report inferior outcomes at any period. Rates of clinically important improvements in all domains were favorable and similar between cohorts.

Predicting patient-reported outcomes following lumbar spine surgery: development and external validation of multivariable prediction models

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.

The effect of perioperative psychological interventions on persistent pain, disability, and quality of life in patients undergoing spinal fusion: a systematic review

PURPOSE

Patients undergoing spinal fusion are prone to develop persisting spinal pain that may be related to pre-existent psychological factors. The aim of this review was to summarize the existing evidence about perioperative psychological interventions and to analyze their effect on postoperative pain, disability, and quality of life in adult patients undergoing complex surgery for spinal disorders. Studies investigating any kind of psychological intervention explicitly targeting patients undergoing a surgical fusion on the spine were included.

METHODS

We included articles that analyzed the effects of perioperative psychological interventions on either pain, disability, and/or quality of life in adult patients with a primary diagnosis of degenerative or neoplastic spinal disease, undergoing surgical fusion of the spine. We focused on interventions that had a clearly defined psychological component. Two independent reviewers used the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) to perform a systematic review on different databases. Risk of bias was evaluated using the Downs and Black checklist. Given study differences in outcome measures and interventions administered, a meta-analysis was not performed. Instead, a qualitative synthesis of main results of included papers was obtained.

RESULTS

Thirteen studies, conducted between 2004 and 2017, were included. The majority were randomized-controlled trials (85%) and most patients underwent lumbar fusion (92%). Cognitive behavioral therapy (CBT) was used in nine studies (69%). CBT in the perioperative period may lead to a postoperative reduction in pain and disability in the short-term follow-up compared to care as usual. There was less evidence for an additional effect of CBT at intermediate and long-term follow-up.

CONCLUSION

The existing evidence suggests that a reduction in pain and disability in the short-term, starting from immediately after surgery to 3 months, is likely to be obtained when a CBT approach is used. However, there is inconclusive evidence regarding the long-term effect of a perioperative psychological intervention after spinal fusion surgery. Further research is necessary to better define the frequency, intensity, and timing of such an approach in relation to the surgical intervention, to be able to maximize its effect and be beneficial to patients.

The Collective Influence of Social Determinants of Health on Individuals Who Underwent Lumbar Spine Revision Surgeries: A Retrospective Cohort Study

OBJECTIVE

To analyze the collective effect of social determinants of health (SDH) on lumbar spine revision surgery outcomes using a retrospective cohort study design.

METHODS

Data from the Quality Outcomes Database were used, including 7889 adults who received lumbar spine revision surgery and completed 3 and 12 months' follow-up. The SDH of interest included race/ethnicity, educational attainment, employment status, insurance payer, and sex. A stepwise regression model using each number of SDH conditions present (0 of 5, 1 of 5, 2 of 5, ≥3 of 5) was used to assess the collective influence of SDH. The odds of demonstrating a minimum clinically important difference was evaluated in back and leg, disability, quality of life, and patient satisfaction at 3-months and 12-months follow-up.

RESULTS

An additive effect for SDH was found across all outcome variables at 3 and 12 months. Individuals with ≥3 SDH were at the lowest odds of meeting the minimum clinically important difference of each outcome. At 12 months, individuals with ≥3 SDH had a 67%, 65%, 71%, 65%, and 46% decrease in the odds of a clinically meaningful outcome in back and leg pain, disability, quality of life, and patient satisfaction.

CONCLUSIONS

Health care teams should evaluate SDH in individuals who may be considered for lumbar spine revision surgery. Viewing social factors in aggregate may be useful as a screening tool for lumbar spine revision surgeries to identify at risk patients who may require pre-emptive care strategies and postoperative resources to mitigate these risks.

Classification of older adults who underwent lumbar-related surgery using pre-operative biopsychosocial predictors and relationships with surgical recovery: An observational study conducted in the United States

Lumbar surgery is a commonly prescribed intervention for low back pain but poses higher risks and worse outcomes for older adults. Identifying clinical phenotypes based on biopsychosocial factors may help identify older adults who are at greatest risk for poor postoperative recovery. This study aimed to (a) classify older adults who underwent lumbar surgery based on preoperative biopsychosocial factors, and (b) quantify the association between preoperative biopsychosocial classifications and 3 and 12 months postoperative improvement outcomes. Latent class analysis was used to identify biopsychosocial classifications in 10,283 individuals aged ≥60 from the Quality Outcomes Database (the United States, 2021-2018). Logistic regression models measured the association between biopsychosocial classifications and 3 and 12 months postoperative outcomes (back/leg pain intensity, disability and quality of life), adjusting for covariates. Three classes were identified based on 19 a priori biopsychosocial factors and were characterised as 'high-risk' (15%), 'physical-/social health-risk' (44%) and 'low-risk' (41%). The high-risk class demonstrated increased odds of failing to recover post-operatively compared to the other classes. Similarly, the physical-/social-risk class demonstrated increased odds of failing to recover in all outcomes and time points compared to the low-risk class. Biopsychosocial factors with higher prevalence in the high versus low-risk class were depression (92.5% vs. 10.6%), multiple morbidities (55.3% vs. 25.7%) and obesity (59.5% vs. 37.2%). This study introduces novel non-recovery phenotypes for older adults undergoing lumbar surgery and may lead to the development of tailored interventions to improve clinical care and outcomes for this population.

Development of a machine-learning based model for predicting multidimensional outcome after surgery for degenerative disorders of the spine

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.

Predictors of Pain and Disability Outcomes Following Spinal Surgery for Chronic Low Back and Radicular Pain: A Systematic Review

OBJECTIVES

Success rates of spinal surgeries to treat chronic back pain are highly variable and useable prognostic indicators are lacking. We aimed to identify and evaluate preoperative predictors of pain and disability after spinal surgery for chronic low back/leg pain.

METHODS

Electronic database (01/1984-03/2021) and reference searches identified 2622 unique citations. Eligible studies included adults with chronic low back/leg pain lasting ≥3 months undergoing first elective lumbar spine surgery, and outcomes defined as change in pain (primary)/disability (secondary) after ≥3 months. We included 21 reports (6899 participants), 7 were judged to have low and 14 high risks of bias. We performed narrative synthesis and determined the quality of evidence (QoE).

RESULTS

Better pain outcomes were associated with younger age, higher education, and no spinal stenosis (low QoE); lower preoperative pain, fewer comorbidities, lower pain catastrophizing, anxiety and depression (very low QoE); but not with symptom duration (moderate QoE), other sociodemographic factors (low QoE), disability, or sensory testing (very low QoE). More favorable disability outcomes were associated with preoperative sensory loss (moderate QoE); lower job-related resignation and neuroticism (very low QoE); but not with socioeconomic factors, comorbidities (low QoE), demographics, pain, or pain-related psychological factors (very low QoE).

DISCUSSION

In conclusion, absence of spinal stenosis potentially predicts greater pain relief and preoperative sensory loss likely predicts reduction in disability. Overall, QoE for most identified associations was low/very low.

Influence of Preoperative 12-Item Short Form Mental Composite Score on Clinical Outcomes in an Isthmic Spondylolisthesis Population Undergoing Minimally Invasive Transforaminal Lumbar Interbody Fusion

OBJECTIVE

To determine preoperative 12-Item Short Form Health Survey (SF-12) Mental Component Summary (MCS) influence on minimally important clinical difference (MCID) and patient-reported outcome measures in patients with isthmic spondylolisthesis receiving minimally invasive transforaminal lumbar interbody fusion.

METHODS

Patients with isthmic spondylolisthesis undergoing primary, single-level minimally invasive transforaminal lumbar interbody fusion at L5-S1 were retrospectively identified and divided into preoperative SF-12 MCS <50 and SF-12 MCS ≥50 groups. Visual analog scale (VAS) back/leg, Oswestry Disability Index (ODI), SF-12 Physical Composite Score (PCS), and Patient-Reported Outcome Measurement Information System physical function (PROMIS-PF) were assessed. Improvements from preoperative score were analyzed via paired samples t test. Patient-reported outcome measures and MCID attainment between groups were evaluated using linear regression and χ², respectively.

RESULTS

SF-12 MCS <50 and SF-12 MCS ≥50 groups included 35 and 26 patients, respectively. SF-12 MCS < 50 group had inferior scores for all VAS back time points except 6 weeks, all VAS leg time points except 6 weeks/1 year, all ODI time points, SF-12 PCS at 6 months/2 years, and PROMIS-PF at preoperative/6 months (all P ≤ 0.049). SF-12 MCS <50 group improved for VAS back/leg to 1 year, ODI and SF-12 PCS from 12 weeks to 1 year, and PROMIS-PF at 1 year only (all P ≤ 0.047). SF-12 MCS ≥50 group improved for VAS back from 12 weeks to 1 year, SF-12 PCS 6 months to 2 years, and VAS leg, ODI, and PROMIS-PF 12 weeks to 2 years (all P ≤ 0.018). MCID attainment differed for ODI at 6 weeks and PROMIS-PF at 12 weeks only (both P ≤ 0.035).

CONCLUSIONS

Patients with SF-12 MCS <50 demonstrated fewer long-term improvements from preoperative to 2 years and inferior patient-reported outcome measures at most time points for pain and disability following minimally invasive transforaminal lumbar interbody fusion. MCID attainment largely did not differ by preoperative mental functioning.

Prognostic factors for outcome following lumbar spine fusion surgery: a systematic review and narrative synthesis

PURPOSE

The objective of this study was to identify and evaluate the value of prognostic factors related to disability, pain and quality of life (QoL) for adult patients undergoing lumbar spine fusion surgery (LSFS).

METHODS

Two reviewers independently searched the literature, assessed eligibility, extracted data and assessed risk of bias and certainty of evidence. Key electronic databases were searched [PubMed, CINAHL, EMBASE, MEDLINE, PEDro and ZETOC] using pre-defined terms [e.g. LSFS] to 20/9/2020; with additional searching of journals, reference lists and unpublished literature. Prospective cohort studies with ≥ 12-month follow-up after LSFS were included. Narrative synthesis was based on recommendations by Cochrane Consumers and Communication Review Group. The GRADE tool enabled assessment of certainty of evidence. Prognostic factors and outcome were analysed and summarised when examined in ≥ 2 studies and when results pointed in the same direction in ≥ 75% of studies.

RESULTS

Sixteen studies (n =  8388, 2 low and 14 high risk of bias) were included with 39 prognostic factors identified. There is low certainty evidence that higher pre-operative severity of leg pain predicts greater improvement of leg pain and that pre-operative working predicts less post-operative disability both at 1-2-year follow-up. Other found associations were of very low certainty evidence.

CONCLUSION

No moderate to high certainty evidence exists. Use of leg pain and pre-operative working may be valuable predictors of outcome to inform clinical decision-making and advice regarding LSFS surgery. There is need for adequately powered low-risk-of-bias prospective observational studies to further investigate candidate prognostic factors.

Self-reported prognostic factors in adults reporting neck or low back pain: An umbrella review

BACKGROUND

Numerous systematic reviews have attempted to synthesize evidence on prognostic factors for predicting future outcomes such as pain, disability and return-to-work/work absence in neck and low back pain populations.

DATABASES AND DATATREATMENT

An umbrella review of systematic reviews was conducted to summarize the magnitude and quality of the evidence for each prognostic factor investigated. Searches were limited to the last 10 years (2008-11th April 2018, updated 28th September 2020). A two-stage approach was undertaken: in stage one, data on prognostic factors was extracted from systematic reviews identified from the systematic search that met the inclusion criteria. Where a prognostic factor was investigated in ≥1 systematic review and where 50% or more of those reviews found an association between the prognostic factor and one of the outcomes of interest, it was taken forward to stage two. In stage two, additional information extracted included the strength of association found, consistency of effects and risk of bias. The GRADE approach was used to grade confidence in the evidence.

RESULTS

Stage one identified 41 reviews (90 prognostic factors), with 35 reviews (25 prognostic factors) taken forward to stage two. Seven prognostic factors (disability/activity limitation, mental health; pain intensity; pain severity; coping; expectation of outcome/recovery and fear-avoidance) were judged as having moderate confidence for robust findings.

CONCLUSIONS

Although there was conflicting evidence for the strength of association with outcome, these factors may be used for identifying vulnerable subgroups or people able to self-manage. Further research can investigate the impact of using such prognostic information on treatment/referral decisions and patient outcomes.

Are Patient-Reported Outcomes of Minimally Invasive Transforaminal Lumbar Interbody Fusion Influenced by Preoperative Mental Health?

STUDY DESIGN

This was a retrospective review of prospectively collected data.

OBJECTIVES

Few studies have described the relationship between mental health and patient-reported outcome measures (PROMs) after minimally invasive spine surgery. Prior studies on open surgery included small cohorts with short follow-ups.

METHODS

Patients undergoing primary minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) for degenerative pathology were retrospectively reviewed and stratified by Short Form (SF-36) Mental Component Summary (MCS): low MCS (<50, n = 436) versus high MCS (≥50, n = 363). PROMs assessed were back pain, leg pain, North American Spine Society Neurogenic Symptoms, Oswestry Disability Index, SF-36 Physical Component Summary, and MCS. Satisfaction, expectation fulfilment, and return to work (RTW) rates also were recorded at 1 month, 3 months, 6 months, and 2 years.

RESULTS

Preoperative MCS was 39.4 ± 8.6 and 58.5 ± 5.4 in the low and high MCS groups, respectively (P < .001). The low MCS group had significantly poorer preoperative PROMs and longer lengths of stay. Despite this, both groups achieved comparable PROMs from 3 months onward. The mean MCS was no longer significantly different by 3 months (P = .353). The low MCS group had poorer satisfaction (P = .022) and expectation fulfilment (P = .020) at final follow-up. RTW rates were initially lower in the low MCS group up to 3 months (P = .034), but the rates converged from 6 months onward.

CONCLUSIONS

Despite poorer PROMs preoperatively, patients with poor baseline mental health still achieved comparable results from 3 months up to 2 years after MIS-TLIF. Preoperative optimization of mental health should still be pursued to improve satisfaction and prevent delayed RTW after surgery.

Seeking Information: A Survey of Rural Spinal Patients' Internet Use and Pain Catastrophizing

Objective  Clinicians are beginning to evaluate the effects that Internet use has on patients. The aim of this study is to provide descriptive information on patients' use of the Internet in regard to their spinal pain. Additionally, this study aims to examine the patient's type of Internet usage (information vs. support) and its relationship to pain-related distress. Materials and Methods  This quantitative-descriptive, survey-based, correlational, cross-sectional design surveyed 143 spinal surgery patients from the Appalachian region. Participants were administered a demographic questionnaire, the pain catastrophizing scale, and an Internet Use and Spine Patients Questionnaire. Descriptive information on patient Internet use was collected through a retrospective recall of the participants' Internet use and was analyzed utilizing a frequency distribution. A Pearson ( r ) correlation was conducted to determine the relationship between Internet use and the severity of pain catastrophizing. Results  Spinal surgery patients more frequently use the Internet for information than for support. For the individuals who do utilize the Internet for information, most are finding this tool to be somewhat helpful. For spinal patients who do use the Internet for support, there was a positively correlated relationship with magnification, helplessness, and overall pain catastrophizing. Conclusion  Patients who present for spinal surgery are generally using the Internet to gain information on their diagnoses. Pain catastrophizing was elevated in relation to Internet use for support. Limitations and future directions are discussed.

A Qualitative Descriptive Study of Patient Experiences of Pain Before and After Spine Surgery

OBJECTIVE

The purpose of this study was to describe the preoperative and postoperative experiences of spine surgery from the patient's perspective to help inform behavioral health services provided before, during, and after hospitalization.

SETTING

Single urban academic tertiary care hospital.

METHODS

Semistructured interviews with 14 adults who underwent spine surgery. Interview transcriptions were analyzed using content analysis by three investigators to identify emergent themes.

RESULTS

Three broad domains with associated themes emerged from the analysis: 1) preoperative experience-preparation, worries, and expectations; 2) recovery process-activity and pain management strategies; and 3) postoperative support in recovery-family and social support.

CONCLUSIONS

The results of this qualitative descriptive study can be used to guide future perioperative behavioral health services for patients undergoing spinal surgery. Establishing realistic expectations of spine surgery and a comprehensive pain management plan are essential for adequate preoperative preparation. Furthermore, family involvement in the preoperative preparation for surgery is important for support of the patient during the recovery process.

Quantifying the collective influence of social determinants of health using conditional and cluster modeling

Objectives

Our objective was to analyze the collective effect of social determinants of health (SDoH) on lumbar spine surgery outcomes utilizing two different statistical methods of combining variables.

Methods

This observational study analyzed data from the Quality Outcomes Database, a nationwide United States spine registry. Race/ethnicity, educational attainment, employment status, insurance payer, and gender were predictors of interest. We built two models to assess the collective influence of SDoH on outcomes following lumbar spine surgery—a stepwise model using each number of SDoH conditions present (0 of 5, 1 of 5, 2 of 5, etc) and a clustered subgroup model. Logistic regression analyses adjusted for age, multimorbidity, surgical indication, type of lumbar spine surgery, and surgical approach were performed to identify the odds of failing to demonstrate clinically meaningful improvements in disability, back pain, leg pain, quality of life, and patient satisfaction at 3- and 12-months following lumbar spine surgery.

Results

Stepwise modeling outperformed individual SDoH when 4 of 5 SDoH were present. Cluster modeling revealed 4 distinct subgroups. Disparities between the younger, minority, lower socioeconomic status and the younger, white, higher socioeconomic status subgroups were substantially wider compared to individual SDoH.

Discussion

Collective and cluster modeling of SDoH better predicted failure to demonstrate clinically meaningful improvements than individual SDoH in this cohort. Viewing social factors in aggregate rather than individually may offer more precise estimates of the impact of SDoH on outcomes.

Effect of change in preoperative depression/anxiety on patient outcomes following lumbar spine surgery

OBJECTIVE

The purpose of this study was to investigate the association between positive change in depression or anxiety within three months post-operation and clinically meaningful changes in long-term clinical outcomes after lumbar spine surgery.

METHODS

This study included adults with preoperative diagnosis of depression or anxiety who underwent lumbar spine surgery in the Quality Outcomes Database (QOD) from 2012 to 2018 with either a 12- or 24-month follow-up. Positive change in depression and anxiety was assessed three months after surgery. Clinical outcomes measured included Numeric Rating Scale (NRS) score for back pain (BP) and leg pain (LP), Oswestry Disability Index score (ODI) for disability, EuroQol Visual Analog Scale score (EQ-VAS) for health-related quality of life (HRQOL), and North American Spine Surgery (NASS) index score for patient satiaction measured at 12- and 24 months after surgery.

RESULTS

Of the 9,656 and 1,393 patients who were included in the 12- and 24-month cohort, respectively, 7,277 patients (75.4 %) and 1,089 (78.2 %) experienced a positive change in depression or anxiety within three months after surgery. At both 12- and 24-month follow-up, patients who had positive change in depression or anxiety were more likely to achieve minimal clinically important changes in NRS-BP/LP, ODI, EQ-VAS, and NASS (all p < 0.01) compared to those who did not experience improvement in depression or anxiety.

CONCLUSION

Depression and anxiety are important comorbidities to consider in patients undergoing lumbar spine surgery. Positive change in depression and anxiety are associated with improvements in pain, disability, satisfaction, and overall functioning.

Correlating Psychological Comorbidities and Outcomes After Spine Surgery

STUDY DESIGN

Literature review.

OBJECTIVE

The aim of this literature review is to examine the effects of psychological disorders on postoperative complications, surgical outcomes, and long-term narcotic use. We also hope to detail the value of preoperative identification and treatment of these pathologies.

METHODS

A series of systematic reviews of the relevant literature examining the effects of psychological disorders and spine surgery was conducted using PubMed and Cochrane databases.

RESULTS

Combined, the database queries yielded 2275 articles for consideration. After applying screening criteria, 96 articles were selected for inclusion. Patients with underlying psychological disease have higher rates of delirium, readmission, longer hospital stays, and higher rates of nonroutine discharge following spine surgery. They also have higher rates of chronic postoperative narcotic use and may experience worse surgical outcomes. Because of these defined issues, researchers have developed multiple screening tools to help identify patients with psychological disorders preoperatively for potential treatment. Treatment of these disorders prior to surgery may significantly improve surgical outcomes.

CONCLUSION

Patients with psychological disorders represent a unique population with respect to their higher rates of spinal pain complaints, postoperative complications, and worsened functional outcomes. However, proper identification and treatment of these conditions prior to surgery may significantly improve many outcome measures in this population. Future investigations in this field should attempt to develop and validate current strategies to identify and treat individuals with psychological disorders before surgery to further improve outcomes.

Multidisciplinary approaches to complication reduction in complex spine surgery: a systematic review

BACKGROUND CONTEXT

Complex spine surgery carries a high complication rate that can produce suboptimal outcomes for patients undergoing these extensive operations. However, multidisciplinary pathways introduced at multiple institutions have demonstrated a promising potential toward reducing the burden of complications in patients being treated for spinal deformities. To date, there has been no effort to systematically collate the multidisciplinary approaches in use at various institutions.

PURPOSE

The present study aims to determine effective multidisciplinary strategies for reducing the complication rate in complex spine surgery by analyzing existing institutional multidisciplinary approaches and delineating common themes across multiple practice settings.

STUDY DESIGN

Systematic review.

METHODS

We followed guidelines established under the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The studies reported on data from PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science and Cochrane. We included articles that described either approaches to, or results from, the implementation of multidisciplinary paradigms during the preoperative, perioperative, and postoperative phases of care for patients undergoing complex spine surgery. We excluded studies that only targeted one complication unless such an approach was in coordination with more extensive multidisciplinary planning at the same institution.

RESULTS

A total of 406 unique articles were identified. Following an initial determination based on title and abstract, 22 articles met criteria for full-text review, and 10 met the inclusion criteria to be included in the review. Key aspects of multidisciplinary approaches to complex spine surgery included extensive preoperative workup and interdisciplinary conferencing, intraoperative communication and monitoring, and postoperative floor management and discharge planning. These strategies produced decreases in surgical duration and complication rates.

CONCLUSIONS

This study represents the first to systematically analyze multidisciplinary approaches to reduce complications in complex spine surgery. This review provides a roadmap toward reducing the elevated complication rate for patients undergoing complex spine surgery.

Adding 3-month patient data improves prognostic models of 12-month disability, pain, and satisfaction after specific lumbar spine surgical procedures: development and validation of a prediction model

BACKGROUND CONTEXT

Prognostic models including early postoperative variables may provide optimal estimates of long-term outcomes and help direct postoperative care.

PURPOSE

To develop and validate prognostic models for 12-month disability, back pain, leg pain, and satisfaction among patients undergoing microdiscectomy, laminectomy, and laminectomy with fusion for degenerative lumbar conditions.

STUDY DESIGN/SETTING

Retrospective cohort study using the Quality Outcomes Database.

PATIENT SAMPLE

Patients receiving elective lumbar spine surgery due to degenerative spine conditions.

OUTCOME MEASURES

Oswestry Disability Index, pain numerical rating scale, and NASS Patient Satisfaction Index.

METHODS

Prognostic models were developed using proportional odds ordinal logistic regression using patient characteristics and baseline and 3-month patient-reported outcome scores. Models were fit for each outcome stratified by type of surgical procedure. Adjusted odds ratio and 95% confidence intervals were reported for all predictors by procedure. Models were internally validated using bootstrap resampling. Discrimination was reported as the c-index and calibration was presented using the calibration slope. We compared the performance of models with and without 3-month patient-reported variables. This research was supported by the Foundation for Physical Therapy's Center of Excellence in Physical Therapy Health Services, and Health Policy Research and Training grant.

RESULTS

The sample consisted of 5,840 patients receiving a microdiscectomy (n=2,085), laminectomy (n=1,837), or laminectomy with fusion (n=1,918). The 3-month Oswestry score was the strongest and most consistent predictor associated with 12-month outcomes. All prognostic models performed well with overfitting-corrected c-index values ranging from 0.718 to 0.795 and all optimism corrected calibration slopes over 0.92. The increase in c-index values ranged from 0.09 to 0.21 when adding 3-month patient-reported outcome scores.

CONCLUSIONS

Models had good discrimination and were well calibrated for estimating 12-month disability, back pain, leg pain, and satisfaction. Patient-reported outcomes at 3 months after surgery, especially 3-month Oswestry scores, improved the 12-month performance of all prognostic models beyond using only baseline variables.

Support for a Three-Item Questionnaire Prior to Spinal Surgery: A Health-Related Quality of Life Outcome Study

Objective  Elective lumbar and cervical operations are becoming more common in the United States. Additionally, there is a movement in the literature and clinical practice to discover short versions of longer measures as a way to anticipate an outcome. This study aims to provide neurosurgeons in practice with a three-item questionnaire that can guide referrals to psychological services presurgery. Ultimately, results could lead to an improvement in health-related quality of life (HRQoL) postspinal surgery.

Methods  This quantitative-descriptive, survey-based design with a retrospective chart review component followed 47 patients at baseline ( N = 47), 3 months ( N = 20), 6 months ( N = 31), and 1 year ( N = 19). A single item from the Coping Strategies Questionnaire, the Survey of Pain Attitudes, and the Tampa Scale of Kinesiophobia were utilized in the three-item questionnaire as a baseline measure. Patient-Reported Outcomes Measurement Information System Global Health measured HRQoL outcome at all time points. A linear regression model was conducted to predict mental health QoL postspinal surgery.

Results  This measure can predict mental health QoL outcomes up to 3-month postsurgery. Six-month and 1-year follow-ups are statistically inconclusive.

Conclusion  Individuals who are undergoing spinal surgery show lower mental health QoL outcome at baseline and 3-month postsurgery when responses on a three-item questionnaire are elevated. Limitations and future directions are discussed.

Translation, Cross-cultural Adaptation and Reliability of Brazilian portuguese version of the DRAM Questionnaire for Psychometric Evaluation in Low Back Pain

Objective  Based on studies regarding pain physiology and its relation to emotional distress conditions, psychological evaluation became essential to determine the most favorable patient profiles to distinct therapeutic approaches. The Distress Risk Assessment Method (DRAM) has been developed as a screening instrument for patients with lumbar pain, classifying them in subgroups as normal, at risk, distressed somatic and distressed depressive, based on the two components of DRAM scores (Modified Somatic Perception Questionnaire [MSPQ] and Zung questionnaires). The objective of the present study is to translate and culturally adapt the DRAM to the Brazilian Portuguese language, and to determine the reliability of the final version.

Methods  As proposed by the International Quality of Life Assessment (IQOLA) method, a Brazilian Portuguese version of the DRAM has been applied to a sample of 85 individuals from 3 participant centers.

Results  The results confirmed the reliability and reproducibility of the DRAM in its Brazilian Portuguese final version: Cronbach alpha of 0.815 (MSPQ) and 0.794 (Zung) and intraclass correlation coefficient (ICC) of 0.688 (MSPQ) and 0.659 (Zung).

Conclusion  The presented DRAM version in Brazilian Portuguese is reliable and is available to clinical practice use.

Effect of depression and anxiety on health-related quality of life outcomes and patient satisfaction after surgery for cervical compressive myelopathy

OBJECTIVE

Preoperative mood disorders such as depression and anxiety are known to be associated with poor health-related quality of life (HRQOL) outcomes after lumbar spine surgery. However, the effects of preoperative depression and anxiety on postoperative HRQOL outcomes and patient satisfaction in cervical compressive myelopathy are yet to be clarified. This study aimed to investigate the effect of depression and anxiety on HRQOL outcomes and patient satisfaction following surgery for cervical compressive myelopathy.

METHODS

The authors reviewed the cases of all consecutive patients with cervical compressive myelopathy who had undergone surgical treatment in the period between January 2012 and March 2017 at their institution. Using the Hospital Anxiety and Depression Scale (HADS), the authors classified patients as depressed (HADS-D+) or not depressed (HADS-D-) and anxious (HADS-A+) or not anxious (HADS-A-). Patient HRQOL was evaluated preoperatively and at the end of at least 1 year after surgery using the physical and mental component summaries of the SF-12 Health Survey, EQ-5D (EuroQol health survey of five dimensions), Neck Disability Index, and Japanese Orthopaedic Association scale. Patient satisfaction was evaluated on the basis of a seven-item questionnaire and divided into two categories: satisfied and dissatisfied. Preoperative HRQOL statuses, postoperative improvements in HRQOL outcomes, and patient satisfaction were compared between the groups.

RESULTS

Among the 121 patients eligible for inclusion in the study, there were 69 patients (57.0%) without depression (HADS-D-) and 52 (43.0%) with depression (HADS-D+) and 82 patients (67.8%) without anxiety (HADS-A-) and 39 (32.2%) with anxiety (HADS-A+). All patients who completed both the preoperative and postoperative questionnaires had significant postoperative improvements in all HRQOL outcomes. The HADS-D+ and HADS-A+ patients had poorer preoperative HRQOL statuses than the HADS-D- and HADS-A- patients, respectively. However, statistically significant improvements in all HRQOL outcomes were observed in both HADS-D+ and HADS-A+ patients. Patient satisfaction was comparable between the HADS-D or HADS-A groups.

CONCLUSIONS

Cervical compressive myelopathy patients with preoperative depression or anxiety according to the HADS tool had worse preoperative HRQOL statuses. However, patients with cervical compressive myelopathy showed significant improvements in HRQOL outcomes and had sufficient levels of satisfaction after surgery regardless of the presence of preoperative depression or anxiety.

Psychological predictors of quality of life and functional outcome in patients undergoing elective surgery for degenerative lumbar spine disease

OBJECTIVE

To quantify the correlation between patients' psychopathological predisposition, disability and health-related quality of life (QOL) after surgery for degenerative lumbar spine disease.

METHODS

We prospectively included patients undergoing decompression for degenerative lumbar spinal stenosis, spondylolisthesis or disc herniation with additional fusion of up to two segments. Patients completed a structured psychological assessment including the Center for Epidemiological Studies Depression Scale (ADS-K), Post-Traumatic Stress Scale-10 (PTSS-10), State Trait Anxiety Inventory-State Anxiety and State Trait Anxiety Inventory-Trait Anxiety (STAI-S and STAI-T) and Anxiety Sensitivity Index-3 (ASI-3) before surgery, after 3 and 12 months. Outcome measures included EuroQol 5D (EQ), Short Form-36 (SF-36) and Oswestry Disability Index (ODI) scores.

RESULTS

In total, 245 patients between March 2013 and November 2017 received surgery, of which 180 (73.5%) fully completed follow-up after 3 months and 12 months. QOL scores significantly increased by 3 months (EQ: +0.2; p < 0.001; SF-36 PCS: +7.0; p < 0.001; SF-36 MCS: +3.3; p = 0.018), a benefit which was retained at 12 months, without statistically significant difference between fused and non-fused patients. Depressed patients exhibited impaired mean scores of EQ (0.58 vs. 0.36; p < 0.001) and ODI mean scores (35.5 vs. 51.9; p < 0.001) at baseline, which significantly improved and converged with scores of non-depressed patients after 12 months. Linear regression analysis identified statistically significant predictors in age, STAI-T and SF-36 MCS for post-operative QOL and disability.

CONCLUSION

Despite exhibiting pronounced psychological distress preoperatively, patients may significantly benefit from surgery with an outcome equal to psychologically healthy patients after 12 months. These slides can be retrieved under Electronic Supplementary Material.

Effect of preoperative psychological interventions on elective orthopaedic surgery outcomes: a systematic review and meta-analysis

BACKGROUND

Orthopaedic surgery is largely successful; however, a proportion of patients are dissatisfied and report pain and poor function. Psychological factors have been shown to influence orthopaedic surgical outcomes. This systematic review and meta-analysis investigates the types and effectiveness of preoperative psychological interventions in elective orthopaedic surgery.

METHODS

A registered systematic review (PROSPERO CRD42017073833) was performed on literature (1960-January 2018) using eight databases. Prospective controlled clinical trials involving adult and adolescent elective orthopaedic surgery were included. Interventions examined included relaxation, cognitive behavioural therapy, hypnosis, emotional counselling and mixed psychotherapies; general procedural education was excluded. Outcomes extracted included pain, anxiety, quality of life and disability.

RESULTS

A total of 19 studies met the inclusion criteria (n = 1893 patients). Meta-analyses were performed for pain, anxiety and quality of life. Analysis did not find enough evidence to confirm reduction in post-operative pain (seven studies, 666 patients; g = -0.15 (95% CI -0.42, 0.13), P = 0.305). Pooled data from six studies on acute post-operative anxiety (589 patients) showed a moderate statistically significant benefit (g = -0.26 (-0.49, -0.03), P = 0.024). There was an improved quality of life (mental component) at longer term follow-up (g = 0.25 (0.02, 0.49), P = 0.034).

CONCLUSIONS

These studies provide evidence that psychological interventions have a positive effect on anxiety in the acute post-operative period, and on mental components of quality of life at longer term follow-up.

Influence of perioperative complication severity on 1- and 2-year outcomes of low back surgery

Background

Several factors potentially influence outcomes of surgery, including perioperative complications. Complications may take many forms and the Clavien–Dindo (CD) classification is designed to categorize them by degree of severity. The aim of this study was to evaluate the influence of perioperative complications by severity categorization on the 1-and 2-year pain and disability outcomes for patients who received low back surgery.

Materials and methods

Data used for the study involved a purposive sample (N = 477; 8.1%) from a spine outcomes registry of 5876 patients who received spine surgery and encountered complications. All complications were categorized using the CD classification and were collapsed according to distribution frequencies, i.e., Grade I–II and Grade III–V. Adjusted and unadjusted regression analyses were used to determine the association between CD classification and 1- and 2-year outcomes.

Results

The majority of surgical complications were Grade III−V (N = 358; 75.1%), with two incidences in which death occurred. For the unadjusted models, there were no significant associations between CD classification categorizations for 1-year outcomes; however, 2-year outcomes were significantly worse (P <0.05) for those with Grade III–V categorization. When adjusted and controlled for baseline characteristics, CD classification did not influence 1-or 2-year pain and disability outcomes.

Conclusions

When control variables are considered, the severity of perioperative surgical complications does not appear to influence 1- or 2-year pain and disability outcomes.

Level of evidence

Level 4.