The patient's perspective on complications after spine surgery

How much are patients willing to pay for spine surgery? An evaluation of attitudes toward out-of-pocket expenses and cost-reducing measures

BACKGROUND CONTEXT

With rising healthcare expenditures in the United States, patients and providers are searching to maintain quality while reducing costs.

PURPOSE

The aim of this study was to investigate patient willingness to pay for anterior cervical discectomy and fusion (ACDF), degenerative lumbar spinal fusions (LF), and adult spine deformity (ASD) surgery.

STUDY DESIGN/SETTING

A survey was developed and distributed to anonymous respondents through Amazon Mechanical Turk (MTurk).

METHODS

The survey introduced 3 procedures: ACDF, LF, and ASD surgery. Respondents were asked sequentially if they would pay at each increasing price option. Respondents were then presented with various cost-saving methods and asked to select the options that made them most uncomfortable, even if those would save them out-of-pocket costs.

RESULTS

In total, 979 of 1,172 total responses (84%) were retained for analysis. The average age was 36.2 years and 44% of participants reported a household income of $50,000 to 100,000. A total of 63% used Medicare and 13% used Medicaid. A total of 40% stated they had high levels of financial stress. A total of 30.1% of participants were willing to undergo an ACDF, 30.3% were willing to undergo a LF, and 29.6% were willing to undergo ASD surgery for the cost of $3,000 (p=.98). Regression demonstrated that for ACDF surgery, a $100 increase in price resulted in a 2.1% decrease in willingness to pay. This is comparable to degenerative LF surgery (1.8% decrease), and ASD surgery (2%). When asked which cost-saving measures participants were least comfortable with for ACDF surgery, 60% stated "Use of the older generation implants/devices" (LF: 51%, ASD: 60%,), 61% stated "Having the surgery performed at a community hospital instead of at a major academic center" (LF: 49%, ASD: 56%), and 55% stated "Administration of anesthesia by a nurse anesthetist" (LF: 48.01%, ASD: 55%). Conversely, 36% of ACDF patients were uncomfortable with a "Video/telephone postoperative visit" to cut costs (LF: 51%, ASD: 39%).

CONCLUSIONS

Patients are unwilling to contribute larger copays for adult spinal deformity correction than for ACDF and degenerative lumbar spine surgery, despite significantly higher procedural costs and case complexity/invasiveness. Patients were most uncomfortable forfeiting newer generation implants, receiving the operation at a community rather than an academic center, and receiving care by physician extenders. Conversely, patients were more willing to convert postoperative visits to telehealth and forgo neuromonitoring, indicating a potentially poor understanding of which cost-saving measures may be implemented without increasing the risk of complications.

Validation of the Calgary Postoperative Pain after Spine Surgery Score for Poor Postoperative Pain Control after Spine Surgery

OBJECTIVE

The Calgary Postoperative Pain after Spine Surgery (CAPPS) score was developed to identify patients at risk of experiencing poorly controlled pain after spine surgery. The goal of this study was to independently validate the CAPPS score on a prospectively collected patient sample.

METHODS

Poor postoperative pain control was defined as a mean numeric rating scale (NRS) for pain >4 at rest in the first 24 hours after surgery. Baseline characteristics in this study (validation cohort) were compared to those of the development cohort used to create the CAPPS score. Predictive performance of the CAPPS score was assessed by the area under the curve (AUC) and percentage misclassification for discrimination. A graphical comparison between predicted probability vs. observed incidence of poorly controlled pain was performed for calibration.

RESULTS

Fifty-two percent of 201 patients experienced poorly controlled pain. The validation cohort exhibited lower depression scores and a higher proportion using daily opioid medications compared to the development cohort. The AUC was 0.74 [95%CI = 0.68-0.81] in the validation cohort compared to 0.73 [95%CI = 0.69-0.76] in the development cohort for the eight-tier CAPPS score. When stratified between the low- vs. extreme-risk and low- vs. high-risk groups, the percentage misclassification was 21.2% and 30.7% in the validation cohort, compared to 29.9% and 38.0% in the development cohort, respectively. The predicted probability closely mirrored the observed incidence of poor pain control across all scores.

CONCLUSIONS

The CAPPS score, based on seven easily obtained and reliable prognostic variables, was validated using a prospectively collected, independent sample of patients.

Intradermal and Intramuscular Bupivacaine Reduces Opioid Use Following Noninstrumented Spine Surgery

OBJECTIVE

To evaluate the efficacy of intraoperative bupivacaine hydrochloride wound infiltration as an adjunct means of pain relief following noninstrumented posterior spine surgery.

METHODS

A retrospective cohort analysis was performed of all patients who underwent posterior spinal decompression surgery at the University of California, San Diego, and at the San Diego VA Medical Center between June 2020 and July 2021, following a change in practice to including bupivacaine infiltration at the end of the surgery. Patients were stratified into groups based on whether they received intrawound bupivacaine during surgery. Demographic and clinical data were extracted from the electronic health record. Postoperative opioid use, visual analog pain scores, heart rate, and blood pressure were compared.

RESULTS

The analysis included 43 patients; 21 received bupivacaine infiltration, and 22 did not. No complications were encountered in the perioperative period. Patients who received bupivacaine consumed significantly less opioids over the 72 hours following surgery, had slightly lower pain scores, and experienced slightly lower heart rates. No significant difference was found between groups with respect to systolic blood pressure, operative time, or length of hospital stay.

CONCLUSIONS

Intraoperative infiltration of the exposed paraspinous musculature and peri-incisional subdermal layer with bupivacaine significantly reduced postoperative opioid consumption for 72 hours after surgery and slightly reduced pain ratings and conferred superior heart rate control. This low-cost intervention produced significant patient benefit with minimal risk and no significant increase in surgical time or hospital stay.

Patient-rated outcome after atlantoaxial (C1-C2) fusion: more than a decade of evaluation of 2-year outcomes in 126 patients

INTRODUCTION

Various surgical techniques have been introduced for atlantoaxial (C1-C2) fusion, the most common being Magerl's (transarticular) or the Harms/Goel screw fixation. Common indications include degenerative osteoarthritis (OA), trauma or rheumatoid arthritis (RA). Only few, small studies have evaluated patient-reported outcomes after C1-C2 fusion. We investigated 2-year outcomes in a large series of consecutive patients undergoing isolated C1-C2 fusion.

METHODS

We analysed prospectively collected data (2005-2016) from our Spine outcomes database, collected within the framework of EUROSPINE's Spine Tango Registry. It included 126 patients (34 (27%) men, 92 (73%) women; mean (SD) age 67 ± 19 y) who had undergone first-time isolated C1-C2 fusion (61% Magerl, 39% Harms(-Goel)) at least 2 years ago for OA (83 (66%)), RA (20 (16%)), fracture (15 (12%)) or other (8 (6%)). Patients completed the multidimensional Core Outcome Measures Index (COMI; 0-10) and various single item outcomes.

RESULTS

Questionnaires were returned by 118/126 (94%) patients, 2 years post-operative. Mean COMI scores showed a significant reduction from baseline: 6.9 ± 2.4 to 2.7 ± 2.5 (p < 0.0001). Overall, 75% patients achieved the MCIC of ≥ 2.2 points reduction in COMI and 88% reported a good global outcome. 91% patients were satisfied/very satisfied with their care. Self-reported complications were declared by 16% patients and further surgery at the same segment, by 2.5%.

CONCLUSION

In this large series with almost complete follow-up, C1-C2 fusion showed extremely good results. Despite the complexity of the intervention, outcomes surpassed those typically reported for simple procedures such as ACDF and lumbar discectomy, suggesting reservations about the procedure should perhaps be reviewed.

Postoperative Single-shot Epidural Fentanyl and Bupivacaine for Postoperative Analgesia After Lumbar Decompression: A Prospective, Double-blind Randomized Study

STUDY DESIGN

Randomized clinical trial.

OBJECTIVE

To evaluate the efficacy of the postoperative single-shot bolus of epidural Fentanyl and Bupivicaine in providing pain relief postlumbar decompression surgery.

SUMMARY OF BACKGROUND DATA

Despite lumbar decompression's success in alleviating symptoms of sciatica, radiculopathy, and neurogenic claudication, transient back and buttock pain has been a common complaint postoperatively. Providing good postoperative pain alleviation predicts patient's quality of recovery.

METHODS

We performed a randomized, double-blinded, clinical trial. Forty-five patients scheduled for lumbar decompression for a year's period who were randomly assigned to receive a postoperative bolus of 10-mL solution of 50 mcg of Fentanyl, 0.125% Bupivacaine, and 0.9% saline solution via an intraoperatively placed epidural catheter immediately after wound closure, before dressing application. Facial pain scale scores (from 0 to 10) were measured at three time points after surgery (fully awake at recovery room, transfer to ward, first postoperative day). Postoperative need for oral analgesics, time to independent ambulation, associated adverse events, and time to hospital discharge were also evaluated.

RESULTS

Pain scores were noted to be significantly lower at all time points in the epidural group (P < 0.001). In turn, they also received less on-demand oral pain medications than those in the control group (P = 0.000). The mean time to ambulation was 0.09 days in the epidural group and 0.91 days in the decompression-alone group (P = 0.000). Criteria for hospital discharge were usually met on Day 0 in the epidural and Day 1 in the control group (P = 0.000). Within the study period, only one infection was noted in the epidural group which necessitated additional lumbar spine surgery (4.3%). No adverse events or complications related to Fentanyl use were observed.

CONCLUSIONS

A postoperative bolus of Fentanyl and Bupivacaine is effective in reducing early postoperative pain without the related complications of opiod administration.

LEVEL OF EVIDENCE

2.

Global Treatment Outcome after Surgical Site Infection in Elective Degenerative Lumbar Spinal Operations

Background: Surgical site infection (SSI) is a serious complication after routine lumbar spinal operations, and its effect on global treatment outcome (GTO) is less reported. The aim of the current study was to measure the impact of SSI on outcome, which was evaluated with patient reported outcome measures (PROMs) and patients' subjective judgment (GTO). Methods: A total of 910 patients underwent primary a single- or two-level lumbar decompression or instrumented fusion surgical procedure. Patients completed Visual Analogue Scale (VAS), Oswestry Disability Index (ODI), and Core Outcome Measurement Index (COMI) at baseline and at two-year follow-up. The rate of improvement in PROMs was measured for the total cohort and the group of patients with SSI. Patients evaluated GTO on a five-point Likert scale. This study was approved by the Scientific and Research Ethics Committee of the Medical Research Council (number: 29970-3/2015/EKU) and the Institutional Review Board. Results: Regardless of the presence of SSI, significant improvement was measured in all PROMs without any difference in the rate of change between the clinical subgroups (non-SSI vs. SSI, dODI: p = 0.370, dCOMI: p = 0.383, dVAS: p = 0.793). In the total cohort, 87.3% of patients reported good outcome (N% = 87.3%). After an SSI, however, more patients (25.7%) reported poor outcome compared with those without the complication (chi-square test: value = 5.66; df = 1; p = 0.017; odds ratio = 2.49). Conclusions: Patients with successfully treated SSI can expect as good objective clinical result as patients without SSI while the subjective treatment outcome can be worse. The GTO could also be improved in complicated cases, however, with more extensive peri-operative patient education and information considering the patients' expectations, too.

Severity of Postoperative Complications From the Perspective of the Patient

Background:

Although provider-derived surgical complication severity grading systems exist, little is known about the patient perspective.

Objective:

To assess patient-rated complication severity and determine concordance with existing grading systems.

Methods:

A survey asked general surgery patients to rate the severity of 21 hypothetical postoperative events representing grades 1 to 5 complications from the Accordion Severity Grading System. Concordance with the Accordion scale was examined. Separately, descriptive ratings of 18 brief postoperative events were ranked.

Results:

One hundred sixty-eight patients returned a mailed survey following their discharge from a general surgery service. Patients rated grade 4 complications highest. Grade 1 complications were rated similarly to grade 5 and higher than grades 2 and 3 (P ≤ .01). Patients rated one event not considered an Accordion scale complication higher than all but grade 4 complications (P < .001). The brief events also did not follow the Accordion scale, other than the grade 6 complication ranking highest.

Conclusion:

Patient-rated complication severity is discordant with provider-derived grading systems, suggesting the need to explore important differences between patient and provider perspectives.

The influence of concomitant syringomyelia on patient reported outcome following hind brain decompression

Objectives: To evaluate the impact of concomitant syringomyelia and self-reported complications on patient reported outcome measures in patients undergoing hindbrain decompression for a Chiari 1 malformation.Methods: Prospective data collection of 95 patients who underwent Foramen magnum decompression between March 2011 and March 2015. Outcome evaluation was performed using the Core Outcome Measure Index questionnaire for neck (COMI-neck) and Gestalt impression (to assess improvement of headaches). Patients were split into two cohorts, those with and those without syringomyelia. Both cohorts were compared in all domains of the COMI neck questionnaires, headache, and complications. Non-parametric data were analysed with Wilcoxon signed rank, Mann-Whitney U and Fisher exact tests. Parametric data were analysed with Student T-test. SPSS Software was used for analysis.Results: 79 patients returned 1 year follow-up COMI-neck questionnaires. Thirty three had concomitant syringomyelia and 46 had no syringomyelia present. There was no statistically significant difference in patient reported outcomes (COMI-neck index median 4.5 +/- 3.3 vs 4.2+/-3.2; p = .376) between the syrinx and non-syrinx cohorts. However postoperative neck pain (median 4 +/- 3.35 vs 1 +/- 3.17; p 0.041) and arm/shoulder pain scores (2 +/- 3.38 vs. 0+/- 2.628; p 0.049) were significantly lower in the non-syrinx cohort. In both cohorts 57% patients had an improvement in headache. 92% patients were 'satisfied' with treatment and 63% stated that the operation 'helped'. 54% patients in the syrinx and 59% in the non-syrinx cohort self-reported complications. There was no statistical difference in outcomes of the patients with and without self-reported complications (p = .121).Conclusions: This study demonstrates that the clinical effectiveness of FMD is lower and reported complications are higher when evaluated by patient reported outcome measures as opposed to surgeon reported complications. Patients with and without concomitant syringomyelia showed equal overall outcomes, although neck and arm pain was worse in syrinx patients.

Patient reporting of complications after surgery: what impact does documenting postoperative problems from the perspective of the patient using telephone interview and postal questionnaires have on the identification of complications after surgery?

OBJECTIVES

To identify the frequency of postoperative complications, including problems identified by patients and complications occurring after discharge from hospital. To identify how these impact on quality of life (QoL) and the patient's perception of the success of their treatment.

DESIGN

Data from three prospective sources: surgical audit, a telephone interview (2 weeks after discharge) and a patient-focused questionnaire (2 months after surgery) were retrospectively analysed.

SETTING

Dunedin Hospital, Dunedin, New Zealand.

PARTICIPANTS

Of the 500 patients, 100 undergoing each of the following types of surgeries: anorectal, biliary, colorectal, hernia and skin.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcomes were complications and the 36-item Short Form Health Survey (SF-36). Secondary outcomes included the patient's ratings of their treatment and a questionnaire-derived patient satisfaction score.

RESULTS

226 patients reported a complication; there were 344 separate complications and 411 reports of complications (16% of complications were reported on more than one occasion). The audit, telephone interview and questionnaire captured 12.6%, 36.3% and 51% of the 411 reports, respectively. Patients with complications had a lower SF-36 Physical Composite Summary (PCS) score (48.5 vs 43.9, p=0.021) and a lower Patient Satisfaction Score (85.6 vs 74.6, p<0.001). Rating of information received, care received, symptoms experienced, QoL and satisfaction with surgery were all significantly worse for patients with complications. On linear regression analysis, surgical complications, American Society of Anaesthesiologists score and age all made a similar contribution to the SF-36 PCS score, with standardised beta coefficients between 0.19 and 0.21.

CONCLUSIONS

Following surgery, over 40% of patients experienced complications. The QoL and satisfaction score were significantly less than for those without complications. The majority of complications were diagnosed after discharge from hospital. Taking more notice of the patient perspective helps us to identify problems, to understand what is important to them and may suggest ways to improve perioperative care.

EUROSPINE 2017 FULL PAPER AWARD: Time to remove our rose-tinted spectacles: a candid appraisal of the relative success of surgery in over 4500 patients with degenerative disorders of the lumbar spine, hip or knee

PURPOSE

Studies comparing the outcome of spine surgery with that of large-joint replacement report equivocal findings. The patient-reported outcome measures (PROMs) used in such studies are typically generic and may not be sufficiently sensitive to the successes/failures of treatment. This study compared different indices of "success" in patients undergoing surgery for degenerative disorders of the lumbar spine, hip, or knee, using a validated, multidimensional, and joint-specific PROM.

METHODS

Preoperatively and 12 months postoperatively, 4594 patients (3937 lumbar spine, 368 hip, 269 knee) undergoing first-time surgery completed a PROM that included the Core Outcome Measures Index (COMI) for the affected joint. The latter comprises a set of single items on pain, function, symptom-specific well-being, quality of life, and disability-all in relation to the specified joint problem. Other single-item ratings of treatment success were made 12 months postoperatively.

RESULTS

In multiple regression analyses, controlling for confounders, the mean improvement in COMI at 12 months was greatest for the hip patients and lowest for those with degenerative spinal deformity (= the statistical reference group) (p < 0.05). Compared with spinal deformity, the odds of achieving "success" were: higher for hip (OR 4.6; 95% CI 2.5-8.5) and knee (OR 4.0; 95% CI 2.1-7.7) (no difference between spine subgroups) for "satisfaction with care"; higher for hip (OR 16.9; 95% CI 7.3-39.6), knee (OR 6.3; 95% CI 3.4-11.6), degenerative spondylolisthesis (OR 1.6; 95% CI 1.2-2.2), and herniated disc (OR 1.7; 95% CI 1.2-2.4) for "global treatment outcome"; and higher for hip (OR 13.8; 95% CI 8.8-21.6), knee (OR 5.3; 95% CI 3.6-7.8), degenerative spondylolisthesis (OR 1.6; 95% CI 1.3-2.1), and herniated disc (1.5; 95% CI 1.1-2.0) for "patient-acceptable symptom state". Patient-rated complications were the greatest in degenerative spinal deformity (29%) and the lowest in hip (18%).

CONCLUSIONS

The current study is the largest of its kind and the first to use a common, but joint-specific instrument to report patient-reported outcomes after surgery for degenerative disorders of the spine, hip, or knee. The findings provide a sobering account of the significantly poorer outcomes after spine surgery compared with large-joint replacement. Further work is required to hone the indications and patient selection criteria for spine surgery. The data should be used to lobby research funding-bodies, governmental agencies, industry, and charitable foundations to invest more in spine research/registries, in the hope of ultimately improving spine outcomes. These slides can be retrieved under Electronic Supplementary Material.

A novel use of the Spine Tango registry to evaluate selection bias in patient recruitment into clinical studies: an analysis of patients participating in the Lumbar Spinal Stenosis Outcome Study (LSOS)

PURPOSE

Patients enrolled in clinical studies typically represent a sub-set of all who are eligible, and selection bias may compromise the generalizability of the findings. Using Registry data, we evaluated whether surgical patients recruited by one of the referring centres into the Lumbar Spinal Stenosis Outcome Study (LSOS; a large-scale, multicentre prospective observational study to determine the probability of clinical benefit after surgery) differed in any significant way from those who were eligible but not enrolled.

METHODS

Data were extracted for all patients with lumbar spinal stenosis registered in our in-house database (interfaced to Eurospine's Spine Tango Registry) from 2011 to 2013. Patient records and imaging were evaluated in relation to the admission criteria for LSOS to identify those who would have been eligible for participation but were not enrolled (non-LSOS). The Tango surgery data and Core Outcome Measures Index (COMI) data at baseline and 3 and 12 months after surgery were analysed to evaluate the factors associated with LSOS enrolment or not.

RESULTS

514 potentially eligible patients were identified, of which 94 (18%) were enrolled into LSOS (range 2-48% for the 6 spine surgeons involved in recruiting patients) and 420 (82%) were not; the vast majority of the latter were due to non-referral to the study by the surgeon, with only 5% actually refusing participation. There was no significant difference in gender, age, BMI, smoking status, or ASA score between the two groups (p ≥ 0.18). Baseline COMI was significantly (p = 0.002) worse in the non-LSOS group (7.4 ± 1.9) than the LSOS group (6.7 ± 1.9). There were no significant group differences in any Tango surgery parameters (additional spine patholothegies, operation time, blood loss, complications, etc.) although significantly more patients in the non-LSOS group had a fusion procedure (38 vs 18% in LSOS; p = 0.0004). Postoperatively, neither the COMI nor its subdomain scores differed significantly between the groups (p > 0.05). Multiple logistic regression revealed that worse baseline COMI (p = 0.021), surgeon (p = 0.003), and having fusion (p = 0.014) predicted non-enrolment in LSOS.

CONCLUSION

A high proportion of eligible patients were not enrolled in the study. Non-enrolment was explained in part by the specific surgeon, worse baseline COMI status, and having a fusion. The findings may reflect a tendency of the referring surgeon not to overburden more disabled patients and those undergoing more extensive surgery with the commitments of a study. Beyond these factors, non-enrolment appeared to be somewhat arbitrary, and was likely related to surgeon forgetfulness, time constraints, and administrative errors. Researchers should be aware of potential selection bias in their clinical studies, measure it (where possible) and discuss its implications for the interpretation of the study's findings.

Complications of surgical intervention in adult lumbar scoliosis

If nonoperative measures are unsuccessful in managing the pain and disability of adult spinal deformities, surgical correction may provide the potential for significant improvement in a patient's quality of life. However, these procedures have a relatively high risk of complications. Identifying patients that may benefit from surgical intervention requires a thorough understanding of potential complications and managing the risks of any individual patient. Complications do not necessarily result in poor outcomes, and good outcomes are not always complication free. Higher risk patients potentially have more to gain, even if they experience complications. With the rapidly expanding senior population and expanded capabilities to manage high-risk patients, it is helpful to consider the lessons provided by ever expanding databases of outcome measures to refine the surgical decision-making process.

Patient-Rated Outcomes of Lumbar Fusion in Patients With Degenerative Disease of the Lumbar Spine: Does Age Matter?

STUDY DESIGN

Single-center retrospective study of prospectively collected data, nested within the Eurospine Spine Tango data acquisition system.

OBJECTIVE

The aim of this study was to assess the patient-rated outcome and complication rates associated with lumbar fusion procedures in three different age groups.

SUMMARY OF BACKGROUND DATA

There is a general reluctance to consider spinal fusion procedures in elderly patients due to the increased likelihood of complications.

METHODS

Before and at 3, 12, and 24 months after surgery, patients completed the multidimensional Core Outcome Measures Index. At the 3-, 12-, and 24-month follow-ups, they also rated the Global Treatment Outcome and their satisfaction with care. Patients were divided into three age groups: younger (≥50 years <65 years; n = 317), older (≥65 years <80 years; n = 350), and geriatric (≥80 years; n = 40).

RESULTS

A total of 707 consecutive patients were included. The preoperative comorbidity status differed significantly (P < 0.0001) between the age groups, with the highest scores in the geriatric group. Medical complications during surgery were lower in the younger age group (7%) than in the older (13.4%; P = 0.006) and geriatric groups (17.5%; P = 0.007); surgical complications tended to be higher in the elderly group (younger, 6.3%; older, 6.0%; geriatric, 15.0%; P = 0.09). There were no significant group differences (P > 0.05) for the scores on any of the Core Outcome Measures Index domains, Global Treatment Outcome, or patient-rated satisfaction at either 3-, 12-, and 24-months of follow-up.

CONCLUSION

Despite greater comorbidity and complication rates in geriatric patients, the patient-rated outcome was as good in the elderly as it was in younger age groups up to 2 years after surgery. These data indicate that geriatric age needs careful consideration of associated risks but is not per se a contraindication for fusion for lumbar degenerative disease.

LEVEL OF EVIDENCE

4.

Evidence and practice in spine registries

BACKGROUND AND PURPOSE

We performed a systematic review and a survey in order to (1) evaluate the evidence for the impact of spine registries on the quality of spine care, and with that, on patient-related outcomes, and (2) evaluate the methodology used to organize, analyze, and report the "quality of spine care" from spine registries.

METHODS

To study the impact, the literature on all spinal disorders was searched. To study methodology, the search was restricted to degenerative spinal disorders. The risk of bias in the studies included was assessed with the Newcastle-Ottawa scale. Additionally, a survey among registry representatives was performed to acquire information about the methodology and practice of existing registries.

RESULTS

4,273 unique references up to May 2014 were identified, and 1,210 were eligible for screening and assessment. No studies on impact were identified, but 34 studies were identified to study the methodology. Half of these studies (17 of the 34) were judged to have a high risk of bias. The survey identified 25 spine registries, representing 14 countries. The organization of these registries, methods used, analytical approaches, and dissemination of results are presented.

INTERPRETATION

We found a lack of evidence that registries have had an impact on the quality of spine care, regardless of whether intervention was non-surgical and/or surgical. To improve the quality of evidence published with registry data, we present several recommendations. Application of these recommendations could lead to registries showing trends, monitoring the quality of spine care given, and ultimately improving the value of the care given to patients with degenerative spinal disorders.

The assessment of complications after spine surgery: time for a paradigm shift?

BACKGROUND CONTEXT

Recent years have witnessed a shift in the assessment of spine surgical outcomes with a greater focus on the patient's perspective. However, this approach has not been widely extended to the assessment of complications.

PURPOSE

The present study sought to quantify the patient-rated impact/severity of complications of spine surgery and directly compare the incidences of surgeon-rated and patient-reported complications.

STUDY DESIGN

Prospective study of patients undergoing surgery for painful degenerative lumbar disorders, being operated in the Spine Center of an orthopedic hospital.

PATIENT SAMPLE

A total of 2,303 patients (mean [standard deviation] age, 61.9 [15.1] years; 1,136 [49.3%] women and 1,167 [50.7%] men).

PATIENTS

Core Outcome Measures Index, self-rated complications, bothersomeness of complications, global treatment outcome, and satisfaction. Surgeons: Spine Tango surgery and follow-up documentation forms registering surgical details and complications.

METHODS

PATIENTS completed questionnaires before and 3 months after surgery. Surgeons documented complications before discharge and at the first postoperative follow-up, 6 to 12 weeks after surgery.

RESULTS

In total, 615 out of 2,303 (27%) patients reported complications, with "bothersomeness" ratings of 1%, not at all; 22%, slightly; 26%, moderately; 34%, very; and 17%, extremely bothersome. PATIENTS most commonly reported sensory disturbances (35% of those reporting a complication) or ongoing/new pain (27%) followed by wound healing problems (11%) and motor disturbances (8%). The surgeons documented complications in 19% of patients. There was a minimal overlap regarding the presence or absence of complications in any given patient.

CONCLUSIONS

Most complications reported by the patient are perceived to be at least moderately bothersome and are, hence, not inconsequential. Surgeons reported lower complication rates than the patients did, and there was only moderate agreement between the ratings of the two. As with treatment outcome, complications and their severity should be assessed from both the patient's and the surgeon's perspectives.

A comparison of patient and surgeon preoperative expectations of spinal surgery

STUDY DESIGN

Cross-sectional study of agreement between patients' and surgeons' expectations of the outcome of spinal surgery.

OBJECTIVE

Patients' satisfaction after spinal surgery depends, in part, on whether their expectations of surgery are fulfilled. Whether the patient always fully understands the key messages conveyed by the surgeon, to formulate realistic expectations, is not known. This study evaluates the level of agreement in expectations declared preoperatively by the patient and the surgeon.

SUMMARY OF BACKGROUND DATA

Previous studies have investigated the importance of realistic expectations for the patients' satisfaction with surgical treatments, but there is still a need for a more detailed analysis in the field of spinal surgery.

METHODS

The study included 225 German-speaking patients (92 men and 133 women; mean ± SD [range] age, 62 ± 15 [15-90] yr) and their treating spinal surgeons (N = 7). Following the preoperative informed consent consultation, the patient and the surgeon independently completed a questionnaire about baseline neurological status and realistic expectations regarding various patient-orientated outcomes (axial pain (back/neck), radiating pain (leg/arm), pain medication usage, sensory and motor function, and the ability to work, do household activities, and play sports). Concordance was given by percent agreement and κ coefficients.

RESULTS

Agreement between the patient and the surgeon about the existence of spine-related neurological deficits occurred in 75% (sensory) and 61% (motor) cases. The patient but not the surgeon reported a sensory deficit in 20% cases and motor deficit in 35% cases; for 4% to 5% cases, the physician reported such a deficit that the patient was seemingly unaware of. The patients consistently had higher expectations than the surgeons, especially for back or neck pain and function (work, household activities, and sports); weighted κ values for agreement were low, ranging from 0.097 to 0.222.

CONCLUSION

The findings demonstrate wide discrepancies between the patient and the surgeon regarding the expected result of surgery. They highlight the need for clearer explanations of the association between the spinal problem and neurological deficits and the improvement that can be expected in pain and function after surgery. Systematic, routine evaluation of outcomes should assist in deriving the information necessary to document the improvement achieved and to formulate realistic expectations of surgery.

Comparison between patient and surgeon perception of degenerative spine disease outcomes--a prospective blinded database study

BACKGROUND

Few have studied the correlation between patients' and spine surgeons' perception on outcomes, or compared these with patient-reported outcome scores. Outcomes studies are increasingly important in evaluating costs and benefits to patients and surgeons, and in developing metrics for payer evaluation and health care policy-making.

OBJECTIVE

To compare patients' and surgeons' assessment of spine treatment outcome in a prospective blinded patient-driven spine surgery outcomes registry, and to correlate perceived outcomes ratings to validated outcomes scores.

METHODS

Patients filled out surveys at baseline, 3 months and 6 months postoperatively, including Visual Analog Scale (VAS), and Neck Disability Index (NDI) or Oswestry Disability Index (ODI). Outcome was rated independently by patients and surgeons on a 7-point Likert-type scale.

RESULTS

Two-hundred and sixty-five consecutive adult patients were surgical candidates. Of these, 154 (58.1 %) opted for surgery, with 69 (44.8 %) cervical and 85 (55.2 %) lumbar patients. One hundred and thirty-five (87.7 %) had both patient and surgeon postoperative ratings. Surgeons' and patients' ratings correlated strongly (Spearman rho = 0.53, p < 0.0001, 45.9 % identical, 88.2 % +/- 1 grade). The surgeon rated outcomes were better than patients in 29.8 % and worse in 21.15 %. Patient rating correlated better with the most recent NDI/ODI and pain scores than with incremental change from baseline. In multivariate analysis, age, location (cervical vs lumbar), pain ratings, and functional scores (NDI, ODI) did not have significant impact on the discrepancy between patient and surgeon ratings.

CONCLUSIONS

Patients' and surgeons' global outcome ratings for spinal disease correlate highly. Patients' ratings correlate better with most recent functional scores, rather than incremental change from baseline.

Initial investigation of ¹⁸F-NaF PET/CT for identification of vertebral sites amenable to surgical revision after spinal fusion surgery

Purpose

A pilot study was performed in patients with recurrent back pain after spinal fusion surgery to evaluate the ability of ¹⁸F-NaF PET/CT imaging to correctly identify those requiring surgical intervention and to locate a site amenable to surgical intervention.

Methods

In this prospective study 22 patients with recurrent back pain after spinal surgery and with equivocal findings on physical examination and CT were enrolled for evaluation with ¹⁸F-NaF PET/CT. All PET/CT images were prospectively reviewed with the primary objective of identifying or ruling out the presence of lesions amenable to surgical intervention. The PET/CT results were then validated during surgical exploration or clinical follow-up of at least 15 months.

Results

Abnormal ¹⁸F-NaF foci were found in 16 of the 22 patients, and surgical intervention was recommended. These foci were located at various sites: screws, cages, rods, fixation hardware, and bone grafts. In 6 of the 22 patients no foci requiring surgical intervention were found. Validation of the results by surgery (15 patients) or on clinical follow-up (7 patients) showed that ¹⁸F-NaF PET/CT correctly predicted the presence of an abnormality requiring surgical intervention in 15 of 16 patients and was falsely positive in 1 of 16.

Conclusion

In this initial investigation, ¹⁸F-NaF PET/CT imaging showed potential utility for evaluation of recurrent symptoms after spinal fusion surgery by identifying those patients requiring surgical management.

The bothersomeness of patient self-rated "complications" reported 1 year after spine surgery

PURPOSE

The last few decades have witnessed a paradigm shift in the assessment of outcome in spine surgery, with patient-centred questionnaires superseding traditional surgeon-based assessments. The assessment of complications after surgery and their impact on the patient has not enjoyed this same enlightened approach. This study sought to quantify the incidence and bothersomeness of patient-rated complications 1 year after surgery.

METHODS

Patients with lumbar degenerative disorders, operated with the goal of pain relief between October 2006 and September 2010, completed a questionnaire 1 year postoperatively enquiring about complications arising as a consequence of their operation. They rated the bothersomeness of any such complications on a 5-point scale. Global outcome of surgery and satisfaction at the 12-month follow-up were also rated on 5-point Likert scales. The multidimensional Core Outcome Measures Index (COMI) was completed preoperatively and at the 12-month follow-up.

RESULTS

Of 2,282 patients completing the questionnaire (92% completion rate), 687 (30.1%) reported complications, most commonly sensory disturbances (36% of those with complications) or ongoing/new pain (26%), followed by motor problems (8%), pain plus neurological disturbances (11%), and problems with wound healing (6%). The corresponding "bothersomeness" ratings for these were: 1% not at all, 23% slightly, 27% moderately, 31% very, and 18% extremely bothersome. The greater the bothersomeness, the worse the global outcome (Rho = 0.51, p < 0.0001), patient satisfaction (Rho = 0.44, p < 0.0001) and change in COMI score (Rho = 0.52, p < 0.0001).

CONCLUSION

Most complications reported by the patient are perceived to be at least moderately bothersome and hence are not inconsequential. Complications and their severity should be assessed from both the patient's and the surgeon's perspectives--not least to better understand the reasons for poor outcome and dissatisfaction with treatment.

Perioperative complications and adverse events after lumbar spinal surgery: evaluation of 1012 operations at a single center

BACKGROUND

Lumbar surgery and associated complications are increasing as society is aging. However, definitions of complications after lumbar surgery have not been established and previous reports have varied in the definition of, and focus on, intraoperative or major postoperative complications. We analyzed the frequency and severity of perioperative complications and all minor adverse events in lumbar surgery at a single center.

METHODS

We retrospectively reviewed all lumbar surgery, including decompression surgery with or without fusion, at Meijo Hospital over a 10-year period. Perioperative complications and all surgery-related adverse events until 1 month postoperatively were reviewed for 1012 operations on 918 patients (average age 54 years old). The incidence of intraoperative complications was compared between junior (<10 years experience of spine surgery) and senior (≥10 years experience) surgeons.

RESULTS

Perioperative complications and adverse events occurred in 159 operations (15.7%) on 127 patients (13.8%). There were a variety of perioperative adverse events, including digestive problems. Of the 159 complications and events, 24 (2.4%) were intraoperative and 135 (13.3%) were postoperative. Incidence of intraoperative complications was not significantly higher for junior surgeons; however, the operations performed by senior surgeons were significantly more invasive. Complications were more frequent in elderly patients (p < 0.01) and in operations that were longer (p < 0.0001), had greater estimated blood loss (p < 0.0001), and involved use of spinal instrumentation (p < 0.0001). Psychotic symptoms occurred significantly more often in older patients (p < 0.001).

CONCLUSION

The absence of a relationship between the experience of the surgeon and incidence of intraoperative complications may be because of the greater effect of invasive surgery. Although age and invasiveness were associated with more perioperative adverse events, we do not conclude that major surgery should be avoided for elderly patients. In contrast, careful focus on the surgical indication and procedure is required for these patients.

Effect of deep wound infection following lumbar arthrodesis for degenerative disc disease on long-term outcome: a prospective study: clinical article

OBJECT

Deep wound infections are one of the most common and serious complications of spinal surgery. The impact of such infections on long-term outcomes is not well understood. The purpose of this study was to evaluate the functional status and satisfaction in patients who suffered a deep wound infection after undergoing lumbar arthrodesis for symptomatic degenerative disc disease.

METHODS

The authors conducted a prospective study in 13 patients with a clinical and radiological diagnosis of symptomatic degenerative lumbar stenosis and instability; after undergoing decompression and instrumentation-augmented arthrodesis, the patients suffered a deep wound infection (infection group). A 3:1 (39-patient) matched cohort was selected for comparison (control group). All surgeries were performed during the same period and by a single surgeon. The postoperative infections were all treated in a similar manner and the instrumentation was not removed. Both groups were followed up and assessed with validated outcome instruments: Numerical Rating Scale of pain, Oswestry Disability Index, 36-Item Short Form Health Survey, Beck Depression Inventory, and Hospital Anxiety and Depression Scale. Patient satisfaction was also determined.

RESULTS

The median follow-up duration was 22 months (range 6-108 months). The mean patient age was 62 ± 10 years, and 59.6% of the patients were female. There was no significant difference between the groups in pain, functional disability, quality of life, or depression and anxiety. However, 53.8% of the patients with infection were not satisfied with the procedure at the final evaluation, compared with 15.4% of the patients without a deep wound infection (p = 0.003).

CONCLUSIONS

Patients with successfully treated postoperative deep wound infections do not have a difference in functional outcome compared with patients who underwent an identical operation but did not suffer a complicating infection. Patients who suffered an infection were more likely to be unsatisfied with the procedure than patients who did not.

An observational study of patient-rated outcome after atlantoaxial fusion in patients with rheumatoid arthritis and osteoarthritis

BACKGROUND

Fusion is used to address several types of abnormality of the atlantoaxial segment. Traditionally, outcome has been assessed by achieving solid bony union. Recently, however, patient-rated outcome instruments have been increasingly used, although these may be influenced by concomitant comorbidity.

QUESTIONS/PURPOSES

We therefore asked whether patients with rheumatoid arthritis (RA), with its associated comorbidity, had worse self-rated outcomes after C1-2 fusion than patients with osteoarthritis (OA).

PATIENTS AND METHODS

We retrospectively reviewed all 30 (23 OA and seven RA) prospectively followed patients in our local Spine Registry (part of the Spine Society of Europe Spine Tango Registry) who had undergone C1-2 fusion. Before surgery and 3 and 12 months later, patients completed the multidimensional Core Outcome Measures Index (COMI) questionnaire. Global outcome and satisfaction with treatment were also assessed.

RESULTS

We found no group differences for duration of operation, blood loss, or perioperative surgical or general complications. Compared with the OA group, the RA group showed a better baseline COMI score and less improvement in the COMI from preoperatively to 12 months followup. However, the proportion of "good" global scores at 12 months followup was similarly high in both groups (87% OA and 86% RA) as was satisfaction (96% for OA versus 86% for RA).

CONCLUSIONS

Symptoms and impairment were less severe in the RA group at baseline and showed less improvement after surgery, but the proportion of "good global outcomes" was similar in both groups, and the great majority of patients in both groups were satisfied with their treatment.

LEVEL OF EVIDENCE

Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Qualitative grading of severity of lumbar spinal stenosis based on the morphology of the dural sac on magnetic resonance images

STUDY DESIGN

Retrospective radiologic study on a prospective patient cohort.

OBJECTIVE

To devise a qualitative grading of lumbar spinal stenosis (LSS), study its reliability and clinical relevance.

SUMMARY OF BACKGROUND DATA

Radiologic stenosis is assessed commonly by measuring dural sac cross-sectional area (DSCA). Great variation is observed though in surfaces recorded between symptomatic and asymptomatic individuals.

METHODS

We describe a 7-grade classification based on the morphology of the dural sac as observed on T2 axial magnetic resonance images based on the rootlet/cerebrospinal fluid ratio. Grades A and B show cerebrospinal fluid presence while grades C and D show none at all. The grading was applied to magnetic resonance images of 95 subjects divided in 3 groups as follows: 37 symptomatic LSS surgically treated patients; 31 symptomatic LSS conservatively treated patients (average follow-up, 2.5 and 3.1 years); and 27 low back pain (LBP) sufferers. DSCA was also digitally measured. We studied intra- and interobserver reliability, distribution of grades, relation between morphologic grading and DSCA, as well relation between grades, DSCA, and Oswestry Disability Index.

RESULTS

Average intra- and interobserver agreement was substantial and moderate, respectively (k = 0.65 and 0.44), whereas they were substantial for physicians working in the study originating unit. Surgical patients had the smallest DSCA. A larger proportion of C and D grades was observed in the surgical group. Surface measurements resulted in overdiagnosis of stenosis in 35 patients and under diagnosis in 12. No relation could be found between stenosis grade or DSCA and baseline Oswestry Disability Index or surgical result. C and D grade patients were more likely to fail conservative treatment, whereas grades A and B were less likely to warrant surgery.

CONCLUSION

The grading defines stenosis in different subjects than surface measurements alone. Since it mainly considers impingement of neural tissue it might be a more appropriate clinical and research tool as well as carrying a prognostic value.

Simple questionnaire for assessing core outcomes in inguinal hernia repair

Background

Patient-oriented questionnaires are indispensable in the assessment of surgical outcome. The psychometric properties of a brief multidimensional instrument were examined in patients with inguinal hernia undergoing surgery.

Methods

Fifty-one patients (mean(s.d.) age 50·6(17·4) years; 48 men) participated. The following questionnaire properties were assessed for the Core Outcome Measures Index adapted for patients with hernia (COMI-hernia) and the EuroQol: practicability, floor and ceiling effects, test–retest reliability (over 2 weeks), construct validity (by comparison with other relevant scales) and responsiveness 9 months after surgery as standardized response mean (SRM).

Results

The questionnaires were easy to implement and well accepted by the patients. Ceiling effects at baseline were 2 per cent for the COMI-hernia, 8 per cent for EuroQol—visual analogue scale (EQ-VAS) and 35 per cent for EuroQol—Five Dimensions (EQ-5D); no instrument showed floor effects. The reproducibility of individual COMI-hernia items was good, with test–retest differences within one grade ranging from 41 of 45 for ‘social/work disability’ to 44 of 45 for ‘general quality of life’. The intraclass correlation coefficients were moderately high for COMI-hernia (0·74) and EQ-VAS (0·77), but low for EQ-5D (0·43). COMI-hernia scores correlated in the expected manner with related scales (r = 0·42–0·72, P &lt; 0·050). COMI-hernia was the most responsive instrument (SRM 1·42).

Conclusion

The COMI-hernia and EQ-VAS general health scale represent reliable, valid and sensitive tools for assessing multidimensional outcome in patients with inguinal hernia undergoing surgical treatment.

Obesity and spine surgery: reassessment based on a prospective evaluation of perioperative complications in elective degenerative thoracolumbar procedures

BACKGROUND CONTEXT

The correlation between obesity and incidence of complications in spine surgery is unclear, with some reports suggesting linear relationships between body mass index (BMI) and complication incidence and others noting no relationship.

PURPOSE

The purpose of this article was to assess the relationship between obesity and occurrence of perioperative complications in an elective thoracolumbar surgery cohort.

STUDY DESIGN/SETTING

Prospective observational cohort study at a tertiary care facility.

PATIENT SAMPLE

Cohort of 87 consecutive patients undergoing elective surgery for degenerative thoracolumbar pathologies over a 6-month period (May to December 2008).

OUTCOME MEASURES

Incidence of perioperative complications (those occurring within 30 days of surgery).

METHODS

A prospective assessment of perioperative spine surgery complications was completed, and data were prospectively entered into a central database. Two independent auditors assessed for the presence and severity of perioperative complications. Previously validated binary definitions of major and minor complications were used. Patient data and early complications (those occurring within 30 days of index surgery) were analyzed using multivariate regression.

RESULTS

Mean BMI in this cohort was 31.3; 40.8% of patients were obese (BMI>30) and 10 patients (11.5%) were morbidly obese (BMI>40). The overall complication incidence was 67%. Minor complications occurred in 50% of patients, and major complications occurred in 17.8% of patients. No positioning palsies occurred in this series. Age correlated with an increase in complication risk (p=.006) as did hypertension (p=.004) and performance of a fusion (p<.0001). BMI did not correlate with the incidence of minor, major, or any complications (p=.58).

CONCLUSIONS

This prospective assessment of perioperative complications in elective degenerative thoracolumbar procedures shows no relationship between patient BMI and the incidence of perioperative minor or major complications. Specific care in perioperative positioning may limit the risk of perioperative positioning palsies in obese patients.

A comparison of outcomes of cervical disc arthroplasty and fusion in everyday clinical practice: surgical and methodological aspects

Randomised controlled trials (RCTs) of cervical disc arthroplasty vs fusion generally show slightly more favourable results for arthroplasty. However, RCTs in surgery often have limited external validity, since they involve a select group of patients who fit very rigid admission criteria and who are prepared to subject themselves to randomisation. The aim of this study was to examine whether the findings of RCTs are verified by observational data recorded in our Spine Center in association with the Spine Society of Europe Spine Tango surgical registry. Patients undergoing fusion/stabilisation or disc arthroplasty for degenerative cervical spinal disease were selected for inclusion. They completed a questionnaire pre-operatively and at 12 and 24 months follow-up (FU). The questionnaire comprised the multidimensional Core Outcome Measures Index (COMI; 0-10 scale) and, at FU, questions on global outcome and satisfaction with treatment (5-point scales, dichotomised to "good" and "poor"), re-operation and patient-rated complications. The surgeon completed a Spine Tango Surgery form. The outcome data from 266 (208 fusion, 58 arthroplasty) out of 284 eligible patients who had reached 12 months FU, and 169 (139 fusion, 30 arthroplasty) out of 178 who had reached 24 months FU, were included. Patients with cervical disc arthroplasty were younger [46 (SD 8) years vs 56 (SD 11) years for fusion; P < 0.05], had less comorbidity (P < 0.05), more often had only mono-segmental pathology (69% arthroplasty, 47% fusion) and only one type of degenerative pathology (69% arthroplasty, 46% fusion). Surgical complication rates were similar in each group (arthroplasty, 1.5%; fusion, 2.6%). The reduction in the COMI score was significantly greater in the arthroplasty group (at 12 months, 4.8 (SD 3.0) vs 3.7 (SD 2.9) points for fusion, and at 24 months 5.1 (SD 2.8) vs 3.8 (SD 2.9) points; each P < 0.05). In the arthroplasty group, a "good" global outcome was recorded in 90% patients (at 12 months) and 93% (at 24 months); in the fusion group the figures were 80 and 82%, respectively (group differences at each timepoint, P > 0.09). Satisfaction with treatment was similar in both groups (89-93%), at each timepoint. In multiple regression analysis, treatment group was of borderline significance as a unique predictor of the change in COMI at FU (P = 0.059 at 12 months, P = 0.055 at 24 months) in a model in which known confounders (age, comorbidity, number of affected levels) were controlled for. Being in the arthroplasty group was associated with an approximately 1-point greater reduction in the COMI score at FU. The results of this observational study appear to support those of the RCTs and suggest that, in patients with degenerative pathology of the cervical spine, disc arthroplasty is associated with a slightly better outcome than fusion. However, given the small size of the difference, its clinical relevance is questionable, especially in view of the a priori more favourable outcome expected in the arthroplasty group due to the more rigorous selection of patients.

The quality of spine surgery from the patient's perspective. Part 1: the Core Outcome Measures Index in clinical practice

The Core Outcome Measures Index (COMI) is a short, multidimensional outcome instrument, with excellent psychometric properties, that has been recommended for use in monitoring the outcome of spinal surgery from the patient's perspective. This study examined the feasibility of implementation of COMI and its performance in clinical practice within a large Spine Centre. Beginning in March 2004, all patients undergoing spine surgery in our Spine Centre (1,000-1,200 patients/year) were asked to complete the COMI before and 3, 12 and 24 months after surgery. The COMI has one question each on back (neck) pain intensity, leg/buttock (arm/shoulder) pain intensity, function, symptom-specific well being, general quality of life, work disability and social disability, scored as a 0-10 index. At follow-up, patients also rated the global effectiveness of surgery, and their satisfaction with their treatment in the hospital, on a five-point Likert scale. After some fine-tuning of the method of administration, completion rates for the pre-op COMI improved from 78% in the first year of operation to 92% in subsequent years (non-response was mainly due to emergencies or language or age issues). Effective completion rates at 3, 12 and 24-month follow-up were 94, 92 and 88%, respectively. The 12-month global outcomes (from N = 3,056 patients) were operation helped a lot, 1,417 (46.4%); helped, 860 (28.1%); helped only little, 454 (14.9%); did not help, 272 (8.9%); made things worse, 53 (1.7%). The mean reductions in COMI score for each of these categories were 5.4 (SD2.5); 3.1 (SD2.2); 1.3 (SD1.7); 0.5 (SD2.2) and -0.7 (SD2.2), respectively, yielding respective standardised response mean values ("effect sizes") for each outcome category of 2.2, 1.4, 0.8, 0.2 and 0.3, respectively. The questionnaire was feasible to implement on a prospective basis in routine practice, and was as responsive as many longer spine outcome questionnaires. The shortness of the COMI and its multidimensional nature make it an attractive option to comprehensively assess all patients within a given Spine Centre and hence avoid selection bias in reporting outcomes.