Considerations in Spinal Fusion Surgery for Chronic Lumbar Pain: Psychosocial Factors, Rating Scales, and Perioperative Patient Education—A Review of the Literature

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.

Impact of Early Depressive Burden on Patient-Reported Outcomes Following Minimally Invasive Transforaminal Lumbar Interbody Fusion

STUDY DESIGN

Retrospective review.

OBJECTIVE

To evaluate mental health influence on minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) patients.

SUMMARY OF BACKGROUND DATA

Poor mental health has been postulated to indicate inferior patient perceptions of surgical outcomes in spine literature. Few studies have assessed mental health as a dynamic metric throughout the perioperative period.

METHODS

A single-surgeon database was retrospectively searched for patients who underwent primary, elective MIS-TLIF for degenerative or isthmic spondylolisthesis. Summative depressive burden (SDB) was defined by the sum of preoperative and 6-week postoperative 9-item Patient Health Questionnaire (PHQ-9), with Lesser Burden (LB, SDB<10) and Greater Burden (GB, SDB≥10) cohorts. Patient-reported outcomes measures (PROMs) were compared preoperatively, at 6 weeks, and at final postoperative follow-up (11.4±10.9 mo), using Patient-Reported Outcomes Measurement Information System-Physical Function (PROMIS-PF), Oswestry disability index (ODI), visual analog scale-back (VAS-B), VAS-leg (VAS-L), and PHQ-9. Improvements at 6-week (∆PROM-6W), final follow-up (∆PROM-FF), and minimum clinically important difference (MCID) achievement were compared.

RESULTS

The GB cohort consisted of 44 of 105 patients. Demographic variations included older age, higher Charlson comorbidity index, increased hypertension prevalence, and private insurance in the LB cohort (P≤0.018). The LB cohort demonstrated better baseline and 6-week PROMIS-PF/ODI/VAS-L (P≤0.032) and better final PROMIS-PF/ODI/VAS-L/PHQ-9 (P≤0.031). Both cohorts improved in all PROMs at 6 weeks and final follow-up (P≤0.029), except for PROMIS-PF at 6 weeks in the GB cohort. ∆PROM-6W, ∆PROM-FF, and MCID achievement rate for PHQ-9 were greater in the GB cohort (P≤0.001).

CONCLUSION

On average, patients undergoing MIS-TLIF for degenerative or isthmic spondylolisthesis improved in all PROMs by final follow-up. Patients with GB suffered inferior perceptions of physical function, disability, and leg pain. MCID rates in mental health were higher for GB cohort. Surgeons are encouraged to adopt a compassionate understanding of depressive burden and educate the patient on possible consequential postoperative outcomes.

Analyzing Large Language Models' Responses to Common Lumbar Spine Fusion Surgery Questions: A Comparison Between ChatGPT and Bard

OBJECTIVE

In the digital age, patients turn to online sources for lumbar spine fusion information, necessitating a careful study of large language models (LLMs) like chat generative pre-trained transformer (ChatGPT) for patient education.

METHODS

Our study aims to assess the response quality of Open AI (artificial intelligence)'s ChatGPT 3.5 and Google's Bard to patient questions on lumbar spine fusion surgery. We identified 10 critical questions from 158 frequently asked ones via Google search, which were then presented to both chatbots. Five blinded spine surgeons rated the responses on a 4-point scale from 'unsatisfactory' to 'excellent.' The clarity and professionalism of the answers were also evaluated using a 5-point Likert scale.

RESULTS

In our evaluation of 10 questions across ChatGPT 3.5 and Bard, 97% of responses were rated as excellent or satisfactory. Specifically, ChatGPT had 62% excellent and 32% minimally clarifying responses, with only 6% needing moderate or substantial clarification. Bard's responses were 66% excellent and 24% minimally clarifying, with 10% requiring more clarification. No significant difference was found in the overall rating distribution between the 2 models. Both struggled with 3 specific questions regarding surgical risks, success rates, and selection of surgical approaches (Q3, Q4, and Q5). Interrater reliability was low for both models (ChatGPT: k = 0.041, p = 0.622; Bard: k = -0.040, p = 0.601). While both scored well on understanding and empathy, Bard received marginally lower ratings in empathy and professionalism.

CONCLUSION

ChatGPT3.5 and Bard effectively answered lumbar spine fusion FAQs, but further training and research are needed to solidify LLMs' role in medical education and healthcare communication.

Qualitative study exploring the views of patients and healthcare providers on current rehabilitation practices after lumbar fusion surgery

OBJECTIVES

To explore the views of patients and healthcare providers on current rehabilitation after lumbar fusion surgery (LFS) to fuel the development of a novel rehabilitation care pathway.

DESIGN

A cross-sectional, qualitative study with an interpretive descriptive design.

SETTING

Academic and non-academic hospital setting in Belgium.

PARTICIPANTS

31 caregivers from (non)-academic settings and 5 patients with LFS were purposefully sampled and in-depth interviewed.

RESULTS

Out of the data of all interviews, participants reported opinions on 23 thematic clusters that were expressed in a time-contingent manner from the preoperative, perioperative to postoperative phase. Afterwards, themes were mapped to the Consolidated Framework for Implementation Research, with a larger role for concepts related to the innovation, inner and individual domain. As an overarching theme, the importance of an 'individualised, patient-centred rehabilitation built on a strong therapeutic alliance with an accessible interprofessional team' was stressed for patients undergoing LFS. Specifically, participants stated that a biopsychosocial approach to rehabilitation should start in the preoperative phase and immediately be continued postoperatively. No consensus was observed for movement restrictions postoperatively. Uniform communication between the involved caregivers was considered essential for optimal therapeutic alliance and clinical outcome. The precise role and competence of each member of the interprofessional team needs, therefore, to be clearly defined, respected and discussed. An accessible case manager to guide the patient trajectory and tackle problems could further support this. Interestingly, only patients, psychologists and physiotherapists addressed return to work as an important outcome after LFS.

CONCLUSIONS

This qualitative study identified key experiences and points to consider in the current and future rehabilitation pathway for LFS. Future research should incorporate these findings to build a novel rehabilitation pathway for LFS and evaluate its feasibility and cost-effectiveness.

TRIAL REGISTRATION NUMBER

This study was registered at clinicaltrials.gov (NCT03427294).

A systematic review of patient-centered interventions for improving pain outcomes and reducing opioid-related risks in acute care settings

Objectives

This systematic review evaluates the literature for patient-oriented opioid and pain educational interventions that aim to optimize pain management using opioid-sparing approaches in the orthopaedic trauma population. The study protocol was registered with PROSPERO (CRD42021234006).

Data Sources

A review of English-language publications in CINAHL (EBSCO), MEDLINE through PubMed, Embase.com, PsycInfo (EBSCO), and Web of Science Core Collection literature databases published between 1980 and February 2021 was conducted using PRISMA guidelines.

Study Selection

Only studies implementing patient-oriented opioid and/or pain education in adult patients receiving acute orthopaedic care were eligible. Outcomes were required to include postinterventional opioid utilization, postoperative analgesia and amount, or patient-reported pain outcomes.

Data Extraction

A total of 480 abstracts were reviewed, and 8 publications were included in the final analysis. Two reviewers independently extracted data from selected studies using a standardized data collection form. Disagreements were addressed by a third reviewer. Quality of studies was assessed using the Cochrane Risk of Bias Tool.

Data Synthesis

Descriptive statistics characterized study findings, and content analysis was used to discern themes across studies.

Conclusion

Our findings indicate the merit for patient-centered educational interventions including verbal/written/audio-visual trainings paired with multimodal approaches to target opioid-sparing pain management and reduce short-term pain scores in urgent and acute care settings after acute orthopaedic injuries. The scarcity of published literature warrants further rigorously designed studies to substantiate the benefit of patient-centric education in reducing prolonged opioid utilization and associated risks after orthopaedic trauma.

Level of Evidence

Therapeutic level III.

The impact of physical and psychological pain management training on pain intensity, anxiety and disability in patients undergoing lumbar surgeries

BACKGROUND/CONTEXT

Lumbar surgery is one of the interventions performed for patients with degenerative conditions.

PURPOSE

This study aimed to investigate the effect of pain management education on pain intensity, anxiety, and disability after the lumbar surgery.

STUDY DESIGN/SETTING

This randomized controlled trial was performed on seventy 30 to 65-year-old patients with lumbar canal stenosis and lumbar disc herniation from 2018 to 2019.

PATIENT SAMPLE

Seventy participants were randomly divided into a control and an intervention group by a randomized block design. Participants in the intervention group received in-person pain management training twice a week for seven 60 to 90-minute sessions.

OUTCOME MEASURES

All participants in the two groups completed the study instruments (numeric rating scale [NRS], Oswestery disability index [ODI], and pain anxiety symptoms scale [PASS]) before, immediately after, and 3 months after the study.

METHODS

Participants in the intervention group received in-person pain management training twice a week for seven 60 to 90-minute sessions. To analyze the treatment effects, repeated-measures multivariate analysis of variance (MANOVA) and effect sizes were used where appropriate and calculated by Partial ɳ². Clinical outcome (MDC) for pain intensity and PASS was also reported. For participants lost to follow-up, we also used an "intention-to-treat" (ITT) approach.

RESULTS

The results of MANOVA indicated that there were significant differences between the two groups on ratings of pain intensity, anxiety, and disability. According to the MDC, the mean differences of pain intensity for the intervention group was also clinically improved. Meanwhile, the mean differences in pain anxiety between three different times in the two groups were not above the MDC (20.14), suggesting that the clinical improvements were not significant. The results were confirmed for all outcome measures; a statistically significant difference was found between the groups in ITT analyses (p<.001).

CONCLUSIONS

Physical and psychological pain management education was shown to be effective in decreasing pain intensity, anxiety, and disability. This strategy may be beneficial for such patients. Variables such as smoking behavior, past history of psychological disorders, and previous surgeries should be considered in future studies.

Measuring Individual Benefits of Medical Treatments Using Longitudinal Hospital Data with Non-Ignorable Missing Responses Caused by Patient Discharge: Application to the Study of Benefits of Pain Management Post Spinal Fusion

Electronic health records (EHR) provide valuable resources for longitudinal studies and understanding risk factors associated with poor clinical outcomes. However, they may not contain complete follow-ups, and the missing data may not be at random since hospital discharge may depend in part on expected but unrecorded clinical outcomes that occur after patient discharge. These non-ignorable missing data requires appropriate analysis methods. Here, we are interested in measuring and analyzing individual treatment benefits of medical treatments in patients recorded in EHR databases. We present a method for predicting individual benefits that handles non-ignorable missingness due to hospital discharge. The longitudinal clinical outcome of interest is modeled simultaneously with the hospital length of stay using a joint mixed-effects model, and individual benefits are predicted through a frequentist approach: the empirical Bayesian approach. We illustrate our approach by assessing individual pain management benefits to patients who underwent spinal fusion surgery. By calculating sample percentiles of empirical Bayes predictors of individual benefits, we examine the evolution of individual benefits over time. We additionally compare these percentiles with percentiles calculated with a Monte Carlo approach. We showed that empirical Bayes predictors of individual benefits do not only allow examining benefits in specific patients but also reflect overall population trends reliably.

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.

Lumbar Decompression Versus Spinal Fusion in a Private Outpatient Setting: A Retrospective Study with Three Years of Follow-up

Objective  To compare pain, function, quality of life and adverse events of lumbar decompression and spinal fusion in patients with degenerative spinal pathologies who participated in a second opinion program for spinal surgeries with a 36-month follow-up.

Methods  The data for this retrospective cohort were withdrawn from a private healthcare system between June 2011 and January 2014. The study sample consisted of 71 patients with a lumbar spine surgical referral. The outcomes for the comparisons between lumbar decompression and spinal fusion were quality of life (evaluated through the EuroQoL 5D), pain (measured by the Numerical Rating Scale) and function (assessed through the Roland Morris Disability Questionnaire) measured at baseline, and at 12 and 36 months after the surgical procedures. The definitions of recovery were established by the minimal clinically important difference (MCID). The baseline differences between the groups were analyzed by non-paired t -test, and the differences in instrument scores between time points, by generalized mixed models. The results were presented as mean values adjusted by the models and 95% confidence intervals.

Results  Concerning the surgical techniques, 22 patients were submitted to spinal fusion and 49 patients, to lumbar decompression. As for the comparisons of the findings before and after the surgical interventions, the MCID was achieved in all outcomes regarding quality of life, pain and function at both time points when compared to baseline scores Moreover, concerning the complication rates, only lumbar decompression presented a surgical rate of 4% ( n  = 3) for recurrence of lumbar disc hernia.

Conclusion  Patients with degenerative spinal pathologies present improvements in long-term outcomes of pain, function and quality of life which are clinically significant, no matter the surgical intervention.

Relevance of a novel external dynamic distraction device for treating back pain

Low back pain is a common, expensive, and disabling condition in industrialized countries. There is still no consensus for its ideal management. Believing in the beneficial effect of traction, we developed a novel external dynamic distraction device. The purpose of this work was to demonstrate that external distraction allows limiting the pressure exerted in standing-up position on the lower intervertebral discs. Numerical and cadaveric studies were used as complementary approaches. Firstly, we implemented the device into a numerical model of a validated musculoskeletal software (Anybody Modeling System) and we calculated the lower disc pressure while traction forces were applied. Secondly, we performed an anatomical study using a non-formalin preserved cadaver placed in a sitting position. A pressure sensor was placed in the lower discs under fluoroscopic control through a Jamshidi needle. The intradiscal pressure was then measured continuously at rest while applying a traction force of 200 N. Both numerical and cadaveric studies demonstrated a decrease in intradiscal pressures after applying a traction force with the external device. Using the numerical model, we showed that tensile forces below 500 N in total were sufficient. The application of higher forces seems useless and potentially deleterious. External dynamic distraction device is able to significantly decrease the intradiscal pressure in a sitting or standing position. However, the therapeutic effects need to be proven using clinical studies.

Perioperative Considerations for Patients With Major Depressive Disorder Undergoing Surgery

In the United States, approximately 15% of adults suffer from major depressive disorder (MDD), which results in an annual cost of over $200 billion per year. In the perioperative setting, MDD is associated with increased morbidity and mortality. The exact causes of the increase in adverse outcomes are unknown. Major depression affects virtually all major systems in the human body, and most antidepressants affect dopamine, norepinephrine, and serotonin levels or alter their target receptors. Unfortunately, anesthesia and medications used in the perioperative period affect the same neurotransmitters. As a result, patients with MDD are at an increased risk for cardiovascular effects, altered thermoregulation, and postoperative cognitive dysfunction. To determine when to continue or hold antidepressants preoperatively and avoid potential drug interactions, perioperative providers must understand the pharmacological action of antidepressants. This article reviews the pathophysiology of MDD, mechanism of action of antidepressants, and perioperative considerations for patients on antidepressant medications.

A Modern Pain Neuroscience Approach in Patients Undergoing Surgery for Lumbar Radiculopathy: A Clinical Perspective

Around 20% of patients undergoing surgery for lumbar radiculopathy develop chronic pain after surgery, leading to high socioeconomic burden. Current perioperative interventions, including education and rehabilitation, are not always effective in preventing prolonged or chronic postoperative pain and disability. Here, a shift in educational intervention from a biomedical towards a biopsychosocial approach for people scheduled for lumbar surgery is proposed. Pain neuroscience education (PNE) is a biopsychosocial approach that aims to decrease the threat value of pain by reconceptualizing pain and increasing the patient's knowledge about pain. This paper provides a clinical perspective for the provision of perioperative PNE, specifically developed for patients undergoing surgery for lumbar radiculopathy. Besides the general goals of PNE, perioperative PNE aims to prepare the patient for postsurgical pain and how to cope with it.

Patient-reported Allergies are Associated With Preoperative Psychological Distress and Less Satisfying Patient Experience in a Lumbar Spine Surgery Population

STUDY DESIGN

This was a retrospective cohort study.

OBJECTIVE

The main objectives of this study were: (1) to determine whether patient-reported allergies (PRAs) are associated with patient satisfaction scores, and (2) to clarify the association between PRAs and preoperative anxiety and depression in a lumbar spine surgery population.

SUMMARY OF BACKGROUND DATA

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is currently used to measure the patient experience and there is concern that psychosocial factors are unaccounted for. Interestingly, PRAs have been linked to concurrent mood and other psychiatric disorders, as well as poor clinical outcomes in the orthopedic surgery setting.

METHODS

HCAHPS survey data, patient demographics, surgical characteristics, and preoperative health status were obtained for each patient. Allergies were categorized as medical (ie, medications) and environmental (ie, food, animals). Univariable and multivariable logistic regression models were used to determine whether the number of medical and environmental PRAs are associated with HCAHPS scores. In addition, multivariable logistic regression was used to analyze the association between PRAs and psychological distress.

RESULTS

In 421 patients included, PRAs were associated with lower HCAHPS scores under several dimensions of the patient experience of care, including: nursing communication, pain management, communication about medicines, and transition of care. Medical PRAs was an independent predictor of low satisfaction with communication about a medication's side effects [odds ratio (OR), 0.88; P=0.03] and understanding the purpose for new medications (OR, 0.90; P=0.03). Environmental PRAs was an independent predictor of low satisfaction with both communication about a medication's side effects (OR, 0.68; P=0.03), and pain control (OR, 0.67; P=0.01). Moreover, having a PRA (OR, 1.64; P=0.04) was associated with EuroQol-5 Dimensions anxiety/depression and having an environmental PRA (OR, 2.13; P=0.03) was associated with depression.

CONCLUSIONS

These findings highlight the potential utility of PRAs to help identify patients with psychological distress who are at risk for a poor experience of lumbar spine surgery.

Which patient-reported factors predict referral to spinal surgery? A cohort study among 4987 chronic low back pain patients

PURPOSE

It is unknown which chronic low back pain (CLBP) patients are typically referred to spinal surgery. The present study, therefore, aimed to explore which patient-reported factors are predictive of spinal surgery referral among CLBP patients.

METHODS

CLBP patients were consecutively recruited from a Dutch orthopedic hospital specialized in spine care (n = 4987). The outcome of this study was referral to spinal surgery (yes/no), and was assessed using hospital records. Possible predictive factors were assessed using a screening questionnaire. A prediction model was constructed using logistic regression, with backwards selection and p < 0.10 for keeping variables in the model. The model was internally validated and evaluated using discrimination and calibration measures.

RESULTS

Female gender, previous back surgery, high intensity leg pain, somatization, and positive treatment expectations increased the odds of being referred to spinal surgery, while being obese, having comorbidities, pain in the thoracic spine, increased walking distance, and consultation location decreased the odds. The model's fit was good (X ² = 10.5; p = 0.23), its discriminative ability was poor (AUC = 0.671), and its explained variance was low (5.5%). A post hoc analysis indicated that consultation location was significantly associated with spinal surgery referral, even after correcting for case-mix variables.

CONCLUSION

Some patient-reported factors could be identified that are predictive of spinal surgery referral. Although the identified factors are known as common predictive factors of surgery outcome, they could only partly predict spinal surgery referral.