Multidisciplinary Evaluation Leads to the Decreased Utilization of Lumbar Spine Fusion: An Observational Cohort Pilot Study

Feasibility of interdisciplinary evaluation in non-arthritic hip pain: A randomized trial

BACKGROUND

Physical therapy and orthopaedic surgery are two common treatments for non-arthritic hip pain. Interdisciplinary evaluation across these disciplines may produce a more supportive treatment-planning process; however, the feasibility of such an evaluation remains unknown.

HYPOTHESIS OBJECTIVE

To assess the feasibility of an interdisciplinary evaluation with an orthopaedic surgeon and physical therapist for non-arthritic hip pain.

STUDY DESIGN

Observational feasibility study of a randomized controlled trial.

METHODS

Participants were randomized to an interdisciplinary (surgeon + physical therapist) or standard (surgeon) evaluation in a hip preservation clinic. Recruitment rate was recorded. Retention rate was calculated for all variables of interest. Enrollment and refusal reasons were recorded as patient quotes and categorized by a single grader. Time spent in clinic was compared across groups using Mann Whitney U tests (P ≤ 0.05). Study clinicians were interviewed, and responses were categorized based on pre-determined themes.

RESULTS

Eighty-one percent of eligible patients enrolled over a 15-month recruitment period. Willingness(n = 16), urgency to resolve pain(n = 10), financial compensation(n = 1), interest in research(n = 42), physical therapy(n = 6), or multiple-provider care(n = 15) were participants' enrollment reasons; reason was not recorded for 22 participants. Time(n = 11), preference for single-provider care(n = 6), current physical therapy treatment(n = 1), and disinterest in physical therapy(n = 7) or research(n = 2) were refusal reasons of patients who did not enroll. Retention for primary variables of interest was 100% in both groups. Participants spent, on average, 23.5 min more time in clinic for the interdisciplinary evaluation compared to the standard (P < 0.001).

CONCLUSIONS

An interdisciplinary evaluation for patients with non-arthritic hip pain that included a physical therapist and orthopaedic surgeon in a hip preservation clinic was feasible and may better inform the treatment planning process.

The effect of antibiotic-impregnated calcium sulfate beads and Medical Optimization Clinic attendance on the acute surgical site infection rate in high-risk pediatric neuromuscular and syndromic scoliosis patients

BACKGROUND

Neuromuscular and syndromic (NMS) scoliosis patients are at higher risk of acute surgical site infections (SSIs). Despite following POSNA's endorsed consensus-based guidelines for SSI prevention, our institutional rates of acute SSI have varied dramatically. This variability drove simultaneous strategies to lower SSI rates: the creation of a preoperative Medical Optimization Clinic (MOC) and use of antibiotic-impregnated (Abx-I) calcium sulfate beads.

METHODS

Patients undergoing index PSF at a single institution between 2016 and 2022 were retrospectively reviewed. Patients with ≥ 2 risk factors were included: (1) BMI < 18.5 or > 25; (2) incontinence; (3) instrumentation to pelvis; (4) non-verbal; (5) GMFCS IV/V. SSI was defined as deep infection within 90 days. We compared patients who attended MOC and received Abx-I (MOC + Abx-I) to those receiving neither intervention (control) nor a single intervention.

RESULTS

282 patients were included. The overall infection rate was 4.26%. Higher GMFCS (p = 0.0147), non-verbal status (p = 0.0048), and longer fusions (p = 0.0298) were independently associated with infection rate. Despite the MOC + Abx-I group having larger Cobb angles (88° ± 26°), higher GMFCS levels (4.5 ± 0.9), ASA class (3 ± 0.4), and more frequent instrumentation to the pelvis (85%), they had the lowest infection rate (2.13%) when compared to the control (4.2%) or single intervention groups (5.7%, 4.6%) (p = 0.9).

CONCLUSION

The study examined the modern infection rate of NMS patients following the implementation of two interventions: MOC and Abx-I. Despite having higher risk factors (curves (88°), GMFCS level (4.5), ASA class (3), higher % instrumentation to the pelvis (85%)), the patients treated with both interventions demonstrated the lowest infection rate (2.13%).

Scoping Review: Anesthesiologist Involvement in Alternative Payment Models, Value Measurement, and Nonclinical Capabilities for Success in the United States of America

The US healthcare sector is undergoing significant payment reforms, leading to the emergence of Alternative Payment Models (APMs) aimed at improving clinical outcomes and patient experiences while reducing costs. This scoping review provides an overview of the involvement of anesthesiologists in APMs as found in published literature. It specifically aims to categorize and understand the breadth and depth of their participation, revolving around 3 main axes or "Aims": (1) shaping APMs through design and implementation, (2) gauging the value and quality of care provided by anesthesiologists within these models, and (3) enhancing nonclinical abilities of anesthesiologists for promoting more value in care. To map out the existing literature, a comprehensive search of relevant electronic databases was conducted, yielding a total of 2173 articles, of which 24 met the inclusion criteria, comprising 21 prospective or retrospective cohort studies, 2 surveys, and 1 case-control cohort study. Eleven publications (45%) discussed value-based, bundled, or episode-based payments, whereas the rest discussed non-payment-based models, such as Enhanced Recovery After Surgery (7 articles, 29%), Perioperative Surgical Home (4 articles, 17%), or other models (3 articles, 13%).The review identified key themes related to each aim. The most prominent themes for aim 1 included protocol standardization (16 articles, 67%), design and implementation leadership (8 articles, 33%), multidisciplinary collaboration (7 articles, 29%), and role expansion (5 articles, 21%). For aim 2, the common themes were Process-Based & Patient-Centric Metrics (1 article, 4%), Shared Accountability (3 articles, 13%), and Time-Driven Activity-Based Costing (TDABC) (3 articles, 13%). Furthermore, we identified a wide range of quality metrics, spanning 8 domains that were used in these studies to evaluate anesthesiologists' performance. For aim 3, the main extracted themes included Education on Healthcare Transformation and Policies (3 articles, 13%), Exploring Collaborative Leadership Skills (5 articles, 21%), and Embracing Advanced Analytics and Data Transparency (4 articles, 17%).Findings revealed the pivotal role of anesthesiologists in the design, implementation, and refinement of these emerging delivery and payment models. Our results highlight that while payment models are shifting toward value, patient-centered metrics have yet to be widely accepted for use in measuring quality and affecting payment for anesthesiologists. Gaps remain in understanding how anesthesiologists assess their direct impact and strategies for enhancing the sustainability of anesthesia practices. This review underscores the need for future research contributing to the successful adaptation of clinical practices in this new era of healthcare delivery.

Appropriateness of specialized care referrals for LBP: a cross-sectional analysis

Background

Low back pain (LBP) accounts for a significant proportion of primary care visits. Despite the development of evidence-based guidelines, studies point to the inefficient use of healthcare resources, resulting in over 60.0% of patients with LBP being referred to spine surgeons without any surgical indication. Centralized waiting lists (CWLs) have been implemented to improve access to specialized care by managing asymmetry between supply and demands. To date, no study has provided data on patients' clinical profiles and referral patterns to medical specialists for LBP in the context of a publicly funded healthcare system operating a prioritization model. The objective of this study was to evaluate the appropriateness of specialized care referrals for LBP after the implementation of a CWL.

Methods

A retrospective cross-sectional analysis of 500 randomly selected electronic health records of patients who attended the outpatient neurosurgery clinic of the administrative Mauricie-et-Centre-du-Québec region was performed. Inclusion criteria were neurosurgery consultation referrals for adults ≥18 years suffering from a primary complaint of LBP, and performed between September 1st, 2018, and September 1st, 2021. Data relevant for drawing a comprehensive portrait of patients referred to the neurosurgery service and for judging referrals appropriateness were manually extracted.

Results

Of the 500 cases analyzed, only 112 (22.4%) were surgical candidates, while 221 (44.2%) were discharge from the neurosurgery service upon initial assessment. Key information was inconsistently documented in medical files, thus preventing the establishment of a comprehensive portrait of patients referred to the neurosurgery service for LBP. Nevertheless, over 80.0% of referrals made during the study period were deemed inappropriate. Inappropriate referrals were characterized by higher proportion of patients symptomatically improved, presenting a back-dominant chief complaint, exhibiting no objective neurological symptoms, and diagnosed with non-specific LBP.

Conclusion

This study reveals a significant proportion of inappropriate referrals to specialized care for LBP. Further research is needed to better understand the factors that prompt referrals to medical specialists for LBP, and the criteria considered by neurosurgeons when selecting the appropriate management strategy. Recent studies suggest that triaging approaches led by musculoskeletal experts may improve referral appropriateness to specialized care.

Telemedical Interdisciplinary Care Team Evaluation and Treatment of People With Low Back Pain: A Retrospective Observational Study

Objective

To evaluate the effects of an interdisciplinary care team (ICT) model delivered by telemedicine on patients with low back pain (LBP).

Design

Retrospective analysis of deidentified pre-existing data.

Setting

Retrospective observational study of patients presenting with LBP to a nationwide telemedicine practice using an ICT model.

Participants

Over a 9-month period all patients with a diagnosis related to LBP and who had an ICT evaluation (medical doctor, advanced practice provider, health coach, and physical therapist) were included in the study (n=36). A minimum of 2 follow-up physical therapy visits were required for inclusion.

Interventions

Patients were evaluated for LBP, received a diagnosis, and were offered a multidisciplinary treatment plan. Additional real-time audio visual medical, health coaching, registered dietician, and physical therapy services were received as deemed clinically appropriate.

Main Outcome Measures

Baseline, 30 day, and final pain (mean 81 day) measurements via numerical pain rating scale (NPRS). Baseline and final Patient-Reported Outcomes Measurement Information System (PROMIS)-10 Global Mental/Physical domains.

Secondary Outcome Measures

Use of prescription medication, referral for imaging, need for injections, or surgery.

Results

36 patients met criteria. Pain levels included mild (n=6, 16.7%), moderate (n=19, 52.8%), and severe (n=11, 30.6%). Clinically significant pain improvements were noted in 83.3% (n=25) of those with moderate or severe pain. PROMIS Mental and Physical Health categorization from Fair/Poor to Good/Excellent significantly improved over time. The initial 20% (n=7) in Fair/Poor Mental Health improved to 6.3% (n=2) at finish, while the 80% (n=28) in Good/Excellent Mental Health at start improved to 93.8% (n=30) at finish. Regarding Physical Health, 51.4% (n=18) rated Fair/Poor at start and 31.3% (n=10) at finish, while the 48.6% (n=17) rated Good/Excellent at start improved to 68.8% (n=22) at finish. The need for prescription medication was low (n=6, 16.7%) and spinal imaging orders were negligible (n=1, 2.8%). Injections were warranted in 11.4% (n=4) of patients and surgical referral with operative treatment in 2.8% (n=1).

Conclusion

Interdisciplinary care delivered through telemedicine can significantly improve pain and support improved health-related quality of life in patients with LBP, with low rates of imaging, prescription, and interventional use.

Personalized Medicine in Orthopaedic Surgery: The Case of Spine Surgery

Personalized medicine has made a tremendous impact on patient care. Although initially, it revolutionized pharmaceutical development and targeted therapies in oncology, it has also made an important impact in orthopaedic surgery. The field of spine surgery highlights the effect of personalized medicine because the improved understanding of spinal pathologies and technological innovations has made personalized medicine a key component of patient care. There is evidence for several of these advancements to support their usage in improving patient care. Proper understanding of normative spinal alignment and surgical planning software has enabled surgeons to predict postoperative alignment accurately. Furthermore, 3D printing technologies have demonstrated the ability to improve pedicle screw placement accuracy compared with free-hand techniques. Patient-specific, precontoured rods have shown improved biomechanical properties, which reduces the risk of postoperative rod fractures. Moreover, approaches such as multidisciplinary evaluations tailored to specific patient needs have demonstrated the ability to decrease complications. Personalized medicine has shown the ability to improve care in all phases of surgical management, and several of these approaches are now readily available to orthopaedic surgeons.

Randomized-controlled trial assessing a digital care program versus conventional physiotherapy for chronic low back pain

Low back pain (LBP) is the world's leading cause of years lived with disability. Digital exercise-based interventions have shown great potential in the management of musculoskeletal conditions, promoting access and easing the economic burden. However, evidence of their effectiveness for chronic LBP (CLBP) management compared to in-person physiotherapy has yet to be unequivocally established. This randomized controlled trial (RCT) aims to compare the clinical outcomes of patients with CLBP following a digital intervention versus evidence-based in-person physiotherapy. Our results demonstrate that patient satisfaction and adherence were high and similar between groups, although a significantly lower dropout rate is observed in the digital group (11/70, 15.7% versus 24/70, 34.3% in the conventional group; P = 0.019). Both groups experience significant improvements in disability (primary outcome), with no differences between groups in change from baseline (median difference: -0.55, 95% CI: -2.42 to 5.81, P = 0.412) or program-end scores (-1.05, 95% CI: -4.14 to 6.37; P = 0.671). Likewise, no significant differences between groups are found for secondary outcomes (namely pain, anxiety, depression, and overall productivity impairment). This RCT demonstrates that a remote digital intervention for CLBP can promote the same levels of recovery as evidence-based in-person physiotherapy, being a potential avenue to ease the burden of CLBP.

Multidisciplinary conference for complex surgery leads to improved quality and safety

INTRODUCTION

Complex surgery for adult spinal deformity has high rates of complications, reoperations, and readmissions. Preoperative discussions of high-risk operative spine patients at a multidisciplinary conference may contribute to decreased rates of these adverse outcomes through appropriate patient selection and surgical plan optimization. With this goal, we implemented a high-risk case conference involving orthopedic and neurosurgery spine, anesthesia, intraoperative monitoring neurology, and neurological intensive care.

METHODS

Included in this retrospective review were patients ≥ 18 years old meeting one of the following high-risk criteria: 8 + levels fused, osteoporosis with 4 + levels fused, three column osteotomy, anterior revision of the same lumbar level, or planned significant correction for severe myelopathy, scoliosis (> 75˚), or kyphosis (> 75˚). Patients were categorized as Before Conference (BC): surgery before 2/19/2019 or After Conference (AC): surgery after 2/19/2019. Outcome measures include intraoperative and postoperative complications, readmissions, and reoperations.

RESULTS

263 patients were included (96 AC, 167 BC). AC was older than BC (60.0 vs 54.6, p = 0.025) and had lower BMI (27.1 vs 28.9, p = 0.047), but had similar CCI (3.2 vs 2.9 p = 0.312), and ASA Classification (2.5 vs 2.5, p = 0.790). Surgical characteristics, including levels fused (10.6 vs 10.7, p = 0.839), levels decompressed (1.29 vs 1.25, p = 0.863), 3 column osteotomies (10.4% vs 18.6%, p = 0.080), anterior column release (9.4% vs 12.6%, p = 0.432), and revision cases (53.1% vs 52.4%, p = 0.911) were similar between AC and BC. AC had lower EBL (1.1 vs 1.9L, p < 0.001) and fewer total intraoperative complications (16.7% vs 34.1%, p = 0.002), including fewer dural tears (4.2% vs 12.6%, p = 0.025), delayed extubations (8.3% vs 22.8%%, p = 0.003), and massive blood loss (4.2% vs 13.2%, p = 0.018). Length of stay (LOS) was similar between groups (7.2 vs 8.2 days, 0.251). AC had a lower incidence of deep surgical site infections (SSI, 1.0% vs 6.6%, p = 0.038), but a higher rate of hypotension requiring vasopressor therapy (18.8% vs 4.8%, p < 0.001). Other postoperative complications were similar between groups. AC had lower rates of reoperation at 30 (2.1% vs 8.4%, p = 0.040) and 90 days (3.1 vs 12.0%, p = 0.014) and lower readmission rates at 30 (3.1% vs 10.2%, p = 0.038) and 90 days (6.3 vs 15.0%, p = 0.035). On logistic regression, AC patients had higher odds of hypotension requiring vasopressor therapy and lower odds of delayed extubation, intraoperative RBC, and intraoperative salvage blood.

CONCLUSIONS

Following implementation of a multidisciplinary high-risk case conference, 30- and 90-day reoperation and readmission rates, intraoperative complications, and postoperative deep SSIs decreased. Hypotensive events requiring vasopressors increased, but did not result in longer LOS or greater readmissions. These associations suggest a multidisciplinary conference may help improve quality and safety for high-risk spine patients. particularly through minimizing complications and optimizing outcomes in complex spine surgery.

Impact on productivity impairment of a digital care program for chronic low back pain: A prospective longitudinal cohort study

BACKGROUND

Low back pain (LBP) is the leading cause of disability in the United States and the main reason for absenteeism. Successful management of chronic LBP (CLBP) is dependent on multimodal evidence-based interventions. Digital interventions (DI) may ease accessibility to such treatments, increasing adherence, while reducing healthcare-related costs.

OBJECTIVES

Assess the impact of a completely remote multimodal DI on productivity impairment in a real-work context cohort of patients with CLBP.

DESIGN

Longitudinal study.

METHODS

Ad-hoc analysis of an interventional, single-arm study of individuals with CLBP undergoing a DI for 12 weeks. Outcomes included the mean change in work productivity and activity impairment (including overall and non-work related activities), pain, depression, anxiety, fear-avoidance beliefs, analgesic usage, and engagement. Minimal clinically important change (MCIC) was calculated for productivity using anchor- and distribution-based methods.

RESULTS

From 560 patients at program start, 78.4% completed the DI. A significant improvement in overall productivity (20.21, 95%CI: 16.48-23.94) and in non-work related activities (21.36, 95%CI: 17.49-25.22) was observed, corresponding to a responder rate of 57.1-83.3% and 60.5-79.8%, respectively, and depending on the MCIC method. Significant improvements were reported for pain (2.32 points, 95%CI: 2.02-2.61), anxiety (5.24, 95%CI: 4.18-6.29), depression (6.38, 95%CI: 4.78-7.98) and fear-avoidance beliefs (8.11, 95%CI: 6.20-10.02). Both engagement (sessions per week) and patient satisfaction scores were high, 2.9 (SD 1.0) and 8.8/10 (SD 1.6), respectively.

CONCLUSIONS

This study demonstrated the utility of a multimodal DI to address productivity impairment. DIs have great potential to ease the burden of CLBP, providing an accessible and cost-effective modality of care.

TRIAL REGISTRATION

The study was approved by the New England IRB (protocol number 120190313) and prospectively registered in ClinicalTrials.gov, NCT04092946, on September 17th, 2019.

Combining time-driven activity-based costing and lean methodology: an initial study of single-level lumbar fusion surgery to assess value-based healthcare in patients undergoing spine surgery

OBJECTIVE

Measuring costs across entire episodes of care, time-driven activity-based costing (TDABC) has recently been described as a novel cost accounting arm of value-based care organizations. Lean methodology is a system used to understand pathways of care at a granular level, allowing for standardization. The current work presents an attempt at combining the 2 methodologies to detect meaningful variation in a patient's care following single-level spine fusion. The objective of this study was to evaluate the combination of TDABC and lean methodologies in detecting meaningful variability in time-based care in patients undergoing single-level spine fusion surgery.

METHODS

This study is a consecutive case series of patients who underwent single-level spine fusion performed by 1 of 5 fellowship-trained spine surgeons. Patients were diagnosed with either lumbar stenosis or spondylolisthesis. Additional inclusion criteria included inpatient stays from 1 to 3 days, discharge to home, and no readmission within 30 days of surgery. Patient demographic data were obtained. Time spent on activities for each personnel role was aggregated in 15-minute increments occurring preoperatively, intraoperatively, and postoperatively. Patients were analyzed in 3 groups based on the duration of their in-hospital stay.

RESULTS

Patients discharged on postoperative day (POD) 3 had statistically significantly more total time spent than those discharged on POD 2. Patients discharged on POD 1 had less total time than those in the former 2 groups. The amount of time spent with patients did not differ for personnel in either preoperative or postanesthesia care unit phases of care. There was a statistically significant difference in time spent in surgery for surgeons, anesthesia attendings, circulators, and scrub technicians.

CONCLUSIONS

In a healthcare setting run by lean methodology, TDABC may detect meaningful variability in an episode of care for single-level spine fusion. Clinicians and administrators can use this combination to allocate costs appropriately, optimize value care streams, and help improve patient care.

Do Multidisciplinary Spine Conferences Alter Management or Impact Outcome?

BACKGROUND

Multidisciplinary spine conferences (MSCs) are a strategy for discussing diagnostic and treatment aspects of patient care. Although they are becoming more common in hospitals, literature investigating how they impact patient care and outcomes is scarce. The aim of this study is to examine the impact of MSCs on surgical management and outcomes in elective spine surgical care.

METHODS

A systematic review of the literature was conducted to evaluate the impact of MSCs on patient management and outcomes. PubMed and Cochrane databases were searched using combinations and variations of search terms "Spine Conferences," "Multidisciplinary," and "Spine Team."

RESULTS

The literature search yielded 435 articles, of which 120 were selected for full-text review. Four articles (N = 529 patients) were included. Surgical plans were discussed in 211 patients. The decision was altered to conservative treatment in 70 patients (33.17%) and a different surgical strategy in 34 patients (16.11%). The differences were significant in 2 studies (P < 0.05). A 51% reduction in 30-day complications rates was observed when MSC was implemented in patients with adult complex scoliosis. Other spinal disorders showed a 30-day complication rate between 0% and 14% after MSC.

CONCLUSIONS

To our knowledge, this is the first systematic review of outcomes of MSCs in elective spine surgery and it confirms that MSCs impact management plan and outcomes. Consistent MSCs that include surgeons and nonsurgeons have the potential to enhance communication between specialists, standardize treatments, improve patient care, and encourage teamwork. More analysis is warranted to determine if patient outcomes are improved with these measures.

Malpractice litigation in elective lumbar spinal fusion: a comprehensive review of reported legal claims in the U.S. in the past 50 years

BACKGROUND CONTEXT

In the U.S., medical malpractice litigation is associated with significant financial costs and often leads to the practice of defensive medicine. Among medical subspecialities, spine surgery is disproportionately impacted by malpractice claims.

PURPOSE

To provide a comprehensive assessment of reported malpractice litigation claims involving elective lumbar spinal fusion (LSF) surgery during the modern era of spine surgery instrumentation in the U.S., to identify factors associated with verdict outcomes, and to compare malpractice claims characteristics between different approaches for LSF.

STUDY DESIGN/SETTING

A retrospective review.

PATIENT SAMPLE

Patients undergoing elective lumbar spinal fusion surgery.

OUTCOME MEASURES

The primary outcome measure was verdict outcome (defendant vs. plaintiff verdict). Secondary outcome measures included alleged malpractice, injury/damage claimed, and award payouts.

METHODS

The Westlaw legal database (Thomson Reuters, New York, NY, USA) was queried for verdict and settlement reports pertaining to elective LSF cases from 1970 to 2021. Data were collected regarding patient demographics, surgeon specialty, fellowship training, state/region, procedure, institutional setting (academic vs. community hospital), alleged malpractice, injury sustained, case outcomes, and monetary award.

RESULTS

A total of 310 cases were identified, yielding 67% (n=181) defendant and 24% (n=65) plaintiff verdicts, with 9% (n=26) settlements. Neurosurgeons and orthopedic spine surgeons were equally named as the defendant (45% vs. 51% respectively, p=0.59). When adjusted for inflation, the median final award for plaintiff verdicts was $1,241,286 (95% CI: $884,850-$2,311,706) while the median settlement award was $925,000 (95% CI: $574,800-$1,787,130), with no stastistically significant differences between verdict and reported settlement payouts (p=0.49). The Northeast region displayed significantly higher award payouts compared to other U.S. regions (p=0.02). There were no associations in awards outcomes when comparing alleged malpractice, alleged injuries/damages, institutional setting, surgical procedures, and surgeon specialty or fellowship training. The most common claims were intraoperative error (28%, n=107) followed by failure to obtain informed consent (24%, n=94). In the analyzed cohort, the most common injuries leading to litigation were refractory pain and suffering (37%, n=149) followed by permanent neurological deficits (26%, n=106). There were no differences in alleged malpractice or injury sustained between cases in which the outcome was favorable to defendant versus plaintiff. Anterior lumbar interbody fusion (ALIF) cases were 2.75 times more likely to be cited for excessive or inappropriate surgery (OR: 2.75 [95% CI: 1.14, 6.86], p=0.02) when compared to posterior surgical approaches.

CONCLUSION

The results of our analysis of reported claims suggest that medical malpractice litigation involving elective LSF is associated with jury verdicts over $1 million per case, with the most common alleged malpractice being intraoperative error and failure to obtain informed consent. Surgeon specialty, fellowship training, procedure type, and institution type were not associated with greater litigation risks; however, ALIF surgery had a significantly higher risk of involving claims of excessive or inappropriate surgery compared to posterior approaches for lumbar fusion. In addition, claims were significantly higher in the Northeast compared to other U.S. regions. Efforts to improve patient education through shared-decision making and proactive strategies to avoid, detect, and mitigate intra-operative procedural errors may decrease the risk of litigation in elective LSF.

Performance of hybrid artificial intelligence in determining candidacy for lumbar stenosis surgery

PURPOSE

Lumbar spinal stenosis (LSS) is a condition affecting several hundreds of thousands of adults in the United States each year and is associated with significant economic burden. The current decision-making practice to determine surgical candidacy for LSS is often subjective and clinician specific. In this study, we hypothesize that the performance of artificial intelligence (AI) methods could prove comparable in terms of prediction accuracy to that of a panel of spine experts.

METHODS

We propose a novel hybrid AI model which computes the probability of spinal surgical recommendations for LSS, based on patient demographic factors, clinical symptom manifestations, and MRI findings. The hybrid model combines a random forest model trained from medical vignette data reviewed by surgeons, with an expert Bayesian network model built from peer-reviewed literature and the expert opinions of a multidisciplinary team in spinal surgery, rehabilitation medicine, interventional and diagnostic radiology. Sets of 400 and 100 medical vignettes reviewed by surgeons were used for training and testing.

RESULTS

The model demonstrated high predictive accuracy, with a root mean square error (RMSE) between model predictions and ground truth of 0.0964, while the average RMSE between individual doctor's recommendations and ground truth was 0.1940. For dichotomous classification, the AUROC and Cohen's kappa were 0.9266 and 0.6298, while the corresponding average metrics based on individual doctor's recommendations were 0.8412 and 0.5659, respectively.

CONCLUSIONS

Our results suggest that AI can be used to automate the evaluation of surgical candidacy for LSS with performance comparable to a multidisciplinary panel of physicians.

Second opinions for spinal surgery: a scoping review

BACKGROUND

Second opinions have the goal of clarifying uncertainties around diagnosis or management, particularly when healthcare decisions are complex, unpleasant, and carry considerable risks. Second opinions might be particularly useful for people recommended surgery for their back pain as surgery has at best a limited role in the management of back pain.

METHODS

We conducted a scoping review. Two independent researchers screened PubMed, EMBASE, Cochrane CENTRAL and CINAHL from inception to May 6th, 2021. Studies of any design published in any language were eligible provided they described a second opinion intervention for people with spinal pain (low back or neck pain with or without radicular pain) either considering surgery or to whom surgery had been recommended. We assessed the methodological quality with the Downs & Black scale. Outcomes were: i) characteristics of second opinion services for people considering or who have been recommended spinal surgery, ii) agreement between first and second opinions in terms of diagnoses, need for surgery and type of surgery, iii) whether they reduce surgery and improve patient outcomes; and iv) the costs and healthcare use associated with these services. Outcomes were presented descriptively.

RESULTS

We screened 6341 records, read 27 full-texts, and included 12 studies (all observational; 11 had poor methodological quality; one had fair). Studies described patient, doctor, and insurance-initiated second opinion services. Diagnostic agreement between first and second opinions varied from 53 to 96%. Agreement for need for surgery between first and second opinions ranged from 0 to 83%. Second opinion services may reduce surgery rates in the short-term, but it is unclear whether these reductions are sustained in the long-term or if patients only delay surgery. Second opinion services may reduce costs and healthcare use (e.g. imaging), but might increase others (e.g. injections).

CONCLUSIONS

Second opinion services typically recommend less surgical treatments compared to first opinions and may reduce surgery rates in the short-term, but it is unclear whether these reductions are sustained in the long-term or if patients only delay surgery. There is a need for high-quality randomised trials to determine the value of second opinion services for reducing spinal surgery.

A Multidisciplinary Spine Surgical Indications Conference Leads to Alterations in Surgical Plans in a Significant Number of Cases: A Case Series

STUDY DESIGN

Case series.

OBJECTIVE

To evaluate the impact of a multidisciplinary spine surgery indications conference (MSSIC) on surgical planning for elective spine surgeries.

SUMMARY OF BACKGROUND DATA

Identifying methods for pairing the proper patient with the optimal intervention is of the utmost importance for improving spine care and patient outcomes. Prior studies have evaluated the utility of multidisciplinary spine conferences for patient management, but none have evaluated the impact of a MSSIC on surgical planning and decision making.

METHODS

We implemented a mandatory weekly MSSIC with all spine surgeons at our institution. Each elective spine surgery in the upcoming week is presented. Subsequently, a group consensus decision is achieved regarding the best treatment option based on the expertise and opinions of the participating surgeons. We reviewed cases presented at the MSSIC from September 2019 to December 2019. We compared the surgeon's initial proposed surgery for a patient with the conference attendees' consensus decision on the best treatment and measured compliance rates with the group's recommended treatment.

RESULTS

The conference reviewed 100 patients scheduled for elective spine surgery at our indications conference during the study period. Surgical plans were recommended for alteration in 19 cases (19%) with the proportion statistically significant from zero indicated by a binomial test (P < 0.001). The median absolute change in the invasiveness index of the altered procedures was 3 (interquartile range [IQR] 1-4). Participating surgeons complied with the group's recommendation in 96.5% of cases.

CONCLUSION

In conjunction with other multidisciplinary methods, MSSICs can lead to surgical planning alterations in a significant number of cases. This could potentially result in better selection of surgical candidates and procedures for particular patients. Although long-term patient outcomes remain to be evaluated, this care model will likely play an integral role in optimizing the care spine surgeons provide patients.

LEVEL OF EVIDENCE

4.

Reduction in mortality in pediatric non-idiopathic scoliosis by implementing a multidisciplinary screening process

STUDY DESIGN

Retrospective comparative study.

OBJECTIVES

To compare complications before and after implementation of the Multi-D screening protocol in complex pediatric patients undergoing spinal instrumentation for non-idiopathic scoliosis. Pediatric patients undergoing surgery for non-idiopathic scoliosis experience significantly more complications than those with idiopathic scoliosis. Operating on these patients can lead to serious complications including death. Recent reports have demonstrated the benefits of establishing a multidisciplinary-based system to reduce complications in adult spinal deformity during the perioperative period. However, there are limited studies examining these benefits in a complex pediatric spine population.

METHODS

This was a retrospective review of all cases involving spinal instrumentation at our institution for 2 years before and after the initiation of our Neuromuscular Spine Surgery Care Plan in July 2014. Study sample was n = 129 cases (107 patients) prior to the initiation of the process and n = 122 cases (109 patients) thereafter. Primary outcome measures included: mortality at 30 days and 1 year; post-operative neurologic deficit, and surgical site infections (SSI). Secondary outcome measures included: instrument failure in 1 year; readmission in 30 days; return to OR in 90 days.

RESULTS

The study populations were matched by age and gender. Patients passing the Multi-D conference had higher BMI. Implementation of the Multi-D conference reduced mortality at 30 days (2 vs 0, p = 0.17) and at 1 year (4 vs 0, p = 0.04), as well as reduced post-operative neurologic deficit (2 vs 0, p = 0.17). The rate of SSI remained unchanged. All other secondary outcome measures also remained unchanged.

CONCLUSIONS

Implementation of a Multi-D conference led to a significant reduction in mortality at 1 year, and is an important safety process to reduce serious complications after non-idiopathic scoliosis surgery.

LEVEL OF EVIDENCE

Level III.

Is there bias in the treatment of degenerative spine disease? Analysis of anonymous voting via a multidisciplinary conference

Many institutions have developed shared decision-making conferences as a mechanism for reducing treatment costs and improving patient outcomes. Little is known about the process of shared decision-making that takes place in these conferences, and there is the possibility of bias among surgeons and nonsurgeons for treatment within their respective specialties. This study was conducted to determine who is contributing to the decision-making process in a multidisciplinary spine conference and to what extent treatment biases exist among the surgical and nonsurgical members of this conference. Voting data were collected during weekly multidisciplinary spine conferences. Descriptive statistics were calculated on the cases presented and the number and type of physicians voting for each case. The likelihood of a particular vote in the surgeon and nonsurgeon cohorts was evaluated using relative risk calculation and multinomial logistic regression. A total of 262 consecutive cases were analyzed. No significant differences in treatment recommendation were observed between surgery and nonsurgical management (relative risk, 1.1; 95% CI, 0.97-1.25) when comparing votes from the surgeon and nonsurgeon cohorts. Multinomial logistic regression showed the odds of nonsurgeons recommending nonsurgical management over surgery was 20% greater than receiving that recommendation from their surgeon colleagues. Individual surgeon and nonsurgeon voters were evenly distributed above and below the mean for treatment recommendation. Individual and group biases exist among surgeons and nonsurgeons treating degenerative spine diseases. Multidisciplinary conferences may or may not level these biases, depending on how they are conducted.

A Multidisciplinary Hand Clinic Using Physiatrists for the Evaluation of Non-Operative Pathologies

Purpose

The purpose of this study was to describe the impact of using a multidisciplinary hand clinic on (1) hand clinic waitlists for urgent operative pathologies and (2) the volume of urgent operative referrals seen by plastic surgery.

Methods

A retrospective data analysis of all new referrals to the Peter Lougheed Centre hand clinic in Calgary, Alberta, was performed. Data were collected from 6 months before and after the introduction of the multidisciplinary model (ie, between January 2017 and January 2018). Demographics for all new referrals were collected from the clinic database, including wait times, triage type, and volume of referrals triaged to each discipline.

Results

Prior to using a multidisciplinary model, 81% (n = 591) of new patient referrals were triaged directly to plastic surgery, 4% (n = 28) to physiotherapy, and 6% (n = 43) to minor surgery (N = 728). However, following the addition of physiatry to the clinic, 62% (n = 451) of new patient referrals were triaged directly to plastic surgery, 24% (n = 173) to physiatry, 2% (n = 17) to physiotherapy, and 4% (n = 31) to minor surgery (N = 730). Overall, the number of urgent operative referrals triaged to plastic surgery proportionally increased by 7%, from 67% to 74%. Mean wait times for urgent referrals to plastic surgery decreased by 1.7 ± 1.0 months (P = .09).

Conclusion

Applying a multidisciplinary model to a hand clinic can allow non-operative cases to be triaged directly to physiotherapy and physiatry, allowing plastic surgeons to manage a higher volume of urgent and operative referrals. Implementing a multidisciplinary hand clinic can, therefore, decrease waitlist volumes and shorten the time to assessment by a plastic surgeon.

Type of Study

Level II Prognostic Study.

Assessment of the efficacy of teriparatide treatment for osteoporosis on lumbar fusion surgery outcomes: a systematic review and meta-analysis

Treatment of osteoporosis with medications like teriparatide, a parathyroid hormone, is known to improve bone density and reduce the risk of osteoporotic vertebral fractures. Anecdotal and limited surgical series have described the utility of this treatment for osteoporotic patients prior to spinal fusion surgery, but there is variability in adoption of this strategy as well as consensus regarding optimal treatment duration before and after surgery. In this study, the clinical results of the use of teriparatide for this application are reviewed and critically examined. We conducted a systematic review of electronic databases using different MeSH terms from 1980 to 2020. Pooled and subgroup analyses were performed using fixed and random effect models based upon the heterogeneity (I²). The results were reported as either mean difference (MD) or odds ratio (OR) with 95% confidence interval (CI). A total of 771 patients from 12 studies were identified. Three hundred seventy-seven patients (90.8% females) were treated with teriparatide. Lumbar spinal fusion rates were significantly higher among patients who received teriparatide compared to the non-teriparatide group (OR 2.15, 95%CI 1.56-2.97, p < 0.00001). Subgroup analysis revealed that patients receiving teriparatide demonstrated 2.12-fold and 2.23-fold higher likelihood of fusion compared to those in the bisphosphonate (OR 2.12, 95%CI 1.45-3.11, p = 0.0001) and placebo (OR 2.23, 95%CI 1.22-4.08, p = 0.009) cohorts, respectively. The treatment effect of teriparatide was associated with significantly reduced subsequent vertebral fractures (OR 0.16, 95%CI 0.06-0.41, p = 0.0002), sagittal malalignment (MD - 3.85, 95%CI: -6.49 to - 1.21, p = 0.004), limb visual analogue score (VAS) (MD - 0.36, 95%CI - 0.64 to - 0.09, p = 0.008), and spinal VAS (MD - 0.24, 95%CI - 0.44 to - 0.04, p = 0.02) compared to the non-teriparatide group. Patients using teriparatide had 30% less likelihood of screw loosening at last follow-up compared to the non-teriparatide group; however, this was not statistically significant (OR 0.70, 95%CI 0.43-1.14, p = 0.15). There did not exist any statistically significant difference between the two comparative groups in terms of pseudoarthrosis (OR 0.54, 95%CI 0.24-1.21, p = 0.13), cage subsidence (OR 1.30, 95%CI 0.38-4.52, p = 0.68), and bone mineral density (MD 0.04, 95%CI - 0.19-0.29, p = 0.74) at last follow-up examination. This meta-analysis corroborates the effectiveness of teriparatide resulting in higher fusion rates. Further study is required to determine the optimal duration of treatment and timing of surgery.

Helping spine surgeons detect pre-surgical psychological distress in complex spine patients: an observational pilot study

STUDY DESIGN

Retrospective analysis.

OBJECTIVE

Analysis of a standardized, pre-surgical psychological evaluation program for complex spine surgery. Adult spinal deformity (ASD) patients have a high rate of comorbid mental health conditions. Although there is a body of literature demonstrating the impact of psychological factors, including anxiety and depression, on spine surgery outcome, it is estimated that spine surgeons utilize a psychological assessment only about one third of the time prior to a patient's spine surgery. At this time, there is not a widely reported pre-surgical psychological evaluation program for ASD patients.

METHODS

129 consecutive complex spine surgery candidates receiving a pre-surgical psychological evaluation were analyzed between January 1st 2014 and December 31st 2018. Based on the available literature and professional experience in our facility, a color code for patients was developed from Green (low psychological or psychosocial co-morbidity) to Red (high psychological or psychosocial co-morbidity). Univariate analysis was used to evaluate between color grades and demographics, mental health disorders and outcomes.

RESULTS

83% of complex spine patients had at least one psychological disorder or psychosocial barrier. Only 17% had a combination of realistic expectations for surgery, a good support plan, and were without a history of mental illness. The pre-surgical psychological color criteria were validated in showing higher rates of major depression, anxiety disorder, and bipolar disorder in moderate to severe color grades (p < .001) in addition to higher PHQ-9 and GAD-7 scores (p < .001). Patients having a more severe color grade had lower rates of a discharge home and were taking higher morphine equivalent dosages (MEDs) at their six-month follow-up, though both did not reach statistical significance (p = .07 and p = .08; respectively).

CONCLUSION

A comprehensive pre-surgical psychological evaluation may be beneficial to risk stratify and counsel patients being evaluated for surgical reconstruction of adult spinal deformities.

LEVEL OF EVIDENCE

3.

Orthopaedic vs. Neurosurgery - Does a surgeon's specialty have an influence on 90-day complications following surgical intervention of spinal metastases?

OBJECTIVES

Spinal metastases are routinely managed and/or operated on by both orthopaedic surgeons and neurological surgeons. However, controversy still exists as to whether the operating surgeon's specialty has an impact on post-operative complication rates.

PATIENTS AND METHODS

The 2007-2017 Humana Administrative Claims database was queried using Current Procedural Terminology codes to identify patients undergoing fusions, laminectomies or osteotomy/corpectomy for spinal metastases. Physician taxonomy codes were used to identify the operating surgeon's specialty (orthopaedic vs. neurosurgery). Multivariate logistic regression analyses were used to assess difference in 90-day complications, readmissions and mortality between the two specialties while controlling for age, gender, race, co-morbidity burden, procedural characteristics (fusion, laminectomy and/or osteotomy/corpectomy) and type of primary cancer.

RESULTS

A total of 887 patients undergoing surgical intervention for spinal metastases were included - out of which 204 (23.0 %) patients were operated on by orthopaedic surgeons and 683 (77.0 %) by neurosurgeons. Following adjustment for difference in patient demographics and baseline clinical characteristics, no statistically significant differences were noted between the two specialties with regards to wound complications (p = 0.992), pulmonary complications (p = 0.461), cardiac complications (p = 0.631), thrombotic complications (p = 0.177), sepsis (p = 0.463), pneumonia (p = 0.767), urinary tract infection (p = 0.916), acute renal failure (p = 0.934), hardware complications (p = 0.892), emergency department visits (p = 0.934), 90-day readmissions (p = 0.277) and 90-day mortality (p = 0.786).

CONCLUSIONS

Based off our findings, it appears that a surgeon's specialty has no influence on intermediate-term complications following surgical intervention for spinal metastases. The findings of the study should support the need for maintaining access of patients to both specialties for appropriate surgical consultation.

Clinicians' Self-Reported Practices Related to End-of-Life Care for Infants in NICUs in Jordan

OBJECTIVE

To examine how clinical decisions are made at the end of life for infants born with specific fatal and disabling conditions in NICUs in Jordan from the perspectives of neonatal health care providers.

DESIGN

A cross-sectional survey of neonatal nurses and physicians.

SETTING

Twenty-four NICUs in Jordan.

PARTICIPANTS

Participants included 213 nurses and 75 physicians who provided direct care for infants in NICUs.

METHODS

Using the EURONIC questionnaire, we asked participants to recall the last experiences of end-of-life decision making in which they were involved. The participants described factors and outcomes related to those experiences, and we used descriptive and inferential statistics to examine these factors.

RESULTS

In 83% of the recalled situations, the physicians in charge of the infants' care or who were on duty were the primary decision makers. Parents, nurses, ethics committees, and NICU heads were less involved. The infants' primary diagnoses were significantly associated with the nature of decisions regarding end-of-life care (p < .001). Age, importance of religion, having their own children, and involvement in research activities were factors that significantly predicted nurses' perceived levels of involvement in decision making (χ²[4] = 23.140, p < .001).

CONCLUSION

Our results suggest the need to improve clinical approaches to decision making regarding end-of-life care for infants in NICUs in Jordan to be more family focused and team based. This process should include parents, physicians, neonatal nurses, and ethics committees.

Tackling low back pain in Brazil: a wake-up call

BACKGROUND

Low back pain is the leading cause of years lived with disability in Brazil based upon Global Burden of Disease estimates. Since 1990, the number of years lived with disability has increased by 79.7%, and this number is expected to continue to rise due to population growth and ageing. Yet, similarly to other countries, little attention has been given to it in both the public and private health systems, arguably making it an overlooked epidemic in Brazil. There is evidence that Brazil has adopted unwarranted practices in the management of low back pain in a similar manner to what has been observed in high-income countries. To tackle the burden of low back pain in Brazil, we need highly coordinated efforts from government, the private sector, universities, health workers and civil society.

OBJECTIVE

This masterclass intends to provide an overview of the challenges faced by Brazil in relation to low back pain management and propose potential solutions that could potentially be implemented based on experiences reported in the literature.

Impact of Multidisciplinary Spine Conferences on Surgical Planning and Perioperative Care in Elective Lumbar Spine Surgeries

Study Design

Pre- and post-implementation analysis.

Purpose

We examined the impact of implementing multidisciplinary spine conferences—“spine board” reviews—on the general utilization of elective lumbar spine surgeries in a tertiary medical institute.

Overview of Literature

A multidisciplinary approach to spine care reportedly improves the appropriate utilization of surgical spine procedures.

Methods

A multidisciplinary spine board was established to review candidates selected for elective lumbar spine surgery. The board comprised representatives from orthopedic spine surgery, neurosurgery, psychology, physical therapy, radiology, pharmacy, primary care, pain management, anesthesiology, and veteran advocacy. Two similar 6-month periods were selected to study the impact of this implementation: pre-implementing (June 1, 2015 to November 30, 2015) and post-implementation (June 1, 2016 to November 30, 2016) periods.

Results

Between March 1, 2016 and December 30, 2016, the spine board discussed 11 patients. All patients underwent clinical examinations and radiological assessments findings that warranted elective lumbar surgery. The board recommended non-surgical interventions before proceeding with the planned surgeries in all cases. In the pre-implementation period, a total of 101 elective lumbar spine surgeries were performed. In the post-implementation period, a total of 51 elective lumbar spine surgeries were performed (p<0.05). The surgical plan for elective lumbar spine surgery in the post-implementation period was not directly influenced by the review of spine board because none of the cases were discussed in the conferences; however, the care occurred at a hospital where the spine board was implemented. There was no significant change in the number of cervical spine surgeries performed (66 preimplementation vs. 56 post-implementation). The average surgery duration was 52 minutes shorter in the post-implementation period compared with that in the pre-implementation period (p<0.05).

Conclusions

Implementation of a multidisciplinary spine board was concurrent with an overall decrease in the utilization of lumbar spine surgeries for elective cases of low back pain in a tertiary medical center.

Impact of acupuncture treatment on the lumbar surgery rate for low back pain in Korea: A nationwide matched retrospective cohort study

INTRODUCTION

Low back pain (LBP) is a globally prevalent disorder with high social significance. Invasive surgical procedures are increasingly being used to treat LBP despite a lack of solid evidence supporting their long-term benefits. This nationwide retrospective cohort study investigated the association between acupuncture treatment and lumbar surgery rate in patients with LBP.

METHODS

Using the National Health Insurance Service Sample Cohort Database for 2002-2013, we identified newly diagnosed LBP patients in Korea between 2004 and 2010 and divided them into an acupuncture group and control group according to whether or not they received acupuncture. Propensity scores based on age, sex, income, and Charlson Comorbidity Index were matched between the two study groups. The lumbar surgery rate in the two years following the first visit (control group) or the first acupuncture session (acupuncture group) was calculated. In addition to the overall analysis, stratified analyses were also conducted in different age, sex, and income strata. Sensitivity analyses were further performed using varying definitions of acupuncture treatment.

RESULTS

After matching, 130,089 subjects were included in each study group. The lumbar surgery rate was significantly lower in the acupuncture group than in the control group (hazard ratio [HR] 0.633, 95% confidence interval [CI] 0.576-0.696). Decrease in HR was consistently observed in the acupuncture group for all age strata, except for patients in their 20s (HR 1.031, 95% CI 0.804-1.323). HR for lumbar surgery tended to be further reduced in the older age groups upon acupuncture treatment, with no apparent sex-related differences. Lowered HR in the acupuncture group was continuously observed across all income groups; the higher income group showed a tendency of greater decrease. Sensitivity analyses showed that the number of acupuncture sessions had no major impact on the likelihood of lumbar surgery, but also that more intensive acupuncture treatment was associated with further reduction in lumbar surgery rates.

CONCLUSION

The present results found that administration of acupuncture treatment is associated with lower lumbar surgery rates for LBP patients in Korea. Prospective studies are warranted in the future to further investigate the effect of acupuncture treatment on lumbar surgery incidence.

Patient-Reported Outcome Measures: Utility for Predicting Spinal Surgery in an Integrated Spine Practice

BACKGROUND

For the majority of patients, spinal surgery is an elective treatment. The decision as to whether and when to pursue surgery is complicated and influenced by myriad factors, including pain intensity and duration, impact on functional activities, referring physician recommendation, and surgeon preference. By understanding the factors that lead a patient to choose surgery, we may better understand the decision-making process, improve outcomes, and provide more effective care.

OBJECTIVE

To investigate the relationship between patient-reported outcome measures (PROMs) at initial physiatry clinic consultation and subsequent decision to pursue surgical treatment. We hypothesized that measures of function, pain, and mental health might identify which patients eventually elect to pursue surgical management.

DESIGN

Retrospective chart review study.

SETTING

Physiatry spine clinic in a tertiary hospital.

PATIENTS

A total of 395 consecutive patients meeting our inclusion criteria were assessed for the presence of chronic pain, self-perceived disability, history of prior spinal surgery, and provision of chronic opioid therapy at the time of their initial visit to the integrated spine clinic.

METHODS

Retrospective chart review of all patients presenting to our spine clinic between August 1, 2014, and July 31, 2015, was performed. At the initial spine clinic consultation, patients were asked to complete the General Anxiety Disorder-7 (GAD-7), Patient Health Questionnaire-8 (PHQ-8), Oswestry Disability Index (ODI), and Patient-Reported Outcomes Measurement Information System (PROMIS) 10-item short-form questionnaire. The primary outcome was surgical intervention within 18 months from their first visit to the integrated spine clinic. We surveyed all patient records until February 2017 for CPT codes associated with spinal surgery, excluding from analysis those patients who were lost to follow-up within 1 year of the index visit. Analysis focused on the risk of spinal surgery, with data points treated as both continuous and categorical variables. We used logistic regression models to determine whether PROMs, either alone or in combination, predicted later decision to pursue surgical intervention.

MAIN OUTCOME MEASUREMENTS

Decision to pursue spinal surgery.

RESULTS

The baseline PROM scores spanning functional, mental health, and pain domains were collected for 94% of the patients presenting to our spine program during the interval of this study. In total, 146 patients were excluded because of missing patient-reported outcome data or less than 1 year of follow-up, leaving 395 patients for analysis. Of these, 40.3% were male with a median age of 58 years, 4.6% presented with a history of prior spinal surgery, and 3.8% were being treated with chronic opioids at their initial consultation. Male gender (P = .01) and older age (P = .05) were associated with subsequent surgery, but no relationship was observed between measured patient-reported outcomes and decision to undergo spinal surgery within 18 months of the index visit.

CONCLUSIONS

Contrary to our hypothesis, this analysis demonstrates that the PROMs evaluated in this study, alone are insufficient to identify patients who may elect to pursue spinal surgery. Male gender and increasing age correlate with decision for later spinal surgery.

LEVEL OF EVIDENCE

II.