ODI Cannot Account for All Variation in PROMIS Scores in Patients With Thoracolumbar Disorders

The Oswestry Disability Index is reflective of pain interference and mobility in children

PURPOSE

The 9-item Oswestry Disability Index version 2.1a (ODI-9) has never been formally validated in children. Our primary purpose was to evaluate the ODI-9 using the Patient-Reported Outcomes Measurement Information System (PROMIS) Pediatric Pain Interference (PI) and Mobility Computer Adapted Test (CAT) and Pain Catastrophizing Scale for Children (PCS-C) as anchors to determine concurrent validity in children.

METHODS

We retrospectively reviewed cross-sectional patient-reported outcomes data using a convenience sample of children referred to a tertiary pediatric orthopedic institution for any spine condition from April 2021 to April 2022. The ODI-9, PI, and Mobility were completed at clinic intake in 2,097 children (1453 girls, 644 boys) aged 14.2 ± 2.6 years (range 5-18 years) during the same visit. The ODI-9 was administered when children or caregivers responded "yes" to the presence of back pain. The PCS-C was administered only when pain intensity was rated as "very severe" or "the worst imaginable" on Item 1 of the ODI-9 (n = 51).

RESULTS

Average ODI-9 scores were 18.3% ± 14.8%, indicating minimal disability (ODI-9 ≤ 20%). Moderate, statistically and clinically significant associations were seen between the ODI-9 and PI (r = 0.68, p < 0.001), the ODI-9 and Mobility (r = - 0.68, p < 0.001), and the ODI-9 and PCS-C (r = 0.59, p < 0.001).

CONCLUSION

Worse ODI-9 scores correlate with worse PROMIS PI scores, worse PROMIS Mobility scores, and worse PCS-C scores. The associations were moderate (PROMIS PI [r = 0.68], PROMIS Mobility [r = - 0.68], PCS-C [r = 0.59]).

Application of Enhanced Recovery After Surgery in Patients with Osteoporotic Vertebral Compression Fractures Undergoing Percutaneous Kyphoplasty

BACKGROUND

The enhanced recovery after surgery (ERAS) program helps patients recover faster and better, postoperatively. The aim of this retrospective study was to assess the clinical effectiveness of the ERAS program after percutaneous kyphoplasty (PKP) for osteoporotic vertebral compression fractures.

METHODS

We enrolled patients with osteoporotic vertebral compression fracture who had undergone PKP between January 2019 and June 2021 and divided them into the control group (CG; n = 296), without the ERAS program, and the intervention group (IG; n = 306), with the ERAS program. The visual analog scale (VAS), Oswestry Disability Index (ODI), and Barthel Index scores of the 2 groups were compared on admission and 2 days and 1, 6, and 12 months postoperatively. Perioperative evaluation parameters included the mean surgery time, length of stay (LOS), and hospitalization expenses. In addition, postoperative complications were compared.

RESULTS

Regarding perioperative parameters, LOS and hospitalization expenses were significantly better in IG than in CG (P < 0.001), but the mean surgery time did not differ significantly (P > 0.05). The VAS, Barthel Index, and ODI scores were significantly better in IG than in CG at 2 days and 1 month postoperatively (P < 0.001). None of the clinical effectiveness parameters (VAS, Barthel Index, and ODI scores) differed between IG and CG at 6 or 12 months postoperatively. In addition, 141 patients in CG and 56 patients in IG experienced postoperative complications, including pressure ulcers, deep vein thrombosis, nausea and vomiting, and refracture (P = 0.970, P = 0.036, P < 0.001, P = 0.002 respectively).

CONCLUSIONS

For patients undergoing PKP, the ERAS program is a reliable and effective perioperative management method that can effectively reduce LOS, postoperative pain, and economic burden and promote recovery of patients.

[Effectiveness of sagittal top compression reduction technique in treatment of thoracolumbar vertebral fractures]

Objective

To investigate the effectiveness of sagittal top compression reduction technique in the treatment of thoracolumbar vertebral fractures.

Methods

A retrospective analysis was conducted on the clinical data of 59 patients with thoracolumbar vertebral fractures who met the selection criteria and were admitted between November 2018 and January 2022. Among them, 34 patients were treated with sagittal top compression reduction technique (top pressure group), and 25 patients were treated with traditional reduction technique (traditional group). There was no significant difference in baseline data between the two groups ( P>0.05), including gender, age, fracture segment, cause of injury, AO classification of thoracolumbar vertebral fractures, thoracolumbar injury classification and severity (TLICS) score, American Spinal Injury Association (ASIA) grading, surgical approach, preoperative vertebral body index, height ratio of the anterior margin of injured vertebra, injured vertebra angle, segmental kyphosis angle, visual analogue scale (VAS) score, and Oswestry disability index (ODI). The operation time, intraoperative blood loss, and incidence of complications between the two groups were recorded and compared. After operation, VAS score and ODI were used to evaluate effectiveness, and X-ray and CT examinations were performed to measure imaging indicators such as vertebral body index, height ratio of the anterior margin of injured vertebra, injured vertebra angle, and segmental kyphosis angle.

Results

There was no significant difference in operation time and intraoperative blood loss between the two groups ( P>0.05). No complication such as dural sac, nerve root, or vascular injury was found during operation, and all incisions healed by first intention. Patients in both groups were followed up 6-48 months, with an average of 20.6 months. No loosening, breakage, or failure of internal fixation occurred during follow-up. The imaging indicators, VAS score, and ODI of the two groups significantly improved at 1 week and last follow-up when compared to preoperative ones ( P<0.05). At last follow-up, the VAS score and ODI further significantly improved when compared to 1 week after operation ( P<0.05). At 1 week after operation and last follow-up, the vertebral body index, segmental kyphosis angle, injured vertebra angle, and ODI in the top pressure group were significantly better than those in the traditional group ( P<0.05). There was no significant difference in VAS score and height ratio of the anterior margin of injured vertebra between the two groups at 1 week after operation ( P>0.05), but the two indicators in the top pressure group were significantly better than those in the traditional group at last follow-up ( P<0.05).

Conclusion

The treatment of thoracolumbar vertebral fractures with sagittal top compression reduction technique can significantly improve the quality of vertebral reduction, and is superior to traditional reduction techniques in relieving pain and improving spinal function.

Multi-domain biopsychosocial postoperative recovery trajectories associate with patient outcomes following lumbar fusion

PURPOSE

The purpose of this study is to describe and assess the impact of multi-domain biopsychosocial (BPS) recovery on outcomes following lumbar spine fusion. We hypothesized that discrete patterns of BPS recovery (e.g., clusters) would be identified, and then associated with postoperative outcomes and preoperative patient data.

METHODS

Patient-reported outcomes for pain, disability, depression, anxiety, fatigue, and social roles were collected at multiple timepoints for patients undergoing lumbar fusion between baseline and one year. Multivariable latent class mixed models assessed composite recovery as a function of (1) pain, (2) pain and disability, and (3) pain, disability, and additional BPS factors. Patients were assigned to clusters based on their composite recovery trajectories over time.

RESULTS

Using all BPS outcomes from 510 patients undergoing lumbar fusion, three multi-domain postoperative recovery clusters were identified: Gradual BPS Responders (11%), Rapid BPS Responders (36%), and Rebound Responders (53%). Modeling recovery from pain alone or pain and disability alone failed to generate meaningful or distinct recovery clusters. BPS recovery clusters were associated with number of levels fused and preoperative opioid use. Postoperative opioid use (p < 0.01) and hospital length of stay (p < 0.01) were associated with BPS recovery clusters even after adjusting for confounding factors.

CONCLUSION

This study describes distinct clusters of recovery following lumbar spine fusion derived from multiple BPS factors, which are related to patient-specific preoperative factors and postoperative outcomes. Understanding postoperative recovery trajectories across multiple health domains will advance our understanding of how BPS factors interact with surgical outcomes and could inform personalized care plans.

Application of enhanced recovery after surgery care protocol in the perioperative care of patients undergoing lumbar fusion and internal fixation

Background

To explore the effects and deficiencies of the enhanced recovery after surgery (ERAS) care protocol on patients undergoing lumbar fusion and internal fixation in perioperative care.

Methods

A total of 166 patients with lumbar fusion and internal fixation were collected and divided into two groups, among which 86 patients received ERAS care protocol were attributed into ERAS group, while the other 80 patients received traditional perioperative care protocol were assigned to control group. Then, the degree of pain, self-care ability and the degree of recovery were assessed using the visual analogue scale (VAS), Barthel index (BI) rating scale and the Sino-version Oswestry Disability Index (ODI) questionnaire, respectively. Moreover, further analysis was performed based on patients’ different age, gender, body mass index (BMI) and education of patients in ERAS group.

Results

The hospitalization time and the incidence of complication in the ERAS group were obviously lower than those in control group (both, P < 0.05). There was no significant difference in hospitalization expenses between the two groups (P > 0.05). The BI score of the ERAS group was higher than that of the control group (P < 0.05), and the percentage of ODI score in ERAS group was significantly downregulated in comparison with that in control group (P < 0.05). Intra-group analysis in ERAS showed that, compared with older patients, younger patients had higher BI scores (P < 0.05) and lower ODI scores (P < 0.05); meanwhile, overweight patients had lower BI scores (P < 0.05), and the ODI score decreased with the increase in education level of the patients.

Conclusions

ERAS care protocol can significantly shorten the hospitalization time and reduce the occurrence of postoperative complications of patients, significantly enhance the self-care ability of patients after discharge and promote the rapid recovery of patients after surgery.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-022-03099-0.

Patient-Reported Outcomes Measurement Information System physical function instruments compare favorably to legacy patient-reported outcome measures in spine patients: a systematic review of the literature

BACKGROUND CONTEXT

Preliminary evidence has suggested favorable correlation between National Institutes of Health (NIH) Patient-Reported Outcomes Measurement Information System (PROMIS) assessments and traditional ("legacy") patient reported outcome measures (PROMs) in spine surgery. There has been a significant increase in PROMIS research with regards to spinal conditions.

PURPOSE

The purpose of this systematic review is to provide an assessment of PROMIS Physical Function (PF) measures in this patient population.

STUDY DESIGN/SETTING

Systematic review.

METHODS

A systematic search of the PubMed/MEDLINE and Embase databases was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify published articles that referenced the various PROMIS PF measures. Two authors independently reviewed selected studies. The search returned 1,060 studies, 124 of which were selected for independent review by two authors. Of these, 37 were selected for inclusion. Mixed linear models were performed to assess for differences between legacy PROMs and PROMIS measures.

RESULTS

The combined sample size of all included studies yielded 10,296 total patients. Overall, PROMIS Physical Function (PF) measures demonstrated strong correlations with legacy PROMs when evaluating spine patients (weighted Pearson correlation, 0.589, standard error [SE]=0.023; weighted Spearman correlation, 0.702, SE=0.028). PROMIS questionnaires had significantly fewer questions than did legacy PROMs (4.2±0.30 vs. 9.53±0.82, p=.015). In spine studies, the PROMIS PF forms were completed in significantly less time than legacy PROMs (48.1±2.9 vs. 174.7±12.6 seconds, p<.001). The differences for the reliability measures and the floor and ceiling effects were not significant.

CONCLUSIONS

Patient-Reported Outcomes Measurement Information System PF forms compare favorably with legacy PROMs with regard to correlations, ease of use, and quality criteria in the field of spine surgery. PROMIS PF scores correlate strongly with commonly used legacy PROMs, particularly in spine patients. Patient-Reported Outcomes Measurement Information System PF forms can be administered efficiently and to a broad patient population while remaining highly reliable.

The Effect of the Severity of Preoperative Disability on Patient-Reported Outcomes and Patient Satisfaction Following Minimally Invasive Transforaminal Lumbar Interbody Fusion

OBJECTIVE

To compare patient-reported outcomes (PROMs), satisfaction, and minimum clinically important difference (MCID) achievement following minimally invasive transforaminal lumbar interbody fusion stratified by preoperative disability.

METHODS

Minimally invasive transforaminal lumbar interbody fusions were grouped by preoperative Oswestry Disability Index (ODI) score: ODI <41 or ODI ≥41. PROMs administered pre/postoperatively included Patient-Reported Outcomes Measurement Information System physical function (PROMIS-PF), visual analog scale (VAS) back/leg, ODI, and 12-Item Short-Form Physical Composite Score (SF-12 PCS)/12-Item Short-Form Mental Composite Score (SF-12 MCS). Satisfaction scores were collected for VAS back/leg and ODI. Coarsened exact match controlled for differences between cohorts. T tests compared mean PROMs and postoperative improvement/satisfaction between cohorts. Simple logistic regression compared MCID achievement.

RESULTS

After coarsened exact matching, there were 118 patients in the ODI ≤41 and 377 patients in the ODI >41 cohort. The ODI >41 cohort saw greater postoperative inpatient VAS pain score and narcotic consumption on days 0/1 (P < 0.018, all). PROMs differed between cohorts: PROMIS-PF, SF-12 PCS, ODI, VAS back/leg at all postoperative time points and SF-12 MCS at 6 weeks/12 weeks/6 months/1 year (P < 0.045, all). Patients in the ODI >41 cohort demonstrated greater proportion achieving MCID for ODI at all postoperative time points and for SF-12 MCS 6-week/12-week/6-month/1-year (P < 0.040, all). The ODI ≤41 cohort demonstrated greater MCID achievement for overall PROMIS-PF and SF-12 PCS 6 months (P < 0.047, all). Postoperative satisfaction was greater in the ODI ≤41 cohort for VAS leg 6 weeks/12 weeks, VAS back 6 weeks/12 weeks, and ODI all postoperative time points (P < 0.048, all).

CONCLUSIONS

Preoperative disability associated with worse postoperative PROMs and patient satisfaction for disability, back/leg pain at multiple time points. MCID achievement rates across cohorts were similar for most PROMs at most postoperative time points. Patients with severe disability may have unrealistic expectations for surgical benefits, influencing corresponding postoperative satisfaction.

Long-term core outcomes in cauda equina syndrome

AIMS

Cauda equina syndrome (CES) can be associated with chronic severe lower back pain and long-term autonomic dysfunction. This study assesses the recently defined core outcome set for CES in a cohort of patients using validated questionnaires.

METHODS

Between January 2005 and December 2019, 82 patients underwent surgical decompression for acute CES secondary to massive lumbar disc prolapse at our hospital. After review of their records, patients were included if they presented with the clinical and radiological features of CES, then classified as CES incomplete (CESI) or with painless urinary retention (CESR) in accordance with guidelines published by the British Association of Spinal Surgeons. Patients provided written consent and completed a series of questionnaires.

RESULTS

In total, 61 of 82 patients returned a completed survey. Their mean age at presentation was 43 years (20 to 77; SD 12.7), and the mean duration of follow-up 58.2 months (11 to 182; SD 45.3). Autonomic dysfunction was frequent: 33% of patients reported bladder dysfunction, and 10% required a urinary catheter. There was a 38% and 53% incidence of bowel and sexual dysfunction, respectively: 47% of patients reported genital numbness. A total of 67% reported significant back pain: 44% required further investigation and 10% further intervention for the management of lower back pain. Quality of life was lower than expected when corrected for age and sex. Half the patients reported moderate or worse depression, and 40% of patients of working age could no longer work due to problems attributable to CES. Urinary and faecal incontinence, catheter use, sexual dysfunction, and genital numbness were significantly more common in patients with CESR.

CONCLUSION

This study reports the long-term outcome of patients with CES and is the first to use validated patient-reported outcome measures to assess the CES Core Outcome Set. Persistent severe back pain and on-going autonomic dysfunction were frequently reported at a mean follow-up of five years. Cite this article: Bone Joint J 2021;103-B(9):1464-1471.