The Relationship Between Preoperative PROMIS Scores With Postoperative Improvements in Physical Function After Anterior Cervical Discectomy and Fusion

Association of Patient-Reported Outcomes Measurement Information System Measures With Injection and Surgical Treatment Response in Patients With De Quervain Tenosynovitis

PURPOSE

Treatment of de Quervain tenosynovitis is largely empiric. Patient-Reported Outcomes Management Information System (PROMIS) scores at the time of diagnosis might provide insights into the probability of success of nonsurgical management and predict the necessity for surgical treatment. We aimed to identify which, if any, of the PROMIS metrics may be used to identify patients who will opt for surgery or be managed with injection alone.

METHODS

Patients presenting to a tertiary academic medical center from 2014 to 2019, with a sole diagnosis of de Quervain tenosynovitis, were identified and separated by initial and most invasive treatment of either injection or surgery. These groups were then dichotomized using cut points of more than one SD from the mean on the PROMIS physical function and pain interference scales, and a logistic regression model was used to determine the odds ratio of surgical intervention.

RESULTS

Patients who had low physical function or high pain interference had significantly increased odds of ultimately undergoing surgery. Age ranging from 40 to 60 years and female sex were also associated with increased odds of undergoing surgery.

CONCLUSIONS

Patients who scored lower than 40 for physical function or higher than 60 for pain interference had significantly increased odds of eventually undergoing surgical release for de Quervain tenosynovitis. PROMIS scores may identify patients who are likely to fail steroid injections as a sole nonsurgical intervention and inform an individualized discussion about surgical management of this condition.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Association between serum multi-protein biomarker profile and real-world disability in multiple sclerosis

Few studies examined blood biomarkers informative of patient-reported outcome (PRO) of disability in people with multiple sclerosis (MS). We examined the associations between serum multi-protein biomarker profiles and patient-reported MS disability. In this cross-sectional study (2017-2020), adults with diagnosis of MS (or precursors) from two independent clinic-based cohorts were divided into a training and test set. For predictors, we examined seven clinical factors (age at sample collection, sex, race/ethnicity, disease subtype, disease duration, disease-modifying therapy [DMT], and time interval between sample collection and closest PRO assessment) and 19 serum protein biomarkers potentially associated with MS disease activity endpoints identified from prior studies. We trained machine learning (ML) models (Least Absolute Shrinkage and Selection Operator regression [LASSO], Random Forest, Extreme Gradient Boosting, Support Vector Machines, stacking ensemble learning, and stacking classification) for predicting Patient Determined Disease Steps (PDDS) score as the primary endpoint and reported model performance using the held-out test set. The study included 431 participants (mean age 49 years, 81% women, 94% non-Hispanic White). For binary PDDS score, combined feature input of routine clinical factors and the 19 proteins consistently outperformed base models (comprising clinical features alone or clinical features plus one single protein at a time) in predicting severe (PDDS ≥ 4) versus mild/moderate (PDDS < 4) disability across multiple machine learning approaches, with LASSO achieving the best area under the curve (AUCPDDS = 0.91) and other metrics. For ordinal PDDS score, LASSO model comprising combined clinical factors and 19 proteins as feature input (R2PDDS = 0.31) again outperformed base models. The two best-performing LASSO models (i.e., binary and ordinal PDDS score) shared six clinical features (age, sex, race/ethnicity, disease subtype, disease duration, DMT efficacy) and nine proteins (cluster of differentiation 6, CUB-domain-containing protein 1, contactin-2, interleukin-12 subunit-beta, neurofilament light chain [NfL], protogenin, serpin family A member 9, tumor necrosis factor superfamily member 13B, versican). By comparison, LASSO models with clinical features plus one single protein at a time as feature input did not select either NfL or glial fibrillary acidic protein (GFAP) as a final feature. Forcing either NfL or GFAP as a single protein feature into models did not improve performance beyond clinical features alone. Stacking classification model using five functional pathways to represent multiple proteins as meta-features implicated those involved in neuroaxonal integrity as significant contributors to predictive performance. Thus, serum multi-protein biomarker profiles improve the prediction of real-world MS disability status beyond clinical profile alone or clinical profile plus single protein biomarker, reaching clinically actionable performance.

Are We Considering the Whole Patient? The Impact of Physical and Mental Health on the Outcomes of Spine Care

STUDY DESIGN

Retrospective, observational.

OBJECTIVE

To evaluate the influence of baseline health status on the physical and mental health (MH) outcomes of spine patients.

SUMMARY OF BACKGROUND DATA

Spine conditions can have a significant burden on both the physical and MH of patients. To date, few studies have evaluated the outcomes of both dimensions of health, particularly in nonoperative populations.

MATERIALS AND METHODS

At their first visit to a multidisciplinary spine clinic, 2668 nonoperative patients completed the Patient-reported Outcomes Measurement Information System-Global Health (PROMIS-GH) instrument and a questionnaire evaluating symptoms and goals of care. Patients were stratified by their baseline percentile score of the MH and physical health (PH) components of the PROMIS-GH. Four groups of patients were compared based on the presence or absence of bottom quartile PH or MH scores. The primary end point was the achievement of a minimal clinically important difference (MCID) on the MH or PH components at follow-up. Multivariate regression assessed the predictors of MCID achievement.

RESULTS

After controlling for demographics, symptoms, and goals, each 1-point increase in baseline PROMIS-GH mental score reduced the odds of achieving MH MCID by 9.0% ( P <0.001). Conversely, each 1-point increase in baseline GH-physical score increased the odds of achieving MCID by 4.5% ( P =0.005). Each 1-point increase in baseline GH-physical score reduced the odds of achieving PH MCID by 12.5% ( P <0.001), whereas each 1-point increase in baseline GH-mental score increased the odds of achieving MCID by 5.0% ( P <0.001).

CONCLUSIONS

Spine patients presenting with the lowest levels of physical or MH were most likely to experience clinically significant improvement in those domains. However, lower levels of physical or mental health made it less likely that patients would experience significant improvement in the alternative domain. Physicians should evaluate and address the complex spine population holistically to maximize improvement in both physical and mental health status.

Comparison of Psychometric Properties of Patient-Reported Outcomes Measurement Information System With Traditional Outcome Metrics in Spine Surgery

OBJECTIVE

Patient-Reported Outcomes Measurement Information System (PROMIS) was developed to address certain shortcomings of traditional, or legacy patient-reported outcome measures (PROMs). Because the use of PROMIS across orthopedic populations continues to increase, the purpose of this study was to provide a comprehensive overview of the use and validation of PROMIS in spine surgery.

METHODS

PubMed and Google Scholar were searched for relevant articles reporting on the use and validation of PROMIS in spine surgery. The PROMIS formats and individual domains used by investigators were noted. Additionally, psychometric properties reported in validation studies were evaluated.

RESULTS

Both individual studies and systematic reviews have demonstrated the convergent validity of PROMIS domains, reporting moderate-to-strong correlations with legacy measures in a variety of spine patient populations. Across spine surgery patient populations, PROMIS instruments are consistently efficient, demonstrating decreased question burden compared with legacy PROMs. PROMIS domains overall exhibit responsiveness comparable with legacy measures, and the normalization of PROMIS scores to a general population allows for broad coverage, resulting in acceptable floor and ceiling effects. Despite the many strengths of PROMIS, there remain some populations where PROMIS is not suited to be used in isolation.

CONCLUSIONS

PROMIS is widely used as an outcome measure in spine surgery and has been validated in a range of patient populations. Although PROMIS domains cannot fully replace legacy measures in spine patients, they can be used in certain settings to provide an efficient and psychometrically sound PROM.

The Influence of Presenting Physical Function on Postoperative Patient Satisfaction and Clinical Outcomes Following Minimally Invasive Lumbar Decompression

STUDY DESIGN

The study of retrospective cohort.

OBJECTIVE

The aim was to compare patient-reported outcome measures (PROMs), satisfaction, and minimum clinically important difference (MCID) achievement following minimally invasive lumbar decompression (MIS-LD) in patients stratified by the preoperative patient-reported outcomes measurement information system physical function (PROMIS-PF) score.

SUMMARY OF BACKGROUND DATA

Although prior studies have assessed the predictive utility of preoperative PROMIS-PF scores on patient outcomes in spinal fusion, its utility has not been studied for patients undergoing MIS-LD.

METHODS

Primary, single/multilevel MIS-LD procedures were identified. PROMs were administered at preoperative/6-week/12-week/6-month/1-year/2-year time points and included PROMIS-PF/visual analog scale (VAS) back and leg/Oswestry Disability Index (ODI). Satisfaction scores were collected postoperatively. The patients were grouped by preoperative PROMIS-PF score (≤35, >35), with higher scores indicating improved physical function. Demographic/perioperative characteristics were compared using χ 2 /Student t test. Mean PROMs/postoperative satisfaction was compared utilizing 2-sample t test. Postoperative PROM improvement from preoperative was calculated with paired t tests. MCID achievement rates were compared using simple logistic regression.

RESULTS

Two hundred and sixteen patients were included, 58 PROMIS-PF≤35 and 158 PROMIS-PF>35. Ethnicity/insurance differed ( P ≤0.004, all). Hospital length of stay was greater for PROMIS-PF>35 ( P =0.042). All preoperative mean PROMs significantly differed except for VAS Back. Several postoperative mean PROMs differed: PROMIS-PF at 6 weeks/12 weeks/6 months/1 year, SF-12 PCS at 6 weeks/12 weeks/1 year, VAS Back at 6 weeks/12 weeks, VAS leg at 6 weeks/12 weeks, and ODI at 6 weeks/12 weeks ( P <0.050, all). All PROMs significantly improved from preoperative at all postoperative time points ( P <0.003, all). The MCID achievement rates differed only for VAS back for 6 weeks, favoring PROMIS-PF>35 cohort ( P =0.001). Postoperative satisfaction was greater in PROMIS-PF>35 cohort for VAS leg at 6 weeks/12 weeks/6 months/2 years, VAS back at 6-weeks/12-weeks, and ODI at all time points ( P <0.037, all). Postoperative satisfaction was greater in PROMIS-PF>35 cohort for individual ODI categories: sleep at 6-weeks/12-weeks/1-year/2-years, lifting, walking, standing, and travel at all time points, and sexual at 6-weeks/12-weeks/1-year/2-years ( P <0.030, all).

CONCLUSION

Poorer preoperative PROMIS-PF scores were associated with worse postoperative clinical outcomes and satisfaction. By stratifying patients with preoperative PROMIS-PF scores, surgeons may better predict postoperative clinical improvement and seek to manage patient expectations.

What is the role of dynamic cervical spine radiographs in predicting pseudarthrosis revision following anterior cervical discectomy and fusion?

BACKGROUND CONTEXT

Postoperative dynamic radiographs are used to assess fusion status after anterior cervical discectomy and fusion (ACDF) with comparable accuracy to computed tomography (CT) scans.

PURPOSE

To (1) determine if dynamic radiographs accurately predict pseudarthrosis revision in a cohort of largely asymptomatic patients who underwent ACDF, (2) determine how adjacent segment motion is affected by fusion status, and (3) analyze how clinical outcomes differ between patients with symptomatic and asymptomatic pseudarthrosis.

STUDY DESIGN

Retrospective cohort study.

PATIENT SAMPLE

Patients ≥ 18 years who underwent primary one- to four-level ACDF at a single institution over a 10-year period.

OUTCOME MEASURES

Interspinous motion on preoperative and postoperative flexion-extension radiographs and preoperative and postoperative Visual Analogue Scale for Neck Pain (VAS Neck) and Arm Pain (VAS Arm), Neck Disability Index (NDI), Modified Japanese Orthopaedic Association scale (mJOA), Mental and Physical Component Scores of the Short-Form 12 (SF-12) Health Survey (MCS-12 and PCS-12) METHODS: The difference in spinous process motion between flexion and extension radiographs was used to determine motion at each level of the ACDF construct. Pseudarthrosis was defined as ≥ 1 mm spinous process motion on dynamic radiographs. A receiver operating characteristic (ROC) curve was generated to predict the probability of surgical revision for pseudarthrosis based on millimeters of interspinous motion at each instrumented level. Patient reported outcome measures (PROMs) were used to assess the effect of pseudarthrosis on clinical outcomes. Alpha was set at p<.05.

RESULTS

A total of 597 patients met inclusion criteria including 1,203 ACDF levels. Of those, 215 patients (36.0%) were diagnosed with a pseudarthrosis on dynamic radiographs with 29 patients (4.9%) requiring pseudarthrosis revision. ROC analysis identified a "cutoff" value of 1.00 mm of interspinous process motion for generating an optimal area under the curve (AUC). The negative predictive value (NPV) was 99.6%, whereas the positive predictive value (PPV) was 13.7%. When analyzing adjacent segment motion, the Δ supra-adjacent interspinous process motion (ISM) was significantly lower for patients with a superior construct pseudarthrosis (-1.06 mm vs. 1.80 mm, p<.001), whereas the Δ infra-adjacent level ISM was significantly lower for patients with an inferior construct pseudarthrosis (-1.21 mm vs. 2.15 mm, p<.001). Patients with a pseudarthrosis not requiring revision had worse postoperative NDI (29.3 vs. 23.4, p=.027), VAS Neck (3.40 vs. 2.63, p=.012), and VAS Arm (3.09 vs. 1.85, p=.001) scores at 3 months, but not 1-year, compared with patients who were fused. Patients requiring pseudarthrosis revision had higher 1-year postoperative NDI (38.0 vs. 23.7, p=.047) and lower 1-year postoperative Δ VAS Arm (-0.22 vs. -2.97, p=.016) scores.

CONCLUSIONS

One-year postoperative dynamic radiographs have a greater than 99% negative predictive value for identifying patients requiring pseudarthrosis revision, but they have a low positive predictive value. Most patients with a pseudarthrosis remain asymptomatic with similar 1-year postoperative patient-reported outcomes compared with patients without a pseudarthrosis.

The Effect of Anterior Cervical Discectomy and Fusion Procedure Duration on Patient-Reported Outcome Measures

OBJECTIVE

To determine whether operative duration of anterior cervical discectomy and fusion (ACDF) significantly affects patient-reported outcome measures (PROMs) 90 days after surgery and at 1-year follow-up.

METHODS

Patients who underwent primary 1-level to 4-level ACDF were retrospectively identified. Demographic data and PROMs were collected through chart review. Patients were split into short, medium, and long tertiles based on procedure duration. PROM surveys were administered preoperatively as baseline measurements, at initial follow-up (between 60 and 120 days postoperatively), and at 1 year postoperatively. Outcomes included Neck Disability Index, Short-Form 12 Physical Component Score (PCS-12), Short-Form 12 Mental Component Score, visual analog scale (VAS) neck score, and VAS arm score.

RESULTS

Significant short-term improvements were found across all groups for all PROMs. All groups showed long-term improvements in Short-Form 12 Mental Component Score, PCS-12, Neck Disability Index, VAS neck score, and VAS arm score, with the exception of the medium-duration group in PCS-12 (P = 0.093). On multivariate analysis, short-duration procedures predicted better improvement in VAS neck score (β = -1.01; P = 0.012) and VAS arm score (β = -1.38; P = 0.002) compared with long-duration procedures, whereas medium-duration procedures resulted in better improvement in VAS arm score (β = -1.00; P = 0.011). Further, short and medium duration was a predictor of decreased length of hospital stay (β = -0.67, P = 0.001 and β = -0.59, P = 0.001, respectively) compared with long-duration procedures.

CONCLUSIONS

All groups improved after ACDF regardless of surgical duration. Further, surgical duration was not a predictor of differing improvement in physical function or disability.

Appropriate Opioid Use After Spine Surgery: Psychobehavioral Barriers and Patient Knowledge

OBJECTIVE

To identify spine patients' barriers to appropriate postoperative opioid use, comfort with naloxone, knowledge of safe opioid disposal practices, and associated factors.

METHODS

We preoperatively surveyed 174 spine patients about psychobehavioral barriers to appropriate opioid use, comfort with naloxone, and knowledge about opioid disposal. Multivariable logistic regression identified factors associated with barriers and knowledge (α = 0.05).

RESULTS

Common barriers were fear of addiction (71%) and concern about disease progression (43%). Most patients (78%) had neutral/low confidence in the ability of nonopioid medications to control pain; most (57%) felt neutral or uncomfortable with using naloxone; and most (86%) were familiar with safe disposal. Anxiety was associated with fear of distracting the physician (adjusted odds ratio [aOR], 3.8; 95% confidence interval [CI], 1.1-14) and with lower odds of knowing safe disposal methods (aOR, 0.18; 95% CI, 0.04-0.72). Opioid use during the preceding month was associated with comfort with naloxone (aOR, 4.9; 95% CI, 2.1-12). Patients with a higher educational level had lower odds of reporting fear of distracting the physician (aOR, 0.30; 95% CI, 0.09-0.97), and those with previous postoperative opioid use had lower odds of concern about disease progression (aOR, 0.25; 95% CI, 0.09-0.63) and with a belief in tolerating pain (aOR, 0.34; 95% CI, 0.12-0.95).

CONCLUSIONS

Many spine patients report barriers to appropriate postoperative opioid use and are neutral or uncomfortable with naloxone. Some are unfamiliar with safe disposal. Associated factors include anxiety, lack of recent opioid use, and no previous postoperative use.

Patient-Reported Outcomes Measurement Information System Physical Function Validation for Use in Anterior Cervical Discectomy and Fusion: A 2-Year Follow-up Study

Objective

Our study aims to evaluate the correlation of Patient-Reported Outcomes Measurement Information System physical function (PROMIS PF) with legacy patient-reported outcome measures (PROMs) among patients undergoing anterior cervical discectomy and fusion (ACDF).

Methods

A prospectively maintained database was retrospectively reviewed for ACDF surgeries performed between May 2015 and September 2017. Inclusion criteria were primary elective, single- or multilevel ACDFs for degenerative spinal pathology. Patients lacking preoperative or 2-year PROMIS PF surveys were excluded. Mean scores were calculated for visual analogue scale (VAS) neck, VAS arm, Neck Disability Index (NDI), 12-Item Short Form Physical Component Score (SF-12 PCS), and PROMIS PF at preoperative and 6-week, 12-week, 6-month, 1-year, and 2-year postoperative timepoints. A t-test and Pearson correlation coefficient were utilized to evaluate score improvement and PROM relationships respectively.

Results

The 50 subject cohort was 60.0% male, 50% obese (body mass index ≥ 30 kg/m²) and had an average age of 50.9 years. Significant improvements were demonstrated for VAS neck and NDI at all postoperative timepoints (p < 0.001) and for SF-12 and PROMIS PF at all timepoints except 6 weeks (p ≤ 0.025). VAS arm improvement was seen up to 1 year (p ≤ 0.016). PROMIS PF demonstrated strong correlations with NDI and SF-12 PCS at all evaluated timepoints and with VAS neck at all postoperative timepoints except 6 weeks (all p < 0.01).

Conclusion

PROMIS PF was strongly correlated with pain, disability, and physical function up to 2 years for patients undergoing ACDF. Our results support the long-term validity of PROMIS PF for measurement of patient-reported physical function among ACDF cohorts.

Safety and Tolerability of Stromal Vascular Fraction Combined with β-Tricalcium Phosphate in Posterior Lumbar Interbody Fusion: Phase I Clinical Trial

The rates of pseudarthrosis remain high despite recent advances in bone graft substitutes for spinal fusion surgery. The aim of this single center, non-randomized, open-label clinical trial was to determine the feasibility of combined use of stromal vascular fraction (SVF) and β-tricalcium phosphate (β-TCP) for patients who require posterior lumbar interbody fusion (PLIF) and pedicle screw fixation. Two polyetheretherketone (PEEK) cages were inserted into the intervertebral space following complete removal of the intervertebral disc. The PEEK cage (SVF group) on the right side of the patient was filled with β-TCP in combination with SVF, and the cage on the left side (control group) was filled with β-TCP alone. Fusion rate and cage subsidence were assessed by lumbar spine X-ray and CT at 6 and 12 months postoperatively. At the 6-month follow-up, 54.5% of the SVF group (right-sided cages) and 18.2% of the control group (left-sided cages) had radiologic evidence of bone fusion (p = 0.151). The 12-month fusion rate of the right-sided cages was 100%, while that of the left-sided cages was 91.6% (p = 0.755). Cage subsidence was not observed. Perioperative combined use of SVF with β-TCP is feasible and safe in patients who require spinal fusion surgery, and it has the potential to increase the early bone fusion rate following spinal fusion surgery.