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

The Veterans Rand-12 Physical Composite Score Prognosticates Postoperative Clinical Outcomes in Patients Undergoing Anterior Cervical Discectomy and Fusion

OBJECTIVE

To determine prognostic value of preoperative Veterans RAND 12-Item Health Survey (VR-12) physical composite score (PCS) on outcomes in patients undergoing anterior cervical discectomy and fusion (ACDF).

METHODS

ACDF patients with preoperative VR-12 PCS formed 2 cohorts: VR-12 PCS <35 and VR-12 PCS ≥35. The following patient-reported outcome measures (PROMs) were gathered preoperatively and postoperatively up to 2 years: VR-12 mental composite score (MCS)/PCS, Neck Disability Index (NDI), Patient-Reported Outcomes Measurement Information System (PROMIS) PF, 9-Item Patient Health Questionnaire (PHQ-9), visual analog scale (VAS) neck/arm pain, and 12-Item Short Form Health Survey (SF-12) PCS/MCS. Comparing PROMs change with established thresholds determined achievement of minimum clinically important difference (MCID). Univariate analysis compared demographics, perioperative characteristics, and preoperative PROMs. Multivariable regression analysis compared postoperative PROMs and MCID achievement.

RESULTS

Of 174 patients, 83 had VR-12 PCS <35. Preoperatively, patients with reduced PF displayed lower patient-reported outcome scores in NDI, PHQ-9, and SF-12 MCS (P ≤ 0.008), but not in VAS arm. At 6 weeks postoperatively, these patients continued to score lower in NDI (P ≤ 0.014) and SF-12 PCS (P ≤ 0.001), among others. By the final check, most scores remained lower (P ≤ 0.002) except for PHQ-9 and VAS arm (P > 0.05). Greater improvements at 6 weeks postoperatively were especially noted in patients with lower initial VR-12 PCS for NDI, PROMIS PF, and SF-12 PCS (P < 0.05). However, by final follow-up, only PROMIS PF showed noteworthy improvement (P = 0.19). Regarding MCID achievement, significant differences were largely absent except in NDI, where patients with reduced PF exhibited more MCID achievement (P = 0.016).

CONCLUSIONS

ACDF patients with VR-12 PCS <35 experienced inferior PF, mental health, and disability postoperatively until final follow-up. There were no significant differences in postoperative improvement magnitude and MCID achievement. Results suggest that baseline VR-12 PCS in ACDF patients may indicate poorer PF, mental health, and disability postoperatively. However, VR-12 PCS does not limit extent of postoperative improvement.

Severe Obesity Is an Independent Risk Factor of Early Readmission and Nonhome Discharge After Cervical Disc Replacement

OBJECTIVE

Despite growing interest in cervical disc replacement (CDR) for conditions such as cervical radiculopathy, limited data exists describing the impact of obesity on early postoperative outcomes and complications. These data are especially important as nearly half of the adult population in the United States is expected to become obese (body mass index [BMI] ≥ 30 kg/m2) by 2030. The goal of this study was to compare the demographics, perioperative variables, and complication rates following CDR.

METHODS

The 2005-2020 American College of Surgeons National Surgical Quality Improvement Program datasets were queried for patients who underwent primary 1- or 2-level CDR. Patients were divided into 3 cohorts: Nonobese (BMI: 18.5-29.9 kg/m2), Obese class-I (BMI: 30-34.9 kg/m2), Obese class-II/III (BMI ≥ 35 kg/m2). Morbidity was defined as the presence of any complication within 30 days postoperatively. Rates of 30-day readmission, reoperation, morbidity, individual complications, length of stay, frequency of nonhome discharge disposition were collected.

RESULTS

A total of 5,397 patients were included for analysis: 3,130 were nonobese, 1,348 were obese class I, and 919 were obese class II/III. There were more 2-level CDRs performed in the class II/III cohort compared to the nonobese group (25.7% vs. 21.5%, respectively; p < 0.05). Class-II/III had more nonhome discharges than class I and nonobese (2.1% vs. 0.5% vs. 0.7%, respectively; p < 0.001). Readmission rates differed as well (nonobese: 0.5%, class I: 1.1%, class II/III: 2.1%; p < 0.001) with pairwise significance between class II/II and nonobese. Class II/III obesity was an independent risk factor for both readmission (odds ratio [OR], 3.32; p = 0.002) and nonhome discharge (OR, 2.51; p = 0.02). Neither 30-day reoperation nor morbidity rates demonstrated significance. No mortalities were reported.

CONCLUSION

Although obese class-II/III were risk factors for 30-day readmission and nonhome discharge, there was no significant difference in reoperation rates or morbidity. CDR procedures can continue to be safely preformed independent of obesity status.

Level-specific Perioperative and Clinical Outcome Comparison: Cervical Disk Replacement Versus Anterior Cervical Diskectomy and Fusion at C5-C6 in Patients With Myeloradiculopathy

INTRODUCTION

This study compares perioperative and postoperative clinical outcomes in patients undergoing anterior cervical diskectomy and fusion (ACDF) or cervical disk replacement (CDR) at C5-C6 in patients with myeloradiculopathy.

METHODS

Primary, elective, single-level CDR or ACDF procedures at C5-C6 for patients with myeloradiculopathy were included. Patient-reported outcome measures (PROMs) included visual analog scale (VAS) neck, VAS arm, Neck Disability Index (NDI), Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF), and Short-Form 12-Item Physical Composite Score (SF-12 PCS) collected at preoperative/6-week/12-week/6-month/1-year time points. Surgical cohorts were assessed for differences in demographics/perioperative characteristics using the chi square test and unpaired Student t-test for categorical and continuous variables, respectively. Achievement of minimum clinically important difference (MCID) was determined by comparing ΔPROMs with established thresholds. Outcome measures were compared at postoperative time points with the Student t-test, and improvement from preoperative baseline was assessed with a paired sample t-test.

RESULTS

One hundred thirty-seven patients were included, 43 CDR and 94 ACDF. CDR patients demonstrated significantly reduced surgical times (46.3 versus 55.1 minutes), estimated blood loss (24.4 versus 43.6 mL), revision surgery rates (0.0% versus 5.3%), postoperative length of stay (8.9 versus 23.0 hours), and postoperative narcotic consumption (P < 0.017, all). Complication rates and mean PROMs did not differ between cohorts. The CDR cohort markedly improved from baseline for all PROMs postoperatively except SF-12 PCS/PROMIS-PF at 6 weeks. The ACDF cohort markedly improved at each time point except VAS arm at 1 year, NDI at 6 weeks/1 year, and SF-12 PCS/PROMIS-PF at 6 weeks. A majority of both cohorts achieved overall MCID for VAS neck/NDI/PROMIS-PF. MCID achievement rates did not differ except NDI at 12 weeks/1 year and SF-12 PCS at 6 months, both favoring CDR.

DISCUSSION

Both procedural cohorts demonstrated similar long-term clinical outcomes for arm/neck pain and physical function; however, patients undergoing CDR at C5-C6 demonstrated an improved ability to maintain 1-year postoperative progress for neck disability with improved 1-year NDI MCID achievement. The CDR cohort, in addition, demonstrated an improved perioperative profile and reduced rate of revision surgery.

The Effect of the Preoperative Severity of Neck Pain on Patient-Reported Outcome Measures and Minimum Clinically Important Difference Achievement After Anterior Cervical Discectomy and Fusion

OBJECTIVE

To compare patient-reported outcome measure (PROM) scores and minimum clinically important difference (MCID) achievement rates among patients undergoing single-level anterior cervical discectomy and fusion (ACDF) in patients with varying severity of preoperative visual analog scale (VAS) neck score.

METHODS

Patients with ACDF were grouped: severity of preoperative VAS neck score ≤8 or >8. Demographic/perioperative variables and PROMs (Patient-Reported Outcomes Measurement Information System Physical Function [PROMIS PF] score, 12-Item Short Form [SF-12] Mental Component Score [MCS], VAS neck/arm score, and Neck Disability Index [NDI]) were collected preoperatively/postoperatively. MCID attainment comparison by grouping was evaluated using χ² analysis.

RESULTS

A total of 137 patients were included (103 VAS neck preoperative score ≤8; 34 VAS neck preoperative score >8). The VAS neck preoperative score ≤8 cohort did not improve: 6 weeks PROMIS-PF score, 6 weeks SF-12 Physical Component Score [PCS], 12 weeks/1 year/2 years SF-12 MCS, 2 years VAS neck score, and 1 years/2 years VAS arm score (P ≤ 0.015, all). VAS neck preoperative score >8 did not improve: 6 weeks/12 weeks/2 years PROMIS-PF score, all time points SF-12 PCS, 6 weeks/12 weeks/1 year/2 years SF-12 MCS, and 2 years VAS arm score (P ≤ 0.013, all). VAS neck preoperative score >8 had inferior PROMIS-PF scores all time points except 1 year (P ≤ 0.036, all), lower SF-12 PCS 6 weeks/6 months (P ≤ 0.043, both), inferior SF-12 MCS at preoperative to 6 months (P ≤ 006, all), higher VAS neck score from preoperative to 6 months (P ≤ 0.018), higher VAS arm score preoperative/12 weeks/6 months (P ≤ 0.020, all), and higher NDI at preoperative/12 weeks/6 months (P ≤ 0.030, all). MCID attainment rates for VAS neck preoperative score >8 were greater for NDI 2 years (P = 0.040), lower for PROMIS-PF score 2 years, and overall (P = 0.018), lower for SF-12 MCS 12 weeks (P = 0.046), lower for VAS neck score 12 weeks to 1 year and overall (P ≤ 0.032, all), and lower for VAS arm score 6 weeks/1 year (P ≤ 0.030, both).

CONCLUSIONS

Patients with single-level ACDF presenting with greater baseline neck pain showed poorer physical function/pain/disability/mental health at preoperative/intermediate postoperative time points, but had comparable long-term PROMs by 2 years. MCID attainment was lower among patients with greater preoperative neck pain; MCID among the VAS neck score >8 cohort were only significantly inferior for neck pain.

Neck Disability at Presentation Influences Long Term Clinical Improvement for Neck Pain, Arm Pain, Disability and Physical Function in Patients Undergoing Anterior Cervical Discectomy and Fusion

STUDY DESIGN

Retrospective cohort PURPOSE: To compare perioperative characteristics, patient-reported outcome measures (PROMs) and minimum clinical important difference (MCID) achievement following anterior cervical discectomy and fusion (ACDF) in patients stratified by preoperative neck disability.

OVERVIEW OF LITERATURE

The Neck Disability Index (NDI) assesses a patient's self-perceived neck disability and is often utilized to assess the efficacy of cervical surgical intervention. Our study evaluates how preoperative severity of patient neck disability influences postoperative clinical improvement following ACDF.

METHODS

Primary, single or multi-level ACDF procedures were included. PROMs were administered at preoperative/6-week/12-week/6-month/1-year/2-year timepoints and included PROMIS-PF, VAS for neck and arm pain, NDI, and SF-12 PCS. Patients were grouped: preoperative NDI score<50 (mild to moderate neck disability) or NDI score≥50 (Severe neck disability). Demographics/perioperative characteristics/postoperative complications/mean PROMs/MCID achievement rates were compared using chi-squared or Student's t-test. Postoperative improvement from preoperative baseline within each cohort was assessed with paired samples t-test. MCID achievement was determined by comparing ΔPROMs to established thresholds.

RESULTS

225 patients were included, 150 NDI<50 and 75 NDI≥50. NDI≥50 cohort was significantly younger(p=0.002). Cohorts did not differ for spinal pathology/operative duration/estimated blood loss/postoperative length of stay/postoperative narcotic consumption/adjacent segment disease rate/1-year arthrodesis rate/6-month pseudoarthrosis rate. Postoperative VAS pain score on POD0 and 1 was significantly increased in NDI≥50 cohort(p<0.048, all). Postoperative complication rates did not differ. All mean PROMs differed at all timepoints(p<0.043, all). NDI<50 patient cohort significantly improved from preoperative baseline for all PROMs and timepoints except SF-12 PCS/PROMIS-PF at 6-weeks. NDI≥50 cohort significantly improved for all PROMs and timepoints except SF-12 PCS at 6-weeks. NDI≥50 cohort demonstrated greater proportion achieving MCID for NDI at 6-weeks/2-years/overall(p<0.037, all).

CONCLUSION

Both cohorts demonstrated significant long-term clinical improvement for neck pain/arm pain/physical function/neck disability, though patients with severe preoperative neck disability reported inferior mean scores for these outcomes at all timepoints.

Preoperative Physical Function Association With Mental Health Improvement After Anterior Cervical Discectomy and Fusion

STUDY DESIGN

This was a retrospective study.

OBJECTIVE

This study investigates the influence of physical function and their influence on postoperative depressive symptom scores as measured by Patient Health Questionnaire-9 (PHQ-9) among anterior cervical decompression and fusion (ACDF) patients.

BACKGROUND

While ACDF is one of the most commonly performed ambulatory surgeries, research is limited on the predictive value of Patient-Reported Outcomes Measurement Information System (PROMIS) scores and their influence on depressive symptoms as measured by the PHQ-9.

METHODS

A prospectively maintained surgical registry was retrospectively reviewed from March 2016 to January 2019. Inclusion criteria were primary or revision ACDF procedures. Patients were grouped by preoperative PROMIS score (≥35.0, <35.0), with higher scores indicating greater physical function. The χ2 and Student t tests assessed categorical and continuous variables (eg, demographics, perioperative, and postoperative values). A t test evaluated postoperative improvement in PROMIS Physical Function (PF) scores between subgroups among PROMIS PF scores and PHQ-9 score improvement at 6, 12 weeks, 6 months, and 1 year. Linear regression assessed preoperative PROMIS scores influence on PHQ-9 score improvement.

RESULTS

The 121 subject cohort was 61.2% male with an average age of 49.6±9.8 years. Compared with the PROMIS ≥35.0 group, the PROMIS <35.0 group also had larger improvement of PROMIS scores at 6 weeks. No significant difference in postoperative PHQ-9 improvement was observed between subgroups. There was a negative association between preoperative PROMIS scores and improvement in PROMIS scores at 6, 12 weeks, 6 months, and 1 year. There was a positive association between preoperative PROMIS scores and magnitude of 1-year PHQ-9 change.

CONCLUSIONS

Individuals with lower preoperative PROMIS PF scores had significantly higher PHQ-9 scores at 1 year. Patients with lower preoperative physical function, as evaluated by PROMIS PF scoring, had greater improvement of mental health at 1 year postoperatively. This suggests that many patients experience multidimensional health benefits after ACDF procedures.

Efficacy for Whitlockite for Augmenting Spinal Fusion

Whitlockite (WH) is the second most abundant inorganic component of human bone, accounting for approximately 25% of bone tissue. This study investigated the role of WH in bone remodeling and formation in a mouse spinal fusion model. Specifically, morphology and composition analysis, tests of porosity and surface area, thermogravimetric analysis, an ion-release test, and a cell viability test were conducted to analyze the properties of bone substitutes. The MagOss group received WH, Group A received 100% beta-tricalcium phosphate (β-TCP), Group B received 100% hydroxyapatite (HAp), Group C received 30% HAp/70% β-TCP, and Group D received 60% HAp/40% β-TCP (n = 10 each). All mice were sacrificed 6 weeks after implantation, and micro-CT, hematoxylin and eosin (HE) staining, and Masson trichome (MT) staining and immunohistochemistry were performed. The MagOss group showed more homogeneous and smaller grains, and nanopores (<500 nm) were found in only the MagOss group. On micro-CT, the MagOss group showed larger fusion mass and better graft incorporation into the decorticate mouse spine than other groups. In the in vivo experiment with HE staining, the MagOss group showed the highest new bone area (mean: decortication group, 9.50%; A, 15.08%; B, 15.70%; C, 14.76%; D, 14.70%; MagOss, 22.69%; p < 0.0001). In MT staining, the MagOss group demonstrated the highest new bone area (mean: decortication group, 15.62%; A, 21.41%; B, 22.86%; C, 23.07%; D, 22.47%; MagOss, 26.29%; p < 0.0001). In an immunohistochemical analysis for osteocalcin, osteopontin, and CD31, the MagOss group showed a higher positive area than other groups. WH showed comparable bone conductivity to HAp and β-TCP and increased new bone formation. WH is likely to be used as an improved bone substitute with better bone conductivity than HAp and β-TCP.