Distal Lumbar Lordosis is Associated With Reoperation for Adjacent Segment Disease After Lumbar Fusion for Degenerative Conditions

STUDY DESIGN

A single centre retrospective review.

OBJECTIVE

Recent studies have suggested that distal lordosis (L4-S1, DL) remains constant across all pelvic incidence (PI) subgroups, whilst proximal lordosis (L1-L4, PL) varies. We sought to investigate the impact of post-operative DL on adjacent segment disease (ASD) requiring reoperation in patients undergoing lumbar fusion for degenerative conditions.

METHODS

Patients undergoing 1-3 level lumbar fusion with the two senior authors between 2007-16 were included. Demographic and radiographic data were recorded. Univariate, multivariate binary logistic regression, and Kaplan Meier survivorship analyses were performed.

RESULTS

335 patients were included in the final analysis. Most had single (67%) or two (31%) level fusions. The mean follow-up was 64-month. Fifty-seven patients (17%) underwent reoperation for ASD at an average of 78-month post-operatively (R group). The R group had a significantly lower mean post-operative DL (27.3 vs 31.1 deg, P < .001) and mean PI (55.5 vs 59.2 deg, P < .05). On univariate analysis, patients with a post-operative DL of <35 deg had higher odds of reoperation for ASD than those with a post-operative DL of ≥35 deg (OR 2.7, P = .016). In the multivariate model, post-operative DL, low/average PI, and spondylolisthesis were all significantly associated with reoperation for ASD.

CONCLUSION

This study provides preliminary support to an association between post-operative distal lumbar lordosis and risk of reoperation for ASD in patients undergoing fusions for degenerative conditions. Further multicentre prospective study is needed to independently confirm this association and identify the impact of restoration of physiological distal lumbar lordosis on long term patient outcomes.

Preoperative risk factors for nonsatisfaction after lumbar interbody fusion

Introduction

Low back pain (LBP) is a common cause of impaired quality of life and disability and studies regarding surgical management of patients with LBP show a high variation in patient-reported success rate.

Research question

To find valuable preoperative clinical risk factors and variables associated with a non-satisfactory patient-reported outcome following surgery.

Materials and methods

The Danish surgical spine database (DaneSpine) was used to collect eight years of pre- and postoperative data on patients undergoing single-level fusions with either posterior- (PLIF) or transforaminal lumbar interbody fusions (TLIF). The primary outcome was patient nonsatisfaction. We collected data on European Quality of Life-5 Dimensions (EQ-5D), visual analogue scale (VAS), Oswestry Disability Index (ODI) score, pain intensity, duration of back pain, previous discectomy, and expectations regarding return to work after surgery at 2-year follow-up.

Results

The cohort included 453 patients of which 19% reported treatment nonsatisfaction. The nonsatisfaction group demonstrated higher preoperative VAS scores for back pain (75 ± 19 vs. 68 ± 21, p = 0.006) and leg pain (65 ± 25 vs. 58 ± 28, p = 0.004). The preoperative EQ-5D score was significantly lower in the nonsatisfaction group (0.203 + 0.262 vs. 0.291 ± 0.312, p = 0.016). There was no statistical significance between patient nonsatisfaction and preoperative ODI score, age, body mass index, duration of back pain or expectations regarding return to work after surgery.

Discussion and conclusion

Low preoperative EQ-5D scores and high VAS leg and back pain scores were statistically significant with patient nonsatisfaction following surgery and may prove to be valuable tools in the preoperative screening and alignment of patient expectations.

sPinal coRd stimulatiOn coMpared with lumbar InStrumEntation for low back pain after previous lumbar decompression (PROMISE): a prospective multicentre RCT

INTRODUCTION

Persistent spine pain syndrome type 2 (PSPS2) represents a significant burden to the individual and society. Treatment options include revision surgery, stabilisation surgery of the spine, neuromodulation, analgesics and cognitive behavioural therapy. Nevertheless, structured treatment algorithms are missing as high-level evidence on the various treatments is sparse. The aim of this study is to compare higher frequency neuromodulation with instrumentation surgery in patients suffering from PSPS2.

METHODS AND ANALYSIS

The sPinal coRd stimulatiOn coMpared with lumbar InStrumEntation for low back pain after previous lumbar decompression (PROMISE) trial is a prospective randomised rater blinded multicentre study. Patients suffering from PSPS2 with a functional burden of Oswestry Disability Index (ODI) >20 points are randomised to treatment via spinal cord stimulation or spinal instrumentation. Primary outcome is back-related functional outcome according to the ODI 12 months after treatment. Secondary outcomes include pain perception (visual analogue scale), Short Form-36, EuroQOL5D, the amount of analgesics, the length of periprocedural hospitalisation and adverse events. Follow-up visits are planned at 3 and 12 months after treatment. Patients with previous lumbar instrumentation, symptomatic spinal stenosis, radiographical apparent spinal instability or severe psychiatric or systemic comorbidities are excluded from the study. In order to detect a significant difference of ≥10 points (ODI) with a power of 80%, n=72 patients need to be included. The recruitment period will be 24 months with a subsequent 12 months follow-up. The beginning of enrolment is planned for October 2022.

ETHICS AND DISSEMINATION

The PROMISE trial is the first randomised rater blinded multicentre study comparing the functional effectiveness of spinal instrumentation versus neuromodulation in patients with PSPS2 in order to achieve high-level evidence for these commonly used treatment options in this severely disabling condition. Patient recruitment will be performed at regular outpatient clinic visits. No further (print, social media) publicity is planned. The study is approved by the local ethics committee (LMU Munich, Germany) and will be conducted according to the Declaration of Helsinki.

TRIAL REGISTRATION NUMBER

NCT05466110.

Patient Satisfaction with Surgery for Tarsal- and Carpal- Tunnel Syndrome - Comparative Study

We compared the treatment satisfaction of patients who had undergone surgery for tarsal tunnel syndrome (TTS) and carpal tunnel syndrome (CTS). We enrolled 44 patients in this study; 23 were operated for CTS and 21 for TTS. All patients had received surgery under a microscope and under local anesthesia. Using the numerical rating scale (NRS) for numbness/pain (range 0-10) we compared their preoperative outcome expectations with their satisfaction with our treatment 6 months after the operation. We also recorded their pre- and postoperative EuroQol 5-dimension 5-level (EQ-5D-5L) scale for their health-related quality of life (QOL). The subjective assessment of their QOL showed that it was significantly lower in TTS- than CTS patients both pre- and postoperatively. Six months after the operation, the NRS for symptoms and the (EQ-5D-5L) scale for the QOL were significantly improved in TTS- and CTS patients; however, these scores were significantly better after CTS- than TTS surgery. Also, the postoperative NRS was significantly lower in the CTS- than the TTS patients. Our comparison of the patients' expected- and actual surgical outcome showed that the result was better than expected after CTS- and TTS surgery; in CTS patients the difference was significant. Overall, CTS- were more satisfied than TTS patients with the treatment outcome. Satisfaction with the treatment was greater after CTS- than TTS surgery. TTS- experienced less symptom relief than CTS patients although the actual- exceeded the expected outcome in patients operated for TTS.

The Effect of the Severity of Preoperative Leg Pain on Patient-Reported Outcomes, Minimum Clinically Important Difference Achievement, and Patient Satisfaction After Minimally Invasive Transforaminal Lumbar Interbody Fusion

OBJECTIVE

To compare patient-reported outcome measures (PROMs), satisfaction, and minimum clinically important difference (MCID) achievement after minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) in patients stratified by preoperative leg pain.

METHODS

Patients undergoing MIS-TLIF were collected through retrospective review of a prospectively maintained single-surgeon database. PROMs administered preoperatively/postoperatively included Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF), visual analog scale (VAS) back/leg pain, Oswestry Disability Index (ODI), and 12-Item Short Form (SF-12) Physical/Mental Component Score (PCS/MCS). Patients were grouped based on preoperative VAS leg scores: VAS leg ≤7 or VAS leg >7. Inferential statistics were used to compare PROMs, MCID achievement rates, and postoperative satisfaction between groups.

RESULTS

A total of 562 patients were eligible (168 VAS leg score ≤7; 394 VAS leg score >7). Significant differences between cohorts in postoperative mean PROMs were noted for PROMIS-PF at 6 weeks/2 years, SF-12 PCS at 6 weeks/2 years, SF-12 MCS at 6 weeks/12 weeks/6 months/1 year, VAS back score at 6 weeks/12 weeks/6 months, VAS leg score at 6 weeks/12 weeks/6 months/2 years and ODI at all postoperative time points (P < 0.045, all). In the VAS leg score >7 cohort, a greater proportion achieving MCID for VAS leg score at all postoperative time points and ODI at 12 weeks (P < 0.010, all). Postoperative satisfaction was greater in VAS back score ≤7 cohort for VAS leg score at 6 weeks/12 weeks/6 months/2 years, VAS back score at 12 weeks/2 years, and ODI at 6 weeks/12 weeks/6 months/2 years (P < 0.046, all).

CONCLUSIONS

Patients with severe preoperative leg pain showed worse postoperative PROM scores and patient satisfaction for disability and back/leg pain. MCID achievement rates across cohorts were similar. Patients with severe leg pain may have expectations for surgical benefits incongruent with their postoperative outcomes, and physicians may seek to manage the preoperative expectations of their patients to reflect likely outcomes after MIS-TLIF.

The Relation of Patient Expectations, Satisfaction, and Outcome in Surgery of the Cervical Spine: A Prospective Study

STUDY DESIGN

We performed a prospective nonblinded single center observational study.

OBJECTIVE

To investigate the relationship between expectations, outcome, and satisfaction with the outcome in patients undergoing cervical spine stabilization surgery.

SUMMARY OF BACKGROUND DATA

In modern healthcare, patient-reported outcome measures and patient satisfaction have become an important aspect of quality control. Therefore, outcome benchmarks for specific diseases are highly desired. Numerous studies have investigated patient-reported outcome measures and what constitutes satisfaction in degenerative lumbar spine disease. In cervical spine surgery, it is less clear what drives the postoperative symptom burden and patient satisfaction and how this depends on the primary diagnosis and other patient factors.

METHODS

This was a prospective, single center, observational study on patients undergoing cervical spine stabilization surgery for degenerative disease, trauma, infection, or tumor. Using the visual analogue scale for neck and arm pain, the neck disability index (NDI), the modified Japanese Orthopedic Association Score (mJOA) and patient-reported satisfaction, patient status and expectations before surgery, at discharge, 6 and 12 months after surgery were evaluated.

RESULTS

One hundred five patients were included. Score-based outcome correlated well with satisfaction at 6 and 12 months. Except for low NDI expectations (≥15 points) that correlated with dissatisfaction, expectations in no other score were correlated with satisfaction. Expectations did influence the outcome in some subgroups and meeting expectations resulted in higher rates of satisfaction. Pain reduction plays an important role for satisfaction, independently from the predominant symptom or pathology.

CONCLUSION

Satisfaction correlates well with outcome. Meeting expectations did influence satisfaction with the outcome. The NDI seems to be a valuable preoperative screening tool for poor satisfaction at 12 months. In degenerative pathology, pain is the predominant variable influencing satisfaction independently from the predominant symptom (including myelopathy).

LEVEL OF EVIDENCE

5.

Meeting Patient Expectations and Achieving a Minimal Clinically Important Difference for Back Disability, Back Pain, and Leg Pain May Provide Predictive Utility for Achieving Patient Satisfaction Among Lumbar Decompression Patients

OBJECTIVE

Our study evaluates minimum clinically important difference (MCID) achievement for back pain/leg pain/disability and meeting preoperative expectations as predictors of patient satisfaction after minimally invasive lumbar decompression (MIS-LD) surgery.

METHODS

Single/multilevel MIS-LD procedures were identified. Patient-reported outcome measures (preoperative/postoperative), expectations (preoperative), and satisfaction (postoperative) were collected for visual analog scale (VAS) back/VAS leg/Oswestry Disability Index (ODI). Student's t-test assessed patient-reported outcome measure improvement from preoperative baseline. Correlations between outcome and satisfaction scores were evaluated using the Pearson correlation coefficient and categorized according to strength of relationship. MCID achievement and meeting expectations were evaluated as predictors of postoperative patient satisfaction with simple linear regression. Comparison of meeting expectations or achieving MCID as predictors of satisfaction scores was performed using a post hoc Suest test comparison of standardized β-coefficients.

RESULTS

A total of 329 patients were included. All outcomes improved from baselines (P < 0.001, all) at all postoperative time points and demonstrated strong and negative correlations with satisfaction scores (P < 0.001, all). Majority of patients had their expectations met for ODI/VAS back/VAS leg and achieved MCID for ODI/VAS back/VAS leg at all time points and overall. Both MCID achievement and meeting preoperative expectations demonstrated significant associations with satisfaction scores at all time points for ODI/VAS back/VAS leg. Post hoc analysis of predictors of patient satisfaction in pain and disability demonstrated that MCID achievement was an equivalent predictor to meeting patient preoperative expectations at all postoperative time points.

CONCLUSION

Pain/disability improved after MIS-LD; improvement was strongly correlated with postoperative satisfaction. Meeting expectations/MCID achievement is associated with satisfaction. MCID achievement was equivalent to meeting expectations in predicting satisfaction at all postoperative time points for pain/disability.

The Effect of the Severity of Preoperative Back Pain on Patient-Reported Outcomes, Recovery Ratios, and Patient Satisfaction Following Minimally Invasive Transforaminal Lumbar Interbody Fusion (MIS-TLIF)

BACKGROUND

Limited literature has addressed impact of preoperative back pain severity on patient-reported outcome measures (PROMs), recovery ratios (RRs), and patient satisfaction following minimally invasive transforaminal lumbar interbody fusion (MIS TLIF).

METHODS

MIS TLIFs were retrospectively identified and grouped: preoperative visual analog scale (VAS) back ≤7 or VAS back >7. PROMs, including PROMIS-PF, VAS back and leg, Oswestry Disability Index (ODI), and SF-12 Physical Composite Score and Mental Composite Score (MCS), were collected pre- and postoperatively. A PROM's RR was calculated as proportion of postoperative improvement to overall potential improvement.

RESULTS

In total, 740 patients were included: 359 patients with VAS back ≤7 and 381 patients with VAS back >7. The VAS back >7 cohort reported significantly greater postoperative inpatient pain (P ≤ .003, both). All preoperative and the following postoperative PROMs favored the VAS back ≤7 cohort: PROMIS-PF 2-years, VAS back overall, SF-12 Physical Composite Score 12 weeks and 1 year, SF-12 MCS 6 weeks/12 weeks, VAS leg 6 weeks, 12 weeks, 6 months, and 2 years, and ODI overall (P ≤ 0.048, all). The VAS back >7 cohort demonstrated greater delta PROMs for all VAS back and ODI except 2 years (P ≤ 0.021, all). A greater proportion of patients in the VAS back >7 group achieved minimal clinically important difference for VAS back overall, ODI 6 weeks/12 weeks, PROMIS-PF 6 weeks, and SF-12 MCS 6 weeks/6 months (P ≤ 0.044, all). The VAS back>7 cohort RR was significantly greater for VAS back 6 months and VAS leg 6 months/2 years (P ≤ 0.034, all). The VAS back ≤7 cohort's postoperative satisfaction was significantly greater for VAS back 12 weeks, VAS leg 12 weeks, and ODI 6 weeks/12 weeks (P ≤ 0.046, all).

CONCLUSIONS

Patients with greater preoperative back pain demonstrated significantly worse postoperative scores for most PROMs at most time points and significantly worse patient satisfaction for disability, back and leg pain at multiple time points.

Meeting Patient Expectations or Achieving a Minimum Clinically Important Difference: Predictors of Satisfaction Among Lumbar Fusion Patients

Study Design

Retrospective cohort.

Purpose

To investigate the impact of meeting a patient’s preoperative expectations for back or leg pain or the achievement of minimum clinically important difference (MCID) on patient satisfaction following lumbar fusion.

Overview of Literature

Few studies have compared if MCID achievement or meeting preoperative expectations for pain reduction affects patient satisfaction.

Methods

A surgical database was reviewed for eligible patients who underwent lumbar fusion. Patient satisfaction and Visual Analog Scale (VAS) for back and leg pain were the outcomes of interest. Meeting expectations was calculated as a difference of ≤0 between preoperative expectations and postoperative VAS scores. MCID achievement was calculated by comparing changes in VAS scores with established values. Meeting preoperative expectations or MCID achievement as predictors of patient satisfaction was evaluated using regression analysis.

Results

A total of 134 patients were included in this study. Patients demonstrated significant improvements in VAS back and VAS leg (p<0.001). At 1 year, 56.4% of patients had their VAS back expectations met compared with 59.5% for VAS leg. Similarly, at 1 year, 77.3% and 71.3% of patients achieved MCID for VAS back and leg, respectively. Meeting expectations for VAS back was significantly associated with patient satisfaction at all postoperative timepoints; however, MCID achievement only demonstrated a significant association with patient satisfaction at 6 and 12 weeks (all, p≤0.024). Meeting VAS leg expectations and MCID achievement both demonstrated a significant association with patient satisfaction at all postoperative timepoints (all, p≤0.02). No differences between MCID achievement and meeting expectations as predictors of satisfaction were noted.

Conclusions

The majority of patients achieved MCID and had their back and leg pain expectations met by 1 year. Both measures were significant predictors of patient satisfaction and suggest that MCID achievement may act as a suitable substitute for patient satisfaction.

Achievement of a Minimum Clinically Important Difference for Back Disability Is a Suitable Predictor of Patient Satisfaction Among Lumbar Fusion Patients

OBJECTIVE

Meeting patient expectations is believed to impact satisfaction scores; however, the influence of achieving a minimum clinically important difference (MCID) is scarcely reported. This study aims to evaluate meeting patient expectations or MCID achievement for pain and disability as predictors of patient satisfaction.

METHODS

A retrospective review of single or multilevel lumbar fusion patients was performed. Patients with missing preoperative Oswestry Disability Index (ODI) expectation questionnaires were excluded. Preoperative expectations and postoperative satisfaction scores for visual analog scale (VAS) back, VAS leg, and ODI were collected. Meeting expectations was defined as scores less than or equal to preoperative expectations. Achievement of MCID was evaluated. Improvement of all outcomes and correlations with satisfaction scores were evaluated using the Student's t-test and Pearson coefficient. Achievement of MCID or meeting expectations as predictors of satisfaction were evaluated and compared using linear regression and Suest test.

RESULTS

The study included 144 patients. All outcomes significantly improved and demonstrated significant correlations with satisfaction scores (P < 0.001, all). Patients reported a mean expectation of 17.7 (ODI), 1.7 (VAS back), and 0.9 (VAS leg). The majority had their expectations met and achieved MCID. Meeting expectations and MCID achievement demonstrated significant associations with satisfaction scores for all outcomes and time points. Achievement of MCID was a stronger predictor of satisfaction for ODI and VAS back.

CONCLUSIONS

Meeting preoperative expectations and achievement of an MCID for pain and disability measures was significantly associated with satisfaction. Achievement of MCID may be a more consistent and suitable replacement as a predictor of satisfaction over meeting patient expectations.