The Use of Patient-Reported Outcomes Measurement Information System in Spine: A Systematic Review

BACKGROUND

The Patient-Reported Outcomes Measurement Information System (PROMIS) was developed to provide an easily administered patient-outcome questionnaire that was adaptable to a variety of medical and surgical subspecialties. Numerous authors have examined the effectiveness of PROMIS in various areas of spine surgery. Our goal was to systematically review PROMIS scores compared with legacy patient-reported outcomes measures (PROMs) in spinal surgery and spine pathology.

METHODS

A systematic search of the PubMed, EMBASE, and Cochrane databases using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines was performed, yielding 254 unique studies reporting on "PROMIS" in "spine." Each study was independently reviewed. A total of 16 studies were selected for inclusion.

RESULTS

The pooled sample size yielded a total of 4268 patients. In the cervical population, PROMIS physical function (PF; |r| = .47-.87, pain intensity (PIn; |r| = .61-.74), pain interference (PIf; |r| = .65-.88), and pain behavior (PB; |r| = .59-.74) correlated with the Neck Disability Index (NDI). PROMIS PF also strongly correlated with the modified Japanese Orthopaedic Association scale (mJOA; |r| = .61-.72). Among patients with lumbar pathology and adult spinal deformities, PROMIS PF (|r| = .53-.85), PIn (|r| = .73-.78), PIf (|r| = .59-.89), and PB (|r| = .58-.82) strongly correlated with the Oswestry Disability Index (ODI). PF (|r| = .51-.78), PIf (|r| = .60-.70), and anxiety (|r| = .73) also strongly correlated with the Scoliosis Research Society (SRS)-22 and SRS-30. When comparing measures of global health, PROMIS PF was strongly correlated with the Short Form (SF)-12 and SF-36 (|r| = .50-.85). On average, all PROMIS domains required less time to complete (49.6-56 seconds) than the ODI (176 seconds), NDI (190.3 seconds), SF-12 (214 seconds), and SF-36 physical function domains (99 seconds). The responsiveness of the PROMIS PF, PIf, and PB was comparable to that of legacy measures ODI, NDI, and SF-12.

CONCLUSIONS

The PROMIS PF, PIn, PIf, and PB demonstrated moderate to strong correlations with NDI, mJOA, ODI, SRS, and SF-12 measures in various populations of spine patients. All PROMIS domains had decreased time to completion and similar responsiveness compared with legacy measures.

LEVEL OF EVIDENCE

2.

CLINICAL RELEVANCE

These results highlight the potential of PROMIS as a valid and reliable tool to assess patient-reported outcomes in spinal surgery patients and support more widespread use of PROMIS in spine.

Radiation Exposure in Minimally Invasive Transforaminal Lumbar Interbody Fusion: The Effect of the Learning Curve

Background

Minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) has comparable fusion rates and outcomes to the open approach, though many surgeons avoid the technique due to an initial learning curve. No current studies have examined the learning curve of MI-TLIF with respect to fluoroscopy time and exposure. Our objective with this retrospective review was to therefore use a repeatable mathematical model to evaluate the learning curve of MI-TLIF with a focus on fluoroscopy time and exposure.

Methods

We conducted a retrospective review of single level, primary fusions performed by a single surgeon during his initial experience with minimally invasive spine surgery. Chronologic case number was plotted against variables of interest, and learning was identified as the point at which the instantaneous rate of change of a curve fit to the data set equaled the average rate of change of the data set.

Results

One hundred nine cases were reviewed. Proficiency in operative time was achieved at 38 cases with the first 38 requiring a median of 137 minutes compared to 104 minutes for the latter 71 cases (P < .0001). Mastery of fluoroscopy use occurred at case 51. The median fluoroscopy time for the first 51 cases was 2.8 minutes, which dropped to 2.1 minutes for cases 52 to 109 (P < .0001). The complication rate plateaued after 43 cases, with 3 of 11 total complications occurring in the latter 76 cases.

Conclusions

Our results demonstrate the most gradual learning occurred with respect to fluoroscopy time and exposure, and operative time improved the quickest.

Level of Evidence

IV.

Clinical Relevance

These findings may guide spine surgeon education and training in minimally invasive techniques, and help determine safe case loads for radiation exposure during the initial learning phase of the technique. The model used to identify the learning curve can also be applied to several fields and surgical techniques.

Predictive Factors and Rates of Fusion in Minimally Invasive Transforaminal Lumbar Interbody Fusion Utilizing rhBMP-2 or Mesenchymal Stem Cells

Background

Several fusion adjuncts exist to enhance fusion rates during minimally invasive transforaminal lumbar interbody fusion (MI-TLIF). The objective of this study was to compare fusion rates in patients undergoing MI-TLIF with either rhBMP-2 or cellularized bone matrix (CBM).

Methods

We conducted a single surgeon retrospective cohort study of patients who underwent MI-TLIF with either rhBMP-2 or CBM placed in an interbody cage. Single and multilevel procedures were included. Fusion was assessed on computed tomography scans at 12-month follow-up by an independent, blinded, board-certified neuroradiologist. Fusion rates and rate of revision surgery were compared with a Fisher exact test between the 2 groups. A multivariate regression analysis was performed to identify patient factors that were predictive of radiographic nonunion after MI-TLIF.

Results

A total of 93 fusion levels in 78 patients were reviewed. Thirty-nine patients received CBM, and 39 patients received rhBMP-2. The patients receiving rhBMP-2 were older on average (61.4 vs 55.6, P = .03). The overall fusion rate was 68% in the CBM group (32/47 levels) and 78% in the rhBMP-2 group (36/46) (P = .35). Only preoperative hypertension was predictive of radiographic nonunion (odds ratio = 3.5, P = .05). There were 3 smokers in the CBM group and 4 smokers in the BMP group, and 1 in each group experienced radiographic pseudarthrosis. A total of 4 patients, 3 in the CBM group and 1 in the BMP group (P = .61), required revision for symptomatic pseudarthrosis. All of these patients had a single-level index procedure.

Conclusions

There were no differences in radiographic fusion and rate of revision surgery in patients who underwent MI-TLIF with either rhBMP-2 or CBM as fusion adjuncts.

Level of Evidence

3.

Clinical Relevance

Both rhBMP-2 and CBMs can be used as effective fusion adjuncts without any clear advantage of one over the other.

[Epidemic situation of imported malaria in Chengdu City from 2012 to 2016]

Objective To understand the malaria epidemic situation in Chengdu City, so as to provide the evidence for effectively carrying out the malaria elimination work. Methods The data of imported malaria in Chengdu City from 2012 to 2016 were collected from the Disease Surveillance Information Reporting System of Chinese Center for Disease Control and Prevention and analyzed respectively. Results A total of 240 imported malaria cases were reported in Chengdu City from 2012 to 2016. In detail, 68.75% of the cases were falciparum malaria cases, 20.41% were vivax malaria cases, 2.50% were quartan malaria cases, 6.25% were ovale malaria cases, and 2.08% were mixed Plasmodium infections. Among them three patients died, with a mortality of 1.25%. All of the cases were infected overseas, among which 224 patients returned from Africa and 16 patients from Southeast Asia. The annual average morbidity was 0.28/100 000, and there was a significantly difference among annual average morbidities (χ² = 23.87, P < 0.001). There were malaria cases reported in every month, and no significantly difference among seasons (χ² = 0.833, P > 0.05). Conclusion The number of overseas imported malaria in Chengdu City increases year by year. The effective measures to control the overseas imported malaria should be strengthened to consolidate the achievements of malaria elimination.

Hydroxymethylglutaryl co-enzyme A reductase inhibition attenuates endotoxin-mediated inflammatory responses

Background

The aim of this study was to investigate whether inhibition of hydroxymethylglutaryl co-enzyme A reductase attenuates leucocyte–endothelial cell interactions and alters expression of endothelial constitutive nitric oxide synthase (ecNOS) and inducible nitric oxide synthase (iNOS) following exposure to endotoxin.

Methods

Male Sprague–Dawley rats were randomized into control, lipopolysaccharide (LPS) and pravastatin + LPS groups (seven per group). Pravastatin sodium was gavaged at 0·4 mg per kg per day for 5 days, after which LPS 15 mg/kg was administered via the jugular vein. Intravital microscopy was used to determine leucocyte–endothelial cell interactions.

Results

Following the administration of LPS there was a significant reduction in leucocyte rolling velocity at 10 min (mean(s.e.m.) 69(3) versus 102(6) per cent of baseline value; P = 0·041), an increase in the number of adherent leucocytes at 10 min (4·5(0·5) versus 2·8(0·3) per 100 µm; P = 0·044) and an increase in the number of leucocytes undergoing transendothelial migration at 30 min (4·2(0·4) versus 1·7(0·4) per field; P = 0·008) compared with controls. Pretreatment with pravastatin significantly attenuated LPS-induced leucocyte–endothelial cell interactions (rolling velocity 89(6) per cent at 10 min, P = 0·038; adherent leucocytes 3·0(0·5) per 100 µm at 10 min, P = 0·038; migrating leucocytes 1·9(0·5) per field at 30 min, P = 0·001). This endothelial protection was associated with maintenance of ecNOS and reduced iNOS expression within mesenteric tissues.

Conclusion

These data show that pravastatin produces anti-inflammatory effects in response to injurious stimuli by attenuation of leucocyte–endothelial cell interactions.

Effect of pirenzepine on gastric endocrine cell kinetics during lansoprazole administration

We studied the effect of pirenzepine on gastric secretion kinetics in rats in a hypochlorhydric state induced by lansoprazole, a proton pump inhibitor. Pirenzepine was administered intramuscularly at a dosage of 20 mg/kg twice daily; and lansorprazole, subcutaneously at 50 mg/kg once daily, both every day for 4 weeks. After the 4-week treatment, serum gastrin and plasma somatostatin levels were determined by radioimmunoassay. In addition, gastrin cells, somatostatin cells, and enterochromaffin-like cells were immunostained and counted. Serum gastrin levels were elevated, and gastrin and enterochromaffin-like cell numbers increased in the group on lansoprazole alone, compared with these values in the control group (which received distilled water). In the group on the lansoprazole and pirenzepine combination, serum gastrin levels decreased, and gastrin and enterochromaffin-like cell numbers were significantly decreased, compared with the respective variables in the group on lansoprazole alone, while the number of somatostatin cells increased in the group on the combination. Plasma somatostatin levels did not vary significantly in any group. It was thus demonstrated that pirenzepine corrects the abnormal gastric secretion kinetics resulting from treatment with lansoprazole alone, such as hypergastrinemia and gastrin and enterochromaffin-like cell hyperplasia.