Baseline Oswestry Disability Index Research Articles

Complications, Readmissions, Revisions, and Patient-reported Outcomes in Patients With Parkinson Disease Undergoing Elective Spine Surgery: A Propensity-matched Analysis.

Retrospective analysis on prospectively collected data. To determine the effectiveness of elective spine surgery in patients with Parkinson disease (PD). PD has become increasingly prevalent in an aging population. While surgical treatment for degenerative spine pathology is often required in this population, previous literature has provided mixed results regarding its effectiveness. Data from the Quality Outcomes Database (QOD) was queried between April 2013 and January 2019. Three surgical groups were identified: (1) elective lumbar surgery, (2) elective cervical surgery for myelopathy, (3) elective cervical surgery for radiculopathy. Patients without PD were propensity matched against patients with PD in a 5:1 ratio without replacement based on American Society of Anesthesiology grade, arthrodesis, surgical approach, number of operated levels, age, and baseline Oswestry Disability Index, Numerical Rating Scale (NRS) extremity pain, NRS back pain, and EuroQol 5-Dimensions (EQ-5D). The mean difference was calculated for continuous outcomes (Oswestry Disability Index, NRS leg pain, NRS back pain, and EQ-5D at 3 and 12mo after surgery) and the risk difference was calculated for binary outcomes (patient satisfaction, complications, readmission, reoperation, and mortality). For the lumbar analysis, PD patients had a higher rate of reoperation at 12 months (risk difference=0.057, P =0.015) and lower mean EQ-5D score at 12 months (mean difference=-0.053, P =0.005) when compared with patients without PD. For the cervical myelopathy cohort, PD patients had lower NRS neck pain scores at 3 months (mean difference=-0.829, P =0.005) and lower patient satisfaction at 3 months (risk difference=-0.262, P =0.041) compared with patients without PD. For the cervical radiculopathy cohort, PD patients demonstrated a lower readmission rate at 3 months (risk difference=-0.045, P =0.014) compared with patients without PD. For the matched analysis, in general, patients with and without PD had similar patient-reported outcomes and complication, readmission, and reoperation rates. These results demonstrate that a diagnosis of PD alone should not represent a major contraindication to elective spine surgery.

Clinical Evaluation of Paraspinal Mini-Tubular Lumbar Decompression and Minimally Invasive Transforaminal Lumbar Interbody Fusion for Lumbar Spondylolisthesis Grade I with Lumbar Spinal Stenosis: A Cohort Study.

ObjectiveTo investigate the clinical outcome data and difference in efficacy between paraspinal mini-tubular lumbar decompression (PMTD) and minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) in the treatment of degenerative lumbar spondylolisthesis grade I with lumbar spinal stenosis (DLS-I-LSS).MethodsPatients with DLS-I-LSS, who underwent PMTD or MIS TLIF from September 2017 to March 2020, were included retrospectively. The follow-up period was 24 months after surgery. Outcome measurements included the Oswestry disability index (ODI) score, visual analog scale (VAS) low back pain score, VAS leg pain score, surgical data, and adverse events.ResultsA total of 104 patients with DLS-I-LSS were included in this study. The average improvement in ODI at 12 months (2.0%, 95% CI, −5.7% to 1.8%; p = 0.30) and 24 months (1.7%, 95% CI, −2.7% to 6.1%; p = 0.45) after surgery between the two groups were not statistically significant. The improvement in VAS low back pain score after 24 months and improvement in VAS leg pain score were not significantly different between the two groups. Compared with the PMTD group, the MIS TLIF group had more estimated blood loss and longer hospital stays. The cumulative reoperation rates were 5.66% and 1.96% in the MIS TLIF and PMTD groups, respectively (p = 0.68). The results of multivariate analysis showed that BMI, diabetes, and baseline ODI score were the main factors influencing the improvement in ODI in patients with DLS-I-LSS after minimally invasive surgery, accounting for 50.5% of the total variance.ConclusionsThe clinical effectiveness of PMTD was non-inferior to that of MIS TLIF for DLS-I-LSS; however, there was a reduced duration of hospital stay, operation time, blood loss, and hospitalization costs in the PMTD group. BMI, presence or absence of diabetes and baseline ODI score were influencing factors for the improvement of ODI (Trial Registration: ChiCTR2000040025).

The association of payer type and opioid use on functional improvement at short-term follow-up after lumbosacral transforaminal epidural steroid injection: Results of a large registry study

BackgroundLumbosacral transforaminal epidural steroid injection (LTFESI) is a commonly performed intervention for treating radicular pain. While factors that predict pain improvement after LTFESI have been evaluated, minimal literature exists regarding predictors of functional improvement. PurposeTo identify factors that are associated with functional improvement at short-term follow-up after LTFESI. Study designRetrospective review of prospectively collected registry data. Patient samplePatients undergoing LTFESI at an academic spine center who completed an Oswestry Disability Index (ODI) questionnaire both pre-procedure and one to three weeks post-procedure. Outcome measuresThe outcomes of interest were the proportions of patients who experienced a minimal clinically important difference (MCID) in function defined as ​≥ ​30% improvement in ODI score, as well as ​≥ ​10-point and ≥15-point improvement in ODI score. MethodsLogistic regression analysis was performed to examine the associations of predictor variables to the ODI responder/non-responder outcome variable. The predictor variables for the analysis included: age, baseline ODI score, Charleston Comorbidity Index (CCI), payer type, prior lumbosacral spine surgery, pre-injection opioid use, two-level injections, bilateral injections, repeat injection, trainee presence during injection, immediate numerical rating scale (NRS) change post-injection. An odds ratio (OR) and its 95% confidence intervals (CIs) were calculated. ResultsA total of 606 patients were included in the analysis. More than half of the patients (56.8%) reported a ≥7.1% improvement in ODI score, and about 30% reported a ≥30% improvement in ODI score. Approximately 36% and 20% of the patients reported ≥10-point and ≥15-point reductions in ODI score, respectively. Medicaid and Medicare payer type and pre-injection opioid use were significantly associated with a lower likelihood of ≥30%, and ≥15-point improvements in ODI, after adjusting for the other factors (p ​< ​0.05). ConclusionsWhen using various common definitions of MCID for ODI score improvement, Medicaid, Medicare, and pre-injection opioid use were identified as factors that are negatively associated with functional improvement at short-term follow-up after LTFESIs.

Lateral Thoracolumbar Listhesis as an Independent Predictor of Disability in Adult Scoliosis Patients: Multivariable Assessment Before and After Surgical Realignment.

Lateral (ie, coronal) vertebral listhesis may contribute to disability in adult scoliosis patients. To assess for a correlation between lateral listhesis and disability among patients with adult scoliosis. This was a retrospective multi-center analysis of prospectively collected data. Patients eligible for a minimum of 2-yr follow-up and with coronal plane deformity (defined as maximum Cobb angle ≥20º) were included (n=724). Outcome measures were Oswestry Disability Index (ODI) and leg pain numeric scale rating. Lateral thoracolumbar listhesis was measured as the maximum vertebral listhesis as a percent of the superior endplate across T1-L5 levels. Linear and logistic regression was utilized, as appropriate. Multivariable analyses adjusted for demographics, comorbidities, surgical invasiveness, maximum Cobb angle, and T1-PA. Minimally clinically important difference (MCID) in ODI was defined as 12.8. In total, 724 adult patients were assessed. The mean baseline maximum lateral thoracolumbar listhesis was 18.3% (standard deviation 9.7%). The optimal statistical grouping for lateral listhesis was empirically determined to be none/mild (<6.7%), moderate (6.7-15.4%), and severe (≥15.4%). In multivariable analysis, listhesis of moderate and severe vs none/mild was associated with worse baseline ODI (none/mild=33.7; moderate=41.6; severe=43.9; P<.001 for both comparisons) and leg pain NSR (none/mild=2.9, moderate=4.0, severe=5.1, P<.05). Resolution of severe lateral listhesis to none/mild was independently associated with increased likelihood of reaching MCID in ODI at 2 yr postoperatively (odds ratio 2.1 95% confidence interval 1.2-3.7, P=.0097). Lateral thoracolumbar listhesis is associated with worse baseline disability among adult scoliosis patients. Resolution of severe lateral listhesis following deformity correction was independently associated with increased likelihood of reaching MCID in ODI at 2-yr follow-up.

Predictors of response following standardized education and self-management recommendations for low back pain stratified by dominant pain location

BackgroundLow back pain (LBP) is a leading cause of disability globally. Risk-stratification systems (e.g. STarT Back) have been proposed to guide treatment, but with varying success. We investigated factors associated with poor response to standardized LBP education and self-management recommendations stratified by dominant pain location (back or leg). MethodsLBP patients underwent a standardized primary care model of care of education and self-management recommendations. Poor response was defined as an Oswestry Disability Index (ODI) change score <10 units by 6 months. Multivariable logistic regression was used to identify poor response risk factors, stratified by back-dominant and leg-dominant back pain. Baseline factors: age, sex, body mass index, ODI, LBP/leg-pain intensity, LBP/leg-pain duration, STarT Back chronicity-risk, smoking, comorbidity count, and self-efficacy. ResultsThe sample consisted of 767 patients (443 back-dominant, 324 leg-dominant). Mean age was 53 years, and 59% were female. Females accounted for 66% of back-dominant and 50% of leg-dominant patients. Chronicity risk was ‘high’ for 18% of back-dominant and 29% of leg-dominant patients. Poor response was higher in back- (57%) compared to leg-dominant (42%) patients. Adjusted stratified analyses: female sex, moderate or high chronicity-risk, and increasing age were associated with increased risk of poor response, and greater self-efficacy with favourable response, in leg-dominant patients; these were not the cases among back-dominant patients. Increased comorbidity count was associated with poor response in back dominant patients. In both patient groups, higher baseline ODI score was associated with favorable response, and smoking and longer pain duration with poor response. ConclusionsDifferences in the influence of sex and chronicity risk in particular on outcome by dominant pain location suggests that considering these patients as a single group may not be appropriate. Furthermore, findings suggest that stratification by pain dominance may enhance the use of established risk stratification tools such as the STarT Back.

Effects of a Remotely Delivered Cognitive Behavioral Coaching Program on the Self-Rated Functional Disability of Participants with Low Back Pain

PurposeA remotely delivered cognitive behavioral coaching (CBC) program was offered as a service benefit for commercial health plan members with low back pain (LBP). This study describes changes in self-rated functional disability in a sample of plan members participating in the program (N=423). MethodsIndependent measures included demographics, length of program enrollment, total CBC sessions, and baseline self-reported patient activation and presenteeism levels. Participants rated their functional disability level due to LBP using the Oswestry Disability Index (ODI). Dependent outcomes quantified change in participant functional disability rating (final ODI score minus baseline ODI score). Nonparametric tests compare differences between groups and within-group ODI score change. Two generalized linear models test for associations between independent variables and the ODI change score. ResultsA significant difference between baseline and final ODI scores was observed at the overall program level (p<.001) and within all independent variable categories of interest. Over 68% of total participants (n=289) reported improved functional ability from baseline to final (decrease in ODI score). Participants who completed more CBC sessions demonstrated significantly greater improvement in functional ability (p=.038) compared to those who completed fewer sessions. Participants aged 55 and older were significantly more likely to show deterioration in functional ability from baseline to final (p=.021). ConclusionOutcomes suggest that program participation can influence self-rated functional disability in the management of LBP.

Incidence of adjacent-segment surgery following stand-alone lateral lumbar interbody fusion.

Adjacent-segment disease (ASD) requiring operative intervention is a relatively common long-term consequence of lumbar fusion surgery. Although the incidence of ASD requiring reoperation is well described for traditional posterior lumbar approaches (2.5%-3.9% per year), it remains poorly characterized for stand-alone lateral lumbar interbody fusion (LLIF). In this study, the authors report their institutional experience with ASD requiring reoperation after LLIF over an extended follow-up period of 4 years. Medical records were reviewed for 276 consecutive patients who underwent stand-alone LLIF by a single surgeon for degenerative spinal disorders. Inclusion criteria (single-stage, stand-alone LLIF without posterior supplementation, with no prior lumbar instrumentation, and a minimum of 4 years of follow-up) were met by 182 patients, who were analyzed for operative ASD incidence (per-year rate), demographics, and Oswestry Disability Index (ODI) score. Operative ASD was strictly defined as new-onset pathology following index surgery at directly adjacent levels to the prior construct. Operative, rather than symptomatic or radiographic, ASD was analyzed to provide a consistent and impactful endpoint while avoiding retrospective diagnosis. The study cohort of 182 patients had an operative ASD rate of 3.3% (n = 6 procedures) over 4 years of follow-up, for an incidence on Kaplan-Meier survival analysis of 0.88% (95% CI 0.67%-1.09%) per year. In comparing patients with operative ASD with those without, there were no significant differences in mean age (53.7 vs 56.2 years), male sex (33.3% vs 44.9%), smoking status (16.7% vs 25.0%), or number of levels fused (mean 1.33 vs 1.46). The operative ASD cohort had a greater mean BMI (37.3 vs 30.2, p < 0.01). Operative ASD patients had lower baseline ODI scores (33.8 vs 48.3, p = 0.02); however, no difference was observed in ODI at 6 weeks (34.0 vs 39.0) or 3 months (16.0 vs 32.8) postoperatively. The incidence of ASD in LLIF for degenerative lumbar etiologies in this cohort was 0.88% (95% CI 0.67%-1.09%) per year. Meanwhile, the reported reoperation rates for ASD in posterior spinal approaches was 2.5% to 3.9% per year, which implies that LLIF may be preferable for well-selected patients.

Increasing Cost Efficiency in Adult Spinal Deformity Surgery: Identifying Predictors of Lower Total Costs.

Retrospective study of a prospective multicenter database. The purpose of this study was to identify predictors of lower total surgery costs at 3 years for adult spinal deformity (ASD) patients. ASD surgery involves complex deformity correction. Inclusion criteria: surgical ASD (scoliosis ≥20°, sagittal vertical axis [SVA] ≥5 cm, pelvic tilt ≥25°, or thoracic kyphosis ≥60°) patients >18 years. Total costs for surgery were calculated using the PearlDiver database. Cost per quality-adjusted life year was assessed. A Conditional Variable Importance Table used nonreplacement sampling set of 20,000 Conditional Inference trees to identify top factors associated with lower cost surgery for low (LSVA), moderate (MSVA), and high (HSVA) SRS Schwab SVA grades. Three hundred sixtee of 322 ASD patients met inclusion criteria. At 3-year follow up, the potential cost of ASD surgery ranged from $57,606.88 to $116,312.54. The average costs of surgery at 3 years was found to be $72,947.87, with no significant difference in costs between deformity groups (P > 0.05). There were 152 LSVA patients, 53 MSVA patients, and 111 HSVA patients. For all patients, the top predictors of lower costs were frailty scores <0.19, baseline (BL) SRS Activity >1.5, BL Oswestry Disability Index <50 (all P < 0.05). For LSVA patients, no history of osteoporosis, SRS Activity scores >1.5, age <64, were the top predictors of lower costs (all P < 0.05). Among MSVA patients, ASD invasiveness scores <94.16, no past history of cancer, and frailty scores <0.3 trended toward lower total costs (P = 0.071, P = 0.210). For HSVA, no history of smoking and body mass index <27.8 trended toward lower costs (both P = 0.060). ASD surgery has the potential for improved cost efficiency, as costs ranged from $57,606.88 to $116,312.54. Predictors of lower costs included higher BL SRS activity, decreased frailty, and not having depression. Additionally, predictors of lower costs were identified for different BL deformity profiles, allowing for the optimization of cost efficiency for all patients.Level of Evidence: 3.

269. Two-year clinical and radiographic outcomes after minimally invasive sacroiliac joint fusion with decortication and none grafting utilizing a threaded implant

269. Two-year clinical and radiographic outcomes after minimally invasive sacroiliac joint fusion with decortication and none grafting utilizing a threaded implant

Does robot-assisted spine surgery for multi-level lumbar fusion achieve better patient-reported outcomes than free-hand techniques?

ObjectiveTo compare the patient-reported outcomes (PROs) between patients undergoing multilevel lumbar fusion with robot-assisted vs. freehand techniques. MethodsThis was a single-institution cohort study of adult patients (≥18 years old) undergoing robot-assisted spine surgery from 2016 to 2018 with minimum 2-year follow-up. A propensity-score matching (PSM) algorithm accounted for several perioperative factors. PROs were measured using the Oswestry Disability Index (ODI). The minimum clinically important difference (MCID) between groups were assessed at each follow-up period (6-weeks/6-months/1-year/2-years). Chi-square/fisher exact test and t-test/ANOVA were used for categorical and continuous variables, respectively. ResultsAfter PSM, a total of 70 patients remained. The mean (standard deviation) charlson comorbidity index was 1.4 (1.0) and 57% of patients were female. The most common diagnoses included degenerative disc disease (37.1%), degenerative scoliosis (27.1%), and high grade spondylolisthesis (grade > 2) (19%), and the mean number of instrumented levels was 4.6 (4.4). Rates for intraoperative/postoperative complications, and any reoperation within 2 years after surgery were low and similar between groups. The baseline ODI scores were similar between freehand (39.1) and robot-assisted surgery (40.5, P-value = 0.736). By two years, substantial improvements in both groups (mean ODI-freehand: 4.6, robot-assisted: 1.5; MCID%-freehand: 77.1%, robot-assisted: 82.9%) were achieved, but not significantly different (P-value > 0.05). No differences were observed for the other follow-up periods. When comparing individual component scores, the robot-assisted group scored higher in “Lifting,” “Sitting,” and “Standing;” however, the magnitudes of these differences were less than 1 point. ConclusionRobot-assisted multi-level lumbar fusion can achieve excellent and similar patient-reported outcomes to conventional freehand techniques. Future studies should include large, prospective randomized controlled trials as well as the inclusion of other patient reported outcome measures.

A randomized controlled trial investigating effects of an individualized pedometer driven walking program on chronic low back pain

BackgroundWalking is an easily prescribed physical activity for people with low back pain (LBP). However, the evidence for its effectiveness to improve pain and disability levels for people with chronic low back pain (CLBP) within a community setting has not been evaluated. This study evaluates the effectiveness of a clinician guided, pedometer-driven, walking intervention for increasing physical activity and improving clinical outcomes compared to education and advice.MethodsRandomized controlled trial recruiting N = 174 adults with CLBP. Participants were randomly allocated into either a standardized care group (SG) or pedometer based walking group (WG) using minimization allocation with a 2:1 ratio to the WG. Prior to randomization all participants were given a standard package of education and advice regarding self-management and the benefits of staying active. Following randomization the WG undertook a physiotherapist guided pedometer-driven walking program for 12 weeks. This was individually tailored by weekly negotiation of daily step targets. Main outcome was the Oswestry Disability Index (ODI) recorded at baseline, 12 weeks, 6 and 12 months. Other outcomes included, numeric pain rating, International Physical Activity Questionnaire (IPAQ), Fear-Avoidance Beliefs Questionnaire (FABQ), Back Beliefs questionnaire (BBQ), Physical Activity Self-efficacy Scale, and EQ-5D-5L quality of life estimate.ResultsN = 138 (79%) participants completed all outcome measures at 12 weeks reducing to N = 96 (55%) at 12 months. Both observed and intention to treat analysis did not show any statistically significant difference in ODI change score between the WG and the SG at all post-intervention time points. There were also no significant between group differences for change scores in all secondary outcome measures. Post hoc sensitivity analyses revealed moderately disabled participants (baseline ODI ≥ 21.0) demonstrated a greater reduction in mean ODI scores at 12 months in the WG compared to SG, while WG participants with a daily baseline step count < 7500 steps demonstrated a greater reduction in mean ODI scores at 12 weeks.ConclusionsOverall, we found no significant difference in change of levels of (ODI) disability between the SG and WG following the walking intervention. However, ODI responses to a walking program for those with moderate levels of baseline disability and those with low baseline step count offer a potential future focus for continued research into the benefit of walking as a management strategy for chronic LBP.Trial registrationUnited States National Institutes of Health Clinical Trails registry (http://ClinicalTrials.gov/) No. NCT02284958 (27/10/2014).

The patient acceptable symptom state for the Oswestry Disability Index following single-level lumbar fusion for degenerative spondylolisthesis

The patient acceptable symptom state (PASS) is a valuable tool for interpreting patient-reported outcomes. Previous studies have attempted to define the PASS in a heterogenous cohort with various lumbar spinal disorders and surgical procedures. We aimed to determine the PASS threshold for the Oswestry Disability Index (ODI) specifically for patients undergoing lumbar fusion for spondylolisthesis-associated functional disability. Retrospective review of prospectively collected registry data. There were 692 patients who underwent primary single-level minimally invasive transforaminal lumbar interbody fusion for degenerative spondylolisthesis between 2006 and 2014. The ODI was collected pre-operatively, at 6 months and 2 years postoperatively. An anchor question was adapted from the NASS questionnaire, "How would you rate the overall results of your treatment?" while a validation question was taken from the same questionnaire, "Has the surgery for your back condition met your expectations so far?" Responses to the anchor question were used to determine whether a PASS was achieved. Receiver operating characteristics curve analysis was performed to assess the ability of the ODI to discriminate between an acceptable/unacceptable symptom state as well as to define PASS thresholds. Sensitivity analyses were performed for different follow-up periods (6 months, 2 years), subgroups (by age, gender, BMI, and comorbidity burden), baseline ODI tertiles, and an alternate definition of PASS. In total, 529 of 692 (76%) patients completed 2-year follow-up, of which, 89% considered their symptom state to be acceptable. Areas under the curve (AUC) ranged from 0.81 to 0.90 for all receiver operating characteristics analyses, indicating that the ODI had an excellent discriminative ability. The PASS threshold was ≤18.09 at 6 months (AUC 0.81, sensitivity 77%, specificity 72%) and ≤15.27 at 2 years (AUC 0.86, sensitivity 79%, specificity 79%). These thresholds proved to be robust in the sensitivity analyses, showing minimal variation across different patient subgroups and baseline score tertiles. Patients with an ODI of ≤15.27 can be considered to have achieved a PASS after lumbar fusion for degenerative spondylolisthesis. These findings will help surgeons to contextualize a patient's functional recovery after lumbar spine surgery and enable researchers to define clinically relevant benchmarks when designing trials utilizing the ODI.

P37. Artificial intelligence clustering of adult spinal deformity morphology predicts surgical characteristics, alignment, and outcomes

BACKGROUND CONTEXT AI algorithms have shown substantial promise in medical image analysis. Previous studies of ASD clusters have analyzed alignment metrics – this study sought to complement these efforts by analyzing images of anatomical landmarks. PURPOSE We hypothesized that a neural-network-based artificial intelligence (AI) algorithm would cluster preoperative lateral radiographs of into groups with distinct morphology. STUDY DESIGN/SETTING Retrospective cohort study. PATIENT SAMPLE A total of 915 patients with adult spinal deformity and preoperative lateral radiographs. OUTCOME MEASURES Schwab modifiers for SVA and PI-LL, three-column osteotomy, upper instrumented vertebrae, baseline Oswestry Disability Index, and 2-year likelihood of reaching MCID in ODI (set at -12.8). Proximal junctional kyphosis and proximal junctional failure were defined using previously published radiographic criteria. METHODS Vertebral locations for C3-L5, sacral endplate, and femoral heads were measured on lateral radiographs. Pixel locations were used to create a black-and-white overlay to the image, which was subsequently standardized for size and position using the femoral heads and sacral endplate. These images were used to train a self-organizing map (SOM). SOMs are a form of artificial neural network frequently employed in unsupervised classification tasks. RESULTS In total, 915 preoperative lateral radiographs were analyzed. A 2 × 3, toroidal SOM was trained. The mean spine shape was plotted for each cluster. Alignment, surgical characteristics, and outcomes were compared between clusters. Clusters C and D exhibited a particularly high proportion of patients with optimal (ie, modifier 0) values of PI-LL (65.0% and 68.5%) and SVA (72.8% and 53.1%). Conversely, clusters B, E, and F tended to have poor (ie, modifier ++) PI-LL (74.8%, 66.9%, and 74.6%) and SVA (75.5%, 48.6%, and 58.7%). 3-CO was most common among cluster A (26.8%), cluster B (32.6%), and cluster F (32.7%). UIV at T7-T12 was most common among cluster B (51.1%) and cluster F (60.3%). ODI CONCLUSIONS This study developed a self-organizing map that clustered preoperative lateral radiographs of ASD patients into groups with highly distinct overall spinal morphology. These clusters predicted alignment, surgical characteristics, and HRQOL. Further studies of this classification approach will expand to compare pre- and postoperative radiographs. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

287. Early postoperative physical activity predicts clinical improvement in disability 1 year following spine surgery

BACKGROUND CONTEXT Walking at least 4,500 steps/day or engaging in at least 60 minutes of moderate-to-vigorous physical activity/week are known to provide multiple health benefits and prevent disability in adults with and without musculoskeletal pain. However, little is known about the impact of physical activity on outcomes following spine surgery. PURPOSE The primary objective of this study was to determine whether early postoperative physical activity is associated with clinically meaningful improvement in disability in patients undergoing spine surgery. A secondary objective was to investigate the physical activity threshold that best discriminates improvement in disability at one year following spine surgery. STUDY DESIGN/SETTING Secondary analysis of randomized controlled trial data. PATIENT SAMPLE A total of 248 participants undergoing elective surgery for a degenerative lumbar spine condition. OUTCOME MEASURES Clinically meaningful improvement in disability was considered a 30% reduction in Oswestry Disability Index (ODI) scores from baseline (6 weeks after surgery) to 1-year follow-up. METHODS Physical activity was measured using an accelerometer (Actigraph GT3X) worn for at least 10 hours/day for at least 3 days at 6-weeks following spine surgery. Physical activity was quantified as steps/day and time spent in moderate-to-vigorous physical activity (ie, at least 2,020 counts/minute). Multivariable logistic regression analysis was conducted to determine the association between steps/day at 6 weeks and clinically meaningful improvement in disability at 1 year, controlling for age, body mass index (BMI), education, race, sex, previous surgery, spinal procedure, baseline ODI score, and back and leg pain. Receiver operating characteristic curves were used to identify steps/day and moderate-to-vigorous physical activity/week that best discriminated the likelihood of achieving clinical improvement. RESULTS Of 248 participants, 216 participants (mean [SD]; age= 63[11] years, BMI= 32[7] kg/m2, 52% female) had physical activity for at least 3 valid days. Of 216 patients, 43% (n=93) achieved clinical improvement in ODI at 1-year following spine surgery. Each additional 1000 steps/day and additional 1 minute of moderate-to-vigorous physical activity/day were associated with 27% (OR=1.27, 95% CI=1.07, 1.51) and 4% (OR=1.04, 95% CI=1.01, 1.08) higher odds of achieving clinically meaningful improvement in ODI, respectively. At 6 weeks following spine surgery, walking less than 3000 steps/day (sensitivity = 68%, specificity = 52%) was associated with 66% (OR=0.34, 95% CI=0.16, 0.69) lower odds of achieving clinical improvement in disability compared to those who walked at least 3000 steps/day. In addition, engaging in less than 21 minutes of moderate-to-vigorous physical activity/week (sensitivity = 62%, specificity = 48%) was associated with a 46% (OR=0.54, 95% CI=0.29, 1.02) lower odds of achieving clinical improvement in disability at 1-year postoperative compared to those who engaged in at least 21 minutes of moderate-to-vigorous physical activity/week. CONCLUSIONS Walking at least 3,000 steps/day or engaging in at least 21 minutes of moderate-to-vigorous physical activity/week may serve as an initial recommendation for patients early after spine surgery. Results suggest that these early postoperative thresholds may optimize clinical improvement in disability at 1 year following spine surgery. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Depression Identified on the Mental Component Score of the Short Form-12 Affects Health Related Quality of Life After Lumbar Decompression Surgery.

This was a retrospective comparative study. The goal of this study was to further elucidate the relationship between preoperative depression and patient-reported outcome measurements (PROMs) following lumbar decompression surgery. The impact of preoperative depression on PROMs after lumbar decompression surgery is not well established. Patients undergoing lumbar decompression between 1 and 3 levels were retrospectively identified. Patients were split into 2 groups using a preoperative Mental Component Score (MCS)-12 threshold score of 45.6 or 35.0 to identify those with and without depressive symptoms. In addition, patients were also split based on a pre-existing diagnosis of depression in the medical chart. Absolute PROM scores, the recovery ratio and the percent of patients achieving minimum clinically important difference between groups were compared, and a multiple linear regression analysis was performed. A total of 184 patients were included, with 125 (67.9%) in the MCS-12 >45.6 group and 59 (32.1%) in the MCS-12 ≤45.6 group. The MCS-12 ≤45.6 and MCS<35.0 group had worse baseline Oswestry Disability Index (ODI) (P<0.001 for both) and Visual Analogue Scale Leg (P=0.018 and 0.024, respectively) scores. The MCS ≤45.6 group had greater disability postoperatively in terms of SF-12 Physical Component Score (PCS-12) (39.1 vs. 43.1, P=0.015) and ODI (26.6 vs. 17.8, P=0.006). Using regression analysis, having a baseline MCS-12 scores ≤45.6 before surgical intervention was a significant predictor of worse improvement in terms of PCS-12 [β=-4.548 (-7.567 to -1.530), P=0.003] and ODI [β=8.234 (1.433, 15.035), P=0.010] scores than the MCS-12 >45.6 group. Although all patients showed improved in all PROMs after surgery, those with MCS-12 ≤45.6 showed less improvement in PCS-12 and ODI scores.

Regional Variance in Disability and Quality-of-Life Outcomes After Surgery for Grade I Degenerative Lumbar Spondylolisthesis: A Quality Outcomes Database Analysis

Regional differences in outcomes after spine surgery are poorly understood. We assessed disability and quality-of-life outcomes by geographic region in the United States using the NeuroPoint Alliance Quality Outcomes Database. We queried the prospective Quality Outcomes Database patient registry to identify patients who underwent elective 1- or 2-level lumbar surgery for grade I degenerative spondylolisthesis from July 2014 through June 2016. Primary outcome measures included Oswestry Disability Index (ODI) and EuroQOL-5D (EQ-5D) reported at 24 months postoperatively. Differences in EQ-5D and ODI were compared across geographic regions of the United States (Northeast, Midwest, South, West). We identified 608 patients from 12 centers who underwent surgery. Of these, 517 (85.0%) had ODI data and 492 (80.9%) had EQ-5D data at 24 months. Southern states had the largest representation (304 patients; 5 centers), followed by Northeastern (114 patients; 3 centers), Midwestern (96 patients; 2 centers), and Western (94 patients; 2 centers) states. Baseline ODI scores were significantly different among regions, with the South having the greatest baseline disability burden (Northeast: 40.9 ± 16.9, South: 51.2 ± 15.8, Midwest: 40.9 ± 17.8, West: 45.0 ± 17.1, P < 0.001). The change in ODI at 24 months postoperatively was significantly different among regions, with the South showing the greatest ODI improvement (Northeast:-21.1 ± 18.2, South:-26.5 ± 20.2, Midwest:-18.2 ± 22.9, West:-21.7 ± 19.6, P < 0.001). All regions had ≥60% achievement of the minimum clinically important difference in ODI at 24 months postoperatively. No regional differences were observed for EQ-5D. Significant regional variation exists for disability outcomes, but not quality of life, at 24 months after spinal surgery for grade I degenerative spondylolisthesis.

Predictors of Treatment Success Following Limited Discectomy With Annular Closure for Lumbar Disc Herniation.

Previous studies have demonstrated bone-anchored annular closure to significantly reduce reherniation and reoperation rates after lumbar discectomy in patients with large annular defects. It is important to identify the prognostic factors that may be associated with successful treatment. This study aimed to identify predictors of treatment success in patients with lumbar disc herniation treated with limited microdiscectomy supplemented by a bone-anchored annular closure device (ACD). This study was a retrospective analysis of 133 consecutive patients with lumbar disc herniation treated with the ACD. Treatment success was defined as ≥24% improvement in visual analog scale (VAS) for back pain, ≥39% improvement in VAS leg pain, and ≥33% in the Oswestry Disability Index (ODI), with the raw ODI score ≤48. Success was calculated at 3, 6, and 12 months after surgery. Potentially predictive outcomes included patient characteristics, operative data, and imaging outcomes, such as disc, facet, and end plate morphology. Logistic regression was used to determine the significant predictive factors for treatment success. After 3, 6, and 12 months, 97 of 131 (74%), 104 of 129 (81%), and 112 of 126 (89%) patients, respectively, achieved the success criteria. At 3 months follow-up, a higher proportion of younger (17-40 years) versus older (41-65 years) patients met the success criteria (P = .025). On the basis of logistic regression, the following factors were significantly associated with treatment success at 1 or more of the follow-up time points: sex (male), lower body mass index, higher baseline pain and ODI scores, lower grade preoperative disc degeneration, and the absence of a postoperative complication. The rates of index-level recurrent herniation and reoperation were 1.5% and 3.0%, respectively. This real-world evidence supports a promising benefit-risk profile for augmenting limited microdiscectomy with a bone-anchored ACD and provides some insights into the patient populations that may have a greater chance of realizing significant improvements in pain and function. 2 (Cohort study).

189. A data-driven approach to assessment of sagittal alignment: defining the spinopelvic ratio's impact on clinical outcomes in adult spinal deformity patients

BACKGROUND CONTEXT Analysis of interactions spinal alignment metrics may uncover novel and powerful alignment parameters, similar to pelvic incidence minus lumbar lordosis (PI-LL). PURPOSE This study utilized a data driven approach to hypothesis generation by testing all possible division interactions between a set of spinal alignment parameters. TPA divided by PI (TPA/PI) was identified and subsequently characterized. STUDY DESIGN/SETTING Retrospective analysis of a multicenter, prospectively-defined, consecutive cohort of ASD patients. PATIENT SAMPLE A total of 1,439 patients with baseline ODI were included for hypothesis generation; 666 patients had 2-year postoperative follow-up and were included for validation. OUTCOME MEASURES The primary outcome measure was Oswestry Disability Index (ODI). METHODS All possible combinations of division interactions between baseline metrics were assessed with linear regression against baseline ODI. Further analyses also utilized linear regression. RESULTS From 247 raw alignment metrics, 32,398 division interactions were considered in hypothesis generation. Low-cervical and high-thoracic pelvic angles divided by pelvic incidence accounted for 7 of the top 10 most significant interactions. Conceptually, the TPA/PI is a measure of the relative alignment of the line connecting T1 to the femoral head and the line perpendicular to the sacral end plate. Among the validation cohort, the mean TPA/PI was 0.41 (SD 0.24) at baseline and 0.30 at 2 years postoperatively (SD 0.18). Higher TPA/PI was linearly associated with worse ODI at baseline (β 28.7 for TPA/PI 1 vs 0, p CONCLUSIONS This study utilized a data-driven approach for hypothesis generation and identified TPA/PI, the spinopelvic ratio (SPR), as a promising measure of sagittal spinal alignment among ASD patients. This value is strongly associated with the Schwab modifier classification system. Patients with SPR ≥0.21 exhibited inferior HRQOL. The SPR classification accounted for a directionally greater proportion of variance in ODI as compared to the three Schwab modifiers. These results highlight the interaction between global sagittal alignment and adequate pelvic structural support. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

213. Adult spinal deformity patients with a decline in certain activities of daily living are likely to fail nonoperative treatment

BACKGROUND CONTEXT The impact of worsening activities of daily living (ADL) such as spine-related financial difficulty and attending work/school have not been studied as potential independent predictors of failing nonoperative management of adult spinal deformity (ASD). PURPOSE To identify which specific ADLs assessed with the Scoliosis Research Society 22r (SRS-22r) can identify patients with ASD who are likely to fail nonoperative management. STUDY DESIGN/SETTING Prospective, observational study. PATIENT SAMPLE A total of 482 patients initially selected for nonoperative treatment of ASD patients were identified from a multicenter database. Of these, 55 (11%) had eventual crossover to operative intervention. Propensity score matching (PSM) was performed using age, gender and baseline Oswestry Disability Index (ODI) to create matched cohorts of 46 crossover (CX) and 46 noncrossover (NC) patients. OUTCOME MEASURES Our primary outcome was crossover to operative treatment among patients who were originally intended to be treated nonoperatively. METHODS Scoliosis Research Society (SRS-22r) questionnaire was administered at baseline, 6-weeks, 6-months and both 1 and 2 years. Change in overall score, subdomains and responses to specific questions over time were classified as increasing, decreasing or unchanged in relation to baseline. Kaplan-Meier curves were produced for time to crossover among patients by change in SRS-22r domains, and compared using log-rank test. Significant was set at 0.05. RESULTS NC and CX groups were similar among age, baseline ODI, and SVA (p>0.05). Patients had a mean age 55 ± 15 years; ODI of 35 ± 15; SVA of 3.5 ± 5.9cm. Mean time to crossover was 1.7 ± 1.4yrs. Decline in SRS-22r Total and Activity domains were associated with increased risk of failing nonoperative management (p=0.005, p=0.006), while decline in SRS-22r pain, appearance and mental health domains were not significantly associated with failure. Analysis of specific ADLs within the activity domain showed worsening financial hardship, level of activity and going out with friends/family to be associated with failure, while work/school activity and doing household chores were not. CONCLUSIONS Decline in SRS-22r Activity is the primary SRS-22r domain independently associated with failing nonoperative management of ASD. Within this domain, worsening physical activity, spine-related financial hardship and decreasing time with family/friends drive patients to undergo surgery, while the ability to perform household chores and attend work/school are not independently associated with failing nonoperative management. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Impact of occupational characteristics on return to work for employed patients after elective lumbar spine surgery

BACKGROUND CONTEXTLow back pain has an immense impact on the US economy. A significant number of patients undergo surgical management in order to regain meaningful functionality in daily life and in the workplace. Return to work (RTW) is a key metric in surgical outcomes, as it has profound implications for both individual patients and the economy at large. PURPOSEIn this study, we investigated the factors associated with RTW in patients who achieved otherwise favorable outcomes after lumbar spine surgery. STUDY DESIGN/SETTINGThis study retrospectively analyzes prospectively collected data from the lumbar module of national spine registry, the Quality Outcomes Database (QOD). PATIENT SAMPLEThe lumbar module of QOD includes patients undergoing lumbar surgery for primary stenosis, disc herniation, spondylolisthesis (Grade I) and symptomatic mechanical disc collapse or revision surgery for recurrent same-level disc herniation, pseudarthrosis, and adjacent segment disease. Exclusion criteria included age under 18 years and diagnoses of infection, tumor, or trauma as the cause of lumbar-related pain. OUTCOME MEASURESThe outcome of interest for this study was the return to work 12-month after surgery. METHODSThe lumbar module of QOD was queried for patients who were employed at the time of surgery. Good outcomes were defined as patients who had no adverse events (readmissions/complications), had achieved 30% improvement in Oswestry disability index (ODI) and were satisfied (NASS satisfaction) at 3-month post-surgery. Distinct multivariable logistic regression models were fitted with 12-month RTW as outcome for a. overall population and b. the patients with good outcomes. The variables included in the models were age, gender, race, insurance type, education level, occupation type, currently working/on-leave status, workers’ compensation, ambulatory status, smoking status, anxiety, depression, symptom duration, number of spinal levels, diabetes, motor deficit, and preoperative back-pain, leg-pain and ODI score. RESULTSOf the total 12,435 patients, 10,604 (85.3%) had successful RTW at 1-year postsurgery. Among patients who achieved good surgical outcomes, 605 (7%) failed to RTW. For both the overall and subgroup analysis, older patients had lower odds of RTW. Females had lower odds of RTW compared with males and patients with higher back pain and baseline ODI had lower odds of RTW. Patients with longer duration of symptoms, more physically demanding occupations, worker's compensation claim and those who had short-term disability leave at the time of surgery had lower odds of RTW independent of their good surgical outcomes. CONCLUSIONSThis study identifies certain risk factors for failure to RTW independent of surgical outcomes. Most of these risk factors are occupational; hence, involving the patient's employer in treatment process and setting realistic expectations may help improve the patients' work-related functionality.