Lumbar Degenerative Surgery Research Articles

Magnetic Resonance Imaging-Based Vertebral Bone Quality Score for Prediction of Cage Subsidence and Screw Loosening in Patients Undergoing Degenerative Lumbar Surgery: A Meta-analysis.

Poor bone quality is a risk factor for postoperative complications after degenerative lumbar fusion surgery. The magnetic resonance imaging-based vertebral bone quality (VBQ) score is a good tool for assessing bone quality, and this is the first meta-analysis performed to summarize the predictive value of the VBQ score for cage subsidence and screw loosening in patients undergoing degenerative lumbar surgery. Studies were comprehensively searched in electronic databases. The quality of the studies was assessed. The pooled sensitivity, specificity and summary receiver operating characteristic curve were calculated. Publication bias was assessed and meta-regression was conducted. We ultimately included 9 studies with a total of 1,404 patients with a mean age of 60.4 years and a percentage of females of 57.0%. According to the QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies 2) tool to assess methodological quality, the quality of the included studies was relatively low and risks of bias might exist. Results showed that a high VBQ was significantly associated with cage subsidence and screw loosening, and risk factor analysis revealed that the merged odds ratio was 5.37 for cage subsidence and 3.87 for screw loosening. With a VBQ cutoff value of 3.34±0.45, the pooled sensitivity and specificity for the diagnosis of postoperative complications were 0.75 and 0.75, respectively, and the area under the curve was 0.82 (95% confidence interval, 0.78-0.85). A high VBQ was associated with a high risk of cage subsidence and screw loosening in patients who underwent degenerative lumbar surgery. The VBQ score could be considered for identifying high-risk patients for further evaluation.

The efficacy of 3D gait analysis to evaluate surgical (and rehabilitation) outcome after degenerative lumbar surgery

BackgroundLumbar degenerative conditions are a major cause of back pain and disability in individuals aged 45 and above. Gait analysis utilizes sensor technology to collect movement data, aiding in the evaluation of various gait aspects like spatiotemporal parameters, joint angles, neuromuscular activity, and joint forces. It is widely used in conditions such as cerebral palsy and knee osteoarthritis. This research aims to assess the effectiveness of 3D gait analysis in evaluating surgical outcomes and postoperative rehabilitation for lumbar degenerative disorders.MethodsA prospective self-controlled before-after study (n = 85) carried out at our Hospital (Sep 2018 - Dec 2021) utilized a 3D motion analysis system to analyze gait in patients with lumbar degenerative diseases. The study focused on the multifidus muscle, a crucial spinal muscle, during a minimally invasive lumbar interbody fusion surgery conducted by Shandong Weigao Pharmaceutical Co., Ltd. Pre- and postoperative assessments included time-distance parameters (gait speed, stride frequency, stride length, stance phase), hip flexion angle, and stride angle. Changes in 3D gait parameters post-surgery and during rehabilitation were examined. Pearson correlation coefficient was employed to assess relationships with the visual analog pain scale (VAS), Oswestry Disability Index (ODI), and Japanese Orthopedic Association (JOA) scores. Patient sagittal alignment was evaluated using “Surgimap” software from two types of lateral radiographs to obtain parameters like pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), lumbar lordosis (LL), intervertebral space height (DH), posterior height of the intervertebral space (PDH) at the operative segment, and anterior height of the intervertebral space (ADH).ResultsBy the 6th week post-operation, significant improvements were observed in the VAS score, JOA score, and ODI score of the patients compared to preoperative values (P < 0.05), along with notable enhancements in 3D gait quantification parameters (P < 0.05). Pearson correlation analysis revealed a significant positive correlation between improvements in 3D gait quantification parameters and VAS score, JOA score, and ODI value (all P < 0.001).Conclusion3D gait analysis is a valuable tool for evaluating the efficacy of surgery and rehabilitation training in patients.

76. Longer wait times for degenerative lumbar surgery are associated with increased time away from work, worse postoperative satisfaction, and higher chronic persistent opioid use

76. Longer wait times for degenerative lumbar surgery are associated with increased time away from work, worse postoperative satisfaction, and higher chronic persistent opioid use

Trend of unplanned reoperation rates after lumbar degenerative surgery from 2011 to 2019: a large patient population study.

Unplanned reoperation is commonly performed due to postoperative complications. Previous studies have reported the incidence of unplanned reoperation following lumbar spinal surgery. But few study focused on the trend of reoperation rates, and the reasons of unplanned reoperation were not clear. In this study, we conducted a retrospective study to determine the trend of unplanned reoperation rates after degenerative lumbar spinal surgery from 2011 to 2019, and the reasons and risk factors of unplanned reoperation were also determined. Data of patients who were diagnosed with degenerative lumbar spinal disease and underwent posterior lumbar spinal fusion surgery in our institution from January 2011 to December 2019 were reviewed. Those who received unplanned reoperation during the primary admission were identified. The demographics, diagnosis, surgical segments and postoperative complications of these patients were recorded. The rates of unplanned reoperation from 2011 to 2019 were calculated, and the reasons of unplanned reoperation were statistically analysed. A total of 5289 patients were reviewed. Of them, 1.91% (n = 101) received unplanned reoperation during the primary admission. The unplanned reoperation rates of degenerative lumbar spinal surgery firstly increased from 2011 to 2014, with a peak rate in 2014 (2.53%). Then, the rates decreased from 2014 to 2019, with the lowest one in 2019 (1.46%). Patients with lumbar spinal stenosis have a higher rate of unplanned reoperation (2.67%) compared with those diagnosed as lumbar disc herniation (1.50%) and lumbar spondylolisthesis (2.04%) (P < 0.05). The main reasons for unplanned reoperation were wound infection (42.57%), followed by wound hematoma (23.76%). Patients who underwent 2-segment spinal surgery had a higher unplanned reoperation rate (3.79%) than those receiving other segments surgery (P < 0.001). And different spine surgeons had different reoperation rates. The rates of unplanned reoperation after lumbar degenerative surgery increased at first and then decreased during past 9 years. Wound infection was the major reason for unplanned reoperation. 2-segment surgery and surgeon's surgical skills were related to the reoperation rate.

Trend of unplanned reoperation rates after lumbar degenerative surgery from 2011 to 2019: A large patient population study

Trend of unplanned reoperation rates after lumbar degenerative surgery from 2011 to 2019: A large patient population study

Prevalence of Asymptomatic Deep Vein Thrombosis in Preoperative State of Spine Surgeries

Deep venous thrombosis (DVT) is considered the most common cause of preventable death among hospitalized patients. A few studies have investigated the risk of venous thromboembolic events (VTE) in patients undergoing elective spine surgery and reported varying incidences. We aim to assess the incidence of preoperative lower limb DVT in lumbar degenerative disease patients undergoing elective surgery. This is a retrospective review of prospectively collected data on adult patients with lumbar degenerative spine diseases (lumbar stenosis; LST, lumbar spondylolisthesis; SPL, or lumbar disc herniation; LDH) who were scheduled for operative management. Each patient underwent a preoperative lower limb venous Duplex (LLVD). Incidence of DVT, risk factors, and clinical course of patients were reported. Forty-nine patients (32 females; 65%) were included. All patients were diagnosed clinically and radiologically with lumbar degenerative diseases; LST (44.9%), SPL (36.7%), and LDH (18.4%), requiring surgical management. Three patients (6.1%) were found to have positive DVT studies, leading to the cancellation or rescheduling of their procedures (p < 0.01). These included one patient with LST (p = 0.045) and two patients with SPL (p = 0.006). Among patients with LST and SPL, higher disability (modified Rankin scale; mRS ≥3) was significantly associated with positive LLVD (p = 0.035). Patients with LST or SPL with higher preoperative disability scores were at higher risk to have preoperative DVT. Further research is needed to evaluate the feasibility and value of preoperative LLVD to detect DVT in patients planned for lumbar degenerative surgery.

P8. Responsiveness of patient derived intervertebral disc cells to mechanobiological treatment

P8. Responsiveness of patient derived intervertebral disc cells to mechanobiological treatment

Development and Initial Internal Validation of a Novel Classification System for Perioperative Expectations Following Minimally Invasive Degenerative Lumbar Spine Surgery.

This was a prospective consecutive clinical cohort study. The purpose of our study was to develop and provide an initial internal validation of a novel classification system that can help surgeons and patients better understand their postoperative course following the particular minimally invasive surgery (MIS) and approach that is utilized. Surgeons and patients are often attracted to the option of minimally invasive spine surgery because of the perceived improvement in recovery time and postsurgical pain. A classification system based on the impact of the surgery and surgical approach(es) on postoperative recovery can be particularly helpful. Six hundred thirty-one patients who underwent MIS lumbar/thoracolumbar surgery for degenerative conditions of the spine were included. Perioperative outcomes-operative time, estimated blood loss, postsurgical length of stay (LOS), 90-day complications, postoperative day zero narcotic requirement [in Morphine Milligram Equivalent (MME)], and need for intravenous patient-controlled analgesia (IV PCA). Postoperative LOS and postoperative narcotic use were deemed most clinically relevant, thus selected as primary outcomes. Type of surgery was significantly associated with all outcomes (P<0.0001), except intraoperative complications. Number of levels for fusion was significantly associated with operative time, in-hospital complications, 24 hours oral MME, and the need for IV PCA and LOS (P<0.0001). Number of surgical approaches for lumbar fusion was significantly associated with operative time, 24 hours oral MME, need for IV PCA and LOS (P<0.001). Based on these parameters, the following classification system ("Qureshi-Louie classification" for MIS degenerative lumbar surgery) was devised: (1) Decompression-only; (2) Fusion-1 and 2 levels, 1 approach; (3) Fusion-1 level, 2 approaches; (4) Fusion-2 levels, 2 approaches; (5) Fusion-3+ levels, 2 approaches. We present a novel classification system and initial internal validation to describe the perioperative expectations following various MIS surgeries in the degenerative lumbar spine. This initial description serves as the basis for ongoing external validation.

Surgical Outcomes of Human Immunodeficiency Virus-positive Patients Undergoing Lumbar Degenerative Surgery.

This was a retrospective cohort studying using a national administrative database. The objective of this study was to determine the postoperative complications and quality outcomes of the human immunodeficiency virus (HIV)-positive patients undergoing surgical management for lumbar degenerative disease (LDD). This study identified patients with who underwent surgery for LDD between 2007 and 2016. Patients were stratified based on whether they were HIV positive at the time of surgery. Multivariate regression was utilized to reduce the confounding of baseline covariates. Patients who underwent 3 or more levels of surgical correction were under the age of 18 years, or those with any prior history of trauma or tumor were excluded from this study. Baseline comorbidities, postoperative complication rates, and reoperation rates were determined. A total of 120,167 patients underwent primary lumbar degenerative surgery, of which 309 (0.26%) were HIV positive. In multivariate regression analysis, the HIV-positive cohort was more likely to be readmitted at 30 days [odds ratio (OR)=1.9, 95% confidence interval (CI): 1.2-2.8], 60 days (OR=1.7, 95% CI: 1.2-2.5), and 90 days (OR=1.5, 95% CI: 1.0-2.2). The HIV-positive cohort was also more likely to experience any postoperative complication (OR=1.7, 95% CI: 1.2-2.3). Of the major drivers identified, HIV-positive patients had significantly greater odds of cerebrovascular disease and postoperative neurological complications (OR=3.8, 95% CI: 1.8-6.9) and acute kidney injury (OR=3.4, 95% CI: 1.3-7.1). Costs of index hospitalization were not significantly different between the 2 cohorts ($30,056 vs. $29,720, P=0.6853). The total costs were also similar throughout the 2-year follow-up period. Patients who are HIV positive at the time of LDD surgery are at a higher risk for postoperative central nervous system and renal complications and unplanned readmissions.

Obesity in Patients Undergoing Lumbar Degenerative Surgery-A Retrospective Cohort Study of Postoperative Outcomes.

Retrospective cohort studying using a national, administrative database. The aim of this study was to determine the postoperative complications and quality outcomes of patients with and without obesity undergoing surgical management for lumbar degenerative disease (LDD). Obesity is a global epidemic that negatively impacts health outcomes. Characterizing the effect of obesity on LDD surgery is important given the growing elderly obese population. This study identified patients with who underwent surgery for LDD between 2007 and 2016. Patients were stratified based on whether the patient had a concurrent diagnosis of obesity at time of surgery. Propensity score matching (PSM) was then utilized to mitigate intergroup differences between patients with and without obesity. Patients who underwent three or more levels surgical correction, were under the age of 18 years, or those with any previous history of trauma or tumor were excluded from this study. Baseline comorbidities, postoperative complication rates, and reoperation rates were determined. A total of 67,215 patients underwent primary lumbar degenerative surgery, of which 22,405 (33%) were obese. After propensity score matching, baseline covariates of the two cohorts were similar. The complication rate was 8.3% in the nonobese cohort and 10.4% in the obese cohort (P < 0.0001). Patients with obesity also had longer lengths of stay (2.7 days vs. 2.4 days, P < 0.05), and higher rates of reoperation and readmission at all time-points through the study follow-up period to their nonobese counterparts (P < 0.05). Including payments after discharge, lumbar degenerative surgery in patients with obesity was associated with higher payments throughout the 2-year follow-up period ($68,061 vs. $59,068 P < 0.05). Patients with a diagnosis of obesity at time of LDD surgery are at a higher risk for postoperative complications, reoperation, and readmission.Level of Evidence: 4.

The Patient-Reported Outcome Measurement Information System (PROMIS) Better Reflects the Impact of Length of Stay and the Occurrence of Complications Within 90 Days Than Legacy Outcome Measures for Lumbar Degenerative Surgery.

The Patient-Reported Outcome Measurement Information System (PROMIS) and legacy outcome measures like the Oswestry Disability Index (ODI) have not been compared for their sensitivity in reflecting the impact of perioperative complications and length of stay (LOS) in a surgical thoracolumbar population. The purpose of this study is to assess the strength of PROMIS and ODI scores as they correlate with LOS and complication outcomes of surgical thoracolumbar patients. Retrospective cohort study. Included: patients ≥18 years undergoing thoracolumbar surgery with available preoperative and 3-month postoperative ODI and PROMIS scores. Pearson correlation assessed the linear relationships between LOS, complications, and scores for PROMIS (physical function, pain intensity, pain interference) and ODI. Linear regression predicted the relationship between complication incidence and scores for ODI and PROMIS. Included: 182 patients undergoing thoracolumbar surgery. Common diagnoses were stenosis (62.1%), radiculopathy (48.9%), and herniated disc (47.8%). Overall, 58.3% of patients underwent fusion, and 50.0% underwent laminectomy. Patients showed preoperative to postoperative improvement in ODI (50.2 to 39.0), PROMIS physical function (10.9 to 21.4), pain intensity (92.4 to 78.3), and pain interference (58.4 to 49.8, all P < .001). Mean LOS was 2.7 ± 2.8 days; overall complication rate was 16.5%. Complications were most commonly cardiac, neurologic, or urinary (all 2.2%). Whereas preoperative to postoperative changes in ODI did not correlate with LOS, changes in PROMIS pain intensity (r = 0.167, P = .024) and physical function (r = -0.169, P = .023) did. Complications did not correlate with changes in ODI or PROMIS score; however, postoperative scores for physical function (r = -0.205, P = .005) and pain interference (r = 0.182, P = .014) both showed stronger correlations with complication occurrence than ODI (r = 0.143, P = .055). Regression analysis showed postoperative physical function (R 2 = 0.037, P = .005) and pain interference (R 2 = 0.028, P = .014) could predict complications; ODI could not. PROMIS domains of physical function and pain interference better reflected perioperative complications and LOS than the ODI. These results suggest PROMIS may offer more utility as an outcomes assessment instrument. 3.

Mental Health Associated With Postoperative Satisfaction in Lumbar Degenerative Surgery Patients.

Retrospective review of prospectively collected data. To assess the association between preoperative and postoperative mental health status with postoperative satisfaction in lumbar degenerative surgery patients. Poor preoperative mental health has been shown to negatively affect postoperative satisfaction among spine surgery patients, but there is limited evidence on the impact of postoperative mental health on satisfaction. Adult patients undergoing surgery for lumbar degenerative conditions at a single institution were included. Mental health was assessed preoperatively and 12 months postoperatively using Patient-Reported Outcomes Measurement Information System Depression and Anxiety scores. Satisfaction was assessed 12 months postoperatively using North American Spine Society Patient Satisfaction Index. The authors evaluated associations between mental health and satisfaction with univariate and multivariable logistic regression to adjust for confounders. Preoperative depression/anxiety level was corrected for postoperative depression/anxiety level, and vice versa. Statistical significance was assessed at α=0.05. A total of 183 patients (47% male individuals; avg. age, 62 y) were included. Depression was present in 27% preoperatively and 29% postoperatively, and anxiety in 50% preoperatively and 31% postoperatively. Ninteen percent reported postoperative dissatisfaction using the North American Spine Society Patient Satisfaction Index. Univariate analysis identified race, family income, relationship status, current smoking status, change in pain interference, and change in physical function as potential confounders. In adjusted analysis, odds of dissatisfaction were increased in those with mild postoperative depression (adjusted odds ratio=6.1; 95% confidence interval, 1.2-32; P=0.03) and moderate or severe postoperative depression (adjusted odds ratio=7.5; 95% confidence interval, 1.3-52; P=0.03). Preoperative and postoperative anxiety and preoperative depression were not associated with postoperative satisfaction. Following lumbar degenerative surgery, patients with postoperative depression, irrespective of preoperative depression status, have significantly higher odds of dissatisfaction. These results emphasize the importance of postoperative screening and treatment of depression in spine patients with dissatisfaction. Level III-nonrandomized cohort study.

P127. PROMIS better reflects the impact of length of stay and the occurrence of complications within 90 days than legacy outcome measures for lumbar degenerative surgery

BACKGROUND CONTEXT The Patient Reported Outcome Measurement Information System (PROMIS) aims to offer a valid, reliable and efficient means of capturing spine surgery patient clinical outcomes. To date, few studies have compared PROMIS and legacy outcome measures like the Oswestry Disability Index (ODI) for their sensitivity in reflecting the impact of perioperative complications and length of stay. PURPOSE Assess differences between PROMIS and ODI scores as they relate to length of stay and complication outcomes of surgical thoracolumbar patients. STUDY DESIGN/SETTING Retrospective review of single institution clinical data and patient-reported outcome measures. PATIENT SAMPLE A total of 182 patients undergoing thoracolumbar surgery. OUTCOME MEASURES Length of stay (LOS), perioperative complications. METHODS Patients >18 years undergoing thoracolumbar surgery with available pre- and 3-month postoperative ODI and PROMIS scores were included. Pearson bivariate correlation assessed the linear relationships between clinical outcomes (including length of stay, complications) and scores for both PROMIS (Physical Function, Pain Intensity, Pain Interference) and ODI. Linear regression predicted the relationship between perioperative complication incidence and postop scores for ODI and PROMIS. Significance was set p RESULTS Included: 182 patients (55.2±16.1 years, 44.5% female, 29.5±6.3 kg/m2) undergoing thoracolumbar surgery. Among the most common diagnoses were stenosis (62.1%), radiculopathy (48.9%), herniated disc (47.8%), and degenerative spondylolisthesis (25.3%). Overall, 58.3% of patients underwent fusion (mean fusion length: 2.6±2.9 levels), 50% underwent laminectomy, 82.9% of cases involved posterior-only approach, 17.6% combined, and 0.5% anterior-only. Patients showed significant pre- to postoperative improvement in both ODI (50.2 to 39.0) and PROMIS Physical Function (10.9 to 21.4), Pain Intensity (92.4 to 78.3) and Pain Interference (58.4 to 49.8, all p 0.05); however, 3-month postoperative scores for Physical Function (r=-0.205, p=0.005) and Pain Interference (r=0.182, p=0.014) both showed stronger correlations with complication occurrence than ODI (r=0.143, p=0.055). Regression analysis showed that while perioperative complication incidence could not predict postoperative ODI (p>0.05), complication occurrence predicted Physical Function (R2=0.037, p=0.005) and Pain Interference (R2=0.028, p=0.014) scores. CONCLUSIONS The PROMIS domains of Physical Function and Pain Interference better reflected perioperative complications and length of stay as compared to the legacy patient reported outcome ODI. These results suggest PROMIS may offer more utility as an outcomes assessment instrument. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Assessment of improvement on quality of life among patients undergoing surgery for treatment of degenerative lumbar spine in Quang Ngai General Hospital

Objectives: To compare quality of life of patients before and one- month after spinal surgery and to identify factors affecting improvement on their quality of life. Materials and Methods: A longitudinal study was conducted in 60 patients who were diagnosed with complicated degenerative lumbar spine and scheduled for surgery of spine at Quang Ngai General Hospital. The SF-36 scale was used to evaluate quality of life of the patients. Results: Findings showed that quality of life after surgery of patients was improved significantly in all components. The better change was found in items of bodily paint and social functioning while the least improvement was reported in physical functioning and role physical. Conclusion: Factors affecting improvement on quality of life of patients after degenerative lumbar surgery were age, BMI and accompanied diseases Key words: degenerative lumbar disease, surgery, quality of life, SF-36, Quang Ngai

P201 - From Degenerative to Deformity: Are We Doing Enough to Restore Sagittal Balance in Short Segment Fusions?

BACKGROUND CONTEXT: Iatrogenic flatback deformity is a common cause of sagittal malalignment resulting in disability and revision surgery. Though not well described, repeat smaller fusions can result in SSD. Few studies report the effect of short lumbar fusions on overall balance and PI-LL mismatch. This study aims to evaluate PI-LL mismatch and SL deficits in degenerative lumbar surgery.

Patient characteristics of smokers undergoing lumbar spine surgery: an analysis from the Quality Outcomes Database.

OBJECTIVE In this analysis the authors compare the characteristics of smokers to nonsmokers using demographic, socioeconomic, and comorbidity variables. They also investigate which of these characteristics are most strongly associated with smoking status. Finally, the authors investigate whether the association between known patient risk factors and disability outcome is differentially modified by patient smoking status for those who have undergone surgery for lumbar degeneration. METHODS A total of 7547 patients undergoing degenerative lumbar surgery were entered into a prospective multicenter registry (Quality Outcomes Database [QOD]). A retrospective analysis of the prospectively collected data was conducted. Patients were dichotomized as smokers (current smokers) and nonsmokers. Multivariable logistic regression analysis fitted for patient smoking status and subsequent measurement of variable importance was performed to identify the strongest patient characteristics associated with smoking status. Multivariable linear regression models fitted for 12-month Oswestry Disability Index (ODI) scores in subsets of smokers and nonsmokers was performed to investigate whether differential effects of risk factors by smoking status might be present. RESULTS In total, 18% (n = 1365) of patients were smokers and 82% (n = 6182) were nonsmokers. In a multivariable logistic regression analysis, the factors significantly associated with patients' smoking status were sex (p < 0.0001), age (p < 0.0001), body mass index (p < 0.0001), educational status (p < 0.0001), insurance status (p < 0.001), and employment/occupation (p = 0.0024). Patients with diabetes had lowers odds of being a smoker (p = 0.0008), while patients with coronary artery disease had greater odds of being a smoker (p = 0.044). Patients' propensity for smoking was also significantly associated with higher American Society of Anesthesiologists (ASA) class (p < 0.0001), anterior-alone surgical approach (p = 0.018), greater number of levels (p = 0.0246), decompression only (p = 0.0001), and higher baseline ODI score (p < 0.0001). In a multivariable proportional odds logistic regression model, the adjusted odds ratio of risk factors and direction of improvement in 12-month ODI scores remained similar between the subsets of smokers and nonsmokers. CONCLUSIONS Using a large, national, multiinstitutional registry, the authors described the profile of patients who undergo lumbar spine surgery and its association with their smoking status. Compared with nonsmokers, smokers were younger, male, nondiabetic, nonobese patients presenting with leg pain more so than back pain, with higher ASA classes, higher disability, less education, more likely to be unemployed, and with Medicaid/uninsured insurance status. Smoking status did not affect the association between these risk factors and 12-month ODI outcome, suggesting that interventions for modifiable risk factors are equally efficacious between smokers and nonsmokers.

Risk factors for 30-day reoperation and 3-month readmission: analysis from the Quality and Outcomes Database lumbar spine registry.

OBJECTIVE The aim of this paper was to use a prospective, longitudinal, multicenter outcome registry of patients undergoing surgery for lumbar degenerative disease in order to assess the incidence and factors associated with 30-day reoperation and 90-day readmission. METHODS Prospectively collected data from 9853 patients from the Quality and Outcomes Database (QOD; formerly known as the N2QOD [National Neurosurgery Quality and Outcomes Database]) lumbar spine registry were retrospectively analyzed. Multivariate binomial regression analysis was performed to identify factors associated with 30-day reoperation and 90-day readmission after surgery for lumbar degenerative disease. A subgroup analysis of Medicare patients stratified by age (< 65 and ≥ 65 years old) was also performed. Continuous variables were compared using unpaired t-tests, and proportions were compared using Fisher's exact test. RESULTS There was a 2% reoperation rate within 30 days. Multivariate analysis revealed prolonged operative time during the index case as the only independent factor associated with 30-day reoperation. Other factors such as preoperative diagnosis, body mass index (BMI), American Society of Anesthesiologists (ASA) class, diabetes, and use of spinal implants were not associated with reoperations within 30 days. Medicare patients < 65 years had a 30-day reoperation rate of 3.7%, whereas those ≥ 65 years had a 30-day reoperation rate of 2.2% (p = 0.026). Medicare beneficiaries younger than 65 years undergoing reoperation within 30 days were more likely to be women (p = 0.009), have a higher BMI (p = 0.008), and have higher rates of depression (p < 0.0001). The 90-day readmission rate was 6.3%. Multivariate analysis demonstrated that higher ASA class (OR 1.46 per class, 95% CI 1.25-1.70) and history of depression (OR 1.27, 95% CI 1.04-1.54) were factors associated with 90-day readmission. Medicare beneficiaries had a higher rate of 90-day readmissions compared with those who had private insurance (OR 1.43, 95% CI 1.17-1.76). Medicare patients < 65 years of age were more likely to be readmitted within 90 days after their index surgery compared with those ≥ 65 years (10.8% vs 7.7%, p = 0.017). Medicare patients < 65 years of age had a significantly higher BMI (p = 0.001) and higher rates of depression (p < 0.0001). CONCLUSIONS In this analysis of a large prospective, multicenter registry of patients undergoing lumbar degenerative surgery, multivariate analysis revealed that prolonged operative time was associated with 30-day reoperation. The authors found that factors associated with 90-day readmission included higher ASA class and a history of depression. The 90-day readmission rates were higher for Medicare beneficiaries than for those who had private insurance. Medicare patients < 65 years of age were more likely to undergo reoperation within 30 days and to be readmitted within 90 days after their index surgery.

Patient-reported Outcomes following Elective Surgery for Lumbar Degenerative Disease: Effect of Peri-operative Complications on Outcomes

Introduction There is a paradigm shift toward rewarding providers for quality rather than volume. Complications appear to occur at a fairly consistent frequency when looking at large aggregate datasets. Understanding how complications affect long-term patient reported outcomes (PROs), following degenerative lumbar surgery, is vital. Our hypothesis was that 90-day complications would adversely affect long term PROs compared with a cohort that did not experience a complication. Methods 906 consecutive patients undergoing elective surgery for degenerative lumbar disease over a period of four-years were enrolled into a prospective longitudinal registry. PROs: ODI, NRS-Back and leg pain (BP, LP), Quality of life (EQ-5D), and NASS satisfaction questionnaire were recorded at baseline and 12-month follow-up. Complications were divided into major (surgical site infection, hardware failure, new neurological deficit, pulmonary embolism, hematoma and MI) and minor (urinary tract infection, pneumonia and deep venous thrombosis). Results Thirteen percent (118) of patients developed complications: (major-12% (108) and 8% (68)-minor) within 90-days after surgery. The patients with complications had significantly higher ODI scores at 12-months (29.43 ± 17.7 versus 25.2 ± 18.33, p = 0.02) after surgery. In a multivariable linear regression analysis, after controlling for array of preoperative variables, the occurrence of a major complication was not associated with worsening ODI scores 12-month after surgery. There was no difference in the percent of patients achieving minimal clinically important difference MCID for disability (66% vs 64%), back (55% vs 56%) and leg pain (62% vs 59%), quality of life (19% vs14%) and patient satisfaction rates (82% vs 80%) between those without and with major complications. Conclusion The occurrence of major complications did not significantly affect the PROs 12-month after surgery. These patients achieve clinically meaningful outcomes and patient satisfaction, as much as those without complication. This information allows a physician to council patients on the fact that a complication creates frustration, cost, and inconvenience, however it does not appear to adversely affect clinically meaningful long-term outcomes and satisfaction.

Effect of complications within 90 days on patient-reported outcomes 3 months and 12 months following elective surgery for lumbar degenerative disease.

OBJECT There is a paradigm shift toward rewarding providers for quality rather than volume. Complications appear to occur at a fairly consistent frequency in large aggregate data sets. Understanding how complications affect long-term patient-reported outcomes (PROs) following degenerative lumbar surgery is vital. The authors hypothesized that 90-day complications would adversely affect long-term PROs. METHODS Nine hundred six consecutive patients undergoing elective surgery for degenerative lumbar disease over a period of 4 years were enrolled into a prospective longitudinal registry. The following PROs were recorded at baseline and 12-month follow-up: Oswestry Disability Index (ODI) score, numeric rating scales for back and leg pain, quality of life (EQ-5D scores), general physical and mental health (SF-12 Physical Component Summary [PCS] and Mental Component Summary [MCS] scores) and responses to the North American Spine Society (NASS) satisfaction questionnaire. Previously published minimum clinically important difference (MCID) threshold were used to define meaningful improvement. Complications were divided into major (surgicalsite infection, hardware failure, new neurological deficit, pulmonary embolism, hematoma and myocardial infarction) and minor (urinary tract infection, pneumonia, and deep venous thrombosis). RESULTS Complications developed within 90 days of surgery in 13% (118) of the patients (major in 12% [108] and minor in 8% [68]). The mean improvement in ODI scores, EQ-5D scores, SF-12 PCS scores, and satisfaction at 3 months after surgery was significantly less in the patients with complications than in those who did not have major complications (ODI: 13.5 ± 21.2 vs 21.7 ± 19, < 0.0001; EQ-5D: 0.17 ± 0.25 vs 0.23 ± 0.23, p = 0.04; SF-12 PCS: 8.6 ± 13.3 vs 13.0 ± 11.9, 0.001; and satisfaction: 76% vs 90%, p = 0.002). At 12 months after surgery, the patients with major complications had higher ODI scores than those without complications (29.1 ± 17.7 vs 25.3 ± 18.3, p = 0.02). However, there was no difference in the change scores in ODI and absolute scores across all other PROs between the 2 groups. In multivariable linear regression analysis, after controlling for an array of preoperative variables, the occurrence of a major complication was not associated with worsening ODI scores 12 months after surgery. There was no difference in the percentage of patients achieving the MCID for disability (66% vs 64%), back pain (55% vs 56%), leg pain (62% vs 59%), or quality of life (19% vs 14%) or in patient satisfaction rates (82% vs 80%) between those without and with major complications. CONCLUSIONS Major complications within 90 days following lumbar spine surgery have significant impact on the short-term PROs. Patients with complications, however, do eventually achieve clinically meaningful outcomes and report satisfaction equivalent to those without major complications. This information allows a physician to counsel patients on the fact that a complication creates frustration, cost, and inconvenience; however, it does not appear to adversely affect clinically meaningful long-term outcomes and satisfaction.

The value and cost-effectiveness of adult degenerative lumbar surgery

Patients often seek surgical treatment for relief of their chronic lower back pain, generally caused by spinal stenosis, disc herniation, or spondylolisthesis. Many studies have reported the effectiveness of these surgical procedures in terms of health-related quality-of-life (HRQOL) measures; however, little has been published regarding the value and cost-effectiveness of surgical intervention. In this systematic review of the literature: (1) we identified studies that reported economic interventional outcomes, specifically cost per quality-adjusted life years (QALY) or incremental cost-effectiveness ratios (ICER) and (2) we determined whether this literature demonstrates the cost-effectiveness of surgical intervention in treating degenerative lumbar conditions. A systematic search of databases such as PubMed and Cochrane Library, as well as hand searching the references of selected works, was focused on surgical and non-operative treatments for degenerative lumbar conditions, specifically spinal stenosis, lumbar disc herniation, and degenerative spondylilolysthesis. Outcomes were collected as cost-effectiveness values reported, as cost per quality-adjusted life years (QALY) gained in cohort studies, and as incremental cost-effectiveness ratios (ICER) in comparative studies. Five studies directly compared the cost-effectiveness of surgery to non-operative treatment. Twelve others simply reported cost-effectiveness in a single cohort manner. From the comparative studies, the mean ICER value was $45,962. From the single cohort studies, the mean cost/QALY was $75,017. Interventions with a value between $50,000 and $100,000, or less, are generally considered cost effective. The results of our literature review suggest that surgical intervention for degenerative lumbar conditions is indeed cost-effective. In fact, the value of surgery appears to increase with additional follow-up time. That is, surgery is more cost effective in the later years of follow-up. Our review also revealed a paucity of quality studies evaluating cost-effectiveness. With the economic burden of degenerative lumbar conditions being so great to the patient and society, we encourage clinicians to continue to report outcomes from an economic standpoint, using cost/QALY and ICER values.