National Spine Registry Research Articles

Racial and Socioeconomic Disparities in Laminoplasty Versus Laminectomy With Fusion in Patients With Cervical Spondylosis.

A retrospective cohort study using prospectively collected data. The aim of this study was to investigate preoperative differences in racial and socioeconomic factors in patients undergoing laminoplasty (LP) versus laminectomy and fusion (LF) for degenerative cervical myelopathy (DCM). DCM is prevalent in the United States, requiring surgical intervention to prevent neurological degeneration. While LF is utilized more frequently, LP is an emerging alternative. Previous studies have demonstrated similar neurological outcomes for both procedures. However, treatment selection is primarily at the discretion of the surgeon and may be influenced by social determinants of health that impact surgical outcomes. The Quality Outcome Database (QOD), a national spine registry, was queried for adult patients who underwent either LP or LF for the management of DCM. Covariates associated with socioeconomic status, pain and disability, and demographic and medical history were collected. Multivariate logistic regression was performed to assess patient factors associated with undergoing LP versus LF. Of 1673 DCM patients, 157 (9.4%) underwent LP and 1516 (90.6%) underwent LF. A significantly greater proportion of LP patients had private insurance (P<0.001), a greater than high school level education (P<0.001), were employed (P<0.001), and underwent primary surgery (P<0.001). LP patients reported significantly lower baseline neck/arm pain and Neck Disability Index (P<0.001). In the multivariate regression model, lower baseline neck pain [odds ratio (OR)=0.915, P=0.001], identifying as non-Caucasian (OR=2.082, P<0.032), being employed (OR=1.592, P=0.023), and having a greater than high school level education (OR=1.845, P<0.001) were associated with undergoing LP rather than LF. In DCM patients undergoing surgery, factors associated with patients undergoing LP versus LF included lower baseline neck pain, non-Caucasian race, higher education, and employment. While symptomatology may influence the decision to choose LP over LF, there may also be socioeconomic factors at play. The trend of more educated and employed patients undergoing LP warrants further investigation.

Postoperative complications after surgery for lumbar spinal stenosis, assessment using two different data sources

PurposeLumbar spinal stenosis (LSS) is a prevalent disorder, and surgery for LSS is a common procedure. Postoperative complications occur after any surgery and impose costs for society and costs and additional morbidity for patients. Since complications are relatively rare, medical registries of large populations may provide valuable knowledge. However, recording of complications in registries can be incomplete.To better estimate the true prevalence of complications after LSS surgery, we reviewed two different sources of data and recorded complications for a sample of Norwegian LSS patients.Methods474 patients treated surgically for LSS during 2015 and 2016 at four hospitals reported to a national spine registry (NORspine).Postoperative complications were recorded by patients in NORspine, and we cross-referenced complications documented in NORspine with the patients´ electronic patient records (EPR) to re-test the complication rates. We performed descriptive statistics of complication rates using the two different data sources above, and analyzed the association between postoperative complications and clinical outcome with logistic regression.ResultsThe mean (95%CI) patient age was 66.3 (65.3–67.2) years, and 254 (53.6%) were females. All patients were treated with decompression, and 51 (10.7%) received an additional fusion during the index surgery. Combining the two data sources, we found a total rate for postoperative complications of 22.4%, the NORspine registry reported a complication rate of 15.6%, and the EPR review resulted in a complication rate of 16.0%. However, the types of complications were inconsistent across the two data sources. According to NORspine, the frequency of reoperation within 90 days was 0.9% and according to EPR 3.4%. The rates of wound infection were for NORspine 3.1% and EPR review 2.1%.There was no association between postoperative complication and patient reported outcome.ConclusionPostoperative complications occurred in 22% of LSS patients. The frequency of different postoperative complications differed between the two data sources.

Surgically Treated Degenerative Lumbar Spine Diseases in Twins.

There is growing evidence to suggest a potential genetic component underlying the development and progression of lumbar spine diseases. However, the heritability and the concordance rates for the phenotypes requiring surgery for the common spine diseases lumbar spinal stenosis (LSS) and lumbar disc herniation (LDH) are unknown. The aim of this study was to determine the heritability and the concordance rates for LSS and LDH requiring surgery by studying monozygotic (MZ) and dizygotic (DZ) twin pairs. Patients between 18 and 85 years of age who underwent surgery for LSS or LDH between 1996 and 2022 were identified in the national Swedish spine registry (LSS: 45,110 patients; LDH: 39,272 patients), and matched with the Swedish Twin Registry to identify MZ and DZ twins. Pairwise and probandwise concordance rates, heritability estimates, and MZ/DZ concordance ratios were calculated. We identified 414 twin pairs (92 MZ and 322 DZ pairs) of whom 1 or both twins underwent surgery for LSS. The corresponding number for LDH was 387 twin pairs (118 MZ and 269 DZ pairs). The probandwise concordance rate for LSS requiring surgery was 0.25 (26 of 105) (95% confidence interval [CI], 0.14 to 0.34) for MZ twins and 0.04 (12 of 328) (95% CI, 0.01 to 0.07) for DZ twins. The corresponding values for LDH requiring surgery were 0.03 (4 of 120) (95% CI, 0 to 0.08) and 0.01 (4 of 271) (95% CI, 0 to 0.04), respectively. The probandwise MZ/DZ concordance ratio was 6.8 (95% CI, 2.9 to 21.5) for LSS and 2.3 (95% CI, 0 to 8.9) for LDH. The heritability was significantly higher in LSS compared with LDH (0.64 [95% CI, 0.50 to 0.74] versus 0.19 [95% CI, 0.08 to 0.35]). Our findings suggest that genetic factors may play an important role in the risk of developing LSS requiring surgery, whereas heredity seems to be of less importance in LDH requiring surgery. Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Impact of Racial/Ethnic Disparities on Patient-Reported Outcomes Following Cervical Spine Surgery: QOD Analysis.

Retrospective analysis of data from the cervical module of a National Spine Registry, the Quality Outcomes Database. To examine the association of race and ethnicity with patient-reported outcome measures (PROMs) at one year after cervical spine surgery. Evidence suggests that Black individuals are 39% to 44% more likely to have postoperative complications and a prolonged length of stay after cervical spine surgery compared with Whites. The long-term recovery assessed with PROMs after cervical spine surgery among Black, Hispanic, and other non-Hispanic groups ( i.e . Asian) remains unclear. PROMs were used to assess disability (neck disability index) and neck/arm pain preoperatively and one-year postoperative. Primary outcomes were disability and pain, and not being satisfied from preoperative to 12 months after surgery. Multivariable logistic and proportional odds regression analyses were used to determine the association of racial/ethnic groups [Hispanic, non-Hispanic White (NHW), non-Hispanic Black (NHB), and non-Hispanic Asian (NHA)] with outcomes after covariate adjustment and to compute the odds of each racial/ethnic group achieving a minimal clinically important difference one-year postoperatively. On average, the sample of 14,429 participants had significant reductions in pain and disability, and 87% were satisfied at one-year follow-up. Hispanic and NHB patients had higher odds of not being satisfied (40% and 80%) and having worse pain outcomes (30%-70%) compared with NHW. NHB had 50% higher odds of worse disability scores compared with NHW. NHA reported similar disability and neck pain outcomes compared with NHW. Hispanic and NHB patients had worse patient-reported outcomes one year after cervical spine surgery compared with NHW individuals, even after adjusting for potential confounders, yet there was no difference in disability and neck pain outcomes reported for NHA patients. This study highlights the need to address inherent racial/ethnic disparities in recovery trajectories following cervical spine surgery.

A propensity-matched study of patients with symptomatic lumbar spinal stenosis opting for surgery versus not

IntroductionAlthough most surgeons treating patients with lumbar spinal stenosis (LSS) believe that surgical treatment is superior to conservative measures, systematics reviews have concluded that no solid evidence support this. Research questionTo compare change at 1-year of walking ability, health-related quality of life, leg and back pain in patients with symptomatic LSS referred to a spine surgery clinic who opted for surgery and those who did not. Material and methodsThe study included 149 operated and 149 non-operated patients seen by spine surgeons and diagnosed with LSS. The non-operated patients were propensity-matched to a cohort retrieved from the Danish national spine registry. Matching was done on demographics and baseline outcome measures. The outcomes was walking improvement measured by item 4 of the Oswestry Disability Index, EQ-5D-3L, global assessment (GA) of back/leg pain, back and leg pain on the Visual Analogue Scale and the Short Form 36 transition item 2. ResultsLess than half of the non-operated reached MCID on EQ-5D-3L, VAS pain legs or VAS pain back where 2/3 of the operated did. The largest difference was VAS back pain where 27.5% of the non-operated reached an MCID of 12 points compared to 71.8% in the operated group. Discussion and conclusionSurgical treated patients improved better than non-operated on all outcome measures. However, further research is required to compare the effectiveness of surgical decompression with non-operative care for LSS patients.

Long-term comparison of anterior (ALIF) versus transforaminal (TLIF) lumbar interbody fusion: a propensity score-matched register-based study.

Anterior (ALIF) and transforaminal (TLIF) lumbar interbody fusion have shown similar clinical outcomes at short- and medium-term follow-ups. Possible advantages of ALIF in the long run could be better disc height and lumbar lordosis and reduced risk of adjacent segment disease. We aimed to study if ALIF could be associated with superior clinical outcomes than TLIF at long-term follow-up. We analysed 535 patients treated with ALIF or TLIF of the L5-S1 spinal segment between 2007 and 2017 who completed long-term follow-up in a national spine registry database (NORspine). We defined treatment success after surgery as at least 30% improvement in Oswestry Disability Index (ODI) at long-term follow-up. Patients treated with ALIF and TLIF and who responded at long term were balanced by propensity score matching. The proportions of successfully treated patients within each group were compared by numbers and percentages with corresponding relative risk. The mean (95%CI) age of the total study population was 50 (49-51) years, and 264 (49%) were females. The mean (95%CI) preoperative ODI score was 40 (39-42), and 174 (33%) had previous spine surgery. Propensity score matching left 120 patients in each treatment group. At a median (95%CI) of 92 (88-97) months after surgery, we found no difference in proportions successfully treated patients with ALIF versus TLIF (68 (58%) versus 77 (65%), RR (95%CI) = 0.88 (0.72 to1.08); p = 0.237). This propensity score-matched national spine register study of patients treated with ALIF versus TLIF of the lumbosacral junction found no differences in proportions of successfully treated patients at long-term follow-up. Diagnostic: individual cross-sectional studies with the consistently applied reference standard and blinding.

The impact of Diabetes in patients with lumbar stenosis – A propensity-score matched study on patient-reported outcomes after surgery

Study designRegistry-based cohort study. ObjectiveTo evaluate the impact of Diabetes (DM) on Patient-reported Outcomes (PROs) after surgery for lumbar spinal stenosis (LSS). MethodPatients from the Danish national spine registry, DaneSpine, scheduled for LSS surgery were identified. MRI of patients with and without DM was graded in regards to lumbar stenosis, disc degeneration (DD), muscular fat infiltration, and Modic changes. In addition, preoperative and two-year postoperative data were collected including PROs. Patients with DM were propensity-score matched (PSM) to non-DM patients. ResultsIn total, 296 patients were included, 41 DM and 255 non-DM. Of these, 27 patients from each group were successfully matched. The PSM DM group had less improvement and worse leg pain at two-year follow-up compared to the non-DM group, VAS 58 vs. 36 (p = 0.004). Physical disability was significantly worse at two-year follow-up in the DM group compared to the non-DM group, Oswestry Disability Index score of 38 vs. 29 (p = 0.05). On the preoperative MRI, the number of patients with severe grade LSS and severe fat infiltration in Multifidus muscles was significantly higher in the PSM DM group compared to the non-DM group, (p < 0.01). ConclusionPatients with concomitant LSS and DM have a significantly reduced improvement in leg pain, more physical disability, and worse leg pain scores at two-year follow-up post-surgery compared to patients without DM. In elderly patients with LSS, there should be an increased focus on DM and the clinically relevant threshold for spine surgery.

Characteristics of patients who return to work after undergoing surgery for cervical spondylotic myelopathy: a Quality Outcomes Database study.

Return to work (RTW) is an important surgical outcome for patients who are employed, yet a significant number of patients with cervical spondylotic myelopathy (CSM) who are employed undergo cervical spine surgery and fail to RTW. In this study, the authors investigated factors associated with failure to RTW in the CSM population who underwent cervical spine surgery and who were considered to have a good surgical outcome yet failed to RTW. This study retrospectively analyzed prospectively collected data from the cervical myelopathy module of a national spine registry, the Quality Outcomes Database. The CSM data set of the Quality Outcomes Database was queried for patients who were employed at the time of surgery and planned to RTW postoperatively. Distinct multivariable logistic regression models were fitted with 3-month RTW as an outcome for the overall population to identify risk factors for failure to RTW. Good outcomes were defined as patients who had no adverse events (readmissions or complications), who had achieved 30% improvement in Neck Disability Index score, and who were satisfied (North American Spine Society satisfaction score of 1 or 2) at 3 months postsurgery. Of the 409 patients who underwent surgery, 80% (n = 327) did RTW at 3 months after surgery. At 3 months, 56.9% of patients met the criteria for a good surgical outcome, and patients with a good outcome were more likely to RTW (88.1% vs 69.2%, p < 0.01). Of patients with a good outcome, 11.9% failed to RTW at 3 months. Risk factors for failing to RTW despite a good outcome included preoperative short-term disability or leave status (OR 3.03 [95% CI 1.66-7.90], p = 0.02); a higher baseline Neck Disability Index score (OR 1.41 [95% CI 1.09-1.84], p < 0.01); and higher neck pain score at 3 months postoperatively (OR 0.81 [95% CI 0.66-0.99], p = 0.04). Most patients with CSM who undergo spine surgery reenter the workforce within 3 months from surgery, with RTW rates being higher among patients who experience good outcomes. Among patients with good outcomes who were employed, failure to RTW was associated with being on preoperative short-term disability or leave status prior to surgery as well as higher neck pain scores at baseline and at 3 months postoperatively.

Validating the predictive precision of the dialogue support tool on Danish patient cohorts

BackgroundDespite advances in surgical techniques and diagnostics, some patients remain unsatisfied with the result following spine surgery. One way to improve patient satisfaction may be found in better alignment of expectations. Prognostic tools might prove useful in strengthening surgeon-patient communication prior to surgery. The purpose of this study is to assess the predictive capabilities of the Swedish based Dialogue Support (DS) tool for spine surgery on a Danish population. MethodsThe study included the diagnoses lumbar disc herniation, lumbar spinal stenosis, and lumbar degenerative disc disease. A total of 5.954 patients were retrieved from the Danish national spine registry (DaneSpine). For each group, 200 random cases with complete preoperative and 1 year follow-up data were selected. Two outcome measures were used: Global assessment of pain (GA pain) and satisfaction with outcome. Predictions were produced by manual entry in the DS application. Goodness of fit tests were used to compare the predicted distribution of proportions with successful outcomes (GA pain) to the actual distribution in the three samples. Binomial tests were performed to evaluate the predicted proportion of satisfied patients. Furthermore, ROC-curves, calibration plots, and metrics were calculated to assess the predictive performance. ResultsROC curves showed comparable AUC values with the values reported by the developing authors of the DS from 0.62 to 0.73 (GA pain) and 0.64 to 0.70 (satisfaction with outcome). The calibration plots, however, revealed a low degree of concordance. For GA pain sensitivity varied from 92.4% to 99.3%, and specificity from 1.5% to 13.4%. For satisfaction, sensitivity varied from 97.1% to 99.2% and specificity from 0.0% to 2.9%. ConclusionsThe predictive capabilities of the DS tool could not be generalized to the Danish sample cohorts. Further research on larger samples, provided full access to the underlying algorithms can be obtained, could produce a different result.

Incidental dural tears associated with worse clinical outcomes in patients operated for lumbar spinal stenosis

Study designRetrospective cohort study.ObjectiveIncidental dural (ID) tear is a common complication of spine surgery with a prevalence of 4–10%. The association between ID and clinical outcome is uncertain. Former studies found only minor differences in Oswestry Disability Index (ODI). We aimed to examine the association of ID with treatment failure after surgery for lumbar spinal stenosis (LSS).MethodsBetween 2007 and 2017, 11,873 LSS patients reported to the national Norwegian spine registry (NORspine), and 8,919 (75.1%) completed the 12-month follow-up. We used multivariate logistic regression to study the association between ID and failure after surgery, defined as no effect or any degrees of worsening; we also compared mean ODI between those who suffered a perioperative ID and those who did not.ResultsThe mean (95% CI) age was 66.6 (66.4–66.9) years, and 52% were females. The mean (95% CI) preoperative ODI score (95% CI) was 39.8 (39.4–40.1); all patients were operated on with decompression, and 1125 (12.6%) had an additional fusion procedure. The prevalence of ID was 4.9% (439/8919), and the prevalence of failure was 20.6% (1829/8919). Unadjusted odds ratio (OR) (95% CI) for failure for ID was 1.51 (1.22–1.88); p < 0.001, adjusted OR (95% CI) was 1.44 (1.11–1.86); p = 0.002. Mean postoperative ODI 12 months after surgery was 27.9 for ID vs. 23.6 for no ID.ConclusionWe demonstrated a significant association between ID and increased odds for patient-reported failure 12 months after surgery. However, the magnitude of the detrimental effect of ID on the clinical outcome was small.

Predictors for failure after surgery for lumbar spinal stenosis: a prospective observational study

Background/contextSome patients do not improve after surgery for lumbar spinal stenosis (LSS), and surgical treatment implies a risk for complications and deterioration. Patient selection is of paramount importance to improve the overall clinical results and identifying predictive factors for failure is central in this work. PurposeWe aimed to explore predictive factors for failure and worsening after surgery for LSS. Study design /settingRetrospective observational study on prospectively collected data from a national spine registry with a 12-month follow-up. Patient sampleWe analyzed 11,873 patients operated for LSS between 2007 and 2017 in Norway, included in the Norwegian registry for spine surgery (NORspine). Twelve months after surgery, 8919 (75.1%) had responded. Outcome measuresOswestry Disability Index (ODI) 12 months after surgery. MethodsPredictors were assessed with uni- and multivariate logistic regression, using backward conditional stepwise selection and a significance level of 0.01. Failure (ODI>31) and worsening (ODI>39) were used as dependent variables. ResultsMean (95%CI) age was 66.6 (66.4–66.9) years, and 52.1% were females. The mean (95%CI) preoperative ODI score was 39.8 (39.4–40.1). All patients had decompression, and 1494 (12.6%) had an additional fusion procedure. Twelve months after surgery, the mean (95%CI) ODI score was 23.9 (23.5–24.2), and 2950 patients (33.2%) were classified as failures and 1921 (21.6%) as worse. The strongest predictors for failure were duration of back pain > 12 months (OR [95%CI]=2.24 [1.93–2.60]; p<.001), former spinal surgery (OR [95%CI]=2.21 [1.94–2.52]; p<.001) and age>70 years (OR (95%CI)=1.97 (1.69–2.30); p<.001). Socioeconomic variables increased the odds of failure (ORs between 1.36 and 1.62). The strongest predictors for worsening were former spinal surgery (OR [95%CI]=2.04 [1.77–2.36]; p<.001), duration of back pain >12 months (OR [95%CI]=1.83 [1.45–2.32]; p<.001) and age >70 years (OR [95%CI]=1.79 [1.49–2.14]; p<.001). Socioeconomic variables increased the odds of worsening (ORs between 1.33–1.67). ConclusionsAfter surgery for LSS, 33% of the patients reported failure, and 22% reported worsening as assessed by ODI. Preoperative duration of back pain for longer than 12 months, former spinal surgery, and age above 70 years were the strongest predictors for increased odds of failure and worsening after surgery.

Assessing the Insurance Deductible Effect on Outcomes After Elective Spinal Surgery

Private insurers use the calendar deductible system, placing pressure on patients and medical personnel to perform medical services before the end of the year to maximize patient savings. The impact of the deductible calendar on patient-reported outcomes (PROs) after spine surgery is poorly understood. The objective of our study was to investigate if patients undergoing surgery in December had different PROs and demographics compared with all other months. The Quality Outcome Database, a national spine registry, was queried for patients who underwent elective spine surgery between January 2012 and January 2021 for degenerative spine conditions. PROs and demographics were compared between the December and non-December groups using various statistical tests. A total of 978 patients (9.3%) underwent anterior cervical discectomy and fusion in December versus 9548 (90.7%) in other months. There was a significantly higher percentage of patients in December who had private insurance and were employed. A total of 1104 patients (8.5%) underwent lumbar fusion in December versus 11,826 (91.5%) in other months. There was a significantly greater chance of undergoing surgery in December if patients had private insurance and were employed. Although some PROs were statistically significant for the lumbar and cervical cohorts between December and non-December patients, none were clinically significant. Patients undergoing elective spine surgery in December were more likely to have private insurance and be employed. PROs for ACDF and lumbar fusions were not affected by surgical timing (December yes/no). Other spinal procedures directed at more chronic diseases might be more susceptible to external influence of insurance deductibles.

The Clinical Significance of the Modic Changes Grading Score.

Cross-sectional retrospective observational study. To evaluate the reliability and clinical utility of the Modic changes (MC) grading score. Patients from the Danish national spine registry, DaneSpine, scheduled for lumbar discectomy were identified. MRI of patients with MC were graded based on vertical height involvement: Grade A (<25%), Grade B (25%-50%), and Grade C (>50%). All MRIs were reviewed by 2 physicians to evaluate the reliability of the MC grade. Of 213 patients included, 142 patients had MC, 71 with MC-1 and 71 with MC-2; 34% were Grade A, 45% were Grade B, and 21% were Grade C. MC grade demonstrated substantial intra-rater (κ = .68) and inter-rater (κ = .61) reliability. A significantly higher proportion (n = 40, 57%) of patients with MC-1 had a severe MC grade compared to patients with MC-2 (n = 30, 43%, P < .001). Severe MC grade was associated with the presence of severe lumbar disc degeneration (DD) (Pfirrmann grade = V, P = .024), worse preoperative ODI (52.49 vs 44.17, P = .021) and EQ-5D scores (.26 vs .46, P = .053). MC alone including type was not associated with a significant difference in patient-reported outcomes (P > .05). The MC grade score was demonstrated to have substantial intra- and inter-observer reliability. Severe MC grade was associated with both severe DD and MC type, being more prevalent in patients with MC-1. The MC grade was also significantly associated with worse disability and reduced health-related quality of life. Results from the study suggest that MC grade is more clinically important than MC type.

Rating Spine Surgeons: Physician Review Websites Versus a Patient-reported Outcomes-derived Ranking.

This was an observational study. This study aims to determine the correlation between patient-reported outcomes (PROs) pulled from a national spine registry and physician ratings from physician review websites (PRWs). PRWs are frequently utilized by patients to make health care decisions; however, many PRWs appear to incorporate subjective experiences unrelated to a surgeon's clinical performance into ratings. As such, their utility as a health care decision-making tool remains unclear. This study evaluated 8834 patients from the Quality Outcomes Database (QOD) who underwent 1-level elective lumbar spine surgery. The lumbar module of QOD was queried to rank 124 surgeons using PROs (Oswestry Disability Index, EuroQOL, Numerical Rating Scale-back/leg pain, and patient satisfaction). The QOD PRO-ranking system was compared against PRWs including Healthgrades, Vitals, WebMD, and Google. The Spearman correlation coefficients, Kruskal-Wallis tests, and multiple linear regression models were used for statistical comparison. The primary outcome was the correlation between PRW scores and PROs. Surgeon PRO-derived ranking showed high intercorrelational congruence with coefficients between the 3 PROs (Oswestry Disability Index, EuroQOL, Numerical Rating Scale back/leg) ranging between 0.70 and 0.88. Low correlations were observed between PRO-derived rankings and PRWs, ranging from 0.23 to 0.37. Healthgrades performed most similarly to PRO-derived rankings, correlating best with patient satisfaction, though the correlation was low (ρ=0.37). While PRWs are often used to evaluate surgeon competency, these results demonstrate they poorly correlate with a surgeon's clinical ability measured by PROs. PRWs should be used with caution when making health care decisions by patients, payers, and administrators. Level III.

Accuracy and agreement of national spine register data for 474 patients compared to corresponding electronic patient records

PurposeData quality is essential for all types of research, including health registers. However, data quality is rarely reported. We aimed to assess the accuracy of data in a national spine register (NORspine) and its agreement with corresponding data in electronic patient records (EPR).MethodsWe compared data in NORspine registry against data in (EPR) for 474 patients operated for spinal stenosis in 2015 and 2016 at four public hospitals, using EPR as the gold standard. We assessed accuracy using the proportion correctly classified (PCC) and sensitivity. Agreement was quantified using Kappa statistics or interaclass correlation coefficient (ICC).ResultsThe mean age (SD) was 66 (11) years, and 54% were females. Compared to EPR, surgeon-reported perioperative complications displayed weak agreement (kappa (95% CI) = 0.51 (0.33–0.69)), PCC of 96%, and a sensitivity (95% CI) of 40% (23–58%). ASA classification had a moderate agreement (kappa (95%CI) = 0.73 (0.66–0.80)). Comorbidities were underreported in NORspine. Perioperative details had strong to excellent agreements (kappa (95% CI) ranging from 0.76 ( 0.68–0.84) to 0.98 (0.95–1.00)), PCCs between 93% and 99% and sensitivities (95% CI) between 92% (0.84–1.00%) and 99% (0.98–1.00%). Patient-reported variables (height, weight, smoking) had excellent agreements (kappa (95% CI) between 0.93 (0.89–0.97) and 0.99 (0.98–0.99)).ConclusionCompared to electronic patient records, NORspine displayed weak agreement for perioperative complications, moderate agreement for ASA classification, strong agreement for perioperative details, and excellent agreement for height, weight, and smoking. NORspine underreported perioperative complications and comorbidities when compared to EPRs. Patient-recorded data were more accurate and should be preferred when available.

Regional variations in lumbar spine surgery in Finland

IntroductionThe regional variation in spine surgery rates has been shown to be large both within and between countries. This variation has been reported to be less in studies from countries with spine registers. The aim of this study was to describe the regional variation in lumbar spine surgery in Finland.Materials and methodsThis is a retrospective register study. Data from the Finnish National Hospital Discharge Register (NHDR) were used to calculate and compare the rates of lumbar disc herniation (LDH), decompression, and fusion surgeries in five University Hospital catchment areas, covering the whole Finnish population, from January 1, 1997, through December 31, 2018.ResultsA total of 138,119 lumbar spine operations (including LDH, decompression, and fusion surgery) were performed in Finland between 1997 and 2018. The regional differences in the rate of LDH surgery were over fourfold (18 vs. 85 per 100,000 person years), lumbar decompression surgery over threefold (41 vs. 129 per 100,000 person years), and lumbar fusion surgery over twofold (14 vs. 34 per 100,000 person years) in 2018. The mean age of the patients increased in all regions during the study period.ConclusionsIn Finland, the regional variations in spine surgeries were vast. In a country with a publicly funded healthcare system, this finding was surprising. The recently created national spine register may serve to shed more light on the reasons for this regional variation.

Impact of predominant symptom location among patients undergoing cervical spine surgery on 12-month outcomes: an analysis from the Quality Outcomes Database.

The impact of the type of pain presentation on outcomes of spine surgery remains elusive. The aim of this study was to assess the impact of predominant symptom location (predominant arm pain vs predominant neck pain vs equal neck and arm pain) on postoperative improvement in patient-reported outcomes. The Quality Outcomes Database cervical spine module was queried for patients undergoing 1- or 2-level anterior cervical discectomy and fusion (ACDF) for degenerative spine disease. A total of 9277 patients were included in the final analysis. Of these patients, 18.4% presented with predominant arm pain, 32.3% presented with predominant neck pain, and 49.3% presented with equal neck and arm pain. Patients with predominant neck pain were found to have higher (worse) 12-month Neck Disability Index (NDI) scores (coefficient 0.24, 95% CI 0.15-0.33; p < 0.0001). The three groups did not differ significantly in odds of return to work and achieving minimal clinically important difference in NDI score at the 12-month follow-up. Analysis from a national spine registry showed significantly lower odds of patient satisfaction and worse NDI score at 1 year after surgery for patients with predominant neck pain when compared with patients with predominant arm pain and those with equal neck and arm pain after 1- or 2-level ACDF. With regard to return to work, all three groups (arm pain, neck pain, and equal arm and neck pain) were found to be similar after multivariable analysis. The authors' results suggest that predominant pain location, especially predominant neck pain, might be a significant determinant of improvement in functional outcomes and patient satisfaction after ACDF for degenerative spine disease. In addition to confirmation of the common experience that patients with predominant neck pain have worse outcomes, the authors' findings provide potential targets for improvement in patient management for these specific populations.

P142. Rating spine surgeons: Physician rating websites versus a patient reported outcomes derived ranking

P142. Rating spine surgeons: Physician rating websites versus a patient reported outcomes derived ranking

5. Impact of racial and ethnic disparities on health outcomes following cervical spine surgery

<h3>BACKGROUND CONTEXT</h3> Evidence suggests that Black non-Hispanic individuals are 39% to 44% more likely to have postoperative complications and prolonged length of stay after cervical spine surgery compared to White non-Hispanics. The long-term recovery of patient-reported health outcomes after cervical spine surgery among Hispanic and other non-Hispanic minorities (ie, Asian) remains unclear. Examining the postoperative recovery trajectory of Hispanic, Asian non-Hispanic, and Black non-Hispanic populations is important for identifying whether strategies are needed to reduce outcome disparities. <h3>PURPOSE</h3> The purpose of this study was to investigate the association of race and ethnicity with patient-reported health outcomes after cervical spine surgery. <h3>STUDY DESIGN/SETTING</h3> Retrospective analysis of data from the cervical module of a national spine registry, the Quality Outcomes Database (QOD). <h3>PATIENT SAMPLE</h3> Data from 14,136 QOD participants (mean±SD; age=56.8±11.5 years; BMI=30.2±6.4 kg/m2 and 49% females) across 28 states in the Unites States who underwent elective surgery for degenerative cervical spine disease and completed 1-year follow-up were analyzed. Participants self-identified as Hispanic (n=343), non-Hispanic Black (n=1,191), Asian (n=112) or White (n=12,490). <h3>OUTCOME MEASURES</h3> Patient-reported outcome measures (PROs) were used for assessing disability (Neck Disability Index: NDI), neck and arm pain (11-point Numeric Rating Scale), and health-related quality of life (EuroQol EQ-5D) at the preoperative and 1-year time point after surgery. Minimal symptom state at 1-year was defined as achieving a score of ≤20 on NDI, and neck and arm pain scores ≤2. Satisfaction was assessed using a single item question at 1-year after surgery (NASS scale). <h3>METHODS</h3> Multivariable linear and logistic regression analyses were conducted to compute effect estimates 95% confidence interval (CI) to determine the association of racial/ethnic groups with PROs. Covariates included sociodemographic items (eg, age, sex, BMI, insurance, education, employment status), US census regions, surgical variables (eg, surgical approach, pathology), opioid use and preop PROs. Multiple imputation using predictive mean matching was used to impute missing demographic characteristics (<5% missing). <h3>RESULTS</h3> Of the 14,136 participants, 48% achieved minimal symptom state at 1-year. Black non-Hispanic had 57% (odds ratio [95%CI]: 1.57 [1.37, 1.81]) and Hispanics had 31% (1.31 [1.02, 1.69]) higher odds of not achieving minimal symptom state at 1-year follow-up compared to White non-Hispanic. Similar findings for Black or Hispanics vs White groups were observed for other PROs and satisfaction. There were no differences in any outcome measures between Asian and White. <h3>CONCLUSIONS</h3> Comparatively, White and Asian groups did not have increased likelihood, but Hispanics and Black groups did have increased likelihood of reporting poor outcomes following cervical spine surgery, even after adjusting for potential confounders. The findings of this study suggest the need to account for inherent racial and ethnic disparities to better understand the recovery trajectories following cervical spine surgery. Also, strategies to minimize racial and ethnic disparities are needed to ensure equitable access to postoperative care in this surgical population. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

P50. The clinical significance and inter-observer reliability of the Modic changes grading score

<h3>BACKGROUND CONTEXT</h3> MC is present in up to 50% of all chronic low back pain patients. MRI finding of MC is associated with low back pain and disability. However, previous studies have shown heterogeneous results regarding the association and the clinical relevance of MC. A grading score for MC has been previously proposed, but the association between the extent of MC involvement in the vertebral body, or MC grade and patient-reported outcomes (PRO) has not been investigated. <h3>PURPOSE</h3> To evaluate the clinical significance and inter-observer reliability of the MC grading score in patients with low back pain and MC. <h3>STUDY DESIGN/SETTING</h3> A register-based study including an intra- and inter-reliability assessment of the Modic change(s) (MC) grading score. <h3>PATIENT SAMPLE</h3> MRI-scans from patients who had a discectomy registered in the Danish national spine register, DaneSpine, were reviewed. Based on the MRI findings the patients were divided into two groups: +MC and -MC.n=300. <h3>OUTCOME MEASURES</h3> The association between MC grade and disability as measured by ODI and EQ-5D were analyzed by t-test. <h3>METHODS</h3> The MRI of patients +MC were graded using the MC grading score from A-C where grade A in the midsagittal vertebral plane affects less than 25 % of the vertebral height grade B between 25% and 50% and grade C more than 50%. All MRIs were reviewed by two physicians to evaluate the intra- and inter-reliability of the MC grading score. <h3>RESULTS</h3> In total 300 patients were included, of these 150 had MC- 73 patients with MC-1 and 77 patients with MC-2. Of the +MC group, 34% had Grade A changes, 45% Grade B, and 21% Grade C. A scatter-plot showed that some patients with Grade B had worse PROs than some patients with grade C. Thus, patients were stratified into Grade A vs Grade B-C. A statistically significant higher percentage of patients with MC-1 had grade B-C changes compared to patients with MC-2 (p<0.001). Grade B-C changes were significantly associated with a worse preoperative ODI-score, 44 vs 52 (p=0.02) and EQ-5D 0.46 vs 0.26 (p=0.05) compared to Grade A. The intra- and inter-reliability of the MC grading score demonstrated substantial reliability, Intra Kappa=0.73, and Inter Kappa=0.64. <h3>CONCLUSIONS</h3> The current study found a significant difference in the vertical extent of MC between MC-1 and MC-2. An increased vertical extent of the intervertebral MC was significantly associated with worse preoperative PROs. The reliability for the grading score was substantial for both intra- and interobserver reliability in a clinically relevant population. We suggest that further studies on degenerative spine changes include a description of the vertebral extent of MC as an MC grading score. Further studies are needed to evaluate the usefulness of this tool in clinical decision-making and guidance of patients with MC suffering from back pain. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.