Quality Outcomes Database Research Articles

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.

23. Outcomes of direct vs indirect decompression for lumbar spondylolisthesis: A propensity matched cohort analysis

<h3>BACKGROUND CONTEXT</h3> Debate persists regarding the optimal surgical strategy to treat lumbar spondylolisthesis. The recent development of novel anterior approaches (direct lateral and oblique lumbar interbody fusion) has led to a rise in the utilization of anterior lumbar interbody fusion procedural codes. These new techniques rely on indirect decompression to treat the patient's neural compression, which is criticized by proponents of direct decompressive techniques. <h3>PURPOSE</h3> To compare 3- and 12-month outcomes between patients with lumbar spondylolisthesis treated with direct decompression (DD) vs indirect decompression (ID) and interbody fusion. <h3>STUDY DESIGN/SETTING</h3> Lumbar module of the Quality Outcomes Database (QOD), a national, multicenter prospective spine registry. <h3>PATIENT SAMPLE</h3> A total of 4,163 patients underwent DD (posterior lumbar laminectomy with interbody fusion) and 86 patients underwent ID (anterior lumbar interbody fusion and posterior instrumentation/fusion without laminectomy). <h3>OUTCOME MEASURES</h3> Oswestry Disability Index (ODI), NRS-back pain, NRS-leg pain, EQ5D, satisfaction, major complication, minor complication, readmission, and return to work at 3- and 12-months postsurgery, return to OR within 30 days. <h3>METHODS</h3> Propensity scores were estimated using logistic regression with surgical procedure as the dependent variable. Independent variables included the baseline covariates that are potentially associated with outcomes. Based on the logit of estimated propensity score, DD patients were one-to-one matched to ID patients using a greedy matching strategy without replacement. Binary outcomes between ID and DD propensity score matched patients were compared using McNemar's test. The estimates of risk difference and relative risk were determined as well as 95% confidence intervals using asymptotic score methods. Continuous outcomes were compared using two sample paired t-test. <h3>RESULTS</h3> In the propensity-matched analysis, the DD and ID cohorts did not differ with respect to their 12 month postoperative improvement in ODI (p=0.262), back pain (p=0.715), leg pain (p=0.144), EQ5D (0.384), satisfaction (0.423), readmission (p=1.00), return to OR within 30 days (p=0.317), return to work (p=0.366), or minor (p=1.00) / major (p=0.480) complication rates. The ID group did demonstrate a statistically-significant lower level of improvement in achieving a 30-percent reduction in leg pain at 3-months vs the DD cohort (p=0.05, RR 0.85, 95% CI 0.7091-0.9996). <h3>CONCLUSIONS</h3> DD and ID strategies to treat lumbar spondylolisthesis were similar in terms of 12-month PRO improvement, readmission, complications, return to work and satisfaction. The ID cohort did demonstrate a statistically-significant lower reduction in leg pain at 3 months, which was not maintained at 12 months. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Discharge destination influences risks of readmission and complications after lumbar spine surgery in severely disabled patients

ObjectiveFor individuals with severe disability requiring spine surgery, appropriate discharge destination is a challenging and complex decision. Past studies have found associations between discharge destination and postoperative outcomes but were limited by biases in sampling characteristics. The purpose of this study was to explore whether there is an association between discharge destination and odds of worse postoperative outcomes in high-risk individuals with severe/crippling/bedbound disability who received lumbar spine surgery. MethodsThis was an observational study using the Quality Outcomes Database Spine Registry. Subjects were limited to age ≥18 years, primary lumbar spine surgery, and severe disability at baseline (Oswestry Disability Index [ODI] ≥50%). Discharge destination was dichotomized to home or healthcare institution. ResultsOf the 13,050 patients, 11,859 patients (90.9%) were discharged home and 1191 (9.1%) patients were discharged to a healthcare institution. Individuals who were discharged to a healthcare institution were older (68.6 vs 56.9 p < 0.001) and had worse baseline characteristics (higher American Society of Anesthesiology [ASA] score, presence of back pain, and prevalence of comorbidities, all p < 0.001) compared to those who were discharged home. In covariate-controlled multivariate analysis, the home discharge cohort had lower rates of hospital readmission (OR = 0.68, 95% CI 0.55, 0.84) and revision surgery (OR = 0.56, 95% CI 0.37, 0.85) within three months and return to operating room (OR = 0.46, 95% CI 0.34–0.63) and complications (all OR < 0.50 except hematoma, p < 0.01) within 30 days than the institution discharge cohort. ConclusionSeverity of disability measured by ODI may influence but does not dictate discharge destination and the associated postoperative outcomes.

Psychological, mobility, and satisfaction variables mediate the relationship between baseline back pain intensity and long-term outcomes in individuals who underwent lumbar spine surgery

BackgroundIn patients who receive spine surgery, pain is relational to disability and quality of life, but exactly how this influence is mediated is not fully understood. Mediation analyses allow an understanding of a known relationship by exploring the underlying mechanism or processes by which one variable influences another. ObjectivesTo determine the mediating influence of psychological, mobility, and satisfaction variables on the relationship between preoperative back pain intensity and 12-month disability and quality of life in individuals who underwent lumbar spine surgery. DesignThis mediation analysis study used data from the Quality Outcomes Database (QOD) Lumbar Spine Surgical Registry. MethodsThere were included individuals who received lumbar spine surgery for degenerative spine conditions. The exposure variable was preoperative back pain intensity. Mediator variables were depression/anxiety, mobility, and satisfaction. Outcomes included disability and quality of life. Separate multiple mediator models were conducted using the Hayes PROCESS, Model 4 with bias-corrected bootstrapping (5000 samples) to predict disability and quality of life. Results26,130 individuals (n = 13,740 males, mean age 60.2 [SD = 13.8) were included. We observed a significant indirect effect through the mediators (anxiety/depression, mobility and satisfaction), for both disability (b = 0.31, 95%CI = 0.26, 0.35) and quality of life (b = −0.44, 95%CI = −0.48, −0.41). ConclusionOur study suggests that the relationship between preoperative back pain intensity (exposure) and long-term disability and quality of life (outcomes) is partially mediated by anxiety/depression, mobility, and patient satisfaction in individuals who received lumbar spine surgery.

Patient-reported outcome improvements at 24-month follow-up after fusion added to decompression for grade I degenerative lumbar spondylolisthesis: a multicenter study using the Quality Outcomes Database.

The ideal surgical management of grade I lumbar spondylolisthesis has not been determined despite extensive prior investigations. In this cohort study, the authors used data from the large, multicenter, prospectively collected Quality Outcomes Database to bridge the gap between the findings in previous randomized trials and those in a more heterogeneous population treated in a typical practice. The objective was to assess the difference in patient-reported outcomes among patients undergoing decompression alone or decompression plus fusion. The primary outcome measure was change in 24-month Oswestry Disability Index (ODI) scores. The minimal clinically important difference (MCID) in ODI score change and 30% change in ODI score at 24 months were also evaluated. After adjusting for patient-specific and clinical factors, multivariable linear and logistic regressions were employed to evaluate the impact of fusion on outcomes. To account for differences in age, sex, body mass index, and baseline listhesis, a sensitivity analysis was performed using propensity score analysis to match patients undergoing decompression only with those undergoing decompression and fusion. In total, 608 patients who had grade I lumbar spondylolisthesis were identified (85.5% with at least 24 months of follow-up); 140 (23.0%) underwent decompression alone and 468 (77.0%) underwent decompression and fusion. The 24-month change in ODI score was significantly greater in the fusion plus decompression group than in the decompression-only group (-25.8 ± 20.0 vs -15.2 ± 19.8, p < 0.001). Fusion remained independently associated with 24-month ODI score change (B = -7.05, 95% CI -10.70 to -3.39, p ≤ 0.001) in multivariable regression analysis, as well as with achieving the MCID for the ODI score (OR 1.767, 95% CI 1.058-2.944, p = 0.029) and 30% change in ODI score (OR 2.371, 95% CI 1.286-4.371, p = 0.005). Propensity score analysis resulted in 94 patients in the decompression-only group matched 1 to 1 with 94 patients in the fusion group. The addition of fusion to decompression remained a significant predictor of 24-month change in the ODI score (B = 2.796, 95% CI 2.228-13.275, p = 0.006) and of achieving the 24-month MCID ODI score (OR 2.898, 95% CI 1.214-6.914, p = 0.016) and 24-month 30% change in ODI score (OR 2.300, 95% CI 1.014-5.216, p = 0.046). These results suggest that decompression plus fusion in patients with grade I lumbar spondylolisthesis may be associated with superior outcomes at 24 months compared with decompression alone, both in reduction of disability and in achieving clinically meaningful improvement. Longer-term follow-up is warranted to assess whether this effect is sustained.

Identifying patients at risk for nonroutine discharge after surgery for cervical myelopathy: an analysis from the Quality Outcomes Database.

Optimizing patient discharge after surgery has been shown to impact patient recovery and hospital/physician workflow and to reduce healthcare costs. In the current study, the authors sought to identify risk factors for nonroutine discharge after surgery for cervical myelopathy by using a national spine registry. The Quality Outcomes Database cervical module was queried for patients who had undergone surgery for cervical myelopathy between 2016 and 2018. Nonroutine discharge was defined as discharge to postacute care (rehabilitation), nonacute care, or another acute care hospital. A multivariable logistic regression predictive model was created using an array of demographic, clinical, operative, and patient-reported outcome characteristics. Of the 1114 patients identified, 11.2% (n = 125) had a nonroutine discharge. On univariate analysis, patients with a nonroutine discharge were more likely to be older (age ≥ 65 years, 70.4% vs 35.8%, p < 0.001), African American (24.8% vs 13.9%, p = 0.007), and on Medicare (75.2% vs 35.1%, p < 0.001). Among the patients younger than 65 years of age, those who had a nonroutine discharge were more likely to be unemployed (70.3% vs 36.9%, p < 0.001). Overall, patients with a nonroutine discharge were more likely to present with a motor deficit (73.6% vs 58.7%, p = 0.001) and more likely to have nonindependent ambulation (50.4% vs 14.0%, p < 0.001) at presentation. On multivariable logistic regression, factors associated with higher odds of a nonroutine discharge included African American race (vs White, OR 2.76, 95% CI 1.38-5.51, p = 0.004), Medicare coverage (vs private insurance, OR 2.14, 95% CI 1.00-4.65, p = 0.04), nonindependent ambulation at presentation (OR 2.17, 95% CI 1.17-4.02, p = 0.01), baseline modified Japanese Orthopaedic Association severe myelopathy score (0-11 vs moderate 12-14, OR 2, 95% CI 1.07-3.73, p = 0.01), and posterior surgical approach (OR 11.6, 95% CI 2.12-48, p = 0.004). Factors associated with lower odds of a nonroutine discharge included fewer operated levels (1 vs 2-3 levels, OR 0.3, 95% CI 0.1-0.96, p = 0.009) and a higher quality of life at baseline (EQ-5D score, OR 0.43, 95% CI 0.25-0.73, p = 0.001). On predictor importance analysis, baseline quality of life (EQ-5D score) was identified as the most important predictor (Wald χ2 = 9.8, p = 0.001) of a nonroutine discharge; however, after grouping variables into distinct categories, socioeconomic and demographic characteristics (age, race, gender, insurance status, employment status) were identified as the most significant drivers of nonroutine discharge (28.4% of total predictor importance). The study results indicate that socioeconomic and demographic characteristics including age, race, gender, insurance, and employment may be the most significant drivers of a nonroutine discharge after surgery for cervical myelopathy.

Impact of surgeon and hospital factors on surgical decision-making for grade 1 degenerative lumbar spondylolisthesis: a Quality Outcomes Database analysis.

Surgical treatment for degenerative spondylolisthesis has been proven to be clinically challenging and cost-effective. However, there is a range of thresholds that surgeons utilize for incorporating fusion in addition to decompressive laminectomy in these cases. This study investigates these surgeon- and site-specific factors by using the Quality Outcomes Database (QOD). The QOD was queried for all cases that had undergone surgery for grade 1 spondylolisthesis from database inception to February 2019. In addition to patient-specific covariates, surgeon-specific covariates included age, sex, race, years in practice (0-10, 11-20, 21-30, > 30 years), and fellowship training. Site-specific variables included hospital location (rural, suburban, urban), teaching versus nonteaching status, and hospital type (government, nonfederal; private, nonprofit; private, investor owned). Multivariable regression and predictor importance analyses were performed to identify predictors of the treatment performed (decompression alone vs decompression and fusion). The model was clustered by site to account for site-specific heterogeneity in treatment selection. A total of 12,322 cases were included with 1988 (16.1%) that had undergone decompression alone. On multivariable regression analysis clustered by site, adjusting for patient-level clinical covariates, no surgeon-specific factors were found to be significantly associated with the odds of selecting decompression alone as the surgery performed. However, sites located in suburban areas (OR 2.32, 95% CI 1.09-4.84, p = 0.03) were more likely to perform decompression alone (reference = urban). Sites located in rural areas had higher odds of performing decompression alone than hospitals located in urban areas, although the results were not statistically significant (OR 1.33, 95% CI 0.59-2.61, p = 0.49). Nonteaching status was independently associated with lower odds of performing decompression alone (OR 0.40, 95% CI 0.19-0.97, p = 0.04). Predictor importance analysis revealed that the most important determinants of treatment selection were dominant symptom (Wald χ2 = 34.7, accounting for 13.6% of total χ2) and concurrent diagnosis of disc herniation (Wald χ2 = 31.7, accounting for 12.4% of total χ2). Hospital teaching status was also found to be relatively important (Wald χ2 = 4.2, accounting for 1.6% of total χ2) but less important than other patient-level predictors. Nonteaching centers were more likely to perform decompressive laminectomy with supplemental fusion for spondylolisthesis. Suburban hospitals were more likely to perform decompression only. Surgeon characteristics were not found to influence treatment selection after adjustment for clinical covariates. Further large database registry experience from surgeons at high-volume academic centers at which surgically and medically complex patients are treated may provide additional insight into factors associated with treatment preference for degenerative spondylolisthesis.

True Differences in Poor Outcome Risks Between Revision and Primary Lumbar Spine Surgeries.

Background: Previous studies have shown that the rates of complications associated with revision spine surgery are higher than those of primary spine surgery. However, there is a lack of research exploring the difference in magnitude of risk of poor outcomes between primary and revision lumbar spine surgeries. Purposes: We sought to compare the risks of poor outcomes for primary and revision lumbar spine surgeries and to analyze different measures of risk to better understand the true differences between the 2 forms of surgery. Methods: This retrospective observational study used data from the Quality Outcomes Database Lumbar Spine Surgical Registry from 2012 to 2018. We included individuals who received primary or revision surgery due to degenerative lumbar disorders. Outcome variables collected were complications within 30 days of surgery and 3 destination variables, specifically, (1) 30-day hospital readmission, (2) 30-day return to operating room, and (3) revision surgery within 3 months. Measures of risk considered were odds ratio (OR), relative risk (RR), relative risk increase (RRI), and absolute risk increase (ARI). Results: There were 31,843 individuals who received primary surgery and 7889 who received revision surgery. After controlling for baseline descriptive variables and comorbidities, revision surgery increased the odds of 4 complications and all 3 destination variables. Risk ratios reflected smaller magnitudes but similar findings as the statistically significant ORs. Conclusion: Revision surgery is related to higher overall risks than primary surgery, but the true magnitudes of these risks are very small. RRI and ARI should be included when reporting ORs to better clarify the significance.

"July Effect" Revisited: July Surgeries at Residency Training Programs are Associated with Equivalent Long-term Clinical Outcomes Following Lumbar Spondylolisthesis Surgery.

Retrospective analysis of a prospective registry. We utilized the Quality Outcomes Database (QOD) registry to investigate the "July Effect" at QOD spondylolisthesis module sites with residency trainees. There is a paucity of investigation on the long-term outcomes following surgeries involving new trainees utilizing high-quality, prospectively collected data. This was an analysis of 608 patients who underwent single-segment surgery for grade 1 degenerative lumbar spondylolisthesis at 12 high-enrolling sites. Surgeries were classified as occurring in July or not in July (non-July). Outcomes collected included estimated blood loss, length of stay, operative time, discharge disposition, complications, reoperation and readmission rates, and patient-reported outcomes (Oswestry Disability Index [ODI], Numeric Rating Scale [NRS] Back Pain, NRS Leg Pain, EuroQol-5D [EQ-5D] and the North American Spine Society [NASS] Satisfaction Questionnaire). Propensity score-matched analyses were utilized to compare postoperative outcomes and complication rates between the July and non-July groups. Three hundred seventy-one surgeries occurred at centers with a residency training program with 21 (5.7%) taking place in July. In propensity score-matched analyses, July surgeries were associated with longer operative times ( average treatment effect = 22.4 minutes longer, 95% confidence interval 0.9-449.0, P = 0.041). Otherwise, July surgeries were not associated with significantly different outcomes for the remaining perioperative parameters (estimated blood loss, length of stay, discharge disposition, postoperative complications), overall reoperation rates, 3-month readmission rates, and 24-month ODI, NRS back pain, NRS leg pain, EQ-5D, and NASS satisfaction score (P > 0.05, all comparisons). Although July surgeries were associated with longer operative times, there were no associations with other clinical outcomes compared to non-July surgeries following lumbar spondylolisthesis surgery. These findings may be due to the increased attending supervision and intraoperative education during the beginning of the academic year. There is no evidence that the influx of new trainees in July significantly affects long-term patient-centered outcomes.Level of Evidence: 3.

Predictors of the Best Outcomes Following Minimally Invasive Surgery for Grade 1 Degenerative Lumbar Spondylolisthesis.

The factors driving the best outcomes following minimally invasive surgery (MIS) for grade 1 degenerative lumbar spondylolisthesis are not clearly elucidated. To investigate the factors that drive the best 24-mo patient-reported outcomes (PRO) following MIS surgery for grade 1 degenerative lumbar spondylolisthesis. A total of 259 patients from the Quality Outcomes Database lumbar spondylolisthesis module underwent single-level surgery for degenerative grade 1 lumbar spondylolisthesis with MIS techniques (188 fusions, 72.6%). Twenty-four-month follow-up PROs were collected and included the Oswestry disability index (ODI) change (ie, 24-mo minus baseline value), numeric rating scale (NRS) back pain change, NRS leg pain change, EuroQoL-5D (EQ-5D) questionnaire change, and North American Spine Society (NASS) satisfaction questionnaire. Multivariable models were constructed to identify predictors of PRO change. The mean age was 64.2±11.5 yr and consisted of 148 (57.1%) women and 111 (42.9%) men. In multivariable analyses, employment was associated with superior postoperative ODI change (β-7.8; 95% CI [-12.9 to -2.6]; P=.003), NRS back pain change (β -1.2; 95% CI [-2.1 to -0.4]; P=.004), EQ-5D change (β 0.1; 95% CI [0.01-0.1]; P=.03), and NASS satisfaction (OR=3.7; 95% CI [1.7-8.3]; P<.001). Increasing age was associated with superior NRS leg pain change (β -0.1; 95% CI [-0.1 to -0.01]; P=.03) and NASS satisfaction (OR=1.05; 95% CI [1.01-1.09]; P=.02). Fusion surgeries were associated with superior ODI change (β -6.7; 95% CI [-12.7 to -0.7]; P=.03), NRS back pain change (β -1.1; 95% CI [-2.1 to -0.2]; P=.02), and NASS satisfaction (OR=3.6; 95% CI [1.6-8.3]; P=.002). Preoperative employment and surgeries, including a fusion, were predictors of superior outcomes across the domains of disease-specific disability, back pain, leg pain, quality of life, and patient satisfaction. Increasing age was predictive of superior outcomes for leg pain improvement and satisfaction.

The Influence of Unemployment and Disability Status on Clinical Outcomes in Patients Receiving Surgery for Low Back-Related Disorders: An Observational Study.

Introduction Employment status plays an essential role as a social determinant of health. Unemployed are more likely to have a longer length of hospital stay and a nearly twofold greater rate of 30 day readmission than those who were well employed at the time of back surgery. This study aimed to investigate whether employment status influenced post-surgery outcomes and if so, the differences were clinically meaningful among groups. Methods This retrospective observational study used data from the Quality Outcomes Database Lumbar Registry. Data refinement was used to isolate individuals 18 to 64 who received primary spine surgeries and had a designation of employed, unemployed, or disabled. Outcomes included 12 and 24 month back and leg pain, disability, patient satisfaction, and quality of life. Differences in descriptive variables, comorbidities, and outcomes measures (at 12 and 24 months) were analyzed using chi-square and linear mixed-effects modeling. When differences were present among groups, we evaluated whether they were clinically significant or not. Results Differences (between employed, unemployed, and disabled) among baseline characteristics and comorbidities were present in nearly every category (p<0.01). In all cases, those who were disabled represented the least healthy, followed by unemployed, and then employed. Clinically meaningful differences for all outcomes were present at 12 and 24 months (p<0.01). In post hoc analyses, differences between each group at nearly all periods were found. Conclusions The findings support that the health-related characteristics are markedly different among employment status groups. Group designation strongly differentiated outcomes. These findings suggest that disability and unemployment should be considered when determining prognosis of the individual.

Is There Additional Value to Flexion-Extension Radiographs for Degenerative Spondylolisthesis?

Multicenter retrospective study. Flexion-extension radiographs are frequently used to assess motion in patients with degenerative spondylolisthesis. However, they expose patients to additional radiation and increase cost. The aim of this study is to determine if flexion-extension radiographs provide additional information not seen on upright neutral radiographs and supine magnetic resonance imaging (MRI) that may guide surgical decision making. Supine MRI and upright neutral radiographs are routinely performed in patients with degenerative spondylolisthesis. It is unclear whether additional flexion-extension views play a significant role in surgical planning for this patient population. From the Quality Outcomes Database, patients who had surgery for grade 1 degenerative spondylolisthesis were identified. Magnitude of slip on pre-op supine MRI, upright neutral, flexion, and extension radiographs were measured. Additional motion was defined as 3 mm or more slip difference between radiographs. For the purpose of this analysis, patients with a slip of 7 mm or more on upright neutral radiographs were assumed to require a fusion. A total of 191 patients were identified. Mean age was 61.6 years (114 females, 60%). Only 31 patients (16%) had additional motion on flexion-extension views not seen on upright neutral x-rays versus supine MRI. Of these 31 patients, 19 had slips less than 7 mm on upright x-ray, generating equipoise for fusion. Flexion-extension radiographs may play a limited role in management of degenerative spondylolisthesis. The subset of patients for which flexion-extension views were most likely to provide value were patients with smaller slips (<7 mm) with no evidence of motion on standing radiographs versus MRI. In 90% of spondylolisthesis cases, information used for surgical planning may be ascertained by comparing motion between supine MRI and upright lateral radiographs.Level of Evidence: 3.

Quantifying the collective influence of social determinants of health using conditional and cluster modeling.

ObjectivesOur objective was to analyze the collective effect of social determinants of health (SDoH) on lumbar spine surgery outcomes utilizing two different statistical methods of combining variables.MethodsThis observational study analyzed data from the Quality Outcomes Database, a nationwide United States spine registry. Race/ethnicity, educational attainment, employment status, insurance payer, and gender were predictors of interest. We built two models to assess the collective influence of SDoH on outcomes following lumbar spine surgery—a stepwise model using each number of SDoH conditions present (0 of 5, 1 of 5, 2 of 5, etc) and a clustered subgroup model. Logistic regression analyses adjusted for age, multimorbidity, surgical indication, type of lumbar spine surgery, and surgical approach were performed to identify the odds of failing to demonstrate clinically meaningful improvements in disability, back pain, leg pain, quality of life, and patient satisfaction at 3- and 12-months following lumbar spine surgery.ResultsStepwise modeling outperformed individual SDoH when 4 of 5 SDoH were present. Cluster modeling revealed 4 distinct subgroups. Disparities between the younger, minority, lower socioeconomic status and the younger, white, higher socioeconomic status subgroups were substantially wider compared to individual SDoH.DiscussionCollective and cluster modeling of SDoH better predicted failure to demonstrate clinically meaningful improvements than individual SDoH in this cohort. Viewing social factors in aggregate rather than individually may offer more precise estimates of the impact of SDoH on outcomes.

Impact of Dominant Symptom on 12-Month Patient-Reported Outcomes for Patients Undergoing Lumbar Spine Surgery.

The impact of symptom characteristics on outcomes of spine surgery remains elusive. To determine the impact of symptom location, severity, and duration on outcomes following lumbar spine surgery. We queried the Quality Outcomes Database (QOD) for patients undergoing elective lumbar spine surgery for lumbar degenerative spine disease. Multivariable regression was utilized to determine the impact of preoperative symptom characteristics (location, severity, and duration) on improvement in disability, quality of life, return to work, and patient satisfaction at 1 yr. Relative predictor importance was determined using an importance metric defined as Wald χ2 penalized by degrees of freedom. A total of 22 022 subjects were analyzed. On adjusted analysis, we found patients with predominant leg pain were more likely to be satisfied (P<.0001), achieve minimum clinically important difference (MCID) in Oswestry Disability Index (ODI) (P=.002), and return to work (P=.03) at 1 yr following surgery without significant difference in Euro-QoL-5D (EQ-5D) (P=.09) [ref=predominant back pain]. Patients with equal leg and back pain were more likely to be satisfied (P<.0001), but showed no significant difference in achieving MCID (P=.22) or return to work (P=.07). Baseline numeric rating scale-leg pain and symptom duration were most important predictors of achieving MCID and change in EQ-5D. Predominant symptom was not found to be an important determinant of return to work. Worker's compensation was found to be most important determinant of satisfaction and return to work. Predominant symptom location is a significant determinant of functional outcomes following spine surgery. However, pain severity and duration have higher predictive importance. Return to work is more dependent on sociodemographic features as compared to symptom characteristics.

Effect of change in preoperative depression/anxiety on patient outcomes following lumbar spine surgery

ObjectiveThe purpose of this study was to investigate the association between positive change in depression or anxiety within three months post-operation and clinically meaningful changes in long-term clinical outcomes after lumbar spine surgery. MethodsThis study included adults with preoperative diagnosis of depression or anxiety who underwent lumbar spine surgery in the Quality Outcomes Database (QOD) from 2012 to 2018 with either a 12- or 24-month follow-up. Positive change in depression and anxiety was assessed three months after surgery. Clinical outcomes measured included Numeric Rating Scale (NRS) score for back pain (BP) and leg pain (LP), Oswestry Disability Index score (ODI) for disability, EuroQol Visual Analog Scale score (EQ-VAS) for health-related quality of life (HRQOL), and North American Spine Surgery (NASS) index score for patient satiaction measured at 12- and 24 months after surgery. ResultsOf the 9,656 and 1,393 patients who were included in the 12- and 24-month cohort, respectively, 7,277 patients (75.4 %) and 1,089 (78.2 %) experienced a positive change in depression or anxiety within three months after surgery. At both 12- and 24-month follow-up, patients who had positive change in depression or anxiety were more likely to achieve minimal clinically important changes in NRS-BP/LP, ODI, EQ-VAS, and NASS (all p < 0.01) compared to those who did not experience improvement in depression or anxiety. ConclusionDepression and anxiety are important comorbidities to consider in patients undergoing lumbar spine surgery. Positive change in depression and anxiety are associated with improvements in pain, disability, satisfaction, and overall functioning.

Measurement Properties of the Oswestry Disability Index in Recipients of Lumbar Spine Surgery.

This is an observational study on the measurement properties of the Oswestry Disability Index (ODI) version 1.0. To (1) determine the construct validity of the tool, specifically structural validity; (2) analyze the criterion validity of the tool, specifically concurrent validity against proxy measures of pain, function, and quality of life and predictive validity of each item to proxy measures of disability; and (3) reliability of the tool, specifically internal consistency. We endeavored to investigate the measurement properties of the ODI on a spine surgery population to test the assumption that a more disabled population may influence the properties of the tool. Data were pulled from the Quality Outcomes Database (QOD) Spine Registry. A total of 57,199 participants who underwent primary or revision lumbar spine surgeries were included. Structural validity was assessed by exploratory and confirmatory factor analysis, concurrent validity, predictive validity by odds ratios, and internal consistency by Cronbach alpha. The Visual Analog Scale for back pain, two standard open questions, and the EuroQol 5 Dimension/Visual Analogue Scale were included as proxy measures of pain, function, and quality of life, respectively. Hospital readmission, return to operating room for treatment and revision surgery (all within 30 days) were included as proxy measures of disability to assess the predictive validity of each ODI item. The ODI demonstrated a two-factor structural solution, which explained 54.9% of the total variance. Fair internal consistency (0.74-0.77), and fair criterion validity (concurrent) and significant findings with predictive validity (P < 0.01) substantiated the use of each item of the ODI as well as the summary score and ODI thresholds. Our study lends value to a burgeoning repository of evidence that suggests the ODI is a useful tool for capturing outcomes in clinical practice. We recommend its continued use in clinical practice.Level of Evidence: 4.

Long-term impact of obesity on patient-reported outcomes and patient satisfaction after lumbar spine surgery: an observational study.

Obese body habitus is a challenging issue to address in lumbar spine surgery. There is a lack of consensus on the long-term influence of BMI on patient-reported outcomes and satisfaction. This study aimed to examine the differences in patient-reported outcomes over the course of 12 and 24 months among BMI classifications of patients who underwent lumbar surgery. A search was performed using the Quality Outcomes Database (QOD) Spine Registry from 2012 to 2018 to identify patients who underwent lumbar surgery and had either a 12- or 24-month follow-up. Patients were categorized based on their BMI as normal weight (≤ 25 kg/m2), overweight (25-30 kg/m2), obese (30-40 kg/m2), and morbidly obese (> 40 kg/m2). Outcomes included the Oswestry Disability Index (ODI) and the visual analog scale (VAS) for back pain (BP) and leg pain (LP), and patient satisfaction was measured at 12 and 24 months postoperatively. A total of 31,765 patients were included. At both the 12- and 24-month follow-ups, those who were obese and morbidly obese had worse ODI, VAS-BP, and VAS-LP scores (all p < 0.01) and more frequently rated their satisfaction as "I am the same or worse than before treatment" (all p < 0.01) compared with those who were normal weight. Receiver operating characteristic curve analysis revealed that the BMI cutoffs for predicting worsening disability and surgery dissatisfaction were 30.1 kg/m2 and 29.9 kg/m2 for the 12- and 24-month follow-ups, respectively. Higher BMI was associated with poorer patient-reported outcomes and satisfaction at both the 12- and 24-month follow-ups. BMI of 30 kg/m2 is the cutoff for predicting worse patient outcomes after lumbar surgery.

260. Preoperative medical comorbidities do not affect minimum clinically important difference (MCID) for lumbar fusion in grade one spondylolisthesis

BACKGROUND CONTEXT Medical comorbidities, particularly anxiety or depression, may potentially influence how patients perceive clinical benefit after surgery. The current study defined and compared minimum clinically important difference (MCID) thresholds in patients with and without anxiety/depression and obesity undergoing fusion for grade 1 degenerative spondylolisthesis. PURPOSE To determine if preoperative psychiatric diagnoses, more than obesity, alters the MCID threshold in patients undergoing fusion for spondylolisthesis. STUDY DESIGN/SETTING Retrospective analysis of multicenter, prospective database. PATIENT SAMPLE Patients who underwent lumbar fusion for grade 1 degenerative spondylolisthesis from January 2014 to August 2017 enrolled in the Quality Outcomes Database (QOD). OUTCOME MEASURES Oswestry Disability Index (ODI), EuroQOL5D (EQ-5D), back (BP, 0-10) and leg pain (LP, 0-10) scores METHODS The QOD was queried for patients who underwent lumbar fusion for grade 1 degenerative spondylolisthesis from January 2014 to August 2017. Patient Reported Outcomes (PROs) included ODI, EQ-5D, BPand LP scores. Both anchor-based and distribution-based methods for MCID calculation were used. RESULTS Of 462 eligible cases, 356 (77%) had complete baseline and 12-month PROs. The MCID values for ODI were similar in patients with and without a diagnosis of obesity (20.58 and 20.69, respectively), and with and without anxiety/depression (24.72 and 22.56, respectively). The MCID values for BP, LP, and EQ-5D were also similar among all groups regardless of method used to determine MCID. CONCLUSIONS MCID thresholds for ODI, EQ5D, back pain and leg pain in patients with and without anxiety/depression and obesity undergoing spinal fusion for grade 1 degenerative spondylolisthesis are similar. Preoperative clinical and shared decision-making may be improved by understanding that preop medical comorbidities do not affect how patients determine an important clinical change postoperatively. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Commentary: A Comparison of Minimally Invasive and Open Transforaminal Lumbar Interbody Fusion for Grade 1 Degenerative Lumbar Spondylolisthesis: An Analysis of the Prospective Quality Outcomes Database.

Correspondence: Luis M. Tumialán, MD, c/o Neuroscience Publications, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd., Phoenix, AZ 85013, USA. Email: [email protected]

A Comparison of Minimally Invasive and Open Transforaminal Lumbar Interbody Fusion for Grade 1 Degenerative Lumbar Spondylolisthesis: An Analysis of the Prospective Quality Outcomes Database

It remains unclear if minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) is comparable to traditional, open TLIF because of the limitations of the prior small-sample-size, single-center studies reporting comparative effectiveness. To compare MI-TLIF to traditional, open TLIF for grade 1 degenerative lumbar spondylolisthesis in the largest study to date by sample size. We utilized the prospective Quality Outcomes Database registry and queried patients with grade 1 degenerative lumbar spondylolisthesis who underwent single-segment surgery with MI- or open TLIF methods. Outcomes were compared 24 mo postoperatively. A total of 297 patients were included: 72 (24.2%) MI-TLIF and 225 (75.8%) open TLIF. MI-TLIF surgeries had lower mean body mass indexes (29.5±5.1 vs 31.3±7.0, P=.0497) and more worker's compensation cases (11.1% vs 1.3%, P<.001) but were otherwise similar. MI-TLIF had less blood loss (108.8±85.6 vs 299.6±242.2 mL, P<.001), longer operations (228.2±111.5 vs 189.6±66.5 min, P<.001), and a higher return-to-work (RTW) rate (100% vs 80%, P=.02). Both cohorts improved significantly from baseline for 24-mo Oswestry Disability Index (ODI), Numeric Rating Scale back pain (NRS-BP), NRS leg pain (NRS-LP), and Euro-Qol-5 dimension (EQ-5D) (P>.001). In multivariable adjusted analyses, MI-TLIF was associated with lower ODI (β = -4.7; 95% CI = -9.3 to -0.04; P=.048), higher EQ-5D (β = 0.06; 95% CI=0.01-0.11; P=.02), and higher satisfaction (odds ratio for North American Spine Society [NASS] 1/2=3.9; 95% CI=1.4-14.3; P=.02). Though trends favoring MI-TLIF were evident for NRS-BP (P=.06), NRS-LP (P=.07), and reoperation rate (P=.13), these results did not reach statistical significance. For single-level grade 1 degenerative lumbar spondylolisthesis, MI-TLIF was associated with less disability, higher quality of life, and higher patient satisfaction compared with traditional, open TLIF. MI-TLIF was associated with higher rates of RTW, less blood loss, but longer operative times. Though we utilized multivariable adjusted analyses, these findings may be susceptible to selection bias.