Back Visual Analog Scale Research Articles

P.132 Is a positive nerve root sedimentation sign associated with better outcomes after lumbar laminectomy?

Background: The nerve root sedimentation sign (SedSign) has been correlated with clinically significant lumbar spinal stenosis (LSS), and promoted as a possible prognostic indicator. However, diagnostic methods were not clearly defined in prior reports. In this study, the clinically validated Saskatchewan Spine Pathway enabled diagnosis of neurogenic claudication due to LSS. The objective was to compare the outcome of lumbar laminectomy for neurogenic claudication with respect to SedSign. Methods: This was a retrospective analysis of prospectively-collected data in patients with neurogenic claudication who underwent lumbar laminectomy. Outcome measures included Oswestry Disability Index, Visual Analogue Scale (VAS) for back and leg pain, and EuroQol 5-Dimension questionnaire. Results: Laminectomy was performed in 106 patients, and 60 were SedSign positive. Outcomes did not differ with respect to SedSign for all outcome measures, in non-instrumented and instrumented cohorts. Improvement in walking distance was associated with dural cross-sectional area of stenosis (p=0.02). VAS back and leg improvements were associated with back dominant (p=0.038) and leg dominant (p=0.0036) pain. Conclusions: This is the largest analysis of SedSign with respect to operative outcomes, and the only study with validated criteria for defining neurogenic claudication. Although other radiological and clinical factors are associated with improvements, SedSign did not correlate with laminectomy outcome.

Comparison of Anterior Approach and Posterior Approach to Instrumented Interbody Fusion for Spondylolisthesis: A Meta-analysis

To compare outcomes of instrumented interbody fusion by the anterior approach (anterior lumbar interbody fusion [ALIF] with posterior pedicle screw fixation [PPF] or lateral lumbar interbody fusion [XLIF] with PPF) or the posterior approach (transforaminal lumbar interbody fusion [TLIF] or posterior lumbar interbody fusion [PLIF]) for spondylolisthesis through meta-analysis. The MEDLINE via PubMed, Cochrane, Scopus, and Embase databases were searched for studies published between January 2010 and January 2019 evaluating outcomes including lumbar lordosis (LL), segmental lordosis (SL), slip rate, disc height (DH), back visual analogue scale (VAS), leg VAS, and Oswestry disability index (ODI) of ALIF with PPF or XLIF with PPF and TLIF or PLIF for spondylolisthesis. Two authors performed the data extraction independently. Any discrepancies were resolved by a consensus. Eight comparative studies were identified. There was no significant difference between the anterior approach and the posterior approach for preoperative LL, SL, and DH. In addition, postoperative back and leg VAS, and ODI between the 2 groups were not different. However, the anterior approach was more effective for restoration of postoperative LL, SL, and DH than the posterior approach. A literature review identified 8 comparative studies reporting outcomes of the anterior approach and the posterior approach in instrumented interbody fusion for spondylolisthesis. Despite heterogeneity, a limited meta-analysis showed that the postoperative restoration of LL, SL, and DH was better in the anterior approach group. Further large multicenter studies would be necessary to substantiate our results.

Outcomes and Quality of Life Improvement After Multilevel Spinal Fusion in Elderly Patients.

Study Design:Retrospective case series.Objectives:Both the rate and complexity of spine surgeries in elderly patients has increased. This study reports the outcomes of multilevel spine fusion in elderly patients and provides evidence on the appropriateness of complex surgery in elderly patients.Methods:We identified 101 patients older than70 years who had ≥5 levels of fusion. Demographic, medical, and surgical data, and change between preoperative and >500 days postoperative health survey scores were collected. Health surveys were visual analogue scale (VAS), EuroQoL 5 Dimensions (EQ-5D), Oswestry Disability Index (ODI), Scoliosis Research Society questionnaire (SRS-30), and Short Form health survey (SF-12) (physical composite score [PCS] and mental composite score [MCS]). Minimal clinically important differences (MCIDs) were defined for each survey.Results:Complications included dural tears (19%), intensive care unit admission (48%), revision surgery within 2 to 5 years (24%), and death within 2 to 5 years (16%). The percentage of patients who reported an improvement in health-related quality of life (HRQOL) of at least an MCID was: VAS Back 69%; EQ-5D 41%; ODI 58%; SRS-30 45%; SF-12 PCS 44%; and SF-12 MCS 48%. Improvement after a primary surgery, as compared with a revision, was on average 13 points higher in ODI (P = .007). Patients who developed a surgical complication averaged an improvement 11 points lower on ODI (P = .042). Patients were more likely to find improvement in their health if they had a lower American Society of Anesthesiologists or Charlson Comorbidity Index score or a higher metabolic equivalent score.Conclusions:In multilevel surgery in patients older than 70 years, complications are common, and on average 77% of patients attain some improvement, with 51% reaching an MCID. Physiological status is a stronger predictor of outcomes than chronological age.

Transforaminal Percutaneous Endoscopic Decompression for Lower Thoracic Spinal Stenosis

To explore the effect and safety of transforaminal percutaneous endoscopic decompression for lower thoracic spinal stenosis. We reviewed 6 patients receiving transforaminal percutaneous endoscopic thoracic decompression for sympathetic symptoms in the lower extremities. Pre- and postoperative Frankel grade and Japanese Orthopaedic Association scale (JOA) score, Oswestry Disability Index (ODI) score, and visual analog scale (VAS) scores of back and lower extremities were also evaluated and recorded. Wilcoxon signed-rank test was performed for statistical analysis. All 6 patients completed the follow-up. Mean follow-up was 12.6 months. Frankel grade in all patients improved to normal at the third month after operation. JOA scores significantly increased from 4.4 (range, 3.5-5.0) preoperatively to 5.5 (range, 5.0-6.5) postoperatively, to 6.5 (range, 6.0-7.0) at 3 months, to 6.6 (range, 6.2-7.0) at 6 months, and to 6.6 (range, 6.2-7.1) at 12 months (P < 0.05). ODI scores significantly decreased from 71.2 (range, 65-78) preoperatively to 50.2 (range, 45-60) postoperatively, to 30.3 (range, 25-40) at 3 months, to 12.2 (range, 0-20) at 6 months, and to 10.2 (range, 0-15) at 12 months (P < 0.05). VAS back scores decreased from 7.8 (range, 7.0-9.0) preoperatively to 6.9 (range, 6.0-7.5) postoperatively, to 3.3 (range, 3.0-4.0) at 3 months, to 2.3 (range, 2.0-3.0) at 6 months, and to 1.9 (range, 1.5-3.0) at 12 months (P < 0.05). VAS lower extremity scores decreased from 8.7 (range, 8.0-9.0) preoperatively to 3.0 (range, 2.5-3.6) postoperatively, to 1.1 (range, 0.5-1.3) at 3 months, to 0.9 (range, 0.2-1.2) at 6 months, and to 0.3 (range, 0.1-1.0) at 12 months (P < 0.05). Four patients reported excellent results and 2 reported good results at the last follow-up. Percutaneous endoscopic transforaminal thoracic decompression is effective and safe in settling lower thoracic spinal stenosis.

PROMIS Physical Function Score Strongly Correlates With Legacy Outcome Measures in Minimally Invasive Lumbar Microdiscectomy.

Retrospective cohort. This study aims to determine the validity of the patient-reported outcomes measurement information system (PROMIS) physical function (PF) in minimally invasive lumbar discectomy (MIS LD) patients. PROMIS was designed to allow for assessment of clinical outcomes in fewer questions than previous outcome measures with the goal of reducing noncompliance associated with longer, time-consuming surveys. However, there exists a paucity of evidence regarding the efficacy of the PROMIS PF domain in patients undergoing MIS LD. A surgical database of patients undergoing 1-3 level MIS LD was retrospectively reviewed. Postoperative changes in PROMIS PF scores were analyzed at 6-weeks, 12-weeks, and 6-months using paired Student t tests. PROMIS scores were compared to Oswestry disability index (ODI), visual analog scale (VAS) back, and VAS leg scores. Correlations were tested using Pearson correlation coefficient. Forty-one MIS LD patients were identified, reporting an average preoperative PROMIS PF score of 35.36 ± 7. Patients demonstrated significant improvement in ODI, VAS back, and VAS leg scores. Additionally, strong associations with PROMIS scores were observed for preoperative and postoperative ODI (r range: 0.5735-0.8543) and postoperative VAS back (r range: 0.5332-0.6522) and VAS leg pain (r range: 0.5257-0.6412). Patients undergoing MIS LD demonstrated significant improvements in PROMIS PF, ODI, VAS back, and VAS leg pain postoperatively. Additionally, improvements in PROMIS physical function scores at each postoperative time point were determined to be significantly correlated with ODI, VAS back, and VAS leg pain. The results of the current study demonstrate PROMIS PF has strong utility as a postoperative outcome assessment tool. 4.

Does Gender Influence Postoperative Outcomes in Minimally Invasive Transforaminal Lumbar Interbody Fusion?

Retrospective cohort. The objective of this study was to determine if an association exists between gender and postoperative improvements in patient-reported outcomes (PRO) measures following minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). Current spine literature presents conflicting findings regarding the influence of gender on clinical outcomes. Patients undergoing primary, single-level MIS TLIF were retrospectively reviewed. PRO measures including Oswestry Disability Index (ODI) and Visual Analog Scale (VAS) back and leg pain scores were collected preoperatively and 6-week, 12-week, and 6-month postoperatively. Rates of minimum clinically important difference (MCID) achievement were determined at 6-months postoperative. Statistical analysis was performed using Pearson χ analysis or Student t test. In total, 169 patients, 40.83% females and 59.17% males, were included. Females experienced greater inpatient pain scores than males (POD 0: 5.30 vs. 4.69, P=0.041; POD 1: 4.80 vs. 4.13, P=0.019). Females demonstrated significantly greater ODI (43.77 vs. 36.22; P=0.002) and VAS leg (6.20 vs. 5.27; P=0.039) scores than males. No differences in postoperative improvements in ODI, VAS back or VAS leg pain scores were identified between genders, with exception to females demonstrating greater improvement in VAS leg pain at 6 months postoperatively (female: -4.40 vs. male: -3.32; P=0.033). Furthermore, no differences in MCID achievement for PROs were identified between cohorts. Females demonstrated greater preoperative pain and disability as well as inpatient VAS pain scores compared to males. Furthermore, gender was not associated with differences in length of stay, perioperative complication rates, or narcotics consumption. Improvements in pain and disability, as well as rates of MCID achievement were similar between genders. These findings suggest that gender is not associated with surgical or clinical outcomes and should not be used as a predictor of outcomes following MIS TLIF. Level III.

Unintended facet fusions after Dynesys dynamic stabilization in patients with spondylolisthesis.

OBJECTIVEThe pedicle screw-based Dynesys dynamic stabilization (DDS) has reportedly become a surgical option for lumbar spondylosis and spondylolisthesis. However, it is still unclear whether the dynamic construct remains mobile or eventually fuses. The aim of this study was to investigate the incidence of unintended facet arthrodesis after DDS and its association with spondylolisthesis.METHODSThis retrospective study was designed to review 105 consecutive patients with 1- or 2-level lumbar spondylosis who were treated with DDS surgery. The patients were then divided into 2 groups according to preexisting spondylolisthesis or not. All patients underwent laminectomies, foraminotomies, and DDS. The clinical outcomes were measured using visual analog scale (VAS) scores for back and leg pain, Japanese Orthopaedic Association (JOA) scores, and Oswestry Disability Index (ODI) scores. All medical records, including pre- and postoperative radiographs, CT scans, and MR images, were also reviewed and compared.RESULTSA total of 96 patients who completed the postoperative follow-up for more than 30 months were analyzed. The mean age was 64.1 ± 12.9 years, and the mean follow-up duration was 46.3 ± 12.0 months. There were 45 patients in the spondylolisthesis group and 51 patients in the nonspondylolisthesis group. The overall prevalence rate of unintended facet fusion was 52.1% in the series of DDS. Patients with spondylolisthesis were older (67.8 vs 60.8 years, p = 0.007) and had a higher incidence rate of facet arthrodesis (75.6% vs 31.4%, p < 0.001) than patients without spondylolisthesis. Patients who had spondylolisthesis or were older than 65 years were more likely to have facet arthrodesis (OR 6.76 and 4.82, respectively). There were no significant differences in clinical outcomes, including VAS back and leg pain, ODI, and JOA scores between the 2 groups. Furthermore, regardless of whether or not unintended facet arthrodesis occurred, all patients experienced significant improvement (all p < 0.05) in the clinical evaluations.CONCLUSIONSDuring the mean follow-up of almost 4 years, the prevalence of unintended facet arthrodesis was 52.1% in patients who underwent DDS. Although the clinical outcomes were not affected, elderly patients with spondylolisthesis might have a greater chance of facet fusion. This could be a cause of the limited range of motion at the index levels long after DDS.

Improvements in Back and Leg Pain After Minimally Invasive Lumbar Decompression.

Few studies have quantified clinical improvement following minimally invasive lumbar decompression based on predominant back pain or leg pain. To quantify improvement in patient-reported outcomes following minimally invasive lumbar decompression and determine the degree of improvement in back pain, leg pain, and disability in patients who present with predominant back pain or predominant leg pain. Patients who underwent primary, one-level minimally invasive lumbar decompression for degenerative pathology were retrospectively reviewed. Comparisons of visual analog scale (VAS) back and leg pain scores, Oswestry Disability Index (ODI) scores, and Short Form-12 (SF-12) mental and physical component scores from pre-operative to 6-week, 12-week, 6-month, and 1-year follow-up. Subgroup analyses were performed for patients with predominant back pain or predominant leg pain. A total of 102 patients were identified. Scores on VAS back and leg pain, ODI, and SF-12 physical component improved from pre-operative to all post-operative time points. After 1year, patients reported a 2.8-point (47%) reduction in back pain and a 4-point (61.1%) reduction in leg pain scores; 52 patients with predominant back pain and 50 patients with predominant leg pain reported reductions in pain throughout the year following surgery. In both the back and leg pain cohorts, patients experienced reductions in ODI during the first 6months and throughout 1-year follow-up, respectively. The majority of patients achieved minimum clinically important difference, regardless of predominant symptom. Patients reported improvements in back and leg pain following minimally invasive lumbar decompression regardless of predominant presenting symptom; however, patients with predominant leg pain may experience greater improvement than those with predominant back pain.

Is achieving optimal spinopelvic parameters necessary to obtain substantial clinical benefit? An analysis of patients who underwent circumferential minimally invasive surgery or hybrid surgery with open posterior instrumentation.

It is now well accepted that spinopelvic parameters are correlated with clinical outcomes in adult spinal deformity (ASD). The purpose of this study was to determine whether obtaining optimal spinopelvic alignment was absolutely necessary to achieve a minimum clinically important difference (MCID) or substantial clinical benefit (SCB). A multicenter retrospective review of patients who underwent less-invasive surgery for ASD was conducted. Inclusion criteria were age ≥ 18 years and one of the following: coronal Cobb angle > 20°, sagittal vertical axis (SVA) > 5 cm, pelvic tilt (PT) > 20°, or pelvic incidence to lumbar lordosis (PI-LL) mismatch > 10°. A total of 223 patients who were treated with circumferential minimally invasive surgery or hybrid surgery and had a minimum 2-year follow-up were identified. Based on optimal spinopelvic parameters (PI-LL mismatch ± 10° and SVA < 5 cm), patients were divided into aligned (AL) or malaligned (MAL) groups. The primary clinical outcome studied was the Oswestry Disability Index (ODI) score. There were 74 patients in the AL group and 149 patients in the MAL group. Age and body mass index were similar between groups. Although the baseline SVA was similar, PI-LL mismatch (9.9° vs 17.7°, p = 0.002) and PT (19° vs 24.7°, p = 0.001) significantly differed between AL and MAL groups, respectively. As expected postoperatively, the AL and MAL groups differed significantly in PI-LL mismatch (-0.9° vs 13.1°, p < 0.001), PT (14° vs 25.5°, p = 0.001), and SVA (11.8 mm vs 48.3 mm, p < 0.001), respectively. Notably, there was no difference in the proportion of AL or MAL patients in whom an MCID (52.75% vs 61.1%, p > 0.05) or SCB (40.5% vs 46.3%, p > 0.05) was achieved for ODI score, respectively. Similarly, no differences in percentage of patients obtaining an MCID or SCB for visual analog scale back and leg pain score were observed. On multivariate analysis controlling for surgical and preoperative demographic differences, achieving optimal spinopelvic parameters was not associated with achieving an MCID (OR 0.645, 95% CI 0.31-1.33) or an SCB (OR 0.644, 95% CI 0.31-1.35) for ODI score. Achieving optimal spinopelvic parameters was not a predictor for achieving an MCID or SCB. Since spinopelvic parameters are correlated with clinical outcomes, the authors' findings suggest that the presently accepted optimal spinopelvic parameters may require modification. Other factors, such as improvement in neurological symptoms and/or segmental instability, also likely impacted the clinical outcomes.

Changes in the Flexion-Relaxation Response After Percutaneous Endoscopic Lumbar Discectomy in Patients with Disc Herniation

Previous studies of percutaneous endoscopic lumbar discectomy (PELD) to treat lumbar disc herniation (LDH) have shown good clinical results. However, limited information has been reported regarding postoperative improvement in back muscle function. We aimed to determine whether changes in neuromuscular patterns, assessed using the flexion-relaxation phenomenon (FRP), could be observed after PELD. A total of 30 patients participated in the present study. The patients' muscle functions were evaluated before and after PELD using surface electromyography and self-report measures. The evaluated action included 3 repetitions of a trunk flexion and extension movement. The association between the FRP measures and patient-reported outcomes was evaluated. At 4 weeks after PELD, the patients had significantly lower visual analog scale and Quebec Back Pain Disability Scale (QBPDS) scores and significantly increased gross range of motion. Also, we observed a reduction in erector spinae muscle activation at L3 in the maximum voluntary flexion phase. Normalized electromyographic root-mean-square values were significantly reduced in the maximum voluntary flexion phase and significantly increased in the extension phase. Postoperatively, 60% of the patients successfully achieved flexion-relaxation compared with 7% of the patients preoperatively. A significant correlation was found between the FRP measures and patient-reported outcomes, except for the Fear-Avoidance Beliefs Questionnaire scale. PELD for individuals with LDH appears to normalize paraspinal muscle activation during lumbar flexion-extension movement. The gross range of motion and disability-related limitations of physical activity also improved.

PROMIS Physical Function for prediction of postoperative pain, narcotics consumption, and patient-reported outcomes following minimally invasive transforaminal lumbar interbody fusion.

This study aimed to determine if the preoperative Patient-Reported Outcomes Measurement Information System, Physical Function (PROMIS PF) score is predictive of immediate postoperative patient pain and narcotics consumption or long-term patient-reported outcomes (PROs) following minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). A prospectively maintained database was retrospectively reviewed. Patients who underwent primary, single-level MIS TLIF for degenerative pathology were identified and grouped by their preoperative PROMIS PF scores: mild disability (score 40-50), moderate disability (score 30-39.9), and severe disability (score 20-29.9). Postoperative pain was quantified using the visual analog scale (VAS), and narcotics consumption was quantified using Oral Morphine Equivalents. PROMIS PF, Oswestry Disability Index (ODI), 12-Item Short-Form Health Survey, Physical Component Summary (SF-12 PCS), and VAS back and leg pain were collected preoperatively and at 6-week, 3-month, 6-month, and 12-month follow-up. Preoperative PROMIS PF subgroups were tested for an association with demographic and perioperative characteristics using 1-way ANOVA or chi-square analysis. Preoperative PROMIS PF subgroups were tested for an association with immediate postoperative pain and narcotics consumption in addition to improvements in PROMIS PF, ODI, SF-12 PCS, and VAS back and leg pain by using linear regression controlling for statistically different demographic characteristics. A total of 130 patients were included in this analysis. Patients were grouped by their preoperative PROMIS PF scores: 15.4% had mild disability, 63.8% had moderate disability, and 20.8% had severe disability. There were no significant differences among the subgroups in terms of age, sex, smoking status, and comorbidity burden. Patients with greater disability were more likely to be obese and to have workers' compensation insurance. There were no differences among subgroups in regard to operative levels, operative time, estimated blood loss, and hospital length of stay. Patients with greater disability reported higher VAS pain scores and narcotics consumption for postoperative day 0 and postoperative day 1. Patients with greater preoperative disability demonstrated lower PROMIS PF, ODI, SF-12 PCS, and worse VAS pain scores at each postoperative time point. Patients with worse preoperative disability, as assessed by PROMIS PF, experienced increased pain and narcotics consumption, along with less improvement in long-term PROs. The authors conclude that PROMIS PF is an efficient and accurate instrument that can quickly assess patient disability in the preoperative period and predict both short-term and long-term surgical outcomes.

Patient-Reported Outcomes Measurement Information System instruments: outperforming traditional quality of life measures in patients with back and neck pain.

The Patient-Reported Outcomes Measurement Information System (PROMIS) has become increasingly popular due to computer adaptive testing methodology. This study aims to validate the association between PROMIS and legacy outcome metrics and compare PROMIS to legacy metrics in terms of ceiling and floor effects and questionnaire burden. A retrospective review of an outcomes database was performed at a single institution from December 2016 to April 2017. Inclusion criteria were age > 18 years and a chief complaint of back pain or neck pain. The PROMIS computer adaptive testing Pain Interference, Physical Function (PF), and Pain Intensity domains; Oswestry Disability Index (ODI); Neck Disability Index (NDI); and visual analog scale (VAS) back, VAS leg, VAS neck, and VAS arm were completed in random order. PROMIS was compared to legacy metrics in terms of the average number of questions needed to complete each questionnaire and the score distributions in the lower and higher bounds of scores. A total of 494 patients with back pain and 130 patients with neck pain were included. For back pain, ODI showed a strong correlation with PROMIS-PF (R = -0.749, p < 0.001), Pain Intensity (R = 0.709, p < 0.001), and Pain Interference (R = 0.790, p < 0.001) domains. Additionally, the PROMIS Pain Intensity domain correlated to both VAS back and neck pain (R = 0.642, p < 0.001 for both). PROMIS-PF took significantly fewer questions to complete compared to the ODI (4.123 vs 9.906, p < 0.001). When assessing for instrument sensitivity, neither survey presented a significant ceiling and floor effect in the back pain population (ODI: 0.40% and 2.63%; PROMIS-PF: 0.60% and 1.41%). In the neck pain cohort, NDI showed a strong correlation with PROMIS-PF (R = 0.771, p < 0.001). Additionally, PROMIS Pain Intensity correlated to VAS neck (R = 0.642, p < 0.001). The mean number of questions required to complete the questionnaire was much lower for PROMIS-PF compared to NDI (4.417 vs 10, p < 0.001). There were no significant differences found in terms of ceiling and floor effects for neck complaints (NDI: 2.3% and 6.92%; PROMIS-PF: 0.00% and 5.38%) or back complaints (ODI: 0.40% and 2.63%; PROMIS-PF: 1.41% and 0.60%). PROMIS correlates strongly with traditional disability measures in patients with back pain and neck pain. For both back and neck pain, the PROMIS-PF required patients to answer significantly fewer questions to achieve similar granularity. There were no significant differences in ceiling and floor effects for NDI or ODI when compared with the PROMIS-PF instrument.

Impact of local steroid application in a minimally invasive transforaminal lumbar interbody fusion: results of a prospective, randomized, single-blind trial.

OBJECTIVELocal epidural steroid application may be associated with decreased pain and narcotic use in the immediate postoperative period following lumbar discectomy. However, local steroid delivery following lumbar fusion procedures has not been well characterized. This study aims to characterize the effect of local intraoperative depomedrol application on perioperative and postoperative outcomes following a single-level minimally invasive transforaminal lumbar interbody fusion (MIS TLIF).METHODSA prospective, randomized, single-blinded study was performed. A priori power analysis determined that 86 patients were needed to detect a difference of 1 point in the visual analog scale (VAS) pain score between groups. Ninety-three patients were randomized into depomedrol (DEPO) and no depomedrol (NODEPO) cohorts. Prior to surgical closure, DEPO patients received 1 ml depomedrol (80 mg) applied directly to the surgical site by using a Gelfoam carrier. NODEPO patients received 1 ml saline on the same Gelfoam carrier. Perioperative outcomes including acute postoperative pain and narcotic use were assessed for the duration of inpatient stay. Patient-reported outcomes (PROs) questionnaires including VAS back and leg pain scores, and Oswestry Disability Index (ODI) were administered preoperatively and at 6-week, 12-week, and 6-month follow-up. Outcomes for DEPO and NODEPO cohorts were compared using linear regression controlled for sex.RESULTSOf the 93 patients, 45 (48.4%) were randomized to DEPO and 48 (51.6%) to NODEPO. A greater percentage of DEPO patients were female (53.3% vs 27.1%, p = 0.010). There were no other significant differences in patient baseline characteristics. Similarly, operating time, estimated blood loss, and length of inpatient stay did not differ between cohorts. Patients in the DEPO cohort consumed fewer hourly narcotics on postoperative day 0 (5.3 vs 6.3 oral morphine equivalents/hour, p = 0.034). However, no differences in acute postoperative pain or total narcotics consumption were observed between groups. Preoperative VAS leg scores were statistically different between cohorts (p = 0.027). However, preoperative ODI and VAS back scores did not differ between groups. Additionally, DEPO and NODEPO groups experienced similar improvements in PROs at all postoperative time points.CONCLUSIONSLocal depomedrol use did not lead to decreases in acute postoperative pain or narcotics consumption after MIS TLIF. Additionally, local depomedrol was not associated with postoperative improvements in PROs. The findings of this randomized trial suggest that surgical and clinical outcomes following MIS TLIF may not be impacted by intraoperative application of depomedrol.Clinical trial registration no.: NCT03308084 (clinicaltrials.gov).

Association between payer status and patient-reported outcomes in adult patients with lumbar spinal stenosis treated with decompression surgery.

OBJECTIVE: Insurance disparities can have relevant effects on outcomes after elective lumbar spinal surgery. The aim of this study was to evaluate the association between private/public payer status and patient-reported outcomes in adult patients who underwent decompression surgery for lumbar spinal stenosis. METHODS: A sample of 100 patients who underwent surgery for lumbar spinal stenosis from 2012 to 2014 was evaluated as part of the prospectively collected Quality Outcomes Database at a single institution. Outcome measures were evaluated at 3 months and 12 months, analyzed in regard to payer status (private insurance vs Medicare/Veterans Affairs insurance), and adjusted for potential confounders. RESULTS: At baseline, patients had similar visual analog scale back and leg pain, Oswestry Disability Index, and EQ-5D scores. At 3 months postintervention, patients with government-funded insurance reported significantly worse quality of life (mean difference 0.11, p < 0.001) and more leg pain (mean difference 1.26, p = 0.05). At 12 months, patients with government-funded insurance reported significantly worse quality of life (mean difference 0.14, p < 0.001). There were no significant differences at 3 months or 12 months between groups for back pain (p = 0.14 and 0.43) or disability (p = 0.19 and 0.15). Across time points, patients in both groups showed improvement at 3 months and 12 months in all 4 functional outcomes compared with baseline (p < 0.001). CONCLUSIONS: Both private and public insurance patients had significant improvement after elective lumbar spinal surgery. Patients with public insurance had slightly less improvement in quality of life after surgery than those with private insurance but still benefited greatly from surgical intervention, particularly with respect to functional status.

Comparison of Transforaminal Percutaneous Endoscopic Lumbar Discectomy with and without Foraminoplasty for Lumbar Disc Herniation: A 2-Year Follow-Up.

Background Both transforaminal percutaneous endoscopic lumbar discectomy with foraminoplasty (TF PELF) and transforaminal percutaneous endoscopic lumbar discectomy without foraminoplasty (TF PELD) were developed for lumbar disc herniation (LDH) patients. However, the safety and effectiveness between the TF PELF and TF PELD have not been investigated. Methods Of the included 140 LDH patients, 62 patients received TF PELF (PELF group) and 78 patients received TF PELD (PELD group). The operation time, the duration of staying at the hospital, and complication incidences were recorded. All patients were followed up for 2 years, where low back and leg visual analogue scale (VAS) pain ratings and Oswestry Disability Index (ODI) were compared between the 2 groups before and after surgery. Modified Macnab criterion was estimated for all patients at postoperative 2 years. Results There were no significant difference of the operation time, number of days staying at the hospital, and the incidence of complications between the 2 groups (P > 0.05). Two cases in the PELF group and 1 case in the PELD group received a second surgery due to unrelieved symptoms postoperatively. Low back and leg VAS and ODI scores decreased in both groups after operation (P < 0.01), respectively, but were not significant between the 2 groups over time (P > 0.05). Six patients in the PELF group and 3 patients in the PELD group did not continue the follow-up; thus, only 131 patients completed Macnab evaluation. The satisfactory rate was reported as 80.4% in the PELF group and 90.7% in the PELD group (P > 0.05). Conclusions This study suggested that the safety and effectiveness of TF PELF are comparable to TF PELD for LDH patients.

Feasibility of Full Percutaneous Segmental Stabilization of the Lumbar Spine With a Combination of an Expandable Interbody Cage and an Interspinous Spacer: Preliminary Results.

We evaluated the feasibility of a full percutaneous approach with an expandable interbody cage and an interspinous spacer for a segmental stabilization of the anterior and posterior columns of the lumbar spine, respectively, with local anesthesia. Patients were prospectively included between 2012 and 2018 in this single-center, feasibility case series. An expandable interbody cage was inserted with endoscopy-based, facet-sparing percutaneous transforaminal lumbar interbody fusion (pTLIF). An interspinous spacer was percutaneously placed through the same skin incision. Pre- and postoperative Visual Analog Scale (VAS) and Oswestry Disability Index (ODI) outcomes at 1, 3, 6, 12, and 24 months were obtained and evaluated with the Student t test. Postoperative outcome was classified according to modified Macnab criteria. A total of 16 patients were included, presenting mean preoperative scores for VAS back of 6.9 ± 2.5, VAS leg 7.9 ± 1.2, and ODI 30.1 ± 4.5. Postoperative mean scores for VAS back of 1.9 ± 2.1, VAS leg 2.1 ± 3.4, and ODI 14.8 ± 13.0 significantly (P < .001) decreased with a mean follow-up of 18.1 ± 16.6 months (range 1-65.2). Postoperative outcome was excellent and good for 13 (81%) cases, fair for 2 (13%), and poor for 1 (6%) case with a preoperative spondylolisthesis, which required revision surgery due to persisting instability. Postoperative complications included 3 cases with transitory, ipsilateral dysesthesia and 2 cases with radiologic cage subsidence but no clinical symptoms. Median postoperative time until hospital discharge was 16 hours. Our preliminary results for this full percutaneous technique show a similar outcome compared to conventional surgery with a fast patient recovery and early postoperative hospital discharge, opening the way to instrumented, outpatient surgery.

The impact of age on surgical goals for spinopelvic alignment in minimally invasive surgery for adult spinal deformity.

OBJECTIVEAchieving appropriate spinopelvic alignment in deformity surgery has been correlated with improvement in pain and disability. Minimally invasive surgery (MIS) techniques have been used to treat adult spinal deformity (ASD); however, there is concern for inadequate sagittal plane correction. Because age can influence the degree of sagittal correction required, the purpose of this study was to analyze whether obtaining optimal spinopelvic alignment is required in the elderly to obtain clinical improvement.METHODSA multicenter database of ASD patients was queried. Inclusion criteria were age ≥ 18 years; an MIS component as part of the index procedure; at least one of the following: pelvic tilt (PT) > 20°, sagittal vertical axis (SVA) > 50 mm, pelvic incidence to lumbar lordosis (PI-LL) mismatch > 10°, or coronal curve > 20°; and minimum follow-up of 2 years. Patients were stratified into younger (< 65 years) and older (≥ 65 years) cohorts. Within each cohort, patients were categorized into aligned (AL) or mal-aligned (MAL) subgroups based on postoperative radiographic measurements. Mal-alignment was defined as a PI-LL > 10° or SVA > 50 mm. Pre- and postoperative radiographic and clinical outcomes were compared.RESULTSOf the 185 patients, 107 were in the younger cohort and 78 in the older cohort. Based on postoperative radiographs, 36 (33.6%) of the younger patients were in the AL subgroup and 71 (66.4%) were in the MAL subgroup. The older patients were divided into 2 subgroups based on alignment; there were 26 (33.3%) patients in the AL and 52 (66.7%) in the MAL subgroups. Overall, patients within both younger and older cohorts significantly improved with regard to postoperative visual analog scale (VAS) scores for back and leg pain and Oswestry Disability Index (ODI) scores. In the younger cohort, there were no significant differences in postoperative VAS back and leg pain scores between the AL and MAL subgroups. However, the postoperative ODI score of 37.9 in the MAL subgroup was significantly worse than the ODI score of 28.5 in the AL subgroup (p = 0.019). In the older cohort, there were no significant differences in postoperative VAS back and leg pain score or ODI between the AL and MAL subgroups.CONCLUSIONSMIS techniques did not achieve optimal spinopelvic alignment in most cases. However, age appears to impact the degree of sagittal correction required. In older patients, optimal spinopelvic alignment thresholds did not need to be achieved to obtain similar symptomatic improvement. Conversely, in younger patients stricter adherence to optimal spinopelvic alignment thresholds may be needed.https://thejns.org/doi/abs/10.3171/2018.4.SPINE171153.

Does minimally invasive fusion technique influence surgical outcomes in isthmic spondylolisthesis?

Objective: To compare the clinical and radiographic results between open transforaminal interbody fusion (TLIF-O) and minimally invasive TLIF (TLIF-M) for single-level low grade isthmic spondylolisthesis (IS).Methods: This study enrolled 45 patients who underwent single-level TLIF with low grade IS. The patients were divided into two groups according to operative method: TLIF-M (20 patients) and TLIF-O (25 patients). TLIF-O group was matched with TLIF-M.Results: At one-year postoperatively, there were no significant differences in any radiologic parameters between the two groups. Perioperative results such as blood loss, operation time, and hospital stay were superior in TLIF-M than in TLIF-O. Fusion was achieved in 17 of 20 patients (85.0%) in TLIF-M and 23 of 25 (92.0%) patients in TLIF-O. Back Visual Analog Scale (VAS) and Oswestry Disability Index (ODI) scores of TLIF-O were significantly lower than TLIF-M at one (back VAS, ODI) and six months (ODI) postoperatively.Conclusions: TLIF-M and TLIF-O produced similar clinical and radiological outcomes, including reduction of spondylolisthesis and disc space height restoration at one-year follow-up for single-level low grade IS. However, considering perioperative outcomes, back pain, and quality of life, TLIF-M might be a better option for single-level low grade IS compared to TLIF-O.

Wednesday, September 26, 2018 10:35 AM – 12:00 PM Understanding Lumbar Stenosis/Spondylolisthesis: 8. Patient-reported outcomes using ODI, VAS back and leg pain, and PROMIS in low-grade degenerative lumbar spondylolisthesis patients with high versus low pelvic incidence

BACKGROUND CONTEXT When evaluating and treating degenerative lumbar spondylolisthesis (DLS) patients, surgeons often do not think about and measure spino-pelvic parameters (SPPs) like they do for spinal deformity and isthmic spondylolisthesis patients. Few studies have looked at the association between patient-reported outcomes (PROs) such as those from Patient-Reported Outcomes Measurement Information System (PROMIS) and SPPs in the low-grade DLS population. A recent study showed an association between global sagittal imbalance and poor PROs in these patients. PURPOSE We aimed to determine if there is an association between PROs and pelvic incidence (PI) in low-grade DLS patients undergoing 1-2 level decompression and fusion. STUDY DESIGN/SETTING Retrospective cohort study, single institution. OUTCOME MEASURES Oswestry Disability Index (ODI), Visual Analog Scale (VAS) Back and Leg Pain. Patient-Reported Outcomes Measurement Information System (PROMIS) Computer Adaptive Tests (CAT) for physical function (PF), pain, depression and anxiety. All measured at baseline, initial, 6-month and 1-year follow-up. METHODS All Myerding grade 1 or 2 DLS patients who underwent 1-2 level decompression and fusion with at least 1-year of follow-up at our institution from August 2015 to October 2017 were retrospectively identified. Patients with high PI (>55°) and low PI ( RESULTS Fifty-nine patients were included with 44 (74.6%) high PI and 15 (25.4%) low PI. Demographics, comorbidities, surgical factors, postoperative complications, fusion status, PI-LL mismatch, and PRO measures were not significantly different (p>0.05) between the groups. In high PI patients, all PRO measures significantly improved (p≤0.05) after surgery compared to baseline at each follow-up. In low PI patients, VAS Back and Leg Pain and PROMIS PF and Pain significantly improved at initial follow-up, PROMIS Pain significantly improved at 6-month follow-up, and ODI, VAS Leg Pain and PROMIS PF and Pain significantly improved at 1-year follow-up. CONCLUSIONS PI does not make a significant difference in PROs in low-grade DLS patients undergoing 1-2 level decompression and fusion. High PI patients significantly improved in all PRO measures after surgery. Low PI patients either significantly improved or trended toward improvement in all PRO measures after surgery. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Wednesday, September 26, 2018 7:35 AM–9:00 AM ePosters: P65. Validity of PROMIS in minimally invasive transforaminal lumbar interbody fusion: a preliminary evaluation

BACKGROUND CONTEXT Patient-reported outcomes are commonly used to evaluate treatment efficacy. Inefficiencies in standard measurement tools often prove to be a barrier to data collection. The Patient-Reported Outcomes Measurement Information System (PROMIS) was developed to overcome these limitations. This tool implements computer adaptive testing, which allows for assessment of physical function in fewer questions than “static” metrics. Within spine surgery populations, moderate to strong correlations with Oswestry Disability Index (ODI) and Short Form (SF)-36 have been reported for PROMIS. However, data is limited regarding the efficacy of this tool in patients undergoing minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). PURPOSE To determine the validity of PROMIS when compared to ODI, VAS, and SF-12 in MIS TLIF. STUDY DESIGN/SETTING Retrospective cohort. PATIENT SAMPLE A total of 74 patients who underwent primary, one-two level MIS TLIF. OUTCOME MEASURES PROMIS, ODI, VAS back, VAS leg, and SF-12 physical function scores at preoperative to postoperative time points (6 weeks, 12 weeks, and 6 months). METHODS A prospectively maintained surgical registry of patients undergoing primary, one-two level MIS TLIF was retrospectively reviewed. Patients with incomplete PROMIS data were excluded. Postoperative changes in PROMIS physical function scores at 6 weeks, 12 weeks, and 6 months were analyzed using paired t-tests. PROMIS scores were compared to traditional outcome measures including SF-12 physical function, ODI, and Visual Analog Scale (VAS) back and leg scores. Correlations were tested using Pearson correlation coefficient with strength of association interpreted as follows: 0.1≤|r| RESULTS A total of 74 patients were included in this analysis after exclusion of those without PROMIS scores. The average preoperative PROMIS score was 35.92±6.98. There were significant improvements in postoperative PROMIS scores at 12 weeks (41.33, p≤.001) and 6 months (43.58, p CONCLUSIONS Physical function as measured by PROMIS improves significantly at 12 weeks and 6 months following MIS TLIF. Additionally, PROMIS scores demonstrate strong correlations with SF-12 and ODI scores. These results suggest that PROMIS scores may be used as a valid assessment of physical function in MIS TLIF. Further work is required to determine the full benefits of this measure in specific spine populations.