A New Possible Standard in Evaluating Lower Extremity Motor Weakness

Kern Singh 대한척추신경외과학회 2020 Neurospine Vol.17 No.1

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Balancing Choices to Recover From the COVID-19 Pandemic

James M. Parrish,Nathaniel W. Jenkins,Kern Singh 대한척추신경외과학회 2020 Neurospine Vol.17 No.2

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Association of Preoperative PROMIS Scores With Short-term Postoperative Improvements in Physical Function After Minimally Invasive Transforaminal Lumbar Interbody Fusion

Nathaniel W. Jenkins,James M. Parrish,Thomas S. Brundage,Nadia M. Hrynewycz,Kern Singh 대한척추신경외과학회 2020 Neurospine Vol.17 No.2

Objective: This study examines the associations between preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) score, measured by PROMIS-PF and the change between pre- and postoperative PROMIS-PF scores. Methods: A prospectively maintained surgical registry was retrospectively reviewed for spine surgeries between May 2015–June 2019. Inclusion criteria were primary, single-level minimally invasive transforaminal lumbar interbody fusions. Revisions, multilevel procedures, and patients missing preoperative surveys were excluded. Patients were grouped by preoperative PROMIS-PF scores of ≥ 35 and < 35, with higher scores indicating greater PF. A chi-squared and Student t-test were used to analyze categorical and continuous variables respectively. Linear regression evaluated the relationship of PROMIS-PF score improvement. Results: Of the 180 subjects, 84 were in the PROMIS-PF < 35 group which had more obese patients (p < 0.001) and more males (p = 0.001). Length of stay was greater for the PROMIS-PF < 35 group (36.2 hours vs. 28.7 hours, p = 0.014). PROMIS-PF and Oswestry Disability Index scores were significantly different between subgroups at all timepoints. PROMIS-PF < 35 cohort had larger postoperative PROMIS-PF improvements at 6 weeks (p = 0.008) and 12 weeks (p = 0.003). Linear regression demonstrated a negative association between preoperative PROMIS-PF scores and improvement at 6 weeks, 12 weeks, 6 months, and 2 years (p < 0.001). PROMIS-PF < 35 demonstrated significantly lower rate of achieving minimum clinically important difference at 6 months, otherwise no difference observed throughout the 2-year follow-up. Conclusion: Up to 6 months postoperatively, lower preoperative PROMIS-PF scores were associated with larger PROMIS-PF improvements. Understanding the relationship preoperative PROMIS-PF scores have with postoperative improvement may enable better patient counseling.

Longitudinal Evaluation of Patient-Reported Outcomes Measurement Information System for Back and Leg Pain in Minimally Invasive Transforaminal Lumbar Interbody Fusion

Nathaniel W. Jenkins,James M. Parrish,Nadia M. Hrynewycz,Thomas S. Brundage,Kern Singh 대한척추신경외과학회 2020 Neurospine Vol.17 No.4

Objective: While visual analogue score (VAS) metrics are among the most universally adopted patient-reported outcome measures (PROMs), there is limited research on the influence of back and leg pain on the Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) scores. Here we assess the association of VAS back and VAS leg scores with PROMIS PF in the setting of minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). Secondarily, we determine if PROMIS PF is more influenced by back or leg pain. Methods: A prospective surgical registry was reviewed from May 2015 to November 2018. Inclusion criteria were primary, single-level MIS TLIFs. We excluded multilevel procedures and patients without preoperative PROMs. Pre- and postoperative PROMIS PF, VAS back, and VAS leg scores were recorded at 6 weeks, 12 weeks, 6 months, and 1 year. A Pearson correlation evaluated PROMIS PF association with VAS back and VAS leg scores. A Fisher z-test compared correlations. Linear regression evaluated PROMIS with VAS back and VAS leg scores. Results: Our cohort was comprised of 146 subjects. 40.4% were female and the average age of 51 years. VAS back demonstrated a stronger correlation than VAS leg with PROMIS PF at all timepoints. PROMIS PF scores were negatively associated with both VAS back and VAS leg at all timepoints. Fisher z-test revealed VAS back to have a stronger correlation with PROMIS PF (p=0.025) than VAS leg. Conclusion: In the setting of MIS TLIF, physical function as evaluated by PROMIS PF, had a stronger correlation with VAS back than VAS leg at 6 months. This suggests that postoperative PROMIS PF scores may be more influenced by back pain than with leg pain.

The Relationship Between Preoperative PROMIS Scores With Postoperative Improvements in Physical Function After Anterior Cervical Discectomy and Fusion

James M. Parrish,Nathaniel W. Jenkins,Nadia M. Hrynewycz,Thomas S. Brundage,Kern Singh 대한척추신경외과학회 2020 Neurospine Vol.17 No.2

Objective: Assess preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) scores and differences between preoperative and postoperative PROMIS-PF scores for patients undergoing anterior cervical discectomy and fusion (ACDF). Methods: After Institutional Review Board approval, a prospectively maintained surgical registry was retrospectively reviewed for elective spine surgeries of nontraumatic, degenerative pathology between 2015–2018. Inclusion criteria were primary or revision, single-level ACDF procedures. Multilevel procedures and patients without preoperative surveys were excluded. A preoperative PROMIS score cutoff of 35 divided patients into PROMIS-PF score categories (e.g. , ≥ 35.0, < 35.0). Categorical and continuous variables were evaluated with chi-square tests and t-tests. Linear regression analyzed PROMIS-PF score improvement. Results: Eighty-six patients were selected, the high and low PROMIS-PF subgroups only differed in mean age (49.1 vs. 41.3, p = 0.002). Significant differences in PROMIS-PF scores were observed among high and low preoperative PROMIS-PF score subgroups at 6 weeks (p = 0.006), 12 weeks (p = 0.006), and 6 months (p = 0.014). Mean differences between preoperative and postoperative PROMIS-PF scores were significantly different between the high and low PROMIS-PF subgroups at 6 weeks (p = 0.041) and 1 year (p = 0.038). A significant negative association was observed between preoperative PROMIS scores and magnitude of improvement at the 6-week postoperative time point (slope = -0.6291, p < 0.001). Conclusion: Patients with low preoperative PROMIS-PF scores demonstrated greater improvements at 6 weeks and 1 year. Clinicians should consider patients with low preoperative PROMIS-PF scores to be in the unique position to potentially experience larger postoperative improvement magnitudes than patients with higher preoperative PROMIS-PF scores.

Commentary on “Complications in Minimally Invasive Spine Surgery in the Last 10 Years: A Narrative Review”

Gregory Snigur,John Sencaj,Sloane Ward,Shriya Patel,Luis Salazar,Kern Singh 대한척추신경외과학회 2024 Neurospine Vol.21 No.3

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History and Evolution of the Minimally Invasive Transforaminal Lumbar Interbody Fusion

Michael C. Prabhu,Kevin C. Jacob,Madhav R. Patel,Hanna Pawlowski,Nisheka N. Vanjani,Kern Singh 대한척추신경외과학회 2022 Neurospine Vol.19 No.3

The minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) is a popular surgical technique for lumbar arthrodesis, widely considered to hold great efficacy while conferring an impressive safety profile through the minimization of soft tissue damage. This elegant approach to lumbar stabilization is the byproduct of several innovations throughout the past century. In 1934, Mixter and Barr’s paper in the New England Journal of Medicine elucidated the role of disc herniation in spinal instability and radiculopathy, prompting surgeons to explore new approaches and instruments to access the disc space. In 1944, Briggs and Milligan published their novel technique, the posterior lumbar interbody fusion (PLIF), involving continuous removal of vertebral bone chips and replacement of the disc with a round bone peg. The following decades witnessed several PLIF modifications, including the addition of long pedicle screws. In 1982, Harms and Rolinger sought to redefine the posterior corridor by approaching the disc space through the intervertebral foramen, establishing the transforaminal lumbar interbody fusion (TLIF). In the 1990s, lumbar spine surgery experienced a paradigm shift, with surgeons placing increased emphasis on tissuesparing minimally invasive techniques. Spurred by this revolution, Foley and Lefkowitz published the novel MIS-TLIF technique in 2002. The MIS-TLIF has demonstrated comparable surgical outcomes to the TLIF, with an improved safety profile. Here, we present a view into the history of the posterior-approach treatment of the discogenic radiculopathy, culminating in the MIS-TLIF. Additionally, we evaluate the hallmark characteristics, technical variability, and reported outcomes of the modern MIS-TLIF and take a brief look at technologies that may define the future MIS-TLIF.

Higher American Society of Anesthesiologists Classification Does Not Limit Safety or Improvement Following Minimally Invasive Transforaminal Lumbar Interbody Fusion

Conor P. Lynch,Elliot D.K. Cha,Cara E. Geoghegan,Caroline N. Jadczak,Shruthi Mohan,Kern Singh 대한척추신경외과학회 2022 Neurospine Vol.19 No.3

Objective: The American Society of Anesthesiologists (ASA) physical status classification has been used to risk stratify surgical candidates. Our study compares outcomes of minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) procedures based on preoperative ASA physical status classification. Methods: A surgical registry was reviewed for primary, single-level MIS TLIF patients. Patients were categorized by preoperative ASA physical status classification: ASA I, ASA II, ASA III+. Perioperative complications were compared among groups. Patient-reported outcome measures (PROMs) for back pain, leg pain, physical function, and disability were recorded preoperatively and at 6-week, 12-week, 6-month, 1-year, and 2-year postoperative timepoints. PROM improvement from baseline (ΔPROM) and minimum clinically important difference (MCID) achievement was calculated for each timepoint and compared among groups. MCID achievement was determined as ΔPROMs that surpassed previously established MCID values. Results: Of the 487 patients, 64 had an ASA classification of I, whereas 336 had an ASA of II, and 87 had an ASA of III or greater. Rates of complications were not associated with ASA classification (all p > 0.050). Neither mean PROM scores nor ΔPROM scores were significantly associated with ASA classification at any timepoint (all p > 0.050). MCID achievement was significantly associated with ASA classification for back pain at 1 year only (p = 0.041). Overall MCID achievement was not significantly associated with ASA classification for any PROM (p > 0.050). Conclusion: While ASA classification has been commonly used to risk stratify surgical candidates for spinal procedures, patients with an ASA of III or greater may be able to achieve similar long-term outcomes following MIS TLIF given proper selection criteria.

Single-Level Anterior Lumbar Interbody Fusion versus Minimally Invasive Transforaminal Lumbar Interbody Fusion at L5/S1 for an Obese Population

Patel Madhav Rajesh,Jacob Kevin Chacko,Zamanian Cameron,Pawlowski Hanna,Prabhu Michael Clifford,Vanjani Nisheka Navin,Singh Kern 대한척추외과학회 2023 Asian Spine Journal Vol.17 No.2

Study Design: Retrospective study.Purpose: To compare perioperative outcomes, patient-reported outcome measures (PROMs), and minimal clinically important difference (MCID) achievement rates for an obese patient cohort between single-level minimally invasive (MIS) transforaminal lumbar interbody fusion (TLIF) vs. anterior lumbar interbody fusion (ALIF).Overview of Literature: To the best of our knowledge, no study has compared the outcomes of MIS TLIF and ALIF in an obese population.Methods: Obese patients (body mass index [BMI] ≥30.0 kg/m2) who underwent single-level MIS TLIF or ALIF at L5/S1 were included in the study. Demographic/perioperative variables, presenting patient pathology, and 1-year arthrodesis statistics were collected. PROM scores for Visual Analog Scale (VAS) back/leg, Oswestry Disability Index, 12-item Short Form Physical Composite Scale, and Patient-Reported Outcome Measurement Information System Physical Function (PROMIS-PF) were collected from preoperative and postoperative (6 weeks, 12 weeks, 6 months, 1 year, 2 years) PROMIS-PF. The obese patients were classified based on the procedure they underwent (MIS TLIF vs. ALIF).Results: The criteria were met by 210 patients in total. After coarsened exact matching for Charlson comorbidity index score, degenerative spondylolisthesis, isthmic spondylolisthesis, degenerative scoliosis, foraminal stenosis, insurance, male, and ethnicity, 94 obese patients were included in the total cohort, with 59 receiving MIS TLIF and 35 receiving ALIF. ALIF recipients had higher PROMIS-PF scores at 6 weeks (p=0.014) and 12 weeks (p=0.030), as well as a higher VAS leg at 2 years (p=0.017). Following multiple regression accounting for differences in baseline BMI, only the 6-week PROMIS-PF significantly differed (p=0.028), with no other intergroup differences in mean PROMs between fusion types. Aside from a significantly higher 6-week MCID achievement rate for PROMIS-PF among ALIF recipients (p=0.006), no differences in attainment were observed.Conclusions: There were no statistically significant differences in perioperative characteristics, fusion rates, PROMs, or MCID achievement between obese patients receiving MIS TLIF vs. ALIF. As a result, our findings indicate that MIS TLIF and ALIF at L5/S1 are equally effective in an obese patient population.

Swallowing Function Following Anterior Cervical Discectomy and Fusion With and Without Anterior Plating: A SWAL-QOL (Swallowing-Quality of Life) and Radiographic Assessment

Brittany E. Haws,Benjamin Khechen,Dil V. Patel,Joon S. Yoo,Jordan A. Guntin,Kaitlyn L. Cardinal,Kern Singh 대한척추신경외과학회 2019 Neurospine Vol.16 No.3

Objective: Anterior cervical plating in anterior cervical discectomy and fusion (ACDF) procedures are associated with improved outcomes compared to stand-alone cages. However, concerns exist regarding increased rates of postoperative dysphagia following an ACDF. This study aims to quantify the effect of anterior plating on swallowing-quality of life (SWAL-QOL) scores and radiographic swelling assessments following a primary, single-level ACDF. Methods: Patients retrospectively reviewed. Patients grouped into those receiving a cage or anterior plate. SWAL-QOL scores were recorded preoperatively and 6 weeks and 12 weeks postoperatively. Lateral radiographs were used to create a swelling index with a ratio of the prevertebral swelling distance to the anterior-posterior diameter of each involved vertebral body. An air index was created using the same methodology. Statistical analysis was performed using chi-square analysis and independent t-tests for categorical and continuous variables. Results: Sixty-eight primary, single-level ACDF patients were included. Forty-one (60.3%) received a stand-alone cage and 27 (39.7%) received a cage with anterior plating. No differences in demographics, comorbidities, operative time, estimated blood loss, or length of hospital stay were identified between Cage and Plate cohorts. Finally, no differences were observed in postoperative SWAL-QOL scores or swelling and air indices between groups. Conclusion: The results demonstrate that patients undergoing a primary, single-level ACDF with or without anterior plating experience similar operative times and lengths of stay. Patients that receive a cage with anterior plating did not experience significant increases in dysphagia as measured by the SWAL-QOL questionnaire compared to patients that received a stand-alone cage. Furthermore, radiographic assessments of swelling are comparable.