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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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.

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.

Comorbidity Influence on Postoperative Outcomes Following Anterior Cervical Discectomy and Fusion

Elliot D.K. Cha,Conor P. Lynch,Caroline N. Jadczak,Shruthi Mohan,Cara E. Geoghegan,Kern Singh 대한척추신경외과학회 2021 Neurospine Vol.18 No.2

Objective: This study aims to detail the association between comorbidity burden and achieving minimum clinically important difference (MCID) following anterior cervical discectomy and fusion (ACDF). Methods: A prospective surgical registry was retrospectively reviewed. Patients with missing preoperative Patient-Reported Outcomes Measurement Information System physical function (PROMIS PF) were excluded. Patients were stratified by Charlson Comorbidity Index (CCI): no comorbidities=0 point; low CCI=1–2 points; high CCI=≥3 points. Demographic and perioperative characteristics were collected and evaluated for differences. Visual analogue scale (VAS), 12-item Short Form health survey (SF-12), and PROMIS PF were collected pre- and postoperatively and assessed for differences. Differences in achievement of MCID were compared using established values: VAS neck=2.6, VAS arm=4.1, NDI=8.5, SF-12 physical composite score (SF-12 PCS)=8.1, PROMIS PF=4.5. Results: One hundred twenty-five ACDF patients were included: 37 had no comorbidities, 64 with low CCI, and 24 with high CCI. Higher CCI groups were older, nonsmokers, diabetic, arthritic, hypertensive, and had cancer. Multilevel fusions, operative time, length of stay, and later discharge day were associated with high CCI. VAS neck differed preoperatively by group. SF-12 PCS and PROMIS PF were inversely associated with CCI groups. CCI did not impact achievement of MCID for all outcomes. A lower rate of reaching MCID was demonstrated at 3 months for SF-12 PCS. Conclusion: Regardless of comorbidity burden, patients undergoing ACDF for cervical pathology demonstrated a similar rate of achieving MCID for VAS neck, VAS arm, NDI, and PROMIS PF. Regardless of CCI score, ACDF can have a significant benefit for patients.

Effects of Anterior Plating on Achieving Clinically Meaningful Improvement Following Single-Level Anterior Cervical Discectomy and Fusion

Conor P. Lynch,Elliot D.K. Cha,Madhav R. Patel,Caroline N. Jadczak,Shruthi Mohan,Cara E. Geoghegan,Kern Singh 대한척추신경외과학회 2022 Neurospine Vol.19 No.2

Objective: The clinical utility of anterior cervical plating for anterior cervical discectomy and fusion (ACDF) procedures remains controversial. This study aims to compare the impact of cervical plating on achievement of minimum clinically important difference (MCID) up to 2 years following ACDF. Methods: Patients undergoing primary, single-level ACDF procedures were grouped based on whether their procedure included application of an anterior cervical plate. Demographics, preoperative spinal diagnoses, operative characteristics, and patient-reported outcome measures (PROMs) were compared between plating groups. Achievement of an MCID was assessed using the following previously established thresholds: 12-item Short Form health survey physical component summary (SF-12 PCS) 8.1, visual analogue scale (VAS) neck 2.6, VAS arm 4.1, Neck Disability Index (NDI) 8.5. Rates of MCID achievement were compared between groups. Results: The cohort included 192 patients of whom 102 received plating and 90 received no plating. Plating status was significantly associated with Charlson Comorbidity Index and insurance status. Operative duration and estimated blood loss were significantly greater for the plating group. Both groups demonstrated significant improvements at the majority of postoperative timepoints. Significant intergroup differences in PROM improvement were demonstrated for VAS neck and NDI at 6 weeks. Rates of MCID achievement differed significantly between groups for NDI at 6 weeks, and 12 weeks, and SF-12 PCS overall. Conclusion: Patients improved significantly in terms of pain, disability and physical function, regardless of plating status, and with the exception of early neck pain and disability, these improvements were similar between groups. Patients that underwent plating as part of their ACDF procedure achieved an MCID for physical function at lower rates overall.

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.

Preoperative Neck Disability Severity Limits Extent of Postoperative Improvement Following Cervical Spine Procedures

Elliot D.K. Cha,Conor P. Lynch,Shruthi Mohan,Cara E. Geoghegan,Caroline N. Jadczak,Kern Singh 대한척추신경외과학회 2021 Neurospine Vol.18 No.2

Objective: Our study aims to evaluate the impact of severity of preoperative Neck Disability Index (NDI) on postoperative patient-reported outcome measures (PROMs). Methods: A retrospective review of primary, elective, single or multilevel anterior cervical discectomy and fusion or cervical disc arthroplasty procedures between 2013 and 2019 was performed. Visual analogue scale (VAS) neck and arm, NDI, 12-item Short Form physical and mental composite score (SF-12 PCS and MCS), Patient-Reported Outcome Measurement Information System physical function, and 9-item Patient Health Questionnaire (PHQ-9) were collected preoperatively and postoperatively. Patients were categorized by preoperative NDI: none-to-mild disability (<30); moderate disability (≥30 to <50); severe disability (≥50 to <70); complete disability (≥70). The impact of preoperative NDI on PROM scores and minimum clinically important difference (MCID) achievement rates were evaluated. Results: The cohort included 74 patients with none-to-mild disability, 95 moderate, 76 severe, and 17 with complete disability. Patients with greater preoperative disability demonstrated significantly different scores for NDI, VAS neck, SF-12 MCS, and PHQ-9 at all timepoints (p<0.001). Patients with more severe disability demonstrated different magnitudes of improvement for NDI (all p<0.001), VAS neck (p≤0.009), VAS arm (p=0.025), and PHQ-9 (p≤0.011). The effect of preoperative severity on MCID achievement was demonstrated for NDI and for PHQ-9 (p≤0.007). Conclusion: Patients with severe neck disability demonstrated differences in pain, disability, physical and mental health. MCID achievement also differed by preoperative symptoms severity. Patients with more severe neck disability may be limited to the degree of improvement in quality of life but perceive them as significant changes.

Meeting Patient Expectations or Achieving a Minimum Clinically Important Difference: Predictors of Satisfaction Among Lumbar Fusion Patients

Cha Elliot D. K.,Lynch Conor P.,Jadczak Caroline N.,Mohan Shruthi,Geoghegan Cara E.,Singh Kern 대한척추외과학회 2022 Asian Spine Journal Vol.16 No.4

Study Design: Retrospective cohort. Purpose: To investigate the impact of meeting a patient’s preoperative expectations for back or leg pain or the achievement of minimum clinically important difference (MCID) on patient satisfaction following lumbar fusion. Overview of Literature: Few studies have compared if MCID achievement or meeting preoperative expectations for pain reduction affects patient satisfaction. Methods: A surgical database was reviewed for eligible patients who underwent lumbar fusion. Patient satisfaction and Visual Analog Scale (VAS) for back and leg pain were the outcomes of interest. Meeting expectations was calculated as a difference of ≤0 between preoperative expectations and postoperative VAS scores. MCID achievement was calculated by comparing changes in VAS scores with established values. Meeting preoperative expectations or MCID achievement as predictors of patient satisfaction was evaluated using regression analysis. Results: A total of 134 patients were included in this study. Patients demonstrated significant improvements in VAS back and VAS leg (p<0.001). At 1 year, 56.4% of patients had their VAS back expectations met compared with 59.5% for VAS leg. Similarly, at 1 year, 77.3% and 71.3% of patients achieved MCID for VAS back and leg, respectively. Meeting expectations for VAS back was significantly associated with patient satisfaction at all postoperative timepoints; however, MCID achievement only demonstrated a significant association with patient satisfaction at 6 and 12 weeks (all, p≤0.024). Meeting VAS leg expectations and MCID achievement both demonstrated a significant association with patient satisfaction at all postoperative timepoints (all, p≤0.02). No differences between MCID achievement and meeting expectations as predictors of satisfaction were noted. Conclusions: The majority of patients achieved MCID and had their back and leg pain expectations met by 1 year. Both measures were significant predictors of patient satisfaction and suggest that MCID achievement may act as a suitable substitute for patient satisfaction.