Study Design: This was a prospective cohort study. Objective: The objective of this study was to establish minimal clinically important difference (MCID) and substantial clinical benefit (SCB) thresholds for Patient-Reported Outcomes Measurement Information System (PROMIS) in cervical spine pathology. Summary of Background Data: PROMIS enables improved psychometric properties with reduced questionnaire burden through computer adaptive testing. Despite studies showing good correlation with “legacy” outcome measures, literature on the clinical significance of changes in PROMIS scores is scarce. Materials and Methods: Adult patients undergoing cervical spine surgery at a single institution between 2016 and 2018 were prospectively enrolled. Patients completed questionnaires [Short Form-36 (SF-36), Neck Disability Index (NDI), Visual Analogue Scale Arm/Neck, and PROMIS Pain Interference (PI) and Physical Function (PF)] preoperatively and at 6 months postoperatively. MCID was calculated using distribution-based and SCB using anchor-based methods. The SF-36 Health Transition Item was utilized as an anchor with the cutoff values chosen using receiver operating characteristic curve analysis. Results: There were 139 patients meeting inclusion criteria, with a mean age of 56.4 years and diagnoses of myelopathy (n=36), radiculopathy (n=48) and myeloradiculopathy (n=49). There were significant improvements in PROMIS PF, PROMIS PI, NDI, and SF-36 preoperatively to postoperatively (P<0.001). The test-retest reliability of all tests was excellent (intraclass correlation coefficients=0.87–0.94). PROMIS, SF-36, and NDI were all correlated with the anchor question (|r|=0.34–0.48, P<0.001). MCIDs were 8.5 (NDI), 11.1 (SF-36 Physical Component Score), 9.7 (SF-36 Mental Component Score), 4.9 (PROMIS PI), and 4.5 (PROMIS PF). SCB was 13.0 (NDI), 24.0 (SF-36 Physical Component Score), 11.8 (SF-36 Mental Component Score), 6.9 (PROMIS PI), and 6.8 (PROMIS PF). MCIDs were greater than standard error of measurement for all measures. Conclusions: We report MCID of 4.9 (PI) and 4.5 (PF) and SCB of 6.9 (PI) and 6.8 (PF). These data support the use of PROMIS computer adaptive tests in cervical spine patients and provide important reference as PROMIS reporting becomes more widespread in the literature.
Study Design. Retrospective review of prospectively collected data. Objective. To investigate if zero profile devices offer an advantage over traditional plate/cage constructs for dysphagia rates in single level anterior cervical discectomy and fusion (ACDF). Summary of Background Data. Dysphagia rates following ACDF have been reported to be as high as 83%, most cases are self-limiting, but chronic dysphagia can continue in up to 35% of patients. Zero profile devices were developed to limit dysphagia, and other plate specific complications, however the literature is currently divided regarding their efficacy. Methods. Dysphagia was assessed by swallowing quality of life (SWAL-QOL) scores preoperatively, at 6 weeks and 12 weeks. Patient reported outcome measures (PROMs) including visual analog scale (VAS) and Neck Disability Index (NDI) were collected preoperatively, at 6 weeks and at 6 months. Univariate and multivariate regression analysis was conducted with SWAL-QOL score as the dependent variable. Results. Sixty-four patients were included, 41 received a zero profile device, and 23 received plate-graft construct. Both groups were similar regarding patient demographics, except operative time, with the zero-profile group having a shorter procedure time than the cage-plate group (44.88 ± 6.54 vs. 54.43 ± 14.71 min, P = 0.001). At all timepoints dysphagia rates were similar between the groups. Regression analysis confirmed preoperative SWAL-QOL and operative time were the only significant variables. PROMs were also similar between groups at all time points, except VAS neck at 6 months, which was lower in the plate-graft group (1.05 ± 1.48 vs. 3.43 ± 3.21, P = 0.007). Conclusion. Operative time and preoperative SWAL-QOL scores are predictive of dysphagia in single level ACDF. Zero profile devices had a significantly shorter operative time, and may provide a benefit in dysphagia rates in this regard. Level of Evidence: 3
Study Design: This was a retrospective cohort study. Objective: This study evaluates if an association exists between preoperative depression and postoperative outcomes following minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). Summary of Background Data: Few studies have quantified preoperative depression symptoms using Patient Health Questionnaire-9 (PHQ-9) to predict postoperative outcomes after lumbar fusion, especially MIS TLIF. Methods: A surgical database of patients undergoing primary, single-level MIS TLIF was retrospectively reviewed. Patients were stratified by predefined preoperative PHQ-9 scores: no depression (<5), mild depression (5–9), and moderate to severe depression (≥10). Inpatient pain scores and narcotics use were recorded. Oswestry Disability Index, Veterans RAND-12 Mental Component Score and Physical Component Score, and Visual Analog Scale (VAS) back and leg pain scores were collected preoperatively and at 6-week, 12-week, and 6-month follow-up. One-way analysis of variance and χ2 analysis determined if an association existed between PHQ-9 subgroups and baseline characteristics or perioperative outcomes. Multivariate linear regression assessed for an association between PHQ-9 and postoperative patient-reported outcomes. Results: In total, 94 patients were included. Patients with higher PHQ-9 scores were younger, obese, and carried workers’ compensation insurance. Higher PHQ-9 scores were associated with worse preoperative Oswestry Disability Index, Veterans RAND-12 Mental Component Score and Physical Component Score, and VAS back and leg pain scores. Patients with higher PHQ-9 reported greater inpatient VAS pain scores on postoperative day 0 and 1 and demonstrated greater hourly narcotics consumption on postoperative day 0. Furthermore, higher PHQ-9 scores exhibited less improvement in all patient-reported outcomes. Conclusions: Patients with severe depression symptoms reported greater pain, increased narcotics consumption, and less clinical improvement after MIS TLIF. Therefore, patients with greater PHQ-9 scores should be monitored more closely and may benefit from additional counseling with regard to postoperative outcomes to better manage pain control and expectations of recovery.
Study Design: This study was a retrospective cohort analysis. Objectives: This study aims to evaluate the concurrent validity of Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) domain as compared with legacy measures of patient-reported outcomes (PROs) among patients undergoing anterior cervical discectomy and fusion (ACDF). Summary of Background Data: As PROMIS becomes increasingly utilized, it is important to assess its validity among procedure-specific populations. Methods: Patients undergoing a primary, 1–3 level ACDF were retrospectively identified from a prospectively maintained surgical registry. PROMIS PF and legacy PRO scores were obtained at preoperative, 6-week, 12-week, and 6-month postoperative visits. Legacy PROs included Neck Disability Index (NDI), Short Form-12 (SF-12) physical composite, Visual Analog Scale (VAS) neck pain, and VAS arm pain. Postoperative improvements in PROs were assessed using paired t tests. Correlations between PROMIS and legacy PROs were tested using Pearson correlation coefficient. Results: A total of 57 ACDF patients were analyzed. The mean preoperative PROMIS PF was 40.0±6.4. PROMIS PF significantly improved at 12-week and 6-month follow-up. NDI, VAS neck pain, and VAS arm pain scores demonstrated significant improvement at all postoperative time points. SF-12 scores only exhibited significant improvement at the 6-month follow-up visit. Significant correlations between PROMIS PF, NDI, and SF-12 were identified at all preoperative and postoperative time points. PROMIS PF exhibited strong correlations with VAS neck pain at postoperative time points, and a moderate correlation preoperatively. Conclusions: Patients undergoing a primary 1–3 level ACDF experience significant improvements in PROMIS PF scores at 12-week and 6-month follow-up. Furthermore, PROMIS PF exhibits strong correlations to NDI and SF-12 at all preoperative and postoperative time points. These results suggest that PROMIS PF accurately measures PF and may be used in lieu of legacy PF instruments for patients undergoing ACDF.
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