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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 (pp≤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.

OBJECTIVE The Physical Component Score of the Veterans RAND 12 Item Health Survey (VR-12 PCS) has been assessed for use at short-term and intermediate-term time points for lumbar fusion populations. This study assesses the long-term validity and establishes minimal clinically important difference (MCID) values of VR-12 PCS in patients undergoing minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). METHODS A surgical registry was retrospectively reviewed for primary, elective, single-level MIS TLIF procedures with posterior instrumentation. Patients missing preoperative and 2-year postoperative VR-12 PCS survey data were excluded. VR-12 PCS, SF-12 Health Survey Physical Component Summary (SF-12 PCS), Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS PF), and Oswestry Disability Index (ODI) patient-reported outcome measures (PROMs) were recorded preoperatively and postoperatively. Responsiveness of the VR-12 measure was assessed in two ways. First, the mean postoperative PROM scores were compared with preoperative baseline values using a paired Student t-test. Second, MCID values were calculated using both distribution-based and anchor-based methods and used to assess improvement in VR-12 score at the 2-year time point. Discriminant validity of the VR-12 was assessed using cross-sectional and longitudinal anchors. Convergent validity of the VR-12 measure was assessed using Pearson’s correlation coefficient and partial time-independent correlation. Floor and ceiling effects were assessed. RESULTS A total of 74 patients who underwent MIS TLIF were included. The VR-12 PCS demonstrated significant improvements at all time points from 12 weeks to 2 years (p < 0.001 for all). VR-12 PCSs were significantly different for patients classified using cross-sectional anchors (p < 0.001) and longitudinal anchors (p ≤ 0.005). Calculated MCID values ranged from 4.1 to 8.5, and 4.1 was selected as the optimal MCID, which 87.8% of patients achieved. Strong, significant correlations of the VR-12 PCS with SF-12 PCS and PROMIS PF were demonstrated at all time points (p < 0.001 for all). No significant floor or ceiling effects were detected. CONCLUSIONS The VR-12 PCS demonstrated excellent responsiveness, discriminant and convergent validity, and no significant floor or ceiling effects up to 2 years after MIS TLIF. Therefore, VR-12 PCS may serve as a valid measure of long-term physical function.

Study Design: Retrospective cohort.Purpose: This study aimed to assess the relationship between preoperative narcotic consumption and patient-reported outcomes (PRO) in patients undergoing minimally invasive (MIS) lumbar decompression (LD).Overview of Literature: Previous studies report negative effects of narcotic consumption on perioperative outcomes and recovery; however, its impact on quality of life and surgical outcomes is not fully understood.Methods: A surgical database was retrospectively reviewed for patients undergoing primary, single-level MIS LD from 2013 to 2020. Patients lacking preoperative narcotic consumption data were excluded. Demographics, spinal pathologies, and operative characteristics were collected. Patients were grouped based on preoperative narcotic consumption. Patient Health Questionnaire-9 (PHQ-9), Visual Analog Scale (VAS) for back and leg, Oswestry Disability Index (ODI), 12-item Short Form Physical Component Summary, and Patient-Reported Outcomes Measurement Information System physical function (PROMIS-PF) were collected preoperatively and postoperatively. Preestablished values were used to calculate achievement of minimum clinically important difference (MCID). Differences in mean PROs and MCID achievement between groups were evaluated.Results: The cohort was 453 patients; 184 used preoperative narcotics and 269 did not. Significant differences were found in American Society of Anesthesiologists classification, ethnicity, insurance type, and estimated blood loss between groups. Significant differences were also found in preoperative PHQ-9, VAS leg, ODI, and PROMIS-PF between groups (all pp>0.05). A higher rate of MCID achievement was associated with the narcotic group for PHQ-9 and PROMIS-PF at 6 weeks (both p≤0.050), VAS leg at 1 year (p=0.009), and overall for ODI and PHQ-9 (both p≤0.050).Conclusions: Preoperative narcotic consumption was associated with worse preoperative depression, leg pain, disability, and physical function. In patients consuming preoperative narcotics, a higher proportion achieved an overall MCID for disability and depressive symptoms. Patients taking preoperative narcotic medications may report significantly worse preoperative PROs but demonstrate greater improvements in postoperative disability and mental health.

BACKGROUND CONTEXT Cervical total disc arthroplasty (TDA) is an alternative procedure to anterior cervical discectomy and fusion that facilitates neural decompression while both preserving motion of the spinal unit and decreasing the risk for degenerative changes at adjacent segments. However, due to its more recent introduction in clinical practice and low complication rates, the modes by which TDA may fail remain to be described. PURPOSE This study sought to identify the modes and frequencies of cervical TDA failure in order to propose a novel classification system. STUDY DESIGN Retrospective Cohort and Systematic Review. PATIENT SAMPLE Patients who underwent single or two-level TDA for cervical radiculopathy or myelopathy at a single institution and in the literature of medium and large prospective studies. OUTCOME MEASURES Cervical TDA failure, defined as subsequent surgical intervention at the index segment. METHODS This study retrospectively reviewed patients who underwent single or two-level TDA for cervical radiculopathy or myelopathy at a single institution to identify the potential implant failure modes. A systematic review and meta-analysis of prospective data in the literature was then performed to further supplement failure mode identification and to describe the rates at which the various failure types occurred. Statistical analysis included between-group comparisons of Non-Failed and Failed patients and frequencies of each failure type among Failed patients. RESULTS A retrospective review at our institution of 169 patients (201 levels) identified eight failures, for a failure rate of 4.7%. Additionally, seven patients were revised who had the primary surgery at an outside institution. The systematic review of 3976 patients (4525 levels) identified 165 (4.1%) additional failures. Using this data, six primary failure types were classified, with several subtypes. These include recurrent or persistent index-level stenosis (Type I); migration (Type II) presenting as gross extrusion (A) or endplate failure with subsidence/acute fracture (B); instability (Type III) due to mechanical loosening (A), septic loosening (B), or device fracture (C); device motion loss (Type IV) such as “locking” of the device in kyphosis; implantation error (Type V) due to malposition (A) or improper sizing (B); and wear (Type VI) either without osteolysis (A) or with wear-particle-induced osteolysis (B). Stenosis (Type I) was the most common mode of failure found both through retrospective review and in the literature. CONCLUSIONS Cervical TDA fails through six primary mechanisms. While rates of certain failures requiring subsequent surgical intervention are low, it is possible that these complications may become more prevalent upon further longitudinal observation. Thus, future application and validation of this classification system is warranted to evaluate how failure frequencies change over time and with larger patient samples.

We sought to assess differences in patient-reported outcome measures (PROMs) between patients who do and do not follow up for 2 years after lumbar fusion.Primary, elective, single-level anterior lumbar interbody fusion, lateral lumbar interbody fusion, or transforaminal lumbar interbody fusion procedures were identified. Patients were grouped by 2-year PROM follow-up completion. Mean and delta PROM scores for visual analog scale (VAS) back and leg, Oswestry Disability Index (ODI), short-form (SF)-12 Physical Composite Score (PCS), and Mental Composite Score (MCS) were computed for both groups preoperatively and postoperatively. Minimum clinically important difference (MCID) achievement was determined for PROM scores using established threshold values. Linear and logistic regression assessed mean and ΔPROM scores as predictors of 2-year follow-up completion and compared MCID achievement between groups, respectively.We included 316 lumbar fusion patients. PROM scores were more favorable for complete follow-up patients for 6-month VAS back (P = 0.003), 6-month and 1-year ODI (P ≤ 0.027, both), and 6-week and 6-month SF-12 PCS (P ≤ 0.015, both). Six-month VAS back (P = 0.007); 6-month and 1-year ODI (P ≤ 0.028, both); 6-week, 6-month, and 1-year SF-12 PCS (P ≤ 0.041, all); and 6-week SF-12 MCS (P ≤ 0.028, both) significantly predicted 2-year follow-up. ΔPROMs significantly differed between groups at 1 year for ΔVAS leg (P = 0.029), ΔODI (P = 0.013), and ΔSF-12 MCS (P = 0.004). One-year ΔVAS leg (P = 0.035), ΔODI (P = 0.011), and ΔSF-12 MCS (P = 0.003) significantly predicted follow-up. MCID achievement for ΔPROMs significantly differed between groups for 6-week VAS leg (P = 0.035), overall ODI (P = 0.034), and SF-12 PCS from 12 weeks through 1 year (P ≤ 0.011, all) and overall (P0.001).Patients with full follow-up demonstrated significantly more favorable outcome scores and improvement in pain, disability, and physical function at several postoperative time points.

Background Limited literature has addressed impact of preoperative back pain severity on patient-reported outcome measures (PROMs), recovery ratios (RRs), and patient satisfaction following minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). Methods MIS TLIFs were retrospectively identified and grouped: preoperative visual analog scale (VAS) back ≤7 or VAS back >7. PROMs, including PROMIS-PF, VAS back and leg, Oswestry Disability Index (ODI), and SF-12 Physical Composite Score and Mental Composite Score (MCS), were collected pre- and postoperatively. A PROM’s RR was calculated as proportion of postoperative improvement to overall potential improvement. Results In total, 740 patients were included: 359 patients with VAS back ≤7 and 381 patients with VAS back >7. The VAS back >7 cohort reported significantly greater postoperative inpatient pain (P ≤ .003, both). All preoperative and the following postoperative PROMs favored the VAS back ≤7 cohort: PROMIS-PF 2-years, VAS back overall, SF-12 Physical Composite Score 12 weeks and 1 year, SF-12 MCS 6 weeks/12 weeks, VAS leg 6 weeks, 12 weeks, 6 months, and 2 years, and ODI overall (P ≤ 0.048, all). The VAS back >7 cohort demonstrated greater delta PROMs for all VAS back and ODI except 2 years (P ≤ 0.021, all). A greater proportion of patients in the VAS back >7 group achieved minimal clinically important difference for VAS back overall, ODI 6 weeks/12 weeks, PROMIS-PF 6 weeks, and SF-12 MCS 6 weeks/6 months (P ≤ 0.044, all). The VAS back>7 cohort RR was significantly greater for VAS back 6 months and VAS leg 6 months/2 years (P ≤ 0.034, all). The VAS back ≤7 cohort’s postoperative satisfaction was significantly greater for VAS back 12 weeks, VAS leg 12 weeks, and ODI 6 weeks/12 weeks (P ≤ 0.046, all). Conclusions Patients with greater preoperative back pain demonstrated significantly worse postoperative scores for most PROMs at most time points and significantly worse patient satisfaction for disability, back and leg pain at multiple time points.

Background Although the Veterans RAND 12-item Physical Component Survey (VR-12 PCS) has been broadly used to evaluate patient-reported outcome measures (PROMs) in spine surgery, its feasibility for use in patients undergoing minimally invasive lumbar discectomy (MIS LD) has not been well studied. This study aimed to assess the feasibility of VR-12 PCS for use up to 2 years postoperatively for MIS LD by correlation with PROMs for physical function. Methods Patients undergoing primary single-level MIS LD procedures were reviewed retrospectively. Results on the VR-12 PCS, 12-Item Short Form (SF-12) PCS, and Patient-Reported Outcomes Measurement Information System (PROMIS PF) were recorded preoperatively and up to 2 years postoperatively. Improvements in postoperative PROMs were calculated and assessed for significant differences from baseline values. Correlation significance and strength were evaluated between VR-12 PCS and SF-12 PCS or PROMIS PF. Scatterplots were constructed to demonstrate relationships of VR-12 PCS with SF-12 PCS and PROMIS PF at each time point. Results Our cohort comprised 402 patients. Patients improved significantly from preoperative baseline for all 3 PROMs at all postoperative time points. Both Pearson's correlation and time-independent partial correlation revealed statistically significant strong correlations of VR-12 PCS with SF-12 PCS and PROMIS PF through 2-years. Discussion Physical function scores for VR-12, SF-12, and PROMIS PF all demonstrated significant improvements following MIS LD. Strongly statistically significant correlations of VR-12 PCS with SF-12 PCS and PROMIS PF from preoperative measures through 2 years demonstrate the feasibility of VR-12 for assessing patient-reported physical function in MIS LD patients.

BACKGROUND: As spine surgery in the ambulatory setting becomes more frequent, patients should comprehend the difference from traditional hospital-based, outpatient settings. Limited research exists on the readability of online articles surrounding spine surgery in the ambulatory surgery center (ASC). In this study, we intend to evaluate the readability of online articles pertaining to spine surgery in the outpatient and ambulatory surgical settings. METHODS: Three search engines were queried, and the first 100 articles pertaining to each outpatient spine surgery search term were collected. Advertisements, videos, and peer-reviewed scientific articles were excluded. Articles were categorized by publishing source as follows: hospital or institution, general medical Websites, private practice, or surgery center. Flesch-Kincaid (FK) grade level, Flesch Reading Ease (FRE) score, word count, sentences per paragraph, words per sentence, and characters per word were evaluated for each article. Student's t tests compared readability metrics between groups based on setting and procedure region. RESULTS: A total of 342 articles was analyzed; 279 articles were outpatient hospital related, and 63 ASC related. Flesch-Kincaid grade levels or FRE scores were not significantly different between outpatient hospital and ambulatory center. Comparison of ASC to outpatient articles from a hospital or institution source significantly differed in FRE score (40.7 versus 32.4) and FK grade level (12.3 versus 13.9; all P < .05). Articles addressing procedure type were significantly different in FRE score (36.2 versus 30.0) and FK grade level (13.0 ± 2.1 versus 14.3 ± 1.8). CONCLUSIONS: Hospital, private practice, and medical journalists should be aware of significant differences in readability of patient-accessible ASC articles. These articles may be more difficult to read than outpatient hospital articles, and production of more reading-level-appropriate online literature is required. LEVEL OF EVIDENCE: 3 CLINICAL RELEVANCE: There is a significant difference in the readability of patient-accessible ASC articles.

Meeting patient expectations is believed to impact satisfaction scores; however, the influence of achieving a minimum clinically important difference (MCID) is scarcely reported. This study aims to evaluate meeting patient expectations or MCID achievement for pain and disability as predictors of patient satisfaction.A retrospective review of single or multilevel lumbar fusion patients was performed. Patients with missing preoperative Oswestry Disability Index (ODI) expectation questionnaires were excluded. Preoperative expectations and postoperative satisfaction scores for visual analog scale (VAS) back, VAS leg, and ODI were collected. Meeting expectations was defined as scores less than or equal to preoperative expectations. Achievement of MCID was evaluated. Improvement of all outcomes and correlations with satisfaction scores were evaluated using the Student's t-test and Pearson coefficient. Achievement of MCID or meeting expectations as predictors of satisfaction were evaluated and compared using linear regression and Suest test.The study included 144 patients. All outcomes significantly improved and demonstrated significant correlations with satisfaction scores (P0.001, all). Patients reported a mean expectation of 17.7 (ODI), 1.7 (VAS back), and 0.9 (VAS leg). The majority had their expectations met and achieved MCID. Meeting expectations and MCID achievement demonstrated significant associations with satisfaction scores for all outcomes and time points. Achievement of MCID was a stronger predictor of satisfaction for ODI and VAS back.Meeting preoperative expectations and achievement of an MCID for pain and disability measures was significantly associated with satisfaction. Achievement of MCID may be a more consistent and suitable replacement as a predictor of satisfaction over meeting patient expectations.

BACKGROUND: There is a scarcity of research on the Charlson Comorbidity Index (CCI) and its influence on minimum clinically important difference (MCID) achievement after minimally invasive (MIS) transforaminal lumbar interbody fusion (TLIF). The objective of this study is to detail the association between the CCI and attaining MCID after MIS TLIF. METHODS: A prospective surgical registry was retrospectively reviewed for spine surgeries between May 2015 and February 2019. Inclusion criteria were primary or revision, 1- or 2-level MIS TLIF procedures. Patients were stratified based on CCI score: 0 points (no comorbidities), 1–2 points (mild CCI), ≥3 points (moderate CCI). Preoperative, intraoperative, and postoperative variables were assessed by subgroup using appropriate statistical analysis. Subgroups were analyzed with linear regression or χ(2) tests for continuous or categorical variables, respectively. Subgroup scores, improvement, and MCID achievement were assessed at postoperative timepoints (eg, 6 weeks, 12 weeks, 6 months, and 1 year) for back and leg pain, Oswestry Disability Index (ODI), SF-12 Physical Composite Score (PCS), and Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS PF). RESULTS: A total of 171 patients were included (n = 51 [no comorbidities], n = 73 [mild CCI], and n = 47 [moderate CCI]). Higher CCI patients were older and more likely to be smokers, diabetic, arthritic, hypertensive, or have a malignancy history (P < 0.003). Preoperatively, ODI and PROMIS PF were the only patient-reported outcomes with a significant association by CCI group (P = 0.015 and 0.014). Back pain was the only measure that had a significant association with the CCI subgroup at 1 year for score (P = 0.002) or MCID (P = 0.028). CONCLUSIONS: By 1 year, regardless of the number of comorbidities, a similar proportion of patients undergoing MIS TLIF were able to achieve MCID for visual analog scale leg, SF-12 PCS, and PROMIS PF. Patients with higher comorbidities are not likely to experience a significant difference in symptom improvement. Regardless of CCI score, MIS TLIF can have a significant benefit for patients. LEVEL OF EVIDENCE: 4. CLINICAL RELEVANCE: Text.

STUDY DESIGN This was a retrospective study. OBJECTIVE This study investigates the influence of physical function and their influence on postoperative depressive symptom scores as measured by Patient Health Questionnaire-9 (PHQ-9) among anterior cervical decompression and fusion (ACDF) patients. BACKGROUND While ACDF is one of the most commonly performed ambulatory surgeries, research is limited on the predictive value of Patient-Reported Outcomes Measurement Information System (PROMIS) scores and their influence on depressive symptoms as measured by the PHQ-9. METHODS A prospectively maintained surgical registry was retrospectively reviewed from March 2016 to January 2019. Inclusion criteria were primary or revision ACDF procedures. Patients were grouped by preoperative PROMIS score (≥35.0

Objective The Patient Health Questionnaire-9 (PHQ-9) is a screening tool for evaluating depressive symptoms. Research is scarce regarding the validity and correlation of PHQ-9 scores with other patient-reported outcomes of mental health after minimally invasive lumbar discectomy (MIS LD). We aim to validate PHQ-9 as a metric for assessing mental health in MIS LD patients. Methods A database was retrospectively reviewed for patients who underwent elective, single-level MIS LD. Patients were excluded if they had incomplete preoperative PHQ-9, 12-item Short Form Health Survey (SF-12), or Veterans RAND 12-item health survey (VR-12). Survey scores were collected preoperatively and postoperatively through 1 year. Mean scores were used to calculate postoperative improvement from preoperative scores. Correlation of PHQ-9 with SF-12 mental composite score (MCS) and VR-12 MCS scores was also calculated. Correlation strength was assessed by the following categories: 0.1 ≤ |r| < 0.3 = low; 0.3 ≤ |r| < 0.5 = moderate; |r| ≥ 0.5 = strong. Results A total of 239 patients underwent single-level MIS LD. PHQ-9, VR-12 MCS, and SF-12 MCS all demonstrated statistically significant increases from preoperative scores at all postoperative timepoints (p ≤ 0.001). SF-12 MCS and VR-12 MCS were each observed to have strong and significant correlations with PHQ-9 at all timepoints when evaluated with both Pearson correlation coefficients and partial correlation coefficients. Conclusion We observed that PHQ-9, SF-12 MCS and VR-12 MCS all significantly improve following lumbar discectomy and that PHQ-9 scores strongly correlated with these previously established measures. Our results substantiate evidence from other surgical fields that PHQ-9 scores are a valid tool to evaluate pre- and postsurgical depressive symptoms.

STUDY DESIGN This was a systematic review study. PURPOSE This study aims to review current literature to determine the rates of complications in relation to spine surgery in ambulatory surgery centers (ASC). BACKGROUND Recent improvements in anesthesia, surgical techniques, and technological advances have facilitated a rise in the use of ASC. Despite the benefits and lower costs associated with ASCs, there is inconsistent reporting of complication rates. METHODS This systematic review was completed utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Pertinent studies were identified through Embase and PubMed databases using the search string ((("ambulatory surgery center") AND "spine surgery") AND "complications"). Articles were excluded if they did not report outpatient surgery in an ASC, did not define complications, were in a language other than English, were non-human studies, or if the articles were classified as reviews, book chapters, single case reports, or small case series (≤10 patients). The primary outcome was the frequency of complications with respect to various categories. RESULTS Our query identified 150 articles. After filtering relevance by title, abstract, and full text, 22 articles were included. After accounting for 2 studies that were conducted on the same study sample, a total of 11,245 patients were analyzed in this study. The most recent study reported results from May 2019. While 5 studies did not list their surgical technique, studies reported techniques including open (6), minimally invasive surgery (2), endoscopic (4), microsurgery (1), and combined techniques (4). The following rates of complications were determined: cardiac 0.29% (3/1027), vascular 0.25% (18/7116), pulmonary 0.60% (11/1839), gastrointestinal 1.12% (2/179), musculoskeletal/spine/operative 0.59% (24/4053), urologic 0.80% (2/250), transient neurological 0.67% (31/4616), persistent neurological 0.61% (9/1479), pain related 0.57% (20/3479), and wound site 0.68% (28/4092). CONCLUSIONS After literature review, this is the first study to comprehensively analyze the current state of literature reporting on the complication profile of all ASC spine surgery procedures. The most common complications were gastrointestinal (1.12%) and the most infrequent were vascular (0.25%). Case reports varied significantly with regard to the type and rate of complications reported. This study provides complication profiles to assist surgeons in counseling patients on the most realistic expectations.

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.

STUDY DESIGN This was a retrospective cohort study. OBJECTIVE The objective of this study was to determine the impact of obesity on postoperative outcomes and minimum clinically important difference (MCID) achievement following minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). SUMMARY OF BACKGROUND DATA Obesity is a proven risk factor for poorer outcomes in MIS TLIF patients. However, few studies have investigated the impact of body mass index (BMI) on achievement of a MCID for Patient-Reported Outcome Measurement Information System Physical Function (PROMIS PF). METHODS A prospective surgical database was retrospectively reviewed for primary, elective, single level MIS TLIF patients. Patients were categorized into BMI groups: nonobese (

INTRODUCTION Physical function evaluated by Patient-Reported Outcomes Measurement Information System (PROMIS PF) instrument has been validated through the short-term postsurgical period in spine surgery patients. Evidence for long-term efficacy of PROMIS PF is lacking in lumbar decompression (LD) patients. The objective of this study was to evaluate correlations between PROMIS PF and legacy patient-reported outcome measures for patients undergoing LD. METHODS Consecutive primary or revision, single-level or multilevel LD surgeries were retrospectively reviewed from May 2015 to September 2017. Patients lacking preoperative or 2-year PROMIS PF scores were excluded. Demographics, baseline pathology, and perioperative characteristics were collected, and descriptive statistics performed. Visual Analogue Scale (VAS) back and leg, Oswestry Disability Index (ODI), 12-Item Short Form (SF-12) Physical Composite Score (PCS), and PROMIS PF were collected at preoperative and postoperative timepoints and evaluated for improvement from baseline values. Correlations between PROMIS PF and VAS back, VAS leg, SF-12 PCS, and ODI were calculated and categorized according to the strength of relationship. RESULTS Ninety-two patients were included in this study with 58.7% of LDs performed at the single level. All patient-reported outcome measures demonstrated significant improvement from baseline values at all assessment timepoints (all P < 0.001). Apart from preoperative VAS back and VAS leg, PROMIS PF demonstrated a significant and strong correlation with VAS back, VAS leg, ODI, and SF-12 PCS at all timepoints (all P < 0.001). CONCLUSION PROMIS PF demonstrated a strong correlation with pain, disability, and PF outcome measures throughout the postoperative period out to 2 years after LD. Our study provides longitudinal evidence that the PROMIS PF instrument is a valid measure for PF for patients undergoing LD.

Background: Patient selection and analgesic techniques, such as the multimodal analgesic (MMA) protocol, aid in ambulatory surgical center (ASC) cervical spine surgery. The purpose of this case series is to characterize patients undergoing anterior cervical discectomy and fusion (ACDF) and total cervical disc replacement (CDR) in an ASC with an enhanced MMA protocol. Methods: A prospectively maintained registry was retrospectively reviewed for cervical surgeries between May 2013 and August 2019. Inclusion criteria included ASC patients who underwent single-level or multilevel CDR or ACDF using an MMA protocol. Baseline, intraoperative, and postoperative characteristics were recorded, including length of stay, visual analog scale pain scores, neck disability index, complications, and narcotics administered. Results: A total of 178 patients met inclusion criteria with 125 single-level, 52 two-level, and 1 three-level procedure. Of those patients, 127 underwent ACDF and 51 underwent CDR. The longest procedure was 95 minutes and the mean length of stay was 6.1 hours, with 2 patients requiring hospital admission. All other patients were discharged within 10 hours. One of the admitted patients experienced a postoperative seizure that was later determined to be secondary to drug use and serotonin syndrome. The second patient developed an anterior cervical hematoma 5 hours postoperatively, which was immediately evacuated. The patient was admitted for observation and discharged the next day. Conclusion: In our study, patients experienced considerable improvement in disability scores, with a low likelihood of postoperative complications. A safe and effective MMA protocol may help facilitate anterior cervical surgery in the outpatient setting. Level of Evidence: 3. Clinical Relevance: Transitioning anterior cervical discectomy and fusions to the ASC requires an appropriate MMA protocol. Our findings reveal that an enhanced MMA protocol will help improve disability scores while keeping the likelihood of postoperative complications low. This supports the ASC setting for cervical spine procedures in appropriate patient populations.

Objective There is a scarcity of research evaluating gender differences in depressive symptoms among patients undergoing cervical surgery. This study investigated gender differences with regard to depressive symptom severity, measured by Patient Health Questionnaire-9 (PHQ-9), in patients following anterior cervical discectomy and fusion (ACDF) or artificial disc replacement (ADR). Methods A prospectively maintained surgical registry was retrospectively reviewed for eligible spine surgeries. Depressive symptom severity was evaluated by PHQ-9 at both preand postoperative timepoints (e.g. , 6 weeks, 12 weeks, 6 months, 1 year, and 2 years). A chi-square test and Student t-test evaluated differences between the gender for demographic and operative variables where appropriate. Differences between the gender subgroup mean PHQ-9 scores were assessed using a t-test pre- and postoperatively (e.g. , 6 weeks, 12 weeks, 6 months, and 1 year) and a paired t-test was used to assess differences from preoperative scores at each postoperative time point. Results A total of 170 subjects underwent 125 ACDFs and 45 ADRs. Both pre- and postoperative timepoints demonstrated no significant differences between mean PHQ-9 scores by gender. Female patients demonstrated statistically significant improvement in PHQ-9 scores at 6 weeks, and 12 weeks, but not through 2 years. Male patients demonstrated statistically significant improvement in PHQ-9 scores at 6 weeks, 12 weeks, 6 months, 1 year, and 2 years. Conclusion Although there were no significant differences between mean PHQ-9 score between the genders, there was a difference in magnitude of improvement. Females had a significant improvement in depressive symptom severity over baseline at the 6- and 12-week timepoints only, whereas males had significant improvement through 2 years postoperatively.

Study design This is a prospective observational study. Objective The aim was to record daily opioid use and pain levels after 1-level or 2-level anterior cervical discectomy and fusion (ACDF) or cervical disc arthroplasty (CDA). Summary of background data Data to inform opioid prescription guidelines following ACDF or CDA is lacking. Understanding postoperative opioid consumption behaviors is critical to provide appropriate postdischarge prescriptions. Methods Patients undergoing 1-level or 2-level primary ACDF or CDA were consecutively enrolled at 2 participating institutions between March 2018 and March 2019. Patients with opioid dependence (defined as daily use ≥6 mo before surgery) were excluded. Starting postoperative day 1, daily opioid use and numeric pain rating scale pain levels were collected through a Health Insurance Portability and Accountability Act-compliant, automated text-messaging system. To facilitate clinical applications, opioid use was converted from oral morphine equivalents into "pills" (oxycodone 5 mg equivalents). After 6 weeks or upon patient-reported cessation of opioid use, final survey questions were asked. Refill data were verified from the state prescription registry. Risk factors for patients in top quartile of consumption were analyzed. Results Of 57 patients, 48 completed the daily queries (84.2%). Mean age of the patient sample was 50.2±10.9 years. Thirty-two patients (66.7%) underwent ACDF and 16 CDA (33.3%); 64.6% one level; 35.4% two levels. Median postdischarge use was 6.7 pills (range: 0-160). Cumulative opioid use did not vary between the 1-level and 2-level groups (median pill consumption, 10 interquartile range: 1.3-31.3 vs. 4 interquartile range: 0-18, respectively, P=0.085). Thirteen patients (27.1%) did not use any opioids after discharge. Of those patients that took opioids after discharge, half ceased opioids by postoperative day 8. Preoperative intermittent opioid use was associated with the top quartile of opioid consumption (9.1% vs. 50%, P=0.006). Conclusion Given that most patients use few opioids, patients could be offered the option of a 12 oxycodone 5 mg (90 oral morphine equivalents) discharge prescription, accompanied by education on appropriate opioid use and disposal.

Objective Our study aims to evaluate the correlation of Patient-Reported Outcomes Measurement Information System physical function (PROMIS PF) with legacy patient-reported outcome measures (PROMs) among patients undergoing anterior cervical discectomy and fusion (ACDF). Methods A prospectively maintained database was retrospectively reviewed for ACDF surgeries performed between May 2015 and September 2017. Inclusion criteria were primary elective, single- or multilevel ACDFs for degenerative spinal pathology. Patients lacking preoperative or 2-year PROMIS PF surveys were excluded. Mean scores were calculated for visual analogue scale (VAS) neck, VAS arm, Neck Disability Index (NDI), 12-Item Short Form Physical Component Score (SF-12 PCS), and PROMIS PF at preoperative and 6-week, 12-week, 6-month, 1-year, and 2-year postoperative timepoints. A t-test and Pearson correlation coefficient were utilized to evaluate score improvement and PROM relationships respectively. Results The 50 subject cohort was 60.0% male, 50% obese (body mass index ≥ 30 kg/m2) and had an average age of 50.9 years. Significant improvements were demonstrated for VAS neck and NDI at all postoperative timepoints (p < 0.001) and for SF-12 and PROMIS PF at all timepoints except 6 weeks (p ≤ 0.025). VAS arm improvement was seen up to 1 year (p ≤ 0.016). PROMIS PF demonstrated strong correlations with NDI and SF-12 PCS at all evaluated timepoints and with VAS neck at all postoperative timepoints except 6 weeks (all p < 0.01). Conclusion PROMIS PF was strongly correlated with pain, disability, and physical function up to 2 years for patients undergoing ACDF. Our results support the long-term validity of PROMIS PF for measurement of patient-reported physical function among ACDF cohorts.

Patient-reported outcome measures (PROMs) are used to capture the true extent of postoperative improvement. Use of lengthier and repetitive PROMs can increase question burden on patients. This study aims to determine whether the length of time to complete (TTC) legacy PROMs has an impact on scores after lumbar decompression.A surgical database was retrospectively reviewed for patients who underwent primary, single-level lumbar decompression from 2013 to 2020. Demographic and perioperative characteristics were collected. Physical function (PF) was measured by 12-Item Short Form (SF-12), 12-Item Veterans RAND (VR-12), and Patient-Reported Outcomes Measurement Information System (PROMIS) and was collected preoperatively and postoperatively. TTC was calculated as the difference between start and ending times for each instance of survey completion. Improvements for PROMs and comparison of TTC between SF-12/VR-12 and PROMIS PF were evaluated using a t-test. Correlation between TTC and PROM scores was evaluated using the Pearson correlation. Impact of TTC on postoperative PROM scores was evaluated using linear regression.A total of 216 patients, of which 68.1% were men, were included with a mean age of 45.8 years. Mean postoperative TTC for SF-12 and VR-12 was significantly longer than preoperative values (all P0.05). No notable difference in TTC was demonstrated for PROMIS PF. TTC PROMIS PF was significantly shorter than SF-12 and VR-12 from 12 weeks through 1 year (all P0.050). A low-strength negative correlation of TTC with SF-12 and VR-12 was observed at the preoperative, 6-week and 1-year timepoint whereas PROMIS PF had a low-strength positive correlation with TTC preoperatively and at 6 months (all P0.05).Time spent completing PROMIS PF did not markedly differ postoperatively, but SF-12 and VR-12 required a longer TTC than PROMIS PF. Although insightful to patient improvement, SF-12 and VR-12 may increase the question burden placed on patients to complete surveys in a timely manner.

As more patients undergo lumbar spine surgery, novel interventions may improve physical and mental health outcomes. Few studies summarize the benefit of cognitive behavioral therapy (CBT) among lumbar spine surgery patients. This study collects randomized control trial data to investigate the influence of CBT on patient reported outcomes among lumbar spine surgery patients. Our study used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and a medical library expert assisted in searching PubMed/MEDLINE, Scopus, CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, PsycINFO, and Google Scholar. We calculated standardized mean differences (SMD) to evaluate the effect size of CBT versus control groups with a sensitivity analysis. Our meta-analysis included seven studies with a total of 531 patients. The majority of included studies evaluated lumbar fusion, with preoperative CBT performed by physiotherapists. The largest effects were observed for overall quality of life (SMD = 0.55 [95% CI 0.05, 1.05], p

STUDY DESIGN Retrospective. OBJECTIVE Evaluate the association between comorbidity burden and reaching minimum clinically important difference (MCID) following lumbar decompression (LD). SUMMARY OF BACKGROUND DATA There is limited research on the influence of preoperative comorbidity burden on patient-reported outcome improvement following LD. METHODS A prospectively maintained surgical registry was retrospectively reviewed for eligible spine surgeries between 2015 and 2019. Inclusion criteria were primary, single, or multilevel LD. Patients were excluded for missing preoperative patient-reported outcome surveys. Stratification was based on Charlson Comorbidity Index (CCI) score: 0 points (no comorbidities), 1-2 points (low CCI), ≥3 points (high CCI). Demographics and perioperative characteristics were evaluated for differences. Linear regression assessed postoperative improvement for visual analogue scale (VAS) back, VAS leg, Oswestry disability index (ODI), Short Form-12 Physical Composite Score (SF-12 PCS), and Patient-Reported Outcomes Measurement Information System physical function (PROMIS-PF) scores through 1 year. Achievement rate of MCID was compared between groups and evaluated for significant predictors. RESULTS Three hundred fourteen patients were included (123 no comorbidities, 100 low CCI, 91 high CCI). Higher CCI patients were older, more likely to smoke, and have comorbid diseases (all P

Study design Retrospective cohort. Objective To investigate and establish minimum clinically important differences (MCID) for Patient Health Questionnaire-9 (PHQ-9) among patients undergoing minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). Summary of background Spine surgery is linked to postoperative improvements in anxiety, depression, and mental health. These improvements have been documented using patient-reported outcome measures such as PHQ-9. Few studies evaluated the clinical significance of PHQ-9 for lumbar spine surgery. Methods Patients who underwent single-level, primary MIS TLIF from 2015 to 2017 were retrospectively reviewed in a prospective database. Patients with incomplete preoperative and 2-year postoperative PHQ-9 surveys were excluded. Demographic and perioperative characteristics were recorded. PHQ-9, 12-Item Short Form (SF-12), and Veterans RAND 12-Item Health Survey (VR-12) Mental Component Summary (MCS) were collected at preoperative, 6-week, 12-week, 6-month, 1-year, and 2-year intervals. MCID was calculated using anchor and distribution-based methods. SF-12 served as an anchor. MCID was assessed using mean change methodology, four receiver operating characteristic curve assessments, and standard error measurement. Cutoff values were selected from receiver operating characteristic curve analysis. MCID achievement rates for all patient-reported outcome measures were calculated. Results A total of 139 patients met inclusion criteria, with a mean age of 55 years and 39% females. The most common spinal pathology was radiculopathy (92%). MCID analysis revealed the following ranges of values: 2.0 to 4.8 (PHQ-9), 6.7 to 12.1 (SF-12 MCS), and 7.5 to 15.9 (VR-12 MCS). Final MCID thresholds were 3.0 (PHQ-9), 9.1 (SF-12 MCS), and 8.1 (VR-12 MCS). MCID achievement at 2-years for PHQ-9, SF-12 MCS, and VR-12 MCS was 89.2%, 85.6%, and 84.9% respectively. Conclusion Our 2-year postoperative MCID analysis is the first mental health calculation from an MIS TLIF cohort. We report a 2-year MCID value for PHQ-9 of 3.0 (2.0-4.8). MCID values for mental health instruments are important for determining overall success of lumbar spine surgery.Level of Evidence: 3.

Background: The transition of minimally invasive (MIS) spine surgery from the inpatient to outpatient setting has been aided by advances in multimodal analgesic (MMA) protocols. This clinical case series of patients demonstrates the feasibility of ambulatory MIS transforaminal lumbar interbody fusion (TLIF) and lateral lumbar interbody fusion (LLIF) procedures while using an enhanced MMA protocol. Methods: Consecutive MIS TLIF or LLIF procedures with percutaneous pedicle screw fixation and direct decompression in the ambulatory setting were reviewed. The procedures were performed using an MMA protocol. The ambulatory surgery center (ASC) did not allow for observation of patients for periods of time greater than 23 hours. We recorded patient demographics, perioperative, and postoperative characteristics. Results: Fifty consecutive patients were identified from September 2016 to July 2019. Forty-one patients (82%) underwent MIS TLIF, and 9 patients underwent MIS LLIF (18.0%). All patients were discharged on the same day of surgery. The mean length of stay was 4.5 hours and 3.8 hours for the TLIF and LLIF cohorts, respectively. Our review of medical records revealed no postoperative complications following either the TLIF or the LLIF procedures. Conclusions: The present study of 50 consecutive patients is the largest clinical series of ASC patients undergoing lumbar fusion procedures in a stand-alone facility with no extended postoperative observation capability. While using MMA protocol within the ASC, no postoperative complications were observed for either MIS TLIF or LLIF procedures. All patients were discharged from the ambulatory surgical center on the day of surgery with well-controlled postoperative pain. Level of Evidence: 4. Clinical Relevance: The MMA protocol is an essential aspect in transitioning minimally invasive lumbar spine surgery to the ASC. Our findings indicate that MIS lumbar fusion spine surgery with an enhanced MMA protocol can lead to safe and timely ASC discharge while minimizing hospital admission.

BACKGROUND: Development and validation of Veterans RAND 12-item (VR-12) physical component survey (PCS) has been established among civilian and veteran populations but it has not been examined among anterior cervical discectomy and fusion (ACDF) patients. PURPOSES/QUESTIONS: We sought to validate legacy patient-reported outcome measures (PROMs) with VR-12 PCS among patients undergoing ACDF procedures. METHODS: A prospectively collected surgical registry was retrospectively evaluated for elective single or multi-level ACDFs performed for degenerative spinal pathologies from January 2014 to August 2019. Exclusion criteria included missing pre-operative surveys and surgery for trauma, metastasis, or infection. Demographic variables, baseline pathologies, and peri-operative variables were collected. A paired t test evaluated the change from the pre-operative score to each post-operative timepoint for VR-12 PCS, the 12-item Short-Form Survey (SF-12) PCS, Patient-Reported Outcomes Measurement Information System physical function (PROMIS-PF), and Neck Disability Index (NDI). Minimal clinically important difference (MCID) achievement was calculated at each timepoint. Correlation was evaluated with a Pearson’s correlation coefficient and time-independent partial correlation. RESULTS: Of the 202 patients who underwent ACDF, 41.1% were female and the average age was 49.5 years. All PROMs had statistically significantly increased from baseline when compared with post-operative timepoints (12 weeks, 6 months, 1 year, and 2 years). MCID achievement rates increased through 2 years. All timepoints revealed strong VR-12 PCS correlations with SF-12 PCS, PROMIS-PF, and NDI scores. CONCLUSION: VR-12 PCS was strongly correlated with the well-validated SF-12 PCS and NDI metrics as well as with the more recent PROMIS-PF. All PROMs demonstrated statistically significant improvement in patients post-operatively. VR-12 PCS is a valid measure of physical function among patients undergoing ACDF. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11420-020-09817-w) contains supplementary material, which is available to authorized users.

OBJECTIVEWhile the anterior lumbar interbody fusion (ALIF) procedure may be amenable to ambulatory surgery, it has been hypothesized that limitations such as the risk of postoperative ileus and vascular complications have hindered transition of this procedure to the outpatient setting. Identification of independent risk factors predisposing patients to inpatient stays of ≥ 24 hours after ALIF may facilitate better postsurgical outcomes, target modifiable risk factors, and assist in the development of screening tools to transition appropriate patients to the ambulatory surgery center (ASC) setting for this procedure. The purpose of this study was to identify the most relevant risk factors that predispose patients to ≥ 24-hour admission following ALIF.METHODSA prospectively maintained surgical registry was reviewed for patients undergoing single ALIF between May 2006 and December 2019. Demographics, preoperative diagnosis, perioperative variables, and postoperative complications were evaluated according to their relative risk (RR) elevation for an inpatient stay of ≥ 24 hours. A Poisson regression model was used to evaluate predictors of inpatient stays of ≥ 24 hours. Risk factors for inpatient admission of ≥ 24 hours were identified with a stepwise backward regression model.RESULTSA total of 111 patients underwent single-level ALIF (50.9% female and 52.6% male, ≤ 50 years old). Eleven (9.5%) patients were discharged in < 24 hours and 116 remained admitted for ≥ 24 hours. The average inpatient stay was > 2 days (53.7 hours). The most common postoperative complications were fever (body temperature ≥ 100.4°F; n = 4, 3.5%) and blood transfusions (n = 4, 3.5%). Bivariate analysis revealed a preoperative diagnosis of retrolisthesis or lateral listhesis to elevate the RR for an inpatient stay of ≥ 24 hours (RR 1.11, p = 0.001, both diagnoses). Stepwise multivariate analysis demonstrated significant predictors for inpatient stays of ≥ 24 hours to be an operation on L4–5, coexisting degenerative disc disease (DDD) with foraminal stenosis, and herniated nucleus pulposus (RR 1.11, 95% CI 1.03–1.20, p = 0.009, all covariates).CONCLUSIONSThis study provides data regarding the incidence of demographic and perioperative characteristics and postoperative complications as they pertain to patients undergoing single-level ALIF. This preliminary investigation identified the most relevant risk factors to be considered before appropriately transitioning ALIF procedures to the ASC. Further studies of preoperative characteristics are needed to elucidate ideal ASC ALIF patients.

STUDY DESIGN This was a retrospective cohort study. OBJECTIVE The purpose of this study is to examine whether the time duration from symptom onset to operative treatment is associated with postoperative clinical improvement after anterior cervical discectomy and fusion (ACDF). SUMMARY OF BACKGROUND DATA There is a paucity of literature regarding the influence of preoperative symptom duration on patient-reported outcomes (PROs) following ACDF. METHODS Patients who underwent primary, single-level ACDF were retrospectively reviewed and stratified according to preoperative symptom duration (

Purpose Our aim is to examine the gender performance of Patient-Reported Outcome Measurement Information System Physical Function (PROMIS-PF) scores among patients undergoing minimally invasive transforaminal lumbar fusion (MIS TLIF). Methods A prospectively collected surgical dataset was retrospectively assessed for eligible patients from March 2015–June 2019. We included patients if they underwent primary MIS TLIF procedures on one or two vertebral levels. We collected baseline demographics, perioperative characteristics, and PROMIS-PF scores for each subject at pre and postoperative timepoints (e.g., 6-weeks, 3-months, 6-months, and 1-year). Chi-squared analyses were utilized to assess categorical variables and a Student’s t-tests analyzed continuous variables. A linear regression was used to analyze PROMIS-PF scores from baseline through all postoperative time points. Finally, we evaluated the PROMIS PF achievement of minimal clinically important difference (MCID) among gender. Results 192 patients were included: 77 were females and 115 were males. No significant differences were observed among gender subgroups for PROMIS-PF scores at pre- or postoperative evaluations. Compared to males, females experienced significantly greater postoperative improvement with PROMIS-PF scores at the 3-month assessments, though no significant gender differences were observed during later follow-up evaluations at 6-months or one year. Females were observed to have significant PROMIS-PF score improvement from their preoperative evaluation to each postoperative score. Males were assessed to have statistically significant postoperative (e.g., at 3-months, 6-months, and 1-year) PROMIS-PF score improvement from their preoperative PROMIS-PF scores. There were no significant differences among gender in achieving MCID at any postoperative time interval. Conclusion Among gender, we observed no statistically significant difference in PROMIS-PF scores during the pre- or postoperative evaluations. Additionally, with no difference in the rate of achieving PROMIS-PF MCID postoperatively, this study established that both genders should experience similar functional outcomes following MIS TLIF.

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.

Study design Retrospective cohort. Objective To determine if the presence of diabetes mellitus as comorbidity is associated with complications, inpatient length of stay, or direct hospital costs after minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). Summary of background data Very few studies have investigated the effect of diabetes on complications, length of stay, or costs in minimally invasive lumbar surgeries. Methods Patients undergoing primary, single-level MIS TLIF were retrospectively reviewed. Diabetic and nondiabetic patients were propensity matched in a 1:1 manner for age, sex, and comorbidity burden. An association between diabetic status and preoperative demographic or perioperative variables, including inpatient length of stay, was tested for using Student t test or χ analysis. Multivariate linear regression was used to test for an association between diabetic status and direct hospital costs. Results After 1:1 propensity matching, 100 patients were included in this analysis. There were no significant differences in age, sex, body mass index, smoking status, or Charlson Comorbidity Index between propensity-matched patients with and without diabetes. In regards to the length of stay, no significant differences existed between diabetic and nondiabetic groups (68.7 vs. 58.3 h, P=0.218). No other significant differences existed in other perioperative variables including operative time, intraoperative blood loss, or complication rate (P≥0.05 for each). Multivariate analysis indicated that diabetic status was not associated with differences in total direct hospital costs (US$20,428 vs. US$20,429, P=0.792) or cost subcategories after MIS TLIF (P≥0.05 for each). Conclusions In this investigation, diabetes was not associated with postoperative complication rates, inpatient length of stay, or direct hospital costs after primary, single-level MIS TLIF. The reduced extent of operative exposure and tissue trauma in MIS TLIF may mitigate the risk of complications in diabetic patients, possibly preventing extensions in hospital stay length and associated hospital costs.

BACKGROUND CONTEXT Dysphagia following anterior cervical discectomy and fusion (ACDF) is a common complication, the etiology of which has not been established. Given that one potential mechanism for dysphagia is local tissue edema, it is thought that a greater number of operative levels may result in higher dysphagia rates. However, prior reports comparing one-level to two-level ACDF have shown varying results. PURPOSE To determine if there is a difference in dysphagia between one-level and two-level ACDF. STUDY DESIGN/SETTING Retrospective review of prospectively collected data. PATIENT SAMPLE Patients who underwent one- or two-level ACDF with a plate-graft construct by a single-surgeon at a high-volume academic medical center. OUTCOME MEASURES Neck Disability Index, Visual Analog Scale for neck pain and arm pain, Short Form-12 physical and mental health components, and Swallowing Quality of Life (SWAL-QOL) Questionnaire. METHODS Patient demographics, operative data, and patient-reported outcome measures (PROMs; Neck Disability Index, Visual Analog Scale, Short Form-12, and SWAL-QOL) of patients undergoing one- and two-level ACDF were compared using Fisher exact test for categorical variables and Student's t test for continuous variables. Regression analyses were conducted to identify factors associated with 6- and 12-week SWAL-QOL scores in order to determine whether the number of surgical levels impacts these outcomes. RESULTS Fifty-eight patients (22 one-level and 36 two-level ACDF) were included. Patients undergoing two-level fusions were older (54.17+8.67 vs 48.06+10.68 years, p=.02) and had longer operative times (69.08+10.51 vs 53.5+14.35 minutes, p 61.5 minutes had a sensitivity and specificity of 62.1% for worse dysphagia scores at 6 weeks compared with baseline. CONCLUSIONS The results of our study indicate that there is no difference in the degree of postoperative dysphagia in one- versus two-level ACDF. However, other variables associated with increased postoperative dysphagia in our population included younger age, male sex, procedural time >61.5 minutes, and worse preoperative dysphagia. Larger studies are required to confirm these findings and identify additional risk factors for postoperative dysphagia.

Study design This was a retrospective study. Objective To evaluate independent demographic and perioperative factors associated with lower Patient-reported Outcome Measurement Information System Physical Function (PROMIS PF) survey completion rates after spine surgery. Summary of background data There has not been a study evaluating factors related to PROMIS PF survey completion following spine surgery. Methods Patients undergoing spine procedures were retrospectively reviewed. The number of PROMIS PF surveys that were completed at each time period and the number of surveys that were completed in succession starting with the first survey were tabulated and reported using descriptive statistics. Independent preoperative and perioperative factors associated with full survey completion up to the 12-month period were identified using χ analysis and Poisson regression with robust error variance. A final multivariate model was created using a backward, stepwise multivariate regression. Results A total of 713 patients were included. Variables positively associated with PROMIS survey completion were aged above 60 years and Patient Health Questionnaire (PHQ)-9≥10. African Americans and Hispanics were negatively associated with survey completion. Postoperative day 0 narcotic use ≥50 oral morphine equivalents was positively associated with survey completion, while outpatient surgical setting and high preoperative radicular arm/leg pain were negatively associated with survey completion. In the final multivariate model, depression was the only variable that was positively associated, while both outpatient surgical setting and high preoperative radicular arm/leg pain were negatively associated with survey completion. Conclusion This study identified demographic and perioperative variables associated with PROMIS survey completion and response rates. Patients who underwent surgery in the outpatient setting and those with high preoperative radicular limb pain were less likely to complete surveys. Interestingly, patients with clinical signs of depression were more likely to fill out surveys. Understanding variables associated with survey completion may provide the clinician with insight into which demographic groups are the most at-risk for not responding to surveys.

Study design This is a retrospective study. Objective The objective of this study was to determine if there is an association between preoperative depression, as quantified by Patient Health Questionnaire-9 (PHQ-9), and postoperative improvement in pain and disability after anterior cervical discectomy and fusion (ACDF). Summary of background data Few studies have quantified depression symptoms in the preoperative period using PHQ-9 and have tracked patient-reported outcomes (PROs) following ACDF. Methods Patients undergoing ACDF were retrospectively reviewed and stratified by their preoperative PHQ-9 score. PROs, including Neck Disability Index (NDI), Visual Analogue Scale (VAS) neck and arm pain, and 12-Item Short Form (SF-12) Physical Component Score (PCS), were measured preoperatively and at 6-week, 3-month, 6-month, and 1-year postoperatively. PRO scores were analyzed amongst PHQ-9 cohorts using multiple linear regression. Achievement of minimum clinically important difference (MCID) was compared using χ analysis. Results Higher PHQ-9 scores were associated with increased preoperative NDI, VAS neck, and VAS arm scores and significantly lower SF-12 PCS scores preoperatively. Cohorts experienced similar VAS pain scores up to 1-year following surgery, except for VAS neck pain at 3 months when patients with greater depression symptoms had more pain. High PHQ-9 patients had higher NDI values at 6 weeks and 3-month marks but had similar NDI scores at 6 months and 1-year. Similarly, SF-12 PCS scores were lower for patients with a higher PHQ-9 score at 3 and 6 months, however, both groups had similar scores at 1-year follow-up. A greater percentage of the high PHQ-9 cohort achieved MCID for NDI, however, there were no differences in MCID achievement for VAS neck, VAS arm, or SF-12 PCS. Conclusions Patients with worse preoperative mental health reported significantly greater preoperative disability and pain. However, both cohorts demonstrated similar clinical recovery at the 1-year follow-up. These findings suggest patients with worse preoperative mental health can expect significant improvements in PROs following surgery.

BACKGROUND: The prevention of perioperative and postoperative complications is necessary to avoid poor postoperative outcomes and increased costs. Previous investigations have identified risk factors for complications after various spine procedures, but no such study exists in a population solely undergoing minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). The purpose of this study is to determine risk factors for the development of complications up to 2 years after MIS TLIF procedures. METHODS: Patients who underwent primary, single-level MIS TLIF from 2007 to 2016 were retrospectively reviewed. The incidence of medical and surgical complications up to 2 years postoperatively was determined. Patients were categorized according to demographic, comorbidity, and procedural characteristics. Bivariate Poisson regression with robust error variance was used to determine if an association existed between patient characteristics and complication incidence. A final multivariate model including all patient characteristics as controls was created using backwards, stepwise regression until only those variables with P < .05 remained. RESULTS: 390 patients were analyzed. Upon bivariate analysis, age >50 years (P = .025), diabetes mellitus (P = .001), and operative duration >105 minutes (P = .016) were associated with increased medical complication rates. Regarding surgical complications, age ≤50 years (P < .001), obesity (P = .012), and diabetes mellitus (P = .042) were identified as risk factors on bivariate analysis. Upon final multivariate analysis, operative time >105 minutes (P = .009) and diabetes mellitus (P = .001) were independent risk factors for medical complications. Independent risk factors for surgical complications on multivariate analysis included age ≤50 years (P < .001), diabetes mellitus (P = .002), and obesity (P = .030). CONCLUSIONS: Diabetic patients and those who underwent longer operations were at increased risk of medical complications, while younger patients, obese patients and those also with diabetes mellitus were at increased risk of surgical complications up to 2 years after MIS TLIF. Practitioners can use this information to identify patients who require preventative care before their procedure or increased postoperative vigilance and monitoring after single-level MIS TLIF. LEVEL OF EVIDENCE: 3.

STUDY DESIGN This was a systematic review. OBJECTIVE The objective of this study was to review radiographic, clinical, and surgical outcomes of expandable interbody device implantation following lumbar fusion. SUMMARY OF BACKGROUND DATA Few studies have evaluated postsurgical outcomes of expandable implants following lumbar interbody fusion. METHODS A systematic review was performed to identify studies investigating expandable intervertebral body devices in lumbar fusion. Radiographic parameters, fusion assessments, patient-reported outcomes (PROs), complications, and revision data were recorded. A comparison of expandable and static devices was performed using a meta-analysis. RESULTS Eleven articles were included. Postoperative improvements for each radiographic parameters for expandable versus static device implantation ranged from: lumbar lordosis, +2.0 to +5.0 degrees (expandable) versus +1.0 to +4.4 degrees (static); segmental lordosis, +1.0 to +5.2 degrees (expandable) versus+1.1 to +2.3 degrees (static); disk height, +0.82 to +4.8 mm (expandable) versus +0.26 to +6.9 mm (static); foraminal height, +0.13 to +2.8 mm (expandable) versus and +0.05 to +3.0 mm (static). Fusion rates ranged from 72.1% at 6 months to 100% at terminal follow-up. Preoperative to final follow-up improvement for the various PROs assessed were: Oswestry Disability Index, -15.4 to -56.3 (expandable) versus -13.6 to -26.3 (static); Visual Analog Scale (VAS) Back, -3.2 to -6.0 (expandable) versus -3.1 to -4.1 (static); and VAS Leg, -2.9 to -7.1 (expandable) -3.0 versus -4.8 (static). Static cages had a reported complication rate ranging from 6.0% to 16.1% and a subsidence rate of 6.0%. Expandable cages had a reported complication rate that ranged from 0.0.% to 10.0% and a subsidence rate of 5.5%-10.0%. A meta-analysis demonstrated a statistically significant difference in the PRO Oswestry Disability Index, but not VAS Back, VAS Leg, or radiographic outcomes (disk height or foraminal height). CONCLUSION There is no clear evidence for the use of expandable interbody devices over static devices.

Objective To assess the relationship of preoperative physical function, as measured by Patient-Reported Outcome Measurement Information System Physical Function (PROMIS PF), to improvement in mental health, as evaluated by Short Form-12 Mental Component Summary (SF-12 MCS) following anterior cervical discectomy and fusion (ACDF). Methods Patients undergoing primary ACDF were retrospectively reviewed and stratified based on preoperative PROMIS PF scores. PROMIS PF cohorts were tested for an association with demographic characteristics and perioperative variables using chi-square analysis and multivariate linear regression. Multivariate linear regression was utilized to determine the association between PROMIS PF cohorts and improvement in SF-12 MCS. Results A total of 129 one- to 3-level ACDF patients were included: 73 had PROMIS PF < 40 (“low PROMIS”) and 56 had PROMIS PF ≥ 40 (“high PROMIS”). The low PROMIS cohort reported worse mental health preoperatively and at all postoperative timepoints except for 1 year. Both cohorts had similar changes in mental health from baseline through the 6-month follow-up. However, at 1 year. postoperatively, the low PROMIS cohort had a statistically greater change in mental health score. Conclusion Patients with worse preoperative physical function reported significantly worse preoperative and postoperative mental health. However, patients with worse preoperative physical function made significantly greater improvements in mental health from baseline. This suggests that patients with worse preoperative physical function can still expect significant improvements in mental health following surgery.

BACKGROUND: Complications occurring after spinal procedures are associated with recurrent symptomatology, new-onset symptomatology, and increased health care costs. The American Society of Anesthesiologists (ASA) score is a commonly cited risk factor for complication incidence. Few investigations have been performed analyzing the relationship between ASA score and complication rate following spinal minimally invasive surgery (MIS) decompressions or fusions. Therefore, the purpose of this study is to determine whether an association exists between preoperative ASA score and the incidence of postoperative complications among patients undergoing MIS posterior lumbar decompression or fusion. METHODS: A surgical registry of patients undergoing single-level MIS posterior lumbar decompressions or fusions between 2007 and 2016 was retrospectively reviewed. Patients were stratified by preoperative ASA score (≤2, >2). The ASA score was tested for an association with preoperative demographic, comorbidity, and perioperative characteristics using the Student t test or χ(2) analysis. Multivariate Poisson regression with robust error variance was used to test for an association between ASA score and the incidence of complications up to 6 months postoperatively. RESULTS: A total of 772 patients were analyzed. Of those, 86.7% had an ASA score ≤2, whereas 13.3% had an ASA score >2. An ASA score >2 was associated with older age (P 2 was also associated with significantly longer operative time (P = .001) and longer length of hospital stay (P

Objective The relationship between bone graft technique and postoperative outcomes for minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) has not been well-defined. This study aims to determine the effect of iliac crest bone grafting (ICBG) on patient-reported outcomes (PROs) and complication rates following MIS TLIF. Methods Primary, single-level MIS TLIF patients were consecutively analyzed. Patients that prospectively received a percutaneous technique of ICBG were compared to patients that retrospectively received bone morphogenetic protein-2 (BMP-2). Complication rates were assessed perioperatively and up to 1 year postoperatively. Changes in Oswestry Disability Index (ODI), visual analogue scale (VAS) back, and VAS leg pain were compared. Rates of minimum clinically important difference (MCID) achievement at final follow-up for ODI, VAS back, and VAS leg scores were compared. Results One hundred forty-nine patients were included: 101 in the BMP-2 cohort and 48 in the ICBG cohort. The ICBG cohort demonstrated increases in intraoperative blood loss and shorter lengths of stay. ICBG patients also experienced longer operative times, though this did not reach statistical significance. No significant differences in complication or reoperation rates were identified. The ICBG cohort demonstrated greater improvements in VAS leg pain at 6-week and 12-week follow-up. No other significant differences in PROs or MCID achievement rates were identified. Conclusion Patients undergoing MIS TLIF with ICBG experienced clinically insignificant increases in intraoperative blood loss and did not experience increases in postoperative pain or disability. Complication and reoperation rates were similar between groups. These results suggest that ICBG is a safe option for MIS TLIF.

Study design This was a retrospective cohort study. Objective To determine the improvement of clinical outcomes in Workers' Compensation (WC) patients compared with non-WC patients utilizing Patient-reported Outcome Measurement Information System Physical Function (PROMIS PF) following anterior cervical discectomy and fusion (ACDF). Summary of background data To our knowledge, there has not been a study to evaluate clinical outcomes of WC patients utilizing the PROMIS PF survey. Methods and materials Patients undergoing a primary, 1 to 3-level ACDF were retrospectively reviewed and stratified according to insurance (WC and non-WC). Demographic and perioperative characteristics were compared using χ test and independent t tests. Change in PROMIS PF scores was calculated using paired t tests. Differences in postoperative PROMIS PF scores and changes in PROMIS PF from baseline were compared using linear regression. Results In total, 124 1 to 3-level ACDF patients were included: 36 had WC insurance and 88 had non-WC insurance. WC patients were younger and more likely to be obese. WC patients reported significantly lower PROMIS PF scores preoperatively and at 6 weeks, 12 weeks, and 6 months timepoints. However, both cohorts reported comparable PROMIS PF scores at the 1-year timepoint. WC patients demonstrated similar improvements from baseline through 1-year postoperatively compared with non-WC patients. For both non-WC and WC cohort, the change in the postoperative PROMIS PF score from baseline was significant at 3 months, 6 months, and 1 year. However, in both cohorts, the change in the postoperative PROMIS PF score from baseline was not significantly different at 6 weeks. Conclusions In our study, WC patients had worse baseline physical function as indicated by lower preoperative PROMIS PF scores and reported lower PROMIS PF scores postoperatively. However, there were no significant differences when comparing the postoperative change from baseline between the cohorts. Both cohorts experienced significant postoperative improvements from baseline. This study established that PROMIS PF is an effective tool to evaluate recovery of WC patients following ACDF.

STUDY DESIGN Retrospective. OBJECTIVE The aim of this study was to evaluate the validity of Patient Health Questionnaire-9 (PHQ-9) among patients undergoing minimally invasive (MIS) lumbar interbody fusion. SUMMARY OF BACKGROUND DATA Few studies have evaluated the utility and concurrent validity of the PHQ-9 survey in patients undergoing spinal procedures. METHODS Patients undergoing a one- or two-level MIS lumbar interbody fusion were retrospectively reviewed. Patient-reported outcome surveys were completed preoperatively and at 6-week, 12-week, 6-month, and 1-year timepoints. Postoperative survey scores were compared to preoperative values using paired t tests. PHQ-9 scores were compared with the Mental Component Summary (MCS) scores of the Short Form-12 (SF-12) and the Veterans RAND-12 (VR-12) surveys at each timepoint using the Pearson correlation coefficient. RESULTS A total of 215 patients were included in the analysis. The mean preoperative scores for the PHQ-9, SF-12 MCS, and VR-12 MCS were 6.78, 49.55, and 50.39, respectively. Significant improvements in each survey outcome measure were observed at all postoperative timepoints. Strong correlations with PHQ-9 scores were identified for SF-12 MCS scores and VR-12 MCS scores at preoperative and postoperative timepoints (|r| ≥ 0.5 and P

Study design Retrospective cohort. Objective To determine if sex is associated with differences in postoperative pain scores, narcotic consumption, and long-term improvements in pain and disability following minimally invasive lumbar discectomy (MIS LD). Summary of background data There exists a question as to what extent sex influences surgical and clinical outcomes following MIS LD. Methods Patients undergoing primary, single-level MIS LD were retrospectively reviewed and stratified on the basis of sex. Immediate postoperative Visual Analog Scale (VAS) pain scores and narcotic consumption were collected. Patient-reported outcomes, including Oswestry Disability Index (ODI), 12-Item Short-Form- (SF-12) Physical Component Score, and VAS back and leg pain, were collected preoperatively and at 6-week, 3-month, 6-month, and 12-month follow-up. Sex differences were tested for an association between immediate postoperative pain, narcotics utilization, and long-term improvements in patient-reported outcomes using linear regression. Results A total of 188 patients were included and 62.8% were male individuals. At the time of surgery, female individuals were older than male individuals (P=0.045). There were no observed differences in other demographic or perioperative characteristics between cohorts. Female individuals had similar inpatient VAS pain scores and narcotic consumption compared with male individuals. Female individuals had a higher ODI score than male individuals preoperatively, however, both cohorts had similar improvements in ODI at all postoperative time points. Both sexes had similar VAS back and leg pain and SF-12 PCS scores preoperatively and at all postoperative time points. Conclusions Our study demonstrated that sex does not affect immediate postoperative pain, narcotic consumption, and long-term recovery following MIS LD. Female individuals demonstrated similar preoperative back and pain scores compared with male individuals but reported greater disability before surgery. However, both sexes experienced similar improvements in pain and disability at all follow-up time points through 12 months. The results of this study may enable providers to better counsel patients regarding the expected improvement in pain and disability.

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.

BACKGROUND: Research focused on postoperative outcomes among men and women undergoing minimally invasive lumbar decompression (MIS LD) spine surgery is sparse. This study aims to assess the influence of sex on postoperative patient-reported outcome measure (PROM) evaluations and achievement of a minimum clinically important difference (MCID). METHODS: A prospectively maintained surgical database was retrospectively queried for patients undergoing primary or revision, single or multilevel LD procedures from 2011 to 2019. Patients with incomplete visual analog scale (VAS) leg or back surveys were excluded. Demographic and operative variables were recorded, and a chi-squared analysis or t tests were used to compare by sex. PROMs were evaluated from preoperative to postoperative time points. PROM score differences and postoperative improvement were evaluated between sexes by a t test. Achievement of MCID by sex was compared using chi-squared analysis. RESULTS: The study cohort (n = 572) was 70% male (n = 398), had an average age of 47 years, and 42% were obese. Sexes differed in preoperative VAS leg, Oswestry Disability Index (ODI), and 12-item short form (SF-12)-physical composite score (PCS) scores (all P < .05) and in ODI at 6 and 12 weeks (P = .048; P = .001) and VAS back and leg scores at 6 months (P = .039; P = .019). Both sexes significantly improved (P < .050) all PROMs at all time points except for VAS back at 1 year for women and ODI at 6 weeks and 6 months for men. The only significant difference in achievement of MCID was for ODI at 6 months (P = .008). CONCLUSIONS: Significant preoperative differences were observed among sexes with ODI, SF-12-PCS, and VAS leg scores. By 1 year, there were no significant sex differences for any PROM or for achievement of MCID. MIS LD has an equivalent role for both sexes in achieving MCID. LEVEL OF EVIDENCE: 3. CLINICAL RELEVANCE: Results demonstrate no sex difference in PROMs following LD.

To compare outcomes between minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) and anterior lumbar interbody fusion (ALIF) at L5/S1.Primary, elective, single, MIS-TLIF, or ALIF with posterior fixation at L5/S1 were identified. Patient-reported outcome measures (PROMs) were collected. Coarsened exact matching was used to control for significant differences. Achievement of minimum clinically important difference [MCID] was determined by comparing ΔPROM scores with threshold values. Demographic/perioperative characteristics were compared between MIS-TLIF and ALIF cohorts using χAfter coarsened exact matching, 93 patients received MIS-TLIF and 50 received ALIF. Cohorts differed in operative time, estimated blood loss, and postoperative narcotic consumption on postoperative day 0 (P0.034, all). Mean PROMs differed significantly on 12-Item Short-Form Physical Component Summary at 6 weeks and 1 year, Patient-Reported Outcomes Measurement Information System Physical Function at 6 weeks, Oswestry Disability Index at 6 weeks, and visual analog scale (VAS) back at 6 weeks, with the ALIF cohort showing significantly improved mean PROMs (P ≤ 0.044, all). Significantly greater rates were reported of MCID achievement for PROMs for the ALIF cohort: VAS back at 6 weeks, Oswestry Disability Index at 12 weeks, 12-Item Short-Form Physical Component Summary at 6 weeks, and Patient-Reported Outcomes Measurement Information System Physical Function at 12 weeks (P ≤ 0.047, all). A greater rate of MCID achievement for the MIS-TLIF cohort was seen for 6-week and overall VAS leg (P0.046, all). Postoperative fever was greater in the TLIF cohort (9.6% vs. 2.0%; P0.047).Patients undergoing ALIF showed significantly improved rates of MCID achievement for disability, physical function, and back pain during the early postoperative period. However, the overall MCID achievement rate for leg pain was higher for the MIS-TLIF cohort.

Purpose The Global Burden of Diseases (GBD) Studies have estimated that low back pain is one of the costliest ailments worldwide. Subsequent to GBD publications, leadership of the four largest global spine societies agreed to form SPINE20. This article introduces the concept of SPINE20, the recommendations, and the future of this global advocacy group linked to G20 annual summits. Methods The founders of SPINE20 advocacy group coordinated with G20 Saudi Arabia to conduct the SPINE20 summit in 2020. The summit was intended to promote evidence-based recommendations to use the most reliable information from high-level research. Eight areas of importance to mitigate spine disorders were identified through a voting process of the participating societies. Twelve recommendations were discussed and vetted. Results The areas of immediate concern were “Aging spine,” “Future of spine care,” “Spinal cord injuries,” “Children and adolescent spine,” “Spine-related disability,” “Spine Educational Standards,” “Patient safety,” and “Burden on economy.” Twelve recommendations were created and endorsed by 31/33 spine societies and 2 journals globally during a vetted process through the SPINE20.org website and during the virtual inaugural meeting November 10–11, 2020 held from the G20 platform. Conclusions This is the first time that international spine societies have joined to support actions to mitigate the burden of spine disorders across the globe. SPINE20 seeks to change awareness and treatment of spine pain by supporting local projects that implement value-based practices with healthcare policies that are culturally sensitive based on scientific evidence.