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Objective: Patient demographics, comorbidities, and baseline quality of life (QOL) are major contributors to postoperative outcomes. The frequency and cost of lumbar spine surgery has been increasing, with controversy revolving around optimal management strategies and outcome predictors. The goal of this study was to generate predictive nomograms and a clinical calculator for postoperative clinical and QOL outcomes following lumbar spine surgery for degenerative disease., Methods: Patients undergoing lumbar spine surgery for degenerative disease at a single tertiary care institution between June 2009 and December 2012 were retrospectively reviewed. Nomograms and an online calculator were modeled based on patient demographics, comorbidities, presenting symptoms and duration of symptoms, indication for surgery, type and levels of surgery, and baseline preoperative QOL scores. Outcomes included postoperative emergency department (ED) visit or readmission within 30 days, reoperation within 90 days, and 1-year changes in the EuroQOL-5D (EQ-5D) score. Bootstrapping was used for internal validation., Results: A total of 2996 lumbar surgeries were identified. Thirty-day ED visits were seen in 7%, 30-day readmission in 12%, 90-day reoperation in 3%, and improvement in EQ-5D at 1 year that exceeded the minimum clinically important difference in 56%. Concordance indices for the models predicting ED visits, readmission, reoperation, and dichotomous 1-year improvement in EQ-5D were 0.63, 0.66, 0.73, and 0.84, respectively. Important predictors of clinical outcomes included age, body mass index, Charlson Comorbidity Index, indication for surgery, preoperative duration of symptoms, and the type (and number of levels) of surgery. A web-based calculator was created, which can be accessed here: https://riskcalc.org/PatientsEligibleForLumbarSpineSurgery/., Conclusions: The prediction tools derived from this study constitute important adjuncts to clinical decision-making that can offer patients undergoing lumbar spine surgery realistic and personalized expectations of postoperative outcome. They may also aid physicians in surgical planning, referrals, and counseling to ultimately lead to improved patient experience and outcomes.

Background: More than 120,000 anterior cervical discectomy and fusions (ACDFs) are performed annually. Pseudarthrosis is a potential delayed adverse event that affects up to 33% of patients. The degree to which this adverse event affects both patient quality-of-life (QOL) outcomes and health care costs is poorly understood., Methods: Patients who underwent revision surgery for pseudarthrosis between 2007 and 2012 were identified and matched to controls not experiencing pseudarthrosis in a 1:2 fashion (case/control). Cases and controls were compared regarding total health care costs incurred in the year after the index ACDF and QOL outcomes on the following metrics: EuroQol Five-Dimensions Questionnaire, Patient Health Questionnaire-9, and Pain Disability Questionnaire., Results: Of 738 patients who underwent ACDF, 11 underwent surgery for pseudarthrosis. No differences were noted between cases and controls regarding any of the matched variables. Patients in the pseudarthrosis cohort had poorer postoperative scores on the EuroQol Five-Dimensions Questionnaire mobility, usual activities, pain/discomfort, and quality-adjusted life-year dimensions. In addition, 64% of patients with pseudarthrosis had worsened quality-adjusted life-year scores compared with only 9% of controls (P < 0.01). Patients with pseudarthrosis also had poorer mental health (P < 0.01) and pain disability outcomes (P < 0.01) than did controls. Pseudarthrosis was associated with significant increases in direct costs, direct postoperative costs, and total costs (all P < 0.01)., Conclusions: This is the first study to characterize the effect of surgical revision for pseudarthrosis on both QOL outcomes and care costs after ACDF. Patients requiring revision experienced significantly poorer QOL outcomes and higher care costs relative to controls., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Surgical site infections (SSI) following spine procedures are serious and costly complications that may reduce patient quality of life (QOL). Deep SSIs may also extend hospitalizations and require surgical debridement or antibiotic therapy, increasing costs to both patients and the healthcare system. Here we sought to evaluate the effect of deep SSI on care cost and QOL outcomes in patients undergoing posterior lumbar decompression and fusion. To do so we performed a retrospective study of patients undergoing lumbar decompression and fusion between 2008 and 2012. Patients experiencing postoperative deep SSI were matched to controls not experiencing a deep SSI. Included patients had prospectively-gathered QOL outcome measures collected preoperatively and at 6 months postoperatively. Health resource utilization was recorded from patient electronic medical records over the 6-month follow-up. Direct costs were estimated using Medicare national payment amounts. Indirect costs were based on missed work days and patient income. We found both cohorts experienced significant improvements in QOL scores following surgery, and there were no significant differences between the cohorts. The average total cost was significantly higher in the infected cohort compared to controls ($37,009 vs. $16,227; p < 0.0001). Compared to controls, patients experiencing deep SSI had greater costs in each of the following categories: hospitalizations (p < 0.01), office visits (p = 0.03), imaging (p < 0.01), and medications (p < 0.01). Among those experiencing deep SSI, there are significant increases in costs, with minimal long-term impact on QOL outcomes as compared with controls at the six-month follow-up., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Objective: Tandem spinal stenosis (TSS) is a degenerative spinal condition characterized by spinal canal narrowing at 2 or more distinct spinal levels. It is an aging-related condition that is likely to increase as the population ages, but which remains poorly described in the literature. Here we sought to determine the impact of primary lumbar decompression on quality-of-life (QOL) outcomes in patients with symptomatic TSS., Patients and Methods: We retrospectively reviewed 803 patients with clinical and radiographic evidence of TSS treated between 2008 and 2014 with a minimum 2-year follow-up. The records of patients with clinical and radiographic evidence of concurrent cervical and lumbar stenosis were reviewed. Prospectively gathered QOL data, including the Pain Disability Questionnaire (PDQ), Patient Health Questionnaire-9 (PHQ-9), EuroQOL-5 Dimensions (EQ-5D), and Visual Analogue Scale (VAS) for low back pain, were assessed at the 6-month, 1-year, and 2-year follow-ups., Results: Of 803 identified patients (mean age 66.2 years; 46.9% male), 19.6% underwent lumbar decompression only, 14.1% underwent cervical + lumbar decompression, and 66.4% underwent conservative management only. Baseline VAS scores were similar across all groups, but patients undergoing conservative management had better baseline QOL scores on all other measures. Both surgical cohorts experienced significant improvements in the VAS, PDQ, and EQ-5D at all time points; patients in the cervical + lumbar cohort also had significant improvement in the PHQ-9. Conservatively managed patients showed no significant improvement in QOL scores at any follow-up interval., Conclusion: Lumbar decompression with or without cervical decompression improves low back pain and QOL outcomes in patients with TSS. The decision to prioritize lumbar decompression is therefore unlikely to adversely affect long-term quality-of-life improvements., (Copyright © 2019. Published by Elsevier B.V.)

Objective: In 2009, 2 randomized controlled trials demonstrated no improvement in pain following vertebral augmentation compared with sham surgery. However, a recent randomized trial demonstrated significant pain relief in patients following vertebroplasty compared to controls treated with conservative medical management. This study is a retrospective review of prospectively collected patient-reported quality of life (QOL) outcomes. The authors hypothesized that vertebral augmentation procedures offer a QOL benefit, but that this benefit would be diminished in patients with a history of depression and/or in patients undergoing vertebral augmentation at more than 1 level., Methods: Multivariable linear regression was used to identify predictors of postoperative pain assessed using the Pain Disability Questionnaire (PDQ), Patient Health Questionnaire 9 (PHQ-9), and EQ-5D scores. Eleven candidate predictors were selected a priori: age, sex, smoking history, coronary artery disease, depression, diabetes, procedure location (thoracic, lumbar), BMI, prior spine surgery, procedure indication (metastases, osteoporosis/osteopenia, other), and number of levels (1, 2, 3, or more)., Results: A total of 143 patients were included in the study. For each 10-year increase in age, postoperative PDQ scores decreased (improved) by 9.7 points (p < 0.001). Patients with osteoporosis/osteopenia had significantly higher (worse) postoperative PDQ scores (+17.97, p = 0.028) than patients with metastatic lesions. Male sex was associated with higher (worse) postoperative PHQ-9 scores (+2.48, p = 0.010). Compared to single-level augmentation, operations at 2 levels were associated with significantly higher PHQ-9 scores (+2.58, p = 0.017). Current smokers had significantly lower PHQ-9 scores (-1.98, p = 0.023) than never smokers. No predictors were associated with significantly different EQ-5D score., Conclusions: Variables associated with worse postoperative PDQ scores included younger age and osteoporosis/osteopenia. Variables associated with decreased (better) postoperative PHQ-9 scores included female sex, single operative vertebral level, and positive smoking status (i.e., current smoker). These clinically relevant predictors may permit identification of patients who may benefit from vertebral augmentation.

Background: Clinical and quality of life (QOL) outcomes vary depending on the patient's demographics, comorbidities, presenting symptoms, pathology, and surgical treatment used. While there have been individual predictors identified, no comprehensive method incorporates a patient's complex clinical presentation to predict a specific individual postoperative outcome., Objective: To create tool that predicts patient-specific outcomes among those undergoing cervical spine surgery., Methods: A total of 952 patients at a single tertiary care institution who underwent anterior or posterior cervical decompression/fusion between 2007 and 2013 were retrospectively reviewed. Outcomes included postoperative emergency department visit or readmission within 30 d, reoperation within 90 d for infection, and changes in QOL outcomes. Nomograms were modeled based on patient demographics and surgical variables. Bootstrap was used for internal validation., Results: Bias-corrected c-index for emergency department visits, readmission, and reoperation were 0.63, 0.78, and 0.91, respectively. For the QOL metrics, the bias-corrected adjusted R-squared was EQ-5D (EuroQOL): 0.43, for PHQ-9 (Patient Health Questionnaire-9): 0.35, and for PDQ (Pain/Disability Questionnaire): 0.47. Variables predicting the clinical outcomes varied, but included race and median income, body mass index, comorbidities, presenting symptoms, indication for surgery, surgery type, and levels. For the QOL nomograms, the predictors included similar variables, but were significantly more affected by the preoperative QOL of the patient., Conclusion: These prediction models enable referring physicians and spine surgeons to provide patients with personalized expectations regarding postoperative clinical and QOL outcomes following a cervical spine surgery. After appropriate validation, use of patient-specific prediction tools, such as nomograms, has the potential to lead to superior spine surgery outcomes and more cost effective care.

Study Design: A retrospective cohort study at a single tertiary care center., Objective: To determine the impact of superior segment facet joint violation (FJV) during lumbar fusion on reoperation rates and quality of life (QOL)., Summary of Background Data: Although lumbar fusion is an efficacious and durable treatment for numerous spinal pathologies, adjacent segment degeneration remains a serious complication. FJV has been suggested to alter load-bearing capability and potentially contribute to adjacent segment degeneration., Materials and Methods: Patients who underwent instrumented lumbar fusion surgery between 2009 and 2013 with postoperative computed tomography imaging were included. Patients were placed in the FJV group if either of the superior segment facet joints were compromised by the pedicle screw or rod. Patients with preserved facet joints were placed in the control group. Demographic, perioperative, QOL, and reoperation data were collected. QOL scores including the Pain Disability Questionnaire, Patient Health Questionnaire-9, and EuroQOL 5 Dimensions (EQ-5D) were acquired., Results: Of 240 patients included, 112 patients were found to have FJV and the remaining 128 patients were placed in the control group. One year following lumbar fusion, QOL outcomes and reoperation rates were similar between the FJV and control groups. At 2-year follow-up, patients in the FJV group were less likely to make a significant improvement in EQ-5D (P=0.041). Also, the reoperation rate in the FJV group was significantly higher than in the control group at 2 years (15.2% vs. 6.3%, respectively; P=0.024) and 3 years (19.6% vs. 9.4%, P=0.023). Multivariable logistic regression showed FJV to be an independent predictor of both (1) failing to make a significant improvement in EQ-5D (P=0.046) and (2) undergoing reoperation at both 2 and 3 years postoperatively (P=0.024 and 0.020, respectively)., Conclusions: FJV was independently associated with a higher reoperation rate and diminished improvement in QOL.

Study Design: A retrospective cohort study at a single institution., Objective: To determine the effect of preoperative depression on Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey scores in a lumbar fusion population., Summary of Background Data: HCAHPS surveys are used to assess the quality of the patient experience, and directly influences reimbursement for hospital systems and spine surgeons nationwide. Untreated depression has been linked to worse functional outcomes in spine surgery. We, however, aimed to elucidate whether HCAHPS survey responses were different in depressed patients., Methods: Prospectively collected functional outcome data including Patient Health Questionnaire 9, EuroQol five dimensions, and Pain Disability Questionnaire were analyzed preoperatively. Preoperative Patient Health Questionnaire 9 scores of greater than or equal to 10 (moderate to severe depression) defined our depressed cohort of patients. HCAHPS responses were obtained for each individual, allowing for real-world analysis of outcomes in this population., Results: In our 237 patient cohort, depressed patients were younger, female; were on full disability; and had lower scores on EuroQol five dimensions and Pain Disability Questionnaire preoperatively. Approximately 73.2% of depressed patients felt doctors treated them with respect, compared to 88.8% of patients without depression (P = 0.005). Also, depressed patients felt nurses treated them with less respect (P = 0.014) and that physicians did not listen to them as carefully (P = 0.029). Multivariate regression analysis revealed that patients with preoperative depression had higher odds of patients feeling less respected by both physicians and nurses. Multivariate analysis also revealed that depression was an independent predictor of lower patient satisfaction with nursing response to their needs., Conclusion: In patients undergoing lumbar fusion, preoperative depression was shown to have negative effect on patient experience measured by the HCAHPS survey. These results suggest that depression may be a modifiable risk factor for poor hospital experience., Level of Evidence: 3.

Background Context: Coexisting Parkinson's disease (PD) and cervical spondylotic myelopathy (CSM) presents a diagnostic and therapeutic challenge due to symptomatic similarities between the diseases. Whereas CSM patients are routinely treated with surgery, PD patients face poorer outcomes following spine surgery. No studies have investigated the quality of life (QOL) outcomes following decompression in coexisting PD and CSM., Purpose: The purpose of the present study was to characterize QOL outcomes for patients with coexisting PD and CSM following cervical decompression., Study Design/setting: This is a matched cohort study at a single tertiary-care center., Patient Sample: Patients with coexisting PD and CSM undergoing cervical decompression between June 2009 and December 2014 were included. These patients were matched to controls with CSM alone by age, gender, American Society of Anesthesiologists classification, Modified Japanese Orthopaedic Association scores, and operative parameters., Outcome Measures: The primary outcome measure was QOL outcomes assessed by change in the EuroQol 5-Dimensions (EQ-5D), Pain Disability Questionnaire (PDQ), and Patient Health Questionnaire-9 (PHQ-9) at last follow-up (LFU). Change in QOL exceeding the minimal clinically important difference (MCID) was secondary., Methods: QOL data were collected using the institutional prospectively collected database of patient-reported health status measures. Simple and multivariable regressions were used to assess the impact of PD upon change in QOL., Results: Eleven PD patients were matched to 44 controls. Control patients experienced QOL improvement across all three measures, whereas PD patients only improved with respect to PDQ(89.9-80.7, p=.03). Despite no significant differences in preoperative QOL, PD patients experienced poorer QOL at LFU in EQ-5D (0.526 vs. 0.707, p=.01) and PDQ (80.7 vs. 51.4, p=.03), and less frequently achieved an EQ-5D MCID (18% vs. 57%, p=.04). However, no differences in the achievement of an MCID in PDQ or PHQ-9 were observed between cohorts. Multivariable regression identified PD as a significant independent predictor of poorer improvement in EQ-5D (β=-0.09, p<.01) and failure to achieve an EQ-5D MCID (odds ratio: 0.08, p<.01)., Conclusions: This is the first study to characterize QOL outcomes following cervical decompression for patients with coexisting PD and CSM. Although myelopathy may have been less severe among PD patients, a significant reduction in pain-related disability was observed following decompression. However, PD predicted diminished improvement in overall QOL measured by the EQ-5D., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background Context: Patients with comorbid disease may experience suboptimal quality of life (QOL) improvement following decompression spinal surgery. Prior studies have suggested the deleterious effect of diabetes upon postoperative QOL; however, these studies have not used minimal clinically important differences (MCIDs) or multivariable statistical techniques., Purpose: The purpose of this study was to assess the effect of preoperative diabetes upon postoperative change in QOL., Study Design/setting: A retrospective cohort study at a single tertiary-care center was carried out., Patient Sample: Patients who underwent lumbar decompression between 2008 and 2014 were included in the study. Inclusion necessitated a minimum follow-up of 6 months., Outcomes Measures: Postoperative changes in the EuroQol 5-Dimensions (EQ-5D), Pain Disability Questionnaire (PDQ), and Patient Health Questionnaire 9 (PHQ-9) at last follow-up were the primary outcome measures. The secondary outcome variable was postoperative change in QOL measures exceeding the MCID., Methods: Quality of life data were collected using the institutional prospectively collected database of patient-reported health status measures. Simple and multivariable logistic regressions were used to assess the impact of diabetes upon normalized change in QOL and improvement exceeding the MCID., Results: There were 212 patients who met inclusion criteria. Whereas non-diabetics experienced significant improvements in EQ-5D, PDQ, and PHQ-9 (p<.01), diabetics experienced no significant changes in any measures. More non-diabetics achieved the EQ-5D MCID compared with diabetics (55% vs. 23%, p<.01). Following multivariable regression, chronic kidney disease (CKD, β=-0.15, p=.04) and diabetes (β=-0.05, p=.04) were identified as significant independent predictors of diminished improvement in EQ-5D postoperatively. Furthermore, diabetes was also identified as a significant independent predictor of failure to achieve an EQ-5D MCID (OR 0.20, p<.01), whereas CKD trended toward predicting diminished improvement (OR<0.01, p=.09)., Conclusion: The burden of comorbidities may impact the QOL benefit of decompression spine surgery. In the present study, diabetes was found to independently predict diminished improvement in QOL after lumbar decompression., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Intramedullary spinal cord tumors are rare but clinically significant entities. Resection is critical to prevent permanent neurological deficits. However, no studies have investigated the quality of life (QOL) benefit of resection in adults., Objective: To investigate QOL outcomes after intramedullary spinal cord tumors resection., Methods: A consecutive retrospective review of all patients who underwent intramedullary spinal cord tumors resection at a single tertiary care institution between January 2008 and December 2013 was conducted. QOL was measured by the EuroQol 5-Dimensions (EQ-5D), Pain Disability Questionnaire (PDQ), and Patient Health Questionnaire-9 (PHQ-9). Multivariable regression was used to identify independent predictors of outcomes., Results: Among 45 patients, the most common pathology was ependymoma (60%). No significant changes between preoperative and postoperative EQ-5D, PDQ, or PHQ-9 were observed. Improvements exceeding the minimal clinically important difference occurred in 28% of patients in EQ-5D, 28% in PDQ, and 16% in PHQ-9. Worse preoperative neurological status predicted worsened EQ-5D (β = -0.09, P = .04) and PDQ (β = 20.77, P < .01), while ependymomas predicted QOL improvement exceeding the minimal clinically important difference in PDQ (OR 14.98, P = .04) and approached significance in EQ-5D (OR 43.52, P = .06). Conversely, cervical tumors predicted worsened PDQ (β = 18.32, P < .01) and failure to achieve EQ-5D minimal clinically important difference (OR <0.01, 95% CI <0.01-0.65, P = .02). Postoperative complications, such as syrinx formation (β = -0.09, P = .04) and cerebrospinal fluid leak (β = 13.85, P = .04), predicted diminished improvement in EQ-5D and PDQ, respectively., Conclusion: Although resection did not significantly improve QOL, it is likely necessary to arrest QOL deterioration. Patients with better preoperative neurological status or ependymoma experienced QOL improvement, while postoperative complications negatively impacted long-term QOL., Abbreviations: EQ-5D, EuroQol 5-DimensionsGTR, gross total resectionIMSCT, intramedullary spinal cord tumorsMCID, minimal clinically important differenceMMS, Modified McCormick ScalePDQ, Pain Disability QuestionnairePHQ-9, Patient Health Questionnaire-9POD, plane of dissectionQOL, quality of lifeSSI, surgical site infection.

Object: Studies comparing surgical treatments for cervical spondylotic myelopathy (CSM) are heterogeneous, using a variety of different quality of life (QOL) outcomes and myelopathy-specific measures. This study sought to evaluate the relationship of these measures to each other, and to better understand their use in evaluating patients with CSM., Methods: A retrospective study was performed in all patients with CSM who underwent either ventral or dorsal cervical spine surgery at a single tertiary-care institution between January 2008 and July 2013. Severity of myelopathy was assessed pre- and postoperatively using both the Nurick scale and the modified Japanese Orthopaedic Association (mJOA) classification of disability. Prospectively collected QOL outcomes data included Pain Disability Questionnaire (PDQ), Patient Health Questionnaire-9 (PHQ-9), and EQ-5D. Spearman rank correlations were calculated to assess the construct convergent validity for each pair of health status measures (HSMs). To assess each HSM's ability to discriminate favorable EQ-5D index, we performed receiver operating characteristic (ROC) curve analysis and assessed the area under the curve (AUC)., Results: A total of 119 patients were included. The PDQ total score had the highest correlation with EQ-5D index (Spearman's rho = -0.82). Neither of the myelopathy scales (mJOA or Nurick) had strong correlations between themselves (0.41) or with the other QOL measures (absolute value range 0.13-0.49). In contrast, the QOL measures correlated relatively well with each other (absolute value range 0.68-0.97). For predicting favorable EQ-5D outcomes, PDQ total score had an AUC of 0.909. The AUCs were significantly greater for the QOL measures in comparison with the myelopathy measures (AUCs were 0.677 and 0.607 for mJOA and Nurick scale scores, respectively)., Conclusions: The authors found that all included measures of QOL and CSM-specific (mJOA or Nurick scale) measures were valid and responsive. The PDQ was the most predictive of positive QOL after surgery (as measured by the EQ-5D index) for patients with CSM. The substantially lower correlation between myelopathy and QOL outcomes, compared with the various QOL measures themselves, suggests that these questionnaires are measuring different aspects of the patient experience. Solely assessing the myelopathy or disease-specific signs and symptoms is likely insufficient to fully understand and appreciate clinical outcome in its totality. These questionnaire types should be used together to best evaluate patients pre- and postoperatively.

Objective: Membrane stabilizing agents (MSAs) improves function and reduces neuropathic pain in a subset of patients with LSS. No study has investigated the pre-treatment demographic and psychosocial factors associated with quality of life (QOL) outcomes following the use of MSAs. In this study we sought to create prediction models for post-treatment outcome., Methods: All patients who were diagnosed with LSS and treated with MSAs at a single institution between September 2010 and March 2013 were retrospectively reviewed. QOL outcomes were collected prospectively. Prediction tools were created using multivariable logistic regression and Cox proportional hazard models. Outcome measures were: 1 - need for surgery within 1 year after initiating MSA treatment, 2 - time until surgery after initiating MSA treatment, 3 - any improvement in EuroQol (EQ)-5D QOL index, 4 - improvement in EQ-5D index exceeding the minimum clinically important difference (MCID)., Results: 1346 patients were included. For goal 1 (need for surgery), the prediction model was less robust. For goal 2 (time to surgery), only age was a significant predictor, with each 10-year increase in age causing the hazard of eventually having surgery to increase by 20%. 382 patients were available for analysis for goals 3 and 4 (predicting improvement in EQ-5D). Prediction models for these goals were good with C-statistics 0.73 and 0.85, respectively. Predictive factors for superior outcomes included lower baseline EQ-5D index (worse QOL), less baseline depression, greater median income, and being married., Conclusion: MSA treatment provides improvements in quality of life for those individuals with LSS. Treatment effects of MSAs will be greatest in those with worse quality of life, less depression, married patients, and those of higher socio-economic status., (Copyright © 2015 Elsevier B.V. All rights reserved.)

Object: Infections following spine surgery negatively affect patient quality of life (QOL) and impose a significant financial burden on the health care system. Postoperative wound infections occur at higher rates following dorsal cervical procedures than ventral procedures. Quantifying the health outcomes and costs associated with infections following dorsal cervical procedures may help to guide treatment strategies to minimize the deleterious consequences of these infections. Therefore, the goals of this study were to determine the cost and QOL outcomes affecting patients who developed deep wound infections following subaxial dorsal cervical spine fusions., Methods: The authors identified 22 (4.0%) of 551 patients undergoing dorsal cervical fusions who developed deep wound infections requiring surgical debridement. These patients were individually matched with control patients who did not develop infections. Health outcomes were assessed using the EQ-5D, Pain Disability Questionnaire (PDQ), Patient Health Questionnaire (PHQ-9), and visual analog scale (VAS). QOL outcome measures were collected preoperatively and after 6 and 12 months. Health resource utilization was recorded from patient electronic medical records over an average follow-up of 18 months. Direct costs were estimated using Medicare national payment amounts, and indirect costs were based on patients' missed workdays and income., Results: No significant differences in preoperative QOL scores were found between the 2 cohorts. At 6 months postsurgery, the noninfection cohort had significant pre- to postoperative improvement in EQ-5D (p = 0.02), whereas the infection cohort did not (p = 0.2). The noninfection cohort also had a significantly higher 6-month postoperative EQ-5D scores than the infection cohort (p = 0.04). At 1 year postsurgery, there was no significant difference in EQ-5D scores between the groups. Health care-associated costs for the infection cohort were significantly higher ($16,970 vs $7658; p < 0.0001). Indirect costs for the infection cohort and the noninfection cohort were $6495 and $2756, respectively (p = 0.03). Adjusted for inflation, the total costs for the infection cohort were $21,778 compared with $9159 for the noninfection cohort, reflecting an average cost of $12,619 associated with developing a postoperative deep wound infection (p < 0.0001)., Conclusions: Dorsal cervical infections temporarily decrease patient QOL postoperatively, but with no long-term impact; they do, however, dramatically increase the cost of care. Knowledge of the financial burden of wound infections following dorsal cervical fusion may stimulate the development and use of improved prophylactic and therapeutic techniques to manage this serious complication.

Object: The goal of this study was to determine whether pretreatment depression is predictive of quality of life (QOL) improvement for patients with lumbar spinal stenosis (LSS) who are treated conservatively., Methods: This retrospective cohort study included patients with LSS and concordant neurogenic claudication who were treated nonoperatively at a single institution between September 2010 and March 2013. Patient QOL measures were recorded pretreatment and then 4 months after treatment. Pretreatment depression was assessed using the Patient Health Questionnaire-9 (PHQ-9). Successful outcome was defined as posttreatment improvement in EuroQol-5D (EQ-5D) index or in Pain and Disability Questionnaire (PDQ) scores. Regression analysis was performed to identify independent predictors of outcome while controlling for confounding variables., Results: A total of 502 patients were included in the study. The average age for these patients was 66.1 years, with 51% female and 90.6% white. After adjusting for baseline demographic and clinical variables, there was a statistically significant association between baseline PHQ-9 score and posttreatment change in EQ-5D index (β = -0.007, p = 0.0002). All other things being equal, a patient with a baseline PHQ-9 score of 0 (no depression) would be expected to improve in the EQ-5D index by 0.14 points (greater than the minimum clinically important difference) more than would a patient with a baseline PHQ-9 score of 20 (major depression). There was no significant association between baseline PHQ-9 score and change in Pain and Disability Questionnaire scores., Conclusions: When controlling for other baseline characteristics, severely depressed patients with LSS who are treated nonoperatively have significantly less improvement in their QOL compared with those with little or no depression. These data are similar to the negative predictive effects of depression on posttreatment QOL following lumbar fusion surgery.

Object: The authors investigated quality of life (QOL) outcomes after primary versus revision discectomy., Methods: A retrospective review was performed for all patients who had undergone a primary or revision discectomy at the Cleveland Clinic Center for Spine Health from January 2008 through December 2011. Among patients in the revision cohort, they identified those who needed a second revision discectomy. Patient QOL measures were recorded before and after surgery. These measures included responses to the EQ-5D health questionnaire, Patient Health Questionnaire-9, Pain and Disability Questionnaire, and quality-adjusted life years (QALYs). Cohorts were compared by using independent-sample t-tests and Fisher exact tests for continuous and categorical variables, respectively. Multivariable logistic regression was performed to adjust for confounding., Results: A total of 196 patients were identified (116 who underwent primary discectomy and 80 who underwent revision discectomy); average follow-up time was 150 days. There were no preoperative QOL differences between groups. Postoperatively, both groups improved significantly in all QOL measures. For QALYs, the primary cohort improved by 0.25 points (p<0.001) and the revision cohort improved by 0.18 points (p<0.001). QALYs improved for significantly more patients in the primary than in the revision cohort (76% vs 59%, respectively; p=0.02), and improvement exceeded the minimum clinically important difference for more patients in the primary cohort (62% vs 45%, respectively; p=0.03). Of the 80 patients who underwent revision discectomy, yet another recurrent herniation (third herniation) occurred in 14 (17.5%). Of these, 4 patients (28.6%) chose to undergo a second revision discectomy and the other 10 (71.4%) underwent conservative management. For those who underwent a second revision discectomy, QOL worsened according to all questionnaire scores., Conclusions: QOL, pain and disability, and psychosocial outcomes improved after primary and revision discectomy, but the improvement diminished after revision discectomy.

Background Context: Some, smaller studies have investigated the effect of preoperative depression on postoperative improvement in quality of life (QOL). However, they have not used the Patient Health Questionnaire 9 (PHQ-9) in self-reported depression., Purpose: To assess the effect of preoperative depression as measured by the PHQ-9 on postoperative improvement in QOL., Study Design: A retrospective review at a single tertiary-care referral center., Patient Sample: Patients who underwent lumbar decompression or fusion between 2008 and 2012., Outcomes Measures: A self-reported EuroQol five-dimensions (EQ-5D) quality-adjusted life-years Index., Methods: Quality of life data were collected using the institutional prospectively collected database of patient-reported health status measures. The EQ-5D questionnare, PDQ, and PHQ-9 were used. Linear and logistic regression analyses were performed to assess the impact of preoperative depression on QOL improvement., Results: Elevated preoperative pain (PDQ, β=-0.0017, p=.0009) and worsened depression (PHQ-9, β=-0.0044, p=.0359) were significantly associated with diminished postoperative improvement in QOL, as measured by the EQ-5D. Furthermore, greater depression (PHQ-9, odds ratio [OR] 0.93, p<.0001) and pain (PDQ, OR 0.99, p=.02) were associated with significantly diminished postoperative improvement exceeding the minimum clinically important difference., Conclusions: Increased preoperative pain and depression were shown to be associated with significantly reduced improvement in postoperative QOL, as measured by the EQ-5D., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background Context: Posterior cervical fusion (PCF) has been shown to be an effective treatment for cervical spondylosis, but is associated with a 9% complication rate and high costs. To limit such complications and costs, it is imperative that proper selection of surgical candidates occur for those most likely to do well with the surgery. Affective disorders, such as depression, are associated with worsened outcomes after lumbar surgery; however, this effect has not been evaluated in patients undergoing cervical spine surgery., Purpose: To assess the predictive value of preoperative depression and the health state on 1-year quality of life (QOL) outcomes after PCF., Study Design: A retrospective cohort analysis., Patient Sample: Eighty-eight patients who underwent PCF for cervical spondylosis were reviewed., Outcome Measures: Preoperative and 1-year postoperative health outcomes were assessed based on the Pain Disability Questionnaire (PDQ), the Patient Health Questionnaire-9 (PHQ-9), and the EuroQol five-dimensions (EQ-5D) questionnaire., Methods: Univariable and multivariable regression analyses were performed to assess for preoperative predictors of 1-year change in health status., Results: Compared with preoperative health states, the PCF cohort showed statistically significant improved PDQ (87.8 vs. 73.6), PHQ-9 (7.7 vs. 6.6), and EQ-5D (0.50 vs. 0.60) scores at 1 year postoperatively. Only 10/88 (11%) patients achieved or surpassed the minimum clinically important difference for the PHQ-9 (5). Multiple linear and logistic regression analyses showed that increasing PHQ-9 and EQ-5D preoperative scores were associated with reduced 1-year postoperative improvement in health status (EQ-5D index)., Conclusions: Of patients who undergo PCF, those with a greater degree of preoperative depression have lower improvements in postoperative QOL compared with those with less depression. Additionally, patients with better preoperative health states also attain lower 1-year QOL improvements., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background Context: C5 palsy is a debilitating postoperative complication of cervical decompression surgery. Although the prognosis is typically good, patients may be unable to perform basic activities of daily living, resulting in a decreased quality of life. No studies have investigated the quality-of-life and financial implications., Purpose: The aim of the study was to determine the impact on quality-of-life and costs of C5 palsy after posterior cervical decompression and fusion (PCDF)., Study Design/setting: A 2:1 matched retrospective cohort study was conducted at a single tertiary-care institution between 2007 and 2012., Patient Sample: Individuals who had undergone PCDF were included., Outcome Measures: Self-reported: Euroqol-5 Dimensions quality-of-life survey. Physiologic: postoperative change in deltoid and biceps strength via manual muscle testing. Functional: cost of interventions and missed workdays postoperatively., Methods: Individuals with postoperative C5 palsy were matched to controls based on age, gender, body mass index, and diagnosis. Demographic, operative, postoperative, quality-of-life, and cost data were collected for both the C5 palsy and control groups, with 1-year follow-up., Results: We reviewed 245 patients who underwent PCDF and 17 were identified (6.9%) with C5 palsy and matched to 34 controls. No significant differences in demographic or operative characteristics were observed between groups. The C5 palsy group had a significantly reduced capacity for self-care in the immediate postoperative (2.0±0.71 vs. 1.2±0.4, p<.001) and long-term (1.6±0.6 vs. 1.2±0.4, p=.004) periods and a significantly reduced capacity for completion of usual activities (2.4±0.7 vs. 1.9±0.6, p=.014) compared with controls. Furthermore, the C5 group had a significantly greater cost of physical/occupational therapy, an increase of $2,078 ($4,386±$2,801 vs. $2,307±$1,907, p=.013). There were no significant differences between groups in the cost of hospital stay, surgery, or other direct or indirect costs. Overall, there was a significantly greater cost ($1,918) for the C5 palsy group compared with the control group ($7,584±$3,992 vs. $5,666±$2,359, respectively, p=.038)., Conclusions: This study represents the first quantification of the impact of C5 palsy on patients' quality of life and the associated costs for care. We found that C5 palsy adds a significant burden on patients' quality of life and presents a financial burden to the health-care system., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Purpose: To investigate the quality of life outcomes following surgical treatment of patients with coexisting multiple sclerosis (MS) and cervical stenosis with associated myelopathy (CS)., Methods: A retrospective review of the medical records and of prospectively acquired quality of life (QOL) data was performed for all patients with symptoms of myelopathy and coexisting diagnoses of MS and CS that underwent cervical decompression surgery between 2008 and 2011. The study population was matched (1:4) to a control cohort of patients that did not have MS but presented with similar myelopathic symptoms due to cervical stenosis, were of the same age and gender, and underwent the same cervical decompression procedure within the same year., Results: Sixty-five patients were reviewed, including 13 in the MS group and 52 in the control group that were followed for an average of 22 and 18 months, respectively. Whereas patients in the MS cohort remained at a Quality-Adjusted Life-Year (QALY) gain of 0.51 both pre- and post-operatively (p = 0.96), patients in the matched control cohort improved from a preoperative QALY of 0.50 to a postoperative QALY of 0.64 (p < 0.0001). The latter represents an improvement that exceeds the minimum clinically important difference. Overall, 70% of patients in the control group experienced an improvement in QALY, compared to only 54% in the MS group (p = 0.4)., Conclusion: Patients in the control cohort had clinically and statistically significant improvements in QALY outcomes. Those in the MS cohort averaged no change in QALY. However, only a minority of MS/CS patients had worsening QALY following surgery, and as such surgery may still be considered for these patients. It is imperative that there are preoperative discussions with the MS/CS patient regarding the likelihood that surgery will only provide limited, if any, improvements in QOL.

Background: Cervical disc arthroplasty (CDA) is a novel motion-preserving procedure that is an alternative to fusion. The Mobi-C disc prosthesis, one of many Food and Drug Administration (FDA)-approved devices for CDA, is the only FDA-approved prosthesis for two-level CDA. Hence, it may allow for improved outcomes compared with multilevel fusion procedures. Purpose: To critically assess the available literature on CDA with the Mobi-C prosthesis, with a focus on two-level CDA. Methods: All clinical articles involving the Mobi-C disc prosthesis for CDA through September 1, 2014 were identified on Medline. Any paper that presented Mobi-C CDA clinical results was included. Study design, sample size, length of follow-up, use of statistical analysis, quality of life outcome scores, conflict of interest, and complications were recorded. Results: Fifteen studies were included that investigated Mobi-C CDA, only one of which was a level Ib randomized control trial. All studies included showed non-inferiority of one-level Mobi-C CDA to one-level anterior cervical discectomy and fusion (ACDF). Only one study analyzed outcomes of one-level versus two-level Mobi-C CDA, and only one study analyzed two-level Mobi-C CDA versus two-level ACDF. In comparison with other cervical disc prostheses, the Mobi-C prosthesis is associated with higher rates of heterotopic ossification (HO). Studies with conflicts of interest reported lower rates of HO. Adjacent segment degeneration or disease, along with other complications, were not assessed in most studies. Conclusion: One-level Mobi-C CDA is non-inferior, but not superior, to one-level ACDF for patients with cervical degenerative disc disease. The Mobi-C CDA procedure is associated with high rates of HO. Two-level Mobi-C CDA may be superior to two-level ACDF. However, insufficient evidence exists, thereby mandating a need for unbiased, well-designed prospective studies with well-defined outcomes in the future. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective review.Objective: The aim of this study was to examine the association between preoperative depression and patient satisfaction in the outpatient spine clinic after lumbar surgery.Summary Of Background Data: The Clinician and Group Assessment of Healthcare Providers and Systems (CG-CAHPS) survey is used to measure patient experience in the outpatient setting. CG-CAHPS scores may be used by health systems in physician incentive programs and quality improvement initiatives or by prospective patients when selecting spine surgeons. Although preoperative depression has been shown to predict poor patient-reported outcomes and less satisfaction with the inpatient experience following lumbar surgery, its impact on patient experience with spine surgeons in the outpatient setting remains unclear.Methods: Patients who underwent lumbar surgery and completed the CG-CAHPS survey at postoperative follow-up with their spine surgeon between 2009 and 2017 were included. Data were collected on patient demographics, Patient Health Questionnaire 9 (PHQ-9) scores, and Patient-Reported Outcome Measurement Information System Global Health Physical Health (PROMIS-GPH) subscores. Patients with preoperative PHQ-9 scores ≥10 (moderate-to-severe depression) were included in the depressed cohort. The association between preoperative depression and top-box satisfaction ratings on several dimensions of the CG-CAHPS survey was examined.Results: Of the 419 patients included in this study, 72 met criteria for preoperative depression. Depressed patients were less likely to provide top-box satisfaction ratings on CG-CAHPS metrics pertaining to physician communication and overall provider rating (OPR). Even after controlling for patient-level covariates, our multivariate analysis revealed that depressed patients had lower odds of reporting top-box OPR (odds ratio [OR]: 0.19, 95% confidence interval [CI]: 0.06-0.63, P = 0.007), feeling that their spine surgeon provided understandable explanations (OR: 0.32, 95% CI: 0.11-0.91, P = 0.032), and feeling that their spine surgeon provided understandable responses to their questions or concerns (OR: 0.19, 95% CI: 0.06-0.63, P = 0.007).Conclusion: Preoperative depression is independently associated with lower OPR and satisfaction with spine surgeon communication in the outpatient setting after lumbar surgery.Level of Evidence: 3. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective cohort study using prospectively collected data OBJECTIVE.: Determine the association between satisfaction with physician communication and patient reported outcomes in the inpatient spine surgery setting.Summary Of Background Data: Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys measure the patient experience of care and influence reimbursement for hospital systems and providers in the United States. It is not known whether patient satisfaction with physician communication is associated with better outcomes following spine surgery. Therefore, we evaluated the association between patient satisfaction with physician communication on the HCAHPS survey and improvements in validated patient-reported outcomes measures in a spine surgery population.Methods: HCAHPS responses were obtained for patients undergoing elective cervical or lumbar spine surgery from 2013 to 2015. Patient reported health status measures were the primary outcomes, including EuroQol Five Dimensions (EQ-5D), Pain Disability Questionnaire (PDQ), and Visual Analog Scores for Back and Neck Pain (VAS-BP/NP). The association between satisfaction with communication and pre- to one-year postoperative changes in each health status measure were evaluated utilizing multivariable linear regression models.Results: Our study included 648 patients, of which, 479 (74.4%) created our satisfied cohort. Demographically, our two cohorts were similar with regards to pre-operative clinical measures, however the satisfied cohort had a higher self-rating of their mental health (p < 0.01), and overall health (p < 0.01). After adjusting for clinically relevant confounders, our results demonstrated no significant association between satisfaction with physician communication and improvement in EQ-5D (p = 0.312), PDQ (p = 0.498), or VAS pain scores (p = 0.592).Conclusion: Patient satisfaction with physician communication was not associated with one-year postoperative improvement in EQ-5D, PDQ, and VAS-Pain following spine surgery. These findings do not diminish the importance of effective communication between doctor and patient, but instead suggest that within the spine surgery setting, using only patient experience data may not accurately reflect the true quality of care received during their inpatient stay.Level Of Evidence: 4. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective cohort study using prospectively collected data.Objective: The aim of this study was to determine the association between preoperative depression and patient experience in a cervical spine surgery population.Summary Of Background Data: The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is used to measure patient experience and its scores directly influence reimbursement in the United States. Although it is well-established in the literature that untreated depression is associated with worse patient-reported outcomes in cervical spine surgery, no previous studies have analyzed the association between depression and patient satisfaction for these patients.Methods: HCAHPS survey responses from patients undergoing cervical spine surgery between 2013 and 2015 were collected at a tertiary care center. HCHAPS survey responses were linked to demographic data as well as patient-reported quality of life (QOL) metrics including Patient Health Questionnaire, EuroQol 5 Dimensions index, and Visual Analog Scale for neck pain for each patient. Preoperative PHQ-9 scores of ≥10 (moderate to severe depression) was used to define preoperative depression. Uni- and multivariable analyses were performed to investigate the association of preoperative depression and top-box scores on several dimensions on the HCAHPS survey.Results: In our 145-patient cohort, depressed patients were on average younger, had higher preoperative neck pain scores, and had a lower health-related QOL. Depressed patients were less likely to report satisfaction with questions related to doctor respect (P = 0.020) and doctors listening (P = 0.030). After adjusting for covariates, multivariable logistic regression analysis revealed that patients with preoperative depression had lower odds of feeling respected by their physicians (odds ratio = 0.14, 95% confidence interval: 0.02-0.87, P = 0.035).Conclusion: In patients undergoing cervical spine surgery, preoperative depression was found to have a negative association with patient perceptions of doctor communication as measured by the HCAHPS survey. These results highlight depression as a risk factor for worse patient experience communicating with their spine surgeon.Level Of Evidence: 3. [ABSTRACT FROM AUTHOR]

Background Context: Lumbar fusion is an effective and durable treatment for symptomatic lumbar spondylolisthesis; however, the current literature provides insufficient evidence to recommend an optimal surgical fusion strategy.Purpose: The present study aims to compare the clinical outcomes, fusion rates, blood loss, and operative times between open posterolateral lumbar fusion (PLF) alone and open transforaminal lumbar interbody fusion (TLIF) + posterolateral fusion for spondylolisthesis.Study Design: This is a systematic literature review and meta-analysis of English language studies for the treatment of spondylolisthesis with PLF versus PLF + TLIF.Patient Sample: Data were obtained from published randomized controlled trials (RCTs) and retrospective cohort studies.Outcome Measures: Clinical outcomes included Oswestry Disability Index (ODI), back pain, leg pain, and health-related quality of life (HRQOL) scores. Fusion rate, operative time, blood loss, and infection rate were also assessed.Methods: A literature search of three electronic databases was performed to identify investigations performed comparing PLF alone with PLF + TLIF for treatment of low-grade lumbar spondylolisthesis. The summary effect size was assessed from pooling observational studies for each of the outcome variables, with odds ratios (ORs) used for fusion and infection rate, mean difference used for improvement in ODI and leg pain as well as operative time and blood loss, and standardized mean difference used for improvement in back pain and HRQOL outcomes. Studies were weighed based on the inverse of the variance and heterogeneity. Heterogeneity was assessed using the I2-an estimate of the error caused by between-study variation. Effect sizes from the meta-analysis were then compared with data from the RCTs to assess congruence in outcomes.Results: The initial literature search yielded 282 unique, English language studies. Seven were determined to meet our inclusion criteria and were included in our qualitative analysis. Five observational studies were included in our quantitative meta-analysis. The pooled fusion success rates were 84.7% (100/118) in the PLF group and 94.3% (116/123) in the TLIF group. Compared with TLIF patients, PLF patients had significantly lower odds of achieving solid arthrodesis (OR 0.33, 95% confidence interval [CI] 0.13-0.82, p=.02; I2=0%). With regard to improvement in back pain, the point estimate for the effect size was -0.27 (95% CI -0.43 to -0.10, p=.002; I2=0%), in favor of the TLIF group. For ODI, the pooled estimate for the effect size was -3.73 (95% CI -7.09 to -0.38, p=.03; I2=35%), significantly in favor of the TLIF group. Operative times were significantly shorter in the PLF group, with a summary effect size of -25.55 (95% CI -43.64 to -7.45, p<.01; I2=54%). No significant difference was observed in leg pain, HRQOL improvement, blood loss, or infection rate. Our meta-analysis results were consistent with RCTs, in favor of TLIF for achieving radiographic fusion and greater improvement in ODI and back pain.Conclusions: Our results demonstrate that for patients undergoing fusion for spondylolisthesis, TLIF is superior to PLF with regard to achieving radiographic fusion. However, current data only provide weak support, if any, favoring TLIF over PLF for clinical improvement in disability and back pain. [ABSTRACT FROM AUTHOR]

Background Context: Transforaminal lumbar interbody fusion (TLIF) or anterior lumbar interbody fusion with percutaneous pedicle screws (ALIFPS) offer significantly higher radiographic fusion rates than other fusion techniques for L5-S1 isthmic spondylolisthesis (IS). As it stands, there is a relative paucity of comparative data of the two techniques.Purpose: To define the clinical, radiographic, and financial differences between TLIF and ALIFPS for L5-S1 IS.Design/setting: A retrospective cohort study conducted at a single tertiary care center.Patient Sample: Sixty-six patients who underwent either TLIF or ALIPFS for L5-S1 IS at a single tertiary care center between 2009 and 2014.Outcome Measures: Quality of life outcome scores including the EuroQol-5 Dimensions (EQ-5D), Pain Disability Questionnaire (PDQ), and Patient Health Questionnaire-9 (PHQ-9). Sagittal balance parameters including: pelvic incidence, pelvic tilt, sacral slope, segmental lordosis, total lordosis, degree of slip, disc height, and L1-axis S1 distance (LASD). Cost measures included in-hospital charges, hospital length of stay (LOS), and post-admission costs accrued over 1 year.Methods: Quality of life (QoL) outcome scores, radiographic data, and financial data were collected with a minimum of 1-year follow-up. Clinical results were investigated using the PDQ, PHQ-9, and EQ-5D. Radiographic measurements included lumbar lordosis, segmental lordosis, pelvic tilt, pelvic incidence, height of disc, L-1 axis S-1 distance, and the degree of slip. Cost data were generated based on patient-level resource utilization. Comparative data were presented as median with interquartile range (IQR). Continuous variables were compared using either independent Student t tests assuming unequal variance or Mann-Whitney U tests for parametric and nonparametric variables, respectively. The minimally clinical important difference (MCID) used for each questionnaire was as follows: PDQ (26), PHQ-9 (5), and EQ-5D (0.4).Results: A total of 66 patients met inclusion criteria. In the ALIFPS cohort, PDQ scores improved from 69 [47, 82] to 26 [18.2, 79.7], p=.02. In the TLIF cohort, PDQ scores improved from 73 [46, 85] to 48.5 [23, 67.5], p=.01. Both groups also showed a significant improvement in EQ-5D scores at 1 year, but the ALIFPS group showed a significantly greater improvement in EQ-5D scores at 1 year (0.1 [0,0.2] vs. 0.2 [0.1, 0.4], p=.02). Furthermore, only the ALIFPS cohort showed a significant improvement in segmental lordosis. The ALIFPS cohort showed a significantly greater improvement in disc height than did TLIF (3.5 [2, 5.5] vs. 6.7 [4.1, 10], p=.01). No significant differences were found in the direct costs of both procedures.Conclusions: Our findings suggest that anterior lumbar interbody fusion with percutaneous pedicle screws can achieve better clinical outcomes compared with TLIF for the treatment of IS. We believe the superior radiographic outcomes achieved through ALIFPS, namely a greater restoration of segmental lordosis and disc height, may have contributed to the improved clinical outcomes presented in the current study. [ABSTRACT FROM AUTHOR]

Background Context: The patient experience of care as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is currently used to determine hospital reimbursement. The current literature inconsistently demonstrates an association between patient satisfaction and surgical outcomes.Purpose: To determine whether patient satisfaction with hospital experience is associated with better clinical outcomes in lumbar spine surgery.Study Design: A retrospective cohort study conducted at a single institution.Patient Sample: A total of 249 patients who underwent lumbar spine surgery between 2013 and 2015 and completed the HCAHPS survey.Outcome Measures: Self-reported health status measures, including the EuroQol 5 Dimensions (EQ-5D), Pain Disability Questionnaire (PDQ), and visual analog score for back pain (VAS-BP).Methods: All patients undergoing lumbar spine surgery between 2013 and 2015 who completed an HCAHPS survey were studied. Patients were excluded from the study if they had been diagnosed with spinal malignancy, scoliosis, or had less than 1 year of follow-up. Patients who selected a 9 or 10 overall hospital rating (OHR) on HCAHPS were placed in the satisfied group, and the remaining patients comprised the unsatisfied group. The primary outcomes of this study include patient-reported health status measures such as EQ-5D, PDQ, and VAS-BP. No funds were received in support of this study, and the authors report no conflict of interest-associated biases.Results: Our study population consisted of 249 patients undergoing lumbar spine surgery. Of these, 197 (79%) patients selected an OHR of 9 or 10 on the HCAHPS survey and were included in the satisfied group. The only preoperative characteristics that differed significantly between the twogroups were gender, a diagnosis of degenerative disc disease (DDD), heavy preoperative narcotic use, and a diagnosis of chronic renal failure. At 1 year follow-up, no statistically significant differences in EQ-5D, PDQ, or VAS-BP were observed. After using multivariable linear regression models to assess the association between patient satisfaction and pre- to 1-year postoperative changes in health status measures, selecting a top-box OHR was not found to be significantly associated with change in either EQ-5D (beta=0.055 [95% confidence interval {CI}: -0.035 to 0.145]), PDQ (beta=-9.013 [95% CI: -23.782 to 5.755]), or VAS-BP (beta=-0.849 [95% CI: -2.125 to 0.426]). These results suggest high satisfaction with the hospital experience may not necessarily correlate with favorable clinical outcomes.Conclusions: Top-box OHR was not associated with pre- to 1-year postoperative improvement in EQ-5D, PDQ, and VAS-BP. Although the associations between high satisfaction and improvement in health status did not reach statistical significance, the best estimates from our multivariable models reflect greater clinical improvement with top-box satisfaction. Future studies should seek to investigate whether HCAHPS are a reliable indicator of quality care in lumbar spine surgery. [ABSTRACT FROM AUTHOR]

Background Context: Multiple studies have determined minimum clinically important difference (MCID) thresholds for EuroQOL-5 Dimensions (EQ-5D) scores in lumbar fusion patients. However, a comprehensive understanding of predictors for a clinically significant improvement (CSI) postoperatively does not exist.Purpose: To determine medical, radiographic, and surgical predictors for obtaining a CSI following lumbar fusion surgery.Study Design: This is a retrospective review of patients who underwent instrumented lumbar fusion.Patient Sample: We included patients who underwent lumbar fusion for any indication between 2008 and 2013.Outcome Measures: Outcome measures included preoperative and postoperative EQ-5D Index scores.Materials and Methods: The medical records of patients who received a lumbar fusion for any indication were retrospectively reviewed to identify patient medical and surgical characteristics. A blinded reviewer assessed radiographs for each patient to examine sagittal alignment following fusion. Multivariable logistic regression was used to model the achievement of a CSI based on two commonly cited MCID values.Results: A total of 231 patients fit the inclusion criteria; 58% exceeded an MCID value for an EQ-5D score of 0.100, and 16% exceeded an MCID value of 0.390. Statistically significant independent predictors of not obtaining a CSI for an MCID threshold of 0.100 included a higher preoperative EQ-5D score (odds ratio [OR]=44.8) and L5-S1 fusion (OR=3.3). For an MCID value of 0.390, a higher preoperative EQ-5D score (OR=2,080.8) and a diagnosis of depression (OR=7.1) were predictive of not achieving a CSI, whereas spondylolisthesis (OR=4.1) was predictive of obtaining a CSI postoperatively. For both MCID values, patients who achieved a CSI had better postoperative quality of life (QOL) scores for all metrics measured, despite worse QOL scores preoperatively.Conclusions: This study is the first to use a combination of medical, surgical, and postoperative sagittal balance variables as determinants for the achievement of a CSI after lumbar fusion. The awareness of these predictors may allow for better patient selection and surgical approach to decrease the probability of acquiring a poor outcome postoperatively. [ABSTRACT FROM AUTHOR]

Background Context: Patients with multiple myeloma (MM) incur significant degradation in quality of life because of progressive osteolytic vertebral fractures. No studies have investigated predictors of fracture progression, and limited data are available for predicting the development of future fractures.Purpose: The purpose of this study was to identify independent predictors of vertebral fracture progression and the development of future vertebral fracture.Study Design/setting: This is a consecutive retrospective chart review at a single tertiary-care center.Patient Sample: Patients with MM and pathologic vertebral fracture with radiographic follow-up between January 2007 and December 2013 were included. Radiographic measurements were recorded at presentation with fracture and first follow-up (FFU) after at least three months. Patients with a history of vertebral fracture not associated with MM were excluded.Outcome Measures: The primary outcome measure was the rate of vertebral body height loss. The development of future vertebral fracture was secondary.Methods: Anterior, middle, and posterior vertebral body heights were measured from midline sagittal T1-weighted magnetic resonance imaging (MRI). Future fracture-free survival was calculated using Kaplan-Meier analysis. Multivariable regression was used to identify independent predictors of the rate of vertebral height loss. Multivariable Cox proportional hazards modeling was used to identify predictors of developing future vertebral fracture.Results: Thirty-three patients with 67 fractures were followed for a median of 10.8 months to FFU. Sixty-four percent of the patients were female and the median age was 66. The median additional vertebral height loss between presentation and FFU was 15%, whereas the median rate of vertebral height loss was 1.01%/month. More rapid vertebral height loss was predicted by dyslipidemia (β=0.36, p=.05), previous non-vertebral pathologic fracture related to MM (β=0.51, p=.01), and Durie-Salmon Stage III (β=0.66, p=.06). The median time to future fracture was 25.1 months; the 5-year future fracture-free survival rate was 34%. Osteopenia/osteoporosis (hazard ratio [HR]: 9.28, p<.01), serum light chains (HR: 1.37, p=.06), and serum calcium (HR: 1.62, p=.05) predicted the development of future vertebral fracture.Conclusions: We observed significant fracture progression over a short follow-up period. Several comorbidities and laboratory measures predicted more rapid vertebral height loss and the development of future fracture. Identifying risk factors for increased fracture burden may allow spine specialists to pursue earlier and appropriate intervention to optimize function and minimize morbidity. [ABSTRACT FROM AUTHOR]

Study Design. Systematic review. Objective. To perform an evidence-based synthesis of the literature assessing the cost-effectiveness of surgery for patients with symptomatic cervical degenerative disc disease (DDD). Summary of Background Data. Cervical DDD is a common cause of clinical syndromes such as neck pain, cervical radiculopathy, and myelopathy. The appropriate surgical intervention(s) for a given problem is controversial, especially with regard to quality-of-life outcomes, complications, and costs. Although there have been many studies comparing outcomes and complications, relatively few have compared costs and, more importantly, cost-effectiveness of the interventions. Methods. We conducted a systematic search in PubMed/MEDLINE, EMBASE, the Cochrane Collaboration Library, the Cost-Effectiveness Analysis registry database, and the National Health Service Economic Evaluation Database for full economic evaluations published through January 16, 2014. Identification of full economic evaluations that were explicitly designed to evaluate and synthesize the costs and consequences of surgical procedures or surgical intervention with nonsurgical management in patients with cervical DDD were considered for inclusion, based on 4 key questions. Results. Five studies were included, each specific to 1 or more of our focus questions. Two studies suggested that cervical disc replacement may be more cost-effective compared with anterior cervical discectomy and fusion. Two studies comparing anterior with posterior surgical procedures for cervical spondylotic myelopathy suggested that anterior surgery was more cost-effective than posterior surgery. One study suggested that posterior cervical foraminotomy had a greater net economic benefit than anterior cervical discectomy and fusion in a military population with unilateral cervical radiculopathy. No studies assessed the cost-effectiveness of surgical intervention compared with nonoperative treatment of cervical myelopathy or radiculopathy, although it is acknowledged that existing studies demonstrate the cost-effectiveness of surgical intervention for these 2 clinical entities. Conclusion. A paucity of high-quality economic literature exists regarding cost-effectiveness of surgical intervention for cervical DDD. Future research is necessary to validate the findings of the few studies that do exist to guide decisions for surgery by the physician and patient with respect to cost-effectiveness. [ABSTRACT FROM AUTHOR]