The Effect of the Severity of Preoperative Back Pain on Patient-Reported Outcomes, Recovery Ratios, and Patient Satisfaction Following Minimally Invasive Transforaminal Lumbar Interbody Fusion (MIS-TLIF)

Time to achievement of minimum clinically important difference after lumbar decompression

OBJECTIVE

The objective of this study is to examine factors associated with delayed time to achieve minimum clinically important difference (MCID) in patients undergoing lumbar decompression (LD) for the Patient-Reported Outcomes (PROs) of Oswestry Disability Index (ODI), Visual Analog Scale (VAS) back, and VAS leg pain.

METHODS

Patients undergoing LD with preoperative and postoperative ODI, VAS back, and VAS leg scores were retrospectively reviewed from April 2016 to January 2021. MCID values from previously established studies were utilized to determine MCID achievement. Kaplan-Meier survival analysis determined the time to achieve MCID. Hazard ratios from multivariable Cox regression were utilized to determine the preoperative factors predictive of MCID achievement.

RESULTS

Three-hundred and forty-three patients were identified undergoing LD. Overall MCID achievement rates were 67.4% for ODI, 67.1% for VAS back, and 65.0% for VAS leg. The mean time in weeks for MCID achievement was 22.52 ± 30.48 for ODI, 18.90 ± 27.43 for VAS back, and 20.96 ± 29.81 for VAS leg. Multivariable Cox regression revealed active smoker status, preoperative Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF), ODI, VAS Back, and VAS Leg (HR 1.03-2.14) as predictors of early MCID achievement, whereas an American Society of Anesthesiologist (ASA) classification of 2, Black ethnicity, workers' compensation, private insurance, and diagnosis of foraminal stenosis were predictors of late MCID achievement (HR 0.34-0.58).

CONCLUSION

Most patients undergoing LD achieved MCID within 6 months of surgery. Significant factors for early MCID achievement were active smoking status and baseline PROs. Significant factors for late MCID achievement were ASA = 2, Black ethnicity, type of insurance, and foraminal stenosis diagnosis. These factors may be considered by surgeons in setting patient expectations.

The Influence of Presenting Physical Function on Postoperative Patient Satisfaction and Clinical Outcomes Following Minimally Invasive Lumbar Decompression

STUDY DESIGN

The study of retrospective cohort.

OBJECTIVE

The aim was to compare patient-reported outcome measures (PROMs), satisfaction, and minimum clinically important difference (MCID) achievement following minimally invasive lumbar decompression (MIS-LD) in patients stratified by the preoperative patient-reported outcomes measurement information system physical function (PROMIS-PF) score.

SUMMARY OF BACKGROUND DATA

Although prior studies have assessed the predictive utility of preoperative PROMIS-PF scores on patient outcomes in spinal fusion, its utility has not been studied for patients undergoing MIS-LD.

METHODS

Primary, single/multilevel MIS-LD procedures were identified. PROMs were administered at preoperative/6-week/12-week/6-month/1-year/2-year time points and included PROMIS-PF/visual analog scale (VAS) back and leg/Oswestry Disability Index (ODI). Satisfaction scores were collected postoperatively. The patients were grouped by preoperative PROMIS-PF score (≤35, >35), with higher scores indicating improved physical function. Demographic/perioperative characteristics were compared using χ 2 /Student t test. Mean PROMs/postoperative satisfaction was compared utilizing 2-sample t test. Postoperative PROM improvement from preoperative was calculated with paired t tests. MCID achievement rates were compared using simple logistic regression.

RESULTS

Two hundred and sixteen patients were included, 58 PROMIS-PF≤35 and 158 PROMIS-PF>35. Ethnicity/insurance differed ( P ≤0.004, all). Hospital length of stay was greater for PROMIS-PF>35 ( P =0.042). All preoperative mean PROMs significantly differed except for VAS Back. Several postoperative mean PROMs differed: PROMIS-PF at 6 weeks/12 weeks/6 months/1 year, SF-12 PCS at 6 weeks/12 weeks/1 year, VAS Back at 6 weeks/12 weeks, VAS leg at 6 weeks/12 weeks, and ODI at 6 weeks/12 weeks ( P <0.050, all). All PROMs significantly improved from preoperative at all postoperative time points ( P <0.003, all). The MCID achievement rates differed only for VAS back for 6 weeks, favoring PROMIS-PF>35 cohort ( P =0.001). Postoperative satisfaction was greater in PROMIS-PF>35 cohort for VAS leg at 6 weeks/12 weeks/6 months/2 years, VAS back at 6-weeks/12-weeks, and ODI at all time points ( P <0.037, all). Postoperative satisfaction was greater in PROMIS-PF>35 cohort for individual ODI categories: sleep at 6-weeks/12-weeks/1-year/2-years, lifting, walking, standing, and travel at all time points, and sexual at 6-weeks/12-weeks/1-year/2-years ( P <0.030, all).

CONCLUSION

Poorer preoperative PROMIS-PF scores were associated with worse postoperative clinical outcomes and satisfaction. By stratifying patients with preoperative PROMIS-PF scores, surgeons may better predict postoperative clinical improvement and seek to manage patient expectations.

The Effect of the Severity of Preoperative Leg Pain on Patient-Reported Outcomes, Minimum Clinically Important Difference Achievement, and Patient Satisfaction After Minimally Invasive Transforaminal Lumbar Interbody Fusion

OBJECTIVE

To compare patient-reported outcome measures (PROMs), satisfaction, and minimum clinically important difference (MCID) achievement after minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) in patients stratified by preoperative leg pain.

METHODS

Patients undergoing MIS-TLIF were collected through retrospective review of a prospectively maintained single-surgeon database. PROMs administered preoperatively/postoperatively included Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF), visual analog scale (VAS) back/leg pain, Oswestry Disability Index (ODI), and 12-Item Short Form (SF-12) Physical/Mental Component Score (PCS/MCS). Patients were grouped based on preoperative VAS leg scores: VAS leg ≤7 or VAS leg >7. Inferential statistics were used to compare PROMs, MCID achievement rates, and postoperative satisfaction between groups.

RESULTS

A total of 562 patients were eligible (168 VAS leg score ≤7; 394 VAS leg score >7). Significant differences between cohorts in postoperative mean PROMs were noted for PROMIS-PF at 6 weeks/2 years, SF-12 PCS at 6 weeks/2 years, SF-12 MCS at 6 weeks/12 weeks/6 months/1 year, VAS back score at 6 weeks/12 weeks/6 months, VAS leg score at 6 weeks/12 weeks/6 months/2 years and ODI at all postoperative time points (P < 0.045, all). In the VAS leg score >7 cohort, a greater proportion achieving MCID for VAS leg score at all postoperative time points and ODI at 12 weeks (P < 0.010, all). Postoperative satisfaction was greater in VAS back score ≤7 cohort for VAS leg score at 6 weeks/12 weeks/6 months/2 years, VAS back score at 12 weeks/2 years, and ODI at 6 weeks/12 weeks/6 months/2 years (P < 0.046, all).

CONCLUSIONS

Patients with severe preoperative leg pain showed worse postoperative PROM scores and patient satisfaction for disability and back/leg pain. MCID achievement rates across cohorts were similar. Patients with severe leg pain may have expectations for surgical benefits incongruent with their postoperative outcomes, and physicians may seek to manage the preoperative expectations of their patients to reflect likely outcomes after MIS-TLIF.

Meeting Patient Expectations and Achieving a Minimal Clinically Important Difference for Back Disability, Back Pain, and Leg Pain May Provide Predictive Utility for Achieving Patient Satisfaction Among Lumbar Decompression Patients

OBJECTIVE

Our study evaluates minimum clinically important difference (MCID) achievement for back pain/leg pain/disability and meeting preoperative expectations as predictors of patient satisfaction after minimally invasive lumbar decompression (MIS-LD) surgery.

METHODS

Single/multilevel MIS-LD procedures were identified. Patient-reported outcome measures (preoperative/postoperative), expectations (preoperative), and satisfaction (postoperative) were collected for visual analog scale (VAS) back/VAS leg/Oswestry Disability Index (ODI). Student's t-test assessed patient-reported outcome measure improvement from preoperative baseline. Correlations between outcome and satisfaction scores were evaluated using the Pearson correlation coefficient and categorized according to strength of relationship. MCID achievement and meeting expectations were evaluated as predictors of postoperative patient satisfaction with simple linear regression. Comparison of meeting expectations or achieving MCID as predictors of satisfaction scores was performed using a post hoc Suest test comparison of standardized β-coefficients.

RESULTS

A total of 329 patients were included. All outcomes improved from baselines (P < 0.001, all) at all postoperative time points and demonstrated strong and negative correlations with satisfaction scores (P < 0.001, all). Majority of patients had their expectations met for ODI/VAS back/VAS leg and achieved MCID for ODI/VAS back/VAS leg at all time points and overall. Both MCID achievement and meeting preoperative expectations demonstrated significant associations with satisfaction scores at all time points for ODI/VAS back/VAS leg. Post hoc analysis of predictors of patient satisfaction in pain and disability demonstrated that MCID achievement was an equivalent predictor to meeting patient preoperative expectations at all postoperative time points.

CONCLUSION

Pain/disability improved after MIS-LD; improvement was strongly correlated with postoperative satisfaction. Meeting expectations/MCID achievement is associated with satisfaction. MCID achievement was equivalent to meeting expectations in predicting satisfaction at all postoperative time points for pain/disability.

Application and thinking of minimally invasive transforaminal lumbar interbody fusion in degenerative lumbar diseases

Background

This study sought to investigate the clinical efficacy and safety of minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) in the treatment of lumbar degenerative diseases.

Methods

The clinical data of 55 patients with lumbar degenerative diseases treated at our hospital from January 2018 to January 2020 were analyzed retrospectively. Of the 55 patients, 35 who underwent MIS-TLIF were included in the MIS-TLIF group, and 20 who underwent posterior lumbar interbody fusion (PLIF) were included in the PLIF group. The visual analogue scale (VAS) score, Oswestry disability index (ODI) score, operation time, incision length, intraoperative bleeding, postoperative drainage, postoperative landing time, postoperative hospital stay, postoperative interbody fusion rate, and complications were compared between the two groups.

Results

The patients in both groups were followed-up for at least 1.5 years (range, 18–30 months; with an average of 27.5±2.6 months). There was no significant difference in the operation time, incision length, intraoperative bleeding, VAS score for low back and leg pain, ODI score, interbody fusion rate, hospitalization expenses, and complication rate between the two groups (P>0.05). One patient had nail failure in the MIS-TLIF group, 1 patient in each group had nerve root irritation, and 1 patient in each group had superficial incision infection and local suture dehiscence. The postoperative drainage volume, postoperative landing time, and postoperative hospital stay of the MIS-TLIF group were less than those of the PLIF group (P<0.05).

Conclusions

Compared to PLIF, the use of MIS-TLIF in the treatment of lumbar degenerative diseases has a number of advantages, including more complete intraoperative hemostasis, less postoperative drainage, earlier landing, and faster discharge, and also significantly improves postoperative lumbar discomfort.

The Effect of the Severity of Preoperative Disability on Patient-Reported Outcomes and Patient Satisfaction Following Minimally Invasive Transforaminal Lumbar Interbody Fusion

OBJECTIVE

To compare patient-reported outcomes (PROMs), satisfaction, and minimum clinically important difference (MCID) achievement following minimally invasive transforaminal lumbar interbody fusion stratified by preoperative disability.

METHODS

Minimally invasive transforaminal lumbar interbody fusions were grouped by preoperative Oswestry Disability Index (ODI) score: ODI <41 or ODI ≥41. PROMs administered pre/postoperatively included Patient-Reported Outcomes Measurement Information System physical function (PROMIS-PF), visual analog scale (VAS) back/leg, ODI, and 12-Item Short-Form Physical Composite Score (SF-12 PCS)/12-Item Short-Form Mental Composite Score (SF-12 MCS). Satisfaction scores were collected for VAS back/leg and ODI. Coarsened exact match controlled for differences between cohorts. T tests compared mean PROMs and postoperative improvement/satisfaction between cohorts. Simple logistic regression compared MCID achievement.

RESULTS

After coarsened exact matching, there were 118 patients in the ODI ≤41 and 377 patients in the ODI >41 cohort. The ODI >41 cohort saw greater postoperative inpatient VAS pain score and narcotic consumption on days 0/1 (P < 0.018, all). PROMs differed between cohorts: PROMIS-PF, SF-12 PCS, ODI, VAS back/leg at all postoperative time points and SF-12 MCS at 6 weeks/12 weeks/6 months/1 year (P < 0.045, all). Patients in the ODI >41 cohort demonstrated greater proportion achieving MCID for ODI at all postoperative time points and for SF-12 MCS 6-week/12-week/6-month/1-year (P < 0.040, all). The ODI ≤41 cohort demonstrated greater MCID achievement for overall PROMIS-PF and SF-12 PCS 6 months (P < 0.047, all). Postoperative satisfaction was greater in the ODI ≤41 cohort for VAS leg 6 weeks/12 weeks, VAS back 6 weeks/12 weeks, and ODI all postoperative time points (P < 0.048, all).

CONCLUSIONS

Preoperative disability associated with worse postoperative PROMs and patient satisfaction for disability, back/leg pain at multiple time points. MCID achievement rates across cohorts were similar for most PROMs at most postoperative time points. Patients with severe disability may have unrealistic expectations for surgical benefits, influencing corresponding postoperative satisfaction.