Predictors of poor outcome following lumbar spinal fusion surgery: a prospective observational study to derive two clinical prediction rules using British Spine Registry data

PURPOSE

Lumbar spinal fusion surgery (LSFS) is common for lumbar degenerative disorders. The objective was to develop clinical prediction rules to identify which patients are likely to have a favourable outcome to inform decisions regarding surgery and rehabilitation.

METHODS

A prospective observational study recruited 600 (derivation) and 600 (internal validation) consecutive adult patients undergoing LSFS for degenerative lumbar disorder through the British Spine Registry. Definition of good outcome (6 weeks, 12 months) was reduction in pain intensity (Numerical Rating Scale, 0-10) and disability (Oswestry Disability Index, ODI 0-50) > 1.7 and 14.3, respectively. Linear and logistic regression models were fitted and regression coefficients, Odds ratios and 95% CIs reported.

RESULTS

Lower BMI, higher ODI and higher leg pain pre-operatively were predictive of good disability outcome, higher back pain was predictive of good back pain outcome, and no previous surgery and higher leg pain were predictive of good leg pain outcome; all at 6 weeks. Working and higher leg pain were predictive of good ODI and leg pain outcomes, higher back pain was predictive of good back pain outcome, and higher leg pain was predictive of good leg pain outcome at 12 months. Model performance demonstrated reasonable to good calibration and adequate/very good discrimination.

CONCLUSIONS

BMI, ODI, leg and back pain and previous surgery are important considerations pre-operatively to inform decisions for surgery. Pre-operative leg and back pain and work status are important considerations to inform decisions for management following surgery. Findings may inform clinical decision making regarding LSFS and associated rehabilitation.

Supporting employers and their employees with Mental hEalth problems to remain eNgaged and producTive at wORk (MENTOR): A feasibility randomised controlled trial protocol

Employees with mental health problems often struggle to remain in employment. During the COVID-19 pandemic, these employees face multiple additional stressors, which are likely to worsen their mental health and work productivity. Currently, it is unclear how to best support employees with mental health problems (and their managers) to improve wellbeing and productivity. We aim to develop a new intervention (MENTOR) that will jointly involve employees, managers, and a new professional (mental health employment liaison worker, MHELW), to help employees who are still at work with a mental health condition and currently receiving professional support for their mental health. A feasibility pilot study will then be undertaken to examine the feasibility and acceptability of the intervention from the perspective of employees and line managers. The study involves a feasibility randomised controlled study comparing outcomes of participants randomised to receive the intervention (MENTOR) with wait-list controls. Participants allocated to the waitlist control group will receive the intervention after three months. We aim to randomise 56 employee-manager pairs recruited from multiple organisations in the Midlands region of England. An intervention including 10 sessions for employees and managers (3 individual sessions and 4 joint sessions) will be delivered over 12 weeks by trained MHELWs. Primary outcomes include measures of feasibility and acceptability of the intervention and work productivity. Secondary outcomes include mental health outcomes. Qualitative interviews will be undertaken with a purposively selected sub-sample of employees and line managers at three-month post-intervention assessment. To our knowledge, this will be the first trial with a joint employee-manager intervention delivered by MHELWs. Anticipated challenges are dual-level consent (employees and managers), participants' attrition, and recruitment strategies. If the intervention and trial processes are shown to be feasible and acceptable, the outcomes from this study will inform future randomised controlled trials. Trial registration: This trial is pre-registered with the ISRCTN registry, registration number: ISRCTN79256498. Protocol version: 3.0_March_2023. https://www.isrctn.com/ISRCTN79256498.

Outcomes of surgical intervention for degenerative lumbar spondylolisthesis: a comparative analysis of different surgical fixation techniques

Background

Debate regarding effectiveness of surgical modalities contributes to a lack of consensus of decision making for surgical interventions. Furthermore, data regarding cost effectiveness, surgical operative time, resources, patient hospital stay and recovery is limited, particularly in the medium term for degenerative lumbar spondylolisthesis. The objective was to compare clinical outcomes following different fixation interventions treating degenerative lumbar spondylolisthesis.

Methods

A retrospective cohort study using the British Spine Registry (BSR) of 1,838 patients aged ≥18 years. Five hundred and five patients undergoing posterior lumbar interbody fusion (PLIF) and 1,333 undergoing transforaminal lumbar interbody fusion (TLIF) with 6 months follow-up, were compared. Demographics, Oswestry Disability Index (ODI), Numerical Rating Scale (NRS) [back and leg], quality of life, complications and cost effectiveness were analysed.

Results

NRS (back and leg) demonstrated a statistically significant difference favouring TLIF at 6 months (P=0.04) and (P<0.05) respectively. There was no difference in ODI improvement at 6 months between PLIF and TLIF (P=0.620), but there was a statistically significant difference in ODI scores preoperatively between PLIF and TLIF (P<0.001). EQ-5D-5L-Health VAS (P=0.136) and EQ-5D-5L (P=0.655) did not show a statistically significant difference in improvement between PLIF and TLIF. Dural tear was the most common complication and was higher in the PLIF group (5.7%) but not statistically significant. Estimated blood loss was greater for PLIF (P=0.041). Implant cost (P<0.001) was higher for TLIF whereas theatre time was higher for PLIF (P=0.031).

Conclusions

Both PLIF and TLIF result in clinically significant improvements in ODI, NRS back pain and NRS leg pain, with superiority of TLIF for improvements in back and leg pain. Surgeons appeared to use ODI preoperatively to decide intervention with comparable improvements for both approaches. Average theatre time and blood loss volume was higher for PLIF. Factors like implant costs and costs of consumables were higher for TLIF. Costs merit further evaluation.

Immediate patient perceptions following lumbar spinal fusion surgery: semi-structured multi-centre interviews exploring the patient journey and experiences of lumbar fusion surgery (FuJourn)

PURPOSE

To understand the patient journey to Lumbar Spinal Fusion Surgery (LSFS) and patients' experiences of surgery.

METHODS

Qualitative study using interpretive phenomenological analysis. Adult participants following LSFS were recruited from 4 UK clinical sites using purposive sampling to ensure representation of key features (e.g. age). Semi-structured interviews informed by a piloted topic guide developed from the literature were audio-recorded and transcribed verbatim. Framework analysis for individual interviews and then across participants (deductive and inductive) identified emerging themes. Trustworthiness of data analyses was enhanced using multiple strategies (e.g. attention to negative cases).

RESULTS

Four emerging themes from n = 31 patients' narratives were identified: decision for surgery, coping strategies, barriers to recovery and recovery after surgery. Decision for surgery and recovery after surgery themes are distinguished by the point of surgery. However, barriers to recovery and coping strategies are key to the whole patient journey encompassing long journeys to surgery and their initial journey after surgery. The themes of coping strategies and barriers to recovery were inter-related and perceived by participants as parallel concepts. The 4 multifactorial themes interacted with each other and shaped the process of an individual patient's recovery. Factors such as sporadic interventions prior to surgery, time-consuming wait for diagnosis and surgery and lack of information regarding recovery strongly influenced perceptions of outcome.

CONCLUSION

Patient driven data enables insights to inform research regarding surgery/rehabilitation through depth of understanding of the patient journey. Awareness of factors important to patients is important; ensuring that patient-driven data informs research and patient care.

A multi-site prospective, observational study of physiotherapist independent prescribing activity across musculoskeletal clinics in the United Kingdom

OBJECTIVE

To establish how advanced practice physiotherapists in the UK working in the musculoskeletal specialty are utilising their independent non-medical prescribing skills.

DESIGN

Multi-site, prospective, descriptive observational study. Ethics reference No: ERN_19-0994).

METHOD

The study was conducted by seven advanced practitioners, across seven clinical sites representative of advanced musculoskeletal practice in the UK, between 1st October 2019-March 31, 2020. Advanced physiotherapy practitioner independent prescribers working in a variety of musculoskeletal specialty areas collected data across 5 contexts of musculoskeletal clinical service: first contact practice, primary care, community triage, secondary care orthopaedics, secondary care rheumatology and private practice. Quantitative data were analysed descriptively with qualitative data analysed/synthesised via thematic analysis.

RESULTS

Prescribing activity data for n = 2470 patients were collected. Prescribing activity was highest for the treatment of nociceptive pain (51.3%) and inflammation (39.6%). Most prescribing activity occurred in the first 2-6 weeks (34.1%) following onset of condition. Medicines optimisation accounted for most of prescribing activity (18.1%), followed by over-the-counter medication recommendation (15.5%). De-prescribing accounted for 10.8% of all prescribing activity recorded. Qualitative data were synthesised into 4 themes: multimodal physiotherapeutic approach, joint decision making and patient choice, working with complexity, and legal and regulatory restriction.

CONCLUSIONS

Physiotherapist independent prescribing was used within all health sectors in conjunction with advanced skills in musculoskeletal physiotherapy as part of a multimodal physiotherapeutic approach. Prescribing activity was dictated by the clinicians' clinical reasoning and use of joint decision-making. Prescribing activity for acute back and neuropathic radicular pain was limited secondary to recent reclassification of gabapentin and pregabalin.

Prediction of walking ability following posterior decompression for lumbar spinal stenosis

PURPOSE

Following surgery for lumbar spinal stenosis (LSS) up to 40% of people report persistent walking disability. This study aimed to identify pre-operative factors that are predictive of walking ability post-surgery for LSS.

METHODS

An observational cohort study was conducted using data from the British Spine Registry (2017-2018) of adults (≥ 50 years) with LSS, who underwent ≤ 2 level posterior lumbar decompression. Patients receiving fixation or who had previous lumbar surgery were excluded. Walking ability was assessed by a single item on the Oswestry Disability Index and dichotomised into poor/good outcome. Multivariable regression models were performed.

RESULTS

14,485 patients were identified. Pre-operatively 30% patients reported poor walking ability, this decreased to 8% at 12 months follow-up. Predictors associated with poor walking ability at 12 months were: increasing age (≥ 75 years OR 1.54, 95% CI 1.07, 2.18), BMI ≥ 35 kg/m² (OR 1.52, 95% CI 1.00, 2.30), severity of leg pain (OR 1.10, CI 95% 1.01, 1.21), disability (OR 1.01, 95% CI 1.01, 1.02) and quality of life (OR 0.72, 95% CI 0.56, 0.89). Pre-operative maximum walking distance (OR 1.10, 95% CI 1.05, 1.25) and higher education (OR 0.90, 95% CI 0.80, 0.96) were associated with reduced risk of poor walking ability at 12 months; p < 0.05. Depression, fear of movement and symptom duration were not associated with risk of poor outcome.

CONCLUSION

Older age, obesity, greater pre-operative pain and disability and lower quality of life are associated with risk of poor walking ability post-operatively. Greater pre-operative walking and higher education are associated with reduced risk of poor walking ability post-operatively. Patients should be counselled on their risk of poor outcome and considered for rehabilitation so that walking and surgical outcomes may be optimised.

Patient journey following lumbar spinal fusion surgery (FuJourn): A multicentre exploration of the immediate post-operative period using qualitative patient diaries

The aim of this study was to capture and understand the immediate recovery journey of patients following lumbar spinal fusion surgery and explore the interacting constructs that shape their journey. A qualitative study using Interpretive Phenomenological Analysis (IPA) approach. A purposive sample of 43 adult patients (≥16 years) undergoing ≤4 level instrumented fusion for back and/or leg pain of degenerative cause, were recruited pre-surgery from 4 UK spinal surgery centres. Patients completed a weekly diary expressed in their own words for the first 4 weeks following surgery to capture their life as lived. Diary content was based on previous research findings and recorded progress, recovery, motivation, symptoms, medications, healthcare appointments, rehabilitation, positive/negative thoughts, and significant moments; comparing to the previous week. To maximise completion and data quality, diaries could be completed in paper form, word document, as online survey or as audio recording. Strategies to enhance diary adherence included a weekly prompt. A framework analysis for individual diaries and then across participants (deductive and inductive components) captured emergent themes. Trustworthiness was enhanced by strategies including reflexivity, attention to negative cases and use of critical co-investigators. Twenty-eight participants (15 female; n = 18 (64.3%) aged 45-64) contributed weekly diaries (12 withdrew post-surgery, 3 did not follow through with surgery). Adherence with diaries was 89.8%. Participants provided diverse and vivid descriptions of recovery experiences. Three distinct recovery trajectories were identified: meaningful recovery (engagement in physical and functional activities to return to functionality/mobility); progressive recovery (small but meaningful improvement in physical ability with increasing confidence); and disruptive recovery (limited purpose for meaningful recovery). Important interacting constructs shaped participants' recovery including their pain experience and self-efficacy. This is the first account of immediate recovery trajectories from patients' perspectives. Recognition of a patient's trajectory may inform patient-centred recovery, follow-up and rehabilitation to improve patient outcomes.

Effect of obstructive sleep apnoea on diabetic retinopathy and maculopathy: a systematic review and meta-analysis

AIMS

To summarize the association between obstructive sleep apnoea and diabetic retinopathy and diabetic maculopathy, and to examine the effects of oxygen desaturation index, mean and minimum oxygen saturation and time spent with < 90% oxygen saturation on diabetic retinopathy and diabetic maculopathy.

METHODS

A systematic search was performed for papers published from inception to January 2014 in MEDLINE, EMBASE and the Cochrane Database of Systematic Reviews using indexed terms and free text. Additional searches were carried out for grey literature. Two authors conducted the study selection and quality assessment. Data extraction was performed by the main author and checked by the other authors.

RESULTS

One cohort study and 15 cross-sectional studies were included for narrative synthesis and three for meta-analyses. There was no convincing evidence that obstructive sleep apnoea was associated with diabetic retinopathy, although some evidence suggested that obstructive sleep apnoea was associated with greater severity of diabetic retinopathy and advanced diabetic retinopathy in people with Type 2 diabetes. Only six studies examined the impact of obstructive sleep apnoea on diabetic maculopathy and our narrative review suggests there is an association in Type 2 diabetes. Oxygen desaturation index, mean oxygen saturation or time spent with < 90% oxygen saturation were not associated with diabetic retinopathy, and insufficient evidence was available to draw conclusions on their effects on diabetic maculopathy; however, there was evidence from both narrative synthesis and meta-analysis that minimum oxygen saturation had an impact on diabetic retinopathy (pooled odds ratio 0.91, 95% CI 0.87-0.95; I(2) = 0%).

CONCLUSIONS

There is a need for large cohort studies with long-term follow-up data to examine the long-term effects of obstructive sleep apnoea and other sleep variables on advanced retinal disease in diabetes.