Publications by authors named "Kern Singh"

275 Publications

Response to Letter to the Editor by Soffin et al.

Int J Spine Surg 2021 Oct 8. Epub 2021 Oct 8.

Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois.

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http://dx.doi.org/10.14444/8110DOI Listing
October 2021

Single Level Minimally Invasive Transforaminal Lumbar Interbody Fusion vs Anterior Lumbar Interbody Fusion with Posterior Instrumentation at L5/S1.

World Neurosurg 2021 Oct 2. Epub 2021 Oct 2.

Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St. Suite #300, Chicago, IL, 60612. Electronic address:

Objective: To compare outcomes between minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) and anterior lumbar interbody fusion (ALIF) at L5/S1.

Methods: Primary, elective, single, MIS-TLIF or ALIF with posterior fixation at L5/S1 were identified. Patient-reported outcome measures (PROMs) were collected. Coarsened exact matching was used to control for significant differences. Achievement of Minimum Clinical Important Difference [MCID] was determined by comparing ΔPROM scores to threshold values. Demographic/perioperative characteristics were compared between MIS-TLIF and ALIF cohorts using chi-squared and Student's t-tests.. Differences in mean PROM scores, MCID rates, , and postoperative complications were evaluated using unpaired t-test.

Results: Following coarsened exact matching, 93 patients received MIS-TLIF and 50 received ALIF. Cohorts differed in operative time, estimated blood loss (EBL), and postoperative narcotic consumption on POD 0 (p<0.034, all). . Mean PROMs differed significantly at: SF-12 PCS 6-weeks, and 1-year, PROMIS-PF 6-weeks, ODI 6-weeks, and VAS back 6-weeks with ALIF cohort demonstrating significantly improved mean PROMs (p ≤ 0.044, all). Significantly greater rates of MCID achievement for PROMS for the ALIF cohort: VAS back 6-weeks, ODI 12 weeks, SF-12 PCS 6-weeks, and PROMIS-PF 12-weeks (p ≤ 0.047, all). Greater rate of MCID achievement for MIS-TLIF cohort were seen for 6-week and overall VAS leg (p<0.046, all) Postoperative fever was greater in TLIF cohort (9.6% vs 2.0%, p<0.047).

Conclusion: ALIF patients demonstrated significantly improved rates of MCID achievement for disability, physical function, and back pain during early postoperative period. However, overall MCID achievement rate for leg pain was higher for MIS-TLIF cohort.
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http://dx.doi.org/10.1016/j.wneu.2021.09.108DOI Listing
October 2021

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).

World Neurosurg 2021 Sep 25. Epub 2021 Sep 25.

Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA. Electronic address:

Background: Limited literature has addressed impact of preoperative back pain severity on patient-reported outcome measures (PROMs), recovery ratios (RRs), and patient satisfaction following minimally invasive transforaminal lumbar interbody fusion (MIS TLIF).

Methods: MIS TLIFs were retrospectively identified and grouped: preoperative visual analog scale (VAS) back ≤7 or VAS back >7. PROMs, including PROMIS-PF, VAS back and leg, Oswestry Disability Index (ODI), and SF-12 Physical Composite Score and Mental Composite Score (MCS), were collected pre- and postoperatively. A PROM's RR was calculated as proportion of postoperative improvement to overall potential improvement.

Results: In total, 740 patients were included: 359 patients with VAS back ≤7 and 381 patients with VAS back >7. The VAS back >7 cohort reported significantly greater postoperative inpatient pain (P ≤ .003, both). All preoperative and the following postoperative PROMs favored the VAS back ≤7 cohort: PROMIS-PF 2-years, VAS back overall, SF-12 Physical Composite Score 12 weeks and 1 year, SF-12 MCS 6 weeks/12 weeks, VAS leg 6 weeks, 12 weeks, 6 months, and 2 years, and ODI overall (P ≤ 0.048, all). The VAS back >7 cohort demonstrated greater delta PROMs for all VAS back and ODI except 2 years (P ≤ 0.021, all). A greater proportion of patients in the VAS back >7 group achieved minimal clinically important difference for VAS back overall, ODI 6 weeks/12 weeks, PROMIS-PF 6 weeks, and SF-12 MCS 6 weeks/6 months (P ≤ 0.044, all). The VAS back>7 cohort RR was significantly greater for VAS back 6 months and VAS leg 6 months/2 years (P ≤ 0.034, all). The VAS back ≤7 cohort's postoperative satisfaction was significantly greater for VAS back 12 weeks, VAS leg 12 weeks, and ODI 6 weeks/12 weeks (P ≤ 0.046, all).

Conclusions: Patients with greater preoperative back pain demonstrated significantly worse postoperative scores for most PROMs at most time points and significantly worse patient satisfaction for disability, back and leg pain at multiple time points.
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http://dx.doi.org/10.1016/j.wneu.2021.09.053DOI Listing
September 2021

Meeting Patient Expectations or Achieving a Minimum Clinically Important Difference: Predictors of Satisfaction Among Lumbar Fusion Patients.

Asian Spine J 2021 Sep 2. Epub 2021 Sep 2.

Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA.

Study Design: Retrospective cohort.

Purpose: To investigate the impact of meeting a patient's preoperative expectations for back or leg pain or the achievement of minimum clinically important difference (MCID) on patient satisfaction following lumbar fusion.

Overview Of Literature: Few studies have compared if MCID achievement or meeting preoperative expectations for pain reduction affects patient satisfaction.

Methods: A surgical database was reviewed for eligible patients who underwent lumbar fusion. Patient satisfaction and Visual Analog Scale (VAS) for back and leg pain were the outcomes of interest. Meeting expectations was calculated as a difference of ≤0 between preoperative expectations and postoperative VAS scores. MCID achievement was calculated by comparing changes in VAS scores with established values. Meeting preoperative expectations or MCID achievement as predictors of patient satisfaction was evaluated using regression analysis.

Results: A total of 134 patients were included in this study. Patients demonstrated significant improvements in VAS back and VAS leg (p<0.001). At 1 year, 56.4% of patients had their VAS back expectations met compared with 59.5% for VAS leg. Similarly, at 1 year, 77.3% and 71.3% of patients achieved MCID for VAS back and leg, respectively. Meeting expectations for VAS back was significantly associated with patient satisfaction at all postoperative timepoints; however, MCID achievement only demonstrated a significant association with patient satisfaction at 6 and 12 weeks (all, p≤0.024). Meeting VAS leg expectations and MCID achievement both demonstrated a significant association with patient satisfaction at all postoperative timepoints (all, p≤0.02). No differences between MCID achievement and meeting expectations as predictors of satisfaction were noted.

Conclusions: The majority of patients achieved MCID and had their back and leg pain expectations met by 1 year. Both measures were significant predictors of patient satisfaction and suggest that MCID achievement may act as a suitable substitute for patient satisfaction.
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http://dx.doi.org/10.31616/asj.2021.0138DOI Listing
September 2021

Validation of VR-12 Physical Function in Minimally Invasive Lumbar Discectomy.

World Neurosurg 2021 Aug 20. Epub 2021 Aug 20.

Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, USA. Electronic address:

Background: Although the Veterans RAND 12-item Physical Component Survey (VR-12 PCS) has been broadly used to evaluate patient-reported outcome measures (PROMs) in spine surgery, its feasibility for use in patients undergoing minimally invasive lumbar discectomy (MIS LD) has not been well studied. This study aimed to assess the feasibility of VR-12 PCS for use up to 2 years postoperatively for MIS LD by correlation with PROMs for physical function.

Methods: Patients undergoing primary single-level MIS LD procedures were reviewed retrospectively. Results on the VR-12 PCS, 12-Item Short Form (SF-12) PCS, and Patient-Reported Outcomes Measurement Information System (PROMIS PF) were recorded preoperatively and up to 2 years postoperatively. Improvements in postoperative PROMs were calculated and assessed for significant differences from baseline values. Correlation significance and strength were evaluated between VR-12 PCS and SF-12 PCS or PROMIS PF. Scatterplots were constructed to demonstrate relationships of VR-12 PCS with SF-12 PCS and PROMIS PF at each time point.

Results: Our cohort comprised 402 patients. Patients improved significantly from preoperative baseline for all 3 PROMs at all postoperative time points. Both Pearson's correlation and time-independent partial correlation revealed statistically significant strong correlations of VR-12 PCS with SF-12 PCS and PROMIS PF through 2-years.

Discussion: Physical function scores for VR-12, SF-12, and PROMIS PF all demonstrated significant improvements following MIS LD. Strongly statistically significant correlations of VR-12 PCS with SF-12 PCS and PROMIS PF from preoperative measures through 2 years demonstrate the feasibility of VR-12 for assessing patient-reported physical function in MIS LD patients.
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http://dx.doi.org/10.1016/j.wneu.2021.08.062DOI Listing
August 2021

Failure in cervical total disc arthroplasty: single institution experience, systematic review of the literature, and proposal of the RUSH TDA failure classification system.

Spine J 2021 Aug 20. Epub 2021 Aug 20.

Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St., Chicago, IL 60612, USA. Electronic address:

Background Context: Cervical total disc arthroplasty (TDA) is an alternative procedure to anterior cervical discectomy and fusion that facilitates neural decompression while both preserving motion of the spinal unit and decreasing the risk for degenerative changes at adjacent segments. However, due to its more recent introduction in clinical practice and low complication rates, the modes by which TDA may fail remain to be described.

Purpose: This study sought to identify the modes and frequencies of cervical TDA failure in order to propose a novel classification system.

Study Design: Retrospective Cohort and Systematic Review.

Patient Sample: Patients who underwent single or two-level TDA for cervical radiculopathy or myelopathy at a single institution and in the literature of medium and large prospective studies.

Outcome Measures: Cervical TDA failure, defined as subsequent surgical intervention at the index segment.

Methods: This study retrospectively reviewed patients who underwent single or two-level TDA for cervical radiculopathy or myelopathy at a single institution to identify the potential implant failure modes. A systematic review and meta-analysis of prospective data in the literature was then performed to further supplement failure mode identification and to describe the rates at which the various failure types occurred. Statistical analysis included between-group comparisons of Non-Failed and Failed patients and frequencies of each failure type among Failed patients.

Results: A retrospective review at our institution of 169 patients (201 levels) identified eight failures, for a failure rate of 4.7%. Additionally, seven patients were revised who had the primary surgery at an outside institution. The systematic review of 3976 patients (4525 levels) identified 165 (4.1%) additional failures. Using this data, six primary failure types were classified, with several subtypes. These include recurrent or persistent index-level stenosis (Type I); migration (Type II) presenting as gross extrusion (A) or endplate failure with subsidence/acute fracture (B); instability (Type III) due to mechanical loosening (A), septic loosening (B), or device fracture (C); device motion loss (Type IV) such as "locking" of the device in kyphosis; implantation error (Type V) due to malposition (A) or improper sizing (B); and wear (Type VI) either without osteolysis (A) or with wear-particle-induced osteolysis (B). Stenosis (Type I) was the most common mode of failure found both through retrospective review and in the literature.

Conclusions: Cervical TDA fails through six primary mechanisms. While rates of certain failures requiring subsequent surgical intervention are low, it is possible that these complications may become more prevalent upon further longitudinal observation. Thus, future application and validation of this classification system is warranted to evaluate how failure frequencies change over time and with larger patient samples.
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http://dx.doi.org/10.1016/j.spinee.2021.08.006DOI Listing
August 2021

Multimodal Analgesic Management for Lumbar Decompression Surgery in the Ambulatory Setting: Clinical Case Series and Review of the Literature.

World Neurosurg 2021 Oct 31;154:e656-e664. Epub 2021 Jul 31.

Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA. Electronic address:

Background: Effective pain control is vital for successful surgery in the ambulatory setting. Our study aims to characterize a case series of patients who underwent lumbar decompression (LD) in the ambulatory surgical center (ASC) with the use of a multimodal analgesic (MMA) protocol.

Methods: A prospective surgical registry was retrospectively assessed for patients who underwent single or multilevel LD in an ASC using MMA from 2013 to 2019. Observation in excess of 23 hours was not permitted at the ASC, and patients were required to be discharged the same day. Length of stay, patient-reported visual analog scale pain scores before discharge, and the quantity of narcotic medications administered to patients before discharge were recorded. Quantity of narcotic medications were converted into units of oral morphine equivalents and summed across all types of narcotic medications prescribed.

Results: A total of 499 patients were included. In total, 86.0% (429) of the patients underwent a single-level decompression procedure, 13.8% (69) of patients underwent a 2-level, and 0.2% (1) of the patients underwent a 3-level procedure; 83.6% (417) of the patients in this study underwent a primary LD, and 14.0% (70) underwent a revision decompression.

Conclusions: This is the largest clinical case series focused on LD procedures within an ASC requiring no planned 23-hour observation. This study demonstrates the feasibility of performing LD surgery in an ASC with proper patient selection, surgical technique, and MMA protocol. All patients were discharged from the surgical center on the same day of surgery.
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http://dx.doi.org/10.1016/j.wneu.2021.07.105DOI Listing
October 2021

Impact of Prolonged Duration of Symptoms on Mental Health in Anterior Cervical Disectomy and Fusion Patients.

J Am Acad Orthop Surg 2021 Jul 30. Epub 2021 Jul 30.

From the Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL.

Introduction: Prolonged duration of symptoms is associated with worse pain and disability in patients undergoing anterior cervical discectomy and fusion (ACDF). Our study aims to determine the effect of symptom duration on severity of depression among ACDF patients.

Methods: We retrospectively reviewed a prospective surgical database from 2006 to 2019 for primary, single, or multilevel ACDF. Patients missing the duration of symptom information or patient-reported outcome measures (PROMs) were excluded. PROMs included Patient Health Questionnaire-9, 12-Item Short Form Mental Component Score, and 12-Item Veterans RAND Mental Component Score and were collected at preoperative, 6-week, 12-week, 6-month, 1-year, and 2-year timepoints. The minimum clinically important difference (MCID) was calculated using the established values. Patients were categorized based on preoperative duration of symptoms as follows: <6 months, ≥6 months and <1 year, 1 to 2 years, and >2 years. Univariate analysis was done to determine differences in demographics and perioperative characteristics. Intergroup differences in PROMs and MCID achievement were evaluated using linear regression and logistic regression, respectively.

Results: Two hundred thirty-one ACDF patients included had a mean age of 49.6 years and most were male (61.0%) and nonobese (<30 kg/m2; 55.0%). The groups differed by their American Society of Anesthesiologists classification (P = 0.029), workers' compensation status (P = 0.022), and diagnosis of herniated nucleus pulposus (P = 0.010). Postoperative mental health outcomes did not significantly differ between duration groups except for Veterans Rand-12 Mental Component Score at 12 weeks (P = 0.044). MCID achievement rates did not significantly differ.

Conclusion: Patients undergoing ACDF largely did not demonstrate differences in mental health scores or achievement of MCID based on the duration of symptoms.
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http://dx.doi.org/10.5435/JAAOS-D-21-00050DOI Listing
July 2021

The Influence of Sex on Clinical Outcomes in Minimally Invasive Lumbar Decompression.

Int J Spine Surg 2021 Aug 27;15(4):763-769. Epub 2021 Jul 27.

Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois.

Background: Research focused on postoperative outcomes among men and women undergoing minimally invasive lumbar decompression (MIS LD) spine surgery is sparse. This study aims to assess the influence of sex on postoperative patient-reported outcome measure (PROM) evaluations and achievement of a minimum clinically important difference (MCID).

Methods: A prospectively maintained surgical database was retrospectively queried for patients undergoing primary or revision, single or multilevel LD procedures from 2011 to 2019. Patients with incomplete visual analog scale (VAS) leg or back surveys were excluded. Demographic and operative variables were recorded, and a chi-squared analysis or tests were used to compare by sex. PROMs were evaluated from preoperative to postoperative time points. PROM score differences and postoperative improvement were evaluated between sexes by a test. Achievement of MCID by sex was compared using chi-squared analysis.

Results: The study cohort ( = 572) was 70% male ( = 398), had an average age of 47 years, and 42% were obese. Sexes differed in preoperative VAS leg, Oswestry Disability Index (ODI), and 12-item short form (SF-12)-physical composite score (PCS) scores (all < .05) and in ODI at 6 and 12 weeks ( = .048; = .001) and VAS back and leg scores at 6 months ( = .039; = .019). Both sexes significantly improved ( < .050) all PROMs at all time points except for VAS back at 1 year for women and ODI at 6 weeks and 6 months for men. The only significant difference in achievement of MCID was for ODI at 6 months ( = .008).

Conclusions: Significant preoperative differences were observed among sexes with ODI, SF-12-PCS, and VAS leg scores. By 1 year, there were no significant sex differences for any PROM or for achievement of MCID. MIS LD has an equivalent role for both sexes in achieving MCID.

Level Of Evidence: 3.

Clinical Relevance: Results demonstrate no sex difference in PROMs following LD.
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http://dx.doi.org/10.14444/8098DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8375674PMC
August 2021

Diabetes Mellitus Does Not Impact Achievement of a Minimum Clinically Important Difference Following Anterior Cervical Discectomy and Fusion.

World Neurosurg 2021 Oct 24;154:e520-e528. Epub 2021 Jul 24.

Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA. Electronic address:

Background: Diabetes mellitus (DM) has been identified as a risk factor for poorer outcomes following anterior cervical discectomy and fusion (ACDF). This study aims to evaluate the impact DM has on achievement of MCID (minimum clinically important difference) following ACDF.

Methods: A surgical database was reviewed for patients who underwent primary, single-level ACDF procedures with posterior instrumentation. Visual analog scales (VAS) Arm and Neck, Neck Disability Index (NDI), and Patient-Reported Outcomes Measurement Information System (PROMIS) and 12-item Short Form (SF-12) scores for physical function (PF) were recorded. MCID achievement was calculated using pre-established values from the literature. Intergroup differences in demographic, perioperative characteristics, mean outcome scores and rates of MCID achievement were calculated.

Results: There were 43 patients with diabetes and 320 patients without diabetes. DM status was significantly associated with age, ethnicity, hypertension, American Society of Anesthesiologists physical classification score, Charlson Comorbidity Index, and insurance type (all P ≤ 0.041). Postoperative length of stay was significantly greater for the DM group (P = 0.011). Mean VAS Arm and NDI differed at 6 months (P ≤ 0.049, both) and PROMIS-PF differed from 6 weeks through 6 months (P ≤ 0.039, all). Patients without diabetes significantly improved in all PROMs by 1 year postoperatively (P < 0.01, all). Patients with diabetes significantly improved in VAS Neck and Arm, SF-12 physical component score, and PROMIS-PF by 1 year (all P ≤ 0.013) but NDI significantly improved only at 12 weeks (P = 0.038). Intergroup differences for MCID achievement were demonstrated at 6 months for NDI and SF-12 physical component score (P ≤ 0.008).

Conclusions: Although moderate intergroup differences in MCID achievement were demonstrated, the results of this study suggest that patients may realize similar benefits of ACDF surgery regardless of DM status.
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http://dx.doi.org/10.1016/j.wneu.2021.07.074DOI Listing
October 2021

Charlson Comorbidity Index: An Inaccurate Predictor of Minimally Invasive Lumbar Spinal Fusion Outcomes.

Int J Spine Surg 2021 Aug 15;15(4):770-779. Epub 2021 Jul 15.

Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois.

Background: There is a scarcity of research on the Charlson Comorbidity Index (CCI) and its influence on minimum clinically important difference (MCID) achievement after minimally invasive (MIS) transforaminal lumbar interbody fusion (TLIF). The objective of this study is to detail the association between the CCI and attaining MCID after MIS TLIF.

Methods: A prospective surgical registry was retrospectively reviewed for spine surgeries between May 2015 and February 2019. Inclusion criteria were primary or revision, 1- or 2-level MIS TLIF procedures. Patients were stratified based on CCI score: 0 points (no comorbidities), 1-2 points (mild CCI), ≥3 points (moderate CCI). Preoperative, intraoperative, and postoperative variables were assessed by subgroup using appropriate statistical analysis. Subgroups were analyzed with linear regression or χ tests for continuous or categorical variables, respectively. Subgroup scores, improvement, and MCID achievement were assessed at postoperative timepoints (eg, 6 weeks, 12 weeks, 6 months, and 1 year) for back and leg pain, Oswestry Disability Index (ODI), SF-12 Physical Composite Score (PCS), and Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS PF).

Results: A total of 171 patients were included (n = 51 [no comorbidities], n = 73 [mild CCI], and n = 47 [moderate CCI]). Higher CCI patients were older and more likely to be smokers, diabetic, arthritic, hypertensive, or have a malignancy history ( < 0.003). Preoperatively, ODI and PROMIS PF were the only patient-reported outcomes with a significant association by CCI group ( = 0.015 and 0.014). Back pain was the only measure that had a significant association with the CCI subgroup at 1 year for score ( = 0.002) or MCID ( = 0.028).

Conclusions: By 1 year, regardless of the number of comorbidities, a similar proportion of patients undergoing MIS TLIF were able to achieve MCID for visual analog scale leg, SF-12 PCS, and PROMIS PF. Patients with higher comorbidities are not likely to experience a significant difference in symptom improvement. Regardless of CCI score, MIS TLIF can have a significant benefit for patients.

Level Of Evidence: 4.

Clinical Relevance: Text.
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http://dx.doi.org/10.14444/8099DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8375692PMC
August 2021

Preoperative Physical Function Association With Mental Health Improvement After Anterior Cervical Discectomy and Fusion.

Clin Spine Surg 2021 Jul 1. Epub 2021 Jul 1.

Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL.

Study Design: This was a retrospective study.

Objective: This study investigates the influence of physical function and their influence on postoperative depressive symptom scores as measured by Patient Health Questionnaire-9 (PHQ-9) among anterior cervical decompression and fusion (ACDF) patients.

Background: While ACDF is one of the most commonly performed ambulatory surgeries, research is limited on the predictive value of Patient-Reported Outcomes Measurement Information System (PROMIS) scores and their influence on depressive symptoms as measured by the PHQ-9.

Methods: A prospectively maintained surgical registry was retrospectively reviewed from March 2016 to January 2019. Inclusion criteria were primary or revision ACDF procedures. Patients were grouped by preoperative PROMIS score (≥35.0, <35.0), with higher scores indicating greater physical function. The χ2 and Student t tests assessed categorical and continuous variables (eg, demographics, perioperative, and postoperative values). A t test evaluated postoperative improvement in PROMIS Physical Function (PF) scores between subgroups among PROMIS PF scores and PHQ-9 score improvement at 6, 12 weeks, 6 months, and 1 year. Linear regression assessed preoperative PROMIS scores influence on PHQ-9 score improvement.

Results: The 121 subject cohort was 61.2% male with an average age of 49.6±9.8 years. Compared with the PROMIS ≥35.0 group, the PROMIS <35.0 group also had larger improvement of PROMIS scores at 6 weeks. No significant difference in postoperative PHQ-9 improvement was observed between subgroups. There was a negative association between preoperative PROMIS scores and improvement in PROMIS scores at 6, 12 weeks, 6 months, and 1 year. There was a positive association between preoperative PROMIS scores and magnitude of 1-year PHQ-9 change.

Conclusions: Individuals with lower preoperative PROMIS PF scores had significantly higher PHQ-9 scores at 1 year. Patients with lower preoperative physical function, as evaluated by PROMIS PF scoring, had greater improvement of mental health at 1 year postoperatively. This suggests that many patients experience multidimensional health benefits after ACDF procedures.
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http://dx.doi.org/10.1097/BSD.0000000000001232DOI Listing
July 2021

Preoperative Neck Disability Severity Limits Extent of Postoperative Improvement Following Cervical Spine Procedures.

Neurospine 2021 Jun 30;18(2):377-388. Epub 2021 Jun 30.

Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA.

Objective: Our study aims to evaluate the impact of severity of preoperative Neck Disability Index (NDI) on postoperative patient-reported outcome measures (PROMs).

Methods: A retrospective review of primary, elective, single or multilevel anterior cervical discectomy and fusion or cervical disc arthroplasty procedures between 2013 and 2019 was performed. Visual analogue scale (VAS) neck and arm, NDI, 12-item Short Form physical and mental composite score (SF-12 PCS and MCS), Patient-Reported Outcome Measurement Information System physical function, and 9-item Patient Health Questionnaire (PHQ-9) were collected preoperatively and postoperatively. Patients were categorized by preoperative NDI: none-to-mild disability ( < 30); moderate disability ( ≥ 30 to < 50); severe disability ( ≥ 50 to < 70); complete disability ( ≥ 70). The impact of preoperative NDI on PROM scores and minimum clinically important difference (MCID) achievement rates were evaluated.

Results: The cohort included 74 patients with none-to-mild disability, 95 moderate, 76 severe, and 17 with complete disability. Patients with greater preoperative disability demonstrated significantly different scores for NDI, VAS neck, SF-12 MCS, and PHQ-9 at all timepoints (p < 0.001). Patients with more severe disability demonstrated different magnitudes of improvement for NDI (all p < 0.001), VAS neck (p ≤ 0.009), VAS arm (p = 0.025), and PHQ-9 (p ≤ 0.011). The effect of preoperative severity on MCID achievement was demonstrated for NDI and for PHQ-9 (p ≤ 0.007).

Conclusion: Patients with severe neck disability demonstrated differences in pain, disability, physical and mental health. MCID achievement also differed by preoperative symptoms severity. Patients with more severe neck disability may be limited to the degree of improvement in quality of life but perceive them as significant changes.
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http://dx.doi.org/10.14245/ns.2142084.042DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8255767PMC
June 2021

Patient Health Questionnaire-9 Is a Valid Assessment for Depression in Minimally Invasive Lumbar Discectomy.

Neurospine 2021 Jun 30;18(2):369-376. Epub 2021 Jun 30.

Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA.

Objective: The Patient Health Questionnaire-9 (PHQ-9) is a screening tool for evaluating depressive symptoms. Research is scarce regarding the validity and correlation of PHQ-9 scores with other patient-reported outcomes of mental health after minimally invasive lumbar discectomy (MIS LD). We aim to validate PHQ-9 as a metric for assessing mental health in MIS LD patients.

Methods: A database was retrospectively reviewed for patients who underwent elective, single-level MIS LD. Patients were excluded if they had incomplete preoperative PHQ-9, 12-item Short Form Health Survey (SF-12), or Veterans RAND 12-item health survey (VR12). Survey scores were collected preoperatively and postoperatively through 1 year. Mean scores were used to calculate postoperative improvement from preoperative scores. Correlation of PHQ-9 with SF-12 mental composite score (MCS) and VR-12 MCS scores was also calculated. Correlation strength was assessed by the following categories: 0.1 ≤ |r| < 0.3 = low; 0.3 ≤ |r| < 0.5 = moderate; |r| ≥ 0.5 = strong.

Results: A total of 239 patients underwent single-level MIS LD. PHQ-9, VR-12 MCS, and SF-12 MCS all demonstrated statistically significant increases from preoperative scores at all postoperative timepoints (p ≤ 0.001). SF-12 MCS and VR-12 MCS were each observed to have strong and significant correlations with PHQ-9 at all timepoints when evaluated with both Pearson correlation coefficients and partial correlation coefficients.

Conclusion: We observed that PHQ-9, SF-12 MCS and VR-12 MCS all significantly improve following lumbar discectomy and that PHQ-9 scores strongly correlated with these previously established measures. Our results substantiate evidence from other surgical fields that PHQ-9 scores are a valid tool to evaluate pre- and postsurgical depressive symptoms.
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http://dx.doi.org/10.14245/ns.2142162.031DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8255766PMC
June 2021

Comorbidity Influence on Postoperative Outcomes Following Anterior Cervical Discectomy and Fusion.

Neurospine 2021 Jun 30;18(2):271-280. Epub 2021 Jun 30.

Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA.

Objective: This study aims to detail the association between comorbidity burden and achieving minimum clinically important difference (MCID) following anterior cervical discectomy and fusion (ACDF).

Methods: A prospective surgical registry was retrospectively reviewed. Patients with missing preoperative Patient-Reported Outcomes Measurement Information System physical function (PROMIS PF) were excluded. Patients were stratified by Charlson Comorbidity Index (CCI): no comorbidities = 0 point; low CCI = 1-2 points; high CCI = ≥ 3 points. Demographic and perioperative characteristics were collected and evaluated for differences. Visual analogue scale (VAS), 12-item Short Form health survey (SF-12), and PROMIS PF were collected pre- and postoperatively and assessed for differences. Differences in achievement of MCID were compared using established values: VAS neck = 2.6, VAS arm = 4.1, NDI = 8.5, SF-12 physical composite score (SF-12 PCS) = 8.1, PROMIS PF = 4.5.

Results: One hundred twenty-five ACDF patients were included: 37 had no comorbidities, 64 with low CCI, and 24 with high CCI. Higher CCI groups were older, nonsmokers, diabetic, arthritic, hypertensive, and had cancer. Multilevel fusions, operative time, length of stay, and later discharge day were associated with high CCI. VAS neck differed preoperatively by group. SF-12 PCS and PROMIS PF were inversely associated with CCI groups. CCI did not impact achievement of MCID for all outcomes. A lower rate of reaching MCID was demonstrated at 3 months for SF-12 PCS.

Conclusion: Regardless of comorbidity burden, patients undergoing ACDF for cervical pathology demonstrated a similar rate of achieving MCID for VAS neck, VAS arm, NDI, and PROMIS PF. Regardless of CCI score, ACDF can have a significant benefit for patients.
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http://dx.doi.org/10.14245/ns.2040646.323DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8255775PMC
June 2021

Spine Surgery Complications in the Ambulatory Surgical Center Setting: Systematic Review.

Clin Spine Surg 2021 Jun 29. Epub 2021 Jun 29.

Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL.

Study Design: This was a systematic review study.

Purpose: This study aims to review current literature to determine the rates of complications in relation to spine surgery in ambulatory surgery centers (ASC).

Background: Recent improvements in anesthesia, surgical techniques, and technological advances have facilitated a rise in the use of ASC. Despite the benefits and lower costs associated with ASCs, there is inconsistent reporting of complication rates.

Methods: This systematic review was completed utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Pertinent studies were identified through Embase and PubMed databases using the search string ((("ambulatory surgery center") AND "spine surgery") AND "complications"). Articles were excluded if they did not report outpatient surgery in an ASC, did not define complications, were in a language other than English, were non-human studies, or if the articles were classified as reviews, book chapters, single case reports, or small case series (≤10 patients). The primary outcome was the frequency of complications with respect to various categories.

Results: Our query identified 150 articles. After filtering relevance by title, abstract, and full text, 22 articles were included. After accounting for 2 studies that were conducted on the same study sample, a total of 11,245 patients were analyzed in this study. The most recent study reported results from May 2019. While 5 studies did not list their surgical technique, studies reported techniques including open (6), minimally invasive surgery (2), endoscopic (4), microsurgery (1), and combined techniques (4). The following rates of complications were determined: cardiac 0.29% (3/1027), vascular 0.25% (18/7116), pulmonary 0.60% (11/1839), gastrointestinal 1.12% (2/179), musculoskeletal/spine/operative 0.59% (24/4053), urologic 0.80% (2/250), transient neurological 0.67% (31/4616), persistent neurological 0.61% (9/1479), pain related 0.57% (20/3479), and wound site 0.68% (28/4092).

Conclusions: After literature review, this is the first study to comprehensively analyze the current state of literature reporting on the complication profile of all ASC spine surgery procedures. The most common complications were gastrointestinal (1.12%) and the most infrequent were vascular (0.25%). Case reports varied significantly with regard to the type and rate of complications reported. This study provides complication profiles to assist surgeons in counseling patients on the most realistic expectations.
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http://dx.doi.org/10.1097/BSD.0000000000001225DOI Listing
June 2021

The Influence of Preoperative Narcotic Consumption on Patient-Reported Outcomes of Lumbar Decompression.

Asian Spine J 2021 Jun 17. Epub 2021 Jun 17.

Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA.

Study Design: Retrospective cohort.

Purpose: This study aimed to assess the relationship between preoperative narcotic consumption and patient-reported outcomes (PRO) in patients undergoing minimally invasive (MIS) lumbar decompression (LD).

Overview Of Literature: Previous studies report negative effects of narcotic consumption on perioperative outcomes and recovery; however, its impact on quality of life and surgical outcomes is not fully understood.

Methods: A surgical database was retrospectively reviewed for patients undergoing primary, single-level MIS LD from 2013 to 2020. Patients lacking preoperative narcotic consumption data were excluded. Demographics, spinal pathologies, and operative characteristics were collected. Patients were grouped based on preoperative narcotic consumption. Patient Health Questionnaire-9 (PHQ-9), Visual Analog Scale (VAS) for back and leg, Oswestry Disability Index (ODI), 12-item Short Form Physical Component Summary, and Patient-Reported Outcomes Measurement Information System physical function (PROMIS-PF) were collected preoperatively and postoperatively. Preestablished values were used to calculate achievement of minimum clinically important difference (MCID). Differences in mean PROs and MCID achievement between groups were evaluated.

Results: The cohort was 453 patients; 184 used preoperative narcotics and 269 did not. Significant differences were found in American Society of Anesthesiologists classification, ethnicity, insurance type, and estimated blood loss between groups. Significant differences were also found in preoperative PHQ-9, VAS leg, ODI, and PROMIS-PF between groups (all p<0.05). Mean postoperative PROs did not differ by group (p>0.05). A higher rate of MCID achievement was associated with the narcotic group for PHQ-9 and PROMIS-PF at 6 weeks (both p≤0.050), VAS leg at 1 year (p=0.009), and overall for ODI and PHQ-9 (both p≤0.050).

Conclusions: Preoperative narcotic consumption was associated with worse preoperative depression, leg pain, disability, and physical function. In patients consuming preoperative narcotics, a higher proportion achieved an overall MCID for disability and depressive symptoms. Patients taking preoperative narcotic medications may report significantly worse preoperative PROs but demonstrate greater improvements in postoperative disability and mental health.
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http://dx.doi.org/10.31616/asj.2020.0582DOI Listing
June 2021

SPINE20 A global advocacy group promoting evidence-based spine care of value.

Eur Spine J 2021 08 9;30(8):2091-2101. Epub 2021 Jun 9.

Ospedale Bambino Gesù, Roma, Italia.

Purpose: The Global Burden of Diseases (GBD) Studies have estimated that low back pain is one of the costliest ailments worldwide. Subsequent to GBD publications, leadership of the four largest global spine societies agreed to form SPINE20. This article introduces the concept of SPINE20, the recommendations, and the future of this global advocacy group linked to G20 annual summits.

Methods: The founders of SPINE20 advocacy group coordinated with G20 Saudi Arabia to conduct the SPINE20 summit in 2020. The summit was intended to promote evidence-based recommendations to use the most reliable information from high-level research. Eight areas of importance to mitigate spine disorders were identified through a voting process of the participating societies. Twelve recommendations were discussed and vetted.

Results: The areas of immediate concern were "Aging spine," "Future of spine care," "Spinal cord injuries," "Children and adolescent spine," "Spine-related disability," "Spine Educational Standards," "Patient safety," and "Burden on economy." Twelve recommendations were created and endorsed by 31/33 spine societies and 2 journals globally during a vetted process through the SPINE20.org website and during the virtual inaugural meeting November 10-11, 2020 held from the G20 platform.

Conclusions: This is the first time that international spine societies have joined to support actions to mitigate the burden of spine disorders across the globe. SPINE20 seeks to change awareness and treatment of spine pain by supporting local projects that implement value-based practices with healthcare policies that are culturally sensitive based on scientific evidence.
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http://dx.doi.org/10.1007/s00586-021-06890-5DOI Listing
August 2021

Impact of Obesity Severity on Achieving a Minimum Clinically Important Difference Following Minimally Invasive Transforaminal Lumbar Interbody Fusion.

Clin Spine Surg 2021 May 28. Epub 2021 May 28.

Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL.

Study Design: This was a retrospective cohort study.

Objective: The objective of this study was to determine the impact of obesity on postoperative outcomes and minimum clinically important difference (MCID) achievement following minimally invasive transforaminal lumbar interbody fusion (MIS TLIF).

Summary Of Background Data: Obesity is a proven risk factor for poorer outcomes in MIS TLIF patients. However, few studies have investigated the impact of body mass index (BMI) on achievement of a MCID for Patient-Reported Outcome Measurement Information System Physical Function (PROMIS PF).

Methods: A prospective surgical database was retrospectively reviewed for primary, elective, single level MIS TLIF patients. Patients were categorized into BMI groups: nonobese (<30 kg/m2); obese I (≥30 and <35 kg/m2); severe (≥35 and <40 kg/m2); and morbid (≥40 kg/m2). Demographic, perioperative information, and complication rates were compared between groups. Visual Analog Scale (VAS) back and leg, Oswestry Disability Index (ODI), 12-Item Short Form-12 Physical Composite Score (SF-12 PCS), and PROMIS PF were collected preoperatively and up to 2-year postoperatively. Impact of BMI on outcome measures and MCID achievement at all timepoints was evaluated.

Results: A total of 162 patients were included with 88 patients categorized as normal weight, 37 obese I, 25 severe, and 12 morbid. SF-12 PCS, and PROMIS PF significantly differed by BMI at all timepoints, but only at 6- and 12-week for VAS back, preoperatively and 12 weeks for VAS leg, and preoperatively to 1-year for ODI. MCID achievement only differed for PROMIS PF and VAS back at 2 years, but did not for overall MCID achievement.

Conclusions: BMI is a significant predictor of ODI, SF-12 PCS, and PROMIS PF preoperatively to 1-year postoperatively, but only through 12-week for VAS scores. MCID achievement varied for PROMIS PF and VAS back, suggesting that though BMI may affect postoperative outcome values, obesity may impact a patient's perception of meaningful improvements in pain and physical function.
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http://dx.doi.org/10.1097/BSD.0000000000001205DOI Listing
May 2021

Achievement of a Minimum Clinically Important Difference for Back Disability Is a Suitable Predictor of Patient Satisfaction Among Lumbar Fusion Patients.

World Neurosurg 2021 08 21;152:e94-e100. Epub 2021 May 21.

Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA. Electronic address:

Objective: Meeting patient expectations is believed to impact satisfaction scores; however, the influence of achieving a minimum clinically important difference (MCID) is scarcely reported. This study aims to evaluate meeting patient expectations or MCID achievement for pain and disability as predictors of patient satisfaction.

Methods: A retrospective review of single or multilevel lumbar fusion patients was performed. Patients with missing preoperative Oswestry Disability Index (ODI) expectation questionnaires were excluded. Preoperative expectations and postoperative satisfaction scores for visual analog scale (VAS) back, VAS leg, and ODI were collected. Meeting expectations was defined as scores less than or equal to preoperative expectations. Achievement of MCID was evaluated. Improvement of all outcomes and correlations with satisfaction scores were evaluated using the Student's t-test and Pearson coefficient. Achievement of MCID or meeting expectations as predictors of satisfaction were evaluated and compared using linear regression and Suest test.

Results: The study included 144 patients. All outcomes significantly improved and demonstrated significant correlations with satisfaction scores (P < 0.001, all). Patients reported a mean expectation of 17.7 (ODI), 1.7 (VAS back), and 0.9 (VAS leg). The majority had their expectations met and achieved MCID. Meeting expectations and MCID achievement demonstrated significant associations with satisfaction scores for all outcomes and time points. Achievement of MCID was a stronger predictor of satisfaction for ODI and VAS back.

Conclusions: Meeting preoperative expectations and achievement of an MCID for pain and disability measures was significantly associated with satisfaction. Achievement of MCID may be a more consistent and suitable replacement as a predictor of satisfaction over meeting patient expectations.
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http://dx.doi.org/10.1016/j.wneu.2021.05.036DOI Listing
August 2021

Impact of Advanced Age on Postoperative Outcomes Following Transforaminal Lumbar Interbody Fusion.

J Am Acad Orthop Surg 2021 Sep;29(17):e869-e879

From the Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL.

Introduction: Age 65 years or older is considered a risk factor for worse outcomes after transforaminal lumbar interbody fusion (TLIF). However, few studies have differentiated this cohort from younger patients. This study compares postoperative outcomes among patients 65 years or older of age with a younger cohort after minimally invasive (MIS) TLIF.

Methods: A database was reviewed for adults undergoing primary, elective, single-level MIS TLIF procedures for degenerative pathology from 2008 to 2019. Outcomes included visual analogue scale (VAS) for back and leg, Oswestry Disability Index (ODI), Short Form 12-Item physical component score (SF-12 PCS), and Patient-Reported Outcome Measurement Information System physical function. Outcomes were collected preoperatively and at 6 weeks, 12 weeks, 6 months, and 1 year postoperatively. Patients were categorized as ≥75 years, 65 to 74 years, or <65 years of age. Propensity score matching was performed, and outcome improvement and minimum clinically important difference (MCID) achievement were evaluated by group. MCID achievement was calculated using previously established values.

Results: Our cohort included 51 patients aged younger than 65 years, 47 patients aged 65 to 74 years, and 16 patients aged 75 years or older. No significant perioperative differences or complications existed between groups. The 65- to 74-year group improved in VAS back, leg, and ODI from 6 weeks to 1 year (all P < 0.001) and SF-12 PCS at 12 weeks to 1 year (all P < 0.005). VAS back, ODI, and SF-12 PCS differed between groups preoperatively (P < 0.050), and VAS back and ODI varied at 6 weeks (P < 0.01). VAS leg differed between groups at 12 weeks and SF-12 PCS at 1 year (both P < 0.050). MCID achievement was similar between groups except for VAS leg at 6 weeks (P = 0.038) and 12 weeks (P = 0.023).

Conclusion: Patients 65 years or older of age markedly improved from baseline, similarly to younger patients. Postoperative outcome scores and MCID achievement demonstrated differences between groups at intermittent timepoints. With appropriate selection criteria, patient age may not act as a notable risk factor for successful MIS TLIF procedures.
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http://dx.doi.org/10.5435/JAAOS-D-20-01382DOI Listing
September 2021

Two-Year Postoperative Validation of Patient-Reported Outcomes Measurement Information System Physical Function After Lumbar Decompression.

J Am Acad Orthop Surg 2021 Sep;29(17):748-757

From the Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL.

Introduction: Physical function evaluated by Patient-Reported Outcomes Measurement Information System (PROMIS PF) instrument has been validated through the short-term postsurgical period in spine surgery patients. Evidence for long-term efficacy of PROMIS PF is lacking in lumbar decompression (LD) patients. The objective of this study was to evaluate correlations between PROMIS PF and legacy patient-reported outcome measures for patients undergoing LD.

Methods: Consecutive primary or revision, single-level or multilevel LD surgeries were retrospectively reviewed from May 2015 to September 2017. Patients lacking preoperative or 2-year PROMIS PF scores were excluded. Demographics, baseline pathology, and perioperative characteristics were collected, and descriptive statistics performed. Visual Analogue Scale (VAS) back and leg, Oswestry Disability Index (ODI), 12-Item Short Form (SF-12) Physical Composite Score (PCS), and PROMIS PF were collected at preoperative and postoperative timepoints and evaluated for improvement from baseline values. Correlations between PROMIS PF and VAS back, VAS leg, SF-12 PCS, and ODI were calculated and categorized according to the strength of relationship.

Results: Ninety-two patients were included in this study with 58.7% of LDs performed at the single level. All patient-reported outcome measures demonstrated significant improvement from baseline values at all assessment timepoints (all P < 0.001). Apart from preoperative VAS back and VAS leg, PROMIS PF demonstrated a significant and strong correlation with VAS back, VAS leg, ODI, and SF-12 PCS at all timepoints (all P < 0.001).

Conclusion: PROMIS PF demonstrated a strong correlation with pain, disability, and PF outcome measures throughout the postoperative period out to 2 years after LD. Our study provides longitudinal evidence that the PROMIS PF instrument is a valid measure for PF for patients undergoing LD.
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http://dx.doi.org/10.5435/JAAOS-D-20-01194DOI Listing
September 2021

Reasons for revision following stand-alone anterior lumbar interbody fusion and lateral lumbar interbody fusion.

J Neurosurg Spine 2021 Apr 30:1-7. Epub 2021 Apr 30.

Objective: Anterior lumbar interbody fusion (ALIF) and lateral lumbar interbody fusion (LLIF) are alternative and less invasive techniques to stabilize the spine and indirectly decompress the neural elements compared with open posterior approaches. While reoperation rates have been described for open posterior lumbar surgery, there are sparse data on reoperation rates following these less invasive procedures without direct posterior decompression. This study aimed to evaluate the overall rate, cause, and timing of reoperation procedures following anterior or lateral lumbar interbody fusions without direct posterior decompression.

Methods: This was a retrospective cohort study of all consecutive patients indicated for an ALIF or LLIF for lumbar spine at a single academic institution. Patients who underwent concomitant posterior fusion or direct decompression surgeries were excluded. Rates, causes, and timing of reoperations were analyzed. Patients who underwent a revision decompression were matched with patients who did not require a reoperation, and preoperative imaging characteristics were analyzed to assess for risk factors for the reoperation.

Results: The study cohort consisted of 529 patients with an average follow-up of 2.37 years; 40.3% (213/529) and 67.3% (356/529) of patients had a minimum of 2 years and 1 year of follow-up, respectively. The total revision rate was 5.7% (30/529), with same-level revision in 3.8% (20/529) and adjacent-level revision in 1.9% (10/529) of patients. Same-level revision patients had significantly shorter time to revision (7.14 months) than adjacent-level revision patients (31.91 months) (p < 0.0001). Fifty percent of same-level revisions were for a posterior decompression. After further analysis of decompression revisions, an increased preoperative canal area was significantly associated with a lower risk of further decompression revision compared to the control group (p = 0.015; OR 0.977, 95% CI 0.959-0.995).

Conclusions: There was a low reoperation rate after anterior or lateral lumbar interbody fusions without direct posterior decompression. The majority of same-level reoperations were due to a need for further decompression. Smaller preoperative canal diameters were associated with the need for revision decompression.
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http://dx.doi.org/10.3171/2020.10.SPINE201239DOI Listing
April 2021

Multimodal Analgesic Management for Cervical Spine Surgery in the Ambulatory Setting.

Int J Spine Surg 2021 Apr 1;15(2):219-227. Epub 2021 Apr 1.

Department of Orthopaedic Surgery, , Rush University Medical Center, Chicago, Illinois.

Background: Patient selection and analgesic techniques, such as the multimodal analgesic (MMA) protocol, aid in ambulatory surgical center (ASC) cervical spine surgery. The purpose of this case series is to characterize patients undergoing anterior cervical discectomy and fusion (ACDF) and total cervical disc replacement (CDR) in an ASC with an enhanced MMA protocol.

Methods: A prospectively maintained registry was retrospectively reviewed for cervical surgeries between May 2013 and August 2019. Inclusion criteria included ASC patients who underwent single-level or multilevel CDR or ACDF using an MMA protocol. Baseline, intraoperative, and postoperative characteristics were recorded, including length of stay, visual analog scale pain scores, neck disability index, complications, and narcotics administered.

Results: A total of 178 patients met inclusion criteria with 125 single-level, 52 two-level, and 1 three-level procedure. Of those patients, 127 underwent ACDF and 51 underwent CDR. The longest procedure was 95 minutes and the mean length of stay was 6.1 hours, with 2 patients requiring hospital admission. All other patients were discharged within 10 hours. One of the admitted patients experienced a postoperative seizure that was later determined to be secondary to drug use and serotonin syndrome. The second patient developed an anterior cervical hematoma 5 hours postoperatively, which was immediately evacuated. The patient was admitted for observation and discharged the next day.

Conclusion: In our study, patients experienced considerable improvement in disability scores, with a low likelihood of postoperative complications. A safe and effective MMA protocol may help facilitate anterior cervical surgery in the outpatient setting.

Level Of Evidence: 3.

Clinical Relevance: Transitioning anterior cervical discectomy and fusions to the ASC requires an appropriate MMA protocol. Our findings reveal that an enhanced MMA protocol will help improve disability scores while keeping the likelihood of postoperative complications low. This supports the ASC setting for cervical spine procedures in appropriate patient populations.
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http://dx.doi.org/10.14444/8030DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8059397PMC
April 2021

The Perioperative Symptom Severity of Higher Patient Health Questionnaire-9 Scores Between Genders in Single-Level Lumbar Fusion.

Int J Spine Surg 2021 Feb 18;15(1):62-73. Epub 2021 Feb 18.

Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois.

Background: Preoperative depression is associated with increased perioperative pain, worse physical function, reduced quality of life, and inferior outcomes. Few studies have evaluated depressive symptoms between genders for individuals undergoing minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). The purpose of this investigation was to assess the severity of Patient Health Questionnaire-9 (PHQ-9) scores among patients with depressive symptoms before and after single-level MIS TLIF.

Methods: A prospective surgical registry was retrospectively reviewed for spine surgeries between March 2016 and December 2018. We included patients with at least mild depressive symptoms (PHQ-9 scores ≥ 5) who underwent primary, single-level MIS TLIF and compared genders using χ tests and tests. Genders were stratified by depressive symptom severity: (5-9), (10-14), and (≥15) and then analyzed at preoperative and postoperative intervals: 6 weeks, 12 weeks, 6 months, and 1 year. Finally, PHQ-9 scores were validated with a Pearson correlation test against the 12-item Short Form (SF-12) Mental Composite Score (MCS) and the Veterans RAND (VR-12) MCS.

Results: Of 75 subjects, 44.0% were women and the mean age was 49.9 years. The preoperative distribution among PHQ-9 subgroups was 38.7%, 26.6%, and 34.7% for mild, moderate, and moderately severe depressive symptoms, respectively. Among PHQ-9 stratifications both genders demonstrated intermittent statistically significant improvements in PHQ-9 scores. The moderately severe PHQ-9 subgroup had improvement at all postoperative time points. The PHQ-9 scores demonstrated a strong correlation with the SF-12 MCS and VR-12 MCS at all postoperative evaluations.

Conclusion: At baseline and by the final 1-year follow-up there were no statistically significant PHQ-9 score differences between genders within any depressive symptom stratifications. Whereas some contend that men and women have substantial mental health differences, this study is aligned with growing evidence that demonstrates similar depressive symptoms between genders.

Level Of Evidence: 3.

Clinical Relevance: Men and women may be at an equivalent risk for perioperative depressive symptoms.
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http://dx.doi.org/10.14444/8007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7931707PMC
February 2021

Role of Gender in Improvement of Depressive Symptoms Among Patients Undergoing Cervical Spine Procedures.

Neurospine 2021 Mar 31;18(1):217-225. Epub 2021 Mar 31.

Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA.

Objective: There is a scarcity of research evaluating gender differences in depressive symptoms among patients undergoing cervical surgery. This study investigated gender differences with regard to depressive symptom severity, measured by Patient Health Questionnaire-9 (PHQ-9), in patients following anterior cervical discectomy and fusion (ACDF) or artificial disc replacement (ADR).

Methods: A prospectively maintained surgical registry was retrospectively reviewed for eligible spine surgeries. Depressive symptom severity was evaluated by PHQ-9 at both preand postoperative timepoints (e.g. , 6 weeks, 12 weeks, 6 months, 1 year, and 2 years). A chi-square test and Student t-test evaluated differences between the gender for demographic and operative variables where appropriate. Differences between the gender subgroup mean PHQ-9 scores were assessed using a t-test pre- and postoperatively (e.g. , 6 weeks, 12 weeks, 6 months, and 1 year) and a paired t-test was used to assess differences from preoperative scores at each postoperative time point.

Results: A total of 170 subjects underwent 125 ACDFs and 45 ADRs. Both pre- and postoperative timepoints demonstrated no significant differences between mean PHQ-9 scores by gender. Female patients demonstrated statistically significant improvement in PHQ-9 scores at 6 weeks, and 12 weeks, but not through 2 years. Male patients demonstrated statistically significant improvement in PHQ-9 scores at 6 weeks, 12 weeks, 6 months, 1 year, and 2 years.

Conclusion: Although there were no significant differences between mean PHQ-9 score between the genders, there was a difference in magnitude of improvement. Females had a significant improvement in depressive symptom severity over baseline at the 6- and 12-week timepoints only, whereas males had significant improvement through 2 years postoperatively.
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http://dx.doi.org/10.14245/ns.2040610.305DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8021839PMC
March 2021

Patient-Reported Outcomes Measurement Information System Physical Function Validation for Use in Anterior Cervical Discectomy and Fusion: A 2-Year Follow-up Study.

Neurospine 2021 Mar 31;18(1):155-162. Epub 2021 Mar 31.

Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA.

Objective: Our study aims to evaluate the correlation of Patient-Reported Outcomes Measurement Information System physical function (PROMIS PF) with legacy patient-reported outcome measures (PROMs) among patients undergoing anterior cervical discectomy and fusion (ACDF).

Methods: A prospectively maintained database was retrospectively reviewed for ACDF surgeries performed between May 2015 and September 2017. Inclusion criteria were primary elective, single- or multilevel ACDFs for degenerative spinal pathology. Patients lacking preoperative or 2-year PROMIS PF surveys were excluded. Mean scores were calculated for visual analogue scale (VAS) neck, VAS arm, Neck Disability Index (NDI), 12-Item Short Form Physical Component Score (SF-12 PCS), and PROMIS PF at preoperative and 6-week, 12-week, 6-month, 1-year, and 2-year postoperative timepoints. A t-test and Pearson correlation coefficient were utilized to evaluate score improvement and PROM relationships respectively.

Results: The 50 subject cohort was 60.0% male, 50% obese (body mass index ≥ 30 kg/m2) and had an average age of 50.9 years. Significant improvements were demonstrated for VAS neck and NDI at all postoperative timepoints (p < 0.001) and for SF-12 and PROMIS PF at all timepoints except 6 weeks (p ≤ 0.025). VAS arm improvement was seen up to 1 year (p ≤ 0.016). PROMIS PF demonstrated strong correlations with NDI and SF-12 PCS at all evaluated timepoints and with VAS neck at all postoperative timepoints except 6 weeks (all p < 0.01).

Conclusion: PROMIS PF was strongly correlated with pain, disability, and physical function up to 2 years for patients undergoing ACDF. Our results support the long-term validity of PROMIS PF for measurement of patient-reported physical function among ACDF cohorts.
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http://dx.doi.org/10.14245/ns.2040458.229DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8021822PMC
March 2021

Early Opioid Consumption Patterns After Anterior Cervical Spine Surgery.

Clin Spine Surg 2021 Mar 29. Epub 2021 Mar 29.

Hospital for Special Surgery, New York, NY Midwest Orthopaedics at Rush, Chicago, IL.

Study Design: This is a prospective observational study.

Objective: The aim was to record daily opioid use and pain levels after 1-level or 2-level anterior cervical discectomy and fusion (ACDF) or cervical disc arthroplasty (CDA).

Summary Of Background Data: Data to inform opioid prescription guidelines following ACDF or CDA is lacking. Understanding postoperative opioid consumption behaviors is critical to provide appropriate postdischarge prescriptions.

Methods: Patients undergoing 1-level or 2-level primary ACDF or CDA were consecutively enrolled at 2 participating institutions between March 2018 and March 2019. Patients with opioid dependence (defined as daily use ≥6 mo before surgery) were excluded. Starting postoperative day 1, daily opioid use and numeric pain rating scale pain levels were collected through a Health Insurance Portability and Accountability Act-compliant, automated text-messaging system. To facilitate clinical applications, opioid use was converted from oral morphine equivalents into "pills" (oxycodone 5 mg equivalents). After 6 weeks or upon patient-reported cessation of opioid use, final survey questions were asked. Refill data were verified from the state prescription registry. Risk factors for patients in top quartile of consumption were analyzed.

Results: Of 57 patients, 48 completed the daily queries (84.2%). Mean age of the patient sample was 50.2±10.9 years. Thirty-two patients (66.7%) underwent ACDF and 16 CDA (33.3%); 64.6% one level; 35.4% two levels. Median postdischarge use was 6.7 pills (range: 0-160). Cumulative opioid use did not vary between the 1-level and 2-level groups (median pill consumption, 10 interquartile range: 1.3-31.3 vs. 4 interquartile range: 0-18, respectively, P=0.085). Thirteen patients (27.1%) did not use any opioids after discharge. Of those patients that took opioids after discharge, half ceased opioids by postoperative day 8. Preoperative intermittent opioid use was associated with the top quartile of opioid consumption (9.1% vs. 50%, P=0.006).

Conclusion: Given that most patients use few opioids, patients could be offered the option of a 12 oxycodone 5 mg (90 oral morphine equivalents) discharge prescription, accompanied by education on appropriate opioid use and disposal.
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http://dx.doi.org/10.1097/BSD.0000000000001176DOI Listing
March 2021

Impact of Depression on Patient Reported Outcomes Following Primary Versus Revision ACDF.

Spine (Phila Pa 1976) 2021 Oct;46(20):1378-1386

Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL.

Study Design: Retrospective cohort.

Objective: To assess the relationship of depressive symptoms with patient reported outcome measures (PROMs) in patients undergoing either primary or revision anterior cervical discectomy and fusion (ACDF) procedures.

Summary Of Background: Depression has been associated with poorer outcomes following ACDF. However, research examining the relationship between depression and PROMs in revision ACDF procedures is limited.

Methods: A prospective database was retrospectively reviewed for primary or revision, single- or multilevel ACDF procedures from 2016 to 2019. Patients lacking preoperative Patient Health Questionnaire-9 (PHQ-9) surveys were excluded. Demographic and perioperative characteristics were recorded and analyzed using Fisher's exact test or t test. Patient-reported outcome measures were collected preoperatively and postoperatively. Postoperative improvement from baseline scores (ΔPROM) was calculated at all postoperative timepoints. Differences in mean PROM and ΔPROM between groups and changes from baseline PROM scores within groups were assessed using Student's t test. Linear regression analyzed the impact of preoperative PHQ-9 on ΔPROM.

Results: A total of 143 patients (121 primary and 22 revision) were included. Significant differences between groups were demonstrated at the preoperative timepoint for Neck Disability Index (NDI) (P = 0.022). ΔPROM values did not significantly differ between groups. Regression analysis revealed significant relationships between preoperative PHQ-9 and ΔPHQ-9 at all timepoints, ΔVAS neck at 6-weeks and 6-months, ΔVAS arm at 6-months, and ΔNDI at 6-weeks and 6-months for the primary group (all P < 0.05). Regression analysis revealed no significant associations for the revision group.

Conclusion: Primary or revision ACDF procedures did not significantly differ in depressive symptoms through 1-year. Primary ACDF patients significantly improved in all PROMs through all timepoints, while revision patients had limited improvement in PROMs. Preoperative depression may have a stronger association on postoperative outcomes for primary procedures.Level of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000004029DOI Listing
October 2021

Time to Complete Legacy Patient-Reported Outcome Measures in Patients with Lumbar Decompression.

J Am Acad Orthop Surg 2021 Feb 16. Epub 2021 Feb 16.

From the Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL.

Introduction: Patient-reported outcome measures (PROMs) are used to capture the true extent of postoperative improvement. Use of lengthier and repetitive PROMs can increase question burden on patients. This study aims to determine whether the length of time to complete (TTC) legacy PROMs has an impact on scores after lumbar decompression.

Methods: A surgical database was retrospectively reviewed for patients who underwent primary, single-level lumbar decompression from 2013 to 2020. Demographic and perioperative characteristics were collected. Physical function (PF) was measured by 12-Item Short Form (SF-12), 12-Item Veterans RAND (VR-12), and Patient-Reported Outcomes Measurement Information System (PROMIS) and was collected preoperatively and postoperatively. TTC was calculated as the difference between start and ending times for each instance of survey completion. Improvements for PROMs and comparison of TTC between SF-12/VR-12 and PROMIS PF were evaluated using a t-test. Correlation between TTC and PROM scores was evaluated using the Pearson correlation. Impact of TTC on postoperative PROM scores was evaluated using linear regression.

Results: A total of 216 patients, of which 68.1% were men, were included with a mean age of 45.8 years. Mean postoperative TTC for SF-12 and VR-12 was significantly longer than preoperative values (all P < 0.05). No notable difference in TTC was demonstrated for PROMIS PF. TTC PROMIS PF was significantly shorter than SF-12 and VR-12 from 12 weeks through 1 year (all P < 0.050). A low-strength negative correlation of TTC with SF-12 and VR-12 was observed at the preoperative, 6-week and 1-year timepoint whereas PROMIS PF had a low-strength positive correlation with TTC preoperatively and at 6 months (all P > 0.05).

Conclusion: Time spent completing PROMIS PF did not markedly differ postoperatively, but SF-12 and VR-12 required a longer TTC than PROMIS PF. Although insightful to patient improvement, SF-12 and VR-12 may increase the question burden placed on patients to complete surveys in a timely manner.
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http://dx.doi.org/10.5435/JAAOS-D-20-01207DOI Listing
February 2021
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