Publications by authors named "Richard L Skolasky"

146 Publications

Perceptions of Telehealth Physical Therapy Among Patients with Chronic Low Back Pain.

Telemed Rep 2021 3;2(1):258-263. Epub 2021 Nov 3.

Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.

Coronavirus disease 2019 prompted the rapid adoption of telehealth to provide physical therapy. Patients' perceptions about telehealth physical therapy are mostly unknown. This study describes perceptions of telehealth physical therapy among patients with chronic low back pain (LBP). This study surveyed participants in an ongoing multisite clinical trial of nonpharmacological LBP treatments. Participants were asked about their willingness to use telehealth for physical therapy and with other providers and completed the PROMIS-29. Surveys were received from 102 participants (mean age = 48.5 [standard deviation; SD = 11.6]). Thirty-six (35.3%) expressed willingness to receive telehealth physical therapy, 22 were neutral (21.6%), and 44 were unwilling (43.1%). The percentage expressing willingness for telehealth physical therapy was lower than it was for family medicine ( < 0.001) or mental health ( < 0.001). Older ( = 0.049) and Black participants ( = 0.01) more likely expressed willingness to use telehealth for physical therapy. Education and familiarity may help patients view telehealth physical therapy more favorably. Clinical Trial Registration (clinicaltrials.gov NCT03859713).
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http://dx.doi.org/10.1089/tmr.2021.0028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8670598PMC
November 2021

If it's information, it's not "bias": a scoping review and proposed nomenclature for future response-shift research.

Qual Life Res 2021 Oct 27. Epub 2021 Oct 27.

Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.

Background: The growth in response-shift methods has enabled a stronger empirical foundation to investigate response-shift phenomena in quality-of-life (QOL) research; but many of these methods utilize certain language in framing the research question(s) and interpreting results that treats response-shift effects as "bias," "noise," "nuisance," or otherwise warranting removal from the results rather than as information that matters. The present project will describe the various ways in which researchers have framed the questions for investigating response-shift issues and interpreted the findings, and will develop a nomenclature for such that highlights the important information about resilience reflected by response-shift findings.

Methods: A scoping review was done of the QOL and response-shift literature (n = 1100 articles) from 1963 to 2020. After culling only empirical response-shift articles, raters characterized how investigators framed and interpreted study research questions (n = 164 articles).

Results: Of 10 methods used, papers using four of them utilized terms like "bias" and aimed to remove response-shift effects to reveal "true change." Yet, the investigators' reflections on their own conclusions suggested that they do not truly believe that response shift is error to be removed. A structured nomenclature is proposed for discussing response-shift results in a range of research contexts and response-shift detection methods.

Conclusions: It is time for a concerted and focused effort to change the nomenclature of those methods that demonstrated this misinterpretation. Only by framing and interpreting response shift as information, not bias, can we improve our understanding and methods to help to distill outcomes with and without response-shift effects.
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http://dx.doi.org/10.1007/s11136-021-03023-9DOI Listing
October 2021

Role of psychosocial factors on the effect of physical activity on physical function in patients after lumbar spine surgery.

BMC Musculoskelet Disord 2021 Oct 18;22(1):883. Epub 2021 Oct 18.

Department of Orthopaedic Surgery, Center for Musculoskeletal Research, Vanderbilt University Medical Center, 1215 21st Ave South, Nashville, TN, 37232, USA.

Background: The purpose of this study was to investigate the longitudinal postoperative relationship between physical activity, psychosocial factors, and physical function in patients undergoing lumbar spine surgery.

Methods: We enrolled 248 participants undergoing surgery for a degenerative lumbar spine condition. Physical activity was measured using a triaxial accelerometer (Actigraph GT3X) at 6-weeks (6wk), 6-months (6M), 12-months (12M) and 24-months (24M) following spine surgery. Physical function (computerized adaptive test domain version of Patient-Reported Outcomes Measurement Information System) and psychosocial factors (pain self-efficacy, depression and fear of movement) were assessed at preoperative visit and 6wk, 6M, 12M and 24M after surgery. Structural equation modeling (SEM) techniques were utilized to analyze data, and results are represented as standardized regression weights (SRW). Overall SRW were computed across five imputed datasets to account for missing data. The mediation effect of each psychosocial factor on the effect of physical activity on physical function were computed [(SRW for effect of activity on psychosocial factor X SRW for effect of psychosocial factor on function) ÷ SRW for effect of activity on function]. Each SEM model was tested for model fit by assessing established fit indexes.

Results: The overall effect of steps per day on physical function (SRW ranged from 0.08 to 0.19, p<0.05) was stronger compared to the overall effect of physical function on steps per day (SRW ranged from non-existent to 0.14, p<0.01 to 0.3). The effect of steps per day on physical function and function on steps per day remained consistent after accounting for psychosocial factors in each of the mediation models. Depression and fear of movement at 6M mediated 3.4% and 5.4% of the effect of steps per day at 6wk on physical function at 12M, respectively. Pain self-efficacy was not a statistically significant mediator.

Conclusions: The findings of this study suggest that the relationship between physical activity and physical function is stronger than the relationship of function to activity. However, future research is needed to examine whether promoting physical activity during the early postoperative period may result in improvement of long-term physical function. Since depression and fear of movement had a very small mediating effect, additional work is needed to investigate other potential mediating factors such as pain catastrophizing, resilience and exercise self-efficacy.
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http://dx.doi.org/10.1186/s12891-021-04622-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8522146PMC
October 2021

Transforming challenges into opportunities: conducting health preference research during the COVID-19 pandemic and beyond.

Qual Life Res 2021 Oct 18. Epub 2021 Oct 18.

School of Health and Related Research, University of Sheffield, Sheffield, UK.

The disruptions to health research during the COVID-19 pandemic are being recognized globally, and there is a growing need for understanding the pandemic's impact on the health and health preferences of patients, caregivers, and the general public. Ongoing and planned health preference research (HPR) has been affected due to problems associated with recruitment, data collection, and data interpretation. While there are no "one size fits all" solutions, this commentary summarizes the key challenges in HPR within the context of the pandemic and offers pragmatic solutions and directions for future research. We recommend recruitment of a diverse, typically under-represented population in HPR using online, quota-based crowdsourcing platforms, and community partnerships. We foresee emerging evidence on remote, and telephone-based HPR modes of administration, with further studies on the shifts in preferences related to health and healthcare services as a result of the pandemic. We believe that the recalibration of HPR, due to what one would hope is an impermanent change, will permanently change how we conduct HPR in the future.
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http://dx.doi.org/10.1007/s11136-021-03012-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8521079PMC
October 2021

In Sync Working Group response-shift.

Qual Life Res 2021 Dec 6;30(12):3363-3364. Epub 2021 Oct 6.

Department of Orthopaedic Surgery and Physical Medicine & Rehabilitation, The Johns Hopkins University, 601 N. Caroline Street, JHOC 5223, Baltimore, MD, 21287, USA.

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http://dx.doi.org/10.1007/s11136-021-03005-xDOI Listing
December 2021

Associations of depression and sociodemographic characteristics with patient activation among those presenting for spine surgery.

J Orthop 2021 Jul-Aug;26:8-13. Epub 2021 Jun 18.

Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.

Purpose: To investigate the associations of sociodemographic characteristics and PROMIS domain scores with patient activation among patients presenting for spine surgery at a university-affiliated spine center.

Methods: Patients completed a survey collecting demographic and social information. Patients also completed the Patient-Reported Outcomes Measurement Information System (PROMIS) and Patient Activation Measure questionnaires. The associations of PROMIS scores and sociodemographic characteristics with patient activation were assessed using linear and ordinal logistic regression (patient activation stage as ordinal).

Results: A total of 1018 patients were included. Most respondents were white (84%), married (73%), and female (52%). Patients were distributed among the 4 activation stages as follows: stage I, 7.7%; stage II, 12%; stage III, 26%; and stage IV, 55%. Mean (±standard deviation) patient activation score was 70 ± 17 points. Female sex (adjusted coefficient [AC] = 4.3; 95% confidence interval [CI] 2.1, 6.4) and annual household income >$80,000 (OR = 3.7; 95% CI 0.54, 6.9) were associated with higher patient activation scores. Lower patient activation scores were associated with worse PROMIS Depression (AC = -0.31; 95% CI -0.48, -0.14), Fatigue (OR = -0.19; 95% CI -0.33, -0.05), Pain (OR = 0.22; 95% CI 0.01, 0.43), and Social Satisfaction (OR = 0.33; 95% CI 0.14, 0.51) scores.

Conclusion: Depression and socioeconomic status, along with PROMIS Pain, Fatigue, and Social Satisfaction domains, were associated with patient activation. Patients with a greater burden of depressive symptoms had lower patient activation; conversely, women and those with higher income had greater patient activation.

Level Of Evidence: Level 1.
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http://dx.doi.org/10.1016/j.jor.2021.06.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8242331PMC
June 2021

The Relationship Between Neighborhood Deprivation and Perceived Changes for Pain-Related Experiences Among US Patients with Chronic Low Back Pain During the COVID-19 Pandemic.

Pain Med 2021 11;22(11):2550-2565

Department of Orthopedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.

Objective: Disruptions caused by the COVID-19 pandemic could disproportionately affect the health of vulnerable populations, including patients experiencing persistent health conditions (i.e., chronic pain), along with populations living within deprived, lower socioeconomic areas. The current cross-sectional study characterized relationships between neighborhood deprivation and perceived changes in pain-related experiences during the COVID-19 pandemic (early-September to mid-October 2020) for adult patients (N = 97) with nonspecific chronic low back pain.

Methods: We collected self-report perceived experiences from participants enrolled in an ongoing pragmatic randomized trial across medical centers within the Salt Lake City, Utah and Baltimore, Maryland metropolitans. The Area Deprivation Index (composite of 17 US Census deprivation metrics) reflected neighborhood deprivation based on participants' zip codes.

Results: Although those living in the neighborhoods with greater deprivation endorsed significantly poorer physical (pain severity, pain interference, physical functioning), mental (depression, anxiety), and social health during the pandemic, there were no significant differences for perceived changes in pain-related experiences (pain severity, pain interference, sleep quality) between levels of neighborhood deprivation since the onset of the pandemic. However, those in neighborhoods with greater deprivation endorsed disproportionately worse perceived changes in pain coping, social support, and mood since the pandemic.

Conclusions: The current findings offer evidence that changes in pain coping during the pandemic may be disproportionately worse for those living in deprived areas. Considering poorer pain coping may contribute to long-term consequences, the current findings suggest the need for further attention and intervention to reduce the negative effect of the pandemic for such vulnerable populations.
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http://dx.doi.org/10.1093/pm/pnab179DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8633737PMC
November 2021

How Many Steps Per Day During the Early Postoperative Period are Associated With Patient-Reported Outcomes of Disability, Pain, and Opioid Use After Lumbar Spine Surgery?

Arch Phys Med Rehabil 2021 10 25;102(10):1873-1879. Epub 2021 Jun 25.

Department of Orthopaedic Surgery, Center for Musculoskeletal Research, Vanderbilt University Medical Center, Nashville, TN; Department of Physical Medicine and Rehabilitation, Osher Center for Integrative Medicine, Vanderbilt University Medical Center, Nashville, TN. Electronic address:

Objective: To investigate whether early postoperative walking is associated with "best outcome" and no opioid use at 1 year after lumbar spine surgery and establish a threshold for steps/day to inform clinical practice.

Design: Secondary analysis from randomized controlled trial.

Setting: Two academic medical centers in the United States.

Participants: We enrolled 248 participants undergoing surgery for a degenerative lumbar spine condition (N=248). A total of 212 participants (mean age, 62.8±11.4y, 53.3% female) had valid walking data at baseline.

Interventions: Not applicable.

Main Outcome Measures: Disability (Oswestry Disability Index), back and leg pain (Brief Pain Inventory), and opioid use (yes vs no) were assessed at baseline and 1 year after surgery. "Best outcome" was defined as Oswestry Disability Index ≤20, back pain ≤2, and leg pain ≤2. Steps/day (walking) was assessed with an accelerometer worn for at least 3 days and 10 h/d at 6 weeks after spine surgery, which was considered as study baseline. Separate multivariable logistic regression analyses were conducted to determine the association between steps/day at 6 weeks and "best outcome" and no opioid use at 1-year. Receiver operating characteristic curves identified a steps/day threshold for achieving outcomes.

Results: Each additional 1000 steps/d at 6 weeks after spine surgery was associated with 41% higher odds of achieving "best outcome" (95% confidence interval [CI], 1.15-1.74) and 38% higher odds of no opioid use (95% CI, 1.09-1.76) at 1 year. Walking ≥3500 steps/d was associated with 3.75 times the odds (95% CI, 1.56-9.02) of achieving "best outcome" and 2.37 times the odds (95% CI, 1.07-5.24) of not using opioids.

Conclusions: Walking early after surgery may optimize patient-reported outcomes after lumbar spine surgery. A 3500 steps/d threshold may serve as an initial recommendation during early postoperative counseling.
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http://dx.doi.org/10.1016/j.apmr.2021.06.002DOI Listing
October 2021

Persistent sleep disturbance after spine surgery is associated with failure to achieve meaningful improvements in pain and health-related quality of life.

Spine J 2021 08 25;21(8):1325-1331. Epub 2021 Mar 25.

Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N. Caroline Street, JHOC 5223, Baltimore, MD 21287, USA. Electronic address:

Background Context: Little is known about the effects of sleep disturbance (SD) on clinical outcomes after spine surgery.

Purpose: To determine the (1) prevalence of SD among patients presenting for spine surgery at an academic medical center; (2) correlations between SD and health-related quality of life (HRQoL) scores; and (3) associations between postoperative SD resolution and short-term HRQoL.

Study Design: Retrospective review of prospectively collected data.

Patient Sample: We included 508 adults undergoing spine surgery at 1 academic center between December 2014 and January 2018.

Outcome Measures: Participants completed the Oswestry Disability Index (ODI) or Neck Disability Index (NDI) and Patient Reported Outcome Measurement System (PROMIS-29) questionnaire preoperatively, during the immediate postoperative period (6-12 weeks), and at 6, 12, and 24 months after surgery.

Methods: Using preoperative PROMIS SD scores, we grouped participants as having no sleep disturbance (score <55), mild disturbance (score, 55-60), moderate disturbance (score 60-70), or severe disturbance (score, 70). For the final analysis, we collapsed these categories into no/mild and moderate/severe. Pearson correlation tests were used to assess correlations between SD and HRQoL measures. Regression analysis (adjusting for age, sex, comorbidities, current opioid use, and occurrence of complications) was used to estimate the effect of postoperative resolved or continuing SD on HRQoL scores and the likelihood of achieving clinically meaningful improvements in HRQoL. Alpha = 0.05.

Results: Preoperative SD was reported by 127 participants (25%). SD was significantly correlated with worse ODI and/or NDI values and worse scores in all PROMIS health domains (all, p<.001). At the immediate postoperative assessment, SD had resolved in 80 of 127 participants (63%). Compared with participants who reported no preoperative SD, those with ongoing SD were significantly less likely to achieve clinically meaningful improvements in Pain Interference (odds ratio [OR], 0.49; 95% confidence interval [CI], 0.28, 0.84), Physical Function (OR, 0.32; 95% CI, 0.13, 0.82), and Satisfaction with Participation in Social Roles (OR, 0.57; 95% CI, 0.37, 0.80).

Conclusion: One-quarter of spine surgery patients reported preoperative SD of at least moderate severity. Poor preoperative sleep quality and ongoing postoperative sleep disturbance were significantly associated with worse scores on several HRQoL measures. These results highlight the importance of addressing patients' sleep disturbance both before and after surgery.
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http://dx.doi.org/10.1016/j.spinee.2021.03.021DOI Listing
August 2021

Appropriate Opioid Use After Spine Surgery: Psychobehavioral Barriers and Patient Knowledge.

World Neurosurg 2021 06 19;150:e600-e612. Epub 2021 Mar 19.

Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA. Electronic address:

Objective: To identify spine patients' barriers to appropriate postoperative opioid use, comfort with naloxone, knowledge of safe opioid disposal practices, and associated factors.

Methods: We preoperatively surveyed 174 spine patients about psychobehavioral barriers to appropriate opioid use, comfort with naloxone, and knowledge about opioid disposal. Multivariable logistic regression identified factors associated with barriers and knowledge (α = 0.05).

Results: Common barriers were fear of addiction (71%) and concern about disease progression (43%). Most patients (78%) had neutral/low confidence in the ability of nonopioid medications to control pain; most (57%) felt neutral or uncomfortable with using naloxone; and most (86%) were familiar with safe disposal. Anxiety was associated with fear of distracting the physician (adjusted odds ratio [aOR], 3.8; 95% confidence interval [CI], 1.1-14) and with lower odds of knowing safe disposal methods (aOR, 0.18; 95% CI, 0.04-0.72). Opioid use during the preceding month was associated with comfort with naloxone (aOR, 4.9; 95% CI, 2.1-12). Patients with a higher educational level had lower odds of reporting fear of distracting the physician (aOR, 0.30; 95% CI, 0.09-0.97), and those with previous postoperative opioid use had lower odds of concern about disease progression (aOR, 0.25; 95% CI, 0.09-0.63) and with a belief in tolerating pain (aOR, 0.34; 95% CI, 0.12-0.95).

Conclusions: Many spine patients report barriers to appropriate postoperative opioid use and are neutral or uncomfortable with naloxone. Some are unfamiliar with safe disposal. Associated factors include anxiety, lack of recent opioid use, and no previous postoperative use.
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http://dx.doi.org/10.1016/j.wneu.2021.03.066DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8187334PMC
June 2021

Reassessment of Relative Value in Shoulder and Elbow Surgery: Do Payment and Relative Value Units Reflect Reality?

Clin Orthop Surg 2021 Mar 7;13(1):76-82. Epub 2021 Jan 7.

Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA.

Backgroud: Many U.S. health care institutions have adopted compensation models based on work relative value units (wRVUs) to standardize payments and incentivize providers. A major determinant of payment and wRVU assignments is operative time. We sought to determine whether differences in estimated operative times between the Centers for Medicare & Medicaid Services (CMS) and the National Surgical Quality Improvement Program (NSQIP) contribute to payment and wRVU misvaluation for the most common shoulder/elbow procedures.

Methods: We collected data on wRVUs, payments, and operative times from CMS for 29 types of isolated arthroscopic and open shoulder/elbow procedures. Using regression analysis, we compared relationships between these variables, in addition to median operative times reported by NSQIP (2013-2016). We then determined the relative valuation of each procedure based on operative time.

Results: Seventy-nine percent of CMS operative time were longer than NSQIP time ( = 0.58), including, but not limited to, shoulder arthroplasty and arthroscopic shoulder surgery. The correlation between payments and operative times was stronger between CMS data ( = 0.61) than NSQIP data ( = 0.43). Similarly, the correlation between wRVUs and operative times was stronger when using CMS data ( = 0.87) than NSQIP data ( = 0.69). Nearly all arthroscopic shoulder procedures (aside from synovectomy, debridement, and decompression) were highly valued according to both datasets. Per NSQIP, compensation for revision total shoulder arthroplasty ($10.14/min; 0.26 wRVU/min) was higher than that for primary cases ($9.85, 0.23 wRVU/min) and nearly twice the CMS rate for revision cases ($5.84/min; 0.13 wRVU/min).

Conclusions: CMS may overestimate operative times compared to actual operative times as recorded by NSQIP. Shorter operative times may render certain procedures more highly valued than others. Case examples show that this can potentially affect patient care and incentivize higher compensating procedures per operative time when less-involved, shorter operations have similar patient-reported outcomes.
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http://dx.doi.org/10.4055/cios20052DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7948050PMC
March 2021

Determining validity, discriminant ability, responsiveness, and minimal clinically important differences for PROMIS in adult spinal deformity.

J Neurosurg Spine 2021 Feb 19:1-9. Epub 2021 Feb 19.

Objective: The aim of this study was to determine the concurrent validity, discriminant ability, and responsiveness of the Patient-Reported Outcomes Measurement Information System (PROMIS) in adult spinal deformity (ASD) and to calculate minimal clinically important differences (MCIDs) for PROMIS scores.

Methods: The authors used data obtained in 186 surgical patients with ASD. Concurrent validity was determined through correlations between preoperative PROMIS scores and legacy measure scores. PROMIS discriminant ability between disease severity groups was determined using the preoperative Oswestry Disability Index (ODI) value as the anchor. Responsiveness was determined through distribution- and anchor-based methods, using preoperative to postoperative changes in PROMIS scores. MCIDs were estimated on the basis of the responsiveness analysis.

Results: The authors found strong correlations between PROMIS Pain Interference and ODI and the Scoliosis Research Society 22-item questionnaire Pain component; PROMIS Physical Function and ODI; PROMIS Anxiety and Depression domains and the 12-Item Short Form Health Survey version 2, Physical and Mental Components, Scoliosis Research Society 22-item questionnaire Mental Health component (anxiety only), 9-Item Patient Health Questionnaire (anxiety only), and 7-Item Generalized Anxiety Disorder questionnaire; PROMIS Fatigue and 9-Item Patient Health Questionnaire; and PROMIS Satisfaction with Participation in Social Roles (i.e., Social Satisfaction) and ODI. PROMIS discriminated between disease severity groups in all domains except between none/mild and moderate Anxiety, with mean differences ranging from 3.7 to 8.4 points. PROMIS showed strong responsiveness in Pain Interference; moderate responsiveness in Physical Function and Social Satisfaction; and low responsiveness in Anxiety, Depression, Fatigue, and Sleep Disturbance. Final PROMIS MCIDs were as follows: -6.3 for Anxiety, -4.4 for Depression, -4.6 for Fatigue, -5.0 for Pain Interference, 4.2 for Physical Function, 5.7 for Social Satisfaction, and -3.5 for Sleep Disturbance.

Conclusions: PROMIS is a valid assessment of patient health, can discriminate between disease severity levels, and shows responsiveness to changes after ASD surgery. The MCIDs provided herein may help clinicians interpret postoperative changes in PROMIS scores, taking into account the fact that they are pending external validation.
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http://dx.doi.org/10.3171/2020.8.SPINE191551DOI Listing
February 2021

How is staging of ALIF following posterior spinal arthrodesis to the pelvis related to functional improvement in patients with adult spinal deformity?

Spine Deform 2021 07 19;9(4):1085-1091. Epub 2021 Jan 19.

Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N. Caroline Street, JHOC 5241, Baltimore, MD, 21287, USA.

Study Design: Retrospective cohort.

Objectives: To compare postoperative functional improvement in patients who underwent staged versus non-staged anterior-posterior spinal arthrodesis for adult spinal deformity (ASD). In patients with ASD, spinal arthrodesis can be performed in 2 stages to avoid the physiologic insult of a lengthy surgery. The association between staged surgery and postoperative functional improvement has not been well studied.

Methods: We included 87 patients (59 women) with ASD who underwent anterior-posterior spinal arthrodesis of > 5 levels with fixation to the pelvis from 2010-2014. Primary outcomes were the frequency of achieving at least a minimal clinically important difference (MCID) in the Scoliosis Research Society-22r (SRS-22r) Activity domain and the timeframe in which it was achieved. The secondary outcome was patient satisfaction (SRS-22r Patient Satisfaction domain). A Cox proportional hazard model was used to compare functional improvement over time between staged and non-staged groups. Our study was powered to detect a relative hazard ratio of 0.53, β = 0.20. α = 0.05.

Results: The frequency of achieving an MCID in SRS-22r Activity score did not differ significantly between the staged group (33/41 patients) and the non-staged group (34/46 patients) (hazard ratio 0.74; 95% confidence interval 0.41-1.36). Median times to achieving an MCID in SRS-22r Activity score were 191 days (interquartile range: 86-674) in the staged group and 181 days (interquartile range: 72-474) in the non-staged group (p = .75). The staged and non-staged groups had similar SRS-22r Patient Satisfaction scores at 3-9 months postoperatively and at final follow-up (both, p > .05).

Conclusion: Patients with ASD who underwent staged anterior-posterior spinal arthrodesis within 3 months after index surgery were similarly likely to experience functional improvement in the same timeframe as patients who underwent non-staged surgery. Patient satisfaction did not differ significantly between staged and non-staged groups.

Level Of Evidence: III.
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http://dx.doi.org/10.1007/s43390-020-00272-5DOI Listing
July 2021

Recurrence of proximal junctional kyphosis after revision surgery for symptomatic proximal junctional kyphosis in patients with adult spinal deformity: incidence, risk factors, and outcomes.

Eur Spine J 2021 05 15;30(5):1199-1207. Epub 2021 Jan 15.

Department of Orthopaedic Surgery, The Johns Hopkins University, 601 North Caroline Street, Baltimore, MD, 21287, USA.

Purpose: Although proximal junctional kyphosis (PJK) is common after long spinal fusion, the outcomes of revision surgery for symptomatic PJK are unclear. Our aim was to assess the outcomes of revision surgery for symptomatic PJK in patients with adult spinal deformity and elucidate the incidence and risk factors for recurrent PJK (rePJK).

Methods: We evaluated standing radiographs and health-related quality of life (HRQOL) in patients who underwent revision surgery for symptomatic PJK with at least 2-year follow-up. Patients were assigned to the non-rePJK or rePJK group according to PJK recurrence.

Results: Thirty-nine consecutive patients (mean age, 63 ± 11 years; 24 women) met the inclusion criteria. RePJK occurred in 12 patients (31%). There were significant differences in the following parameters between groups (non-rePJK vs. rePJK): initial proximal junctional sagittal Cobb angle (PJA) (26.6° vs. 35.6°), thoracic kyphosis (TK) (38.6° vs. 52.8°), and sagittal vertical axis (SVA) (9.3 vs. 15.9 cm), and pre- to postoperative SVA decrease (6.1 vs. 12.2 cm). Significant risk factors for rePJK were initial PJA > 40°, preoperative TK > 60°, preoperative SVA > 10.0 cm, correction of TK > 15°, and correction of SVA > 5.0 cm. HRQOL scores improved significantly; however, postoperative SRS-22r activity scores were significantly worse in the rePJK group vs the non-rePJK group.

Conclusion: The incidence of rePJK was 31%. Risk factors for rePJK were large initial PJA, high preoperative TK and SVA, and greater correction of TK and SVA. HRQOL did not differ significantly between patients with vs without rePJK, except immediate postoperative SRS-22r activity scores.

Level Of Evidence: III.
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http://dx.doi.org/10.1007/s00586-020-06669-0DOI Listing
May 2021

Mental Health Associated With Postoperative Satisfaction in Lumbar Degenerative Surgery Patients.

Clin Spine Surg 2021 Dec;34(10):E588-E593

Departments of Orthopaedic Surgery.

Study Design: Retrospective review of prospectively collected data.

Objective: To assess the association between preoperative and postoperative mental health status with postoperative satisfaction in lumbar degenerative surgery patients.

Summary Of Background Data: Poor preoperative mental health has been shown to negatively affect postoperative satisfaction among spine surgery patients, but there is limited evidence on the impact of postoperative mental health on satisfaction.

Materials And Methods: Adult patients undergoing surgery for lumbar degenerative conditions at a single institution were included. Mental health was assessed preoperatively and 12 months postoperatively using Patient-Reported Outcomes Measurement Information System Depression and Anxiety scores. Satisfaction was assessed 12 months postoperatively using North American Spine Society Patient Satisfaction Index. The authors evaluated associations between mental health and satisfaction with univariate and multivariable logistic regression to adjust for confounders. Preoperative depression/anxiety level was corrected for postoperative depression/anxiety level, and vice versa. Statistical significance was assessed at α=0.05.

Results: A total of 183 patients (47% male individuals; avg. age, 62 y) were included. Depression was present in 27% preoperatively and 29% postoperatively, and anxiety in 50% preoperatively and 31% postoperatively. Ninteen percent reported postoperative dissatisfaction using the North American Spine Society Patient Satisfaction Index. Univariate analysis identified race, family income, relationship status, current smoking status, change in pain interference, and change in physical function as potential confounders. In adjusted analysis, odds of dissatisfaction were increased in those with mild postoperative depression (adjusted odds ratio=6.1; 95% confidence interval, 1.2-32; P=0.03) and moderate or severe postoperative depression (adjusted odds ratio=7.5; 95% confidence interval, 1.3-52; P=0.03). Preoperative and postoperative anxiety and preoperative depression were not associated with postoperative satisfaction.

Conclusions: Following lumbar degenerative surgery, patients with postoperative depression, irrespective of preoperative depression status, have significantly higher odds of dissatisfaction. These results emphasize the importance of postoperative screening and treatment of depression in spine patients with dissatisfaction.

Level Of Evidence: Level III-nonrandomized cohort study.
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http://dx.doi.org/10.1097/BSD.0000000000001106DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8184861PMC
December 2021

Physical Performance Tests Provide Distinct Information in Both Predicting and Assessing Patient-Reported Outcomes Following Lumbar Spine Surgery.

Spine (Phila Pa 1976) 2020 Dec;45(23):E1556-E1563

Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, TN.

Study Design: Secondary analysis of randomized controlled trial data.

Objective: The aim of this study was to examine whether preoperative physical performance is an independent predictor of patient-reported disability and pain at 12 months after lumbar spine surgery.

Summary Of Background Data: Patient-reported outcome measures (PROMs) are commonly used to assess clinical improvement after lumbar spine surgery. However, there is evidence in the orthopedic literature to suggest that PROMs should be supplemented with physical performance tests to accurately evaluate long-term outcomes.

Methods: A total of 248 patients undergoing surgery for degenerative lumbar spine conditions were recruited from two institutions. Physical performance tests (5-Chair Stand and Timed Up and Go) and PROMs of disability (Oswestry Disability Index: ODI) and back and leg pain (Brief Pain Inventory) were assessed preoperatively and at 12 months after surgery.

Results: Physical performance tests and PROMs significantly improved over 12 months following lumbar spine surgery (P < 0.01). Weak correlations were found between physical performance tests and disability and pain (ρ = 0.15 to 0.32, P < 0.05). Multivariable regression analyses controlling for age, education, preoperative outcome score, fusion, previous spine surgery, depressive symptoms, and randomization group found that preoperative 5-Chair Stand test was significantly associated with disability and back pain at 12-month follow-up. Each additional 10 seconds needed to complete the 5-Chair Stand test were associated with six-point increase in ODI (P = 0.047) and one-point increase in back pain (P = 0.028) scores. The physical performance tests identified an additional 14% to 19% of patients as achieving clinical improvement that were not captured by disability or pain questionnaires.

Conclusion: Results indicate that physical performance tests may provide distinct information in both predicting and assessing clinical outcomes in patients undergoing lumbar spine surgery. Our findings suggest that the 5-Chair Stand test may be a useful test to include within a comprehensive risk assessment before surgery and as an outcome measure at long-term follow-up.

Level Of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000003665DOI Listing
December 2020

Health Care Resource Utilization in Commercially Insured Patients Undergoing Anterior Cervical Discectomy and Fusion for Degenerative Cervical Pathology.

Global Spine J 2021 Jan 14;11(1):108-115. Epub 2020 Jan 14.

1466The Johns Hopkins University, Baltimore, MD, USA.

Study Design: Retrospective review of an administrative database.

Objectives: The aim of our study was to investigate the distribution of spending for the entire episode of care among nonelderly, commercially insured patients undergoing elective, inpatient anterior cervical discectomy and fusion (ACDF) surgeries for degenerative cervical pathology.

Methods: Using a private insurance claims database, we identified patients who underwent single-level, inpatient ACDF for degenerative spinal disease. Patients were selected using a combination of Current Procedural Terminology (CPT) and International Classification of Diseases (ICD) codes. Entire episode of care was defined as 6-months before (preoperative) to 6 months after (postoperative) the surgical admission.

Results: In our cohort containing 33 209 patients, perioperative median spending per patient (MSPP) within the year encompassing surgery totaled $37 020 (interquartile range [IQR] $28 363-$49 206), with preoperative, surgical admission, and postoperative spending accounting for 9.8%, 80.7%, and 9.5% of total spending, respectively. Preoperatively, MSPP was $3109 (IQR $1806-$5215), 48% of patients underwent physical therapy, and 31% underwent injections in the 6 months period prior to surgery. Postoperatively, MSPP was $1416 (IQR $398-$3962), and unplanned hospital readmission (6% incidence) accounted for 33% of the overall postoperative spending. Discharge to a nonhome discharge disposition was associated with higher postoperative spending ($14 216) compared with patients discharged home ($1468) and home with home care ($2903), < .001.

Conclusion: Understanding the elements and distribution of perioperative spending for the episode of care in patients undergoing ACDF surgery for degenerative conditions is important for health care planning and resource allocation.
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http://dx.doi.org/10.1177/2192568219899340DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7734273PMC
January 2021

Changes in racial and ethnic disparities in lumbar spinal surgery associated with the passage of the Affordable Care Act, 2006-2014.

Spine J 2021 01 5;21(1):64-70. Epub 2020 Aug 5.

Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 N. Caroline Street, Baltimore, MD 21287, USA; Department of Physical Medicine and Rehabilitation, The Johns Hopkins University School of Medicine, 601 N. Caroline Street, Baltimore, MD 21287, USA. Electronic address:

Background Context: Since implementation of the Patient Protection and Affordable Care Act (ACA) in 2010, more Americans have health insurance, and many racial/ethnic disparities in healthcare have improved. We previously reported that Black and Hispanic patients undergo surgery for spinal stenosis at lower rates than do white patients.

Purpose: To assess changes in racial/ethnic disparities in rates of lumbar spinal surgery after passage of the ACA.

Study Design: Retrospective analysis.

Patient Sample: Approximately 3.2 million adults who underwent lumbar spinal surgery in the US from 2006 through 2014.

Outcome Measures: Racial disparities in discharge rates before versus after ACA passage.

Methods: Using the Nationwide Inpatient Sample, the U.S. Census Bureau Current Population Survey Supplement, and International Classification of Diseases, Ninth Revision, Clinical Modification, criteria for definite lumbar spinal surgery, we calculated rates of lumbar spinal surgery as the number of hospital discharges divided by population estimates and stratified patients by race/ethnicity after controlling for sociodemographic characteristics. Calendar years were stratified as before ACA passage (2006-2010) or after ACA passage (2011-2014). Poisson regression was used to model hospital discharge rates as a function of race/ethnicity before and after ACA passage after adjustment for potential confounders.

Results: All rates are expressed per 1,000 persons. The overall median discharge rate decreased from 1.9 before ACA passage to 1.6 after ACA passage (p < .001). After adjustment for sociodemographic factors, the Black:White disparity in discharge rates decreased from 0.40:1 before ACA to 0.44:1 after ACA (p < .001). A similar decrease in the Hispanic:White disparity occurred, from 0.35:1 before ACA to 0.38:1 after ACA (p < .001).

Conclusion: Small but significant decreases occurred in racial/ethnic disparities in hospital discharge rates for lumbar spinal surgery after ACA passage.
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January 2021

Bouncing back after lumbar spine surgery: early postoperative resilience is associated with 12-month physical function, pain interference, social participation, and disability.

Spine J 2021 01 28;21(1):55-63. Epub 2020 Jul 28.

Department of Orthopaedic Surgery, Center for Musculoskeletal Research, Department of Physical Medicine and Rehabilitation, Osher Center for Integrative Medicine, Vanderbilt University Medical Center, 1215 21st Ave South, Medical Center East-South Tower, Suite 4200, Nashville, TN 37232, USA. Electronic address:

Background Context: Positive psychosocial factors early after surgery, such as resilience and self-efficacy, may be important characteristics for informing individualized postoperative care.

Purpose: To examine the association of early postoperative resilience and self-efficacy on 12-month physical function, pain interference, social participation, disability, pain intensity, and physical activity after lumbar spine surgery.

Study Design/setting: Pooled secondary analysis of prospectively collected trial data from two academic medical centers.

Patient Sample: Two hundred and forty-eight patients who underwent laminectomy with or without fusion for a degenerative lumbar condition.

Outcome Measures: Physical function, pain inference, and social participation (ability to participate in social roles and activities) were measured using the Patient Reported Outcomes Measurement Information System. The Oswestry Disability Index, Numeric Rating Scale, and accelerometer activity counts were used to measure disability, pain intensity, and physical activity, respectively.

Methods: Participants completed validated outcome questionnaires at 6 weeks (baseline) and 12 months after surgery. Baseline positive psychosocial factors included resilience (Brief Resilience Scale) and self-efficacy (Pain Self-Efficacy Questionnaire). Multivariable linear regression analyses were used to assess the associations between early postoperative psychosocial factors and 12-month outcomes adjusting for age, sex, study site, randomized group, fusion status, fear of movement (Tampa Scale for Kinesiophobia), and outcome score at baseline. This study was funded by Patient-Centered Outcomes Research Institute and Foundation for Physical Therapy Research. There are no conflicts of interest.

Results: Resilience at 6 weeks after surgery was associated with 12-month physical function (unstandardized beta=1.85 [95% confidence interval [CI]: 0.29; 3.40]), pain interference (unstandardized beta=-1.80 [95% CI: -3.48; -0.12]), social participation (unstandardized beta=2.69 [95% CI: 0.97; 4.41]), and disability (unstandardized beta=-3.03 [95% CI: -6.04; -0.02]). Self-efficacy was associated with 12-month disability (unstandardized beta=-0.21 [95% CI: -0.37; -0.04].

Conclusions: Postoperative resilience and pain self-efficacy were associated with improved 12-month patient-reported outcomes after spine surgery. Future work should consider how early postoperative screening for positive psychosocial characteristics can enhance risk stratification and targeted rehabilitation management in patients undergoing spine surgery.
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January 2021

Preoperative patient expectations and pain improvement after adult spinal deformity surgery.

J Neurosurg Spine 2020 Jun 12:1-6. Epub 2020 Jun 12.

Objective: Patients' expectations for pain relief are associated with patient-reported outcomes after treatment, although this has not been examined in patients with adult spinal deformity (ASD). The aim of this study was to identify associations between patients' preoperative expectations for pain relief after ASD surgery and patient-reported pain at the 2-year follow-up.

Methods: The authors analyzed surgically treated ASD patients at a single institution who completed a survey question about expectations for back pain relief. Five ordinal answer choices to "I expect my back pain to improve" were used to categorize patients as having low or high expectations. Back pain was measured using the 10-point numeric rating scale (NRS) and Scoliosis Research Society-22r (SRS-22r) patient survey. Preoperative and postoperative pain were compared using analysis of covariance.

Results: Of 140 ASD patients eligible for 2-year follow-up, 105 patients (77 women) had pre- and postoperative data on patient expectations, 85 of whom had high expectations. The mean patient age was 59 ± 12 years, and 46 patients (44%) had undergone previous spine surgery. The high-expectations and low-expectations groups had similar baseline demographic and clinical characteristics (p > 0.05), except for lower SRS-22r mental health scores in those with low expectations. After controlling for baseline characteristics and mental health, the mean postoperative NRS score was significantly better (lower) in the high-expectations group (3.5 ± 3.5) than in the low-expectations group (5.4 ± 3.7) (p = 0.049). The mean postoperative SRS-22r pain score was significantly better (higher) in the high-expectations group (3.3 ± 1.1) than in the low-expectations group (2.6 ± 0.94) (p = 0.019).

Conclusions: Despite similar baseline characteristics, patients with high preoperative expectations for back pain relief reported less pain 2 years after ASD surgery than patients with low preoperative expectations.
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http://dx.doi.org/10.3171/2020.3.SPINE191311DOI Listing
June 2020

Correction to: Opioid prescribing practices after posterior spinal arthrodesis for adolescent idiopathic scoliosis.

Spine Deform 2020 Oct;8(5):975

Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N. Caroline Street, Baltimore, MD, JHOC 5223, 21287, USA.

The original version of this article unfortunately contained a mistake.
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http://dx.doi.org/10.1007/s43390-020-00152-yDOI Listing
October 2020

Opioid use after adult spinal deformity surgery: patterns of cessation and associations with preoperative use.

J Neurosurg Spine 2020 Jun 5:1-6. Epub 2020 Jun 5.

Objective: The objectives of the study were to determine, among patients with adult spinal deformity (ASD), the following: 1) how preoperative opioid use, dose, and duration of use are associated with long-term opioid use and dose; 2) how preoperative opioid use is associated with rates of postoperative use from 6 weeks to 2 years; and 3) how postoperative opioid use at 6 months and 1 year is associated with use at 2 years.

Methods: Using a single-center, longitudinally maintained registry, the authors identified 87 patients who underwent ASD surgery from 2013 to 2017. Fifty-nine patients reported preoperative opioid use (37 high-dose [≥ 90 morphine milligram equivalents daily] and 22 low-dose use). The duration of preoperative use was long-term (≥ 6 months) for 44 patients and short-term for 15. The authors evaluated postoperative opioid use at 6 weeks, 3 months, 6 months, 1 year, and 2 years after surgery. Multivariate logistic regression was used to determine associations of preoperative opioid use, dose, and duration with use at each time point (alpha = 0.05).

Results: The following preoperative factors were associated with opioid use 2 years postoperatively: any opioid use (adjusted odds ratio [aOR] 14, 95% CI 2.5-82), high-dose use (aOR 7.3, 95% CI 1.1-48), and long-term use (aOR 17, 95% CI 2.2-123). All patients who reported high-dose opioid use at the 2-year follow-up examination had also reported preoperative opioid use. Preoperative high-dose use (aOR 247, 95% CI 5.8-10,546) but not long-term use (aOR 4.0, 95% CI 0.18-91) was associated with high-dose use at the 2-year follow-up visit. Compared with patients who reported no preoperative use, those who reported preoperative opioid use had higher rates of use at each postoperative time point (from 94% vs 62% at 6 weeks to 54% vs 7.1% at 2 years) (all p < 0.001). Opioid use at 2 years was independently associated with use at 1 year (aOR 33, 95% CI 6.8-261) but not at 6 months (aOR 4.3, 95% CI 0.95-24).

Conclusions: Patients' preoperative opioid use, dose, and duration of use are associated with long-term use after ASD surgery, and a high preoperative dose is also associated with high-dose opioid use at the 2-year follow-up visit. Patients using opioids 1 year after ASD surgery may be at risk for long-term use.
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http://dx.doi.org/10.3171/2020.3.SPINE20111DOI Listing
June 2020

The OPTIMIZE study: protocol of a pragmatic sequential multiple assessment randomized trial of nonpharmacologic treatment for chronic, nonspecific low back pain.

BMC Musculoskelet Disord 2020 May 11;21(1):293. Epub 2020 May 11.

Department of Physical Therapy and Athletic Training, University of Utah, 201 Presidents' Cir, Salt Lake City, UT, 84112, USA.

Background: Low back pain is a prevalent condition that causes a substantial health burden. Despite intensive and expensive clinical efforts, its prevalence is growing. Nonpharmacologic treatments are effective at improving pain-related outcomes; however, treatment effect sizes are often modest. Physical therapy (PT) and cognitive behavioral therapy (CBT) have the most consistent evidence of effectiveness. Growing evidence also supports mindfulness-based approaches. Discussions with providers and patients highlight the importance of discussing and trying options to find the treatment that works for them and determining what to do when initial treatment is not successful. Herein, we present the protocol for a study that will evaluate evidence-based, protocol-driven treatments using PT, CBT, or mindfulness to examine comparative effectiveness and optimal sequencing for patients with chronic low back pain.

Methods: The Optimized Multidisciplinary Treatment Programs for Nonspecific Chronic Low Back Pain (OPTIMIZE) Study will be a multisite, comparative effectiveness trial using a sequential multiple assessment randomized trial design enrolling 945 individuals with chronic low back pain. The co-primary outcomes will be disability (measured using the Oswestry Disability Index) and pain intensity (measured using the Numerical Pain Rating Scale). After baseline assessment, participants will be randomly assigned to PT or CBT. At week 10, participants who have not experienced at least 50% improvement in disability will be randomized to cross-over phase-1 treatments (e.g., PT to CBT) or to Mindfulness-Oriented Recovery Enhancement (MORE). Treatment will consist of 8 weekly sessions. Long-term outcome assessments will be performed at weeks 26 and 52.

Discussion: Results of this study may inform referring providers and patients about the most effective nonoperative treatment and/or sequence of nonoperative treatments to treat chronic low back pain.

Trial Registration: This study was prospectively registered on March 1, 2019, with Clinicaltrials.gov under the registration number NCT03859713 (https://clinicaltrials.gov/ct2/show/NCT03859713).
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http://dx.doi.org/10.1186/s12891-020-03324-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7216637PMC
May 2020

Opioid prescribing practices after posterior spinal arthrodesis for adolescent idiopathic scoliosis.

Spine Deform 2020 10 6;8(5):965-973. Epub 2020 May 6.

Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N. Caroline Street, Baltimore, MD, JHOC 5223, 21287, USA.

Study Design: Retrospective review.

Objective: To identify national trends in postoperative opioid prescribing practices after posterior spinal fusion (PSF) in patients with adolescent idiopathic scoliosis (AIS). Opioids are an important component of pain management after PSF for AIS. Given the national opioid crisis, it is important to understand opioid prescribing practices in these patients.

Methods: Using a commercial prescription drug claims database, we identified AIS patients who underwent PSF from 2010 to 2016 and who were prescribed opioids postoperatively. An initial prescription at hospital discharge of ≥ 90 morphine milligram equivalents daily (MMED) was used to identify patients at risk of overdose according to the US Centers for Disease Control and Prevention (CDC) guidelines. Prescriptions for skeletal muscle relaxants were also identified. α = 0.05.

Results: We included 3762 patients (75% female) with a mean (± standard deviation) age of 15 ± 2.1 years. 56% of patients filled only 1 opioid prescription after discharge, and 44% had ≥ 1 refills. 91% of opioid prescriptions were for hydrocodone (median strength, 43 MMED; mean strength, 65 ± 270 MMED) or oxycodone formulations (median strength, 60 MMED; mean strength, 79 ± 174 MMED). 82% of prescriptions complied with CDC guidelines (< 90 MMED). Overall, 612 patients (16%) filled ≥ 1 prescription for skeletal muscle relaxants, the most common being cyclobenzaprine (45%) and methocarbamol (29%). The percentage of patients filling > 1 prescription declined from 54% in 2010 to 31% in 2016 (p < 0.001). The proportion of patients receiving prescriptions for ≥ 90 MMED was highest in the West (29%) and lowest in the South (16%) (p < 0.001).

Conclusion: Most opioid prescriptions after PSF in patients with AIS comply with CDC guidelines. Temporal and geographic variations show an opportunity for standardizing opioid prescribing practices in these patients.

Level Of Evidence: III.
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http://dx.doi.org/10.1007/s43390-020-00127-zDOI Listing
October 2020

Beta-amyloid (Aβ) uptake by PET imaging in older HIV+ and HIV- individuals.

J Neurovirol 2020 06 8;26(3):382-390. Epub 2020 Apr 8.

Department of Neurology, Johns Hopkins Bayview Medical Center, 4940 Eastern Avenue, 301 Building, Suite 2100, Baltimore, MD, 21224, USA.

The causes of cognitive impairment among older HIV+ individuals may overlap with causes among elderly HIV seronegative (HIV-) individuals. The objective of this study was to determine if beta-amyloid (Aβ) deposition measured by [F] AV-45 (florbetapir) positron emission tomography (PET) is increased in older HIV+ individuals compared to HIV- individuals. Forty-eight HIV+ and 25 HIV- individuals underwent [F] AV-45 PET imaging. [F] AV-45 binding to Aβ was measured by standardized uptake value ratios (SUVR) relative to the cerebellum in 16 cortical and subcortical regions of interest. Global and regional cortical SUVRs were compared by (1) serostatus, (2) HAND stage, and (3) age decade, comparing individuals in their 50s and > 60s. There were no differences in median global cortical SUVR stratified by HIV serostatus or HAND stage. The proportion of HIV+ participants in their 50s with elevated global amyloid uptake (SUVR > 1.40) was significantly higher than the proportion in HIV- participants (67% versus 25%, p = 0.04), and selected regional SUVR values were also higher (p < 0.05) in HIV+ compared to HIV- participants in their 50s. However, these group differences were not seen in participants in their 60s. In conclusion, PET imaging found no differences in overall global Aβ deposition stratified by HIV serostatus or HAND stage. Although there was some evidence of increased Aβ deposition in HIV+ individuals in their 50s compared to HIV- individuals which might indicate premature aging, the most parsimonious explanation for this is the relatively small sample size in this cross-sectional cohort study.
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June 2020

Are preoperative depression and anxiety associated with patient-reported outcomes, health care payments, and opioid use after anterior discectomy and fusion?

Spine J 2020 08 13;20(8):1167-1175. Epub 2020 Mar 13.

Department of Orthopedic Surgery, The Johns Hopkins University, Baltimore, MD, USA. Electronic address:

Background Context: Depression and anxiety are common psychiatric conditions among US adults, and anterior cervical discectomy and fusion (ACDF) is one of the most commonly performed spinal surgeries. Mental health conditions can affect physical health, and thus have the potential to contribute to adverse outcomes after spine surgery; however, a comprehensive assessment of long-term outcomes and the additive economic burden of these conditions in patients undergoing ACDF has not been well described.

Purpose: Our goal was to assess the associations between depression/anxiety and adverse outcomes and health-resource utilization after anterior cervical discectomy and fusion (ACDF).

Study Design: Retrospective database study.

Patient Sample: We retrospectively analyzed a private administrative health claims database to identify patients who underwent ACDF in the United States from 2010 to 2013. A total of 16,306 patients met our inclusion criteria. Mean (± standard deviation) patient age was 50±7.9 years. Approximately 4,800 patients (30%) had a depression diagnosis and 4,000 (25%) had a diagnosis of anxiety.

Outcome Measures: The primary outcomes of interest were intensive care unit admission, multiday hospitalization, discharge disposition, 30- and 90-day hospital readmission, 1- and 2-year rates of revision surgery, and chronic postoperative opioid use. Secondary outcomes were 1- and 2-year total cumulative health care payments and cumulative postoperative opioid consumption.

Methods: Regression models controlled for demographic and medical covariates, alpha=0.05.

Results: A preoperative diagnosis of depression was associated with higher odds of multiday hospitalization (odds ratio [OR] 1.09, 95% confidence interval [CI] 1.01-1.19), 90-day readmission (OR 1.71, 95% CI 1.46-2.02), revision surgery within 2 years (OR 1.43 95% CI 1.16-1.76), and chronic postoperative opioid use (OR 1.58, 95% CI 1.45-1.72) and an increase of $5,915 in adjusted 2-year health care payments (p<.001). Patients with a preoperative diagnosis of anxiety had higher odds of multiday hospitalization (OR 1.15, 95% CI 1.06-1.25), revision surgery within 2 years (OR 1.33, 95% CI 1.07-1.65), and chronic postoperative opioid use (OR 1.62, 95% CI 1.48-1.77) and an increase of $4,471 in adjusted 2-year health care payments (p<.001). Neither anxiety nor depression was associated with intensive care unit admission, discharge disposition, 30-day readmission, revision surgery within 1 year, 1-year cumulative health care payments, or cumulative postoperative opioid consumption.

Conclusions: Patients with preoperative diagnoses of depression or anxiety have a greater likelihood of adverse outcomes, increased opioid consumption, and increased cumulative health care payments after ACDF compared with patients without depression or anxiety.
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August 2020

Lupus and Perioperative Complications in Elective Primary Total Hip or Knee Arthroplasty.

Clin Orthop Surg 2020 Mar 13;12(1):37-42. Epub 2020 Feb 13.

Department of Orthopaedic Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA.

Background: The number of patients with systemic lupus erythematosus (herein, lupus) undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA) is increasing. There is disagreement about the effect of lupus on perioperative complication rates. We hypothesized that lupus would be associated with higher complication rates in patients who undergo elective primary THA or TKA.

Methods: Records of more than 6.2 million patients from the National Inpatient Sample who underwent elective primary THA or TKA from 2000 to 2009 were reviewed. Patients with lupus (n = 38,644) were compared with those without lupus (n = 6,173,826). Major complications were death, pulmonary embolism, myocardial infarction, stroke, pneumonia, and acute renal failure. Minor complications were wound infection, seroma, deep vein thrombosis, hip dislocation, wound dehiscence, and hematoma. Patient age, sex, duration of hospital stay, and number of Elixhauser comorbidities were assessed for both groups. Multivariate logistic regression models using comorbidities, age, and sex as covariates were used to assess the association of lupus with major and minor perioperative complications. The alpha level was set to 0.001.

Results: Among patients who underwent THA, those with lupus were younger (mean age, 56 vs. 65 years), were more likely to be women (87% vs. 56%), had longer hospital stays (mean, 4.0 vs. 3.8 days), and had more comorbidities (mean, 2.5 vs. 1.4) than those without lupus (all < 0.001). In patients with THA, lupus was independently associated with major complications (odds ratio [OR], 1.4; 95% confidence interval [CI], 1.1 to 1.7) and minor complications (OR, 1.2; 95% CI, 1.0 to 1.5). Similarly, among patients who underwent TKA, those with lupus were younger (mean, 62 vs. 67 years), were more likely to be women (93% vs. 64%), had longer hospital stays (mean, 3.8 vs. 3.7 days), and had more comorbidities (mean, 2.8 vs. 1.7) than those without lupus (all < 0.001). However, in TKA patients, lupus was not associated with greater odds of major complications (OR, 1.2; 95% CI, 0.9 to 1.4) or minor complications (OR, 1.1; 95% CI, 0.9 to 1.3).

Conclusions: Lupus is an independent risk factor for major and minor perioperative complications in elective primary THA but not TKA.
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http://dx.doi.org/10.4055/cios.2020.12.1.37DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7031438PMC
March 2020

SpineCloud: image analytics for predictive modeling of spine surgery outcomes.

J Med Imaging (Bellingham) 2020 May 18;7(3):031502. Epub 2020 Feb 18.

Johns Hopkins University, Department of Biomedical Engineering, Baltimore, Maryland, United States.

Data-intensive modeling could provide insight on the broad variability in outcomes in spine surgery. Previous studies were limited to analysis of demographic and clinical characteristics. We report an analytic framework called "SpineCloud" that incorporates quantitative features extracted from perioperative images to predict spine surgery outcome. A retrospective study was conducted in which patient demographics, imaging, and outcome data were collected. Image features were automatically computed from perioperative CT. Postoperative 3- and 12-month functional and pain outcomes were analyzed in terms of improvement relative to the preoperative state. A boosted decision tree classifier was trained to predict outcome using demographic and image features as predictor variables. Predictions were computed based on SpineCloud and conventional demographic models, and features associated with poor outcome were identified from weighting terms evident in the boosted tree. Neither approach was predictive of 3- or 12-month outcomes based on preoperative data alone in the current, preliminary study. However, SpineCloud predictions incorporating image features obtained during and immediately following surgery (i.e., intraoperative and immediate postoperative images) exhibited significant improvement in area under the receiver operating characteristic (AUC): ( to 0.83) at 3 months and ( to 0.82) at 12 months. Predictive modeling of lumbar spine surgery outcomes was improved by incorporation of image-based features compared to analysis based on conventional demographic data. The SpineCloud framework could improve understanding of factors underlying outcome variability and warrants further investigation and validation in a larger patient cohort.
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http://dx.doi.org/10.1117/1.JMI.7.3.031502DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7026518PMC
May 2020

The engaged patient: patient activation can predict satisfaction with surgical treatment of lumbar and cervical spine disorders.

J Neurosurg Spine 2020 Feb 7:1-7. Epub 2020 Feb 7.

Departments of1Orthopaedic Surgery and.

Objective: Care satisfaction is an important metric to health systems and payers. Patient activation is a hierarchical construct following 4 stages: 1) having a belief that taking an active role in their care is important, 2) having knowledge and skills to manage their condition, 3) having the confidence to make necessary behavioral changes, and 4) having an ability to maintain those changes in times of stress. The authors hypothesized that patients with a high level of activation, measured using the Patient Activation Measure (PAM), will be more engaged in their care and, therefore, will be more likely to be satisfied with the results of their surgical treatment.

Methods: Using a prospectively collected registry at a multiprovider university practice, the authors examined patients who underwent elective surgery (n = 257) for cervical or lumbar spinal disorders. Patients were assessed before and after surgery (6 weeks and 3, 6, and 12 months) using Patient-Reported Outcomes Measurement Information System (PROMIS) health domains and the PAM. Satisfaction was assessed using the Patient Satisfaction Index. Using repeated-measures logistic regression, the authors compared the likelihood of being satisfied across stages of patient activation after adjusting for baseline characteristics (i.e., age, sex, race, education, income, and marital status).

Results: While a majority of patients endorsed the highest level of activation (56%), 51 (20%) endorsed the lower two stages (neither believing that taking an active role was important nor having the knowledge and skills to manage their condition). Preoperative patient activation was weakly correlated (r ≤ 0.2) with PROMIS health domains. The most activated patients were 3 times more likely to be satisfied with their treatment at 1 year (OR 3.23, 95% CI 1.8-5.8). Similarly, patients in the second-highest stage of activation also demonstrated significantly greater odds of being satisfied (OR 2.8, 95% CI 1.5-5.3).

Conclusions: Patients who are more engaged in their healthcare prior to elective spine surgery are significantly more likely to be satisfied with their postoperative outcome. Clinicians may want to implement previously proven techniques to increase patient activation in order to improve patient satisfaction following elective spine surgery.
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http://dx.doi.org/10.3171/2019.11.SPINE191159DOI Listing
February 2020

Changes in patients' depression and anxiety associated with changes in patient-reported outcomes after spine surgery.

J Neurosurg Spine 2020 Jan 31:1-20. Epub 2020 Jan 31.

Departments of1Orthopaedic Surgery and.

Objective: The authors conducted a study to analyze associations between changes in depression/anxiety before and 12 months after spine surgery, as well as changes in scores using the Patient-Reported Outcomes Measurement Information System (PROMIS) at the same time points.

Methods: Preoperatively and 12 months postoperatively, the authors assessed PROMIS scores for depression, anxiety, pain, physical function, sleep disturbance, and satisfaction with participation in social roles among 206 patients undergoing spine surgery for deformity correction or degenerative disease. Patients were stratified according to preoperative/postoperative changes in depression and anxiety, which were categorized as persistent, improved, newly developed postoperatively, or absent. Multivariate regression was used to control for confounders and to compare changes in patient-reported outcomes (PROs).

Results: Fifty patients (24%) had preoperative depression, which improved in 26 (52%). Ninety-four patients (46%) had preoperative anxiety, which improved in 70 (74%). Household income was the only preoperative characteristic that differed significantly between patients whose depression persisted and those whose depression improved. Compared with the no-depression group, patients with persistent depression had less improvement in all 4 domains, and patients with postoperatively developed depression had less improvement in pain, physical function, and satisfaction with social roles. Compared with the group of patients with postoperatively improved depression, patients with persistent depression had less improvement in pain and physical function, and patients with postoperatively developed depression had less improvement in pain. Compared with patients with no anxiety, those with persistent anxiety had less improvement in physical function, sleep disturbance, and satisfaction with social roles, and patients with postoperatively developed anxiety had less improvement in pain, physical function, and satisfaction with social roles. Compared with patients with postoperatively improved anxiety, patients with persistent anxiety had less improvement in pain, physical function, and satisfaction with social roles, and those with postoperatively developed anxiety had less improvement in pain, physical function, and satisfaction with social roles. All reported differences were significant at p < 0.05.

Conclusions: Many spine surgery patients experienced postoperative improvements in depression/anxiety. Improvements in 12-month PROs were smaller among patients with persistent or postoperatively developed depression/anxiety compared with patients who had no depression or anxiety before or after surgery and those whose depression/anxiety improved after surgery. Postoperative changes in depression/anxiety may have a greater effect than preoperative depression/anxiety on changes in PROs after spine surgery. Addressing the mental health of spine surgery patients may improve postoperative PROs.■ CLASSIFICATION OF EVIDENCE Type of question: causation; study design: prospective cohort study; evidence: class III.
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http://dx.doi.org/10.3171/2019.11.SPINE19586DOI Listing
January 2020
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