Background

Depression, anxiety, catastrophising, and fear-avoidance beliefs are some of the so-called “yellow flags” that predict a poor outcome in back patients. Many surgeons have difficulty assessing yellow flags, perhaps due to the complexity of existing instruments and time constraints during consultations. We developed a brief tool to allow the systematic evaluation of core flags.

Background

Patient-rated measures are the gold standard for assessing spine surgery outcomes, but there is no consensus on the appropriate timing of follow-up. Journals often demand a minimum 2-year follow-up, but the indiscriminate application of this principle may not be warranted. We examined the course of change in patient outcomes up to 5 years postoperatively.

Purpose

A new approach to the reporting of health outcomes involves assessing the proportion of patients achieving a level of symptoms that they feel they could live with. We evaluated the acceptable level of pain in patients after surgery for lumbar disc herniation (LDH).

Background/Purpose of study

The increasing aging of the population will see a growing number of patients presenting for spine surgery with appropriate indications but numerous medical comorbidities. This complicates decision-making, requiring that the likely benefit of surgery (outcome) be carefully weighed up against the potential risk (complications). We assessed the influence of comorbidity on the risks and benefits of spine surgery.

Background

Recent years have witnessed a paradigm shift in the assessment of outcome in spine surgery, with patient-centred questionnaires replacing traditional surgeon-based assessments. The assessment of “complications” — loosely defined as new/unexpected problems arising as a result of surgery — has not enjoyed this same enlightened approach.

Introduction: Recent years have witnessed something of a paradigm shift in relation to the assessment of outcome in spine surgery: multidimensional patient-centred questionnaires have superseded the traditional surgeon-based rating of global outcome, and surgical registries have been developed to capitalise on the principle of “strength in numbers”. Interestingly, although recognised as a potential determinant of the patient’s view of the success of the surgery, the assessment of complications — in this context defined as new or unexpected problems arising as a result of surgery — has not enjoyed the same enlightened approach in relation to the patient’s perspective. The present study sought to fill this gap in the current array of outcome measures.

Methods: All German-speaking patients undergoing spinal surgery within our Spine Unit in the two years from Jan 2005 to Dec 2006 were asked to complete the patient-orientated Core-Measures-Index of the SSE Spine Tango Spine Surgery Registry 12 mo after surgery; the surgeon completed a Spine Tango surgery form and follow-up forms at various intervals up to 12 mo postop. In the patient questionnaire, the patient was asked “did any complications arise as a consequence of your operation 1 year ago (e.g. problems with wound healing, paralysis, sensory disturbances, etc.)? If so, give details.” Patients were also asked about their satisfaction with the operation and the global outcome of surgery.

Results: 2080/2259 (92%) patients returned a 12-month questionnaire. 28% patients answered “yes” to the complications question. This compares with complication rates of 3–10% recorded during the various Spine Tango Surgical follow-ups up to 12 months post-op. Patients sometimes listed “complications” that would rarely classify as such in the traditional sense; however, the incidence of their reported complications was significantly associated with outcome/satisfaction, suggesting they were not trivial to the patient. The more recent addition of a question concerning the “bothersomeness” of the reported complications revealed that 6% patients thought the complications were not at all bothersome; 21%, slightly bothersome; 30%, moderately bothersome; 27%, very bothersome and 16%, extremely bothersome.

Discussion: The results indicate that, just like outcome, “complications” should be assessed from both the patient’s and the surgeon’s perspectives, not least to better understand the reasons accounting for dissatisfaction and a poor patient-rated outcome.

Introduction: Fusion is typically indicated for degenerative spinal disorders with concomitant instability or painful spondylosis. Numerous techniques are used, with considerable variation in their invasiveness, risks and costs, although few can boast superiority for a given indication, particularly in relation to patient-orientated outcomes. This cohort study compared outcomes after fusion with translaminar screws (TS) versus transforaminal lumbar interbody fusion plus pedicular fixation (TLIF) plus pedicular fixation (both with decompressive procedures).

Methods: The study was nested within our SSE Spine Tango data acquisition system. The suitability (or otherwise) for inclusion of every Spine Unit patient was indicated at the pre-operative consultation. Inclusion criteria: mono/bisegmental degenerative disc disease, facet syndrome or degenerative spondylolisthesis; German language; no previous surgery (except discectomy). Each surgeon consistently used his pre-stated, preferred method (TS or TLIF) for all his patients fitting the inclusion criteria. Before and 12 and 24 months post-surgery, patients completed the multidimensional Core Outcome Measures Index (COMI; 0–10 scale); after 12-months, global outcome was rated on a Likert-scale and dichotomised into “good” and “poor” groups.

Results: 121 patients took part; 57 in the TS group (1 surgeon) and 64 in the TLIF group (4 surgeons). Gender distribution was identical in the two groups (67% women); TS were significantly older than TLIF (67±10y and 56±15y respectively, p< 0.05). There were no significant group differences at baseline for any COMI domain scores (all p> 0.05). TS had a significantly lower operation duration (p=0.0001) and blood-loss (p=0.01) but a longer hospital stay (p=0.005) than TLIF. Complication rates prior to discharge were similar in each group (2–4%). 94% patients returned questionnaires at 12-months. The groups did not differ in: reduction in COMI score, 3.5±2.9 (TS) vs 4.1±2.6 (TLIF)(p=0.23); % good outcomes, 72% (TS) vs 77% (TLIF)(p=0.58); satisfaction with treatment, 82% (TS) vs 88% (TLIF) (p=0.36). Thus far, 75 patients have reached the 2-yr follow-up and the trend for no group differences remains: % good outcomes, 81% (TS) vs 79% (TLIF)(p=0.91); satisfaction with treatment, 83% (TS) vs 85% (TLIF) (p=0.88)

Discussion: This cohort study showed similar subjective results up to 2 years later for two different surgical techniques done for identical indications, but with differing surgical time, invasiveness and implant costs. The data thus far suggest that, for these degenerative disorders, optimal but invasive three-point stabilization is not required to achieve satisfactory results. Although the study design is not the highest in the “hierarchy-of-evidence”, it includes every single eligible patient and allows each surgeon to use his regular surgical procedure; it hence represents a practicable, complementary approach to the randomised-controlled-trial, with higher external validity (relevance/generalisability).