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Orthopaedic Proceedings
Vol. 101-B, Issue SUPP_10 | Pages 28 - 28
1 Oct 2019
Mannion A Mariaux F Porchet F Fekete T Jeszenszky D Haschtmann D Kleinstuck F Loibl M Elfering A
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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.

Methods

Data from 4 questionnaires (ZUNG depression (N=399); Hospital Anxiety and Depression Scale (Anxiety-subscale) (N=308); Pain Catastrophising (N=766); Fear Avoidance Beliefs (N=736)) were analysed to identify the respective single item that best represented the full scale score. The 4 items formed the “Core Yellow Flags Index” (CYFI). 1'768 patients completed CYFI and a Core Outcome Measures Index (COMI) preoperatively, and COMI 3 and 12mo later (FU).


Orthopaedic Proceedings
Vol. 99-B, Issue SUPP_10 | Pages 28 - 28
1 May 2017
Zehnder P Fekete T Aghayev E Kleinstück F Becker H Pigott T Banczerowski P Mannion A
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Background

Previous surgery is known to increase the risk of complications during spine surgery, but few studies have quantified the dose-response effect using multivariate models to account for confounders. We quantified the effect of the number of prior spine surgeries on perioperative complications in patients undergoing surgery for lumbar degenerative disorders.

Methods

We included data from 4′940 patients documented in Eurospine's Spine Tango Registry from 2004 to 2015. Medical history and surgical details were documented on the Tango Surgery form, as were surgical and general medical complications arising between admission and discharge. Multiple logistic regression models were built to investigate the relationship between the number of any previous surgeries and the presence of a perioperative complication, controlling for other potential confounders (age, sex, smoking, BMI, comorbidity, number of vertebral levels affected).


Orthopaedic Proceedings
Vol. 99-B, Issue SUPP_10 | Pages 27 - 27
1 May 2017
Fekete T Haschtmann D Becker H Kleinstück F Porchet F Jeszenszky D Banczerowski P Mannion A
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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.

Methods

The data from 3′334 consecutive patients (1′789 women, 1′545 men; aged 61±15 years) undergoing first-time surgery between 1.1.2005 and 31.12.2010 for differing lumbar degenerative disorders were evaluated. The Core Outcome Measures Index (COMI) was completed by 3′124 (94%) patients preoperatively, 3′164 (95%) at 3 months follow-up, 3′153 (95%) at 1 year, 3′112 (93%) at 2 years, and 2′897 (87%) at 5 years. 2′502 (75%) completed COMI at all five timepoints.


Orthopaedic Proceedings
Vol. 96-B, Issue SUPP_4 | Pages 21 - 21
1 Feb 2014
Mannion A Kleinstück F Jeszenszky D Porchet F Haschtmann D Fekete T
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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).

Methods

12 mo after first-time surgery for LDH, patients completed 0–10 scales for back pain and leg pain and a question: “if you had to spend the rest of your life with the symptoms you have now, how would feel about it?,” answered on a 5-point Likert scale from “very satisfied” to “very dissatisfied”. This was dichotomised and used as the external criterion in receiver operating characteristics (ROC) analysis to derive the cut-off score for pain that best indicated being at least “somewhat satisfied” with the symptom state.


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_4 | Pages 14 - 14
1 Jan 2013
Mannion A Fekete F Kleinstueck F Mutter U Lattig F Porchet F Jeszenszky D Grob D
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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.

Methods

Patients with lumbar degenerative disorders operated with the goal of pain relief, completed a questionnaire 1 year post-operatively enquiring about complications arising as a consequence of their operation. They rated the bothersomeness of any such complications on a 5-point adjectival scale. Global outcome of surgery and satisfaction were rated on 5-point Likert scales.


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_4 | Pages 21 - 21
1 Jan 2013
Caporaso F Pulkovski N Sprott H Mannion A
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Background

Self-rated disability scores in patients with chronic LBP (cLBP) do not always relate well to performance in traditional physical tests (e.g. back strength, fatigability, etc.). Therefore tests using “functional activities” that challenge for example trunk mobility and movement speed have been suggested as alternative “objective” outcome measures. We examined the relationship between self-reported disability and a battery of such functional tests.

Methods

37 patients with cLBP took part (45±12y; 23f, 14m); 32 completed 9 weeks' physiotherapy. Before and after therapy, the patients completed the Roland Morris disability questionnaire (RM) and performed a battery of 8 simple tests (stair climb, prolonged flexion, stand to floor, lift test, sock test, roll-up test, pick-up test, fingertip-to-floor test).


Orthopaedic Proceedings
Vol. 92-B, Issue SUPP_IV | Pages 526 - 527
1 Oct 2010
Naal F Impellizzeri F Leunig M Mannion A Munzinger U Sieverding M
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During the last decade, outcome assessment in orthopaedic surgery has increasingly focused on patient self-report questionnaires. The Oxford Hip and Knee Scores (OHS and OKS) were developed for the self-assessment of pain and function in patients undergoing joint replacement surgery. These scores proved to be reliable, valid, and responsive to clinical change, however, no German version of these useful measures exists. We therefore cross-culturally adapted the OHS and OKS according to the recommended forward/backward translation protocol and assessed the following metric properties of the questionnaires in 105 (OHS) and 100 (OKS) consecutive patients undergoing total hip or knee replacement in our clinic: feasibility (percentage of fully completed questionnaires), reliability (intraclass correlation coefficients (ICC) and Bland and Altman’s limits of agreement), construct validity (correlation with the Western Ontario and McMaster Universities Index (WOMAC), Harris Hip Score (HHS), Knee Society Score (KSS), Activities of Daily Living Scale (ADLS), and Short Form (SF-)12), floor and ceiling effects, and internal consistency (Cronbach’s alpha, CA). We received 96.6% (OHS) and 91.9% (OKS) fully completed questionnaires. Reliability of both questionnaires was excellent (ICC > 0.90). Bland and Altman’s limits of agreement revealed no significant bias. Correlation coefficients with the other questionnaires ranged from −0.30 (SF-12 Mental Component Scale) to 0.82 (WOMAC) for the OHS, and from −0.22 (SF-12 Mental Component Scale) to −0.77 (ADLS) for the OKS. For both questionnaires, we observed no floor or ceiling effects. The internal consistency was good with a CA of 0.87 for the OHS and 0.83 for the OKS. In conclusion, the German versions of the OHS and OKS are reliable and valid questionnaires for the self-assessment of pain and function in German-speaking patients with hip or knee osteoarthritis. Considering the present results and the brevity of the measures, we recommend their use in the clinical routine.


Orthopaedic Proceedings
Vol. 92-B, Issue SUPP_IV | Pages 526 - 526
1 Oct 2010
Naal F Impellizzeri F Leunig M Mannion A
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The goal of this study was to develop and validate a short, evaluative self-report questionnaire for the clinical self-assessment of patients with hip osteoarthritis (OA). If used together with other self-report outcome tools (e.g. generic or physical activity measures), such a short joint-specific questionnaire could avoid an increased burden to the patients and decrease the risk of data loss. All items of the new score (Schulthess Hip Score, SHS) were generated solely on patient perceptions, for item removal we used the clinical severity-importance rating and inter-item correlation methods. The final score consisted of only five items. We then assessed the following metric properties of the SHS in 105 consecutive patients with symptomatic hip OA (mean age, 63.4 ± 11 years, 48 women) undergoing total hip arthroplasty (THA) in our clinic: proportion of evaluable questionnaires, reproducibility, internal consistency, concurrent validity, and responsiveness. 97% of the questionnaires were evaluable. Reproducibility of the SHS was excellent (intraclass correlation coefficient (ICC) 0.90; standard error of the measure (SEM) 6.4). Exploratory factor analysis indicated that all items loaded on only 1 factor which accounted for 69.4% of the total variance. Cronbach’s alpha was 0.88. Evidence of convergent validity was provided by moderate to high correlations with scores and subscales of the WOMAC (r = 0.58–0.78), Oxford Hip Score (r = 0.78), Harris Hip Score (r = 0.37), SF-12 physical component scale (r = 0.57), UCLA activity scale (r = 0.48), and Tegner score (r = 0.53). Evidence of divergent validity was provided by a lower correlation with the SF-12 mental component scale (r = 0.37). The SHS proved to be responsive with an effect size (ES) of 2.15 and a standard response mean (SRM) of 1.74 six months after THA. Taken together, the results of this study provide evidence to support the use of the five-item self-report SHS in patients with hip osteoarthritis. Considering the brevity of this score, it could be easily used together with other measures such as generic and physical activity assessment tools, without overburdening patients with an inordinate number of items and questions.


Orthopaedic Proceedings
Vol. 91-B, Issue SUPP_III | Pages 440 - 440
1 Sep 2009
Grob D Mannion A Bartanusz V Kleinstück F Lattig F Jeszenszky D Dvorak J Porchet F
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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.


Orthopaedic Proceedings
Vol. 91-B, Issue SUPP_III | Pages 439 - 439
1 Sep 2009
Grob D Mannion A Bartanusz V Jeszenszky D Kleinstück F Lattig F
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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).