Predictive model for long-term patient satisfaction after surgery for grade I degenerative lumbar spondylolisthesis: insights from the Quality Outcomes Database

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OBJECTIVE

Since the enactment of the Affordable Care Act in 2010, providers and hospitals have increasingly prioritized patient-centered outcomes such as patient satisfaction in an effort to adapt the “value”-based healthcare model. In the current study, the authors queried a prospectively maintained multiinstitutional spine registry to construct a predictive model for long-term patient satisfaction among patients undergoing surgery for Meyerding grade I lumbar spondylolisthesis.

METHODS

The authors queried the Quality Outcomes Database for patients undergoing surgery for grade I lumbar spondylolisthesis between July 1, 2014, and June 30, 2016. The primary outcome of interest for the current study was patient satisfaction as measured by the North American Spine Surgery patient satisfaction index, which is measured on a scale of 1–4, with 1 indicating most satisfied and 4 indicating least satisfied. In order to identify predictors of higher satisfaction, the authors fitted a multivariable proportional odds logistic regression model for ≥ 2 years of patient satisfaction after adjusting for an array of clinical and patient-specific factors. The absolute importance of each covariate in the model was computed using an importance metric defined as Wald chi-square penalized by the predictor degrees of freedom.

RESULTS

A total of 502 patients, out of a cohort of 608 patients (82.5%) with grade I lumbar spondylolisthesis, undergoing either 1- or 2-level decompression (22.5%, n = 113) or 1-level decompression and fusion (77.5%, n = 389), met the inclusion criteria; of these, 82.1% (n = 412) were satisfied after 2 years. On univariate analysis, satisfied patients were more likely to be employed and working (41.7%, n = 172, vs 24.4%, n = 22; overall p = 0.001), more likely to present with predominant leg pain (23.1%, n = 95, vs 11.1%, n = 10; overall p = 0.02) but more likely to present with lower Numeric Rating Scale score for leg pain (median and IQR score: 7 [5–9] vs 8 [6–9]; p = 0.05). Multivariable proportional odds logistic regression revealed that older age (OR 1.57, 95% CI 1.09–2.76; p = 0.009), preoperative active employment (OR 2.06, 95% CI 1.27–3.67; p = 0.015), and fusion surgery (OR 2.3, 95% CI 1.30–4.06; p = 0.002) were the most important predictors of achieving satisfaction with surgical outcome.

CONCLUSIONS

Current findings from a large multiinstitutional study indicate that most patients undergoing surgery for grade I lumbar spondylolisthesis achieved long-term satisfaction. Moreover, the authors found that older age, preoperative active employment, and fusion surgery are associated with higher odds of achieving satisfaction.

ABBREVIATIONS ASA = American Society of Anesthesiologists; BMI = body mass index; CAD = coronary artery disease; LOS = length of stay; NASS = North American Spine Surgery; NRS = Numeric Rating Scale; ODI = Oswestry Disability Index; PRO = patient-reported outcome; QOD = Quality Outcomes Database.

OBJECTIVE

Since the enactment of the Affordable Care Act in 2010, providers and hospitals have increasingly prioritized patient-centered outcomes such as patient satisfaction in an effort to adapt the “value”-based healthcare model. In the current study, the authors queried a prospectively maintained multiinstitutional spine registry to construct a predictive model for long-term patient satisfaction among patients undergoing surgery for Meyerding grade I lumbar spondylolisthesis.

METHODS

The authors queried the Quality Outcomes Database for patients undergoing surgery for grade I lumbar spondylolisthesis between July 1, 2014, and June 30, 2016. The primary outcome of interest for the current study was patient satisfaction as measured by the North American Spine Surgery patient satisfaction index, which is measured on a scale of 1–4, with 1 indicating most satisfied and 4 indicating least satisfied. In order to identify predictors of higher satisfaction, the authors fitted a multivariable proportional odds logistic regression model for ≥ 2 years of patient satisfaction after adjusting for an array of clinical and patient-specific factors. The absolute importance of each covariate in the model was computed using an importance metric defined as Wald chi-square penalized by the predictor degrees of freedom.

RESULTS

A total of 502 patients, out of a cohort of 608 patients (82.5%) with grade I lumbar spondylolisthesis, undergoing either 1- or 2-level decompression (22.5%, n = 113) or 1-level decompression and fusion (77.5%, n = 389), met the inclusion criteria; of these, 82.1% (n = 412) were satisfied after 2 years. On univariate analysis, satisfied patients were more likely to be employed and working (41.7%, n = 172, vs 24.4%, n = 22; overall p = 0.001), more likely to present with predominant leg pain (23.1%, n = 95, vs 11.1%, n = 10; overall p = 0.02) but more likely to present with lower Numeric Rating Scale score for leg pain (median and IQR score: 7 [5–9] vs 8 [6–9]; p = 0.05). Multivariable proportional odds logistic regression revealed that older age (OR 1.57, 95% CI 1.09–2.76; p = 0.009), preoperative active employment (OR 2.06, 95% CI 1.27–3.67; p = 0.015), and fusion surgery (OR 2.3, 95% CI 1.30–4.06; p = 0.002) were the most important predictors of achieving satisfaction with surgical outcome.

CONCLUSIONS

Current findings from a large multiinstitutional study indicate that most patients undergoing surgery for grade I lumbar spondylolisthesis achieved long-term satisfaction. Moreover, the authors found that older age, preoperative active employment, and fusion surgery are associated with higher odds of achieving satisfaction.

Degenerative lumbar spondylolisthesis is one of the most common causes of low-back pain, with a reported prevalence of 11.5% in the United States.27 Surgical intervention may be considered for carefully selected patients in whom conservative management has failed, and it has been found to be associated with superior outcomes compared to nonsurgical therapy for this subset of patients.41 However, it remains unclear what factors are associated with optimum patient-reported outcomes (PROs).

Since the enactment of the Patient Protection and the Affordable Care Act of 2010, providers and hospitals have increasingly prioritized patient-centered outcomes in an effort to adapt the “value”-based healthcare model that is geared toward increasing access and quality of healthcare while simultaneously controlling cost.22 In its annual report to Congress on National Quality Strategy for Quality Improvement, the Department of Health and Human Services listed “patient satisfaction” as one of the metrics of public reporting to improve quality.2 Low-back pain and spinal surgery have been increasingly targeted for quality improvement initiatives in recent years due to the high prevalence and also the billions of dollars in direct and indirect cost associated with treating low-back pain.30,36,38

In the current study, we queried a prospectively maintained multiinstitutional spine registry to construct a predictive model for long-term patient satisfaction by using demographic, clinical, and operative factors obtained in patients undergoing surgery for grade I lumbar spondylolisthesis.

Methods

Cohort

We queried the Quality Outcomes Database (QOD) for patients undergoing surgery for Meyerding grade I degenerative lumbar spondylolisthesis between July 1, 2014, and June 30, 2016. The QOD is a prospective, multiinstitutional registry, established in 2012, with the objective to assess risk-adjusted expected morbidity and 30-day and 12-month PROs and clinical outcomes in order to establish a data-driven mechanism of providing insights into improving quality of care for routinely performed spine surgeries in the United States.16,32 As of December 2018, over 107,000 patients across 216 participating sites nationwide have been enrolled in the Spine Surgery QOD (https://www.neuropoint.org/registries/qod/). Among these sites, 12 sites came together to initiate a focused project to assess the impact of fusion on PROs in patients undergoing surgery for grade I lumbar spondylolisthesis.7–10,35 This focused group consisted of 1) sites with a study coordinator and 2) a centralized auditing mechanism to ensure data accuracy. To determine the diagnosis of grade I spondylolisthesis, surgeons at each of the participating sites evaluated preoperative standing or dynamic radiographs.7–10,35 Intraoperative variables, including laminectomy performed, fusion performed, and number of levels of fusion or laminectomy, and minimally invasive versus open surgery, were also abstracted for all eligible patients.7–10,35 For the current article, we only included patients who underwent elective 1- or 2-level decompression or 1-level decompression and fusion for grade I spondylolisthesis, according to the Meyerding classification,33 and who had available data for North American Spine Surgery (NASS) satisfaction after 2 years.

Outcome of Interest

The primary outcome of interest for the current study was patient satisfaction after 2 years, as defined by the NASS patient satisfaction index, which is measured on a scale of 1–4, with the choices representing, respectively: “the treatment met my expectations” (score of 1), “I did not improve as much as I had hoped, but I would undergo the same treatment for the same outcome” (score of 2), “I did not improve as much as I had hoped, and I would not undergo the same treatment for the same outcome” (score of 3), and “I am the same or worse than before treatment” (score of 4). For descriptive univariate analysis, patients were classified as following: patients with NASS satisfaction scores of 1 and 2 were considered “satisfied” while patients with scores of 3 and 4 were considered “not satisfied.” This binary categorization captured patients who would undergo surgery again (i.e., scores 1 and 2) compared with those who would not be willing to undergo surgery again (i.e., scores 3 and 4). In addition, for our multivariable proportional odds logistic regression model, we used the NASS satisfaction score in its natural ranked order with 1 indicating highest satisfaction and 4 indicating lowest satisfaction.

Covariates

The following covariates were included in the analysis:7–10,35 demographic characteristics, including age, sex, body mass index (BMI), ethnicity, type of insurance, education level, employment status, workers’ compensation; comorbidities, including smoking status, diabetes, anxiety, osteoporosis, depression, American Society of Anesthesiologists (ASA) classification; clinical characteristics such as symptom duration, dominant symptom, ambulatory status, presence of a motor deficit; and baseline PROs, including Oswestry Disability Index (ODI),19 EQ-5D score,18 and Numeric Rating Scale (NRS) back and leg pain scores.28 Other surgical variables, such as intraoperative blood loss, operative time, placement of an interbody graft, and employment of minimally invasive techniques, were also documented. A case was classified as a minimally invasive procedure if there was documentation of utilization of percutaneous or tubular screw fixation or tubular laminectomy, with or without intervertebral body graft placement.

Statistical Analysis

Continuous variables were summarized using medians with interquartile ranges (IQRs), while categorical variables were summarized using frequencies with proportions. In order to identify predictors of higher satisfaction, we fitted a multivariable proportional odds logistic regression model for ≥ 2 years of patient satisfaction after adjusting for age, BMI, sex, insurance status, education status, employment status at the time of surgery, dominant symptom, length of stay (LOS), coronary artery disease (CAD), diabetes, anxiety, depression, osteoporosis, baseline ODI score, EQ-5D score, NRS back and leg score, ambulation status, symptom duration, ASA class, and discharge disposition. Odds ratios were obtained by exponentiating the estimates obtained from the regression model. Furthermore, we also analyzed the absolute importance of each covariate in the model on predicting patient satisfaction by using an importance metric defined as Wald chi-square penalized by the predictor degrees of freedom.25 As per this method, the higher the metric, the more important the variable. The analysis was performed using R 3.1.2 (R: A language and environment for statistical computing. R Foundation for Statistical Computing. https://www.R-project.org) and Package rms. p values were two-tailed and were considered significant at < 0.05.

Results

A total of 502 patients, out of a cohort of 608 patients (82.5%), with grade I lumbar spondylolisthesis, undergoing either a 1- or 2-level decompression (22.5%, n = 113) or 1-level decompression and fusion (77.5%, n = 389) met the inclusion criteria. Among these, 61.5% (n = 309) had an NASS satisfaction score of 1 (highest satisfaction), 20.5% (n = 103) had a score of 2, 7.56% (n = 38) had a score of 3, and 10.3% (n = 52) had a satisfaction score of 4 (lowest satisfaction) (Table 1). Patients with a score of 1 or 2 were classified as satisfied (n = 412), while patients with a score of 3 or 4 were classified as not satisfied (n = 90).

TABLE 1.

Distribution of patient satisfaction scores

ScoreNASS Satisfaction Measure15No. of Patients (%)
1The treatment met my expectations309 (61.5%)
2I did not improve as much as I had hoped, but I would undergo the same treatment for the same outcome103 (20.5%)
3I did not improve as much as I had hoped, and I would not undergo the same treatment for the same outcome38 (7.6%)
4I am the same or worse than before treatment52 (10.3%)
Total502

Demographic Characteristics

Patients who were satisfied did not differ significantly from those who were not satisfied in terms of age (median 63.1 [IQR 55.7–70.9] vs 61 [IQR 51.2–71]; p = 0.16), sex (females: 60%, n = 54, vs 57.5%, n = 237; p = 0.666), ethnicity (Hispanic: 4.6%, n = 19, vs 4.4%, n = 4; overall p = 0.976), BMI (median 29.2 [IQR 25.6–33.6] vs 29.7 [IQR 26.3–34.9]; p = 0.33), or education status (college and above: 57.6%, n = 232, vs 51.1%, n = 44; overall p = 0.86). We also found no difference in insurance status between patients satisfied and not satisfied at follow-up (private insurance: 51.7%, n = 213, vs 52.2%, n = 47; Medicare: 40.3%, n = 166, vs 37.8%, n = 34; Medicaid: 5.1%, n = 21, vs 7.8%, n = 7; Veterans Affairs/government: 2.7%, n = 11, vs 2.2%, n = 11; overall p = 0.853). Satisfied patients were more likely to have workers’ compensation compared to those who were not satisfied (4.9%, n = 20, vs 2.2%, n = 2; p = 0.006). Finally, satisfied patients were more likely to be employed and working, compared to those who were not satisfied (41.7%, n = 172, vs 24.4%, n = 22; overall p = 0.001). These results are summarized in Table 2.

TABLE 2.

Demographic characteristics of patients stratified by satisfaction status

VariableTotal (n = 502)Not Satisfied (n = 90)Satisfied (n = 412)p Value
Age (yrs)0.155
 Median636163.1
 Q1, Q355, 70.951.2, 7155.7, 70.9
Female, no. (%)291 (58.0%)54 (60%)237 (57.5%)0.666
Ethnicity, no. (%)0.976
 Hispanic23 (4.6%)4 (4.4%)19 (4.6%)
 Non-Hispanic464 (92.4%)83 (92.2%)381 (92.5%)
 Prefer not to answer15 (3.0%)3 (3.3%)12 (2.9%)
BMI0.333
 Median29.329.729.2
 Q1, Q325.7, 33.726.3, 34.925.6, 33.6
Insurance, no. (%)0.853
 Medicaid28 (5.6%)7 (7.8%)21 (5.1%)
 Medicare200 (39.8%)34 (37.8%)166 (40.3%)
 Private260 (51.8%)47 (52.2%)213 (51.7%)
 VA/government13 (2.6%)2 (2.2%)11 (2.7%)
Education, no. (%)0.861
 Less than high school14 (2.8%)3 (3.3%)11 (2.7%)
 High school diploma or GED199 (39.6%)39 (43.3%)160 (38.8%)
 2-yr college degree87 (17.3%)13 (14.4%)74 (18.0%)
 4-yr college degree97 (19.3%)16 (17.8%)81 (19.7%)
 Post-college92 (18.3%)15 (16.7%)77 (18.7%)
Workers’ compensation, no. (%)22 (4.4%)2 (2.2%)20 (4.9%)0.006
Employment, no. (%)0.001
 Employed & working194 (38.6%)22 (24.4%)172 (41.7%)
 Employed, not working28 (5.6%)10 (11.1%)18 (4.4%)
 Unemployed271 (54.0%)57 (63.3%)214 (51.9%)

Q1 = 25th quartile; Q3 = 75th quartile; VA = Veterans Affairs.

Boldface type indicates statistical significance.

Baseline Clinical Characteristics, Comorbidities, and PROs

Compared to patients who were not satisfied with their surgery after 2 years, satisfied patients were found to have a comparable incidence of past surgery (10.9%, n = 45, vs 11.1%, n = 10; p = 0.96), diabetes (16.3%, n = 67, vs 18.9%, n = 17; p = 0.54), CAD (10.7%, n = 44, vs 10%, n = 9; p = 0.84), anxiety (17.2%, n = 71, vs 13.3%, n = 12; p = 0.367), depression (18.4%, n = 76, vs 24.4%, n = 22; p = 0.193), and osteoporosis (5.3%, n = 22, vs 6.7%, n = 6; p = 0.619). We also compared clinical characteristics between satisfied and not satisfied patients and found that satisfied patients were more likely to present with leg pain greater than back pain (23.1%, n = 95, vs 11.1%, n = 10) and less likely to present with equal degrees of leg and back pain (39.8%, n = 164, vs 52.2%, n = 47; overall p = 0.021). However, the two groups did not differ in incidence of motor deficit (24.1%, n = 99, vs 21.1%, n = 19; p = 0.54), ambulation at presentation (not independent: 10.7%, n = 44, vs 11.1%, n = 10; overall p = 0.989), and symptom duration (> 3 months: 93.7%, n = 386, vs 93.3%, n = 84; p = 0.93). Comparing the baseline PROs between the two groups revealed similar scores in NRS-measured back pain (median 7 [IQR 6–9] vs 8 [IQR 6–9]; p = 0.73), ODI (median 48 [IQR 38–60] vs 47 [IQR 32–56]; p = 0.104), and EQ-5D (median 0.597 [0.33–0.71] vs 0.551 [0.31–0.71]; p = 721); however, the not-satisfied patients were likely to present with higher NRS leg pain scores, with p value approaching significance (median 7 [IQR 5–9] vs 8 [IQR 6–9]; p = 0.05). These results are presented in Table 3.

TABLE 3.

Comorbidities, clinical characteristics, and baseline PROs stratified by satisfaction status

VariableTotal (n = 502)Not Satisfied (n = 90)Satisfied (n = 412)p Value
Major past surgery, no. (%)55 (11.0%)10 (11.1%)45 (10.9%)0.959
Diabetes, no. (%)84 (16.7%)17 (18.9%)67 (16.3%)0.545
CAD, no. (%)53 (10.6%)9 (10%)44 (10.7%)0.849
Anxiety, no. (%)83 (16.5%)12 (13.3%)71 (17.2%)0.367
Depression, no. (%)98 (19.5%)22 (24.4%)76 (18.4%)0.193
Osteoporosis, no. (%)28 (5.6%)6 (6.7%)22 (5.3%)0.619
Dominant symptom, no. (%)0.021
 Back pain dominant186 (37.1%)33 (36.7%)153 (37.1%)
 Back equals leg pain211 (42.0%)47 (52.2%)164 (39.8%)
 Leg pain dominant105 (20.9%)10 (11.1%)95 (23.1%)
Motor deficit, no. (%)118 (23.6%)19 (21.1%)99 (24.1%)0.547
Ambulation, no. (%)0.989
 Independently ambulatory448 (89.2%)80 (88.9%)368 (89.3%)
 Ambulatory w/ assistive device49 (9.8%)9 (10.0%)40 (9.7%)
 Wheelchair bound5 (1.0%)1 (1.1%)4 (1.0%)
Symptom duration, no. (%)0.934
 <3 months14 (2.8%)3 (3.3%)11 (2.7%)
 >3 months470 (93.6%)84 (93.3%)386 (93.7%)
 Unknown18 (3.6%)3 (3.3%)15 (3.6%)
Baseline NRSBP score0.737
 Median787
 Q1, Q36, 96, 96, 9
Baseline NRSLP score0.058
 Median787
 Q1, Q35, 96, 95, 9
Baseline ODI score0.104
 Median484748
 Q1, Q338, 6032, 5638, 60
Baseline EQ-5D score0.721
 Median0.5970.5510.597
 Q1, Q30.312, 0.7080.308, 0.7080.330, 0.708

NRSBP = NRS back pain; NRSLP = NRS leg pain.

Boldface type indicates statistical significance.

Operative Characteristics and Perioperative Outcomes

On univariate analysis, patients in the two groups did not differ in incidence of higher ASA class (class 3 or 4: 36.9%, n = 152, vs 40.0%, n = 36; p = 0.757), the type of surgical approach (posterior: 90.8%, n = 374, vs 94.4%, n = 85; p = 0.558), fusion procedure (77.9%, n = 321, vs 75.6%, n = 68; p = 628), minimally invasive decompression (36.2%, n = 149; vs 38.9%, n = 35; p = 0.627), and minimally invasive interbody (26.9%, n = 11, vs 17.8%, n = 16; p = 0.07). The two groups also did not differ in length of surgery (median 171 minutes [IQR 118–222] vs 157 minutes [IQR 116.2–230.5]; p = 0.866), LOS (median 3 days [IQR 2–4] vs 3 days [IQR 1–4]; p = 0.718), discharge disposition (home routine: 86.7%, n = 357, vs 82.2%, n = 74; p = 0.06), or related reoperations (5.8%, n = 24, vs 10%, n = 9; p = 0.148). These results are summarized in Table 4.

TABLE 4.

Operative characteristics and perioperative outcomes stratified by satisfaction status

VariableTotal (n = 502)Not Satisfied (n = 90)Satisfied (n = 412)p Value
ASA class0.857
 Median222
 Q1, Q32, 32, 32, 3
Surgical approach, no. (%)0.558
 Anterior13 (2.6%)2 (2.2%)11 (2.7%)
 Lateral7 (1.4%)0 (0.0%)7 (1.7%)
 Posterior459 (91.4%)85 (94.4%)374 (90.8%)
 Two-stage23 (4.6%)3 (3.3%)20 (4.9%)
Group, no. (%)0.628
 Decompression alone113 (22.5%)22 (24.4%)91 (22.1%)
 Fusion389 (77.5%)68 (75.6%)321 (77.9%)
 MIS decompression184 (36.7%)35 (38.9%)149 (36.2%)0.627
 MIS interbody fusion127 (25.3%)16 (17.8%)11 (26.9%)0.070
Length of surgery0.866
 Median171157171
 Q1, Q3117.5, 222.5116.2, 230.5118, 222
LOS0.718
 Median333
 Q1, Q32, 41.2, 42, 4
Discharge disposition, no. (%)0.061
 Home routine431 (85.9%)74 (82.2%)357 (86.7%)
 Home w/ home healthcare services25 (5.0%)3 (3.3%)22 (5.4%)
 Post– or non–acute care setting40 (8.0%)13 (14.4%)27 (6.6%)
 Transferred to another acute care facility4 (0.8%)0 (0.0%)4 (1.0%)
Related reoperations33 (6.6%)9 (10.0%)24 (5.8%)0.148

MIS = minimally invasive surgery.

Multivariable Analysis and Predictor Importance

Multivariable proportional odds logistic regression revealed that older patients were more likely to have a higher satisfaction score (OR 1.57, 95% CI 1.09–2.76; p = 0.009). Moreover, patients who were employed and working at the time of surgery, compared to those who were unemployed, were more likely to have a higher satisfaction score (OR 2.06, 95% CI 1.27–3.67; p = 0.015). Finally, the addition of fusion was found to be associated with a higher satisfaction score (OR 2.3, 95% CI 1.30–4.06; p = 0.002). These results are shown in Fig. 1. Predictor importance revealed that the most important predictors of patient satisfaction were employment (Wald χ2 = 13.5, accounting for 25.7% of total Wald χ2; p = 0.003), fusion (Wald χ2 = 8.4, accounting for 16% of total Wald χ2; p = 0.003), and age (Wald χ2 = 5.9, accounting for 11.2% of total Wald χ2; p = 0.01). These results are summarized in Fig. 2.

Fig. 1.
Fig. 1.

Multivariable proportional odds logistic regression model for at least 2 years of patient satisfaction after surgery for grade I lumbar spondylolisthesis. NRSBP = NRS back pain; NRSLP = NRS leg pain; RecalcBL = recalculated baseline; Sx = symptom; VA = Veterans Affairs.

Fig. 2.
Fig. 2.

Predictor importance analysis for factors associated with patient satisfaction following surgery for lumbar spondylolisthesis. df = degree of freedom.

Discussion

To the best of our knowledge, this is the largest study to assess predictors of long-term patient satisfaction for patients undergoing 1- or 2-level decompression or 1-level decompression and fusion for grade I spondylolisthesis. It is important to note that 82% patients were satisfied with their surgery after 2 years, having answered the NASS satisfaction questionnaire with either “the treatment met my expectations” or with “I did not improve as much as I had hoped, but I would undergo the same treatment for the same outcome.”

Among baseline demographic factors, older age was predictive of a higher satisfaction score after 2 years. This finding has previously been reported in the literature for patients undergoing lumbar surgery, notably by Crawford et al., who reported that older age was predictive of best outcomes in a cohort of 396 patients.14 On the other hand, Sigmundsson et al. investigated 5100 patients undergoing surgery for spinal stenosis and found that older age was associated with slightly lower odds of satisfaction.37

Work-related factors are also known to impact patient outcomes after spinal surgery. Asher et al., in their analysis of 4695 patients, showed that work-related factors accounted for 33.3% of predictability of outcomes following elective lumbar surgery for degenerative surgery.6 To that end, we found that patients who were employed and working preoperatively were more likely to have higher satisfaction scores after 2 years. Active employment has previously been shown to be associated with positive outcomes following surgical intervention.5,6,12,24 This may be attributed to the fact that these represent a more driven subset of patients who have better social support, work satisfaction, healthier psychological state, availability of modified duty, optimum physical demand at work, and employer-employee relations including the availability of litigation issues.4,5,12,26,31,34,40 Together, these factors may contribute to these patients having superior outcomes after spine surgery.

Finally, the addition of fusion was found to be associated with higher satisfaction scores in our cohort. The current literature is conflicted on the role of instrumented fusion for lumbar degenerative lumbar spondylolisthesis.20,21,23 A recent meta-analysis of 3 randomized controlled trials and 3 observational studies showed no benefit of adding fusion in the treatment of spondylolisthesis in terms of patient satisfaction.11 However, it is important to note that several independent observational studies have demonstrated the beneficial role of adding instrumented fusion for patients undergoing surgical intervention for degenerative spondylolisthesis.1,3,8,9,17

Some notable associations with patient satisfaction previously identified but not found to be significant in our cohort are worth discussing here. A preoperative diagnosis of depression has been found to be associated with lower odds of satisfaction in previous studies, which was not found to be significantly associated in our cohort. In their study, which analyzed preoperative factors associated with patient satisfaction scores, as documented using the Hospital Consumer Assessment of Healthcare Providers and Systems survey, Levin et al. observed that depression negatively impacted the scores.29 Moreover, an integrative review by Strøm et al. highlighted the prevalence and challenges faced by providers and surgeons in treating spine surgery patients with anxiety and depression.39 Smoking status has also been shown to adversely affect outcomes. Crawford et al., in their analysis of 7207 patients undergoing lumbar spine surgery, found that smokers were less likely to be satisfied than nonsmokers.13 Sigmundsson et al. also reported a 41% decrease in the odds of achieving satisfaction after surgery for smokers among patients undergoing surgery for lumbar spinal stenosis.37

Limitations

Our study may have some limitations. The current study is a retrospective analysis derived from a prospectively maintained registry that has its associated limitations, most notable of which may be selection bias due to lack of standardized operative technique and patient selection. Moreover, we did not collect other important variables that have been shown to affect outcomes, such as nature of occupation, race, and socioeconomic status. Moreover, the NASS satisfaction instrument may not be an accurate measure of overall satisfaction as it is primarily dependent on whether preoperative expectations were met; a different satisfaction measure may have yielded results different from our findings. Nevertheless, the NASS satisfaction scale is still considered one of the most widely used measures for assessing patient satisfaction with clinical outcomes and not with other nonclinical factors, such as experience with allied health staff, hospital environment, and appointment process. Finally, we were also unable to investigate directly the impact of fusion status on patient satisfaction. We used related reoperations as a surrogate for this factor and found that reoperation did not impact long-term satisfaction. We believe that future studies should investigate the association between fusion status at follow-up and patient satisfaction.

Despite these limitations, the current study is one of the largest to date and represents a diverse population derived from 12 institutions across the United States, utilizing prospectively maintained data to analyze patient satisfaction among a homogeneous cohort of patients with Meyerding grade I spondylolisthesis who have undergone either 1- or 2-level decompression or a 1-level fusion procedure.

Conclusions

The results from a large multiinstitutional study indicate that most patients with Meyerding grade I lumbar spondylolisthesis undergoing surgery achieved long-term satisfaction. Moreover, we found that patient age, preoperative active employment, and the addition of fusion may be associated with higher odds of achieving high level of satisfaction. These results are important in that they may help the surgeons to have a better preoperative discussion with their patients to optimize their outcomes.

Disclosures

Dr. Mummaneni reports the following: consultant for DePuy Spine, Globus Medical, and Stryker; direct stock ownership in Spinicity/ISD; clinical or research support for the present study from NREF; support of non–study-related clinical or research work that he oversees from ISSG; honoraria from Spineart and AOSpine; and royalties from DePuy Spine, Thieme Medical Publishers, and Springer Publishing. Dr. Chan reports support of non–study-related clinical or research work that he oversees from Orthofix. Dr. Glassman reports the following: employed by Norton Healthcare; patent holder with Medtronic; a nonfinancial relationship with the Scoliosis Research Society; and consultant for Medtronic and K2M. Dr. Foley reports the following: consultant for Medtronic; direct stock ownership in Medtronic, Discgenics, Durastat, Digital Surgical Solutions, and NuVasive; patent holder with Medtronic; royalties for patents from Medtronic; and board of directors with Discgenics, Durastat, and Digital Surgical Solutions. Dr. C. Shaffrey reports the following: direct stock ownership in NuVasive; patent holder with NuVasive, Medtronic, and Zimmer Biomet; and consultant for NuVasive, Medtronic, and EOS. Dr. Coric reports the following: consultant for Spine Wave, Medtronic, Globus Medical, Stryker, Integrity Implants, and Premia Spine; and direct stock ownership in Spine Wave. Dr. Park reports being a consultant for Globus Medical, NuVasive, Medtronic, and Allosource and receiving royalties from Globus Medical. Dr. Wang reports being a consultant for DePuy Synthes, K2M, Stryker, and Spineology; being a patent holder with DePuy Synthes; and direct stock ownership in ISD and Medical Device Partners. Dr. Slotkin reports being a consultant for Stryker and Medtronic. Dr. Virk reports being a consultant for Globus Medical and DePuy Synthes. Dr. Haid reports receiving royalties from NuVasive, Globus Medical, Medtronic Sofamor Danek, and Elsevier; being a consultant for NuVasive; and direct stock ownership in NuVasive, Spine Wave, and Vertical Health. Dr. Bisson reports being a consultant for nView.

Author Contributions

Conception and design: Bydon, Mummaneni. Acquisition of data: Alvi, Chan. Analysis and interpretation of data: Alvi, Chan. Drafting the article: Bydon, Mummaneni, Alvi, Chan. Critically revising the article: Bydon, Mummaneni, Alvi, Chan, Glassman, Foley, Potts, CI Shaffrey, ME Shaffrey, Knightly, Park, Wang, Fu, Slotkin, Asher, Virk, Kerezoudis, Guan, Haid, Bisson. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Bydon. Statistical analysis: Mummaneni, Alvi, Coric. Administrative/technical/material support: Bydon, Mummaneni. Study supervision: Bydon, Mummaneni.

Supplemental Information

Videos

References

  • 1

    Abdu WALurie JDSpratt KFTosteson ANAZhao WTosteson TD: Degenerative spondylolisthesis: does fusion method influence outcome? Four-year results of the spine patient outcomes research trial. Spine (Phila Pa 1976) 34:235123602009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Agency for Healthcare Research and Quality: 2011 Report to Congress: National Strategy for Quality Improvement in Health Care. Washington, DC: Department of Health and Human Services2011 (https://www.ahrq.gov/workingforquality/reports/2011-annual-report.html) [Accessed March 8 2019]

    • Search Google Scholar
    • Export Citation
  • 3

    Andersen TChristensen FBNiedermann BHelmig PHøy KHansen ES: Impact of instrumentation in lumbar spinal fusion in elderly patients: 71 patients followed for 2–7 years. Acta Orthop 80:4454502009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Anderson JTHaas ARPercy RWoods STAhn UMAhn NU: Return to work after diskogenic fusion in workers’ compensation subjects. Orthopedics 38:e1065e10722015

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 5

    Anderson PASchwaegler PECize k DLeverson G: Work status as a predictor of surgical outcome of discogenic low back pain. Spine (Phila Pa 1976) 31:251025152006

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Asher ALDevin CJArcher KRChotai SParker SLBydon M: An analysis from the Quality Outcomes Database, Part 2. Predictive model for return to work after elective surgery for lumbar degenerative disease. J Neurosurg Spine 27:3703812017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Asher ALKerezoudis PMummaneni PVBisson EFGlassman SDFoley KT: Defining the minimum clinically important difference for grade I degenerative lumbar spondylolisthesis: insights from the Quality Outcomes Database. Neurosurg Focus 44(1):E22018

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Chan AKBisson EFBydon MGlassman SDFoley KTPotts EA: Laminectomy alone versus fusion for grade 1 lumbar spondylolisthesis in 426 patients from the prospective Quality Outcomes Database. J Neurosurg Spine 30:2342412018 (Erratum in J Neurosurg Spine [epub ahead of print February 22 2019; DOI: 10.3171/2019.1.SPINE17913a])

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Chan AKBisson EFBydon MGlassman SDFoley KTPotts EA: Obese patients benefit, but do not fare as well as nonobese patients, following lumbar spondylolisthesis surgery: an analysis of the quality outcomes database. Neurosurgery [epub ahead of print] 2018

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Chan AKBisson EFBydon MGlassman SDFoley KTPotts EA: Women fare best following surgery for degenerative lumbar spondylolisthesis: a comparison of the most and least satisfied patients utilizing data from the Quality Outcomes Database. Neurosurg Focus 44(1):E32018

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Chen ZXie PFeng FChhantyal KYang YRong L: Decompression alone versus decompression and fusion for lumbar degenerative spondylolisthesis: a meta-analysis. World Neurosurg 111:e165e1772018

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 12

    Cole DCIbrahim SShannon HSScott FEEyles J: Work and life stressors and psychological distress in the Canadian working population: a structural equation modelling approach to analysis of the 1994 National Population Health Survey. Chronic Dis Can 23:91992002

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Crawford CH IIICarreon LYBydon MAsher ALGlassman SD: Impact of preoperative diagnosis on patient satisfaction following lumbar spine surgery. J Neurosurg Spine 26:7097152017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Crawford CH IIIGlassman SDDjurasovic MOwens RK IIGum JLCarreon LY: Prognostic factors associated with best outcomes (minimal symptom state) following fusion for lumbar degenerative conditions. Spine J 19:1871902019

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Daltroy LHCats-Baril WLKatz JNFossel AHLiang MH; The North American Spine Society lumbar spine outcome assessment instrument: reliability and validity tests. Spine (Phila Pa 1976) 21:7417491996

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Devin CJBydon MAlvi MAKerezoudis PKhan ISivaganesan A: A predictive model and nomogram for predicting return to work at 3 months after cervical spine surgery: an analysis from the Quality Outcomes Database. Neurosurg Focus 45(5):E92018

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Endler PEkman PMöller HGerdhem P: Outcomes of posterolateral fusion with and without instrumentation and of interbody fusion for isthmic spondylolisthesis: a prospective study. J Bone Joint Surg Am 99:7437522017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    EuroQol Group: EuroQol—a new facility for the measurement of health-related quality of life. Health Policy 16:1992081990

  • 19

    Fairbank JCPynsent PB: The Oswestry Disability Index. Spine (Phila Pa 1976) 25:294029522000

  • 20

    Försth PMichaëlsson KSandén B: Does fusion improve the outcome after decompressive surgery for lumbar spinal stenosis?: a two-year follow-up study involving 5390 patients. Bone Joint J 95-B:9609652013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Försth PÓlafsson GCarlsson TFrost ABorgström FFritzell P: A randomized, controlled trial of fusion surgery for lumbar spinal stenosis. N Engl J Med 374:141314232016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Gentry SBadrinath P: Defining health in the era of value-based care: lessons from England of relevance to other health systems. Cureus 9:e10792017

  • 23

    Ghogawala ZDziura JButler WEDai FTerrin NMagge SN: Laminectomy plus fusion versus laminectomy alone for lumbar spondylolisthesis. N Engl J Med 374:142414342016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Gum JLGlassman SDCarreon LY: Is type of compensation a predictor of outcome after lumbar fusion? Spine (Phila Pa 1976) 38:4434482013

  • 25

    Harrell FE Jr: Regression Modeling Strategies: With Applications to Linear Models Logistic and Ordinal Regression and Survival Analysis. Cham: Springer2015

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 26

    Hodges SDHumphreys SCEck JCCovington LAHarrom H: Predicting factors of successful recovery from lumbar spine surgery among workers’ compensation patients. J Am Osteopath Assoc 101:78832001

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27

    Ko SBLee SW: Prevalence of spondylolysis and its relationship with low back pain in selected population. Clin Orthop Surg 3:34382011

  • 28

    Langley GBSheppeard H: The visual analogue scale: its use in pain measurement. Rheumatol Int 5:1451481985

  • 29

    Levin JMWinkelman RDSmith GATanenbaum JEBenzel ECMroz TE: Impact of preoperative depression on hospital consumer assessment of healthcare providers and systems survey results in a lumbar fusion population. Spine (Phila Pa 1976) 42:6756812017

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 30

    Luo XPietrobon RSun SXLiu GGHey L: Estimates and patterns of direct health care expenditures among individuals with back pain in the United States. Spine (Phila Pa 1976) 29:79862004

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31

    Maxwell TDGatchel RJMayer TG: Cognitive predictors of depression in chronic low back pain: toward an inclusive model. J Behav Med 21:1311431998

  • 32

    McGirt MJSperoff TDittus RSHarrell FE JrAsher AL: The National Neurosurgery Quality and Outcomes Database (N2QOD): general overview and pilot-year project description. Neurosurg Focus 34(1):E62013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 33

    Meyerding HW: Diagnosis and roentgenologic evidence in spondylolisthesis. Radiology 20:1081201933

  • 34

    Mroz TENorvell DCEcker EGruenberg MDailey ABrodke DS: Fusion versus nonoperative management for chronic low back pain: do sociodemographic factors affect outcome? Spine (Phila Pa 1976) 36 (21 Suppl):S75S862011

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 35

    Mummaneni PVBisson EFKerezoudis PGlassman SFoley KSlotkin JR: Minimally invasive versus open fusion for Grade I degenerative lumbar spondylolisthesis: analysis of the Quality Outcomes Database. Neurosurg Focus 43(2):E112017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 36

    Parker SLGodil SSZuckerman SLMendenhall SKDevin CJMcGirt MJ: Extent of preoperative depression is associated with return to work after lumbar fusion for spondylolisthesis. World Neurosurg 83:6086132015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 37

    Sigmundsson FGJönsson BStrömqvist B: Determinants of patient satisfaction after surgery for central spinal stenosis without concomitant spondylolisthesis: a register study of 5100 patients. Eur Spine J 26:4734802017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 38

    Stewart WFRicci JAChee EMorganstein DLipton R: Lost productive time and cost due to common pain conditions in the US workforce. JAMA 290:244324542003

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 39

    Strøm JBjerrum MBNielsen CVThisted CNNielsen TLLaursen M: Anxiety and depression in spine surgery—a systematic integrative review. Spine J 18:127212852018

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 40

    Than KDCurran JNResnick DKShaffrey CIGhogawala ZMummaneni PV: How to predict return to work after lumbar discectomy: answers from the NeuroPoint-SD registry. J Neurosurg Spine 25:1811862016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 41

    Weinstein JNLurie JDTosteson TDHanscom BTosteson ANABlood EA: Surgical versus nonsurgical treatment for lumbar degenerative spondylolisthesis. N Engl J Med 356:225722702007

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation

If the inline PDF is not rendering correctly, you can download the PDF file here.

Article Information

Correspondence Mohamad Bydon: Mayo Clinic, Rochester, MN. bydon.mohamad@mayo.edu.

INCLUDE WHEN CITING DOI: 10.3171/2019.2.FOCUS18734.

Disclosures Dr. Mummaneni reports the following: consultant for DePuy Spine, Globus Medical, and Stryker; direct stock ownership in Spinicity/ISD; clinical or research support for the present study from NREF; support of non–study-related clinical or research work that he oversees from ISSG; honoraria from Spineart and AOSpine; and royalties from DePuy Spine, Thieme Medical Publishers, and Springer Publishing. Dr. Chan reports support of non–study-related clinical or research work that he oversees from Orthofix. Dr. Glassman reports the following: employed by Norton Healthcare; patent holder with Medtronic; a nonfinancial relationship with the Scoliosis Research Society; and consultant for Medtronic and K2M. Dr. Foley reports the following: consultant for Medtronic; direct stock ownership in Medtronic, Discgenics, Durastat, Digital Surgical Solutions, and NuVasive; patent holder with Medtronic; royalties for patents from Medtronic; and board of directors with Discgenics, Durastat, and Digital Surgical Solutions. Dr. C. Shaffrey reports the following: direct stock ownership in NuVasive; patent holder with NuVasive, Medtronic, and Zimmer Biomet; and consultant for NuVasive, Medtronic, and EOS. Dr. Coric reports the following: consultant for Spine Wave, Medtronic, Globus Medical, Stryker, Integrity Implants, and Premia Spine; and direct stock ownership in Spine Wave. Dr. Park reports being a consultant for Globus Medical, NuVasive, Medtronic, and Allosource and receiving royalties from Globus Medical. Dr. Wang reports being a consultant for DePuy Synthes, K2M, Stryker, and Spineology; being a patent holder with DePuy Synthes; and direct stock ownership in ISD and Medical Device Partners. Dr. Slotkin reports being a consultant for Stryker and Medtronic. Dr. Virk reports being a consultant for Globus Medical and DePuy Synthes. Dr. Haid reports receiving royalties from NuVasive, Globus Medical, Medtronic Sofamor Danek, and Elsevier; being a consultant for NuVasive; and direct stock ownership in NuVasive, Spine Wave, and Vertical Health. Dr. Bisson reports being a consultant for nView.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Multivariable proportional odds logistic regression model for at least 2 years of patient satisfaction after surgery for grade I lumbar spondylolisthesis. NRSBP = NRS back pain; NRSLP = NRS leg pain; RecalcBL = recalculated baseline; Sx = symptom; VA = Veterans Affairs.

  • View in gallery

    Predictor importance analysis for factors associated with patient satisfaction following surgery for lumbar spondylolisthesis. df = degree of freedom.

References

  • 1

    Abdu WALurie JDSpratt KFTosteson ANAZhao WTosteson TD: Degenerative spondylolisthesis: does fusion method influence outcome? Four-year results of the spine patient outcomes research trial. Spine (Phila Pa 1976) 34:235123602009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Agency for Healthcare Research and Quality: 2011 Report to Congress: National Strategy for Quality Improvement in Health Care. Washington, DC: Department of Health and Human Services2011 (https://www.ahrq.gov/workingforquality/reports/2011-annual-report.html) [Accessed March 8 2019]

    • Search Google Scholar
    • Export Citation
  • 3

    Andersen TChristensen FBNiedermann BHelmig PHøy KHansen ES: Impact of instrumentation in lumbar spinal fusion in elderly patients: 71 patients followed for 2–7 years. Acta Orthop 80:4454502009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Anderson JTHaas ARPercy RWoods STAhn UMAhn NU: Return to work after diskogenic fusion in workers’ compensation subjects. Orthopedics 38:e1065e10722015

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 5

    Anderson PASchwaegler PECize k DLeverson G: Work status as a predictor of surgical outcome of discogenic low back pain. Spine (Phila Pa 1976) 31:251025152006

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Asher ALDevin CJArcher KRChotai SParker SLBydon M: An analysis from the Quality Outcomes Database, Part 2. Predictive model for return to work after elective surgery for lumbar degenerative disease. J Neurosurg Spine 27:3703812017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Asher ALKerezoudis PMummaneni PVBisson EFGlassman SDFoley KT: Defining the minimum clinically important difference for grade I degenerative lumbar spondylolisthesis: insights from the Quality Outcomes Database. Neurosurg Focus 44(1):E22018

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Chan AKBisson EFBydon MGlassman SDFoley KTPotts EA: Laminectomy alone versus fusion for grade 1 lumbar spondylolisthesis in 426 patients from the prospective Quality Outcomes Database. J Neurosurg Spine 30:2342412018 (Erratum in J Neurosurg Spine [epub ahead of print February 22 2019; DOI: 10.3171/2019.1.SPINE17913a])

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Chan AKBisson EFBydon MGlassman SDFoley KTPotts EA: Obese patients benefit, but do not fare as well as nonobese patients, following lumbar spondylolisthesis surgery: an analysis of the quality outcomes database. Neurosurgery [epub ahead of print] 2018

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Chan AKBisson EFBydon MGlassman SDFoley KTPotts EA: Women fare best following surgery for degenerative lumbar spondylolisthesis: a comparison of the most and least satisfied patients utilizing data from the Quality Outcomes Database. Neurosurg Focus 44(1):E32018

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Chen ZXie PFeng FChhantyal KYang YRong L: Decompression alone versus decompression and fusion for lumbar degenerative spondylolisthesis: a meta-analysis. World Neurosurg 111:e165e1772018

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 12

    Cole DCIbrahim SShannon HSScott FEEyles J: Work and life stressors and psychological distress in the Canadian working population: a structural equation modelling approach to analysis of the 1994 National Population Health Survey. Chronic Dis Can 23:91992002

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Crawford CH IIICarreon LYBydon MAsher ALGlassman SD: Impact of preoperative diagnosis on patient satisfaction following lumbar spine surgery. J Neurosurg Spine 26:7097152017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Crawford CH IIIGlassman SDDjurasovic MOwens RK IIGum JLCarreon LY: Prognostic factors associated with best outcomes (minimal symptom state) following fusion for lumbar degenerative conditions. Spine J 19:1871902019

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Daltroy LHCats-Baril WLKatz JNFossel AHLiang MH; The North American Spine Society lumbar spine outcome assessment instrument: reliability and validity tests. Spine (Phila Pa 1976) 21:7417491996

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Devin CJBydon MAlvi MAKerezoudis PKhan ISivaganesan A: A predictive model and nomogram for predicting return to work at 3 months after cervical spine surgery: an analysis from the Quality Outcomes Database. Neurosurg Focus 45(5):E92018

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Endler PEkman PMöller HGerdhem P: Outcomes of posterolateral fusion with and without instrumentation and of interbody fusion for isthmic spondylolisthesis: a prospective study. J Bone Joint Surg Am 99:7437522017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    EuroQol Group: EuroQol—a new facility for the measurement of health-related quality of life. Health Policy 16:1992081990

  • 19

    Fairbank JCPynsent PB: The Oswestry Disability Index. Spine (Phila Pa 1976) 25:294029522000

  • 20

    Försth PMichaëlsson KSandén B: Does fusion improve the outcome after decompressive surgery for lumbar spinal stenosis?: a two-year follow-up study involving 5390 patients. Bone Joint J 95-B:9609652013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Försth PÓlafsson GCarlsson TFrost ABorgström FFritzell P: A randomized, controlled trial of fusion surgery for lumbar spinal stenosis. N Engl J Med 374:141314232016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Gentry SBadrinath P: Defining health in the era of value-based care: lessons from England of relevance to other health systems. Cureus 9:e10792017

  • 23

    Ghogawala ZDziura JButler WEDai FTerrin NMagge SN: Laminectomy plus fusion versus laminectomy alone for lumbar spondylolisthesis. N Engl J Med 374:142414342016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Gum JLGlassman SDCarreon LY: Is type of compensation a predictor of outcome after lumbar fusion? Spine (Phila Pa 1976) 38:4434482013

  • 25

    Harrell FE Jr: Regression Modeling Strategies: With Applications to Linear Models Logistic and Ordinal Regression and Survival Analysis. Cham: Springer2015

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 26

    Hodges SDHumphreys SCEck JCCovington LAHarrom H: Predicting factors of successful recovery from lumbar spine surgery among workers’ compensation patients. J Am Osteopath Assoc 101:78832001

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27

    Ko SBLee SW: Prevalence of spondylolysis and its relationship with low back pain in selected population. Clin Orthop Surg 3:34382011

  • 28

    Langley GBSheppeard H: The visual analogue scale: its use in pain measurement. Rheumatol Int 5:1451481985

  • 29

    Levin JMWinkelman RDSmith GATanenbaum JEBenzel ECMroz TE: Impact of preoperative depression on hospital consumer assessment of healthcare providers and systems survey results in a lumbar fusion population. Spine (Phila Pa 1976) 42:6756812017

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 30

    Luo XPietrobon RSun SXLiu GGHey L: Estimates and patterns of direct health care expenditures among individuals with back pain in the United States. Spine (Phila Pa 1976) 29:79862004

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31

    Maxwell TDGatchel RJMayer TG: Cognitive predictors of depression in chronic low back pain: toward an inclusive model. J Behav Med 21:1311431998

  • 32

    McGirt MJSperoff TDittus RSHarrell FE JrAsher AL: The National Neurosurgery Quality and Outcomes Database (N2QOD): general overview and pilot-year project description. Neurosurg Focus 34(1):E62013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 33

    Meyerding HW: Diagnosis and roentgenologic evidence in spondylolisthesis. Radiology 20:1081201933

  • 34

    Mroz TENorvell DCEcker EGruenberg MDailey ABrodke DS: Fusion versus nonoperative management for chronic low back pain: do sociodemographic factors affect outcome? Spine (Phila Pa 1976) 36 (21 Suppl):S75S862011

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 35

    Mummaneni PVBisson EFKerezoudis PGlassman SFoley KSlotkin JR: Minimally invasive versus open fusion for Grade I degenerative lumbar spondylolisthesis: analysis of the Quality Outcomes Database. Neurosurg Focus 43(2):E112017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 36

    Parker SLGodil SSZuckerman SLMendenhall SKDevin CJMcGirt MJ: Extent of preoperative depression is associated with return to work after lumbar fusion for spondylolisthesis. World Neurosurg 83:6086132015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 37

    Sigmundsson FGJönsson BStrömqvist B: Determinants of patient satisfaction after surgery for central spinal stenosis without concomitant spondylolisthesis: a register study of 5100 patients. Eur Spine J 26:4734802017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 38

    Stewart WFRicci JAChee EMorganstein DLipton R: Lost productive time and cost due to common pain conditions in the US workforce. JAMA 290:244324542003

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 39

    Strøm JBjerrum MBNielsen CVThisted CNNielsen TLLaursen M: Anxiety and depression in spine surgery—a systematic integrative review. Spine J 18:127212852018

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 40

    Than KDCurran JNResnick DKShaffrey CIGhogawala ZMummaneni PV: How to predict return to work after lumbar discectomy: answers from the NeuroPoint-SD registry. J Neurosurg Spine 25:1811862016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 41

    Weinstein JNLurie JDTosteson TDHanscom BTosteson ANABlood EA: Surgical versus nonsurgical treatment for lumbar degenerative spondylolisthesis. N Engl J Med 356:225722702007

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation

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