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Sanjeev Ariyandath Sreenivasan, Kanwaljeet Garg, Shashwat Mishra, Pankaj Kumar Singh, Manmohan Singh and Poodipedi Sarat Chandra

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Ankur S. Narain, Fady Y. Hijji, Brittany E. Haws, Krishna T. Kudaravalli, Kelly H. Yom, Jonathan Markowitz and Kern Singh

OBJECTIVE

Given the increasing prevalence of obesity, more patients with a high body mass index (BMI) will require surgical treatment for degenerative spinal disease. In previous investigations of lumbar spine pathology, obesity has been associated with worsened postoperative outcomes and increased costs. However, few studies have examined the association between BMI and postoperative outcomes following anterior cervical discectomy and fusion (ACDF) procedures. Thus, the purpose of this study was to compare surgical outcomes, postoperative narcotics consumption, complications, and hospital costs among BMI stratifications for patients who have undergone primary 1- to 2-level ACDF procedures.

METHODS

The authors retrospectively reviewed a prospectively maintained surgical database of patients who had undergone primary 1- to 2-level ACDF for degenerative spinal pathology between 2008 and 2015. Patients were stratified by BMI as follows: normal weight (< 25.0 kg/m2), overweight (25.0–29.9 kg/m2), obese I (30.0–34.9 kg/m2), or obese II–III (≥ 35.0 kg/m2). Differences in patient demographics and preoperative characteristics were compared across the BMI cohorts using 1-way ANOVA or chi-square analysis. Multivariate linear or Poisson regression with robust error variance was used to determine the presence of an association between BMI category and narcotics utilization, improvement in visual analog scale (VAS) scores, incidence of complications, arthrodesis rates, reoperation rates, and hospital costs. Regression analyses were controlled for preoperative demographic and procedural characteristics.

RESULTS

Two hundred seventy-seven patients were included in the analysis, of whom 20.9% (n = 58) were normal weight, 37.5% (n = 104) were overweight, 24.9% (n = 69) were obese I, and 16.6% (n = 46) were obese II–III. A higher BMI was associated with an older age (p = 0.049) and increased comorbidity burden (p = 0.001). No differences in sex, smoking status, insurance type, diagnosis, presence of neuropathy, or preoperative VAS pain scores were found among the BMI cohorts (p > 0.05). No significant differences were found among these cohorts as regards operative time, intraoperative blood loss, length of hospital stay, and number of operative levels (p > 0.05). Additionally, no significant differences in postoperative narcotics consumption, VAS score improvement, complication rates, arthrodesis rates, reoperation rates, or total direct costs existed across BMI stratifications (p > 0.05).

CONCLUSIONS

Patients with a higher BMI demonstrated surgical outcomes, narcotics consumption, and hospital costs comparable to those of patients with a lower BMI. Thus, ACDF procedures are both safe and effective for all patients across the entire BMI spectrum. Patients should be counseled to expect similar rates of postoperative complications and eventual clinical improvement regardless of their BMI.

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Brittany E. Haws, Benjamin Khechen, Jordan A. Guntin, Kaitlyn L. Cardinal, Daniel D. Bohl and Kern Singh

OBJECTIVE

Patient-reported outcomes are commonly used to evaluate treatment efficacy. Inefficiencies in standard measurement tools often prove to be a barrier to data collection. The Patient-Reported Outcomes Measurement Information System (PROMIS) was developed to overcome these limitations. This tool implements computer-adaptive testing, which enables the assessment of physical function in fewer questions than those required for “static” metrics. In spine surgery patients, moderate to strong correlations with Oswestry Disability Index (ODI) and the 36-Item Short Form Survey (SF-36) scores have been reported for PROMIS. However, to date, data regarding the efficacy of this tool for patients undergoing minimally invasive (MIS) transforaminal lumbar interbody fusion (TLIF) have been limited.

METHODS

A prospectively maintained registry of patients who have undergone primary 1- or 2-level MIS TLIF was reviewed retrospectively. Patients with incomplete PROMIS data were excluded. Changes in PROMIS physical function scores 6 weeks, 12 weeks, and 6 months after surgery were analyzed using paired t-tests. PROMIS scores were compared with traditional outcome measures, including SF-12 physical function, ODI, and visual analog scale (VAS) back and leg scores. Correlations were tested using the Pearson correlation coefficient, and the strength of association was interpreted as follows: small, 0.1 ≤ |r| < 0.3; moderate, 0.3 ≤ |r| < 0.5; and large, |r| ≥ 0.5. Statistical significance was set at p < 0.05.

RESULTS

Seventy-four patients were included in this analysis after the exclusion of those without PROMIS scores. The mean preoperative PROMIS score was 35.92 ± 6.98. Significant improvements were demonstrated in PROMIS scores 12 weeks (41.33, p < 0.001) and 6 months (43.58, p < 0.001) after surgery. PROMIS scores demonstrated a significant correlation with SF-12, ODI, and VAS leg scores (p < 0.05). Strong associations with PROMIS scores were observed for SF-12 (r = 0.650 to 0.854), ODI (r = −0.525 to −0.831), and 6-month VAS back (r = −0.693) scores.

CONCLUSIONS

Physical function as measured by PROMIS improves significantly 12 weeks and 6 months after MIS TLIF. In addition, PROMIS scores have strong correlations with SF-12 and ODI scores. These results suggest that PROMIS scores can be used as a valid assessment of physical function in MIS TLIF patients. Further work is required to determine the full benefits of this measure in other spine populations.

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Junyoung Ahn, Daniel D. Bohl, Ehsan Tabaraee, Khaled Aboushaala, Islam M. Elboghdady and Kern Singh

OBJECT

Little is known about the accuracy of reporting of preoperative narcotic utilization in spinal surgery. As such, the purpose of this study is to compare postoperative narcotic consumption between preoperative narcotic utilizers who do and do not accurately self-report preoperative utilization.

METHODS

Patients who underwent anterior cervical discectomy and fusion, minimally invasive lumbar discectomy, or minimally invasive transforaminal lumbar interbody fusion procedures between 2013 and 2014 were prospectively identified. The accuracy of self-reporting preoperative narcotic consumption was determined utilizing the Illinois Prescription Monitoring Program. Total inpatient narcotic consumption during postoperative Days 0 and 1 was compared according to the demographics and preoperative narcotic reporting accuracy. Similarly, the proportion of patients who continued to be dependent on narcotic medications at each postoperative visit was compared according to the demographics and preoperative narcotic reporting accuracy.

RESULTS

A total of 195 patients met the inclusion criteria. Of these, 25% did not use narcotics preoperatively, while 47% and 28% did do so with accurate and inaccurate reporting, respectively. Patients who used narcotics preoperatively were more likely to demonstrate elevated inpatient narcotic consumption (adjusted RR 5.3; 95% CI 1.4–20.1; p = 0.013). However, such patients were no more or less likely to be dependent on narcotic medications at the first (p = 0.618) or second (p = 0.798) postoperative visit. Among patients who used narcotics preoperatively, no differences were demonstrated in terms of inpatient narcotic consumption (p = 0.182) or narcotic dependence following the first (p = 0.982) or second (p = 0.866) postoperative visit according to the self-reported accuracy of preoperative narcotic utilization. The only preoperative factors that were independently associated with elevated inpatient narcotic consumption were workers’ compensation status and procedure type. The only preoperative factors that were independently associated with narcotic dependence at the first postoperative visit were female sex, workers’ compensation status, and procedure type. The only preoperative factor that was independently associated with narcotic dependence at the second postoperative visit was procedure type.

CONCLUSIONS

The findings suggest that determining the actual preoperative narcotic utilization in patients who undergo spine surgery may help optimize postoperative pain management. Approximately 75% of patients used narcotics preoperatively. Patients who used narcotics preoperatively demonstrated significantly higher inpatient narcotic consumption, but this difference did not persist following discharge. Finally, postoperative narcotic consumption (inpatient and following discharge) was independent of the self-reported accuracy of preoperative narcotic utilization. Taken together, these findings suggest that corroboration between the patient’s self-reported preoperative narcotic utilization and other sources of information (e.g., family members and narcotic registries) may be clinically valuable with respect to minimizing narcotic requirements, thereby potentially improving the management of postoperative pain.

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Dil V. Patel, Joon S. Yoo, Brittany E. Haws, Benjamin Khechen, Eric H. Lamoutte, Sailee S. Karmarkar and Kern Singh

OBJECTIVE

In a large, consecutive series of patients treated with anterior cervical discectomy and fusion (ACDF) performed by a single surgeon, the authors compared the clinical and surgical outcomes of patients who underwent ACDF in an inpatient versus outpatient setting.

METHODS

Patients undergoing primary ACDF were retrospectively reviewed and stratified by surgical setting: hospital or ambulatory surgical center (ASC). Data regarding perioperative characteristics, including hospital length of stay and complications, were collected. Neck Disability Index (NDI) and visual analog scale (VAS) scores were used to analyze neck and arm pain in the preoperative period and at 6 weeks, 3 months, 6 months, and 12 months postoperatively. Postoperative outcomes were compared using chi-square analysis and linear regression.

RESULTS

The study included 272 consecutive patients undergoing a primary ACDF, of whom 172 patients underwent surgery at a hospital and 100 patients underwent surgery at an ASC. Patients undergoing ACDF in the hospital setting were older, more likely to be diabetic, and had a higher comorbidity burden. Patients receiving treatment in the ASC were more likely to carry Workers’ Compensation insurance. Patients in the hospital cohort were more likely to have multilevel procedures, had greater blood loss, and experienced a longer length of stay. In the hospital cohort, 48.3% of patients were discharged within 24 hours, while 43.0% were discharged between 24 and 48 hours after admission. Both cohorts had similar VAS pain scores on postoperative day (POD) 0; however, the hospital cohort consumed more narcotics on POD 0. One patient in the ASC cohort had a pretracheal hematoma that was evacuated immediately in the same surgical center. There were 8 cases of dysphagia in the hospital cohort and 3 cases in the ASC cohort, all of which resolved before the 6-month follow-up. Both cohorts demonstrated similar NDI and VAS neck and arm pain scores preoperatively and at every postoperative time point.

CONCLUSIONS

Although patients undergoing ACDF in the hospital setting were older, had a greater comorbidity burden, and underwent surgery on more levels than patients undergoing ACDF at an outpatient center, this study demonstrated comparable surgical and clinical outcomes for both patient groups. Based on the results of this single surgeon’s experience, 1- to 2-level ACDFs may be performed successfully in the outpatient setting in appropriately selected patient populations.

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Joon S. Yoo, Dil V. Patel, Benjamin C. Mayo, Dustin H. Massel, Sailee S. Karmarkar, Eric H. Lamoutte and Kern Singh

OBJECTIVE

Due to the reported benefits associated with minimally invasive spine surgery (MIS), patients seeking out minimally invasive surgery may have higher expectations regarding their outcomes. In this study the authors aimed to assess the effects of preoperative expectations and postoperative outcome actuality, and the difference between the two, on postoperative satisfaction following MIS for lumbar fusion procedures.

METHODS

Patients scheduled for either a 1- or 2-level lumbar fusion MIS were administered confidential surveys preoperatively and at 6 months postoperatively. The surveys administered preoperatively consisted of 2 parts: preoperative patient-reported outcomes (PROs), including the Oswestry Disability Index (ODI), visual analog scale (VAS) back pain, and VAS leg pain, and expected postoperative PROs. The surveys administered 6 months postoperatively consisted of 2 parts: postoperative PROs and satisfaction. Preoperative symptoms, expected postoperative symptoms, and actual postoperative symptoms were compared using paired t-tests. Pearson correlation was used to compare the association between 1) postoperative change in PROs and satisfaction, 2) expectation and satisfaction, 3) expectation-actuality discrepancy and satisfaction, and 4) actuality and satisfaction.

RESULTS

In total, 101 patients completed all surveys. Patients expected to improve in all PROs from baseline, except for ODI personal care, in which they expected to get worse after surgery. In actuality, patients improved in all PROs from baseline, except for ODI personal care, in which they did not demonstrate improvement or worsening. Patients did not surpass any expectations regarding PRO improvement. The association between patient satisfaction and postoperative change was strong for the VAS back pain score, while ODI and VAS leg pain scores showed moderate correlations. Preoperative expectation and postoperative satisfaction demonstrated weak to moderate correlations for all outcome measures. All 3 PROs demonstrated moderate correlation between patient satisfaction and the expectation-actuality discrepancy. All 3 PROs demonstrated strong correlations between satisfaction and actual postoperative outcomes, with ODI having the strongest correlation.

CONCLUSIONS

In this observational study, the authors determined that the actual postoperative results following surgery were strongly correlated with patient satisfaction, while the patients’ expectation, the expectation-actuality discrepancy, and the postoperative improvement did not demonstrate strong correlations for all patient-reported outcome measures utilized in this study. The investigation results suggest that the most important indicator of how satisfied patients feel following surgery may be the actual outcome itself, rather than the preoperative expectation or the degree to which the expected result was met.

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Brittany E. Haws, Benjamin Khechen, Ankur S. Narain, Fady Y. Hijji, Daniel D. Bohl, Dustin H. Massel, Benjamin C. Mayo, Junyoung Ahn and Kern Singh

OBJECTIVE

Intraoperative local steroid application has been theorized to reduce swelling and improve swallowing in the immediate period following anterior cervical discectomy and fusion (ACDF). Therefore, the purpose of this study was to quantify the impact of intraoperative local steroid application on patient-reported swallow function and swelling after ACDF.

METHODS

A prospective, randomized single-blind controlled trial was conducted. A priori power analysis determined that 104 subjects were needed to detect an 8-point difference in the Quality of Life in Swallowing Disorders (SWAL-QOL) questionnaire score. One hundred four patients undergoing 1- to 3-level ACDF procedures for degenerative spinal pathology were randomized to Depo-Medrol (DEPO) or no Depo-Medrol (NODEPO) cohorts. Prior to surgical closure, patients received 1 ml of either Depo-Medrol (DEPO) or saline (NODEPO) applied to a Gelfoam carrier at the surgical site. Patients were blinded to the application of steroid or saline following surgery. The SWAL-QOL questionnaire was administered both pre- and postoperatively. A ratio of the prevertebral swelling distance to the anteroposterior diameter of each vertebral body level was calculated at the involved levels ± 1 level by using pre- and postoperative lateral radiographs. The ratios of all levels were averaged and multiplied by 100 to obtain a swelling index. An air index was calculated in the same manner but using the tracheal air window diameter in place of the prevertebral swelling distance. Statistical analysis was performed using the Student t-test and chi-square analysis. Statistical significance was set at p < 0.05.

RESULTS

Of the 104 patients, 55 (52.9%) were randomized to the DEPO cohort and 49 (47.1%) to the NODEPO group. No differences in baseline patient demographics or preoperative characteristics were demonstrated between the two cohorts. Similarly, estimated blood loss and length of hospitalization did not differ between the cohorts. Neither was there a difference in the mean change in the scaled total SWAL-QOL score, swelling index, and air index between the groups at any time point. Furthermore, no complications were observed in either group (retropharyngeal abscess or esophageal perforation).

CONCLUSIONS

The results of this prospective, randomized single-blind study did not demonstrate an impact of local intraoperative steroid application on patient-reported swallowing function or swelling following ACDF. Neither did the administration of Depo-Medrol lead to an earlier hospital discharge than that in the NODEPO cohort. These results suggest that intraoperative local steroid administration may not provide an additional benefit to patients undergoing ACDF procedures.

■ CLASSIFICATION OF EVIDENCE Type of question: therapeutic; study design: randomized controlled trial; evidence: Class I.

Clinical trial registration no.: NCT03311425 (clinicaltrials.gov)

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Dil V. Patel, Mundeep S. Bawa, Brittany E. Haws, Benjamin Khechen, Andrew M. Block, Sailee S. Karmarkar, Eric H. Lamoutte and Kern Singh

OBJECTIVE

This study aimed to determine if the preoperative Patient-Reported Outcomes Measurement Information System, Physical Function (PROMIS PF) score is predictive of immediate postoperative patient pain and narcotics consumption or long-term patient-reported outcomes (PROs) following minimally invasive transforaminal lumbar interbody fusion (MIS TLIF).

METHODS

A prospectively maintained database was retrospectively reviewed. Patients who underwent primary, single-level MIS TLIF for degenerative pathology were identified and grouped by their preoperative PROMIS PF scores: mild disability (score 40–50), moderate disability (score 30–39.9), and severe disability (score 20–29.9). Postoperative pain was quantified using the visual analog scale (VAS), and narcotics consumption was quantified using Oral Morphine Equivalents. PROMIS PF, Oswestry Disability Index (ODI), 12-Item Short-Form Health Survey, Physical Component Summary (SF-12 PCS), and VAS back and leg pain were collected preoperatively and at 6-week, 3-month, 6-month, and 12-month follow-up. Preoperative PROMIS PF subgroups were tested for an association with demographic and perioperative characteristics using 1-way ANOVA or chi-square analysis. Preoperative PROMIS PF subgroups were tested for an association with immediate postoperative pain and narcotics consumption in addition to improvements in PROMIS PF, ODI, SF-12 PCS, and VAS back and leg pain by using linear regression controlling for statistically different demographic characteristics.

RESULTS

A total of 130 patients were included in this analysis. Patients were grouped by their preoperative PROMIS PF scores: 15.4% had mild disability, 63.8% had moderate disability, and 20.8% had severe disability. There were no significant differences among the subgroups in terms of age, sex, smoking status, and comorbidity burden. Patients with greater disability were more likely to be obese and to have workers’ compensation insurance. There were no differences among subgroups in regard to operative levels, operative time, estimated blood loss, and hospital length of stay. Patients with greater disability reported higher VAS pain scores and narcotics consumption for postoperative day 0 and postoperative day 1. Patients with greater preoperative disability demonstrated lower PROMIS PF, ODI, SF-12 PCS, and worse VAS pain scores at each postoperative time point.

CONCLUSIONS

Patients with worse preoperative disability, as assessed by PROMIS PF, experienced increased pain and narcotics consumption, along with less improvement in long-term PROs. The authors conclude that PROMIS PF is an efficient and accurate instrument that can quickly assess patient disability in the preoperative period and predict both short-term and long-term surgical outcomes.

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Benjamin C. Mayo, Dustin H. Massel, Daniel D. Bohl, Ankur S. Narain, Fady Y. Hijji, William W. Long, Krishna D. Modi, Bryce A. Basques, Alem Yacob and Kern Singh

OBJECTIVE

Prior studies have correlated preoperative depression and poor mental health status with inferior patient-reported outcomes following lumbar spinal procedures. However, literature regarding the effect of mental health on outcomes following cervical spinal surgery is limited. As such, the purpose of this study is to test for the association of preoperative SF-12 Mental Component Summary (MCS) scores with improvements in Neck Disability Index (NDI), SF-12 Physical Component Summary (PCS), and neck and arm pain following anterior cervical discectomy and fusion (ACDF).

METHODS

A prospectively maintained surgical database of patients who underwent a primary 1- or 2-level ACDF during 2014–2015 was reviewed. Patients were excluded if they did not have complete patient-reported outcome data for the preoperative or 6-week, 12-week, or 6-month postoperative visits. At baseline, preoperative SF-12 MCS score was assessed for association with preoperative NDI, neck visual analog scale (VAS) score, arm VAS score, and SF-12 PCS score. The preoperative MCS score was then tested for association with changes in NDI, neck VAS, arm VAS, and SF-12 PCS scores from the preoperative visit to postoperative visits. These tests were conducted using multivariate regression controlling for baseline characteristics as well as for the preoperative score for the patient-reported outcome being assessed.

RESULTS

A total of 52 patients were included in the analysis. At baseline, a higher preoperative MCS score was negatively associated with a lower preoperative NDI (coefficient: −0.74, p < 0.001) and preoperative arm VAS score (−0.06, p = 0.026), but not preoperative neck VAS score (−0.03, p = 0.325) or SF-12 PCS score (0.04, p = 0.664). Additionally, there was no association between preoperative MCS score and improvement in NDI, neck VAS, arm VAS, or SF-12 PCS score at any of the postoperative time points (6 weeks, 12 weeks, and 6 months, p > 0.05 for each). The percentage of patients achieving a minimum clinically important difference at 6 months did not differ between the bottom and top MCS score halves (p > 0.05 for each).

CONCLUSIONS

The results of this study suggest that better preoperative mental health status is associated with lower perceived preoperative disability but is not associated with severity of preoperative neck or arm pain. In contrast to other studies, the present study was unable to demonstrate that preoperative mental health is predictive of improvement in patient-reported outcomes at any postoperative time point following an ACDF.