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Taylor E. Purvis, Brian J. Neuman, Lee H. Riley III and Richard L. Skolasky

OBJECTIVE

In this paper, the authors demonstrate to spine surgeons the prevalence and severity of anxiety and depression among patients presenting for surgery and explore the relationships between different legacy and Patient-Reported Outcomes Measurement Information System (PROMIS) screening measures.

METHODS

A total of 512 adult spine surgery patients at a single institution completed the 7-item Generalized Anxiety Disorder questionnaire (GAD-7), 8-item Patient Health Questionnaire (PHQ-8) depression scale, and PROMIS Anxiety and Depression computer-adaptive tests (CATs) preoperatively. Correlation coefficients were calculated between PROMIS scores and GAD-7 and PHQ-8 scores. Published reference tables were used to determine the presence of anxiety or depression using GAD-7 and PHQ-8. Sensitivity and specificity of published guidance on the PROMIS Anxiety and Depression CATs were compared. Guidance from 3 sources was compared: published GAD-7 and PHQ-8 crosswalk tables, American Psychiatric Association scales, and expert clinical consensus. Receiver operator characteristic curves were used to determine data-driven cut-points for PROMIS Anxiety and Depression. Significance was accepted as p < 0.05.

RESULTS

In 512 spine surgery patients, anxiety and depression were prevalent preoperatively (5% with any anxiety, 24% with generalized anxiety screen-positive; and 54% with any depression, 24% with probable major depression). Correlations were moderately strong between PROMIS Anxiety and GAD-7 scores (r = 0.72; p < 0.001) and between PROMIS Depression and PHQ-8 scores (r = 0.74; p < 0.001). The observed correlation of the PROMIS Depression score was greater with the PHQ-8 cognitive/affective score (r = 0.766) than with the somatic score (r = 0.601) (p < 0.001). PROMIS Anxiety and Depression CATs were able to detect the presence of generalized anxiety screen-positive (sensitivity, 86.0%; specificity, 81.6%) and of probable major depression (sensitivity, 82.3%; specificity, 81.4%). Receiver operating characteristic curve analysis demonstrated data-driven cut-points for these groups.

CONCLUSIONS

PROMIS Anxiety and Depression CATs are reliable tools for identifying generalized anxiety screen-positive spine surgery patients and those with probable major depression.

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Andrew B. Harris, Floreana Kebaish, Lee H. Riley III, Khaled M. Kebaish and Richard L. Skolasky

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

Patients who are more engaged in their healthcare prior to elective spine surgery are significantly more likely to be satisfied with their postoperative outcome. Clinicians may want to implement previously proven techniques to increase patient activation in order to improve patient satisfaction following elective spine surgery.

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Michael C. Ain, Madeel A. Abdullah, Beverlie L. Ting, Richard L. Skolasky, Emily Streyer Carlisle, Joshua G. Schkrohowsky and Daniele Rigamonti

Object

The aim of this study was to assess the natural history of pain associated with spinal stenosis in individuals with achondroplasia and to characterize pain patterns and associated functional and psychological effects.

Methods

The authors measured pain severity, spatial distribution of pain, functional disability, psychological distress, physical symptoms other than pain, and healthcare utilization in 181 individuals with achondroplasia. They also assessed low back and/or lower extremity pain at the initial visit and 1-year follow-up via self-rated patient questionnaires, calculated composite scores from responses via component analyses, and used repeated measures linear regression analyses for score changes (significance, p ≤ 0.05).

Results

At the follow-up, back pain severity was unchanged. Patients reported significant progression of pain toward involvement of the lower extremities and significant increases in lower extremity pain severity overall. There were also significant increases in healthcare utilization overall. Compared with patients with back pain only, those with back pain and proximal or distal leg pain had higher self-rated pain severity; higher functional disability; and more bowel and bladder dysfunction symptoms, sleep disturbances, extremity numbness, and psychological distress.

Conclusions

Individuals with achondroplasia and symptomatic spinal stenosis often experience back pain, which may progress to lower extremity pain and debilitating consequences. A more thorough understanding of the progression of spatial pain characteristics and pain severity may aid clinical decision making regarding the optimal timing for intervention.

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Mark Ren, Barry R. Bryant, Andrew B. Harris, Khaled M. Kebaish, Lee H. Riley III, David B. Cohen, Richard L. Skolasky and Brian J. Neuman

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

Patients’ preoperative opioid use, dose, and duration of use are associated with long-term use after ASD surgery, and a high preoperative dose is also associated with high-dose opioid use at the 2-year follow-up visit. Patients using opioids 1 year after ASD surgery may be at risk for long-term use.

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Micheal Raad, Andrew B. Harris, Varun Puvanesarajah, Mostafa H. El Dafrawy, Floreana N. Kebaish, Brian J. Neuman, Richard L. Skolasky, David B. Cohen and Khaled M. Kebaish

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

Despite similar baseline characteristics, patients with high preoperative expectations for back pain relief reported less pain 2 years after ASD surgery than patients with low preoperative expectations.

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Micheal Raad, Callum J. Donaldson, Mostafa H. El Dafrawy, Daniel M. Sciubba, Lee H. Riley III, Brian J. Neuman, Khaled M. Kebaish and Richard L. Skolasky

OBJECTIVE

Recommendations for the surgical treatment of isolated lumbar spinal stenosis (LSS) (i.e., in the absence of concomitant scoliosis or spondylolisthesis) are unclear. The aims of this study were to investigate trends in the surgical treatment of isolated LSS in US adults and determine implications for outcomes.

METHODS

The authors analyzed inpatient and outpatient claims from the Truven Health Analytics MarketScan Commercial Claims and Encounters Database for 20,279 patients aged 40–64 years who underwent surgery for LSS between 2010 and 2014. Only patients with continuous 12-month insurance coverage after surgery were included. The rates of decompression with arthrodesis versus decompression only and of simple (1- or 2-level, single-approach) versus complex (> 2-level or combined-approach) arthrodesis were analyzed by year and geographic region. These trends were further analyzed with respect to complications, length of hospital stay, payments made to the hospital, and patient discharge status. Statistical significance was set at p < 0.05.

RESULTS

The proportion of patients who underwent decompression with arthrodesis compared with decompression only increased significantly and linearly from 2010 to 2014 (OR 1.08; 95% CI 1.06–1.10). Arthrodesis was more likely to be complex rather than simple with each subsequent year (OR 1.4; 95% CI 1.33–1.49). This trend was accompanied by an increased likelihood of postoperative complications (OR 1.11; 95% CI 1.02–1.21), higher costs (payments increased by a mean of US$1633 per year; 95% CI 1327–1939), and greater likelihood of being discharged to a skilled nursing facility as opposed to home (OR 1.11; 95% CI 1.03–1.20). The South and Midwest regions of the US had the highest proportions of patients undergoing arthrodesis (48% and 42%, respectively). The mean length of hospital stay did not change significantly (p = 0.324).

CONCLUSIONS

From 2010 to 2014, the proportion of adults undergoing decompression with arthrodesis versus decompression only for the treatment of LSS increased, especially in the South and Midwest regions of the US. A greater proportion of these fusions were complex and were associated with more complications, higher costs, and a greater likelihood of being discharged to a skilled nursing facility.

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Micheal Raad, Jay S. Reidler, Mostafa H. El Dafrawy, Raj M. Amin, Amit Jain, Brian J. Neuman, Lee H. Riley III, Daniel M. Sciubba, Khaled M. Kebaish and Richard L. Skolasky

OBJECTIVE

It is important to identify differences in the treatment of common diseases over time and across geographic regions. Several studies have reported increased use of arthrodesis to treat lumbar spinal stenosis (LSS). The purpose of this study was to investigate geographic variations in the treatment of LSS by US region.

METHODS

The authors reviewed inpatient and outpatient medical claims from 2010 to 2014 using the MarketScan Commercial Claims and Encounters database (Truven Health Analytics), which includes data on commercially insured members younger than 65 years. ICD-9 code 724.02 was used to identify patients aged ≥ 40 and < 65 years who underwent surgery for “spinal stenosis of the lumbar region” and for whom LSS was the only principal diagnosis. The primary outcome was the performance of spinal arthrodesis as part of the procedure. Geographic regions were based on patient residence and defined according to the US Census Bureau as the Northeast, Midwest, South, and West.

RESULTS

Rates of arthrodesis, as opposed to decompression alone, varied significantly by region, from 48% in the South, to 42% in the Midwest, 36% in the Northeast, and 31% in the West. After controlling for patient age, sex, and Charlson Comorbidity Index values, the differences remained significant. Compared with patients in the Northeast, those in the South (OR 1.6, 95% CI 1.50–1.75) and Midwest (OR 1.3, 95% CI 1.18–1.41) were significantly more likely to undergo spinal arthrodesis. On multivariate analysis, patients in the West were significantly less likely to have a prolonged hospital stay (> 3 days) than those in the Northeast (OR 0.84, 95% CI 0.75–0.94). Compared with the rate in the Northeast, the rates of discharge to a skilled nursing facility were lower in the South (OR 0.41, 95% CI 0.31–0.55) and West (OR 0.72, 95% CI 0.53–0.98). The 30-day readmission rate was significantly lower in the West (OR 0.81, 95% CI 0.65–0.98) than in the Northeast and similar between the other regions. Mean payments were significantly higher in the Midwest (mean difference $5503, 95% CI $4279–$6762), South (mean difference $6187, 95% CI $5041–$7332), and West (mean difference $7732, 95% CI $6384–$9080) than in the Northeast.

CONCLUSIONS

The use of spinal arthrodesis, as well as surgical outcomes and payments for the treatment of LSS, varies significantly by US region. This highlights the importance of developing national recommendations for the treatment of LSS.

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Rafa Rahman, Alvaro Ibaseta, Jay S. Reidler, Nicholas S. Andrade, Richard L. Skolasky, Lee H. Riley III, David B. Cohen, Daniel M. Sciubba, Khaled M. Kebaish and Brian J. Neuman

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

Many spine surgery patients experienced postoperative improvements in depression/anxiety. Improvements in 12-month PROs were smaller among patients with persistent or postoperatively developed depression/anxiety compared with patients who had no depression or anxiety before or after surgery and those whose depression/anxiety improved after surgery. Postoperative changes in depression/anxiety may have a greater effect than preoperative depression/anxiety on changes in PROs after spine surgery. Addressing the mental health of spine surgery patients may improve postoperative PROs.

CLASSIFICATION OF EVIDENCE Type of question: causation; study design: prospective cohort study; evidence: class III.