Dil V. Patel, Joon S. Yoo, Brittany E. Haws, Benjamin Khechen, Eric H. Lamoutte, Sailee S. Karmarkar and Kern Singh
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.
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.
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.
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.
Joon S. Yoo, Dil V. Patel, Benjamin C. Mayo, Dustin H. Massel, Sailee S. Karmarkar, Eric H. Lamoutte and Kern Singh
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.
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.
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.
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.
Dil V. Patel, Mundeep S. Bawa, Brittany E. Haws, Benjamin Khechen, Andrew M. Block, Sailee S. Karmarkar, Eric H. Lamoutte and Kern Singh
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).
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.
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.
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.