PROMIS Physical Function for prediction of postoperative pain, narcotics consumption, and patient-reported outcomes following minimally invasive transforaminal lumbar interbody fusion

Dil V. Patel Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois

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Mundeep S. Bawa Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois

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Brittany E. Haws Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois

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Benjamin Khechen Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois

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Andrew M. Block Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois

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Sailee S. Karmarkar Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois

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Eric H. Lamoutte Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois

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Kern Singh Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois

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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.

ABBREVIATIONS

BMI = body mass index; CCI = Charlson Comorbidity Index; LOS = length of hospital stay; MIS TLIF = minimally invasive transforaminal lumbar interbody fusion; ODI = Oswestry Disability Index; OME = Oral Morphine Equivalent; POD = postoperative day; PRO = patient-reported outcome; PROMIS PF = Patient-Reported Outcomes Measurement Information System, Physical Function; SF-12 PCS = 12-Item Short-Form Health Survey, Physical Component Summary; VAS = visual analog scale.

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.

Patient-reported outcomes (PROs) have historically been used by spine surgeons to gather clinical data before and after surgery. In recent years, the Patient-Reported Outcomes Measurement Information System (PROMIS) has emerged as a valuable instrument in evaluating patient health.21 PROMIS is a time-efficient survey that dynamically modifies subsequent questions based on responses, potentially improving patient compliance with long-term data collection. The PROMIS domain Physical Function (PROMIS PF) may be particularly useful in relation to spine surgery because it quantifies patients’ mobility, strength, and coordination.6,20 Whereas various preoperative legacy PROs have been successfully correlated with surgical outcomes, the association between PROMIS PF scores and patient health after surgery is currently an underexplored topic in the spine literature.1,8,9,14–16,29

Two related outcomes that are a major area of interest to spine surgeons and patients alike are postoperative pain and narcotics use.2,13 Providing adequate postoperative pain control while limiting narcotics use remains a challenge for spine surgeons.24 Currently, no study has identified if preoperative patient disability, as measured by PROMIS PF, is associated with immediate postoperative pain and narcotics use or long-term PROs after lumbar procedures, especially minimally invasive lumbar fusion. As such, the purpose of this investigation was to determine if preoperative PROMIS PF is predictive of immediate postoperative patient pain and narcotics consumption or of long-term PROs after minimally invasive transforaminal lumbar interbody fusion (MIS TLIF).

Methods

Patient Population

A prospectively maintained surgical database was retrospectively reviewed. Patients were included in the analysis if they underwent primary, single-level MIS TLIF for degenerative pathology between 2015 and 2017. Patients were categorized by preoperative disability, as measured by PROMIS PF scores, into 3 groups: mild disability (score 40–50), moderate disability (score 30–39.9), and severe disability (score 20–29.9). A score of 50 is the mean score of the general United States population, and each 10-point interval equals 1 SD below the mean PF score.6 No patients included in this study had preoperative PROMIS PF scores below 20 or above 50. Patients were excluded from the analysis if preoperative PROMIS data were unavailable or if immediate postoperative pain or narcotics data were insufficient. A total of 179 patients met the primary inclusion criteria for the study. Forty-six patients were excluded for incomplete PRO data, and 3 were excluded due to missing inpatient pain scores and narcotics consumption data. Thus, 130 patients were included in the study. All procedures were performed by the senior author (K.S.) at a single academic medical center.

Data Collection

Baseline patient information such as age, sex, body mass index (BMI), insurance status, and comorbidity burden was recorded. Comorbidity was calculated using the Charlson Comorbidity Index (CCI). Perioperative outcomes that were assessed included operative time, estimated blood loss, and length of hospital stay (LOS). Postoperative pain was quantified using the visual analog scale (VAS), and narcotics consumption was quantified using Oral Morphine Equivalents (OMEs).

PRO measures including 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. ODI is a 10-item questionnaire scored from 0 to 5 points that evaluates functional disability, and is reported as a percentage of total possible points, with higher scores indicating greater disability.7 SF-12 PCS is a survey that evaluates physical health and has a mean score of 50 and an SD of 10, with higher scores representing better health.27 VAS back and leg assess pain in these respective anatomical regions on a scale of 0 (minimum pain) to 10 (maximum pain).28

Statistical Analysis

Preoperative PROMIS PF subgroups were tested for an association with demographic and perioperative characteristics by using 1-way ANOVA or chi-square analysis for continuous and categorical variables, respectively. 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 scores by using linear regression controlling for BMI and workers’ compensation insurance status, because these 2 demographic variables were statistically significant. Statistical significance was set at p < 0.05.

Results

A total of 130 patients were included in this analysis. Patients were subcategorized by their preoperative PROMIS PF scores: 15.4% (20) had mild disability (score 40–50); 63.8% (83) had moderate disability (score 30–39.9); and 20.8% (27) had severe disability (score 20–29.9). Table 1 presents demographic and perioperative characteristics. The average age was 52.1 years, and 58.5% (76) of the patients were males. There were no significant differences among the subgroups in terms of age, sex, smoking status, and CCI (p > 0.05 for each). Patients with greater disability were more likely to be obese (63.0% vs 45.8% vs 20%; p = 0.014) and to have workers’ compensation insurance (59.3% vs 14.5% vs 15.0%; p < 0.001). There were no differences among subgroups in regard to operative levels, operative time, estimated blood loss, and LOS (p > 0.05 for each).

TABLE 1.

Patient demographic and perioperative characteristics

CharacteristicMild Disability, n = 20Mod Disability, n = 83Severe Disability, n = 27p Value*
Age (mean ± SD, yrs)47.8 ± 13.653.4 ± 10.851.0 ± 9.80.121
Sex (no.)0.089
 Female20.0% (4)47.0% (39)40.7% (11)
 Male80.0% (16)53.0% (44)59.3% (16)
BMI (no.)0.014
 Nonobese; <30 kg/m280.0% (16)54.2% (45)37.0% (10)
 Obese; ≥30 kg/m220.0% (4)45.8% (38)63.0% (17)
Smoking status (no.)0.616
 Nonsmoker85.0% (17)85.5% (71)92.6% (25)
 Smoker15.0% (3)14.5% (12)7.4% (2)
Insurance (no.)<0.001
 No workers’ compensation85.0% (17)85.5% (71)40.7% (11)
 Workers’ compensation15.0% (3)14.5% (12)59.3% (16)
CCI (mean ± SD)1.7 ± 2.22.0 ± 1.61.6 ± 1.40.393
Op level (no.)0.254
 L3–45.0% (1)3.61% (3)11.1% (3)
 L4–535.0% (7)55.4% (46)40.7% (11)
 L5–S160.0% (12)41.0% (34)48.2% (13)
Estimated blood loss (mean ± SD, ml)45.0 ± 26.455.9 ± 55.463.0 ± 83.00.589
Op time (mean ± SD, mins)110.3 ± 27.4112.9 ± 23.4108.5 ± 26.10.694
LOS (mean ± SD, hrs)24.3 ± 16.632.5 ± 18.934.9 ± 19.70.135

Mod = moderate.

Boldface type indicates statistical significance.

p value calculated using chi-square analysis (categorical) or 1-way ANOVA (continuous).

Table 2 compares immediate postoperative VAS pain scores and narcotics consumption among cohorts. Patients with greater disability reported higher VAS pain scores for postoperative day (POD) 0 (6.0 vs 4.7 vs 4.7; p = 0.007) and POD 1 (5.6 vs 4.3 vs 3.9; p = 0.002). Additionally, patients with greater disability consumed more narcotics on POD 0 (73.2 vs 60.0 vs 53.4 OMEs; p = 0.019) and on POD 1 (64.1 vs 52.1 vs 42.5 OMEs; p = 0.027).

TABLE 2.

Postoperative VAS pain scores and narcotics use

VariableMild Disability, n = 20Mod Disability, n = 83Severe Disability, n = 27p Value*
Inpatient VAS pain scores (mean ± SD)
 POD 04.7 ± 1.44.7 ± 1.96.0 ± 2.00.007
 POD 13.9 ± 2.14.3 ± 1.55.6 ± 1.90.002
Narcotics consumption (mean ± SD, OME)
 POD 053.4 ± 27.060.0 ± 25.473.2 ± 23.20.019
 POD 142.5 ± 23.352.1 ± 24.864.1 ± 24.80.027

Boldface type indicates statistical significance.

p value calculated using linear regression controlling for BMI and insurance status.

Table 3 compares PROs among subgroups preoperatively and at 6-week, 3-month, 6-month, and 12-month follow-up. Patients with greater preoperative disability demonstrated worse PROMIS PF, ODI, and SF-12 PCS scores at each postoperative time point (p < 0.001 for each). Similarly, patients with greater preoperative disability had worse VAS leg pain at pre- and postoperative time points and worse VAS back pain at all postoperative time points (p ≤ 0.020 for each) (Fig. 1). See Table 4 for changes and improvements in PROs from baseline.

TABLE 3.

Improvement in PROs

VariableMild Disability, n = 20Mod Disability, n = 83Severe Disability, n = 27p Value*
PROMIS PF (mean ± SD)
 Preop43.2 ± 2.835.4 ± 2.827.6 ± 2.5<0.001
 6-wk40.2 ± 5.838.3 ± 6.332.0 ± 5.8<0.001
 3-mo45.5 ± 4.841.9 ± 7.036.4 ± 8.3<0.001
 6-mo49.6 ± 5.543.9 ± 6.938.6 ± 8.0<0.001
 12-mo54.3 ± 10.945.4 ± 7.337.7 ± 11.5<0.001
ODI (mean ± SD)
 Preop29.2 ± 12.837.8 ± 14.855.4 ± 12.8<0.001
 6-wk28.0 ± 19.229.2 ± 17.946.3 ± 19.5<0.001
 3-mo15.9 ± 11.423.6 ± 16.644.1 ± 17.9<0.001
 6-mo12.6 ± 15.219.8 ± 17.137.6 ± 21.1<0.001
 12-mo5.5 ± 6.317.9 ± 17.838.4 ± 22.6<0.001
SF-12 PCS (mean ± SD)
 Preop37.0 ± 7.730.6 ± 7.525.4 ± 3.5<0.001
 6-wk36.5 ± 8.832.8 ± 8.526.1 ± 7.4<0.001
 3-mo41.4 ± 10.837.7 ± 10.228.8 ± 7.1<0.001
 6-mo47.4 ± 11.640.2 ± 11.733.4 ± 12.2<0.001
 12-mo52.4 ± 7.640.7 ± 10.735.0 ± 14.4<0.001
VAS back (mean ± SD)
 Preop5.6 ± 2.26.1 ± 2.67.3 ± 2.50.083
 6-wk3.4 ± 2.23.3 ± 2.54.9 ± 2.5<0.001
 3-mo2.2 ± 2.02.9 ± 2.45.1 ± 2.7<0.001
 6-mo2.5 ± 2.13.1 ± 2.75.1 ± 3.1<0.001
 12-mo1.5 ± 1.32.4 ± 2.35.1 ± 2.8<0.001
VAS leg (mean ± SD)
 Preop3.4 ± 2.75.3 ± 2.86.9 ± 2.40.001
 6-wk2.1 ± 2.72.3 ± 2.44.3 ± 3.2<0.001
 3-mo1.2 ± 1.72.0 ± 2.43.8 ± 2.8<0.001
 6-mo1.1 ± 1.42.0 ± 2.53.6 ± 3.0<0.001
 12-mo0.6 ± 1.22.2 ± 2.83.8 ± 3.00.020

Boldface type indicates statistical significance.

p value calculated using linear regression controlling for BMI and insurance status.

FIG. 1.
FIG. 1.

Line graphs demonstrating improvements in PROs by disability subgroups, as defined by preoperative PROMIS PF scores. Figure is available in color online only.

TABLE 4.

Changes and improvement in PROs

VariableMild Disability, n = 20Mod Disability, n = 83Severe Disability, n = 27p Value*
PROMIS PF
 Preop43.235.427.6<0.001
 6-wk Δ−3.02.94.4<0.001
 3-mo Δ2.36.58.8<0.001
 6-mo Δ6.48.511.00.023
 12-mo Δ11.110.010.10.012
ODI
 Preop29.237.855.4<0.001
 6-wk Δ−1.2−8.6−9.10.077
 3-mo Δ−13.3−14.2−11.30.031
 6-mo Δ−16.6−18.0−17.8<0.001
 12-mo Δ−23.7−19.9−17.00.497
SF-12 PCS
 Preop37.030.625.4<0.001
 6-wk Δ−0.52.20.70.282
 3-mo Δ4.47.13.40.080
 6-mo Δ10.49.68.00.002
 12-mo Δ15.410.19.60.040
VAS back
 Preop5.66.17.30.083
 6-wk Δ−2.2−2.8−2.40.261
 3-mo Δ−3.4−3.2−2.20.015
 6-mo Δ−3.1−3.0−2.20.165
 12-mo Δ−4.1−3.7−2.20.222
VAS leg
 Preop3.45.36.90.001
 6-wk Δ−1.3−3.0−2.60.024
 3-mo Δ−2.2−3.3−3.10.026
 6-mo Δ−2.3−3.3−3.30.076
 12-mo Δ−2.8−3.1−3.10.229

Boldface type indicates statistical significance.

p value calculated using linear regression controlling for BMI and insurance status.

Discussion

In recent years, PROMIS PF was developed to better quantify physical health in terms of mobility, strength, and coordination. However, no study has identified if the preoperative PROMIS PF score is associated with immediate postoperative pain and narcotics use or long-term PROs after lumbar fusion. As such, the purpose of this investigation was to determine if preoperative PROMIS PF scores are predictive of immediate postoperative patient pain and narcotics consumption or long-term PROs after MIS TLIF.

This investigation retrospectively identified patients undergoing primary, single-level MIS TLIF for degenerative disease. Patients were stratified by preoperative PROMIS PF scores based on predetermined cutoffs: mild disability (score 40–50), moderate disability (score 30–39.9), and severe disability (score 20–29.9). Patients with lower preoperative PROMIS PF scores experienced greater pain and consumed more narcotics in the immediate postoperative period. Additionally, patients with greater preoperative disability consistently demonstrated less improvement in PROs including PROMIS PF, ODI, SF-12 PCS, and VAS back and leg pain at long-term follow-up.

Our investigation suggests that patients with greater preoperative disability, as measured by PROMIS PF, experience increased immediate postoperative pain. There are several studies that correlate preoperative functional status to pain after spine surgery. Kim and colleagues and Kanaan et al. investigated patients undergoing lumbar procedures and identified preoperative symptom severity and duration as predictive factors for increased back pain in the immediate postoperative hours.12,15 Similarly, in patients undergoing lumbar surgery, Skolasky et al. analyzed preoperative physical function and disability, measured by ODI and SF-12 PCS. These authors established a strong relationship between preoperative disability and improvements in pain in the postoperative period.26 Collectively, the aforementioned investigations along with data from the current study suggest that patients with greater preoperative disability will have increased pain in the early postoperative period after lumbar surgery, especially in the case of MIS TLIF.

Our study also demonstrates that greater preoperative disability is associated with increased postoperative narcotics use during the hospital stay. Currently, there is a paucity of evidence in the literature with regard to the association between preoperative physical function and inpatient narcotics use. However, in their prospective analysis of patients undergoing lumbar fusion, Lall and Restrepo determined that preoperative pain and disability was correlated with continued opioid consumption 12 weeks after surgery (r = 0.290; p = 0.044).17 As such, further investigation is needed to support the premise of preoperative physical function as a predictive indicator for narcotics consumption in the immediate postoperative period after lumbar fusion.

This study establishes that lower preoperative PROMIS PF scores are predictive of less postoperative PRO improvement with respect to ODI, SF-12 PCS, and VAS back and leg. The results of this study are fairly consistent with the existing literature. In a prospective study of patients undergoing surgery for lumbar degenerative diseases, Patel et al. determined that PROMIS PF was able to accurately discriminate between disease severity and was strongly correlated with ODI (r = −0.58; p < 0.01) and SF-12 PCS (0.50; p < 0.01) improvement at 3-month follow-up.21 Similarly, Crawford et al. determined that patients receiving lumbar fusion who suffered greater preoperative disability, as measured by ODI scores, were more likely to maintain increased disability and back and leg pain scores at 12-month follow-up.5 Thus, along with our data, these studies support the finding that preoperative PROMIS PF scores may predict long-term PRO improvement after lumbar fusion.

In general, PROMIS has been established as a more effective survey tool in terms of accurate data collection over a wide spectrum of health conditions compared to other legacy measures such as the ODI or SF-36.3,4,10,22,23 PROMIS allows for a time-efficient and accurate analysis by using computer adaptive testing, ultimately shortening survey completion time and improving long-term patient compliance.4,11,19 Our results suggest that preoperative PROMIS PF scores are predictive of postoperative pain and narcotics consumption during inpatient stay as well as PRO improvement up to the 12-month follow-up evaluation. Therefore, PROMIS may be a suitable replacement for assessment of preoperative physical health, and it may be used as a predictive measure for both short-term and long-term outcomes after lumbar fusion surgery, especially MIS TLIF.

In the present study, patients with greater disability were more likely to be obese and to have workers’ compensation insurance. These demographic differences have also been observed with other investigations in the literature. In their prospective assessment of patients undergoing lumbar spine surgery, McGirt et al.18 used the Quality Outcomes Database to demonstrate that preoperative disability, as expressed by ODI scores, obesity, and workers’ compensation insurance status, was predictive of overall disability, pain, and quality of life. Similarly, Sielatycki et al.25 established that obese patients were more likely to have greater preoperative ODI scores than nonobese patients at baseline for degenerative spinal conditions (BMI < 35: ODI 47.2, BMI ≥ 35: ODI 50.6; p < 0.01). Furthermore, these studies support our observation that greater BMI and insurance status are associated with patients who have lumbar degenerative disease reporting greater preoperative disability.

The present study is not without limitations. First, the retrospective nature of this study as well as patient inclusion and exclusion criteria may have introduced an element of selection bias. Second, all patients were treated by a single surgeon at a single academic institution, which may limit the generalizability of these results to larger, more diverse populations. Third, narcotics consumption data were not available after discharge. As such, further investigation with detailed opioid prescription data in the long term may allow comparison with preoperative PROMIS PF scores. Fourth, we did not record preoperative narcotics use, and therefore could not account for patients who might have used more narcotics at baseline due to greater disability. Moving forward, large-scale prospective studies using preoperative PROMIS PF scores are necessary before forming predictive models for postoperative recovery in procedure-specific spine populations such as MIS TLIF.

Conclusions

In this investigation, patients with worse preoperative disability, assessed by PROMIS PF, experienced increased pain and narcotics consumption in the immediate postoperative period following MIS TLIF. Additionally, patients with worse preoperative physical function experienced less improvement in long-term PROs including ODI, SF-12 PCS, and VAS back and leg pain. We 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. At this time, further investigation is needed to determine the utility of PROMIS PF with respect to long-term narcotics consumption and other postoperative outcomes in patients undergoing MIS TLIF.

Disclosures

Dr. Singh is a consultant for Zimmer Biomet and K2M. He is a member of the board of directors for Vital 5 LLC, TDi LLC, and the Minimally Invasive Spine Study Group. He is on the editorial board for Contemporary Spine Surgery, Orthopedics Today, and Vertebral Columns. He receives royalties from Zimmer Biomet, Stryker, RTI Surgical, Lippincott Williams and Wilkins, Thieme, Jaypee Publishing, and Slack Publishing. He receives grants from the Cervical Spine Research Society.

Author Contributions

Conception and design: Patel, Bawa, Haws, Khechen. Acquisition of data: Patel, Haws, Khechen, Karmarkar, Lamoutte. Analysis and interpretation of data: Patel, Haws, Khechen. Drafting the article: Patel, Bawa, Block. Critically revising the article: Singh, Patel, Bawa, Block. Reviewed submitted version of manuscript: Singh, Patel, Bawa. Approved the final version of the manuscript on behalf of all authors: Singh. Statistical analysis: Patel. Administrative/technical/material support: Karmarkar, Lamoutte. Study supervision: Singh.

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    Kim HJ, Lee JI, Kang KT, Chang BS, Lee CK, Ruscheweyh R, et al.: Influence of pain sensitivity on surgical outcomes after lumbar spine surgery in patients with lumbar spinal stenosis. Spine (Phila Pa 1976) 40:193200, 2015

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

    Kim HJ, Park JH, Kim JW, Kang KT, Chang BS, Lee CK, et al.: Prediction of postoperative pain intensity after lumbar spinal surgery using pain sensitivity and preoperative back pain severity. Pain Med 15:20372045, 2014

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

    Koerner JD, Glaser J, Radcliff K: Which variables are associated with patient-reported outcomes after discectomy? Review of SPORT disc herniation studies. Clin Orthop Relat Res 473:20002006, 2015

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

    Lall MP, Restrepo E: Predictors of weeks to opioid cessation after lumbar fusion: a prospective cohort study. Pain Manag Nurs 19:525534, 2018

  • 18

    McGirt MJ, Bydon M, Archer KR, Devin CJ, Chotai S, Parker SL, et al.: An analysis from the Quality Outcomes Database, Part 1. Disability, quality of life, and pain outcomes following lumbar spine surgery: predicting likely individual patient outcomes for shared decision-making. J Neurosurg Spine 27:357369, 2017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Papuga MO, Barnes AL: Correlation of PROMIS CAT instruments with Oswestry Disability Index in chiropractic patients. Complement Ther Clin Pract 31:8590, 2018

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Papuga MO, Mesfin A, Molinari R, Rubery PT: Correlation of PROMIS Physical Function and Pain CAT instruments with Oswestry Disability Index and Neck Disability Index in spine patients. Spine (Phila Pa 1976) 41:11531159, 2016

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

    Patel AA, Dodwad SM, Boody BS, Bhatt S, Savage JW, Hsu WK, et al.: Validation of Patient Reported Outcomes Measurement Information System (PROMIS) Computer Adaptive Tests (CATs) in the surgical treatment of lumbar spinal stenosis. Spine (Phila Pa 1976) 43:15211528, 2018

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

    Purvis TE, Andreou E, Neuman BJ, Riley LH III, Skolasky RL: Concurrent validity and responsiveness of PROMIS health domains among patients presenting for anterior cervical spine surgery. Spine (Phila Pa 1976) 42:E1357E1365, 2017

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Purvis TE, Neuman BJ, Riley LH III, Skolasky RL: Discriminant ability, concurrent validity, and responsiveness of PROMIS health domains among patients with lumbar degenerative disease undergoing decompression with or without arthrodesis. Spine (Phila Pa 1976) 43:15121520, 2018

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

    Sabatino MJ, Kunkel ST, Ramkumar DB, Keeney BJ, Jevsevar DS: Excess opioid medication and variation in prescribing patterns following common orthopaedic procedures. J Bone Joint Surg Am 100:180188, 2018

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

    Sielatycki JA, Chotai S, Stonko D, Wick J, Kay H, McGirt MJ, et al.: Is obesity associated with worse patient-reported outcomes following lumbar surgery for degenerative conditions? Eur Spine J 25:16271633, 2016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26

    Skolasky RL, Wegener ST, Maggard AM, Riley LH III: The impact of reduction of pain after lumbar spine surgery: the relationship between changes in pain and physical function and disability. Spine (Phila Pa 1976) 39:14261432, 2014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27

    Ware J Jr, Kosinski M, Keller SD: A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Med Care 34:220233, 1996

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28

    Williamson A, Hoggart B: Pain: a review of three commonly used pain rating scales. J Clin Nurs 14:798804, 2005

  • 29

    Wong SE, Zhang AL, Berliner JL, Ma CB, Feeley BT: Preoperative patient-reported scores can predict postoperative outcomes after shoulder arthroplasty. J Shoulder Elbow Surg 25:913919, 2016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • Collapse
  • Expand

Multidisciplinary surgical planning for a patient with myxoid liposarcoma extending from C4 to T1. See the article by Ahmed et al. (pp 424–431).

  • Line graphs demonstrating improvements in PROs by disability subgroups, as defined by preoperative PROMIS PF scores. Figure is available in color online only.

  • 1

    Anderson MR, Houck JR, Saltzman CL, Hung M, Nickisch F, Barg A, et al.: Validation and generalizability of preoperative PROMIS scores to predict postoperative success in foot and ankle patients. Foot Ankle Int 39:763770, 2018

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  • 2

    Bobbitt KL, Keplinger LM, Althari HK: Understanding addiction: the orthopedic surgical perspective to a significant problem. Clin Podiatr Med Surg 25:493515, viii, 2008

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  • 3

    Brodke DJ, Saltzman CL, Brodke DS: PROMIS for orthopaedic outcomes measurement. J Am Acad Orthop Surg 24:744749, 2016

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    Brodke DS, Goz V, Voss MW, Lawrence BD, Spiker WR, Hung M: PROMIS PF CAT outperforms the ODI and SF-36 Physical Function Domain in spine patients. Spine (Phila Pa 1976) 42:921929, 2017

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  • 5

    Crawford CH III, Glassman SD, Djurasovic M, Owens RK II, Gum JL, Carreon LY: Prognostic factors associated with best outcomes (minimal symptom state) following fusion for lumbar degenerative conditions. Spine J [epub ahead of print], 2018

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  • 6

    Department of Health and Human Services : Patient-Reported Outcomes Measurement Information System. Physical Function. (http://www.healthmeasures.net/administrator/components/com_instruments/uploads/PROMIS%20Physical%20Function%20Scoring%20Manual.pdf) [Accessed December 28, 2018]

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  • 7

    Fairbank JC, Pynsent PB: The Oswestry Disability Index. Spine (Phila Pa 1976) 25:29402952, 2000

  • 8

    Hey HWD, Luo N, Chin SY, Lau ETC, Wang P, Kumar N, et al.: The predictive value of preoperative health-related quality-of-life scores on postoperative patient-reported outcome scores in lumbar spine surgery. Global Spine J 8:156163, 2018

    • Crossref
    • PubMed
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    • Export Citation
  • 9

    Ho B, Houck JR, Flemister AS, Ketz J, Oh I, DiGiovanni BF, et al.: Preoperative PROMIS scores predict postoperative success in foot and ankle patients. Foot Ankle Int 37:911918, 2016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Hung M, Hon SD, Franklin JD, Kendall RW, Lawrence BD, Neese A, et al.: Psychometric properties of the PROMIS physical function item bank in patients with spinal disorders. Spine (Phila Pa 1976) 39:158163, 2014

    • Crossref
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  • 11

    Joeris A, Knoll C, Kalampoki V, Blumenthal A, Gaskell G: Patient-reported outcome measurements in clinical routine of trauma, spine and craniomaxillofacial surgeons: between expectations and reality: a survey among 1212 surgeons. BMJ Open 8:e020629, 2018

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  • 12

    Kanaan SF, Arnold PM, Burton DC, Yeh HW, Loyd L, Sharma NK: Investigating and predicting early lumbar spine surgery outcomes. J Allied Health 44:8390, 2015

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Kee JR, Smith RG, Barnes CL: Recognizing and reducing the risk of opioid misuse in orthopaedic practice. J Surg Orthop Adv 25:238243, 2016

  • 14

    Kim HJ, Lee JI, Kang KT, Chang BS, Lee CK, Ruscheweyh R, et al.: Influence of pain sensitivity on surgical outcomes after lumbar spine surgery in patients with lumbar spinal stenosis. Spine (Phila Pa 1976) 40:193200, 2015

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

    Kim HJ, Park JH, Kim JW, Kang KT, Chang BS, Lee CK, et al.: Prediction of postoperative pain intensity after lumbar spinal surgery using pain sensitivity and preoperative back pain severity. Pain Med 15:20372045, 2014

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

    Koerner JD, Glaser J, Radcliff K: Which variables are associated with patient-reported outcomes after discectomy? Review of SPORT disc herniation studies. Clin Orthop Relat Res 473:20002006, 2015

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

    Lall MP, Restrepo E: Predictors of weeks to opioid cessation after lumbar fusion: a prospective cohort study. Pain Manag Nurs 19:525534, 2018

  • 18

    McGirt MJ, Bydon M, Archer KR, Devin CJ, Chotai S, Parker SL, et al.: An analysis from the Quality Outcomes Database, Part 1. Disability, quality of life, and pain outcomes following lumbar spine surgery: predicting likely individual patient outcomes for shared decision-making. J Neurosurg Spine 27:357369, 2017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Papuga MO, Barnes AL: Correlation of PROMIS CAT instruments with Oswestry Disability Index in chiropractic patients. Complement Ther Clin Pract 31:8590, 2018

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Papuga MO, Mesfin A, Molinari R, Rubery PT: Correlation of PROMIS Physical Function and Pain CAT instruments with Oswestry Disability Index and Neck Disability Index in spine patients. Spine (Phila Pa 1976) 41:11531159, 2016

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

    Patel AA, Dodwad SM, Boody BS, Bhatt S, Savage JW, Hsu WK, et al.: Validation of Patient Reported Outcomes Measurement Information System (PROMIS) Computer Adaptive Tests (CATs) in the surgical treatment of lumbar spinal stenosis. Spine (Phila Pa 1976) 43:15211528, 2018

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

    Purvis TE, Andreou E, Neuman BJ, Riley LH III, Skolasky RL: Concurrent validity and responsiveness of PROMIS health domains among patients presenting for anterior cervical spine surgery. Spine (Phila Pa 1976) 42:E1357E1365, 2017

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Purvis TE, Neuman BJ, Riley LH III, Skolasky RL: Discriminant ability, concurrent validity, and responsiveness of PROMIS health domains among patients with lumbar degenerative disease undergoing decompression with or without arthrodesis. Spine (Phila Pa 1976) 43:15121520, 2018

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

    Sabatino MJ, Kunkel ST, Ramkumar DB, Keeney BJ, Jevsevar DS: Excess opioid medication and variation in prescribing patterns following common orthopaedic procedures. J Bone Joint Surg Am 100:180188, 2018

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

    Sielatycki JA, Chotai S, Stonko D, Wick J, Kay H, McGirt MJ, et al.: Is obesity associated with worse patient-reported outcomes following lumbar surgery for degenerative conditions? Eur Spine J 25:16271633, 2016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26

    Skolasky RL, Wegener ST, Maggard AM, Riley LH III: The impact of reduction of pain after lumbar spine surgery: the relationship between changes in pain and physical function and disability. Spine (Phila Pa 1976) 39:14261432, 2014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27

    Ware J Jr, Kosinski M, Keller SD: A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Med Care 34:220233, 1996

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28

    Williamson A, Hoggart B: Pain: a review of three commonly used pain rating scales. J Clin Nurs 14:798804, 2005

  • 29

    Wong SE, Zhang AL, Berliner JL, Ma CB, Feeley BT: Preoperative patient-reported scores can predict postoperative outcomes after shoulder arthroplasty. J Shoulder Elbow Surg 25:913919, 2016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation

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