Cognitive Processes during Recovery: Moving toward Personalized Spine Surgery Outcomes

# Presentation CPSS1: Spinal insufficiency fracture in the geriatric pediatric spine {#article-title-2} Regular corticosteroid has become standard for slowing disease progression in Duchenne muscular dystrophy (DMD). However, patients must contend with the insidious side effect of osteopenia and

What's New in Spine Surgery.

BackgroundTotal hip arthroplasty (THA) is a successful procedure that provides pain relief, restores function, and improves quality of life (QOL) for patients with advanced arthritis in their hip joint. To date, little research has examined the role of cognitive appraisal processes in THA outcomes. This study examined the role of cognitive appraisal processes in THA outcomes in the first year post-surgery.MethodsThis longitudinal cohort study collected data at pre-surgery, 6 weeks post-surgery, 3 months post-surgery, and 12 months post-surgery. Adults (n = 189) with a primary diagnosis of osteoarthritis were consecutively recruited from an active THA practice at a Canadian academic teaching hospital. Measures included the Hip Disability and Osteoarthritis Outcome Score (HOOS), the Mental Component Score (MCS) of the Rand-36, and the Brief Appraisal Inventory (BAI). Analysis of Variance examined the association between BAI items and the HOOS or MCS scores. Random effects models investigated appraisal main effects and appraisal-by-time interactions for selected BAI items.ResultsHOOS showed great improvement over the first 12 months after THA, and was mitigated by three appraisal processes in particular: focusing on problems with healthcare or living situation, and preparing one’s family for health changes. MCS was stable and low over time, and the following appraisal processes were implicated by very large effect sizes: not comparing themselves to healthier people, focusing on money problems, preparing their family for their health changes, or trying to shed responsibilities.ConclusionsAppraisal processes are relevant to health outcomes after THA, with different processes coming into play at different points in the recovery trajectory.

BackgroundAround 20% of patients undergoing spinal fusion surgery have persistent back or leg pain despite surgery. Pain catastrophizing is the strongest psychological predictor for chronic postsurgical pain. Psychological variables are modifiable and could be target for intervention. However, randomized controlled trials evaluating the effectiveness of psychological interventions to reduce chronic pain and disability after spinal fusion in a population of patients with high preoperative pain catastrophizing scores are missing. The aim of our study is to examine whether an intervention targeting pain catastrophizing mitigates the risk of chronic postsurgical pain and disability. Our primary hypothesis is that targeted perioperative cognitive behavioral therapy decreases the risk of chronic postsurgical pain and disability after spinal fusion surgery in high catastrophizing patients.MethodsWe will perform a two-center prospective, single-blind, randomized, controlled study comparing lumbar spinal fusion surgery outcome between 2 cohorts. Adult patients selected for lumbar spinal fusion with decompression surgery and a minimum score of 24 on the pain catastrophizing scale will be randomized with 1:1 allocation for either perioperative cognitive behavioral therapy (intervention group) or a perioperative education plus progressive exercise program (control group). Patients randomized to the intervention group will receive six individual sessions of cognitive behavioral therapy, two sessions before the operation and four after. Primary outcome is the Core Outcome Measures Index at 12 months. Secondary outcomes include pain, disability, depression and quality of life.DiscussionThis is the first trial that evaluates the effectiveness of cognitive behavioral therapy as a perioperative tool to improve pain and disability after spinal fusion surgery in comparison with an educational/exercise control intervention, in patients with high levels of pain catastrophizing. If perioperative cognitive behavioral therapy proves to be effective, this might have important clinical implications, reducing the incidence of chronic postsurgical pain and improving outcome after spinal fusion surgery.Trial registrationClinicaltrials (NCT03969602). Registered 31 May 2019,

Rates, Predictive Factors, and Adverse Outcomes of Fusion Surgery for Lumbar Degenerative Disorders in Ontario, Canada, Between 2006 and 2015: A Retrospective Cohort Study

This study aimed to compare the efficacy of liposomal bupivacaine ultrasound-guided erector spinae plane block (ESPB) with wound infiltration (WI) on postoperative analgesia and quality of recovery in patients undergoinglumbar spinal fusion surgery. Eighty patients scheduled for lumbar fusion surgery were randomized to receive either WI (n = 40) or ultrasound-guided bilateral ESPB (n = 40). Pain intensity in the postanesthesia care unit (PACU) and at 6, 12, 24, 48 and 72h after surgery was the primary outcome. The secondary outcomes included quality of recovery, intraoperative opioid consumption, use of rescue analgesics within 72h and postoperative lumbar function. Adverse events were recorded. Compared with the WI group, the ESPB group demonstrated lower pain scores in the PACU (median [IQR]: 2 [1,2] vs. 2 [2,3]; median difference, -1; 95% confidence interval [CI] -2 to -1; P < 0.001) and at 6h after surgery (median [IQR]: 2 [1,2] vs. 3 [2,3]; median difference, -1; 95% CI -1 to -1; P < 0.001). There were no significant differences in VAS scores between the two groups beyond 6h. In addition, the ESPB group had higher Quality of Recovery-15 scale scores at 72h after surgery (mean ± SD: [119.49 ± 5.01] vs. [116.61 ± 4.33]; P = 0.009). The doses of sufentanil (median [IQR]: 20 [20,22] vs. 25 [23,30]; P < 0.001) and remifentanil (median [IQR]: 680 [560,850] vs 775 [647.5,1005]; P = 0.042) were significantly lower in the ESPB group than those in the WI group. However, there were no differences in the Oswestry Disability Index between the groups at 1 or 3months after surgery. For patients undergoing lumbar spinal fusion surgery, compared with WI, ultrasound‑guided ESPB with liposomal bupivacaine provided a slight advantage in improving postoperative analgesia and quality of recovery, and reduced intraoperative opioid consumption. However, these findings probably lack clinical significance. This study was registered at the Chinese Clinical Trial Registry ( http://www.chictr.org.cn , ChiCTR240084425; Registration Date: May 16, 2024).

BackgroundA postoperative magnetic resonance imaging (MRI) is performed as a routine to assess decompression of the spinal cord as well as to evaluate postoperative complications. The purpose of this study is to analyze the efficacy of postoperative MRI for hematoma in spinal decompression surgery.MethodsBetween January 1, 2008 and January 31, 2015, 185 patients who underwent postoperative MRI after spinal decompression surgery were included in this study. We checked the history of the use of an anticoagulant or antiplatelet agent, withdrawal period, blood platelet count, and prothrombin time (international normalized ratio [INR]). We measured the total amount of suction drainage and duration until removal. We retrospectively reviewed the presence of hematoma and thecal sac compression. Postoperative prognosis was evaluated by a visual analog scale (VAS) and the Oswestry Disability Index (ODI).ResultsHematomas were found on postoperative MRI scans in 97 out of 185 patients (52.4%). Thirty patients had a thecal sac compressing hematoma: 7 in the cervical spine, 1 in the thoracic spine, and 22 in the lumbar spine. The occurrence of hematoma did not show significant difference according to the use of an anticoagulant (p = 0.157). The blood platelet count, prothrombin time (INR), and suction drainage duration did not have a statistically significant correlation with the occurrence of hematoma (p = 0.562, p = 0.506, and p = 0.429, respectively). The total amount of suction drainage was significantly different according to the presence of hematoma (p = 0.022). The total 185 patients had a significant decrease in the postoperative VAS score (p < 0.001), and the diminution of VAS score was not significantly different according to the occurrence of hematoma (p = 0.243). Even in the cases of thecal sac compressing hematoma, the reduction of VAS score was not significantly different (p = 0.689).ConclusionsPostoperative MRI for hematoma in spinal decompression surgery has little effect on prognosis or management. Therefore, indiscriminate postoperative MRI should be avoided and MRI should be performed depending on the patient's status.

BackgroundTranexamic acid (TXA) has been routinely delivered in multisegmental spinal decompression and bone graft fusion surgeries with satisfactory outcomes in minimizing gross blood loss and transfusion demands. However, concerns remain that intravenously delivered TXA (ivTXA) may increase risks of postoperative convulsive seizures and systemic thrombogenicity. Topical use of TXA (tTXA), being more targeted to the surgical bleeding site while minimizing patient systemic exposure to ivTXA, has been successfully applied to attenuate blood losses and transfusion requirements in hip and knee arthroplasty. Yet, randomized controlled trials on tTXA efficacy and safety are still lacking in spinal surgeries. With this knowledge gap, we hypothesize that tTXA exhibits non-inferiority to ivTXA in blood conservation and clinical safety in multisegmental spinal decompression and bone graft fusion surgeries.MethodsA prospective, randomized, double-blind, non-inferiority study design will be adopted. The target sample size is 176. Eligible patients will be randomly allocated to receive either ivTXA or tTXA treatment. The primary end point is the perioperative total blood loss. Secondary end points consist of visible blood losses (intraoperative, postoperative 0–24 h, postoperative 0–48 h, combined perioperative blood loss, total postoperative blood loss), postoperative hidden blood loss, plasma TXA levels, postoperative conventional coagulation monitoring (prothrombin time, activated partial thromboplastin time, fiber Bragg grating, international normalized ratio), postoperative thromboelastography monitoring (reaction time, clot formation time, clot strength, fibrinolysis), postoperative hemoglobin nadir (within postoperative 48 h), perioperative transfusion amounts and rates, and length of hospital stay. Safety end points will be monitored too.DiscussionThis proposed study will contribute to expanding clinical evidences of tTXA for bleeding management in major spinal surgeries. This will be a high-quality prospective randomized trial with sufficient sample size, strict methodology, and few design deficits. It will investigate the potentiality of tTXA as an alternative to ivTXA in improving the current standard of care in multisegmental spinal surgeries, thereby optimizing the enhanced recovery after surgery scheme in spinal surgeries.Trial registrationClinicalTrials.gov, NCT03011866. Registered on 5 January 2017.

Prior bariatric surgery is associated with lower complications, in-hospital mortality, and healthcare utilization after elective spine fusion surgery.

Stratifying outcome based on the Oswestry Disability Index for operative treatment of adult spinal deformity on patients 60 years of age or older: a multicenter, multi-continental study on Prospective Evaluation of Elderly Deformity Surgery (PEEDS)

To investigate mid-long-term effects of the lowest instrumented vertebra (LIV) selection on adolescent idiopathic scoliosis (AIS) patients who had posterior spinal fusion (PSF) surgery. Forty-eight patients were recruited. Inclusion criteria were AIS patients who have had PSF surgery more than 10 years ago. Patients were divided into G1: LIV L3 or higher and G2: LIV L4 or lower. MRI evaluation was classified using Pfirrmann grades. Pfirrmann scores were average of Pfirrmann grades for all unfused discs below LIV. SRS-22r, SF-36, Oswestry Disability Index (ODI) and Modified Cincinnati Sports Activity Scale (MCSAS) were used. There were 19 patients in G1 and 29 patients in G2. Demographic parameters showed no significant differences. We found no significant differences in Pfirrmann grades or scores between G1 and G2. There was significant correlation between age and mean Pfirrmann scores (r = 0.546, p < 0.001), Pfirrmann grade for adjacent disc + 1 below LIV (r = 0.475, p = 0.001) and adjacent disc below LIV (r = 0.365, p = 0.011). G2 had significantly lower scores for SRS-22r pain (G1: 4.3 ± 0.5, G2: 4.0 ± 0.6, p = 0.044) and the SF-36 bodily pain (G1: 88.7 ± 12.3, G2: 77.8 ± 18.7, p = 0.018) domains. There were no significant differences in ODI and MCSAS between the two groups. Patients with fusion to L4 or lower had more significant back pain. However, both groups had similar physical function, self-image, satisfaction with treatment, mental health, and functional sports activity. We did not find any significant association between lumbar discs degeneration and the selection of LIV.

221. Change in sagittal alignment after decompression alone in patients with lumbar spinal stenosis: a prospective cohort study

BACKGROUND CONTEXTDefining success in spine surgery lacks a standardized approach, and all existing concepts are based on registrations after surgery. PURPOSETo examine patients’ expectations before spine surgery assessed by a modified Oswestry Disability Index (ODI) and Numeric Rating Scale (NRS). The authors asked: how do the expectations align with actual outcomes and can a patient's individual expectations be used as a success criterion in itself? STUDY DESIGN /SETTINGProspective single-center study. PATIENT SAMPLEPatients scheduled for spine surgery at Akershus University Hospital (AHUS) were included in the study. They underwent 1 of 3 procedures: decompression for spinal stenosis, disc removal for lumbar disc herniation, or spinal fusion for degenerative disc disease. OUTCOME MEASURESModified and standard version of ODI and NRS (back and leg pain). METHODSPreoperatively, the patients were given a modified ODI and NRS questionnaire in which they were asked to register the minimum acceptable functional impairment and pain they anticipated to have postsurgery. The patients’ expectations were compared with 3-and 12-month follow-up data from the Norwegian Registry for Spine Surgery (NORspine) with ODI, NRS and Global Perceived Effect (GPE) scale. We used simple descriptive statistics. RESULTSA total of 93 patients completed the preop questionnaire. Of these, 65 responded to the 3-month follow-up and 53 at 12-month follow-up. The mean (95%CI) ODI before surgery was 38.3 (34.2–42.3), the mean (95% CI) preoperative NRS back pain was 6.34 (5.81–6.88), and leg pain was 6.67 (6.08–7.26). The patients expected a mean (95% CI) ODI of 10.5 (7.5–13.5), mean (95%CI) NRS back pain of 2.5 (2.1–3.0), and NRS leg pain of 1.8 (1.5–2.2). The actual clinical outcome after 12 months were a mean (95% CI) ODI of 21.7 (17.0–26.5), NRS back pain of 3.4 (2.8–4.1), and leg pain of 2.8 (2.0–3.5). Only 12 (30.8%) patients achieved their expected ODI, while 26 (65.0%) classified themselves as significantly better according to GPE. CONCLUSIONSPatients seem to have high expectations before spine surgery, and the expectations may exceed the clinical outcome. Only 30.8% had their ODI expectations met, but perceived benefit was higher. High expectations may be due to inadequate preoperative information and/or the unsuitability of ODI for capturing expectations.

The authors' objective was to investigate whether sagittal balance improves in patients with spinal stenosis after decompression alone. This prospective longitudinal cohort study compared preoperative and 6-month postoperative 36-inch full-length radiographs in patients aged older than 60 years. Patients underwent decompression alone for central lumbar spinal stenosis with either a minimally invasive bilateral laminotomy for central decompression, unilateral laminectomy as an over-the-top procedure for bilateral decompression, or traditional wide laminectomy with removal of the spinous processes on both sides. The following radiographic parameters were measured: sagittal vertical axis (SVA), lumbar lordosis (LL), pelvic tilt (PT), pelvic incidence (PI), PI-LL mismatch, coronal Cobb angle, and sacral slope (SS). Patient-reported outcome measures (PROMs) were collected, including scores on the Oswestry Disability Index (ODI), visual analog scale (VAS) for leg and back pain, and EQ-5D. Forty-five patients (24 males) with a mean ± SD age of 71.8 ± 5.6 years were included. Sagittal balance showed statistically significant improvement, with the mean SVA decreasing from 52.3 mm preoperatively to 33.9 mm postoperatively (p = 0.0001). The authors found an increase in LL, from mean -41.5° preoperatively to -43.9° postoperatively, but this was not statistically significant (p = 0.055). A statistically significant decrease in PI-LL mismatch from mean 8.4° preoperatively to 5.8° postoperatively was found (p = 0.002). All PROM scores showed significant improvement after spinal decompression surgery. The correlations between SVA and all PROMs were statistically significant at both preoperative and postoperative time points, although most correlations were weak except for those between preoperative SVA and ODI (r = 0.55) and between SVA and VAS for leg pain (r = 0.58). Sagittal balance and PROMs show improvement at short-term follow-up evaluations in patients who have undergone decompression alone for lumbar spinal stenosis.

Cross-sectional study. Alcohol abuse (AA) and alcohol withdrawal (AW), both belonging to alcohol use disorders, bring about vast health consequences, social issues, and financial burden in United States. This study aims to explore the relationship of AA and AW with perioperative outcomes following elective spine fusion surgery. Large studies evaluating the outcomes of spine surgery in patients with AA or AW are lacking. We used the National Inpatient Sample (NIS) from 2006 to 2014 to extract records with a primary procedure of spinal fusion surgery. Multivariable regression analysis was used to assess the association of AA and AW with in-hospital mortality, perioperative complications, cost and length of stay (LOS). Among 3,132,192 patients undergoing elective spinal fusion surgery, the prevalence of AA and AW was 1.14% (35,833) and 0.15% (4623), respectively. Among the AA admissions, 12.90% of patients developed AW. The incidence of overall complications was 6.14%, 10.15%, and 33.73% in patients without AA, with AA and with AW, respectively. After multivariable adjustment, AW was associated with elevated risk of overall complications (odds ratio [OR]: 4.51; 95% confidence interval [CI]: 3.86-5.27), neurologic (OR: 2.58; 95% CI: 1.62-4.12), respiratory (OR: 8.04; 95% CI: 6.62-9.77), cardiac (OR: 3.58; 95% CI: 2.60-4.93), gastrointestinal (OR: 2.31; 95%CI: 1.68-3.17), urinary and renal (OR: 2.68; 95% CI: 2.11-3.39), venous thromboembolism (OR: 3.06; 95% CI: 1.94-4.82), wound-related complications (OR: 3.84; 95% CI: 2.96-4.98) and in-hospital mortality (OR: 5.95; 95% CI: 3.25-10.90). AW was also linked to 40% higher cost and 85% longer LOS. Both AA and AW are associated with adverse outcomes in patients undergoing spinal fusion surgery with more pronounced risks for AW. Aggressive management in perioperative period is required to improve outcomes in these patients.Level of Evidence: 3.