Spinal pathology and outcome post-THA: does segment of arthrodesis matter?

INTRODUCTION: The presence of lumbar spine arthrodesis (SA) is associated with abnormal spinopelvic characteristics and inferior outcome post total hip arthroplasty (THA). However, whether patients with upper segment SA are also at increased risk of complications is unknown. This study aims to (1) determine if upper segment SA is associated with inferior THA outcomes; (2) assess spino-pelvic characteristics; and (3) test whether static or dynamic spinopelvic characteristics correlate with outcome post-THA. MATERIALS AND METHODS: In this retrospective, case-matched, cohort study from a tertiary referral centre, 40 patients (59 hips) that had undergone both THA and any level of spinal arthrodesis (49 THA-Lumb and 10 THA-Cerv) were compared with 41 patients (59 hips) who had THA-only without known spinal pathology. Spino-pelvic characteristics [including severity of Degenerative-Disc-Disease (DDD); spinal balance and stiffness] and outcome, including patient reported outcome measures (PROMs), at minimum of 1-year post-THA were assessed. RESULTS: THA-Lumb and THA-Cerv groups had greater number of complications and inferior hip and spinal PROMs compared to THA-Only (p < 0.001). Similar spinopelvic characteristics were seen between the THA-Cerv and THA-Lumb, which were significantly different to the THA-only group. The presence of DDD and unbalanced or stiff spine was associated with increased dislocation and inferior PROMs in the whole cohort. CONCLUSIONS: THA in the presence of SA, regardless of level, is associated with inferior outcomes and an increased risk for dislocation. The presence of a SA is associated with increased risk of adverse spinopelvic characteristics. Such characteristics were strongly associated with increased dislocation-risk and inferior PROMs. It is likely that these adverse characteristics are the most important adverse predictor, rather than segment of SA per se.

The Use of a Self-Administered Questionnaire to Reduce Consultation Wait Times for Potential Elective Lumbar Spinal Surgical Candidates: A Prospective, Pragmatic, Blinded, Randomized Controlled Quality Improvement Study.

BACKGROUND: In a public health-care system, patients often experience lengthy wait times to see a spine surgeon for consultation, and most patients are found not to be surgical candidates, thereby prolonging the wait time for those who are. The aim of this study was to evaluate whether a self-administered 3-item questionnaire (3IQ) could reprioritize consultation appointments and reduce wait times for lumbar spinal surgical candidates. METHODS: This prospective, pragmatic, blinded, randomized controlled quality improvement study was conducted at a single Canadian academic health-care center. This study enrolled 227 consecutive eligible participants with an elective lumbar condition who were referred for consultation with a spine surgeon. All participants were mailed the 3IQ after their referral was received. Patients were randomized into the intervention group, in which leg-dominant pain reported on the 3IQ resulted in an upgrade in priority to be seen, or into the control group, in which no change to wait-list priority occurred. The main outcome measured was time to consultation for participants who were deemed surgical candidates following consultation. RESULTS: There were no significant differences between groups with regard to demographics, overall group wait times, proportion of surgical candidates, or disability. A total of 33 patients were deemed surgical candidates after consultation. The median wait from referral to consultation was shorter for the 16 surgical candidates in the intervention group (2.5 months; interquartile range [IQR]: 2.0 to 4.8 months) compared with the 17 surgical candidates in the control group (4.5 months; IQR: 3.4 to 6.9 months; p = 0.090). The odds of seeing a surgical candidate within the acceptable time frame of 3 months were 5.4 times greater (95% confidence interval: 1.2 to 24.5 times; p = 0.024) in the intervention group. CONCLUSIONS: The use of a simple, self-administered questionnaire to reprioritize referrals resulted in shorter consultation wait times for patients who required a surgical procedure and significantly increased the number of surgical candidates seen within the acceptable time frame. It may be valuable to consider adding the 3IQ to clinical care practices to better triage these patients on waiting lists.

Activities performed and treatments conducted before consultation with a spine surgeon: are patients and clinicians following evidence-based clinical practice guidelines?

BACKGROUND CONTEXT: Clinical practice guidelines (CPGs) are designed to ensure that evidence-based treatment is easily put into action. Whether patients and clinicians follow these guidelines is equivocal. PURPOSE: The objectives of this study were to examine how many patients complaining of low back pain (LBP) underwent evidence-based medical interventional treatment in line with CPG recommendations before consultation with a spine surgeon, and to evaluate any associations between adherence to CPG recommendations and baseline factors. STUDY DESIGN/SETTING: This is a cross-sectional cohort analysis at a tertiary care center. PATIENT SAMPLE: A total of 229 patients were referred for surgical consultation for an elective lumbar spinal condition. OUTCOME MEASURES: The outcome measures include the number of CPG-recommended treatments undertaken by patients at or before the time of referral, the validated pain score, the EuroQol-5D (EQ-5D) health status, and the Oswestry Disability Index (ODI) score. METHODS: Questionnaires assessing demographic and functional characteristics as well as overall health care use were sent to patients immediately after their referral was received by the surgeon's office. RESULTS: Medications were the most common modality before consultation (74.2% of patients), of which 46.3% received opioids. The number of medications taken was significantly related to a higher ODI score (R=0.23, p=.0004), a higher pain score (R=0.15, p=.026), and a lower EQ-5D health status (R=-0.15, p=.024). In contrast, a lower pain score (7.2 vs. 7.7, p=.037) and a lower ODI score (26.6 vs. 29.9, p=.0023) were associated with performing adequate amounts of exercise. There was a significant association between lower numbers of treatments received and higher numerical pain rating scores (R=-0.14, p=.035). The majority (61.1%) of patients received two or less forms of treatment. CONCLUSIONS: Evidence-based medical interventional treatments for patients with LBP are not being taken advantage of before spine surgery consultation. If more patients were to undertake CPG-endorsed conservative modalities, it may result in fewer unnecessary referrals from primary care physicians, and patients might not deteriorate as much while lingering on long wait lists. Further studies incorporating knowledge translation or health system pathway changes are necessary.