Differences in presurgical MMPI-3 scores across trajectories of recovery from spine surgery.

Approximately 30% of patients who undergo spinal surgery for chronic back pain continue to experience significant pain and disability up to 2 months following surgery. Prior studies have identified mental health variables including depression and anxiety as predictors of poorer postsurgical outcomes using screening instruments, but no studies have examined long-term outcomes using the Minnesota Multiphasic Personality Inventory-3 (MMPI-3), a commonly used tool used in presurgical psychological evaluations (PPE). Using group-based trajectory modeling and a sample of 404 spine surgery evaluees, the present study examined the trajectories of changes in disability scores from presurgery through 3, 12, and 24 months postsurgery. We then compared scores on MMPI-3 scales between trajectory groups. We identified three trajectory groups of change in disability over time: a rapid-remitting group (8%), characterized by moderate presurgical disability that rapidly and substantially remitted by 12 and 24 months; a steady-recovering group (68%), characterized by moderate presurgical disability, slower change over time, and mild levels of disability at the 2-year time point; and a persisting disability group (24%), characterized by severe presurgical disability that continued into long-term follow-ups. Participants in the persisting pain group produced higher presurgical scores on somatic/cognitive and internalizing MMPI-3 scales than participants in the rapid-remitting and steady-recovering groups. Our results support the clinical utility of the MMPI-3 in PPEs and highlight the importance of evaluating somatic/cognitive concerns and internalizing dysfunction to identify patients who are likely to have poorer postsurgical outcomes. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Incremental Contribution of the Minnesota Multiphasic Personality Inventory - 3 to Predicting One-Year Postoperative Spinal Cord Surgery/Spinal Cord Stimulation Outcomes.

Pre-surgical psychological assessments are becoming common in the United States and are recommended or required prior to surgical/spinal cord stimulator intervention for chronic back pain. Psychological testing is often recommended for these evaluations and the various versions of the Minnesota Multiphasic Personality Inventory (MMPI) have demonstrated utility for predicting outcomes in this setting. This investigation sought to extend that literature with the newest version of the MMPI, the MMPI-3. The sample comprised of 909 patients (50.5% men, 49.5% women) who consented to participating in an outcome study and took the MMPI-3 along with other self-report measures of pain, functional disability, and emotional functioning prior to surgery as part of their pre-surgical psychological assessment. Self-report measures of pain, functional disability, and emotional functioning were administered again one-year following the intervention. MMPI-3 scale scores accounted for up to 9% of additional variance in the outcomes after controlling for pre-surgical measures. Measures of emotional/internalizing dysfunction, somatic dysfunction, and, to a lesser extent, behavioral/externalizing dysfunction contributed the most to the prediction of poorer outcomes.

Surgical Treatment of Pediatric Scoliosis: Historical Origins and Review of Current Techniques.

The treatment of scoliosis has been explored and debated in medicine since the first recorded texts. Scoliosis treatment has shifted over time from external modalities, such as traction and bracing, to internal stabilization techniques that leverage surgical advances. Surgical fixation constructs can generally be separated into two different modalities: dynamic vs. static constructs. For skeletally immature individuals with progressive deformities, surgical options range from traditional or magnetically controlled growing rods to vertebral body staples or tethering. For individuals who have reached skeletal maturity, many devices have been developed that provide static length constructs. Understanding the surgical options available is critical for the appropriate management of this varied patient population. With this article, we sought to provide a summary of past and present techniques and devices used in the treatment of scoliosis.

Characterizing the Residual SCFE Deformity: Utility of the 45-degree Dunn View.

BACKGROUND: After treatment with in situ stabilization, slipped capital femoral epiphysis (SCFE) patients have variable degrees of deformity that can contribute to femoroacetabular impingement (FAI). To evaluate the severity of residual deformity most physicians currently use biplanar radiographs of an anteroposterior pelvis which profiles the lateral head-neck deformity and a frog lateral view which profiles the anterior head-neck deformity. However, the assessment of FAI morphology commonly relies on the 45-degree Dunn view to profile the anterolateral head-neck junction where FAI deformity is maximal. Therefore, the purpose of this study was to compare the magnitude of residual SCFE deformity detected on the frog lateral radiograph to the 45-degree Dunn radiograph. METHODS: A retrospective review of radiographic images of 50 hips (47 patients) diagnosed with SCFE at a single academic institution from 2014 to 2018 was performed. The group included 25 hips evaluated postoperatively after fixation (Group 1) and 25 hips presenting with residual symptomatic SCFE deformity after previous pinning (Group 2). The alpha angle was assessed on both the 45-degree Dunn and frog lateral views for comparison. The modified Southwick slip angle was assessed on the frog lateral view only as a measure of SCFE severity. RESULTS: The Dunn view showed the maximal residual SCFE deformity as measured by the alpha angle in 88% (44/50) of cases. Overall, the mean alpha angle (70.7 degree vs. 60.1 degree, P <0.001) was significantly larger on the Dunn view as compared with frog lateral. Subgroup analysis showed a larger alpha angle on Dunn view compared with frog lateral in both immediate postoperative and residual SCFE deformities as well: Group 1 (69.5 degree vs. 60.9 degree, P <0.001) and Group 2 (71.9 degree vs. 59.3 degree, P <0.001). CONCLUSION: In patients with SCFE, the maximal residual deformity of the proximal femur can typically be seen on the 45-degree Dunn view, rather than on the frog lateral view. Our findings suggest the 45-degree Dunn view may be beneficial part of the postoperative assessment of SCFEs to quantify the true maximal deformity present. LEVEL OF EVIDENCE: Level IV.

PROMIS Utilization in Pediatric Orthopaedics: A Scoping Review.

BACKGROUND: The lack of a common patient-reported outcome metric used among the orthopaedic population is a problem that has been previously identified by the American Academy of Orthopaedic Surgeons. The Patient-Reported Outcomes Measurement Information System (PROMIS) was developed by the National Institute of Health with the goal of creating a precise and efficient measurement tool for patient-reported symptoms, functioning, and health-related quality of life to be used in clinical research. A study summarizing its use in the pediatric orthopaedic population has not been previously performed. METHODS: We performed a literature search of Ovid Medline, Embase, Scopus, and the Cochrane Central Register of Controlled Trials from 2010 to August 2021. There were 1961 unique citations included after the removal of 1756 duplicates. After initial screening, 183 studies were screened under full-text review leaving a final number of 51 studies included in this scoping review. RESULTS: Pediatric PROMIS studies were grouped by body part or sub-speciality: "Hand and Upper Extremity" (25.5%, n=13), "Sports" (23.5%, n=12), "Spine" (13.7%, n=7), "Trauma" (13.7%, n=7), "General Pediatric Orthopaedics" (11.8%, n=6), "Lower Extremity" (9.8%, n=5), and "Orthopaedic Oncology" (2%, n=1). An increase in studies utilizing PROMIS was seen throughout the study period with only 3 studies published from 2013 to 2016 to 39 in 2020 and 2021 alone. The 3 most frequently used pediatric PROMIS domains were Pain Interference (76.5%, n=39/51), Mobility (60.8%, n=31/51), and Upper Extremity (54.9%, n=28/51). 64.3% (n=9/14) of the included studies which reported on the floor effects of Pain Interference exhibited a significant floor effect. In all, 77.8% (n=7/9) of the included studies which reported on ceiling effects of Upper Extremity exhibited a significant ceiling effect. CONCLUSION: The use of PROMIS increased significantly since the first publication in 2013 suggesting orthopaedic providers have increasingly utilized PROMIS in their day-to-day practice as an outcome measure. Ceiling and floor effects were prominent in several of the included domains (Pain Interference and Upper Extremity). Overall, PROMIS measures are efficient, reliable, and effective to use. LEVEL OF EVIDENCE: IV.

Orthopaedic Surgery Pediatric Sports Medicine: Characterizing Practice Patterns and Subspecialization.

BACKGROUND: Pediatric sports medicine is a new and rapidly growing subspecialty within orthopaedic surgery. However, there is very limited literature on the practice of pediatric sports medicine in North America. Therefore, the purpose of this study was to evaluate and describe the current practice patterns of orthopaedic surgeons specializing in pediatric sports medicine. METHODS: An online survey was distributed to orthopaedic surgeons specializing in pediatric sports medicine through the Pediatric Research in Sports Medicine Society. The purpose of the survey was to characterize (1) surgeon demographics, (2) the breakdown of different joint specialization, and (3) the specific procedures for joints that the surgeons specialize in. RESULTS: Responses from 55 orthopaedic surgeons were collected and analyzed. Most respondents considered pediatric sports medicine as the primary focus of their practice (89.1%, n=49/55). The number of fellowships completed was almost evenly split between either a single fellowship (52.7%, n=29/55) or 2 or more (47.3%, n=26/55). The most common combination of fellowships was pediatric orthopaedics and adult sports medicine (32.7%, n=18/55). Most survey respondents had been in practice for <10 years (69.0%, n=38/55) and were affiliated with an academic center (61.8%, n=34/55). On average, 77.5% of the patients treated were <18 years old. The knee joint was the most specialized joint, with 98.2% (n=54/55) respondents reporting that the knee joint constituted ≥25% of their practice. The knee joint constituted a mean of 52.1% of the respondents' overall practice, followed by the shoulder (15.2%), hip (13.9%), ankle (7.5%), elbow (7.1%), and wrist (4.2%). CONCLUSIONS: Pediatric sports medicine practices are variable and have distinct practice patterns in pediatric, orthopaedic, and adult sports practices. In the current study, most surgeons are less than 10 years into practice, affiliated with academic centers, and have typically completed either 1 or 2 fellowships after residency. Surgeons were most commonly specialized in the knee joint and cared for patients <18 years old. LEVEL OF EVIDENCE: Level of evidence IV.

Meniscal Repair Outcomes at Greater Than 5 Years: A Systematic Review and Meta-Analysis.

BACKGROUND: The utilization of meniscal repair techniques continues to evolve in an effort to maximize the rate of healing. Meniscal repair outcomes at a minimum of 5 years postoperatively appear to better represent the true failure rates. Thus, a systematic review and meta-analysis of the current literature was conducted to assess the rate of failure at a minimum of 5 years after meniscal repair. METHODS: We performed a systematic review of studies reporting the outcomes of meniscal repair at a minimum of 5 years postoperatively. A standardized search and review strategy was utilized. Failure was defined as recurrent clinical symptoms or a meniscal reintervention to repair or resect the meniscus in any capacity, as defined by the study. When reported, outcomes were assessed relative to anterior cruciate ligament (ACL) status, sex, age, and postoperative rehabilitation protocol. Meta-analyses were performed with a random-effects model. RESULTS: A total of 27 studies of 1,612 patients and 1,630 meniscal repairs were included in this review and meta-analysis. The pooled overall failure rate was 22.6%, while the failure rate of modern repairs (excluding early-generation all-inside devices) was 19.5%. Medial repairs were significantly more likely to fail compared with lateral repairs (23.9% versus 12.6%, p = 0.04). Failure rates were similar for inside-out (14.2%) and modern all-inside repairs (15.8%). Early-generation all-inside devices had a significantly higher failure rate (30.2%) compared with modern all-inside devices (15.8%, p = 0.01). There was no significant difference in meniscal failure rate between repairs with concomitant ACL reconstruction (21.2%) and repairs in ACL-intact knees (23.3%, p = 0.54). CONCLUSIONS: Modern meniscal repair had an overall failure rate of 19.5% at a minimum of 5 years postoperatively. Modern all-inside techniques appear to have improved the success rate of meniscal repair compared with use of early-generation all-inside devices. Lateral repairs were significantly more likely to be successful compared with medial repairs, while no difference was seen between patients undergoing meniscal repair with and without concomitant ACL reconstruction. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Treatment Trends in Meniscal Pathology in the Setting of Concomitant ACL Injuries in Pediatric and Young Adult Patients: An Insurance Database Study.

BACKGROUND: Meniscal pathology is commonly encountered in the setting of anterior cruciate ligament (ACL) rupture and is increasingly common in the pediatric and adolescent population. Studies have shown that over half of individuals presenting with ACL rupture will have concurrent meniscal pathology. PURPOSE: To define trends in the utilization of meniscal procedures (ie, meniscus repair vs partial meniscectomy) and short-term complications in pediatric and young adult patients with meniscal pathology in the setting of a concurrent ACL reconstruction. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: The IBM MarketScan Commercial Database was utilized to identify ACL reconstruction procedures performed between 2006 and 2018 for individuals aged 5 to 30 years. Annual proportions of meniscectomy and meniscal repair were analyzed, and short-term complications were compared between pediatric/adolescent patients (aged 5-17 years) and young adults (aged 18-30 years). RESULTS: An overall 40,736 records of individuals <18 years old with ACL tears were included. The pediatric/adolescent population had a significantly lower proportion of concomitant meniscal procedures (56.8%; 23,149/40,736) than the young adult population (59.7%; 33,764/56,515; P < .01). From 2006 to 2018, utilization of meniscal repair in the setting of ACL reconstruction steadily increased (20.1% to 35.1% [+15 percentage points], P < .01), while the proportion with meniscectomy decreased (34.4% to 21.3% [-13.1 percentage points], P < .01). There was no difference in rate of reoperation for repeat meniscal repair or meniscectomy in the pediatric/adolescent population for those undergoing meniscal repair versus meniscectomy within 180 days of primary surgery (1.7% [188/10,766] vs 1.5% [186/12,383]; P = .14). CONCLUSION: From 2006 to 2018, the proportion of patients receiving ACL reconstruction with concomitant meniscal repair increased (20.1% to 35.1%) while the proportion with meniscectomy decreased (34.4% to 21.3%) in the pediatric/adolescent population. Meniscal repair was not associated with a higher 180-day rate of reoperation for repeat meniscal repair or meniscectomy than meniscectomy in the setting of ACL reconstruction.

Rates of Infection After ACL Reconstruction in Pediatric and Adolescent Patients: A MarketScan Database Study of 44,501 Patients.

BACKGROUND: Numerous studies have demonstrated an increase in the number of anterior cruciate ligament (ACL) reconstruction procedures performed in pediatric patients. Despite this, most knowledge of surgical site infection rates after these procedures are based on adult studies and data is currently limited in pediatric patients. The purpose of this study was to describe and analyze the rates of infection after ACL reconstruction among pediatric patients and adolescent patients (compared with young adult patients) utilizing the MarketScan Commercial Claims and Encounters Database. METHODS: The Truven Health Analytics MarketScan Commercial Claims and Encounters database was assessed to access health care utilization data for privately insured individuals aged 5 to 30 years old. ACL reconstruction records performed between 2006 and 2018 were identified using Current Procedures Terminology (CPT) codes. International Classification of Diseases Ninth Revision (ICD-9), Tenth (ICD-10) codes and CPT codes were used to identify patients requiring treatment for infection. All patients had at least 180 days of insurance coverage after intervention. RESULTS: A total of 44,501 individuals aged below 18 years old and 63,495 individuals aged 18 to 30 years old that underwent arthroscopic ACL reconstruction were identified. There were no differences in infection rates between those below 18 years old (0.52%) and those above 18 years old (0.46%, P=0.227). However, among patients below 18 years old, patients below 15 years old had a significantly lower rate of infection at 0.37% compared with adolescents (15 to 17 y old) at 0.55% (P=0.039). Among young adults, males had higher rates of infection than females (0.52% vs. 0.37%), while no difference was observed in the pediatric and adolescent population (0.58% vs. 0.47%, P=0.109). CONCLUSION: Utilizing an insurance database, this study demonstrated that rates of infection after ACL Reconstruction in a pediatric/adolescent population are low (0.52%) and similar to rates in young adults. Infection rates after ACLR reconstruction appear to be slightly lower in patients under 15 years of age (0.37%). LEVEL OF EVIDENCE: Level III-Retrospective comparative study.

Reliability and validity of Minnesota Multiphasic Personality Inventory-3 (MMPI-3) scale scores among patients seeking spine surgery.

The Minnesota Multiphasic Personality Inventory (MMPI) family of instruments has been commonly used for the evaluation of patients seeking surgical intervention for back pain. A new version of the MMPI, the Minnesota Multiphasic Personality Inventory-3 (MMPI-3), has been released with updated normative data, expanded and revised item content, and updated scales. The purpose of this investigation is to report reliability and validity findings for MMPI-3 scale scores of patients seeking spine surgery. Using a sample of 761 spine surgery candidates (390 men and 371 women), descriptive data, reliability and standard error of measurement, and zero-order correlations using external criteria (self-report and information gathered from a medical record review/clinical interview) were calculated. By and large, men and women produced MMPI-3 scale scores that were similar with a few exceptions. Many reliability estimates and standard errors of measurement were replicable compared to those reported for the MMPI-3 normative sample for scales that yielded adequate range. The scale scores of the MMPI-3 also yielded evidence of good convergent and discriminant validity when correlated with external criteria. Indeed, MMPI-3 scale scores accounted for 2%-15% of incremental variance in data obtained via the clinical interview and medical chart, once other self-report measures were accounted for. Overall, many of the MMPI-3 scale scores used in spine surgery evaluations appear to be reliable and valid. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Insurance Coverage Criteria for Femoroacetabular Impingement Surgery: Are They Responding to Improving Evidence?

BACKGROUND: With the rapidly growing body of FAI literature in the last decade, improved evidence exists to support FAI surgery. However, it remains unclear how well third-party insurance company's FAI policies have adapted over time to improved evidence. The purpose of this study was (1) to compare the 2020 FAI surgery criteria of four major insurance companies utilizing a multi-center cohort of FAI patients undergoing surgery to identify rates and causes of ineligibility, and (2) to compare the rates of approval based on changes in policy from 2012 to 2020. METHODS: Four major insurance companies' coverage policies with specific criteria for the surgical treatment of FAI were applied to this population at two time points (2012 and 2020). The policies listed various combinations of age, symptom duration, radiographic signs of FAI, radiographic signs of osteoarthritis, and physical exam findings. A prospective, multi-center cohort of 712 patients (including 45.5% males and 54.5% females with a mean age of 28.7 years) undergoing surgical treatment of FAI was utilized for analysis of insurance policies. RESULTS: Based on 2020 FAI policies across 4 insurers, 22.5% (range 18.4-28.4%) of FAI patients would be deemed ineligible. In 2012, the average percent exclusion of the four companies was 23.7%. The most likely reason to be excluded was either failure to meet imaging criteria (alpha angle >50° or positive cross-over sign) [13%, n=94]) or the absence of an impingement sign (9%, n=65). Other causes of exclusion were <6-month symptom duration (6%, n=44), age <15 years (4%, n=28), or skeletally immaturity (3%, n=23). CONCLUSION: Our study shows that despite a six-year span of growing literature and updated policies, nearly 1 in 5 patients diagnosed with FAI would still potentially be denied coverage. This highlights a continued divide between surgeons and insurance companies. There is a major need for improved consensus regarding the diagnosis of FAI and appropriate indications for surgical intervention.Level of Evidence: IV.

Normative PROMIS Scores in Healthy Collegiate Athletes: Establishing a Target for Return to Function in the Young Adult Athlete.

BACKGROUND: The Patient-Reported Outcomes Measurement Information System (PROMIS) computer-adaptive testing (CAT) has been shown to be a valid and reliable means of assessing patient-reported outcomes. However, normal scores and distributions for a subset of a healthy young athletic population have not been established. PURPOSE: To establish normative PROMIS scores for the domains of Physical Function (PF-CAT), Mobility (M-CAT), Upper Extremity Function (UE-CAT), and Pain Interference (PI-CAT) and determine the frequency of floor and ceiling effects in a population of healthy collegiate athletes. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Healthy collegiate athletes (18-23 years of age) were prospectively enrolled to complete the 4 PROMIS CAT domains. Additionally, the athletes provided information regarding their age, sex, and sport(s). Mean scores (±SD) and identification of ceiling or floor effects were calculated. Ceiling and floor effects were considered significant if >15% of the participants obtained the highest or lowest possible score on a domain. RESULTS: A total of 194 healthy athletes (mean age, 19.1 years) were included in the study: 118 (60.8%) men and 76 (39.2%) women. Mean scores were 62.9 ± 6.7 for PF-CAT, 58.2 ± 4.1 for M-CAT, 57.4 ± 5.8 for UE-CAT, and 43.2 ± 6.2 for PI-CAT. Distributions of scores for M-CAT and UE-CAT indicated strong ceiling effects by 77.3% and 66.0% of the participants, respectively. In healthy athletes, the PF-CAT differed most from the expected population-based mean score (50), with the mean being >1 SD above (62.9), without a ceiling effect observed. There were no significant sex- or age-based differences on any of the PROMIS domain scores. CONCLUSION: Healthy collegiate athletes scored nearly 1 SD from population-based means for all of the domains tested. M-CAT and UE-CAT demonstrated ceiling effects in more than two-thirds of healthy athletes, which may limit their utility in this population. The PF-CAT did not demonstrate floor or ceiling effects and demonstrated differences in a young adult athletic population from the population mean. The mean PF-CAT score of 62.9 can represent a target for return of function in injured athletes.

Utility of the Merchant View Radiograph for Assessment of Tibial Tubercle-Trochlear Groove Distance: A Comparison to MRI in Pediatric and Adolescent Patients.

BACKGROUND: Plain radiographic evaluation remains the standard initial assessment of patellar instability, while 3-dimensional imaging is obtained in some patients. Merchant radiographs can demonstrate the tibial tubercle relative to the trochlear groove (TT-TG), but the determination of the TT-TG from these radiographs has been abandoned since its original description. The purpose of this study is to evaluate the utility of the TT-TG measured on Merchant radiographs for the assessment of patellar instability. METHODS: A prospective cohort study was performed of pediatric and adolescent patients aged 10 to 18 who underwent standardized Merchant radiographs, including a total of 98 knees (in 57 patients). Merchant TT-TG was measured as the distance between the center of the trochlear groove and the tibial tubercle, with both lines perpendicular to the anterior femoral condylar axis. In Part 1, the Merchant TT-TG measured by the tibial tubercle radiographic appearance was compared with the measurement utilizing a radiographic marker. In Part 2, the Merchant TT-TG was compared with the magnetic resonance imaging (MRI) TT-TG distance using bivariate linear regression analysis. TT-TG measurements were compared in patients with and without patellar instability with receiver operating characteristic curve analysis. RESULTS: The tibial tubercle was identified on Merchant radiograph in 81.7% (67/82) of knees, and there was an excellent correlation (Pearson correlation coefficient=0.85) between the Merchant TT-TG and the measurement based on marker placement. Merchant TT-TG was on average 4.5 mm less than MRI TT-TG (12.8±4.4 vs. 8.4±7.7 mm, P<0.001) and was moderately correlated (Pearson correlation coefficient=0.58, P<0.01). TT-TG distance was increased in patients with patellar instability compared with those without patellar instability on the Merchant view (10.5±6.9 vs. 2.0±5.5 mm, P<0.001) and MRI (13.9±4.4 vs. 10.5±2.9 mm, P=0.012). Merchant TT-TG also demonstrated a higher area under the curve than MRI TT-TG (0.872 vs. 0.775) in differentiating patients with and without patellar instability. CONCLUSIONS: Standardized Merchant radiographs allow for reliable assessment of the Merchant TT-TG distance when the tibial tubercle is visualized and moderately correlate with MRI TT-TG (with Merchant TT-TG on average 4.5 mm less than MRI). LEVEL OF EVIDENCE: Level III.

Functional Ability Classification Based on Moderate and Severe Kinesophobia and Demoralization Scores in Degenerative Spine Patients.

STUDY DESIGN: A prospective cohort study. OBJECTIVE: To assess the relationship of fear avoidance and demoralization on gait and balance and determine a threshold score for the Tampa Scale for Kinesophobia (TSK) and the Demoralization Scale (DS) that identifies spine patients with gait and balance dysfunction amplified by underlying psychological factors. SUMMARY OF BACKGROUND DATA: Fear avoidance and demoralization are crucial components of mental health that impact the outcomes in spine surgery. However, interpreting their effect on patient function remains challenging. Further establishing this correlation and identifying a threshold of severity can aid in identifying patients in whom a portion of their altered gait and balance may be amplified by underlying psychologic distress. METHODS: Four hundred five symptomatic spine patients were given the TSK and DS questionnaires. Patient's gait and balance were tested with a human motion capture system. A TSK score of 41 and a DS score of 30 were chosen as thresholds to classify moderate versus severe dysfunction based on literature and statistical analysis. RESULTS: Higher TSK and DS scores were correlated with worse walking speed (P < 0.001), longer stride time (P = 0.001), decreased stride length (P < 0.048), and wider step width (<0.001) during gait as well as increased sway across planes (P = 0.001) during standing balance. When classified by TSK scores >41, patients with more severe fear avoidance had slower walking speed (P < 0.001), longer stride time (P = 0.001), shorter stride length (P = 0.004), increased step width (P < 0.001), and increased sway (P = 0.001) compared with their lower scoring counterparts. Similarly, patients with DS > 30 had slower walking speed (P = 0.012), longer stride time (P = 0.022), and increased sway (P = 0.003) compared with their lower scoring counterparts. CONCLUSION: This study demonstrates that fear avoidance and demoralization directly correlate with worsening gait and balance. Furthermore, patients with TSK > 41 and DS > 30 have more underlying psychological factors that contribute to significantly worse function compared with lower scoring peers. Understanding this relationship and using these guidelines can help identify and treat patients whose gait dysfunction may be amplified by psychologic distress.Level of Evidence: 3.

Validity of a pre-surgical algorithm to predict pain, functional disability, and emotional functioning 1 year after spine surgery.

Psychopathology has been associated with patient reports of poor outcome and an algorithm has been useful in predicting short-term outcomes. The objective of this study is to investigate whether a pre-surgical psychological algorithm could predict 1-year spine surgery outcome reports, including pain, functional disability, and emotional functioning. A total of 1,099 patients consented to participate. All patients underwent spine surgery (e.g., spinal fusion, discectomy, etc.). Pre-operatively, patients completed self-report measures prior to surgery. An algorithm predicting patient prognosis based on data from the pre-surgical psychological evaluation was filled out by the provider for each patient prior to surgery. Post-operatively, patients completed self-report measures at 3- and 12-months after surgery. Longitudinal latent class growth analysis (LCGA) was used to derive patient outcome groups. These outcome groups were then compared to pre-surgical predictions made. LCGA analyses derived three groups of patients from the reported outcome data (entropy = .84): excellent outcomes, good outcomes, and poor outcomes. The excellent and good groups demonstrated improvements over time, but the poor outcome groups, on some measures, reported worsening of pain, functional disability, and emotional functioning over time. The pre-surgical algorithm yielded good concordance with the statistically derived outcome groups (Kendall's W = .81). Using a pre-surgical psychological evaluation algorithm for predicting long-term spine surgery outcomes can identify patients who are unlikely to report good outcomes, and point to areas for psychological intervention that can either improve surgery results or to be utilized as alternatives to elective spine surgery. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Cone of economy classification: evolution, concept of stability, severity level, and correlation to patient-reported outcome scores.

STUDY DESIGN: A prospective cohort study OBJECTIVE: To determine a classification system for cone of economy (CoE) measurements that defines clinically significant changes in altered balance and to assess if the CoE measurements directly impacts patients reported outcome measures (PROMs). Preoperative functional data is a crucial component of determining patient disability and prognosis. The CoE has been theorized to be the foundation of biomechanical changes that leads to increased energy expenditure and disability in spine patients. PROMs have been developed to quantify the level of debilitation in spine patients but have various limitations. METHODS: A total of 423 symptomatic adult patients with spine pathology completed a series of PROMs preoperatively including VAS, ODI, Tampa Scale for Kinesiophobia (TSK), Fear and Avoidance Beliefs Questionnaire (FABQ), and Demoralization (DS). Functional balance was tested in this group using a full-body reflective marker set to measure head and center of mass (CoM) sway. RESULTS: PROMs scores were correlated with the magnitude of the CoE measurements. Patients were separated by the following proposed classification: CoM coronal sway > 1.5 cm, CoM sagittal sway > 3.0 cm, CoM total sway > 30.0 cm, head coronal sway > 3.0 cm, head sagittal sway > 6.0 cm, and head total sway > 60.0 cm. Significant differences were noted in the ODI (< 0.001), FABQ physical activity (< 0.001-0.009), DS (< 0.001-0.023), and TSK (< 0.001-0.032) across almost all planes of motion for both CoM and head sway. The ODI was most sensitive to the difference between groups across CoM and head sway planes with a mean ODI of 47.5-49.5 (p < 0.001) in the severe group versus 36.6-39.3 (p < 0.001) in the moderate group. CONCLUSIONS: By classifying CoE measurements by the cutoffs proposed, clinically significant alterations in balance can be quantified. Furthermore, this study demonstrates that across spinal pathology, higher magnitude CoE and range of sway measurements correlate with worsening PROMs. The Haddas' CoE classification system in this study helps to identify patients that may benefit from surgery and guide their postoperative prognosis.

Lumbar Decompression and Interbody Fusion Improves Gait Performance, Pain, and Psychosocial Factors of Patients With Degenerative Lumbar Spondylolisthesis.

STUDY DESIGN: Prospective cohort study. OBJECTIVE: Evaluate changes in gait, pain, and psychosocial factors among degenerative lumbar spondylolisthesis (DLS) patients before and 3 months after surgical intervention. METHODS: Forty-four symptomatic DLS patients performed clinical gait analysis 1 week before surgery and 3 months after surgery. Patients performed a series of over-ground gait trials at a self-selected speed. Twenty-two matched asymptomatic controls underwent the same battery of tests. Three-dimensional motion tracking was used to analyze gait kinematics. Patient-reported outcomes, gait range of motion, and spatiotemporal parameters compared before and after lumbar decompression with fusion. RESULTS: Surgical intervention resulted in significant improvements in walking speed (P = .021), stride time (P = .020), step time (P = .014), and single-support time (P = .038). Significant improvements in joint range-of-motion were found for knee (P = .002) and hip flexion (P = .006). Degenerative lumbar spondylolisthesis patients reported significant reductions in pain, disability, and improved psychological perceptions for fear-avoidance of pain and motion (all P < .001). CONCLUSIONS: Surgical treatment of DLS resulted in a faster, more efficient gait in addition to significant reductions in pain, disability, and psychological fear associated with pain and motion. These beneficial changes that we identified early in the postoperative period indicate that patients return to the quality of life they seek early on. Clinical gait analysis provides objective, quantifiable measures of gait parameters that provide new insight into both the preoperative disability associated with DLS and into the early postoperative function of patients during their rehabilitation.

Fear-avoidance and Patients' Reported Outcomes are Strongly Correlated With Biomechanical Gait Parameters in Cervical Spondylotic Myelopathy Patients.

STUDY DESIGN: This was a prospective cohort study. OBJECTIVE: The aim was to explores whether fear-avoidance is associated with altered gait patterns in cervical spinal myelopathy (CSM) patients. SUMMARY OF BACKGROUND DATA: Fear-avoidance is associated with activity restriction and emotional distress in chronic pain patients and with poorer spine surgery outcomes. In adults with spinal deformity, fear and avoidance correlates with gait pattern disruptions. Patients having CSM also display distorted gait. METHODS: Ninety CSM patients completed the Tampa Scale for Kinesiophobia (TSK) questionnaire, and the Fear-avoidance Beliefs Questionnaire (FABQ). Each patient performed a series of gait trials. Pearson's product correlation analysis was used to determine the relationship between the self-reported fear of movement measures and the objective gait biomechanical data. RESULTS: The TSK total score was correlated with walking speed ( P =0.003), cadence ( P =0.012), stride ( P =0.010) and step ( P =0.036) time, and stride ( P =0.018) and step ( P =0.035) length. The FABQ physical dimension was correlated with walking speed ( P <0.001), cadence ( P <0.001), stride ( P <0.001) and step ( P =0.006) time, stride ( P <0.001) and step ( P <0.001) length, and gait deviation index ( P <0.001). The FABQ work dimension was correlated with walking speed ( P =0.001), cadence ( P =0.001), stride ( P =0.001) and step ( P =0.008) time, and stride ( P =0.014) and step ( P =0.002) length. CONCLUSIONS: These results provide a framework for further investigation of the relationship between psychosocial factors and objectively measured function in patients with CSM. This study demonstrates a strong correlation between fear and avoidance of movement, as measured with the TSK and FABQ and multiple biomechanical gait parameters, as measured with gait analysis. The current results may imply that fear and avoidance may compound and worsen functional deficits arising from CSM, and strongly suggest that fear and avoidance beliefs should be included as a component of presurgical diagnostic process for CSM patients.

The Effect of Surgical Decompression and Fusion on Functional Balance in Patients With Degenerative Lumbar Spondylolisthesis.

STUDY DESIGN: Prospective cohort study. OBJECTIVE: To quantify the effect of lumbar decompression and fusion surgery on balance and stability in patients with degenerative lumbar spondylolisthesis (DLS) and compare them to controls. SUMMARY OF BACKGROUND DATA: DLS is a condition in which one vertebra subluxates relative to an adjacent vertebra in the absence of a disruption in the neural arch. While the existing literature demonstrates that decompression and fusion can successfully alleviate pain and reduce disability in patients with DLS, no studies to date have used quantitative dynamic testing to determine the effect of surgery on cone of economy (CoE) measures in this patient population. METHODS: Forty-five DLS patients performed a series of functional balance tests a week before and 3 months after surgery and were compared to 28 controls. The outcome measures included range of sway (RoS) and total sway for the center of mass (CoM) and head in the sagittal, coronal, and axial planes, along with leg and back Visual Analog Scale (VAS), Oswestry Disability Index (ODI), Fear/Avoidance Behavior Questionnaire (FABQ), Tampa Scale of Kinesophobia (TSK), and Demoralization scale. RESULTS: RoS for the CoM (P < 0.005) and head (P < 0.017) decreased in all planes postoperatively. Reductions in CoM (P = 0.001) and head total sway (P = 0.001) were also observed after surgery. Furthermore, patients with DLS reported strong improvements in VAS low back (P = 0.001), VAS leg (P = 0.001), ODI (P = 0.001), FABQ Physical (P = 0.003), TSK (P = 0.001), and demoralization (P = 0.044) with surgical intervention. Although total sway was reduced after surgery, it did not return to the level of normal controls as demonstrated with more total sway of their CoM (P = 0.002) and head (P = 0.001) as well as more sagittal head RoS (P = 0.048). CONCLUSION: This study confirms that surgical intervention for degenerative spondylolisthesis is effective at reducing disability, back and leg pain, demoralization, kinesiophobia, and fear-avoidance beliefs related to physical activity in patients with DLS. Furthermore, such patients exhibit a significantly more stable stance after surgery. However, balance parameters did not completely normalize by 3 months postoperatively. LEVEL OF EVIDENCE: 3.

Diabetes Does Not Increase Complications, Length of Stay, or Hospital Costs After Minimally Invasive Transforaminal Lumbar Interbody Fusion.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: To determine if the presence of diabetes mellitus as comorbidity is associated with complications, inpatient length of stay, or direct hospital costs after minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). SUMMARY OF BACKGROUND DATA: Very few studies have investigated the effect of diabetes on complications, length of stay, or costs in minimally invasive lumbar surgeries. METHODS: Patients undergoing primary, single-level MIS TLIF were retrospectively reviewed. Diabetic and nondiabetic patients were propensity matched in a 1:1 manner for age, sex, and comorbidity burden. An association between diabetic status and preoperative demographic or perioperative variables, including inpatient length of stay, was tested for using Student t test or χ analysis. Multivariate linear regression was used to test for an association between diabetic status and direct hospital costs. RESULTS: After 1:1 propensity matching, 100 patients were included in this analysis. There were no significant differences in age, sex, body mass index, smoking status, or Charlson Comorbidity Index between propensity-matched patients with and without diabetes. In regards to the length of stay, no significant differences existed between diabetic and nondiabetic groups (68.7 vs. 58.3 h, P=0.218). No other significant differences existed in other perioperative variables including operative time, intraoperative blood loss, or complication rate (P≥0.05 for each). Multivariate analysis indicated that diabetic status was not associated with differences in total direct hospital costs (US$20,428 vs. US$20,429, P=0.792) or cost subcategories after MIS TLIF (P≥0.05 for each). CONCLUSIONS: In this investigation, diabetes was not associated with postoperative complication rates, inpatient length of stay, or direct hospital costs after primary, single-level MIS TLIF. The reduced extent of operative exposure and tissue trauma in MIS TLIF may mitigate the risk of complications in diabetic patients, possibly preventing extensions in hospital stay length and associated hospital costs.