COLUMNS International Society for the Advancement of Spine Surgery
THE IMPACT OF COVID-19 ON ELECTIVE SURGERY Also: Laminectomy Bone as a Bone Graft Substitute How to Prescribe Opioids Responsibly: A Summary of the Evidence and a Framework for Postoperative Narcotic Prescription Triage Pathways in Lumbar Spine Care Regional Anesthesia for Lumbar Spine Surgery Why Do We Still Make Patients “NPO Past Midnight”? How Does PROMIS Correlate With Commonly Used Outcomes Tools in Spine Surgery? What Spine Surgeons Need to Know
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EDITORIAL The Impact of COVID-19 on Elective Surgery
BIOLOGICS Laminectomy Bone as a Bone Graft Substitute
OPIOIDS How to Prescribe Opioids Responsibly: A Summary of the Evidence and a Framework for Postoperative Narcotic Prescription
CLINICAL PRACTICE Regional Anesthesia for Lumbar Spine Surgery
CLINICAL PRACTICE Triage Pathways in Lumbar Spine Care
CLINICAL PRACTICE
Editor in Chief Kern Singh, MD Editorial Board Peter Derman, MD, MBA Brandon Hirsch, MD Sravisht Iyer, MD Safdar Khan, MD Yu-Po Lee, MD Sheeraz Qureshi, MD Grant Shifflett, MD Managing Editor Audrey Lusher Designer Randy Schirz
Why Do We Still Make Patients “NPO Past Midnight”?
PATIENT OUTCOMES How Does PROMIS Correlate With Commonly Used Outcomes Tools in Spine Surgery? What Spine Surgeons Need to Know
Become a member today Vertebral Columns is published quarterly by the International Society for the Advancement of Spine Surgery. ©2020 ISASS. All rights reserved. Opinions of authors and editors do not necessarily reflect positions taken by the Society.
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This publication is available digitally at www.isass.org/news/vertebralcolumns-spring-2020
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EDITORIAL
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The Impact of COVID-19 on Elective Surgery The first case of the novel coronavirus, COVID-19, in the United States was confirmed on January 14, 2020.1 In 3 months, the spread exploded to the point that the United States now has nearly 4 times more cases of COVID-19 than any other country. By mid-April, more than 500,000 cases were reported in the United States, with more than 20,000 succumbing to the virus.1 Based on data from March 17, case-fatality rates indicated anywhere between a 2.3% fatality rate in China to a 7.2% fatality rate in Italy.2
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The pandemic has also resulted Kern Singh, MD in a substantial economic crisis and potent ia lly an unprecedented unemployment rate of 30%. 3 Approximately 3.3 million people in the United States filed unemployment claims the week of March 21, and more than 65 million people are working jobs that are likely in jeopardy. 3 About a month ago, the Dow Jones Industrial Average dropped approximately 25%, which is the second worst
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decline after the Great Depression.4 It is likely that more than 47 million jobs will be lost, ultimately leading to unemployment rates higher than that of the Great Depression. 3 Information is limited regarding how contagious the disease is from asymptomatic infected individuals, but local and national government officials, hospital workers, and patients in the United States are doing whatever possible to slow the spread of the virus. However, much of the battle against COVID-19 has been hindered by the struggle to find adequate personal protective equipment (PPE). Healthcare workers have not been spared from the PPE shortage, with workers facing significant supply chain concerns with a shortage of N95 masks. 5 In fact, some healthcare workers are being given a single mask to wear for indefinite periods, putting themselves, their families, and patients at risk.6 Elective surgeries are being cancelled or drastically reduced as a result of the pandemic.7 England’s National Health Service hospital system has suspended all nonurgent elective surgeries for a minimum of 3 months starting April 15.8 Stateside, we are observing similar trends to halt elective surgeries among health groups in an effort to slow the spread of COVID-19. In a recent report, National Coronavirus Response: A Roadmap to Reopening, Gottlieb et al recommend a 4-phase response, initially slowing the spread, moving to state-by-state reopening, reducing physical distancing once immune protection has been established, and finally rebuilding our readiness for the next pandemic.9 Spring 2020
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Currently we are in Phase I: slowing the transmission of COVID-19 to ensure the healthcare system can handle the patient burden. Protecting the functioning of our healthcare system requires that hospitals be able to rapidly respond to surges in demand. The reassignment of discretionary resources such as elective procedures is one of those requirements. Secondary to infection control, limited resources also require a revaluation of what is essential in the hospital. Unexpected postoperative patient stays, ventilation requirements, or intensive care unit visits all might come at the cost of removing capabilities to offer care for COVID-19 patients. The phrase “life over limb� has become ever more applicable. Chronic low back pain with radicular symptoms will now need to undergo more extensive empirical treatment with conservative therapy than before. Those complaining of saddle anesthesia, bladder and bowel incontinence, or trauma will consequently require emergent evaluation and surgery. Once the initial spread of this disease is brought to a halt for roughly 2 weeks, we will move to Phase II, which will be characterized as the precautionary reopening of schools, businesses, and universities. 9 Even during this time, significant discretion will be exercised with vulnerable populations, such as those older than 60 years and patients with compromised heart and lung function. Apart from the detrimental economic effects that we will have endured by this point, a major part of our precautionary management will likely entail a significant reduction in the number of elective procedures performed. isass.org
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One possible silver lining of this delay in elective surgery could be the opportunity to optimize patients. Given the stressors of increasing unemployment, a global pandemic, and the corresponding uncertainty, a patient’s mental health will become critical to quality outcomes. Treatments such as cognitive behavioral therapy can be modified for telehealth and have been shown to reduce preoperative symptoms of anxiety and depression. Unfortunately, people will continue to require orthopedic surger y during this pandemic, and they may experience extended suffering given the current moratorium on elective surgery. How, then, do we best alleviate our patients’ pain and ensure quality outcomes while our operating room time is restricted? We now have to reach into our bag of tricks to find social-distancing-appropriate meth-
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ods of treating patients. Telehealth may have been on the back burner for years, but now it is thrusted into the forefront as an essential modality to evaluate, diagnose, and treat patients. Now more than ever we need to empower our patients with the knowledge and skills to manage their symptoms. Over the coming months, as we progress through summer and fall, we can expect a waxing and waning of this pandemic. We will slowly start to awaken from this protective hibernation, although the world we will return to will be different. With high unemployment rates and signs of economic recession, people may not have the financial means to undergo elective surgeries. The contraction of the market will entail a compensatory reduction in practices until economies start to recover. Until that recovery occurs, we will need to adapt our practices to adjust to the COVID-19 world. n
References 1. Centers for Disease Control and Prevention. Coronavirus Disease 2019 (COVID-19): Cases in U.S. https://www.cdc.gov/ coronavirus/2019-ncov/cases-updates/ cases-in-us.html. Accessed April 13, 2020.
4. DeCambre M. The Dow is on pace for its worst month since the Great Depression, but here’s why all hope isn’t lost amid the coronavirus crisis. MarketWatch. March 23, 2020.
2. Onder G, Rezza G, Brusaferro S. Case-fatality rate and characteristics of patients dying in delation to COVID-19 in Italy [published online ahead of print March 23, 2020]. JAMA. https:// doi.org/10.1001/jama.2020.4683
5. Putting healthcare workers first during the coronavirus outbreak. 3M News Center. April 1, 2020. https://news.3m.com/ blog/3m-stories/3m-responds-2019-novel-coronavirus. Accessed April 9, 2020.
3. Cox J. Coronavirus job losses could total 47 million, unemployment rate may hit 32%, Fed estimates. CNBC. March 30, 2020. https://www.cnbc.com/2020/03/30/ coronavirus-job-losses-could-total-47million-unemployment-rate-of-32percentfed-says.html. Accessed April 9, 2020.
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6. Parshley L. The mask shortage is forcing health workers to disregard basic coronavirus infection control. Vox. April 3, 2020. https://www.vox. com/2020/4/3/21206726/coronavirusmasks-n95-hospitals-health-care-doctorsppe-shortage. Accessed April 9, 2020.
7. Mills N. Non-urgent elective surgeries have been cancelled for now because of coronavirus. Here’s what that means. ABC News. https://www.abc.net.au/ news/2020-03-26/coronavirus-what-dothe-changes-to-elective-surgery-mean-foryou/12091804. Accessed April 9, 2020. 8. Iacobucci G. Covid-19: all non-urgent elective surgery is suspended for at least three months in England. BMJ. 2020;368:m1106. https://doi.org/10.1136/bmj.m1106 9. Gottlieb S, Rivers C, McClellan MB, Silvis L, Watson C. National Coronavirus Response: A Road Map to Reopening. American Enterprise Institute; March 28, 2020. https://www.aei.org/wp-content/ uploads/2020/03/National-Coronavirus-Response-a-Road-Map-to-Recovering-2.pdf. Accessed April 9, 2020.
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Laminectomy Bone as a Bone Graft Substitute Yu-Po Lee, MD
The number of lumbar spinal fusions has increased in the United States over the past decade.1 The number of elective lumbar fusions increased 62.3%, from 122,679 cases in 2004 to 199,140 in 2015.1 Hospital costs also increased 177% during those 12 years, exceeding $10 billion in 2015.1 The number of lumbar spinal fusions is expected to continue to increase with our aging population. Therefore, keeping hospital costs under control will be of growing importance. Spine surgeons have many choices available for treating patients with degenerative spinal conditions such as instruments, approaches, interbody devices, and bone grafts. Careful thought and surgical planning can improve patient outcomes and reduce costs. Several investigations have reported better outcomes with solid fusion than with pseudoarthrosis. 2,3 One of the goals of surgery is to maximize the chances of achieving a solid fusion while making judicious use of instrumentation, interbody devices, and bone grafts. Spine surgeons have many choices for bone grafts, including autograft, allograft, and various synthetic materials. Autologous iliac crest bone graft (ICBG) is still considered the gold standard in lumbar spinal fusion. However, ICBG harvesting is
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associated with morbidities such as infection, hematoma, fracture, impaired wound healing, and donor site pain. One method of avoiding donor site morbidity is to use bone harvested from the laminectomy during the decompression. In addition, various allograft materials and bone morphogenetic protein have been used as substitutes for autologous ICBG. However, questions remain as to the comparative effectiveness and safety of the bone graft substitutes. Bone morphogenetic protein is costly and carries the risk of seroma formation and iatrogenic tumor formation. Allografts are less costly than bone morphogenetic protein, but they still add to the cost burden of a case, and there is a risk of disease transmission. Exploring the use of laminectomy bone could be beneficial in terms of safety and cost. The use of local bone graft har vested during decompression for fusion has the potential to eliminate the morbidity of harvesting iliac crest bone graft while reducing the risk of disease transmission and costs. There is evidence that laminectomy bone is an effective substitute for iliac crest bone graft. In a prospective, randomized study by Ohtori et al, the authors evaluated 42 patients undergoing a single-level fusion with local bone vs 40 patients fused with ICBG. Visual analog scale (VAS) scores, Japanese Orthopaedics Association Score (JOAS), and isass.org
BIOLOGICS
Oswestry Disability Index (ODI) scores were not significantly different between the 2 groups before and after surgery (P>0.05).4 The fusion rate and average duration of bone union were 90% and 8.5 months, respectively, in the local bone graft group and 85% and 7.7 months in the ICBG group. Surprisingly, the local bone fusion rate was higher but not significantly different (P>0.05). The authors also noted longer surgical times and an increased rate of complications such as donor site pain (8 patients) and sensory disturbance (6 patients) in the ICBG group. In another investigation, Inage et al performed randomized, prospective study evaluating laminectomy bone for fusion in isass.org
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1-, 2-, and 3- level fusions.5 The rate of bone union was 88% in the 1-level group, 85% in the 2-level group, and 62.5% in the 3-level group, which was significantly lower than in the 1- and 2-level groups (P<0.05). In another study by Sengupta et al,6 the authors performed a retrospective review on patients undergoing single and multi-level lumbar fusions. There was no significant difference in overall clinical outcome between the 2 groups. The overall fusion rate was higher in the ICBG group (75% [27 of 36 patients]) compared with the laminectomy bone group (65% [26 of 40 patients]), but the finding was not significantly different (P=0.391). The laminectomy bone group achieved a similar Vertebral Columns
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“Laminectomy bone has efficacy as a bone graft substitute for iliac crest bone graft. However, it is important to consider the limitations of laminectomy bone. ”
fusion rate (approximately 80%) in single-level fusion but a much smaller fusion rate in multilevel fusion (20% vs 66%, P=0.029) compared with the ICBG group. One conclusion that can be drawn from these studies is that laminectomy bone has efficacy in 1- and 2-level fusions, but it may not be effective for longer fusions. However, the fusion rates of laminectomy bone have not been universally good. In a study by Park et al, the authors performed a prospective, multi-center, randomized trial comparing laminectomy bone for a single-level posterolateral fusion.7 This study used computed tomography to evaluate the fusions. Posterolateral fusion was noted bilaterally in 18% and unilaterally in 28.8% of
patients at 6 months and 35.7% and 50.3% of patients at 12 months, respectively. Closer evaluation with more stringent criteria for fusion and the use of advanced imaging reduces the fusion rates of laminectomy bone to approximately 50%. In conclusion, laminectomy bone has efficacy as a bone graft substitute for iliac crest bone graft. However, it is important to consider the limitations of laminectomy bone. The true fusion rate of laminectomy bone may only be as high as 50% when evaluated critically. It is less effective for fusions longer than 1 or 2 levels. These studies report statistically similar outcomes even though the fusion rates are different. In some cases, a “stable nonunion” may be good enough for patients to have as good of a clinical outcome as a solid, bony fusion. Further investigation is needed to learn more about the efficacy of laminectomy bone as a bone graft substitute. n
References 1. Martin BI, Mirza SK, Spina N, Spiker WR, Lawrence B, Brodke DS. Trends in lumbar fusion procedure rates and associated hospital costs for degenerative spinal diseases in the United States, 2004 to 2015. Spine (Phila Pa 1976). 2019;44(5):369-376. https://doi. org/ 10.1097/BRS.0000000000002822 2. Ghogawala Z, Dziura J, Butler WE, et al. Laminectomy plus fusion versus laminectomy alone for lumbar spondylolisthesis. N Engl J Med. 2016;374(15):1424-1434. https://doi.org/10.1056/NEJMoa1508788
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3. Kornblum MB, Fischgrund JS, Herkowitz HN, Abraham DA, Berkower DL, Ditkoff JS. Degenerative lumbar spondylolisthesis with spinal stenosis: a prospective long-term study comparing fusion and pseudarthrosis. Spine (Phila Pa 1976). 2004;29(7):726-733; discussion 733-734. 4. Ohtori S, Suzuki M, Koshi T, et al. Single-level instrumented posterolateral fusion of the lumbar spine with a local bone graft versus an iliac crest bone graft: a prospective, randomized study with a 2-year follow-up. Eur Spine J. 2011;20(4):635-639. https:// doi.org/10.1007/s00586-010-1656-7
5. Inage K, Ohtori S, Koshi T, et al. One, two-, and three-level instrumented posterolateral fusion of the lumbar spine with a local bone graft: a prospective study with a 2-year follow-up. Spine (Phila Pa 1976). 2011;36(17):1392-1396. 6. Sengupta DK, Truumees E, Patel CK, et al. Outcome of local bone versus autogenous iliac crest bone graft in the instrumented posterolateral fusion of the lumbar spine. Spine (Phila Pa 1976). 2006;31(9):985-991. 7. Park DK, Roberts R, Arnold P, et al. Lumbar spine fusion rates with local bone in posterolateral and combined posterolateral and interbody approaches. J Am Acad Orthop Surg Glob Res Rev. 2019;3(11):e018.
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OPIOIDS
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How to Prescribe Opioids Responsibly: A Summary of the Evidence and a Framework for Postoperative Narcotic Prescription Opioid epidemic. For many of us, these words may be associated with a sort of “alert fatigue,” a natural response to the inundation of opioid-related policy changes, presentations, and publications over the past few years. A recent PubMed search of “opioid” AND “spine” turned up 2,126 results, 588 of which were published since 2017. Sorting through this mountain of information can be overwhelming, especially considering that the use of opioids for pain relief is a complex issue colored by politics and personal sentiments. In this body of literature, however, are several salient messages for today’s spine surgeon. This article aims to distill these lessons as they relate to 2 important goals: (1) protection of the patient and (2) protection of society. Recognizing and achieving these goals can help providers responsibly manage pain while ensuring a functional, comfortable recovery for their patients. When prescribing opioids postoperatively, it is important to recognize patients with preoperative opioid use and remember that these patients are distinct from opioid-naïve patients. Data from the past few years sugisass.org
gests that it is extremely import- Francis Lovecchio, MD ant to consult a pain specialist when considering surgery in the opioid-dependent patient. Additionally, if surgery is indicated, the specialist should be involved in formulating the perioperative pain management plan through well into recovery.1 In opioid-naïve patients, one Sravisht Iyer, MD goal is to prevent acute postsurgical pain from becoming chronic pain. For opioid-naïve or intermittent-use patients, the rate of transition from acute to chronic opioid use after spine surgery has varied depending on the population, the procedure, and the investigator’s chronological definition of chronic use (eg, 3 months vs 1 year). Among opioid-naïve patients with military insurance who underwent fusion or decompression procedures, continued opioid use at 1 year was reported at 0.1%.2 However, general population-based studies have shown much higher rates, from 4% to 20% for fusions or decompressions, reaching as high Vertebral Columns
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as 52% after major spine surgery.3-7 Notably, preoperative opioid use is almost uniformly quoted as the most influential risk factor for the development of chronic opioid use, with a seemingly dose-dependent relationship.3,6 However, this relationship appears to apply to the whole perioperative period—higher initial postoperative prescriptions are also associated with chronic use.8,9 Other traditionally quoted factors, such as psychiatric disorders, male gender, socioeconomic status, and younger age, have had weak and inconsistent relationships with the development of chronic opioid use. Providers should hang their hat on one simple fact—opioids beget more opioids, at any point in the process. This makes sense from a pathophysiologic standpoint, as opioid tolerance and opioid-induced hyperalgesia are 2 phenomena that likely begin in the intra- and early postoperative period (ie, hospitalization).8 Therefore, although insurance claims–based studies help us understand the rate of continued use at 3 months, it is likely well past the critical period for intervention. Spring 2020
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Instead, providers should focus on normative opioid use data that can help them ident i f y aber ra nt opioid consu mpt ion behaviors early, and they should consider en list ing t hese pat ients in taper ing schedules or referring them to specialists well before 3 months, if necessary. At our institution, we found that out of the 10% of patients who continued to take opioids 2 weeks after anterior cervical discectomy and fusion or cervical disc arthroplasty (1 or 2 levels), all of them continued to have nonspecific pain complaints 1 year after surgery. What drives patients to consume opioids in the first place is likely a complex combination of genetic, behavioral, and nuanced psychosocial factors that are difficult to define and may ultimately prove clinically unfeasible to measure in most spine surgery practices.4,10 Instead, identifying aberrant behaviors and intervening early is likely a more effective strategy that surgeons can use to protect their patients from transitioning into chronic users. It is crucial, however, to avoid an unnecessarily painful recovery while limiting opioid use. Opioid research has inherently led to a deeper understanding of postoperative pain in general. Much of the pain experience is related to the patient’s views on pain itself, and not necessarily the nociceptive effects of surgery.11,12 Thus, preoperative patient education is a key element in helping patients manage postoperative pain. Components of an educational program (whether formal or informal) should include information on the postsurgical recovery, expectations for pain, nonpharmaceutical strategies for pain isass.org
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relief, first-line use of adjunct analgesics, and guidelines for the appropriate use of opioids.13 In line with these recommendations, surgeons should re-evaluate the evidence on nonsteroidal anti-inflammatory medications (NSAIDs), as the effect of NSAIDs on fusion is most likely dependent on the dose, duration, and drug.14 Additionally, studies on normative opioid use data can help surgeons decide on procedure-specific quantities for discharge prescriptions, as the “appropriate necessary quantity” of opioids to prescribe is certainly much lower than has been issued in the past.15,16 The second goal of the spine care provider is to protect society from adverse sequelae related to the prescription of opioids. Reducing the amount of leftover narcotic is the most effective way that surgeons can achieve this goal. Medications in the home are the number one way that opioids first become accessible to family or friends to experiment with recreational opioid use.17 To this end, 2 strategies can be employed— increased disposal or source control. Preoperative education on proper pill disposal, improving access to institutional disposal centers, or creative methods to dispose of unused opioids are all part of the former approach.18 However, the disposal of unused medications ultimately relies on the patient, who is preoccupied with his or her surgical recovery. Furthermore, while the costs of this approach are likely small on a case basis, they are likely greater on a national scale, considering the amount of leftover opioids generated by the healthcare system. On the other hand, reducing leftover pills through isass.org
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source control places responsibility back into the providers hands and decreases the demand for opioids. Normative use data can inform providers on the minimal discharge prescription quantity that will allow for pain relief for most patients while also minimizing the number of leftover pills.15 Of note, our own institutional findings have been corroborated by database research showing that approximately one third of patients may never take opioids after hospital discharge, supporting the practice of giving patients the option, rather than the instruction, to fill an opioid prescription.16 The final part of the provider’s role in protecting society is the responsibility to debunk societal misconceptions about opioids for pain relief. General pain management practices are still mired in the idea that “pain is the fifth vital sign,” where differential opioid dosing is performed based on a pain scale that is often poorly understood by the patient. The connection between pain scores and opioid consumption is weak (ie, more opioid use does not consistently translate to increased pain relief). Rather, increased consumption has been linked to less satisfaction with pain relief.12,19 International investigations have shown that many orthopedic surgeries are performed in developed countries using drastically different postoperative pain regimens.20 Spine care providers should inform their patients about these discrepancies between opioid use and pain relief, educating patients that opioids are not the end-all solution to pain but rather play a small role in a comprehensive pain management plan. Vertebral Columns
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In conclusion, essential advances in our knowledge about the role opioids are to play in future pain management strategies have developed over the past few years. The opioid epidemic has taught us that providers must protect both their patients and society when prescribing opioids for pain relief. To
this end, we hope this article provides a framework for how providers should think about opioid research. When presented with new research, providers should ask how the results can help them utilize opioids in an individually effective but socially responsible manner. n
References 1. Soffin EM, Waldman SA, Stack RJ, Liguori GA. An evidence-based approach to the prescription opioid epidemic in orthopedic surgery. Anesth Analg. 2017;125(5):1704-1713. 2. Schoenfeld AJ, Nwosu K, Jiang W, et al. Risk factors for prolonged opioid use following spine surgery, and the association with surgical intensity, among opioid-naive patients. J Bone Joint Surg Am. 2017;99(15):1247-1252. 3. Deyo RA, Hallvik SE, Hildebran C, et al. Use of prescription opioids before and after an operation for chronic pain (lumbar fusion surgery). Pain. 2018;159(6):1147-1154. https://doi. org/10.1097/j.pain.0000000000001202 4. Dunn LK, Durieux ME, Fernández LG, et al. Influence of catastrophizing, anxiety, and depression on in-hospital opioid consumption, pain, and quality of recovery after adult spine surgery. J Neurosurg Spine. 2018;28(1):119-126. 5. Dunn LK, Yerra S, Fang S, et al. Incidence and risk factors for chronic postoperative opioid use after major spine surgery: a cross-sectional study with longitudinal outcome. Anesth Analg. 2018;127(1):247-254. https://doi. org/10.1213/ANE.0000000000003338 6. Pugely AJ, Bedard NA, Kalakoti P, et al. Opioid use following cervical spine surgery: trends and factors associated with long-term use. Spine J. 2018;18(11):1974-1981.
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7. Karhade AV, Cha TD, Fogel HA, et al. Predicting prolonged opioid prescriptions in opioid-naïve lumbar spine surgery patients [published online ahead of print December 31, 2019]. Spine J. https:// doi.org/ 10.1016/j.spinee.2019.12.019
14. Sivaganesan A, Chotai S, White-Dzuro G, McGirt MJ, Devin CJ. The effect of NSAIDs on spinal fusion: a cross-disciplinary review of biochemical, animal, and human studies. Eur Spine J. 2017;26(11):2719-2728.
8. Hayhurst CJ, Durieux ME. Differential opioid tolerance and opioid-induced hyperalgesia: a clinical reality. Anesthesiology. 2016;124(2):483-488.
15. Lovecchio F, Premkumar A, Stepan JG, et al. Opioid consumption patterns after lumbar microdiscectomy or decompression. Spine (Phila Pa 1976). 2019;44(22):1599-1605.
9. Wright AK, Sikora M, Leveque JC. Characterizing the risk of long-term opioid utilization in patients undergoing lumbar spine surgery. Spine (Phila Pa 1976). 2020;45(1):E54-E60. 10. Nickel BT, Klement MR, Byrd WA, et al. The James A. Rand Young Investigator’s Award: battling the opioid epidemic with prospective pain threshold measurement. J Arthroplasty. 2018;33(7S):S3-S7. https:// doi.org/10.1016/j.arth.2018.02.060 11. Goesling J, Moser SE, Zaidi B, et al. Trends and predictors of opioid use after total knee and total hip arthroplasty. Pain. 2016;157(6):1259-1265. 12. Bot AGJ, Bekkers S, Arnstein PM, Smith RM, Ring D. Opioid use after fracture surgery correlates with pain intensity and satisfaction with pain relief. Clin Orthop Relat Res. 2014;472(8):2542-2549. 13. Syed UAM, Aleem AW, Wowkanech C, et al. Neer Award 2018: the effect of preoperative education on opioid consumption in patients undergoing arthroscopic rotator cuff repair: a prospective, randomized clinical trial. J Shoulder Elbow Surg. 2018;27(6):962-967. https:// doi.org/10.1016/j.jse.2018.02.039
16. Cook DJ, Kaskovich S, Pirkle S, et al. Benchmarks of duration and magnitude of opioid consumption after common spinal procedures: a database analysis of 47,823 patients. Spine (Phila Pa 1976). 2019;44:1668-1675. 17. American Society of Addiction Medicine. Opioid addiction 2016 facts & figures. https://www.asam.org/ docs/default-source/advocacy/opioid-addiction-disease-facts-figures. pdf. Accessed April 8, 2020. 18. Brummett CM, Steiger R, Englesbe M, et al. Effect of an activated charcoal bag on disposal of unused opioids after an outpatient surgical procedure: a randomized clinical trial. JAMA Surg. 2019;154(6):558-561. https://doi. org/10.1001/jamasurg.2019.0155 19. Nota SP, Spit SA, Voskuyl T, Bot AG, Hageman MG, Ring D. Opioid use, satisfaction, and pain intensity after orthopedic surgery. Psychosomatics. 2015;56(5):479-485. 20. H elmerhorst GT, Lindenhovius AL, Vrahas M, Ring D, Kloen P. Satisfaction with pain relief after operative treatment of an ankle fracture. Injury. 2012;43(11):1958-1961.
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Regional Anesthesia for Lumbar Spine Surgery Lumbar spine surger y (LSS) has been traditionally performed under general endotracheal anesthesia (GETA). However, regional anesthesia (RA) techniques utilizing local anesthetic are also available. Interest in RA for LSS has grown as providers strive to reduce or eliminate the need for opioid anesthesia and analgesia. In this article, we describe common regional blocks and review the existing literature on their use. Spinal-based regional anesthesia (SBRA) includes spinal and epidural anesthesia techniques. These can be used in isolation or in conjunction with GETA and are performed by an anesthesiologist before, during, or after LSS. With spinal anesthesia, local anesthetic (LA) is placed directly into the intrathecal (subarachnoid) space via a single injection and produces both motor and sensory blockade. It is only performed in the mid- to lower lumbar region to avoid damage to the spinal cord and prevent blockade in the cervical and thoracic regions.1 Isolated spinal anesthesia is recommended for procedures lasting less than 2 hours and for those performed below the T10 level, thus being most appropriate for 1- and 2-level lumbar decompression procedures.2 The use of different LAs has been shown to affect the duration of the blockade. 3 When epidural anesthesia is used for LSS, LA is placed into the epidural space via either isass.org
single-injection4 or catheter 5 2 Alexander Satin, MD levels above the operative level. Care is taken to avoid intrathecal or intravascular injection of LA. The type, volume, and dosage of LA injected into the epidural space affects the duration, dermatomal spread, and density of sensory/motor blockade. Spinal anesthesia is utilized more com- Peter B. Derman, monly than epidural anesthesia MD, MBA in LSS because it is more time efficient, requires less LA, is more reliable, and avoids the presence of foreign material (catheter) within the surgical field.2,6,7 Our focus is on the use of SBRA initiated before incision supplemented with intravenous sedation rather than GETA. Hip and knee joint arthroplasty are almost universally performed in this manner due to the known advantages over GETA, including decreased pulmonary complications, 8 intraoperative blood loss,9 thrombotic events,10 and postoperative cognitive dysfunction. SBRA offers some potential benefits specific to LSS. Surgery performed in the prone position with SBRA avoids any potential intraoperative endotracheal tube loss and allows the patient to self-position, thus minimizing the risk of positioning-related Vertebral Columns
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nerve injury and/or pressure necrosis. The barriers to wider adoption of SBRA for LSS include both patient- and physician-related factors. Certain patients are not candidates for SBRA. Contraindications include patient refusal, seizure history, severe spinal stenosis, intracranial hypertension, coagulopathy, infection at needle site, hypovolemia, and arachnoiditis.11 Unlike GETA, which can easily be extended if the procedure duration runs longer than expected, SBRA, particularly via a single injection technique, has a finite duration and cannot be extended. In addition, establishing an emergency airway once the patient is in the prone position can be challenging. Surgeon concerns pertaining to SBRA include technique-related neurologic complications and the potential impact on neurological function in the immediate postoperative period. In addition, post-anesthesia care unit times may be elevated with SBRA because hemodynamic stability and recovery of motor/sensory block is regularly required for patient discharge.2 Despite these Spring 2020
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concerns, SBRA for LSS has been successfully employed in the clinical setting.12-14 Individual studies comparing GETA and SBRA for LSS have produced disparate results. Zorrilla-Vaca et al15 performed a meta-analysis of randomized studies that combined the findings of 15 clinical trials with a total of 961 patients. The use of SBRA was associated with a significant reduction in intraoperative blood loss, length of stay, and postoperative nausea and vomiting at 24 hours. There were no significant differences in pain scores, surgical time, post-anesthesia care unit time, intraoperative hypotension, urinary retention, or analgesic requirement. However, other studies have demonstrated favorable results for SBRA in terms of analgesic requirements, cost, surgical time, and urinary retention.16,17 SBRA may be beneficial for both healthy patients undergoing simple lumbar decompression procedures and elderly patients who are at high risk for complications with GETA.18 Ultrasound-guided fascial plane blocks, such as t he erector spinae plane (ESP) isass.org
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block, target ner ves located bet ween 2 fascial layers. They are also used for LSS as a supplement to GETA. The ESP block was first described in 2016 by Forero et al19 for the treatment of thoracic neuropathic pain. The erector spinae (ES) muscles are part of the posterior paraspinal muscle column that overlies the bony elements of the spine and are enveloped by a complex sheet of blended aponeuroses and fascia. 20 Loca l anest het ic injected into t he ESP (deep to the ES muscles and superficial to the transverse processes) can spread ventrally to the paravertebral and epidural space and block the spinal nerves as well as the ventral and dorsal rami. 21,22 The ESP block therefore effectively anesthetizes the spine and paraspinal muscles. There is also potential for local anesthetic to spread laterally to the lateral cutaneous nerves. 23 A single point of injection within the ESP can cover multiple nerve territories. The ESP block can be utilized to anesthetize areas ranging from the shoulder girdle to the hip and proximal lower limb.24 For example, LA injection in the ESP at T10-11 can provide RA for lumbosacral spine surgery. 25 The ESP block can consist of a single injection or continuous infusion via a catheter. It is performed by an anesthesiologist either before incision or after completion of surgery. Placement prior to incision may reduce intraoperative opioid administration and avoids any interference from surgical dressings and/or drains. Proponents of the ESP block cite its relative simplicity, efficacy, and wide range of application. 24 Given the potential for blockade of the ventral isass.org
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rami and spinal nerves, some authors have expressed concern regarding the impact of the ESP block on intraoperative neuromonitoring.26 However, such an impact has not been observed in the literature.25 Singh et al 27 performed a randomized clinical trial to evaluate ultrasound-guided ESP blocks as an adjunct to GETA for LSS. Their study included 40 patients undergoing lumbar decompressive procedures and focused on the first 24 hours after surgery. Patients in the experimental group received GETA with bilateral ESP blocks prior to intubation, and those in the control group had GETA alone. ESP was associated with significantly less morphine consumption in the first 24 hours after surgery; all patients in the control group required supplemental morphine, compared with 45% of patients in the block group. Furthermore, ESP block use was associated with significantly higher patient satisfaction as well as lower pain scores immediately after and 6 hours after the surgical procedure. There were no block failures or block-related complications. Despite the favorable evidence for ESP blocks, some authors feel that the ultrasound-guided thoracolumbar interfascial plane (TLIP) block may be a better option for patients undergoing LSS.26 The TLIP block is a peripheral nerve block in which a local anesthetic is injected into the fascial plane between the multifidus and longissimus muscles. Therefore, it exclusively targets the dorsal rami and their branches.28 By sparing the ventral rami, the TLIP block avoids any potential interference with neuromonitoring or the immediate postoperative neurologic Vertebral Columns
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examination. 29 Placing local anesthetic exclusively within the fascial plane avoids intraoperative washout and may provide longer lasting analgesia. 26 A recent prospective, randomized, double-blinded trial demonstrated that supplementing GETA with TLIP blocks placed before incision significantly reduced pain scores, analgesic requirements, and complications in the first 48 hours after LSS. 30 However, high-quality studies directly comparing the ESP and TLIP blocks are needed.
Ultrasound-guided transversus abdominus plane (TAP) blocks may be used for LSS via an anterior approach. The TAP lies between the internal oblique and transversus abdominis muscles. This location is where the intercostal, subcostal, and L1 segmental nerves communicate to form the upper and lower TAP plexuses, which in turn innervate the anterolateral abdominal wall, including the parietal peritoneum. A TAP block delivers local anesthetic to these nerves and thus provides anesthetic coverage to the anterior
References 1. Olawin AM, Das JM. Spinal Anesthesia. StatPearls [Internet]. StatPearls Publishing; 2019. 2. Mergeay M, Verster A, Van Aken D, Vercauteren M. Regional versus general anesthesia for spine surgery. A comprehensive review [editorial]. Acta Anaesthesiol Belg. 2015;66(1):1-9. 3. Şahin AS, Türker G, Bekar A, Bilgin H, Korfalı G. A comparison of spinal anesthesia characteristics following intrathecal bupivacaine or levobupivacaine in lumbar disc surgery. Eur Spine J. 2014;23(3):695-700. 4. Papadopoulos EC, Girardi FP, Sama A, Pappou IP, Urban MK, Cammisa FP Jr. Lumbar microdiscectomy under epidural anesthesia: a comparison study. Spine J. 2006;6(5):561-564. 5. Demirel CB, Kalayci M, Ozkocak I, Aktunkaya H, Ozer Y, Acikgoz B. A prospective randomized study comparing perioperative outcome variables after epidural or general anesthesia for lumbar disc surgery. J Neurosurg Anesthesiol. 2003;15(3):185-192. 6. Benyahia N, Breebaart M, Sermeus L, Vercauteren M. Regional analgesia techniques for spine surgery: a review with special reference to scoliosis fusion. J Spine. 2015;4:208.
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7. Zorrilla-Vaca A, Grant MC, Mirski MA. Anesthesia for spine surgery. In: Prabhakar H, Ali Z, eds. Textbook of Neuroanesthesia and Neurocritical Care: Volume I - Neuroanesthesia. Singapore: Springer Singapore; 2019:189-200. 8. Scott NB, Kehlet H. Regional anaesthesia and surgical morbidity. Br J Surg. 1988;75(4):299-304. 9. Modig J, Karlström G. Intra- and post-operative blood loss and haemodynamics in total hip replacement when performed under lumbar epidural versus general anaesthesia. Eur J Anaesthesiol. 1987;495):345-55. 10. Rodgers A, Walker N, Schug S, et al. Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials. BMJ. 2000;321(7275):1493. 11. Attari MA, Mirhosseini SA, Honarmand A, Safavi MR, et al. Spinal anesthesia versus general anesthesia for elective lumbar spine surgery: A randomized clinical trial. J Res Med Sci. 2011;16(4):524-529. 12. McLain R, Tetzlaff J, Bell G, Lewandrowski KU, Yoon HJ, Rana M. Microdiscectomy: spinal anesthesia offers optimal results in general patient population. J Surg Orthop Adv. 2007;16(1):5-11.
13. McLain RF, Bell GR, Kalfas I, Tetzlaff JE, Yoon HJ. Complications associated with lumbar laminectomy: a comparison of spinal versus general anesthesia. Spine (Phila Pa 1976). 2004;29(22):2542-2547. 14. McLain RF, Kalfas I, Bell GR, Tetzlaff JE, Yoon HJ, Rana M. Comparison of spinal and general anesthesia in lumbar laminectomy surgery: a case-controlled analysis of 400 patients. J Neurosurg Spine. 2005;2(1):17-22. 15. Zorrilla-Vaca A, Healy RJ, Mirski MA. A comparison of regional versus general anesthesia for lumbar spine surgery: a meta-analysis of randomized studies. J Neurosurg Anesthesiol. 2017;29(4):415-425. 16. Morris MT, Morris J, Wallace C, et al. An analysis of the cost-effectiveness of spinal versus general anesthesia for lumbar spine surgery in various hospital settings. Global Spine J. 2019;9(4):368-374. 17. De Rojas JO, Syre P, Welch WC. Regional anesthesia versus general anesthesia for surgery on the lumbar spine: a review of the modern literature. Clin Neurol Neurosurg. 2014;119:39-43.
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abdominal skin, subcutaneous tissue, and musculature. TAP blocks have been shown to reduce postoperative pain and narcotic requirements in the first 24 hours after anterior abdominal surgery. 31-34 More rapid mobilization and less opioid intake may also be expected to be protective against postoperative ileus that can complicate the anterior approach. However, despite their use in LSS, there is a scarcity of literature investigating the impact of TAP blocks in this setting.
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Although a number of different RA techniques exist for LSS, additional high-quality evidence is needed to better evaluate their safety, efficacy, and feasibility for routine clinical practice. Ultimately, the type of anesthetic used for LSS should be based on the comfort of the anesthesiologist, surgeon, and patient. Given the current opioid epidemic in the United States, we are obligated to continue exploring methods that reduce the potential for opioid dependence after LSS. n
References 18. Li Z, Long H, Huang F, Zhang Y, Xu J, Wang X. Impact of epidural versus general anesthesia on major lumbar surgery in elderly patients. Clin Spine Surg. 2019;32(1):E7-E12. 19. Forero M, Adhikary SD, Lopez H, et al. The erector spinae plane block: a novel analgesic technique in thoracic neuropathic pain. Reg Anesth Pain Med. 2016;41(5):621-627. 20. Willard FH, Vleeming A, Schuenke MD, Danneels L, Schleip. The thoracolumbar fascia: anatomy, function and clinical considerations. J Anat. 2012;221(6):507-536. 21. Adhikary SD, Bernard S, Lopez H, Chin KJ. Erector spinae plane block versus retrolaminar block: a magnetic resonance imaging and anatomical study. Reg Anesth Pain Med. 2018;43(7):756-762. 22. Schwartzmann A, Peng P, Maciel MA, Forero M. Mechanism of the erector spinae plane block: insights from a magnetic resonance imaging study. Can J Anesth. 2018;65(10):1165-1166. 23. Ivanusic J, Konishi Y, Barrington MJ. A cadaveric study investigating the mechanism of action of erector spinae blockade. Reg Anesth Pain Med. 2018;43(6):567-571.
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24. Chin KJ, Adhikary SD, Forero M. Erector spinae plane (ESP) block: a new paradigm in regional anesthesia and analgesia. Curr Anesthesiol Rep. 2019;9:271-280. 25. Melvin JP, Schrot RJ, Chu GM, Chin KJ. Low thoracic erector spinae plane block for perioperative analgesia in lumbosacral spine surgery: a case series. Can J Anesth. 2018;65(9):1057-1065. 26. Tseng V, Xu JL. Erector spinae plane block for postoperative analgesia in lumbar spine surgery: is there a better option [published online ahead of print July 22, 2019]? J Neurosurg Anesthesiol. https:// doi.org/10.1097/ANA.0000000000000631 27. Singh S, Chaudhary NK. Bilateral ultasound guided erector spinae plane block for postoperative pain management in lumbar spine surgery: a case series. J Neurosurg Anesthesiol. 2019;31(3):354. 28. Hand WR, Taylor JM, Harvey NR, et al. Thoracolumbar interfascial plane (TLIP) block: a pilot study in volunteers. Can J Anesth. 2015;62(11):1196-1200. 29. Xu JL, Doherty T, Patel R, Galeno J, Dotzauer B. Analgesic efficacy of ultrasound-guided modified thoracolumbar interfascial plane block performed with the use of neurophysiology monitoring for postoperative lumbar surgery. J Clin Anesth. 2019;52:21-23.
30. Ueshima H, Hara E, Otake H. Thoracolumbar interfascial plane block provides effective perioperative pain relief for patients undergoing lumbar spinal surgery; a prospective, randomized and double blinded trial. J Clin Anesth. 2019;58:12-17. 31. Baeriswyl M, Kirkham KR, Kern C, Albrecht E. The analgesic efficacy of ultrasound-guided transversus abdominis plane block in adult patients: a meta-analysis. Anesth Analg. 2015;121(6):1640-1654. 32. Brogi E, Kazan R, Cyr S, Giunta F, Hemmerling TM. Transversus abdominal plane block for postoperative analgesia: a systematic review and meta-analysis of randomized-controlled trials. Can J Anesth. 2016;63(10):1184-1196. 33. Ma N, Duncan JK, Scarfe AJ, Schuhmann S, Cameron AL. Clinical safety and effectiveness of transversus abdominis plane (TAP) block in post-operative analgesia: a systematic review and meta-analysis. J Anesth. 2017;31(3):432-452. 34. RipollÊs J, Mezquita SM, Abad A, Calvo J. Analgesic efficacy of the ultrasound-guided blockade of the transversus abdominis plane—a systematic review. Braz J Anesthesiol. 2015;65(4):255-280.
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Triage Pathways in Lumbar Spine Care Brandon P. Hirsch, MD
Back pain is among the most common reasons for patients to seek healthcare, and it is estimated to affect about two thirds of individuals during their lifetime.1 Worldwide, back and neck pain are the fourth-leading cause of disability, behind heart disease, cerebrovascular disease, and respiratory infection.2 Despite the prevalence of back and neck pain, the initial treatment of spinal disorders tends to be fragmented and variable.3 While primary care providers are often the first point of contact for a patient with a spine-related complaint, care is increasingly carried out via specialist referral.4 Although procedural treatment is appropriate for only a small number of patients with spinal disorders, procedural specialists (eg, surgeons, interventional spine providers) often direct care. In most healthcare systems, the availability of specialists has understandably not kept pace with the increasing prevalence of spine-related complaints, leading to delayed access to care, an increase in lost workdays, and reduced patient satisfaction. Several healthcare systems have looked to clinical pathways to improve the appropriateness and timeliness of care for spine-related complaints. In general, the goals of triage pathways in spine care are to reduce the proportion of nonsurgical candidates cared
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for by surgeons while reducing wait times for those patients who meet surgical indications. A variety of mechanisms for triage of referrals exist, including spine surgeon evaluation of referral information, in-person multidisciplinary evaluation by mid-level providers or physiotherapists, evaluation with advanced imaging, and/or use of patient questionnaires regarding their pain pattern.5-8 Protocol-based treatment for low back disorders has long been advocated for in the literature. The Pennsylvania Plan, described in 1979 by Holmes and Rothman, is one of the earliest published algorithmic approaches to spinal complaints.9 This approach describes an initial period of rest and oral medication followed by symptom-directed nonsurgical treatment with a combination of exercise, isass.org
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education, and interventional treatments; selective diagnostic imaging is performed for those patients who fail to respond. Surgical treatment with laminectomy or fusion was considered only for those patients who had failed to respond to nonoperative modalities and who had clear imaging findings that confirmed nerve compression or spinal instability. This approach continues to be taught in training programs and informs the way many spine surgeons think about surgical indications today. In 1988, Garfin et al 5 described the experience of a nurse practitioner who used this protocol to manage new patients at a spinal disorders clinic. While objective outcome measurements were not standard in research studies of the time, the authors concluded that the program was cost effective, provided accurate diagnosis without missing serious conditions, and left patients satisfied. Other systems in the United Kingdom, Ireland, Australia, and Canada have successfully utilized physiotherapists (PTs) in the triage of low back complaints.10-12 Robarts et al published an analysis of the first 102 patients seen by an advanced practice physiotherapist who had undergone training by 2 senior spine surgeons.7 Patients were assessed separately by both the therapist and spine surgeon. The authors found agreement as to the need for surgical consultation in 86% of patients. In this series, 70% of patients were deemed not to need a consultation with a surgeon. A similar study in Australia evaluated the outcomes of a PT-led triage clinic for 105 patients presenting with low back complaints.13 Of these patients, 5% required only 1 visit prior isass.org
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to symptom resolution, 71% were successfully treated by the PT, and 16% were referred to a surgeon. Half of the patients referred to a surgeon went on to have spine surgery. Primary care providers were satisfied with management via the PT-led clinic for 87% of patients, compared with 58% of those patients referred to the general orthopedic clinic. Surgeons and patients alike have a favorable view of non-physician screening to assess lumbar spine complaints. Both groups were surveyed regarding their attitudes toward nonphysician triage in separate Canadian studies.14,15 In a survey of 85 members of the Canadian Spine Society, 78% indicated they would be willing to have a nonphysician provider screen patients with low back pain, while 14% were undecided and 8% were opposed. Of 80 patients responding, 89% were willing to be seen by a nonphysician for their complaint. Of these, 50% of patients indicated they would travel more than 50 kilometers for such a visit. The Canadian system is particularly challenged by a shortage of spine specialists and long waiting lists for care and is thus responsible for much of the published literature on triage. The Saskatchewan Spine Pathway (SSP) is a first of its kind, province-wide care model that was launched in 2010 to improve quality and access to care for lumbar complaints.6 The program trained a majority of the province’s 900+ primary care providers and included financial incentives and expedited referrals in exchange for compliance with the pathway. The pathway begins with classification of symptoms into 4 syndromes described by Hall et al,16 with each syndrome receiving Vertebral Columns
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pattern-specific exercise-based treatment. Patients with traditional red-flag symptoms are referred immediately for evaluation by a surgeon. Initial exercise-based treatment is directed by the primary care providers in the province, including family physicians, chiropractors, and nurse practitioners. Patients who do not respond are then referred to specialized SSP clinics staffed by PTs. Patients with back-dominant symptoms are reassessed and referred for additional mechanical treatment, whereas patients with leg-dominant pain are referred for advanced imaging and surgical consultation. Kindrachuk and Fourney17 published an early retrospective analysis of 87 patients triaged through the SSP and demonstrated promising results with regard to magnetic resonance imaging (MRI) utilization, surgical yield, and accurate identification of red-flag symptoms. Sixty-two of 87 patients (71%) were discharged without requiring surgeon evaluation. SSP clinics were able to identify all patients with red-flag symptoms, ultimately identified by the surgeon. The authors estimated that the SSP reduced the incidence of unnecessary MRI utilization by 53% in this early cohort. Although the overall percentage of patients in the cohort being offered surgery (13%) was in line with historical controls, the surgical yield among patients ultimately referred to a surgeon via the pathway was 44%. The Saskatchewan group published a follow-up study comparing patients presenting to a spine surgeon via the SSP versus the conventional referral process.18 Although the patients were similar demographically, patients referred via the SSP had a significantly higher likelihood Spring 2020
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of being a surgical candidate (59% vs 38%). Patients referred via the SSP had a dramatically reduced wait time for consultation (70 vs 130 days, P<0.0001), as well as shorter wait times for MRI (27 vs 64 days, P<0.0001).18 While the SSP demonstrates the ability of a large-scale regional effort to enhance patient access to care and surgical yield, it required significant governmental resources, time, and effort to implement. Other studies suggest that triage may be accomplished effectively with a simple patient questionnaire designed to differentiate patients with primarily leg symptoms from those with back-dominant symptoms. Published literature has shown this approach to be as effective as evaluation by pain specialists while more accurate than using imaging findings as a screening test.19 Work from the same group also shows that this questionnaire can be used to reprioritize surgical referrals effectively to reduce wait times and increase the proportion of patients seen by a spine surgeon within 3 months of referral.20 This simple intervention is deserving of further investigation in other health systems to determine its applicability to other practice environments. Efficient and appropriate access to spine surgeons remains a challenge in nearly all healthcare systems worldwide. Effective triage of referrals has the potential to significantly reduce patient wait times, improve patient satisfaction, and limit wasteful care. Many methods exist to achieve these system-wide goals, with varying levels of resources required for implementation. The most successful triage endeavors have been carried out within large single-payer environments like the Canadian isass.org
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system, where demand for spine care is high and the supply of spine specialists is insufficient. By contrast, in commercial healthcare systems increasingly focused on improving the value equation for spine care, triage has
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yet to be effectively implemented on a large scale. Future study of triage pathways outside of traditional single-payer systems could have a transformative impact on the cost and quality of modern spine care. n
References 1. Deyo RA, Mirza SK, Martin BI. Back pain prevalence and visit rates: estimates from U.S. national surveys, 2002. Spine (Phila Pa 1976). 2006;31(23):2724-2727. https://doi. org/10.1097/01.brs.0000244618.06877.cd 2. Hurwitz EL, Randhawa K, Yu H, Côté P, Haldeman S. The Global Spine Care Initiative: a summary of the global burden of low back and neck pain studies. Eur Spine J. 2018;27(suppl 6):796-801. https:// doi.org/10.1007/s00586-017-5432-9 3. Fourney DR, Andersson G, Arnold PM, et al. Chronic low back pain: a heterogeneous condition with challenges for an evidence-based approach. Spine (Phila Pa 1976). 2011;36(21 suppl):S1-S9. https:// doi.org/10.1097/BRS.0b013e31822f0a0d 4. Barnett ML, Song Z, Landon BE. Trends in physician referrals in the United States, 1999-2009. Arch Intern Med. 2012;172(2):163-170. https://doi. org/10.1001/archinternmed.2011.722 5. Garfin SR, Kurz LT, Harlow SJ, Katz MM, Weisman M. The effectiveness of a nurse practitioner in screening patients in a spinal disorders clinic. Spine (Phila Pa 1976). 1988;13(1):121-123. https://doi. org/10.1097/00007632-198801000-00031 6. Fourney DR, Dettori JR, Hall H, Härtl R, McGirt MJ, Daubs MD. A systematic review of clinical pathways for lower back pain and introduction of the Saskatchewan Spine Pathway. Spine (Phila Pa 1976). 2011;36(21 suppl):S164-S171. https:// doi.org/10.1097/BRS.0b013e31822ef58f 7. Robarts S, Stratford P, Kennedy D, Malcolm B, Finkelstein J. Evaluation of an advanced-practice physiotherapist in triaging patients with lumbar spine pain: surgeon-physiotherapist level of agreement and patient satisfaction. Can J Surg. 2017;60(4):266-272. https://doi.org/10.1503/cjs.013416
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8. Zarrabian M, Bidos A, Fanti C, et al. Improving spine surgical access, appropriateness and efficiency in metropolitan, urban and rural settings. Can J Surg. 2017;60(5):342-348. https://doi.org/10.1503/cjs.016116
15. Busse JW, Riva JJ, Nash JV, et al. Surgeon attitudes toward nonphysician screening of low back or low back–related leg pain patients referred for surgical assessment. Spine (Phila Pa 1976). 2013;38(7):E402-E408.
9. Holmes HE, Rothman RH. The Pennsylvania Plan: An algorithm for the management of lumbar degenerative disc disease. Spine (Phila Pa 1976). 1979;4(2):156-162. https://doi. org/10.1097/00007632-197903000-00012
16. Hall H, McIntosh G, Boyle C. Effectiveness of a low back pain classification system. Spine J. 2009;9(8):648-657. https://doi. org/10.1016/j.spinee.2009.04.017
10. Bath B, Grona SL, Janzen B. A spinal triage programme delivered by physiotherapists in collaboration with orthopaedic surgeons. Physiother Can. 2012;64(4):356366. https://doi.org/10.3138/ptc.2011-29 11. Murphy S, Blake C, Power CK, Fullen BM. The role of clinical specialist physiotherapists in the management of low back pain in a spinal triage clinic. Ir J Med Sci. 2013;182(4):643-650. https:// doi.org/10.1007/s11845-013-0945-7 12. Wood L, Hendrick P, Boszczyk B, Dunstan E. A review of the surgical conversion rate and independent management of spinal extended scope practitioners in a secondary care setting. Ann R Coll Surg Engl. 2016;98(3):187-191. https:// doi.org/10.1308/rcsann.2016.0054 13. Blackburn MS, Cowan SM, Cary B, Nall C. Physiotherapy-led triage clinic for low back pain. Aust Health Rev. 2009;33(4):663670. https://doi.org/10.1071/AH090663 14. Rempel J, Busse JW, Drew B, et al. Patients’ attitudes toward nonphysician screening of low back and low back related leg pain complaints referred for surgical assessment. Spine (Phila Pa 1976). 2017;42(5):E288-E293.
17. Kindrachuk DR, Fourney DR. Spine surgery referrals redirected through a multidisciplinary care pathway: effects of nonsurgeon triage including MRI utilization. J Neurosurg Spine. 2014;20(1):87-92. https:// doi.org/10.3171/2013.10.spine13434 18. Wilgenbusch CS, Wu AS, Fourney DR. Triage of spine surgery referrals through a multidisciplinary care pathway: a value-based comparison with conventional referral processes. Spine (Phila Pa 1976). 2014;39(22 suppl 1):S129-S135. 19. Simon D, Coyle M, Dagenais S, O’Neil J, Wai EK. Potential triaging of referrals for lumbar spinal surgery consultation: a comparison of referral accuracy from pain specialists, findings from advanced imaging and a 3-item questionnaire. Can J Surg. 2009;52(6):473-480. 20. Coyle MJ, Roffey DM, Phan P, Kingwell SP, Wai EK. 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. J Bone Jt Surg Am. 2018;100(24):2125-2131.
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Why Do We Still Make Patients “NPO Past Midnight”? Grant D. Shifflett, MD
Implementation of evidence-based practices into perioperative care are often beset by obstinate leadership, a fierce defense of traditional methodology, and the status quo. There is perhaps no more obvious example of this than the practice of making patients nil Hanna Jantzi, PA-C per os (NPO, or nothing by mouth) past midnight before a surgical procedure. This has remained a standard protocol for many institutions for three-quarters of a century despite extensive evidence to suggest it is not best practice. So, why do we continue to starve our patients the night before surgery? Under general anesthesia, laryngeal reflexes are absent, allowing stomach contents to pass into the lungs if the patient vomits or has reflux of gastric contents. This concept of perioperative “aspiration pneumonitis” was first published by Mendelson in 1946 after observing women in labor vomiting and aspirating their stomach contents; two of the women died as a result.1 Following his publication, it became standard of care to advise patients to fast before an operation. The purpose of this intervention was to limit the volume of gastric contents and to decrease acidity of those contents, thereby diminishing the risk of aspiration. Spring 2020
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By the 1960s, the dictum shifted to the modern-day concept of NPO past midnight; this “rule” was set without any significant evidence to support the shift in clinical practice. It was not until nearly 40 years later—in 1999—that the American Society of Anesthesiologists (ASA) convened to review the available evidence and reconsider this practice. After careful analysis of the available scientific data and expert opinion, they released new recommendations that patients have a light meal 6 hours before and clear fluids up to 2 hours before their procedure.2 Despite these recommendations and a significant growth in data to support these guidelines, most patients in the US today are st ill subject to t he outdated, more draconian measures from the 1960s. For example, a report looking at hospitals in Michigan indicated that only 25% were compliant with the “modern” ASA recommendations. 3 There are a variety of reasons changes in clinical practice have been nothing short of sluggish. First, “NPO past midnight” is the default position of comfort for most. Many providers and administrators elect to be on the “safe side” by following the most stringent precautions to get the risk of aspiration as close to zero as possible. Furthermore, there is a level of convenience and efficiency that goes along with mainisass.org
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taining the same protocol for all patients irrespective of surgical time. Additionally, if a patient’s surgical time were to move up significantly, he or she would still be ready for surgery and avoid any potential delays. Patient confusion and protocol disobedience may also be mitigated. Lastly, a refusal to accept available evidence and claims that the risks of prolonged fasting are overstated have contributed to slow adoption. A lt houg h ma ny faci lit ies have eit her ignored, are resistant to, or are unaware of t he recommendat ions, t here are innumerable reasons why physicians and facilit ies should make t he move. First, anesthesia practice has evolved dramatically since Mendelson’s original report. Among other things, endotracheal tubes were not employed in the mid 1900s and isass.org
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anesthesiologists are no longer using “ether rags,” which had a known side effect of nausea. Furthermore, perioperative use of antacids and anti-emetics have been shown to improve gastric emptying and increase gastric pH.4 As the understanding of gastric emptying has advanced, researchers have shown that gastric volumes are no greater when consuming f luids up to 2 hours preoperatively when compared to prolonged fasting. 5 Additionally, a host of deleterious effects are associated with prolonged fasting, including dehydration, hypoglycemia, electrolyte imbalance, anxiety, irritability, headaches, and even nausea. 6 Putting the human body through surgery is like a metabolic Ironman—would a trainer advise an athlete to undergo prolonged fasting in preparation? Vertebral Columns
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“It is well described that the stress of a surgical intervention prompts the human body to mount a massive catabolic response that is associated with perioperative insulin insensitivity, among other significant deleterious effects.”
To say “the jury is still out” would be to ignore t he prepondera nce of available evidence. A 2010 Cochrane review article looked at 38 randomized controlled trials comparing the effect on postoperative complications of different preoperative fasting regimens on adults.7 They found that patients who were permitted a shortened preoperative f luid fast had no significant difference in gastric volume or pH when compared to t he sta nda rd N PO past m id n ig ht g roup. Flu ids assessed in t hese t ria ls i ncluded water, cof fee, fruit juice, and clear f luids, as well as carbohydrate drinks. A group of resea rc her s i n Sweden went a step furt her and allowed pediatric patients to have f luids up until the moment they were called to the operating room for surgery (approximately 30 minutes on average). They found that aspiration occurred in less than 1% of patients and none of them died as a result. 8 Moreover, new guidelines from the ASA in 2017 as well as recommendations from the European Society of Anesthesiologists both support a liberalized preoperative nutrition protocol over prolonged fasting. 5,6 The debate on the merits is clearly over.
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It took the forward-thinking leaders interested in “fast-track surgery” and “enhanced recovery after surgery” programs to take perioperative nutritional considerations to the next level. It is well described that the stress of a surgical intervention prompts the human body to mount a massive catabolic response that is associated w ith perioperative insulin insensitivity, among other significant deleterious effects. The net effect is prolonged hyperglycemia, which can be associated with significant morbidity. 6 The concept behind preoperative carbohydrate loading is simply to diminish the downstream effects—namely, insulin insensitivity—of the body in “starvation mode” during prolonged NPO. Commonly studied protocols have employed up to 400 mL of clear beverages with 12.5 g carbohydrates per 100 mL of f luid. 9-11 Robust animal studies and clinical trials have likewise shown reductions in postoperative insulin resistance compared to overnight fasting with no significant increase in residual gastric volume.6,12 A 2014 Cochrane review article that examined 19 trials and included more than 1300 patients concluded that preoperative carbohydrate treatment was associated with shortened length of stay compared with placebo or fasting.13 Additionally, an article in the British Journal of Anesthesia in 2017 showed a reduction in the length of hospital stays and improved postoperative muscle function.14 Furthermore, a number of studies have shown significant improvement in key areas of patient comfort such as hunger, thirst, malaise, anxiety, and nausea without any isass.org
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significant perioperative complications.6,7,15 Patient satisfaction is an essential component of achieving high quality outcomes, and, therefore, the value of these markers cannot be overstated. Primum non nocere—first, do no harm— remains a fundamental ethos in the provision of medical care. But, in the modern era, our patients deserve better and our aspirations should undoubtedly be higher. If putting the human body through sur-
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gery is the ultimate stress test, shouldn’t we do more to optimize our patients for surgery? At a bare minimum, adherence to the American Society of Anesthesiologists’ guidelines on preoperative fasting should be ex pected. A nd, whi le per ioperat ive interventional nutritional programs may warrant further investigation, when the evidence is sufficient, let’s hope it doesn’t take another 75 years for surgeons to get onboard. n
References 1. Mendelson CL. The aspiration of stomach contents into the lungs during obstetric anesthesia. Am J Obstet Gynecol. 1946;52(2):191-205. https://doi. org/10.1016/s0002-9378(16)39829-5 2. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: an updated report by the American Society of Anesthesiologists Task Force on Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration. Anesthesiology. 2017;126(3):376-393. https:// doi.org/10.1097/ALN.0000000000001452 3. Thampy MS, Issa HA, Schostak ML, Soto RG. To eat or not to eat: examining adherence to ASA NPO guidelines among Michigan hospitals. Presented at: American Society of Anesthesiologists, October 22, 2016. http://www.asaabstracts. com/strands/asaabstracts/abstract. htm?year=2016&index=1&absnum=4845 4. Mahajan V, Hashmi J, Singh R, Samra T, Aneja S. Comparative evaluation of gastric pH and volume in morbidly obese and lean patients undergoing elective surgery and effect of aspiration prophylaxis. J Clin Anesth. 2015:27(5):396-400. https:// doi.org/10.1016/j.jclinane.2015.03.004
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5. Maekawa N, Mikawa K, Yaku H, Nishina K, Obara H. Effects of 2-, 4- and 12-hour fasting intervals on preoperative gastric fluid pH and volume, and plasma glucose and lipid homeostasis in children. Acta Anaesthesiol Scand. 1993;37(8):783-787. https://doi. org/10.1111/j.1399-6576.1993.tb03810.x 6. Nygren J. The metabolic effects of fasting and surgery. Best Practice Res Clin Anaesthesiol. 2006;20(3):429-438. https://doi.org/10.1016/j.bpa.2006.02.004 7. Brady MC, Kinn S, Stuart P, Ness V. Preoperative fasting for adults to prevent perioperative complications. Cochrane Database Syst Rev. 2003;(4):CD004423. https:// doi.org/10.1002/14651858.CD004423. 8. Andersson H, Zarén B, Frykholm P. Low incidence of pulmonary aspiration in children allowed intake of clear fluids until called to the operating suite. Pediatr Anesth. 2015;25(8):770–777. https://doi.org/10.1111/pan.12667 9. Bisgaard T, Kristiansen VB, Hjortsø NC, Jacobsen LS, Rosenberg J, Kehlet H. Randomized clinical trial comparing an oral carbohydrate beverage with placebo before laparoscopic cholecystectomy. Br J Surg. 2004;91(2):151-158. https://doi.org/10.1002/bjs.4412
10. Mathur S, Plank LD, McCall JL, et al. Randomized controlled trial of preoperative oral carbohydrate treatment in major abdominal surgery. Br J Surg. 2010;97(4):485-494. https://doi.org/10.1002/bjs.7026 11. Wang ZG, Wang Q, Wang WJ, Qin HL. Randomized clinical trial to compare the effects of preoperative oral carbohydrate versus placebo on insulin resistance after colorectal surgery. Br J Surg. 2010;97(3):317-327. https://doi.org/10.1002/bjs.6963 12. Ljungqvist O, Søreide E. Preoperative fasting [review]. Br J Surg. 2003;90(4):400406. https://doi.org/10.1002/bjs.4066 13. Smith MD, McCall J, Plank L, Herbison GP, Soop M, Nygren J. Preoperative carbohydrate treatment for enhancing recovery after elective surgery. Cochrane Database Syst Rev. 2014;(8):CD009161. https://doi. org/10.1002/14651858.cd009161.pub2 14. Fawcett WJ, Ljungqvist O. Starvation, carbohydrate loading, and outcome after major surgery. BJA Educ. 2017;17(9):312316. https://doi.org/10.1093/bjaed/mkx015 15. Hausel J, Nygren J, Lagerkranser M, et al. A carbohydrate-rich drink reduces preoperative discomfort in elective surgery patients. Anesth Analg. 2001;93(5):1344-1350. https://doi. org/10.1097/00000539-200111000-00063
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How Does PROMIS Correlate With Commonly Used Outcomes Tools in Spine Surgery? What Spine Surgeons Need to Know Avani Vaishnav, MBBS
Patient-Reported Outcomes Measurement Information System (PROMIS), the development of which was sponsored by the National Institutes of Health, is a relatively new patient-reported outcome measure tool that is increasingly being utilized. Catherine Himo Gang, PROMIS was designed to be a MPH general health measure that can be used across diseases and patient populations, and it includes more than 300 domains relating to physical health and function, various symptomatology, behavioral patterns and changes, and Sheeraz Qureshi, MD, mental health. PROMIS domains MBA are available as static short forms (SFs), computer adaptive tests, and profiles. Due to the large number of domains, as well as the various formats of administration, there is a wide variability in the literature on the type of PROMIS used. While this variability in the literature allows for customization in terms of selectSpring 2020
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ing the most applicable domains and the most feasible methods of administration, it also makes it difficult to synthesize the current literature and understand how the utility and clinically important thresholds (eg, minimal clinically important difference; substantial clinical benefit) vary with changes in the above factors. Furthermore, published studies have used varying thresholds for the correlation coefficient (r) to determine the strength of correlation. Thus, when assessing studies that use PROMIS, it is imperative to note these details and interpret the findings in the appropriate context. To determine the clinical relevance and value of PROMIS in patients undergoing spine surgery, numerous studies have evaluated the psychometric properties of PROMIS domains and assessed their correlation with legacy measures. A recent systematic review1 found that physical function (PF) and pain interference (PI) are the most commonly used domains in spine literature, with an equal distribution between computer adaptive tests and SF instruments. Overall, the Oswestry Disability Index (ODI) has been shown to be highly correlated with isass.org
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the PF and PI1-10 domains at various follow-up time points and in patients with diverse pathology (eg, degenerative disease, deformity, tumors). The ODI has been observed to have strong correlations (r>0.7) in a majority of studies, regardless of the format or method of administration. The ODI also showed a strong correlation with Pain Intensity 2 and a moderate to strong correlation with Pain Behavior.3-5 Similarly, the correlation between the Neck Disability Index and PROMIS-PF and PI was reported as strong in a majority of studies.4,6-11 One study did, however, find a moderate correlation,12 and another reported varying degrees of correlation depending on the time point of assessment.13 Correlation of PI and visual analog scale (VAS) pain scores is variable, with moderate to strong correlations reported between PI and back pain,2,14-16 but the correlations for neck pain range from weak to strong. 2,8,11,16 The values for radicular pain in the arm or leg varied from weak to moderate.2,7,11,15,16 The correlation between VAS and PF was generally moderate.10 While one study showed the revised Scoliosis Research Society 22-Item (SRS-22r) pain and activity scores were correlated with PROMIS-PI and PF, respectively, this study did not directly collect PROMIS responses and instead utilized PROsetta Stone crosswalk tables to obtain PROMIS scores, thereby biasing the results.17 However, other studies evaluating the correlation between SRS-22r and PROMIS domains have found moderate18 to strong19,20 correlations. Similar results were seen in pediatric patients using pediatric PROMIS domains.21 isass.org
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“To determine the clinical relevance and value of PROMIS in patients undergoing spine surgery, numerous studies have evaluated the psychometric properties of PROMIS domains and assessed their correlation with legacy measures.“ Other patient-reported outcomes such as the SF for physical health showed a moderate to strong correlation with PF3,5,10,12,15,22 and a moderate correlation with PI and Pain Behavior. 3,12,22 Additionally, although evaluation of anxiety and depression is not routinely performed in spine patients, legacy measures such as the Generalized Anxiety Disorder 7-Item scale and the Patient Health Questionnaire-9 were found to be highly correlated with corresponding PROMIS domains in these patients.22,23 Thus, PROMIS physical function appears to be highly correlated with the ODI and the Neck Disability Index in patients with lumbar and cervical pathology, respectively. Additionally, PROMIS pain domains show a moderate-to-strong correlation with VAS back, but not with VAS neck or VAS extremities. While the correlation between SRS-22r domains and corresponding PROMIS domains was also moderate to strong, there are currently few studies on this topic, thus limiting the degree of confidence with which these results can be interpreted. Despite the SF and PROMIS being general health tools, both showed only a moderate correlation. In contrast, PROMIS anxiety and depression demonstrated a strong correlation with legacy measures. n Vertebral Columns
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References 1. Haws BE, Khechen B, Bawa MS, et al. The Patient-Reported Outcomes Measurement Information System in spine surgery: a systematic review. J Neurosurg Spine. 2019;30(3):405-413. https:// doi.org/10.3171/2018.8.SPINE18608 2. Tishelman JC, Vasquez-Montes D, Jevotovsky DS, et al. Patient-Reported Outcomes Measurement Information System instruments: outperforming traditional quality of life measures in patients with back and neck pain. J Neurosurg Spine. 2019;30(4):545-550. https://doi. org/10.3171/2018.10.SPINE18571 3. Bhatt S, Boody BS, Savage JW, Hsu WK, Rothrock NE, Patel AA. Validation of Patient-reported Outcomes Measurement Information System computer adaptive tests in lumbar disk herniation surgery. J Am Acad Orthop Surg. 2019;27(3):95-103. https://doi. org/10.5435/JAAOS-D-17-00300 4. 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). 2016;41(14):1153-1159. https:// doi.org/10.1097/BRS.0000000000001518 5. Patel AA, Dodwad S-NM, Boody BS, 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). 2018;43(21):1521-1528. https://doi. org/10.1097/BRS.0000000000002648 6. Bernstein DN, Bakhsh W, Papuga MO, Menga EN, Rubery PT, Mesfin A. An evaluation of PROMIS in patients with primary or metastatic spine tumors. Spine (Phila Pa 1976). 2019;44(10):747-752. https:// doi.org/10.1097/BRS.0000000000002934 7. Hung M, Saltzman CL, Voss MW, et al. Responsiveness of the Patient-Reported Outcomes Measurement Information System (PROMIS), Neck Disability Index (NDI) and Oswestry Disability Index (ODI) instruments in patients with spinal disorders. Spine J. 2019;19(1):34-40. https:// doi.org/10.1016/j.spinee.2018.06.355 8. Owen RJ, Khan AZ, McAnany SJ, Peters C, Zebala LP. PROMIS correlation with NDI and VAS measurements of physical function and pain in surgical patients with cervical disc herniations and radiculopathy. J Neurosurg Spine. 2019;31(4):519-524. https://
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doi.org/10.3171/2019.4.spine18422 9. Owen RJ, Zebala LP, Peters C, McAnany S. PROMIS physical function correlation with NDI and mJOA in the surgical cervical myelopathy patient population. Spine (Phila Pa 1976). 2018;43(8):550-555. https://doi. org/10.1097/BRS.0000000000002373 10. Khechen B, Patel DV, Haws BE, et al. Evaluating the concurrent validity of PROMIS physical function in anterior cervical discectomy and fusion. Clin Spine Surg. 2019;32(10):449-453. https:// doi.org/10.1097/BSD.0000000000000786 11. Moses MJ, Tishelman JC, Stekas N, et al. Comparison of Patient Reported Outcome Measurement Information System (PROMIS) with Neck Disability Index (NDI) and Visual Analog Scale (VAS) in patients with neck pain. Spine (Phila Pa 1976). 2019;44(3):E162-E167. https://doi. org/10.1097/BRS.0000000000002796 12. Boody BS, Bhatt S, Mazmudar AS, Hsu WK, Rothrock NE, Patel AA. Validation of Patient-Reported Outcomes Measurement Information System (PROMIS) computerized adaptive tests in cervical spine surgery. J Neurosurg Spine. 2018;28(3):268-279. https:// doi.org/10.3171/2017.7.SPINE17661 13. Vaishnav AS, Gang CH, Iyer S, McAnany S, Albert T, Qureshi SA. Correlation between NDI, PROMIS and SF-12 in cervical spine surgery. Spine J. 2020;20(3):409-416. https://doi. org/10.1016/j.spinee.2019.10.017 14. Khechen B, Haws BE, Patel DV, et al. PROMIS Physical Function Score strongly correlates with legacy outcome measures in minimally invasive lumbar microdiscectomy. Spine (Phila Pa 1976). 2019;44(6):442-446. https://doi. org/10.1097/BRS.0000000000002841 15. Haws BE, Khechen B, Guntin JA, Cardinal KL, Bohl DD, Singh K. Validity of PROMIS in minimally invasive transforaminal lumbar interbody fusion: a preliminary evaluation. J Neurosurg Spine. 2018;29(1):28-33. https://doi. org/10.3171/2017.11.SPINE17989 16. Sharma M, Ugiliweneza B, Beswick J, Boakye M. Concurrent validity and comparative responsiveness of PROMIS-SF versus legacy measures in the cervical and lumbar spine population: longitudinal analysis from baseline to postsurgery. World Neurosurg. 2018;115:e664-e675. https://
doi.org/10.1016/j.wneu.2018.04.131 17. Kelly MP, Kallen MA, Shaffrey CI, et al. Examining the Patient-Reported Outcomes Measurement Information System versus the Scoliosis Research Society–22r in adult spinal deformity. J Neurosurg Spine. 2019;30(6):801-806. https://doi. org/10.3171/2018.11.SPINE181014 18. Raad M, Jain A, Huang M, et al. Validity and responsiveness of PROMIS in adult spinal deformity: the need for a self-image domain. Spine J. 2019;19(1):50-55. https://doi. org/10.1016/j.spinee.2018.07.014 19. Ibaseta A, Rahman R, Skolasky RL, Reidler JS, Kebaish KM, Neuman BJ. SRS-22r legacy scores can be accurately translated to PROMIS scores in adult spinal deformity patients. Spine J. 2020;20(2):234-240. https://doi. org/10.1016/j.spinee.2019.09.006 20. Bernstein DN, Papuga MO, Sanders JO, Rubery PT, Menga EN, Mesfin A. Evaluating the correlation and performance of PROMIS to SRS questionnaires in adult and pediatric spinal deformity patients. Spine Deform. 2019;7(1):118-124. https:// doi.org/10.1016/j.jspd.2018.05.010 21. Fedorak GT, Larkin K, Heflin JA, Xu J, Hung M. Pediatric PROMIS is equivalent to SRS-22 in assessing health status in adolescent idiopathic scoliosis. Spine (Phila Pa 1976). 2019;44(20):E1206-E1210. https://doi. org/10.1097/brs.0000000000003112 22. P urvis TE, Neuman BJ, Riley LH 3rd, 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). 2018;43(21):1512-1520. https://doi. org/10.1097/BRS.0000000000002661 23. Purvis TE, Neuman BJ, Riley LH III, Skolasky RL. Comparison of PROMIS anxiety and depression, PHQ-8, and GAD-7 to screen for anxiety and depression among patients presenting for spine surgery. J Neurosurg Spine. 2019;30(4):524-531. https:// doi.org/10.3171/2018.9.SPINE18521
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