Helen Salisbury: The performance of kindness

Patients arrive at a GP appointment with all manner of symptoms and varying degrees of unease, anxiety, pain, and fear. If we aim for patients to leave feeling better than when they came, they need...

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A Prospective, Psychometric Validation of National Institutes of Health Patient-Reported Outcomes Measurement Information System Physical Function, Pain Interference, and Upper Extremity Computer Adaptive Testing in Cervical Spine Patients: Successes and Key Limitations

Study Design. Prospective Cohort Study Objective. The aim of this study was to validate the Patient Reported Outcomes Measurement Information System (PROMIS) against existing patient-reported outcomes in the cervical spine. Summary of Background Data. Current patient-reported outcomes in cervical spine have substantial limitations. PROMIS offers the potential for improved psychometric properties with reduced questionnaire burden. Methods. Adult patients undergoing cervical spine surgery at a single institution between 2016 and 2018 were prospectively enrolled. Patients completed questionnaires (36-Item Short Form Health Survey [SF-36], Neck Disability Index (NDI), Visual Analog Scale arm/neck, and PROMIS pain Interference [PI], physical Function [PF], and Upper Extremity [UE]) preoperatively and at 6 months postoperatively. Demographic data, diagnosis, and procedural data were recorded. Validation of the instruments was completed with a Rasch Model as well as measurement of coverage, efficiency, test–retest reliability, responsiveness, and convergent validity. Results. Of 197 patients who completed the preoperative survey, 164 were eligible for 6-month follow-up and 139 completed 6-month postoperative surveys. The most common diagnoses were radiculopathy (37.6%), myeloradiculopathy (30.5%), and myelopathy (28.4%). All studied instruments had acceptable fit to a Rasch model. PROMIS computer adaptive testings (CATs) demonstrated improved average time to completion for PI (39 seconds), PF (47 seconds), and UE (54  seconds), compared to NDI (117 s) and SF-36 PCS (175 seconds). Responsiveness for PROMIS CATs was similar to NDI and SF-36, test–retest reliability was lower for PI (intraclass correlation: 0.68), PF (0.70), and UE (0.59), compared to NDI (0.86) and PCS (0.85). For convergent validity, PI was strongly correlated to NDI and PF to SF-36 PCS. There were no significant floor or ceiling effects for the PROMIS domains, although UE had preoperative clustering (n = 18) at a high score (56.4) and PI had postoperative clustering (n = 27) at a low score (38.7). Conclusion. PROMIS CATs demonstrate several advantages, including efficiency and responsiveness, while demonstrating good convergent validity with legacy instruments. Nevertheless, CATs had lower test–retest reliability and had significant clustering at higher levels of function for the PI and UE CATs. These limitations must be considered before broad adoption of CATs in cervical spine patients. Level of Evidence: 3

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Inpatient Pain Scores and Narcotic Utilization Based on American Society of Anesthesiologists Score Following Anterior Cervical Discectomy and Fusion

Study Design. Retrospective. Objective. To examine the relationship between American Society of Anesthesiologists (ASA) score and inpatient pain and narcotics consumption following anterior cervical discectomy and fusion (ACDF). Summary of Background Data. Higher ASA scores have been previously linked to increased postoperative complication rates, healthcare costs, length of stay, and hospital readmissions. However, to our knowledge, there have not been previous investigations into the association between ASA scores and postoperative inpatient pain and narcotics utilization following ACDF. Methods. Patients who underwent a single-level, primary ACDF were retrospectively reviewed and stratified into two cohorts based on ASA score less than or equal to 2 or ASA score more than 2. ASA score was tested for association with demographic variables and perioperative characteristics using student's t test, chi-squared analysis, and Fisher exact test. Inpatient pain scores and narcotics consumption on each postoperative day were then compared between cohorts using bivariate linear regression. Results. Two hundred eleven patients who underwent ACDF were included: 184 had an ASA score less than or equal to 2 and 27 had an ASA score more than 2. Higher ASA score was associated with older age, higher comorbidity burden as measured by the modified Charlson Comorbidity Index (CCI), and lower prevalence of obesity. Higher ASA scores were associated with longer duration of hospital stay, while other perioperative characteristics were similar between ASA score cohorts. There were no differences in inpatient Visual Analog Scale (VAS) pain scores, or hourly, daily, and cumulative inpatient narcotic consumption between cohorts on any postoperative day. Conclusion. This retrospective investigation demonstrated that a higher ASA score is associated with increased operative time following ACDF. However, ASA score was determined not to be an independent risk factor that can predict postoperative pain or narcotics consumption among patients who undergo ACDF. Therefore, postoperative pain in the inpatient setting can be managed with similar modalities regardless of ASA score for patients undergoing ACDF. Level of Evidence: 3

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Broad External Validation and Update of a Prediction Model for Persistent Neck Pain After 12 Weeks

Study Design. A prospective observational study. Objective. To externally validate the prediction model developed by Schellingerhout and colleagues predicting global perceived effect at 12 weeks in patients with neck pain and to update and internally validate the updated model. Summary of Background Data. Only one prediction model for neck pain has undergone some external validation with good promise. However, the model needs testing in other populations before implementation in clinical practice. Methods. Patients with neck pain (n = 773) consulting Norwegian chiropractors were followed for 12 weeks. Parameters from the original prediction model were applied to this sample for external validation. Subsequently, two random samples were drawn from the full study sample. One sample (n = 436) was used to update the model; by recalibration, removing noninformative covariates, and adding new possible predictors. The updated model was tested in the other sample (n = 303) using stepwise logistic regression analysis. Main outcomes for performance of models were discrimination and calibration plots. Results. Three hundred seventy patients (47%) in the full study sample reported persistent pain at 12 weeks. The performance of the original model was poor, area under the receiver operating characteristics curve was 0.55 with a Confidence Interval of 0.51–0.59. The updated model included Radiating pain to shoulder and/or elbow, education level, physical activity, consultation-type (first- time, follow-up or maintenance consultation), expected course of neck pain, previous course of neck pain, number of pain sites, and the interaction term Physical activity##Number of pain sites. The area under the receiver operating characteristics curve was 0.65 with a 95% Confidence Interval of 0.58–0.71 for the updated model. Conclusion. The predictive accuracy of the original model performed insufficiently in the sample of patients from Norwegian chiropractors and the model is therefore not recommended for that setting. Only one predictor from the original model was retained in the updated model, which demonstrated reasonable good performance predicting outcome at 12 weeks. Before considering clinical use, a new external validation is required. Level of Evidence: 3

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Are 15-Year Trajectories of Low Back Pain and Sciatica Associated With Cardiovascular Autonomic Function in the General Population?: The Northern Finland Birth Cohort 1966 Study

Study Design. A population-based cohort study. Objective. The aim of this study was to examine whether 15-year trajectories of low back pain (LBP) and sciatica are associated with cardiovascular autonomic function in a large general population sample. Summary of Background Data. Previous studies using mainly small patient samples have suggested that LBP and sciatica are associated with abnormal cardiovascular autonomic function, namely altered heart rate variability (HRV) and baroreflex sensitivity (BRS). We examined this association in a large general population sample. Methods. The data collections of the Northern Finland Birth Cohort 1966 consisted of pain questionnaires at 31 and 46 years (history of LBP, sciatica, and other musculoskeletal pains during the previous year; yes/no for each) and measurements of HRV and BRS at 46 years (heart rate, HR; root mean square of successive differences in beat-to-beat intervals, rMSSD; low-frequency systolic blood pressure variability, SBPV; cross-spectral BRS, BRS; each while seated and standing). The data collections also comprised several confounders. Trajectories for LBP, sciatica, and both together (“no pain,” “decreasing,” “increasing,” “long-term pain”) were constructed and general linear models were used to perform comparisons between trajectories (for HR/rMSSD, n = 3398; for SBPV/BRS, n = 1667). Results. In the crude models, LBP and sciatica were associated with higher HR, lower rMSSD, higher SBPV, and lower BRS, but these associations were mostly attenuated by adjustments. Regarding both LBP and sciatica, only the “increasing” trajectory was associated with two of the eight outcomes (standing SBPV, seated BRS) after adjustments. Regarding LBP, the “increasing” trajectory was associated with three (standing SBPV, seated BRS, standing BRS), the “long-term pain” trajectory with one (standing BRS), and the “decreasing” trajectory with one outcome (seated SBPV) after adjustments. Sciatica showed no association with the outcomes after adjustments. Conclusion. We conclude that the 15-year trajectories of LBP and sciatica do not have a consistent independent association with cardiovascular autonomic function among the general population. Level of Evidence: 3

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Regional Differences in the Cost and Utilization of Nonoperative Management Within 3 Months Prior to Lumbar Microdiscectomy

Study Design. Retrospective cohort study. Objective. The purpose of this investigation was to evaluate the regional variations in the use of nonoperative therapies in patients diagnosed with a lumbar intervertebral disc herniation 3 months prior to undergoing microdiscectomy surgery. Summary of Background Data. Regional variations in the management of chronic pain conditions have been previously identified. Patients suffering from a lumbar intervertebral disc herniation are typically treated with a brief course of conservative management prior to attempting microdiscectomy surgery. Whether regional differences exist in the utilization or costs of maximum nonoperative therapy (MNT) remains unknown. Methods. Medical records from patients diagnosed with a lumbar intervertebral disc herniation undergoing 1, 2, or 3-level index microdiscectomy operations between 2007 and 2017 were gathered from the HORTHO insurance database consisting of private/commercially insured and Medicare Advantage beneficiaries. Patient regional designation was divided into Midwest, Northeast, South, and West territories and was derived from the insurance claim location. The utilization of MNT within 3 months after initial lumbar herniation diagnosis in adult patients was analyzed. Results. Our population consisted of 13,106 patients who underwent primary index microdiscectomy surgery. Significant regional variation was identified in the nonoperative therapy failure rate (P<0.0001), with the highest proportion of Midwest patients failing (2.7%). There were statistical differences in the regional distribution of patients utilizing NSAIDs (P<0.0001), muscle relaxants (P <0.0001), lumbar epidural steroid injections (P <0.0001), physical therapy and occupational therapy sessions (P <0.0001), chiropractor treatments (P <0.0001), and emergency department services (P = 0.0049). The total direct cost associated with all MNT prior to microdiscectomy was $13,205,924, with 59.6% from the South, 31.1% from the Midwest, 8.3% from the West, and 1.1% from the Northeast. Conclusion. These findings indicate that regional differences exist in the utilization and costs of MNT of a lumbar intervertebral herniated disc prior to microdiscectomy surgery. Level of Evidence: 3

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Opioid Consumption Patterns After Lumbar Microdiscectomy or Decompression

Study Design. Prospective observational study Objective. The aim of this study was to record daily opioid use and pain levels after 1-level lumbar decompression or microdiscectomy. Summary of Background Data. The standardization of opioid-prescribing practices through guidelines can decrease the risk of misuse and lower the number of pills available for diversion in this high-risk patient population. However, there is a paucity of quantitative data on the “minimum necessary amount” of opioid appropriate for post-discharge prescriptions. Methods. At two institutions between September 2017 and 2018, we prospectively enrolled 85 consecutive adult patients who underwent one-level lumbar decompression or microdiscectomy. Patients with a history of opioid dependence were excluded. Daily opioid consumption and pain scores were collected using an automated text-messaging-based platform for 6 weeks or until consumption ceased. Refills during the study period were monitored. Patients were asked for the number of pills left over and the method of disposal. Opioid use was converted to oral morphine equivalents (OMEs). Results are also reported in terms of “pills” (oxycodone 5 mg equivalents) to facilitate clinical applications. Risk factors were compared between patients in the top and bottom half of opioid consumption. Results. Total opioid consumption ranged from 0 to 118 pills, with a median consumption of 32 pills (236.3 OME). Seventy-five percent of patients consumed ≤57 pills (431.3 OME). Mean Numeric Rating Scale pain scores declined steadily over the first 2 weeks. By postoperative day 7 half of the study population had ceased taking opioids altogether. Only 22.4% of patients finished their initial prescription, and only 9.4% of patients obtained a refill. Conclusion. These data may be used to formulate evidence-based opioid prescription guidelines, establish benchmarks, and identify patients at the higher end of the opioid use spectrum. Level of Evidence: 2

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