CSRS 2015

SAN DIEGO – The overall rate of hospital-acquired pneumonia following cervical spinal cord injury is about 20%, results from a study of national data demonstrated.

“Cervical spinal cord injury patients are at an increased risk for the development of hospital-acquired pneumonia,” lead study author Dr. Pablo J. Diaz-Collado said in an interview after the annual meeting of the Cervical Spine Research Society.

“Complete cord injuries, longer length of stay, ICU stay and ventilation time lead to significantly increased risk of HAP, which then leads to poor inpatient outcomes,” he said. “It is of crucial importance to keep these risk factors in mind when treating patients with cervical spinal cord injuries. There is a need to optimize the management protocols for these patients to help prevent the development of HAPs.”

Dr. Diaz-Collado, an orthopedic surgery resident at Yale–New Haven (Conn.) Hospital, and his associates identified 5,198 cervical spinal cord injury patients in the 2011 and 2012 National Trauma Data Bank (NTDB) to analyze risk factors for the development of HAP and inpatient outcomes in this population. They used multivariate logistic regression to identify independent associations of various risk factors with the occurrence of HAP.

The researchers found that the overall incidence of HAP among cervical spinal cord injury patients was 20.5%, which amounted to 1,065 patients. Factors independently associated with HAP were complete spinal cord injuries (compared to central cord injuries; OR 1.44; P = .009); longer inpatient length of stay (OR 3.08 for a stay that lasted 7-13 days, OR 10.21 for 21-27 days, and OR 14.89 for 35 days or more; P = .001 or less for all associations); longer ICU stay (OR 2.86 for a stay that lasted 9-11 days, OR 3.05 for 12-14 days, and OR 2.94 for 15 days or more; P less than .001 for all associations), and longer time on mechanical ventilation (OR 2.68 for ventilation that lasted 3-6 days, OR 3.76 for 7-13 days, OR 3.98 for 14-20 days, and OR 3.99 for 21 days or more; P less than .001 for all associations).

After the researchers controlled for all other risk factors, including patient comorbidities, Injury Severity Score, and other inpatient complications, HAP was associated with increased odds of death (OR 1.60; P = .005), inpatient adverse events (OR 1.65; P less than .001), discharge to an extended-care facility (OR 1.93; P = .001), and longer length of stay (a mean of an additional 10.93 days; P less than .001).

Dr. Diaz-Collado acknowledged that the study is “limited by the quality of the data entry. In addition, the database does not include classifications of fractures, and thus stratification of the analysis in terms of the different kinds of fractures in the cervical spine is not possible. Finally, procedural codes are less accurate and thus including whether or not patients underwent a surgical intervention is less reliable.”

Dr. Diaz-Collado reported having no financial disclosures.

[email protected]

SAN DIEGO – The overall rate of hospital-acquired pneumonia following cervical spinal cord injury is about 20%, results from a study of national data demonstrated.

“Cervical spinal cord injury patients are at an increased risk for the development of hospital-acquired pneumonia,” lead study author Dr. Pablo J. Diaz-Collado said in an interview after the annual meeting of the Cervical Spine Research Society.

“Complete cord injuries, longer length of stay, ICU stay and ventilation time lead to significantly increased risk of HAP, which then leads to poor inpatient outcomes,” he said. “It is of crucial importance to keep these risk factors in mind when treating patients with cervical spinal cord injuries. There is a need to optimize the management protocols for these patients to help prevent the development of HAPs.”

Dr. Diaz-Collado, an orthopedic surgery resident at Yale–New Haven (Conn.) Hospital, and his associates identified 5,198 cervical spinal cord injury patients in the 2011 and 2012 National Trauma Data Bank (NTDB) to analyze risk factors for the development of HAP and inpatient outcomes in this population. They used multivariate logistic regression to identify independent associations of various risk factors with the occurrence of HAP.

The researchers found that the overall incidence of HAP among cervical spinal cord injury patients was 20.5%, which amounted to 1,065 patients. Factors independently associated with HAP were complete spinal cord injuries (compared to central cord injuries; OR 1.44; P = .009); longer inpatient length of stay (OR 3.08 for a stay that lasted 7-13 days, OR 10.21 for 21-27 days, and OR 14.89 for 35 days or more; P = .001 or less for all associations); longer ICU stay (OR 2.86 for a stay that lasted 9-11 days, OR 3.05 for 12-14 days, and OR 2.94 for 15 days or more; P less than .001 for all associations), and longer time on mechanical ventilation (OR 2.68 for ventilation that lasted 3-6 days, OR 3.76 for 7-13 days, OR 3.98 for 14-20 days, and OR 3.99 for 21 days or more; P less than .001 for all associations).

After the researchers controlled for all other risk factors, including patient comorbidities, Injury Severity Score, and other inpatient complications, HAP was associated with increased odds of death (OR 1.60; P = .005), inpatient adverse events (OR 1.65; P less than .001), discharge to an extended-care facility (OR 1.93; P = .001), and longer length of stay (a mean of an additional 10.93 days; P less than .001).

Dr. Diaz-Collado acknowledged that the study is “limited by the quality of the data entry. In addition, the database does not include classifications of fractures, and thus stratification of the analysis in terms of the different kinds of fractures in the cervical spine is not possible. Finally, procedural codes are less accurate and thus including whether or not patients underwent a surgical intervention is less reliable.”

Dr. Diaz-Collado reported having no financial disclosures.

[email protected]

SAN DIEGO – The overall rate of hospital-acquired pneumonia following cervical spinal cord injury is about 20%, results from a study of national data demonstrated.

“Cervical spinal cord injury patients are at an increased risk for the development of hospital-acquired pneumonia,” lead study author Dr. Pablo J. Diaz-Collado said in an interview after the annual meeting of the Cervical Spine Research Society.

“Complete cord injuries, longer length of stay, ICU stay and ventilation time lead to significantly increased risk of HAP, which then leads to poor inpatient outcomes,” he said. “It is of crucial importance to keep these risk factors in mind when treating patients with cervical spinal cord injuries. There is a need to optimize the management protocols for these patients to help prevent the development of HAPs.”

Dr. Diaz-Collado, an orthopedic surgery resident at Yale–New Haven (Conn.) Hospital, and his associates identified 5,198 cervical spinal cord injury patients in the 2011 and 2012 National Trauma Data Bank (NTDB) to analyze risk factors for the development of HAP and inpatient outcomes in this population. They used multivariate logistic regression to identify independent associations of various risk factors with the occurrence of HAP.

The researchers found that the overall incidence of HAP among cervical spinal cord injury patients was 20.5%, which amounted to 1,065 patients. Factors independently associated with HAP were complete spinal cord injuries (compared to central cord injuries; OR 1.44; P = .009); longer inpatient length of stay (OR 3.08 for a stay that lasted 7-13 days, OR 10.21 for 21-27 days, and OR 14.89 for 35 days or more; P = .001 or less for all associations); longer ICU stay (OR 2.86 for a stay that lasted 9-11 days, OR 3.05 for 12-14 days, and OR 2.94 for 15 days or more; P less than .001 for all associations), and longer time on mechanical ventilation (OR 2.68 for ventilation that lasted 3-6 days, OR 3.76 for 7-13 days, OR 3.98 for 14-20 days, and OR 3.99 for 21 days or more; P less than .001 for all associations).

After the researchers controlled for all other risk factors, including patient comorbidities, Injury Severity Score, and other inpatient complications, HAP was associated with increased odds of death (OR 1.60; P = .005), inpatient adverse events (OR 1.65; P less than .001), discharge to an extended-care facility (OR 1.93; P = .001), and longer length of stay (a mean of an additional 10.93 days; P less than .001).

Dr. Diaz-Collado acknowledged that the study is “limited by the quality of the data entry. In addition, the database does not include classifications of fractures, and thus stratification of the analysis in terms of the different kinds of fractures in the cervical spine is not possible. Finally, procedural codes are less accurate and thus including whether or not patients underwent a surgical intervention is less reliable.”

Dr. Diaz-Collado reported having no financial disclosures.

[email protected]

SAN DIEGO – When necessary, long fusions that extend from the C-spine to the pelvis can result in health-related quality of life improvements, results from a multicenter study suggest.

“Patients with spinal deformities will sometimes require long fusion constructs that extend into the cervical spine,” lead study author Dr. Han-Jo Kim said at the annual meeting of the Cervical Spine Research Society. “The prevalence of these cases is increasing, especially as revision surgery for conditions such as proximal junctional kyphosis increase. They are also indicated for other diagnoses, such a progressive cervical deformity, cervical myelopathy as well as neuromuscular disorders.”

Prior investigations that have examined outcomes for these long constructs usually focus on patients who have had fusions from the upper thoracic spine to the pelvis, added Dr. Kim, an orthopedic spine surgeon at the Hospital for Special Surgery, New York. “To my knowledge, there are no studies in the literature that report on the subset of patients who have had fusions from the cervical spine to the pelvis,” he said. “The question is, even though these revisions may be necessary, does surgical intervention result in improved outcomes for these patients despite the extent of these long fusions?”

In an effort to determine the outcomes and rates of complications in patients who had fusions from the cervical spine to the pelvis, Dr. Kim and his associates conducted a retrospective review of patients who underwent fusions from the cervical spine to the pelvis at four institutions during 2003-2014. The researchers administered outcome scores utilizing the Scoliosis Research Society 22 (SRS-22r) questionnaire; the Oswestry Disability Index (ODI); and the Neck Disability Index (NDI); and collected demographic data including age, body mass index, and follow-up time; medical history including comorbidity data, operative details, radiographic and articular outcomes data; and postoperative complications.

Of 55 patients initially included in the study, complete data were available for 46 (84%). Their average age was 42 years, nearly one-third (30%) were classified as ASA III, 4.2% were smokers, and the average follow-up time was 2.7 years. “The majority of these cases were revision operations, and osteotomies were performed in close to 60% of these patients,” Dr. Kim said. “The average operating time was over 300 minutes, and there was an average of over 2 L of blood loss for these cases.”

The researchers observed improvements in the activity, pain, and mental health domains of the SRS, as well as an improvement in the SRS total score, which improved from an average of 3.0 preoperatively to 3.5 postoperatively (P less than .01). This was greater than the minimally clinically important difference for the SRS-22r. “At least one [minimally clinically important difference] was met in all of the SRS domains, as well as in the NDI,” Dr. Kim said. “There was no change in the ODI, as we would expect for this patient subset.”

Radiographic outcomes improved significantly, he continued, with an average 31-degree correction in maximum kyphosis and a 3.3-cm improvement in sagittal vertical axis. The overall rate of complications was 71%, with major complications comprising about 39% of these cases. Medical complications were high as well (a rate of 61%), as was the rate of surgical complications (43%). More than half of the patients (54%) required reoperation during the follow-up period, and the rate of pseudarthrosis was 29%.

“These results demonstrate improved outcomes following cervical to pelvic fusions, despite the magnitude of their operations and extent of fusion,” Dr. Kim concluded. “In addition, despite the high rate of complications and reoperations, we noted a significant improvement in radiographic and clinical outcomes.”

Dr. Kim disclosed that he is a consultant for Zimmer Biomet and K2M.

[email protected]

SAN DIEGO – When necessary, long fusions that extend from the C-spine to the pelvis can result in health-related quality of life improvements, results from a multicenter study suggest.

“Patients with spinal deformities will sometimes require long fusion constructs that extend into the cervical spine,” lead study author Dr. Han-Jo Kim said at the annual meeting of the Cervical Spine Research Society. “The prevalence of these cases is increasing, especially as revision surgery for conditions such as proximal junctional kyphosis increase. They are also indicated for other diagnoses, such a progressive cervical deformity, cervical myelopathy as well as neuromuscular disorders.”

Prior investigations that have examined outcomes for these long constructs usually focus on patients who have had fusions from the upper thoracic spine to the pelvis, added Dr. Kim, an orthopedic spine surgeon at the Hospital for Special Surgery, New York. “To my knowledge, there are no studies in the literature that report on the subset of patients who have had fusions from the cervical spine to the pelvis,” he said. “The question is, even though these revisions may be necessary, does surgical intervention result in improved outcomes for these patients despite the extent of these long fusions?”

In an effort to determine the outcomes and rates of complications in patients who had fusions from the cervical spine to the pelvis, Dr. Kim and his associates conducted a retrospective review of patients who underwent fusions from the cervical spine to the pelvis at four institutions during 2003-2014. The researchers administered outcome scores utilizing the Scoliosis Research Society 22 (SRS-22r) questionnaire; the Oswestry Disability Index (ODI); and the Neck Disability Index (NDI); and collected demographic data including age, body mass index, and follow-up time; medical history including comorbidity data, operative details, radiographic and articular outcomes data; and postoperative complications.

Of 55 patients initially included in the study, complete data were available for 46 (84%). Their average age was 42 years, nearly one-third (30%) were classified as ASA III, 4.2% were smokers, and the average follow-up time was 2.7 years. “The majority of these cases were revision operations, and osteotomies were performed in close to 60% of these patients,” Dr. Kim said. “The average operating time was over 300 minutes, and there was an average of over 2 L of blood loss for these cases.”

The researchers observed improvements in the activity, pain, and mental health domains of the SRS, as well as an improvement in the SRS total score, which improved from an average of 3.0 preoperatively to 3.5 postoperatively (P less than .01). This was greater than the minimally clinically important difference for the SRS-22r. “At least one [minimally clinically important difference] was met in all of the SRS domains, as well as in the NDI,” Dr. Kim said. “There was no change in the ODI, as we would expect for this patient subset.”

Radiographic outcomes improved significantly, he continued, with an average 31-degree correction in maximum kyphosis and a 3.3-cm improvement in sagittal vertical axis. The overall rate of complications was 71%, with major complications comprising about 39% of these cases. Medical complications were high as well (a rate of 61%), as was the rate of surgical complications (43%). More than half of the patients (54%) required reoperation during the follow-up period, and the rate of pseudarthrosis was 29%.

“These results demonstrate improved outcomes following cervical to pelvic fusions, despite the magnitude of their operations and extent of fusion,” Dr. Kim concluded. “In addition, despite the high rate of complications and reoperations, we noted a significant improvement in radiographic and clinical outcomes.”

Dr. Kim disclosed that he is a consultant for Zimmer Biomet and K2M.

[email protected]

SAN DIEGO – When necessary, long fusions that extend from the C-spine to the pelvis can result in health-related quality of life improvements, results from a multicenter study suggest.

“Patients with spinal deformities will sometimes require long fusion constructs that extend into the cervical spine,” lead study author Dr. Han-Jo Kim said at the annual meeting of the Cervical Spine Research Society. “The prevalence of these cases is increasing, especially as revision surgery for conditions such as proximal junctional kyphosis increase. They are also indicated for other diagnoses, such a progressive cervical deformity, cervical myelopathy as well as neuromuscular disorders.”

Prior investigations that have examined outcomes for these long constructs usually focus on patients who have had fusions from the upper thoracic spine to the pelvis, added Dr. Kim, an orthopedic spine surgeon at the Hospital for Special Surgery, New York. “To my knowledge, there are no studies in the literature that report on the subset of patients who have had fusions from the cervical spine to the pelvis,” he said. “The question is, even though these revisions may be necessary, does surgical intervention result in improved outcomes for these patients despite the extent of these long fusions?”

In an effort to determine the outcomes and rates of complications in patients who had fusions from the cervical spine to the pelvis, Dr. Kim and his associates conducted a retrospective review of patients who underwent fusions from the cervical spine to the pelvis at four institutions during 2003-2014. The researchers administered outcome scores utilizing the Scoliosis Research Society 22 (SRS-22r) questionnaire; the Oswestry Disability Index (ODI); and the Neck Disability Index (NDI); and collected demographic data including age, body mass index, and follow-up time; medical history including comorbidity data, operative details, radiographic and articular outcomes data; and postoperative complications.

Of 55 patients initially included in the study, complete data were available for 46 (84%). Their average age was 42 years, nearly one-third (30%) were classified as ASA III, 4.2% were smokers, and the average follow-up time was 2.7 years. “The majority of these cases were revision operations, and osteotomies were performed in close to 60% of these patients,” Dr. Kim said. “The average operating time was over 300 minutes, and there was an average of over 2 L of blood loss for these cases.”

The researchers observed improvements in the activity, pain, and mental health domains of the SRS, as well as an improvement in the SRS total score, which improved from an average of 3.0 preoperatively to 3.5 postoperatively (P less than .01). This was greater than the minimally clinically important difference for the SRS-22r. “At least one [minimally clinically important difference] was met in all of the SRS domains, as well as in the NDI,” Dr. Kim said. “There was no change in the ODI, as we would expect for this patient subset.”

Radiographic outcomes improved significantly, he continued, with an average 31-degree correction in maximum kyphosis and a 3.3-cm improvement in sagittal vertical axis. The overall rate of complications was 71%, with major complications comprising about 39% of these cases. Medical complications were high as well (a rate of 61%), as was the rate of surgical complications (43%). More than half of the patients (54%) required reoperation during the follow-up period, and the rate of pseudarthrosis was 29%.

“These results demonstrate improved outcomes following cervical to pelvic fusions, despite the magnitude of their operations and extent of fusion,” Dr. Kim concluded. “In addition, despite the high rate of complications and reoperations, we noted a significant improvement in radiographic and clinical outcomes.”

Dr. Kim disclosed that he is a consultant for Zimmer Biomet and K2M.

[email protected]

SAN DIEGO – Among patients undergoing elective surgical spine procedures, the Short Form–6D derived from the Neck Disability Index was more valid and a better responsive measure of general health and quality of life, compared with the Short Form–6D derived from the Short Form–12 or the EuroQol-5D, results from a single-center study showed.

For such quality of life measures to be useful and meaningful, they “should be reproducible, responsive, economical, easy to use, and sensitive to responder burden,” Dr. John A. Sielatycki said at the annual meeting of the Cervical Spine Research Society.

“The EQ-5D is well established and commonly used in many of these studies, as is SF-6D, which in some cases has been shown to be more sensitive in certain disease states,” explained Dr. Sielatycki, a resident in the department of orthopedics at Vanderbilt University, Nashville, Tenn. “The differences between SF-6D and EQ-5D have been studied in a wide variety of disease conditions, but to our knowledge few have looked at this specifically in the setting of cervical spine operations.”

To analyze the validity and responsiveness of the SF-6D (derived from both the SF-12 and the NDI) and the EQ-5D in determining overall health and quality of life following elective cervical spine procedures, Dr. Sielatycki and his associates compared the three tools in 420 consecutive patients who presented over the course of 2 years. Trauma and workers’ compensation cases were excluded from the study, as were patients who had a tumor or an infection.

The researchers collected outcome measures at baseline, 3 months, 6 months, 12 months, and yearly thereafter, and defined meaningful improvement as having a North American Spine Society patient satisfaction score of 1, indicating the procedure “met the patient’s expectations.” Next, they generated receiver operating characteristic curves to discriminate between meaningful and nonmeaningful improvement.

The SF-6D (NDI) was a more valid discriminator of meaningful improvement, compared with the SF-6D (SF-12) or the EQ-5D (area under the curve of .69, .65, and .62, respectively). It was also a more responsive measure, compared with the SF-6D (SF-12) and the EQ-5D (standardized response means difference of .66, .48, and .44, respectively).

“Surgeons, outcomes researchers, and payers should use health metrics that are most responsive to changes in the particular disease in question,” Dr. Sielatycki said. “Based on this analysis, SF-6D derived from NDI may be a more valid and responsive measure of improvement in patients undergoing cervical procedures. We suggest that this metric be used in cost-effectiveness analysis and in calculating quality-adjusted life years for cervical spine patients.”

Dr. Sielatycki acknowledged certain limitations of the study, including the fact that it “should have some external validation done to further corroborate our findings. Our gold standard of meaningful improvement has not been established.”

Dr. Sielatycki reported having no financial disclosures.

[email protected]

SAN DIEGO – Among patients undergoing elective surgical spine procedures, the Short Form–6D derived from the Neck Disability Index was more valid and a better responsive measure of general health and quality of life, compared with the Short Form–6D derived from the Short Form–12 or the EuroQol-5D, results from a single-center study showed.

For such quality of life measures to be useful and meaningful, they “should be reproducible, responsive, economical, easy to use, and sensitive to responder burden,” Dr. John A. Sielatycki said at the annual meeting of the Cervical Spine Research Society.

“The EQ-5D is well established and commonly used in many of these studies, as is SF-6D, which in some cases has been shown to be more sensitive in certain disease states,” explained Dr. Sielatycki, a resident in the department of orthopedics at Vanderbilt University, Nashville, Tenn. “The differences between SF-6D and EQ-5D have been studied in a wide variety of disease conditions, but to our knowledge few have looked at this specifically in the setting of cervical spine operations.”

To analyze the validity and responsiveness of the SF-6D (derived from both the SF-12 and the NDI) and the EQ-5D in determining overall health and quality of life following elective cervical spine procedures, Dr. Sielatycki and his associates compared the three tools in 420 consecutive patients who presented over the course of 2 years. Trauma and workers’ compensation cases were excluded from the study, as were patients who had a tumor or an infection.

The researchers collected outcome measures at baseline, 3 months, 6 months, 12 months, and yearly thereafter, and defined meaningful improvement as having a North American Spine Society patient satisfaction score of 1, indicating the procedure “met the patient’s expectations.” Next, they generated receiver operating characteristic curves to discriminate between meaningful and nonmeaningful improvement.

The SF-6D (NDI) was a more valid discriminator of meaningful improvement, compared with the SF-6D (SF-12) or the EQ-5D (area under the curve of .69, .65, and .62, respectively). It was also a more responsive measure, compared with the SF-6D (SF-12) and the EQ-5D (standardized response means difference of .66, .48, and .44, respectively).

“Surgeons, outcomes researchers, and payers should use health metrics that are most responsive to changes in the particular disease in question,” Dr. Sielatycki said. “Based on this analysis, SF-6D derived from NDI may be a more valid and responsive measure of improvement in patients undergoing cervical procedures. We suggest that this metric be used in cost-effectiveness analysis and in calculating quality-adjusted life years for cervical spine patients.”

Dr. Sielatycki acknowledged certain limitations of the study, including the fact that it “should have some external validation done to further corroborate our findings. Our gold standard of meaningful improvement has not been established.”

Dr. Sielatycki reported having no financial disclosures.

[email protected]

SAN DIEGO – Among patients undergoing elective surgical spine procedures, the Short Form–6D derived from the Neck Disability Index was more valid and a better responsive measure of general health and quality of life, compared with the Short Form–6D derived from the Short Form–12 or the EuroQol-5D, results from a single-center study showed.

For such quality of life measures to be useful and meaningful, they “should be reproducible, responsive, economical, easy to use, and sensitive to responder burden,” Dr. John A. Sielatycki said at the annual meeting of the Cervical Spine Research Society.

“The EQ-5D is well established and commonly used in many of these studies, as is SF-6D, which in some cases has been shown to be more sensitive in certain disease states,” explained Dr. Sielatycki, a resident in the department of orthopedics at Vanderbilt University, Nashville, Tenn. “The differences between SF-6D and EQ-5D have been studied in a wide variety of disease conditions, but to our knowledge few have looked at this specifically in the setting of cervical spine operations.”

To analyze the validity and responsiveness of the SF-6D (derived from both the SF-12 and the NDI) and the EQ-5D in determining overall health and quality of life following elective cervical spine procedures, Dr. Sielatycki and his associates compared the three tools in 420 consecutive patients who presented over the course of 2 years. Trauma and workers’ compensation cases were excluded from the study, as were patients who had a tumor or an infection.

The researchers collected outcome measures at baseline, 3 months, 6 months, 12 months, and yearly thereafter, and defined meaningful improvement as having a North American Spine Society patient satisfaction score of 1, indicating the procedure “met the patient’s expectations.” Next, they generated receiver operating characteristic curves to discriminate between meaningful and nonmeaningful improvement.

The SF-6D (NDI) was a more valid discriminator of meaningful improvement, compared with the SF-6D (SF-12) or the EQ-5D (area under the curve of .69, .65, and .62, respectively). It was also a more responsive measure, compared with the SF-6D (SF-12) and the EQ-5D (standardized response means difference of .66, .48, and .44, respectively).

“Surgeons, outcomes researchers, and payers should use health metrics that are most responsive to changes in the particular disease in question,” Dr. Sielatycki said. “Based on this analysis, SF-6D derived from NDI may be a more valid and responsive measure of improvement in patients undergoing cervical procedures. We suggest that this metric be used in cost-effectiveness analysis and in calculating quality-adjusted life years for cervical spine patients.”

Dr. Sielatycki acknowledged certain limitations of the study, including the fact that it “should have some external validation done to further corroborate our findings. Our gold standard of meaningful improvement has not been established.”

Dr. Sielatycki reported having no financial disclosures.

[email protected]

SAN DIEGO – Functional dependence following elective cervical spine procedures was associated with a significantly increased risk of almost all 30-day complications analyzed, including mortality, a large retrospective analysis of national data demonstrated.

The findings suggest that physicians should “include the patient’s level of functional independence, in addition to more traditional medical comorbidities, in the risk-benefit analysis of surgical decision making,” Dr. Alpesh A. Patel said in an interview in advance of the annual meeting of the Cervical Spine Research Society. “Those individuals with dependence need to be counseled appropriately about their increased risk of complications including mortality.”

Dr. Patel, professor and director of orthopedic spine surgery at Northwestern University Feinberg School of Medicine, Chicago, and his associates retrospectively reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data files from 2006 to 2013 and limited their analysis to patients undergoing elective anterior cervical fusions, posterior cervical fusions, cervical laminectomy, cervical laminotomy, cervical discectomy, or corpectomy. They divided patients into one of three groups based on the following preoperative functional status parameters: independent, comprising those not requiring assistance or any equipment for activities of daily living (ADLs); partially dependent, including those with equipment such as prosthetics, equipment, or devices and requiring some assistance from another person for ADLs; and totally dependent, in which patients require total assistance for all ADLs. The researchers used univariate analysis to compare patient demographics, comorbidities, and 30-day postoperative complications among the three groups, followed by multivariate logistic regression to analyze the independent association of functional dependence on 30-day complications when controlling for procedure and comorbidity variances.

Dr. Patel reported findings from 24,357 patients: 23,620 (97.0%) functionally independent, 664 (2.7%) partially dependent, and 73 (0.3%) totally dependent. Dependent patients were significantly older and had higher rates of all comorbidities (P less than .001), with the exception of obesity (P = .214). In addition, 30-day complication rates were higher for all complications (P less than .001) other than neurological (P =.060) and surgical site complications (P =.668). When the researchers controlled for type of procedure and for disparities in patient preoperative variables, multivariate analyses demonstrated that functional dependence was independently associated with sepsis (odds ratio 6.40; P less than .001), pulmonary (OR 4.13; P less than .001), venous thromboembolism (OR 4.27, P less than .001), renal (OR 3.32; P less than .001), and cardiac complications (OR 4.68; P =.001), along with mortality (OR 8.31; P less than .001).

“The very strong association between functional dependence and mortality was quite surprising,” Dr. Patel said. “It was, to the contrary, also surprising to see that, despite wide variance in medical comorbidities and functional status, surgical complications such as infection and neurological injury were similar in all groups.” He characterized the study as “the first large-scale assessment of functional status as a predictor of patient outcomes after cervical spine surgery. It fits in line with other studies utilizing large databases. Big data analysis of outcomes can be used to identify risk factors for complications including death after surgery. Identifying these factors is important if we are going to improve the care we provide. Accurately quantifying the impact of these risk factors is also critical when we risk stratify and compare hospitals and physicians.”

He acknowledged certain limitations of the study, including the fact that it is a retrospective study “with a heterogeneous population of patients, surgeons, hospitals, and procedures. This adds uncertainty to the analysis at the level of the individual patient but does provide generalizability to a broader patient population.”

Dr. Patel reported having no conflicts of interest.

[email protected]

SAN DIEGO – Functional dependence following elective cervical spine procedures was associated with a significantly increased risk of almost all 30-day complications analyzed, including mortality, a large retrospective analysis of national data demonstrated.

The findings suggest that physicians should “include the patient’s level of functional independence, in addition to more traditional medical comorbidities, in the risk-benefit analysis of surgical decision making,” Dr. Alpesh A. Patel said in an interview in advance of the annual meeting of the Cervical Spine Research Society. “Those individuals with dependence need to be counseled appropriately about their increased risk of complications including mortality.”

Dr. Patel, professor and director of orthopedic spine surgery at Northwestern University Feinberg School of Medicine, Chicago, and his associates retrospectively reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data files from 2006 to 2013 and limited their analysis to patients undergoing elective anterior cervical fusions, posterior cervical fusions, cervical laminectomy, cervical laminotomy, cervical discectomy, or corpectomy. They divided patients into one of three groups based on the following preoperative functional status parameters: independent, comprising those not requiring assistance or any equipment for activities of daily living (ADLs); partially dependent, including those with equipment such as prosthetics, equipment, or devices and requiring some assistance from another person for ADLs; and totally dependent, in which patients require total assistance for all ADLs. The researchers used univariate analysis to compare patient demographics, comorbidities, and 30-day postoperative complications among the three groups, followed by multivariate logistic regression to analyze the independent association of functional dependence on 30-day complications when controlling for procedure and comorbidity variances.

Dr. Patel reported findings from 24,357 patients: 23,620 (97.0%) functionally independent, 664 (2.7%) partially dependent, and 73 (0.3%) totally dependent. Dependent patients were significantly older and had higher rates of all comorbidities (P less than .001), with the exception of obesity (P = .214). In addition, 30-day complication rates were higher for all complications (P less than .001) other than neurological (P =.060) and surgical site complications (P =.668). When the researchers controlled for type of procedure and for disparities in patient preoperative variables, multivariate analyses demonstrated that functional dependence was independently associated with sepsis (odds ratio 6.40; P less than .001), pulmonary (OR 4.13; P less than .001), venous thromboembolism (OR 4.27, P less than .001), renal (OR 3.32; P less than .001), and cardiac complications (OR 4.68; P =.001), along with mortality (OR 8.31; P less than .001).

“The very strong association between functional dependence and mortality was quite surprising,” Dr. Patel said. “It was, to the contrary, also surprising to see that, despite wide variance in medical comorbidities and functional status, surgical complications such as infection and neurological injury were similar in all groups.” He characterized the study as “the first large-scale assessment of functional status as a predictor of patient outcomes after cervical spine surgery. It fits in line with other studies utilizing large databases. Big data analysis of outcomes can be used to identify risk factors for complications including death after surgery. Identifying these factors is important if we are going to improve the care we provide. Accurately quantifying the impact of these risk factors is also critical when we risk stratify and compare hospitals and physicians.”

He acknowledged certain limitations of the study, including the fact that it is a retrospective study “with a heterogeneous population of patients, surgeons, hospitals, and procedures. This adds uncertainty to the analysis at the level of the individual patient but does provide generalizability to a broader patient population.”

Dr. Patel reported having no conflicts of interest.

[email protected]

SAN DIEGO – Functional dependence following elective cervical spine procedures was associated with a significantly increased risk of almost all 30-day complications analyzed, including mortality, a large retrospective analysis of national data demonstrated.

The findings suggest that physicians should “include the patient’s level of functional independence, in addition to more traditional medical comorbidities, in the risk-benefit analysis of surgical decision making,” Dr. Alpesh A. Patel said in an interview in advance of the annual meeting of the Cervical Spine Research Society. “Those individuals with dependence need to be counseled appropriately about their increased risk of complications including mortality.”

Dr. Patel, professor and director of orthopedic spine surgery at Northwestern University Feinberg School of Medicine, Chicago, and his associates retrospectively reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data files from 2006 to 2013 and limited their analysis to patients undergoing elective anterior cervical fusions, posterior cervical fusions, cervical laminectomy, cervical laminotomy, cervical discectomy, or corpectomy. They divided patients into one of three groups based on the following preoperative functional status parameters: independent, comprising those not requiring assistance or any equipment for activities of daily living (ADLs); partially dependent, including those with equipment such as prosthetics, equipment, or devices and requiring some assistance from another person for ADLs; and totally dependent, in which patients require total assistance for all ADLs. The researchers used univariate analysis to compare patient demographics, comorbidities, and 30-day postoperative complications among the three groups, followed by multivariate logistic regression to analyze the independent association of functional dependence on 30-day complications when controlling for procedure and comorbidity variances.

Dr. Patel reported findings from 24,357 patients: 23,620 (97.0%) functionally independent, 664 (2.7%) partially dependent, and 73 (0.3%) totally dependent. Dependent patients were significantly older and had higher rates of all comorbidities (P less than .001), with the exception of obesity (P = .214). In addition, 30-day complication rates were higher for all complications (P less than .001) other than neurological (P =.060) and surgical site complications (P =.668). When the researchers controlled for type of procedure and for disparities in patient preoperative variables, multivariate analyses demonstrated that functional dependence was independently associated with sepsis (odds ratio 6.40; P less than .001), pulmonary (OR 4.13; P less than .001), venous thromboembolism (OR 4.27, P less than .001), renal (OR 3.32; P less than .001), and cardiac complications (OR 4.68; P =.001), along with mortality (OR 8.31; P less than .001).

“The very strong association between functional dependence and mortality was quite surprising,” Dr. Patel said. “It was, to the contrary, also surprising to see that, despite wide variance in medical comorbidities and functional status, surgical complications such as infection and neurological injury were similar in all groups.” He characterized the study as “the first large-scale assessment of functional status as a predictor of patient outcomes after cervical spine surgery. It fits in line with other studies utilizing large databases. Big data analysis of outcomes can be used to identify risk factors for complications including death after surgery. Identifying these factors is important if we are going to improve the care we provide. Accurately quantifying the impact of these risk factors is also critical when we risk stratify and compare hospitals and physicians.”

He acknowledged certain limitations of the study, including the fact that it is a retrospective study “with a heterogeneous population of patients, surgeons, hospitals, and procedures. This adds uncertainty to the analysis at the level of the individual patient but does provide generalizability to a broader patient population.”

Dr. Patel reported having no conflicts of interest.

[email protected]

SAN DIEGO – Compared with age-matched controls, patients with cervical spondylotic myelopathy had a significantly increased incidence of falls, hip fractures, and other injuries, preliminary results from a study of Medicare data suggest.

“Cervical myelopathy is the most common cause of spinal cord dysfunction in patients over age 55,” Dr. Daniel J. Blizzard said at the annual meeting of the Cervical Spine Research Society. “In general, it’s cord compression secondary to their ossification of posterior latitudinal ligament, congenital stenosis, and/or degenerative changes to vertebral bodies, discs, and facet joints. These create an upper motor neuron lesion, which causes gait disturbances, imbalance, loss of manual dexterity and coordination, and sensory changes and weakness.”

Dr. Blizzard, an orthopedic surgery resident at Duke University, Durham, N.C., noted that myelopathy gait is the most common presenting symptom in cervical spondylotic myelopathy (CSM), affecting almost 30% of patients. “It’s present in three-quarters of CSM patients undergoing decompression,” he said. “Cord compression can lead to impaired proprioception, spasticity, and stiffness. We know that this gait dysfunction is multifactorial. Imbalance and unsteadiness lead to compensatory broad-based arrhythmic shuffling and clumsy-appearing gait to maintain balance.”

An estimated one-third of people over age 65 fall at least once per year and this may lead to significant morbidity, including institutionalization, loss of independence, and mortality, Dr. Blizzard continued. “We know that gait dysfunction is a significant risk factor for falls,” he said. “This can be CSM, lower extremity osteoarthritis, deconditioning, or poor vision. The primary cause of a gait disturbance may not be accurately identified, especially if a more obvious cause is already known.”

The researchers set out to determine the fall and injury risk of patients with CSM, “with the goal of guiding attention to what we thought might be a potentially underestimated disease with regard to morbidity, and to provide data to consider when determining the type and timing of CSM treatment,” Dr. Blizzard said. They used the PearlDiver database to search the Medicare sample during 2005-2012, and used ICD-9 codes to identify patients with CSM. They also identified a subpopulation of CSM patients that underwent decompression, “not for the purpose of comparing the effect of decompression, but to identify a population with more severe disease,” he explained. They included a control population with no CSM, vestibular disease, or Parkinson’s disease.

Dr. Blizzard reported preliminary results from a total of 601,390 patients with CSM, 77,346 patients with CSM plus decompression, and 49,550,651 controls. They looked at the incidence of falls, head injuries, skull fractures, subdural hematomas, and other orthopedic injuries including fractures of the hip, femur, leg, ankle, pelvis, and lower extremity sprains. The researchers found that when compared with controls, patients with CSM had a statistically significant increased incidence of all injuries, including hip fracture (risk ratio, 2.62), head injury (RR, 7.34), and fall (RR, 8.08). The incidence of hip fracture, head injury, and fall was also increased among the subset of CSM patients who had undergone decompression (RR of 2.25, 8.34, and 9.62, respectively).

Dr. Blizzard acknowledged certain limitations of the study, including its retrospective design. “Statistical and clinical significance are two very different things,” he emphasized. “When we get numbers this big, everything will become statistically significant, but whether things are clinically significant is up to interpretation. The presence of disease and complications is contingent upon proper coding and recognition by providers. We have no measures of severity, extent, or chronicity of disease.”

Despite such limitations, he concluded that the findings suggest that impact of CSM on morbidity “is probably underestimated by many. Symptoms of CSM can be insidious or masked. Patients can often attribute these to normal effects of aging, and often primary care physicians will not recognize these initial symptoms, especially if there is another confounding presenting complaint.”

Conservative interventions for CSM patients, he said, include gait training/physical therapy, assistive aids, hip pads, exercise programs with balance training, and an assessment of hazards in the home environment. From a surgical standpoint, the findings raise the possibility that surgeons may want to “be more aggressive” in their decision to operate on patients with CSM. “This dataset is in no way able to address this question, but I think it provides interesting information regarding the true morbidity of the disease,” Dr. Blizzard said. “There is clear risk and morbidity with cervical compression. Studies show improvement in patients regardless of age, severity, and chronicity.”

Dr. Blizzard reported having no financial disclosures.

[email protected]

SAN DIEGO – Compared with age-matched controls, patients with cervical spondylotic myelopathy had a significantly increased incidence of falls, hip fractures, and other injuries, preliminary results from a study of Medicare data suggest.

“Cervical myelopathy is the most common cause of spinal cord dysfunction in patients over age 55,” Dr. Daniel J. Blizzard said at the annual meeting of the Cervical Spine Research Society. “In general, it’s cord compression secondary to their ossification of posterior latitudinal ligament, congenital stenosis, and/or degenerative changes to vertebral bodies, discs, and facet joints. These create an upper motor neuron lesion, which causes gait disturbances, imbalance, loss of manual dexterity and coordination, and sensory changes and weakness.”

Dr. Blizzard, an orthopedic surgery resident at Duke University, Durham, N.C., noted that myelopathy gait is the most common presenting symptom in cervical spondylotic myelopathy (CSM), affecting almost 30% of patients. “It’s present in three-quarters of CSM patients undergoing decompression,” he said. “Cord compression can lead to impaired proprioception, spasticity, and stiffness. We know that this gait dysfunction is multifactorial. Imbalance and unsteadiness lead to compensatory broad-based arrhythmic shuffling and clumsy-appearing gait to maintain balance.”

An estimated one-third of people over age 65 fall at least once per year and this may lead to significant morbidity, including institutionalization, loss of independence, and mortality, Dr. Blizzard continued. “We know that gait dysfunction is a significant risk factor for falls,” he said. “This can be CSM, lower extremity osteoarthritis, deconditioning, or poor vision. The primary cause of a gait disturbance may not be accurately identified, especially if a more obvious cause is already known.”

The researchers set out to determine the fall and injury risk of patients with CSM, “with the goal of guiding attention to what we thought might be a potentially underestimated disease with regard to morbidity, and to provide data to consider when determining the type and timing of CSM treatment,” Dr. Blizzard said. They used the PearlDiver database to search the Medicare sample during 2005-2012, and used ICD-9 codes to identify patients with CSM. They also identified a subpopulation of CSM patients that underwent decompression, “not for the purpose of comparing the effect of decompression, but to identify a population with more severe disease,” he explained. They included a control population with no CSM, vestibular disease, or Parkinson’s disease.

Dr. Blizzard reported preliminary results from a total of 601,390 patients with CSM, 77,346 patients with CSM plus decompression, and 49,550,651 controls. They looked at the incidence of falls, head injuries, skull fractures, subdural hematomas, and other orthopedic injuries including fractures of the hip, femur, leg, ankle, pelvis, and lower extremity sprains. The researchers found that when compared with controls, patients with CSM had a statistically significant increased incidence of all injuries, including hip fracture (risk ratio, 2.62), head injury (RR, 7.34), and fall (RR, 8.08). The incidence of hip fracture, head injury, and fall was also increased among the subset of CSM patients who had undergone decompression (RR of 2.25, 8.34, and 9.62, respectively).

Dr. Blizzard acknowledged certain limitations of the study, including its retrospective design. “Statistical and clinical significance are two very different things,” he emphasized. “When we get numbers this big, everything will become statistically significant, but whether things are clinically significant is up to interpretation. The presence of disease and complications is contingent upon proper coding and recognition by providers. We have no measures of severity, extent, or chronicity of disease.”

Despite such limitations, he concluded that the findings suggest that impact of CSM on morbidity “is probably underestimated by many. Symptoms of CSM can be insidious or masked. Patients can often attribute these to normal effects of aging, and often primary care physicians will not recognize these initial symptoms, especially if there is another confounding presenting complaint.”

Conservative interventions for CSM patients, he said, include gait training/physical therapy, assistive aids, hip pads, exercise programs with balance training, and an assessment of hazards in the home environment. From a surgical standpoint, the findings raise the possibility that surgeons may want to “be more aggressive” in their decision to operate on patients with CSM. “This dataset is in no way able to address this question, but I think it provides interesting information regarding the true morbidity of the disease,” Dr. Blizzard said. “There is clear risk and morbidity with cervical compression. Studies show improvement in patients regardless of age, severity, and chronicity.”

Dr. Blizzard reported having no financial disclosures.

[email protected]

SAN DIEGO – Compared with age-matched controls, patients with cervical spondylotic myelopathy had a significantly increased incidence of falls, hip fractures, and other injuries, preliminary results from a study of Medicare data suggest.

“Cervical myelopathy is the most common cause of spinal cord dysfunction in patients over age 55,” Dr. Daniel J. Blizzard said at the annual meeting of the Cervical Spine Research Society. “In general, it’s cord compression secondary to their ossification of posterior latitudinal ligament, congenital stenosis, and/or degenerative changes to vertebral bodies, discs, and facet joints. These create an upper motor neuron lesion, which causes gait disturbances, imbalance, loss of manual dexterity and coordination, and sensory changes and weakness.”

Dr. Blizzard, an orthopedic surgery resident at Duke University, Durham, N.C., noted that myelopathy gait is the most common presenting symptom in cervical spondylotic myelopathy (CSM), affecting almost 30% of patients. “It’s present in three-quarters of CSM patients undergoing decompression,” he said. “Cord compression can lead to impaired proprioception, spasticity, and stiffness. We know that this gait dysfunction is multifactorial. Imbalance and unsteadiness lead to compensatory broad-based arrhythmic shuffling and clumsy-appearing gait to maintain balance.”

An estimated one-third of people over age 65 fall at least once per year and this may lead to significant morbidity, including institutionalization, loss of independence, and mortality, Dr. Blizzard continued. “We know that gait dysfunction is a significant risk factor for falls,” he said. “This can be CSM, lower extremity osteoarthritis, deconditioning, or poor vision. The primary cause of a gait disturbance may not be accurately identified, especially if a more obvious cause is already known.”

The researchers set out to determine the fall and injury risk of patients with CSM, “with the goal of guiding attention to what we thought might be a potentially underestimated disease with regard to morbidity, and to provide data to consider when determining the type and timing of CSM treatment,” Dr. Blizzard said. They used the PearlDiver database to search the Medicare sample during 2005-2012, and used ICD-9 codes to identify patients with CSM. They also identified a subpopulation of CSM patients that underwent decompression, “not for the purpose of comparing the effect of decompression, but to identify a population with more severe disease,” he explained. They included a control population with no CSM, vestibular disease, or Parkinson’s disease.

Dr. Blizzard reported preliminary results from a total of 601,390 patients with CSM, 77,346 patients with CSM plus decompression, and 49,550,651 controls. They looked at the incidence of falls, head injuries, skull fractures, subdural hematomas, and other orthopedic injuries including fractures of the hip, femur, leg, ankle, pelvis, and lower extremity sprains. The researchers found that when compared with controls, patients with CSM had a statistically significant increased incidence of all injuries, including hip fracture (risk ratio, 2.62), head injury (RR, 7.34), and fall (RR, 8.08). The incidence of hip fracture, head injury, and fall was also increased among the subset of CSM patients who had undergone decompression (RR of 2.25, 8.34, and 9.62, respectively).

Dr. Blizzard acknowledged certain limitations of the study, including its retrospective design. “Statistical and clinical significance are two very different things,” he emphasized. “When we get numbers this big, everything will become statistically significant, but whether things are clinically significant is up to interpretation. The presence of disease and complications is contingent upon proper coding and recognition by providers. We have no measures of severity, extent, or chronicity of disease.”

Despite such limitations, he concluded that the findings suggest that impact of CSM on morbidity “is probably underestimated by many. Symptoms of CSM can be insidious or masked. Patients can often attribute these to normal effects of aging, and often primary care physicians will not recognize these initial symptoms, especially if there is another confounding presenting complaint.”

Conservative interventions for CSM patients, he said, include gait training/physical therapy, assistive aids, hip pads, exercise programs with balance training, and an assessment of hazards in the home environment. From a surgical standpoint, the findings raise the possibility that surgeons may want to “be more aggressive” in their decision to operate on patients with CSM. “This dataset is in no way able to address this question, but I think it provides interesting information regarding the true morbidity of the disease,” Dr. Blizzard said. “There is clear risk and morbidity with cervical compression. Studies show improvement in patients regardless of age, severity, and chronicity.”

Dr. Blizzard reported having no financial disclosures.

[email protected]

SAN DIEGO – The Neck Disability Index–10 did not perform as well as the Neck Disability Index–5 in assessing patient-reported outcomes in cervical spine patients – and neither was as good as the PROMIS physical function domain delivered by computerized adaptive testing.

Those are the key findings from an analysis of data from more than 500 cervical spine patients treated at University of Utah Health Care in Salt Lake City.

“Previous studies by us and others have shown problems with the NDI [Neck Disability Index] as it is commonly administered” in 10 questions, lead study author Dr. Darrel S. Brodke said in an interview in advance of the annual meeting of the Cervical Spine Research Society. “It has a very poor floor effect, meaning that it does not differentiate between minimally disabled patients, and the scores cannot be appropriately handled with the kinds of statistics that we normally use – though because few of us know this, we still use it as a standard parametric measure.”

In what he said is the first study of its kind, Dr. Brodke, professor of orthopedics at the University of Utah, and his associates set out to compare the psychometric performance of the National Institutes of Health–funded PROMIS (Patient Reported Outcomes Measurement Information System) physical function (PF) domain, administered by computerized adaptive testing, with the standard NDI-10, the NDI-5, and the 36-Item Short Form physical function domain (SF-36 PFD).

In all, 566 patients completed the NDI and PROMIS PF computerized adaptive testing assessments, while 490 also completed the SF-36 PFD.

On average, the NDI-10 took the longest to complete (10 questions in a mean of 183 seconds), followed by the SF-36 PFD (5 questions in a mean of 123 seconds), the NDI-5 (5 questions in a mean of 99 seconds), and the PROMIS PF computerized adaptive testing (between 4 and 12 questions in a mean of 62 seconds).

The psychometric properties of the PROMIS PF computerized adaptive testing were superior to the other outcome measurement tools studied, Dr. Brodke reported. Specifically, the ceiling and floor effects were “excellent” for the PROMIS PF computerized adaptive testing (1.94% and 4.06%, respectively), while the ceiling effects were “fine” for the NDI-10 (4.77%), NDI-5 (7.60%), and SF-36 PFD (11.84%), he said.

However, the floor effects of these three instruments were poor (45.58%, 48.59% and 21.55%, respectively). “The NDI-10 also has the additional challenge of extremely poor raw score to measure correlation,” the researchers noted in their abstract.

“The legacy scale scores significantly predicted the PROMIS PF CAT scores (P less than .0001), with fair correlation for the PF CAT and NDI-10 (0.53) and good correlation of PF CAT and SF-36 PFD (0.62), allowing use of conversion equations to predict scores, which were generated,” the investigators explained.

PROMIS PF computerized adaptive testing “does much better than the NDI or the SF-36 physical function domain at characterizing patients’ physical function, with much better coverage,” Dr. Brodke said. “Not only this, but it is also much faster to fill out, so less burdensome to the patient and the clinic.”

One limitation of the study is that the researchers did not measure the responsiveness aspect of PROMIS performance. “We did not have enough pre- and posttreatment scores to do this measurement yet,” Dr. Brodke said. “The other thing is that minimum clinically important difference [MCID] is not yet worked out for PROMIS in this patient population, though we can infer an MCID as one-half of a standard deviation. More to come in future studies.”

Dr. Brodke reported having no financial disclosures.

[email protected]

SAN DIEGO – The Neck Disability Index–10 did not perform as well as the Neck Disability Index–5 in assessing patient-reported outcomes in cervical spine patients – and neither was as good as the PROMIS physical function domain delivered by computerized adaptive testing.

Those are the key findings from an analysis of data from more than 500 cervical spine patients treated at University of Utah Health Care in Salt Lake City.

“Previous studies by us and others have shown problems with the NDI [Neck Disability Index] as it is commonly administered” in 10 questions, lead study author Dr. Darrel S. Brodke said in an interview in advance of the annual meeting of the Cervical Spine Research Society. “It has a very poor floor effect, meaning that it does not differentiate between minimally disabled patients, and the scores cannot be appropriately handled with the kinds of statistics that we normally use – though because few of us know this, we still use it as a standard parametric measure.”

In what he said is the first study of its kind, Dr. Brodke, professor of orthopedics at the University of Utah, and his associates set out to compare the psychometric performance of the National Institutes of Health–funded PROMIS (Patient Reported Outcomes Measurement Information System) physical function (PF) domain, administered by computerized adaptive testing, with the standard NDI-10, the NDI-5, and the 36-Item Short Form physical function domain (SF-36 PFD).

In all, 566 patients completed the NDI and PROMIS PF computerized adaptive testing assessments, while 490 also completed the SF-36 PFD.

On average, the NDI-10 took the longest to complete (10 questions in a mean of 183 seconds), followed by the SF-36 PFD (5 questions in a mean of 123 seconds), the NDI-5 (5 questions in a mean of 99 seconds), and the PROMIS PF computerized adaptive testing (between 4 and 12 questions in a mean of 62 seconds).

The psychometric properties of the PROMIS PF computerized adaptive testing were superior to the other outcome measurement tools studied, Dr. Brodke reported. Specifically, the ceiling and floor effects were “excellent” for the PROMIS PF computerized adaptive testing (1.94% and 4.06%, respectively), while the ceiling effects were “fine” for the NDI-10 (4.77%), NDI-5 (7.60%), and SF-36 PFD (11.84%), he said.

However, the floor effects of these three instruments were poor (45.58%, 48.59% and 21.55%, respectively). “The NDI-10 also has the additional challenge of extremely poor raw score to measure correlation,” the researchers noted in their abstract.

“The legacy scale scores significantly predicted the PROMIS PF CAT scores (P less than .0001), with fair correlation for the PF CAT and NDI-10 (0.53) and good correlation of PF CAT and SF-36 PFD (0.62), allowing use of conversion equations to predict scores, which were generated,” the investigators explained.

PROMIS PF computerized adaptive testing “does much better than the NDI or the SF-36 physical function domain at characterizing patients’ physical function, with much better coverage,” Dr. Brodke said. “Not only this, but it is also much faster to fill out, so less burdensome to the patient and the clinic.”

One limitation of the study is that the researchers did not measure the responsiveness aspect of PROMIS performance. “We did not have enough pre- and posttreatment scores to do this measurement yet,” Dr. Brodke said. “The other thing is that minimum clinically important difference [MCID] is not yet worked out for PROMIS in this patient population, though we can infer an MCID as one-half of a standard deviation. More to come in future studies.”

Dr. Brodke reported having no financial disclosures.

[email protected]

SAN DIEGO – The Neck Disability Index–10 did not perform as well as the Neck Disability Index–5 in assessing patient-reported outcomes in cervical spine patients – and neither was as good as the PROMIS physical function domain delivered by computerized adaptive testing.

Those are the key findings from an analysis of data from more than 500 cervical spine patients treated at University of Utah Health Care in Salt Lake City.

“Previous studies by us and others have shown problems with the NDI [Neck Disability Index] as it is commonly administered” in 10 questions, lead study author Dr. Darrel S. Brodke said in an interview in advance of the annual meeting of the Cervical Spine Research Society. “It has a very poor floor effect, meaning that it does not differentiate between minimally disabled patients, and the scores cannot be appropriately handled with the kinds of statistics that we normally use – though because few of us know this, we still use it as a standard parametric measure.”

In what he said is the first study of its kind, Dr. Brodke, professor of orthopedics at the University of Utah, and his associates set out to compare the psychometric performance of the National Institutes of Health–funded PROMIS (Patient Reported Outcomes Measurement Information System) physical function (PF) domain, administered by computerized adaptive testing, with the standard NDI-10, the NDI-5, and the 36-Item Short Form physical function domain (SF-36 PFD).

In all, 566 patients completed the NDI and PROMIS PF computerized adaptive testing assessments, while 490 also completed the SF-36 PFD.

On average, the NDI-10 took the longest to complete (10 questions in a mean of 183 seconds), followed by the SF-36 PFD (5 questions in a mean of 123 seconds), the NDI-5 (5 questions in a mean of 99 seconds), and the PROMIS PF computerized adaptive testing (between 4 and 12 questions in a mean of 62 seconds).

The psychometric properties of the PROMIS PF computerized adaptive testing were superior to the other outcome measurement tools studied, Dr. Brodke reported. Specifically, the ceiling and floor effects were “excellent” for the PROMIS PF computerized adaptive testing (1.94% and 4.06%, respectively), while the ceiling effects were “fine” for the NDI-10 (4.77%), NDI-5 (7.60%), and SF-36 PFD (11.84%), he said.

However, the floor effects of these three instruments were poor (45.58%, 48.59% and 21.55%, respectively). “The NDI-10 also has the additional challenge of extremely poor raw score to measure correlation,” the researchers noted in their abstract.

“The legacy scale scores significantly predicted the PROMIS PF CAT scores (P less than .0001), with fair correlation for the PF CAT and NDI-10 (0.53) and good correlation of PF CAT and SF-36 PFD (0.62), allowing use of conversion equations to predict scores, which were generated,” the investigators explained.

PROMIS PF computerized adaptive testing “does much better than the NDI or the SF-36 physical function domain at characterizing patients’ physical function, with much better coverage,” Dr. Brodke said. “Not only this, but it is also much faster to fill out, so less burdensome to the patient and the clinic.”

One limitation of the study is that the researchers did not measure the responsiveness aspect of PROMIS performance. “We did not have enough pre- and posttreatment scores to do this measurement yet,” Dr. Brodke said. “The other thing is that minimum clinically important difference [MCID] is not yet worked out for PROMIS in this patient population, though we can infer an MCID as one-half of a standard deviation. More to come in future studies.”

Dr. Brodke reported having no financial disclosures.

[email protected]