Association of Preoperative Physical Function and Changes in Mental Health After Minimally Invasive Transforaminal Lumbar Interbody Fusion

Nathaniel W. Jenkins; James M. Parrish; Conor P. Lynch; Elliot D.K. Cha; Caroline N. Jadczak; Shruthi Mohan; Cara E. Geoghegan; Kern Singh

doi:10.14444/8197

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Figure 1
6-week (A) Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS PF) and (B) Patient Health Questionnaire-9 (PHQ-9) improvement plotted against preoperative PROMIS PF scores. PROMIS score change slope was −0.4827 (P < 0.0001), and PHQ-9 score change slope was 0.0284 (P = 0.7362).
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Figure 2
12-week (A) Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS PF) and (B) Patient Health Questionnaire-9 (PHQ-9) improvement plotted against preoperative PROMIS PF scores. PROMIS score change slope was −0.7039 (P < 0.0001), and PHQ-9 score slope was 0.8258 (P = 0.2661).
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Figure 3
6-month (A) Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS PF) and (B) Patient Health Questionnaire-9 (PHQ-9) improvement plotted against preoperative PROMIS PF scores. PROMIS score change slope was −0.6751 (P < 0.0001), and PHQ-9 score change slope was 0.08389 (P = 0.3149).
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Figure 4
1-year (A) Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS PF) and (B) Patient Health Questionnaire-9 (PHQ-9) improvement plotted against preoperative PROMIS PF scores. PROMIS score change slope was −0.3493 (P = 0.0705), and PHQ-9 score change slope was −0.0459 (P = 0.7642).

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Table 1

Patient demographics by PROMIS score.

Demographic	Total (N = 119)	PROMIS ≥35 (n = 55)	PROMIS <35 (n = 64)	P Value^a
Age (mean + SD)	52.2 ± 10.7	51.7 ± 11.6	52.6 ± 10.0	0.619
Gender, n (%)				0.002
Female	55 (46.2%)	17 (31.0%)	38 (59.4%)
Male	64 (53.8%)	38 (69.0%)	26 (40.6%)
Body mass index, n (%)				0.002
Nonobese (<30 kg/m²)	62 (52.1%)	37 (67.3%)	25 (39.1%)
Obese (≥30 kg/m²)	57 (47.9%)	18 (32.7%)	39 (60.9%)
Smoking status, n (%)				0.996
Non-smoker	106 (89.1%)	49 (89.1%)	57 (89.1%)
Smoker	13 (10.9%)	6 (10.9%)	7 (10.9%)
Insurance coverage, n (%)				0.387
Private or WC	115 (96.6%)	54 (98.2%)	61 (95.3%)
Medicare/Medicaid	4 (3.4%)	1 (1.8%)	3 (4.7%)
Ageless CCI, mean ± SD	0.96 ± 1.0	0.84 ± 1.1	1.06 ± 1.0	0.233
Preoperative PHQ-9, mean ± SD	6.9 ± 6.6	5.4 ± 6.0	8.3 ± 6.8	0.018
Preoperative diagnoses, n (%)^b
Myocardial infarction	3 (2.5%)	2 (3.6%)	1 (1.6%)	0.472
Uncomplicated diabetes	10 (8.4%)	3 (5.5%)	7 (11.0%)	0.282
Complicated diabetes	2 (1.7%)	1 (1.8%)	1 (1.6%)	0.914
Hypertension	39 (32.8%)	16 (29.1%)	23 (36.0%)	0.428
Neurologic disease	2 (1.7%)	1 (1.8%)	1 (1.6%)	0.914
Arthritis	22 (18.5%)	7 (12%)	15 (23.4%)	0.133
Malignancy	12 (10.1%)	5 (9.1%)	7 (11.0%)	0.739

Boldface indicates statistical significance (P < 0.05).
aP value was calculated using Student t test (continuous), χ ² (categorical), or Fisher exact test (categorical).
bThere were no patients in our study with a recorded medical history of AIDS, paraplegia, congestive heart failure, peripheral vascular disease, metastatic disease, liver disease, renal failure, chronic obstructive pulmonary disease, or gastrointestinal bleeds.
CCI, Charlson Comorbidity Index; PROMIS, Patient-Reported Outcomes Measurement Information System; SD, standard deviation; WC, workers compensation.

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Table 2

Operative characteristics by PROMIS score.

Characteristic	PROMIS ≥35 (n = 55)	PROMIS <35 (n = 64)	P Value^a
Operative time^b (min), mean ± SD	121.8 ± 19.4 (n = 54)	128.0 ± 22.3	0.133
Estimated blood loss (mL), mean ± SD	43.3 ± 19.9	54.5 ± 54.9	0.165
Length of hospital stay (h), mean ± SD	23.2 ± 17.7 (n = 54)	34.4 ± 19.9	0.002
Discharge day (%)			0.003
POD 0	22 (40.0%)	7 (10.9%)
POD 1	26 (47.3%)	38 (59.4%)
POD 2	6 (10.9%)	14 (21.9%)
POD 3	0 (0%)	3 (4.7%)
POD 4	1 (1.8%)	2 (3.1%)

Boldface indicates statistical significance (P < 0.05).
aP value was calculated using Student t test (continuous), χ² analysis (categorical), or Fisher exact test (categorical).
bOperative time was measured from skin incision to skin closure.
POD, postoperative day; PROMIS, Patient-Reported Outcomes Measurement Information System.

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Table 3

PROMIS PF and PHQ-9 score distribution by preoperative subgroup.

Time Period	PROMIS ≥35 Mean ± SD (n)	PROMIS <35 Mean ± SD (n)	P Value^a
PROMIS
Preoperative	40.2 ± 4.7 (55)	30.2 ± 3.5 (64)	<0.001
6 weeks	40.8 ± 6.5 (43)	34.0 ± 5.6 (48)	<0.001
12 weeks	43.5 ± 5.2 (33)	39.0 ± 8.6 (38)	0.011
6 months	46.7 ± 5.8 (36)	40.6 ± 7.2 (33)	<0.001
1 year	48.3 ± 8.1 (24)	41.0 ± 8.3 (31)	0.002
PHQ-9
Preoperative	5.4 ± 6.0 (55)	8.3 ± 6.8 (64)	0.018
6 weeks	3.8 ± 5.4 (46)	6.2 ± 5.7 (54)	0.029
12 weeks	2.4 ± 3.7 (38)	4.5 ± 4.4 (53)	0.017
6 months	2.8 ± 4.2 (45)	4.7 ± 5.3 (46)	0.056
1 year	2.8 ± 4.4 (24)	4.7 ± 5.7 (31)	0.180

Boldface indicates statistical significance (P < 0.05).
aP value was calculated using Student t test (continuous).
PF, Physical Function; PHQ-9, Patient Health Questionnaire-9; PROMIS, Patient-Reported Outcome Measurement Information System.

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Table 4

Postoperative improvement over predetermined time periods.

Time Period	Postoperative Improvement Mean ± SD (n) PROMIS ≥35	Postoperative Improvement Mean ± SD (n) PROMIS <35	R ²	P Value^a
PROMIS
Preoperative	—	—	—	—
6 weeks	0.85 ± 7.0 (43)	4.0 ± 6.2 (54)	0.054	0.026
12 weeks	3.3 ± 5.8 (33)	9.2 ± 9.6 (38)	0.120	0.003
6 months	5.8 ± 7.1 (36)	11.1 ± 9.0 (33)	0.101	0.008
1 year	8.3 ± 7.4 (24)	10.7 ± 8.9 (31)	0.019	0.305
PHQ-9
Preoperative	__	__	__	__
6 weeks	−2.2 ± 4.6 (46)	−1.9 ± 5.4 (54)	0.001	0.808
12 weeks	−2.4 ± 4.5 (38)	−2.8 ± 5.1 (53)	0.001	0.712
6 months	−2.4 ± 4.5 (45)	−3.2 ± 6.1 (46)	0.005	0.490
1 year	−2.0 ± 5.0 (24)	−1.5 ± 7.9 (31)	0.001	0.807

Boldface indicates statistical significance (P < 0.05).
aP value was calculated using linear regression
PHQ-9, Patient Health Questionnaire-9; PROMIS, Patient-Reported Outcomes Measurement Information System.

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Table 5

Effect of PROMIS PF improvement on improvement in PHQ-9.

	Effect Size	95% CI	R ²	P Value^a
Delta PHQ-9
Preoperative	—	—	—	—
6 weeks	−0.143	[−0.030, 0.012]	0.038	0.071
12 weeks	−0.117	[−0.25,−0.015]	0.047	0.083
6 months	−0.144	[−0.28,−0.005]	0.061	0.042
1 year	−0.225	[−0.42,−0.259]	0.101	0.028

Boldface indicates statistical significance (P < 0.05).
aP value was calculated using linear regression.
PHQ-9, Patient Health Questionnaire-9; PROMIS PF, Patient-Reported Outcomes Measurement Information System Physical Function.

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Table 6

Postoperative improvement over predetermined time periods for other patient-reported outcomes.

	Postoperative Improvement Mean ± SD (n) PROMIS ≥35	P Value^a	Postoperative Improvement Mean ± SD (n) PROMIS ≥35	P Value^a
ODI
Preoperative	—	—	—	—
6 weeks	9.7 ± 17.7 (49)	<0.001	8.4 ± 18.2 (57)	0.001
12 weeks	13.4 ± 14.6 (42)	<0.001	14.5 ± 21.1 (55)	<0.001
6 months	17.1 ± 15.0 (47)	<0.001	19.7 ± 20.3 (44)	<0.001
1 year	19.5 ± 10.8 (20)	<0.001	18.8 ± 27.1 (26)	<0.001
VAS Back
Preoperative	—	—	—	—
6 weeks	2.9 ± 2.7 (47)	<0.001	2.3 ± 3.2 (57)	<0.001
12 weeks	2.9 ± 2.6 (41)	<0.001	2.7 ± 3.1 (55)	<0.001
6 months	2.9 ± 3.1 (46)	<0.001	2.2 ± 3.6 (43)	<0.001
1 year	4.1 ± 3.1 (20)	<0.001	2.8 ± 4.5 (26)	0.004
VAS Leg
Preoperative	—	—	—	—
6 weeks	2.6 ± 3.1 (47)	<0.001	3.2 ± 3.0 (57)	<0.001
12 weeks	2.9 ± 2.9 (42)	<0.001	3.7 ± 3.2 (55)	<0.001
6 months	2.9 ± 3.4 (47)	<0.001	3.7 ± 3.3 (43)	<0.001
1 year	3.7 ± 3.0 (20)	<0.001	2.7 ± 4.0 (26)	0.002
SF-Physical
Preoperative	—	—	—	—
6 weeks	−2.5 ± 9.9 (45)	<0.001	−2.2 ± 7.2 (57)	<0.001
12 weeks	−3.1 ± 11.0 (36)	0.099	−6.9 ± 10.8 (51)	<0.001
6 months	−7.6 ± 10.8 (38)	<0.001	−8.6 ± 10.7 (37)	<0.001
1 year	−12.0 ± 9.5 (22)	<0.001	−9.8 ± 13.0 (33)	<0.001
SF-Mental
Preoperative	—	—	—	—
6 weeks	−3.7 ± 9.1 (45)	<0.001	−1.6 ± 8.4 (57)	<0.001
12 weeks	−3.5 ± 7.7 (36)	0.011	−2.6 ± 8.4 (51)	0.036
6 months	−1.9 ± 5.7 (38)	0.046	−4.3 ± 8.8 (37)	0.005
1 year	−3.1 ± 10.4 (22)	0.179	−3.0 ± 8.9 (33)	0.067

Boldface indicates statistical significance.
aP value was calculated using paired Student t test (continuous).
ODI, Oswestry Disability Index; PHQ-9, Patient Health Questionnaire-9; SD, standard deviation; SF, Short Form; VAS, visual analog scale.