Lightning Podiums: Value and Outcomes in Spinal Surgery - Room 801B

Presented by: M. Rigaud

Author(s):

C. Mancuso(1), M. Rigaud(1), A. Fong(1), R. Duculan(1), F. Cammisa(1), A. Sama(1), A. Hughes(1), D. Lebl(1), R. Huang(1), H. Sandhu(1), F. Girardi(1)

(1) Hospital for Special Surgery, New York, NY, United States

Abstract

Background: Patients are instructed to restrict physical activity for several months after complex lumbar surgery in order to safely recuperate. Although these instructions usually do not include restrictions in prudent activities such as walking, many patients perpetuate and augment preoperative sedentary lifestyles. Because subsequently prescribed physical therapy (PT) is targeted to restore spine health, unless specifically addressed, patients may not regain physical activity levels that are recommended for long-term fitness (i.e. ≥ 2000 Kcal/week; or ≥ 1000 Kcal/week for mobility limited individuals).

Purpose: To measure patient-reported physical activity 3 months postop when many activity restrictions are lifted and PT is prescribed, and to ascertain what variables predict greater inactivity.

Study Design/Setting: Cross-sectional study, tertiary spine center

Patient Sample: 134 patients approximately 3 months after complex lumbar surgery

Outcome Measures: Paffenbarger Physical Activity and Exercise Index (PAEI)

Methods: This is a report of enrollment data from a trial to increase long-term physical activity after lumbar surgery. Patients completed the valid 3-domain PAEI measuring average number of blocks walked and stairs climbed daily and sports during the past week. Kcal/week were calculated for each domain and for an overall total; the 1000 Kcal/week threshold was used for analysis. Patients also reported current pain (0 none, 10 worst) and opioid use, and surgeons were asked to rate current technical outcome (0 worst, 10 best). Operative records were reviewed for fusion, instrumentation and approach from which a Surgical Invasiveness Index (SII) summed value was calculated with a maximum of 10 points per vertebral level; higher value is greater complexity.

Results: Mean age was 63, 50% were men, 90% had multilevel surgery; the mean SII was 11 (1-41). Time since surgery was 2.9 months (2.3-4.8). At enrollment the mean back pain was 3 (0-8), and 35% were taking opioids. Surgeons' ratings were a mean of 8 (5-10) for current technical outcome and 73% for amount of anticipated ultimate improvement achieved to date. 93% were given a prescription for 6-12 weeks of PT; mostly for strengthening exercises. The median total PAEI was 1190 Kcal/week with most derived from walking (ie 1120 Kcal/week). 43% of patients did not meet the 1000 Kcal/week threshold. Not meeting the threshold was associated with more back pain (OR 1.2, 95% CI 1.0-1.4; p=.01), opioid use (OR 3.7, CI 1.8-7.8; p=.0006), worse surgeon's assessment of outcome (OR 1.7, CI 1.2-2.3; p=.004), and more complex surgery (OR 1.1, CI 1.0-1.2, p=.007). In multivariable analysis more pain (OR 1.2, CI 1.0-1.4, p=.02), worse surgeon's assessment (OR 1.7, CI 1.2-2.4; p=.006), and more complex surgery (OR 1.1, CI 1.0-1.2; p=.004) remained associated with not meeting the threshold.

Conclusions: Many patients did not meet the lower physical activity threshold 3 months postop. More symptoms and more complex surgery were associated with less activity. Maintaining prudent physical activity in the postop period is an important general health issue that has been relatively overlooked in the management of lumbar surgery patients. Our study highlights the extent of inactivity postop and the need to guide patients in prudently regaining activity levels that will promote long-term spine and overall health.