What's New in Spine Surgery

categorized as direct or indirect PRO questionnaires. The direct PRO questionnaires are forms completed by the patients about their quality of life – the SF-36 is an example. The indirect PRO questionnaires are multidimensional indices that utilize a wide variety of criteria that are combined to produce a finalized score – the Core Outcome Measures Index, for example. The PRO questionnaires provide us with a better understanding of the impact spine surgery has on patients’ lives, but these are still subjective measures. Thus, there remains a need for objective measures utilized concurrently with PRO questionnaires, anchoring the subjective data to objective data. Currently, some of those outcome measures are time to return to work, the presence or absence of complications, and the number and types of medications prescribed. Almost needless to say, these are not entirely objective either and depend on factors related to the type of work the patient does, economic and legal incentives, and other medical conditions affecting the patient. The advances in spine surgery outcome research are particularly relevant in the larger context – the efficacy of spine surgery. Addressing this issue, the concept of minimal clinically important difference has been developed, an approximate minimal standard difference on a subjective report that correlates with a clinically significant change for a patient in response to a treatment [7] . The minimal clinically important difference is not a direct index and needs to be defined according to an ‘anchor’. One of the more dramatic trends in spine surgery is increased and systematic attention to outcomes. Patientreported outcome (PRO) questionnaires are becoming the standard measure for treatment effectiveness following spine surgery, as opposed to surgeon-reported results. The new trend assumes that the patient’s perceptions are the true measure of success [1] . To this end, a number of PRO questionnaires have been developed. The Oswestry Disability Index, Short Form 36 (SF-36), Core Outcome Measures Index, and Neck Disability Index are common, subjective indices currently used [2] . The Oswestry Disability Index is a functional index that asks patients to rate outcomes including pain, functional limitations (walking, lifting, sitting, and standing), social life, sexual behavior, sleep, and personal care. This is an ascending scale with 100 as the maximum disability [3] . The SF-36 is a questionnaire which asks the patients to rate 36 items concerning their quality of life – physical functioning and limitations, pain, general health, social health, emotional health, mental health, and vitality. This scale is a descending scale with 100 as maximal health, where the physical and mental component are often reported separately [4] . The Core Outcome Measures Index is a multidimensional index addressing pain (lower extremity, buttock, and lower back pain intensity), function, symptom-specific well-being, quality of life, and social and occupational disability [5] . The Neck Disability Index is a 10-item assessment of physical disability due to neck pain, asking patients to evaluate pain intensity, personal care, lifting, work, headache, concentration, sleep, driving, reading, and recreation [6] . These indices are Received: October 30, 2012 Accepted: December 4, 2012 Published online: January 10, 2013