Minimal Clinically Important Difference in Patient-Reported Outcome Measures with the Transforaminal Endoscopic...

Patient-reported outcome measures (PROMs) have become widely used to better measure patients' judgment of treatment benefits from surgical spine care. The concept of determining the minimal clinically important differences (MCIDs) of PROMs is aimed at assessing the benefits of lumbar spine care that are meaningful to the patient. The goal of this study was to validate the utility of MCIDs of the visual analog score (VAS) and Oswestry Disability Index (ODI) in patients with sciatica-type low back and leg pain due to lateral recess and foraminal stenosis who were treated with directly visualized transforaminal outpatient endoscopic decompression.

The retrospective study population consisted of 406 patients on whom PROMs were obtained preoperatively, and again postoperatively at final follow-up. Employing an anchor-based approach with a patient satisfaction index based on the modified Macnab criteria, a receiver operating characteristics (ROC) and area under the curve (AUC) analysis was performed using IBM SPSS 25.0 to define the optimal MCID in VAS and ODI with the transforaminal endoscopy using the top-left-corner criteria and the Youden index. Improvements in walking endurance were recorded as an additional parameter of patient functioning and correlated with PROMs to test for statistical significance.

The patients' average age was 41.08 years, ranging from 30 to 84 years. The mean follow-up was 33.59 months, ranging from 24 to 85 months, with a standard deviation of 12.79. The MCIDs for VAS and ODI were 2.5 to 3.5 and 15 to 16.5, respectively. Patients were dichotomized as improved (377/406; 92.9%) if they reported excellent (224/406; 55.2%), good (112/406; 27.6%), and fair (41/406; 10.1%) Macnab outcomes. Patients were dichotomized as failed if they reported poor (29/406; 7.1%) Macnab outcomes. Preoperatively, only 32.5% (132/406) of patients had unlimited walking endurance compared to 77.6% (315/406) of patients postoperatively. The ROC and AUC analysis showed better accuracy with the single-integer VAS score (0.926) than with the 10-item ODI score (0.751).

Transforaminal outpatient endoscopic decompression for symptomatic foraminal and lateral recess stenosis is an effective surgical treatment to alleviate sciatica-type and back symptoms in 92.9% of patients. Of the PROMs analyzed, the VAS provided a more meaningful and accurate reflection of patients' interpretation of outcome with the transforaminal endoscopic spinal decompression procedure than ODI. Understanding which patient expectations drive these MCIDs may aid in replacing open surgeries for sciatica-type low back and leg pain currently preferred by traditional spine surgeons with a personalized early-staged transforaminal endoscopic hybrid decompressive/ablative procedures favored by the authors. These may prove more cost effective by focusing on significant pain generators validated with a diagnostic interventional workup instead of employing image-based indication criteria for surgery.