Part I : Characteristics of Surgical Spine Patients at Bangkok Spine Academy ( BSA )

OBJECTIVE. To use the Oswestry Disability Index (ODI) and Euro Quality of Life (EuroQol) as pre-screening assessment tools to improve surgery outcomes for patients with spinal disorders. 
 
MATERIALS AND METHODS. Prior to surgical intervention, 223 (out of 311 lumbar spine) patients who were eventually treated with surgery at Bangkok Spine Academy between August 2010 and June 2011, filled out the above mentioned questionnaires pre-operatively. ODI and EuroQol were used to assess their mobility, activities, pain, anxiety etc., which could help better determine their spine disability together with their medical history and physical examination. 
 
RESULTS. Mobility: Pre-operative 157 (92.9%) had problems,12 (7.1%) had no problems. Self-care: Pre-operative 97 (57.4%) had problems, 72 (42.6%) had no problems. Usual activities: Pre-operative 157 (92.9%) had problems, 12 (7.1%) had no problems. Pain/discomfort: Pre-operative 167 (98.82%) had problems, 2 (1.18%) had no problems. Anxiety/depression: Pre-operative 137 (81.07%) had problems, 32 (18.93%) had no problems. 
 
CONCLUSION. All patients who underwent surgery for the treatment of low back pain were found to be having significant disability and restrictions in their lives; using the pre-operative ODI and EuroQol measurements they could be categorized as having moderate to severe disability.


B
ack pain is second only to the common cold as the most frequent reason for seeing a physician.Low back pain is experienced by most individuals, with 70 to 80% of the world's population experiencing low back pain sometime during their lives. 1 international comparative study by Cherklin DC, et al showed the rate of back surgery in the United States was at least 40% higher than in any other country and was more than five times that of England and Scotland.Back surgery rates increased almost linearly with the per capita supply of orthopedic and neurosurgeons in the country.These findings illustrate the potentially large impact of health system differences on rates of back surgery. 2 Surgical goals are improvements in pain, functional status and quality of life.It is well known that some patients operated on for spinal disorders will have a poor result, regardless of the apparent technical success of the operative procedure itself. 35][6] In order to make the correct diagnosis, Bangkok Spine Academy (BSA) always focuses on the history of medical illness and a thorough physical examination of all patients.We follow the Joint Clinical Practice Guidelines from the American College of Physicians and the American Pain Society for diagnosing and treating Low Back Pain. 7e BSA had 2,994 low back pain patients in 2010 and 223 (7.44%) underwent surgery.BSA has begun to develop a spine registration for patients who underwent lumbar spine surgery in order to study patient's history, population, epidemic, quality of life and ability to perform daily activities.The analysis of this information will help us to improve our care and treatment of our patients.
Currently, there are several assessment tools used to measure the treatment results of patients who undergo lumbar spine surgery.Oswestry Disability Index (ODI) is an internationally accepted measure for spine disability and is used in most if not all spinal treatment result assessments.Additional measures are also used to supplement the ODI in order to fully define the patient's spine condition; commonly used questionnaires include the SF-36, SF-12 and the Euro Quality of Life (EuroQol).Therefore we decided to utilize the ODI and EuroQol 8 with our prospective surgery candidates as a pre-screening procedure and so we could also have effective tracking of the patient's improvement on follow up.The following data then shows the pre-operative state of our patients, using the abovementioned measures.

Sample Size
The focus of this study is the 223 (out of 311 lumbar spine) patients treated with surgery at BSA between August 2010 and June 2011.

EuroQol
Pre-operative measurements of mobility, self-care, activities of daily life, pain, and anxiety and/or depression were determined by EuroQol using visual analogue scale (VAS) and 5 Dimensions (5D). 9e EuroQol Visual Analogue Scale (EQ-VAS) The EQ-VAS is a part of the EuroQol Questionnaire.The patients rate their current health state on the line, which ranges from 0 -100 (The worst to the best imaginable health). 10westry Disability Index (ODI) ODI versions with a scale ranging from 0-5 were used.Questionnaires addressing 10 common activities were administered, using both English and validated translations into other languages.Points were added up each section and plugged in to the following formula in order to calculate the patient's level of disability: Point total / 50 x 100 = % disability (aka: 'point total' divided by '50' multiply by ' 100 = percent disability). 11,12 Thai patients the authenticated Thai ODI was used; in non-Thai speaking patients, the English ODI (version 0.1) was used. 13ai score In a study of the quality of life of Thai people across the country, using the EuroQol questionnaire, the formula to calculate the quality of life of Thai people was called Thai score.

0% to 20% Minimal disability:
The patient can cope with most living activities.Usually no treatment is indicated apart from advice on lifting, sitting and exercise.

21%-40% Moderate disability:
The patient experiences more pain and difficulty with sitting, lifting and standing.Travel and social life are more difficult and they may be disabled from work.Personal care, sexual activity and sleeping are not grossly affected and the patient can usually be managed by conservative means.

41%-60%
Severe disability: Pain remains the main problem in this group but activities of daily living are affected.These patients require a detailed investigation.

61%-80%
Crippled: Back pain impinges on all aspects of the patient's life.Positive intervention is required.

81%-100%
These patients are either bed-bound or exaggerating their symptoms.

SPSS Data Analysis
This descriptive statistic is used to analyze demographic data.EuroQol-5D is composed of five dimensions (mobility, self-care, usual activities, pain/discomfort and anxiety/depression).Each dimension has 3 levels: no problem, some problem, extreme problems. 15The ratings in the different possible health states will be transformed into an index value.We decided to adapt this and say that each dimension has two levels of severity: No problem and problem.No problem states were those rated the health as full health (all dimensions rated as 1).The problems which were proportionally ranked from 1-3 were analyzed.

Results
Patients who filled out a questionnaire asking them to respond to questions in their native language before undergoing a surgical procedure at BSA between August 2010 and June 2011.

Discussion
Our patients'ages ranged from 20-88.Seventy-five percent (75%) were Thai and 25% were non-Thai.Both groups received pre-operation ODI and EuroQol assessment and were reevaluated at 6 months after surgery.At entry surgical patients showed a wide range of ODI values but most were in the moderately disabled range of 40-60 indicating to us a justification to consider surgical treatment.
Additional data from the EuroQol confirmed the surgical patients' disability and gave expanded detail about which aspects of the patients lives were most affected.The majority of patients experienced significant pain, with chronic pain (pain ≥ 3 months) being felt more severely than acute pain (pain ≤ 3 months).Pain/discomfort was also reported very frequently, by 98.21% of patients.Difficulty with Usual activities 92.83%, Mobility 91.93%, Anxiety/Depression 80. Seventy-two percent (72%), and Self-care 57.85% were reported respectively: see Table 3.We found the sexual dysfunction assessment not to be well defined in our patient population, which is very likely due to unspoken cultural restriction amongst Thais to fully discuss this aspect of their clinical symptoms.

Conclusion
All patients who underwent surgery for the treatment of low back pain were found to be having significant disability and restrictions in their lives; using the pre-operative ODI and EuroQol measurements, they could be categorized as having moderate to severe disability.The major problems reported were pain and mobility, there were also some problems with self-care and performance of usual activities.Some differences were found between patients who underwent fusion and who only received laminectomies for decompression, or a herniated disc.Most patients who underwent fusion were elderly and had more comobility.Visual analog scale for patients with fusion was 60 and without fusion it was 50.We believe the preoperative ODI and EuroQol are both very useful in confirming the patients' disability and impaired quality of life and these same indices will be useful in reliably documenting the improvement after surgical treatment.

5D Index (Thai score)
Average mean Oswestry Disability Index score Pre-operation in each procedure