Back Pain After Lumbar Surgery

Measure Specification

Mechanical low back pain (LBP) remains the second most common symptom-related reason for seeing a physician in the United States. Of the US population, 85% will experience an episode of mechanical LBP at some point during their lifetime. Fortunately, the LBP resolves for the vast majority within 2-4 weeks. For individuals younger than 45 years, mechanical LBP represents the most common cause of disability and is generally associated with a work-related injury.

For individuals older than 45 years, mechanical LBP is the third most common cause of disability, and a careful history and physical examination are vital to evaluation, treatment, and management. Overall, spine surgery rates have declined slightly from 2002-2007, but the rate of complex fusion procedures increased 15-fold, from 1.3 to 19.9 per 100,000 Medicare beneficiaries.

Complications increased with increasing surgical invasiveness, from 2.3% among patients having decompression alone to 5.6% among those having complex fusions. After adjustment for age, comorbidity, previous spine surgery, and other features, the odds ratio (OR) of life-threatening complications for complex fusion compared with decompression alone was 2.

95 (95% confidence interval [CI], 2.50- 3.49). A similar pattern was observed for rehospitalization within 30 days, which occurred for 7.8% of patients undergoing decompression and 13.0% having a complex fusion (adjusted OR, 1.94; 95% CI, 1.74-2.17). Adjusted mean hospital charges for complex fusion procedures were US $80,888 compared with US $23,724 for decompression alone.

The MNCM Spine Surgery Measure development workgroup developed patient reported outcome measures for two populations of patients undergoing different lumbar spine procedures, a more complex procedure (lumbar fusion) and a second procedure that represented the most common procedure CPT code 63030 for the most common diagnosis of disc herniation. In 2018, the development workgroup reconvened and redesigned the measure construct to a target-based measure and additionally expanded the denominator for this measure to include all lumbar discectomy laminectomy procedures.

Rationale for measure construct and calculation change: Target score based on 2016 study in the Spine Journal Fetke, TF et al “What level of pain are patients happy to live with after surgery for lumbar degenerative disorders?” This study compared the Core Outcomes Measures Index (COMI) and symptom well-being questions to two 0 to 10 graphic ratings scales for back and leg pain.

Most spine interventions decrease pain, but rarely do they totally eliminate it. Reporting of the percent of patients achieving a pain score equivalent to the "acceptable symptom state" may represent a more stringent target for denoting surgical success in the treatment of painful spinal disorders. For disc herniation, this is less than or equal to 2, and for other degenerative pathologies it is less than or equal to 3.

The OR benchmark of change (5.0) derived from MNCM data (3 years); the average change in points of patients that did achieve the target of less than or equal to 3.0. Rationale for the expansion of the denominator and addition of exclusions: During the original development of this measure, the intent was to have a homogeneous population procedure that represented the most common procedure CPT code 63030 for the most common diagnosis of disc herniation.

This strategy did not translate well from ICD-9 to ICD-10 diagnosis codes and the volume of eligible denominator patients dropped significantly. In 2018, the MNCM development workgroup reconvened for measure construct redesign and adopted a broader denominator population; all applicable discectomy laminectomy procedure codes and not limited by a type of diagnosis (includes all).

With this decision, the workgroup decided to adopt the same exclusions for the spine fusion population and added exclusions for spine related cancer, acute fracture or infection, neuromuscular, idiopathic or congenital scoliosis.

Journal of Neurosurgery guidelines indicate that there is no evidence that conflicts with the previous recommendations published in the original version of the guideline. This recommendation is for the use of reliable, valid and responsive outcomes instrument to assess functional outcome in lumbar spinal fusion patients. It is recommended that when assessing functional outcome in patients treated for low-back pain due to degenerative disease, a reliable, valid, and responsive outcomes instrument, such as the disease-specific Oswestry Disability Index (ODI), be used (Level II evidence).

This measure contains two strata defined by two submission criteria. This measure produces two performance rates which are used for a weighted average. There are 2 Submission Criteria for this measure: 1) Back pain improvement at three months post lumbar discectomy/laminectomy procedure AND 2) Back pain improvement at one year post lumbar fusion procedure This measure will be calculated with 2 performance rates: 1) Percentage of lumbar discectomy/laminectomy procedures for which the patient reports back pain less than or equal to 3.

0 OR an improvement of 5.0 points or greater on the VAS or Numeric Pain scale at three months (6 to 20 weeks) postoperatively 2) Percentage of lumbar fusion procedures for which the patient reports back pain less than or equal to 3.0 OR an improvement of 5.0 points or greater on the VAS or Numeric pain scale at one year (9 to 15 months) postoperatively A weighted average, which is the sum of the performance numerator values divided by the sum of performance denominator values, will be used to calculate performance.

For the purposes of MIPS implementation, this procedure measure is submitted each time a procedure is performed during the performance period. The most recent quality data code will be used if the measure is submitted more than once. This measure is a target-based measure with two ways to meet the numerator; either a postoperative VAS Pain score or numeric pain scale score that is less than or equal to 3.

0 OR an improvement of 5.0 points or greater from the preoperative to postoperative score. It is expressed as a proportion or rate. Patients having received a lumbar discectomy/laminectomy or fusion procedure who are not assessed for back pain postoperatively remain in the denominator and are considered as not meeting the target. The measure intent is that MIPS eligible clinicians will submit all denominator eligible procedures to be utilized for performance calculation.