For decades, spine surgery has relied heavily on patient-reported outcome measures such as pain scores, the Oswestry Disability Index and the Neck Disability Index to assess treatment success. These instruments remain important and are deeply embedded in clinical research, regulatory assessment and payer decision-making.
Kai-Uwe Lewandrowski, MD, founder of the Center for Advanced Spine Care of Southern Arizona in Tucson, said as crucial as the measures are, they should not be used in isolation. Dr. Lewandrowski, who has practiced endoscopic spine surgery since 2006, spoke with Becker’s about his research into more granular and performance-based measures of recovery, and why combining traditional patient-reported outcomes with objective functional and cognitive measures could improve clinical decision-making and healthcare utilization.
Limitations of composite outcome scores
The ODI and NDI each combine 10 domains into a single disability score. Dr. Lewandrowski said although the instruments are well validated and clinically useful, an aggregate number can sometimes obscure which aspects of a patient’s function are improving.
“The issue is not that the ODI or NDI are bad instruments,” he said. “They have been enormously useful. The question is whether a single composite number always captures the clinical information we need for an individual patient.”
A patient’s travel score, for instance, may improve or worsen for reasons that have nothing to do with whether their spine is healing; financial means, time off work or personal circumstances can all affect it. Changes in walking tolerance, personal care or lifting ability, by contrast, more directly reflect whether the treatment is working.
“Sitting across from a patient on Monday morning, I want to know what changed,” Dr. Lewandrowski said. “Can they walk farther? Can they work? Can they take care of themselves? Those are clinically interpretable outcomes.”
Adding a performance-based measure
To complement conventional patient-reported outcomes, Dr. Lewandrowski and collaborators have been studying a brief Continuous Visual Attention Test that takes about 90 seconds to complete, evaluating reaction time, reaction-time variability, and error rates in response to visual stimuli. The hypothesis is that pain and pain relief may influence attentional performance in measurable ways that pain scores alone do not capture.
“We are not trying to replace the ODI, NDI or visual analog scale,” he said. “We are asking whether we can add another layer of measurement that is performance-based rather than entirely dependent on self-report.”
Pain, he noted, is shaped by nociception, sleep, mood, medications, expectations and social circumstances.
“A pain score tells you what the patient is experiencing, and that is critically important,” Dr. Lewandrowski said. “But it does not necessarily tell you why.”
Identifying recovery trajectories earlier
Many spine surgery studies evaluate outcomes at one or two years — appropriate for studying durability, but not for some decisions clinicians face much sooner.
“At two years I may know whether an operation ultimately succeeded,” Dr. Lewandrowski said. “But at six weeks or three months, I need to know whether this patient is progressing normally or whether something deserves closer evaluation.”
Combining patient-reported measures with more sensitive longitudinal data, he said, could help distinguish which patients simply need more healing time from those who need further intervention — potentially reducing prolonged cycles of repeated consultations, imaging or injections when a patient’s trajectory is unclear.
Why chronic pain requires multidimensional assessment
The limits of a single pain score are especially apparent in chronic pain, which is shaped by biological, psychological and social factors.
“That is not a criticism of the patient,” Dr. Lewandrowski said. “It is the biology of pain. A zero-to-10 number necessarily compresses a great deal of information.” A patient may continue reporting pain while showing meaningful gains in walking, sleep or work capacity — or the reverse. “Pain intensity, disability, function and participation are related, but they are not identical constructs.”
He noted that performance-based testing is not free of confounders either; sleep, medications, caffeine and practice effects can all influence results, which is why validation matters. The CVAT has undergone clinical validation in patients with spine-related pain, with findings from a study he co-led published May 6 in the European Journal of Pain. “The next step is to determine how much additional information it provides alongside established patient-reported outcome measures,” he said.
Why endoscopic surgery makes measurement especially important
Because endoscopic procedures are highly targeted, Dr. Lewandrowski said outcomes depend heavily on correctly identifying the pain generator beforehand.
“If the pathology you treat is not the primary source of the patient’s symptoms, minimizing the surgical exposure alone does not solve the diagnostic problem.”
But he emphasized the broader principle applies to more than endoscopic technique: “Every spine surgeon eventually faces the same question — is this patient recovering along an expected trajectory, or is there something we need to reconsider?”
Connecting outcome science with value-based care
Dr. Lewandrowski also sees implications for value-based care.
“We have to become better at translating clinical outcomes into measures that demonstrate functional recovery, appropriate utilization and durable value,” he said — not reducing patient care to economics, but connecting clinical success with outcomes that matter to patients, physicians and health systems. A patient who returns to work and no longer needs repeated interventions represents both a clinical success and more efficient resource use.
The larger goal: functional and social reintegration
Asked what ultimately defines success in his own practice, Dr. Lewandrowski pointed to reintegration over any single score: “Can the patient return to work? Can they function independently? Can they participate in family and social life again?”
He also emphasized better coordination between spine surgeons, rehabilitation physicians and pain specialists, so patients move through the system according to clinical need rather than remaining siloed in one specialty.
“The objective is not to find one new score that replaces everything else,” he said. “It is to combine patient-reported outcomes, functional information and objective measures in a way that gives us a more complete picture of the patient and helps us make better decisions earlier.”
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.
