Concomitant back and leg pain as predictors for trajectories of poor outcome after single level lumbar micro-decompression alone and with micro-discectomy: a study of 3,308 patients.

Abstract

Lumbar decompression is the commonest spinal intervention. One in four patients have suboptimal outcome postoperatively, however no large studies identified clear poor outcome predictors. The aim of this study was to study low back pain (LBP) as a predictor of poor outcome following lumbar micro-decompression. Prospectively collected spinal registry data was analysed for patients who underwent primary, single-level, decompression with or without discectomy at single spinal centre (2011-2017). Based on the response to the Likert global outcome question, we had two outcome groups (good & poor). Percentage of achievement of minimum clinically relevant change (MCRC) for Core Outcome Measures Index (COMI) score, LBP and leg pain (LP) was examined. A two-step approach was adopted. First, COMI score, LBP and LP visual analogue scales (VAS) trajectories were modelled using a discrete mixture model. Second, multinomial logistic regression was used to determine the association between variables and trajectories. We included 3,308 patients with mean follow up (1.4 y). MCRC was achieved in COMI score in 63% of cases, 42% in LBP and 62% in LP. A three-group trajectory model was identified: large-improvement (LI) (n=980), moderate-improvement (MI) (n=1,364) and no-improvement (NI) (n=966) with 99.5%, 84.5% and 31.5% of patients presenting good outcome, respectively. Higher pre-operative LBP and COMI score and smoking were strongly associated with MI and NI. In addition, higher LP, post-operative surgical complications, previous surgery at same level, conservative treatment >6 months and anxiety/depression were associated with NI. This is the first large-scale study reporting preoperative LBP severity, spinal stenosis and smoking as predictors for poor functional outcomes post lumbar decompression with or without discectomy. This is very useful while counselling patients for surgery to meet realistic expectations.