Abstract
Longitudinal analysis of prospectively collected data. Investigate potential predictors of poor outcome following surgery for degenerative lumbar spinal stenosis (LSS). LSS is the most common reason for an older person to undergo spinal surgery, yet little information is available to inform patient selection. We recruited LSS surgical candidates from 13 orthopedic and neurological surgery centers. Potential outcome predictors included demographic, health, clinical, and surgery-related variables. Outcome measures were leg and back numeric pain rating scales and Oswestry disability index scores obtained before surgery and after 3, 12, and 24 postoperative months. We classified surgical outcomes based on trajectories of leg pain and a composite measure of overall outcome (leg pain, back pain, and disability). Data from 529 patients (mean [SD] age = 66.5 [9.1] yrs; 46% female) were included. In total, 36.1% and 27.6% of patients were classified as experiencing a poor leg pain outcome and overall outcome, respectively. For both outcomes, patients receiving compensation or with depression/depression risk were more likely, and patients participating in regular exercise were less likely to have poor outcomes. Lower health-related quality of life, previous spine surgery, and preoperative anticonvulsant medication use were associated with poor leg pain outcome. Patients with ASA scores more than two, greater preoperative disability, and longer pain duration or surgical waits were more likely to have a poor overall outcome. Patients who received preoperative chiropractic or physiotherapy treatment were less likely to report a poor overall outcome. Multivariable models demonstrated poor-to acceptable (leg pain) and excellent (overall outcome) discrimination. Approximately one in three patients with LSS experience a poor clinical outcome consistent with surgical non-response. Demographic, health, and clinical factors were more predictive of clinical outcome than surgery-related factors. These predictors may assist surgeons with patient selection and inform shared decision-making for patients with symptomatic LSS. 2.
Highlights
Clinical Outcome Trajectories The group-based multi-trajectory model of overall surgical outcome achieved satisfactory performance according to our predefined criteria (Table 2)
We previously reported the results of a univariate group-based trajectory model that demonstrated three distinct leg pain groups, with 36.1% of patients categorized as experiencing a poor outcome (Figure 2).[10]
27.6% of patients were classified as following pain and disability trajectories indicative of poor overall outcome (Table 3, Figure 3)
Summary
Study Design and Participants This study was a longitudinal analysis of prospectively collected data from patients enrolled in the Canadian Spine Outcomes and Research Network (CSORN) database. Potential Predictors of Outcome All patients completed preoperative assessments, including standardized forms and questionnaires to collect demographic, health-related, and clinical information. The attending spine surgeon and surgical staff recorded surgical details including the use of fusion or minimally invasive techniques, the total time to complete the surgery, estimated blood loss, and the occurrence of intraoperative or postoperative adverse events. Clinical Outcomes Pain and disability patient-reported outcomes were collected at preoperative baseline and 3, 12, and 24 months after surgery. Benchmarks were the minimum important change (30%) in leg pain, back pain, and disability,[22] as well as relative (50% improvement)[24] and absolute ( 22)[25] estimates of clinical success based on Oswestry scores. All analyses were performed with Stata 15.1 software (StataCorp, College Station, TX)
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