Elsevier

The Spine Journal

Volume 11, Issue 7, July 2011, Pages 613-617
The Spine Journal

Clinical Study
Predictive factors influencing clinical outcome with operative management of lumbar spinal stenosis

https://doi.org/10.1016/j.spinee.2011.03.008Get rights and content

Abstract

Background context

Lumbar spinal stenosis is now the most common and fastest growing reason for spinal surgery in adults older than 65 years. There are not yet clearly identified preoperative predictive factors for postoperative clinical outcome. We have previously reported on the clinical outcome of patients treated operatively and nonoperatively.

Purpose

The purpose of this study was to identify independent predictors of clinical outcome in our operative group to guide management in future patients.

Study design/setting

This is a prospective nonrandomized cohort study done in a university center providing secondary and tertiary care.

Patient sample

Ninety-four consecutive patients were evaluated.

Outcome measures

We used a validated patient-oriented disability questionnaire.

Methods

We evaluated patients treated operatively for lumbar spinal stenosis. Ninety-four patients were treated surgically. Clinical outcomes were measured using the modified Roland-Morris questionnaire with 2-year follow-up.

Results

Patients treated surgically had significant improvement at 2-year follow-up. Higher values of body mass index and a history of psychiatric disease were factors associated with a worse outcome, whereas those with more preoperative disability had a better outcome. Age, gender, cardiovascular or musculoskeletal comorbidities, duration of symptoms for more than 1 year, multiple-level decompression, spinal fusion, history of neurogenic claudication, symptomatic lumbosacral extension, subjective numbness or weakness, and objective decrease in sensation or reflex abnormalities were not predictive of outcome.

Conclusions

On average, patients who choose to have surgery will have improvement. However, not all patients having surgery will note improvement, and there are factors predictive for outcome.

Introduction

Evidence & Methods

Delineation of factors associated with a greater or lesser likelihood of success with interventions is important for decision making and for informed consent. This article looks for factors impacting outcomes following surgery for lumbar spinal stenosis.

This prospective study of 94 patients with 2-year follow-up using the Roland–Morris questionnaire (RMDQ) found that higher body mass index and psychiatric factors were associated with poorer outcomes; while patients with more severe preoperative disability did better.

These findings provide some valuable insights, lending support for more casual observations/suspicions and previous study findings. It is of note that this study used only one dimension of outcome, the RMDQ, which focuses upon reported disability in activities of daily living and is not disease-specific. Other dimensions, such as subsequent medication usage, medical care intensity, and satisfaction, were not assessed. Accordingly, these findings may not fully measure the benefit (or lack of benefit) of an intervention for individual patients; patients with severe obesity or depression may show a poor response on RMDQ but may be delighted that their sciatic pain is greatly reduced or that they can now walk around the grocery store.

—The Editors

Lumbar spinal stenosis is now the most common and fastest growing reason for spinal surgery in adults older than 65 years [1]. However, few studies have directly examined preoperative clinical factors to help physicians and patients determine who would benefit from surgical treatment. Some studies have suggested that psychosocial factors, in particular depression, are associated with poorer outcome after surgery for lumbar stenosis [2], [3]. Other studies have found that older age [2], greater medical comorbidity [3], [4], multiple laminectomy [5], the predominance of back pain as opposed to leg pain [3], [6], [7], worse preoperative functional status [3], [7], delayed presentation to the physician [6], [7], and female gender [8] were associated with decreased patient satisfaction. Nevertheless, there is still disagreement in the literature as other studies have not found the same associations with age [3], [9], [10], comorbidity [10], the number of segments decompressed [10], delay to treatment of less than 3 years [9], and female gender [3], [10]. All the published trials to date have some limitations and have not yet clearly identified preoperative predictive factors for postoperative clinical outcome.

We have previously reported on the clinical outcome of patients treated operatively and nonoperatively for lumbar spinal stenosis using a validated patient-oriented outcome questionnaire, at 2-year follow-up [11]. We hypothesize that positive and negative preoperative predictive factors exist that could help with patient selection for surgical treatment. The purpose of this prospective study was to identify independent predictors of clinical outcome in patients treated in the operative group.

Section snippets

Methods

We prospectively enrolled 94 consecutive patients with symptomatic lumbar stenosis referred by community family physicians to one spine surgeon (DY). These patients had clinical and radiographic evidence of lumbar spinal stenosis and were believed not to be improving with nonsurgical care. All patients were assessed clinically by the senior author (DY). Subjects with vascular claudication were excluded. Patients whose chief complaint was inconsistent with neurogenic claudication and those who

Results

Patients treated surgically had a 6.54-point improvement in RM questionnaire score at 2-year follow-up. A change in score of more than 4 points is considered clinically significant [13]. There was no difference in preoperative or change in RM questionnaire scores at 2-year follow-up between the decompression alone and decompression with fusion groups (Table 1). We did not find age (p=.221), gender (p=.438), cardiovascular disease (p=.411), musculoskeletal disease (p=.875), duration of pain over

Discussion

Lumbar spinal stenosis is an important cause of disability and health-care expenditure in developed countries. Surgical investigations and interventions account for up to 30% of health-care costs for spinal disorders [14]. Our operative patients had a mean improvement in RM questionnaire score consistent with the results reported by Amundsen et al. [9], Atlas et al. [7] in the Maine study, and Weinstein et al. [15] in the SPORT trial.

We found that higher values of BMI (n=90, p=.031) were

Conclusion

It is well known that radiologic stenosis correlates poorly with clinical disability [17]. As such, a thorough clinical examination of patients with lumbar spinal stenosis, including assessment of psychosocial factors, is crucial in determining which patients may benefit from surgery. A history of psychiatric disease and a higher preoperative BMI are factors that predict poor outcome after surgical treatment with more preoperative disability associated with a good outcome. Identification of

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FDA device/drug status: not applicable.

Author disclosures: AA: Nothing to disclose. ZAW: Nothing to disclose. DY: Nothing to disclose.

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