Freyr Gauti Sigmundsson

Correlation between disability and MRI findings in lumbar spinal stenosis A prospective study of 109 patients operated on by decompression

Background and purpose MRI is the modality of choice when diagnosing spinal stenosis but it also shows that stenosis is prevalent in asymptomatic subjects over 60. The relationship between preoperative health-related quality of life, functional status, leg and back pain, and the objectively measured dural sac area in single and multilevel stenosis is unknown. We assessed this relationship in a prospective study. Patients and methods The cohort included 109 consecutive patients with central spinal stenosis operated on with decompressive laminectomy or laminotomy. Preoperatively, all patients completed the questionnaires for EQ-5D, SF-36, Oswestry disability index (ODI), estimated walking distance and leg and back pain (VAS). The cross-sectional area of the dural sac was measured at relevant disc levels in mm2, and spondylolisthesis was measured in mm. For comparison, the area of the most narrow level, the number of levels with dural sac area < 70 mm2, and spondylolisthesis were studied. Results Before surgery, patients with central spinal stenosis had low HRLQoL and functional status, and high pain levels. Patients with multilevel stenosis had better general health (p = 0.04) and less leg and back pain despite having smaller dural sac area than patients with single-level stenosis. There was a poor correlation between walking distance, ODI, the SF-36, EQ-5D, and leg and back pain levels on the one hand and dural sac area on the other. Women more often had multilevel spinal stenosis (p = 0.05) and spondylolisthesis (p < 0.001). Spondylolisthetic patients more often had small dural sac area (p = 0.04) and multilevel stenosis (p = 0.06). Interpretation Our findings indicate that HRQoL, function, and pain measured preoperatively correlate with morphological changes on MRI to a limited extent.

Prognostic factors in lumbar spinal stenosis surgery. A prospective study of imaging- and patient-related factors in 109 patients who were operated on by decompression

Background and purpose A considerable number of patients who undergo surgery for spinal stenosis have residual symptoms and inferior function and health-related quality of life after surgery. There have been few studies on factors that may predict outcome. We tried to find predictors of outcome in surgery for spinal stenosis using patient- and imaging-related factors. Patients and methods 109 patients in the Swedish Spine Register with central spinal stenosis that were operated on by decompression without fusion were prospectively followed up 1 year after surgery. Clinical outcome scores included the EQ-5D, the Oswestry disability index, self-estimated walking distance, and leg and back pain levels (VAS). Central dural sac area, number of levels with stenosis, and spondylolisthesis were included in the MRI analysis. Multivariable analyses were performed to search for correlation between patient-related and imaging factors and clinical outcome at 1-year follow-up. Results Several factors predicted outcome statistically significantly. Duration of leg pain exceeding 2 years predicted inferior outcome in terms of leg and back pain, function, and HRLQoL. Regular and intermittent preoperative users of analgesics had higher levels of back pain at follow-up than those not using analgesics. Low preoperative function predicted low function and dissatisfaction at follow-up. Low preoperative EQ-5D scores predicted a high degree of leg and back pain. Narrow dural sac area predicted more gains in terms of back pain at follow-up and lower absolute leg pain. Interpretation Multiple factors predict outcome in spinal stenosis surgery, most importantly duration of symptoms and preoperative function. Some of these are modifiable and can be targeted. Our findings can be used in the preoperative patient information and aid the surgeon and the patient in a shared decision making process.

Outcome of decompression with and without fusion in spinal stenosis with degenerative spondylolisthesis in relation to preoperative pain pattern - A register study of 1,624 patients.

BACKGROUND CONTEXT Patients with spinal stenosis with concomitant degenerative spondylolisthesis (DS) and predominant back pain (PBP) have been shown to have inferior outcome after surgery. Studies comparing outcome according to preoperative pain predominance and treatment received are lacking. PURPOSE The purpose was to study if adding spinal fusion to the decompression in DS affects outcome in patients with PBP (back pain [BP] Visual Analog Scale [VAS] more than or equal to leg pain [LP] VAS) compared with predominant leg pain (PLP) (BP VAS less than LP VAS). PATIENT SAMPLE The Swedish Spine Register was used and included 1,624 patients operated for DS at the L4-L5 level. OUTCOME MEASURES Self-reported measures were used, including a VAS for BP and LP, the EuroQol-5D (EQ-5D), and the physical and mental component summaries of the Short-Form 36 to estimate health-related quality of life and the Oswestry disability index (ODI) to estimate function. METHODS Inclusion criterion was single-level DS operated on with either decompression only (D) or decompression and instrumented posterolateral fusion (DF). Based on preoperative LP and BP scores, the patients were assigned to one of the two groups: LP predominance or BP predominance. The patients completed the outcome protocol at 1- and 2-year follow-ups. Statistical analysis was performed using linear regression adjusting for multiple potential confounders. RESULTS In the adjusted outcome at the 1-year follow-up, patients with PLP reported a 7.9-mm more improvement on the VAS for BP with fusion, compared with D (95% confidence interval [CI], 0.7-15.2), p=.03. Despite more change in the fused group, the reported BP levels remained similar in the D versus decompressed and fused at the 1-year follow-up (28 vs. 24, p=.77). The patients with PBP benefited from adding fusion in terms of BP 7.1 (95% CI, 0.3-13.9, p=.04), LP 8.8 (2-15.7, p=.01), the ODI 5.7 (1.6-9.9, p=.006), and the EQ-5D 0.09 (1.7-0.02, p=.02) at the 1-year follow-up as the DF group reported greater change in the outcome compared with the D group. At the 2-year follow-up, no significant differences were found between D and decompressed and fused in either the LP or the PBP groups. CONCLUSIONS Patients with PBP operated with DF report better outcomes in terms of pain, function, and health-related quality of life than patients with D. Although these differences are significant on a group level, they may fail to reach minimal clinical significant difference. Patients with PLP report significantly more improvement in terms of BP with DF compared with D, but because of baseline differences in preoperative BP, these improvements may not be explained by the added fusion per se. At the 2-year follow-up, no significant differences were observed between the D and DF patients in either the PBP or PLP groups, but greater loss to follow-up in the DF groups could potentially bias these findings.

Preoperative Pain Pattern Predicts Surgical Outcome more than Type of Surgery in Patients With Central Spinal Stenosis Without Concomitant Spondylolisthesis: A Register Study of 9,051 Patients.

Study Design. A register cohort study. Objective. To evaluate outcome of surgery for lumbar spinal stenosis without concomitant degenerative spondylolisthesis according to predominance of pain and to analyze the role of spinal fusion in conjunction with decompression in patients with predominant back pain (BP) or leg pain (LP). Summary of Background Data. Predominance of BP is associated with inferior outcome of surgery for central spinal stenosis. It is unknown if using spinal fusion improves outcomes. Methods. In a register study of 9051 patients, we studied outcome of surgery in terms of BP and LP visual analogue scale, function (the Oswestry Disability Index and self-estimated walking distance), health-related quality of life (Short-Form 36 and EuroQol), and patient satisfaction. Outcome was analyzed for 4 groups at 1- and 2-year follow-ups; preoperative BP was equal to or worse than LP and decompression, preoperative BP was equal to or worse than LP and decompression and fusion, preoperative BP was less than LP and decompression, preoperative BP was less than decompression and fusion. Results. Patients with concomitant fusion were younger and had higher BP and Oswestry Disability Index scores and lower preoperative EuroQol. Predominant BP was associated with inferior outcome in terms of pain, health-related quality of life, and function. Patients most often satisfied (69%) were patients with BP less than LP treated with decompression and fusion and the least satisfied group was patients with BP equal to or worse than LP treated with decompression (54%). Fusion was not only associated with higher EuroQol at 1-year follow-up for patients with predominant BP, but also associated with increased LP at 2-year follow-up in patients with predominant LP. Patients with predominant BP experienced small gains in the physical component summary with fusion. Conclusion. Predominance of BP is associated with inferior outcome. Using spinal fusion improves unadjusted outcome but the benefit is small and not clinically significant and generally disappears in the adjusted analysis. Level of Evidence: 4

The Impact of Pain on Function and Health Related Quality of Life in Lumbar Spinal Stenosis: A Register Study of 14.821 patients.

Study Design. Descriptive register study. Objective. To describe preoperative levels of leg and back pain in patients operated for lumbar spinal stenosis, and to obtain information on how 3 different pain constellations (back pain < leg pain, back pain > leg pain, back pain = leg pain) correlate to health related quality of life (HRQoL) and function in different morphological types of stenosis. Summary of Background Data. Degenerative lumbar spinal stenosis is considered a poorly defined clinical syndrome and knowledge of what uniquely characterizes the different morphological types of stenosis is lacking. Methods. Using the Swedish Spine Register, we studied (1) the pain characteristics of patients with central spinal stenosis (CSS), lateral recess stenosis, and spinal stenosis with spondylolisthesis (2) how HRQoL and function correlate to leg and back pain. Results. Grading leg pain higher than back pain was the most common pain constellation (49%) followed by grading back pain more than leg pain (39%). Twelve percent had the same intensity of leg and back pain. The type of stenosis grading the highest burden of back pain was spinal stenosis with spondylolisthesis (ratio = 0.93; [95% confidence interval, CI] = 0.92–0.95), followed by central spinal stenosis (ratio = 0.88; [95% CI] = 0.88–0.89). Lateral recess stenosis had the lowest burden of back pain (ratio = 0.85; [95% CI] = 0.83–0.87). The lowest HRQoL and function was found in spinal stenosis with spondylolisthesis (back pain = leg pain group) where 55% ([95% CI] = 50–59) of patients could not walk more than 100 m. Patients with lateral recess stenosis had better self-estimated walking distance. Conclusion. Back pain is generally experienced to a high extent by patients scheduled for spinal stenosis surgery. HRQoL and function are low preoperatively irrespective of whether back or leg pain is predominant. In this large patient material patients who grade their back and leg pain as likeworthy have significantly lower values for HRQoL and function compared to patients reporting predominant leg or back pain but the difference is not clinically relevant. Level of Evidence: 4

No difference in health-related quality of life in hip osteoarthritis compared to degenerative lumbar instability at pre- and 1-year postoperatively: a prospective study of 101 patients.

Background Total hip replacement (THR) is a very successful and refined surgical procedure when compared to crude bony fusion in degenerative lumbar segmental instability (LF). We compared the pre- and postoperative health-related quality of life status of THR and LF patients. Patients and methods We prospectively studied 51 THR patients and 50 LF patients. The outcome parameters were SF-36 and Oswestry Disability Index (ODI), measured preoperatively and at 1 year postoperatively. The status of the patients was compared to that of an age-matched healthy control group. Results The preoperative SF-36 and ODI scores were similar between the groups, except for the subscale role emotional. One year postoperatively, only the differences in 3 subscales (physical functioning, role physical, and role emotional) and in the standardized physical component reached statistical significance; the THR-patients scored worse than the LF-patients. The improvements in SF-36 and ODI reached statistical significance in both groups. Interpretation The differences in quality of life between the THR and LF patients were similar pre- and postoperatively. The quality of life of both cohorts improved considerably and significantly after the treatment, but they remained at a level significantly below that of a general age-matched population.

Incidental durotomy in degenerative lumbar spine surgery – a register study of 64,431 operations

BACKGROUND Incidental durotomy (ID) is one of the most common intraoperative complications seen in spine surgery. Conflicting evidence has been presented regarding whether or not outcomes are affected by the presence of an ID. PURPOSE To evaluate whether outcomes following degenerative spine surgery are affected by ID and the incidence of ID with different diagnoses and different surgical procedures. MATERIALS By using SweSpine, the national Swedish Spine Surgery Register, preoperative, surgical and postoperative 1-year follow-up data were obtained for 64,431 surgeries. All patients were surgically treated due to lumbar spinal stenosis (LSS) without or with concomitant degenerative spondylolisthesis (DS) or lumbar disc herniation (LDH) between 2000 and 2015. Gender, age, smoking habits, walking distance, consumption of analgesics, back and leg pain (Visual Analogue Scale [VAS]), quality of life (EuroQol [EQ5D] and Short Form 36 [SF-36]), and disability (Oswestry Disability Index [ODI]) were recorded. RESULTS Overall, incidence of ID during the study period was 5.0%. For the LDH, LSS, and DS subgroups, it was 2.8%, 6.5%, and 6.5%, respectively. Laminectomy was associated with a higher incidence of ID than discectomy (p<.001). ID was more common in all three subgroups if the patient had previously been subjected to spine surgery and with increasing age of the patients (p<.001). LDH patients with an ID reported a higher degree of residual leg pain, inferior mental quality of life (SF-36 MCS), and higher disability (ODI) than LDH patients without ID (all p<.001) 1-year after surgery. LSS patients with an ID reported inferior SF-36 MCS (p<.001) and DS patients with an ID had inferior SF-36 MCS and higher ODI compared to patients with the same diagnosis but without an ID (p<.001). However, these numerical differences are well below references for MCID, for all three subgroups. ID was associated with a higher frequency of patients being dissatisfied with the surgical outcome at 1-year follow-up. In patients who did not improve in back and leg pain following surgery (delta-value), ID was less common than in patients reporting improved back and leg pain from before as compared to following surgery. CONCLUSIONS The overall occurrence of ID in the present study was 5%, with higher figures in LSS and DS and lower figures in LDH. Higher age of the patient and previous surgery were associated with higher frequencies of ID. The outcome at 1 year following surgery was not affected to a clinically relevant extent when an ID was obtained. However, ID was associated with a higher degree of patient dissatisfaction and a longer hospital length of stay.