Vol. 150 No. 3738 (2020)
Outcomes after spinal stenosis surgery by type of surgery in adults aged 60 years and older
AIMS OF THE STUDY
Mobility disability due to spinal stenosis is common in the senior population and often surgery is warranted for patients with severe symptoms and neurological dysfunction. However, although current clinical guidelines recommend stabilisation surgery in addition to decompression in patients with spinal stenosis and instability due to degenerative spondylolisthesis, the relationship between outcomes and the specific type of surgery have not been well studied. We therefore assessed the postoperative recovery timeline for 12 months and compared patient-reported outcomes dependent on the extent of decompression and additional stabilisation among seniors undergoing spinal stenosis surgery.
We investigated 457 patients (mean age 76.0 ± 10.7 years, 58% women) from a consecutive cohort prior to spinal stenosis surgery. Follow-up was at 3 or 6months and at 12 months postoperatively. At each visit, pain, neurological dysfunction and disability were assessed using the North American Spine Society questionnaire. Repeated-measures analysis compared outcomes by type of surgery adjusting for baseline symptoms, gender, age, number of comorbidities, centre and year of surgery.
Most improvement occurred within the first 3 to 6 months with little or no further improvement at 12 months. Over 12 months and in adjusted models, patients receiving one-segment versus multi-segment decompression experienced significantly greater reduction of pain (−49.2% vs −41.9%, p = 0.013) and neurological dysfunction (−37.1% vs −25.9%, p <0.0001), but only borderline greater reduction of disability (−32.7% vs −28.2%, p = 0.051). Moreover, reduction in pain and neurological function did not differ with or without additional stabilisation and extend of decompression. However, patients who received one-segment (−28.9%) or multi-segment (−28.3%) stabilisation experienced significantly less reduction in disability after surgery compared with those who were not stabilised (−34.1%, p <0.043).
Among senior patients undergoing spinal stenosis surgery, recovery was largely complete by 3 to 6 months after surgery and differed little by type of surgery independently of symptoms prior to surgery and other covariates. However we could document a trend toward more improvement in particularly neurological dysfunction and disability with less invasive surgery.
- Kalichman L, Cole R, Kim DH, Li L, Suri P, Guermazi A, et al. Spinal stenosis prevalence and association with symptoms: the Framingham Study. Spine J. 2009;9(7):545–50. doi:.https://doi.org/10.1016/j.spinee.2009.03.005
- Ishimoto Y, Yoshimura N, Muraki S, Yamada H, Nagata K, Hashizume H, et al. Prevalence of symptomatic lumbar spinal stenosis and its association with physical performance in a population-based cohort in Japan: the Wakayama Spine Study. Osteoarthritis Cartilage. 2012;20(10):1103–8. doi:.https://doi.org/10.1016/j.joca.2012.06.018
- Ishimoto Y, Yoshimura N, Muraki S, Yamada H, Nagata K, Hashizume H, et al. Association of Lumbar Spondylolisthesis With Low Back Pain and Symptomatic Lumbar Spinal Stenosis in a Population-based Cohort: The Wakayama Spine Study. Spine. 2017;42(11):E666–71. doi:.https://doi.org/10.1097/BRS.0000000000001960
- Fraser JF, Huang RC, Girardi FP, Cammisa FP, Jr. Pathogenesis, presentation, and treatment of lumbar spinal stenosis associated with coronal or sagittal spinal deformities. Neurosurg Focus. 2003;14(1):e6. doi:.https://doi.org/10.3171/foc.2003.14.1.7
- Kim HJ, Chun HJ, Han CD, Moon SH, Kang KT, Kim HS, et al. The risk assessment of a fall in patients with lumbar spinal stenosis. Spine. 2011;36(9):E588–92. doi:.https://doi.org/10.1097/BRS.0b013e3181f92d8e
- Lee JH, Sung E. The effects of aquatic walking and jogging program on physical function and fall efficacy in patients with degenerative lumbar spinal stenosis. J Exerc Rehabil. 2015;11(5):272–5. doi:.https://doi.org/10.12965/jer.150231
- Chou R, Hashimoto R, Friedly J, Fu R, Bougatsos C, Dana T, et al. Epidural Corticosteroid Injections for Radiculopathy and Spinal Stenosis: A Systematic Review and Meta-analysis. Ann Intern Med. 2015;163(5):373–81. doi:.https://doi.org/10.7326/M15-0934
- Friedly JL, Comstock BA, Turner JA, Heagerty PJ, Deyo RA, Sullivan SD, et al. A randomized trial of epidural glucocorticoid injections for spinal stenosis. N Engl J Med. 2014;371(1):11–21. doi:.https://doi.org/10.1056/NEJMoa1313265
- Spinal stenosis. Severity determines treatment plan. Mayo Clin Health Lett. 2001;19(6):1–3.
- Bischoff-Ferrari HA, Lingard EA, Losina E, Baron JA, Roos EM, Phillips CB, et al. Psychosocial and geriatric correlates of functional status after total hip replacement. Arthritis Rheum. 2004;51(5):829–35. doi:.https://doi.org/10.1002/art.20691
- Sobottke R, et al. Predictors of improvement in quality of life and pain relief in lumbar spinal stenosis relative to patient age: a study based on the Spine Tango registry. Eur Spine J. 2017;26(2):462–72. doi:.https://doi.org/10.1007/s00586-015-4078-8
- North American Spine Society. Diagnosis and treatment of degenerative spinal stenosis. 2011. Available from: https://www.spine.org/Documents/ResearchClinicalCare/Guidelines/LumbarStenosis.pdf [accessed 2015 Nov 19].
- Birkelbach O, Mörgeli R, Spies C, Olbert M, Weiss B, Brauner M, et al. Routine frailty assessment predicts postoperative complications in elderly patients across surgical disciplines - a retrospective observational study. BMC Anesthesiol. 2019;19(1):204. doi:.https://doi.org/10.1186/s12871-019-0880-x
- Vitaz TW, Raque GH, Shields CB, Glassman SD. Surgical treatment of lumbar spinal stenosis in patients older than 75 years of age. J Neurosurg. 1999;91(2, Suppl):181–5.
- Daltroy LH, Cats-Baril WL, Katz JN, Fossel AH, Liang MH. The North American spine society lumbar spine outcome assessment Instrument: reliability and validity tests. Spine. 1996;21(6):741–8. doi:.https://doi.org/10.1097/00007632-199603150-00017
- Schaeren S, Bischoff-Ferrari HA, Knupp M, Dick W, Huber JF, Theiler R. A computer touch-screen version of the North American Spine Society outcome assessment instrument for the lumbar spine. J Bone Joint Surg Br. 2005;87-B(2):201–4. doi:.https://doi.org/10.1302/0301-620X.87B2.15548
- Kirrstetter AR, Brenig C, Gengenbacher M, Meier B, Ott A, Theiler R. Erfahrungen bei der Messung der Ergebnisqualität in der interventionellen Schmerztherapie [Experience in measuring the quality of treatment in interventional pain therapy : The Activity Index on a touchscreen PC]. Schmerz. 2017;31(2):131–8. Article in German. doi:.https://doi.org/10.1007/s00482-016-0173-y
- Sangha O, Stucki G, Liang MH, Fossel AH, Katz JN. The Self-Administered Comorbidity Questionnaire: a new method to assess comorbidity for clinical and health services research. Arthritis Rheum. 2003;49(2):156–63. doi:.https://doi.org/10.1002/art.10993
- Micankova Adamova B, Vohanka S, Dusek L, Jarkovsky J, Bednarik J. Prediction of long-term clinical outcome in patients with lumbar spinal stenosis. Eur Spine J. 2012;21(12):2611–9. doi:.https://doi.org/10.1007/s00586-012-2424-7
- Galiano K, Obwegeser AA, Gabl MV, Bauer R, Twerdy K. Long-term outcome of laminectomy for spinal stenosis in octogenarians. Spine. 2005;30(3):332–5. doi:.https://doi.org/10.1097/01.brs.0000152381.20719.50
- Hurri H, Slätis P, Soini J, Tallroth K, Alaranta H, Laine T, et al. Lumbar spinal stenosis: assessment of long-term outcome 12 years after operative and conservative treatment. J Spinal Disord. 1998;11(2):110–5. doi:.https://doi.org/10.1097/00002517-199804000-00003
- Shabat S, Arinzon Z, Folman Y, Leitner J, David R, Pevzner E, et al. Long-term outcome of decompressive surgery for lumbar spinal stenosis in octogenarians. Eur Spine J. 2008;17(2):193–8. doi:.https://doi.org/10.1007/s00586-007-0514-8
- Bachmeier CJ, March LM, Cross MJ, Lapsley HM, Tribe KL, Courtenay BG, et al.; Arthritis Cost and Outcome Project Group. A comparison of outcomes in osteoarthritis patients undergoing total hip and knee replacement surgery. Osteoarthritis Cartilage. 2001;9(2):137–46. doi:.https://doi.org/10.1053/joca.2000.0369
- Martin CR, Gruszczynski AT, Braunsfurth HA, Fallatah SM, O’Neil J, Wai EK. The surgical management of degenerative lumbar spondylolisthesis: a systematic review. Spine. 2007;32(16):1791–8. doi:.https://doi.org/10.1097/BRS.0b013e3180bc219e
- Försth P, Michaëlsson K, Sandén B. Does fusion improve the outcome after decompressive surgery for lumbar spinal stenosis?: A two-year follow-up study involving 5390 patients. Bone Joint J. 2013;95-B(7):960–5. doi:.https://doi.org/10.1302/0301-620X.95B7.30776
- Martin BI, Mirza SK, Comstock BA, Gray DT, Kreuter W, Deyo RA. Reoperation rates following lumbar spine surgery and the influence of spinal fusion procedures. Spine. 2007;32(3):382–7. doi:.https://doi.org/10.1097/01.brs.0000254104.55716.46
- Deyo RA, Mirza SK, Martin BI, Kreuter W, Goodman DC, Jarvik JG. Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults. JAMA. 2010;303(13):1259–65. doi:.https://doi.org/10.1001/jama.2010.338
- Burgstaller JM, Wertli MM, Ulrich NH, Pichierri G, Brunner F, Farshad M, et al.; LSOS Study Group. Evaluating the Minimal Clinically Important Difference of EQ-5D-3L in Patients with Degenerative Lumbar Spinal Stenosis: A Swiss Prospective Multi-Center Cohort Study. Spine. 2020 March 19. Volume Publish Ahead of Print. doi:.https://doi.org/10.1097/BRS.0000000000003501
- Betz M, Burgstaller JM, Held U, Andreisek G, Steurer J, Porchet F, et al.; LSOS Study Group. Influence of Paravertebral Muscle Quality on Treatment Efficacy of Epidural Steroid Infiltration or Surgical Decompression in Lumbar Spinal Stenosis-Analysis of the Lumbar Spinal Outcome Study (LSOS) Data: A Swiss Prospective Multicenter Cohort Study. Spine. 2017;42(23):1792–8. doi:.https://doi.org/10.1097/BRS.0000000000002233
- Ulrich NH, Burgstaller JM, Gravestock I, Pichierri G, Wertli MM, Steurer J, et al. Outcome of unilateral versus standard open midline approach for bilateral decompression in lumbar spinal stenosis: is “over the top” really better? A Swiss prospective multicenter cohort study. J Neurosurg Spine. 2019;31(2):1–10. doi:.https://doi.org/10.3171/2019.2.SPINE181309
- Held U, Steurer J, Pichierri G, Wertli MM, Farshad M, Brunner F, et al. What is the treatment effect of surgery compared with nonoperative treatment in patients with lumbar spinal stenosis at 1-year follow-up? J Neurosurg Spine. 2019;31(2):1–9. doi:.https://doi.org/10.3171/2019.1.SPINE181098