Introduction Clinical symptoms in lumbar degenerative spondylolisthesis (LDS) vary from predominantly radiating pain to severe mechanical low back pain. We examined whether the outcome of surgery for LDS varied depending on the predominant baseline symptom and the treatment administered [decompression with fusion (D&F) or decompression alone (D)]. Methods 213 consecutive patients (69 ± 9 years; 155f, 58 m) participated. Inclusion criteria were LDS, maximum three affected levels, no previous surgery at the affected level, and D (N = 56) or D&F (N = 157) as the operative procedure. Pre-op and at 12 months' follow-up (FU), patients completed the multidimensional Core Outcome Measures Index (COMI) including 0-10 leg-pain (LP) and LBP scales. At 12 months' FU, patients rated global outcome which was then dichotomised into ''good'' and ''poor''. Results Pre-operatively, LBP and COMI scores were significantly worse (p \ 0.05) in the D&F group than in the D group. The improvement in COMI at 12 months' FU was significantly greater for D&F than for D (p \ 0.001) and was not influenced by the patient's declared ''main problem'' at baseline (back pain, leg pain, or neurological disturbances) (p [ 0.05). There was a higher proportion (p = 0.01) of ''good'' outcomes at 12 months' FU in D&F (86%) than in D (70%). Multiple regression analysis, controlling for possible confounders, revealed treatment group to be the only significant predictor of outcome (adding fusion = better outcome).
DiscussionOur study indicated that LDS patients showed better patient-based outcome with instrumented fusion and decompression than with decompression alone, regardless of baseline symptoms. This may be due to the fact that the underlying slippage as the cause of the stenosis is better addressed with fusion.
Facet joint effusion is clearly correlated with spontaneous reduction of the extent of slippage in the supine position compared to the upright position. Also, the greater the difference in right and left facet effusion, the higher the likelihood of having a RT. Future studies should assess whether analysis of facet joint effusion measured on routine MRI can help in decision-making regarding the optimal surgical treatment to be applied (decompression alone or combined with fusion).
The findings demonstrate wide discrepancies between the patient and the surgeon regarding the expected result of surgery. They highlight the need for clearer explanations of the association between the spinal problem and neurological deficits and the improvement that can be expected in pain and function after surgery. Systematic, routine evaluation of outcomes should assist in deriving the information necessary to document the improvement achieved and to formulate realistic expectations of surgery.
Purpose The ageing of the population will see a growing number of patients presenting for spine surgery with appropriate indications but numerous medical comorbidities. This complicates decision-making, requiring that the likely benefit of surgery (outcome) be carefully weighed up against the potential risk (complications). We assessed the influence of comorbidity on the risks and benefits of spine surgery. Methods 3,549/4,053 patients with degenerative lumbar disorders, undergoing surgery with the goal of pain relief, completed the multidimensional Core Outcome Measures Index (COMI; scored 0-10) before and 12 months after surgery. At 12 months postoperatively, they also rated the global treatment outcome and their satisfaction with care. Using the Eurospine Spine Tango Registry, surgeons documented surgical details, American Society of Anesthesiologists comorbidity (ASA) grades and perioperative surgical and general complications. Results 29.0 % patients were rated as ASA1 (normal healthy), 45.7 % as ASA2 (mild/moderate systemic disease), 24.9 % as ASA3 (severe), and just 0.4 % as ASA4 (life-threatening). In going from ASA1 to ASA3 (ASA4 group too small), surgical complications increased significantly from 5.0 to 14.5 % and general complications increased from 2.9 to 15.7 %; 12-month outcomes showed a corresponding decline, with a good global outcome being reported by 79 % ASA1 patients, 76 % ASA2, and 68 % ASA3. Satisfaction with treatment was 87, 85, and 79 %, respectively, and reduction in COMI was 4.2 ± 2.9, 3.7 ± 3.0, and 3.4 ± 3.0 points, respectively. Multiple regression analysis revealed a significant (p \ 0.0001) independent effect of ASA grade on both complications and outcome. Conclusion The negative impact of comorbidity on the outcome of spine surgery has not been well investigated/ quantified to date. The ASA grade may be helpful in producing algorithms for decision-making and preoperative counselling regarding the corresponding risks and benefits of surgery.
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