Physical prognostic factors predicting outcome following lumbar discectomy surgery: systematic review and narrative synthesis

Abstract

Background: Success rates for lumbar discectomy are estimated as 78-95% patients at 1-2 years post-surgery, supporting its effectiveness. However, ongoing pain and disability is an issue for some patients, and recurrence contributing to reoperation is reported. It is important to identify prognostic factors predicting outcome to inform decision-making for surgery and rehabilitation following surgery. The objective was to determine whether pre-operative physical factors are associated with post-operative outcomes in adult patients [≥16 years old] undergoing lumbar discectomy or microdiscectomy.Methods: A systematic review was conducted according to a registered protocol [PROSPERO CRD42015024168]. Key electronic databases were searched [PubMed, CINAHL, EMBASE, MEDLINE, PEDro and ZETOC] using pre-defined terms [e. g. radicular pain] to 31/3/2017; with additional searching of journals, reference lists and unpublished literature. Prospective cohort studies with ≥1-year follow-up, evaluating candidate physical prognostic factors [e.g. leg pain intensity and straight leg raise test], in adult patients undergoing lumbar discectomy/microdiscectomy were included. Two reviewers independently searched information sources, evaluated studies for inclusion, extracted data, and assessed risk of bias [QUIPS]. GRADE determined the overall quality of evidence. Results: 1189 title and abstracts and 45 full texts were assessed, to include 6 studies; 1 low and 5 high risk of bias. Meta-analysis was not possible [risk of bias, clinical heterogeneity]. A narrative synthesis was performed. There is low level evidence that higher severity of pre-operative leg pain predicts better Core Outcome Measures Index at 12 months and better post-operative leg pain at 2 and 7 years. There is very low level evidence that a lower pre-operative EQ-5D predicts better EQ-5D at 2 years. Low level evidence supports duration of leg pain pre-operatively not being associated with outcome, and very low-quality evidence supports other factors [pre-operative ODI, duration back pain, severity back pain, ipsilateral SLR and forward bend] not being associated with outcome [range of outcome measures used].Conclusion: An adequately powered low risk of bias prospective observational study is required to further investigate candidate physical prognostic factors owing to existing low/very-low level of evidence.

Predicting patient-reported outcomes following lumbar spine surgery: development and external validation of multivariable prediction models

“…Relevance of several of the identified predictors was also supported by previous research on patient-reported outcomes from the Spine Tango registry in other countries (Sobottke et al, 2017; Staub et al, 2020). Our results are also consistent with systematic reviews supporting prognostic value of age, preoperative pain intensity and disability, type of spinal pathology, previous surgeries, and smoking (Dorow et al, 2017; Halicka et al, under review ; Rushton et al, 2018; Wilhelm et al, 2017; Wilson et al, 2016). In contrast, we did not find any effect of symptom duration, here recorded indirectly as treatment duration.…”

“…Reliable predictive factors could maximise patient benefit and cost-effectiveness of surgery. Although several systematic reviews concluded that medical, sociodemographic, and psychological factors are linked to improvement in pain and disability following lumbar spine surgery (Dorow et al, 2017; Halicka et al, under review ; Rushton et al, 2018; Wilhelm et al, 2017; Wilson et al, 2016), we lack clear clinical guidelines on the reliable predictors (de Campos, 2017) and predictive factors are rarely formally documented.…”

Predictors of Pain and Disability Outcomes Following Spinal Surgery for Chronic Low Back and Radicular Pain

“…Several health-related factors were identified as potential predictors of reduction in pain or disability after surgery. Previous systematic reviews concerned with this class of predictors focused only on disk herniation cohorts,15,18,19 thus our review extends the existing evidence synthesis to a broader range of spinal pathologies. In fact, the type of diagnosis itself may be an important predictor, as cohorts with spinal stenosis presented with less reduction in back and leg pain after surgery compared with degenerative disk disease and disk herniation cohorts (low-quality evidence).…”

“…For instance, fusion surgery for back pain has better outcomes if patients have successfully completed a pain management course with cognitive-behavioral therapy. 14 Previous systematic reviews addressing similar questions were restricted to specific pathologies such as disk herniation [15][16][17][18][19] or surgical interventions such as spinal fusion. [20][21][22] However, the prognostic value of sociodemographic, health-related, and psychological patient characteristics for reduction in pain and disability may be independent of medical diagnosis and type of surgery, and considering broader LBP population could potentially mitigate the issues of insufficient amount or quality of evidence faced by previous reviews.…”

Association of quantitative sensory testing parameters with clinical outcome in patients with lumbar radiculopathy undergoing microdiscectomy

“…Identification of clinical predictors of outcome in these patients likely involves analysis of many potential interacting factors including psychological and cognitive‐behavioural factors such as fear avoidance behaviour, negative outcome expectancy (den Boer, Oostendorp, Beems, Munneke, & Evers, 2006a; den Boer, Oostendorp, Beems, Munneke, Oerlemans, et al, 2006; Johansson, Linton, Rosenblad, Bergkvist, & Nilsson, 2010), pain catastrophizing (Lautenbacher et al., 2010), depression, anxiety (Chaichana, Mukherjee, Adogwa, Chen, & McGirt, 2011) and physical factors (Rushton, Zoulas, Powell, & Staal, 2018; Werner et al., 2017). While such multidimensional predictors of outcome to inform surgical patient selection are valuable and may guide alternative clinical pathways of care, the predictive value of sensory nerve fibre function has yet to be systematically investigated in people with painful lumbar radiculopathy.…”