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Rinnakkaistallenteet Terveystieteiden tiedekunta
2020
Preoperative Predictors of Better Long-Term Functional Ability and Decreased Pain Following LSS
Surgery: A Prospective Observational Study with a 10-year Follow-Up Period
Tuomainen, I
Ovid Technologies (Wolters Kluwer Health)
Tieteelliset aikakauslehtiartikkelit
© 2020 Wolters Kluwer Health, Inc.
CC BY-NC http://creativecommons.org/licenses/by-nc/4.0/
http://dx.doi.org/10.1097/BRS.0000000000003374
https://erepo.uef.fi/handle/123456789/23653
Downloaded from University of Eastern Finland's eRepository
SPINE An International Journal for the study of the spine, Publish Ahead of Print DOI: 10.1097/BRS.0000000000003374
Preoperative predictors of better long-term functional ability and decreased pain following LSS surgery—a prospective observational study with a 10-year follow-up period
Iina Tuomainen, MD1,2, Janne Pesonen, MD1,2, Marinko Rade, MD1,3,4,
Maarit Pakarinen, PhD5, Ville Leinonen, PhD6, Heikki Kröger, PhD7, Olavi Airaksinen, PhD1,2, Timo Aalto, PhD8
1. Department of Physical and Rehabilitation Medicine, Kuopio University Hospital, Kuopio, Finland
2. Department of Surgery (incl. Physiatry), Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
3. Josip Juraj Strossmayer University of Osijek, Faculty of Medicine, Orthopaedic and Rehabilitation Hospital “Prim. dr.Martin Horvat”
4. Juraj Dobrila University of Pula, Department of Natural and Health Studies, Pula, Croatia.
5. Department of Psychiatry, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
6. Institute of Clinical Medicine – Neurosurgery, University of Eastern Finland; Department of Neurosurgery, Kuopio University Hospital, Kuopio, Finland and Unit of Clinical Neuroscience, Neurosurgery, University of Oulu; Medical Research Center, Oulu University Hospital, Oulu, Finland
6. Department of Orthopaedics and Traumatology, Kuopio University Hospital and Kuopio Musculoskeletal Research Unit, University of Eastern Finland
7. Medical Center Ikioma, Mikkeli, Finland Corresponding Author:
Iina Tuomainen
Department of Physical and Rehabilitation Medicine
Kuopio University Hospital PL 100, FI-70029 KYS, Finland
Tel +358443438562, e-mail: iina.tuomainen@uef.fi
The manuscript submitted does not contain information about medical device(s)/drug(s).
The Research Committee of the Kuopio University Hospital Catchment Area for the State Research Funding and the Finnish Cultural Foundation Grant, North Savo Regional Fund were received in support of this work.
No relevant financial activities outside the submitted work.
Study design A prospective observational 10-year follow-up study
Objective This study aimed to examine preoperative predictors for better surgical outcomes in patients with lumbar spinal stenosis (LSS) 10 years after surgery.
Summary of Background Data LSS is a leading cause of low back surgery in patients older than 65 years. Limited data is available for predictors of long-term surgical outcomes in patients with LSS.
Methods At the baseline, 102 patients with LSS underwent decompressive surgery, and 72 of the original study sample participated in a 10-year follow-up study. Study patients filled out a questionnaire preoperatively, and follow-up data were collected at 3 months, 6 months, 1 year, 2 years, 5 years, and 10 years postoperatively. Surgical outcomes were evaluated in terms of disability with the Oswestry Disability Index (ODI) and pain with the visual analog scale (VAS).
Predictors in the models were non-smoking status, absence of previous lumbar surgery, self-rated health, regular use of painkillers for symptom alleviation, and BMI. Statistical analyses included longitudinal associations, subgroup analyses, and cross-sectional analyses.
Results Using multivariate analysis, statistically significant predictors for lower ODI and VAS scores at 10 years were non-smoking status, absence of previous lumbar surgery, better self-rated health, and regular use of painkillers for less than 12 months. Patients who smoked
preoperatively or had previous lumbar surgery experienced more pain and disability at the 10- year follow-up.
Conclusion These study results can enhance informed decision-making processes for patients considering surgical treatment for LSS by showing preoperative predictors for surgical outcomes up to 10 years after surgery. Smokers and patients with previous lumbar surgery showed a decline in surgical benefits after five years.
Key Words: lumbar spinal stenosis, decompressive surgery, predictors, surgical outcome, follow-up, Oswestry disability index, visual analog scale, non-smoking, self-rated health, regular use of painkillers, first lumbar operation
Level of Evidence: 3
Key points
The current study’s results can enhance informed decision-making processes for patients considering surgical treatment for LSS by showing preoperative predictors for surgical outcomes up to 10 years after surgery.
Smoking cessation should be strongly recommended preoperatively in order to improve surgical recovery.
Patients who have undergone previous lumbar surgery are less likely to benefit from subsequent lumbar surgery as much as patients without previous lumbar surgeries.
Preoperative positive self-rated health and symptoms controlled by the regular use of painkillers for less than 12 months were also associated with better functional ability and less pain.
Introduction
Lumbar spinal stenosis (LSS) is a leading cause of low back surgery in patients older than 65 years [1] and often results from degenerative changes in the lumbar spine [2]. The most characteristic symptom in LSS is neurogenic claudication [3], with symptomatic LSS being defined as a debilitating condition leading toward a decrease in the quality of life [2–4].
Surgery is usually utilized as a second line of symptom relief for LSS if conservative treatment fails to improve symptoms in three to six months [5–7]. When surgery is indicated, outcomes seem to be superior to those of continuous conservative treatment for at least four years, even if the benefits of surgery decline over time [7–12]. To date, no clear guidance for treatment choice in patients with LSS can be recommended [13], and decisions for the choice of treatment can be subjective and vary among physicians [14]. Moreover, associations between radiological findings and the degree of severity of clinical symptoms have seldom been found [15]. Therefore, a shared decision-making process with the patient is a key part of the decision to choose surgical treatment [6].
Previous studies have demonstrated various preoperative predictors for disability and pain following LSS surgery up to four years postoperatively [16–25]. Psychological factors such as depression, life dissatisfaction, and a weak sense of coherence have shown an association with poorer surgical outcomes even after 10 years postoperatively [26–28]. However, other preoperative variables predicting better surgical outcomes up to 10 years after surgery have not been identified.
Although surgical treatment, when indicated, has been shown to be more beneficial than continuous conservative treatment up to four years postoperatively with benefits narrowing over time [7–12], more studies are needed to establish patient-related factors that may affect long- term surgical outcomes in order to improve patient selection for surgical treatment of LSS. In this view, and in order to fill the gap in the existing literature, preoperative predictors for long- term surgical outcomes were evaluated in patients with LSS for up to 10 years postoperatively.
Methods
Study population and design
The original study population was selected from LSS patients being treated at Kuopio University Hospital, Kuopio, Finland, between 2001 and 2004. Selection for surgery was carried out at either the Department of Orthopedics or the Department of Neurosurgery. At baseline, 102 LSS patients met the inclusion criteria for the current study.
The inclusion criteria were as follows: 1) presence of severe pain in the back, buttocks, or lower extremities with radiographic evidence (computed tomography (CT), magnetic resonance imaging (MRI), or rhizography) of compression of the cauda equina or exiting nerve roots linked to degenerative changes (ligamentum flavum, facet joints, osteophytes, and/or disc material), and 2) the surgeon's judgement that the patient had clinically significant, degenerative LSS as the main diagnosis, indicative of a need for operative treatment. Additionally, all patients had a history of insufficient response to continuous conservative treatment for several months before undergoing a clinical evaluation for degenerative LSS requiring operative treatment. Previous spine surgery or co-existing disc herniation were not exclusion criteria if LSS was confirmed as the main reason for the surgery. However, patients with only low back pain were not included.
The exclusion criteria were urgent or emergency spinal surgery preventing recruitment, cognitive impairment prohibiting completion of the questionnaires or other failures in co-operation, and the presence of ferrometal instrumentation in the body preventing radiographic investigation [29].
All patients underwent open or microscopic decompressive surgery of the affected level(s), (i.e., laminotomy, hemilaminectomy, or laminectomy with undercutting facetectomy). Nineteen patients had additional fusion, two of them with instrumentation. The indication for additional lumbar fusion was concomitant spondylolisthesis. Patients’ demographics and surgery details are presented in Tables 1 and 2 [30].
Surgical outcome measures and preoperative variables were collected with a detailed questionnaire that patients completed preoperatively, while follow-up data were collected at 3 months, 6 months, 1 year, 2 years, 5 years, and 10 years postoperatively. Of the original participants, 72 responded to the 10-year follow-up questionnaire. Of the missing subjects, 17
patients had died, and 13 patients were unavailable for evaluation. Ethical approval was provided by the University of Kuopio Research Ethics Board.
Outcome measures
The main surgical outcome measures in this study were as follows: 1) subjective disability and 2) overall pain. Subjective disability was measured using the Oswestry Disability Index (ODI, 0–
100%) [31,32], while pain intensity was evaluated with the visual analog scale (VAS, 0–100 mm) [33].
Preoperative variables
The following preoperative variables were recorded and analyzed:
1. Smoking status: patients were divided into two groups according to their preoperative smoking status. Those who had quit smoking at any time before surgery or had never smoked were defined as non-smokers.
2. Previous lumbar surgery prior to study baseline.
3. Self-rated health status: This variable was assessed by a five-item questionnaire; answers equivalent to the median of the group (3) and higher were interpreted as an indicator of better self-rated health.
4. Regular use of painkillers for LSS symptom alleviation: patients were divided into three groups according to the period time of their regular use of painkillers: 0–3 months, 3–12 months, or more than 12 months
5. Body mass index (BMI): calculated preoperatively and dichotomized into two groups with a cutoff of 30 kg/m2.
Statistical analysis
Statistical analyses were performed using SPSS software (IBM SPSS for Statistics) version 25.0 (2017). The distribution of the data was determined using the Shapiro-Wilk test. Comparisons between two different groups were made using Student’s t test, and a Mann-Whitney test if dictated by data normality values. Categorical variables were evaluated using a Chi-Square test.
A paired sample t test and, if needed, a Wilcoxon-Signed Rank test were used to evaluate improvements from the baseline to the various follow-up points.
Due to the availability of longitudinal data, linear mixed models were used to evaluate the association of preoperative variables with longitudinal outcomes (ODI and VAS scores). In the first analyses, separate univariate analyses were made for each predictor and outcome. In the second analyses, multivariate analyses were adjusted for preoperative age, marital status, gender, and follow-up time. Preoperative predictors and adjusted variables were set as fixed factors, and unstructured covariance was used for repeated measures. Regular use of painkillers for more than 12 months was set as a reference for two other groups in the analyses, and a group comparison was made between all three groups. The assumption of a normal distribution was visually checked from the residuals. Missing values were assumed to be completely random.
Results
This study had an overall participation rate of 72% at the 10-year follow-up marker. The patients who participated in the 10-year follow-up were younger at baseline compared to those who dropped out (mean age 58 years vs. 70 years, p < 0.001). Other baseline characteristics (ODI, VAS, self-rated health, BMI, previous lumbar surgery, use of painkillers, gender) were comparable between groups.
Compared to baseline values, smokers and patients with previous lumbar surgery showed improvement in both ODI and VAS scores in time points up to 5 years; however, no significant improvements were apparent after 10 years. Furthermore, when compared to baseline, all other preoperative subgroups showed statistically improved ODI and VAS scores at all follow-up points.
In cross-sectional analyses, smokers showed higher ODI scores at the 10-year follow-up point than non-smoking patients. Furthermore, patients with previous lumbar surgery had significantly higher ODI and VAS scores compared with patients undergoing their first lumbar surgery at the 3-month and 2-year follow-up points and better ODI scores at the 6-month follow-up point.
Patients with poorer self-rated health had higher ODI and VAS scores preoperatively and higher ODI scores at the 10-year follow-up than patients with better self-rated health. Significant differences in ODI scores were also seen among the three different painkiller groups
preoperatively and at all follow-up time points. Similarly, the different painkiller groups also had significant differences in VAS scores at the preoperative phase and the 6-month and 2-year follow-up points. These results are shown in Tables 3 and 4.
In univariate analyses, the following preoperative variables showed significant associations with lower ODI scores during the 10-year follow-up period: 1) absence of previous lumbar surgery (estimate (SD) -10.8 (3.9), 95% Confidence Interval -18.4; -3.1, p = 0.006), 2) better self-rated health (-10.9 (3.0), -16.8; -4.9, p = 0.000), 3) regular preoperative use of painkillers for less than 3 months (-14.5 (3.5), -21.4; -7.5, p = 0.000), and 4) regular preoperative use of painkillers for 3–12 months (-9.9 (3.5), -16.8; -2.9, p = 0.006) when compared to regular preoperative use of painkillers for more than 12 months. Furthermore, the following preoperative variables showed significant associations with lower VAS scores: 1) non-smoking status (-8.1 (3.9), -15.8; -0.3, p
= 0.042), 2) absence of previous lumbar surgery (-13.3 (4.2), -21.6; -4.9, p = 0.002), 3) better self-rated health (-10.9 (3.4), -17.6; -4.2, p = 0.002), 4) regular preoperative use of painkillers for less than 3 months (-13.3 (4.0) -21.2; -5.5, p = 0.001), and 5) regular preoperative use of painkillers for 3–12 months (-10.7 (4.0) -18.7; -2.8, p = 0.009) when compared to regular preoperative use of painkillers for more than 12 months.
Subsequently, the preoperative variables found to predict better ODI and VAS scores in multivariate analysis during the 10-year follow-up period as follows: 1) non-smoking status, 2) absence of previous lumbar surgery, and 3) better self-rated health. Furthermore, baseline variables such as 4) regular preoperative use of painkillers for less than 3 months and 5) regular preoperative use of painkillers for 3–12 months were also associated with better ODI and VAS scores when compared to the group who regularly used painkillers preoperatively for more than 12 months. Results from these multivariate analyses are shown in Table 5.
Discussion
This study aimed to evaluate preoperative predictors for long-term surgical outcomes among patients with LSS extending up to 10 years postoperatively. Preoperative variables such as non- smoking status, absence of previous lumbar surgery, LSS-related symptoms controlled by the regular use of painkillers for less than 12 months, and better self-rated health showed significant positive associations with improved functional ability and decreased pain during the 10-year
postoperative period. Furthermore, to the best of our knowledge, this is the first study to report a decline in surgical benefits after five years among smokers.
Although non-smoking status showed a significant association with functional ability and decreased pain only in the multivariate models, the results highlight the adverse impact of smoking on surgical outcomes in this patient population. More importantly, a regress towards preoperative levels of pain and disability at the 10-year follow-up point was seen among smokers. Previous two-year follow-up studies also demonstrated the negative effect of smoking on postoperative functional ability and pain [17,25]. A study by Pearson et al. also found that smoking is a strong predictor of worse surgical outcomes in a four-year follow-up [22]. Smoking is a risk factor for disability-adjusted life years [34], which in turn may decrease patients’
function over time despite symptoms due to LSS. Furthermore, smoking has been shown to be associated with increased disc degeneration [35]. This study’s results showing that the benefits of LSS surgery for non-smokers can last up to 10 years serve to emphasize the importance of preoperative smoking cessation.
Previous surgical procedures to the lumbar spine at baseline were found to predict worse disability levels (ODI) and pain (VAS score) at all follow-up time points (3 and 6 months, 1, 2, 5, and 10 years). Such data imply that patients who have undergone previous lumbar surgery are less likely to benefit from the new lumbar surgery as those with no previous lumbar surgeries.
Patients with previous lumbar surgeries also had average postoperative ODI levels comparable to the preoperative ODI levels of patients without past lumbar surgery, lowering the odds of a substantial recovery in the case of reoperation. This finding is in line with previous data, where patients with LSS who underwent re-operation showed worse long-term surgical outcome in terms of disability and pain compared to patients with no reoperation [36,37]. However, patients with earlier lumbar surgery had statistically significant and obvious clinically improvement in their ODI and VAS scores up to five years postoperatively; at the 10-year follow-up, the outcome measures were still better than they were before surgery.
The study group was divided into three subgroups according to the length of regular use of painkillers to control LSS-related symptoms in order to find further clinically significant outcomes. Doing so revealed that the duration of symptoms controlled by regular use of painkillers for less than 12 months was highly predictive of better outcomes in terms of disability
and pain at all follow-up time points. Regular use of painkillers may imply prolonged persistent symptoms that could not be alleviated by conservative treatment. In a four-year follow-up study by Radcliff et al., patients experiencing symptoms for less than a year had better outcomes from both surgical and conservative treatments than patients with symptoms lasting for more than a year [20]. One underlying explanation for the poorer outcomes for patients taking painkillers for more than 12 months could be that prolonged symptoms translate into prolonged disability, which in turn can directly affect patients’ physical reserve capacity prior to surgery and, hence, in recovery after surgery.
Similar to the present study, previous studies with shorter follow-up periods have shown an association between regular use of painkillers and surgical outcome. Sigmundson et al. found that patients with regular or intermittent preoperative analgesic consumption reported more pain at their one-year follow-up compared to those who did not use analgesics [21]. Furthermore, in our previous two-year follow-up study, regular use of painkillers for less than 12 months was associated with improved ODI-scores [17]. Thus, if surgical treatment is indicated, the length of time in which symptoms are controlled by the regular use of painkillers may help to decide the timing of the surgery. However, further studies are needed to investigate whether stopping the use of painkillers prior to surgery would have an effect on surgical outcomes.
In our study, the subjects who evaluated their overall general health to be average or better than average showed less disability (ODI) and pain (VAS scores) during the 10-year follow-up period. The positive association between better self-rated health and surgical outcome has also been reported in two previous two-year follow-up studies; our previous study reported an association between better preoperative self-rated health and improved postoperative disability [17], while Katz et al. [18] found that better self-rated health was strongly associated with improved postoperative symptom severity, walking capacity scales, and satisfaction with the outcome. Even if associations between better preoperative self-rated health and better surgical outcomes is not straightforward, preoperative evaluation of patients’ perceptions of their health via this simple questionnaire may help to recognize those patients who are more likely to gain benefits from surgical treatment for up to 10 years postoperatively.
Body mass index (BMI) was not shown to be associated with disability or pain during the 10- year follow-up period in this study. Similar results with a four-year follow-up period were
reported by Rihn et al., who also found that higher BMI did not influence surgical outcomes [19]. A study by McGuire et al. showed similar LSS surgery outcomes in highly obese (BMI ≥ 35 kg/m2) and non-obese patients [23]. While Knutsson et al. found higher BMI to be associated with greater pain, they still concluded that patients with higher BMI achieved some benefits from surgery after two years [24]. Thus, obese patients also seem to benefit from surgical treatment in the long-term, and higher BMI does not seem to be a risk factor for poorer surgical outcomes.
Decompression surgery with fusion is usually recommended when concomitant spondylolisthesis or spinal instability is present [38,39]. When we compared patients, who had decompression surgery with fusion to decompression alone, no significant differences in their outcomes were found, as both groups gained notable improvements in disability and pain up to 10-year follow- up. In their study by Försth et al., they also found that decompression plus fusion procedure, among patients with or without degenerative spondylolisthesis, achieved similar results in terms of disability compared to decompression surgery alone up to 5-year follow-up [40]. However, our study was not designed to compare surgical techniques.
The current study has some limitations. First, missing data at different time points during the long follow-up period were partially due to the deaths of study subjects, and the small sample size within some subgroups might affect the generalization of data originating from these subgroups to the general population. In order to address these limitations, the discussion and conclusions were limited to statistically robust data. Second, possible effects linked to the subjectivity of the outcome measures employed (VAS and ODI) should be kept in mind. Third, although associations between preoperative variables and better surgical outcomes in the longitudinal assessment were observed, the possibility that the results are partially due to better surgical performance over other factors not evaluated in this study cannot be completely excluded. However, this study is unique in demonstrating the patient-related factors influencing postoperative pain and disability for up to 10 years after surgery. The outcome measures used (ODI and VAS) are validated tools in spinal research and regarded as useful in measuring patients’ disability and pain [41].
Conclusion
These results can enhance the informed decision-making processes for patients with LSS who are considering surgical treatment by showing preoperative predictors for surgical outcomes up to 10 years postoperatively. Preoperative variables found to predict better ODI and VAS scores in multivariate analysis during the 10-year follow-up period were as follows: 1) non-smoking status, 2) absence of previous lumbar surgery, 3) better self-rated health, and 4) regular use of painkillers for symptom alleviation for less than 12 months. Smokers and patients with previous lumbar surgery showed a decline in the benefits from surgery after five years.
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Table 1. Patients’ demographic at baseline (n = 102) and 10-year follow-up (n = 72) Baseline (n =
102)
Baseline (n = 72)
10 years (n = 72) Age: mean (SD)
61.7 (11.2) 58.0 (9.6) 68.5 (9.6) Gender: female (%)
58% (n = 59) 63% (n = 45) 63% (n = 45) Marital status: married or
cohabitating (%) 64% (n = 65) 65% (n = 47) 58% (n = 42)
ODI: mean (SD)
43.9 (15.2) 42.6 (15.4) 29.4 (20.9) VAS overall: mean (SD)
55.3 (26.8) 56.4 (25.9) 32.8 (28.2) Smoking status: non-smoking (%) *
80% (n = 80) 75% (n = 53) 85% (n = 57) had quit smoking (%)
26% (n = 26) 18% (n = 13) 24% (n = 16) mean age at smoking cessation (SD)
23.1 y (13.9) 18.8 y (12.9) 24.7 y (16.5) Self-rated health†
70% (n = 70) 68% (n = 49) 87% (n = 62) Regular use of painkillers 0–3
months 19% (n = 19) 20% (n = 14)
Regular use of painkillers 3–12
months 19% (n = 19) 23% (n = 16)
Regular use of painkillers more than
12 months 61% (n = 60) 58% (n = 41)
Previous lumbar operation: yes (%)
16% (n = 16) 17% (n = 12) Body Mass Index (BMI): mean (SD) 29.5 (4.0) 29.4 (4.0)
ODI = Oswestry disability index; VAS = visual analog scale; SD = standard deviation
* Patients who had quit smoking at any time before surgery or had never smoked were defined as non-smokers.
† Assessed by a five-item questionnaire. Answers equivalent to the median of the group (3) or higher were interpreted as an indicator of better self-rated health.
Table 2. Patients’ radiographic characteristics at baseline and surgery details
Type of stenosis All study patients (n = 102)
Patients who respondent after 10 years (n = 72) Central stenosis and lateral stenosis 84 (82%) 59 (59%)
Only lateral stenosis 18 (18%) 13 (18%) Mean dural sac area at most stenotic level 68.6 mm2 * 68.0†
Level of decompression
One level 59 (58%) 46 (64%)
Two levels 35 (34%) 20 (28%)
Three levels 8 (8%) 6 (8%)
Spondylolisthesis 25 (26%) 18 (25%)
L1–L2 0 0
L2–L3 1 0
L3–L4 7 4
L4–L5 16 13
L5–S1 1 1
Fusion performed 19 (19%) 16 (22%)
Single level 16 14
Two levels 3 2
Extirpation of concomitant disc herniation 7 (7%) 4 (6%)
L2–L3 1 0
L3–L4 1 0
L4–L5 4 3
L5–S1 1 1
*Available for 98 patients. †Available for 69 patients.
Table 3. The mean (standard deviation, SD) Oswestry disability index (ODI) scores at preoperative baseline and different follow-up time points according to preoperative variable groups.
αdata missing from 1 patient. βdata missing from 2 patients. §data missing from 22 patients.
The indication for additional lumbar fusion was concomitant spondylolisthesis
*significant improvement from preoperative to follow-up point, significance level p 0.001
significant improvement from preoperative to follow-up point, significance level p 0.005
†significant improvement from preoperative to follow-up point, significance level p 0.01
×significant improvement from preoperative to follow-up point, significance level p 0.05 preoperative 3-month
follow-up 6-month
follow-upα 1-year
follow-upβ 2-year
follow-up 5-year
follow-up§ 10-year follow-up smoking
no
(n = 54) 41.8 (16.3) 21.8
(16.5)* 19.3
(15.3)* 22.9
(17.7)* 21.5
(14.9)* 25.4
(17.2)* 26.7 (19.6)*
yes
(n = 18) 44.6 (13.2) 26.9
(20.0)* 24.8 (20.7)*
28.2
(22.1) 27.2
(23.7)† 22.5
(18.7)* 38.9 (22.0)
self-rated health
better
(n = 49) 39.0 (14.9) 21.1
(15.4)* 19.4
(15.5)* 22.8
(17.6)* 21.1
(15.9)* 22.2
(17.7)* 26.3 (19.9)*
poor
(n = 22) 50.3 (14.4) 27.6
(21.1)* 23.6
(19.7)* 27.4
(21.7)* 27.0
(20.6)* 31.4 (15.2)*
37.5 (21.2)
previous lumbar surgery no
(n = 60) 41.0 (15.0) 20.4 (15.2)*
18.4 (15.5)*
22.5 (18.2)*
20.8 (16.0)*
24.8 (17.7)*
28.1 (20.2)*
yes
(n = 12) 50.3 (15.8) 36.4
(21.8)× 33.0
(18.4) 32.7
(19.6) 34.3
(20.4)× 25.6
(15.6) 35.8 (24.2) regular use of painkillers
less than 3
months (n = 14) 33.5 (16.8) 15.7 (9.5)* 13.5 (13.3)*
15.8
(14.8) 15.1 (16.6)*
14.1
(13.5) 18.6 (16.5)
3–12 months
(n = 16) 42.8 (11.8) 13.8
(10.0)* 11.3
(11.8)* 17.9
(15.6)* 17.9
(15.6)* 20.5
(15.1)* 26.3 (20.1)†
over 12 months
(n = 41) 45.5 (15.6) 29.3 (19.3)*
27.1 (17.2)*
30.1 (18.9)*
27.6 (17.4)*
30.2 (17.8)*
34.9 (21.0)*
BMI
≤ 30 (n = 39) 43.0 (14.1) 23.3
(16.2)* 20.2
(16.8)* 23.0
(16.8)* 22.4
(16.6)* 24.9
(15.8)* 26.0 (19.2)*
> 30 (n = 33) 42.0 (17.1) 22.9
(18.8)* 21.6
(17.0)* 25.6
(10.9)* 23.7
(18.6)* 24.9
(19.7)* 33.4(22.5)×
Fusion
no 42.0 (15.9) 23.0
(17.6)* 21.0
(17.2)* 24.5
(18.3)* 23.3
(16.8)* 23.3
(15.1)* 29.9 (20.9)*
yes 44.6 (13.8) 23.5
(16.9)* 20.6
(16.0)* 23.4
(20.7)* 22.1
(19.9)* 29.9
(22.7)× 27.7 (21.7)#
Paired sam Signifi follow-up p Mann-Whi
Table 4.
baseline
αdata mis 8 patients
The indi
*significa
mple T test or W cant difference points. One-wa itney test for ot
The mean and differen
sing for 2 pat s.
ication for ad nt improvem
Wilcoxon Signe e among group
ay ANOVA or ther variables.
(standard de nt follow-up
tients. βdata m
dditional lumb ent from preo
ed Ranks Test ps between the r Kruskal-Wall
eviation, SD time points
missing for 4 p
bar fusion wa operative to f
for paired vari means of diffe lis Test for regu
D) visual ana according to
patients. §dat
s concomitan follow‐up poi
iables.
erent preoperat ular use of pain
alog scale (V o preoperativ
ta missing for
nt spondylolis int, significan
tive groups at th nkillers and Stu
VAS) score ve variable g
17 patients.
sthesis
nce level p 0
he preoperativ udent’s T test o
es at preoper groups.
¶data missing
0.001
ve or or
rative
g for
significant improvement from preoperative to follow‐up point, significance level p 0.005
†significant improvement from preopera ve to follow‐up point, significance level p 0.01
×significant improvement from preoperative to follow‐up point, significance level p 0.05 Paired sample t test or Wilcoxon Signed Ranks Test for paired variables.
Significant difference among groups between the means of different preoperative groups at the preoperative or follow‐up points. One‐way ANOVA or Kruskal‐Wallis Test for regular use of painkillers and Student’s T test or Mann‐Whitney test for other variables.
Table 5. Multivariate linear mixed models for longitudinal ODI- and VAS-scores in the 10-year follow-up period.
ODI VAS
Preoperative variable
Estimate (SD) P-value 95% CI Estimate (SD) P-value 95% CI
Non-smoking -8.9 (3.2) 0.006 -15.2; -2.6 -8.5 (3.7) 0.026 -15.9; -1.0
Body Mass Index
(BMI) ≤ 30 kg/m2 3.2 (2.3) 0.176 -1.5; 7.9 2.6 (2.8) 0.366 -3.1; 8.2
No previous lumbar
surgery -8.7 (3.3) 0.011 -15.3; -2.1 -12.4 (4.0) 0.003 -20.3; -4.5
Better self-rated
health -10.9 (2.6) 0.000 -16.1; -5.6 -10.8 (3.2) 0.001 -17.2; -4.4
Regular use of painkillers for less than 3 months*
-13.9 (3.1) 0.000 -20.0; -7.7 -11.8 (3.6) 0.002 -19.0; -4.5
Regular use of painkillers 3–12 months*
-11.1 (3.1) 0.001 -17.3; -4.8 -13.1 (3.8) 0.001 -20.6; -4.7
*Regular use of painkillers for more than 12 months was set as a reference
ODI = Oswestry disability index; VAS = visual analog scale, SD = standard deviation, 95% CI = 95% Confidence Interval
