Assessment of health-related quality of life after surgical treatment of focal symptomatic spinal stenosis compared with osteoarthritis of the hip or knee

Division of Orthopaedic Surgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada M5T-2S8.
The Spine Journal (Impact Factor: 2.43). 03/2008; 8(2):296-304. DOI: 10.1016/j.spinee.2007.05.003
Source: PubMed


In the last decade, the number of patients undergoing surgical treatment for lumbar spinal stenosis (LSS), particularly instrumented fusions, has significantly increased. The surgical procedures for LSS represent a significant cost to the health-care system and are a priority focus for most governments, insurers, hospital administrators, and spine care physicians.
The purpose of this study was to directly compare the relative improvement in self-reported quality of life after surgical intervention for matched groups of patients with primary hip or knee osteoarthritis (H-OA/K-OA) and focal lumbar spinal stenosis (FLSS).
Observational cohort study of prospectively collected outcomes.
Patients, following elective primary one- to two-level spinal decompression (n=90) with (n=28/90) or without fusion for FLSS, were compared with a matched (age, sex, and time of surgery) cohort of patients who had undergone elective total hip (n=90) or total knee (n=90) arthroplasty (total joint arthroplasty [TJA]) for primary osteoarthritis.
Medical Outcomes Study Short Form-36 (SF-36).
Patents were obtained for prospective outcomes databases (TJA and spine). Inclusion and exclusion criteria were independently applied, and matching was performed in a blinded fashion. The primary outcome measure was the relative change between preoperative and 2-year postoperative SF-36 questionnaires. Data were analyzed with the t test and repeated measures analysis of variance (ANOVA).
The three groups (FLSS/H-OA/K-OA) were equally matched with respect to mean age (64/63/65 years), sex (female/male, 51/39 for all groups), body mass index (BMI) (27/24/27), and American Society of Anesthesiologists (ASA) physical status (2/2/2). Comparison of preoperative SF-36 physical component summary (PCS) scores and mental component summary (MCS) scores between groups showed no statistical difference (PCS: FLSS=32.0, H-OA=30.2, K-OA=31.3 [p=.32, ANOVA]/MCS: FLSS=43.5, H-OA=45.0, K-OA=46.2 [p=.25, ANOVA]). Postoperatively, PCS improved significantly for all groups (1 year-PCS: FLSS=39.6, H-OA=44.5, K-OA=38.5 [p<.0001 for all groups]; 2 years-PCS: FLSS=38.6, H-OA=43.2, K-OA=37.1 [p<.0001 for all groups]). At both 1- and 2-year follow-ups, the PCS improvement between groups was greater for the H-OA group compared with the FLSS (p=.0037, p=.0073) and K-OA (p=.00016, p=.00053) groups. At the 1-year follow-up, MCS did not significantly increase for any group; however, 2 years postoperatively, MCS improved significantly for the FLSS and H-OA groups (2 years-MCS: FLSS=50.3, H-OA=50.9, K-OA=44.8 [p=.00021, p=.00079, p=.35]). At the 1-year follow-up, there was no statistical difference in MCS improvement between groups (p=.45, ANOVA). Two years postoperatively, the MCS for both the FLSS and H-OA groups was significantly greater than that for the K-OA group (p=.0014, p=.00055).
The results of this study show that surgical intervention for FLSS can obtain and maintain improvement in self-reported quality of life comparable to that of total hip and knee arthroplasty. This study provides data to support the need for prospective cost-effectiveness studies for the surgical management of appropriately selected patients suffering from FLSS.

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    • "The relatively consistent results achieved among hospital centers in our multicenter study suggest that unlike the surgical management of low back pain for degenerative disc disease, consistent surgical outcome for the management of FLSS is achievable on a national scale [57] [58]. Furthermore, our early findings at 2 years postintervention are in line with several other similar studies that have been conducted in different countries [33] [34] [35] [36] [37]. The consistency across multiple studies affords a greater degree of confidence in our findings. "
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    ABSTRACT: It is well accepted that hip and knee arthroplasty (THA/TKA) for osteoarthritis (OA) is associated with reliable and sustained improvements in postoperative health related quality of life (HRQoL). Although several studies have demonstrated comparable outcomes to THA/TKA following surgical intervention for lumbar spinal stenosis (LSS), the sustainability of the outcome following LSS surgery compared to THA/TKA remains uncertain. The primary purpose of this study is to assess whether improvements in HRQoL following surgical management of focal LSS (FLSS) with or without spondylolisthesis is sustainable over the long-term compared to that of THA/TKA for OA. Single-center, retrospective longitudinal matched cohort study of prospectively collected outcomes, with minimum 5-year follow-up. Patients who had primary 1-2 level spinal decompression with or without instrumented fusion for FLSS and THA/TKA for primary osteoarthritis. Postoperative change from baseline to last follow-up in SF-36 physical component summary (PCS) scores and mental component summary (MCS) scores between groups was used as the primary outcome measure. An age, sex matched inception cohort of primary 1-2 level spinal decompression with or without instrumented fusion for FLSS (n=99) was compared to a cohort of primary THA (n=99) and TKA (n=99) for OA and followed for a minimum of 5 years. Linear regression was utilized for the primary analysis. Mean follow-up in months and (percent follow-up) was 80.5 + 16.04 (79%), 94.6 + 16.62 (92%), and 80.6 + 16.84 (85%) for the FLSS, THA and TKA cohorts respectively with a range of 5 to 10 years for all three cohorts. The number of patients that have undergone revision including those lost to follow-up, for the FLSS, THA and TKA cohorts was n=20 (20.2% - same site (n=7) and adjacent segment(n=13)) requiring 27 operations, n=3 (3% -same site) requiring 5 operations and n=8 (8.1% -same site) requiring 12 operations, respectively (p<0.01). The average time to first revision was 56/65/43 months, respectively. Mean postoperative PCS (p<0.0001) and MCS (p<0.02) improved significantly and was durable for all groups at the last follow-up. The mean change from baseline PCS / MCS to last follow-up, was 8.5 / 6.4, 12.3 /7.0 and 8.3 /4.9 for FLSS, THA and TKA respectively. Adjusting for baseline age, sex, BMI, PCS and MCS, there was a strong trend in favour of greater sustained change in the PCS of THA over FLSS (p=0.07) and TKA (p=0.08). No difference was noted between change in PCS between FLSS and TKA (p=0.95). No differences were noted for change in MCS between all three cohorts (p>0.1). Significant improvements in HRQoL following surgical treatment of FLSS with or without spondylolisthesis, and hip and knee osteoarthritis are sustained for a mean of 7-8 years, with a minimum of 5 years, follow-up. Despite a higher revision rate, patients undergoing surgery for FLSS can expect a comparable long-term average improvement in HRQoL from baseline compared to their peers undergoing TKA and to a lesser extent THA.
    The spine journal: official journal of the North American Spine Society 12/2013; 14(2). DOI:10.1016/j.spinee.2013.12.010 · 2.43 Impact Factor
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    • "The patient population and interventions are as described in part one of the current study and in previous publications [3] [5]. "
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    ABSTRACT: While total hip arthroplasty (THA) and total knee arthroplasty (TKA) have been widely accepted as highly cost-effective procedures, spine surgery for the treatment of degenerative conditions does not share the same perception among stakeholders. In particular, the sustainability of the outcome and cost-effectiveness following LSS surgery compared to THA/TKA remain uncertain. To estimate the lifetime incremental cost-utility ratios for decompression and decompression with fusion for focal LSS versus THA and TKA for osteoarthritis (OA) from the perspective of the provincial health insurance system (predominantly from the hospital perspective) based on long-term health status data at a median of 5 years post-surgical intervention. An incremental cost-utility analysis from a hospital perspective was based on a single-center, retrospective longitudinal matched cohort study of prospectively collected outcomes and retrospectively collected costs. Patients who had undergone primary one- to two-level spinal decompression with or without fusion for focal LSS (FLSS) were compared with a matched cohort of patients who had undergone elective THA or TKA for primary OA. Incremental cost-utility ratio ($/QALY) determined using perioperative costs (direct and indirect) and Short Form-6D (SF-6D) utility scores converted from the SF-36. Patient outcomes were collected using the SF-36 survey preoperatively and annually for a minimum of 5 years. Utility was modeled over the lifetime and quality-adjusted-life-years (QALY) were determined using the median 5-year health status data. The primary outcome measure, cost per QALY gained, was calculated by estimating the mean incremental lifetime costs and QALYs for each diagnosis group after discounting costs and QALYs at 3%. Sensitivity analyses adjusting for, + 25% primary and revision surgery cost, + 25% revision rate, upper and lower confidence interval utility score, variable inpatient rehabilition rate for THA/TKA and discounting at 5%, were conducted to determine factors affecting the value of each type of surgery. At a median of 5 years (4-7 years), follow-up and revision surgery data was attained for 85%-FLSS, 80%-THA and 75%-THA of the cohorts. The 5-year ICURs were $21,702/QALY for THA; $28,595/QALY for TKA; $12,271/QALY for spinal decompression; and $35,897/QALY for spinal decompression with fusion. The estimated lifetime ICURs using the median 5-year follow-up data was $5,682/QALY for THA; $6,489/QALY for TKA; $2,994/QALY for spinal decompression; and $10,806/QALY for spinal decompression with fusion. The overall spine (decompression alone and decompression and fusion) ICUR was $5,617/QALY. The estimated best and worst-case lifetime ICURs varied from $1,126/QALY for the best-case (spinal decompression) to $39,323/QALY for the worst case (spinal decompression with fusion). Surgical management of primary OA of the spine, hip and knee results in durable costutility ratios that are well below accepted thresholds for cost-effectiveness. Despite a significantly higher revision rate, the overall surgical management of FLSS for those who have failed medical management results in similar median 5-year and lifetime cost-utility compared to those of THA and TKA for the treatment of OA from the limited perspective of a public health insurance system.
    The spine journal: official journal of the North American Spine Society 11/2013; 13(9). DOI:10.1016/j.spinee.2013.11.011 · 2.43 Impact Factor
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    • "The aim of using HRQoL instruments is to measure the influence of a disorder/disease on a patient's daily life and activities; they have come to be used frequently to evaluate outcome after different types of surgery (Rampersaud et al. 2008, Rolfson et al. 2009). The most popular health status instruments are the EuroQol-5 Dimension (EQ-5D) (Dolan 1997) and the 36-Item Short-Form Health Survey (SF-36) (Ware et al. 1995), which are both patient-based questionnaires. "
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    ABSTRACT: Health-related quality of life (HRQoL) instruments have been of increasing interest for evaluation of medical treatments over the past 10-15 years. In this prospective, long-term follow-up study we investigated the influence of preoperative factors and the change in HRQoL over time after lumbar disc herniation surgery. 117 patients surgically treated for lumbar disc herniation (L4-L5 or L5-S1) were evaluated with a self-completion HRQoL instrument (EQ-5D) preoperatively, after 2 years (96 patients) and after 7 years (89 patients). Baseline data (age, sex, duration of leg pain, surgical level) and degree of leg and back pain (VAS) were obtained preoperatively. The mean age was 39 (18-66) years, 54% were men, and the surgical level was L5-S1 in 58% of the patients. The change in EQ-5D score at the 2-year follow-up was analyzed by testing for correlation and by using a multiple regression model including all baseline factors (age, sex, duration of pain, degree of leg and back pain, and baseline EQ-5D score) as potential predictors. 85% of the patients reported improvement in EQ-5D two years after surgery and this result remained at the long-term follow-up. The mean difference (change) between the preoperative EQ-5D score and the 2-year and 7-year scores was 0.59 (p < 0.001) and 0.62 (p < 0.001), respectively. However, the HRQoL for this patient group did not reach the mean level of previously reported values for a normal population of the same age range at any of the follow-ups. The changes in EQ-5D score between the 2- and 7-year follow-ups were not statistically significant (mean change 0.03, p = 0.2). There was a correlation between baseline leg pain and the change in EQ-5D at the 2-year (r = 0.33, p = 0.002) and 7-year follow-up (r = 0.23, p = 0.04). However, when using regression analysis the only statistically significant predictor for change in EQ-5D was baseline EQ-5D score. Our findings suggest that HRQoL (as measured by EQ-5D) improved 2 years after lumbar disc herniation surgery, but there was no further improvement after 5 more years. Low quality of life and severe leg pain at baseline are important predictors of improvement in quality of life after lumbar disc herniation surgery.
    Acta Orthopaedica 03/2011; 82(2):198-203. DOI:10.3109/17453674.2011.566136 · 2.77 Impact Factor
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