Lumbar spinal stenosis: comparison of surgical practice variation and clinical outcome in three national spine registries

Publication date: January 2019

Source: The Spine Journal, Volume 19, Issue 1

Author(s): Greger Lønne, Peter Fritzell, Olle Hägg, Dennis Nordvall, Paul Gerdhem, Tobias Lagerbäck, Mikkel Andersen, Søren Eiskjaer, Martin Gehrchen, Wilco Jacobs, Miranda L. van Hooff, Tore K. Solberg

Abstract

Background Context

Decompression surgery for lumbar spinal stenosis (LSS) is the most common spinal procedure in the elderly. To avoid persisting low back pain, adding arthrodesis has been recommended, especially if there is a coexisting degenerative spondylolisthesis. However, this strategy remains controversial, resulting in practice-based variation.

Purpose

The present study aimed to evaluate in a pragmatic study if surgical selection criteria and variation in use of arthrodesis in three Scandinavian countries can be linked to variation in treatment effectiveness.

Study Design

This is an observational study based on a combined cohort from the national spine registries of Norway, Sweden, and Denmark.

Patient Sample

Patients aged 50 and older operated during 2011–2013 for LSS were included.

Outcome Measures

Patient-Reported Outcome Measures (PROMs): Oswestry Disability Index (ODI) (primary outcome), Numeric Rating Scale (NRS) for leg pain and back pain, and health-related quality of life (Euro-Qol-5D) were reported. Analysis included case-mix adjustment. In addition, we report differences in hospital stay.

Methods

Analyses of baseline data were done by analysis of variance (ANOVA), chi-square, or logistic regression tests. The comparisons of the mean changes of PROMs at 1-year follow-up between the countries were done by ANOVA (crude) and analysis of covariance (case-mix adjustment).

Results

Out of 14,223 included patients, 10,890 (77%) responded at 1-year follow-up. Apart from fewer smokers in Sweden and higher comorbidity rate in Norway, baseline characteristics were similar. The rate of additional fusion surgery (patients without or with spondylolisthesis) was 11% (4%, 47%) in Norway, 21% (9%, 56%) in Sweden, and 28% (15%, 88%) in Denmark. At 1-year follow-up, the mean improvement for ODI (95% confidence interval) was 18 (17–18) in Norway, 17 (17–18) in Sweden, and 18 (17–19) in Denmark. Patients operated with arthrodesis had prolonged hospital stay.

Conclusions

Real-life data from three national spine registers showed similar indications for decompression surgery but significant differences in the use of concomitant arthrodesis in Scandinavia. Additional arthrodesis was not associated with better treatment effectiveness.

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