Home Medicine Results of lumbar spine surgery: A postal survey
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Results of lumbar spine surgery: A postal survey

  • Voitto Järvimäki , Lotta Juurikka , Merja Vakkala EMAIL logo , Hannu Kautiainen and Maija Haanpää
Published/Copyright: January 1, 2015
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Scandinavian Journal of Pain
From the journal Scandinavian Journal of Pain Volume 6 Issue 1

Abstract

Background and aim

No studies have been published regarding the results of lumbar spine surgery a in population-based setting in Finland. Our objective was to investigate functional capacity and quality of life after lumbar spine surgery in a population-based cohort in Northern Finland, focusing on working-age patients.

Methods

This was a cross-sectional postal survey. Three questionnaires (a self-made questionnaire, the Oswestry Low Back Disability Questionnaire and the SF-36) were sent the patients aged 18-65 years who had undergone lumbar spine surgery due to disc herniation, instability or spinal stenosis in the Oulu University Hospital between June 2005 and May 2008.

Results

The postal survey was sent to 814 patients, of whom 537 patients (66%) replied. Of these, 361 (67%) underwent disc surgery, 85 (16%) stabilizing surgery and 91 (17%) decompression. Pain was absent or present only occasional in 51% in the disc surgery group, whereas it was present daily in 59% in the stabilizing surgery group and in 58% in the decompression group (P < 0.001). Axial pain was slightly more intense than radicular pain. Pain was milder in the disc surgery group compared with the stabilizing surgery and decompression groups: mean (SD) axial pain with 0-10 NRS was 4.0 (2.3), 4.7 (2.4) and 4 (2.3) respectively (P = 0.002) and radicular pain 3.5 (2.6), 4.2 (2.8), 4.5 (2.6) respectively (P < 0.001). The total ODI score (mean, SD) was 20 (17) in the disc surgery group, 35 (17) in the stabilizing surgery group and 32 (17) in the decompression group (P < 0.001). The physical dimension sum score from the SF-was 42 (11) in the disc surgery group and 34 (10) in the stabilizing surgery and decompression grou (P < 0.001). Mental sum scores did not vary significantly between the groups.

Conclusions and Implications

Outcome was good after lumbar disc operations but less favourable after stabilizing surgery and decompression regarding pain, functional capacity and quality of life. Implications. This study offers important information about outcome after lumbar spine surgery in Oulu University Hospital. It also brings out that in Finland we need systematic national spine register, with accurate pre-and postoperative data.

Keywords: Disc surgery; Spinal fusion; Decompression surgery; Pain; Oswestry disability Index; SF-36 health survey

1 Introduction

Spinal disorders are a major health and economic burden for developed countries [1]. According to statistics on pensions in Finland from The Social Insurance Institution, musculoskeletal problems have the highest disability pension occurrence numbers (2010; 34%) [2]. Within the musculoskeletal group of disability pension, spinal disorders are the leading cause (2010; 42%) [3].

The direct yearly cost of lumbar spine surgery is slightly over 20 million euros in Finland, and a lumbar spine operation is performed in about 6000 patients/year in Finland (population 5.4 million) [4]. To improve diagnostics, treatment and rehabilitation of back disorders Current Care Guidelines for low back pain were published in Finland in 1998 and updated in 2008 [5]. The ministry of Social Affairs and Health of Finland published uniform criteria for access to non-emergency treatment in 2005, provided criteria for the most common surgeries, including lumbar spine surgery to ensure uniform treatment throughout the country [6].

Research on spinal surgery is abundant in Finland, but no studies have been published on the results of spinal surgery in a population-based setting, to the best of our knowledge. Follow-up studies of surgery are important to improve patient selection and treatment.

The aim of this study was to investigate the results of lumbar spine surgery in a Finnish population-based cohort concentrating on working-age patients.

2 Materials and methods

2.1 Patients and data collection

The Oulu University Hospital provides specialist care for a population of 730,000, being the main centre of spinal surgery in Northern Finland. Only a small minority of lumbar spine operations are performed in other hospitals. To investigate the results of lumbar spine surgery in Oulu University Hospital, patients were identified using ICD-10 procedure codes for lumbar spine operations during the period 1.6.2005 to 31.5.2008. Surgical procedures due to acute traumas were not included. Only patients of a working-age (18–65 years) were included. Each patient was listed only once, and the index operation was defined as the latest lumbar spine surgery during the above-mentioned period. Based on medical records, patient who had undergone lumbar spine reoperation after 1.6.2008 and patients with insufficient capacity in the Finnish language, major abuse problem or progressive, severe illness (e.g., cancer, dementia) were excluded. The ICD-10 diagnosis code for spinal disease and the previous lumbar spine operations before the index surgery were recorded.

The questionnaires and a consent form were sent to all traceable patients in September 2009. The patients were asked to fill in three questionnaires: (1) a self-made questionnaire, (2) the Oswestry Low Back Pain Disability Questionnaire [7,8] and (3) the SF-36 [9].

The self-made questionnaire included questions regarding the occurrence of pain (never, occasionally, daily or almost daily, and all the time), the average intensity of pain (NRS 0–10) and pain-associated disability (NRS 0–10). Axial low back pain and radicular pain were assessed separately. Weight and height were queried for body mass index (BMI) calculation.

The ODI contains ten items, each with six statements graded from zero (lowest disability) to five (greatest disability). The total score is calculated as a sum of each completed item and expressed as a percentage of the maximum number of possible points, i.e. related to the number of items the patient has answered [10]. Scores are defined by a scale according to the original publication: 0–20 minimal, 20–40 moderate and 40–60 severe disability. A score of 60–80 indicates a crippled patient and 80–100 indicates that the patient is either bed-bound or exaggerating their symptoms [7].

The short form 36 health survey (SF-36) is a self-administered 36-item questionnaire. It measures health status and outcomes of the following 8 health concepts: (1) physical functioning (PF), (2) role physical (RF), (3) bodily pain (BP), (4) social functioning (SF), (5) mental health (MH), (6) role emotional (RE), (7) vitality (VT) and (8) general health (GH). Item scores are coded, summed and transformed on to a scale from 0 (worst possible health state measured by questionnaire) to 100 (best possible health state) for each variable. These eight domains were aggregated into two distinct summary components - mental and physical [11,12].

2.2 Statistical methods

The data are presented as means with standard deviations (SD) or as counts with percentages. Statistical comparisons were made using the chi-square test, Fisher’s exact test, analysis of variance (ANOVA) or bootstrap type analysis of covariance (ANCOVA) taking gender and age values as covariates. Ninety-five percent confidence intervals (95% CI) were obtained by bias-corrected bootstrapping (5000 replications). The bootstrap method is significantly helpful when the theoretical distribution of the test statistic is unknown or in the case of violation of the assumptions. No adjustment was made for multiple testing. The STATA 13.1, StataCorp LP (College Station, TX, USA) statistical package was used for the analyses.

2.3 Ethical aspects

The study protocol was approved by the local ethics committee, and the patients gave their informed consent in writing.

3 Results

During the study period 1.6.2005 to 31.5.2008, a lumbar spine operation due to non-traumatic lumbar diseases was performed to 1180 patients in our hospital. Of these, 11 had passed away by the beginning of this study. Of the surviving patients, 273 were excluded due to age, 43 due to other diseases, 28 due to a subsequent lumbar spine surgery after the index operation, 7 due to severe abuse problem and 4 due to insufficient capacity in the Finnish language. Hence the postal survey was mailed to 814 patients, of whom 537 (66%) replied.

The respondents and the non-respondents were compared regarding gender, age and type of surgery. The respondents were older compared to non-respondents (45 years vs. 42 years). Of the respondents, 361 (67%) had undergone surgery for lumbar disc her-niation, 85 (16%) stabilizing surgery and 91 (17%) decompression. The follow-up time (median, IQR) for the disc surgery patients was 31 (23, 39) months, for the stabilizing surgery patients 31 (22, 42) months and for the decompression patients 33 (22, 41) months, with no significant difference between the groups (P = 0.89).

The demographic and clinical characteristics of the patients are presented in Table 1. The mean age of the patients was 42 years in the disc surgery group, 48 years in the stabilizing surgery group and 55 years in the decompression group. Males dominated slightly disc surgeries and decompressions (proportion of males 59 and 54%, respectively), while more females underwent stabilizing surgery (65%). The index operation was the first lumbar surgery procedure in most cases (88% in the disc surgery group, 82% in the stabilizing surgery group and 90% in the decompression group).

Table 1

Demographic and clinical characteristics of 537 patients.

Type of surgery
 P-value
Discus surgery N = 361 Stabilizing surgery N = 85 Decompression N = 91
Number of female (%) 147 (41) 55 (65) 42 (46) <0.001
Age, mean (SD) 42 (10) 48 (10) 55 (8) <0.001
BMI, mean (SD) 26.8 (4.2) 27.3 (5.4) 29.8 (5.8) <0.001
Index operation first, n (%) 317 (88) 69 (82) 82 (90) 0.18
Diagnose, n (%)
 M51.1[a] 357 (99) 11 (13) 9 (10)
 M51.3[b] 4 (1) 16 (19) 0 (0)
 M48.0[c] 1 (0.3) 15 (18) 80 (88)
 M43.1[d] 0 (0) 20 (24) 1 (1)
 M96[e] 0 (0) 23 (27) 1 (1)

The results regarding patient-reported pain and pain-related disability are presented in Table 2. Only a small minority of the patients was completely pain-free (1% in the stabilizing surgery group, 6% in the decompression group and 9% in the disc surgery group). Pain occurred most frequently in the stabilizing and decompression groups; 74% of the patients in the stabilizing surgery group and 70% in the decompression group suffered from constant or daily pain. Pain was milder in the disc surgery group compared to the stabilizing surgery and decompression groups: mean (SD) axial pain with 0–10 NRS was 4.0 (2.3), 4.7 (2.4) and 4.8 (2.3) respectively (P= 0.002) and radicular pain 3.5 (2.6), 4.2 (2.8), 4.5 (2.6), respectively (P< 0.001). Mean axial pain was slightly more intense than radicular pain in all surgical groups. Pain-associated disability was less severe in the disc surgery group (mean 4.6 with 0–10 NRS) compared to the stabilizing surgery and decompression groups (mean 5.8 and 5.7, respectively, P< 0.001).

Table 2

Pain and pain-associated disability according to self-made questionnaire.

Type of surgery P-value
Discus surgery N = 361 Stabilizing surgery N = 85 Decompression N = 91
Occurrence, n (%) <0.001
 None 34 (9) 1 (1) 5 (6)
 Occasionally 149 (42) 21 (25) 21 (24)
 Daily 147 (41) 50 (59) 51 (58)
 All the time 30 (8) 13 (15) 11 (12)
Intensity NRS (0–10), mean (SD)
 Axial low back pain 4.0 (2.3) 4.7 (2.4) 4.8 (2.3) 0.002
 Radiculating pain 3.5 (2.6) 4.2 (2.8) 4.5 (2.6) <0.001
Disability NRS (0–10), mean (SD) 4.6 (2.7) 5.8 (2.7) 5.7 (2.3) <0.001

The total ODI score (mean, SD) was 20 (17) in the disc surgery group, 35 (17) in the stabilizing surgery group and 32 (17) in the decompression group (P< 0.001 after adjusting for age and sex). The frequencies of various disability categories according to the ODI score are presented in Fig. 1. The majority of the disc surgery patient had minimal disability, while the most common disability category was moderate disability both in the stabilizing surgery and decompression groups. Results of the ODI dimensions in the three surgical groups are shown in Fig. 2. There was an age and sex adjusted significant difference in all ODI dimensions, and the disc surgery group had the best results in all dimensions.

Fig. 1 The frequencies of various ODI score groups in the three surgical groups. A score. 0–20 indicates minimal disability, 20–40 moderate, 40–60 severe, 60–80 very severe disability and a score 80–100 bed-bound or exaggerating patient [7].
Fig. 1

The frequencies of various ODI score groups in the three surgical groups. A score. 0–20 indicates minimal disability, 20–40 moderate, 40–60 severe, 60–80 very severe disability and a score 80–100 bed-bound or exaggerating patient [7].

Fig. 2 The age- and sex-adjusted mean of ODI dimensions in the three surgical groups. ○ = disc surgery, ● = stabilizing surgery, ■= decompression.
Fig. 2

The age- and sex-adjusted mean of ODI dimensions in the three surgical groups. ○ = disc surgery, ● = stabilizing surgery, ■= decompression.

The results of the SF-36 scales in the three surgical groups are presented in Fig. 3. There was an age and sex adjusted significant difference between the surgical groups in all scales except the mental health scale. The results for the disc surgery group were the best in all scales. The physical component summary score (mean, SD) was 42 (11) in the disc surgery group and 34 (10) in the stabilizing surgery and decompression groups (P < 0.001 after adjusted age and sex). The mental component summary score was 51 (12) in the disc surgery group, 46 (15) in the stabilizing surgery group and 50 (12) in the decompression group, with no significant difference between the groups (P = 0.12 after adjusting for age and sex).

Fig. 3 The age- and sex-adjusted mean of SF-36 scales in the three surgical groups. ○ = disc surgery, ● = stabilizing surgery, ■ = decompression.
Fig. 3

The age- and sex-adjusted mean of SF-36 scales in the three surgical groups. ○ = disc surgery, ● = stabilizing surgery, ■ = decompression.

4 Discussion

Our interest was to study working-age patients. This delineation led to the exclusion of 23% of the original surgical cohort (273 out of 1180 patients). The disc surgery group was the youngest (mean age 42 years) and the decompression group was the oldest (mean age 55 years), while the mean age of the stabilizing surgery was 48 years. This reflects the natural course of the degenerative spine disorders.

The main finding of our study was a good outcome in the disc surgery group compared to the stabilizing and decompression surgery groups regarding pain, functional capacity and quality of life. Disc surgery resulted in a pain-free condition or only occasionally presenting pain in 51% of cases. The mean ODI score in the disc surgery group was 20, which corresponds to a minimal disability [7], and is in line with the result of the Swedish register [13] and Dewing et al. [14].

The majority of the patients who had undergone stabilizing surgery or decompression had daily or continuous pain. The mean ODI score was 35 after stabilizing surgery, which corresponds to a moderate disability. This is in agreement with previously published results [15, 16,17]. The mean ODI score was 32 (moderate disability) after decompression surgery. Our study population was of a working-age, and the mean age in our decompression group was 55 years, which is lower than in other studies of decompression surgery. In spite of this, our results are in line with previous results. According to the literature, ODI tends to stay at the level of moderate disability after decompression [18,19]. The mean pain intensity was relatively low in our patients (3.5–4.8 in all surgical groups), and radicular pain was milder than axial pain. This is in line with the fact that - in general - spinal surgery alleviates mainly radicular pain.

Lower scores on the SF-36 reflect a poorer health-related quality of life [11]. Our disc surgery patients had a relatively good outcome regarding quality of life. This is in line with previous publication [17,20]. Their SF-36 results are, however, below the published normative data for working-age people [12]. The difference was especially observable in the physical components (PF, RP, BP and GH). The SF-36 results for our patients were significantly poorer after stabilizing surgery or decompression. Their mental component summary results did not, however, differ significantly from those of the disc surgery group.

The uniform criteria for access to non-emergency treatment [6] were launched and Current Care Guidelines for low back pain [5] were consolidated before the commencement of this study. Lumbar disc surgery is considered in patients with disabling symptoms lasting longer than 6 weeks in cases of lumbar nerve root compression confirmed with MRI or CT scan. Stabilizing surgery is considered in patients with a disability in daily activities due to symptoms caused by lumbar instability in spite of adequate conservative treatment, and decompression in patients with lumbar spinal stenosis and short walking distance, disabling pain and impaired functional capacity in daily life. Younger age, shorter history of symptoms and less extensive surgical procedure are the most likely explanations for the better outcome in the disc prolapse group compared to the other groups.

During the last decade, spinal surgery in Finland has been centralized to university hospitals and large central hospitals, aiming at sufficient experience of the team and high quality of the procedures. Our material represents spinal surgery results in Oulu University Hospital, which is the main spinal surgical centre of Northern Finland. The response rate in our survey was satisfactory (66%). In spite of minor differences in age, the respondents did not differ from the non-respondents in other known respects. The reasons explaining patients’ motivation to participate in our postal survey are not known. Hence the possible bias due to surgical result remains speculative.

The weaknesses of our study are its cross-sectional setting, the lack of a control group, a limited number of measurements and the lack of preoperative information regarding pain, ODI and quality of life. Excellent examples of systematic evaluation of the results of spine surgery are the Swedish and Norwegian spine registers Swespine and NORspine [13,21,22], which provide comprehensive pre- and postsurgical scoring of pain, functional capacity and quality of life. A systematic register has been planned to be established also in Finland. It would serve as a monitor of surgical activities, and enable the observation of changes in trends regarding indications, techniques utilized, and outcome.

5 Conclusion

Our study confirmed a good outcome for lumbar disc operations and less favourable functional capacity and quality of life in stabilizing surgery and decompression groups.

Highlights

  • We studied the results of lumbar spine surgery in Northern Finland.

  • We used three questionnaires: a self-made questionnaire, ODI and SF36.

  • The outcome after lumbar disc operation was good (pain, functional capacity and QOL).

  • After stabilizing and decompression surgery outcome were less favourable.

DOI of refers to article: http://dx.doi.org/10.1016/j.sjpain.2014.10.001.

Department of Anesthesiology, Oulu University Hospital, PO Box 21, 90029 Oulu, Finland. Tel.: +358 8 315 2011; fax: +358 8 315 6227.
1

These authors contributed equally to the study.

  1. Funding: This study received financial support from the Health Care Foundation of North Finland and the research funds of Rehabilitation Orton, Finland. The research group planned this study independently and had full access to all of the data. We have analyzed the data and prepared this manuscript independently. The authors take complete responsibility for the integrity of the data and the accuracy of the data analysis.

  2. Conflict of interest: There are no conflicts of interest.

Acknowledgments

The authors would like to thank personnel of pain clinic in Oulu University Hospital for their help collecting the data and Michael Spalding, M.D., Ph.D., for his language revision. The study received financial support from the Health Care Foundation of North Finland and the research funds of Rehabilitation Orton, Finland.

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Received: 2014-05-26
Revised: 2014-08-26
Accepted: 2014-08-30
Published Online: 2015-01-01
Published in Print: 2015-01-01

© 2014 Scandinavian Association for the Study of Pain

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https://doi.org/10.1016/j.sjpain.2014.08.007
Keywords for this article
Disc surgery; Spinal fusion; Decompression surgery; Pain; Oswestry disability Index; SF-36 health survey

Articles in the same Issue

  2. Scandinavian Journal of Pain
  3. Editorial comment
  4. Neuroinflammation and glial cell activation in pathogenesis of chronic pain
  5. Topical review
  6. Perspectives in Pain Research 2014: Neuroinflammation and glial cell activation: The cause of transition from acute to chronic pain?
  7. Editorial comment
  8. Outcome of spine surgery: In a clinical field with few randomized controlled studies, a national spine surgery register creates evidence for practice guidelines
  9. Observational study
  10. Results of lumbar spine surgery: A postal survey
  11. Editorial comment
  12. Partner validation in chronic pain couples
  13. Original experimental
  14. I see you’re in pain – The effects of partner validation on emotions in people with chronic pain
  15. Editorial comment
  16. Pain management with buprenorphine patches in elderly patients: Quality of life—As good as it gets?
  17. Clinical pain research
  18. Evaluation of the cost-effectiveness of buprenorphine in treatment of chronic pain using competing EQ-5D weights
  19. Editorial comment
  20. Invisible pain – Complications from too little or too much empathy among helpers of chronic pain patients
  21. Observational study
  22. Although unseen, chronic pain is real–A phenomenological study
  23. Editorial comment
  24. Knee osteoarthritis patients with intact pain modulating systems may have low risk of persistent pain after knee joint replacement
  25. Clinical pain research
  26. The dynamics of the pain system is intact in patients with knee osteoarthritis: An exploratory experimental study
  27. Editorial comment
  28. Ultrasound-guided high concentration tetracaine peripheral nerve block: Effective and safe relief while awaiting more permanent intervention for tic douloureux
  29. Educational case report
  30. Real-time ultrasound-guided infraorbital nerve block to treat trigeminal neuralgia using a high concentration of tetracaine dissolved in bupivacaine
  31. Original experimental
  32. Modulation of the muscle and nerve compound muscle action potential by evoked pain
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