Outcome of spine surgery: In a clinical field with few randomized controlled studies, a national spine surgery register creates evidence for practice guidelines
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Frode Kolstad
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Harald Breivik
In this issue of the Scandinavian Journal of Pain Järvimäki and co-workers [1] from Northern Finland publish a cross-sectional postal questionnaire survey on functional capacity and quality of life 1-4 years after lumbar spine surgery due to disc herniation, instability (stabilizing-spondylosyndesis), or spinal stenosis (decompression). They focused on patients in working age, i.e.18-65 years of age, operated in the Oulu University Hospital during 3 years from June 2005. Their response rate was 66%. Among the 537 responders 2/3 had disc surgery, 1/6 had stabilizing, and 1/6 had decompression surgery. Half of those who had disc-surgery had no or negligible pain, whereas after both stabilizing and decompressing lumbar spine surgery almost 2/3 had daily pain with axial pain around 5/10 and slightly less radicular pain. Results from the Owestry Low Back Disability Questionnaire and the SF-36 Quality of Life Questionnaire documented acceptable outcome for the disc-surgery patients, but significantly poorer functional and quality of life outcomes after stabilizing fusion surgery and after decompression surgery for spinal stenosis.
1 Bias from non-responders in spine-surgery follow-up surveys
These results mostly agree with other outcome surveys of lumbar spinal surgery [2-4], however, there may be a source of bias due to the 34% who did not respond to the postal survey [1]. An in-depth study of responders (78%) and non-responders (22%) in a survey of spine surgery patients by Solberg and co-workers [5], documented that among the non-responders there were more young patients and more patients who had not had any complications after surgery. Thus, the bias caused by 34% non-responders in the Järvimäki study [1] may or may not have inflated the beneficial outcome results.
Some of this unknown bias could have been reduced by cross-searching in disability retirement registries: The most frequent cause of work disability pension in Norway is chronic pain [6,7]. In major pain surveys about 30% of the adult populations report chronic non-cancer pain [7-9], and chronic back pain comprises 21-47% of all non-cancer pain [9]. Similar statistics are available in Finland where about 15% of all disability pensions are due to spinal disorders [1]. So that if permitted by data security authorities in Finland, finding more (or less) of the non-responders than the responders of the Järvimäki study in the disabilities-register in Finland would have been interesting.
2 Complete national registries and unbiased follow-up of spine surgery patients in Scandinavia
We agree with Järvimäki and co-workers [1] that they would have had more reliable results if they had a nation-wide compulsory spine-surgery register, with which they also could have compared the results from Northern Finland with those after similar back surgery in other regions of Finland. The national spine surgery registries in Sweden [10] and in Norway [11] demonstrate important details of outcome, related to technique, to regional differences, as well as demographic variables. We agree with Järvimäki and co-workers [1] that it is about time that the spine surgeons of Finland establish a national registry for back surgery. Back pain, especially when treated with various surgical interventions, is one of the most costly health care problems for society, also in Finland [1]. A comprehensive national spine surgery register is important for the benefit of future patients who may or may not need surgery for spinal pain conditions. Solid statistics for beneficial outcomes as well as risks for minor and major complications are necessary during the often difficult decisions on whether to try to remove the pain with the surgeon’s knife [11].
Such national outcome data, based on all patients having back surgery, are necessary in order to compare outcomes with different, or new and promising techniques (e.g. open versus minimally invasive back surgery). Also, the Norwegian back surgery register was behind a RCT of surgery compared with of non-surgical therapies [3]. Thus, one of the few outcome studies comparing back surgery with cognitive behavioural therapy for lumbar spinal stenosis demonstrated that nonsurgical therapies can be more effective than surgical interventions in spinal stenosis, avoiding potential complications of such major back surgery [3].
3 Benefits of national registries
In his Ph.D. thesis from 2013, Solberg [11] emphasizes the benefits of the Norwegian spine surgery register: Well designed and well-conducted registry studies can provide essential information with high level of evidence about risk factors, safety and out comes, when new treatments are transferred from the ideal setting of a proof of effect RCT into routine medical practice [11]. Registry data will reveal risks of complications, it may reveal different outcomes of different techniques used for similar back pain conditions by different surgeons in different institutions. He emphasizes that few areas of clinical medicine are as controversial as the surgical treatment of some of the conditions related to instability and spondylosis, and that a national register may reveal optimal surgical techniques and can contribute to guideline developments, strongly warranted in the field of spine surgery [1,11].
Lacking a nation-wide spine surgery register in the otherwise extremely well advanced Finnish health care system, Järvimäki and co-workers have performed a very valuable cross-sectional survey of outcome of the three most common types of lumbar spine surgery, confirming that herniated lumbar disc surgery in well selected patients is an effective treatment, whereas surgery for spinal stenosis and for lumbar instability demonstrate much less effectiveness. Their study concerns the Northern part of Finland, only a nation-wide spine surgery register can tell us whether the back surgeons in Oulu are better or worse than surgeons in other parts of Finland.
DOI of refers to article: http://dx.doi.org/10.1016/j.sjpain.2014.08.007.
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Conflict of interest: None declared.
References
[1] Järvimäki V, Juurikka L, Vakkala M, Kautiainen H, Haanpää M. Results of lumbar spine surgery: a postal survey. Scand J Pain 2015;6:9–13.Suche in Google Scholar
[2] Dewing CB, Provencher MT, Riffenburgh RH, Kerr S, Manos RE. The outcomes of lumbar microdiscectomy in a young, active population: correlation by herniation type and level. Spine (Phila Pa 1976) 2008;33: 33–8.Suche in Google Scholar
[3] Brox JI, Reikeras O, Nygaard O, Sorensen R, Indahl A, Holm I, Keller A, Ingebrigtsen T, Grundnes O, Lange JE, Friis A. Lumbar instrumented fusion compared with cognitive intervention and exercises in patients with chronic back pain after previous surgery for disc herniation: a prospective randomized controlled study. Pain 2006;122:145–55.Suche in Google Scholar
[4] Jones AD, Wafai AM, Easterbrook AL. Improvement in low back pain following spinal decompression: observational study of 119 patients. Eur Spine J 2014;23:135–41.Suche in Google Scholar
[5] Solberg T, Sørlie A, Sjaavik K, Nygaard Ø, Ingebrigtsen T. Would loss to follow-up bias the outcome evaluation of patients operated for degenerative disorders of the lumbar spine? Acta Orthop 2011;82:56–63.Suche in Google Scholar
[6] Nielsen CS. Chronic pain is strongly associated with work disability. Scand J Pain 2013;4:180–1.Suche in Google Scholar
[7] Landmark T, Romundstad P, Dale O, Borchgrevink PC, Vatten L, Kaasa S. Chronic pain: one year prevalence and associated characteristics (the HUNT pain study). Scand J Pain 2013;4:182–7.Suche in Google Scholar
[8] Gunnarsdottir S, Ward SE, Serlin RC. A population based study of the prevalence of pain in Iceland. Scand J Pain 2010;1:151–7.Suche in Google Scholar
[9] Breivik H, Collett B, Ventafridda V, Cohen R, Gallacher D. Survey of chronic pain in Europe: prevalence, impact on daily life, and treatment. Eur J Pain 2006;10:287–333.Suche in Google Scholar
[10] Stromqvist B, Fritzell P, Hagg O, Jonsson B, Swedish Society of Spinal Surgeons. The Swedish spine register: development, design and utility. Eur Spine J 2009;18:294–304.Suche in Google Scholar
[11] Solberg TK (thesis for dissertation of Philosophiae Doctor) Ensuring valid and reliable data for quality control and research from a clinical registry for spine surgery. Tromsø: University of Tromsø, Faculty of Medicine, Department of Neurosurgery, and Institute of Clinical medicine; 2013.Suche in Google Scholar
© 2014 Scandinavian Association for the Study of Pain
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- Scandinavian Journal of Pain
- Editorial comment
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- Topical review
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- Editorial comment
- Partner validation in chronic pain couples
- Original experimental
- I see you’re in pain – The effects of partner validation on emotions in people with chronic pain
- Editorial comment
- Pain management with buprenorphine patches in elderly patients: Quality of life—As good as it gets?
- Clinical pain research
- Evaluation of the cost-effectiveness of buprenorphine in treatment of chronic pain using competing EQ-5D weights
- Editorial comment
- Invisible pain – Complications from too little or too much empathy among helpers of chronic pain patients
- Observational study
- Although unseen, chronic pain is real–A phenomenological study
- Editorial comment
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- Clinical pain research
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- Editorial comment
- Ultrasound-guided high concentration tetracaine peripheral nerve block: Effective and safe relief while awaiting more permanent intervention for tic douloureux
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