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

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

doi:10.1016/j.spinee.2018.05.028

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

Spine J. 2019 Jan;19(1):41-49. doi: 10.1016/j.spinee.2018.05.028. Epub 2018 May 21.

Authors

Affiliations

¹ Department of Orthopaedics, Innlandet Hospital Trust, Anders Sandvigs gt. 17, 2629 Lillehammer, Norway; National Advisory Unit on Spinal Surgery, St. Olavs Hospital, Trondheim University Hospital, Olav Kyrres gate 17, 7006 Trondheim, Norway; The Norwegian Registry for Spine Surgery (NORspine), Northern Norway Regional Health Authority, Helse Nord RHF, Postboks 1445, 8038 Bodø, Norway. Electronic address: gloenne@mac.com.
² Department of Orthopaedics, Capio St Göran Hospital, Sankt Göransplan 1, 112 81 Stockholm, Sweden; Department of Surgical Sciences, Division of Orthopaedics, Uppsala University, Akademiska sjukhuset entrence 70, 1 tr, 751 85 Uppsala, Sweden; Strömstad akademi, Norra Bergsgatan 23, 45280 Strömstad, Sweden; Qulturum Center for Learning and Innovation in Healthcare, Hus B4 Länssjukhuset Ryhov, 553 05 Jönköping, Sweden.
³ Spine Center Göteborg, Gruvgatan 8, 421 30, Västra Frölunda, Göteborg, Sweden; Swespine Steering Group, Swedish National Spine Register, Sveriges Kommuner och Landsting, SE-118 82 Stockholm, Sweden.
⁴ Qulturum Center for Learning and Innovation in Healthcare, Hus B4 Länssjukhuset Ryhov, 553 05 Jönköping, Sweden.
⁵ Department of Orthopaedics, Karolinska University Hospital Huddinge, K54, SE-14186 Stockholm, Sweden; Department of Clinical Science, Intervention and Technology, Karolinska Institutet, K54, SE-14186, Stockholm, Sweden.
⁶ Sector for Spine Surgery and Research, Lillebaelt Hospital, Østre Hougvej 55, 5500 Middelfart, Denmark.
⁷ Department of Orthopedic Surgery, Aalborg University Hospital, Aalborg, Denmark.
⁸ Spine Unit, Department of Orthopaedic Surgery, Rigshospitalet University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark.
⁹ The Health Scientist, Fraeylemastraat 13, 2532 TX, The Hague, The Netherlands.
¹⁰ Department Research, Sint Maartenskliniek, Nijmegen, Hengstdal 3, 6574 NA Ubbergen, The Netherlands; Department of Orthopedics, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands.
¹¹ The Norwegian Registry for Spine Surgery (NORspine), Northern Norway Regional Health Authority, Helse Nord RHF, Postboks 1445, 8038 Bodø, Norway; Department of Neurosurgery, University Hospital of Northern Norway, Breivika, 9038, Tromsø, Norway; Institute of Clinical Medicine, University of Tromsø The Arctic University of Norway, Hansine Hansens veg 18, 9037, Tromsø, Norway.

PMID: 29792994
DOI: 10.1016/j.spinee.2018.05.028

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.

Keywords: Case-mix adjustment; Decompressive surgery; Lumbar spinal stenosis; Spine arthrodesis; Spine fusion; Spine registry.

Publication types

Comparative Study
Research Support, Non-U.S. Gov't

MeSH terms

Aged
Decompression, Surgical / adverse effects*
Decompression, Surgical / methods
Female
Humans
Laminectomy / adverse effects*
Laminectomy / methods
Lumbar Vertebrae / surgery
Male
Middle Aged
Patient Reported Outcome Measures
Postoperative Complications / epidemiology*
Quality of Life
Registries / statistics & numerical data*
Scandinavian and Nordic Countries
Spinal Stenosis / surgery*
Spondylolisthesis / surgery*
Treatment Outcome