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Lower Urinary Tract Symptoms and Urinary Bother Are Common in Patients Undergoing Elective Cervical Spine Surgery

Lieberman, Elizabeth G., MD; Radoslovich, Stephanie, BA; Marshall, Lynn M., ScD; Yoo, Jung U., MD

Clinical Orthopaedics and Related Research®: April 2019 - Volume 477 - Issue 4 - p 872–878
doi: 10.1097/CORR.0000000000000666

Background Lower urinary tract symptoms (LUTS) and urinary bother have been reported in adults undergoing surgery and have been associated with urinary tract infections, longer hospital stays, increased surgical costs, and decreased patient satisfaction. Previous reports indicate that up to one in two patients with lumbar spine pathology have moderate-to-severe LUTS, but little is known about LUTS in patients with cervical spine conditions.

Questions/purposes (1) What is the prevalence of moderate-to-severe LUTS and clinically relevant urinary bother among patients undergoing elective cervical spine surgery? (2) Does the presence of myelopathy affect frequency of moderate-to-severe LUTS or clinically relevant urinary bother among patients undergoing elective cervical spine surgery? (3) Do MRI findings of spinal cord injury or compression correlate with presence and severity of LUTS?

Methods We performed a cross-sectional study using clinical data collected from adult patients undergoing elective cervical spine surgery. Over an approximately 30-month period, we approached all patients who were evaluated in the preoperative clinic before undergoing elective cervical spine surgery. Of the 257 approached, 242 participated (94%). Study participants ranged in age from 34 to 83 years with a mean age of 58 years (SD 12). There were 108 males (45%) and 134 females (55%). A validated questionnaire, the International Prostate Symptom Score (IPSS), was used to identify LUTS. The IPSS score ranges from 0 to 35 points with LUTS presence defined as a score of ≥ 8 and LUTS severity categorized as mild (IPSS 0-7), moderate (IPSS 8-19), or severe (IPSS 20-35). Quality of life resulting from urinary bother is scored 0 to 6 with scores ≥ 4 considered clinically relevant urinary bother. Patients were grouped into a myelopathy group and a nonmyelopathy group based on diagnosis as assigned by the operating surgeon. MRIs were analyzed by one spine surgeon to identify the presence of cord signal, number of levels with cord compression (mm), and a calculated compression ratio score with cord compression and with compression ratio among patients with myelopathy.

Results The prevalence of moderate LUTS in our patient sample was 40% (97 of 242; 95% confidence interval [CI], 34%–47%). The prevalence of severe LUTS in our patient sample was 8% (19 of 242; 95% CI, 5%–12%). Clinically relevant urinary bother was reported in 18% of patients (41 of 228; 95% CI, 13%–24%). After adjustment for age and sex, the odds of moderate-to-severe LUTS among patients with myelopathy was greater than that observed in patients without myelopathy (adjusted odds ratio, 2.0; p = 0.015). The prevalence of clinically relevant urinary bother was higher in patients with myelopathy (30% [26 of 88]) compared with those with no myelopathy (11% [15 of 140]; p < 0.001). With the numbers available, among patients with myelopathy, there was no difference in distribution of LUTS symptom severity or IPSS score according to cord signal presence (50% [23 of 46]) and absence (65% [31 of 48]; p = 0.153), number of levels with compression (70% [seven of 10 with four levels]; 59% [13 of 22 with three levels]; 51% [19 of 37] with two levels; and 60% [15 of 25] with one level; p = 0.730), millimeters of cord compression (r = 0.02; p = 0.854), or compression ratio (r = 0.09; p = 0.413).

Conclusions Nearly half of all patients undergoing elective cervical spine surgery had moderate-to-severe LUTS. This is more than double the prevalence that has been reported in a community-dwelling adult population. These symptoms can impair quality of life, lead to surgical complications (urinary retention or incontinence), and may be mistaken for cauda equina, prompting potentially unnecessary imaging and studies. Given that urinary bother is reported less frequently than LUTS, patients may be less likely to seek care for urinary symptoms before undergoing surgery. Therefore, it is important to increase provider awareness of the high prevalence of LUTS.

Level of Evidence Level III, prognostic study.

E. G. Lieberman, S. Radoslovich, L. M. Marshall, J. U. Yoo, Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, OR, USA

J. U. Yoo, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA, Email:

One of the authors certifies that she (EGL) received research support, during the study period, an amount of USD 10,000 to USD 100,000, from the Cervical Spine Research Society Resident/Fellow grant.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.

Clinical Orthopaedics and Related Research® neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA approval status, of any drug or device before clinical use.

Each author certifies that his or her institution approved the reporting of this investigation and that all investigations were conducted in conformity with ethical principles of research.

Received September 22, 2018

Accepted January 16, 2019

© 2019 Lippincott Williams & Wilkins LWW
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