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Does Multilevel Lumbar Stenosis Lead to Poorer Outcomes?: A Subanalysis of the Spine Patient Outcomes Research Trial (SPORT) Lumbar Stenosis Study

Park, Daniel K. MD*; An, Howard S. MD*; Lurie, Jon D. MD, MS; Zhao, Wenyan MS; Tosteson, Anna ScD†§; Tosteson, Tor D. ScD§; Herkowitz, Harry MD; Errico, Thomas MD; Weinstein, James N. DO, MS

doi: 10.1097/BRS.0b013e3181bdafb9
Health Services Research

Study Design. A subanalysis study.

Objective. The purpose of this study was to determine the impact of multilevel lumbar stenosis with or without degenerative spondylolisthesis compared to single level disease on patients' baseline symptoms and clinical outcomes over time.

Summary of Background Data. Previous studies have demonstrated better clinical outcomes with surgery than nonoperative treatment in patients with spinal stenosis with or without degenerative spondylolisthesis. However, the impact of multilevel stenosis has not been studied in these patients.

Methods. The results from a multicenter randomized and observational study, the Spine Patient Outcomes Research Trial (SPORT) comparing surgical versus nonoperative treatment for spinal stenosis with or without spondylolisthesis, were analyzed. The primary outcomes measures were the Bodily Pain and Physical Function scales of the Medical Outcomes Study 36-item Short-Form General Health Survey (SF-36) and the modified Oswestry Disability Index at 6 weeks, 3 months, 6 months, 1 year, and 2 years. Secondary outcome measures included the stenosis bothersomeness index, leg pain bothersomeness, low back pain bothersomeness, and patient satisfaction.

Results. In this subanalysis of SPORT data, multilevel spinal stenosis did not demonstrate worse baseline symptoms or worse treatment outcomes in isolated spinal stenosis; however, if concomitant degenerative spondylolisthesis existed, patients with only single level stenosis tended to improve more than those with multilevel stenosis, particularly after surgery.

Conclusion. Patients with spinal stenosis without associated degenerative spondylolisthesis or scoliosis can be managed nonoperatively irrespective of the number of levels involved. If surgery is performed, the number of levels treated does not predict outcome. In contrast, patients with concomitant degenerative spondylolisthesis and single level stenosis do better surgically than those with additional levels of stenosis. This study emphasizes the importance of shared decision-making between the physician and patient when considering treatment for spinal stenosis.

Previous studies have demonstrated a benefit for patients with spinal stenosis with or without degenerative spondylolisthesis treated surgically. The effect of multilevel stenosis has not been studied. This subanalysis studies the effect of multilevel stenosis in baseline and treatment outcome in patients with isolated stenosis and those with concomitant degenerative spondylolisthesis at L4–L5.

From the *Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL; Departments of †Medicine, ‡Orthopaedics, and §Community and Family Medicine, Dartmouth Medical School, Lebanon, NH; ¶William Beaumont Hospital, Royal Oak, MI; and ∥New York University– Hospital for Joint Diseases, NY, NY.

Acknowledgment date: November 12, 2009. Revision date: May 4, 2009. Acceptance date: May 26, 2009.

The manuscript submitted does not contain information about medical device(s)/drug(s).

Federal funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript.

The National Institute of Arthritis and Musculoskeletal and Skin Diseases (U01-AR45444) and the Office of Research on Women's Health, the National Institutes of Health, and the National Institute of Occupational Safety and Health, the Centers for Disease Control and Prevention. The Multidisciplinary Clinical Research Center in Musculoskeletal Diseases is funded by NIAMS (P60-AR048094).

Address correspondence and reprint requests to James N. Weinstein, DO, MS, The Dartmouth Institute for Health Policy and Clinical Practice; Department of Orthopaedics, One Medical Center Dr., Lebanon, NH; E-mail:

© 2010 Lippincott Williams & Wilkins, Inc.