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Preoperative Pain Pattern Predicts Surgical Outcome More Than Type of Surgery in Patients With Central Spinal Stenosis Without Concomitant Spondylolisthesis: A Register Study of 9051 Patients

Sigmundsson, Freyr Gauti MD; Jönsson, Bo MD, PhD; Strömqvist, Björn MD, PhD

doi: 10.1097/BRS.0000000000000101

Study Design. A register cohort study.

Objective. To evaluate outcome of surgery for lumbar spinal stenosis without concomitant degenerative spondylolisthesis according to predominance of pain and to analyze the role of spinal fusion in conjunction with decompression in patients with predominant back pain (BP) or leg pain (LP).

Summary of Background Data. Predominance of BP is associated with inferior outcome of surgery for central spinal stenosis. It is unknown if using spinal fusion improves outcomes.

Methods. In a register study of 9051 patients, we studied outcome of surgery in terms of BP and LP visual analogue scale, function (the Oswestry Disability Index and self-estimated walking distance), health-related quality of life (Short-Form 36 and EuroQol), and patient satisfaction. Outcome was analyzed for 4 groups at 1- and 2-year follow-ups; preoperative BP was equal to or worse than LP and decompression, preoperative BP was equal to or worse than LP and decompression and fusion, preoperative BP was less than LP and decompression, preoperative BP was less than decompression and fusion.

Results. Patients with concomitant fusion were younger and had higher BP and Oswestry Disability Index scores and lower preoperative EuroQol. Predominant BP was associated with inferior outcome in terms of pain, health-related quality of life, and function. Patients most often satisfied (69%) were patients with BP less than LP treated with decompression and fusion and the least satisfied group was patients with BP equal to or worse than LP treated with decompression (54%). Fusion was not only associated with higher EuroQol at 1-year follow-up for patients with predominant BP, but also associated with increased LP at 2-year follow-up in patients with predominant LP. Patients with predominant BP experienced small gains in the physical component summary with fusion.

Conclusion. Predominance of BP is associated with inferior outcome. Using spinal fusion improves unadjusted outcome but the benefit is small and not clinically significant and generally disappears in the adjusted analysis.

Level of Evidence: 4

Outcome of decompressive surgery for lumbar spinal stenosis and predominance of back pain has room for improvement. It is speculated, but unknown, if spinal fusion in these patients improves outcome. Our study shows patients with predominant back pain to have inferior outcomes with small gains in health-related quality of life and function by undergoing fusion.

From the Department of Orthopedics, Clinical Sciences, Lund University, Skåne University Hospital, Malmö, Sweden.

Address correspondence and reprint requests to Freyr Gauti Sigmundsson, MD, Department of Orthopedics, Malmö, Skåne University Hospital, S-205 02 Malmö, Sweden; E-mail:

Acknowledgment date: May 22, 2013. First revision date: September 1, 2013. Second revision date: October 16, 2013. Acceptance date: October 21, 2013.

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

This study was supported by grants from Erik och Angelica Sparres forskningsstiftelse and Greta and Johan Kocks forskningsstiftelse.

No relevant financial activities outside the submitted work.

© 2014 by Lippincott Williams & Wilkins