Health related quality of life after lumbar disc surgery: A prospective study of 145 patients

Trajectory of health-related quality of life and its determinants in patients who underwent lumbar spine surgery: a 1-year longitudinal study

PURPOSE

The purpose of the study was to investigate the trajectory and determinants of changes in health-related quality of life (HRQoL) in the first year after lumbar spine surgery.

METHODS

A total of 154 consecutive patients who underwent lumbar spine surgery were included in this prospective longitudinal observational study. All participants were asked to complete a battery of questionnaires (Taiwanese version of World Health Organization Quality of Life-BREF, Numerical Rating Scale for leg and back pain, Mandarin Chinese version of the Clinically Useful Depression Outcome Scale, and Chinese version of the Pittsburgh Sleep Quality Index). The Japanese Orthopedic Association score was evaluated by neurosurgeons. The measurement time points were 1 week before and on the first, sixth, and twelfth month after lumbar spinal surgery. A linear mix model was used for data analyses.

RESULTS

The analyses revealed significant upward trends in HRQoL, particularly in physical health and social relationships during the study period. Patients who aged < 65 years and reported a higher level of functional status experienced a more favorable HRQoL in physical health over time (p = .002 and .02, respectively). Participants who complained of poor sleep quality yielded poorer HRQoL in physical health over time (p = .03). More severe depressive symptom was associated with the poorer HRQoL in social relationships over time (p < .001).

CONCLUSIONS

To improve the HRQoL, healthcare providers need to pay attention to changes in sleep quality, neurological functions, and depressive symptoms in people receiving lumbar surgery, particularly individuals with increasing age. Concrete interventions and strategies aimed to enhancing HRQoL in these patients are essential.

A systematic review of preoperative predictors for postoperative clinical outcomes following lumbar discectomy

BACKGROUND CONTEXT

Sciatica is often caused by a herniated lumbar intervertebral disc. When conservative treatment fails, a lumbar discectomy can be performed. Surgical treatment via lumbar discectomy is not always successful and may depend on a variety of preoperative factors. It remains unclear which, if any, preoperative factors can predict postsurgical clinical outcomes.

PURPOSE

This review aimed to determine preoperative predictors that are associated with postsurgical clinical outcomes in patients undergoing lumbar discectomy.

STUDY DESIGN

This is a systematic review.

METHODS

This systematic review of the scientific literature followed the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. MEDLINE and PubMed were systematically searched through June 2014. Results were screened for relevance independently, and full-text studies were assessed for eligibility. Reporting quality was assessed using a modified Newcastle-Ottawa Scale. Quality of evidence was assessed using a modified version of Sackett's Criteria of Evidence Support. No financial support was provided for this study. No potential conflict of interest-associated biases were present from any of the authors.

RESULTS

The search strategy yielded 1,147 studies, of which a total of 40 high-quality studies were included. There were 17 positive predictors, 20 negative predictors, 43 non-significant predictors, and 15 conflicting predictors determined. Preoperative predictors associated with positive postoperative outcomes included more severe leg pain, better mental health status, shorter duration of symptoms, and younger age. Preoperative predictors associated with negative postoperative outcomes included intact annulus fibrosus, longer duration of sick leave, worker's compensation, and greater severity of baseline symptoms. Several preoperative factors including motor deficit, side and level of herniation, presence of type 1 Modic changes and degeneration, age, and gender had non-significant associations with postoperative clinical outcomes.

CONCLUSIONS

It may be possible for certain preoperative factors to be targeted for clinical evaluation by spine surgeons to assess the suitability of patients for lumbar discectomy surgery, the hope being to thereby improve postoperative clinical outcomes. Prospective cohort studies are required to increase the level of evidence with regard to significant predictive factors.

Patient-reported outcomes in the Swedish National Quality Registers

Patient-reported outcomes (PROs) are important in the healthcare system to gain understanding of patients' views on the effects of a treatment. There is an abundance of available patient-reported outcome measures (PROMs), both disease specific and generic. In the Swedish healthcare system, the national quality registers are obliged to incorporate PROs for certification at a high level. A review of the latest annual applications for funding (n = 108) shows that at present, 93 national quality registers include some form of PROM or patient-reported experience measure (PREM). Half of the registers include some type of generic measure, more than half include disease/symptom-specific measures, and around 40% include PREMs. Several different measures and combinations of measures are used, the most common of which are the EQ-5D, followed by the SF-36/RAND-36. About one-fifth of the registers report examples of how patient-reported data are used for local quality improvement. These examples include enhancing shared decision-making in clinical encounters (most common), as a basis for care plans, clinical decision aids and treatment guidelines, to improve the precision of indications for surgery (patient and healthcare professional assessments may differ), to monitor complications after the patient has left hospital and to improve patient information. In addition, funding applications reveal that most registers plan to extend their array of PROMs and PREMs in future, and to increase their use of patient-reported data as a basis for quality improvement.

Predictors of clinical outcome following lumbar disc surgery: the value of historical, physical examination, and muscle function variables

PURPOSE

Explore the relationships between preoperative findings and clinical outcome following lumbar disc surgery, and investigate the prognostic value of physical examination findings after accounting for information acquired from the clinical history.

METHODS

We recruited 55 adult patients scheduled for first time, single-level lumbar discectomy. Participants underwent a standardized preoperative evaluation including real-time ultrasound imaging assessment of lumbar multifidus function, and an 8-week postoperative rehabilitation programme. Clinical outcome was defined by change in disability, and leg and low back pain (LBP) intensity at 10 weeks. Linear regression models were used to identify univariate and multivariate predictors of outcome.

RESULTS

Univariate predictors of better outcome varied depending on the outcome measure. Clinical history predictors included a greater proportion of leg pain to LBP, pain medication use, greater time to surgery, and no history of previous physical or injection therapy. Physical examination predictors were a positive straight or cross straight leg raise test, diminished lower extremity strength, sensation or reflexes, and the presence of postural abnormality or pain peripheralization. Preoperative pain peripheralization remained a significant predictor of improved disability (p = 0.04) and LBP (p = 0.02) after accounting for information from the clinical history. Preoperative lumbar multifidus function was not associated with clinical outcome.

CONCLUSIONS

Information gleaned from the clinical history and physical examination helps to identify patients more likely to succeed with lumbar disc surgery. While this study helps to inform clinical practice, additional research confirming these results is required prior to confident clinical implementation.

Association of Modic changes with health-related quality of life among patients referred to spine surgery

Background and purpose Modic changes (MC) are bone marrow and vertebral endplate lesions seen in magnetic resonance imaging (MRI) which have been found to be associated with low back pain (LBP), but the association between MC and health-related quality of life (HRQoL) is poorly understood. The aim of this study was to assess the relationship between MC and HRQoL among patients referred to spine surgery. Methods The study population consisted of 181 patients referred to lumbar spine surgery in Northern and Eastern Finland between June 2007 and January 2011. HRQoL was assessed using RAND-36 health survey. Lumbar MC were evaluated and classified into 'No MC', 'Type I' (Type I or I/II), and 'Type II' (Type II, II/III or III). Results In total, 84 patients (46%) had MC. Of these, 37% had 'Type I' and 63% 'Type II'. Patients with MC were older, more likely females, had longer duration of LBP and a higher degree of disc degeneration than patients without MC. The total physical component or physical dimensions did not differ significantly between the groups. The total mental component of RAND-36 (P = 0.010), and dimensions of energy (P = 0.023), emotional well-being (P = 0.012) and emotional role functioning (P = 0.016) differed significantly between the groups after adjustments for age and gender. In the mental dimension scores, a statistically significant difference was found between 'No MC' and 'Type II'. Conclusions Among patients referred to spine surgery, MC were not associated with physical dimensions of HRQoL including dimension of pain. However, 'Type II' MC were associated with lower mental status of HRQoL. Implications Our study would suggest that Type II MC were associated with a worse mental status. This may affect the outcome of surgery as it is well recognized that patients with depression, for instance, have smaller improvements in HRQoL and disability. Thus the value of operative treatment for these patients should be recognized and taken into consideration in treatment. Our study shows that MC may affect outcome and thus clinicians and researchers should be cognizant of this and take this into account when comparing outcomes of surgical treatment in the future. A longitudinal study would be needed to properly address the relationship of MC with surgical outcome.

An evaluation of a postoperative rehabilitation program after spinal surgery and its impact on outcome

STUDY DESIGN

This study invited patients to evaluate the content and style of a rehabilitation program used as an intervention in a multicenter, factorial, randomized controlled trial of the postoperative management of spinal surgery patients.

OBJECTIVE

To determine the acceptability and content of the rehabilitation program.

SUMMARY OF BACKGROUND DATA

The use of rehabilitation after spinal surgery is sporadic, and the evidence for its benefit is mixed. A randomized controlled trial was conducted to determine whether functional outcome of spinal surgery could be improved by a postoperative rehabilitation program and/or an educational booklet provided at hospital discharge, each compared with usual care.

METHODS

Patients randomized to postoperative rehabilitation began the course 6 weeks after surgery. At the end of the course of 12 classes, patients completed an evaluation of content, style, and length using forced choice and open questions. Patients not attending the final class completed the evaluation at their 3-month review.

RESULTS

Compliance with rehabilitation was poor, with 41% of subjects failing to attend any classes and 16% attending less than half. Compliance with the evaluation was 100% for the 105 patients attending 1 or more classes. The length, content, and approach to the classes were rated positively, and patients gave the class a median rating of 9 of 10, range 5 to 10, with 91% rating the classes as 7 or above.

CONCLUSION

Compliance with a postoperative rehabilitation program was disappointing, but the program was assessed positively and of benefit by those who attended. Issues were raised in relation to timing and location of classes.

Patients' views on an education booklet following spinal surgery

PURPOSE

This study evaluated an evidence-based education booklet developed for patients undergoing spinal surgery which was used as a treatment intervention in a multi-centre, factorial, randomised controlled trial (FASTER: Function after spinal treatment, exercise and rehabilitation) investigating the post-operative management of spinal surgery patients. This study sought to determine the acceptability and content of the booklet to patients.

METHODS

Patients receiving the educational booklet before discharge from hospital as part of the FASTER study were asked to complete an evaluation, which rated the booklet "Your Back Operation" with regard to content, information, usability, etc. using forced and open questions. This assessment was conducted at the same time as the initial 6-week post-operative review performed as part of the larger study.

RESULTS

Therefore, 97% of the 117 trial participants who returned their 6-week evaluation and randomised to receive a booklet returned their questionnaire. The booklet was highly rated receiving an overall rating of 7 or more out of 10 from 101/111 (91%), and high ratings for content, readability and information. The booklet's key messages were clear to the majority of patients; however, many patients highlighted deficiencies with respect to content particularly in relation to wound care and exercise.

CONCLUSIONS

Patients valued the booklet and rated its content highly. Many suggested that the booklet be developed further and there was a clear desire for specific exercises to be included even though there is no evidence to support specific exercise prescription.

Postoperative rehabilitation following lumbar discectomy with quantification of trunk muscle morphology and function: a case report and review of the literature

STUDY DESIGN

A case report and literature review.

BACKGROUND

Optimizing clinical outcomes following lumbar disc surgery is a research priority; however, relatively little attention has been paid to the postoperative management of this population. The transversus abdominis and lumbar multifidus (LM) muscles appear to play a unique role in lumbar spine stability, and may relate to clinical outcome following lumbar disc surgery. The purpose of this case report was to describe the preoperative LM morphology, clinical outcome, and change in transversus abdominis and LM muscle activation in a patient following lumbar disc surgery and motor control exercise initiated in the early postoperative period.

CASE DESCRIPTION

A 29-year-old female underwent an 8-week postoperative rehabilitation program emphasizing motor control exercises to restore trunk muscle function 10 days following lumbar disc surgery.

OUTCOMES

The patient experienced clinically important improvements in pain and disability following the postoperative rehabilitation program. Substantial improvements in muscle activation were observed of the transversus abdominis and the LM at the L4-5 level. Minimal change in LM activation and a higher proportion of intramuscular fat was observed at the L5-S1 level.

DISCUSSION

This case report represents limited evidence regarding the feasibility of instituting a rehabilitation program in the early postoperative period following lumbar disc surgery. Improvements in clinical status and muscle function were observed, and a differential change in muscle activation between the L4-5 and L5-S1 levels was noted. The literature regarding rehabilitation following lumbar disc surgery, as well as the neuromuscular changes observed in this population, was reviewed. Additionally, a novel method of examining LM morphology was described and suggestions were made for directions of future research.

LEVEL OF EVIDENCE

Therapy, level 4.

Function after spinal treatment, exercise and rehabilitation (FASTER): improving the functional outcome of spinal surgery

Background

The life-time incidence of low back pain is high and diagnoses of spinal stenosis and disc prolapse are increasing. Consequently, there is a steady rise in surgical interventions for these conditions. Current evidence suggests that while the success of surgery is incomplete, it is superior to conservative interventions. A recent survey indicates that there are large differences in the type and intensity of rehabilitation, if any, provided after spinal surgery as well as in the restrictions and advice given to patients in the post-operative period.

This trial will test the hypothesis that functional outcome following two common spinal operations can be improved by a programme of post-operative rehabilitation that combines professional support and advice with graded active exercise and/or an educational booklet based on evidence-based messages and advice.

Methods/Design

The study design is a multi-centre, factorial, randomised controlled trial with patients stratified by surgeon and operative procedure. The trial will compare the effectiveness and cost-effectiveness of a rehabilitation programme and an education booklet for the postoperative management of patients undergoing discectomy or lateral nerve root decompression, each compared with "usual care"using a 2 × 2 factorial design. The trial will create 4 sub-groups; rehabilitation-only, booklet-only, rehabilitation-plus-booklet, and usual care only. The trial aims to recruit 344 patients, which equates to 86 patients in each of the four sub-groups. All patients will be assessed for functional ability (through the Oswestry Disability Index - a disease specific functional questionnaire), pain (using visual analogue scales), and satisfaction pre-operatively and then at 6 weeks, 3, 6 and 9 months and 1 year post-operatively. This will be complemented by a formal analysis of cost-effectiveness.

Discussion

This trial will determine whether the outcome of spinal surgery can be enhanced by either a post-operative rehabilitation programme or an evidence-based advice booklet or a combination of the two and as such will contribute to our knowledge on how to manage spinal surgery patients in the post-operative period.

Trial Registration

Current controlled trials ISRCTN46782945

UK CRN ID: 2670

Relationship between health-related quality of life, pain, and functional disability in neuropathic pain patients with failed back surgery syndrome

OBJECTIVES

Patients with failed back surgery syndrome (FBSS) and chronic neuropathic pain experience levels of health-related quality of life (HRQoL) that are considerably lower than those reported in other areas of chronic pain. The aim of this article was to quantify the extent to which reductions in (leg and back) pain and disability over time translate into improvements in generic HRQoL as measured by the EuroQoL-5D and SF-36 instruments.

METHODS

Using data from the multinational Prospective, Randomized, Controlled, Multicenter Study of Patients with Failed Back Surgery Syndrome trial, we explore the relationship between generic HRQoL--assessed using two instruments often used in clinical trials (i.e., the SF-36 and EuroQol-5D)--and disease-specific outcome measures (i.e., Oswestry disability index [ODI], leg and back pain visual analog scale [VAS]) in neuropathic patients with FBSS.

RESULTS

In our sample of 100 FBSS patients, generic HRQoL was moderately associated with ODI (correlation coefficient: -0.462 to -0.638) and mildly associated with leg pain VAS (correlation coefficient: -0.165 to -0.436). The multilevel regression analysis results indicate that functional ability (as measured by the ODI) is significantly associated with HRQoL, regardless of the generic HRQoL instrument used. On the other hand, changes over time in leg pain were significantly associated with changes in the EuroQoL-5D and physical component summary scores, but not with the mental component summary score.

CONCLUSIONS

Reduction in leg pain and functional disability is statistically significantly associated with improvements in generic HRQoL. This is the first study to investigate the longitudinal relationship between generic and disease-specific HRQoL of neuropathic pain patients with FBSS, using multinational data.

Health-related quality of life in patients after lumbar disc surgery: a longitudinal observational study

OBJECTIVES

Objectives of this study are (1) to compare health-related quality of life (HRQOL) of patients after lumbar disc surgery with reference data from the German general population; (2) to examine whether changes in HRQOL occur over time; (3) to investigate associations between HRQOL and socio-demographic and health-related factors.

METHODS

The study sample consisted at baseline of 189 patients who underwent lumbar disc surgery. Baseline assessment was carried out 1-4 days after surgery, the first follow-up 2 months, the second follow-up 6 months after surgery. HRQOL was assessed by means of the WHOQOL-BREF.

RESULTS

During follow-up, patients showed significant improvement in "physical well being" and "overall quality of life." However, it did not reach the level of the general population at any assessment point. There was also a slight improvement of "psychological well being." The domains "social relationships" and "environment" remained unchanged and showed persistently higher scores than the general population. Cohabitating was positively associated with QoL. Negatively associated were unemployment, part-time employment, desire for early retirement, higher intensity of pain and depression.

CONCLUSION

Supplementing physical rehabilitation by psychosocial interventions may help improve patients' HRQOL.