Functional outcome study of patients after surgical decompression for lumbar spinal stenosis: effects of concomitant pathology

Assessment of Patient-Reported Outcome Instruments to Assess Chronic Low Back Pain

Objective

To identify patient-reported outcome (PRO) instruments that assess chronic low back pain (cLBP) symptoms (specifically pain qualities) and/or impacts for potential use in cLBP clinical trials to demonstrate treatment benefit and support labeling claims.

Design

Literature review of existing PRO measures.

Methods

Publications detailing existing PRO measures for cLBP were identified, reviewed, and summarized. As recommended by the US Food & Drug Administration (FDA) PRO development guidance, standard measurement characteristics were reviewed, including development history, psychometric properties (validity and reliability), ability to detect change, and interpretation of observed changes.

Results

Thirteen instruments were selected and reviewed: Low Back Pain Bothersomeness Scale, Neuropathic Pain Symptom Inventory, PainDETECT, Pain Quality Assessment Scale Revised, Revised Short Form McGill Pain Questionnaire, Low Back Pain Impact Questionnaire, Oswestry Disability Index, Pain Disability Index, Roland-Morris Disability Questionnaire, Brief Pain Inventory and Brief Pain Inventory Short Form, Musculoskeletal Outcomes Data Evaluation and Management System Spine Module, Orebro Musculoskeletal Pain Questionnaire, and the West Haven-Yale Multidimensional Pain Inventory Interference Scale. The instruments varied in the aspects of pain and/or impacts that they assessed, and none of the instruments fulfilled all criteria for use in clinical trials to support labeling claims based on recommendations outlined in the FDA PRO guidance.

Conclusions

There is an unmet need for a validated PRO instrument to evaluate cLBP-related symptoms and impacts for use in clinical trials.

[Long-term survival analysis after surgical management for degenerative lumbar stenosis]

PURPOSE OF THE STUDY

The short- and mid-term symptom-relief of surgical treatment for lumbar stenosis is generally acknowledged, but the probability of a long-term reoperation remains to be studied. The purpose of this work was to determine the long-term risk of reoperation after surgical treatment of degenerative lumbar stenosis and to search for factors influencing this probability.

MATERIAL AND METHODS

All patients who underwent from 1989 to 1992 surgical treatment for degenerative lumbar spine stenosis were included in this work. At last follow-up, we noted functional outcome using a specific self-administered questionnaire, patient satisfaction, lumbalgia and radiculalgia using a visual analog scale, SF36 quality-of-life, reoperation or not with time since first operation if performed and the reasons and modalities of the reoperation. The probability of reoperation was determined with the acturarial method. A Cox model was used to search for factors linked with the probability of reoperation; variables studied were: age, comorbid factors, extent of the release, posterolateral arthrodesis or not, extent of the potential fusion, use or not of instrumentation for arthrodesis.

RESULTS AND DISCUSSION

The study included 262 patients. At last follow-up, 61 patients had died a mean 3.7+/-3 years after the operation; only one of these patients had a second operation 22 months after the first. Forty-four patients were lost to follow-up at mean 6.6+/-3 years. Among these 44 patients, four had a second operation during their initial follow-up at mean 47 months. One hundred fifty-seven patients were retained for this analysis at mean 15+/-1 years follow-up. Among these 157 patients, 29 had a second operation a mean 75 months after the first. There were four reasons for reoperating: insufficient release, destabilization within or above the zone of release, development or renewed zone of stenosis, development or renewed discal herniation. The risk of a second operation was 7.4% [95% CI 4.8-11.6], 15.4% [95% CI 10.7-21.1] and 16.5% [95% CI 11.7-219] at five, 10 and 15 years respectively after the first operation. Among the risk factors studied, only one had a significant impact on reoperation: extent of the zone of release (p=0.003). Compared with a release limited to one level, the risk of reoperation after release of three levels or more was five times greater [95% CI 1.8-12.7].

Patient outcome following rehabilitation for rotator cuff repair surgery: the impact of selected medical comorbidities

STUDY DESIGN

Prospective, multicenter research design.

OBJECTIVES

To assess functional and health status outcomes in patients following a physical therapy program after rotator cuff repair surgery, and to determine the impact of selected patient medical comorbidities on rehabilitation outcomes.

BACKGROUND

While authors have studied the influence of multiple factors on patient outcomes after rotator cuff repair surgery, little research has been done on the impact of comorbidities, particularly as it relates to establishing an accurate patient prognosis. eighteen patients who had recently undergone a rotator cuff repair surgical procedure were recruited at 1 of 30 Physiotherapy Associates, Inc outpatient clinics located in 13 states. A rehabilitation protocol was implemented and included the following interventions, as indicated: therapeutic exercise, manual therapy, electrotherapeutic modalities, and physical agents. Patient health history factors were documented during the initial examination, including age, race, body mass index, smoking, rotator cuff tear size, type of surgical procedure, and selected medications and comorbidities. The Disabilities of the Arm, Shoulder, and Hand (DASH) and the Short-Form-36 (SF-36) were completed prior to rehabilitation, at discharge, and at 6 months postdischarg

RESULTS

DASH andmost SF-36 domain mean scores obtained postrehabilitation were significantly improved from pretherapy scores. Most health status outcomes were maintained at 6-month follow-up, with slight further improvement noted in SF-36 physical dimensions and DASH scores. Having a greater number of comorbidities was associated with worse postrehabilitation SF-36 scores, but not with the DASH shoulder function scores. The mean change scores (difference between prerehabilitation and postrehabilitation status) for the DASH and SF-36 were not significantly different for patients with 0 to 1, 2, or at least 3 or more comorbidities (except for emotional role). In regression analyses a model with baseline physical function score (P = .0001), age (P = .03), and number of comorbidities (P = .003) fitted the data well and explained 38% of the variance in the physical function score at discharge.

CONCLUSIONS

A higher number of comorbidities had a negative effect on general health status outcomes but not on shoulder function outcomes at the time of patient discharge following rehabilitation. Despite a negative effect of more comorbidities on health status outcomes, the specific number of medical comorbidities did not affect the overall level of improvement prerehabilitation to postrehabilitation in function and health status. The findings describing the influence of comorbidities on rehabilitation outcomes may assist therapists in establishing accurate patient prognosis.