Not All Lumbar Stenosis Patients Are Candidates for Surgery
A subgroup analysis of the SPORT trial identifies patients who are more likely to have a poor outcome and require reoperation following surgical intervention for a diagnosis of lumbar spinal stenosis.
Shaleen Vira, MD, and Peter Passias, MD
Gerling MC, Leven D, Passias PG, et al. Risk factors for reoperation in patients treated surgically for lumbar stenosis: a subanalysis of the 8 year data from the SPORT trial. Spine (Phila Pa 1976). 2015 Dec 9. [Epub ahead of print]
This study was a retrospective subgroup analysis of the Spine Patient Outcomes Research Trial (SPORT) lumbar spinal stenosis arm. Baseline characteristics were analyzed for lumbar spinal stenosis patients who underwent reoperation versus those who did not undergo reoperation in an effort to elucidate risk factors for reoperation.
At 8-year follow-up, the reoperation rate of the 417 patients included in this study was 18%: 52% for recurrent stenosis of progressive spondylolisthesis, 25% for a complication or other reason, and 16% for a new condition.
Nearly half (42%) of reoperations occurred within 2 years of the index procedure.
Patients who underwent reoperation were less likely to have presented with any neurologic deficit. No differences in reoperation rates were identified between fusion and non-fusion procedures, and multi-level (>2 level) laminectomy was not associated with an increased risk of reoperation.
Patients who did not undergo reoperation had better patient reported outcomes at 8-year follow up than those who underwent reoperation.
The original SPORT trial results demonstrated the benefits of surgical intervention for lumbar spinal stenosis. The subgroup analysis focuses on identifying potential risk factors for poor outcomes, which is critical for preoperative counseling and surgical decision-making.
The severity and type of patient symptoms certainly is an important consideration in determining whether to treat lumbar spinal stenosis surgically. Although back pain is one of the most common presenting complaints, only a very small subgroup of these patients benefits from surgical intervention.
Specifically, the presence of neurologic findings suggests symptomatic cauda or root impingement that may be amenable to decompression. In contrast, generalized back pain without neurologic findings may suggest the presence of other etiologies or more generally pathology that is not as amenable to decompression of the neural elements.
The present study demonstrates this differential finding and, indeed, the lack of neurologic findings should warrant hesitation on the part of the clinician to indicate a patient for surgery.
This study also reports the overall reoperation rate for the surgically treated lumbar spinal stenosis group at 18%, of which almost half occurred within 2 years of the index procedure for etiologies such as recurrent stenosis and spondylolisthesis. Surgeons can potentially prevent these common causes of reoperation with adequate decompression, meticulous attention to surgical technique, and dynamic assessment of the lumbar spine to evaluate for spondylolisthesis.
It is possible that adoption of less-invasive decompressive surgical techniques may influence the occurrence of reoperation in more contemporary series. Further research is necessary to investigate other pathophysiological mechanisms for postoperative recurrent stenosis and spondylolisthesis.
Overall, this study extends the results of the well-known SPORT trial by focusing on risk factors for reoperation, which can help clinicians appropriately indicate and preoperatively counsel patients with lumbar spinal stenosis.
Shaleen Vira, MD, is an orthopaedic surgery resident at NYU Langone Medical Center – Hospital for Joint Diseases, New York, New York. Peter Passias, MD, is a Clinical Assistant Professor of Orthopaedic Surgery, Division of Spine Surgery, Department of Orthopaedic Surgery, at NYU Langone Medical Center – Hospital for Joint Diseases, New York, New York.