2007 Outstanding Paper Award: Surgical ScienceAssessment of health-related quality of life after surgical treatment of focal symptomatic spinal stenosis compared with osteoarthritis of the hip or knee
Introduction
The aging population is resulting in an increasing burden of degenerative illness that will only continue to have a progressive impact on both human and financial health-care resources [1], [2], [3], [4], [5], [6], [7]. For musculoskeletal disorders this is already evident in the increasing rates of patients undergoing surgery for degenerative conditions such as hip or knee osteoarthritis (H-OA/K-OA) and lumbar spinal stenosis (LSS) [2], [3], [4], [5]. The surgical management of symptomatic hip and knee arthritis typically involves the use of joint replacement implants (total joint arthroplasty [TJA]), whereas the current management for symptomatic LSS involves decompression alone or decompression and fusion. In particular, procedures requiring implants potentially represent a significant cost to any health-care system and are under significant scrutiny [2]. As the demand for such procedures is on a predictable increase, issues such as utilization, cost-effectiveness, surgical waiting times, and the resultant effects on scarce health-care resources are an ongoing priority health policy focus [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15].
The general demographics and comorbidities of patients with symptomatic LSS and hip or knee arthritis are very similar. Numerous studies have demonstrated reliable and sustained improvements in overall patient satisfaction, quality of life, and function after primary TJA [16]. In addition, hip and knee arthroplasty have shown to be cost-effective compared with other nonmusculoskeletal surgical procedures [16], [17], [18], [19]. Consequently, lower extremity TJA has gained widespread acceptance from governmental on and nongovernmental funding agencies. This, however, has not been the case for LSS.
The population of LSS patients represents a growing public health challenge for spinal surgeons around the world. For neurogenic claudication, the literature has shown that good outcomes after elective surgical management of LSS and stable relief can be maintained for up to 10 years [20], [21], [22]. Although there are increasing levels of scientific evidence demonstrating improved outcomes with surgical management of LSS, the heterogeneity of the indication(s) for and the outcomes of surgery makes strong conclusions and recommendations regarding health care difficult [20], [23]. The impact of surgical treatment of LSS on patient self-reported quality of life has never been directly compared with the benchmark set by TJA. To date, no study has directly compared the relative improvement in quality of life after surgical intervention for matched groups of patients with primary H-OA/K-OA and LSS. Our hypothesis is that contemporary patient selection and surgical management of LSS achieves a positive impact on patient quality of life comparable to that resulting from hip and knee arthroplasty for osteoarthritis.
Section snippets
Study design
Observational cohort study of prospectively collected outcomes.
Patient population
Patients who had undergone TJA for H-OA/K-OA or decompression with or without fusion for LSS from January 2000 to December 2003 were assessed. All patients had undergone at least 6 months of conservative care before surgical assessment. Inclusion criteria for the LSS patients were neurogenic claudication (leg-dominant pain, relieved by postural change) resulting from one- or two-level spinal stenosis (ie, focal disease [focal lumbar
Patient characteristics
Patient demographics are presented in Table 1. The three groups (FLSS/H-OA/K-OA) were equally matched with respect to mean age (64/63/65 years), sex (female/male, 51/39 for all groups), body mass index (27/24/27), and American Society of Anesthesiologists physical status (2/2/2). Within the FLSS group, 62 patients had decompression alone (n=30: one-level, n=32: two-level) and 28 had decompression and instrumented fusions (n=12: one-level, n=16: two-level). Thirty-eight patients within the FLSS
Discussion
The current study demonstrates that in properly selected patients with leg-dominant symptoms secondary to FLSS, surgical intervention can achieve an improvement in self-reported Health Related Quality of Life (HRQOL) comparable to that attained by TJA for patients with H-OA/K-OA. Furthermore, these improvements are sustained for at least 2 years. This is the first study that has directly compared a matched cohort of LSS patients with patients who had undergone the gold standard procedure (ie,
Conclusions
The results of this study confirm our hypothesis that contemporary patient selection and surgical management of FLSS achieves an improvement in patient quality of life comparable to that attained by hip and knee TJA for osteoarthritis. These findings support surgical treatment for FLSS with leg-dominant symptoms in patients who have failed conservative management. This study provides valuable information to support increased advocacy for this patient population.
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