What’s the Claim?
An eye-opening study from a national spine registry characterized results of surgery for lumbar spinal stenosis in one-third of patients as a failure (based on an Oswestry Disability Index [ODI] score of >31 out of 100). More than one in five patients in this report were reported to be worsening (based on an ODI of >39) rather than improving a year after surgery. Patients with long-standing back pain (more than a year of antecedent symptoms before surgery), prior surgery, and age >70 years were more likely to have done poorly after surgery in this registry report. Most patients in this study had decompression without fusion.
How’s It Stack Up?
The top-line finding here — “failure” in one-third of patients — seems worse than many single-center case series or even the typical randomized trial, but before you hit “delete” thinking that it doesn’t apply to you, consider why it may. National registries like the one used here (NORspine) mandate participation and capture a broad cross-section of surgeons and patients. They therefore reflect “everyday practice” much more closely than do case series and RCTs from high-volume academic centers whose patients and surgeons often differ considerably from those treated in the community. As with all registry studies, it’s impossible to know the indications that were applied, but because it represents the experience of an entire country, one generally can surmise the indications reflect spine surgery as it’s commonly practiced.
What’s Our Take?
It would sure be nice to ignore this one — it’s something of a downer, to be sure — but we don’t recommend doing that. While this was something of a mixed bag in terms of patients, diagnoses, and procedures (with/without spondylolisthesis, deformities not well defined), and the ODI scores may be a bit severe, it probably reflects very well a sort of “all comers” community experience in spine surgery for stenosis, likely more than the typical (and more cheerful) case series whose results we like to quote our patients because they report success in >90% of lumbar decompressions. It’s likely we all feel that we’re in that >90% range on these operations, but remember, a high percentage of our patients don’t report back at a year or two. We don’t necessarily know how they’re doing, and it’s likely some are not doing as well as we’d hope and have gone elsewhere for follow-up. A higher percentage were missing here than we like to see in registry studies, but, again, if anything, this means that these patients may even be doing worse than it appears. It’s unlikely they’re doing better, since the missing usually are not as happy as the accounted for. We’d use the numbers here to counsel our patients and lower expectations before surgery. They look trustworthy.
Alhaug OK, Dolatowski FC, Solberg TK, Lønne G. Predictors for Failure After Surgery for Lumbar Spinal Stenosis: A Prospective Observational Study. Spine J. 2023;23:261-270.