Elsevier

The Spine Journal

Volume 8, Issue 2, March–April 2008, Pages 380-384
The Spine Journal

Clinical Study
Prospective analysis of clinical evaluation and self-assessment by patients after decompression surgery for degenerative lumbar canal stenosis

https://doi.org/10.1016/j.spinee.2007.01.010Get rights and content

Abstract

Background context

Objective measures including neurological findings, radiographic evaluation, and the Japanese Orthopaedic Association (JOA) score are commonly used for the evaluation of surgical outcomes. Because many surgeries are performed primarily to improve quality of life, a patient's subjective evaluations are also important for accurately assessing surgical outcomes. Currently available instruments for assessing quality of life include the Short-Form 36 (F-36), the Oswestry disability index (ODI), and the visual analog scale (VAS) clinical pain scale.

Purpose

The aims of this study were to measure surgical outcomes by using both objective measures and subjective measures including patient self-assessments and psychological changes; to assess the adequacy of the JOA alone for measuring outcome; and to determine which measures, the SF-36v2, ODI, VAS, or JOA correlate with the VAS pain scale score in lumbar canal stenosis.

Study design

We performed a prospective study to measure surgical outcomes for lumbar canal stenosis using traditional objective measures such as neurological findings and subjective measures such as performance of ADLs, patient self-assessments, and psychological changes.

Patient sample

Forty-two surgical patients with a mean age of 66.8±10.9 years at the time of surgery were included in the study. All cases were followed for more than 2 years. Surgical indications included no response to conservative treatment and neurological deterioration. Neurological symptoms were classified as nerve root type, cauda equine type, or combined type. We performed surgical decompression at the location of the dural or root indentation by myelography. The concomitant diagnosis causing the spinal stenosis was degenerative spondylolisthesis in 20 cases undergoing posterolateral fusion with pedicle screws.

Outcome measures

Surgical outcomes were assessed by comparing preoperative and 24-month postoperative JOA scores for low back pain, SF-36v2, ODI-v2, and VAS scores. Statistical analysis was performed by using the analysis of variance. A p value<0.05 was considered statistically significant.

Methods

Objective clinical measures, patient self-assessments, and psychological changes were measured before and at 24 months postoperatively. We also examined which measurements correlated with the VAS scale for pain evaluation, thereby relating patient satisfaction to surgery outcome.

Results

All JOA, SF-36v2, ODI-v2, and VAS scores significantly improved postoperatively. The physical component summary (PCS) of the SF-36 v2 showed significant improvement, although all scores remained less than the Japanese norm-based scores (NBSs). The mental component summary (MCS) exhibited such a significant improvement that all postoperative subscales were higher than the Japanese NBS. JOA scores significantly correlated only with postoperative lower-extremity VAS score. All PCS and two MCS scores significantly correlated with the VAS score for low back pain. Parts of the PCS and MCS significantly correlated with the lower-extremity VAS. The ODI significantly correlated with both the preoperative and postoperative VAS scores for low back pain as well as with the postoperative lower-extremity VAS score.

Conclusions

The JOA, SF-36, ODI, and VAS questionnaires are all useful instruments for measuring surgical outcomes. The VAS score is a better assessment of physical rather than mental health. The ODI is more reflective of patients' subjective symptoms. Finally, the SF-36 is particularly informative because it includes questions addressing both psychological and physical status. Therefore, when combined, the SF-36v2, VAS, and ODI scores are a valuable complement to the JOA scores in evaluating outcomes of surgery for lumbar canal stenosis.

Introduction

Clinical outcomes after decompression surgery for degenerative lumbar canal stenosis have most commonly been assessed with traditional, objective outcome measures. These measures include neurological findings, radiographic evaluation, and the Japanese Orthopaedic Association (JOA) scoring system for low back pain (Table 1). Subjective evaluations by patients, however, are becoming increasingly important for measuring surgical outcome because many modern procedures are performed primarily to improve a patient's quality of life. Currently available instruments for assessing quality of life include the Short-Form 36 (SF-36) [1], [2] questionnaire for generic health status, the Oswestry disability index (ODI) [3], [4], [5] for low back pain, and the visual analog scale (VAS, a clinical pain scale). The purpose of this study was to validate various subjective and objective measures of surgical outcome, including patient self-assessment and psychological changes after surgery. The study also analyzed the validity of the JOA scoring system and determined the degree of correlation between VAS pain scale scores and SF-36 Version 2 (SF-36v2), ODI Version 2 (ODIv2), and JOA scores.

Section snippets

Patients and methods

We conducted a prospective study of 42 patients (20 men and 22 women) undergoing surgical treatment with a mean age of 66.8±10.9 years ranging from 33 to 88 years at the time of surgery. All patients gave their informed consent to participate in this study, which had been approved by the institutional review board of our school of medicine (no. 183). Surgical indications included no response to conservative treatment including medications or physical therapy and neurological deterioration

Results

The overall JOA scores as well as the subscores for subjective symptoms, clinical signs with the exception of urinary dysfunction, and restriction of ADLs were all significantly improved 24 months postoperatively when compared with the corresponding preoperative scores (Fig. 1). The SF-36v2 scores for all subscales were also significantly higher after surgery (Fig. 2). Although the physical component subset showed significant improvement, all scores were less than the Japanese adjusted norms.

Discussion

In this study, all JOA, SF-36v2, ODI-v2, and VAS measures significantly improved postoperatively. The JOA score for low back pain is composed of four categories of subjective symptoms, clinical signs, restriction of ADLs, and urinary dysfunction. Three categories, subjective symptoms, clinical signs, and restriction of ADLs showed significant improvement postoperatively, whereas there was no postoperative change in the score for urinary dysfunction. This is likely because the patients enrolled

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