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, 14 (11), e0224200
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Patients Undergoing Surgery for Lumbar Spinal Stenosis Experience Unique Courses of Pain and Disability: A Group-Based Trajectory Analysis

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Patients Undergoing Surgery for Lumbar Spinal Stenosis Experience Unique Courses of Pain and Disability: A Group-Based Trajectory Analysis

Jeffrey J Hebert et al. PLoS One.

Abstract

Objective: Identify patient subgroups defined by trajectories of pain and disability following surgery for degenerative lumbar spinal stenosis, and investigate the construct validity of the subgroups by evaluating for meaningful differences in clinical outcomes.

Methods: We recruited patients with degenerative lumbar spinal stenosis from 13 surgical spine centers who were deemed to be surgical candidates. Study outcomes (leg and back pain numeric rating scales, modified Oswestry disability index) were measured before surgery, and after 3, 12, and 24 months. Group-based trajectory models were developed to identify trajectory subgroups for leg pain, back pain, and pain-related disability. We examined for differences in the proportion of patients achieving minimum clinically important change in pain and disability (30%) and clinical success (50% reduction in disability or Oswestry score ≤22) 12 months from surgery.

Results: Data from 548 patients (mean[SD] age = 66.7[9.1] years; 46% female) were included. The models estimated 3 unique trajectories for leg pain (excellent outcome = 14.4%, good outcome = 49.5%, poor outcome = 36.1%), back pain (excellent outcome = 13.1%, good outcome = 45.0%, poor outcome = 41.9%), and disability (excellent outcome = 30.8%, fair outcome = 40.1%, poor outcome = 29.1%). The construct validity of the trajectory subgroups was confirmed by between-trajectory group differences in the proportion of patients meeting thresholds for minimum clinically important change and clinical success after 12 postoperative months (p < .001).

Conclusion: Subgroups of patients with degenerative lumbar spinal stenosis can be identified by their trajectories of pain and disability following surgery. Although most patients experienced important reductions in pain and disability, 29% to 42% of patients were classified as members of an outcome trajectory subgroup that experienced little to no benefit from surgery. These findings may inform appropriate expectation setting for patients and clinicians and highlight the need for better methods of treatment selection for patients with degenerative lumbar spinal stenosis.

Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Fig 1
Fig 1. Study flow diagram.
Fig 2
Fig 2
Average trajectories for a. leg pain, b. back pain, and c. disability. Point estimates are average outcome scores. Dotted lines represent 95% confidence intervals.
Fig 3
Fig 3. Clinical outcome trajectory groups with prevalence estimates.
a. leg pain trajectories (N = 529); b. low back pain trajectories (N = 510); c. disability trajectories (N = 519). Point estimates are average outcome scores (0–10 numeric pain rating scale or 0–100 modified Oswestry index). Dotted lines represent 95% confidence intervals.

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Grant support

The authors received no specific funding for this work.
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