Long-term outcomes of surgical and nonsurgical management of lumbar spinal stenosis: 8 to 10 year results from the Maine Lumbar Spine Study
Long-term outcomes of surgical and nonsurgical management of lumbar spinal stenosis: 8 to 10 year results from the Maine Lumbar Spine Study
复制标题
DOI：
10.1097/01.brs.0000158953.57966.c0
复制
发表时间：
2005-04-15
期刊：
影响因子：
3
通讯作者：
Singer, DE
中科院分区：
文献类型：
--
作者：
Atlas, SJ;Keller, RB;Singer, DE
研究设计.一项前瞻性观察性队列研究。评估腰椎管狭窄症患者手术或非手术治疗的长期预后。腰椎管狭窄症的各种治疗方法的相对受益是不确定的。手术治疗与短期改善有关，但有记录表明症状复发。很少有研究比较手术和非手术治疗的长期结果。从整个缅因州的整形外科医生、神经外科医生和职业医学医生的实践中招募的患者进行了基线访谈，并在10年内定期邮寄随访问卷。临床数据在基线时从医生问卷中获得。大多数初次接受手术的患者进行了椎板切除术，未进行融合。在8- 10年随访时评估了结局，包括患者报告的腿部和背部疼痛症状、功能状态和满意度。主要分析基于接受的初始治疗，次要分析检查10年前接受的实际治疗。在最初入组的148名符合条件并同意的患者中，105名患者在10年后仍存活（生存率为67.7%）。在存活的患者中，123例患者中有97例（79%）接受了8 - 10年的长期随访（包括11例在10年随访前死亡但完成了8或9年调查的患者）; 63例患者中有56例（89%）最初接受了手术治疗，60例患者中有41例（68%）最初接受了非手术治疗。接受手术治疗的患者的基线症状和功能状态比最初接受非手术治疗的患者更差。1年和4年的结果有利于初始手术治疗。8 - 10年后，相似比例的手术和非手术患者报告他们的腰痛得到改善（53% vs. 50%，P = 0.8），他们的主要症状（背痛或腿痛）得到改善（54% vs. 42%，P = 0.3），他们对目前的状况感到满意（55% vs. 49%，P = 0.5）。在多变量模型中调整结果的其他决定因素后，这些治疗组发现仍然存在。然而，与非手术治疗的患者相比，最初手术治疗的患者报告的腿部疼痛症状不太严重，8至10年后背部特异性功能状态的改善更大。到10年时，23%的手术患者至少接受过一次额外的腰椎手术，39%的非手术患者至少接受过一次腰椎手术。接受后续外科手术的患者比继续接受初始治疗的患者结局更差。根据10年时接受的实际治疗结果没有差异，因为接受额外手术的个体比继续接受初始治疗的个体结局更差。在完成8- 10年随访的腰椎管狭窄症患者中，最初手术或非手术治疗的患者在腰痛缓解、主要症状改善和对当前状态的满意度方面相似。然而，腿部疼痛缓解和更大的背部相关功能状态继续有利于那些最初接受手术治疗。这些结果支持医生和患者在考虑腰椎管狭窄症治疗方案时的共同决策方法。
Study Design. A prospective observational cohort study.Objective. To assess long-term outcomes of patients with lumbar spinal stenosis treated surgically or nonsurgically.Summary of Background Data. The relative benefit of various treatments for lumbar spinal stenosis is uncertain. Surgical treatment has been associated with short-term improvement, but recurrence of symptoms has been documented. Few studies have compared long-term outcomes of surgical and nonsurgical treatments.Methods. Patients recruited from the practices of orthopaedic surgeons, neurosurgeons, and occupational medicine physicians throughout Maine had baseline interviews with follow-up questionnaires mailed at regular intervals over 10 years. Clinical data were obtained at baseline from a physician questionnaire. Most patients initially undergoing surgery had a laminectomy without fusion performed. Outcomes including patient-reported symptoms of leg and back pain, functional status, and satisfaction were assessed at 8- to 10-year follow-up. Primary analyses were based on initial treatment received with secondary analyses examining actual treatment received by 10 years.Results. Of 148 eligible consenting patients initially enrolled, 105 were alive after 10 years (67.7% survival rate). Among surviving patients, long-term follow-up between 8 and 10 years was available for 97 of 123 (79%) patients ( including 11 patients who died before the 10-year follow-up but completed a 8 or 9 year survey); 56 of 63 (89%) initially treated surgically and 41 of 60 (68%) initially treated nonsurgically. Patients undergoing surgery had worse baseline symptoms and functional status than those initially treated nonsurgically. Outcomes at 1 and 4 years favored initial surgical treatment. After 8 to 10 years, a similar percentage of surgical and nonsurgical patients reported that their low back pain was improved 53% vs. 50%, P = 0.8), their predominant symptom ( either back or leg pain) was improved (54% vs. 42%, P = 0.3), and they were satisfied with their current status (55% vs. 49%, P = 0.5). These treatment group findings persisted after adjustment for other determinants of outcome in multivariate models. However, patients initially treated surgically reported less severe leg pain symptoms and greater improvement in back-specific functional status after 8 to 10 years than nonsurgically treated patients. By 10 years, 23% of surgical patients had undergone at least one additional lumbar spine operation, and 39% of nonsurgical patients had at least one lumbar spine operation. Patients undergoing subsequent surgical procedures had worse outcomes than those continuing with their initial treatment. Outcomes according to actual treatment received at 10 years did not differ because individuals undergoing additional surgical procedures had worse outcomes than those continuing with their initial treatment.Conclusions. Among patients with lumbar spinal stenosis completing 8- to 10-year follow-up, low back pain relief, predominant symptom improvement, and satisfaction with the current state were similar in patients initially treated surgically or nonsurgically. However, leg pain relief and greater back-related functional status continued to favor those initially receiving surgical treatment. These results support a shared decision-making approach among physicians and patients when considering treatment options for lumbar spinal stenosis.