Physical Therapy and Health Care Utilization for Older Adults With Lumbar Spinal Stenosis.

BACKGROUND AND PURPOSE: Lumbar spinal stenosis (LSS) is associated with high health care utilization for older adults. Physical therapy (PT) offers low medical risk and reduced cost burden with functional outcomes that appear to be equivalent to higher risk interventions such as surgery. However, it is unknown whether receipt of PT following incident LSS diagnosis is associated with reduced health care utilization. The objectives of this study were to: (1) compare health characteristics for Medicare beneficiaries who received outpatient PT within 30 days of incident LSS diagnosis to those who did not; (2) compare the 1-year utilization rates for specific health care services for these 2 groups; and (3) quantify the likelihood of progression to specific health services based on the receipt of PT. METHODS: This was a retrospective cohort study using nationally representative claims data for Medicare Part B beneficiaries between 2007 and 2010. Lumbar spinal stenosis was determined using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Beneficiaries 65 years and older were classified into 2 groups (PT and no PT) based on receipt of PT within 30 days of initial diagnosis. Baseline characteristics were identified at incident diagnosis. Hazard ratios (HRs) were estimated for the risk of receiving health services outcomes including spinal surgery, spinal injections, chiropractic care, advanced imaging, spinal radiographs, opioid medication, nonopioid analgesics, and hospitalizations beginning on day 31 up to 1 year following incident LSS diagnosis. RESULTS AND DISCUSSION: Among 60 646 Medicare beneficiaries with incident LSS who met the inclusion criteria, 1124 were classified in the PT group and 59 522 in the no PT group. Compared with the PT group, beneficiaries in the no PT group had a greater risk of having hospitalizations (HR = 1.40), opioid medications (HR = 1.29), spinal surgery (HR = 1.29), and spinal radiographs (HR = 1.19) within 1 year. CONCLUSIONS: Fewer than 2% of Medicare beneficiaries received PT within 30 days of initial LSS diagnosis. Receipt of PT was associated with less utilization of higher risk and costly health services for 1 year. These results may inform practitioners when making early decisions about rehabilitative care for older adults with LSS.

Preoperative Factors Predict Postoperative Trajectories of Pain and Disability Following Surgery for Degenerative Lumbar Spinal Stenosis.

STUDY DESIGN: Longitudinal analysis of prospectively collected data. OBJECTIVE: Investigate potential predictors of poor outcome following surgery for degenerative lumbar spinal stenosis (LSS). SUMMARY OF BACKGROUND DATA: LSS is the most common reason for an older person to undergo spinal surgery, yet little information is available to inform patient selection. METHODS: We recruited LSS surgical candidates from 13 orthopedic and neurological surgery centers. Potential outcome predictors included demographic, health, clinical, and surgery-related variables. Outcome measures were leg and back numeric pain rating scales and Oswestry disability index scores obtained before surgery and after 3, 12, and 24 postoperative months. We classified surgical outcomes based on trajectories of leg pain and a composite measure of overall outcome (leg pain, back pain, and disability). RESULTS: Data from 529 patients (mean [SD] age = 66.5 [9.1] yrs; 46% female) were included. In total, 36.1% and 27.6% of patients were classified as experiencing a poor leg pain outcome and overall outcome, respectively. For both outcomes, patients receiving compensation or with depression/depression risk were more likely, and patients participating in regular exercise were less likely to have poor outcomes. Lower health-related quality of life, previous spine surgery, and preoperative anticonvulsant medication use were associated with poor leg pain outcome. Patients with ASA scores more than two, greater preoperative disability, and longer pain duration or surgical waits were more likely to have a poor overall outcome. Patients who received preoperative chiropractic or physiotherapy treatment were less likely to report a poor overall outcome. Multivariable models demonstrated poor-to acceptable (leg pain) and excellent (overall outcome) discrimination. CONCLUSION: Approximately one in three patients with LSS experience a poor clinical outcome consistent with surgical non-response. Demographic, health, and clinical factors were more predictive of clinical outcome than surgery-related factors. These predictors may assist surgeons with patient selection and inform shared decision-making for patients with symptomatic LSS. LEVEL OF EVIDENCE: 2.

Perioperative Risk Factors for Early Revisions in Stand-Alone Lateral Lumbar Interbody Fusion.

BACKGROUND: Lateral lumbar interbody fusion can be performed without supplemental posterior instrumentation. Previous reports have shown favorable results with stand-alone lateral lumbar interbody fusion (SA-LLIF); however, a reoperation rate of up to 26% has been reported. It remains unclear what perioperative factors are associated with early failure after SA-LLIF. The objective of this study is to determine perioperative factors that increase the risk of early revisions after SA-LLIF. METHODS: Data of consecutive patients with SA-LLIF were reviewed. All revisions or recommendations for revision surgery within 12 months after the LLIF procedure were documented. As potential contributors, operative levels, preoperative clinical diagnosis, number of fusion levels, and the average L1/L2 quantitative computed tomography-volumetric bone mineral density value were obtained along with other demographic factors. Cage subsidence (grade 0-III as per Marchi et al.), was also evaluated in patients who had radiographs/computed tomography between 6 and 12 months postoperatively (n = 122). Logistic regression analyses were conducted. RESULTS: Of 133 eligible patients, 21 (15.8%) underwent revision surgery and 4 (3.0%) were recommended for revision surgery within 1 year primarily because of neurologic symptoms or pain (68%). Baseline demographics showed no significant difference between the revision and the nonrevision group. The average number of levels fused was 2.12 (revision group) and 2.14 (nonrevision group) (P = 0.55). Significantly more patients in the revision group had the diagnosis of foraminal stenosis (64.0% vs. 39.8%; P = 0.04). CONCLUSIONS: Patients with foraminal stenosis were more likely to have early revision surgery after SA-LLIF primarily because of neurologic symptoms/pain. This information can assist in preoperative discussions and management of patient expectations.

Degenerative lumbar spinal stenosis in older people: current treatment options.

BACKGROUND: Degenerative lumbar spinal stenosis is increasingly being diagnosed in persons over age 65. In 2011, 55 793 older people with this condition were treated as inpatients in German hospitals. Among physicians, there is much uncertainty about the appropriate treatment strategy. METHOD: Selective literature review. RESULTS: Lumbar spinal stenosis in older people is characterized by spinal claudication and neurological deficits. A precise clinical history and physical examination and ancillary radiological studies are the necessary prerequisites for treatment. Magnetic resonance imaging is the radiological study of choice. Conservative treatment consists of physiotherapy, drugs, and local injections; various surgical treatments can be considered, depending on the severity of the problem. The main purpose of surgery is to decompress the spinal canal. If the lumbar spine is demonstrably unstable, an instrumented fusion should be performed in addition. There is, however, only moderately good evidence supporting the superiority of surgery over conservative treatment. In a prospective study, the complication rate of purely decompressive surgery was found to be 18%. The utility of the current operative techniques cannot be definitively assessed, because they are applied to a wide variety of patients in different stages of the disease and at different degrees of severity, and the reported results are thus not comparable from one trial to another. CONCLUSION: No evidence-based recommendation on the diagnosis and treatment of lumbar spinal stenosis in older people can be formulated at present because of the lack of pertinent randomized trials.

Characteristics of chronic pain associated with sleep difficulty in older adults: the Maintenance of Balance, Independent Living, Intellect, and Zest in the Elderly (MOBILIZE) Boston study.

OBJECTIVES: To evaluate pain severity and distribution in relation to sleep difficulty in older adults. DESIGN: Population-based cross-sectional study. SETTING: Community within a 5-mile radius of the study center at the Institute for Aging Research, Hebrew SeniorLife (HSL), Boston. PARTICIPANTS: Seven hundred sixty-five participants of the Maintenance of Balance, Independent Living, Intellect, and Zest in the Elderly (MOBILIZE) Boston Study aged 64 and older. MEASUREMENTS: Pain severity was measured using the Brief Pain Inventory (BPI) Pain Severity Subscale. Musculoskeletal pain distribution was grouped according to no pain, single site, two or more sites, and widespread pain (upper and lower extremities and back pain). Three aspects of sleep difficulty were measured using items from the Center for Epidemiologic Studies Depression Scale, Revised (trouble getting to sleep, sleep more than usual, and restless sleep). RESULTS: Prevalence of trouble getting to sleep according to BPI severity was 17.8%, 19.7%, 32.0%, and 37.0% for the lowest to highest pain severity quartiles, respectively. Similar relationships between pain and sleep were observed across sleep measures according to pain severity and distribution. Adjusted for sociodemographic characteristics, chronic conditions, and health behaviors, chronic pain was strongly associated with trouble sleeping (≥ 1 d/wk) (single-site pain, odds ratio (OR)=1.77, 95% confidence interval (CI)=1.10-2.87; multisite pain, OR=2.38, 95% CI=1.48-3.83; widespread pain, OR=2.55, 95% CI=1.43-4.54, each compared with no pain). Similar associations were observed for restless sleep and sleeping more than usual. For specific pain sites alone or in combination with other sites of pain, only modest associations were observed with sleep problems. CONCLUSION: Widespread or other multisite pain and moderate to severe pain are strongly associated with sleep difficulty in older adults. Further research is needed to better understand the burden and consequences of pain-related sleep problems in older adults.

Assessment and management of neurogenic claudication associated with lumbar spinal stenosis in a UK primary care musculoskeletal service: a survey of current practice among physiotherapists.

BACKGROUND: Neurogenic claudication (NC) is the clinical syndrome commonly associated with lumbar spinal stenosis (LSS). Non-surgical management is recommended as initial treatment, but little is known about current practice in relation to the assessment and management of these patients in the non-surgical setting. METHODS: We conducted a questionnaire survey of physiotherapists in a large UK primary care musculoskeletal service which provides a city-wide multidisciplinary assessment and treatment facility for patients with spinal and other musculoskeletal problems. Data on therapists' recognition and management of patients with NC and LSS were collected. RESULTS: Fifty out of 54 therapists completed questionnaires, and all but one of these identified a clearly recognised posture-related clinical syndrome of NC. Almost all respondents (48: 96%) reported the routine use of physiotherapy treatments. In particular, advice and education (49: 98%) along with an exercise programme (47: 94%) incorporating flexion-based exercises (41: 82%) and trunk muscle stabilising exercises (35: 70%) were favoured. CONCLUSION: Musculoskeletal physiotherapy clinicians in this survey recognised a clear clinical syndrome of NC, based on the findings of posture-dependent symptoms. Most therapists reported the routine use of flexion-based exercise, reflecting recommendations in the literature which are based on theoretical benefits, but for which trial evidence is lacking. There is a need for research evidence to guide the choice of physiotherapy treatments.

An analysis of noninstrumented posterolateral lumbar fusions performed in predominantly geriatric patients using lamina autograft and beta tricalcium phosphate.

BACKGROUND CONTEXT: The artificial bone-volume expander, beta tricalcium phosphate (B-TCP, Vitoss, OrthoVita, Malvern, PA), is increasingly used to supplement autograft in posterolateral lumbar fusions. PURPOSE: To determine fusion rates/outcomes using B-TCP/autograft. STUDY DESIGN/SETTING: Fusion rates and outcomes were assessed for 60 predominantly geriatric patients undergoing multilevel lumbar laminectomies and 1- to 2-level noninstrumented fusions using B-TCP/autograft. PATIENT SAMPLE: Patients on average were 70 years old. OUTCOME MEASURES: Odom's criteria and Short-Form 36 (SF-36) outcomes were studied 2 years postoperatively. METHODS: Sixty patients underwent an average of 5.4-level laminectomies with 1- to 2-level noninstrumented fusions. Based on dynamic X-ray/magnetic resonance/computed tomography (CT) studies, laminectomies addressed multilevel stenosis (60 patients), ossification of the yellow ligament (46 patients), disc herniations (20 patients), or synovial cysts (8 patients), and fusions addressed degenerative spondylolisthesis (48 patients), spondylolisthesis/lysis (2 patients), or degenerative scoliosis (10 patients). The fusion mass on each side contained half of all harvested autograft combined with one to 1.5 strips of B-TCP (saturated in 10cc of bone marrow aspirate/strip). Fusion rates were documented by two independent neuroradiologists using both dynamic X-rays, and thin-cut CT (2-dimensional/3-dimensional CT) studies obtained up to 2 years postoperatively. Odom's criteria and SF-36 outcomes were assessed over the same interval. RESULTS: Pseudarthrosis was documented in nine (15%) patients. Two years postoperatively, Odom's criteria revealed 28 excellent, 23 good, 5 fair, and 4 poor results, whereas SF-36 data revealed improvement on 6 of 8 Health Scales in all patients. CONCLUSIONS: A 15% pseudarthrosis rate followed multilevel laminectomy and 1- to 2-level noninstrumented posterolateral fusion using lamina autograft/B-TCP.

Descriptive epidemiology and prior healthcare utilization of patients in the Spine Patient Outcomes Research Trial's (SPORT) three observational cohorts: disc herniation, spinal stenosis, and degenerative spondylolisthesis.

STUDY DESIGN: Prospective observational cohorts. OBJECTIVE: To describe sociodemographic and clinical features, and nonoperative (medical) resource utilization before enrollment, in patients who are candidates for surgical intervention for intervertebral disc herniation (IDH), spinal stenosis (SpS), and degenerative spondylolisthesis (DS) according to SPORT criteria. SUMMARY OF BACKGROUND DATA: Intervertebral disc herniation, spinal stenosis, and degenerative spondylolisthesis with stenosis are the three most common diagnoses of low back and leg symptoms for which surgery is performed. There is a paucity of descriptive literature examining large patient cohorts for the relationships among baseline characteristics and medical resource utilization with these three diagnoses. METHODS: The Spine Patient Outcomes Research Trial (SPORT) conducts three randomized and three observational cohort studies of surgical and nonsurgical treatments for patients with IDH, SpS, and DS. Baseline data include demographic information, prior treatments received, and functional status measured by SF-36 and the Oswestry Disability Index (ODI-AAOS/Modems version). The data presented represent all 1,411 patients (743 IDH, 365 SpS, 303 DS) enrolled in the SPORT observational cohorts. Multiple logistic regression was used to generate independent predictors of utilization adjusted for sociodemographic variables, diagnosis, and duration of symptoms. RESULTS: The average age was 41 years for the IDH group, 64 years for the SpS group, and 66 years for the DS group. At enrollment, IDH patients presented with the most pain as reported on the SF-36 (BP 26.3 vs. 33.2 SpS and 33.8 DS) and were the most impaired (ODI 51 vs. 42.3 SpS and 41.5 DS). IDH patients used more chiropractic treatment (42% vs. 33% SpS and 26% DS), had more Emergency Department (ED) visits (21% vs. 7% SpS and 4% DS), and used more opiate analgesics (49% vs. 29% SpS and 27% DS). After adjusting for age, gender, diagnosis, education, race, duration of symptoms, and compensation, Medicaid patients used significantly more opiate analgesics (58% Medicaid vs. 41% no insurance, 42% employer, 33% Medicare, and 32% private) and had more ED visits compared with other insurance types (31% Medicaid vs. 22% no insurance, 16% employer, 3% Medicare, and 11% private). CONCLUSION: IDH patients appear to have differences in sociodemographics, resource utilization, and functional impairment when compared with the SpS/DS patients. In addition, the differences in resource utilization for Medicaid patients may reflect differences in access to care. The data provided from these observational cohorts will serve as an important comparison to the SPORT randomized cohorts in the future.