Recovery pattern after decompression of central lumbar spinal stenosis: a prospective observational cohort study.

BACKGROUND: Detailed preoperative information is associated with superior outcomes. We aimed to describe the recovery pattern after decompression of central lumbar spinal stenosis (CLSS). METHODS: 50 patients aged 51-85 years who underwent decompression without fusion due to CLSS were followed from before to after surgery (post-op day 1, 7, and 14). Back and leg pain were evaluated using the Numeric Rating Scale (NRS; 0 = no pain 0, 10 = worst pain) and quality of life using the EuroQol-5D index (0 = death, 1 = best), and EQ-5D-visual analogue scale (VAS; 0 = worst, 100 = best). RESULTS: NRS leg pain was reduced from preoperative to first postoperative day by 5.2 (6.1, 4.3) (mean (95%CI)], and NRS back pain from postoperative day 1-7 by 0.6 (1.2, 0.03) and from day 7 to 14 by 0.7 (1.3, 0.2)]. In contrast, EQ-5D index increased from preoperative to first postoperative day by 0.09 (0.06, 0.13) and from day 1 to 7 by 0.05 (0.02,0.08), and EQ-5D VAS from preoperative to first postoperative day by 13.7 (9.1, 18.3) and from day 1 to 7 by 6.0 (2.0, 10.0). After two weeks, 51% of the patients had improved above the minimal clinically important difference (MCID) in back pain and 71% in leg pain. CONCLUSIONS: Patients scheduled for decompression due to CLSS should be informed that improvement in leg pain and quality of life in general can be expected within one day of surgery, that quality of life improves a little further in the first postoperative week, and that back pain improves in the first 2 postoperative weeks. In most patients, decompression without fusion due to CLSS seems to achieve clinically relevant improvement within 2 weeks.

A comparison study on patient-reported outcome between obese and non-obese patients with central lumbar spinal stenosis undergoing surgical decompression: 14,984 patients in the National Swedish Quality Registry for Spine Surgery.

BACKGROUND AND PURPOSE: Obesity has been associated with inferior outcomes after laminectomy due to central lumbar spinal stenosis (CLSS); we evaluated whether this occurs in surgery on national bases. PATIENTS AND METHODS: We retrieved pre- and 1-year postoperative data from the National Swedish Quality Registry for Spine Surgery regarding patients aged ≥ 50 with laminectomy due to CLSS in 2005-2018. 4,069 patients had normal weight, 7,044 were overweight, 3,377 had class I obesity, 577 class II obesity, and 94 class III obesity ("morbid obesity"). Patient-reported outcome included satisfaction after 1 year, leg pain (Numerical Rating Scale [NRS], rating 0-10), disability (Oswestry Disability Index [ODI], rating 0-100). Complications were also retrieved. RESULTS: 1-year postoperatively, 69% of patient of normal weight, 67% who were overweight, and 62% with obesity (classes I-III aggregated) were satisfied (p < 0.001) and 62%, 60%, and 57% in obese groups I-III, respectively (p = 0.7). NRS leg pain improved in normal-weight patients by 3.5 (95% CI 3.4-3.6), overweight by 3.2 (CI 3.1-3.2), and obese by 2.6 (CI 2.5-2.7), and 2.8 (CI 2.7-2.9), 2.5 (CI 2.2-2.7), and 2.6 (CI 2.0-3.2) in obese classes I-III, respectively. ODI improved in normal weight by 19 (CI 19-20), overweight by 17 (CI 17-18), and obese by 14 (CI 13-15), and 16 (CI 15-17), 14 (CI 13-16), 14 (CI 11-18) in obese classes I-III, respectively. 8.1% of normal weight, 7.0% of overweight, and 8.1% of obese patients suffered complications (p = 0.04) and 8.1%, 7.0%, and 17% among obese classes I-III, respectively (p < 0.01). CONCLUSION: Most obese patients are satisfied after laminectomy due to CLSS, even if satisfaction rate is inferior compared with normal-weight patients. The morbidly obese have more complications than patients with lower BMI.

A study comparing outcomes between obese and nonobese patients with lumbar disc herniation undergoing surgery: a study of the Swedish National Quality Registry of 9979 patients.

BACKGROUND: This study aimed to evaluate whether an increasing grade of obesity is associated with inferior outcomes after lumbar disc herniation (LDH) surgery. METHODS: We retrieved data from the Swedish register for spine surgery regarding patients aged 20-64 who underwent LDH surgery from 2006-2016 and had preoperative and one-year postoperative data. A total of 4156 patients were normal weight, 4063 were overweight, 1384 had class I obesity, 317 had class II obesity and 59 had class III obesity ("morbid obesity"). Data included patient satisfaction, improvement in leg pain (assessed using the National Rating Scale; NRS; rating 0-10), disability (assessed using the Oswestry Disability Index; ODI; rating 0-100) and complications. RESULTS: At one year postsurgery, 80% of normal-weight patients, 77% of overweight patients and 74% of obese patients (class I-III evaluated together) were satisfied (p < 0.001) [75%, 71%, 75% in obesity classes I, II, and III, respectively (p = 0.43)]. On average, all groups improved by more than the minimal clinically important difference (MCID) in both NRS leg pain (> 3.5) and ODI (> 20). NRS leg pain improved by 4.8 in normal weight patients (95% CI 4.7-4.9), by 4.5 in overweight patients (4.5-4.6) and by 4.3 in obese patients (4.2-4.4) (p < 0.001) [4.4 (4.3-4.6), 3.8 (3.5-4.1) and 4.6 (3.9-5.3) in obesity classes I, II, and III, respectively (p < 0.001)]. The ODI improved by 30 in normal weight patients (30-31), by 29 in overweight patients (28-29) and by 26 in obese patients (25-27) (p < 0.001) [29 (28-29), 25 (22-27) and 27 (22-32) in obesity classes I, II, and III, respectively (p < 0.01)]. A total of 3.0% of normal-weight patients, 3.9% of overweight patients and 3.9% of obese patients suffered complications (p = 0.047) [3.8%, 4.4%, 3.5% in obesity classes I, II, and III, respectively (p = 0.90)]. CONCLUSIONS: LDH surgery is also generally associated with favourable outcomes and few complications in patients with morbid obesity.

Back pain is also improved by lumbar disc herniation surgery.

Background and purpose - Indication for lumbar disc herniation (LDH) surgery is usually to relieve sciatica. We evaluated whether back pain also decreases after LDH surgery.Patients and methods - In the Swedish register for spinal surgery (SweSpine) we identified 14,097 patients aged 20-64 years, with pre- and postoperative data, who in 2000-2016 had LDH surgery. We calculated 1-year improvement on numeric rating scale (rating 0-10) in back pain (Nback) and leg pain (Nleg) and by negative binomial regression relative risk (RR) for gaining improvement exceeding minimum clinically important difference (MCID).Results - Nleg was preoperatively (mean [SD]) 6.7 (2.5) and Nback was 4.7 (2.9) (p < 0.001). Surgery reduced Nleg by mean 4.5 (95% CI 4.5-4.6) and Nback by 2.2 (CI 2.1-2.2). Mean reduction in Nleg) was 67% and in Nback 47% (p < 0.001). Among patients with preoperative pain ≥ MCID (that is, patients with significant baseline pain and with a theoretical possibility to improve above MCID), the proportion who reached improvement ≥ MCID was 79% in Nleg and 60% in Nback. RR for gaining improvement ≥ MCID in smokers compared with non-smokers was for Nleg 0.9 (CI 0.8-0.9) and -Nback 0.9 (CI 0.8-0.9), and in patients with preoperative duration of back pain 0-3 months compared with > 24 months for Nleg 1.3 (CI 1.2-1.5) and for Nback 1.4 (CI 1.2-1.5).Interpretation - LDH surgery improves leg pain more than back pain; nevertheless, 60% of the patients with significant back pain improved ≥ MCID. Smoking and long duration of pain is associated with inferior recovery in both Nleg and Nback.

Predictors of satisfaction after lumbar disc herniation surgery in elderly.

BACKGROUND: The aim of this study was to evaluate satisfaction and factors associated with satisfaction in elderly undergoing lumbar disc herniation surgery. METHODS: In the national Swedish register for spinal surgery (SweSpine) we identified 2095 patients aged > 65 years (WHO definition of elderly) whom during 2000-2016 had undergone LDH surgery and had pre- and one-year postoperative data (age, gender, preoperative duration and degree of back- and leg pain, quality of life (SF-36) and one-year satisfaction (dissatisfied, uncertain, satisfied). We utilized a logistic regression model to examine preoperative factors that were independently associated with low and high satisfaction and after LDH surgery. RESULTS: One year after surgery, 71% of the patients were satisfied, 18% uncertain and 11% dissatisfied. Patients who were satisfied were in comparison to others, younger, had shorter preoperative duration of leg pain, higher SF-36 mental component summary and more leg than back pain (all p < 0.01). Patients who were dissatisfied were compared to others older, had longer preoperative duration of leg pain and lower SF-36 scores (all p < 0.01). 81% of patients with leg pain up to 3 months were satisfied in comparison with 57% of patients with leg pain > 2 years (p < 0.001). CONCLUSION: Only one out of ten elderly, is dissatisfied with the outcome of LDH surgery. Age, preoperative duration of leg pain, preoperative SF 36 score, and for satisfaction also dominance of back over leg pain, are in elderly factors associated to good and poor subjective outcome after LDH surgery.

Integrative genomics reveals frequent somatic NF1 mutations in sporadic pheochromocytomas.

Pheochromocytomas are neuroendocrine tumors of the adrenal medulla which can occur either sporadically or in the context of hereditary tumor syndromes. Whereas the genetic background of hereditary pheochromocytomas is becoming rather well-defined, very little is known about the more common sporadic form of the disease which constitutes ∼70% of all cases. In this study, we elucidate some of the molecular mechanisms behind sporadic pheochromocytoma by performing a comprehensive analysis of copy number alterations, gene expression, promoter methylation and somatic mutations in the genes RET, VHL, NF1, SDHA, SDHB, SDHC, SDHD, SDHAF2, KIF1Bß, TMEM127 and MAX, which have been associated with hereditary pheochromocytoma or paraganglioma. Our genomic and genetic analyses of 42 sporadic pheochromocytomas reveal that a large proportion (83%) has an altered copy number in at least one of the known susceptibility genes, often in association with an altered messenger RNA (mRNA) expression. Specifically, 11 sporadic tumors (26%) displayed a loss of one allele of the NF1 gene, which significantly correlated with a reduced NF1 mRNA expression. Subsequent sequencing of NF1 mRNA, followed by confirmation in the corresponding genomic DNA (gDNA), revealed somatic truncating mutations in 10 of the 11 tumors with NF1 loss. Our results thus suggest that the NF1 gene constitutes the most frequent (24%) target of somatic mutations so far known in sporadic pheochromocytomas.