Predominant leg pain is associated with better surgical outcomes in degenerative spondylolisthesis and spinal stenosis: results from the Spine Patient Outcomes Research Trial (SPORT).

STUDY DESIGN: As-treated analysis of the Spine Patient Outcomes Research Trial. OBJECTIVE: To compare baseline characteristics and surgical and nonoperative outcomes in degenerative spondylolisthesis (DS) and spinal stenosis (SpS) patients stratified by predominant pain location (i.e., leg vs. back). SUMMARY OF BACKGROUND DATA: Evidence suggests that DS and SpS patients with predominant leg pain may have better surgical outcomes than patients with predominant low back pain (LBP). METHODS: The DS cohort included 591 patients (62% underwent surgery), and the SpS cohort included 615 patients (62% underwent surgery). Patients were classified as leg pain predominant, LBP predominant, or having equal pain according to baseline pain scores. Baseline characteristics were compared between the 3 predominant pain location groups within each diagnostic category, and changes in surgical and nonoperative outcome scores were compared for 2 years. Longitudinal regression models including baseline covariates were used to control for confounders. RESULTS: Among DS patients at baseline, 34% had predominant leg pain, 26% had predominant LBP, and 40% had equal pain. Similarly, 32% of SpS patients had predominant leg pain, 26% had predominant LBP, and 42% had equal pain. DS and SpS patients with predominant leg pain had baseline scores indicative of less severe symptoms. Leg pain predominant DS and SpS patients treated surgically improved significantly more than LBP predominant patients on all primary outcome measures at 1 and 2 years. Surgical outcomes for the equal pain groups were intermediate to those of the predominant leg pain and LBP groups. The differences in nonoperative outcomes were less consistent. Conclusion. Predominant leg pain patients improved significantly more with surgery than predominant LBP patients. However, predominant LBP patients still improved significantly more with surgery than with nonoperative treatment.

Spine patient outcomes research trial: radiographic predictors of clinical outcomes after operative or nonoperative treatment of degenerative spondylolisthesis.

STUDY DESIGN: Subgroup analyses according to treatment received. OBJECTIVE: To evaluate whether baseline radiographic findings predicted outcomes in patients with degenerative spondylolisthesis. SUMMARY OF BACKGROUND DATA: The spine patient outcomes research trial combined randomized and observational DS cohorts. METHODS: The Meyerding listhesis grade was determined on the neutral radiograph (n = 222). Patients were classified as having low disc height if disc height was less than 5 mm. Flexion-extension radiographs (n = 185) were evaluated for mobility. Those with greater than 10 degrees rotation or 4 mm translation were considered hypermobile. Changes in outcome measures were compared between listhesis (grade 1 vs. grade 2), disc height (low vs. normal), and mobility (stable vs. hypermobile) groups using longitudinal regression models adjusted for potential confounders. Outcome measures included SF-36 bodily pain and physical function scales, oswestry disability index (ODI), stenosis bothersomeness index, and low back pain bothersomeness scale. RESULTS: Overall, 86% had a grade 1 listhesis, 78% had normal disc height, and 73% were stable. Baseline symptom severity was similar between groups. Overall, surgery patients improved more than patients treated nonoperatively. At 1 year, outcomes were similar in surgery patients across listhesis, disc height, and mobility groups (ODI: grade 1 -23.7 vs. grade 2 -23.3, P = 0.90; normal disc height -23.5 vs. low disc height -21.9, P = 0.66; stable -21.6 vs. hypermobile -25.2, P = 0.30). Among those treated nonoperatively, grade 1 patients improved more than grade 2 patients (bodily pain + 13.1 vs. -4.9, P = 0.019; ODI -8.0 vs. + 4.8, P = 0.010 at 1 year), and hypermobile patients improved more than stable patients (ODI -15.2 vs. -6.6, P = 0.041; stenosis bothersomeness index -7.8 vs. -2.7, P = 0.002 at 1 year). DISCUSSION: Regardless of listhesis grade, disc height or mobility, patients who had surgery improved more than those treated nonoperatively. These differences were due, in part, to differences in nonoperative outcomes, which were better in patients classified as grade 1 or hypermobile.

SPORT lumbar intervertebral disk herniation and back pain: does treatment, location, or morphology matter?

STUDY DESIGN: Diskectomy candidates with at least 6 weeks of sciatica and confirmatory imaging were enrolled in a randomized or observational cohort. OBJECTIVE: This study sought to determine: (1) whether diskectomy resulted in greater improvement in back pain than nonoperative treatment, and (2) whether herniation location and morphology affected back pain outcomes. SUMMARY OF BACKGROUND DATA: Previous studies have reported that lumbar diskectomy is less successful for relief of back pain than leg pain and patients with central disc herniations or protrusions have worse outcomes. METHODS: Patients underwent diskectomy or received "usual" nonoperative care. Data from the randomized cohort and observational cohort were combined in an as-treated analysis. Low back pain was recorded on a 0 to 6 point scale, and changes in low back pain were compared between the surgical and nonoperative treatment groups. The effects of herniation location and morphology on back pain outcomes were determined. RESULTS: The combined analysis included 1191 patients with 775 undergoing surgery within 2 years, whereas 416 remained nonoperative. Overall, leg pain improved more than back pain in both treatment groups. Back pain improved in both surgical and nonoperative patients, but surgical patients improved significantly more (treatment effect favoring surgery -0.9 at 3 months, -0.5 at 2 years, P < 0.001). Patients who underwent surgery were more likely to report no back pain than nonoperative patients at each follow-up period (28.0% vs. 12.0% at 3 months, P < 0.001, 25.5% vs. 17.6% at 2 years, P = 0.009). At baseline, central herniations were associated with more severe back pain than more lateral herniations (4.3 vs. 3.9, P = 0.012). Patients with central herniations and protrusionshad a beneficial treatment effect from surgery similar to the overall surgical group. CONCLUSION: Diskectomy resulted in greater improvement in back pain than nonoperative treatment, and this difference was maintained at 2 years for all herniation locations and morphologies.

Physician-patient communication: a lost art?

In the face of rapid advances in technology, there has been a progressive deterioration of effective physician-patient communication. The American Academy of Orthopaedic Surgeons has identified that patients rate the orthopaedic profession as high in technical and low in communication skills. Poor communication, especially patient-interviewing skills, has been identified in medical students as well as in practicing physicians. Effective communication is associated with improved patient and physician satisfaction, better patient compliance, improved health outcomes, better-informed medical decisions, and reduced malpractice suits, and it likely contributes to reduced costs of care. Recognition of the importance of communication has influenced medical schools to revise curricula and to teach communication skills in residency training and continuing medical education programs. National certifying examinations also are being designed to incorporate these skills. Although written material is useful in increasing awareness of the importance of good physician-patient communication, behavioral change is more likely to occur in a workshop environment. The American Academy of Orthopaedic Surgeons is taking leadership in designing and implementing such an approach for its membership.