EUROSPINE 2017 FULL PAPER AWARD: Time to remove our rose-tinted spectacles: a candid appraisal of the relative success of surgery in over 4500 patients with degenerative disorders of the lumbar spine, hip or knee

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Journal Article
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European Spine Journal, 2018, 27 (4), pp. 778 - 788
Issue Date:
2018-04-01
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© 2018, Springer-Verlag GmbH Germany, part of Springer Nature. Purpose: Studies comparing the outcome of spine surgery with that of large-joint replacement report equivocal findings. The patient-reported outcome measures (PROMs) used in such studies are typically generic and may not be sufficiently sensitive to the successes/failures of treatment. This study compared different indices of “success” in patients undergoing surgery for degenerative disorders of the lumbar spine, hip, or knee, using a validated, multidimensional, and joint-specific PROM. Methods: Preoperatively and 12 months postoperatively, 4594 patients (3937 lumbar spine, 368 hip, 269 knee) undergoing first-time surgery completed a PROM that included the Core Outcome Measures Index (COMI) for the affected joint. The latter comprises a set of single items on pain, function, symptom-specific well-being, quality of life, and disability—all in relation to the specified joint problem. Other single-item ratings of treatment success were made 12 months postoperatively. Results: In multiple regression analyses, controlling for confounders, the mean improvement in COMI at 12 months was greatest for the hip patients and lowest for those with degenerative spinal deformity (= the statistical reference group) (p < 0.05). Compared with spinal deformity, the odds of achieving “success” were: higher for hip (OR 4.6; 95% CI 2.5–8.5) and knee (OR 4.0; 95% CI 2.1–7.7) (no difference between spine subgroups) for “satisfaction with care”; higher for hip (OR 16.9; 95% CI 7.3–39.6), knee (OR 6.3; 95% CI 3.4–11.6), degenerative spondylolisthesis (OR 1.6; 95% CI 1.2–2.2), and herniated disc (OR 1.7; 95% CI 1.2–2.4) for “global treatment outcome”; and higher for hip (OR 13.8; 95% CI 8.8–21.6), knee (OR 5.3; 95% CI 3.6–7.8), degenerative spondylolisthesis (OR 1.6; 95% CI 1.3–2.1), and herniated disc (1.5; 95% CI 1.1–2.0) for “patient-acceptable symptom state”. Patient-rated complications were the greatest in degenerative spinal deformity (29%) and the lowest in hip (18%). Conclusions: The current study is the largest of its kind and the first to use a common, but joint-specific instrument to report patient-reported outcomes after surgery for degenerative disorders of the spine, hip, or knee. The findings provide a sobering account of the significantly poorer outcomes after spine surgery compared with large-joint replacement. Further work is required to hone the indications and patient selection criteria for spine surgery. The data should be used to lobby research funding-bodies, governmental agencies, industry, and charitable foundations to invest more in spine research/registries, in the hope of ultimately improving spine outcomes. Graphical abstract: These slides can be retrieved under Electronic Supplementary Material.[Figure not available: see fulltext.].
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