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On Surgery for Lumbar Spinal Stenosis
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
2015 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The incidence of lumbar spinal stenosis (LSS) is steadily rising, mostly because of a noticeably older age structure. In Sweden, LSS surgery has increased continuously over the years and is presently the most common argument to undergo spine surgery. The purpose of the surgery is to decompress the neural elements in the stenotic spinal canal. To avoid instability, there has been a tradition to do the decompression with a complementary fusion, especially if degenerative spondylolisthesis is present preoperatively.

The overall aims of this thesis were to evaluate which method of surgery that generally can be considered to give sufficiently good clinical results with least cost to society and risk of complications and to determine whether there is a difference in outcome between smokers and non-smokers.

The Swespine Register was used to collect data on clinical outcome after LSS surgery. In two of the studies, large cohorts were observed prospectively with follow-up after 2 years. Data were analysed in a multivariate model and logistic regression. In a randomised controlled trial (RCT, the Swedish Spinal Stenosis Study), 233 patients were randomised to either decompression with fusion or decompression alone and then followed for 2 years. The consequence of preoperative degenerative spondylolisthesis on the results was analysed and a health economic evaluation performed. The three-dimensional CT technique was used in a radiologic biomechanical pilot study to evaluate the stabilising role of the segmental midline structures in LSS with preoperative degenerative spondylolisthesis by comparing laminectomy with bilateral laminotomies.

Smokers, in comparison with non-smokers, showed less improvement after surgery for LSS. Decompression with fusion did not lead to better results compared with decompression alone, no matter if degenerative spondylolisthesis was present preoperatively or not; nor was decompression with fusion found to be more cost-effective than decomression alone. The instability caused by a decompression proved to be minimal and removal of the midline structures by laminectomy did not result in increased instability compared with the preservation of these structures by bilateral laminotomies.

In LSS surgery, decompression without fusion should generally be the treatment of choice, regardless of whether preoperative degenerative spondylolisthesis is present or not. Special efforts should be targeted towards smoking cessation prior to surgery.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2015. , 66 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1135
Keyword [en]
spinal stenosis, decompression, fusion, degenerative spondylolisthesis
National Category
Orthopedics
Research subject
Orthopaedics; Neurosurgery
Identifiers
URN: urn:nbn:se:uu:diva-262525ISBN: 978-91-554-9340-0 (print)OAI: oai:DiVA.org:uu-262525DiVA: diva2:854229
Public defence
2015-11-06, Eva Netzeliussalen, Blåsenhus, von Kraemers Allé 1A, Uppsala, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2015-10-15 Created: 2015-09-16 Last updated: 2015-10-27
List of papers
1. Smokers Show Less Improvement Than Nonsmokers Two Years after Surgery for Lumbar Spinal Stenosis: A study of 4555 Patients from the Swedish Spine Register
Open this publication in new window or tab >>Smokers Show Less Improvement Than Nonsmokers Two Years after Surgery for Lumbar Spinal Stenosis: A study of 4555 Patients from the Swedish Spine Register
2011 (English)In: Spine, ISSN 0362-2436, E-ISSN 1528-1159, Vol. 36, no 13, 1059-1064 p.Article in journal (Refereed) Published
Abstract [en]

Study Design. A cohort study based on the Swedish Spine Register.

Objective. To determine the relation between smoking status and disability after surgical treatment for lumbar spinal stenosis.

Summary of Background Data. Smoking and nicotine have been shown to inhibit lumbar spinal fusion and promote disc degeneration. No association, however, has previously been found between smoking and outcome after surgery for lumbar spinal stenosis. A large prospective study is therefore needed.

Methods. All patients with a completed 2-year follow-up in the Swedish Spine Register operated for central lumbar stenosis before October 1, 2006 were included. Logistic regression was used to assess the association between smoking status and outcomes.

Results. Of 4555 patients enrolled, 758 (17%) were current smokers at the time of surgery. Smokers had an inferior health-related Quality of Life at baseline. Nevertheless, adjusted for differences in baseline characteristics, the odds ratio (OR) for a smoker to end up dissatisfied at the 2-year follow-up after surgery was 1.79 [95% confidence interval (CI) 1.51-2.12]. Smokers had more regular use of analgesics (OR 1.86; 95% CI 1.55-2.23). Walking ability was less likely to be significantly improved in smokers with an OR of 0.65 (95% CI 0.51-0.82). Smokers had inferior Quality of Life also after taking differences before surgery into account, either when measured with the Oswestry Disability Index (ODI; P < 0.001), EuroQol (P < 0.001) or Short Form (36) Health Survey (SF-36) BP and SF-36 PF (P < 0.001). The differences in results between smokers and nonsmokers were evident, irrespective of whether the decompression was done with or without spinal fusion.

Conclusion. Smoking is an important predictor for 2-year results after surgery for lumbar spinal stenosis. Smokers had less improvement after surgery than nonsmokers.

Keyword
smoking, spinal stenosis, surgical results
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-146290 (URN)10.1097/BRS.0b013e3181e92b36 (DOI)000290750200011 ()21224770 (PubMedID)
Available from: 2011-02-16 Created: 2011-02-16 Last updated: 2017-12-11Bibliographically approved
2. Does fusion improve the outcome after decompressive surgery for lumbar spinal stenosis?: a two-year follow-up study involving 5390 patients
Open this publication in new window or tab >>Does fusion improve the outcome after decompressive surgery for lumbar spinal stenosis?: a two-year follow-up study involving 5390 patients
2013 (English)In: The Bone & Joint Journal, ISSN 2049-4408, Vol. 95-B, no 7, 960-965 p.Article in journal (Refereed) Published
Abstract [en]

Whether to combine spinal decompression with fusion in patients with symptomatic lumbar spinal stenosis remains controversial. We performed a cohort study to determine the effect of the addition of fusion in terms of patient satisfaction after decompressive spinal surgery in patients with and without a degenerative spondylolisthesis.                  

The National Swedish Register for Spine Surgery (Swespine) was used for the study. Data were obtained for all patients in the register who underwent surgery for stenosis on one or two adjacent lumbar levels. A total of 5390 patients fulfilled the inclusion criteria and completed a two-year follow-up. Using multivariable models the results of 4259 patients who underwent decompression alone were compared with those of 1131 who underwent decompression and fusion. The consequence of having an associated spondylolisthesis in the operated segments pre-operatively was also considered.                

At two years there was no significant difference in patient satisfaction between the two treatment groups for any of the outcome measures, regardless of the presence of a pre-operative spondylolisthesis. Moreover, the proportion of patients who required subsequent further lumbar surgery was also similar in the two groups.                  

In this large cohort the addition of fusion to decompression was not associated with an improved outcome.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-210450 (URN)10.1302/0301-620X.95B7.30776 (DOI)23814250 (PubMedID)
Available from: 2013-11-08 Created: 2013-11-08 Last updated: 2016-11-22
3. Efficacy of fusion surgery for lumbar spinal stenosis- Clinical and economic results from a 2-year multicenter randomised controlled trial in sweden.
Open this publication in new window or tab >>Efficacy of fusion surgery for lumbar spinal stenosis- Clinical and economic results from a 2-year multicenter randomised controlled trial in sweden.
2015 (English)In: New England Journal of Medicine, ISSN 0028-4793, E-ISSN 1533-4406Article in journal (Other academic) Submitted
National Category
Orthopedics
Identifiers
urn:nbn:se:uu:diva-262518 (URN)
Available from: 2015-09-16 Created: 2015-09-16 Last updated: 2017-12-04
4. 3D motion analysis using provocation computed tomography in lumbar spinal stenosis with degenerative spondylolisthesis before and after decompressive surgery: A randomised comparative pilot study of laminectomy versus bilateral laminotomy
Open this publication in new window or tab >>3D motion analysis using provocation computed tomography in lumbar spinal stenosis with degenerative spondylolisthesis before and after decompressive surgery: A randomised comparative pilot study of laminectomy versus bilateral laminotomy
(English)Manuscript (preprint) (Other academic)
National Category
Orthopedics
Identifiers
urn:nbn:se:uu:diva-262522 (URN)
Available from: 2015-09-16 Created: 2015-09-16 Last updated: 2015-10-27

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