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2013년 10월 3일 목요일

Who should have surgery for spinal stenosis?: Treatment effect predictors in SPORT

Brief review

*Title: Who should have surgery for spinal stenosis?: Treatment effect predictors in SPORT.
누가 척추 협착증을 위한 수술을 받아야 하는가?
: SPORT(Spine Patient Outcome Research Trial)에서의 치료효과의 예측변수

*Author: Adam Pearson, Jon Lurie, Tor Tosteson, Wenyan Zhao, William Abdu, James N. Weinstein

STUDY DESIGN: Combined prospective randomized controlled trial and observational cohort study of spinal stenosis (SpS) with an as-treated analysis.

OBJECTIVE: To determine modifiers of the treatment effect (TE) of surgery (the difference between surgical and nonoperative outcomes) for SpS using subgroup analysis.

SUMMARY OF BACKGROUND DATA: The Spine Patient Outcomes Research Trial demonstrated a positive surgical TE for SpS at the group level. However, individual characteristics may affect TE. No previous studies have evaluated TE modifiers in SpS.

Study design: Spinal stenosis patients were treated with either surgery (n = 419) or nonoperative care (n = 235) and were analyzed according to treatment received.

Patient Population
-Inclusion criteria: had neurogenic claudication or radicular pain for at least 12 weeks, a confirmatory cross-sectional imaging study demonstrating stenosis at 1 or more levels.
-Exclusion criteria: cauda equina syndrome, malignancy, significant deformity, previous back surgery, instability on flexion-extension radiographs, and other established contraindications to elective surgery.

Statistical Considerations: The TE of surgery was defined as:
TE (Treatment Effect)= change in ODI (surgery) – change in ODI (nonoperative)

-All analyzed subgroups improved significantly more with surgery than with nonoperative treatment 
(P < 0.05).

-Details of the below were associated with greater TE.
baseline ODI ≤ 56 (TE -15.0 vs. -4.4, ODI > 56, P < 0.001),
not smoking (TE -11.7 vs. -1.6 smokers, P < 0.001),
neuroforaminal stenosis (TE -14.2 vs. -8.7 no neuroforaminal stenosis, P = 0.002),
predominant leg pain (TE -11.5 vs. -7.3 predominant back pain, P = 0.035),
not lifting at work (TE -12.5 vs. -0.5 lifting at work, P = 0.017),
the presence of a neurological deficit (TE -13.3 vs. -7.2 no neurological deficit, P < 0.001).

-Patients improved more with surgery than with nonoperative treatment, regardless of other specific characteristics.
-However, TE varied significantly across certain subgroups, and these data can be used to individualize shared decision making discussions about likely outcomes.

Key Points
Other than smokers, all patient subgroups improved more with surgery than with nonoperative treatment.

Baseline ODI score less than 56, not smoking, neuroforaminal stenosis, predominant leg pain, not lifting at work, and baseline neurological deficit predicted a greater TE of surgery.

Smoking cessation should be considered before surgery for SpS.

These data can be used to help to individualize shared decision-making discussions about likely outcomes after surgical or nonoperative treatment for SpS.