Journal List > J Korean Soc Spine Surg > v.25(Suppl 1) > 1120067

Ahn, Im, and Park: Factors Associated with Conversion from Conservative to Surgical Treatment in Single-Level Lumbar Spinal Stenosis Patients

Abstract

Study Design

Retrospective study of prospectively-collected data.

Objectives

To determine the factors associated with conversion from conservative to surgical treatment in single-level lumbar spinal stenosis patients.

Summary of Literature Review

Various reports have presented clinical outcomes after the surgical and nonsurgical treatment of spinal stenosis. However, few reports have investigated factors predicting conversion to surgery during the course of conservative treatment.

Materials and Methods

We analyzed 40 patients who visited our hospital from May 2010 to May 2015 and were traceable for at least 3 years after being advised to undergo surgery following 3 months of conservative treatment. Of these patients, 20 underwent surgery and 20 did not. We then investigated the factors associated with conversion to surgical treatment. Clinical assessments were conducted using a questionnaire, and the overall area of the spinal canal and the muscle area within the spinal canal were measured using magnetic resonance imaging.

Results

The average area of the spinal canal was 81.40±53.61 mm2 in the surgical group, compared to 127.75±82.55 mm2 in the nonsurgical group (p=0.042). The muscle area in the spinal canal was 5.17±1.30 cm2 in the surgical group, whereas it was 6.40±1.56 cm2 in the nonsurgical group (p=0.010). The patients in the surgical group were more likely to have experienced repetitive strain and to have frequently visited health clubs (p=0.047, p=0.037, respectively). However, regular stretching was more common in the nonsurgical group (p=0.028).

Conclusions

The factors associated with conversion to surgical treatment were a narrow spinal canal, a small muscle area within the spinal canal, visiting health clubs, repetitive sprain, and not stretching. A small muscle area within the spinal canal can be considered as a key factor related to surgical conversion.

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Fig. 1.
We measured the spinal canal dimensions using the free-line region of interest calculator of the Infinitt picture archiving and communication system for axial magnetic resonance images. These dimensions are represented as an inverted triangle on the image.
jkss-25-160f1.tif
Fig. 2.
The individual paraspinal muscles were outlined using the free-line region of interest calculator of the picture archiving and communication system. m1, m2: psoas major; m3, m4: quadrates lumborum; m5, m6: multifidus; m7, m8: erector spinae.
jkss-25-160f2.tif
Fig. 3.
Flow of the patients through each stage of the study.
jkss-25-160f3.tif
Table 1.
Base line characteristics, compared between the patients with single level lumbar spinal stenosis who received surgical or nonoperative treatment
Base line factors Surgical (n=20) Nonsurgical (n=20) p-value
Age (years), mean (SD) 60.75±9.90 60.80±8.38 0.986
Gender (Male) 16 17 0.677
BMI (kg/m2), mean (SD) 25.3±2.7 24.8±3.4 0.680
Educational background (At least a college graduate) 8 4 0.168
Work related features (Employed) 10 10 1.000
Residence type (Alone) 2 3 0.633
Comorbid illnesses      
  Hypertension 8 12 0.206
  DM 6 9 0.327
  Hypothyroid 3 0 0.072
  BPH 4 1 0.151
  Hyperlipidemia 6 5 0.723
  Stroke 1 0 0.311
  Arrythemia 1 1 1.000
  RA ds 1 0 0.311
Onset of symptoms (months) 43.5±45.7 50.3±52.1 0.663
Duration of illness (months), (After op recommended)     0.000
  <12 19 0  
  12-36 1 0  
  ≥36 0 20  
Nerve block (<5) 16 11 0.091
Conservative treatment      
  PT 8 10 0.525
  PO medication 19 17 0.292
  TPI 2 1 0.548
  ESWT 0 0  
  ESWT Manual therapy 02 05 0.212
Table 2.
Base line characteristics, compared between the patients with single level lumbar spinal stenosis who received surgical or nonoperative treatment
Base line factors Surgical (n = 20) Nonsurgical (n = 20) p-value
Activity      
  Walking 11 10 0.752
  Running 1 2 0.548
  Bicycle 2 6 0.114
  Golf 4 4 1.000
  Tennis 2 0 0.147
  Badminton 1 0 0.311
  Hiking 4 5 0.705
  Fitness 6 1 0.037
  Back Stretching 2 8 0.028
Alcohol use 5 5 1.000
Cigarette use (current or quit in past 6 mo onths) 7 5 0.490
Trauma history 10 4 0.047
Traffic / Industrial accident 0 0  
Spinal stenosis Family history 6 2 0.114
Level affected on MRI      
  L3-L4 2 1 0.548
  L4-L5 15 18 0.212
  L5-S1 3 1 0.292
Spinal canal dimension (mm2), mean (SD) )81.40±53.61 127.75±82.55 0.042
  <73.1 14 4  
  <73.173.1-172.5 145 412  
  ≥172.5 1 4  
Back muscle (cm2), mean (SD) 5.17±1.30 6.40±1.56 0.010
Degenerative spondylolisthesis (<5 mm) 15 14 0.723
Scoliosis (<15°) 20 19 0.311
Instability 2 0 0.147
Table 3.
Simple and multiple linear regression analysis of associated factors of surgical treatment
Base line factors Simple Multiple
Coefficient±SE p-value Coefficient±SE p-value
Fitness (yes/no) 0.329±0.202 0.038 0.221±0.200 0.155
Back Stretching (yes/no) −0.346±0.176 0.029 −0.159±0.206 0.379
Trauma history (yes/no) 0.314±0.161 0.048 0.198±0.185 0.272
Spinal canal dimension (mm2) −0.020±0.001 0.088 −0.020±0.002 0.099
Back muscle (cm2) −0.402±0.000 0.010 −0.349±0.000 0.028

Multiple model fit: R=0.575; R2 =0.331; adjusted R2 =0.232.

SE: Standard Error

Yes=1 or no=0.

Table 4.
Changes of VAS over time in surgical group and nonoperative group
  VAS score p-value
  OP group Non-OP group
Initial 5.45±2.21 6.40±1.79 0.144
OP recommend 8.55±1.50 7.20±1.44 0.006
After 3 years 2.70±2.58 3.95±2.16 0.105

VAS: Visual Analog Scale.

Table 5.
Changes of K-ODI over time in surgical group and nonoperative group
  K-ODI score p-value
  OP group Non-OP group
OP recommend 23.35±10.03 19.10±8.90 0.165
After 3years 4.70±7.91 9.50±7.10 0.050

K-ODI: Korean oswestry disability index.

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