A. Soroka1, A. Lubetzky Vilnai2, O. Murphy3, J. Leitner4, s. shabat5, E. Ashkenazi6, Y. Floman6, m. Moffat2, y. Masharawi1
1Tel Aviv University, Spinal Research Laboratory, Department of Physical Therapy, The Stanley Steyer School of Health Professions, Sackler Faculty of Medicine, Tel Aviv, Israel, 2New York University, Department of Physical Therapy, Steinhardt School of Culture Education and Human Development, New York, United States, 3McMaster University, Department of Mathematics and Statistics, New York, United States, 4Israel Meir Medical Center, Spine Unit, Kfar Saba, Israel, 5Meir Medical Center, Spine Unit, Kfar Saba, Israel, 6Assuta Hospital, Israel Spine Center, Tel Aviv, Israel

Background: Patients with chronic low back pain accompanied by severe degenerative changes and neurological symptoms are often given the recommendation by spine surgeons to undergo lumbar surgery to ease the compression on the nerves with or without fusion of the involved segments. Some patients follow the surgeon’s advice whereas others choose to avoid surgery. Studies regarding post-surgical outcomes report varying success rates. Clinical characteristics associated with a favorable outcome are lacking. The question remains what drives certain patients to choose surgery and how to determine whether an individual patient made the appropriate choice for them.

Purpose: To compare patients, who made the decision to undergo lumbar surgery, to those who chose to avoid surgery in terms of physical function and disability.

Methods: 108 patients aged 40–80 years were included in this prospective study.  All patients were recommended for lumbar surgery by their physicians. Seventy-seven of them underwent surgery ('surgical' group) whereas 31 of them chose to avoid surgery (“wait and see” group). The following functional and self-reported measurements were collected by a physical therapist at the day of the surgeon’s assessment: Oswestry Disability Index (ODI) , Ronald Morris Disability Questionnaire, Bournemouth Questionnaire, Fear‐Avoidance Belief Questionnaire (FABQ), International Physical Activity Questionnaire (IPAQ), Numeric Rating Scale (NRS), 30 second sit to stand, straight leg raise (SLR), Time Up and Go (TUG), Four Square Step Test (FSST), grip strength, chair sit and reach, long distance corridor walk (LDCW distance covered in 2 minutes), and the heel raise test on the weaker leg. Short-term changes on the ODI were evaluated 3 months post-surgery in the surgery group or 3 months post the initial assessment in the "wait and see" group.  

Results: At baseline, the "wait and see" group demonstrated better ODI scores (p=0.008), FABQ work subscale score (α=0.006), IPAQ score (weekly walking time), 30-second sit to stand, FSST, and long distance corridor walk for 2 minutes (p=0.001). All other measures were comparable between groups. Following 3 months, a significant main effect of time was observed (p<0.001) for ODI score post-surgery or “wait and see” with no main effect of group (p=0.96) . In addition, a significant time by group interaction was observed (p<0.045) such that even though both groups ended up with a similar ODI score, the surgery group started higher and showed greater improvement over time.

Conclusion(s): Some simple physical tests, not commonly done in surgeons’ office settings, could help in the decision-making process pre-lumbar spine surgery. Patients who chose not to do surgery appeared to perform better on physical tests even though the score of these tests was not part of the decision making.

Implications: Currently, the decision about surgery is made according to patients’ complaint and the presence of radiological findings that could explain the complaint.  Our findings suggest that an interdisciplinary evaluation including a functional assessment conducted by a physical therapist may improve long-term outcomes. This should be investigated in future studies.

Funding, acknowledgements: The work was not funded.

Keywords: functional outcomes, lumbar surgery, ODI

Topic: Musculoskeletal: spine

Did this work require ethics approval? Yes
Institution: Assuta medical center, Meir Medical Center
Committee: IRB-Helsinki Committee
Ethics number: #MMC-0006-15 and #0020-16-ASMC

All authors, affiliations and abstracts have been published as submitted.

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