Impact of Preoperative Duration of Symptoms on Patient Satisfaction, Outcomes and Complications After Lumbar Discectomy

A Propensity-Matched Comparison

Mikkel Ø Andersen, MD; Andreas Killerich Andresen, MD, PhD; Leah Y. Carreon, MD, MSc; Casper Friis Pedersen, MSoc

Disclosures

Spine. 2023;48(17):1191-1196.

Abstract and Introduction

Abstract

Study Design: Observational study.

Objective: To identify associations between preoperative symptom duration and postoperative patient satisfaction.

Summary of Background Data: Sciatica due to lumbar disk herniation (LDH) is a cause of disability and reduced quality life. Patients with severe pain and disability or were recovery is unacceptably slow, surgical intervention can be advised. For these patients, evidence-based recommendations on the timing of the surgical intervention needs to be established.

Methods: All patients who underwent discectomy at a Spine Centre, due to radicular pain from June 2010 to May 2019 were included. Pre- and postoperative data including demographic data, smoking, consumption of pain medication, comorbidity, back and leg-pain, health-related quality of life as measured by EQ-5D, ODI, previous spine surgery, sick leave, and duration of back and leg-pain before surgery were utilized. The patients were divided into four groups based on their self-reported duration of leg-pain before surgery. To minimize baseline differences between the groups, propensity-score matching was employed in a 1:1 fashion, balancing the groups on all reported preoperative factors.

Results: Of 1607 patients undergoing lumbar discectomy, four matched cohorts based on their self-reported duration of leg-pain before surgery were created. Each cohort consisted of 150 patients well balanced on preoperative factors. Overall 62.7% of the patients were satisfied with the surgical result ranging from 74.0% in the <3 months group to 48.7% in the >24 months group (P < 0.000). The portion of patients achieving a minimum clinically important difference for EQ-5D decreased from 77.4% with early intervention to 55.6% in the late group (P < 0.000). The number of surgical complications were not affected by the duration of preoperative leg-pain.

Conclusion: We found significant difference in patient satisfaction and health-related quality of life in patients related to the duration of preoperative leg-pain due to symptomatic LDH.

Level of Evidence: 3.

Introduction

Sciatica due to lumbar herniated disk (LDH) is a frequent cause of disability and reduced quality life.^[1] In general, the natural history of sciatica is favorable with spontaneous remission in the majority of patients.^[2] Surgical intervention in the form of a decompression or discectomy is clearly indicated in the presence of a neurologic deficit. However, in patients with severe pain and disability or in patients whom recovery is unacceptably slow, surgical intervention can also be recommended.^[3–6] For these patients, in whom there is no clear-cut surgical indication, evidence-based recommendations on the timing of the surgical intervention have not been established.

The NASS Evidence-Based Clinical Guidelines Committee raised the question regarding optimal timing for surgical intervention in 2012 when they published the Clinical Guidelines for Multidisciplinary Spine Care: "Diagnosis and Treatment of Lumbar Disc Herniation with Radiculopathy". https://www.spine.org/Portals/0/Assets/Downloads/ResearchClinicalCare/Guidelines/LumbarDiscHerniation.pdf. As there was no literature specifically addressing the question, they made their recommendations based on four available papers addressing the issue of surgical timing.^[7–10] The committee suggests surgical intervention within six months if the patients' symptoms are severe enough to warrant surgery. In general, the committee concluded that surgery within one year of symptoms is associated with faster recovery and improved long-term outcomes. Since the publication of the NASS guideline several publications have addressed the timing of surgical intervention.^[11–13] In a systematic review published in 2015 by Schoenfeld and Bono,^[11] they conclude "A possible point beyond which outcomes may be compromised is six months after symptom onset". Siccoli et al.^[13] suggested reducing the maximum time to surgery down to between 14 to 22 weeks.

The ideal method to determine the optimal timing of surgical intervention of symptomatic LDH would be to perform a randomized study in which patients are assigned surgery at different time points. A similar design has been attempted to reveal whether surgical intervention of LDH was better than non-surgical treatment^[14,15] but the large group of patients choosing to cross over from the assigned groups complicated the interpretation of these results. Furthermore, there is an ethical problem in conducting a trial where some patients with severe pain are expected to wait for a long time to be treated.

The purpose of this study is to evaluate if the time to surgery is associated with postoperative patient satisfaction, health-related quality of life, leg and back pain, complications, and reoperations following surgery for LDH using propensity-matched cohorts.

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Table 1. Preoperative Characteristics of Subgroups Before Propensity Match
Duration of preoperative leg pain	<3 mo n=486	3–<12 mo n=796	12–24 mo n=157	>24 mo n=158	P
Age, mean (SD)	46.9±11.7	45.8±12. 5	44.7±12.2	44.0±12.1	0.038
Sex (male), n (%)	267 (54.9)	407 (51.1)	77 (48.4)	90 (57.0)	0.254
BMI	25.6±4.9	26.8±4.8	26.3±4.3	27.0±4.7	0.453
Smokers, n (%)	127 (26.1)	253 (31.8)	44 (28.3)	57 (36.1)	0.052
Pain medication, n (%)	486 (100)	796 (100)	157 (100)	158 (100)	1.000
Comorbidity, n (%)
Hearth disease	3 (0.6)	9 (1.1)	2 (1.3)	0 (0)	0.449
Neurological disease	5 (1,0)	13 (1.6)	2 (1.3)	9 (5.7)	0.001
Cancer	3 (0.6)	8 (1.0)	0 (0)	0 (0)	0.336
Leg pain, mean (SD)	71.1±22.7	68.9±21.6	69.5±21.3	72.6±21.8	0.135
Back pain, mean (SD)	45.0±29.1	48,2±28.5	53.1±26.8	60.2±26.7	>0.00
EQ-5D, mean (SD)	0.21±0.35	0.33±0.32	0.35±0.31	0.24±0.33	>0.00
ODI, mean (SD)	54.7±19.3	47.1±16.2	45.1±15.7	50.2±16.5	>0.00
SF36 MCS	42.7±13.1	43.1±12.7	40.7±13.1	41.3±13.2	0.091
Previous spine surgery, n (%)	58 (11.9)	58 (15.7)	37 (23.6)	53 (33.5)	>0.00
Sick leave, n (%)	399 (82.1)	566 (71.1)	112 (71.3)	102 (64.6)	>0.00

Table 2. Postoperative Satisfaction of Surgical Outcome, Surgical Complications and Reoperation Rates Before Propensity Match
Duration of preoperative leg ain	<3 months	3–<12 months	12–24 months	>24 months	P
Satisfaction with outcome, n (%)					>0.00
Satisfied	356 (73,3)	507 (71.6)	93 (59.2)	76 (48.1)
Neither nor	106 (21.8)	151 (19.0)	46 (29.3)	48 (30.4)
Dissatisfied	24 (4.9)	75 (9.4)	18 (11.5)	34 (21.5)
Surgical complications, n (%)
Dural tear	15 (3.1)	22 (3.3)	3 (1.9)	6 (3.8)	0.773
Hematoma	2 (0.4)	4 (0.5)	2 (1.3)	1 (0.6)	0.641
Infection	0 (0)	1 (0.13)	0 (0)	0 (0)	0.800
Nerve root lesions	0 (0)	3 (0.38)	0 (0)	0 (0)	0.388
Cauda equina	1 (0.21)	1 (0.13)	0 (0)	0 (0)	0.886
Reoperations, n (%)
During primary admission	8 (1.6)	13 (1.6)	6 (3.8)	1 (0.6)	0.287
Within 12 months postop.	10 (6.7)	12 (8.0)	18 (12.0)	13 (8.7)	0.421

Table 3. Preoperative Characteristics of Subgroups after Propensity Match
Duration of preoperative leg pain	<3 mo n=150	3–<12 mo n=150	12–24 mo n=150	>24 mo n=150	P
Age, mean (SD)	46.4±11.9	44.3±13.8	44.8±12.3	43.9±12.3	0.346
Sex (male), n (%)	80 (53.9)	77 (51.3)	72 (48.0)	85 (56.7)	0.501
BMI mean (SD)	27.1±8.3	26.6±5.2	26.4±4.3	27.0±4.7	0.644
Smokers, n (%)	45 (30.0)	50 (33.3)	44 (29.3)	53 (35.2)	0.654
Pain medication, n (%)	150 (100)	150 (100)	150 (100)	150 (100)	1.000
Comorbidity, n (%)
Hearth disease	1 (0.7)	0 (0)	2 (1.3)	0 (0)	0.623
Neurological disease	3 (2)	7 (4.7)	2 (1.3)	5 (3.3)	0.354
Cancer	1 (0.7)	0 (0)	0 (0)	0 (0)	1.000
Leg pain, mean (SD)	69.8±21.6	71.3±20.8	69.2±21.5	71.7±21.8	0.715
Back pain, mean (SD)	51.7±28.4	54.0±28.9	53.4±26.8	60.1±26.8	0.050
EQ-5D, mean (SD)	0.27±0.33	0.28±0.32	0.35±0.31	0.26±0.32	0.071
ODI, mean (SD)	50.3±18.8	48.2±16.6	45.3±15.8	48.7±15.4	0.078
SF36 MCS, mean (SD)	42.7±13.9	42.7±12.5	41.1±12.4	41.7±12.8	0.641
Previous spine surgery, n (%)	33 (22.0)	42 (28.0)	35 (23.3)	48 (32.0)	0.188
Sick leave, n (%)	114 (76.0)	98 (65.3)	106 (70.7)	91 (60.7)	0.058

Table 4. Postoperative Satisfaction of Surgical Outcome, Surgical Complications, and Reoperation Rates
Duration of preoperative leg pain	<3 mo	3–<12 mo	12–24 mo	>24 mo	P
Satisfaction with outcome, n (%)					>0.000
Satisfied	111 (74.0)	104 (69.3)	88 (58.7)	73 (48.7)
Neither nor	32 (21.3)	28 (18.7)	45 (30.0)	44 (29.3)
Dissatisfied	7 (4.7)	18 (12.0)	17 (11.3)	33 (22.0)
Surgical complications, n (%)
Dural tear	6 (4.0)	5 (3.3)	3 (2.0)	5 (3.3)	0.844
Hematoma	1 (0.7)	0 (0)	2 (1.3)	0 (0)	0.623
Infection	0 (0)	0 (0)	0 (0)	0 (0)	n/a
Nerve root lesions	0 (0)	2 (1.3)	0 (0)	0 (0)	0.249
Cauda equina	0 (0)	0 (0)	0 (0)	0 (0)	n/a
Reoperations, n (%)
During primary admission	1 (0.7)	4 (2.7)	6 (4.0)	1 (0.7)	0.124
Within 12 months postop.	10 (6.7)	12 (8.0)	18 (12.0)	13 (8.7)	0.421

Table 5. Postoperative Outcome and Achievement of MCID
Duration of preoperative leg pain	<3 mo	3–<12 mo	12–24 mo	>24 mo	P
EQ-5D Δ, SD (n)	0.478±0.364 (146)	0.389±0.394 (145)	0.247±0.411 (143)	0.286±0.398 (144)	0.000
Oswestry Index Δ, SD (n)	−30.1±20.1 (140)	−25.8±20.3 (137)	−17.2±21.7 (138)	−16.5±19.2 (143)	0.000
Leg pain VAS Δ, SD (n)	−45.1±32.3 (149)	−44.3±34.2 (148)	−33.7±34.0 (150)	−28.9±34.9 (150)	0.000
Back pain VAS Δ, SD (n)	−28.8±29.7 (149)	−22,4±32.7 (148)	−15.1±31.0 (150)	−17.6±30.8 (150)	0.01
	% achieving MCID
EQ-5D MCID, n (%)	113 (77.4)	101 (69.7)	75 (52.4)	80 (55.6)	0.000
Oswestry Index MCID, n (%)	105 (75.0)	96 (70.1)	73 (52.9)	71 (49.7)	0.000
Leg pain VAS MCID, n (%)	118 (79.2)	107 (72.3)	98 (65.3)	90 (60.0)	0.002
Back pain VAS MCID, n (%)	98 (65.8)	83 (56.1)	61 (40.7)	74 (49.3)	0.000