Introduction: While spinal decompression has demonstrable quality of life (QOL) benefit, patients with multiple comorbidities may experience marginal QOL benefit after these invasive and expensive procedures. While prior studies have identified the deleterious effect of diabetes and chronic renal failure (CRF) upon QOL, these studies have been small and utilized univariate statistics. The purpose of this study was to quantify the deleterious effect of diabetes and CRF upon postoperative QOL improvement.
Methods: A retrospective cohort study of patients who underwent lumbar decompression at a single tertiary-care center was conducted. Inclusion necessitated a 6-month minimum follow-up. The primary outcome measure was postoperative improvement in self-reported EQ-5D. QOL data was collected using the institutional prospectively-collected database of patient-reported health status measures. Multivariable regression was used to assess the impact of preoperative diabetes and CRF upon normalized QOL improvement. No funding sources or conflicts of interest were present.
Results: 212 patients met inclusion criteria. Four variables, including race, surgical indication, renal failure, and diabetes, were significant independent predictors of EQ-5D improvement postoperatively. Caucasian relative to black race (ß=0.10,p<0.05) and disc displacement relative to spinal stenosis (ß<0.01,p=0.03) were favorable with respect to EQ-5D improvement. In contrast, CRF (ß=-0.30,p=0.03) and diabetes (ß=-0.11,p=0.03) were associated with suboptimal QOL improvement. Simple and multivariable regression was also performed to assess the effect of diabetes and CRF upon postoperative QOL improvement exceeding the EQ-5D MCID (0.1). After multivariable regression modeling, race and diabetes remained statistically significant. Caucasian relative to black race (OR 3.23,p=0.03) was found to be favorable with respect to EQ-5D improvement, while diabetes (OR 0.19,p<0.01) predicted suboptimal improvement in EQ-5D exceeding the MCID.
Conclusions: Diabetes and CRF were significant independent predictors of suboptimal improvement in QOL after lumbar decompression. These data may be used to select optimal surgical candidates and counsel those who may be at risk for marginal QOL improvement.
Patient Care: Effective management of degenerative lumbar disease remains a significant clinical challenge despite multimodality therapy. In patients with multiple comorbidities, the quality of life benefit among these modalities may certainly differ. Our data suggest that diabetes and chronic renal failure are independent risk factors for suboptimal quality of life benefit after lumbar decompressive surgery. While this does not suggest that decompressive surgery should be avoided in these patients, it raises the question as to when surgical intervention should be considered. Given the greater perioperative morbidity in patients with comorbid diseases, effective preoperative comorbidity management and evaluation may yield superior quality of life outcomes after surgery.
Learning Objectives: By the conclusion of this session, participants should be able to:
1) Describe the importance of comorbid disease in identifying patients with the greatest expected quality of life (QOL) benefit after decompressive spine surgery.
2) Discuss, in small groups, the underlying mechanisms for suboptimal quality of life benefit in diabetes and chronic renal failure.
3) Identify an effective preoperative management protocol for patients with these comorbid diseases in an effort to maximize quality of life benefit from decompressive spine surgery.
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