Post-operative Pain and QoL
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Table 1. Patient and treatment characteristics of studies reporting postoperative pain and QoL following surgery for LBP.
Author
(year)
Becker1
(2010)
Berg2
(2009)
Study design
(LoE)
Follow-up
(% followed)
Retrospective
cohort
2 years (82%)
RCT
2 years
(100%)
Demographics
N = 239
Male: NR
Mean age (± SD): 76
± 4.0 years (70–89)
Total
N = 152
Male: 41%
Mean age (± SD): 39
± 8.0 years
TDR
N = 80
Male: 40%
Mean age (± SD): 40
± 8.1 years
Fusion
N = 72
Male: 42%
Mean age (± SD): 39
± 7.8 years
Patient characteristics
• Aged 70–89
• Preoperative diagnoses: spinal
Interventions
• Fusion with pedicle screws
stenosis, spondylolisthesis,
osteochondrosis, and degenerative
scoliosis
• ASA class I (9%), class II (69%),
and class III (22%)
•
• Smokers
•
Total: 11%
TDR: 10%
Fusion: 11%
• Previous spinal surgery
Total: 12%
TDR: 12%
Fusion: 11%
• LBP ≥ 2 years
Total: 83%
TDR: 79%
Fusion: 87%
•
•
•
1
and rod instrumentation with
or without intervertebral
cages introduced by PLIF
Average number of fused
levels was 1.7 ± 1.2 (range,
1–7)
Postoperative management
included early included early
mobilization without a brace
on day 1
TDR with 1 of 3 devices:
Charité, Prodisc or Maverick
Fusion instrumented from a
posterior approach - either
PLF (n = 44) or PLIF (n =
28) per surgeon preference
1-level surgery
Total: 51%
TDR: 56%
Fusion: 46%
Inclusion/Exclusion
• Patients older than 70 years who
underwent spinal fusion surgery in the
period from 2002 to 2005
Included
• LBP with or without leg pain for more than
1 year; if leg pain, back pain should
dominate
• Failed conservative treatment of > 3
months
• Confirmation of disc degeneration on MRI
• Age 20–55 years
• ODI over 30 or back pain (VAS) over
50/100 the week before inclusion
• Open mind to treatment options
Excluded
• Spinal stenosis requiring compression
• Moderate or worse facet joint arthritis
• 3+ painful levels at clinical exam
• No obvious painful level, or levels, at
diagnostic injection evaluation
• Isthmic spondylolisthesis/olisthesis
• Degenerative spondylolisthesis > 3 mm
• Major deformity
• Manifest osteoporosis
• Previous lumbar fusion or decompression
with postoperative instability
Post-operative Pain and QoL
Author
(year)
Study design
(LoE)
Follow-up
(% followed)
Demographics
Patient characteristics
Interventions
Inclusion/Exclusion
•
•
•
•
Carreon3
(2009)
Prospective
longitudinal
cohort
2 years (90%)
N = 546
Male: 39%
Mean age (± SD): 56
± 13 years (18–87)
•
•
•
•
•
•
•
•
•
•
•
•
•
Jenis6
(2006)
Prospective
cohort
2 years (97%)
AGF
N = 15
Male: 67%
Mean age (± SD): 40
± 7.5 years (30–52)
•
Autograft
N = 22
Male: 64%
Mean age (± SD): 41
± 8.0 years (28–58)
•
•
•
Workers’ compensation: 6%
Current smokers: 20%
Disc pathology: 13%
Scoliosis: 5%
Spondylolisthesis: 23%
Stenosis: 13%
Instability: 5%
Nonunion: 9%
Postdecompression instability:
22%
Adjacent level degeneration: 10%
Equal back and leg pain: 42%
Back pain more severe than leg
pain: 25%
Leg pain more severe than back
pain: 33%
Nicotine use
AGF: 40%
Autograft: 23%
Previous discectomy
AGF: 0
Autograft: 0.5%
Workers’ compensation
AGF: 60%
Autograft: 68%
Preoperative VAS
AGF: 7.5 ± 1.1 (4–8)
Autograft: 7.7 ± 1.7 (4–10)
• Posterolateral fusion (76%)
• Combined anteroposterior
fusion (12%)
• Transforaminal interbody
fusion (9%)
• Anterior interbody fusion
(3%)
• Number of levels fused
1-level: 45%
2-level: 30%
3+ levels: 25%
• Anterior retroperitoneal
•
•
•
•
2
Compromised vertebral body
Previous spinal infection or tumor
Inability to understand information
Language difficulties with inability to
understand follow-up instruments
• Pregnancy or other medical condition that
would be a contraindication to surgery
• Undergoing lumbar fusion for degenerative
disorders from January 2001 to December
2005
approach to fusion; radical
discectomy with preservation
of peripheral cortical end
plates
Postoperative management
included pain control via IV
narcotics, early mobilization,
home exercises, and
avoidance of nonsteroidal
anti-inflammatory agents
Total levels operated
AGF, n = 25
Autograft, n = 32
1-level
AGF: 33%
Autograft: 55%
2-levels
AGF: 67%
Autograft: 45%
• Candidates for anterior-posterior lumbar
fusion with diagnosis of degenerative disc
disease and/or up to grade I spondylolytic
spondylolisthesis based on positive
provocative discography
Post-operative Pain and QoL
McKenna7
(2005)
RCT
2 years
(100%)
FRA
N = 37
Male: 46%
Mean age: 39 years
(24–53)
• Previous
• Circumferential fusion using
Included:
• DDD from L3 to S1
Single-center
• Maximum of 2 consecutive motion
•
segments to be fused
• Pain/functional deficit present ≥ 6 months
• Failure to respond to conservative
Titanium cage
•
treatment of ≥ 3 months
N = 41
• Osteophyte formation
Male: 44%
• Sclerosis
Mean age: 41 years
• Facet joint degeneration
(29–65)
• ≥ 50% loss of intervertebral disc height
•
• 3.5 mm movement on flexion-extension
radiographs
• Disc dehydration ± reactive changes in
•
vertebral body endplate (MRI criteria)
• Abnormal morphology at target level;
concordant pain reproduction at target
level (Provocative discography criteria)
Excluded:
• Age < 18 or > 70 years
• Previous spinal fusion
• ≥ grade II spondylolisthesis
• >2 motion segments to be fused
• Systematic infection
• Active malignancy
• Known osteoporosis
AGF = autologous growth factors; ASA = American Society of Anesthesiologists; DDD = degenerative disc disease; FRA = femoral ring allograft; LBP = low back pain; NR = not reported; MRI =
magnetic resonance imaging; ODI = Oswestry Disability Index; SD = standard deviation; TDR = total disc replacement; TED = thrombo-embolic deterrent; VAS = visual analog scale.
discectomy/decompression
FRA: 11%
Titanium cage: 15%
• Smoking
FRA: 27%
Titanium cage: 24%
3
femoral ring allografts or
titanium cages
Lumbar spine exposed
anteriorly via a
retroperitoneal approach
Postoperative management
included antibiotics, TED
stockings for 6 weeks, and
mobilization the day after
surgery
1-level fused
FRA: 59%
Titanium cage: 54%
2-levels fused
FRA: 41%
Titanium cage: 46%
Post-operative Pain and QoL
Table 2. Results of included studies evaluating the relationship between postop pain and QoL following surgery for low back pain.
Author
(year)
Becker
(2010)
Berg
(2009)
Study
Design
Follow-up
(%
followed)
Caseseries
2 years
(82%)
RCT
2 years
(100%)
Pain and
QoL
measures
VAS (10
mm) for
back and leg
pain
SF-36 PCS
and MCS
VAS (100
mm) for
back and leg
pain
Mean baseline scores
Pain
Back: 6.0 ±
2.5
Leg: 5.6 ± 2.8
QoL
PCS: 28.2 ±
6.6
MCS: 37.8
± 12.4
Fusion
Back: 58.5 ±
21.7
Leg: 43.7 ±
28.2
Fusion
0.36 ± 0.27
TDR
Back: 62.3 ±
20.8
Leg: 32.8 ±
26.4
TDR
0.42 ± 0.31
ODI
53.1 ± 18.2
Fusion
41.2 ± 14.6
EQ5D
TDR
41.8 ± 11.8
Mean change scores
Pain
1 year*
Back: -2.7
Leg: -2.8
QoL
2 years*
PCS: 4.7
MCS: 3.0
ODI
2 years*
13.8
2 years*
Back: -1.7
Leg: -2.2
Fusion
1 year
Back: -25.1 ±
34.2
Leg: -23.1 ±
32.7
Fusion
1 year
0.33 ± 0.38
Fusion
1 year
16.3 ± 18.4
2 years
0.33 ± 0.38
2 years
18.2†
TDR
1 year
0.25 ± 0.36
TDR
1 year
22.4 ± 17.8
2 years
0.25 ± 0.36
2 years
21.9 ± 18.9
2 years
Back: -29.3 ±
31.6
Leg: -23.2 ±
28.1
TDR
1 year
Back: -36.8 ±
30.0
Leg: -19.6 ±
32.1
2 years
Back: -36.9 ±
31.0
Leg: -21.0 ±
26.4
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Questionnaires
Randomized?
No
No
Post-operative Pain and QoL
Carreon
(2009)
Jenis
(2006)
Caseseries
Pro
cohort
2 years
(90%)
2 years
(97%)
NRS (0-10)
for back and
leg pain
SF-36 PCS
and MCS
VAS (10
mm) for
back pain
SF-36 PCS
and MCS
McKenna
(2005)
RCT
2 years
(100%)
Back: 7.7 ±
1.9
Leg: 7.3 ± 2.4
Total:
PCS: 27.8 ±
6.3
MCS: 37.1
± 13.4
53.2 ± 14.1
Back: -2.5 ±
2.84
Leg: -2.3 ±
3.4
Total:
PCS: 4.6 ±
11.2
MCS: 2.8 ±
14.8
14.4 ± 17.8
No
AGF
7.5 ± 1.1
AGF
Total:
PCS: 27.7 ±
5.9
MCS: 36.9
± 7.9
AGF
59.5 ± 13.1
AGF
-2.7
(4.8 ± 3.2)
AGF
Total:
PCS: 6.4
(34.1 ± 11.1)
MCS: 1.5
(38.4 ± 12.2)
AGF
12.5
(47.0 ± 19.8)
No
Autograft
7.7 ± 1.7
VAS (10
mm) for
back and leg
pain
FRA
Back: 7.2 ±
1.7
Leg: 3.8 ± 2.7
SF-36
subscales
TC
Back: 7.1 ±
1.9
Leg: 4.3 ± 3.2
Autograft
60.0 ± 18.8
Autograft
Total:
PCS: 29.0 ±
6.5
MCS: 32.9
± 10.2
FRA
Total: 34.4§
FRA
57 ± 14
TC
Total: 37.4§
TC
54 ± 14
Autograft
-2.9
(4.8 ± 3.0)
FRA
1 year
Back: -2.4
Leg: -1.0
2 years
Back:-2.0
Leg: -1.3
TC
1 year
Back: -0.7
Leg: +0.3
Autograft
Total:
PCS: 9.1
(38.1 ± 11.6)
MCS: 6.8
(39.7 ± 12.8)
FRA
2 years
Total: 11.4§
TC
2 years
Total: 4.9§
Autograft
23.3
(36.7 ± 24.7)
FRA
1 year:
18
No
2 years:
15
TC
1 year:
5
2 years:
6
2 years
Back: -1.1
Leg: +0.4
AGF: autologous growth factors; FRA: femoral ring allograft; MCS: mental component score of SF-36; PCS: physical component score of SF-36; TC: titanium cage;
TDR: total disc replacement.
*Scores were calculated using the percent improvement provided in the text for each time point.
†No standard deviation was available for the change score at 2 years due to a typo in the results table of the original paper. Change score only was able to be calculated
from the pre and post scores given.
§Total SF-36 score calculated by taking the average of the 8 subscale scores.
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