Patients with spinal deformity and leg pain fared better after surgery than those with lower back pain

Pearson A. Spine. 2011; doi:10.1097/BRS.obo13e3181d77c21.

Patients with degenerative spondylolisthesis and spinal stenosis and predominant leg pain had better surgical outcomes compared with patients with predominant low back pain, according to Sport Patient Outcomes Research Trial results.

Adam Pearson, MD, MS, of Rothman Institute in Philadelphia, and colleagues compared baseline characteristics, as well as surgical and nonsurgical outcomes, in patients with degenerative spondylolisthesis and spinal stenosis who were separated according to whether they had predominant pain in their leg or back.

There were 591 patients in the degenerative spondylolisthesis cohort and 615 patients in the spinal stenosis group. Sixty-two percent of patients in each group underwent surgery.

The investigators classified the patients as either leg pain predominant, low back pain (LBP) predominant or having equal pain according to baseline scores. The investigators compared baseline characteristics among the three predominant pain location groups within each diagnostic category. For 2 years, they compared changes in surgical and nonsurgical outcome scores.

At baseline, 34% of degenerative spondylolisthesis patients had predominant leg pain, 26% had predominant LBP and 40% had equal pain. Also at baseline, 32% of spinal stenosis patients had predominant leg pain, 26% had predominant LBP and 42% had equal pain. Patients with degenerative spondylolisthesis and spinal stenosis with predominant leg pain had baseline scores that indicated less severe symptoms.

At 1 and 2 years, patients with leg pain predominant degenerative spondylolisthesis and spinal stenosis who underwent surgery showed more significant improvements compared with patients with predominant LBP on all primary outcome measures.

“However, predominant LBP patients still improved significantly more with surgery than with nonoperative treatment,” the authors wrote.

James Weinstein and the SPORT team are to again be applauded for their herculean efforts to perform and report on a randomized surgical trial over the last decade. This particular report confirms other studies with less clean methodology that suggested stenosis and degenerative spondylolisthesis patients with predominant leg pain have better post-surgical outcomes than those with significant amounts of low back pain.

However, somewhat surprisingly, this study also showed that patients with these same two diagnoses experiencing predominant low back pain still fared better with surgery than nonoperative treatment. Undoubtedly, neural element compression resulting from either diagnosis can also be a source of low back pain and thus may be relieved by surgical decompression.

Of course, the art of medicine requires the surgeon to distinguish which low back pain predominant patients with the radiographic findings of stenosis or spondylolisthesis are most likely to improve.

– Scott D. Boden, MD
Orthopedics Today Editorial Board Member
Professor of orthopedic surgery
Director, Emory Orthopaedics & Spine Center
Emory University
Atlanta