Gender differences in the surgical management of lumbar degenerative disease: a scoping review

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OBJECTIVE

Despite efforts toward achieving gender equality in clinical trial enrollment, females are often underrepresented, and gender-specific data analysis is often unavailable. Identifying and reducing gender bias in medical decision-making and outcome reporting may facilitate equitable healthcare delivery. Gender disparity in the utilization of surgical therapy has been exemplified in the orthopedic literature through studies of total joint arthroplasty. A paucity of literature is available to guide the management of lumbar degenerative disease, which stratifies on the basis of demographic factors. The objective of this study was to systematically map and synthesize the adult surgical literature regarding gender differences in pre- and postoperative patient-reported clinical assessment scores for patients with lumbar degenerative disease (disc degeneration, disc herniation, spondylolisthesis, and spinal canal stenosis).

METHODS

A systematic scoping review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines. MEDLINE, Embase, and the Cochrane Registry of Controlled Trials were searched from inception to September 2018. Study characteristics including patient demographics, diagnoses, procedures, and pre- and postoperative clinical assessment scores (pain, disability, and health-related quality of life [HRQoL]) were collected.

RESULTS

Thirty articles were identified, accounting for 32,951 patients. Six studies accounted for 84% of patients; 5 of the 6 studies were published by European groups. The most common lumbar degenerative conditions were disc herniation (59.0%), disc degeneration (20.3%), and spinal canal stenosis (15.9%). The majority of studies reported worse preoperative pain (93.3%), disability (81.3%), and HRQoL (75%) among females. The remainder reported equivalent preoperative scores between males and females. The majority of studies (63.3%) did not report preoperative duration of symptoms, and this represents a limitation of the data. Eighty percent of studies found that females had worse absolute postoperative scores in at least one outcome category (pain, disability, or HRQoL). The remainder reported equivalent absolute postoperative scores between males and females. Seventy-three percent of studies reported either an equivalent or greater interval change for females.

CONCLUSIONS

Female patients undergoing surgery for lumbar degenerative disease (disc degeneration, disc herniation, spondylolisthesis, and spinal canal stenosis) have worse absolute preoperative pain, disability, and HRQoL. Following surgery, females have worse absolute pain, disability, and HRQoL, but demonstrate an equal or greater interval change compared to males. Further studies should examine gender differences in preoperative workup and clinical course.

ABBREVIATIONS DSL = degenerative spondylolisthesis; EQ-5D = EuroQol-5D; HRQoL = health-related quality of life; LDH = lumbar disc herniation; MCID = minimal clinically important difference; MSC = modified Stauffer-Coventry; NRS = numeric rating scale; OA = osteoarthritis; ODI = Oswestry Disability Index; OFI = Objective Functional Impairment; PRISMA-ScR = Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews; QST = quantitative sensory testing; RCT = randomized controlled trial; RDQ = Roland-Morris Disability Questionnaire; SF-12 = Short-Form 12; SF-36 = Short-Form 36; SIP-PD = Sickness-Impact-Profile Physical Dimension; SPORT = Spine Outcomes Research Trial; TJA = total joint arthroplasty; TUG = Timed-Up-and-Go; VAS = visual analog scale.

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Contributor Notes

Correspondence Gwynedd E. Pickett: Dalhousie University and Nova Scotia Health Authority, Halifax, NS, Canada. gepickett@dal.ca.INCLUDE WHEN CITING Published online January 31, 2020; DOI: 10.3171/2019.11.SPINE19896.Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.
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