Health-related quality-of-life improvement with lumbar fusion in patients with lower-extremity arthritis

Mladen DjurasovicNorton Leatherman Spine Center, Louisville, Kentucky

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Steven GlassmanNorton Leatherman Spine Center, Louisville, Kentucky

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Jeffrey L. GumNorton Leatherman Spine Center, Louisville, Kentucky

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Charles H. Crawford IIINorton Leatherman Spine Center, Louisville, Kentucky

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R. Kirk Owens IINorton Leatherman Spine Center, Louisville, Kentucky

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Leah Y. CarreonNorton Leatherman Spine Center, Louisville, Kentucky

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OBJECTIVE

Lumbar fusion can lead to significant improvements in patient-reported outcomes (PROs) in patients with degenerative conditions. It is unknown whether the presence of hip or knee arthritis confounds the responses of patients to low-back–specific PROs. This study examined PROs with lumbar fusion in patients with concomitant lower-extremity arthritis. The purpose of the current study was to examine whether patients with significant lower-extremity arthritis who undergo lumbar fusion achieve similar improvements in low-back–specific PROs compared to patients without lower-extremity arthritis.

METHODS

Patients were identified from a prospectively enrolled multicenter registry of patients undergoing lumbar fusion surgery for degenerative conditions. Two hundred thirty patients identified with lumbar fusion and who also had concomitant lower-extremity arthritis were propensity matched to 233 patients who did not have lower-extremity arthritis based on age, BMI, sex, smoking status, American Society of Anesthesiologists grade, number of levels fused, and surgical approach. One-year improvement in PROs, numeric rating scales (0–10) for back and leg pain, and the Oswestry Disability Index and EuroQol-5D scores were compared for patients with and without lower-extremity arthritis.

RESULTS

Baseline demographics and preoperative outcome measures did not differ between the two propensity-matched groups with 110 cases each. Patients with concomitant lower-extremity arthritis achieved similar improvement in health-related quality-of-life measures to patients without lower-extremity arthritis, with no significant differences between the groups (p > 0.10).

CONCLUSIONS

The presence of lower-extremity arthritis does not adversely affect the results of lumbar fusion in properly selected patients. Patients with lower-extremity arthritis who undergo lumbar fusion can achieve meaningful improvement in PROs similar to patients without arthritis.

ABBREVIATIONS

ASA = American Society of Anesthesiologists; EQ-5D = EuroQol-5D; ODI = Oswestry Disability Index; PRO = patient-reported outcome; QOD = Quality Outcomes Database; SHAR = Swedish Hip Arthroplasty Registry; Swespine = Swedish Spine Registry.

OBJECTIVE

Lumbar fusion can lead to significant improvements in patient-reported outcomes (PROs) in patients with degenerative conditions. It is unknown whether the presence of hip or knee arthritis confounds the responses of patients to low-back–specific PROs. This study examined PROs with lumbar fusion in patients with concomitant lower-extremity arthritis. The purpose of the current study was to examine whether patients with significant lower-extremity arthritis who undergo lumbar fusion achieve similar improvements in low-back–specific PROs compared to patients without lower-extremity arthritis.

METHODS

Patients were identified from a prospectively enrolled multicenter registry of patients undergoing lumbar fusion surgery for degenerative conditions. Two hundred thirty patients identified with lumbar fusion and who also had concomitant lower-extremity arthritis were propensity matched to 233 patients who did not have lower-extremity arthritis based on age, BMI, sex, smoking status, American Society of Anesthesiologists grade, number of levels fused, and surgical approach. One-year improvement in PROs, numeric rating scales (0–10) for back and leg pain, and the Oswestry Disability Index and EuroQol-5D scores were compared for patients with and without lower-extremity arthritis.

RESULTS

Baseline demographics and preoperative outcome measures did not differ between the two propensity-matched groups with 110 cases each. Patients with concomitant lower-extremity arthritis achieved similar improvement in health-related quality-of-life measures to patients without lower-extremity arthritis, with no significant differences between the groups (p > 0.10).

CONCLUSIONS

The presence of lower-extremity arthritis does not adversely affect the results of lumbar fusion in properly selected patients. Patients with lower-extremity arthritis who undergo lumbar fusion can achieve meaningful improvement in PROs similar to patients without arthritis.

The aging of the US population has been associated with a significant increase in musculoskeletal disease burden. Nearly 10,000 members of the “baby boomer” cohort reach retirement age every day,1 and with their aging there will be continued growth in the treatment of both lumbar spine and lower-extremity degenerative disease. Lumbar spinal stenosis with or without spondylolisthesis is the most common cause for lumbar surgery in the US, with nearly 200,000 elective lumbar fusions performed in 2015.2 This represents a growth of 62% over the previous decade, and this growth in volume has been greatest among patients aged 65 years or older. Similarly, lower-extremity arthritis affects between 7% and 37% of the US population,3–5 and the volume of primary total hip and knee arthroplasty is projected to exceed 2 million procedures per year by 2030.6 Because the prevalence of both lumbar degeneration and lower-extremity arthritis increases with age, clinicians will encounter an increasing number of patients who have both conditions.

Lumbar fusion is an effective intervention for a variety of clinical scenarios, but it is unclear whether the presence of lower-extremity arthritis will compromise results. Strong, pain-free, and functional lower extremities are important for rehabilitation and recovery after lumbar fusion. In addition, patient-reported outcomes (PROs), which measure disease-specific and generic health-related quality of life after lumbar surgery, such as the Oswestry Disability Index (ODI)7 and EuroQol-5D (EQ-5D),8 have components that could be dramatically affected by lower-extremity arthritis, such as pain, mobility, and self-care. It is unclear whether lumbar fusion patients with lower-extremity arthritis should expect improvements in PROs similar to patients with isolated lumbar degenerative disease.

Previous research in this area has been limited, mostly focused on the relationship in the opposite direction, examining whether spinal disease compromises the results of lower-extremity arthroplasty. Several studies have demonstrated that preexisting low-back pain is associated with less improvement following total hip or total knee arthroplasty.9,10 Spinal disease has been shown to also increase costs associated with total hip arthroplasty11 and may be a cause of persistent pain after an otherwise successful arthroplasty. Few studies have examined whether lower-extremity arthritis affects the results of lumbar surgery. Eneqvist and colleagues12 demonstrated that patients with prior total hip arthroplasty overall had successful results with low-back surgery, but that low-back pain levels were worse at 1 year in patients undergoing hip arthroplasty. This study only examined patients who had already undergone hip arthroplasty surgery and did not include subjects with nonoperatively treated hip arthritis or patients with knee arthritis. The current study uses the Quality Outcomes Database (QOD; formerly known as the National Neurosurgery Quality and Outcomes Database [N2QOD]), which is a national, prospective, multicenter registry designed to improve evidence-based practice in spine surgery.13 We specifically used this database to examine whether the presence of lower-extremity arthritis compromises the results of lumbar fusion surgery.

Methods

Study Population

From the subjects enrolled locally from one institution in the QOD, those who reached a minimum of 1-year follow-up after the index surgery were included in the analysis. A retrospective review of medical records was performed to determine whether the patient had lower-extremity pathology or surgery that could affect clinical outcomes after lumbar surgery. Information collected included the presence of hip or knee osteoarthritis and any lower-extremity surgeries, including total knee or hip arthroplasty by patient report, through medical history or interventions noted within our institution.

Data Collection

Patients were divided into two cohorts: those who had lower-extremity pathology based on the review of the patient’s chart and those who did not. Patients with lower-extremity arthritis were then propensity matched to patients who did not have lower-extremity arthritis based on age, BMI, sex, smoking status, American Society of Anesthesiologists (ASA) grade, number of levels fused, and surgical approach for the spine. One-year improvement in PROs, numeric rating scales (0–10) for back and leg pain, and the ODI7 and EQ-5D8 scores were compared for patients with and without lower-extremity arthritis. T-tests for continuous variables and the Fisher’s exact test for categorical variables were used to compare the two groups. A subanalysis of the impact of the type of lower-extremity pathology present was conducted by stratifying the cohort with lower-extremity arthritis into those who had not had surgery, those who had an arthroscopy, and those who had a joint replacement.

Results

Of 566 cases that met inclusion criteria, 463 cases (82%) had 1-year follow-up available, 230 (50%) with lower-extremity arthritis and 233 (50%) without. Before propensity matching, patients with lower-extremity arthritis were older, had a greater proportion of females, and had worse ASA grades compared to patients without. After propensity matching, the 110 patients in each group were similar in age, BMI, sex distribution, smoking status, ASA grades, ambulatory status, employment status, diagnosis, number of levels fused, and spine surgical approach (Table 1).

TABLE 1.

Baseline demographic data

Lower-Extremity Osteoarthritis
VariableNoYesp Value
No. of patients110110
Mean age ± SD, yrs58.62 ± 12.1059.05 ± 11.090.784
Mean BMI ± SD, kg/m231.27 ± 6.1030.75 ± 5.610.520
Sex1.000
 Female68 (62)68 (62)
 Male42 (38)42 (38)
ASA grade0.512
 10 (0)1 (<1)
 233 (30)36 (33)
 373 (66)66 (60)
 44 (4)7 (6)
Ambulatory status0.614
 Independent103 (94)100 (91)
 Assistive device7 (6)10 (9)
Employment status0.147
 Unemployed or retired71 (65)69 (63)
 Employed & currently working31 (28)22 (20)
 Employed on short-term disability7 (6)15 (14)
 Attending school0 (0)2 (2)
Diagnosis0.052
 Symptomatic lumbar disc herniation12 (11)2 (2)
 Lumbar stenosis20 (18)22 (20)
 Single-level mechanical disc collapse11 (10)9 (8)
 Lumbar spondylolisthesis (grade 1)47 (43)61 (55)
 Lumbar adjacent-segment disease20 (18)15 (14)
No. of levels fused0.722
 174 (67)75 (68)
 228 (25)26 (24)
 37 (6)9 (8)
Fusion technique0.210
 Transforaminal lumbar fusion56 (51)43 (39)
 Posterolateral fusion44 (40)54 (49)
 Combined anteroposterior fusion10 (9)13 (12)
Smoking status0.650
 Never smoker52 (47)50 (45)
 Former smoker43 (39)40 (36)
 Current smoker15 (14)20 (18)

Data are presented as the number (%) of patients unless otherwise indicated.

There were no significant differences in terms of baseline and follow-up PRO scores between the two groups (Table 2). A subanalysis of the impact of the type of lower-extremity pathology present for the entire cohort with lower-extremity arthritis showed no differences in baseline or follow-up PROs among patients who had not had surgery, those who had an arthroscopy, and those who had a joint replacement (Table 3). Complication rates and discharge dispositions were similar in the two groups (Table 4).

TABLE 2.

Summary of PROs in patients with and without lower-extremity arthritis

Lower-Extremity Osteoarthritis
PRONoYesp Value
No. of patients110110
Baseline
 Back pain7.35 (1.68)7.09 (1.94)0.283
 Leg pain6.87 (2.24)6.41 (2.59)0.157
 ODI51.78 (14.54)50.62 (16.04)0.574
 EQ-5D0.47 (0.23)0.48 (0.24)0.812
12 mos postop
 Back pain4.36 (2.99)4.63 (2.87)0.495
 Leg pain3.84 (3.31)3.59 (3.11)0.571
 ODI35.67 (22.58)37.57 (20.73)0.517
 EQ-5D0.57 (0.37)0.56 (0.36)0.973
12-mo change from baseline
 Back pain3.00 (2.50)2.45 (2.49)0.105
 Leg pain3.03 (3.29)2.83 (3.32)0.664
 ODI16.11 (17.26)13.05 (14.57)0.157
 EQ-5D0.09 (0.32)0.09 (0.36)0.914

Data are presented as the mean (SD) unless otherwise indicated.

TABLE 3.

Summary of PROs in the entire cohort of patients with lower-extremity arthritis stratified by treatment

PRONo SurgeryArthroscopyJoint Replacementp Value
No. of patients1053095
Baseline
 Back pain7.31 (1.83)7.60 (1.91)7.02 (1.85)0.481
 Leg pain6.98 (2.36)6.53 (2.56)6.69 (2.22)0.621
 ODI53.24 (14.93)53.68 (17.02)49.61 (16.03)0.246
 EQ-5D0.43 (0.24)0.44 (0.24)0.48 (0.25)0.531
12 mos postop
 Back pain4.46 (2.86)4.50 (2.93)4.76 (2.87)0.910
 Leg pain3.80 (3.10)3.53 (3.07)3.83 (3.22)0.975
 ODI36.60 (20.72)37.45 (21.57)38.57 (19.46)0.936
 EQ-5D0.54 (0.36)0.53 (0.36)0.54 (0.36)0.999
12-mo change from baseline
 Back pain2.85 (3.00)3.14 (2.82)2.27 (2.59)0.393
 Leg pain3.22 (3.51)2.93 (2.79)2.90 (3.40)0.891
 ODI16.64 (15.94)16.23 (17.85)11.04 (14.23)0.090
 EQ-5D0.11 (0.36)0.09 (0.34)0.07 (0.34)0.858

Data are presented as the mean (SD) unless otherwise indicated.

TABLE 4.

Discharge disposition and complications

Lower-Extremity Osteoarthritis
VariableNoYesp Value
No. of patients110110
Discharge disposition0.832
 Home61 (55)57 (52)
 Home healthcare21 (19)19 (17)
 Skilled nursing unit26 (24)31 (28)
 Rehab facility2 (2)3 (3)
Complication
 DVT01
 New neurologic deficit10
 MI11
 UTI2 (2)0
 Wound infection2 (2)7 (6)0.170
 CSF leak10
 Implant positioning02 (2)

DVT = deep vein thrombosis; MI = myocardial infarction; UTI = urinary tract infection.

Data are presented as the number (%) of patients unless otherwise indicated.

Discussion

The current study has demonstrated that the presence of lower-extremity arthritis does not compromise the results of lumbar fusion surgery. We utilized the QOD database, a national, multicenter spine registry that reflects common clinical practice throughout the country. The patient sample also included patients with varying levels of severity of hip or knee arthritis, including those treated with nonoperative measures, arthroscopy, and joint replacement. We found that patients with lower-extremity arthritis achieved similar improvements to a cohort of lumbar fusion patients who did not have lower-extremity arthritis, not only with respect to low-back–specific disability but also with respect to overall generic health-related quality of life.

Our study would suggest that patients with lower-extremity arthritis can successfully undergo lumbar fusion for proper indications, and they can be counseled to expect similar improvement to patients without lower-extremity arthritis. A patient presenting to a spine surgeon with lumbar stenosis, spondylolisthesis, or other lumbar degenerative disease, who also has hip or knee arthritis, is a common clinical scenario and will become more common in the future. A reasonable concern is whether such a patient will be capable of proper rehabilitation and recovery following lumbar fusion. Elderly lumbar fusion patients often require a walker or cane for initial ambulation retraining.

Several previous studies have examined the interaction between surgically treated lumbar degenerative disease and lower-extremity arthritis. The clinical entity of “hip-spine syndrome” has now been well described and reflects the overlapping symptoms and functional disability observed with lumbar stenosis and hip osteoarthritis.14–18 Many previous studies have focused on whether back pain and stenosis symptoms compromise the results of total joint arthroplasty. Eneqvist and colleagues10 searched both the Swedish Hip Arthroplasty Registry (SHAR) and the Swedish Spine Registry (Swespine) and found that 3.5% of the total hip arthroplasty population had undergone prior lumbar surgery. Compared to patients who had no history of lumbar surgery, these patients had worse visual analog scale (VAS) pain scores, EQ-5D scores, and satisfaction at 1 year following hip arthroplasty.10 Prather and colleagues demonstrated that when patients with diagnosed lumbar degenerative disease underwent total hip arthroplasty, their hip outcome scores were lower and incurred $2700 more charges per episode of care compared to patients without lumbar disease.11 Jauregui and coworkers showed that hip arthroplasty patients with coexisting lumbar stenosis had similar implant survivorship but lower Harris Hip scores, UCLA scores, 36-Item Short-Form Health Survey physical component score (SF-36 PCS) improvement, and satisfaction.19 Similarly, with respect to total knee arthroplasty, Clement et al. found low-back pain was an independent predictor of lower 1-year PRO scores and satisfaction.20 In a prospective cohort study, Ayers and coworkers found that concomitant hip arthritis, contralateral knee arthritis, or low-back pain led to lower SF-36 PCS scores following otherwise successful total knee arthroplasty.21 As a whole, the literature suggests that low-back pain and lumbar stenosis have a slightly negative effect on the results of lower-extremity arthroplasty.

Studies examining whether lower-extremity arthritis affects the results of lumbar surgery have been much less common. This question has been addressed indirectly in cohort studies of surgically treated lumbar spinal stenosis; a common finding has been that patients’ preoperative ambulatory status is a predictor of postoperative pain and function.22–26 Aalto and colleagues summarized these results in a systematic review that examined preoperative factors that predicted success with surgical treatment of lumbar spinal stenosis.27 Their review included prospective cohort studies and randomized trials and demonstrated that preoperative ambulatory ability was a significant predictor of postoperative function, walking ability, and satisfaction. Although arthritis was not mentioned specifically, certainly clinically significant hip or knee arthritis would be a cause of impaired preoperative ambulatory ability. Eneqvist et al. examined this more directly,12 again using the SHAR and Swespine registries. They compared outcomes of lumbar surgery in patients who had undergone prior total hip arthroplasty to a matched cohort of patients who had not. At 1 year, they found that patients with a history of hip arthroplasty had somewhat worse VAS low-back pain scores, but that overall results including leg pain, ODI, and EQ-5D scores were similar to those for control patients. Our results would agree with these findings. We have shown that lower-extremity arthritis that is either mild or adequately treated does not compromise the results of lumbar fusion surgery. Patients with adequately managed hip or knee arthritis improve with lumbar fusion to a similar degree as patients without arthritis.

Study Limitations

Our study has several limitations. Data were retrospective and not randomized, although we did compare lumbar fusion results in patients with lower-extremity arthritis to a group of controls. The retrospective study design may allow inadvertent selection bias. This limitation is, however, balanced by the fact that we used registry data that led to a study sample which likely reflects common clinical practice. Outcomes were measured only to 1 year; thus, there may be a differential deterioration in results in one group versus another. For instance, patients with nonoperatively treated lower-extremity arthritis may have some decline in their ODI or EQ-5D scores as their lower-extremity arthritis progresses. However, this would reflect a change in their health status secondary to their arthritis and not a reflection of their lumbar surgery. Data on the timing of the intervention for the arthritis were not included in the analysis. Patients with more recent surgeries for their lower-extremity arthritis may have worse or better outcomes than those with less-recent interventions. Finally, our cohort with lower-extremity arthritis reflects a group that has relatively well-treated arthritis (either nonoperative treatment, arthroscopy, or arthroplasty). Thus, our patient sample does not allow us to answer what to do with a patient who presents with clinically significant and severely symptomatic lumbar and lower-extremity problems in terms of which should be addressed first.

Conclusions

Our study demonstrates that patients with lower-extremity arthritis who undergo lumbar spinal fusion can obtain similar benefit to patients who do not have arthritis. Patients can be counseled that their lower-extremity arthritis is not a contraindication for lumbar surgery. In patients who present with both lumbar degenerative disease and lower-extremity arthritis, a collaborative approach should be undertaken between the patient’s primary care provider, spine surgeon, and orthopedic surgeon to provide comprehensive musculoskeletal care. Ideally, decision-making should take into account the level of symptoms and the impairment of function that arises from each of the patient’s musculoskeletal problems, and prioritizing treatment based on this. Further prospective research should address which order of treatment leads to the greatest functional improvement with the lowest complication risk.

Disclosures

Dr. Djurasovic reports receiving royalties from Medtronic and NuVasive. Dr. Glassman reports being an employee of Norton Healthcare; being a consultant to K2M/Stryker and Medtronic; receiving clinical or research support for the study from NuVasive, Integra, Intellirod, and the International Spine Study Group (ISSG); receiving royalties from Medtronic; and being a past president/chair of the SRS and American Spine Registry. Dr. Gum reports being an employee of Norton Healthcare; being a consultant to Medtronic, Acuity, K2M/Stryker, NuVasive, and Mazor; being on the speakers bureau for DePuy; receiving royalties from Acuity and NuVasive; receiving honoraria from Pacira Pharmaceuticals, Baxter, Broadwater, and the NASS; receiving clinical or research support for the study from Integra, Intellirod Spine, Pfizer, ISSG, NuVasive, and Norton Healthcare; having direct stock ownership in Cingulate Therapeutics; being a patent holder for Medtronic; and being on the Advisory/Editorial Board of K2M/Stryker, Medtronic, and the National Spine Health Foundation. Dr. Crawford reports receiving royalties from Alphatec and being a consultant to DePuy-Synthes, Medtronic, and NuVasive. Dr. Owens reports being a consultant to Medtronic and NuVasive, receiving royalties from NuVasive, and receiving support of non–study-related clinical or research from OREF, ISSG, Pfizer, Intellirod, SRS, Cerapedics, Medtronic, and Alan L. & Jacqueline B. Stuart Spine Research. Dr. Carreon reports being an employee of Norton Healthcare and the University of Southern Denmark; being a consultant for the National Spine Health Foundation; receiving support of non–study-related clinical or research effort from OREF, NIH, ISSG, SRS, TSRH, Pfizer, Lifesciences Corp., Intellirod, Cerapedics, Medtronic, Empirical Spine, and NeuroPoint Alliance; being a member of the Editorial Advisory Board for Spine Deformity, The Spine Journal, and Spine; and being a member of the University of Louisville IRB.

Author Contributions

Conception and design: Carreon, Djurasovic, Glassman, Crawford. Acquisition of data: Djurasovic, Glassman, Gum, Owens. Analysis and interpretation of data: Carreon, Djurasovic, Glassman. Drafting the article: Djurasovic. Critically revising the article: all authors. Reviewed submitted version of manuscript: Carreon, Djurasovic, Glassman, Gum, Owens. Approved the final version of the manuscript on behalf of all authors: Carreon. Statistical analysis: Carreon.

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Illustration from Mummaneni et al. (pp 13–21). Artist: Kenneth Probst. Copyright UCSF Department of Neurological Surgery. Published with permission.

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