Marshman Laurence A G, Kasis Ata, Krishna Manoj, Bhatia Chandra K
From the Department of Spinal Surgery, University Hospital of North Tees, Hardwick, Stockton on Tees, United Kingdom.
Spine (Phila Pa 1976). 2010 Mar 15;35(6):657-65. doi: 10.1097/BRS.0b013e3181bb8ebd.
Original report.
To investigate the putative negative correlation between the duration of symptoms (DOS) and outcome after surgery for chronic low back pain (CLBP).
Posterior lumbar interbody fusion (PLIF) is a well established treatment for CLBP. Anecdotally, a prolonged DOS is associated with a poor prognosis for recovery of CLBP. In one recent study, a DOS greater than 3 years predicted a poor prognosis for subsequent clinical improvement with CLBP.
Patients (n = 209) underwent PLIF for CLBP who had proven unresponsive to nonoperative management for at least 6 months. A wide variety of physical and mental outcome scores were simultaneously assessed pre- and after surgery: i.e., the Oswestry Disability Index (ODI), SF-36 body score, SF-36 mental score, Visual Analogue Score (VAS) for back pain, VAS for leg pain, Hospital Anxiety Score (HAS), and Hospital Depression Score.
Despite a prolonged mean DOS of 84.3 ± 6.6 months, there was a significant postoperative improvement in all 7 outcome scores after PLIF. Significant improvement occurred in 181 patients (i.e., 86.6%) and was sustained at 51.6 ± 12.0 months follow-up. No significant correlation was found between DOS and any outcome score (ODI: rs = 0.013, P = 0.877; SF-36 bodily pain: rs = 0.013, P = 0.87; VAS for back pain: rs = 0.038, P = 0.656; VAS for leg pain: rs = 0.086, P = 0.310; HAS: rs = 0.511, P = 0.056; Hospital Depression Score: rs = 0.056, P = 0.509, or SF-36 mental score rs = 0.007, P = 0.935). No arbitrary DOS "cut-off" was found for which significantly different outcomes were recorded either side of the cut-off; or for which a significant correlation was revealed either side of the cut-off. Finally, no significant partial correlation was found between DOS and any outcome score after controlling for pain severity (VAS(back pain)) before surgery. There were no significant differences in terms of age, sex, or DOS between those with improved ODI scores less than 10 compared with those with improved ODI scores greater than 10.
The putative negative correlation between DOS and outcome was not observed under any analysis in our study. PLIF procured a rapid and sustained improvement in CLBP, even where the DOS was excessively prolonged; and even after having allowed for pain severity. Symptom chronicity, therefore, does not represent a poor prognostic indicator for CLBP outcome after PLIF: PLIF should be considered irrespective of DOS. Because DOS and pain severity are likely mediators of "central sensitization," the hypothesis that central sensitization may be prevalent in CLBP patients selected for PLIF is therefore questioned.
原始报告。
探讨慢性下腰痛（CLBP）手术症状持续时间（DOS）与术后结果之间可能存在的负相关关系。
后路腰椎椎间融合术（PLIF）是治疗CLBP的一种成熟方法。据传闻，症状持续时间延长与CLBP恢复预后不良有关。在最近的一项研究中，症状持续时间超过3年预示着CLBP后续临床改善的预后不良。
209例因CLBP接受PLIF手术的患者，这些患者经证实对非手术治疗至少6个月无反应。术前和术后同时评估多种身体和心理结果评分，即Oswestry功能障碍指数（ODI）、SF-36身体评分、SF-36心理评分、背痛视觉模拟评分（VAS）、腿痛VAS、医院焦虑评分（HAS）和医院抑郁评分。
尽管平均症状持续时间延长至84.3±6.6个月，但PLIF术后所有7项结果评分均有显著改善。181例患者（即86.6%）有显著改善，且在51.6±12.0个月的随访中持续存在。未发现症状持续时间与任何结果评分之间存在显著相关性（ODI：rs = 0.013，P = 0.877；SF-36身体疼痛：rs = 0.013，P = 0.87；背痛VAS：rs = 0.038，P = 0.656；腿痛VAS：rs = 0.086，P = 0.310；HAS：rs = 0.511，P = 0.056；医院抑郁评分：rs = 0.056，P = 0.509，或SF-36心理评分rs = 0.007，P = 0.935）。未发现任何可区分不同结果的任意症状持续时间“临界值”；也未发现临界值两侧存在显著相关性。最后，在控制术前疼痛严重程度（背痛VAS）后，未发现症状持续时间与任何结果评分之间存在显著偏相关性。ODI评分改善小于10分的患者与ODI评分改善大于10分的患者在年龄、性别或症状持续时间方面无显著差异。
在我们的研究中，任何分析均未观察到症状持续时间与结果之间存在假定的负相关关系。PLIF即使在症状持续时间过长的情况下，甚至在考虑疼痛严重程度后，也能使CLBP迅速且持续改善。因此，症状慢性化并不代表PLIF术后CLBP结果的不良预后指标：无论症状持续时间如何，均应考虑PLIF。由于症状持续时间和疼痛严重程度可能是“中枢敏化”的介导因素，因此对中枢敏化可能在选择接受PLIF的CLBP患者中普遍存在这一假设提出质疑。
