Suri Pradeep, Carlson M Jake, Rainville James
VA Puget Sound Healthcare System, 1660 S Columbian Way, RCS-117, Seattle, WA, 98108, USA,
Clin Orthop Relat Res. 2015 Jun;473(6):1931-9. doi: 10.1007/s11999-014-3677-8.
Prior studies of nonoperative treatment for lumbosacral radiculopathy have identified potential predictors of treatment failure, defined by persistent pain, persistent disability, lack of recovery, or subsequent surgery. However, few predictors have been replicated, with the exception of higher leg pain intensity, as a predictor of subsequent surgery.
QUESTIONS/PURPOSES: We asked two research questions: (1) Does higher baseline leg pain intensity predict subsequent lumbar surgery? (2) Can other previously identified "candidate" predictors of nonoperative treatment failure be replicated?
Between January 2008 and March 2009, 154 participants with acute lumbosacral radicular pain were enrolled in a prospective database; 128 participants (83%) received nonoperative treatment and 26 (17%) received surgery over 2-year followup. Ninety-four nonoperative participants (73%) responded to followup questionnaires. We examined associations between previously identified "candidate" predictors and treatment failure defined as (1) subsequent surgery; (2) persistent leg pain on a visual analog scale; (3) persistent disability on the Oswestry Disability Index; or (4) participant-reported lack of recovery over 2-year followup. Confounding variables including sociodemographics, clinical factors, and imaging characteristics were evaluated using an exploratory bivariate analysis followed by a multivariate analysis.
With the numbers available, higher baseline leg pain intensity was not an independent predictor of subsequent surgery (adjusted odds ratio [aOR], 1.22 per point of baseline leg pain; 95% confidence interval [CI], 0.98-1.53; p = 0.08). Prior low back pain (aOR, 4.79; 95% CI, 1.01-22.7; p = 0.05) and a positive straight leg raise test (aOR, 4.38; 95% CI, 1.60-11.9; p = 0.004) predicted subsequent surgery. Workers compensation claims predicted persistent leg pain (aOR, 9.04; 95% CI, 1.01-81; p = 0.05) and disability (aOR, 5.99; 95% CI, 1.09-32.7; p = 0.04). Female sex predicted persistent disability (aOR, 3.16; 95% CI, 1.03-9.69; p = 0.05) and perceived lack of recovery (aOR, 2.44; 95% CI, 1.02-5.84; p = 0.05).
Higher baseline leg pain intensity was not confirmed as a predictor of subsequent surgery. However, the directionality of the association seen was consistent with prior reports, suggesting Type II error as a possible explanation; larger studies are needed to further examine this relationship. Clinicians should be aware of potential factors that may predict nonoperative treatment failure, including prior low back pain or a positive straight leg raise test as predictors of subsequent surgery, workers compensation claims as predictors of persistent leg pain and disability, and female sex as a predictor of persistent disability and lack of recovery.
Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.
先前关于腰骶神经根病非手术治疗的研究已确定了治疗失败的潜在预测因素，治疗失败定义为持续疼痛、持续残疾、未恢复或后续手术。然而，除了较高的腿部疼痛强度作为后续手术的预测因素外，很少有预测因素得到重复验证。
问题/目的：我们提出了两个研究问题：（1）较高的基线腿部疼痛强度是否能预测后续的腰椎手术？（2）其他先前确定的非手术治疗失败的“候选”预测因素能否得到重复验证？
在2008年1月至2009年3月期间，154名急性腰骶神经根性疼痛患者被纳入一个前瞻性数据库；在2年的随访中，128名患者（83%）接受了非手术治疗，26名患者（17%）接受了手术。94名接受非手术治疗的患者（73%）回复了随访问卷。我们研究了先前确定的“候选”预测因素与治疗失败之间的关联，治疗失败定义为：（1）后续手术；（2）视觉模拟量表上的持续腿部疼痛；（3）Oswestry功能障碍指数上的持续残疾；或（4）患者报告在2年随访中未恢复。使用探索性双变量分析随后进行多变量分析来评估包括社会人口统计学、临床因素和影像学特征在内的混杂变量。
就现有数据而言，较高的基线腿部疼痛强度不是后续手术的独立预测因素（调整后的优势比[aOR]，基线腿部疼痛每增加1分，aOR为1.22；95%置信区间[CI]，0.98 - 1.53；p = 0.08）。既往腰痛（aOR，4.79；95% CI，1.01 - 22.7；p = 0.05）和直腿抬高试验阳性（aOR，4.38；95% CI，1.60 - 11.9；p = 0.004）可预测后续手术。工伤赔偿申请可预测持续腿部疼痛（aOR，9.04；95% CI，1.01 - 81；p = 0.05）和残疾（aOR，5.99；95% CI，1.09 - 32.7；p = 0.04）。女性可预测持续残疾（aOR，3.16；95% CI，1.03 - 9.69；p = 0.05）和感觉未恢复（aOR，2.44；95% CI，1.02 - 5.84；p = 0.05）。
较高的基线腿部疼痛强度未被证实为后续手术的预测因素。然而，所观察到的关联方向与先前报告一致，提示可能存在II类错误；需要更大规模的研究来进一步检验这种关系。临床医生应意识到可能预测非手术治疗失败的潜在因素，包括既往腰痛或直腿抬高试验阳性作为后续手术的预测因素、工伤赔偿申请作为持续腿部疼痛和残疾的预测因素以及女性作为持续残疾和未恢复的预测因素。
II级，预后研究。有关证据水平的完整描述，请参阅作者指南。
