Passias Peter G, Poorman Gregory, Lurie Jon, Zhao Wenyan, Morgan Tamara, Horn Samantha, Bess Robert Shay, Lafage Virginie, Gerling Michael, Errico Thomas J
New York Spine Institute, NYU Langone Orthopedic Hospital, New York, NY.
The Dartmouth Institute for Health Policy and Clinical Practice (J.L. and T.M.), and Department of Biomedical Data Sciences (W.Z.), Geisel School of Medicine at Dartmouth, Hanover, New Hampshire.
JB JS Open Access. 2018 May 8;3(2):e0051. doi: 10.2106/JBJS.OA.17.00051. eCollection 2018 Jun 28.
Factors that are relevant to the decision regarding the use of surgical treatment for degenerative spondylolisthesis include disease-state severity and patient quality-of-life expectations. Some factors may not be easily appraised by the surgeon. In prospective trials involving patients undergoing nonoperative and operative treatment, there are instances of crossover in which patients from the nonoperative group undergo surgery. Identifying and understanding patient characteristics that may influence crossover from nonoperative to operative treatment will aid understanding of what motivates patients toward pursuing surgery.
Patients with degenerative spondylolisthesis who were randomized to nonoperative care in a prospective, multicenter study were evaluated over 8 years of enrollment. Two cohorts were defined: (1) the surgery cohort (patients who underwent surgery at any point) and (2) the nonoperative cohort (patients who did not undergo surgery). A Cox proportional hazards model, modeling time to surgery, was used to explore demographic data, clinical diagnoses, and patient expectations and attitudes after adjusting for other variables. A subanalysis was performed on surgery within 6 months after enrollment and surgery >6 months after enrollment.
One hundred and forty-five patients who had been randomized to nonoperative treatment, 80 of whom crossed over to surgery, were included. In analyzing baseline differences between the 2 cohorts, patients who underwent surgery were younger; however, there were no significant difference between the cohorts in terms of race, sex, or comorbidities. Treatment preference, greater Oswestry Disability Index score, marital status, and no joint problems were predictors of crossover to surgery. Clinical factors, including stenosis, neurological deficits, and listhesis levels, did not show a significant relationship with crossover. At the time of long-term follow-up, the surgery cohort showed significantly greater long-term improvement in health-related quality of life (p < 0.001). The difference was maintained throughout follow-up.
Neurological symptoms and diagnoses, including listhesis and stenosis severity, did not predict crossover from nonoperative care to surgery. Attitudes toward surgery, greater Oswestry Disability Index score, marital status, and no joint problems were independent predictors of crossover from nonoperative to operative care. Certain demographic characteristics were associated with higher rates of crossover, although they were connected to patient attitudes toward surgery.
Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
与决定是否采用手术治疗退变性腰椎滑脱症相关的因素包括疾病严重程度和患者的生活质量期望。有些因素外科医生可能难以评估。在涉及接受非手术和手术治疗患者的前瞻性试验中，存在交叉情况，即非手术组的患者接受了手术。识别和理解可能影响从非手术治疗转向手术治疗的患者特征，将有助于理解促使患者寻求手术的因素。
在一项前瞻性多中心研究中，对随机分配接受非手术治疗的退变性腰椎滑脱症患者进行了8年的随访评估。定义了两个队列：（1）手术队列（在任何时间点接受手术的患者）和（2）非手术队列（未接受手术的患者）。使用Cox比例风险模型对手术时间进行建模，在调整其他变量后，探索人口统计学数据、临床诊断以及患者的期望和态度。对入组后6个月内的手术和入组后>6个月的手术进行了亚分析。
纳入了145例随机分配接受非手术治疗的患者，其中80例转而接受了手术。在分析两个队列的基线差异时，接受手术的患者更年轻；然而，在种族、性别或合并症方面，队列之间没有显著差异。治疗偏好、更高的Oswestry功能障碍指数评分、婚姻状况以及无关节问题是转向手术治疗的预测因素。包括狭窄、神经功能缺损和滑脱程度在内的临床因素与交叉情况没有显著关系。在长期随访时，手术队列在健康相关生活质量方面显示出显著更大的长期改善（p < 0.001）。这种差异在整个随访过程中一直存在。
神经症状和诊断，包括滑脱和狭窄的严重程度，不能预测从非手术治疗转向手术治疗的情况。对手术的态度、更高的Oswestry功能障碍指数评分、婚姻状况以及无关节问题是从非手术治疗转向手术治疗的独立预测因素。某些人口统计学特征与更高的交叉率相关，尽管它们与患者对手术的态度有关。
预后II级。有关证据水平的完整描述，请参阅作者须知。
