Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands.
Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands; Menzies Health Institute Queensland, Griffith University, Brisbane, Gold Coast, Australia; School of Health Sciences and Social Work, Griffith University, Brisbane, Gold Coast, Australia.
Clin Neurol Neurosurg. 2023 Jan;224:107551. doi: 10.1016/j.clineuro.2022.107551. Epub 2022 Dec 6.
The clinical course of lumbar radiculopathy following microdiscectomy and post-operative physiotherapy varies substantially. No prior studies assessed this variability by deriving outcome trajectories. The primary aims of this study were to evaluate the variability in long-term recovery after lumbar microdiscectomy followed by post-operative physiotherapy and to identify outcome trajectories. The secondary aim was to assess whether demographic, clinical characteristics and patient-reported outcome measures routinely collected at baseline could predict poor outcome trajectories.
We conducted a prospective cohort study with a 24-month follow-up. We included 479 patients with clinical signs and symptoms of lumbar radiculopathy confirmed by Magnetic Resonance Imaging findings, who underwent microdiscectomy and post-operative physiotherapy. Outcomes were leg pain and back pain measured with Visual Analogue Scales, and disability measured with the Roland-Morris Disability Questionnaire. Descriptive statistics were performed to present the average and the individual clinical course. A latent class trajectory analysis was conducted to identify leg pain, back pain, and disability outcome trajectories. The best number of clusters was determined using the Bayesian Information Criterion, Akaike's information criteria, entropy, and overall interpretability. Prediction models for poor outcome trajectories were assessed using multivariable logistic regression analyses.
Several outcome trajectories were identified. Most patients were assigned to the 'large improvement' trajectory (leg pain: 79.3%; back pain: 70.2%; disability: 59.5% of patients). Smaller proportions of patients were assigned to the 'moderate improvement' trajectory (leg pain: 7.9%; back pain: 10.6%; disability: 20.7% of patients), the 'minimal improvement' trajectory (leg pain: 4.9%, back pain: 6.7%, disability: 16.3% of patients) and the 'relapse' trajectory (leg pain: 7.9%; back pain: 12.5%; disability: 3.5%). Approximately one-third of patients (32.6%) belonged to one or more than one poor outcome trajectory. Patients with previous treatment (prior back surgery, injection therapy, and medication use) and those who had higher baseline pain and disability scores were more likely to belong to the poor outcome trajectories in comparison to the large improvement trajectories in back pain, leg pain and disability, and the moderate improvement trajectory in disability. The explained variance (Nagelkerke R2) of the prediction models ranged from 0.06 to 0.13 and the discriminative ability (Area Under the Curve) from 0.66 to 0.73.
The clinical course of lumbar radiculopathy varied following microdiscectomy and post-operative physiotherapy, and several outcome trajectories could be identified. Although most patients were allocated to favorable trajectories, one in three patients was assigned to one or more poor outcome trajectories following microdiscectomy and post-operative physiotherapy for lumbar radiculopathy. Routinely gathered data were unable to predict the poor outcome trajectories accurately. Prior to surgery, clinicians should discuss the high variability and the distinctive subgroups that are present in the clinical course with their patients.
腰椎间盘突出症患者在接受微创手术和术后物理治疗后，其临床病程存在很大差异。之前没有研究通过得出结果轨迹来评估这种可变性。本研究的主要目的是评估腰椎间盘突出症患者接受微创手术和术后物理治疗后的长期恢复情况，并确定结果轨迹。次要目的是评估基线时常规收集的人口统计学、临床特征和患者报告的结果测量是否可以预测不良结果轨迹。
我们进行了一项前瞻性队列研究，随访时间为 24 个月。我们纳入了 479 例经磁共振成像（MRI）证实存在腰椎神经根病临床症状和体征的患者，他们接受了微创手术和术后物理治疗。采用视觉模拟量表（VAS）测量腿部疼痛和背部疼痛，采用 Roland-Morris 残疾问卷（Roland-Morris Disability Questionnaire）测量残疾。采用描述性统计方法展示平均和个体临床病程。采用潜在类别轨迹分析（latent class trajectory analysis）确定腿部疼痛、背部疼痛和残疾结果轨迹。使用贝叶斯信息准则（Bayesian Information Criterion）、赤池信息量准则（Akaike's information criteria）、熵（entropy）和整体可解释性来确定最佳聚类数。使用多变量逻辑回归分析评估不良结果轨迹的预测模型。
确定了几种结果轨迹。大多数患者被分配到“明显改善”轨迹（腿部疼痛：79.3%；背部疼痛：70.2%；残疾：59.5%的患者）。较小比例的患者被分配到“中度改善”轨迹（腿部疼痛：7.9%；背部疼痛：10.6%；残疾：20.7%的患者）、“轻度改善”轨迹（腿部疼痛：4.9%，背部疼痛：6.7%，残疾：16.3%的患者）和“复发”轨迹（腿部疼痛：7.9%；背部疼痛：12.5%；残疾：3.5%）。大约三分之一的患者（32.6%）属于一种或多种不良结果轨迹。与“明显改善”的背部疼痛、腿部疼痛和残疾轨迹以及“中度改善”的残疾轨迹相比，有先前治疗（先前的背部手术、注射治疗和药物使用）的患者和基线时疼痛和残疾评分较高的患者更有可能属于不良结果轨迹。预测模型的解释方差（Nagelkerke R2）范围为 0.06 至 0.13，判别能力（曲线下面积）为 0.66 至 0.73。
腰椎间盘突出症患者在接受微创手术和术后物理治疗后，其临床病程存在差异，可以确定几种结果轨迹。尽管大多数患者被分配到有利的轨迹，但三分之一的患者在接受微创手术和术后物理治疗后，腿部疼痛、背部疼痛和残疾的轨迹为“明显改善”，而残疾的轨迹为“中度改善”。常规收集的数据无法准确预测不良结果轨迹。在手术前，临床医生应与患者讨论手术过程中存在的高变异性和不同亚组。
