At NASS: Is Spine Surgery More Risky or Less Successful Than Knee and Hip Replacement?

This year, the North American Spine Society (NASS) found itself—and about 3,000 attendees—in New Orleans, La., for its 28th annual meeting. Anyone who’s been to New Orleans before knows that the city’s oft-quoted, yet unofficial motto is “Laissez les bons temps rouler!” or “Let the good times roll.”

Perhaps if you’ve let the good times roll just a bit too much, you could find yourself with a wrenched back or wobbly knee—and then be facing surgery for one or the other. But which procedure is safer?

The results of a new study presented during NASS refutes the commonly-held belief that routine spine surgery is more prone to “fail” or be more dangerous than popular knee and hip replacement surgeries.

“Thanks to misplaced fear and a mistaken belief, millions of patients are living with daily pain from spinal stenosis, a very treatable condition,” said Eeric Truumees, M.D., an Austin, Texsas-based orthopedic surgeon and NASS Annual Meeting Program Co-Chair. “This study demonstrates that properly indicated and performed spine surgery has a high long-term success rate, similar to that of popular knee and hip replacement surgeries.”

This study, “Comparative Outcomes and Cost Utility Following Surgical Treatment of Focal Lumbar Spinal Stenosis Compared with Osteoarthritis of the Hip or Knee: Part 1. Long-Term Change in Health-Related Quality of Life and Part 2. Estimated Lifetime Incremental Cost-Utility Ratios,” was awarded a 2013 “Outstanding Paper Award” from The Spine Journal.

The researchers assessed whether the early improvements in health-related quality of life (HRQoL) following surgical management of focal symptomatic spinal stenosis (FLSS) with or without spondylolisthesis (a condition in which a vertebra in the spine slips out of the proper position onto the bone below it) is sustainable over the long-term compared to total hip arthroplasty/total knee arthroplasty (THA/TKA) for osteoarthritis (OA).

Warning: Prepare yourself for a lot of data and research jargon …

Researchers performed a prospective, observational cohort study, (with a minimum five-year follow-up), of patients who had a primary one- to two-level spinal decompression with or without instrumented fusion for FLSS and THA/TKA for primary osteoarthritis. To measure postoperative change from baseline to last follow-up in SF-36 physical component summary (PCS) scores and mental component summary (MCS) scores between groups were used as the primary outcome measures. An age, sex-matched inception cohort of primary 1-2 level spinal decompression with or without instrumented fusion for FLSS (n=99) was compared to a cohort of primary THA (n=99) and TKA (n=99) for OA and followed for a minimum of five years.

Mean follow-up in months and (percent follow-up) was 80.5 + 16.04 (79 percent), 94.6 + 16.62 (92 percent) and 80.6 + 16.84 (85 percent) for the FLSS, THA and TKA cohorts respectively, with a range of five to 10 years for all three cohorts. Postoperative PCS (p<0.0001) and MCS (p<0.02) improved significantly for all groups at median five years and at the last follow-up. The proportion of patients reaching minimal clinically important differences (MCID) for PCS was not significantly different between cohorts (p=0.30: FLSS, 61 percent; H-OA, 68 percent; K-OA, 57 percent) at the last follow-up. Similar unadjusted MCID proportions were noted at the median five-year period (p=0.11: FLSS, 62 percent; H-OA, 75 percent; K-OA, 65 percent).

Adjusting for baseline age, sex, body mass index, PCS and MCS, there was no statistically significant difference in the change from baseline PCS or MCS to last follow-up between groups. The change from baseline was significantly greater in the H-OA cohort for both PCS (p=0.003) and MCS (p=0.007) for the H-OA versus FLSS at a median at five years. The proportion of patients reaching PCS-MCID or greater was not significantly different between groups at the last follow-up or at the five-year median follow-up.

The researchers concluded that significant improvement in health-related quality of life following surgical treatment of focal symptomatic spinal stenosis with or without spondylolisthesis, hip and knee osteoarthritis is sustained to a mean of seven to eight years with a minimum of five-year follow-up. The long-term change in HRQoL from baseline and the proportion of patients reaching MCID for PCS was comparable across all three cohorts at a mean of seven to eight years.

Bottom line? Back surgery doesn’t seem to warrant its stigma and appears to have the same quality of outcomes as knee and hip replacement procedures. Researchers did note that no specific devices or drugs were evaluated.

The study’s authors are:
Part 1: Raja Y. Rampersaud, M.D., FRCSC; Stephen J. Lewis, M.D.; Rajiv Gandhi, M.D.; Roderick Davey, M.D., FRCSC and Nizar Mahomed, M.D.

Part 2: Raja Y. Rampersaud, M.D., FRCSC ; Peggy Tso, BHSc, MSc Candidate; Kevin Walker, BSc, MSc; Stephen J. Lewis, M.D., FRCSC1; Rajiv Gandhi, M.D., FRCSC; Roderick Davey, M.D., FRCSC; Nizar Mahomed, M.D., Sc.D., FRCSC; Peter Coyte MA, Ph.D.