INTRODUCTION
Conservative therapy is considered the first-line treatment for lumbar degenerative spondylolisthesis (LDS). Failure to relieve the patient's pain and symptoms often leads to a change in course, to surgical treatment. It is not clear at the start of treatment which patients will experience good results with a non-surgical approach, and which will ultimately go on to require surgery. The aim of this study was to investigate whether baseline patient characteristics could statistically predict the change from non-surgical to surgical treatment over the course of a year.
METHODS
This was a retrospective analysis of data collected prospectively during a multicentre observational study of patients with LDS. The course of treatment was decided upon between the patient and their physician and typically comprised (but was not limited to) physical therapy, steroid infiltrations and/or pain medication. Patients were followed-up by questionnaire and examination of the clinic information system. Patient baseline variables, including clinical characteristics as well as patient-rated variables (Core Yellow Flags Index (CYFI; scaled 1-5) and Core Outcome Measures Index (COMI; scaled 0-10)), were analysed using multiple logistic regression to identify factors associated with cross-over from conservative to surgical treatment by the time of the 12- month follow-up.
RESULTS
347 patients included in the original study began conservative treatment. Of these, 238 (69±9y, 72% female) had a complete dataset, including 12-month follow-up data, and were analysed: 65 had undergone surgery before the 12-month follow-up was reached, while 173 had pursued non-surgical therapy. The presence of radicular pain (OR=3.44, 95% CI=1.62-7.78) and higher kinesiophobia scores (OR 1.45, 95% CI=1.10-1.92) were significantly associated with undergoing surgery (p<0.01), as were clinician-determined relevant instability (OR=2.44, 95% CI=1.25-4.92), higher intensities of patient-reported leg/buttock pain (OR=1.19, 95% CI=1.05-1.38) and more severe comorbidity (OR=1.99, 95% CI=1.02-3.90) (p<0.05). Age, sex, the presence of foraminal or central stenosis or of neurological abnormality, the severity of disability and the Meyerding grade of LDS were not independently associated with changing the treatment course.
DISCUSSION
Patients with radicular pain and higher intensities of leg/buttock pain, and presenting with instability, more severe comorbidities and kinesiophobia, were more likely to fail conservative treatment and undergo surgery than were other patients. These factors should potentially be taken into account by healthcare providers when discussing treatment options and in managing patients' expectations of the future course of their spinal disorder.