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Original Investigation
March 7, 2018

Development and Validation of a Prediction Model for Pain and Functional Outcomes After Lumbar Spine Surgery

Author Affiliations
  • 1Surgical Outcomes Research Center, University of Washington, Seattle
  • 2Department of Orthopaedic and Sports Medicine, University of Washington, Seattle
  • 3Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington
  • 4Valley Medical Center, Renton, Washington
  • 5Skagit Northwest Orthopedics, Proliance Surgeons, Inc, Mount Vernon, Washington
  • 6Franciscan Neurosurgery Associates at St Joseph, CHI Franciscan Health, Tacoma, Washington
  • 7Rainier Orthopedic Institute, Proliance Surgeons, Inc, Puyallup, Washington
  • 8Department of Anesthesiology and Pain Medicine, University of Washington, Seattle
  • 9Department of Surgery, University of Washington, Seattle
JAMA Surg. Published online March 7, 2018. doi:10.1001/jamasurg.2018.0072
Key Points

Question  Which patients are most likely to have improvement in function, back pain, and leg pain after lumbar fusion surgery?

Findings  Using statewide prospective data from 15 hospitals and 1965 adult surgical candidates, 3 prediction tools were generated to predict the likelihood of improvements in function, back pain, and leg pain after lumbar fusion surgery. The predictive ability and calibration of these predictive tools were confirmed in a validation cohort.

Meaning  These predictive tools could be incorporated into decision-making activities in the clinic and may be helpful in managing expectations for patients considering lumbar fusion surgeries.


Importance  Functional impairment and pain are common indications for the initiation of lumbar spine surgery, but information about expected improvement in these patient-reported outcome (PRO) domains is not readily available to most patients and clinicians considering this type of surgery.

Objective  To assess population-level PRO response after lumbar spine surgery, and develop/validate a prediction tool for PRO improvement.

Design, Setting, and Participants  This statewide multicenter cohort was based at 15 Washington state hospitals representing approximately 75% of the state’s spine fusion procedures. The Spine Surgical Care and Outcomes Assessment Program and the survey center at the Comparative Effectiveness Translational Network prospectively collected clinical and PRO data from adult candidates for lumbar surgery, preoperatively and postoperatively, between 2012 and 2016. Prediction models were derived for PRO improvement 1 year after lumbar fusion surgeries on a random sample of 85% of the data and were validated in the remaining 15%. Surgical candidates from 2012 through 2015 were included; follow-up surveying continued until December 31, 2016, and data analysis was completed from July 2016 to April 2017.

Main Outcomes and Measures  Functional improvement, defined as a reduction in Oswestry Disability Index score of 15 points or more; and back pain and leg pain improvement, defined a reduction in Numeric Rating Scale score of 2 points or more.

Results  A total of 1965 adult lumbar surgical candidates (mean [SD] age, 61.3 [12.5] years; 944 [59.6%] female) completed baseline surveys before surgery and at least 1 postoperative follow-up survey within 3 years. Of these, 1583 (80.6%) underwent elective lumbar fusion procedures; 1223 (77.3%) had stenosis, and 1033 (65.3%) had spondylolisthesis. Twelve-month follow-up participation rates for each outcome were between 66% and 70%. Improvements were reported in function, back pain, and leg pain at 12 months by 306 of 528 surgical patients (58.0%), 616 of 899 patients (68.5%), and 355 of 464 patients (76.5%), respectively, whose baseline scores indicated moderate to severe symptoms. Among nonoperative patients, 35 (43.8%), 47 (53.4%), and 53 (63.9%) reported improvements in function, back pain, and leg pain, respectively. Demographic and clinical characteristics included in the final prediction models were age, sex, race, insurance status, American Society of Anesthesiologists score, smoking status, diagnoses, prior surgery, prescription opioid use, asthma, and baseline PRO scores. The models had good predictive performance in the validation cohort (concordance statistic, 0.66-0.79) and were incorporated into a patient-facing, web-based interactive tool (https://becertain.shinyapps.io/lumbar_fusion_calculator).

Conclusions and Relevance  The PRO response prediction tool, informed by population-level data, explained most of the variability in pain reduction and functional improvement after surgery. Giving patients accurate information about their likelihood of outcomes may be a helpful component in surgery decision making.