Lumbar spinal stenosis (LSS) is a common disease for spinal surgeries among elderly adults. However, the health-related quality of life (HRQoL) after LSS has not been thoroughly investigated. In the present study, we evaluated the HRQoL after surgery in 127 patients with LSS in a Chinese population. The Medical Outcome Short Form 36 (SF-36) was used to evaluate the HRQoL before surgery and one year after the treatment. We observed improvements in all 8 domains of the HRQoL one year after discharge, though only those in two mental health domains and three physical health domains. Nevertheless, comparing with a healthy reference group, the HRQoL among these patients remained poorer in all domains. Our study suggests that surgical treatment may improve HRQoL in patients with LSS. This study also implies that the HRQoL assessment is a useful tool to assess the outcomes in patients with LSS after surgeries
|Lumbar spinal stenosis, HRQoL, Quality of life, Prognosis, Surgery.
|Lumbar spinal stenosis (LSS) is a common disease for
surgeries, which mostly affects adults aged 65 years or
above and can result in both functional problems and
severe symptoms at lower limbs. . Despite that the first
choice for the treatment of LSS is widely accepted as a
non-operative therapy, a large proportion of patients still
warrant surgical treatment if the conservative therapies are
not effective. Previous studies evaluating the prognosis
after surgeries for LSS has mainly involved routine clinical
investigations [2-5]. During the past decade, there have
been emerging studies employing health-related quality
of life (HRQoL) in assessing the outcomes in patients
with LSS after surgeries [6-8]. It has been reported that
patients with LSS had significant improvements in the
HRQoL of patients after surgical treatment, although the
scores were still lower than heathy reference populations
. Nevertheless, existing evidence remains limited and
more studies are needed to confirm these observations.
Particularly, to our best knowledge, there are scare studies
which have evaluated the HRQoL in patients with LSS
after surgeries in the Chinese population. Considering the
extremely limited evidence in Chinese populations, we
investigated the HRQoL in a group of Chinese patients with
LSS after surgical treatment with a prospective design.
|We recruited study subjects from a large public hospital
in Wuhan, China. This hospital houses one of the largest orthopedic surgery centers serving a population of over 10
million. All consecutive patients who had undergone surgical
treatment for LSS during July 2012 to December 2013 were
invited to participate. Among the 148 patients who had been
invited, 127 agreed to participate and the major reasons for
unparticipating were unwillingness  and impaired hearing
or mental problems . We performed surgical treatment, i.e.,
spinal decompression and a partial undercutting facetectomy,
in all these patients according to a standard protocol. The
specific surgical procedures were developed based on
considerations of patients’ clinical features and radiographic
and/or magnetic resonance imaging results. We also included
an age- and sex-matched reference group from out-patients
in the same hospital who underwent general health checkups
during the study period. There were 104 participants out
of 115 people who were invited, with a participation rate of
90.4%, in the reference group.
|We conducted in-person interviews with all participants to
collect basic demographic and medical information, as well
as to evaluate the HRQoL with the well validated Medical
Outcome Short Form 36 (SF-36) [9,10]. This generic tool
consists of a total of 36 items and the results can be used
to calculate separate summarizing scores for both aspects,
i.e., the physical component summary (PCS) and the mental
component summary (MCS). The first administration of the
questionnaire was performed on the first day of patients’
admission to the hospital. Patients with LSS were invited to
visit the hospital to finish the second questionnaire one year
after discharge. They were provided with a medical follow-up to improve the completeness of follow-up. Only five of
them did not participated in the second interview because
of changes of contact information and lost to follow-up.
We performed this study after being approved by the ethics
committees of the university and the hospital. In addition,
we obtained written informed consents from all participants
|We compared the measurements of HRQoL with the nonparameter
Wilcoxon’s rank sum tests. We also calculated
odds ratios (ORs) associated with a set of factors
potentially influencing the HRQoL scores one year after
surgery, together with the corresponding 95% confidence
intervals (CIs), in non-conditional logistic regressions.
Patients were dichotomized into two groups according to
the median values of HRQoL scores. Variables included in
the models are: gender, age at diagnosis (≤ 60, >60 years), education level, as well as the Roland-Morris (RM) score.
We performed all statistical analyses with the statistical
software package SAS 9.4 for windows (SAS Institute
Inc., Cary, NC, USA), and the predefined significance
level was 0.05.
|The patients group included 83 men (65.4%) and 44 women
(34.6%) with the average age at diagnosis of 60.3 (± 11.7)
years. The reference group was well matched by sex and
age. There was no substantial difference in education
level or marital status between these two groups, although
the heathy control subjects seemed to be better educated
than patients with SLL. More detailed basic and clinical
information are shown in Table 1.
|As shown in Table 2, the HRQoL in patients with LSS had evident improvements in both mental and physical
health domains one year after surgery compared with
measurements before the surgery. However, only such
improvements in two mental health domains and three
physical health domains were statistically significant.
Furthermore, the HRQoL scores remained statistically
lower in these patients who had received surgery for SLL
compared with the healthy reference population.
|Table 1: Basic and clinical information in participants
||Patients with LSS (n=127)
||Healthy controls (n=104)
|Sex, n (%)
|Age at diagnosis or interview, years
| ≥ 60
|Mean (SD), years
|Educational level, n (%)
| Less than high school
| High school or above
|Marital status, n (%)
| Married or cohabitant
| Single or divorced
|Duration of symptoms, months
| Mean (SD)
|Spinal levels involved in treatment
|LSS: lumbar spinal stenosis; SD: standard deviation
|Table 2: Health-related quality of life (mean ± standard deviation) among patients with lumbar spinal stenosis (LSS) and the healthy
||Patients with LSS
(n = 104)
(n = 127 )
|1 year after surgery
(n = 122 )
||64.4 (27.8)* #
||58.5 (21.8)* #
||52.5 (21.0) #
||48.4 (20.7)* #
||59.4 (25.7) #
||63.4 (26.2) #
||58.6 (22.4)* #
|*P<0.05 compared with measurements before treatment.
# P<0.05 compared with the reference group.
1 Role limitations due to physical health; 2 Role limitations due to emotional health.
|Results from logistic regressions showed that being aged
60 years or above was associated with a poorer physical
health outcome (adjusted OR=1.6, 95% CI: 1.1-2.3),
while men were shown to have better mental health
scores than women (adjusted OR=1.8, 95% CI: 1.0-3.2).
Severe disability as indicated by a higher RM score was
associated with lower scores on both mental and physical
health aspects, but only the association with physical
health was statistically significant (adjusted OR=1.9, 95%
|LSS is a common musculoskeletal disease closely
associated with impaired HRQoL in patients. Typical
symptoms such as server pain and numbness have been
shown to have a strong negative influence on HRQoL in
LSS patients . Surgery has been widely performed in
the treatment for LSS if the nonsurgical measures are not
effective. Previous studies have shown that the surgical
treatment was more effective than nonsurgical therapies
in both relieving symptoms and improving function .
However, whether surgical treatment could improve the
patients’ HRQoL remains inconclusive by far.
|In the present study, we have evaluated HRQoL in a
group of Chinese patients suffering from LSS after
surgical treatments with a prospective design. Our results
suggested significantly improved HRQoL in patients
with LSS one year after discharge. Such findings were
consistent with earlier lines of evidence [6-8]. This study
also confirmed the need for continuous supports for a
better HRQoL in these patients, as their HRQoL scores
remain lower than the healthy reference group in spite of
the acknowledgeable improvements.
|A major strength of this study is that we conducted face to-
face interview for HRQoL measurements both before
and one year after the treatment. Some previous studies
only conducted such interviews for the first time but
interviewed participants on telephone for a later followup
. Such differential interviewing methods might
have introduced information bias if there were systematic
differences dependent on interview methods. Further
advantages of our study include a prospective design and
the inclusion of a healthy reference group. However, there
are some limitations in our study. For example, as similar
to previous studies, we only recruited participants from a
single hospital and the results might not be generalized
to other settings or populations, particularly those
with distinct socioeconomic or clinical backgrounds.
|Furthermore, we observed increased scores for general
health, social function and role emotion, although the
differences were not statistically significant. It is probably
because the sample size of this study did not have sufficient
statistical power to detect significant findings for these
domains. More studies with larger sample sizes are still
|In summary, we have observed improved HRQoL over
time in a group of Chinese patients with LSS after surgery.
This study also highlighted the usefulness of measuring
HRQoL in evaluating prognosis after surgery for LSS. The
findings in our study still need to be further confirmed by
more investigations with larger sample sizes in external
|We appreciate all colleagues within the Department of
Orthopaedic Surgery in Wuhan Puai Hospital for their
assistance in coordinating the study and collecting data.
- Ciol MA, Deyo RA, Howell E, Kreif S. An assessment of surgery for spinal stenosis: time trends, geographic variations, complications, and reoperations. J Am Geriatr Soc 1996; 44:285-290.
- Herno A, Airaksinen O, Saari T, Sihvonen T. Surgical results of lumbar spinal stenosis. A comparison of patients with or without previous back surgery. Spine (Phila Pa 1976) 1995; 20:964-969.
- Sigmundsson FG. Determinants of outcome in lumbar spinal stenosis surgery. Acta Orthop 2014; 85:1-45.
- Omidi-Kashani F, Hasankhani EG, Ashjazadeh A. Lumbar spinal stenosis: who should be fused? An updated review. Asian Spine J 2014; 8:521-530.
- Athiviraham A, Wali ZA, Yen D. Predictive factors influencing clinical outcome with operative management of lumbar spinal stenosis. Spine J 2011; 11:613-617.
- Padua L, Padua R, Mastantuoni G, Pitta L, Caliandro P, Aulisa L. Health-related quality of life after surgical treatment for lumbar stenosis. Spine (Phila Pa 1976) 2004; 29:1670-1674.
- Schillberg B, Nystrom B. Quality of life before and after microsurgical decompression in lumbar spinal stenosis. J Spinal Disord 2000; 13:237-241.
- Hsu KY, Zucherman JF, Hartjen CA. Quality of life of lumbar stenosis-treated patients in whom the X STOP interspinous device was implanted. J Neurosurg 2006; 5:500–507.
- Sararaks S, Azman AB, Low LL, Rugayah B, Aziah AM, Hooi LN. Validity and reliability of the SF-36: the Malaysian context. Med J Malaysia 2005; 60:163-179.
- Li L, Wang HM, Shen Y. Chinese SF-36 Health Survey: translation, cultural adaptation, validation, and normalisation. J Epidemiol Community Health 2003; 57:259-263.
- Pahl MA, Brislin B, Boden S. The impact of four common lumbar spine diagnoses upon overall health status. Spine J 2006; 6:125-130.
- Kovacs FM, Urrútia G, Alarcón JD. Surgery versus conservative treatment for symptomatic lumbar spinal stenosis: a systematic review of randomized controlled trials. Spine (Phila Pa 1976) 2011; 36:E1335-1351.
- Battié MC, Jones CA, Schopflocher DP. Health-related quality of life and comorbidities associated with lumbar spinal stenosis. Spine J 2012; 12:189-195.