European Spine Journal

, Volume 28, Issue 6, pp 1423–1432 | Cite as

Predicting clinical outcome and length of sick leave after surgery for lumbar spinal stenosis in Sweden: a multi-register evaluation

  • Hanna IderbergEmail author
  • Carl Willers
  • Fredrik Borgström
  • Rune Hedlund
  • Olle Hägg
  • Hans Möller
  • Ewald Ornstein
  • Bengt Sandén
  • Holger Stalberg
  • Hans Torevall-Larsson
  • Tycho Tullberg
  • Peter Fritzell
Original Article



Lumbar spinal stenosis (LSS) can be surgically treated, with variable outcome. Studies have linked socioeconomic factors to outcome, but no nation-wide studies have been performed. This register-based study, including all patients surgically treated for LSS during 2008–2012 in Sweden, aimed to determine predictive factors for the outcome of surgery.


Clinical and socioeconomic factors with impact on outcome in LSS surgery were identified in several high-coverage registers, e.g., the national quality registry for spine surgery (Swespine, FU-rate 70–90%). Multivariate regression analyses were conducted to assess their effect on outcome. Two patient-reported outcome measures, Global Assessment of leg pain (GA) and the Oswestry Disability Index (ODI), as well as length of sick leave after surgery were analyzed.


Clinical and socioeconomic factors significantly affected health outcome (both GA and ODI). Some predictors of a good outcome (ODI) were: being born in the EU, reporting no back pain at baseline, a high disposable income and a high educational level. Some factors predicting a worse outcome were previous surgery, having had back pain more than 2 years, having comorbidities, being a smoker, being on social welfare and being unemployed.


The study highlights the relevance of adding socioeconomic factors to clinical factors for analysis of patient-reported outcomes, although the causal pathway of most predictors’ impact is unknown. These findings should be further investigated in the perspective of treatment selection for individual LSS patients. The study also presents a foundation of case mix algorithms for predicting outcome of surgery for LSS.

Graphical abstract

These slides can be retrieved under Electronic Supplementary Material.


Lumbar spinal stenosis Regression analysis Patient-reported outcome Sick leave Prediction algorithms Spine surgery Global assessment Functional disability Socioeconomic factors Multi-register study 



The authors thank Swespine, Swedish Society of Spinal Surgery (4 s) and all participating county councils. Partial funding from Forte programme Grant 2012/1688 (“Value and choice”) is gratefully acknowledged.


Funding for this research was provided by Sveus, through the Ministry of Health and Social Affairs (Dnr S2012/8356/FS) and seven Swedish regions. Sveus is a research collaboration in which seven Swedish regions develop systems for value-based monitoring of health care. The overarching aim of Sveus is to stimulate a value-driven, efficient and patient-centered health care, and the work has been carried out for a number of different patient groups, of which spine surgery is one.

Compliance with ethical standards

Conflict of interest

HI, CW and FB are employees at Ivbar Institute (a healthcare research consultancy), which has received research grants from Sveus (county council consortium) for the submitted work. FB holds shares in Ivbar Institute. The other authors declare that they have no conflict of interest.

Supplementary material

586_2018_5842_MOESM1_ESM.pptx (208 kb)
Supplementary material 1 (PPTX 207 kb)
586_2018_5842_MOESM2_ESM.docx (92 kb)
Supplementary material 2 (DOCX 92 kb)


  1. 1.
    Amundsen T, Weber H, Lilleas F, Nordal HJ, Abdelnoor M, Magnaes B (1995) Lumbar spinal stenosis. Clinical and radiologic features. Spine (Phila Pa 1976) 20(10):1178–1186CrossRefGoogle Scholar
  2. 2.
    Stromqvist B, Fritzell P, Hagg O, Jonsson B, Sanden B, Swedish Society of Spinal S (2013) Swespine: the Swedish spine register: the 2012 report. Eur Spine J 22(4):953–974CrossRefGoogle Scholar
  3. 3.
    Weinstein JN, Tosteson TD, Lurie JD, Tosteson AN, Blood E, Hanscom B et al (2008) Surgical versus nonsurgical therapy for lumbar spinal stenosis. N Engl J Med 358(8):794–810CrossRefGoogle Scholar
  4. 4.
    Försth P, Olafsson G, Carlsson T, Frost A, Borgström F, Fritzell P et al (2016) A randomized controled trial of fusion surgery for lumbar spinal stenosis. N Engl J Med 374(15):1413–1423CrossRefGoogle Scholar
  5. 5.
    Iversen MD, Daltroy LH, Fossel AH, Katz JN (1998) The prognostic importance of patient pre-operative expectations of surgery for lumbar spinal stenosis. Patient Educ Couns 34(2):169–178CrossRefGoogle Scholar
  6. 6.
    Abbott AD, Tyni-Lenne R, Hedlund R (2010) The influence of psychological factors on pre-operative levels of pain intensity, disability and health-related quality of life in lumbar spinal fusion surgery patients. Physiotherapy 96(3):213–221CrossRefGoogle Scholar
  7. 7.
    Knutsson B, Michaelsson K, Sanden B (2013) Obesity is associated with inferior results after surgery for lumbar spinal stenosis: a study of 2633 patients from the Swedish spine register. Spine (Phila Pa 1976) 38(5):435–441CrossRefGoogle Scholar
  8. 8.
    Sanden B, Forsth P, Michaelsson K (2011) Smokers show less improvement than nonsmokers two years after surgery for lumbar spinal stenosis: a study of 4555 patients from the Swedish spine register. Spine (Phila Pa 1976) 36(13):1059–1064CrossRefGoogle Scholar
  9. 9.
    Stromqvist F, Ahmad M, Hildingsson C, Jonsson B, Stromqvist B (2008) Gender differences in lumbar disc herniation surgery. Acta Orthop 79(5):643–649CrossRefGoogle Scholar
  10. 10.
    Cobo Soriano J, Sendino Revuelta M, Fabregate Fuente M, Cimarra Diaz I, Martinez Urena P, Deglane Meneses R (2010) Predictors of outcome after decompressive lumbar surgery and instrumented posterolateral fusion. Eur Spine J 19(11):1841–1848CrossRefGoogle Scholar
  11. 11.
    Fritzell P, Hagg O, Wessberg P, Nordwall A, Swedish Lumbar Spine Study G (2001) Volvo Award Winner in Clinical Studies: lumbar fusion versus nonsurgical treatment for chronic low back pain: a multicenter randomized controlled trial from the Swedish Lumbar Spine Study Group. Spine (Phila Pa 1976) 26(23):2521–2532 (discussion 32-4) CrossRefGoogle Scholar
  12. 12.
    Fairbank JC, Couper J, Davies JB, O’Brien JP (1980) The Oswestry low back pain disability questionnaire. Physiotherapy 66(8):271–273Google Scholar
  13. 13.
    EuroQol G (1990) EuroQol—a new facility for the measurement of health-related quality of life. Health Policy 16(3):199–208CrossRefGoogle Scholar
  14. 14.
    Huskisson EC (1974) Measurement of pain. Lancet 2(7889):1127–1131CrossRefGoogle Scholar
  15. 15.
    Elixhauser A, Steiner C, Harris DR, Coffey RM (1998) Comorbidity measures for use with administrative data. Med Care 36(1):8–27CrossRefGoogle Scholar
  16. 16.
    Hermansen E, Romild UK, Austevoll IM, Solberg T, Storheim K, Brox JI et al (2017) Does surgical technique influence clinical outcome after lumbar spinal stenosis decompression? A comparative effectiveness study from the Norwegian Registry for Spine Surgery. Eur Spine J 26(2):420–427CrossRefGoogle Scholar
  17. 17.
    Mobbs RJ, Li J, Sivabalan P, Raley D, Rao PJ (2014) Outcomes after decompressive laminectomy for lumbar spinal stenosis: comparison between minimally invasive unilateral laminectomy for bilateral decompression and open laminectomy: clinical article. J Neurosurg Spine. 21(2):179–186CrossRefGoogle Scholar
  18. 18.
    Hagg O, Fritzell P, Oden A, Nordwall A, Swedish Lumbar Spine Study G (2002) Simplifying outcome measurement: evaluation of instruments for measuring outcome after fusion surgery for chronic low back pain. Spine (Phila Pa 1976) 27(11):1213–1222CrossRefGoogle Scholar
  19. 19.
    Hedlund R, Johansson C, Hagg O, Fritzell P, Tullberg T, Swedish Lumbar Spine Study G (2016) The long-term outcome of lumbar fusion in the Swedish lumbar spine study. Spine J 16(5):579–587CrossRefGoogle Scholar
  20. 20.
    Gunzburg R, Szpalski M (2003) The conservative surgical treatment of lumbar spinal stenosis in the elderly. Eur Spine J 12(Suppl 2):S176–S180CrossRefGoogle Scholar
  21. 21.
    King MT (2011) A point of minimal important difference (MID): a critique of terminology and methods. Expert Rev Pharmacoecon Outcomes Res 11(2):171–184CrossRefGoogle Scholar
  22. 22.
    Parker SL, Adogwa O, Mendenhall SK, Shau DN, Anderson WN, Cheng JS et al (2012) Determination of minimum clinically important difference (MCID) in pain, disability, and quality of life after revision fusion for symptomatic pseudoarthrosis. Spine J 12(12):1122–1128CrossRefGoogle Scholar
  23. 23.
    Ghogawala Z, Benzel EC, Amin-Hanjani S, Barker FG 2nd, Harrington JF, Magge SN et al (2004) Prospective outcomes evaluation after decompression with or without instrumented fusion for lumbar stenosis and degenerative Grade I spondylolisthesis. J Neurosurg Spine 1(3):267–272CrossRefGoogle Scholar
  24. 24.
    Herkowitz HN, Kurz LT (1991) Degenerative lumbar spondylolisthesis with spinal stenosis. A prospective study comparing decompression with decompression and intertransverse process arthrodesis. J Bone Joint Surg Am 73(6):802–808CrossRefGoogle Scholar
  25. 25.
    Forsth P, Michaelsson K, Sanden B (2013) Does fusion improve the outcome after decompressive surgery for lumbar spinal stenosis?: a two-year follow-up study involving 5390 patients. Bone Joint J 95-B(7):960–965CrossRefGoogle Scholar
  26. 26.
    Piha K, Laaksonen M, Martikainen P, Rahkonen O, Lahelma E (2010) Interrelationships between education, occupational class, income and sickness absence. Eur J Public Health 20(3):276–280CrossRefGoogle Scholar
  27. 27.
    Solberg TK, Sorlie A, Sjaavik K, Nygaard OP, Ingebrigtsen T (2011) Would loss to follow-up bias the outcome evaluation of patients operated for degenerative disorders of the lumbar spine? Acta Orthop 82(1):56–63CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  • Hanna Iderberg
    • 1
    • 2
    Email author
  • Carl Willers
    • 1
    • 3
  • Fredrik Borgström
    • 1
    • 2
  • Rune Hedlund
    • 4
  • Olle Hägg
    • 5
  • Hans Möller
    • 6
  • Ewald Ornstein
    • 7
  • Bengt Sandén
    • 8
  • Holger Stalberg
    • 9
  • Hans Torevall-Larsson
    • 10
  • Tycho Tullberg
    • 11
  • Peter Fritzell
    • 12
    • 13
  1. 1.Ivbar InstituteStockholmSweden
  2. 2.Department of Learning, Informatics, Management and Ethics, Medical Management CentreKarolinska InstitutetStockholmSweden
  3. 3.Department for Clinical Science and EducationKarolinska InstitutetStockholmSweden
  4. 4.Department of OrthopaedicsSahlgrenska University HospitalGothenburgSweden
  5. 5.Spine Center GöteborgGothenburgSweden
  6. 6.Department of Clinical Sciences, Intervention and Technology (CLINTEC)Karolinska InstitutetStockholmSweden
  7. 7.Department of OrthopaedicsÖrebro University HosiptalÖrebroSweden
  8. 8.Section of Orthopedics, Department of Surgical SciencesUppsala UniversityUppsalaSweden
  9. 9.Hälso- o. sjukvårdsförvaltningen, Stockholm County CouncilStockholmSweden
  10. 10.Falu LasarettFalunSweden
  11. 11.Stockholm Spine Center ABLöwenströmska SjukhusetUpplands VäsbySweden
  12. 12.Futurum AcademyJönköpingSweden
  13. 13.S:t Göran HospitalStockholmSweden

Personalised recommendations