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1.  Recurrent Versus Primary Lumbar Disc Herniation Surgery: Patient-reported Outcomes in the Swedish Spine Register Swespine 
Lumbar disc herniation (LDH) is a common indication for lumbar spine surgery. The proportion of patients having a second surgery within 2 years varies in the literature between 0.5% and 24%, with recurrent herniation being the most common cause. Several studies have not found any relevant outcome differences between patients undergoing surgery for primary LDH and patients undergoing reoperation for a recurrent LDH, but these studies have limitations, including small sample size and retrospective design.
We (1) compared patient-reported outcomes between patients operated on for primary LDH and patients reoperated on for recurrent LDH within 1 year after index surgery and (2) determined risk factors for worse outcomes.
We obtained data from the Swedish National Spine Register, Swespine, where patient-reported outcomes are collected using mailed protocols at 1, 2, 5, and 10 years after surgery. Of the 13,562 patients identified who underwent LDH between January 2000 and May 2011, 13,305 (98%) underwent primary surgery for LDH and 257 (2%) underwent reoperation for a recurrent LDH within the first year. Patient-reported outcomes at 1 to 2 years were available for 8497 patients (63%), 8350 of 13,305 (63%) in the primary LDH group and 147 of 257 (57%) in the recurrent LDH group (p = 0.068). We compared leg and back pain (VAS: 0–100), function (Oswestry Disability Index [ODI]: 0–100), quality of life (EQ-5D: −0.59 to 1.0), patient satisfaction, and global assessment of leg pain between groups. We also analyzed rsik factors for worse global assessment and satisfaction.
Mean (95% CI) differences in improvement between groups favoring patients with primary LDH were VAS leg pain 9 (4–14), ODI 6 (3–9), and EQ-5D 0.09 (0.04–0.15). While statistically significant, these effect sizes may be lower than the minimal clinically important differences often referred to. Percentage of satisfied patients was 79% and 58% in the primary and recurrent LDH groups, respectively (p < 0.001), and percentage of patients with no or better leg pain (global assessment) was 74% and 65%, respectively (p = 0.008). Reoperation for recurrent LDH represented the largest independent risk for dissatisfaction; this factor and smoking represented similar risks for less improvement in leg pain.
Repeat surgery for a recurrent LDH was performed with good probability for improvement, although not as good as for primary LDH surgery, and patients undergoing repeated surgery were less satisfied. Studies on risk factors for recurrence are warranted.
Level of Evidence
Level II, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.
PMCID: PMC4418986  PMID: 24711131
2.  Dural lesions in decompression for lumbar spinal stenosis: incidence, risk factors and effect on outcome 
European Spine Journal  2011;21(5):825-828.
Decompression for lumbar spinal stenosis is one of the most frequent operations on the spine today. The most common complication seems to be a peroperative dural lesion. There are few prospective studies on this complication regarding incidence and effect on long-term outcome; this is the background for the current study.
Materials and methods
Swespine, the Swedish Spine Register documents the majority (>80%) of lumbar spine operations in Sweden today. Within the framework of this register, totally 3,699 operations for spinal stenosis during a 5-year period were studied regarding complications and 1-year postoperative outcome. Mean patient age was 66 (37–92) years and 44% were males. Fourteen percent were smokers and 19% had undergone previous lumbar spine surgery.
The overall incidence of a peroperative dural lesion was 7.4%, 8.5% of patients undergoing decompressive surgery only and 5.5% of patients undergoing decompressive surgery + fusion (p < 0.001). A logistic regression analysis demonstrated that (high) age (p < 0.0004), previous surgery (p < 0.036) and smoking (p < 0.049) were significantly predictive factors for dural lesions. An odds ratio estimate demonstrated an age-related risk increase with 2.7% per year. The risk for dural lesions also increased with number of levels decompressed. The 1-year outcome was identical in the two groups with and without a dural lesion.
A dural lesion was seen in 7.4% of decompressive operations for spinal stenosis. High age, previous surgery and smoking were risk factors for sustaining a lesion, which, however, did not affect the 1-year outcome negatively.
PMCID: PMC3337897  PMID: 22146791
Spinal stenosis; Complication; Surgery; Outcome
3.  Swespine: the Swedish spine register 
European Spine Journal  2013;22(4):953-974.
Swespine, the Swedish National Spine Register, has existed for 20 years and is in general use within the country since over 10 years regarding degenerative lumbar spine disorders. Today there are protocols for registering all disorders of the entire spinal column.
Materials and methods
Patient-based pre- and postoperative questionnaires, completed before surgery and at 1, 2, 5 and 10 years postoperatively. Among patient-based data are VAS pain, ODI, SF-36 and EQ-5D. Postoperatively evaluation of leg and back pain as compared to preoperatively ("global assessment"), overall satisfaction with outcome and working conditions are registered in addition to the same parameters as preoperatively evaluation. A yearly report is produced including an analytic part of a certain topic, in this issue disc prosthesis surgery.
More than 75,000 surgically treated patients are registered to date with an increasing number yearly. The present report includes 7,285 patients; 1-, 2- and 5-year follow-up data of previously operated patients are also included for lumbar disorders as well as for disc prosthesis surgery.
For the degenerative lumbar spine disorders (disc herniation, spinal stenosis, spondylolisthesis and DDD) significant improvements are seen in all aspects as exemplified by pronounced improvement regarding EQ-5D and ODI. Results seem to be stable over time. Spinal stenosis is the most common indication for spine surgery. Disc prosthesis surgery yields results on a par with fusion surgery in disc degenerative pain. The utility of spine surgery is well documented by the results.
Results of spine surgery as documented on a national basis can be utilized for quality assurance and quality improvement as well as for research purposes, documenting changes over time and bench marking when introducing new surgical techniques. A basis for international comparisons is also laid.
PMCID: PMC3631024  PMID: 23575657
Spine surgery; Outcome; Register; Disc herniation; Spondylolisthesis; Spinal stenosis
4.  Prognostic factors in lumbar spinal stenosis surgery 
Acta Orthopaedica  2012;83(5):536-542.
Background and purpose
A considerable number of patients who undergo surgery for spinal stenosis have residual symptoms and inferior function and health-related quality of life after surgery. There have been few studies on factors that may predict outcome. We tried to find predictors of outcome in surgery for spinal stenosis using patient- and imaging-related factors.
Patients and methods
109 patients in the Swedish Spine Register with central spinal stenosis that were operated on by decompression without fusion were prospectively followed up 1 year after surgery. Clinical outcome scores included the EQ-5D, the Oswestry disability index, self-estimated walking distance, and leg and back pain levels (VAS). Central dural sac area, number of levels with stenosis, and spondylolisthesis were included in the MRI analysis. Multivariable analyses were performed to search for correlation between patient-related and imaging factors and clinical outcome at 1-year follow-up.
Several factors predicted outcome statistically significantly. Duration of leg pain exceeding 2 years predicted inferior outcome in terms of leg and back pain, function, and HRLQoL. Regular and intermittent preoperative users of analgesics had higher levels of back pain at follow-up than those not using analgesics. Low preoperative function predicted low function and dissatisfaction at follow-up. Low preoperative EQ-5D scores predicted a high degree of leg and back pain. Narrow dural sac area predicted more gains in terms of back pain at follow-up and lower absolute leg pain.
Multiple factors predict outcome in spinal stenosis surgery, most importantly duration of symptoms and preoperative function. Some of these are modifiable and can be targeted. Our findings can be used in the preoperative patient information and aid the surgeon and the patient in a shared decision making process.
PMCID: PMC3488183  PMID: 23083437
5.  Correlation between disability and MRI findings in lumbar spinal stenosis 
Acta Orthopaedica  2011;82(2):204-210.
Background and purpose
MRI is the modality of choice when diagnosing spinal stenosis but it also shows that stenosis is prevalent in asymptomatic subjects over 60. The relationship between preoperative health-related quality of life, functional status, leg and back pain, and the objectively measured dural sac area in single and multilevel stenosis is unknown. We assessed this relationship in a prospective study.
Patients and methods
The cohort included 109 consecutive patients with central spinal stenosis operated on with decompressive laminectomy or laminotomy. Preoperatively, all patients completed the questionnaires for EQ-5D, SF-36, Oswestry disability index (ODI), estimated walking distance and leg and back pain (VAS). The cross-sectional area of the dural sac was measured at relevant disc levels in mm2, and spondylolisthesis was measured in mm. For comparison, the area of the most narrow level, the number of levels with dural sac area < 70 mm2, and spondylolisthesis were studied.
Before surgery, patients with central spinal stenosis had low HRLQoL and functional status, and high pain levels. Patients with multilevel stenosis had better general health (p = 0.04) and less leg and back pain despite having smaller dural sac area than patients with single-level stenosis. There was a poor correlation between walking distance, ODI, the SF-36, EQ-5D, and leg and back pain levels on the one hand and dural sac area on the other. Women more often had multilevel spinal stenosis (p = 0.05) and spondylolisthesis (p < 0.001). Spondylolisthetic patients more often had small dural sac area (p = 0.04) and multilevel stenosis (p = 0.06).
Our findings indicate that HRQoL, function, and pain measured preoperatively correlate with morphological changes on MRI to a limited extent.
PMCID: PMC3235292  PMID: 21434811
6.  Dural lesions in lumbar disc herniation surgery: incidence, risk factors, and outcome 
European Spine Journal  2009;19(3):439-442.
In lumbar disc herniation surgery, dural lesions seem to be the most common complication today. Studies on incidence of and outcome after a dural lesion are mainly based on retrospective studies. In a prospective study within the framework of the Swedish Spine Register, 4,173 patients operated on for lumbar disc herniation were evaluated using pre- and 1-year postoperative protocols and complication registration. Mean patient age was 41 (18–81) years and 53% of the patients were male. 93% of the operations were performed on the two lowermost lumbar levels. The incidence of dural lesions in the material was 2.7%. In patients with previous disc surgery, the incidence was doubled, 5%, a significant increase (P = 0.02). Patients with dural lesions preoperatively had more back pain and inferior scores in general health and role emotional domains of the SF-36. These factors, however, were because they had been operated on previously, not related to the dural lesion as such. The relative improvement after surgery was similar whether a dural lesion had occurred or not. It is concluded that a dural lesion is a technical complication which must be solved at the time of surgery but which does not bear any negative implications on the long-term outcome for the patient.
PMCID: PMC2899750  PMID: 20013002
Lumbar disc herniation; Complication; Surgery; Outcome
7.  The Swedish Spine Register: development, design and utility 
European Spine Journal  2009;18(Suppl 3):294-304.
The Swedish Spine Register enables monitoring of surgical activities focusing on changes in trends over time, techniques utilized and outcome, when implemented in general clinical practice. Basic requirements for a prosperous register are unity within the profession, mainly patient-based documentation and a well functioning support system. This presentation focuses on the development and design of the register protocol, problems encountered and solutions found underway. Various examples on how the results can be presented and utilized are given as well as validation. Register data demonstrate significant gender differences in lumbar disc herniation surgery with females having more pain, lower quality of life and more pronounced disability preoperatively while improvement after surgery is similar between genders. Quality of life after surgery for degenerative disorders is significantly improved for disc herniation, stenosis, spondylolisthesis and disc degenerative disorders. Over the last 10 years, surgical treatment for spinal stenosis has increased gradually while disc herniation surgery decreases regarding yearly number of procedures. An added function to the register enables more complex prospective clinical studies to include register data together with data suitable for the individual study. A common core set of demographic, surgical and outcome parameters would enable comparisons of clinical studies within and between nations.
PMCID: PMC2899320  PMID: 19495812
Spine Register; Development; Degenerative lumbar spine; Core data set
8.  Early neuromuscular customized training after surgery for lumbar disc herniation: a prospective controlled study 
European Spine Journal  2006;16(1):19-26.
A prospective and controlled study of training after surgery for lumbar disc herniation (LDH). The objective was to determine the effect of early neuromuscular customized training after LDH surgery. No consensus exists on the type and timing of physical rehabilitation after LDH surgery. Patients aged 15–50 years, disc prolapse at L4–L5 or L5–S1. Before surgery, at 6 weeks, 4, and 12 months postoperatively, the following evaluations were performed: low back pain and leg pain estimated on a visual analog scale, disability according to the Roland–Morris questionnaire (RMQ) and disability rating index (DRI). Clinical examination, including the SLR test, was performed using a single blind method. Consumption of analgesics was registered. Twenty-five patients started neuromuscular customized training 2 weeks after surgery (early training group=ETG). Thirty-one patients formed a control group (CG) and started traditional training after 6 weeks. There was no significant difference in pain and disability between the two training groups before surgery. Median preoperative leg pain was 63 mm in ETG and 70 mm in the CG. Preoperative median disability according to RMQ was 14 in the ETG and 14.5 in the CG. Disability according to DRI (33/56 patients) was 5.3 in the ETG vs. 4.6 in the CG. At 6 weeks, 4 months, and 12 months, pain was significantly reduced in both groups, to the same extent. Disability scores were lower in the ETG at all follow-ups, and after 12 months, the difference was significant (RMQ P=.034, DRI P=.015). The results of the present study show early neuromuscular customized training to have a superior effect on disability, with a significant difference compared to traditional training at a follow-up 12 months after surgery. No adverse effects of the early training were seen. A prospective, randomized study with a larger patient sample is warranted to ultimately demonstrate that early training as described is beneficial for patients undergoing LDH surgery.
PMCID: PMC2198880  PMID: 16421747
Lumbar disc herniation; Neuromuscular training; Neutral position; Surgery
9.  A practical approach to spine registers in Europe: the Swedish experience 
European Spine Journal  2005;15(Suppl 1):S57-S63.
Today there is growing awareness among spine surgeons of the advantages in using registers to facilitate the analyses and reporting of treatment outcome. The Swedish Spine register is among the first to be used on a national scale and annual reports are published in international journals. In this paper we discuss our experiences and lessons learned from a paper-based version in 1993, to an online web-based solution in 2005. We emphasise the advantages of registers being owned by the national spine society, a support function available during working hours, online feedback to participating departments and professional assistance in designing a register program for web use. Hopefully, our experiences will be of help to colleagues who are planning to start registering.
PMCID: PMC3454551  PMID: 16328224
Spine register; Outcome; Web-based
10.  A method to evaluate the in vivo behaviour of lumbar spine implants 
European Spine Journal  2000;9(3):230-234.
The aim of the study was to design a method for evaluating the stabilizing effect of different lumbar spine implants in vivo, and to apply this method to a comparison of plates versus rods in lumbar spine posterolateral fusion using transpedicular screw fixation. Fourteen patients, seven operated on with transpedicular plates and screws (VSP), and seven operated on with rods and screws (Diapason), matched according to number of levels fused, had tantalum markers inserted in the vertebrae at surgery, enabling roentgen stereophotogrammetric analysis (RSA). Mean patient age was 45 (range 33–56) years. In each group, two patients underwent fusion between L4 and L5, three between L5 and S1, and two from L4 to S1. In three patients, concomitant nerve root decompression was performed using a facet joint preserving technique. RSA was performed 4 weeks after surgery. This interval was chosen to allow enough time for soft tissue healing, but not fusion healing, to occur. RSA was performed in supine and standing position without any mobility provocation, in line with the postoperative regimen given. Movements between the outermost vertebrae of the fusion were calculated along the transverse, vertical and sagittal axes. The method of measurement along these three axes has previously been determined to be accurate to 0.3, 0.6 and 0.7 mm, respectively. One patient stabilized with rods and screws between L5 and S1 displayed a sagittal translation of 1.01 mm but no mobility along the transverse or vertical axes. In the remaining 13 patients, positional change from supine to standing did not provoke any intervertebral mobility above the RSA accuracy along any of the axes. With the limited provocation described, in line with the postoperative regimen for lumbar fusion patients, plates with transpedicular screws and rods with transpedicular screws both seem to give adequate intervertebral stability in posterolateral lumbar fusions.
PMCID: PMC3611399  PMID: 10905442
Key words Lumbar spine; Posterolateral fusion; Transpedicular fixation; Stereophotogrammetry; Intervertebral translation

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