European Spine Journal

, Volume 20, Issue 10, pp 1626–1634 | Cite as

Leg pain and psychological variables predict outcome 2–3 years after lumbar fusion surgery

  • Allan D. AbbottEmail author
  • Raija Tyni-Lenné
  • Rune Hedlund
Original Article


Prediction studies testing a thorough range of psychological variables in addition to demographic, work-related and clinical variables are lacking in lumbar fusion surgery research. This prospective cohort study aimed at examining predictions of functional disability, back pain and health-related quality of life (HRQOL) 2–3 years after lumbar fusion by regressing nonlinear relations in a multivariate predictive model of pre-surgical variables. Before and 2–3 years after lumbar fusion surgery, patients completed measures investigating demographics, work-related variables, clinical variables, functional self-efficacy, outcome expectancy, fear of movement/(re)injury, mental health and pain coping. Categorical regression with optimal scaling transformation, elastic net regularization and bootstrapping were used to investigate predictor variables and address predictive model validity. The most parsimonious and stable subset of pre-surgical predictor variables explained 41.6, 36.0 and 25.6% of the variance in functional disability, back pain intensity and HRQOL 2–3 years after lumbar fusion. Pre-surgical control over pain significantly predicted functional disability and HRQOL. Pre-surgical catastrophizing and leg pain intensity significantly predicted functional disability and back pain while the pre-surgical straight leg raise significantly predicted back pain. Post-operative psychomotor therapy also significantly predicted functional disability while pre-surgical outcome expectations significantly predicted HRQOL. For the median dichotomised classification of functional disability, back pain intensity and HRQOL levels 2–3 years post-surgery, the discriminative ability of the prediction models was of good quality. The results demonstrate the importance of pre-surgical psychological factors, leg pain intensity, straight leg raise and post-operative psychomotor therapy in the predictions of functional disability, back pain and HRQOL-related outcomes.


Disability Pain Predictors Quality of life Spinal fusion 



This study was funded by a research grant obtained from the Health Care Sciences Postgraduate School, Karolinska Institute.

Conflict of interest



  1. 1.
    Abbott AD, Tyni-Lenné R, Hedlund R (2010) The influence of psychological factors on pre-operative levels of pain intensity, disability and HRQOL in lumbar spinal fusion surgery patients. Physiotherapy 96(3):213–221Google Scholar
  2. 2.
    Abbott AD, Tyni-Lenné R, Hedlund R (2010) Early rehabilitation targeting cognition, behaviour and motor function after lumbar fusion. A randomized controlled trial. Spine 35(8):848–857PubMedCrossRefGoogle Scholar
  3. 3.
    Block AR, Ohnmeiss DD, Guyer RD et al (2001) The use of presurgical psychological screening to predict the outcome of spine surgery. Spine J 1:274–282PubMedCrossRefGoogle Scholar
  4. 4.
    Christensen F, Laurberg I, Bunger C (2003) Importance of the back-café concept to rehabilitation after lumbar spinal fusion: a randomised clinical study with a 2-year follow-up. Spine 28:2561–2569PubMedCrossRefGoogle Scholar
  5. 5.
    de Groot KI, Boeke S, Passchier J (1999) Preoperative expectations of pain and recovery in relation to postoperative disappointment in patients undergoing lumbar surgery. Med Care 37:149–156PubMedCrossRefGoogle Scholar
  6. 6.
    Devillé WL, van der Windt DA, Dzaferagic A et al (2000) The test of Laségue: a systematic review of accuracy in diagnosing herniated discs. Spine 25:1140–1147PubMedCrossRefGoogle Scholar
  7. 7.
    Dolan P (1997) Modelling valuations for EuroQol health states. Med Care 35:1095–1108PubMedCrossRefGoogle Scholar
  8. 8.
    Efron BE (1983) Estimating the error rate of a prediction rule: improvements in cross-validation. J Am Stat Assoc 78:313–316CrossRefGoogle Scholar
  9. 9.
    Ekman P, Möller H, Hedlund R (2009) Predictive factors for the outcome of fusion in adult isthmic spondylolisthesis. Spine 11:1204–1210CrossRefGoogle Scholar
  10. 10.
    Elfving B (2006) Back Beleifs Questionnaire (BBQ) Translation to Swedish and pilot test of reliability and validity. Nordisk Fysioterapi 10:1–12Google Scholar
  11. 11.
    Estlander A, Vanharanta H, Moneta G et al (1994) Anthropometric variables, self-efficacy beliefs, and pain and disability ratings on the isokinetic performance of low back pain patients. Spine 19:941–947PubMedCrossRefGoogle Scholar
  12. 12.
    Group EuroQol (1990) EuroQol—a new facility for the measurement of health related quality of life. Health Policy 16:199–208CrossRefGoogle Scholar
  13. 13.
    Fairbank JC, Couper J, Davies JB et al (1980) The Oswestry low back pain disability questionnaire. Physiotherapy 66:271–273PubMedGoogle Scholar
  14. 14.
    Fairbank JC, Pynsent PB (2000) The Oswestry Disability Index. Spine 25:2940–2953PubMedCrossRefGoogle Scholar
  15. 15.
    Gifi A (1990) Nonlinear multivariate analysis, 2nd edn. Wiley, ChilchesterGoogle Scholar
  16. 16.
    Grotle M, Brox JI, Vollestad NK (2003) Cross-cultural adaptation of the Norwegian versions of the Roland-Morris Disability Questionnaire and the Oswestry Disability Index. J Rehab Med 35:241–247CrossRefGoogle Scholar
  17. 17.
    Huskisson EC (1974) Measurement of pain. Lancet 2:1127–1131PubMedCrossRefGoogle Scholar
  18. 18.
    Hägg O, Fritzell P, Nordwall A (2003) The clinical importance of changes in outcome scores after treatment for chronic low back pain. Eur Spine J 12:12–20PubMedGoogle Scholar
  19. 19.
    Hägg O, Fritzell P, Ekselius L et al (2003) Swedish Lumbar Spine Study. Predictors of outcome in fusion surgery for chronic low back pain. Eur Spine J 12:22–33PubMedGoogle Scholar
  20. 20.
    Iversen MD, Daltroy LH, Fossel AH et al (1998) The prognostic importance of patient pre-operative expectations of surgery for lumbar spinal stenosis. Patient Educ Couns 34:169–178PubMedCrossRefGoogle Scholar
  21. 21.
    Jensen I, Linton SJ (1993) Coping strategies questionnaire (CSQ): reliability of the Swedish version of the CSQ. Scand J Behav Ther 22:139–145Google Scholar
  22. 22.
    Johansson E, Lindberg P (2000) Low back pain patients in primary care: subgroups based on the Multidimensional Pain Inventory. Int J Behav Med 7:340–352CrossRefGoogle Scholar
  23. 23.
    LaCaille RA, DeBerard MS, Masters KS et al (2005) Presurgical biopsychosocial factors predict multidimensional patient: outcomes of interbody cages lumbar fusion. Spine J 5:71–78PubMedCrossRefGoogle Scholar
  24. 24.
    Lauridsen HH, Hartvigsen J, Manniche C et al (2006) Danish version of the Oswestry Disability Index for patients with low back pain. Part 1: cross-cultural adaptation, reliability and validity in two different populations. Eur Spine J 15:1705–1716PubMedCrossRefGoogle Scholar
  25. 25.
    Leeuw M, Goosens MEJB, Linton SJ et al (2007) The fear-avoidance model of musculoskeletal pain: current state of scientific evidence. J Behav Med 30:77–94PubMedCrossRefGoogle Scholar
  26. 26.
    Lundberg M, Styf J, Carlsson S (2004) A psychometric evaluation of the Tampa Scale for Kinesiophobia—from a physiotherapeutic perspective. Physiother Theory Pract 20:121–133CrossRefGoogle Scholar
  27. 27.
    Mannion AF, Elfering A (2006) Predictors of surgical outcome and their assessment. Eur Spine J 15:93–108CrossRefGoogle Scholar
  28. 28.
    Mannion AF, Elfering A, Staerkle R et al (2007) Predictors of multidimensional outcome after spinal surgery. Eur Spine J 16:777–786PubMedCrossRefGoogle Scholar
  29. 29.
    Mannion AF, Junge A, Elfering A et al (2009) Great expectations: really the novel predictor of outcome after spinal surgery? Spine 34:1590–1599PubMedCrossRefGoogle Scholar
  30. 30.
    Price D, McGrath P, Rafii A et al (1983) The validation of visual analogue scales as ratio scale measures for chronic and experimental pain. Pain 17:45–46PubMedCrossRefGoogle Scholar
  31. 31.
    Riley JI, Robinson ME, Geisser ME et al (1995) Relationship between MMPI-2 cluster profiles and surgical outcome in low-back pain patients. J Spinal Disord 8:213–219PubMedCrossRefGoogle Scholar
  32. 32.
    Rosenstiel A, Keefe F (1983) The use of coping strategies in chronic low back pain patients: relationships to patient characteristics and current adjustment. Pain 17:33–44PubMedCrossRefGoogle Scholar
  33. 33.
    Saban KL, Penckofer SM (2007) Patient expectations of quality of life following lumbar spinal surgery. J Neurosci Nurs 39:180–189PubMedCrossRefGoogle Scholar
  34. 34.
    Steyerberg EW (2009) Clinical Prediction Models: a practical approach to development validation and updating. Springer, New YorkGoogle Scholar
  35. 35.
    Stromqvist B, Fritzell P, Hagg O et al (2007) Follow-up of lumbar surgery in Sweden 2007, The Swedish National Spine Register. The Swedish Spinal Surgery Society. Accessed 20 Dec 2008
  36. 36.
    Sullivan M, Karlsson J, Ware JE (1992) The Swedish SF-36 Health Survey—1. Evaluation of data quality, scaling assumptions, reliability and construct validity across general populations in Sweden. Soc Sci Med 41:1349–1358CrossRefGoogle Scholar
  37. 37.
    Symonds T, Burton A, Tillotson K, Main C (1996) Do attitudes and beliefs influence work loss due to low back trouble? Occup Med 46:25–32Google Scholar
  38. 38.
    Tabachnick BG, Fidell LS (2007) Using multivariate statistics, 5th edn. Allyn & Bacon, Needham HeightsGoogle Scholar
  39. 39.
    Toyone T, Tanaka T, Kato D et al (2005) Patients’ expectations and satisfaction with lumbar spine surgery. Spine 30:2689–2694PubMedCrossRefGoogle Scholar
  40. 40.
    Trief PM, Grant W, Fredrickson BE (2000) A prospective study of psychological predictors of lumbar surgery outcome. Spine 25:2616–2621PubMedCrossRefGoogle Scholar
  41. 41.
    Trief PM, Ploutz-Snyder R, Fredrickson BE (2006) Emotional health predicts pain and function after fusion: a prospective multicenter study. Spine 31:823–830PubMedCrossRefGoogle Scholar
  42. 42.
    Van der Kooij A, Meulman JJ (2004) Regression with optimal scaling. In: Meulman JJ, Heiser WJ (eds) SPSS categories 13.0, 10th edn. SPSS, Chicago, pp 107–157Google Scholar
  43. 43.
    Van der Kooij A (2007) Prediction accuracy and stability of regression with optimal scaling transformations. Dissertation, Leiden University. Accessed 16 Mar 2009
  44. 44.
    Van Susante J, Van de Schaaf D, Pavlov P (1998) Psychological distress deteriorates the subjective outcome of lumbosacral fusion. A prospective study. Acta Orthop Belg 64:371–377PubMedGoogle Scholar
  45. 45.
    Vlaeyen JW, Kole-Snijders AM, Boeren RG et al (1995) Fear of movement/(re)injury in chronic low back pain and its relation to behavioural performance. Pain 62:363–372PubMedCrossRefGoogle Scholar
  46. 46.
    Vlaeyen JW, Linton SJ (2000) Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain 85:317–332PubMedCrossRefGoogle Scholar
  47. 47.
    Ware JE, Sherbourne CD (1992) The MOS 36-item short-form health survey (SF-36): I. Conceptual framework and item selection. Med Care 30:473Google Scholar
  48. 48.
    Yee A, Adjei N, Do J, Ford M et al (2008) Do patient expectations of spinal surgery relate to functional outcome? Clin Orthop Relat Res 466:1154–1161PubMedCrossRefGoogle Scholar
  49. 49.
    Zou H, Hastie TJ (2005) Regulatization and variable selection via the elastic net. J R Stat Soc Series B Stat Methodol 67:301–320CrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2011

Authors and Affiliations

  • Allan D. Abbott
    • 1
    • 2
    Email author
  • Raija Tyni-Lenné
    • 1
    • 3
  • Rune Hedlund
    • 4
  1. 1.Department of Physical TherapyKarolinska University Hospital, HuddingeStockholmSweden
  2. 2.Division of Orthopaedics, Department of Clinical Science, Intervention and TechnologyKarolinska InstituteStockholmSweden
  3. 3.Division of Physiotherapy, Department of Neurobiology, Care Sciences and SocietyKarolinska InstituteStockholmSweden
  4. 4.Department for Orthopaedics, Institute for Clinical SciencesSahlgrenska University HospitalGothenburgSweden

Personalised recommendations