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Evaluation of “appropriate use criteria” for surgical decision-making in lumbar degenerative spondylolisthesis. A controlled, multicentre, prospective observational study

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Abstract

Introduction

Selecting patients with lumbar degenerative spondylolisthesis (LDS) for surgery is difficult. Appropriate use criteria (AUC) have been developed to clarify the indications for LDS surgery but have not been evaluated in controlled studies.

Methods

This prospective, controlled, multicentre study involved 908 patients (561 surgical and 347 non-surgical controls; 69.5 ± 9.7y; 69% female), treated as per normal clinical practice. Their appropriateness for surgery was afterwards determined using the AUC. They completed the Core Outcome Measures Index (COMI) at baseline and 12 months’ follow-up. Multiple regression adjusting for confounders evaluated the influence of appropriateness designation and treatment received on the 12-month COMI and achievement of MCIC (≥ 2.2-point-reduction).

Results

As per convention, appropriate (A) and uncertain (U) groups were combined for comparison with the inappropriate (I) group. For the adjusted 12-month COMI, the benefit of surgery relative to non-surgical care was not significantly greater for the A/U than the I group (p = 0.189). There was, however, a greater treatment effect of surgery for those with higher baseline COMI (p = 0.035). The groups’ adjusted probabilities of achieving MCIC were: 83% (A/U, receiving surgery), 71% (I, receiving surgery), 50% (A/U, receiving non-surgical care), and 32% (I, receiving non-surgical care).

Conclusions

A/U patients receiving surgery had the highest chances of achieving MCIC, but the AUC were not able to identify which patients had a greater treatment effect of surgery relative to non-surgical care. The identification of other characteristics that predict a greater treatment effect of surgery, in addition to baseline COMI, is required to improve decision-making.

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Acknowledgements

We thank all the patients from the different centres who contributed their data. We are grateful to Dave O’Riordan, Gordana Balaban, Stéphanie Dosch and Selina Nauer for their administration of the Spine Tango Surgery and Patient Self-Assessment forms. We also thank Laura Zimmermann, Manuela Kobelt, Domenique Mai, Stefania Mare, Lisa Davis and Amy Hall for their help with collecting and managing the data. We are grateful to Dr Federico Balagué for his valuable help, advice and support throughout the project.

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Authors and Affiliations

  1. Spine Centre Division, Department of Teaching, Research and Development, Schulthess Klinik, Lengghalde 2, 8008, Zurich, Switzerland

    Anne F. Mannion & Francine Mariaux

  2. Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA

    Paul M. Werth, Adam M. Pearson & Jon D. Lurie

  3. Spine Centre, Schulthess Klinik, Zurich, Switzerland

    Tamas F. Fekete, Daniel Haschtmann, Frank S. Kleinstueck, Dezsoe Jeszenszky, Markus Loibl & François Porchet

  4. Bethesda Spital Basel, Basel, Switzerland

    Markus Kohler

  5. Clinique Générale, Fribourg, Switzerland

    Philippe Otten

  6. Centre Médical de Lavey-les-Bains, Lavey-les-Bains, Switzerland

    Michael Norberg

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  1. Anne F. Mannion
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Correspondence to Anne F. Mannion.

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Mannion, A.F., Mariaux, F., Werth, P.M. et al. Evaluation of “appropriate use criteria” for surgical decision-making in lumbar degenerative spondylolisthesis. A controlled, multicentre, prospective observational study. Eur Spine J (2024). https://doi.org/10.1007/s00586-024-08157-1

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