Does the order of total hip replacement and lumbar spinal stenosis surgery influence patient-reported outcomes: An observational register study.

Abstract

Patients with degenerative hip and lumbar spine disorders requiring surgery in both locations is fairly common in clinical practice. We investigated if the order of total hip replacement (THR) and lumbar spinal stenosis surgery (LSSS) influences patient-reported outcomes (PROs). We used data from the Swedish Hip Arthroplasty Register (SHAR) and the Swedish Spine Register (Swespine), on patients operated with THR and LSSS in years 2002 to 2012. To increase the probability of having symptomatic disorders in both locations at the time of the first surgery, we only included patients with both LSSS and THR performed within 2 years. Linear and logistic regression analyses adjusted for age, sex, preoperative PROs, and time between surgeries were used to investigate the association between order of surgeries and the generic PRO measurements EQ-5D and EQ VAS. Eighty-four patients had THR prior to LSSS and 171 patients LSSS prior to THR. Linear regression showed that LSSS prior to THR was associated with higher EQ-5D index (B = 0.09, 95% confidence interval [CI] 0.03-0.16) and EQ VAS (B = 5.6, 95% CI 0.4-10.9) 1 year after the last surgery. Logistic regression showed that the odds ratio [OR] for not having any problems in the "pain" (OR = 3.0, 95% CI 1.5-6.3) and "anxiety/depression" (OR = 2.3, 95% CI 1.3-4.1) dimensions were higher for LSSS before THR. In our cohort, LSSS before THR was associated with better health-related quality of life outcomes compared to the reverse order. The results from our cohort can be helpful in a clinical situation where the physician gives advice to an individual patient when choosing the order of procedures. However, further studies are necessary in order to confirm these results in other cohorts. At present, standard of care remains that order of surgery should be individualized for each patient, with guidance from the operating surgeons.