The Association of Operative versus Nonoperative Treatment for Lumbar Spondylolisthesis and Stenosis with Future Metabolic Conditions and Allostatic Burden: An Emulated Target Trial.

Abstract

Lumbar spinal stenosis adversely impacts mobility and function. Persistent lack of exercise and ambulatory capacity may contribute to the development of metabolic conditions. To determine the effect of surgical intervention, as compared to non-operative treatment, on the development of metabolic conditions, chronic pain, frailty, and allostatic load (AL). Retrospective emulation target trial. 2,521,827 patients were included, of which 329,314 (13.1%) underwent surgery. Development of metabolic conditions, chronic pain, frailty, and allostatic load (AL). Data was sourced from EPIC COSMOS. We conducted a clone analysis using inverse probability censoring weights and inverse probability of treatment weights that accounted for confounders. Risk ratios (RR) were calculated at 1- and 3-years post-index diagnosis for post-operative metabolic burden and frailty, and at 1 and 2 years for active opioid prescription, using weighted pooled logistic regression. Generalized Estimating Equation was used to determine the mean difference in AL at 1 and 3 years. Surgery within 12 months of index diagnosis demonstrated a significantly lower risk of metabolic burden (1-year RR [95% confidence interval (CI)]: 0.98 [0.98 - 0.98]; 3-year: 0.98 [0.98 - 0.98]) and frailty (1-year: 0.98 [0.98 - 0.99]; 3-year: 0.99 [0.98 - 0.99]). The risk of metabolic burden was lowest if surgery occurred within 6 months (1-year RR [95% CI]: 0.93 [0.93 - 0.94]; 3-year RR [95% CI]: 0.94 [0.94 - 0.95]). No significant difference in AL was noted at 1-year, and the difference was negligible at 3-years. The surgery cohort had a higher risk of active opioid prescription at 1-year (RR [95% CI]: 1.04 [1.04 - 1.04]) and 3-year (RR [95% CI]: 1.19 [1.17 - 1.20]) follow-up. We found that surgical intervention was associated with greater reductions in metabolic burden and frailty up to three years following the procedure. We also found evidence of a time-dependent effect such that maximal benefit was appreciated when surgery was performed within 6-months of presentation.