Scientific Papers

Impact of spinal surgery on locomotive syndrome in patients with lumbar spinal stenosis in clinical decision limit stage 3: a retrospective study | BMC Musculoskeletal Disorders

Patient and public involvement

This retrospective study was conducted between May 2020 and April 2021 at the Department of Orthopaedic Surgery at University Hospital, and 157 patients aged ≥ 65 years with lumbar spinal stenosis who underwent lumbar spinal surgery without serious complications (such as ischemic heart disease or stroke) were enrolled. The inclusion and exclusion criteria are shown in Fig. 1. Among the 157 patients enrolled in this study, patients with CDL stages 0, 1, and 2 (n = 56) and patients with missing data (n = 30) were excluded. Finally, patients in CDL stage 3 were included in this study (n = 71).

Fig. 1
figure 1

Diagram of the inclusion and exclusion criteria in this study. Abbreviations: CDL, clinical decision limit; LSS, lumbar spinal canal stenosis

This study was conducted following the Declaration of Helsinki and was approved by the Ethics Committee of the University. Consent to participate in the study was obtained using an opt-out approach.

Recorded data

A physical therapist performed physical function tests, and the patients completed the questionnaire. Age, sex, BMI, TUG, trunk and limb skeletal muscle mass, grip strength, life-space assessment (LSA), prognostic nutritional index (PNI), low back pain, lower limb pain, lower limb numbness, surgical method, and symptoms of lumbar spinal stenosis were adopted as survey items for preoperative factors related to the improvement in LS. Furthermore, the 25-Question Geriatric Locomotive Function scale (GLFS-25) and JOA Back Pain Evaluation Questionnaire (JOABPEQ) were used to examine patients before and after lumbar spinal surgery.


The TUG was conducted using a stopwatch to measure the time elapsed from when the subject’s body moved to the time they turned at a cone 3 m away and returned to sitting on the chair. A chair with a height of 42.0 cm and elbow rests was used. The subject was given the following instruction: “Please get up from the chair, walk as fast as possible, turn at the cone 3 m ahead, and sit on the chair again. You may turn in either direction.”

Trunk and limb skeletal muscle mass

Skeletal muscle mass was assessed using the bioelectrical impedance method (Inbody720, Inbody Co., Ltd., Seoul, Korea). All patients were assessed on the day of admission. The participants grasped the handle of the analyzer with embedded electrodes and stood on a platform with the soles of their feet in contact with the electrodes (two electrodes each were placed on the feet and hands).

Hand grip strength

Grip strength was measured using a Smedley-type grip strength meter (Takei model T.K.K. 5101, Takei Kiki Kogyo, Akiha-ku Niigata, Japan). The participants were instructed to grip the strength meter as firmly as possible after hearing the signal. They were instructed as follows: “Please hold the grip strength meter for 3 s.” The right side was measured twice, and the maximum value was adopted.

Life-space assessment (LSA)

The LSA was originally developed as a simple questionnaire to assess physical activity in older adults. It is a clinically useful index that has been utilized in clinical practice and research [14]. The total score is 120, with higher scores indicating higher activity levels.

Prognostic nutritional index (PNI)

The PNI scale reflects a patient’s inflammatory and nutritional status and is associated with postoperative complications in spinal diseases [15, 16].

Evaluation of pain

Low back pain, lower limb pain, and lower limb numbness were evaluated using a visual analog scale (VAS), with a score of 100 indicating extreme pain and 0 indicating no pain.


The GLFS-25 test focuses on physical pain and ADL in the preceding month. For this study, each item was scored from “no disability” (0 points) to “severe disability” (4 points), and the total score was used to evaluate the CDL stage of the LS patient. Scores were classified as follows: stage 1, ≥ 7 points to < 16 points; stage 2, 16 points to < 24 points; and stage 3, 24 points [17].


The JOA developed the JOABPEQ, a quality-of-life assessment specific to lumbar spine disease that uses patient-oriented and self-reported functional status. The JOABPEQ is a disease-specific tool consisting of 25 items corresponding to five subscales: low back pain, lumbar spine function, walking ability, social function, and mental health. The score for each subscale ranges from 0–100, with higher scores indicating better conditions [18].

Statistical analysis

All statistical analyses were performed using JMP version 15.0 statistical software (SAS Institute Inc., Cary, NC, USA). The GLFS-25 was used to evaluate the CDL stage. Patients with preoperative CDL stage 3 were included in the study, and those with at least one improvement in the CDL stage after lumbar spinal surgery were included in the improvement group [19]. The patients were evaluated before the operation and three months after surgery.

The Wilcoxon rank-sum test was used to compare the improved and non-improved groups. Logistic regression and decision tree analyses were used to investigate the preoperative factors associated with improvements in LS. The Spearman rank correlation coefficient was used to determine correlations between Δ lower limb pain, Δ lower limb numbness, Δ low back pain, and Δ GLFS-25. In all cases, statistical significance was set at p < 0.05. All data are expressed as the median (interquartile range) and range.

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