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PLoS One. 2018 Nov 8;13(11):e0207126. doi: 10.1371/journal.pone.0207126. eCollection 2018.

Prognostic function to estimate the probability of meaningful clinical improvement after surgery - Results of a prospective multicenter observational cohort study on patients with lumbar spinal stenosis.

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Horten Centre for Patient Oriented Research and Knowledge Transfer, University of Zurich, Zurich, Switzerland.
Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland.
Division of General Internal Medicine, Bern University Hospital, Bern University, Bern, Switzerland.
Department of Neuroradiology, University Hospital Zurich, Zurich, Switzerland.
Department of Physical Medicine and Rheumatology, Balgrist University Hospital, Zurich, Switzerland.
Department of Orthopedics and Neurosurgery, Spine Center, Schulthess Clinic, Zurich, Switzerland.
Spine Division, Balgrist University Hospital, Zurich, Switzerland.



Approximately two thirds of patients with lumbar spinal stenosis (LSS) who undergo surgical treatment benefit from the surgery. The objective of this study was to derive a prognostic probability function (PPF) to identify patients with a high probability of post-surgical improvement because there is currently no method available.


In this multicenter, prospective, observational study, we collected data from eight medical centers in Switzerland in which patients underwent surgery for LSS. The endpoints were meaningful clinically important differences (MCID) in pain and disability one year after baseline. We developed a PPF named PROCESS (PostopeRative OutComE Spinal Stenosis), based on a large set of prognostic indicators extracted from the literature. The PPF was derived using data from a random subset of two thirds of the patients and validated in the remaining third. We addressed overfitting by shrinking the regression coefficients. The area under the ROC curve (AUC) and calibration determined the accuracy of the PPF.


In this study, 452 LSS patients received surgery. 73% of the 300 patients in the derivation subset reached an MCID in pain and 68% reached an MCID in disability. The corresponding values were 70% and 63% in the validation subset, respectively. In the derivation subsample, the AUC was 0.64 (95% CI 0.57 to 0.71) for of the PPF predicting MCID in pain and 0.71 (0.64 to 0.77) for MCID in disability, after shrinkage. The corresponding numbers were 0.62 (0.52 to 0.72) and 0.70 (0.60 to 0.79) in the validation subsample, and the PPF showed good calibration.


Surgical treatment for patients with lumbar spinal stenosis is being performed with increasing frequency. PROCESS is conditional on the individual pattern of preoperatively available prognostic indicators, and may be helpful for clinicians in counselling patients and in guiding the discussion on individual treatment decision in the era of personalized medicine.

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