Introduction: Lumbar spinal stenosis (LSS) is primarily a degenerative condition among older adults associated with narrowing of the spinal canal affecting the neurovascular structures contained within. LSS is the most common diagnosis associated with spine surgery in adults over 65 and the decision to undergo elective spine surgery may be the most consequential decision patients with this condition make. The aim of this study was to examine patient-related factors that may affect surgical treatment decision-making for LSS.

Methods: We used data from the Alberta Lumbar Spinal Stenosis Study, a prospective cohort study on prognostic factors and outcomes in LSS, to investigate the association between baseline factors and subsequent spine surgery for LSS within two years. Participants of the inception cohort, formed at the time of clinical imaging, completed a structured interview at baseline. Measures included the Swiss Spinal Stenosis (SSS) Physical Function and Symptom Severity subscales, the Oswestry Disability Index (ODI), the Health Utilities Index (HUI3) for health-related quality of life, number of comorbidities, and a series of questions on participants’ beliefs about spine surgery benefits and risks, and satisfaction with prior care and continuing life with current symptoms. Surgery was determined from self-report during interviews and administrative health data through two years of follow-up. Data analysis included univariate and multivariable logistic regression.

Results: Of the 245 participants from the original cohort with the diagnosis of LSS, 225 (92%, mean age 65.6+11.7) were included in the present study. Within two years of baseline interviews, 56 underwent spine surgery (mean age 63.9/SD 10.8) and 169 did not (mean age 66.2/SD 11.9). In the univariate logistic regression analyses, the ODI, HUI3, SSS Physical Function and Symptom Severity subscales, level of satisfaction with continuing life with current symptoms (negatively correlated), belief that surgery would help their current condition, and satisfaction with prior care (negatively correlated) were all significantly associated with the decision to undergo spine surgery within two years. In the multivariable analysis, the only factors that remained significantly associated with the decision to undergo spine surgery were level of satisfaction with continuing life with current symptoms (7-point ordinal scale) with a regression coefficient of -0.413 (-0.816, -0.01, p<0.001) and patients’ beliefs that surgery would help their current condition (4-point ordinal scale) with a regression coefficient of 1.157 (0.693, 1.621, p=0.035).

Discussion: We found that patients’ level of dissatisfaction living with their current symptoms, and beliefs about the benefits of surgery, were more predictive of the decision to undergo spine surgery for lumbar spinal stenosis than perceptions of the risks of surgery, which were similarly high for both surgical and non-surgical groups, or level of LSS-related pain and disability, sex or age. This finding emphasizes the importance of providing patients with evidence-informed, realistic expectations about surgical outcomes.