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The Oswestry Low Back Pain Disability Questionnaire a Two-Year Follow-Up

of Spine Surgery Patients

Article  in  Scandinavian journal of surgery: SJS: official organ for the Finnish Surgical Society and the Scandinavian Surgical Society · February 2002
DOI: 10.1177/145749690209100214 · Source: PubMed

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Scandinavian Journal of Surgery 91: 208–211, 2002

THE OSWESTRY LOW BACK PAIN DISABILITY QUESTIONNAIRE

A TWO-YEAR FOLLOW-UP OF SPINE SURGERY PATIENTS

R. O. Niskanen
Päijät-Häme Central Hospital, Department of Orthopaedics, Lahti, Finland

ABSTRACT

Background and Aims: So far there is no golden standard for the measurement of func-
tional disability in spinal problems. The Oswestry index can be used to monitor the
response to treatment and rehabilitation. It is based on a patient’s subjective impres-
sion of his or her own state of disability. The purpose of this prospective study is to
give a graphic presentation of the behaviour of the Oswestry index in different spine
surgery groups.
Material and Methods: The material includes 193 discectomy and decompressive
operations. 37 of these patients had been operated earlier. The patients were observed
for two years after the index operation through the mail with the Oswestry question-
naire.
Results: Before an operation the average Oswestry index corresponded to severe disa-
bility on average. After successful treatment the Oswestry index dropped by 20–40 points
on average. The more complex the problem the higher the postoperative lines remained.
Conclusions: The results compared well with those of earlier studies. The graphs pre-
sented in this study may help the treating clinician to make conclusions on how his or
her patients are doing on average after surgery.
Key words: Oswestry; spine surgery; outcome; disability score

INTRODUCTION ly represent the process of ageing and something

A variety of criteria have been used to assess the out-
come of spinal operations. A disability score can be
used to monitor the response to treatment and reha-
bilitation. The most frequently used scores in spinal
problems are Roland-Morris, Oswestry, Million and
Waddell questionnaires. Though these are disease-
specific questionnaires, one must not forget the limi-
tations of this kind of questionnaires. They can part-
Correspondence:
Raimo Niskanen, M.D.
Maisterinkatu 4
FIN - 15100 Lahti
Finland
Email: raimo.niskanen@pp.fimnet.fi
other than spinal disability.
The patient’s own subjective estimate of his or her
function and its changes over time is perhaps the
most important outcome measure (1, 2). The Os-
westry disability index was originally developed as
a self-assessment score for chronic back pain patients.
The Oswestry index is based on a patient’s subjec-
tive impression on his or her own state of disability.
Though the questionnaire is rather old, it has been
validated and its reliability and sensitivity to chang-
es in functional status have been proved (3, 4). Re-
cently the Oswestry questionnaire was incorporated
into AAOS and NASS more detailed questionnaires
(5). The index has been shown to react to changes in
a patient’s functional status and it differentiates im-
provement and non-improvement well (6, 7).
 The Oswestry low back pain disability questionnaire
The Oswestry disability index is based on ten ques-
tions, each followed by six alternatives (Table 1) (3).
Each question is scored from 0–5, and the sum of the
scores is then expressed as a percentage.
The Oswestry questionnaire has also been in sci-
entific use to some extent in Finland to assess spine
surgery patients. But the practising clinicians may
not be so familiar with the questionnaire. The pur-
pose of this prospective study is to present the be-
haviour of the Oswestry index in lumbar discecto-
my and decompression patients graphically.
MATERIAL AND METHODS
The patient population included 193 patients operated on
for spinal disorders in Lahti City Hospital during 1995 and
1996. The patients lived in the city of Lahti and represent-
ed all the social classes. The operations included were lum-
bar disc prolapse surgery and decompressive surgery. The
use of the microscope was arbitrary and decided on by the
operating surgeon. Fusion patients were not included, nor
were there any trauma or tumour patients treated in the
hospital.
The decision to operate or not to operate was not influ-
enced by the Oswestry-index. The patients were observed
using the Oswestry questionnaire for two years after the
index operation. The questionnaire was filled in independ-
ently the day before surgery with the help of a physiother-
apist. Every patient was followed up with an Oswestry
questionnaire at six months, at one and two years after the
index operation. The follow-up questionnaires were deliv-
ered and returned by mail at the afore-mentioned inter-
vals without any connection with a possible clinical follow-
TABLE 1
The ten questions and the degree of disability according to the
Oswestry disability score.
Pain intensity 0–20 %, minimal disability
Personal care 21–40 %, moderate disability
Lifting 41–60 %, severe disability
Walking 61–80 %, crippled
Sitting 81–100 %, bed-bound or exaggerative patients
Standing
Sleeping
Sex life
Social life
Travelling
TABLE 2
The distribution of the patient material in different operations. The figures in parentheses represent the average age of the corresponding
patient group.
Patients
Primary discectomy 096
Primary decompression 060
Earlier operations 037
Together 193 patients
209
up visit. Usually the patients visited the outpatient depart-
ment once every six weeks after the operation. Patients
were not aware of the scoring or their previous answers.
The Oswestry questionnaire was a Finnish version, but it
has not been validated as far as we know. If a repeat oper-
ation was carried out during the two-year follow-up peri-
od, the follow-up for the study was discontinued. The in-
dication for a repeat operation was in most cases a new
prolapse, or stenosis or need for a fusion operation.
The Oswestry-index is expressed graphically as a mean
at every index point. The lines are not compared with each
other. No statistical tests were used, because this is not a
comparative study and the groups are not comparable.
RESULTS
Before the operation the average Oswestry index cor-
responded on average to severe disability. The Os-
westry scale for primary decompressions without re-
operations remained higher than the line for disc pro-
lapse surgery correspondingly (Fig. 1). The pattern
of earlier discectomy patients was the same as that
of primary discectomy patients (Fig 2). Individual
lines for discectomy group show the treatment effect
for each patient well (Fig. 3).
DISCUSSION
Lack of standardization in reporting outcomes and
variations of various treatment methods make it dif-
ficult to compare different studies with each other.
To avoid this, only commonly used scores should be
used. These scores should be valid both in conserva-
tive and operative treatment groups. So far no gold-
en standard exists for measuring functional disabili-
ty in spinal problems.
National or international comparisons cannot be
performed if everyone uses one’s own questionnaire.
On the other hand these questionnaires cannot be
changed frequently because then the evaluation of
the results over a period of time is impossible. In-
stead, the linguistic form and expressiveness of the
questionnaire can be checked from time to time and
revisions for computer use can be made (8). If a com-
mon functional questionnaire is used, a multi-centre
or a national spine surgery survey can be easily per-
No. reoperations Reoperations during
the 2 year follow-up
50 open (45 yrs) 11 (44 yrs)
30 microscope (41 yrs) 05 (37 yrs)
34 root decompression, 06
or hemilaminectomy (55 yrs)
15 laminectomy (71 yrs) 05
20 discectomy (39 yrs) 03
12 any decompression (56 yrs) 02
210 R. O. Niskanen
Fig. 1. The average Oswestry disability index of primary disc pro-
lapse surgery patients and primary decompressive surgery pa-
tients expressed as line graphs.
Fig. 2. The average Oswestry disability index of the 80 primary
discectomy patients and the 20 rediscectomy (previous operations
before the study) patients expressed as line graph.
formed. For this purpose the Oswestry index seems
to be capable of detecting a patient’s functional dis-
ability in different spinal disorders (9). Its percent-
age change modification has been found to have use
in lumbar surgery (10).
In a Finnish study the preoperative Oswestry in-
dex value and the number of previous surgeries have
been noted to be the best predictors of the outcome
of a lumbar surgery (11). In this report the mean Os-
westry index for a miscellaneous group of 80 lum-
bar surgery patients was 41 before the operation, and
25 at five years. In another study of patients with low
back pain the mean score was 33, and of patients with
radiculopathy the score totalled 49 (9). These figures
correspond well with the results in this study.
In a material of 83 anterior spinal fusions the aver-
age Oswestry index before the operation was 49 and
31 at the follow-up. A statistical difference could be
found between the successfully fused and pseudoar-
throsis patients (12). According to another study (an-
terior fusion, 134 patients) the index averaged 48 be-
fore the operation, and 20 at the follow-up. The in-
Fig. 3. The individual patient lines for the 80 primary discectomy
patients without reoperations.
dex remained higher for patients with previous spine
surgery (13). The author’s experience with fusion pa-
tients is quite similar. So, the preoperative level
seems to be equal regardless of the type and need
for spinal operation.
A change of more than 10 points has been consid-
ered clinically significant (14). In our clinic we con-
sider a change to a lower level of disability, or a
change of a minimum of 20 percentage points, a sig-
nificant clinical improvement. This average change
can be seen in all figures presented in this study. On
an individual level, however, the index can behave
quite unexpectedly (Fig. 3).
There are only few studies comparing open and
microsurgery for lumbar disc disease. According to
an older study there is no difference in results be-
tween these methods (15). However, according to
more recent studies, tissue preserving methods
should be used (16, 17). In this study, if viewed sep-
arately, the open disc surgery and microscope assist-
ed disc surgery lines did not differ. Corresponding-
ly the line for laminectomy was only on a slightly
higher level than that of other decompressive sur-
gery.
Some patients did not answer the questionnaire in
the two years. They were typically young men and
belonged to the most simple surgery groups. Those
with a more complex disease remained better in the
follow-up. The Oswestry values of the drop-out pa-
tients are included in the lines. However, if the pa-
tients who did not answer at some of the index points
were excluded, the lines remained the same. The Os-
westry scale did not predict the patients who needed
a second operation during the two-year follow-up.
Most health status instruments are designed for
use in groups, but their use to affect the decision of
individual patients may be limited (18). The disabil-
ity score should not be used alone since it does not
take into consideration the patient’s job, age or state
of mind (3). However, the graphs presented in this
study may help the treating clinician to make con-
clusions on how his or her patients are doing on av-
erage after surgery.
 The Oswestry low back pain disability questionnaire 211

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