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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

other than spinal disability.
A variety of criteria have been used to assess the out- The patient’s own subjective estimate of his or her
come of spinal operations. A disability score can be function and its changes over time is perhaps the
used to monitor the response to treatment and reha- most important outcome measure (1, 2). The Os-
bilitation. The most frequently used scores in spinal westry disability index was originally developed as
problems are Roland-Morris, Oswestry, Million and a self-assessment score for chronic back pain patients.
Waddell questionnaires. Though these are disease- The Oswestry index is based on a patient’s subjec-
specific questionnaires, one must not forget the limi- tive impression on his or her own state of disability.
tations of this kind of questionnaires. They can part- 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-
Correspondence:
Raimo Niskanen, M.D. cently the Oswestry questionnaire was incorporated
Maisterinkatu 4 into AAOS and NASS more detailed questionnaires
FIN - 15100 Lahti (5). The index has been shown to react to changes in
Finland a patient’s functional status and it differentiates im-
Email: raimo.niskanen@pp.fimnet.fi provement and non-improvement well (6, 7).
 The Oswestry low back pain disability questionnaire 209

The Oswestry disability index is based on ten ques- up visit. Usually the patients visited the outpatient depart-
tions, each followed by six alternatives (Table 1) (3). ment once every six weeks after the operation. Patients
Each question is scored from 0–5, and the sum of the were not aware of the scoring or their previous answers.
scores is then expressed as a percentage. The Oswestry questionnaire was a Finnish version, but it
has not been validated as far as we know. If a repeat oper-
The Oswestry questionnaire has also been in sci- ation was carried out during the two-year follow-up peri-
entific use to some extent in Finland to assess spine od, the follow-up for the study was discontinued. The in-
surgery patients. But the practising clinicians may dication for a repeat operation was in most cases a new
not be so familiar with the questionnaire. The pur- prolapse, or stenosis or need for a fusion operation.
pose of this prospective study is to present the be- The Oswestry-index is expressed graphically as a mean
haviour of the Oswestry index in lumbar discecto- at every index point. The lines are not compared with each
my and decompression patients graphically. other. No statistical tests were used, because this is not a
comparative study and the groups are not comparable.

MATERIAL AND METHODS

RESULTS
The patient population included 193 patients operated on
for spinal disorders in Lahti City Hospital during 1995 and Before the operation the average Oswestry index cor-
1996. The patients lived in the city of Lahti and represent- responded on average to severe disability. The Os-
ed all the social classes. The operations included were lum- westry scale for primary decompressions without re-
bar disc prolapse surgery and decompressive surgery. The operations remained higher than the line for disc pro-
use of the microscope was arbitrary and decided on by the lapse surgery correspondingly (Fig. 1). The pattern
operating surgeon. Fusion patients were not included, nor of earlier discectomy patients was the same as that
were there any trauma or tumour patients treated in the
hospital. of primary discectomy patients (Fig 2). Individual
The decision to operate or not to operate was not influ- lines for discectomy group show the treatment effect
enced by the Oswestry-index. The patients were observed for each patient well (Fig. 3).
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- DISCUSSION
apist. Every patient was followed up with an Oswestry
questionnaire at six months, at one and two years after the Lack of standardization in reporting outcomes and
index operation. The follow-up questionnaires were deliv- variations of various treatment methods make it dif-
ered and returned by mail at the afore-mentioned inter-
vals without any connection with a possible clinical follow-
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-
TABLE 1 tive and operative treatment groups. So far no gold-
en standard exists for measuring functional disabili-
The ten questions and the degree of disability according to the
Oswestry disability score.
ty in spinal problems.
National or international comparisons cannot be
Pain intensity 0–20 %, minimal disability performed if everyone uses one’s own questionnaire.
Personal care 21–40 %, moderate disability On the other hand these questionnaires cannot be
Lifting 41–60 %, severe disability changed frequently because then the evaluation of
Walking 61–80 %, crippled the results over a period of time is impossible. In-
Sitting 81–100 %, bed-bound or exaggerative patients
Standing stead, the linguistic form and expressiveness of the
Sleeping questionnaire can be checked from time to time and
Sex life revisions for computer use can be made (8). If a com-
Social life mon functional questionnaire is used, a multi-centre
Travelling
or a national spine surgery survey can be easily per-

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 No. reoperations Reoperations during

the 2 year follow-up

Primary discectomy 096 50 open (45 yrs) 11 (44 yrs)

30 microscope (41 yrs) 05 (37 yrs)
Primary decompression 060 34 root decompression, 06
or hemilaminectomy (55 yrs)
15 laminectomy (71 yrs) 05
Earlier operations 037 20 discectomy (39 yrs) 03
12 any decompression (56 yrs) 02
Together 193 patients
210 R. O. Niskanen

Fig. 1. The average Oswestry disability index of primary disc pro- Fig. 3. The individual patient lines for the 80 primary discectomy
lapse surgery patients and primary decompressive surgery pa- patients without reoperations.
tients expressed as line graphs.

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-
Fig. 2. The average Oswestry disability index of the 80 primary tween these methods (15). However, according to
discectomy patients and the 20 rediscectomy (previous operations more recent studies, tissue preserving methods
before the study) patients expressed as line graph. 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-
formed. For this purpose the Oswestry index seems ly the line for laminectomy was only on a slightly
to be capable of detecting a patient’s functional dis- higher level than that of other decompressive sur-
ability in different spinal disorders (9). Its percent- gery.
age change modification has been found to have use Some patients did not answer the questionnaire in
in lumbar surgery (10). the two years. They were typically young men and
In a Finnish study the preoperative Oswestry in- belonged to the most simple surgery groups. Those
dex value and the number of previous surgeries have with a more complex disease remained better in the
been noted to be the best predictors of the outcome follow-up. The Oswestry values of the drop-out pa-
of a lumbar surgery (11). In this report the mean Os- tients are included in the lines. However, if the pa-
westry index for a miscellaneous group of 80 lum- tients who did not answer at some of the index points
bar surgery patients was 41 before the operation, and were excluded, the lines remained the same. The Os-
25 at five years. In another study of patients with low westry scale did not predict the patients who needed
back pain the mean score was 33, and of patients with a second operation during the two-year follow-up.
radiculopathy the score totalled 49 (9). These figures Most health status instruments are designed for
correspond well with the results in this study. use in groups, but their use to affect the decision of
In a material of 83 anterior spinal fusions the aver- individual patients may be limited (18). The disabil-
age Oswestry index before the operation was 49 and ity score should not be used alone since it does not
31 at the follow-up. A statistical difference could be take into consideration the patient’s job, age or state
found between the successfully fused and pseudoar- of mind (3). However, the graphs presented in this
throsis patients (12). According to another study (an- study may help the treating clinician to make con-
terior fusion, 134 patients) the index averaged 48 be- clusions on how his or her patients are doing on av-
fore the operation, and 20 at the follow-up. The in- erage after surgery.
 The Oswestry low back pain disability questionnaire 211

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