LONG-TERM OUTCOMES OF LUMBAR FUSION AMONG WORKERS' COMPENSATION SUBJECTS: AN HISTORICAL COHORT STUDY
 
   

Long-term Outcomes of Lumbar Fusion
Among Workers' Compensation Subjects:
An Historical Cohort Study

This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to:
   Frankp@chiro.org
 
   

FROM:   Spine (Phila Pa 1976) 2011 (Feb 15);   36 (4):   320–331

Nguyen TH, Randolph DC, Talmage J, Succop P, Travis R.

From the Division of Epidemiology and Biostatistics,
Department of Environmental Health,
University of Cincinnati College of Medicine, Milford, OH;
Meharry Medical College, Nashville, TN; and
Department of Physical Medicine and Rehabilitation,
University of Kentucky College of Medicine, Lexington, KY.


Researchers reviewed records from 1,450 patients in the Ohio Bureau of Workers’ Compensation database who had diagnoses of disc degeneration, disc herniation or radiculopathy, a nerve condition that causes tingling and weakness of the limbs. Half of the patients had surgery to fuse two or more vertebrae in hopes of curing low back pain. The other half had no surgery, even though they had comparable diagnoses.

After two years, only 26 percent of those who had surgery had actually returned to work.   That translates to a resounding 74% failure rate!

It also suggests that you have a 257% better chance of returning to work IF YOU AVOID SURGERY in the first place!
  That's because 67 percent of patients who had the same exact diagnosis, but DIDN'T get the surgery, DID return to work.

In another troubling finding, the researchers determined that there was a 41 percent increase in the use of painkillers, particularly opiates, in those who had the surgery. Last year we reported that deaths from addictive painkillers has doubled in the last 10 years. [6]

“The study provides clear evidence that for many patients, fusion surgeries designed to alleviate pain from degenerating discs don’t work”, says the study’s lead author Dr. Trang Nguyen, a researcher at the University of Cincinnati College of Medicine. [2]


Commentary from an MSNBC.com article titled:
“Back Surgery May Backfire on Patients in Pain”


Experts estimate that nearly 600,000 Americans opt for back operations each year. But for many like Scatena, surgery is just an empty promise, say pain management experts and some surgeons.

A new study in the journal Spine shows that in many cases surgery can even backfire, leaving patients in more pain.

Researchers reviewed records from 1,450 patients in the Ohio Bureau of Workers’ Compensation database who had diagnoses of disc degeneration, disc herniation or radiculopathy, a nerve condition that causes tingling and weakness of the limbs. Half of the patients had surgery to fuse two or more vertebrae in hopes of curing low back pain. The other half had no surgery, even though they had comparable diagnoses.

After two years, just 26 percent of those who had surgery returned to work. That’s compared to 67 percent of patients who didn’t have surgery. In what might be the most troubling study finding, researchers determined that there was a 41 percent increase in the use of painkillers, specifically opiates, in those who had surgery.

The study provides clear evidence that for many patients, fusion surgeries designed to alleviate pain from degenerating discs don’t work, says the study’s lead author Dr. Trang Nguyen, a researcher at the University of Cincinnati College of Medicine.

Unfortunately, for most patients with bad backs, there is no easy solution, no magic bullet. Pain management experts — and some surgeons — say that patients need to scale back their expectations. With the right treatments, pain can be eased, but a complete cure is unlikely.

27 million adults with back problems

A recent report by the Agency for Healthcare Research and Quality, a federal organization, found that in 2007, 27 million adults reported back problems with $30.3 billion spent on treatments to ease the pain. While some of that money is spent on physical therapy, pain management, chiropractor visits, and other non invasive therapies, the biggest chunk pays for spine surgeries.


Commentary from:
Mark Russi
Yale University School of Medicine,
New Haven, CT, USA.

This article is noteworthy as an examination of outcomes among patients with work-related low back injuries who have undergone fusion surgery. While it is a retrospective study and adequate comparability between the surgically treated group and the non-surgically treated group cannot be guaranteed, outcomes among those undergoing fusion surgery revealed an alarming number of poor clinical outcomes.

The authors compared 725 lumbar fusion cases with 725 controls. All study subjects were drawn from a Workers? Compensation database. At 2 years, only 26% of individuals who underwent fusion surgery had returned to work, compared to 67% of those not treated surgically. Of those undergoing fusion surgery, 36% suffered surgical complications and 27% required additional surgery.

The rates of permanent disability were 11% among those who underwent fusions and 2% among those who did not undergo surgery. Over the course of the study, 17 surgical patients died, compared to 11 controls. While the baseline characteristics of surgical and non-surgical patients were examined, including diagnosis, weekly wages, legal representation, total days off, magnetic resonance imaging (MRI) findings, number of vocational and rehabilitation sessions, body mass index (BMI), daily opioid dose and discogram performance -- and no statistically important interactions were found -- it is still not possible to guarantee that the fusion and control populations were truly equivalent with respect to severity of lumbar disc disease.

That said, even with absent comparison with a non-surgical group, the outcomes among those undergoing fusion were alarming. An implication of this study would include the need to examine in a prospective way outcomes among clinically comparable patients randomized to fusion surgery or conservative therapy.

On a practical clinical level, the study suggests that patients contemplating lumbar fusion surgery need to be educated regarding the sub-optimal outcomes associated with the procedure. Patients contemplating lumbar fusion surgery should be informed regarding the outcomes associated with the procedure, including the low likelihood of returning to work, high rate of reoperation, high rate of complications and the possibility of permanent disability.



The Abstract:

STUDY DESIGN:   Historical cohort study.

OBJECTIVE:   To determine objective outcomes of return to work (RTW), permanent disability, postsurgical complications, opiate utilization, and reoperation status for chronic low back pain subjects with lumbar fusion. Similarly, RTW status, permanent disability, and opiate utilization were also measured for nonsurgical controls.

SUMMARY OF BACKGROUND DATA:   A historical cohort study of workers' compensation (WC) subjects with lumbar arthrodesis and randomly selected controls to evaluate multiple objective outcomes has not been previously published.

METHODS:   A total of 725 lumbar fusion cases were compared to 725 controls who were randomly selected from a pool of WC subjects with chronic low back pain diagnoses with dates of injury between January 1, 1999 and December 31, 2001. The study ended on January 31, 2006. Main outcomes were reported as RTW status 2 years after the date of injury (for controls) or 2 years after date of surgery (for cases). Disability, reoperations, complications, opioid usage, and deaths were also determined.

RESULTS:   Two years after fusion surgery, 26% (n = 188) of fusion cases had RTW, while 67% (n = 483) of nonsurgical controls had RTW (P= 0.001) within 2 years from the date of injury. The reoperation rate was 27% (n = 194) for surgical patients. Of the lumbar fusion subjects, 36% (n = 264) had complications. Permanent disability rates were 11% (n = 82) for cases and 2% (n = 11) for nonoperative controls (P= 0.001). Seventeen surgical patients and 11 controls died by the end of the study (P = 0.26). For lumbar fusion subjects, daily opioid use increased 41% after surgery, with 76% (n = 550) of cases continuing opioid use after surgery. Total number of days off work was more prolonged for cases compared to controls, 1140 and 316 days, respectively (P < 0.001). Final multivariate, logistic regression analysis indicated the number of days off before surgery odds ratio [OR], 0.94 (95% confidence interval [CI], 0.92-0.97); legal representation OR, 3.43 (95% CI, 1.58-7.41); daily morphine usage OR, 0.83 (95% CI, 0.71-0.98); reoperation OR, 0.42 (95% CI, 0.26-0.69); and complications OR, 0.25 (95% CI, 0.07-0.90), are significant predictors of RTW for lumbar fusion patients.

CONCLUSIONS:   This Lumbar fusion for the diagnoses of disc degeneration, disc herniation, and/or radiculopathy in a WC setting is associated with significant increase in disability, opiate use, prolonged work loss, and poor RTW status.


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