Lumbar Surgery in Work-Related Chronic Low Back Pain: Can a Continuum of Care Enhance Outcomes?

Abstract

Background Context-Systematic reviews of lumbar fusion outcomes in purely workers' compensation (WC) patient populations have indicated mixed results for efficacy. Recent studies on lumbar fusions in the WC setting have reported return-to-work rates of 26-36%, re-operation rates of 22-27%, and high rates of persistent opioid use two years post-surgery. Other types of lumbar surgery in WC populations are also acknowledged to have poorer outcomes than in non-WC. The possibility of improving outcomes by employing a biopsychosocial model with a continuum of care, including post-operative functional restoration in this "at risk" population, has been suggested as a possible solution.

Exercise Therapy for Chronic Pain

“…In the 40 years since this study, there have been multiple studies, meta-analyses, and systematic reviews assessing the benefit of this type of comprehensive treatment with a clear conclusion that this treatment provides benefit for reducing disability, reducing fearavoidance, decreasing pain, enhancing quality of life, and facilitating return to work. [63][64][65][66][67][68][69] Monticone and colleagues 70 found persistence of benefits at 1 year posttreatment.…”

Chronic Opioid Therapy After Lumbar Fusion Surgery for Degenerative Disc Disease in a Workers’ Compensation Setting

“…The poor RTW outcomes in both the COT (11.0%) and TOT (38.4%) groups are in line with other studies citing low RTW rates after lumbar fusion among WC subjects. 14,16,[24][25][26][27][28] Additionally, the high rates of psychiatric disease after fusion and the strong impact depression had on rates of COT may indicate a possible impact of better screening and treatment for psychiatric disease before lumbar fusion. Also, the significantly greater use of psychotherapy after fusion between both groups may suggest worsening psychological health after fusion within our study population.…”

“…23 Additionally, studies of WC subjects from several states report return to work (RTW) rates ranging from 26% to 36%, reoperation rates from 22% to 27%, and high rates of chronic opioid use after fusion. 14,16,[24][25][26][27][28] The prevalence of opioid use among the entire WC population is approximately 32%. 29 Receiving opioids early for acute LBP in a WC setting has been associated with higher rates of disability, surgery, and chronic opioid therapy (COT).…”

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“…For example, complex occupational spine injury patients characteristically have poor outcomes after lumbar spine surgery. 42,43 For these patients a highly intensive, highly structured rehabilitation program administered with lumbar spine surgery can yield acceptable outcomes. 42,43 Perhaps a broader application of rehabilitation with integration of cognitive restructuring could improve outcomes for traditional surgical patients with fear avoidance beliefs or psychosocial confounders.…”

“…42,43 For these patients a highly intensive, highly structured rehabilitation program administered with lumbar spine surgery can yield acceptable outcomes. 42,43 Perhaps a broader application of rehabilitation with integration of cognitive restructuring could improve outcomes for traditional surgical patients with fear avoidance beliefs or psychosocial confounders. Finally, participation in a rehabilitation program can help patients minimize ambivalence about participation in elective spine surgery, with lasting effect on decisions and acceptance of care pathways.…”