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. Purpose To compare objective socioeconomic and patient-reported outcomes for WC patients with different lumbar surgeries followed by functional restoration, relative to matched comparison patients without surgery. Study Design/Setting A prospective cohort study of chronic disabling occupational lumbar spinal disorder (CDOLD) patients with WC claims treated in an interdisciplinary functional restoration program. Patient Sample A consecutive cohort of 564 patients with pre-rehab surgery completed an functional restoration and was divided into groups based on surgery type: lumbar fusion (F group, n = 331) and non-fusion lumbar spine surgery (NF group, n = 233). An unoperated comparison group was matched for length of disability (U group, n = 349). Outcome Measures Validated patient-reported measures of pain, disability and depression were administered PRE- and POST-rehab. Socioeconomic outcomes were collected via a structured one-year POST interview. Methods All patients completed an intensive, medically-supervised FRP, combining quantitatively-directed exercise progression with a multimodal disability management approach. The writing of this manuscript was supported in part by NIH Grant 1K05-MH-71892 and no conflicts of interest are noted among the authors. Results The F group had a longer length of disability compared to the NF and U groups (M = 31.6, 21.7, and 25.9 months, respectively, p < .001). There were relatively few statistically significant differences for any socioeconomically-relevant outcome among groups, with virtually identical POST-rehab return-to-work (F=81%, NF=84%, U=85%, p =.409). The groups differed significantly after surgery on diagnosis of major depressive disorder and opioid dependence disorder, as well as patient-reported depressive symptoms and pain intensity PRE-rehab. However, no significant differences in patient-reported outcomes were found POST-rehab. PRE-rehab opioid dependence disorder significantly predicted lower rates of work return and work retention, as well as higher rates of treatment-seeking behavior. Higher levels of PRE-rehab perceived disability and depressive symptoms were significant risk factors for poorer work return and retention outcomes. Conclusions Lumbar surgery in the WC system (particularly lumbar fusion) have the potential achieve positive outcomes that are comparable t...

Clinical Depression Is a Strong Predictor of Poor Lumbar Fusion Outcomes Among Workersʼ Compensation Subjects

“…[1][2][3][4][5][6][7] Because relatively few studies exist examining risk factors for poor lumbar fusion outcomes among the WC population, 4-5 , 8 , 12 we wanted to examine how psychosocial factors, chiefl y depression, impact lumbar fusion outcomes in a WC setting. WC patients tend to have worse lumbar fusion outcomes and lower postoperative RTW rates.…”

“…[1][2][3][4][5][6][7] A 2010 case-control study reported that WC subjects, when compared with the general population, had signifi cantly less improvement in mean Oswestry Disability Index and 36-Item Short Form Health Survey scores after fusion. [1][2][3][4][5][6][7] A 2010 case-control study reported that WC subjects, when compared with the general population, had signifi cantly less improvement in mean Oswestry Disability Index and 36-Item Short Form Health Survey scores after fusion.…”

Opioids for low back pain

“…116 After multidisciplinary rehabilitation for back pain, opioid dependent patients were less likely to return to work and more likely to seek new sources of care. 117 It is unclear whether these problems result from the pharmacologic effects of opioids, characteristics of patients most likely to receive them, or some combination. …”

Nursing care of the patient undergoing lumbar spinal fusion

“…[52] Among patients with work-related injuries, preoperative depression and preoperative opioid dependence have been associated with higher postoperative medical costs, lower return to work rates, lower work retention rates, and longer postoperative pain medication use compared to other patients. [53,54] Although additional research is needed to develop and evaluate the efficacy of specific strategies to improve perioperative outcomes, conducting a holistic evaluation of every patient should enable nurses to recognize psychological and social barriers to recovery.…”