When Do the Benefits of Lumbar Fusion Outweigh the Risks?When faced with surgery to fuse the spine, patients with low back pain have to weigh the risks against the benefits in deciding to go ahead with the procedure. But what is the patient's minimum acceptable change in symptoms and/or function before having the operation? Is a drop in pain levels enough to make it worth it? If it were you, would you have the fusion even if it meant you still weren't going to get back to work?
These are just some of the questions surgeons from Stanford University School of Medicine (Department of Orthopedic Surgery) examined in this study. They surveyed 165 low back pain patients who were planning to have a lumbar fusion.
Everyone was given a variety of questionnaires to fill out along with an expectation survey. For those who are interested in knowing what was used, some of the questionnaires included the Visual Analog Scale (VAS), Oswestry Disability Index (ODI), and the Zung Depressive Index. The results were designed to identify minimum acceptable outcomes from surgery. Anything less than the minimum would indicate it's not worth having the procedure done.
The main measures included were: 1) pain intensity, 2) function, 3) use of narcotic medications, and 4) return to work. There are many other ways to assess success of surgery like spinal fusion. Some surgeons use scales that measure patient satisfaction or patient goals.
Others rely on X-rays to show the biologic success of bone fusion as a means of measuring success. But the authors of this report believe that pain, function, medication usage, and return-to-work status are the most practical when measuring minimum acceptable outcomes after lumbar spinal fusion.
All 156 patients were operated on by one surgeon performing the same procedure (lumbar spinal fusion). The testing was done after the patients had already decided to have the surgery but before the actual procedure was done. Additional tests were given after surgery including work status, medication usage, and a satisfaction survey.
Here's what they found. Patients wanted at least a four-point improvement in pain when pain was measured on a 10-point scale (zero for no pain, 10 for maximum pain). They wanted to be free of the need for any narcotic medication. And they considered being disabled, unable to work, or only able to work part-time or with work restrictions as unacceptable.
Overall, the minimum expectation was for a high level of improvement in pain and function. The group did not think it was worth having the surgery if they couldn't get back to work within two years of the operation. In fact, more than 90 per cent of the group said they wouldn't have the surgery if they weren't sure they would be working again.
And it turned out that those patients who did meet their own minimum expectations were, indeed, satisfied with the results. The patients who indicated satisfaction even though their goals weren't met tended to be those who had other problems with chronic pain, psychologic distress, or who were on Worker's Comp.
The authors of this study have been investigating the concept of minimally clinically important difference related to spine surgeries for a while now. The results of this study adds information to the overall trends they are seeing.
They are finding that the minimum acceptable outcome varies based on the underlying problem (diagnosis) and type of procedure performed. They also noticed that most patients have a much higher expectation than what surgeons think patients can expect.
Older patients with spinal stenosis (narrowing of the spinal canal) seem to have the lowest expectations for recovery. Patients with degenerative disc disease also have lower expectations than those folks who have spondylolisthesis.
Spondylolisthesis is a defect in the supporting column of the lumbar vertebrae that allows the main body of the bone to shift forward or slip over the vertebra below it. Fusion is done to stabilize the defect and prevent further slippage.
In summary, defining the clinically minimum acceptable outcomes after lumbar spinal fusion shows that most patients have high hopes and high expectations after surgery. Anything less than a major shift in pain, improvement in function, and return-to-work is not acceptable.
Surgeons counseling patients may not want to limit expectations of recovery but should be aware of how high patient expectations really are. The surgeon can use age, diagnosis, and type of surgery as factors in gauging patient expectations when offering information and advice regarding lumbar spinal fusion. When only marginal improvements are expected, patients may not be satisfied with the overall results.
Eugene J. Carragee, MD, and Ivan Cheng, MD. Minimum Acceptable Outcomes After Lumbar Spinal Fusion. In The Spine Journal. April 2010. Vol. 10. No. 4. Pp. 313-320.
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