Clinical decision making in spinal fusion for chronic low back pain. Results of a nationwide survey among spine surgeons

Abstract

ObjectivesTo assess the use of prognostic patient factors and predictive tests in clinical decision making for spinal fusion in patients with chronic low back pain.Design and settingNationwide survey among spine surgeons in the Netherlands.ParticipantsSurgeon members of the Dutch Spine Society were questioned on their surgical treatment strategy for chronic low back pain.Primary and secondary outcome measuresThe surgeons' opinion on the use of prognostic patient factors and predictive tests for patient selection were addressed on Likert scales, and the degree of uniformity was assessed. In addition, the influence of surgeon-specific factors, such as clinical experience and training, on decision making was determined.ResultsThe comments from 62 surgeons (70% response rate) were analysed. Forty-four surgeons (71%) had extensive clinical experience. There was a statistically significant lack of uniformity of opinion in seven of the 11 items on prognostic factors and eight of the 11 items on predictive tests, respectively. Imaging was valued much higher than predictive tests, psychological screening or patient preferences (all p<0.01). Apart from the use of discography and long multisegment fusions, differences in training or clinical experience did not appear to be of significant influence on treatment strategy.ConclusionsThe present survey showed a lack of consensus among spine surgeons on the appreciation and use of predictive tests. Prognostic patient factors were not consistently incorporated in their treatment strategy either. Clinical decision making for spinal fusion to treat chronic low back pain does not have a uniform evidence base in practice. Future research should focus on identifying subgroups of patients for whom spinal fusion is an effective treatment, as only a reliable prediction of surgical outcome, combined with the implementation of individual patient factors, may enable the instalment of consensus guidelines for surgical decision making in patients with chronic low back pain.

The Recent Trend in Diagnosis and Treatment of Chronic Low Back Pain

“…Furthermore, frequency of spinal fusion depends on physician's enthusiasm 77) . Many trials have been made to identify the prognostic patient factors and predictive tests for patient selection, but there is no consensus [78][79][80] . Evidence does not support the use of current tests for patient selection 81) .…”

Which patient-reported factors predict referral to spinal surgery? A cohort study among 4987 chronic low back pain patients

“…Similar studies using patient referral data are lacking, but Willems et al evaluated the opinion of 62 Dutch spine surgeons on the use of patient-reported factors (e.g., age, BMI) and predictive tests (e.g., magnetic resonance imaging) in clinical decision-making for spinal fusion [6]. That study showed a lack of professional consensus and indicated that patientreported factors were not consistently incorporated in the surgeons' treatment strategy [6].…”

“…Improved insight into the current spine surgery decisionmaking process for CLBP patients may clarify some of the aforementioned variations in spinal surgery rates [4], and may ultimately support spine surgery decision-making guidelines [6,11]. Amongst others, it would be insightful to know which CLBP patients are typically referred to spinal surgery, whether patient-reported factors can be identified that are predictive of spinal surgery referral, and if so, to what extent spinal surgery referral is explained by these factors.…”

“…These variations in spinal surgery rates seem to indicate a lack of professional consensus. Moreover, as in many fields of healthcare, conclusive evidence for the long-term (cost-) effectiveness of spinal surgeries is lacking, and risk is inherent to any surgical procedure [5][6][7]. Therefore, reducing the number of unnecessary spine surgeries is important for improving patient safety, patient outcomes, and healthcare efficiency [7].…”

“…Therefore, reducing the number of unnecessary spine surgeries is important for improving patient safety, patient outcomes, and healthcare efficiency [7]. Proper patient referral and selection is expected to improve the outcome of spinal surgery [6,8,9] but no classification system currently exists that is supported by sufficient evidence to be broadly implemented [8,10].…”