Prospective Assessment of Outcomes Improvement Following Fusion for Low Back Pain

Background: This prospective study was performed to improve the quality of outcomes data in patients undergoing spinal fusion for low back pain. There is an accepted deficiency of this form of outcomes assessment in the literature. The aim was to determine the effectiveness of the surgical procedure in terms of patient satisfaction, outcome scores, and third-party measures. Methods: The measures of outcomes assessment included patient satisfaction, pain scores, low back outcome and Prolo scores, medication use, and employment status. Data collection was prospective prior to and at final follow-up. Eighty percent of 35 patients were followed for a mean of 31 months. Results: Patient satisfaction was 71%; however, only 28.6% of patients followed achieved good or excellent low back outcome scores. Yet significant improvement occurred: 46.4% achieved a good or excellent outcome using the Prolo score. There was a 75% reduction in medication usage, and 75% of nonworking compensation patients returned to gainful employment. Patient satisfaction was markedly higher than improvement measured by the outcome scores. Dramatic improvements in medication usage and return to work were achieved, despite less than spectacular outcome scores. Conclusions: These findings support cautious use of posterior spinal fusion. Patients must appreciate improvement rather than normality as a realistic aim.

[1]  J. Weinstein,et al.  Lumbar discography in normal subjects. A controlled, prospective study. , 1990, The Journal of bone and joint surgery. American volume.

[2]  P. Robertson,et al.  Natural History of Posterior Iliac Crest Bone Graft Donation for Spinal Surgery: A Prospective Analysis of Morbidity , 2001, Spine.

[3]  R. Keller.  Outcomes Research in Orthopaedics , 1993, Instructional course lectures.

[4]  R. Fraser,et al.  Anterior Lumbar Interbody Fusion: A Minimum 10‐Year Follow‐Up , 1997 .

[5]  G. Rechtine,et al.  The Effect of Pedicle Screw/Plate Fixation on Lumbar/Lumbosacral Autogenous Bone Graft Fusions in Patients With Degenerative Disc Disease , 1995, Spine.

[6]  Assessment of clinical articles. , 2001, Journal of spinal disorders.

[7]  R. Fraser,et al.  Instrumented Posterolateral Lumbar Fusion: Results and Comparison With Anterior Interbody Fusion , 1998, Spine.

[8]  L. Nolte,et al.  Improved Accuracy of Pedicle Screw Insertion With Computer-Assisted Surgery: A Prospective Clinical Trial of 30 Patients , 1997, Spine.

[9]  T. Albert,et al.  Accuracy of SPECT scanning in diagnosing pseudoarthrosis: a prospective study. , 1998, Journal of spinal disorders.

[10]  J. Kaiser,et al.  Normal Magnetic Resonance Imaging with Abnormal Discography , 1988, Spine.

[11]  J. O'Brien.  Lumbar Disc Disease With Discogenic Pain: What Surgical Treatment Is Most Effective? , 1996, Spine.

[12]  B. Beynnon,et al.  Placement of Transpedicular Vertebral Screws Close to Anterior Vertebral Cortex: Description of Methods , 1989, Spine.

[13]  S. Jabbur,et al.  From electrical wiring to plastic neurons: evolving approaches to the study of pain , 1999, Pain.

[14]  A. Nordwall,et al.  2001 Volvo Award Winner in Clinical Studies: Lumbar Fusion Versus Nonsurgical Treatment for Chronic Low Back Pain: A Multicenter Randomized Controlled Trial From the Swedish Lumbar Spine Study Group , 2001, Spine.

[15]  R. Fraser,et al.  The Graf Ligamentoplasty Procedure: Comparison With Posterolateral Fusion in the Management of Low Back Pain , 1998, Spine.

[16]  E. Carragee,et al.  False-positive findings on lumbar discography. Reliability of subjective concordance assessment during provocative disc injection. , 1999, Spine.

[17]  N. Colterjohn.  Procurement of Bone Graft from the Iliac Crest. An Operative Approach with Decreased Morbidity* , 1997, The Journal of bone and joint surgery. American volume.

[18]  D. Singer,et al.  Relationship between rates and outcomes of operative treatment for lumbar disc herniation and spinal stenosis. , 1999, The Journal of bone and joint surgery. American volume.

[19]  J. Gibson,et al.  The Cochrane review of surgery for lumbar disc prolapse and degenerative lumbar spondylosis. , 1999, Spine.

[20]  R. Fraser,et al.  Anterior lumbar fusion. A comparison of noncompensation patients with compensation patients. , 1994, Clinical orthopaedics and related research.

[21]  J. Fischgrund,et al.  Degenerative Lumbar Spondylolisthesis With Spinal Stenosis: A Prospective Long-Term Study Comparing Fusion and Pseudarthrosis , 2004, Spine.

[22]  W. J. Daum,et al.  Evaluation of Lumbar Spine Fusion: Plain Radiographs Versus Direct Surgical Exploration and Observation , 1995, Spine.

[23]  T. Zdeblick.  A prospective, randomized study of lumbar fusion. Preliminary results. , 1993, Spine.

[24]  R. Winter.  The prospective, randomized, controlled clinical trial in spine surgery: fact or fiction? , 1999, Spine.

[25]  J N Weinstein,et al.  The Impact of Spinal Problems on the Health Status of Patients: Have We Underestimated the Effect? , 2000, Spine.

[26]  M. Modic,et al.  Lumbar discography. , 1996, Spine.

[27]  M. Mackay,et al.  1997 Volvo Award Winner in Clinical Studies: Degenerative Lumbar Spondylolisthesis With Spinal Stenosis: A Prospective, Randomized Study Comparing Decompressive Laminectomy and Arthrodesis With and Without Spinal Instrumentation , 1997, Spine.

[28]  A. E. Brodsky,et al.  Correlation of Radiologic Assessment of Lumbar Spine Fusions with Surgical Exploration , 1991, Spine.

[29]  E. Hanley,et al.  The Indications for Lumbar Spinal Fusion With and Without Instrumentation , 1995, Spine.

[30]  R. Fraser,et al.  Assessment of Outcome in Patients with Low‐Back Pain , 1992, Spine.

[31]  D. Ohnmeiss,et al.  Lumbar Discography: Position Statement From the North American Spine Society Diagnostic and Therapeutic Committee , 1995, Spine.

[32]  T. Zdeblick.  The Treatment of Degenerative Lumbar Disorders: A Critical Review of the Literature , 1995, Spine.

[33]  K. Gill,et al.  Can lumbar spine radiographs accurately determine fusion in postoperative patients? Correlation of routine radiographs with a second surgical look at lumbar fusions. , 1993, Spine.

[34]  Greenough Cg,et al.  Assessment of outcome in patients with low-back pain. , 1992 .

[35]  E. Hanley,et al.  Lumbar arthrodesis for the treatment of back pain. , 1999, The Journal of bone and joint surgery. American volume.

[36]  J. Katz,et al.  A Review of the 2001 Volvo Award Winner in Clinical Studies: Lumbar Fusion Versus Nonsurgical Treatment for Chronic Low Back Pain: A Multicenter Randomized Controlled Trial From the Swedish Lumbar Spine Study Group , 2006, Spine.

[37]  D. Prolo,et al.  Toward Uniformity in Evaluating Results of Lumbar Spine Operations: A Paradigm Applied to Posterior Lumbar Interbody Fusions , 1986, Spine.

[38]  N. Semmer,et al.  The impact of clinical, morphological, psychosocial and work-related factors on the outcome of lumbar discectomy , 1999, Pain.

[39]  A. Vaccaro,et al.  Internal Fixation (Pedicle Screw Fixation) for Fusions of the Lumbar Spine , 1995, Spine.

[40]  Nicholas,et al.  Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. , 1990, The Journal of bone and joint surgery. American volume.