Lumbar Fusion among workers’ compensation subjects- A review and meta-analysis

Trang Nguyen M.D. FAADEPDavid C. Randolph MD, MPH, FAADEPRussell Travis M.D. FAADEPJanuary 18th, 2008San Antonio, Texas

Background• Developed in 1911• Original indications:

– Spinal instability– Tuberculosis– Tumors– Trauma– Scoliosis

• Literature– degenerative disc disease (51%)– spondylolisthesis (25%)– spinal stenosis (11%)– spondylosis (10%)– lumbar fracture (7%)

• (1995, Katz; Davis spine 94)

Background• Today

– 60 % - 65 % of the lumbar fusion is performed for the diagnosis of degenerative disc disorders (Lee, Spine j. 04)

– 1996-2001, the rate of spinal arthrodesis increased by 77% (Deyo, 2004)

– 250,000 cases of spinal arthrodesis performed in 2003. (Surgical neuro. 2004, 61:316-7, and Pawl 2004)

– In 1994, of the ten developed countries analyzed for lumbar surgical rates, the US ranked the highest in surgical rate (Cherkin, spine 1994 v. 19).

Objective

To perform a systematic review and meta-analysis of the outcomes of lumbar fusion among workers’ compensation subjects

Methods

• Inclusion criteria– Strictly workers compensation

subjects– Historical cohort study design– Lumbar fusion only– US workers’ compensation

systems

• Outcomes of Interest– Return to work status– Disability status– Complications– Re-operation– Pain medication usage

Methods

• Data Sources– Search performed on

10/16/07– Terms used in electronics

search• Workers’ compensation• Lumbar fusion

Methods

SourcesMEDLINE 1950 to presentCochrane database- no new articlesScopus (EMBASE)- US only

Lumbar Fusion-491 articles Workers’ Compensation- 5632 articles

Matching of lumbar fusion and workers’ compensation terms

3 articles – Maghout-Juratli- Spine2006DeBerard- J. of Southern Orthopedic Association- 2002Franklin- Spine- 1994

13 articles

Excluded

1-obesity, litigation & costs

2- guidelines & quality of care

1-biopsychosocial & costs

3- duplicates

2- prospective

1-German subjects

Methods

– Two authors reviewed all abstracts (TN & DR)

– No blinding to authors’ names

– Information extracted from each article in a uniform format

– Disagreement- discussed with 3rd researcher

Methods

• WinBUGS Software, version 1.4

• Re-operation & Disability– Rates (%) analyzed

quantitatively

Results• Descriptive statistics of study populations

Results• Descriptive statistics of surgeries

Results• Outcomes Measured

ResultsMaghout-Juratli, 2006- 63.9%DeBerard, 2002- PL= 24.6 %,BAK= 18.2% Franklin, 1994- 68%

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0

Disability Rate

Stu

dy

DeBerard, 2002 -- PL

Franklin, 1994

DeBerard, 2002 -- BAK

Pooled Random

Effects Estimate

Maghout-Juratli, 2006

ResultsMaghout-Juratli, 2006- 22.1%DeBerard, 2002- PL= 23.8 %,BAK= 14.3% Franklin, 1994- 22.9%

0.00 0.05 0.10 0.15 0.20 0.25 0.30 0.35 0.40 0.45 0.50

Re-Operation Rate

Stu

dy

DeBerard, 2002 -- PL

Franklin, 1994

DeBerard, 2002 -- BAK

Pooled Random effects Estimate

Maghout-Juratli, 2006

Discussion•Outcomes Measured

Discussion• Definitions

Discussion

• Re-operation – Within 2 years of index

fusion included repeated fusion or instrumentation removal

– Fairly consistent results (22%)

Discussion

• Post-surgery complications – In the 3 months after index

fusion– (anesthetic, DVT, device

complications, neural and PE)

• Maghout-Juratli, 2006 • 11.8%

Discussion

• Work disability – 2 years post fusion- TT or

PTD – Maghout-Juratli, 2006

Franklin, 1994 – 64% and 68%

– Self reported as “totally disabled at follow up”.

– DeBerard, 2002 – 22%

Discussion

• Return to work status – Self reported at F/U – same, lighter work or no

RTW• DeBerard, 2002 -78%• Franklin, 1994 - 41%

– 1yr, 2yrs., at the end of the study?

Conclusions

• True effects are difficult to determined:– too few studies (3)– sample sizes at follow up in

one study is too small– lost to follow up rates were

moderately high in 2 of 3 studies

Conclusions

• Re-operation rate appears to be consistent (22%)– Should be interpreted with

caution

• Additional studies with large sample sizes are much needed

• Future studies should consider standardization of outcomes measured

References• Maghout Juratli, Sham; Franklin, Gary M;

Mirza, Sohail K; Wickizer, Thomas M; Fulton-Kehoe, Deborah. Lumbar fusion outcomes in Washington State workers' compensation. Spine. vol. 31, no. 23 (2006 Nov 1): 2715-23.

• Franklin, G M; Haug, J; Heyer, N J; McKeefrey, S P; Picciano, J F. Outcome of lumbar fusion in Washington State workers' compensation. Spine. vol. 19, no. 17 (1994 Sep 1): 1897-903.

• DeBerard, M Scott; Colledge, Alan L; Masters, Kevin S; Schleusener, Rand L; Schlegel, John D. Outcomes of posterolateral versus BAK titanium cage interbody lumbar fusion in injured workers: a retrospective cohort study. Journal of the Southern Orthopaedic Association. vol. 11, no. 3 (2002 Fall): 157-66.

Authors

• The authors have no financial and no conflict of interest relating to this article.

THANK YOU!