EK HEALTH

by Richard Thompson, MD
EK Health Services' Chief Medical Officer

I am quite certain most of you are aware of the recent article in Spine, February 2011; 36: p. 320 – 331 entitled, “Long-term Outcomes of Lumbar Fusion Among Workers’ Compensation Subjects.” The study looked at 725 lumbar fusion surgeries in workers’ compensation patients and followed them for two years. The results showed that lumbar fusions for the diagnoses of disc degeneration, disc herniation, and/or radiculopathy in a workers’ compensation setting is associated with significant increase in disability, increased opiate use, prolonged work loss and poor return to work results, all of which results in significant costs, mortality, morbidity, and reoperation rates!

The results, when viewed two years after surgery and compared to a nonsurgical control group, looked like this:

1)    26% returned to work compared to 67% for the control group

2)    27% required reoperation

3)    36% had surgical and post-surgical complications

4)    11% had a permanent disability rating compared to 2% for the control group

5)    17 surgical patients died during the post-op period of two years compared to 11 in the control group

6)    Total days off work for surgical cases was 1140 compared to 316 for controls

7)    76% continued opioid use and the daily opioid use increased 41 % after surgery

The number of lumbar fusions has increased by more than 220% in the US over the past 20 years. Good results have been shown for spondylolisthesis with instability, traumatic fractures, or tumor. However, it would appear from this study that lumbar fusions, while effective in certain categories, as noted above, should be cautiously considered and recommended for workers’ compensation patients only when they have clear indications that meet evidence-based medicine treatment guidelines.

My comments: MTUS spells out two types of chronic pain, namely the biomedical model (MM) and the biopsychosocial model (BPS). Maybe we should start to demand that “chronic pain” as a diagnosis is not enough. Instead, it should be called chronic pain-MM or chronic pain-BPS. The distinction implies prognosis for future therapy and recognizes the role certain central mechanisms play in the pain experience and recognizes the importance of illness behavior in chronic pain.

As the above study shows (for lumbar fusion), if you operate for pain on a chronic pain - BPS patient, the results are poor. On the other hand, MM patients with instability, fractures, tumor, or certain herniated discs with radiculopathy do well with surgery and other aggressive medications and interventions. If we continue to authorize interventions, surgery, and/or large doses of controlled substances for chronic pain - BPS, both the therapy and the patient, are doomed to fail.

Incidentally, the authors of this article will be following up very soon with a separate article addressing the opioid use in these same patients.