Outcomes/Effectiveness Research

Back pain studies examine outcomes of surgery as well as long-term disability and return to work

Most Americans have suffered from back pain at one time or another. In fact, low back problems are one of the most frequent reasons for disability compensation claims in workers. A typical decision for chronic back pain is whether to undergo surgery or whether nonsurgical approaches will eventually reduce pain and improve functioning. Three recent studies, supported by the Agency for Healthcare Research and Quality and summarized here, examine these issues.

The first study (AHRQ grant HS06344) shows that surgery improved the outcomes of patients with severe lumbar spinal stenosis compared with nonsurgical treatments. The second study (AHRQ grant HS09804) finds that patients who have high hopes that surgery will improve their sciatica fare better than patients who have lower expectations. The third study (AHRQ grant HS06344) demonstrates that surgically treated patients with herniated discs or sciatica had fewer symptoms and better functional status than nonsurgically treated patients, even though disability and work outcomes were comparable.

Atlas, S.J., Keller, R.B., Robson, D., and others. (2000, March). "Surgical and nonsurgical treatment of lumbar spinal stenosis: Four year outcomes from the Maine Lumbar Spine Study." Spine 25, pp. 556-562.

In this study, the researchers found that of 119 patients with symptomatic lumbar spinal stenosis, surgically treated patients (decompressive laminectomy with or without fusion) had more severe symptoms and worse functional status at baseline, yet had better outcomes 4 years later compared with nonsurgically treated patients. At that point, 70 percent of patients who had surgery and 52 percent of nonsurgically treated patients reported that their predominant symptom, either leg or back pain, was better. Nonsurgical treatment ranged from bedrest, back exercises, physical therapy, and spinal manipulation to narcotic analgesics and epidural steroids.

After 4 years, 63 percent of surgically treated patients and 42 percent of nonsurgically treated patients were satisfied to spend the rest of their lives with their current back symptoms. Also, 79 percent of surgically treated patients said that if they had the choice to make again, they would still choose surgery. Outcomes of nonsurgically treated patients improved modestly and remained stable over 4 years, with differences narrowing between the two groups during that time.

Nevertheless, 30 to 40 percent of patients treated surgically and 50 to 60 percent of patients treated nonsurgically had unsatisfactory outcomes after 4 years. The researchers conclude that the treatment options offered to individual patients should be based on their symptoms, functional impairment, and other limiting medical conditions. They interviewed patients at baseline and via mailed questionnaires at 3, 6, 12, 24, 36, and 48 months. Physicians completed a standard baseline questionnaire of patients' medical history, physical and neurologic findings, diagnostic procedures, and planned treatment.

Lutz, G.K., Butzlaff, M.E., Atlas, S.J., and others. (1999, December). "The relation between expectations and outcomes in surgery for sciatica." Journal of General Internal Medicine 14, pp. 740-744.

Patients who expect symptom relief and a short recovery from surgery for their sciatica (low back pain with radiating leg pain, numbness, or weakness) have better surgical outcomes than patients with lower expectations, according to this study. The researchers recruited 273 patients from the offices of orthopedic surgeons, neurosurgeons, and occupational medicine physicians in Maine; the patients all underwent diskectomy for sciatica. They measured patients' and physicians' expectations before surgery and their satisfaction with care and changes in symptoms and functional status 1 year after surgery.

About two-thirds of patients expected less than a 3-month recovery time after surgery and expected to return to their usual health state. These patients were twice as likely to be pleased or delighted with their outcomes a year later than patients who expected recovery to last longer than 3 months. Also, more patients who preferred surgery, even after learning that sciatica could get better without surgery, had nearly three times the likelihood of lower symptom scores a year after surgery than patients who did not prefer surgery.

On the other hand, physicians' expectations for surgery were often overblown. When physicians predicted a "great deal of improvement" after surgery, 39 percent of patients were not satisfied with their outcomes, and 25 percent said their symptoms had not improved. The researchers conclude that asking patients about what they expect from the surgery may help physicians identify patients who are more likely to benefit from diskectomy for sciatica.

Atlas, S.J., Chang, Y., Kammann, E., and others. (2000, January). "Long-term disability and return to work among patients with lumbar disc herniation: The impact of disability compensation at baseline." Journal of Bone and Joint Surgery 82(1), pp. 4-15.

Workers' compensation status does not seem to affect the long-term outcomes of workers with sciatica, concludes this study. The researchers prospectively studied patients with sciatica seeking care from specialist physicians in community-based practices throughout Maine. About half were receiving worker's compensation at baseline and half were not. Followup questionnaires at 4 years were used to assess patients' disability compensation and work status, as well as symptom relief, functional status, and quality of life.

At baseline, patients receiving workers' compensation reported worse functional status, even though clinical findings were similar to patients not receiving workers' compensation. Four years later, patients who received workers' compensation at baseline were more apt to be receiving disability benefits (27 vs. 7 percent) but were only slightly less likely to be working (80 vs. 87 percent). Operative treatment did not influence these comparisons, although it did improve symptoms and functional status.

Surgically treated patients, whether receiving workers' compensation at baseline or not, reported greater improvement in symptoms and functional status at 4 years, even though disability and work outcomes were comparable in those treated nonsurgically. The researchers conclude that physician reluctance to operate on patients with sciatica who are receiving workers' compensation—and thus perceived as more likely to exaggerate their symptoms—must be tempered by the fact that the patients may benefit from surgery.

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