1. Lumbar Fusion among workers’ compensation subjects- A review and meta-analysis Trang Nguyen M.D. FAADEP David C. Randolph MD, MPH, FAADEP Russell Travis M.D. FAADEP January 18 th, 2008 San Antonio, Texas

2. 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)

3. 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).

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

5. 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

6. Methods Data Sources –Search performed on 10/16/07 –Terms used in electronics search Workers’ compensation Lumbar fusion

7. Methods Sources MEDLINE 1950 to present Cochrane database- no new articles Scopus (EMBASE)- US only

8. Lumbar Fusion-491 articles Workers’ Compensation- 5632 articles Matching of lumbar fusion and workers’ compensation terms 3 articles – Maghout-Juratli- Spine2006 DeBerard- J. of Southern Orthopedic Association- 2002 Franklin- Spine- 1994 13 articles Excluded 1-obesity, litigation & costs 2- guidelines & quality of care 1-biopsychosocial & costs 3- duplicates 2- prospective 1-German subjects

9. 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 3 rd researcher

10. Methods WinBUGS Software, version 1.4 Re-operation & Disability –Rates (%) analyzed quantitatively

11. Results Descriptive statistics of study populations

12. Results Descriptive statistics of surgeries

13. Results Outcomes Measured

14. Results Maghout-Juratli, 2006- 63.9% DeBerard, 2002- PL= 24.6 %,BAK= 18.2% Franklin, 1994- 68%

15. Results Maghout-Juratli, 2006- 22.1% DeBerard, 2002- PL= 23.8 %,BAK= 14.3% Franklin, 1994- 22.9%

16. Discussion Outcomes Measured

17. Discussion Definitions

18. Discussion Re-operation –Within 2 years of index fusion included repeated fusion or instrumentation removal –Fairly consistent results (22%)

19. Discussion Post-surgery complications –In the 3 months after index fusion –(anesthetic, DVT, device complications, neural and PE) Maghout-Juratli, 2006 11.8%

20. 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%

21. 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?

22. 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

23. 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

24. 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.

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

26. THANK YOU!