Carreon et al. reported their results for lumbar fusion in worker’s compensation (WC) patients compared to a propensity-score matched control group in the September 1 issue. Echoing the findings of prior studies, this paper demonstrated worse results in the WC group, despite matching for potential confounders. Given that this finding has been reported throughout the spine and general orthopaedic literature for almost all musculoskeletal conditions, we should not be surprised. Rather, we should ask how should we treat this challenging patient population? As Steven Atlas points out in his thoughtful commentary, the only way to answer this question is to perform RCTs in the WC population comparing various treatment modalities. This would allow for the calculation of treatment effect—the difference in outcomes between two different treatments, i.e. fusion and physical therapy. It is this relative difference in outcomes that should drive the treatment decision rather than the absolute outcome. It may turn out that while WC patients benefit less from fusion than the non-WC population, they may do even worse with non-operative treatment (this was the case in the SPORT disc herniation cohort on some outcome measures ). The definitive answer to this question will probably only come from a well-designed RCT of a WC population.
One of the challenges in interpreting the findings of this paper is the heterogeneous diagnoses among the study patients. As this group has shown, results of lumbar fusion are markedly better for patients with degenerative spondylolisthesis compared to those with post-discectomy “instability” or pseudarthrosis from a prior attempt at fusion . As such, it is difficult to extrapolate these findings to all WC patients undergoing fusion. This study provides us with more data that can be used to counsel WC patients considering fusion, but we still do not know the optimal treatment for this population (which likely varies depending on the underlying diagnosis).
Please read the accompanying commentary by Dr. Carreon, the lead author on this study as well as the commentaries by Steven Atlas and Terry Corbin. Will this article change your approach to treating WC patients considering fusion?
1. Pearson AM, Lurie JN, Tosteson TD, et al. SPORT intervertebral disc herniation: indications matter most. ISSLS Annual Meeting, Auckland, 2010.
2.Glassman SD, Carreon LY, Djurasovic M, et al. Lumbar fusion outcomes stratified by specific diagnostic indication. Spine J 2009;9:13-21.
Adam Pearson, MD, MS