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

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. Background. Developed in 1911 Original indications: Spinal instability

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

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  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 18th, 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 13 articles Excluded 1-obesity, litigation & costs 2- guidelines & quality of care 1-biopsychosocial & costs 3- duplicates 2- prospective 1-German subjects 3 articles – Maghout-Juratli- Spine2006 DeBerard- J. of Southern Orthopedic Association- 2002 Franklin- Spine- 1994

  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 3rd 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. ResultsMaghout-Juratli, 2006- 63.9%DeBerard, 2002- PL= 24.6 %,BAK= 18.2% Franklin, 1994- 68%

  15. ResultsMaghout-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!

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