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Some WorkCover fusions work
- 1. Some WorkCover fusions work: Presence of leg pain influences outcome Emma Johnston Dr Ben Goss Taylor Major Adj Prof Paul Licina Brisbane Private Hospital Research Group
- 2. Some WorkCover fusions work: Presence of leg pain influences outcome We declare that in relation to this talk there are no conflicts of interest to disclose. In relation to all other possible conflicts of interest: • Institutional support from Brisbane Private Hospital Research Group has been received and used to employ a research assistant. • Dr Ben Goss is an employee of NuVasive. Paul Licina (principal author) Emma Johnston Ben Goss Taylor Major Disclaimer
- 3. Compensation and Fusion Some WorkCover fusions work: Presence of leg pain influences outcome • Compensation patients have low return to work rates after surgery (50%) • A large number still required some form of ongoing treatment two years postoperatively (77%)
- 4. Compensation and Fusion Some WorkCover fusions work: Presence of leg pain influences outcome • Compensation patients have higher rates of surgery but poorer outcomes • Little or no improvement seen in function and disability scores, with some worsening
- 5. ? Our WorkCover patients weren’t as bad as papers suggested • Location of preoperative pain Some WorkCover fusions work: Presence of leg pain influences outcome Observations
- 6. Some WorkCover fusions work: Presence of leg pain influences outcome Aims 1. To quantify the outcomes of WorkCover fusion patients 2. To determine if preoperative location of pain influences outcome
- 7. Method Prospectively collected data Retrospectively reviewed 10 year period (2006-2015) Single surgeon Single level primary interbody lumbar fusions Degenerative conditions Some WorkCover fusions work: Presence of leg pain influences outcome
- 8. Some WorkCover fusions work: Presence of leg pain influences outcome Patient Reported Outcomes Pre-operative 6/52 postop 6/12 postop
- 9. Private WorkCover Total 465 42 507 nt back 103 12 115 g equal 269 17 286 nt leg 93 13 106 WorkCover Some WorkCover fusions work: Presence of leg pain influences outcome Results
- 10. Pre-operative 6 weeks 6 months 0 20 40 60 80 100 Time ODI% Private (n=465) WorkCover (n= 42) Some WorkCover fusions work: Presence of leg pain influences outcome ODI
- 11. Pre-operative 6 weeks 6 months 0 2 4 6 8 10 Time BackVAS WorkCover (n=42) Private (n=465) Some WorkCover fusions work: Presence of leg pain influences outcome Back VAS
- 12. Pre-operative 6 weeks 6 months 0 2 4 6 8 10 Time LegVAS WorkCover (n=42) Private (n=465) Some WorkCover fusions work: Presence of leg pain influences outcome Leg VAS
- 13. Some WorkCover fusions work: Presence of leg pain influences outcome ODI improvement - Private -50 -25 0 25 50 75 100 DODI n = 465 71.83% MCID better 9.89% Subjectively better 1.29% No change 4.52% Subjectively worse 0.65% MCID worse Private change in ODI 81% improved 1% worse 18% no clinically relevant change
- 14. -50 -25 0 25 50 75 100 DODI Private (n=465) WorkCover (n= 42 ) Some WorkCover fusions work: Presence of leg pain influences outcome ODI improvement 81% 53% improved 1% 5% worse 18% 42% no clinically relevant change
- 15. Some WorkCover fusions work: Presence of leg pain influences outcome Back VAS improvement - Private -10 -5 0 5 10 DBackVAS n = 465 67.53% MCID better 6.88% Subjectively better 3.87% No change 3.66% Subjectively worse 3.44% MCID worse Private change in Back VAS 17% no clinically relevant change 77% improved 4% worse
- 16. Some WorkCover fusions work: Presence of leg pain influences outcome Back VAS improvement 79% 61% improved 4% 11% worse 17% 28% no clinically relevant change
- 17. Some WorkCover fusions work: Presence of leg pain influences outcome Leg VAS improvement - Private -10 -5 0 5 10 DLegVAS n = 465 65.38% MCID better 7.31% Subjectively better 7.53% No change 3.23% Subjectively worse 1.94% MCID worse Private change in Leg VAS 19% no clinically relevant change 77% improved 4% worse
- 18. Some WorkCover fusions work: Presence of leg pain influences outcome Leg VAS improvement 77% 61% improved 4% 8% worse 19% 31% no clinically relevant change
- 19. Some WorkCover fusions work: Presence of leg pain influences outcome Aims 1. To quantify the outcomes of WorkCover fusion patients Postoperative improvement in both groups WorkCover did not improve as much
- 20. Some WorkCover fusions work: Presence of leg pain influences outcome Aims 1. To quantify the outcomes of WorkCover fusion patients 2. To determine if preoperative location of pain influences outcome
- 21. Results Private Some WorkCover fusions work: Presence of leg pain influences outcome Equal Leg Back Back Equal WorkCover Leg Back Equal 58% 22% 31%20% 40% 29%
- 22. Pre-operative 6 weeks 6 months 0 20 40 60 Time ODI% LPD WorkCoverLPD Private BPD WorkCoverBPD Private BLE WorkCoverBLE Private Some WorkCover fusions work: Presence of leg pain influences outcome ODI Back VAS Leg VAS
- 23. Some WorkCover fusions work: Presence of leg pain influences outcome ODI Pre-operative 6 weeks 6 months 0 20 40 60 Time ODI% LPD Private BPD Private BLE Private
- 24. Pre-operative 6 weeks 6 months 0 20 40 60 Time ODI% LPD WorkCoverLPD Private BPD WorkCoverBPD Private BLE WorkCoverBLE Private Some WorkCover fusions work: Presence of leg pain influences outcome ODI
- 25. Some WorkCover fusions work: Presence of leg pain influences outcome Pre-operative 6 weeks 6 months 0 2 4 6 8 10 Time BackVAS BPD WorkCoverBPD Private BLE WorkCoverBLE Private Back VAS
- 26. Some WorkCover fusions work: Presence of leg pain influences outcome Leg VAS Pre-operative 6 weeks 6 months 0 2 4 6 8 10 Time LegVAS LPD WorkCoverLPD Private
- 27. Pre-operative 6 weeks 6 months 0 2 4 6 8 10 Time LegVAS LPD WorkCoverLPD Private BLE WorkCoverBLE Private Some WorkCover fusions work: Presence of leg pain influences outcome Leg VAS
- 28. Some WorkCover fusions work: Presence of leg pain influences outcome Aims 1. To quantify the outcomes of WorkCover fusion patients 2. To determine if preoperative location of pain influences outcome WorkCover patients with leg pain do well
- 29. • WorkCover patients have less improvement in ODI and VAS • Especially with significant preoperative back pain • Very few are worse (5-10%) • WorkCover patients with dominant leg pain do better Some WorkCover fusions work: Presence of leg pain influences outcome Conclusions
- 30. • Study limited by small numbers • If a patient has predominant leg pain, their WorkCover status should not exclude them from surgery • Research into back pain treatment should focus on identifying subgroups that respond to treatment Some WorkCover fusions work: Presence of leg pain influences outcome Impressions
Editor's Notes
- Good morning my name is Emma Johnston and I am a second year medical student at the University of Melbourne. Prior to this I was our groups research assistant for nearly 5 years. Thank you for allowing me to present today.
- These are our disclosures.
- As we are all well aware, the perception of spinal fusion for compensation patients is negative This paper was published by professor Ian Harris in 2012 showing poor outcomes in workers compensation patients after surgery.
- A more recent study had similar conclusions.
- However, anecdotally, our outcomes weren’t as bad as some of these papers indicated WorkCover being the QLD Workers Compensation scheme We thought that the type of pre-operative pain may be important
- So we conducted this study to quantify the outcomes we were seeing for WorkCover patients And to also look at whether the location of preoperative pain influences postoperative outcome
- We retrospectively reviewed data that was prospectively collected. All primary single level interbody fusions performed over a 10 year period for degenerative conditions by a single surgeon were included.
- PRO were collected pre-operatively and at 6 wks, 6 months postoperatively. Standard protocol for patient review meant that all patient data was available Oswestry Disability Index and back and leg Visual Analogue Score were collected
- 507 patients were included in the study WC patients represented less than 10% of the cohort
- As expected, we found that the average ODI improved for both groups but that the improvement was greater in the private patient group.
- The same trend was seen for back pain
- And for leg pain.
- To look at this data more closely we analysed the amount of change in each of the patient reported outcomes from preop to 6 months postop. Most patients improved. But taking into account the Minimum Clinically Important Difference or MCID of 12.8 for ODI, some patients fell into the grey zone of no clinically meaningful improvement. More than 80% of private patients achieved this MCID.
- However, just over half of WorkCover patients improved above the MCID. More WorkCover than private patients fell into the group of no clinically meaningful improvement. Importantly, however, very few were worse.
- For back VAS the MCID is 1.2. Again, nearly 80% of private patients improved above this level.
- However, only 60% of WorkCover patients had a meaningful improvement.
- We saw a similar trend for leg pain with almost 80% of private patients
- And just over 60% of WorkCover patients achieving MCID.
- So for our first aim, we found that there was postoperative improvement in both groups but that the WorkCover group did not improve as much. We also felt the WorkCover results were not as dismal as some people think.
- Now to our second aim which is to determine whether the location of preoperative pain has any influence on outcome
- To assess this the private and WorkCover groups were further subdivided based on the dominant preoperative pain location. ____ The 3 groups were patients who had predominantly leg pain, predominately back pain or equal amounts of back and leg pain. Patients were considered equal if their back and leg VAS were within 2 points of each other. There was some difference in the proportion of each group between private and WorkCover patients.
- Next I am going to show you a series of graphs focusing on pain location. The LPD patients are in the darkest shade (of blue for private and red for WC) We will look at the PROMS being ODI and back and leg VAS.
- First ODI We saw that private patients did equally well, regardless of their dominant preoperative pain location.
- Whereas in the WC group leg pain patients did better, nearly as well as private patients.
- For Back VAS we saw that patients were very different, depending on whether they were private or WC
- In contrast, for leg VAS, the patients with predominatley leg pain had very similar improvements, regardless of their WC status.
- As soon as there is a significant element of back pain the numbers are very different.
- So for our second aim, we have isolated a group where WC status does not seem to influence outcome. These are patients where preoperative leg pain exceeds back pain. Another way of looking at that is if back pain is equal or greater than leg pain, WC patients do poorly.
- In conclusion, WC patients undergoing spinal fusion do not do as well as private patients. Especially if they have significant preoperative back pain. Fortunately, very few are subjectively worse. A sub-group of WC patients, those with mainly leg pain preoperatively, do well.
- This study and its results are significantly limited by the small numbers. But maybe we can draw from this that WC patients with leg pain should not necessarily be excluded from surgery. As we have heard at this meeting from Dr McCombe and others, as clinicians we know many interventions are effective even if unable to be proven in RCTs. We recognise patients with back pain are heterogenous and combining them into one big group may mask possible benefits in subgroups. Perhaps this type of study is where the focus should be. It may be fruitless to undertake more and more large RCTs to prove a treatment works or doesn’t work. We need to look at treatments where outcome varies and further define the factors which are associated with a good clinical outcome.