Elsevier

The Spine Journal

Volume 19, Issue 12, December 2019, Pages 1969-1976
The Spine Journal

Clinical Study
Impact of occupational characteristics on return to work for employed patients after elective lumbar spine surgery

https://doi.org/10.1016/j.spinee.2019.08.007Get rights and content

Abstract

BACKGROUND CONTEXT

Low back pain has an immense impact on the US economy. A significant number of patients undergo surgical management in order to regain meaningful functionality in daily life and in the workplace. Return to work (RTW) is a key metric in surgical outcomes, as it has profound implications for both individual patients and the economy at large.

PURPOSE

In this study, we investigated the factors associated with RTW in patients who achieved otherwise favorable outcomes after lumbar spine surgery.

STUDY DESIGN/SETTING

This study retrospectively analyzes prospectively collected data from the lumbar module of national spine registry, the Quality Outcomes Database (QOD).

PATIENT SAMPLE

The lumbar module of QOD includes patients undergoing lumbar surgery for primary stenosis, disc herniation, spondylolisthesis (Grade I) and symptomatic mechanical disc collapse or revision surgery for recurrent same-level disc herniation, pseudarthrosis, and adjacent segment disease. Exclusion criteria included age under 18 years and diagnoses of infection, tumor, or trauma as the cause of lumbar-related pain.

OUTCOME MEASURES

The outcome of interest for this study was the return to work 12-month after surgery.

METHODS

The lumbar module of QOD was queried for patients who were employed at the time of surgery. Good outcomes were defined as patients who had no adverse events (readmissions/complications), had achieved 30% improvement in Oswestry disability index (ODI) and were satisfied (NASS satisfaction) at 3-month post-surgery. Distinct multivariable logistic regression models were fitted with 12-month RTW as outcome for a. overall population and b. the patients with good outcomes. The variables included in the models were age, gender, race, insurance type, education level, occupation type, currently working/on-leave status, workers’ compensation, ambulatory status, smoking status, anxiety, depression, symptom duration, number of spinal levels, diabetes, motor deficit, and preoperative back-pain, leg-pain and ODI score.

RESULTS

Of the total 12,435 patients, 10,604 (85.3%) had successful RTW at 1-year postsurgery. Among patients who achieved good surgical outcomes, 605 (7%) failed to RTW. For both the overall and subgroup analysis, older patients had lower odds of RTW. Females had lower odds of RTW compared with males and patients with higher back pain and baseline ODI had lower odds of RTW. Patients with longer duration of symptoms, more physically demanding occupations, worker's compensation claim and those who had short-term disability leave at the time of surgery had lower odds of RTW independent of their good surgical outcomes.

CONCLUSIONS

This study identifies certain risk factors for failure to RTW independent of surgical outcomes. Most of these risk factors are occupational; hence, involving the patient's employer in treatment process and setting realistic expectations may help improve the patients' work-related functionality.

Introduction

Low back pain is a leading cause of global disability [1]. Estimated costs of low back pain in the United States (US) are more than $100 billion annually, with two-thirds of the cost directly related to decreased productivity and lost wages [2]. Around 10% of all the acute pain episodes progress to chronic refractory nature and require surgical management in order to reduce their disability and regain meaningful functionality in daily life and in the workplace [3], [4], [5], [6], [7]. In recent decades, there has been an exponential rise in the rates of low back surgeries. Deyo et al. reported a 15-fold increase in spinal fusion from 2002 to 2007 [8], [9], [10], [11], [12]. Given the increasing prevalence of these procedures and the significant costs they impose on individual patients, payers and the healthcare system as a whole, it is imperative to develop metrics to determine which patients will benefit the most from surgery and identify the modifiable risks.

Return to work (RTW) is a key metric in surgical outcomes, as it has profound implications for both individual patients and the economy at large [13]. The literature identifies around 82% of patients successfully returning to work after elective lumbar spine surgery [14]. A myriad of factors have been reported to impact a patient's likelihood of RTW after surgical management of back related disability. Chief among these are various work-related factors such as occupational intensity and worker's compensation status. However, these predictors for failure to RTW are similar to predictors identified for poor improvement in ODI (Oswestry Disability Index), satisfaction or having an adverse event after surgery and one may argue that the limited improvement in pain related disability or postoperative adverse events put the patients at risk for failure to RTW [12]. There is a paucity of literature on those that do well as measured by legacy metrics yet do not RTW.

In this study, we investigated the factors associated with RTW in patients who achieved otherwise favorable outcomes after lumbar spine surgery. We hypothesized that occupational characteristics will play a major role in determining whether patients return to work after an otherwise successful lumbar surgery.

Section snippets

Quality outcomes database registry

The Quality and Outcomes Database is a nationwide web-based registry prospectively enrolling patients undergoing surgery for degenerative spine diseases. A standardized enrollment process is used across over 86 participating sites (academic and private, high and low volume) [15]. For this study, we queried the lumbar module and extracted data for patients with complete 12-month follow-up. The average 1-year follow-up for the contributing sites was 78.5%, ranging from 66.7% to 95.3%. Full

Results

Of the total 12,435 patients that were employed at the time of surgery, 9,768 (78.6%) returned to work at 3-month and an additional 836 (6.7%) returned to work at 12-month follow-up. A total of 10,604 (85.3%) returning to work at 1-year postsurgery; 69.7% of the patients had good surgical outcomes and had no adverse events (readmissions/complications), had achieved 30% improvement in ODI and were satisfied at 3-month postsurgery, whereas 30.3% had poor surgical outcomes. Among patients who had

Discussion

Surgical management of lumbar pathology has been proven to effectively improve functionality and allow patients to RTW. However, around 25% of the surgically managed patients report minimal improvement in quality of life and up to 10% experiences a major complication or hospital readmission postsurgery [18], [19], [20], [21]. In the present age of patient-centered care and detailed emphasis on patient-reported outcomes, postsurgical RTW has been identified as an important metric. Previous

Conclusions

This study identifies two sets of risk factors for failure to RTW—those that are dependent on the outcomes and safety profile of the surgery and those that are independent of those factors. Most of the occupational risk factors identified are independent of patient reported outcomes of surgical success. Patients who were not working actively and were on leave or short-term disability, those within more physically demanding jobs, and those who had filed for worker's compensation before their

Acknowledgments

This study did not receive funding from any institution or grant. Financial support and industry affiliations: Dr. Khan reports receiving a grant from the CSRS $25,000 outside the submitted work. Dr. Archer reports personal fees from Pacira, Palladian Health, NeuroPoint Alliance, Inc., American Physical Therapy Board outside the submitted work. Dr. Shaffrey reports royalties from Medtronic, Nuvasive, Zimmer, Biomet, In Vivo, Stryker, and K2M outside the submitted work. Dr. Devin reports a

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    FDA device/drug status: Not applicable.

    Author disclosures: IK: NeuroPoint Alliance = Level D. $25,001-50,000, Research Grant CSRS = Level C. $10,001- 25,000. KRA: NeuroPoint Alliance = Level E. $50,001- 100,000, No financial benefits from: PACIRA, Palladin Health or American Physical Therapy Board. CS: Royalties from Medtronic, Royalties: Medtronic, Nuvasive, Zimmer, Bionet, In VIVO, Stryker, K2M = Level D. $25,001-50,000. CJD: Royalties from Wright Medical; Consulting: Stryker, Medtronic Legal; Board of Directors: Defense Expert Witness; Grants: Stryker = Level D. $25,001-50,000.

    IRB approval/Research Ethics Committee: The QOD project is designated as a non-research, clinical quality improvement effort and base on existing federal guidelines exempted from IRB review.

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