To assess the use of prognostic patient factors and predictive tests in clinical decision making for spinal fusion in patients with chronic low back pain.
Design and setting
Nationwide survey among spine surgeons in the Netherlands.
Surgeon members of the Dutch Spine Society were questioned on their surgical treatment strategy for chronic low back pain.
Primary and secondary outcome measures
The surgeons' opinion on the use of prognostic patient factors and predictive tests for patient selection were addressed on Likert scales, and the degree of uniformity was assessed. In addition, the influence of surgeon-specific factors, such as clinical experience and training, on decision making was determined.
The comments from 62 surgeons (70% response rate) were analysed. Forty-four surgeons (71%) had extensive clinical experience. There was a statistically significant lack of uniformity of opinion in seven of the 11 items on prognostic factors and eight of the 11 items on predictive tests, respectively. Imaging was valued much higher than predictive tests, psychological screening or patient preferences (all p<0.01). Apart from the use of discography and long multisegment fusions, differences in training or clinical experience did not appear to be of significant influence on treatment strategy.
The present survey showed a lack of consensus among spine surgeons on the appreciation and use of predictive tests. Prognostic patient factors were not consistently incorporated in their treatment strategy either. Clinical decision making for spinal fusion to treat chronic low back pain does not have a uniform evidence base in practice. Future research should focus on identifying subgroups of patients for whom spinal fusion is an effective treatment, as only a reliable prediction of surgical outcome, combined with the implementation of individual patient factors, may enable the instalment of consensus guidelines for surgical decision making in patients with chronic low back pain.
What is the level of professional consensus among spine surgeons regarding spinal fusion surgery for chronic low back pain?
How are tests for patient selection appreciated and to what extent are they used in clinical practice?
Are prognostic patient factors incorporated in the process of surgical decision making for chronic low back pain?
In clinical practice, there is no professional consensus on surgical treatment strategy for chronic low back pain.
Prognostic patient factors as well as tests for patient selection are not consistently used in clinical decision making for spinal fusion.
Because of a lack of consensus on spinal fusion strategy for chronic low back pain in clinical practice, no guidelines for proper patient counselling can be installed at present.
Strengths and limitations of this study
A survey among physicians provides valuable insight in the actual decision-making process in clinical practice. Understanding contributory factors in treatment strategy may help in the creation of consensus guidelines.
The introduction of an interviewer bias could be avoided by the use of a neutral intermediary instead of direct questions from peers in spine surgery.
This study focused on surgeon members of the Dutch Spine Society whose practice may not reflect that of all surgeons performing spinal fusion for chronic low back pain. Moreover, no information on conservative treatment options was acquired.
To define consensus, we chose for uniformity of opinion of at least 70%, which we considered to be sufficient for implementation in guidelines. Such a cut-off level remains arbitrary.