Socioeconomic outcomes of combined spine surgery and functional restoration in workers' compensation spinal disorders with matched controls.

STUDY
DESIGN: A longitudinal cohort study (n = 448) comparing functionally restored discectomy (n = 123) and fusion (n = 101) workers' compensation patients to matched, unoperated control patients (n = 123 and n = 101, respectively).
OBJECTIVES: To determine successful treatment outcomes uniquely important in a workers' compensation environment when spine surgery is combined with comprehensive tertiary rehabilitation, to optimize anatomic and social sequelae. SUMMARY OF BACKGROUND DATA: Multiple recent studies confirm suboptimal socioeconomic outcomes for spinal surgery for degenerative conditions in a workers' compensation venue. In other musculoskeletal regions, there is a clear relationship between the quality of postsurgical rehabilitation and the impact on disability, recurrent injury, and future health care use. It is hypothesized that poor surgical outcomes in compensation injuries may result from outmoded postoperative methods, rather than failures of patient selection or surgical technique. No previous combination of surgery plus rehabilitation has been carefully evaluated with disabled workers undergoing spine surgery. Functional restoration is an individualized medically directed, interdisciplinary program using quantitatively directed exercise progression, psychotherapeutic interventions, and monitoring of specific socioeconomic outcomes for chronically disabled workers.
METHODS: This study prospectively evaluated a cohort of consecutive functional restoration program graduates (n = 1202). Two surgical groups, discectomy (n = 123) and fusion (n = 101) were matched to two groups of unoperated control patients, control/discectomy and control/fusion, selected from the same cohort of patients with chronic spinal disorders based on age, gender, race, length of disability, and workers' compensation jurisdiction. A structured clinical interview was administered 12 months after program completion, with a contact rate of 95% to 98%.
RESULTS: Socioeconomic outcomes for work return, health care use, and recurrent lost-time injury were assessed. All groups demonstrated a return-to-work incidence of more than 85%, but work retention at 1 year was higher for the fusion group than for the discectomy or control/fusion groups. Health care use was significantly higher for the discectomy group than the control/discectomy or fusion groups for reoperation (8% vs. 4%/ 2%), as well as other factors. All groups showed comparable recurrent lost-time injury rates (2-3.3%), and made comparable improvements in prospectively collected physical and psychological measures.
CONCLUSIONS: Discectomy patients had work, health care utilization, and recurrent injury outcomes comparable with those for unoperated control patients. Fusion patients had better outcomes of work retention, reoperation, and health care use compared with the unoperated control patients and even with discectomy patients, in spite of more cases of previous surgery and greater duration of disability. The discectomy and fusion cohorts of operated chronic spinal disorder compensation patients with subsequent functional restoration had the best documented outcomes found in the literature for this population. In spite of the common presumption that spine surgery patients fare poorly in a workers' compensation environment, these results demonstrate that such patients can show remarkably successful objective outcomes if accompanied by effective rehabilitation, documenting efficacy and clinical utility. A new clinical approach is required to evaluate prospectively the combination of surgery and rehabilitation in chronic pain/disability workers' compensation patients, in which the surgical role is to correct an anatomic lesion, but the socioeconomic outcomes either occur spontaneously or are effected through some form of rehabilitation.