Issue 1, Volume 1
Implications of the SPORT Study
Recent Research on Operative and Non-operative Spine Care

Spinal fusion for chronic low back pain: No consensus in clinical decision making

BMJ Open. 2011;1:e000391 doi:10.1136/bmjopen-2011-000391

Introduction:  The authors of this study wanted to examine how spine surgeons used prognostic patient factors and predictive tests in deciding if patients with chronic low back pain should undergo spinal fusion.

Methods:  This study was done in the Netherlands; surgeons belonging to the Dutch Spine Society were sent surveys with questions on their chronic low back treatment strategy.  Their opinions were assessed on Likert scales.  The degree of uniformity was also assessed, and other factors that may influence decision making—such as clinical experience and training—were also considered.

Results:  There was a 70% response rate; 62 surgeons replied, and their answers were analyzed.  Of those 62, 44 had extensive clinical experience (71%).

The prognostic factors considered were:

  1. Maximum number of levels for fusion
  2. Minimum age of patient
  3. Maximum age of patient
  4. Minimal length of time of conservative therapy
  5. Maximum body mass index
  6. Maximum number of cigarettes/day
  7. Referral of overweight patients to a dietitian for weight loss
  8. Referral for a psychological screening
  9. Different criteria for patients with DDD vs prior spine surgery
  10. Work status affects outcome
  11. Litigation procedures affect outcome

Of these 11, 7 showed a statistically significant lack of uniformity of opinion.

The surgeons were asked about their use of the following tests:

  1. Facet joint blocks
  2. Cast immobilization
  3. Provocative discography
  4. Temporary transpedicular external fixation

The surgeons were asked their opinions of the following statements about the predictive tests:

  1. MRI for decision making
  2. Cast immobilization is a valuable test
  3. Cost immobilization is too unpleasant
  4. Provocative discography (PD) proven valuable test
  5. PD has too many complications
  6. Temporary external trandspedicular fixation (TETF) is a valuable test
  7. TETF has too many complications

Of those 11 items relating to predictive tests, there was a statistically significant lack of uniformity of opinion for 8 of them.

The surgeons valued imaging above predictive tests, psychological screening, or patient preference (p < 0.01 for all).

In considering surgeon training or clinical experience, there was little that had a significant influence on treatment strategy, beyond the use of discography and long multisegment fusions.

Conclusions:  The study authors suggest further research to identify patient subgroups who would most benefit from spinal fusion.  This needs to be done to move spine surgeons toward consensus guidelines for how best to treat patients with chronic low back pain.

The present study reveals that there is little consensus, and clinical decision making for spinal fusion for chronic low back pain patients does not have a reliable, uniform evidence base.


Surgeons often espouse the need for evidence-based medicine and predictive outcomes, but they often neglect to implement existing practice guidelines.

Approximately half of the surgeons in this study operate on patients who are obese, smoke, or have had only one year of conservative therapy, despite literature recommending the contrary.  The Dutch study suggests that surgeons worldwide share the same clinical decision challenges and at the same time demonstrate significantly variable styles in practice.


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