Evaluation of current surgeon practice for patients undergoing lumbar spinal fusion surgery in the United Kingdom

Table 1 Information used to predict post surgery outcomes

Patient characteristics and history

Patient personality and expectations1, including motivation

Age, occupation/unemployment, social issues, smoking, weight

Presence or absence of personal injury or yellow flags

Diabetes, other medical co-morbidities

Clinical information including patient history, e.g., symptoms duration

Use of outcome data, e.g., DRAM, GAD7, ODI, PHQ9, SF36, SRS, VAS pain, walking

Response to previous approaches, e.g., physiotherapy, facet joint injections, discogram, disc block

Pathology or degree of deformity

Number of levels predominant leg pain; more leg than back pain

Performance based outcome measures

Neurological examination

Imaging: CT scans, CT with 3D reconstruction, discography, MRI scans, X-ray

Evidence

Audit of data from past patients

Literature or empirical evidence

Experiential clinical experience

Other

Pathology: segmental instability, single level, spondylolisthesis, central disc protrusion

Pain mechanism: no features of chronic regional pain syndrome (allodynia, non-anatomical pain), stenosis

¹Realistic expectations (VAS 4/10 end result would be satisfactory). DRAM: Distress Risk Assessment Method; GAD7: Generalized Anxiety Disorder 7-item scale; ODI: Oswestry Disability Index; PHQ9: Patient health questionnaire - depression component; VAS: Visual analogue scale; SRS: Session rating scale.

Table 2 Key indicators for performing spinal fusion (n = 29 responders)

Key indicator for surgery	Surgeons n (%)
Instability	25 (86)
Leg pain	21 (72)
Back pain	18 (62)
Failed conservative treatment	17 (59)
Failed previous surgery	16 (55)
Degenerative disc disease	15 (52)
Neurological changes	13 (48)
Other1	12 (41)

¹Other indicators included: deformity stabilisation ± degenerate scoliosis (n = 4), infection (n = 2), tumours (n = 2), trauma (n = 1), degenerative spondylolisthesis or spondylolysis (n = 7), recurrent disc prolapse (n = 2), stenosis (n = 3).

Table 3 Complications of lumbar spinal fusion surgery reported by surgeons (n = 29 surgeons)

Complications of lumbar spinal fusion surgery	Surgeons n (%)
Persistent symptoms	18 (62)
Dislodged instrumentation/implant failure	14 (48)
Infection	9 (31)
Failure of fusion	7 (24)
Dural tear	6 (21)
Nerve injury	5 (17)
Failure at adjacent level	4 (14)
No improvement	3 (10)
Other1	8 (28)

¹Epidural hematoma, cauda equina, DVT/PE, pain at donor site, wound problems, respiratory problems, urinary tract infection, and pseudo bowel obstruction.

Table 4 Pre-discharge advice on time (weeks post discharge) to return to functional activities

Functional activity	No. (%) of surgeons
	Weeks1						Months1
	1	2	3	4	6	8	3	6	9
Sitting	22 (85)	2 (8)	1 (4)	0	1 (4)	0	0	0	0
Driving	0	4 (15)	3 (12)	10 (39)	10 (39)	2 (8)	0	0	0
Sex	2 (10)	3 (15)	2 (10)	6 (30)	9 (45)	2 (10)	1 (5)	0	0
Work	0	2 (8)	3 (12)	2 (8)	13 (50)	4 (15)	9 (35)	1 (4)	0
Sport	0	1 (4)	0	1 (4)	4 (17)	0	10 (42)	6 (25)	2 (8)
Contact sports	0	0	0	0	0	0	5 (21)	8 (33)	2 (8)
Jogging/running	0	0	0	1 (4)	6 (25)	1 (4)	5 (21)	10 (42)	1 (4)
Weight training	0	0	0	0	1 (5)	0	5 (21)	9 (41)	3 (14)
Heavy lifting	0	0	0	0	2 (8)	0	5 (21)	10 (42)	1 (4)
Extreme range of lumbar movements	0	1 (5)	0	0	0	0	8 (36)	6 (27)	2 (9)

¹Time (in weeks post discharge) at which patients were advised to return to each functional activity.

Table 5 Post-operative outpatient use of patient reported outcome measures (n = 29 surgeons)

Domain	Questionnaire	Surgeons n (%)
Disability	ODI	17 (90)
Pain	VAS or NPRS	14 (74)
	MSP	1 (5)
	Pain drawing	1 (5)
Health	SF-26	6 (32)
	SF-12	1 (5)
	PHQ-9	1 (5)
	EQ-5D	1 (5)
Depression	Zung Depression Index	2 (10)
	Hospital Depression Scale	1 (10)
Anxiety	Hospital Anxiety Scale	1 (10)
	GAD-7	1 (10)
Other1		2 (10)

¹GPOS: Global Patient Outcome System, own questionnaire. GAD: Generalized Anxiety Disorder; NPRS: Numerical Pain Rating Scale; ODI: Oswestry Disability Index; PHQ: Patient Health Questionnaire; VAS: Visual analogue scale; MSP: Multidimensional scale of pain.