How Much Better Is Evidence Based Spine Surgery?

Ok. The answer to this question may, at first glance, appear to be self evident. Sort of like: Is the Pope Catholic? Or do bears poop in the woods?

But this new study from the Department of Neurological Surgery at Thomas Jefferson University Hospital in Philadelphia, Pennsylvania, actually took a look at how much better spine surgery is when it is based on evidence-based best practices. Their conclusion? Patients had 3x better outcomes. Their work, “Are Guidelines Important? Results of a Prospective Quality Improvement Lumbar Fusion Project,” was published in the March 17, 2021 of Neurosurgery.

“Unfortunately, we don’t know how many lumbar fusion surgeries are not based on evidence-based best practice, or how these patients do clinically,” says co-author and neurosurgeon James Harrop, M.D., professor and chief of the Spine and Peripheral Nerve Surgery division at the Vickie and Jack Farber Institute for Neuroscience–Jefferson Health.

Looking at 325 lumbar fusion cases, the researchers set out to determine whether they conformed to the North American Spine Society’s (NASS) lumbar fusion guidelines. Patients were followed for six months after surgery and completed the Oswestry Disability Index (ODI) to assess patient-reported outcomes measures.

The team demonstrated that of all of the variables they examined—alignment with NASS guidelines, type of surgeon, whether the surgery was the primary or a revision—following guidelines was most strongly associated with positive patient ODI outcomes.

They also determined that the patients meeting their criteria for a successful surgery were three times higher in these cases. “This study shows that the majority of patients did well with a lumbar fusion,” says Dr. Harrop, “But for the wrong patients, lumbar fusion can at best do nothing and at worst, create other problems.”

The NASS guidelines cover things such as trauma, spinal deformity, certain kinds of axial back pain, tumor, or infection. Uncertainty remains, however, as to when patients fit the criteria.

“For example, after a trauma with a ‘broken’ back, where we know the spine is unstable—we also know a fusion can help,” says Dr. Harrop. “That is a minority of the problems we see in practice. For our most common patient, one with degenerative diseases, spinal stability and instability has not been defined and understood as well as it should be. The NASS guidelines certainly help, but we need more research to understand what qualifies as normal range of movement, when is something pathologic and is immobilization through fusion the best option.”

This Jefferson-initiated and funded work is part of a larger effort to improve patient care and outcomes through rigorous research. “What we really need is support from insurance companies and other agencies to fund and promote research on best practices and evidence-based care. Without that, we cannot debate value,” says Dr. Harrop.

As for what he thought before the study about what drove the best clinical outcomes for lumbar fusion, Dr. Harrop told OTW, “I thought individual surgeons’ decisions on who to operate and what surgical approach they took to address the pathology determined outcomes. I was wrong in that it turns out if you followed the best evidence you got the best results over all other factors. This to me was very important in that we have a paucity of truly great evidence and lack significant support to get more evidence to improve care.”

“Not only for spine problems, but all patient care should be based on what the evidence in the literature shows as optimal treatment. This evidence is compiled as guidelines to help direct care. However, guidelines only assist in that all patients are individuals and many factors are not appreciated in the limited studies we presently have available.”