Use of evidence-based guidelines for lumbar fusion improved patient outcomes
Patients who met evidence-based medicine guidelines for elective lumbar fusion had a greater than three times improvement in outcomes compared with patients who did not meet evidence-based medicine guideline criteria, according to results.
James S. Harrop, MD, and colleagues prospectively evaluated all elective lumbar fusion cases from March 2018 to August 2019 and categorized each based on whether they were deemed concordant with evidence-based medicine guidelines. Researchers collected baseline Oswestry Disability Index (ODI) and clinical variables and defined the minimum clinically significant difference as a reduction of five or more points in the ODI.
Of the 325 patients who underwent lumbar fusion, 95% had 6-month follow-up data available. Results showed a mean preoperative ODI of 24.4, with a median 6-month improvement of seven points. Researchers found ODI improved among 79.6% of patients, stayed the same in 3.8% of patients and worsened in 16% of patients. Researchers also noted 191 patients had ODI improvement reaching minimal clinically important difference (MCID), with 93.2% cases concordant with and 6.7% not concordant with evidence-based medicine guidelines.
Multivariate analysis results showed a significant association between improved functional outcome with evidence-based medicine concordance, lower preoperative ODI, lower American Society of Anesthesiologists score and primary surgeries. After adjusting for other factors, investigators found patients who met evidence-based medicine guidelines had a 3.04 times greater odds of achieving MCID in ODI at 6 months.
“Patients obtained the best clinical results if the surgeons followed evidence-based guidelines. This has more of an impact on successful outcome over who the surgeon was and what operative procedure was performed,” Harrop told Healio Orthopedics. “[The results] reinforce and highlight the need for high-level evidence-based clinical studies and the need for significant investment by stakeholders, including insurance companies, to support clinical trials.”
Perspective
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Both the indications and ramifications of a lumbar fusion have a significant impact on the United States health care resources. The regional variability of how this procedure is offered to patients highlights the need for evidence-based medicine guidelines to more closely standardize the approach for all patients across the country.
The spine research group from the department of neurological surgery, headed by James Harrop, MD, looked at a prospective cohort of patients at their academic center and compared outcomes based on adherence to the North American Spine Society criteria for elective lumbar fusion surgery. Out of a total of 309 patients who completed 6-month follow-up, 288 (93%) were evidence-based medicine concordant, while 21 (7%) were not. Although there was an unequal distribution of subjects in each group (which demonstrates the surgeons’ general adherence to this criteria), multivariate data analysis demonstrated that evidence-based medicine-concordance led to three times greater odds of achieving the minimal clinically important difference in outcome at the 6-month timepoint after surgery. This data suggests that the utilization of a standardized set of guidelines to aid the preoperative decision-making process for surgeons can lead to optimized outcomes after lumbar fusion surgery which has historically led to variable results.
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