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Abstract

Study Design

Cross-sectional Survey.

Objectives

The objective of this study was to describe clinicians’ decision-making regarding suitability of patient cases for lumbar fusion surgery or conservative care and the level of equipoise to randomise participants into a randomised controlled trial (RCT).

Methods

An online survey distributed via Australian professional networks to clinicians involved in low back pain care, collected data on clinical discipline, clinical experience, practice setting and preferred care of five patient case vignettes (ranging in age, pain duration, BMI, imaging findings, neurological signs/symptoms). Clinicians were asked about preferred clinical care and willingness to randomise each case.

Results

Of 101 respondents (31 orthopaedic surgeons, 17 neurosurgeons, 50 allied health professionals (AHPs), 1 pain physician, 1 nurse), 44% worked in public health services only, 36.4% in both public and private, 19.2% in private only. 46.5% had over 20 years clinical experience. Conservative care was preferred for all cases (83.1%–90.9%). Surgeons preferred an anterior approach to lumbar fusion (range 40.6%–68.4%). On average 51.9% (range: 47%–55%) indicated willingness to randomise cases, with orthopaedic (61.5%) and neurosurgeons (64.9%) more willing than AHPs (44.4%). Willingness to randomise was highest in younger cases with shorter pain duration, no neurological symptoms/signs and localised degeneration, and lowest when cases had high BMI, longer pain duration, and inadequate conservative management. Willingness to randomise was higher in those in private (70.3%) vs public health care services (43.6%).

Conclusions

Over half of respondents reported willingness to randomise cases, indicating sufficient clinical equipoise for a future RCT.

Keywords

low back pain lumbar fusion surgery conservative care equipoise

Introduction

Persistent low back pain (LBP) is the leading cause of disability worldwide.¹ It causes significant burden for individuals, communities and society more broadly, with an estimated $4.8 billion Australian dollars spent managing persistent LBP in Australia per year.² While most individuals will recover from an episode of acute LBP,³ recurrence rates are high and around 33% will have another episode of LBP within 12 months.^4,5 Many clinical guidelines around the world advocate education, physical and psychological interventions for persistent LBP, reserving invasive treatments for specific groups of patients such as those who do not respond to conservative care.^6-8

While evidence supports the role of decompressive surgery in the management of LBP in the presence of neurological compromise including radicular leg pain following disc herniation^9,10 or neurogenic claudication resulting from spinal canal stenosis,¹¹ the indication for stabilisation spinal surgery for LBP associated with degenerative findings on spinal imaging, in the absence of neurological compromise, is less clear. The uncertainty regarding the role of lumbar fusion surgery for treatment of degenerative LBP led to The National Institute for Clinical Excellence (NICE) guidelines recommending against it use unless as part of a randomised controlled trial (RCT).⁶ Worldwide, only six RCTs have been conducted evaluating lumbar spine fusion surgery vs non-surgical care,^12-17 summarised in several systematic reviews, with the most recent meta-analysis¹⁸ showing a between group difference of 7.51 points on the Oswestry Disability Index (ODI) scores in favour of surgery at two years follow-up, a difference that was not statistically significant. Surgical complication rates are reported to be between 9%–18%.¹⁹ Where longer term RCT follow-up data have been published (mean 12.8 years, range 9-22 years) these show similar outcomes in ODI scores between surgical and non-surgical groups.¹⁶ Criticisms of previous trials include small samples, large cross-over, and varied non-surgical care. Where non-surgical care comprised more intensive physiotherapy and cognitive behavioural therapy approaches, results were similar to surgery.²⁰ Trials concluding surgery was superior to conservative care have tended to offer less intensive conservative interventions (eg, stretching and walking),¹⁷ or physical therapy that was inadequately described,²¹ in populations that have likely already undergone (and failed) these treatments. Despite the collective uncertainty about the place of lumbar spine fusion surgery for degenerative LBP, and the wide variation in rates of this type of surgery across Australia,²² the overall rate has increased, particularly in the Australian private sector.^23,24

Based on the above RCT evidence, the collective uncertainty is also reflected in clinical practice guidelines. The American Pain Society guidelines conclude that lumbar fusion surgery is no better than intensive rehabilitation combined with cognitive behavioural therapy, but slightly superior to standard, non-intensive conservative management.²⁵ In the UK, NICE released guidance on the management of LBP which stated that lumbar spinal fusion surgery should not be offered for the management of degenerative low back pain except as part of a clinical trial.⁶ This prompted calls in 2021 from the National Institute for Health Research (NIHR) Health Technology Assessment (HTA), and through collaboration with the Australian National Health and Medical Research Council (NHMRC), for new RCT evidence comparing lumbar fusion surgery with conservative care for persistent degenerative LBP.

In response, two, soon-to-commence RCTs - FusiOn veRsus bEst coNServatIve Care (the FORENSIC-UK and FORENSIC-Australia trials) will compare lumbar fusion surgery vs continued best conservative care in individuals with persistent severe LBP and who have imaging evidence of lumbar spine degenerative changes. In advance of these trials being conducted, it is important to better understand i) which clinical features of patients mean that health care professionals are more likely to consider lumbar fusion surgery or conservative care to be the most appropriate treatment, and ii) whether the necessary equipoise (ie, collective clinical uncertainty) exists amongst health care professionals for randomisation of cases into either intervention arm. A recent cross-sectional survey concluded that the necessary equipoise exists amongst UK health care professionals.²⁶ The aims of this study were to describe Australian health care professionals’ decision-making about the suitability of case examples of patients for either lumbar fusion surgery or best conservative care, and to determine if there is sufficient equipoise to randomise participants into each arm of the future FORENSIC-Australia trial.

Materials and Methods

Design and Setting

A cross-sectional electronic survey was developed and distributed to health care professionals in Australia involved in the management of patients with LBP, between June-July 2023. Ethics approval was obtained from the University of Queensland Human Research Ethics Committee (2023/HE000438). Consent was assumed if individuals completed and submitted survey responses.

Questionnaire Sampling and Mailing Process

The sampling frames comprised relevant professional bodies in Australia (Spine Society of Australia, Australian Pain Society, Neurosurgical Society of Australasia, Australian Physiotherapy Association) in addition to Australian email distribution lists accessible to the authors (Queensland Neurosurgical/Orthopaedic Physiotherapy Screening Clinic and Multidisciplinary Service, Queensland Directors of Physiotherapy) and through highlighting the survey at scientific conferences in Australia (Spineweek 2023, Queensland Orthopaedic Research Foundation 2023).

Survey

The survey was administered electronically through Qualtrics XM (Qualtrics International Inc., Seattle, WA US) and took approximately 10 minutes to complete. Survey questions related to respondent demographics (country of work, profession, practicing sector (public and/or private), years of experience managing LBP) followed by five clinical case vignettes (see Table 1). Each vignette provided a short summary of the patient’s presenting history and previous management, with MRI findings (either a mid-sagittal T2 weighted image or a T2 weighted axial image of the relevant disc level). Vignettes were developed to describe individuals of various sex, age, body size, and occupation, and differed in both duration and severity of LBP symptoms, neurological symptoms, imaging findings and previous treatment. Respondents were asked to state their preferred treatment for each case (ie, best conservative care, spinal fusion surgery), and if they perform surgery, to nominate their preferred surgical approach (where applicable), their recommended intervention(s) for best conservative care, recommended analgesic medication(s), factors impacting preferred management option, and willingness to randomise this vignette patient to a trial of best conservative care or lumbar fusion surgery. Respondents were also asked to define a good outcome from either conservative care or fusion surgery for LBP. Finally, respondents were asked to indicate on a 5-point likert scale anchored by (‘very unlikely’ to ‘very likely’) their likelihood of supporting a RCT comparing lumbar fusion surgery and best conservative care for patients with LBP and degenerative lumbar spine disease on imaging without neurological signs or requiring decompressive surgery.

Table 1.

Case Vignettes.

Case Vignette 1

26-year-old (F) Teaching Assistant with an 8-month History of LBP (Severity 7/10). Her BMI is 16.4 kg/m2 and she has no Neurological Symptoms or Signs. Has Outpatient Physiotherapy (Education and Exercise Programme) and Daily NSAIDs with no Improvement over Time. Significant L5/S1 Disc Degeneration Only

Case vignette 2

49-year-old (M) surgeon with a BMI of 23 kg/m2. He has a history LBP of 3 years and has had to reduce operating hours. He has had outpatient combined exercise and psychological programme. The pain radiates to the legs but there are no features of neural compression. L4/L5 disc degeneration only on imaging

Case vignette 3

58-year-old (M) with a BMI of 42 kg/m2 who has had fluctuating LBP for 15 years. He is now unable to work and has daily oral opioids in addition to occasional exercise and manual therapy. He had bilateral leg pain. Neural compression has been ruled out on imaging. Significant L5/S1 disc degeneration only

Case vignette 4

37-year-old (F) who previously played rugby with ongoing LBP for 5 years. She is allergic to opioids and cannot tolerate NSAIDs. Paracetamol and self-help exercises performed (not via accessing health professionals - yoga, pilates classes) have been of no help. Her BMI is 20 kg/m2 and she had no leg pain and no neurological symptoms or signs. Minor spondylolisthesis (Grade 1) at L5/S1

Case vignette 5

63-year-old (M) construction worker with BMI of 18.5 kg/m2 has had previous self-limiting episodes of low back pain over the last 20 years. LBP has been persistent since he stumbled in the street 12 months ago. No success with inpatient pain management in addition to CBT. He has intermittent numbness in both feet. Imaging shows only significant L4/L5 + L5/S1 disc degeneration with no neural compression

Data Management and Analysis

Upon completion of the survey period, data were exported into Microsoft Excel (Microsoft, Redmond, Washington US) for cleaning prior to exporting to SPSS (version 28) for analysis. Presence of bot activity was evaluated from mean reCaptcha scores, with scores <0.5 considered to be likely a bot. Possible duplicate responses were flagged for consideration. Respondent demographics were analysed using descriptive statistics. Continuous data was reported as either means (standard deviation) or medians (inter-quartile range) while categorical data were presented as n (%). Management decisions for each vignette were evaluated using descriptive statistics, with equipoise regarding willingness to randomise patients to best conservative care or lumbar fusion surgery determined a priori and deemed sufficient if at least 50% of respondents were willing to randomise. Differences in choice of management across different disciplines (eg, orthopaedic spine surgeon, neurosurgeon, allied health professional (AHP), pain specialist), time in practice, and practicing sector (public, private) were analysed using descriptive statistics and chi-square tests. Significance level was set at α = 0.05 for all analyses.

Results

A total of 101 survey responses were obtained. Recaptcha data indicated a mean (SD) score of 0.91 (0.11) indicating high likelihood of human responses, and no duplicate submissions were noted. Respondent demographics are presented in Table 2. Respondents included 50 AHPs, 31 orthopaedic spine surgeons, 17 neurosurgeons, a pain registrar and a nurse. Forty-three respondents (44.3%) worked in the public health care sector only, with 18 (18.6%) in the private sector and 36 (37.1%) working in both public and private sectors. Nearly half of respondents (47.4%) had over 20 years’ experience managing patients with LBP.

Table 2.

Survey Respondent Demographics.

Country of Work	Australia	91 (90.1%)
	Overseas^a	10 (9.9%)
Role in management of LBP	Orthopaedic spine surgeon	31 (30.7%)
	Neurosurgeon	17 (16.8%)
	Allied health professional	50 (49.5%)
	Physiotherapist	44
	Psychologist	3
	Occupational Therapist	2
	Pain registrar	1 (1%)
	Nursing	1 (1%)
	Missing	1 (1%)
Sector predominantly practicing in	Public	44 (44.4%)
	Private	19 (19.2%)
	Both public and private	36 (36.4%)
Years of experience outside of training in managing low back pain	≤5	9 (9.1%)
	6-10	12 (12.1%)
	11-15	18 (18.2%)
	16-20	14 (14.1%)
	>20	46 (46.5%)

^aOverseas respondents included New Zealand (n = 3), UK (n = 2), Europe (n = 2), North America (n = 1), and not stated (n = 2).

Preferred Management

Preferred management approaches are shown in Table 3. Across all case vignettes, conservative care was the preferred option in 85.7% of responses, ranging from 83.1%–90.9% across individual patient cases. Across professions, best conservative care as preferred management was higher for AHPs (Mean 90.9%), and neurosurgeons (average 88.1%) compared to orthopaedic spinal surgeons (Mean 77.8%), although the distribution was significantly different only for vignette 4 (χ² (4,76) = 10.00, P = 0.040). When explored by sector, best conservative care as the preferred management option was higher amongst respondents working in the public (Mean 88.5%) and both public and private (Mean 87.5%) sectors, compared to the private (Mean 80.3%) sector. This distribution was significantly different for vignette 4, with 97.7% of AHPs preferring conservative care compared to 71.4% of orthopaedic surgeons (χ² (4,76) = 26.1, P < 0.001).

Table 3.

Preferred management Across vignettes by Profession and Sector.

Vignette	All respondents		Preferred management by Profession		Sig	Preferred management by Sector		Sig
1	Conservative care	90.9%	Orthopaedic spinal surgeon	80.0%	X² (6,88) = 6.94, P = 0.33	Public	97.6%	X² (4,88) = 8.01, P = 0.09
			Neurosurgeon	87.5%		Private	87.5%
			Allied health profession	97.8%		Both public & private	83.9%
	Spinal fusion	3.4%	Orthopaedic spinal surgeon	8.0%		Public	0.0%
			Neurosurgeon	6.3%		Private	0.0%
			Allied health profession	0.0%		Both public & private	9.7%
	Other	5.7%	Orthopaedic spinal surgeon	12.0%		Public	2.4%
			Neurosurgeon	6.3%		Private	12.5%
			Allied health profession	2.2%		Both public & private	6.5%
2	Conservative care	87.8%	Orthopaedic spinal surgeon	82.6%	X² (6,82) = 1.62, P = 0.95	Public	84.2%	X² (4,82) = 2.33, P = 0.68
			Neurosurgeon	92.9%		Private	85.7%
			Allied health profession	88.6%		Both public & private	93.3%
	Spinal fusion	8.5%	Orthopaedic spinal surgeon	13.0%		Public	10.5%
			Neurosurgeon	7.1%		Private	7.1%
			Allied health profession	6.8%		Both public & private	6.7%
	Other	3.7%	Orthopaedic spinal surgeon	4.4%		Public	5.3%
			Neurosurgeon	0.0%		Private	7.1%
			Allied health profession	4.6%		Both public & private	0.0%
3	Conservative care	84.6%	Orthopaedic spinal surgeon	76.2%	X² (4,78) = 4.54, P = 0.34	Public	89.2%	X² (4,78) = 4.74, P = 0.32
			Neurosurgeon	76.9%		Private	84.6%
			Allied health profession	90.5%		Both public & private	78.6%
	Spinal fusion	6.4%	Orthopaedic spinal surgeon	14.3%		Public	2.7%
			Neurosurgeon	7.7%		Private	15.4%
			Allied health profession	2.4%		Both public & private	7.1%
	Other	9.0%	Orthopaedic spinal surgeon	9.5%		Public	8.1%
			Neurosurgeon	15.4%		Private	0.0%
			Allied health profession	7.1%		Both public & private	14.3%
4	Conservative care	88.2%	Orthopaedic spinal surgeon	71.4%	X² (4,76) = 10.0, P = 0.04*	Public	94.6%	X² (4,76) = 26.1, P < 0.001*
			Neurosurgeon	83.3%		Private	63.6%
			Allied health profession	97.7%		Both public & private	89.3%
	Spinal fusion	5.3%	Orthopaedic spinal surgeon	14.3%		Public	0.0%
			Neurosurgeon	8.3%		Private	36.4%
			Allied health profession	0.0%		Both public & private	0.0%
	Other	6.6%	Orthopaedic spinal surgeon	14.3%		Public	5.4%
			Neurosurgeon	8.3%		Private	0.0%
			Allied health profession	2.3%		Both public & private	10.7%
5	Conservative care	83.1%	Orthopaedic spinal surgeon	79.0%	X² (4,71) = 3.2, P = 0.53	Public	77.1%	X² (4,71) = 3.3, P = 0.51
			Neurosurgeon	100.0%		Private	80.0%
			Allied health profession	80.0%		Both public & private	92.3%
	Spinal fusion	11.3%	Orthopaedic spinal surgeon	15.8%		Public	17.1%
			Neurosurgeon	0.0%		Private	10.0%
			Allied health profession	12.5%		Both public & private	3.9%
	Other	5.6%	Orthopaedic spinal surgeon	5.3%		Public	5.7%
			Neurosurgeon	0.0%		Private	10.0%
			Allied health profession	7.5%		Both public & private	3.9%

Factors associated with respondents’ decisions regarding clinical management are displayed in Figure 1. Radiological appearance was the strongest factor across vignettes 2-5 (23.2%–30.8% of all responses), with age being the most significant factor in vignette 1 (26 year old female). Body mass index was a strong factor in vignette 3 (22.8% of all responses, BMI of 42 kg/m²).

Figure 1.

Factors influencing decision-making regarding preferred management for vignettes. Examples of ‘Other’ responses included duration and severity of symptoms, lack of neurological symptoms, psychological factors, and need for further investigations/work up.

Willingness to Randomise

Willingness to randomise the vignettes to either lumbar fusion surgery or best conservative care is shown in Table 4. In total, over half (51.9%) of respondents were willing to randomise the patients to best conservative care or spinal fusion surgery, with rates ranging from 47.4% to 55.7% across individual vignettes. Willingness to randomise was higher amongst orthopaedic spinal surgeons (Mean 61.5%, range 56.3%–72.0%) and neurosurgeons (Mean 64.9%, range 50.0%–75.0%) compared to AHPs (Mean 44.4%, range 40.9%–52.5%), and this was significant for vignette 1 (χ² (3,88) = 10.3, P = 0.017). Willingness to randomise was also higher in respondents working solely in the private sector (Mean 70.1%, range 61.5%–75.0%) compared to those solely in the public sector (Mean 43.8%, range 37.8%–54.3%) and respondents working across both sectors (Mean 51.6%, range 42.3-60.0). Generally, willingness to randomise was highest when cases were young with shorter pain duration, no neurological symptoms/signs and significant, localised degeneration, and lowest when cases had high BMI, longer pain duration, and inadequate conservative management. However, across professions, the highest willingness to randomise for both orthopaedic spinal surgeons and neurosurgeons was observed for vignette one (72.0% and 75.0% respectively) yet this vignette was rated lowest by AHPs (41.3%). Vignette five was rated highest in willingness to randomise by AHPs (52.5%) yet lowest by orthopaedic spinal surgeons (56.3%).

Table 4.

Willingness to Randomise Across vignettes by Profession and Sector.

Vignette	All respondents		Willingness to Randomise by Profession		Sig	Willingness to Randomise by Sector		Sig
1	Yes	55.7%	Orthopaedic spinal surgeon	72.0%	X² (3,88) = 10.3, P = 0.017*	Public	39.0%	X² (2,88) = 8.9,P = 0.012*
			Neurosurgeon	75.0%		Private	75.0%
			Allied health profession	41.3%		Both public & private	55.7%
2	Yes	54.9%	Orthopaedic spinal surgeon	65.2%	X² (3,82) = 5.3, P = 0.149	Public	44.7%	X² (2,82) = 3.4, P = 0.179
			Neurosurgeon	71.4%		Private	71.4%
			Allied health profession	45.5%		Both public & private	60.0%
3	Yes	48.7%	Orthopaedic spinal surgeon	57.1%	X² (2,78) = 2.5, P = 0.283	Public	37.8%	X² (2,78) = 3.4, P = 0.18
			Neurosurgeon	61.5%		Private	61.5%
			Allied health profession	40.9%		Both public & private	57.1%
4	Yes	47.4%	Orthopaedic spinal surgeon	57.1%	X² (2,76) = 1.4, P = 0.51	Public	43.2%	X² (2,76) = 3.3, P = 0.190
			Neurosurgeon	50.0%		Private	72.7%
			Allied health profession	41.9%		Both public & private	42.9%
5	Yes	52.1%	Orthopaedic spinal surgeon	56.3%	X² (2,71) = .36, P = 0.84	Public	54.3%	X² (2,71) = 2.4, P = 0.31
			Neurosurgeon	66.7%		Private	70.0%
			Allied health profession	52.5%		Both public & private	42.3%

Preferred Surgical Approach

The preferred surgical approach if choosing lumbar fusion is displayed in Figure 2. Of respondents performing spinal surgery, Anterior Lumbar Interbody Fusion (ALIF) was most preferred across all vignettes (Mean 54%, range 40.6%–68.4%). Posterior Lumbar Interbody Fusion (PLIF, Mean 11.3%, range 5.0%–15.7%) and Transforaminal Lumbar Interbody Fusion (TLIF, Mean 10.3%, range 3.1%–15.1%) showed similar rates.

Figure 2.

Preferred surgical approach for individual vignettes (for respondents who perform lumbar fusion surgery). Respondents were asked ‘How will you perform the surgery if you choose spinal fusion surgery?’

Preferred Conservative Care and Analgesia

Preferred conservative care across vignettes is demonstrated in Figure 3. Advice and self-management (range 17.2%–20.8% of all responses) was most commonly selected, followed by education (14%–18% of all responses), a combined physical and psychological programme (13.5%–20.5%), and exercise (14%–18%).

Figure 3.

Preferred conservative care for individual vignettes. Respondents were asked ‘If choosing the best conservative care for this patient, what will you offer?’. Examples of ‘other’ responses include cognitive functional therapy, specific exercises, and weight loss/dietetics.

Figure 4 demonstrates respondents’ preferred analgesia for the case vignettes. Simple analgesia was the preferred option across all vignettes (range 53.1%–71.3%). Higher rates of pregabalin/gabapentin were noted for vignettes 2 (13.5%), 3 (15.8%), and 5 (15.2%), where leg pain or numbness was mentioned in the case description.

Figure 4.

Preferred analgesia for individual vignettes. Respondents were asked ‘What medication will you use for best conservative care?’ Examples of ‘other’ responses included Amitriptyline, baclofen, duloxetine, and referral to pain specialist.

Discussion

This is the first Australian descriptive survey of health care professionals’ decision-making regarding suitability of patient cases for lumbar fusion surgery or conservative care. This study demonstrated that best conservative care was seen as the preferred option in all hypothetical vignettes. Over half of surveyed clinicians reported being willing to randomise patients with back pain without features of neurological compromise to either lumbar fusion surgery or best conservative care, indicating that there is clinical equipoise (collective uncertainty) required for RCT recruitment. However, willingness to randomise differed by profession and by sector, with lower willingness to randomise amongst AHPs and respondents working in the public sector only.

Comparing our findings with the UK survey results,²⁶ we found that similar rates were seen for preferred management, with best conservative care selected in 84.4% of cases in the UK data compared to 85.7% in this study. Willingness to randomise amongst health care professionals was very similar (50.7% in the UK study compared to 51.9%) although the data from this study demonstrated less variation across vignettes (47.4%–55.7% in Australia vs 37.0%–60.3% in the UK). These similarities were apparent despite a lower number of respondents from AHPs in the UK study (20.5% of respondents compared to 49.5% in this study), who tended to show higher preference for conservative care management and lower willingness to randomise. Two key differences between studies were apparent: firstly, with respect to best conservative care, UK survey respondents much more often preferred a combined physical and psychological program compared to our Australian respondents (48.5% vs 13.5%–20.5%). This is likely explained by the response options (the UK survey forced one response only to this question whereas the Australian survey allowed respondents to choose multiple conservative care interventions). Secondly with respect to preferred surgical approach, TLIF was the preferred approach in the UK (36.4% across vignettes) while in Australia ALIF was, by far, most preferred (54.0%), with TLIF comparatively lower (Mean 10.3%). The reasons for this disparity are unclear, however the preference for TLIF in the UK mirrors the findings of a UK cross-sectional survey of surgeons, with TLIF most frequently performed,²⁷ and database evidence in the United States also indicate a higher rate of TLIF to ALIF procedures.²⁸ No data relating to trends in surgical approach for lumbar fusion surgery were available in the Australian context. Discrepancies may reflect an economic driver in the UK, particularly as UK survey respondents were mostly currently practising in the NHS (91.7%). Anterior Lumbar Interbody Fusion approaches are significantly more costly than TLIF procedures,²⁹ while evidence to date suggests similar fusion rates and clinical outcomes between these approaches.³⁰

Results highlighted that across all professions and sectors, over half of respondents were willing to randomise the hypothetical vignettes to either lumbar fusion surgery or best conservative care, indicating sufficient equipoise for a future RCT in the Australian context. However, willingness to randomise was lower amongst AHPs (Mean 44.4%) and those working solely in the public sector (43.8%). These findings are consistent with the increasing rates of private lumbar fusion surgeries relative to the public sector in Australia,^23,24 which may reflect over-servicing in the private sector (and potential under-servicing in the public sector). It is also likely that health care professionals will favour selection of treatments they have most experience with. For example, a pilot implementation of multidisciplinary case conferences including both surgical and non-surgical (including physiotherapy) health care professionals reduced recommendations for lumbar fusion surgery compared to surgical consultations alone.³¹ Further, while over half of respondents were willing to randomise the vignettes to either approach, the preferred management option was overwhelmingly for best conservative care, perhaps indicating that although both interventions were considered appropriate, there is a preference to trial adequate conservative management (both in type and duration) prior to undergoing lumbar fusion surgery. Survey results also indicated potential differences between professions regarding their willingness to randomise, with AHPs favouring older patients with longer duration of pain and long-term conservative management, while surgeons favouring younger patients with shorter duration of symptoms. Our survey findings have potential implications for health care professional engagement with, and patient recruitment into, the FORENSIC-Australia RCT. Targeted strategies may be required to both explore and address potential barriers to recruitment³² that may include differing health care professional views around preferred management approach and equipoise.³³

From a clinical perspective, these findings suggest the need for careful consideration in determining treatment options for individuals with LBP associated with degenerative findings. While younger patients with shorter duration of symptoms may be seen as more favourable candidates for lumbar fusion surgery, they may also be more amenable to appropriate conservative care, particularly if this has not already been tried. Conversely, individuals with longstanding low back pain that has been recalcitrant to appropriate conservative management may also present as higher risk of poor outcome following lumbar fusion surgery, and alternative pathways (eg, pain specialist review) should be considered. Finally, willingness to randomise was impacted by vignette features such as BMI and opioid use (vignette 3). These are factors known to impact treatment outcomes following lumbar fusion surgery for degenerative low back pain,^34,35 and a wider multidisciplinary review including dietetics and pharmacy could be considered for individuals presenting as surgical candidates with these features.

This study has strengths and limitations. It had representation across multiple professions and sectors, enhancing the generalisability of findings to the wider Australian context. It comprised multiple sampling frames including relevant national professional bodies, advertisement at relevant conferences and through email distribution lists. However this also prevented us from accurately estimating a survey response rate. Although participation was also influenced by eligibility criteria (eg, currently involved in management of individuals with low back pain), given the membership of the Australian Physiotherapy Association (32 000 members), Spine Society of Australia (169 members), Neurosurgical Society of Australasia (>200 members) and Australian Pain Society (>800 members), it represents a low response rate, likely introducing an unknown influence of responder bias. We believe those more interested in the topic are more likely to have responded to this online survey. There were also limited responses from pain specialists (one pain registrar, one pain nurse) preventing any meaningful description of these health care professionals’ decision-making. We also acknowledge that our analysis included multiple statistical tests, without adjustment in the alpha level to identify statistically significant findings. Finally, hypothetical case vignettes were used in the survey. While vignettes have demonstrated validity and reliability in evaluating clinical decisions^36,37 they may not provide a true representation of the real world but rather an approximation of it. However, the vignettes in this study were developed to reflect realistic case descriptions consistent with the real-world environment, a necessary feature of vignette-based surveys.³⁷

Conclusion

This is the first Australian descriptive survey of clinicians’ decision-making regarding suitability of cases for lumbar fusion surgery or conservative care. This study demonstrated that conservative care was the preferred management, however clinical equipoise (collective uncertainty) exists regarding willingness to randomise individuals with severe, persistent low back pain into an RCT investigating lumbar fusion surgery vs best conservative care. Willingness to randomise was higher amongst orthopaedic surgeons and those working in the private sector, and targeted recruitment strategies may need to be considered for recruitment through AHPs and clinicians in the public sector.

Footnotes

Acknowledgments

We would like to thank all the survey participants for taking the time to complete the survey.

Author Contributions

P. Window: Conceptualization, Data curation, Formal analysis, Methodology, Project administration, Validation, Visualization, Writing – original draft.

E. S. Bada: Conceptualization, Data curation, Methodology, Writing – Writing – review & editing.

M. Stovell: Methodology, Writing – review & editing.

S. Ahuja: Conceptualization, Methodology, Writing – review & editing.

D. J. Beard: Conceptualization, Methodology, Writing – review & editing.

A. C. Gardner: Conceptualization, Methodology, Writing – review & editing.

N. E. Foster: Conceptualization, Formal analysis, Methodology, Project administration, Visualization, Writing – review & editing.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

DB, SA, AG and NEF have funding from the National Institute for Health Research UK [NIHR134859], NEF, DB and SA have funding from the Australian National Health and Medical Research Council (NHMRC) [GA268233] and NEF is funded through an Australian National Health and Medical Research Council (NHMRC) Investigator Grant (ID: 2018182). AG has funding from Orthopaedic Research UK (combined with British Association of Spine Surgeons and British Scoliosis Society) and Innovate UK.

Ethical Statement

ORCID iD

Peter Window

References

Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet (London, England). 2018;392(10159):1789-1858. doi:10.1016/s0140-6736(18)32279-7

Australian Institute of Health and Welfare . Musculoskeletal conditions and comorbidity in Australia. Arthritis series no.25. Cat. no. PHE 241. Canberra: AIHW; 2019.

da C Menezes Costa

Maher

Hancock

, et al. The prognosis of acute and persistent low-back pain: a meta-analysis. CMAJ (Can Med Assoc J) : Canadian Medical Association journal = journal de l'Association medicale canadienne. 2012;184(11):E613-E624. doi:10.1503/cmaj.111271

da Silva

Mills

Brown

Herbert

Maher

Hancock

. Risk of recurrence of low back pain: a systematic review. J Orthop Sports Phys Ther. 2017;47(5):305-313. doi:10.2519/jospt.2017.7415

Hartvigsen

Hancock

Kongsted

, et al. What low back pain is and why we need to pay attention. Lancet (London, England). 2018;391(10137):2356-2367. doi:10.1016/s0140-6736(18)30480-x

National Institute for Health and Care Excellence: Guidelines . Low Back Pain and Sciatica in over 16s: Assessment and Management. National Institute for Health and Care Excellence (NICE). Copyright © NICE; 2016.

Australian Commission on Safety and Quality in Health Care . Low Back Pain Clinical Care Standard. Sydney: ACSQHC; 2022.

WHO guideline for non-surgical management of chronic primary low back pain in adults in primary and community care settings. Geneva: World Health Organization; 2023.

Bailey

Rasoulinejad

Taylor

, et al. Surgery versus conservative care for persistent sciatica Lasting 4 to 12 Months. N Engl J Med. 2020;382(12):1093-1102. doi:10.1056/NEJMoa1912658

10.

Wilby

Best

Wood

, et al. Surgical microdiscectomy versus transforaminal epidural steroid injection in patients with sciatica secondary to herniated lumbar disc (NERVES): a phase 3, multicentre, open-label, randomised controlled trial and economic evaluation. Lancet Rheumatol. 2021;3(5):e347-e356. doi:10.1016/s2665-9913(21)00036-9

11.

Zhao

Wang

. Effectiveness of surgery versus conservative treatment for lumbar spinal stenosis: a system review and meta-analysis of randomized controlled trials. Int J Surg. 2017;44:329-338. doi:10.1016/j.ijsu.2017.07.032

12.

Brox

Reikerås

Nygaard

, et al. Lumbar instrumented fusion compared with cognitive intervention and exercises in patients with chronic back pain after previous surgery for disc herniation: a prospective randomized controlled study. Pain. 2006;122(1-2):145-155. doi:10.1016/j.pain.2006.01.027

13.

Brox

Sørensen

Friis

, et al. Randomized clinical trial of lumbar instrumented fusion and cognitive intervention and exercises in patients with chronic low back pain and disc degeneration. Spine. 2003;28(17):1913-1921. doi:10.1097/01.Brs.0000083234.62751.7a

14.

Fairbank

Frost

Wilson-MacDonald

Barker

Collins

Spine Stabilisation Trial Group . Randomised controlled trial to compare surgical stabilisation of the lumbar spine with an intensive rehabilitation programme for patients with chronic low back pain: the MRC spine stabilisation trial. BMJ (Clinical research ed). 2005;330(7502):1233. doi:10.1136/bmj.38441.620417.8F

15.

Froholdt

Reikeraas

Holm

Keller

Brox

. No difference in 9-year outcome in CLBP patients randomized to lumbar fusion versus cognitive intervention and exercises. Eur Spine J. 2012;21(12):2531-2538. doi:10.1007/s00586-012-2382-0. official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society .

16.

Hedlund

Johansson

Hägg

Fritzell

Tullberg

Swedish Lumbar Spine Study Group . The long-term outcome of lumbar fusion in the Swedish lumbar spine study. Spine J. 2016;16(5):579-587. doi:10.1016/j.spinee.2015.08.065

17.

Ohtori

Koshi

Yamashita

, et al. Surgical versus nonsurgical treatment of selected patients with discogenic low back pain: a small-sized randomized trial. Spine. 2011;36(5):347-354. doi:10.1097/BRS.0b013e3181d0c944

18.

Ran

Luo

. Is lumbar fusion necessary for chronic low back pain associated with degenerative Disk disease? A meta-analysis. World neurosurgery. 2021;146:298-306. doi:10.1016/j.wneu.2020.11.121

19.

Bydon

De la Garza-Ramos

Macki

Baker

Gokaslan

Bydon

. Lumbar fusion versus nonoperative management for treatment of discogenic low back pain: a systematic review and meta-analysis of randomized controlled trials. J Spinal Disord Tech. 2014;27(5):297-304. doi:10.1097/bsd.0000000000000072

20.

Evans

O'Donohoe

Morokoff

Drummond

. The role of spinal surgery in the treatment of low back pain. Med J Aust. 2023;218(1):40-45. doi:10.5694/mja2.51788

21.

Fritzell

Hägg

Wessberg

Nordwall

. Volvo award winner in clinical studies: lumbar fusion versus nonsurgical treatment for chronic low back pain: a multicenter randomized controlled trial from the Swedish lumbar spine study group. Spine. 2001;26(23):2521-2532; discussion 2532-4. doi:10.1097/00007632-200112010-00002

22.

Australian Commission on Safety and Quality in Health Care and Australian Institute of Health and Welfare . The Fourth Australian Atlas of Healthcare Variation. Sydney: ACSQHC; 2021.

23.

Harris

Dao

. Trends of spinal fusion surgery in Australia: 1997 to 2006. ANZ J Surg. 2009;79(11):783-788. doi:10.1111/j.1445-2197.2009.05095.x

24.

Tran

Lewin

Jorm

Harris

. Elective spinal surgery in New South Wales adults, 2001-20, by procedure funding type: a cross-sectional study. Med J Aust. 2023;219(7):303-309. doi:10.5694/mja2.52046

25.

Chou

Loeser

Owens

, et al. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society. Spine. 2009;34(10):1066-1077. doi:10.1097/BRS.0b013e3181a1390d

26.

Bada

Gardner

Ahuja

, et al. Lumbar spine fusion surgery versus best conservative care for patients with severe, persistent low back pain. Bone Jt Open. 2024;5(7):612-620. doi:10.1302/2633-1462.57.Bjo-2023-0147.R1

27.

Provaggi

Capelli

Leong

JJH

Kalaskar

. A UK-based pilot study of current surgical practice and implant preferences in lumbar fusion surgery. Medicine. 2018;97(26):e11169. doi:10.1097/md.0000000000011169

28.

Lambrechts

Siegel

Heard

, et al. Trends in single-level lumbar fusions over the past decade using a national database. World Neurosurg. 2022;167:e61-e69. doi:10.1016/j.wneu.2022.07.092

29.

Crawford

Lightsey

4th Xiong

, et al. Variability and contributions to cost associated with anterior versus posterior approaches to lumbar interbody fusion. Clin Neurol Neurosurg. 2021;206:106688. doi:10.1016/j.clineuro.2021.106688

30.

Phan

Thayaparan

Mobbs

. Anterior lumbar interbody fusion versus transforaminal lumbar interbody fusion--systematic review and meta-analysis. Br J Neurosurg. 2015;29(5):705-711. doi:10.3109/02688697.2015.1036838

31.

Yanamadala

Kim

Buchlak

, et al. Multidisciplinary evaluation leads to the decreased utilization of lumbar spine fusion: an observational Cohort pilot study. Spine. 2017;42(17):E1016-E1023. doi:10.1097/brs.0000000000002065

32.

Donovan

Rooshenas

Jepson

, et al. Optimising recruitment and informed consent in randomised controlled trials: the development and implementation of the Quintet Recruitment Intervention (QRI). Trials. 2016;17(1):283. doi:10.1186/s13063-016-1391-4

33.

Realpe

Blackstone

Griffin

, et al. Barriers to recruitment to an orthopaedic randomized controlled trial comparing two surgical procedures for ankle arthritis : a qualitative study. Bone Jt Open. 2021;2(8):631-637. doi:10.1302/2633-1462.28.Bjo-2021-0074.R1

34.

Mendoza-Elias

Dunbar

Ghogawala

Whitmore

. Opioid Use, risk factors, and outcome in lumbar fusion surgery. World Neurosurg. 2020;135:e580-e587. doi:10.1016/j.wneu.2019.12.073

35.

De la Garza-Ramos

Bydon

Abt

, et al. The impact of obesity on short- and long-term outcomes after lumbar fusion. Spine. 2015;40(1):56-61. doi:10.1097/brs.0000000000000655

36.

Bachmann

Mühleisen

Bock

ter Riet

Held

Kessels

. Vignette studies of medical choice and judgement to study caregivers' medical decision behaviour: systematic review. BMC Med Res Methodol. 2008;8:50. doi:10.1186/1471-2288-8-50

37.

Veloski

Tai

Evans

Nash

. Clinical vignette-based surveys: a tool for assessing physician practice variation. Am J Med Qual. 2005;20(3):151-157. doi:10.1177/1062860605274520

Healthcare Professionals’ Decision-Making Regarding Lumbar Fusion Surgery or Conservative Care for Adults With Severe,Persistent Low Back Pain: An Australian Cross-Sectional Survey Using Case Vignettes

Abstract

Study Design

Objectives

Methods

Results

Conclusions

Keywords

Introduction

Materials and Methods

Design and Setting

Questionnaire Sampling and Mailing Process

Survey

Data Management and Analysis

Results

Preferred Management

Willingness to Randomise

Preferred Surgical Approach

Preferred Conservative Care and Analgesia

Discussion

Conclusion

Footnotes

Acknowledgments

Author Contributions

Declaration of Conflicting Interests

Funding

Ethical Statement

ORCID iD

References