Prognosis of Multifactorial Outcome in Lumbar Discectomy

Lumbar disc herniation with radiculopathy: a comparison of NASS guidelines and ChatGPT

Background

ChatGPT is an advanced language AI able to generate responses to clinical questions regarding lumbar disc herniation with radiculopathy. Artificial intelligence (AI) tools are increasingly being considered to assist clinicians in decision-making. This study compared ChatGPT-3.5 and ChatGPT-4.0 responses to established NASS clinical guidelines and evaluated concordance.

Methods

ChatGPT-3.5 and ChatGPT-4.0 were prompted with fifteen questions from The 2012 NASS Clinical Guidelines for the diagnosis and treatment of lumbar disc herniation with radiculopathy. Clinical questions organized into categories were directly entered as unmodified queries into ChatGPT. Language output was assessed by two independent authors on September 26, 2023 based on operationally-defined parameters of accuracy, over-conclusiveness, supplementary, and incompleteness. ChatGPT-3.5 and ChatGPT-4.0 performance was compared via chi-square analyses.

Results

Among the fifteen responses produced by ChatGPT-3.5, 7 (47%) were accurate, 7 (47%) were over-conclusive, fifteen (100%) were supplementary, and 6 (40%) were incomplete. For ChatGPT-4.0, ten (67%) were accurate, 5 (33%) were over-conclusive, 10 (67%) were supplementary, and 6 (40%) were incomplete. There was a statistically significant difference in supplementary information (100% vs. 67%; p=.014) between ChatGPT-3.5 and ChatGPT-4.0. Accuracy (47% vs. 67%; p=.269), over-conclusiveness (47% vs. 33%; p=.456), and incompleteness (40% vs. 40%; p=1.000) did not show significant differences between ChatGPT-3.5 and ChatGPT-4.0. ChatGPT-3.5 and ChatGPT-4.0 both yielded 100% accuracy for definition and history and physical examination categories. Diagnostic testing yielded 0% accuracy for ChatGPT-3.5 and 100% accuracy for ChatGPT-4.0. Nonsurgical interventions had 50% accuracy for ChatGPT-3.5 and 63% accuracy for ChatGPT-4.0. Surgical interventions resulted in 0% accuracy for ChatGPT-3.5 and 33% accuracy for ChatGPT-4.0.

Conclusions

ChatGPT-4.0 provided less supplementary information and overall higher accuracy in question categories than ChatGPT-3.5. ChatGPT showed reasonable concordance to NASS guidelines, but clinicians should caution use of ChatGPT in its current state as it fails to safeguard against misinformation.

Clinical Analysis of Minimally Invasive Percutaneous Treatment of Severe Lumbar Disc Herniation with UBE Two-Channel Endoscopy and Foraminal Single-Channel Endoscopy Technique

For surgical treatment, herniation of traditional open surgery is the traditional approach and the representative operation for lamina windowing excision of nucleus pulposus. In recent years, the unilateral dual channel spine endoscopic technology (UBE/BESS) has caused extensive concern of spine surgery performer. This research compared the results of minimally invasive percutaneous treatment of severe lumbar disc herniation with foraminal single-channel endoscopy and unilateral biportal endoscopy (UBE). A retrospective study was conducted on 50 patients with severe disc herniation treated with minimally invasive percutaneous treatment in MinDong Hospital affiliated to Fujian Medical University from September 2019 to September 2021. According to different surgical methods, they were divided into two groups: foraminal single-channel endoscopic group and UBE dual-channel endoscopic group. There were 22 cases in the UBE surgery group and 28 cases in the interforaminal endoscopic group. The comparison included operation time, postoperative hospital stays, preoperative and postoperative pain scale (VAS), and postoperative MRI to observe the residual condition of prolapsed nucleus pulposus and the occurrence of complications. There were no significant differences between the UBE group and the interforaminal endoscopic group in incision length, operation time, postoperative hospital stays, and improvement of VAS score before and after surgery. In terms of postoperative nucleus pulposus residual rate and postoperative recurrence rate, the two-channel UBE group was significantly better than the single-channel interforaminal endoscopic group. The incidence of postoperative anemia in the interforaminal endoscopic group was significantly lower than that in the UBE group. In the treatment of severe disc herniation, UBE two-channel endoscopy has the advantages of lower recurrence rate, lower nucleus pulposus residual rate, shorter learning curve, and better field of vision than foraminal single-channel endoscopy, which is worth promoting in primary hospitals.

Feasibility and Assessment of a Machine Learning-Based Predictive Model of Outcome After Lumbar Decompression Surgery

STUDY DESIGN

Retrospective study at a unique center.

OBJECTIVE

The aim of this study is twofold, to develop a virtual patients model for lumbar decompression surgery and to evaluate the precision of an artificial neural network (ANN) model designed to accurately predict the clinical outcomes of lumbar decompression surgery.

METHODS

We performed a retrospective study of complete Electronic Health Records (EHR) to identify potential unfavorable criteria for spine surgery (predictors). A cohort of synthetics EHR was created to classify patients by surgical success (green zone) or partial failure (orange zone) using an Artificial Neural Network which screens all the available predictors.

RESULTS

In the actual cohort, we included 60 patients, with complete EHR allowing efficient analysis, 26 patients were in the orange zone (43.4%) and 34 were in the green zone (56.6%). The average positive criteria amount for actual patients was 8.62 for the green zone (SD+/- 3.09) and 10.92 for the orange zone (SD 3.38). The classifier (a neural network) was trained using 10,000 virtual patients and 2000 virtual patients were used for test purposes. The 12,000 virtual patients were generated from the 60 EHR, of which half were in the green zone and half in the orange zone. The model showed an accuracy of 72% and a ROC score of 0.78. The sensitivity was 0.885 and the specificity 0.59.

CONCLUSION

Our method can be used to predict a favorable patient to have lumbar decompression surgery. However, there is still a need to further develop its ability to analyze patients in the "failure of treatment" zone to offer precise management of patient health before spinal surgery.

Predictors of the conservative management outcomes in patients with lumbar herniated nucleus pulposus: A prospective study in Indonesia

BACKGROUND

The objective of this study was to identify the predictors of the conservative management outcomes in patients with lumbar herniated nucleus pulposus (HNP).

METHODS

A prospective study was conducted between June 2010 and April 2012 in Banda Aceh, Indonesia. Clinical and baseline neurologic examinations such as passive straight leg raising test (SLRT), cross SLRT, and patellar and Achilles reflexes were assessed prior to the conservative management. The patients were evaluated at 2nd, 4th, 8th, 12th and 24th week following commencement of the conservative management.

RESULTS

We recruited and followed 171 HNP patients of which 35.7% of them had good outcome. At univariate analysis, patients with more than 12 months duration of complaint, those with dominant radicular pain, severe pain intensity (visual analogue scale 7-10), positive SLRT, positive cross SLRT, and reduced motor power of knee extensors (muscle strength grade 1-4), were associated with poor outcome. Multivariate analysis suggested that patients with dominant radicular type of pain were likely to had poor outcome compared to those with dominant back pain (odd ratio (OR) 10.57 with 95% confidence interval (CI) 1.15-96.93). Patients with reduced motor power of knee extensors also had a higher chance to have poor outcome compared to those who were normal (OR: 10.57; 95% CI: 1.15-96.93).

CONCLUSION

Type of pain and the strength of lower extremities could be able to predict the failure of conservative management in patients with lumbar disc herniation. However, further studies with the bigger sample size are warrant to validate our results.

Development and temporal validation of a prognostic model for 1-year clinical outcome after decompression surgery for lumbar disc herniation

PURPOSE

Surgeons need tools to provide individualised estimates of surgical outcomes and the uncertainty surrounding these, to convey realistic expectations to the patient. This study developed and validated prognostic models for patients undergoing surgical treatment of lumbar disc herniation, to predict outcomes 1 year after surgery, and implemented these models in an online prediction tool.

METHODS

Using the data of 1244 patients from a large spine unit, LASSO and linear regression models were fitted with 90% upper prediction limits, to predict scores on the Core Outcome Measures Index, and back and leg pain. Candidate predictors included sociodemographic factors, baseline symptoms, medical history, and surgeon characteristics. Temporal validation was conducted on 364 more recent patients at the same unit, by examining the proportion of observed outcomes exceeding the threshold of the 90% upper prediction limit (UPL), and by calculating mean bias and other calibration measures.

RESULTS

Poorer outcome was predicted by obesity, previous spine surgery, and having basic obligatory (rather than private) insurance. In the validation data, fewer than 12% of outcomes were above the 90% UPL. Calibration plots for the model validation showed values for mean bias < 0.5 score points and regression slopes close to 1.

CONCLUSION

While the model accuracy was good overall, the prediction intervals indicated considerable predictive uncertainty on the individual level. Implementation studies will assess the clinical usefulness of the online tool. Updating the models with additional predictors may improve the accuracy and precision of outcome predictions. These slides can be retrieved under Electronic Supplementary Material.

Return to work following surgery for lumbar radiculopathy: a systematic review

BACKGROUND CONTEXT

Informing patients about postoperative return to work (RTW) expectations is of utmost importance because of the influence of realistic expectations on RTW outcomes.

PURPOSE

We aimed to give an overview of the duration of sick leave and RTW rates after surgery for lumbar radiculopathy and to list predictors of and factors related to RTW.

STUDY DESIGN

A systematic review was carried out.

METHODS

A systematic literature search was conducted in PubMed, Web of Science, EMBASE, and SCOPUS. Full-text articles on RTW following surgery for lumbar radiculopathy were included through double-blind screening. Risk of bias was assessed using a modified version of the Downs and Black checklist.

RESULTS

Sixty-three full-text articles (total sample size: 7,100 patients) were included. Risk of bias was scored low to high. Mean duration of sick leave ranged from 0.8 to 20 weeks. Within 0.1-240 months post surgery, 3%-100% of patients resumed work. Most important predictors for work resumption were preoperative work status, presence of comorbidities, age, sex and duration of preoperative symptoms. Duration of sick leave can be predicted by the preoperative level of pain or disability and presence of symptoms of depression, occupational mental stress, and lateral disc prolapse. Furthermore, less invasive surgical techniques were found to result in better RTW outcomes compared with more invasive techniques.

CONCLUSIONS

Diverse results were found for RTW rates and duration of sick leave. Preoperative work status, presence of comorbidities, and several demographic factors were retrieved as predictors of RTW and duration of sick leave.

An analysis from the Quality Outcomes Database, Part 1. Disability, quality of life, and pain outcomes following lumbar spine surgery: predicting likely individual patient outcomes for shared decision-making

OBJECTIVE Quality and outcomes registry platforms lie at the center of many emerging evidence-driven reform models. Specifically, clinical registry data are progressively informing health care decision-making. In this analysis, the authors used data from a national prospective outcomes registry (the Quality Outcomes Database) to develop a predictive model for 12-month postoperative pain, disability, and quality of life (QOL) in patients undergoing elective lumbar spine surgery. METHODS Included in this analysis were 7618 patients who had completed 12 months of follow-up. The authors prospectively assessed baseline and 12-month patient-reported outcomes (PROs) via telephone interviews. The PROs assessed were those ascertained using the Oswestry Disability Index (ODI), EQ-5D, and numeric rating scale (NRS) for back pain (BP) and leg pain (LP). Variables analyzed for the predictive model included age, gender, body mass index, race, education level, history of prior surgery, smoking status, comorbid conditions, American Society of Anesthesiologists (ASA) score, symptom duration, indication for surgery, number of levels surgically treated, history of fusion surgery, surgical approach, receipt of workers' compensation, liability insurance, insurance status, and ambulatory ability. To create a predictive model, each 12-month PRO was treated as an ordinal dependent variable and a separate proportional-odds ordinal logistic regression model was fitted for each PRO. RESULTS There was a significant improvement in all PROs (p < 0.0001) at 12 months following lumbar spine surgery. The most important predictors of overall disability, QOL, and pain outcomes following lumbar spine surgery were employment status, baseline NRS-BP scores, psychological distress, baseline ODI scores, level of education, workers' compensation status, symptom duration, race, baseline NRS-LP scores, ASA score, age, predominant symptom, smoking status, and insurance status. The prediction discrimination of the 4 separate novel predictive models was good, with a c-index of 0.69 for ODI, 0.69 for EQ-5D, 0.67 for NRS-BP, and 0.64 for NRS-LP (i.e., good concordance between predicted outcomes and observed outcomes). CONCLUSIONS This study found that preoperative patient-specific factors derived from a prospective national outcomes registry significantly influence PRO measures of treatment effectiveness at 12 months after lumbar surgery. Novel predictive models constructed with these data hold the potential to improve surgical effectiveness and the overall value of spine surgery by optimizing patient selection and identifying important modifiable factors before a surgery even takes place. Furthermore, these models can advance patient-focused care when used as shared decision-making tools during preoperative patient counseling.

Assessment and Determinants of Spinal Pain in the Course of Disc Disorders Treated Surgically

Background

Intervertebral disc disease is defined as a complex of structural changes in the aftermath of disorders of mutual elements, the structure of which form the discus intervertebralis and the spinal canal. The present work assessed pain in patients who were surgically treated due to spinal discopathy and analyzed factors that determine the condition.

Material/Methods

The research was carried on a group of 187 patients diagnosed with discopathy of the lumbosacral and cervical segment. The data are discussed in the context of medical records and the Visual Analogue Scale used for pain assessment. We used a prospective study plan with a 3-time assessment.

Results

The pain level observed among patients prior to the procedure (M=6.52) was higher than after 7 days (M=3.15) and 6 months from the operation (M= 3.45). The highest level of pain (M=6.88), with a relatively high consistency among the patients (SD=2.25), was observed in the case of left-side hernia (H=7.31; p=0.023). The influence of the analyzed factors on pain experience markedly increased by the third assessment (R2=0.14), and was strongly associated with the type of work performed by the patient.

Conclusions

Surgical operation significantly reduces pain in patients with disc disorders. The level of pain is predominantly affected by the location of the hernia and the type of work performed by the patient.

A systematic review of preoperative predictors for postoperative clinical outcomes following lumbar discectomy

BACKGROUND CONTEXT

Sciatica is often caused by a herniated lumbar intervertebral disc. When conservative treatment fails, a lumbar discectomy can be performed. Surgical treatment via lumbar discectomy is not always successful and may depend on a variety of preoperative factors. It remains unclear which, if any, preoperative factors can predict postsurgical clinical outcomes.

PURPOSE

This review aimed to determine preoperative predictors that are associated with postsurgical clinical outcomes in patients undergoing lumbar discectomy.

STUDY DESIGN

This is a systematic review.

METHODS

This systematic review of the scientific literature followed the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. MEDLINE and PubMed were systematically searched through June 2014. Results were screened for relevance independently, and full-text studies were assessed for eligibility. Reporting quality was assessed using a modified Newcastle-Ottawa Scale. Quality of evidence was assessed using a modified version of Sackett's Criteria of Evidence Support. No financial support was provided for this study. No potential conflict of interest-associated biases were present from any of the authors.

RESULTS

The search strategy yielded 1,147 studies, of which a total of 40 high-quality studies were included. There were 17 positive predictors, 20 negative predictors, 43 non-significant predictors, and 15 conflicting predictors determined. Preoperative predictors associated with positive postoperative outcomes included more severe leg pain, better mental health status, shorter duration of symptoms, and younger age. Preoperative predictors associated with negative postoperative outcomes included intact annulus fibrosus, longer duration of sick leave, worker's compensation, and greater severity of baseline symptoms. Several preoperative factors including motor deficit, side and level of herniation, presence of type 1 Modic changes and degeneration, age, and gender had non-significant associations with postoperative clinical outcomes.

CONCLUSIONS

It may be possible for certain preoperative factors to be targeted for clinical evaluation by spine surgeons to assess the suitability of patients for lumbar discectomy surgery, the hope being to thereby improve postoperative clinical outcomes. Prospective cohort studies are required to increase the level of evidence with regard to significant predictive factors.

Obesity has an impact on outcome in lumbar disc surgery

PURPOSE

To investigate the effect of obesity on outcome in lumbar discectomy.

METHODS

A cross-sectional postal survey; a self-made questionnaire, Beck depression inventory IA (BDI IA) and the Oswestry low back disability questionnaire (ODI) were sent to the patients, who had undergone lumbar disc surgery in the Oulu University Hospital between June 2005 and May 2008. Patients were divided into three groups according to BMI: normal, pre-obese and obese. The ODI was also examined in the framework of the international classification of functioning, disability and health (ICF) to investigate its ability to describe various dimensions of functioning (body structure and functions, activities and participation).

RESULTS

The postal survey was sent to 642 patients, of whom 355 (55%) replied. Males dominated in the pre-obese (66%) and obese (62%) groups (p=0.01). Normal-weighted and pre-obese patients had lower BDI scores compared to obese patients (mean BDI: 8.0, 7.6, 11.2, respectively, p=0.035). Total ODI score was highest in the obese group compared to normal-weighted or pre-obese (20.3, 18.6, 26.4, respectively, p=0.011). When ODI was linked to the ICF there were significant differences in all activity domains (mobility, self-care and interpersonal interactions and relationships) and the mobility component of the participation domain between the weight groups.

CONCLUSIONS AND IMPLICATIONS

Obesity has an impact on outcome in lumbar discectomy. Obese patients had higher scores in BDI and ODI indicating mild mood disturbances and moderate functional disability. According to ICF, functional disability of obese patients was observed to some extent in all activity domains. Obese patients will be more frequently present for disc surgery and increased morbidity risk must be recognized. We need a strategy to rehabilitate and activate obese patients pre- and postoperatively.

Influence of gender on patient-oriented outcomes in spine surgery

PURPOSE

Few studies have examined gender differences in patient-oriented health-related quality of life before and after spine surgery. This study examined the influence of gender on baseline status and 1-year postoperative outcomes in a large series of patients undergoing surgery for different degenerative spinal disorders.

METHODS

The study included 1518 patients [812 men and 706 women; mean (SD) age 61.4 ± 16.2 years], with three different pathologies (disc herniation, degenerative spondylolisthesis, or spinal stenosis), treated with specified surgical approaches. Preoperatively and 12 months postoperatively, patients completed the multidimensional Core Outcome Measures Index (COMI). Medical history, surgical details and perioperative complications were documented with the Eurospine "Spine Tango" Surgery 2006 form.

RESULTS

Preoperatively and for all three pathologies, women had significantly (p < 0.05) worse COMI-scores than men, especially for the sub-domains "leg/buttock pain", "dominant pain intensity", and "general quality of life"; the change in the COMI sum score 12 months postoperatively showed no significant gender differences for any pathology (p > 0.05). 71.3 % males and 72.9 % females achieved the minimal clinically important change score (MCIC; 2.2 point reduction) for the COMI. Controlling for potential cofounders (preoperative COMI, ASA, complications, pathology), gender showed no significant association with the failure to achieve MCIC.

CONCLUSIONS

This results show that women do not differ significantly from men regarding their postoperative outcome, even though they present with a worse preoperative status. The management of a patient's condition should not differ depending on their gender, since both men and women are able to improve to a similar extent.

Predictors of clinical outcome following lumbar disc surgery: the value of historical, physical examination, and muscle function variables

PURPOSE

Explore the relationships between preoperative findings and clinical outcome following lumbar disc surgery, and investigate the prognostic value of physical examination findings after accounting for information acquired from the clinical history.

METHODS

We recruited 55 adult patients scheduled for first time, single-level lumbar discectomy. Participants underwent a standardized preoperative evaluation including real-time ultrasound imaging assessment of lumbar multifidus function, and an 8-week postoperative rehabilitation programme. Clinical outcome was defined by change in disability, and leg and low back pain (LBP) intensity at 10 weeks. Linear regression models were used to identify univariate and multivariate predictors of outcome.

RESULTS

Univariate predictors of better outcome varied depending on the outcome measure. Clinical history predictors included a greater proportion of leg pain to LBP, pain medication use, greater time to surgery, and no history of previous physical or injection therapy. Physical examination predictors were a positive straight or cross straight leg raise test, diminished lower extremity strength, sensation or reflexes, and the presence of postural abnormality or pain peripheralization. Preoperative pain peripheralization remained a significant predictor of improved disability (p = 0.04) and LBP (p = 0.02) after accounting for information from the clinical history. Preoperative lumbar multifidus function was not associated with clinical outcome.

CONCLUSIONS

Information gleaned from the clinical history and physical examination helps to identify patients more likely to succeed with lumbar disc surgery. While this study helps to inform clinical practice, additional research confirming these results is required prior to confident clinical implementation.

Extent of preoperative depression is associated with return to work after lumbar fusion for spondylolisthesis

BACKGROUND

The ability to understand factors associated with an increased duration of missed work postoperatively could be used to more effectively select patients with the greatest opportunity for a successful outcome. We set out to determine the effect of preoperative depression on postoperative return to work in patients undergoing transforaminal lumbar interbody fusion (TLIF) for degenerative spondylolisthesis.

METHODS

Fifty-eight patients undergoing TLIF for symptomatic grade I degenerative lumbar spondylolisthesis were included in this analysis. Patient demographics, clinical presentation, indications for surgery, radiologic studies, and operative variables were assessed for each case. Patient-assessed outcome measures were obtained prospectively at baseline and 2 years postoperatively. To understand the factors associated with prolonged return to work, univariate linear regression analysis and stepwise multivariate Cox proportional hazards model was used.

RESULTS

All patient-reported outcomes assessed were significantly improved 2 years after TLIF (P < 0.001). Of the 32 patients working preoperatively, 26 (81%) returned to work postoperatively. Median time to return to work was 56 days (range, 10-150 days). Independent of patient age; preoperative pain, disability, and quality of life; and extent of postoperative improvement, increased preoperative Zung depression score remained associated with prolonged return to work (P = 0.02).

CONCLUSIONS

Independent of postoperative improvement in pain, disability, and quality of life, the extent of preoperative depression was an independent predictor of time to return to work in patients undergoing TLIF for spondylolisthesis, suggesting that regardless of how successful TLIF surgery may be at improving a patient's pain, disability, or quality of life, greater depression will delay or prohibit their ability to return to work postoperatively.

Lumbar disk herniation surgery: outcome and predictors

Study Design A retrospective cohort study. Objectives To determine the outcome and any differences in the clinical results of three different surgical methods for lumbar disk herniation and to assess the effect of factors that could predict the outcome of surgery. Methods We evaluated 148 patients who had operations for lumbar disk herniation from March 2006 to March 2011 using three different surgical techniques (laminectomy, microscopically assisted percutaneous nucleotomy, and spinous process osteotomy) by using Japanese Orthopaedic Association (JOA) Back Pain Evaluation Questionnaire, Resumption of Activities of Daily Living scale and changes of visual analog scale (VAS) for low back pain and radicular pain. Our study questionnaire addressed patient subjective satisfaction with the operation, residual complaints, and job resumption. Data were analyzed with SPSS version 16.0 (SPSS, Inc., Chicago, Illinois, United States). Statistical significance was set at 0.05. For statistical analysis, chi-square test, Mann-Whitney U test, Kruskal-Wallis test, and repeated measure analysis were performed. For determining the confounding factors, univariate analysis by chi-square test was used and followed by logistic regression analysis. Results Ninety-four percent of our patients were satisfied with the results of their surgeries. VAS documented an overall 93.3% success rate for reduction of radicular pain. Laminectomy resulted in better outcome in terms of JOA Back Pain Evaluation Questionnaire. The outcome of surgery did not significantly differ by age, sex, level of education, preoperative VAS for back, preoperative VAS for radicular pain, return to previous job, or level of herniation. Conclusion Surgery for lumbar disk herniation is effective in reducing radicular pain (93.4%). All three surgical approaches resulted in significant decrease in preoperative radicular pain and low back pain, but intergroup variation in the outcome was not achieved. As indicated by JOA Back Pain Evaluation Questionnaire-Low Back Pain (JOABPQ-LBP) and lumbar function functional scores, laminectomy achieved significantly better outcome compared with other methods. It is worth mentioning that relief of radicular pain was associated with subjective satisfaction with the surgery among our study population. Predictive factors for ineffective surgical treatment for lumbar disk herniation were female sex and negative preoperative straight leg raising. Age, level of education, and preoperative VAS for low back pain were other factors that showed prediction power.

An evidence-based clinical guideline for the diagnosis and treatment of lumbar disc herniation with radiculopathy

BACKGROUND CONTEXT

The objective of the North American Spine Society's (NASS) Evidence-Based Clinical Guideline for the Diagnosis and Treatment of Lumbar Disc Herniation with Radiculopathy is to provide evidence-based recommendations to address key clinical questions surrounding the diagnosis and treatment of lumbar disc herniation with radiculopathy. The guideline is intended to reflect contemporary treatment concepts for symptomatic lumbar disc herniation with radiculopathy as reflected in the highest quality clinical literature available on this subject as of July 2011. The goals of the guideline recommendations are to assist in delivering optimum efficacious treatment and functional recovery from this spinal disorder.

PURPOSE

To provide an evidence-based educational tool to assist spine specialists in the diagnosis and treatment of lumbar disc herniation with radiculopathy.

STUDY DESIGN

Systematic review and evidence-based clinical guideline.

METHODS

This guideline is a product of the Lumbar Disc Herniation with Radiculopathy Work Group of NASS' Evidence-Based Guideline Development Committee. The work group consisted of multidisciplinary spine care specialists trained in the principles of evidence-based analysis. A literature search addressing each question and using a specific search protocol was performed on English-language references found in Medline, Embase (Drugs and Pharmacology), and four additional evidence-based databases to identify articles. The relevant literature was then independently rated using the NASS-adopted standardized levels of evidence. An evidentiary table was created for each of the questions. Final recommendations to answer each clinical question were developed via work group discussion, and grades were assigned to the recommendations using standardized grades of recommendation. In the absence of Level I to IV evidence, work group consensus statements have been developed using a modified nominal group technique, and these statements are clearly identified as such in the guideline.

RESULTS

Twenty-nine clinical questions were formulated and addressed, and the answers are summarized in this article. The respective recommendations were graded by strength of the supporting literature, which was stratified by levels of evidence.

CONCLUSIONS

The clinical guideline has been created using the techniques of evidence-based medicine and best available evidence to aid practitioners in the care of patients with symptomatic lumbar disc herniation with radiculopathy. The entire guideline document, including the evidentiary tables, suggestions for future research, and all the references, is available electronically on the NASS Web site at http://www.spine.org/Pages/PracticePolicy/ClinicalCare/ClinicalGuidlines/Default.aspx and will remain updated on a timely schedule.

Do preoperative fear avoidance model factors predict outcomes after lumbar disc herniation surgery? A systematic review

BACKGROUND

Lumbar disc herniation (LDH) surgery is usually recommended when conservative treatments fail to manage patients' symptoms. However, many patients undergoing LDH surgery continue to report pain and disability. Preoperative psychological factors have shown to be predictive for postoperative outcomes. Our aim was to systematically review studies that prospectively examined the prognostic value of factors in the Fear Avoidance Model (FAM), including back pain, leg pain, catastrophizing, anxiety, fear-avoidance, depression, physical activity and disability, to predict postoperative outcomes in patients undergoing LDH surgery.

METHODS

We performed a systematic literature review of prospective studies that measured any FAM factors preoperatively to predict postoperative outcomes for patients undergoing LDH surgery. Our search databases included PubMed, CINAHL, and PsycINFO. We assessed the quality of each included study using a certain quality assessment list. Degree of agreement between reviewers on quality assessment was examined. Results related to FAM factors in the included studies were summarized.

RESULTS

Thirteen prospective studies met our inclusion criteria. Most studies were considered high quality. Heterogeneity was present between the included studies in many aspects. The most common FAM factors examinered were baseline pain, disability and depression. In, general, depression, fear-avoidance behaviors, passive pain coping, and anxiety FAM factors appeared to have negative influence on LDH surgical outcome. Baseline back pain and leg pain appeared to have differing prognostic value on LDH surgical outcomes.

CONCLUSIONS

FAM factors seem to influence LDH surgical outcomes. Patients with high levels of depression, anxiety and fear-avoidance behaviors are more likely to have poor outcomes following LDH surgery. Conversely, high levels of leg pain, but not back pain seem to be predictor for favorable LDH surgery outcome. More research is needed to determine the exact role of FAM factors on LDH surgical outcome and the value for screening for these factors.

A method for quantitative measurement of lumbar intervertebral disc structures: an intra- and inter-rater agreement and reliability study

Background

There is a shortage of agreement studies relevant for measuring changes over time in lumbar intervertebral disc structures. The objectives of this study were: 1) to develop a method for measurement of intervertebral disc height, anterior and posterior disc material and dural sac diameter using MRI, 2) to evaluate intra- and inter-rater agreement and reliability for the measurements included, and 3) to identify factors compromising agreement.

Methods

Measurements were performed on MRIs from 16 people with and 16 without lumbar disc herniation, purposefully chosen to represent all possible disc contours among participants in a general population study cohort. Using the new method, MRIs were measured twice by one rater and once by a second rater. Agreement on the sagittal start- and end-slice was evaluated using weighted Kappa. Length and volume measurements were conducted on available slices between intervertebral foramens, and cross-sectional areas (CSA) were calculated from length measurements and slice thickness. Results were reported as Bland and Altman’s limits of agreement (LOA) and intraclass correlation coefficients (ICC).

Results

Weighted Kappa (K_w (95% CI)) for start- and end-slice were: intra-: 0.82(0.60;0.97) & 0.71(0.43;0.93); inter-rater: 0.56(0.29;0.78) & 0.60(0.35;0.81). For length measurements, LOA ranged from [−1.0;1.0] mm to [−2.0;2.3] mm for intra-; and from [−1.1; 1.4] mm to [−2.6;2.0] mm for inter-rater. For volume measurements, LOA ranged from [−293;199] mm³ to [−582;382] mm³ for intra-, and from [−17;801] mm³ to [−450;713] mm³ for inter-rater. For CSAs, LOA ranged between [−21.3; 18.8] mm² and [−31.2; 43.7] mm² for intra-, and between [−10.8; 16.4] mm² and [−64.6; 27.1] mm² for inter-rater. In general, LOA as a proportion of mean values gradually decreased with increasing size of the measured structures. Agreement was compromised by difficulties in identifying the vertebral corners, the anterior and posterior boundaries of the intervertebral disc and the dural sac posterior boundary. With two exceptions, ICCs were above 0.81.

Conclusions

Length measurements and calculated CSAs of disc morphology and dural sac diameter from MRIs showed acceptable intra- and inter-rater agreement and reliability. However, caution should be taken when measuring very small structures and defining anatomical landmarks.

Percutaneous Disc Coagulation Therapy (PDCT) comparing with Automated Percutaneous Lumbar Discectomy (APLD) in Patients of Herniated Lumbar Disc Disease: Preliminary Report

OBJECTIVE

Percutaneous techniques are rapidly replacing traditional open surgery. This is a randomized controlled trial study of clinical outcomes of Percutaneous Plasma Disc Coagulation Therapy (PDCT) in patients with HLD(herniated lumbar disc) as a new percutaneous access in comparison with Automated Percutaneous Lumbar Discectomy (APLD) in its clinical application and usefulness as a reliable alternative method.

METHODS

The authors analyzed 25 patients who underwent PDCT randomized 1:1 to 25 who underwent APLD between June, 2010 and October, 2011. All patients had herniated lumbar disc diseases. The clinical outcomes were evaluated using Visual Analog Scales (VAS) score and MacNab's criteria.

RESULTS

The age of the patients who underwent PDCT ranged from 29 to 88 years with a mean age of 51.8 years. The age of the APLD undergone patients' population ranged from 30 to 66 with a mean age of 46.0 years. The average preoperative VAS score in PDCT was 7.60 and 1.94 at 7months post-operatively, and in APLD was 7.32, and 3.53 at 7 months post-operatively (p<0.001). In Macnab's criteria, 20 patients (80%) had achieved favorable improvement (excellent and good) in PDCT group. In Macnab's criteria, 16 patients (64%) had achieved favorable improvement in APLD group (p<0.001).

CONCLUSION

PDCT can be considered a viable option as a new percutaneous access to herniated lumbar disc. PDCT showed to be more effective than APLD in this study, allowing stable decompression and safe minimally invasive operation to an area desired by the operator in lumbar disc herniation patients, although further long term clinical evaluations are still necessary.

Preoperative Zung Depression Scale predicts outcome after revision lumbar surgery for adjacent segment disease, recurrent stenosis, and pseudarthrosis

BACKGROUND CONTEXT

Persistent back pain and leg pain after index surgery is distressing to patients and spinal surgeons. Revision surgical treatment is technically challenging and has been reported to yield unpredictable outcomes. Recently, affective disorders, such as depression and anxiety, have been considered potential predictors of surgical outcomes across many disease states of chronic pain. There remains a paucity of studies assessing the predictive value of baseline depression on outcomes in the setting of revision spine surgery.

PURPOSE

To assess the predictive value of preoperative depression on 2-year postoperative outcome after revision lumbar surgery for symptomatic pseudarthrosis, adjacent segment disease (ASD), and same-level recurrent stenosis.

STUDY DESIGN

Retrospective cohort study.

PATIENT SAMPLE

One hundred fifty patients undergoing revision surgery for symptomatic ASD, pseudarthrosis, and same-level recurrent stenosis.

OUTCOME MEASURES

Patient-reported outcome measures were assessed using an outcomes questionnaire that included questions on health-state values (EQ-5D), disability (Oswestry Disability Index [ODI]), pain (visual analog scale), depression (Zung Self-Rating Depression Scale), and 12-Item Short Form Health Survey physical and mental component scores.

METHODS

One hundred fifty patients undergoing revision neural decompression and instrumented fusion for ASD (n=50), pseudarthrosis (n=47), or same-level recurrent stenosis (n=53) were included in this study. Preoperative Zung Self-Reported Depression Scale score was assessed for all patients. Preoperative and 2-year postoperative visual analog scale for back pain and leg pain scores and ODI were assessed. The association between preoperative Zung Depression Scale score and 2-year improvement in disability was assessed via multivariate regression analysis.

RESULTS

Compared to preoperative status, VAS-BP was significantly improved 2 years after surgery for ASD (8.72±1.85 vs. 3.92±2.84, p=.001), pseudoarthrosis (7.31±0.81 vs. 5.06±2.64, p=.001), and same-level recurrent stenosis (9.28±1.00 vs. 5.00±2.94, p=.001). Two-year ODI was also significantly improved after surgery for ASD (28.72±9.64 vs. 18.48±11.31, p=.001), pseudoarthrosis (29.74±5.35 vs. 25.42±6.00, p=.001), and same-level recurrent stenosis (36.01±6.00 vs. 21.75±12.07, p=.001). Independent of age, BMI, symptom duration, smoking, comorbidities, and level of preoperative pain and disability, increasing preoperative Zung depression score was significantly associated with less 2-year improvement in disability (ODI) after revision surgery for ASD, pseudoarthrosis, and recurrent stenosis.

CONCLUSIONS

Our study suggests that the extent of preoperative depression is an independent predictor of functional outcome after revision lumbar surgery for ASD, pseudoarthrosis, and recurrent stenosis. Future comparative effectiveness studies assessing outcomes after revision lumbar surgery should account for depression as a potential confounder. The Zung depression questionnaire may help risk stratify patients presenting for revision lumbar surgery.

Predictors of long-term pain and disability in patients with low back pain investigated by magnetic resonance imaging: a longitudinal study

Background

It is possible that clinical outcome of low back pain (LBP) differs according to the presence or absence of spinal abnormalities on magnetic resonance imaging (MRI), in which case there could be value in using MRI findings to refine case definition of LBP in epidemiological research. We therefore conducted a longitudinal study to explore whether spinal abnormalities on MRI for LBP predict prognosis after 18 months.

Methods

A consecutive series of patients aged 20-64 years, who were investigated by MRI because of mechanical LBP (median duration of current episode 16.2 months), were identified from three radiology departments, and those who agreed completed self-administered questionnaires at baseline and after a mean follow-up period of 18.5 months (a mean of 22.2 months from MRI investigation). MRI scans were assessed blind to other clinical information, according to a standardised protocol. Associations of baseline MRI findings with pain and disability at follow-up, adjusted for treatment and for other potentially confounding variables, were assessed by Poisson regression and summarised by prevalence ratios (PRs) with their 95% confidence intervals (CIs).

Results

Questionnaires were completed by 240 (74%) of the patients who had agreed to be followed up. Among these 111 men and 129 women, 175 (73%) reported LBP in the past four weeks, 89 (37%) frequent LBP, and 72 (30%) disabling LBP. In patients with initial disc degeneration there was an increased risk of frequent (PR 1.3, 95%CI 1.0-1.9) and disabling LBP (PR 1.7, 95%CI 1.1-2.5) at follow-up. No other associations were found between MRI abnormalities and subsequent outcome.

Conclusions

Our findings suggest that the MRI abnormalities examined are not major predictors of outcome in patients with LBP. They give no support to the use of MRI findings as a way of refining case definition for LBP in epidemiological research.

Instrumentos de avaliação clínica e funcional em cirurgia da coluna vertebral

Alguns dos indivíduos submetidos à cirurgia de coluna vertebral terão desfechos pós-operatório desfavoráveis, independente do êxito técnico. Esse insucesso gera aumento da morbidade e dos custos socioeconômicos. Sabe-se que fatores psicossociais interferem na impressão do sujeito. Com o propósito de identificá-los, tem-se estimulado a busca de preditores prognósticos por meio de instrumentos de triagem. Porém, a eleição do mais adequado pode ser difícil, já que existe um grande número de questionários. Entre os aspectos abordados por eles, podemos citar: incapacidade funcional, qualidade de vida, satisfação, dor, depressão, distúrbios do humor e atividade funcional. O trabalho objetiva revisar as particularidades, indicações e limitações dos instrumentos de avaliação do paciente com doença na coluna vertebral.

Clinical factors of importance for outcome after lumbar disc herniation surgery: long-term follow-up

Factors as age, sex, smoking, duration of leg pain, working status, type/level of disc herniation and psychosocial factors have been demonstrated to be of importance for short-term results after lumbar discectomy. There are few studies with long-term follow-up. In this prospective study of lumbar disc herniation patients undergoing surgery, the result was evaluated at 2 and 5-10 (mean 7.3) years after surgery. Predictive factors for satisfaction with treatment and objective outcome were investigated. Out of the included 171 patients undergoing lumbar discectomy, 154 (90%) patients completed the 2-year follow-up and 140 (81%) completed the long-term follow-up. Baseline data and questionnaires about leg- and back pain intensity (VAS), duration of leg pain, disability (Oswestry Disability Index), depression (Zung Depression Scale), sick leave and employment status were obtained preoperatively, at 2-year- and long-term follow-up. Primary outcome included patient satisfaction with treatment (at both time points) and assessment of an independent observer at the 2-year follow-up. Secondary outcomes at 2-year follow-up were improvement of leg and back pain, working capacity and the need for analgesics or sleeping pills. In about 70% of the patients excellent or good overall result was reported at both follow-ups, with subjective outcome measurements. The objective evaluation after 2 years was in agreement with this result. Time on sick leave was found to be a clinically important predictor of the primary outcomes, with a potential of changing the probability of a satisfactory outcome (both objective and subjective) from around 50% (sick leave >3 months) to 80% (sick leave <2 months). Time on sick leave was also an important predictor for several of the secondary outcomes; e.g. working capacity and the need for analgesics.

An analysis of the prognostic factors affecing the clinical outcomes of conventional lumbar open discectomy : clinical and radiological prognostic factors

Study Design

This is a retrospective study.

Purpose

We wanted to examine the clinical and radiological prognostic factors affecting the postoperative clinical outcome of patients with lumbar disc herniation and who underwent open discectomy.

Overview of Literature

Conventional open discectomy has been widely used as a treatment regimen for the management of lumbar disc herniation. Still, much controversy exists regarding the factors that affect the postoperative clinical outcomes.

Methods

The current study was conducted on 40 patients who were diagnosed with lumbar disc herniation by the senior surgeon of our department from March 2004 to June 2007. These patients were refractory to conservative treatment and they could be followed up for more than one year following their surgical treatments. Preoperatively, after postoperative year 1 and at the final follow-up, a comparison was made for the Oswestry disability index (ODI) scores and the visual analogue scale (VAS) scores that indicated low back pain and radiating pain. For identifying prognostic factors, an analysis was also performed for such factors as age, gender, the operated level, the duration of preoperative low back pain and radiating pain, a smoking history, the body mass index and whether the surgery was revision or the primary operation. A radiological analysis, based on the preoperative plain flexion-extension radiography, was performed for the presence of mild segmental instability of < 3 mm, spondylolysis and disc space narrowing. Pfirrmann's degenerative grade of the disc, the degree of herniation and whether a herniation was central or massive on the magnetic resonance imaging scans.

Results

At the final follow-up, the ODI was significantly higher in the cases of revision as compared with the cases of primary operation. The female gender also had a tendency for a poor ODI as compared with that of the men, but this had only borderline statistical significance. There was significant correlation between the preoperative ODI and the preoperative VAS indicating radiating pain. At a final follow up, the low back pain VAS score was significantly lower in the extruded cases as compared with that of the protruded or sequestrated cases.

Conclusions

Following an analysis for detecting the prognostic factors of open discectomy, the final clinical outcome was found to be poor for the revision surgery cases. In regard to the type of herniation, the degree of low back pain was relatively lower at a final follow-up for the extruded cases as compared with that for the protruded or sequestrated cases. Open discectomy surgery should be performed after evaluating the patients' various prognostic factors that could affect the final clinical outcome.

Physical examination for lumbar radiculopathy due to disc herniation in patients with low-back pain

BACKGROUND

Low-back pain with leg pain (sciatica) may be caused by a herniated intervertebral disc exerting pressure on the nerve root. Most patients will respond to conservative treatment, but in carefully selected patients, surgical discectomy may provide faster relief of symptoms. Primary care clinicians use patient history and physical examination to evaluate the likelihood of disc herniation and select patients for further imaging and possible surgery.

OBJECTIVES

(1) To assess the performance of tests performed during physical examination (alone or in combination) to identify radiculopathy due to lower lumbar disc herniation in patients with low-back pain and sciatica;(2) To assess the influence of sources of heterogeneity on diagnostic performance.

SEARCH STRATEGY

We searched electronic databases for primary studies: PubMed (includes MEDLINE), EMBASE, and CINAHL, and (systematic) reviews: PubMed and Medion (all from earliest until 30 April 2008), and checked references of retrieved articles.

SELECTION CRITERIA

We considered studies if they compared the results of tests performed during physical examination on patients with back pain with those of diagnostic imaging (MRI, CT, myelography) or findings at surgery.

DATA COLLECTION AND ANALYSIS

Two review authors assessed the quality of each publication with the QUADAS tool, and extracted details on patient and study design characteristics, index tests and reference standard, and the diagnostic two-by-two table. We presented information on sensitivities and specificities with 95% confidence intervals (95% CI) for all aspects of physical examination. Pooled estimates of sensitivity and specificity were computed for subsets of studies showing sufficient clinical and statistical homogeneity.

MAIN RESULTS

We included 16 cohort studies (median N = 126, range 71 to 2504) and three case control studies (38 to100 cases). Only one study was carried out in a primary care population. When used in isolation, diagnostic performance of most physical tests (scoliosis, paresis or muscle weakness, muscle wasting, impaired reflexes, sensory deficits) was poor. Some tests (forward flexion, hyper-extension test, and slump test) performed slightly better, but the number of studies was small. In the one primary care study, most tests showed higher specificity and lower sensitivity compared to other settings.Most studies assessed the Straight Leg Raising (SLR) test. In surgical populations, characterized by a high prevalence of disc herniation (58% to 98%), the SLR showed high sensitivity (pooled estimate 0.92, 95% CI: 0.87 to 0.95) with widely varying specificity (0.10 to 1.00, pooled estimate 0.28, 95% CI: 0.18 to 0.40). Results of studies using imaging showed more heterogeneity and poorer sensitivity. The crossed SLR showed high specificity (pooled estimate 0.90, 95% CI: 0.85 to 0.94) with consistently low sensitivity (pooled estimate 0.28, 95% CI: 0.22 to 0.35).Combining positive test results increased the specificity of physical tests, but few studies presented data on test combinations.

AUTHORS' CONCLUSIONS

When used in isolation, current evidence indicates poor diagnostic performance of most physical tests used to identify lumbar disc herniation. However, most findings arise from surgical populations and may not apply to primary care or non-selected populations. Better performance may be obtained when tests are combined.

[Can failed back surgery be prevented? Psychological risk factors for postoperative pain after back surgery]

Aside from the surgical technique used, the development of peri- and postoperative pain and impairments in patients following intervertebral disk surgery is also determined to a crucial extent by psychological factors. Based on a systematic literature review, we checked whether evidence-based recommendations could be deduced on how to take into account psychological risk factors in back surgery in order to avoid postoperative complications, such as failed back surgery syndrome. The current state of research suggests three groups of risk factors: (1) negative psychological factors, (2) preexisting pain chronification, and (3) psychological disorders. In the case of elective intervertebral disk surgery, these factors should therefore be determined and identified preoperatively and taken into account in the indication for surgery. Multimodal treatments could conceivably prove to be more effective, or else psychological pain management therapy might be considered prior to surgery so as to avoid postoperative complications. If surgery is medically unavoidable despite existing risk factors, postoperative treatment should incorporate psychological pain management therapy at an early stage in the context of a multidisciplinary approach.

Psychosocial predictors and correlates for chronic post-surgical pain (CPSP) - a systematic review

Chronic post-surgical pain (CPSP) is a serious problem. Incidence as high as 50% has been reported, depending on type of surgery undergone. Because the etiology of chronic pain is grounded in the bio-psychosocial model, physical, psychological, and social factors are implicated in the development of CPSP. Biomedical factors such as pre-operative pain, severe acute post-operative pain, modes of anesthesia, and surgical approaches have been extensively examined, therefore this systematic review focuses on psychosocial elements. A systematic search was performed using the PubMed, PsychINFO, Embase, and Cochrane Databases. Fifty relevant publications were selected from this search, in which psychosocial predictors for and correlates to CPSP were identified. The level of evidence was assessed for each study, and corresponding score points were awarded for ease of comparison. The grade of association with CPSP for each predictor/correlate was then determined. Depression, psychological vulnerability, stress, and late return to work showed likely correlation with CPSP (grade of association=1). Other factors were determined to have either unlikely (grade of association=3) or inconclusive (grade of association=2) correlations. In addition, results were examined in light of the type of surgery undergone. This review is intended as a first step to develop an instrument for identifying patients at high risk for CPSP, to optimize clinical pain management.

Risk factors for back pain-related loss of working time after surgery for lumbar disc herniation: a 5-year follow-up study

The aim of this study is to explore the occurrence and the risk factors of back-related loss of working time in patients undergoing surgery for lumbar disc herniation. One hundred and fifty-two gainfully employed patients underwent surgery for lumbar disc herniation. Two months postoperatively, those patients completed a self-report questionnaire including queries on back and leg pain (VAS), functional capacity (Oswestry disability index--ODI, version 1.0), and motivation to work. After 5 years, lost working time was evaluated by means of a postal questionnaire about sick leave and disability pensions. The cumulative number of back pain-related days-off work was calculated for each patient. All 152 patients, 86 men and 66 women, were prescribed sick leave for the first 2 months. Thereafter, 80 (53%) of them reported back pain-related sick leave or early retirement. A permanent work disability pension due to back problems was awarded to 15 (10%) patients, 5 men (6%) and 10 women (15%). Median number of all work disability days per year was 11 (interquartile range [IQR] 9-37); it was 9 days (IQR 9-22) in patients with minimal disability (ODI score 0-20) at 2 months postoperatively and 67 days (IQR 9-352) in those with moderate or severe disability (ODI > 20; P < 0.001). The respective means were 61, 29, and 140 days/year. Multivariate analysis showed ODI > 20, leg pain, and poor motivation to work to be the risk factors for extension of work disability. Results of the present study show that after the lumbar disc surgery, poor outcome in questionnaire measures the physical functioning (ODI) and leg pain at 2 months postoperatively, as well as poor motivation to work, are associated with the loss of working time. Patients with unfavourable prognosis should be directed to rehabilitation before the loss of employment.

Health-related quality of life in patients after lumbar disc surgery: a longitudinal observational study

OBJECTIVES

Objectives of this study are (1) to compare health-related quality of life (HRQOL) of patients after lumbar disc surgery with reference data from the German general population; (2) to examine whether changes in HRQOL occur over time; (3) to investigate associations between HRQOL and socio-demographic and health-related factors.

METHODS

The study sample consisted at baseline of 189 patients who underwent lumbar disc surgery. Baseline assessment was carried out 1-4 days after surgery, the first follow-up 2 months, the second follow-up 6 months after surgery. HRQOL was assessed by means of the WHOQOL-BREF.

RESULTS

During follow-up, patients showed significant improvement in "physical well being" and "overall quality of life." However, it did not reach the level of the general population at any assessment point. There was also a slight improvement of "psychological well being." The domains "social relationships" and "environment" remained unchanged and showed persistently higher scores than the general population. Cohabitating was positively associated with QoL. Negatively associated were unemployment, part-time employment, desire for early retirement, higher intensity of pain and depression.

CONCLUSION

Supplementing physical rehabilitation by psychosocial interventions may help improve patients' HRQOL.

Predictors of surgical outcome and their assessment

The relatively high rate of failed back surgery has prompted the search for "risk factors" to predict the result of spinal surgery in a given individual. However, the literature reveals few unequivocal predictors and they often explain a relatively low proportion of variance in outcome. This suggests that we have a long way to go before being able to rest easily, having refused someone surgery on the basis of unfavourable baseline characteristics. The best recommendation is to ensure, firstly, that the indication for surgery is absolutely clear-cut (i.e. that surgically remediable pathology exists) and then to consider the various factors that may influence the "typical" outcome. Consistent risk factors for a poor outcome regarding return-to-work include long-term sick leave/receipt of disability benefit. Hence, every effort should be made to keep the individual in the workforce, despite the ongoing symptoms and plans for surgery. In patients with a particularly heavy job, consultation with occupational physicians might later ease the patient's way back into the workplace. Patients with degenerative disorders and/or comorbidity should be counselled that few of them will have complete/lasting pain relief or a complete return to pre-morbid function. Patients with a high level of distress may benefit from psychological treatment, before and/or accompanying the surgical treatment. The opportunity (time), encouragement (education and positive messages), and resources (referral to appropriate support services) to modify risk factors that are indeed modifiable should be offered, and realistic expectations should be discussed with the patient before the decision to operate is made.