Applying Shared Decision Making to Low Back Pain

Lumbar fusion surgery. Given that patients with chronic LBP have no significant neurological compression, laminectomy/diskectomy designed to decompress the nerves serves no role in surgical treatment. However, based on the idea that abnormal motion at the level of a degenerative disk is the source of pain, fusion aimed at eliminating the motion has arisen as the surgical procedure of choice.

Although several studies have evaluated the efficacy of fusion in this patient population, 3 high-quality studies have been most influential. In separate studies, Brox and Fairbank demonstrated a moderate improvement in pain and function after fusion. However, the results were similar to those for patients who were randomized to nonoperative CBT rehabilitation programs. Fritzell also found benefits to surgical intervention; surgical outcomes were superior to "usual" nonoperative care, but the study did not have a group undergoing CBT rehabilitation.

Disk replacement surgery. Several RCTs have compared outcomes of fusion and disk replacement surgery. There currently is no evidence to indicate that the outcomes with disk replacement are better than those with fusion; the risks/learning curves are higher, and the costs are higher. Accordingly, at this point there is just theory but no evidence to support the use of disk replacements in the lumbar spine.

SUMMARY: Fusion appears to afford better outcomes than usual care for patients with chronic LBP but similar outcomes to those achieved with intensive CBT. Because fusion is invasive, it should be reserved for patients who have no red flags and no or minimal yellow flags; have intolerable pain; have not succeeded with appropriate therapy; and have single-level, severe degenerative disk disease.

Regional variation and spine care revisited
Based on the fairly well-sized and high-quality evidence base outlined above, the following "logical plan" for the care of a patient with chronic LBP makes sense:

• Medications should be used sparingly and for the short term.
• Exercise, physical therapy, a light corset, and chiropractic may provide some relief.
• At some level,work should resume as soon as possible.
• Reassurance should be given that activities might cause some pain but no harm and, eventually, some benefit.
• Truly resistant cases of LBP should be referred for intensive CBT rehabilitation.
• Fusion might be considered as a last resort for a select group of patients.

However, although this logical plan has been recognized for the past decade or so, the most recent studies clearly demonstrate that regional variation in the care of patients with chronic LBP persists. Wennberg's theory that variation is the result of physician factors rather than an insufficient evidence base appears to be correct. Medication use (especially narcotic analgesics), injections (especially lumbar epidural injections and facet joint blocks), interventions (especially radiofrequency ablations and IDET procedures), and surgery (fusions and disk replacements) are being used and performed at ever-increasing rates despite the evidence, and which treatments the patients receive depends mostly on which physician they happen to see (just like with tonsillectomies in 1920).

Shared decision making revisited
How can we overcome such regional variation? How can we avoid putting our therapeutic personal preference stamp on our patients based solely on a broad diagnostic category or ICD-9 code? The answers appear to lie in recognizing the following:

• That not all of the patients who present with chronic LBP and degenerative disk disease are best served by fusion (or injection, or narcotic analgesics, etc) and accordingly, that individual patient and physician factors/preferences need to be weighed carefully and will have a great impact on patient outcomes.

• That the best way to facilitate such careful weighing is to provide unbiased presentation of the best available evidence on the patient's therapeutic options (personally or via use of accurate, up-to-date educational tools, including DVDs and online resources) and to listen carefully to the patient's expression of desires and expectations. This process may be one-on-one or, given common difficulties and the time commitment required to afford proper patient understanding, shared decision centers may be used. Then, a mutually decided plan of action may be put forth. Because the plan will be individualized, the problem of variation will be lessened. Also, the plan will be directed by the patient. Therefore, the modern ideals of autonomy and consumerism are allowed to trump the paternalistic and potentially profit-driven decisions of the past.