Editorial. Return to work after spine surgery: do patients or physicians make the decision?

Marjorie C. Wang Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin

Search for other papers by Marjorie C. Wang in
jns
Google Scholar
PubMed
Close
 MD, MPH
Free access

The concept of return to work/return to function after spine surgery could be considered the ultimate patient-centered outcome. Return to work and related outcomes, such as absenteeism and ability to work full-time, continue to garner significant attention not only from patients and employers, but also from key stakeholders such as employer-based insurance organizations and funding agencies. However, questions remain as to whether return to work represents a patient-driven metric versus an outcome most strongly influenced by other factors such as physician recommendations.

Singh et al.1 evaluated return to work after elective lumbar spine surgery using the Canadian Spine Outcomes and Research Network (CSORN) registry. They performed a retrospective review of data collected from neurosurgical and orthopedic spine surgeons practicing in 19 centers across Canada. The study cohort was restricted to adult employed patients who underwent nonrevision elective 1- or 2-level lumbar surgery (discectomy, laminectomy, and/or fusion) for degenerative conditions and had a 2-year follow-up. The primary outcome was the number of postoperative days before the patient resumed work, and the secondary outcome was the proportion of patients who returned to work within 90 days. Patient and surgical characteristics were further evaluated to determine their association with the outcomes using multivariable modeling. Although characteristics were introduced in “clusters,” the independent variables were analyzed separately (i.e., not as a “cluster” of variables), and the authors state that their data set did not support further analysis of differences between hospitals or surgeons, such as in a linear mixed model.

The authors found the overall median time to return to work was 61 days, and 71% of the cohort returned to work within 2 years after surgery. Subanalysis revealed significant differences between patients who were working before surgery and those who were employed but not working before surgery, with 81% of the working cohort returning to work compared to 49% of the nonworking but employed cohort. Another factor related to return to work was the type of surgery performed. Interestingly, 76%–77% of laminectomy and discectomy patients returned to work and the median return to work time was 46 and 51 days, respectively, compared to 62% of fusion patients and a median of 90 days. Education level was associated with the independent variable of type of surgery as well as the outcomes of return to work in less than 90 days and within 2 years.

Return to work in less than 90 days was defined as “early” return to work mainly because of the low numbers of patients who returned to work at 30 or 60 days, which limited the analysis. Factors predictive of return to work in less than 90 days included male sex, higher education, better physical function, working preoperatively, nonfusion surgery, and geographic province in which the surgery was performed. In analyzing factors predictive of not returning to work within 2 years, the authors found a significant association with lower education level, longer symptom duration, greater number of comorbid conditions, and active workers’ compensation claim.

These study findings are similar to those in several prior publications. Huysmans et al.,2 in their systematic review of patients undergoing surgery for lumbar radiculopathy, found that preoperative work status, presence of comorbidities, age, sex, and duration of preoperative symptoms were the most important predictors of return to work. A wide variation in return to work was noted, even within groups having similar types of surgical procedures (3% to 100% in 0.1 to 240 months after surgery). Using the Quality Outcomes Database, Asher et al.3 found that 82% of patients returned to work within 3 months of elective surgery for degenerative lumbar conditions. Patients were less likely to return to work if they were not working but employed before surgery or if they had a lower level of education, a manual labor occupation, workmans’ compensation or liability insurance for disability, and worse function (higher ODI or numeric rating scale score for back pain). Demographic factors such as sex, race, and comorbid conditions were additional predictive factors. Using this same database, Khan et al.4 reported that postoperative ODI and adverse events were also associated with return to work along with the factors listed by Asher et al.3

Is return to work a patient-driven metric? The authors note that patient expectations may play a major role in the decision to return to work. While prior studies have shown a relationship between type of work and return to work, this information was not available in the CSORN registry. The associations among education, type of surgery, and return to work in this study1 also raise suspicion that the relationship among these variables is multifactorial. Types of work that could accommodate light duty or part-time options might allow for earlier return to work. Socioeconomic factors, such as a dual income household or amount/length of compensation while employed but not working, might also allow for variable thresholds for patients to return to work. As the authors also noted, labor laws and employee regulations may differ, and this may influence both return to work and the decision of the patient to stop working before surgery.

Another major concern regarding the current and prior studies is the lack of information about surgeon characteristics and postoperative protocols. Who makes the decision that a patient cannot work before surgery or that a patient is ready to return to work? While the current study is limited to an analysis of variables that are available in the database, this limitation should not lead us to conclude that the available variables are causative for the measured outcome. Provider practices likely vary for return to work recommendations, use of collars and braces, and opioid prescribing patterns. Postoperative orthosis use varies widely5,6 and has a limited evidence base,7 and orthosis use may limit driving or the ability to function at work. Data about the use and duration of opioids after surgery was not measured in this study and could also play a major role in the ability to drive and return to work.

One of the most significant predictors of return to work may be provider recommendations.8 As the authors point out, there is no generally accepted consensus about the “right” time to return to work. One study by Carragee et al.9 evaluated 50 patients who were given no postoperative restrictions after lumbar discectomy surgery. Patients had a minimum 2-year follow-up, and no early reherniations or return to sick leave statuses were reported. There remains a lack of research in this area, with published recommendations for activity limitations and time off from work dating back many years.10 Patients may also seek information from friends and family as well as from the internet. A quick internet search for “when can you return to work after spine surgery” revealed these recommendations from MyHealthAlberta: “Avoid strenuous activities, such as bicycle riding, jogging, weightlifting, or aerobic exercise, until your doctor says it is okay. Do not drive for 2 to 4 weeks after your surgery or until your doctor says it is okay. Avoid riding in a car for more than 30 minutes at a time for 2 to 4 weeks after surgery.”11 After lumbar discectomy, HealthLink BC provides the following recommendations: “If you work in an office, you may go back to work in 2 to 4 weeks. If your job requires physical labour (such as lifting or operating machinery that vibrates) you may be able to go back to work 4 to 8 weeks after surgery.”12 Singh et al.1 discuss variations in recommendations for time off from work after discectomies, citing a prior Canadian survey showing that the majority of surgeons recommend 6 weeks off from work. Therefore, it would seem that these study findings support patients following their doctor’s orders.

In summary, Singh et al.1 add to the existing literature in highlighting return to work as a measure of outcome after spine surgery and further supporting the evidence base about patient and surgical characteristics associated with this metric. However, this study also shows that time to return to work appears to correlate with what physicians are recommending for time off from work. Is return to work a self-fulfilling prophecy in that patients follow doctors’ orders? Further study should focus on physician practice patterns and social media and other sources of information that likely influence return to work and patient expectations. Return to work should not be attributed entirely to patient and surgical characteristics without further study of these potentially modifiable practice patterns.

Disclosures

The author reports no conflict of interest.

References

  • 1

    Singh S, Ailon T, McIntosh G, et al. Time to return to work after elective lumbar spine surgery. J Neurosurg. Published online September 24, 2021. doi:10.3171/2021.2.SPINE202051

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Huysmans E, Goudman L, Van Belleghem G, et al. Return to work following surgery for lumbar radiculopathy: a systematic review. Spine J. 2018;18(9):16941714.

  • 3

    Asher AL, Devin CJ, Archer KR, et al. An analysis from the Quality Outcomes Database, Part 2. Predictive model for return to work after elective surgery for lumbar degenerative disease. J Neurosurg Spine. 2017;27(4):370381.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Khan I, Bydon M, Archer KR, et al. Impact of occupational characteristics on return to work for employed patients after elective lumbar spine surgery. Spine J. 2019;19(12):19691976.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Bogaert L, Van Wambeke P, Thys T, et al. Postoperative bracing after lumbar surgery: a survey amongst spinal surgeons in Belgium. Eur Spine J. 2019;28(2):442449.

  • 6

    Bible JE, Biswas D, Whang PG, et al. Postoperative bracing after spine surgery for degenerative conditions: a questionnaire study. Spine J. 2009;9(4):309316.

  • 7

    Nasi D, Dobran M, Pavesi G. The efficacy of postoperative bracing after spine surgery for lumbar degenerative diseases: a systematic review. Eur Spine J. 2020;29(2):321331.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Claréus B, Renström EA. Patients’ return-to-work expectancy relates to their beliefs about their physician’s opinion regarding return to work volition and ability. J Pain Res. 2019;12:353362.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Carragee EJ, Helms E, O’Sullivan GS. Are postoperative activity restrictions necessary after posterior lumbar discectomy? A prospective study of outcomes in 50 consecutive cases. Spine (Phila Pa 1976).1996;21(16):18931897.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Weber H. Lumbar disc herniation. A controlled, prospective study with ten years of observation. Spine (Phila Pa 1976).1983;8(2):131140.

  • 11

    Lumbar spinal fusion: what to expect at home. MyHealth.Alberta.ca. March 2, 2020. Accessed May 14, 2021.https://myhealth.alberta.ca/Health/aftercareinformation/pages/conditions.aspx?hwid=zx4099

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Discectomy or microdiscectomy for a lumbar herniated disc. HealthLinkBC. June 26, 2019. Accessed May 14, 2021.https://www.healthlinkbc.ca/health-topics/hw218424

    • PubMed
    • Search Google Scholar
    • Export Citation
Supriya Singh Combined Neurosurgical and Orthopedic Spine Service, Department of Orthopedic Surgery, University of British Columbia, Vancouver, British Columbia, Canada

Search for other papers by Supriya Singh in
jns
Google Scholar
PubMed
Close
 MD, MSc, FRCSC
and
Raphaële Charest-Morin Combined Neurosurgical and Orthopedic Spine Service, Department of Orthopedic Surgery, University of British Columbia, Vancouver, British Columbia, Canada

Search for other papers by Raphaële Charest-Morin in
jns
Google Scholar
PubMed
Close
 MD, FRCSC

Response

The editorial written by Dr. Wang nicely summarizes our study as well as the existing literature in the area of postoperative return to work (RTW) in spine surgery. Our specific objectives were to examine time to RTW after elective lumbar spine surgery and determinants of early RTW and failure to RTW at 2 years in a multicentric Canadian population. There are likely a whole host of factors that contribute to RTW after spine surgery, and our study tried to narrow the patient population to eliminate complicating factors that are known to affect RTW—complex revision surgery, trauma cases, spinal cord injuries/neurological injuries, patients on disability, etc.—because of the nature of the surgical intervention as well as the protracted postoperative course.

RTW is multifactorial in nature. The type and nature of surgery, patient factors, and specific work characteristics, as well as patient and physician expectations, may influence RTW. Our study reviews in a retrospective light the patient factors and surgical factors that play a role in RTW. For 1- to 2-level elective lumbar spine surgery, RTW occurred at a rate of 71% and most patients undergoing nonfusion surgery returned to work after 6–8 weeks. In our analysis of data from our national spine surgical registry, predictors of early RTW included male gender, actively working up until the surgery, a higher level of education, a nonfusion procedure as well as a higher preoperative Physical Component Summary score. Predictors of not returning to work included not working preoperatively, symptoms lasting longer than 2 years, multiple comorbidities, a lower education level, and an active workers’ compensation claim.

As pointed out by Dr. Wang, there are still knowledge gaps in our understanding of RTW after spine surgery. Physicians’ recommendations and patients’ expectations with respect to their RTW are not captured in our national registry but are likely to play a significant role. Although there is no literature that has specifically explored patients’ expectations about their RTW, there is a growing body of literature about patient expectations and spine surgery. It has been demonstrated that, overall, patients’ expectations are overly optimistic with respect to pain improvement and general function.1–10 It has been postulated that a discrepancy between expectations and the actual results predicts dissatisfaction.11 Hence, setting appropriate expectations is crucial.

Physicians need to set appropriate expectations about RTW when discussing and obtaining patient consent for surgery. Unfortunately, there is a lack of known standardization of postoperative recovery protocols. According to a Canadian survey, most spine surgeons recommend RTW around 6 weeks for a discectomy.12 However, this is not considering other factors that affect a surgeon’s recommendation, such as the type of work the patient is returning to, the physical nature of the work, how well the patient’s pain is controlled, and if they are on narcotic medications that may influence their ability to RTW. Although no specific standardization exists to our knowledge, we are investigating current Canadian practice patterns and surgeon recommendations based on patient and work factors. The objectives are to better delineate the role of work type and workload on RTW for this same patient population to further contribute to our understanding of factors contributing to RTW after surgery.

Lastly, despite all best efforts, certain factors likely affecting RTW remain elusive. Some factors are difficult to capture such as work environment, emotional fulfillment of employment, work flexibility, etc. In conclusion, RTW is influenced by a number of factors, including socioeconomic factors, patient and surgical factors, and work type. This study is adding to the body of literature about patient and surgical factors contributing to postoperative RTW. Recognizing the importance of patient expectations, using our national network, we are currently acquiring data about surgeon recommendations and their influence on RTW.

References

  • 1

    Lattig F, Fekete TF, O’Riordan D, et al. A comparison of patient and surgeon preoperative expectations of spinal surgery. Spine (Phila Pa 1976).2013;38(12):10401048.

  • 2

    Licina P, Johnston M, Ewing L, Pearcy M. Patient expectations, outcomes and satisfaction: related, relevant or redundant?. Evid Based Spine Care J. 2012;3(4):1319.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Mancuso CA, Duculan R, Stal M, Girardi FP. Patients’ expectations of lumbar spine surgery. Eur Spine J. 2015;24(11):23622369.

  • 4

    Mancuso CA, Duculan R, Cammisa FP, et al. Fulfillment of patients’ expectations of lumbar and cervical spine surgery. Spine J. 2016;16(10):11671174.

  • 5

    Mancuso CA, Reid MC, Duculan R, Girardi FP. Improvement in pain after lumbar spine surgery: the role of preoperative expectations of pain relief. Clin J Pain. 2017;33(2):9398.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Mannion AF, Junge A, Elfering A, et al. Great expectations: really the novel predictor of outcome after spinal surgery? Spine. (Phila Pa 1976).2009;34(15):15901599.

  • 7

    Soroceanu A, Ching A, Abdu W, McGuire K. Relationship between preoperative expectations, satisfaction, and functional outcomes in patients undergoing lumbar and cervical spine surgery: a multicenter study. Spine (Phila Pa 1976).2012;37(2):E103E108.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Toyone T, Tanaka T, Kato D, et al. Patients’ expectations and satisfaction in lumbar spine surgery. Spine (Phila Pa 1976).2005;30(23):26892694.

  • 9

    van der Horst AY, Trompetter HR, Pakvis DFM, et al. Between hope and fear: a qualitative study on perioperative experiences and coping of patients after lumbar fusion surgery. Int J Orthop Trauma Nurs. 2019;35:100707.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Yee A, Adjei N, Do J, et al. Do patient expectations of spinal surgery relate to functional outcome?. Clin Orthop Relat Res. 2008;466(5):11541161.

  • 11

    Canizares M, Gleenie RA, Perruccio AV, et al. Patients’ expectations of spine surgery for degenerative conditions: results from the Canadian Spine Outcomes and Research Network (CSORN). Spine 2020;20(3):399408.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Cenic A, Kachur E. Lumbar discectomy: a national survey of neurosurgeons and literature review. Can J Neurol Sci. 2009;36(2):196200.

  • Collapse
  • Expand

Illustrations from Sugawara et al. (pp 185–192). Copyright Taku Sugawara. Published with permission.

  • 1

    Singh S, Ailon T, McIntosh G, et al. Time to return to work after elective lumbar spine surgery. J Neurosurg. Published online September 24, 2021. doi:10.3171/2021.2.SPINE202051

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Huysmans E, Goudman L, Van Belleghem G, et al. Return to work following surgery for lumbar radiculopathy: a systematic review. Spine J. 2018;18(9):16941714.

  • 3

    Asher AL, Devin CJ, Archer KR, et al. An analysis from the Quality Outcomes Database, Part 2. Predictive model for return to work after elective surgery for lumbar degenerative disease. J Neurosurg Spine. 2017;27(4):370381.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Khan I, Bydon M, Archer KR, et al. Impact of occupational characteristics on return to work for employed patients after elective lumbar spine surgery. Spine J. 2019;19(12):19691976.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Bogaert L, Van Wambeke P, Thys T, et al. Postoperative bracing after lumbar surgery: a survey amongst spinal surgeons in Belgium. Eur Spine J. 2019;28(2):442449.

  • 6

    Bible JE, Biswas D, Whang PG, et al. Postoperative bracing after spine surgery for degenerative conditions: a questionnaire study. Spine J. 2009;9(4):309316.

  • 7

    Nasi D, Dobran M, Pavesi G. The efficacy of postoperative bracing after spine surgery for lumbar degenerative diseases: a systematic review. Eur Spine J. 2020;29(2):321331.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Claréus B, Renström EA. Patients’ return-to-work expectancy relates to their beliefs about their physician’s opinion regarding return to work volition and ability. J Pain Res. 2019;12:353362.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Carragee EJ, Helms E, O’Sullivan GS. Are postoperative activity restrictions necessary after posterior lumbar discectomy? A prospective study of outcomes in 50 consecutive cases. Spine (Phila Pa 1976).1996;21(16):18931897.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Weber H. Lumbar disc herniation. A controlled, prospective study with ten years of observation. Spine (Phila Pa 1976).1983;8(2):131140.

  • 11

    Lumbar spinal fusion: what to expect at home. MyHealth.Alberta.ca. March 2, 2020. Accessed May 14, 2021.https://myhealth.alberta.ca/Health/aftercareinformation/pages/conditions.aspx?hwid=zx4099

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Discectomy or microdiscectomy for a lumbar herniated disc. HealthLinkBC. June 26, 2019. Accessed May 14, 2021.https://www.healthlinkbc.ca/health-topics/hw218424

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 1

    Lattig F, Fekete TF, O’Riordan D, et al. A comparison of patient and surgeon preoperative expectations of spinal surgery. Spine (Phila Pa 1976).2013;38(12):10401048.

  • 2

    Licina P, Johnston M, Ewing L, Pearcy M. Patient expectations, outcomes and satisfaction: related, relevant or redundant?. Evid Based Spine Care J. 2012;3(4):1319.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Mancuso CA, Duculan R, Stal M, Girardi FP. Patients’ expectations of lumbar spine surgery. Eur Spine J. 2015;24(11):23622369.

  • 4

    Mancuso CA, Duculan R, Cammisa FP, et al. Fulfillment of patients’ expectations of lumbar and cervical spine surgery. Spine J. 2016;16(10):11671174.

  • 5

    Mancuso CA, Reid MC, Duculan R, Girardi FP. Improvement in pain after lumbar spine surgery: the role of preoperative expectations of pain relief. Clin J Pain. 2017;33(2):9398.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Mannion AF, Junge A, Elfering A, et al. Great expectations: really the novel predictor of outcome after spinal surgery? Spine. (Phila Pa 1976).2009;34(15):15901599.

  • 7

    Soroceanu A, Ching A, Abdu W, McGuire K. Relationship between preoperative expectations, satisfaction, and functional outcomes in patients undergoing lumbar and cervical spine surgery: a multicenter study. Spine (Phila Pa 1976).2012;37(2):E103E108.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Toyone T, Tanaka T, Kato D, et al. Patients’ expectations and satisfaction in lumbar spine surgery. Spine (Phila Pa 1976).2005;30(23):26892694.

  • 9

    van der Horst AY, Trompetter HR, Pakvis DFM, et al. Between hope and fear: a qualitative study on perioperative experiences and coping of patients after lumbar fusion surgery. Int J Orthop Trauma Nurs. 2019;35:100707.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Yee A, Adjei N, Do J, et al. Do patient expectations of spinal surgery relate to functional outcome?. Clin Orthop Relat Res. 2008;466(5):11541161.

  • 11

    Canizares M, Gleenie RA, Perruccio AV, et al. Patients’ expectations of spine surgery for degenerative conditions: results from the Canadian Spine Outcomes and Research Network (CSORN). Spine 2020;20(3):399408.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Cenic A, Kachur E. Lumbar discectomy: a national survey of neurosurgeons and literature review. Can J Neurol Sci. 2009;36(2):196200.

Metrics

All Time Past Year Past 30 Days
Abstract Views 779 0 0
Full Text Views 1518 735 56
PDF Downloads 1134 514 27
EPUB Downloads 0 0 0