Effect of workers’ compensation status on pain, disability, quality of life, and return to work after lumbar spine surgery: a 1-year propensity-matched analysis

Ummey Hani Department of Neurosurgery, Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina;
SpineFirst, Charlotte, North Carolina; and

Search for other papers by Ummey Hani in
jns
Google Scholar
PubMed
Close
 MBBS
,
Steve H. Monk Department of Neurosurgery, Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina;
SpineFirst, Charlotte, North Carolina; and

Search for other papers by Steve H. Monk in
jns
Google Scholar
PubMed
Close
 MD
,
Deborah Pfortmiller Department of Neurosurgery, Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina;
SpineFirst, Charlotte, North Carolina; and

Search for other papers by Deborah Pfortmiller in
jns
Google Scholar
PubMed
Close
 PhD, MA
,
Gerry Stanley Harvard MedTech, Las Vegas, Nevada

Search for other papers by Gerry Stanley in
jns
Google Scholar
PubMed
Close
 MD
,
Paul K. Kim Department of Neurosurgery, Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina;
SpineFirst, Charlotte, North Carolina; and

Search for other papers by Paul K. Kim in
jns
Google Scholar
PubMed
Close
 MD
,
Michael A. Bohl Department of Neurosurgery, Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina;
SpineFirst, Charlotte, North Carolina; and

Search for other papers by Michael A. Bohl in
jns
Google Scholar
PubMed
Close
 MD
,
Christopher M. Holland Department of Neurosurgery, Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina;
SpineFirst, Charlotte, North Carolina; and

Search for other papers by Christopher M. Holland in
jns
Google Scholar
PubMed
Close
 MD, PhD
, and
Matthew J. McGirt Department of Neurosurgery, Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina;
SpineFirst, Charlotte, North Carolina; and

Search for other papers by Matthew J. McGirt in
jns
Google Scholar
PubMed
Close
 MD
Free access

OBJECTIVE

Workers’ compensation (WC) and litigation have been shown to adversely impact prognoses in a vast range of health conditions. Low-back pain is currently the most frequent reason for WC claims. The objective of this study was to conduct the largest propensity-matched comparison of outcomes between patients with WC and non-WC status who underwent lumbar spinal decompression with and without fusion.

METHODS

Complete data sets for patients who underwent 1- to 4-level lumbar spinal fusion or decompression alone were retrospectively retrieved from the Quality Outcomes Database (QOD), which included 1-year patient-reported outcomes from more than 200 hospital systems collected from 2012 to 2021. Population demographics, perioperative safety, facility utilization, patient satisfaction, disability, pain, EQ-5D quality of life, and return to work (RTW) rates were compared between cohorts for both subgroups. Statistical significance was set at p < 0.05.

RESULTS

There were 29,652 patients included in the study. Laminectomy was performed in 16,939 with non-WC status and in 615 with WC, whereas fusion was performed in 11,767 with non-WC status and in 331 with WC. WC patients were more frequently male, a minority race, younger, less educated, more frequently a smoker, had a healthier American Society of Anesthesiologists grade, and with greater baseline visual analog scale (VAS) and Oswestry Disability Index (ODI) scores (p < 0.001). One-year postoperative improvements in VAS, ODI, quality-adjusted life years (QALYs), RTW rates, and satisfaction were all significantly worse for WC versus non-WC patients for both procedures. After adjusting for baseline differences via propensity matching, WC versus non-WC patients continued to demonstrate worse 3- and 12-month VAS and ODI scores, reduced 12-month QALY gain, and delayed RTW after both procedure types.

CONCLUSIONS

WC status was associated with significantly greater residual disability and pain postoperatively, a lower quality of life, and delayed RTW. Utilizing resources to identify the negative influences on outcomes for WC patients may be valuable in preoperative optimization and could yield better outcomes in these patients.

ABBREVIATIONS

ASA = American Society of Anesthesiologists; EBL = estimated blood loss; HRQOL = health-related quality of life; LBP = low-back pain; LOS = length of stay; ODI = Oswestry Disability Index; PRO = patient-reported outcome; PROM = PRO measure; QALY = quality-adjusted life year; QOD = Quality Outcomes Database; RTW = return to work; VAS = visual analog scale; WC = workers’ compensation.

OBJECTIVE

Workers’ compensation (WC) and litigation have been shown to adversely impact prognoses in a vast range of health conditions. Low-back pain is currently the most frequent reason for WC claims. The objective of this study was to conduct the largest propensity-matched comparison of outcomes between patients with WC and non-WC status who underwent lumbar spinal decompression with and without fusion.

METHODS

Complete data sets for patients who underwent 1- to 4-level lumbar spinal fusion or decompression alone were retrospectively retrieved from the Quality Outcomes Database (QOD), which included 1-year patient-reported outcomes from more than 200 hospital systems collected from 2012 to 2021. Population demographics, perioperative safety, facility utilization, patient satisfaction, disability, pain, EQ-5D quality of life, and return to work (RTW) rates were compared between cohorts for both subgroups. Statistical significance was set at p < 0.05.

RESULTS

There were 29,652 patients included in the study. Laminectomy was performed in 16,939 with non-WC status and in 615 with WC, whereas fusion was performed in 11,767 with non-WC status and in 331 with WC. WC patients were more frequently male, a minority race, younger, less educated, more frequently a smoker, had a healthier American Society of Anesthesiologists grade, and with greater baseline visual analog scale (VAS) and Oswestry Disability Index (ODI) scores (p < 0.001). One-year postoperative improvements in VAS, ODI, quality-adjusted life years (QALYs), RTW rates, and satisfaction were all significantly worse for WC versus non-WC patients for both procedures. After adjusting for baseline differences via propensity matching, WC versus non-WC patients continued to demonstrate worse 3- and 12-month VAS and ODI scores, reduced 12-month QALY gain, and delayed RTW after both procedure types.

CONCLUSIONS

WC status was associated with significantly greater residual disability and pain postoperatively, a lower quality of life, and delayed RTW. Utilizing resources to identify the negative influences on outcomes for WC patients may be valuable in preoperative optimization and could yield better outcomes in these patients.

In Brief

The authors conducted a study to compare clinical and patient-reported outcomes between patients who underwent lumbar spine surgery with and without workers' compensation (WC) status. The results showed significantly worse postoperative pain, disability, and quality of life, as well as delayed return to work, in patients receiving WC. The study adds value by generating discussion among peers to analyze reasons for the increased correlation between adverse outcomes and compensation status, as well as generating ideas to equalize outcomes between both groups.

Low-back pain (LBP) is a leading cause of global disability that accounts for one-third of all workers’ compensation (WC) claims and 40% of lost work days.13 It is characterized by a range of biopsychosocial dimensions that impair function, societal participation, and personal financial prosperity.4 The economic impact of LBP is subsequently experienced at a societal level where it is responsible for a disproportionate consumption of the overall healthcare expenditure in the US as well as straining the gross domestic product through lost wages and reduced work productivity.3,5,6 Multiple studies have demonstrated lumbar decompression with or without fusion to be effective for medically refractory LBP with or without radiculopathy. However, several factors, including WC claims and claimant behavior, have been shown to affect outcomes after surgery.

Compensation policies provide temporary aid in the form of full or partial wage replacement and healthcare services to patients with work-related injuries or occupational diseases.2,7 But treatment for a vast range of health conditions, including orthopedic procedures, has demonstrated inferior clinical outcomes in WC populations.810 The reasons can be multifactorial, suggesting a combination of injury severity, socioeconomic factors, and biopsychosocial profiles that may include secondary gains such as exacerbated illness behavior promoting disability payments.1113 Heterogeneous results have been reported following spine surgery, demonstrating a controversial impact of WC claims on outcomes.11,14,15

Few studies have analyzed the impact of WC on outcomes following lumbar spine surgery. Most studies range from small case series to comparative effectiveness studies between unmatched groups. In this study, we conducted the largest analysis and first propensity-matched comparison of outcomes between WC and non-WC patients undergoing lumbar spine decompression, with or without fusion.

Methods

Study Cohort and Design

We performed a retrospective cohort analysis comparing outcomes in patients with WC and non-WC status who underwent 1- to 4-level lumbar fusion or decompression alone for lumbar degenerative disc disease causing LBP, with or without radiculopathy. A complete data set of 29,652 patients prospectively enrolled in the Quality Outcomes Database (QOD)16 undergoing 1- to 4-level lumbar spine surgery was reviewed. The QOD includes 1-year patient reported outcomes (PROs) from more than 200 hospital systems in the US over a 10-year period (2012–2021). All patients with a preoperative American Society of Anesthesiologists (ASA) class I, II, III, or IV were included. Patients were excluded if they had undergone a previous lumbar surgery at the same level, had an extraspinal cause of back and/or leg pain, had a preexisting spinal neoplasm, or had incomplete follow-up data. Propensity score–matched analysis was performed to control for selection bias in both subsets (lumbar decompression alone and lumbar fusion) to generate parity between WC and non-WC cohorts. Propensity-score matching allows the analysis of an observational, nonrandomized study to reduce the effects of confounding variables. The analysis looks for matched sets of subjects within each cohort with similar propensity scores. In this analysis, propensity scores were estimated using a logistic regression model. The baseline variables used in the fitted regression model were age, BMI, gender, race, education, smoking status, diabetes, ASA class, preoperative back pain, preoperative leg pain, preoperative Oswestry Disability Index (ODI), and preoperative EQ-5D. Approval was obtained from the Atrium Health IRB in collaboration with SpineFirst and Carolina Neurosurgery & Spine Associates.

Demographic and Clinical Data

Demographic data, comorbidities, and relevant clinical information were collected for all patients. Perioperative safety and healthcare utilization data, discharge disposition, hospital readmissions, and reoperation rates during the 90-day Medicare global period were prospectively collected. Analyses were performed post hoc.

Patient-Reported Outcome Measures

PRO measures (PROMs) were prospectively recorded in the data set via patient-assessed questionnaires administered by full-time research employees through email or interviews preoperatively, at 3 months, and at 1-year follow-up evaluations. These PROMs included the visual analog scale (VAS) for back and leg pain,17 the ODI to assess disability,18 self-reported postoperative satisfaction, and the EQ-5D for quality of life. The EQ-5D is a valid, reliable, and commonly used 5-question preference-based instrument that measures health-related quality of life (HRQOL) in the form of a global index value (0 = death, 1 = perfect health).19 Cumulative improvement on the EQ-5D over the 1-year follow-up period provided an estimate of quality-adjusted life years (QALYs) gained for each treatment group.

Statistical Analysis

All statistical analyses were performed using SPSS (version 29, IBM Corp.). Univariable parametric data are provided as means ± standard deviations and nonparametric data are provided as percentages. Bivariate analyses were conducted using independent t-tests, paired t-tests, and chi-square tests. The statistical significance level was set at p < 0.050.

Results

Total Cohort

Table 1 displays the full population demographics with bivariable comparison results between the WC and non-WC cohorts. For decompression alone, 17,554 (16,939 non-WC and 615 WC) patients met the inclusion criteria. Numerous significant differences existed between groups. The WC cohort was younger (mean age 48 ± 12.2 vs 59 ± 15.0 years, p < 0.001) and more overweight (mean BMI 31.06 ± 6.1 vs 30.35 ± 6.2, p = 0.005). It included more males (74.1% vs 57.5%, p < 0.001) and Black patients (13.5% vs 5.8%, p < 0.001). Patients in the WC cohort were less likely to have a college or postgraduate education (p < 0.001) and were more likely to be employed (86.8% vs 49.8%, p < 0.001). Multiple comorbidities such as diabetes and osteoporosis were significantly less frequent in the WC cohort (p < 0.001). However, more patients in the WC cohort (30.7% vs 15.8%, p < 0.001) were smokers. While back pain was the more common complaint in the WC group (82.9% vs 75.7%, p < 0.001), patients in this group were healthier, with lower ASA classes (1–2 vs higher classes in the non-WC group, p < 0.001) and generally required 1- to 2-level decompression instead of 3 or 4 levels (p = 0.002).

TABLE 1.

Patient population baseline demographics and clinical history

VariableDecompression AloneFusion
Non-WCWCt/χ2 valuep ValueNon-WCWCt/χ2 valuep Value
No. of patients16,93961511,767331
Demographics
 Mean age ± SD, yrs59 ± 15.048 ± 12.2t = 22.15<0.00163 ± 11.552 ± 10.916.85<0.001
 Mean BMI ± SD30.35 ± 6.231.06 ± 6.1t = −2.80 0.00530.79 ± 6.231.18 ± 6.0−1.14 0.253
 Male, %57.574.1χ2 = 67.8 <0.00144.462.8χ2 = 44.02 <0.001
 Race, %
  White91.783.3χ2 = 63.40 <0.00191.584.9χ2 = 18.19 <0.001
  Black5.813.56.211.5
  Other2.53.32.33.6
 Hispanic/Latino, %2.03.1χ2 = 3.45 0.0632.13.4χ2 = 2.75 0.097
 Education, %
  ≤HS grad/GED44.962.6χ2 = 96.86 <0.00148.457.4χ2 = 24.90 <0.001
  2–4 yrs college38.732.737.637.8
  Post-college16.44.714.04.8
 Employed49.886.8χ2 = 325.45 <0.00139.063.1χ2 = 78.72 <0.001
Comorbidities, %
 Smoker15.830.7χ2 = 97.64 <0.00112.123.6χ2 = 39.07 <0.001
 Diabetes18.812.5χ2 = 15.64 <0.00120.010.9χ2 = 17.00 <0.001
 Depression18.817.2χ2 = 0.94 0.33324.019.0χ2 = 4.38 0.036
 Anxiety16.414.5χ2 = 1.58 0.20918.416.9χ2 = 0.46 0.497
 Osteoporosis3.81.3χ2 = 10.18 0.0016.62.1χ2 = 10.59 0.001
Clinical history, %
 Back pain75.782.9χ2 = 16.82 <0.00187.492.1χ2 = 6.71 0.010
 Leg pain86.287.6χ2 = 1.08 0.29977.777.3χ2 = 0.03 0.874
 ASA class
  17.611.4χ2 = 67.46 <0.0012.33.3χ2 = 24.22 <0.001
  254.366.348.661.0
  337.222.047.835.0
  41.00.31.40.6
 Decompression levels
  152.256.9χ2 = 15.04 0.00255.357.1χ2 = 7.20 0.066
  234.234.531.334.4
  310.57.510.76.6
  43.11.12.81.8
Preop PROMs
 Mean ODI ± SD46.57 ± 17.353.92 ± 15.9t = −10.40<0.00147.85 ± 15.356.36 ± 13.3t = −11.44 <0.001
 Mean EQ-5D QALY index ± SD0.5494 ± 0.20.4779 ± 0.2t = 8.01 <0.0010.5445 ± 0.20.4603 ± 0.2t = 7.22 <0.001
 Mean VAS back pain ± SD6.21 ± 2.96.96 ± 2.3t = −7.92 <0.0016.95 ± 2.57.49 ± 2.0t = −4.91 <0.001
 Mean VAS leg pain ± SD6.87 ± 2.77.08 ± 2.3t = −2.20 0.0286.60 ± 2.86.73 ± 2.7t = −0.87 0.383

GED = General Educational Development; HS = high school.

Boldface type indicates statistical significance.

Similar observations were made for the fusion group, in which 12,098 (11,767 non-WC and 331 WC) patients met the inclusion criteria. The WC cohort was younger (mean age 52 ± 10.9 vs 63 ± 11.5 years, p < 0.001) and included more males (62.8% vs 44.4%, p < 0.001) and Black patients (11.5% vs 6.2%, p < 0.001). Patients in the WC cohort were less likely to have a postgraduate education (4.8% vs 14%, p < 0.001) and were more likely to be employed (63.1% vs 39.0%, p < 0.001). Multiple comorbidities such as diabetes and osteoporosis were significantly less frequent in the WC cohort (p < 0.001). Significantly more people in the non-WC group were depressed (24% vs 19%, p = 0.036); however, more patients in the WC cohort (23.6% vs 12.1%, p < 0.001) were smokers. While back pain was the more common complaint in the WC group (92.1% vs 87.4%, p = 0.010), patients in this group were healthier, with lower ASA classes (1–2 vs higher classes in the non-WC group, p < 0.001).

Matched Cohort

Table 2 displays the propensity-matched population demographics with bivariable comparison results between the WC and non-WC cohorts. For the subset that underwent decompression alone, propensity matching yielded 561 pairs of WC and non-WC patients. For the lumbar fusion subset, the data were propensity matched to create 331 pairs for both cohorts. All significant differences except employment status between the WC and non-WC groups were controlled for and negated in the matched population: 86.8% vs 64.7% (p < 0.001) and 63.1% vs 52.3% (p = 0.005) patients in the WC versus non-WC groups were employed in the laminectomy and fusion groups, respectively.

TABLE 2.

Baseline demographics and clinical history of the propensity-matched patient population

VariableDecompression AloneFusion
Non-WCWCt/χ2 valuep ValueNon-WCWCt/χ2 valuep Value
No. of patients561561331331
Demographics
Mean age ± SD, yrs46 ± 13.747 ± 12.2t = −1.32 0.18651 ± 12.552 ± 10.9t = −0.85 0.339
Mean BMI ± SD31.02 ± 6.530.89 ± 6.00.35 0.72731.26 ± 6.131.18 ± 6.0t = 0.18 0.858
Male, %73.874.5χ2 = 0.07 0.78559.562.8χ2 = 0.77 0.380
Race, %
 White87.385.2χ2 = 3.89 0.14386.184.9χ2 = 0.70 0.706
 Black8.611.89.711.5
 Other4.13.04.23.6
Hispanic/Latino, %2.73.1χ2 = 0.14 0.7124.03.4χ2 = 0.17 0.683
Education, %
 ≤HS grad/GED62.263.6χ2 = 0.44 0.80152.357.4χ2 = 4.17 0.124
 2–4 yrs college33.531.739.337.8
 Post-college4.34.68.54.8
Employed, %64.786.8χ2 = 74.62 <0.00152.363.1χ2 = 8.02 0.005
Comorbidities, %
 Smoker27.631.7χ2 = 2.26 0.13320.823.6χ2 = 0.71 0.400
 Diabetes10.311.8χ2 = 0.58 0.44610.910.9χ2 = 0.00 >0.99
 Depression18.716.9χ2 = 0.61 0.43525.419.0χ2 = 3.86 0.050
 Anxiety19.315.0χ2 = 3.62 0.05723.016.9χ2 = 3.79 0.052
 Osteoporosis1.11.2χ2 = 0.08 0.7804.52.1χ2 = 3.01 0.083
Clinical history, %
 Back pain84.382.5χ2 = 0.64 0.42290.692.1χ2 = 0.48 0.488
 Leg pain89.187.2χ2 = 1.03 0.31077.677.3χ2 = 0.01 0.926
 ASA class
  113.411.1χ2 = 1.43 0.4896.33.3χ2 = 4.23 0.238
  265.867.955.661.0
  320.921.037.535.0
  40.00.00.60.6
 Decompression levels
  156.557.0χ2 = 0.52 0.91556.857.1χ2 = 0.96 0.811
  236.234.832.634.4
  36.17.08.56.6
  41.21.22.11.8
Preop PROs
 Mean ODI ± SD53.27 ± 16.953.99 ± 15.9t = −0.74 0.45956.77 ± 14.656.36 ± 13.3t = 0.38 0.706
 Mean EQ-5D QALY index ± SD0.4870 ± 0.20.4781 ± 0.2t = 0.68 0.4980.4686 ± 0.20.4603 ± 0.2t = 0.50 0.618
 Mean VAS back pain ± SD6.93 ± 2.66.96 ± 2.3t = −0.21 0.4187.45 ± 2.27.49 ± 2.0t = −0.24 0.808
 Mean VAS leg pain ± SD7.14 ± 2.67.06 ± 2.3t = 0.54 0.5896.77 ± 2.86.73 ± 2.7t = 0.19 0.853

Boldface type indicates statistical significance.

Ninety-Day Safety and Facility Utilization

Table 3 shows the propensity-matched safety and facility utilization by the patients in each cohort for the subset who underwent decompression alone. No significant differences were observed in the mean estimated blood loss (EBL), length of surgery, and hospital length of stay (LOS) between both groups. Similar 90-day readmission and unplanned reoperation rates were observed between groups. Table 4 shows propensity-matched safety and facility utilization by the patients in each cohort for the lumbar fusion subset. There were no significant differences observed in the mean EBL, length of surgery, and hospital LOS between both groups. However, the WC cohort had significantly lower rates of readmission (1.5% vs 5.7%, p = 0.004) and reoperation (1.8% vs 5.1%, p = 0.020) within the 90-day global period.

TABLE 3.

Propensity-matched 90-day safety and facility utilization in the lumbar decompression alone group

VariableNon-WC (n = 561)WC (n = 561)t/χ2 Valuep Value
Mean EBL ± SD, ml69.81 ± 104.766.04 ± 91.3t = 0.560.575
Mean length of surgery ± SD, mins80.30 ± 40.478.88 ± 38.3t = 0.61 0.545
Mean LOS ± SD, days0.62 ± 1.30.63 ± 1.1t = −0.15 0.880
Discharge to facility, %1.20.5χ2 = 1.61 0.204
Hospital readmission w/in 90 days, %5.24.5χ2 = 0.31 0.577
Unplanned return to OR w/in 90 days, %4.53.7χ2 = 0.36 0.547

OR = operating room.

TABLE 4.

Propensity-matched 90-day facility utilization and safety in the lumbar decompression with fusion group

VariableNon-WC (n = 331)WC (n = 331)t/χ2 Valuep Value
Mean EBL ± SD, ml209.24 ± 250.1236.89 ± 296.2t = −1.25 0.214
Mean length of surgery ± SD, mins192.28 ± 91.2191.14 ± 86.5t = 0.17 0.869
Mean LOS ± SD, days2.92 ± 1.93.18 ± 1.8t = −1.74 0.082
Discharge to facility, %9.17.6χ2 = 0.50 0.481
Hospital readmission w/in 90 days, %5.71.5χ2 = 8.47 0.004
Unplanned return to OR w/in 90 days, %5.11.8χ2 = 5.45 0.020

Boldface type indicates statistical significance.

PROs, Satisfaction Rates, and Return to Work

Table 1 shows the four PROM scores at preoperative interviews, before propensity matching. For the subset undergoing decompression alone, the WC cohort showed significantly higher preoperative ODI (53.92 ± 15.9 vs 46.57 ± 17.3, p < 0.001), back pain (6.96 ± 2.3 vs 6.21 ± 2.9, p < 0.001) and leg pain scores (7.08 ± 2.3 vs 6.87 ± 2.7, p = 0.028), and a significantly lower EQ-5D QALY index (0.4779 ± 0.2 vs 0.5494 ± 0.2, p < 0.001). For the subset undergoing lumbar fusion, the WC cohort showed significantly higher preoperative ODI (56.36 ± 13.3 vs 47.85 ± 15.3, p < 0.001) and back pain scores (7.49 ± 2.0 vs 6.95 ± 2.5, p < 0.001) and a significantly lower EQ-5D QALY index (0.4603 ± 0.2 vs 0.5445 ± 0.2, p < 0.001). These significance differences were negated after propensity matching (Table 2).

Figures 1 and 2 represent the mean PROM scores preoperatively, at 3-month follow-up, and at 12-month follow-up interviews after propensity matching for both decompression alone and fusion subsets, respectively. For all patients in both cohorts and in both subsets, there was a significant improvement from baseline to 3-month follow-up across all PROMs that was maintained at 12 months (all significant at p < 0.001). For each of the PROMs assessed, improvement in PROs was similar for both cohorts at all time points. For both subsets, while the baseline PROMs were not significantly different between WC and non-WC cohorts, as represented in the graphs by similar starting points, the 3-month and 1-year PROMs between both cohorts differed significantly, with the WC group reporting significantly less improvement in outcomes when compared with the non-WC patients. The non-WC group also showed significantly improved 1-year patient satisfaction rates in both the decompression without (χ2 = 19.71, p < 0.001) and with fusion (χ2 = 6.46, p = 0.011) subsets.

FIG. 1.
FIG. 1.

A–D: Results for patients undergoing lumbar decompression only, preoperatively and at 3 months and 1 year postoperatively, for the ODI (A), EQ-5D (B), VAS back pain (C), and VAS leg pain (D) PROMs. Scores for each PROM were significantly improved at 3 months postoperatively and maintained at 12 months. Although baseline values were similar after propensity matching, improvements were significantly lower in WC patients than in non-WC patients. E: One-year patient satisfaction rates were significantly lower in WC patients than in non-WC patients. Figure is available in color online only.

FIG. 2.
FIG. 2.

A–D: Results for patients undergoing lumbar decompression with fusion, preoperatively and at 3 months and 1 year postoperatively, for the ODI (A), EQ-5D (B), VAS back pain (C), and VAS leg pain (D) PROMs. Scores for each PROM were significantly improved at 3 months postoperatively and maintained at 12 months. Although baseline values were similar after propensity matching, improvements were significantly lower in WC patients than in non-WC patients. E: One-year patient satisfaction rates were significantly lower in WC patients than in non-WC patients. Figure is available in color online only.

The Kaplan-Meier survival curve in Fig. 3 demonstrates the return-to-work (RTW) rate between WC and non-WC patients after propensity matching, who underwent lumbar decompression alone. The estimated median time to RTW was 5.7 weeks for the non-WC and 9.6 weeks for WC cohort, which was significantly different (χ2 = 95.68, p < 0.001). The Kaplan-Meier survival curve in Fig. 4 demonstrates the RTW rate between WC and non-WC patients after propensity matching, who underwent lumbar fusion. The estimated median time to RTW was 8.4 weeks for the non-WC and 13.3 weeks for the WC cohort, which was significantly different (χ2 = 22.74, p < 0.001).

FIG. 3.
FIG. 3.

Kaplan-Meier survival curves for those undergoing only lumbar decompression show significantly delayed RTW in WC patients compared with non-WC patients. Figure is available in color online only.

FIG. 4.
FIG. 4.

Kaplan-Meier survival curves for those undergoing lumbar decompression with fusion show significantly delayed RTW in WC patients compared with non-WC patients. Figure is available in color online only.

Discussion

As the oldest type of social insurance in North America, WC provides universal insurance benefits, income security, and unrestricted access to medical care for the working population.20,21 In the early part of the 20th century, common law disputes often favored employers and led to widespread resentment among workers. This subsequently resulted in decreased wage-earning capacity in the country, and as a result the first WC legislation in the US was implemented in 1911.11,21 Implemented as a no-fault system, WC has made employers liable for any illness contracted at work to facilitate prompt and specialized care, with the additional aim of reducing lawsuits for injuries sustained at work. However, despite the advantages of improved access to necessary medical care, the WC population has seen inferior clinical outcomes for a variety of medical disorders.811,22

Spinal pathologies, including back pain, are the most frequent indication for WC claims.23 Significantly improved patient satisfaction rates and better clinical improvement were observed in patients with whiplash injuries and degenerative disc disease when those patients were not involved in associated litigation.24,25 A more recent meta-analysis by Cheriyan et al. showed a 2.10 relative risk of unsatisfactory outcomes and a 1.68 relative risk of delayed RTW after cervical, thoracic, and lumbar spine surgery in WC patients.26 The literature has previously demonstrated some evidence linking compensation status to poorer clinical outcomes in lumbar spine surgery. These studies either reported outcomes in a single specific type of fusion procedure, or with lumbar spine surgery in general, without stratifying groups into fusion and nonfusion procedures.

In 2000, Slosar et al. compared satisfaction after anterior and posterior lumbar fusion in WC and non-WC patients, and reported no statistical difference.27 Similar results were reported by Phan et al. in 2017, who found no significant difference between WC and non-WC patients in terms of fusion rates, complications, and clinical outcomes, but RTW and quality-of-life metrics were not evaluated.28 These results were not comparable to those in other studies. In 1999, Agazzi et al. reported posterior lumbar interbody fusion improved clinical outcomes in 84% versus 47% of non-WC versus WC patients, respectively. Unlike 80% of the patients in the employed non-WC group, only 2 of 33 WC patients resumed work.29 Similar results were reported with lumbar discectomy by Atlas et al. in 2000 and Asch et al. in 2002, who reported poorer improvement in pain, disability, and patient satisfaction, as well as delayed RTW within the WC population.30,31 In 2015, Montgomery et al. compared the Low-Back Outcome Score, HRQOL, and functional status using the Roland-Morris Disability Questionnaire between WC and non-WC patients undergoing lumbar spinal fusion. They demonstrated significantly improved 1-year and long-term HRQOL and Low-Back Outcome Score, as well low Roland-Morris Disability Questionnaire scores, indicating better functional status in non-WC compared with WC patients.32 A more recent meta-analysis including 2668 WC and non-WC patients reported worse outcomes in the WC population as well. These results are consistent with our findings.2

These studies were either retrospective case series, small prospective studies, or unmatched comparison groups, all of which do not control for factors known to impact clinical outcomes. Indeed, the only meta-analysis assessing all studies conducted for lumbar spine surgery outcomes in WC patients included only approximately 2500 patients.2 This represents a serious gap in the literature due to the economic burden caused by one of the most common ailments plaguing the workforce. To the best of our knowledge, our study is by far the largest study of outcomes in WC patients undergoing 1- to 4-level lumbar spine surgery, the first to present the analysis in a propensity-matched population that controls for all confounders, and the only study to evaluate outcomes in two separate subsets of patients: those undergoing decompression with fusion, and those undergoing lumbar decompression alone.

In this large, propensity-matched, case-control study of prospectively collected data, WC patients exhibited universally poorer outcomes and worse patient satisfaction in both procedure subsets when compared with the non-WC group. Notably, these results were present despite WC patients representing a significantly younger patient cohort with a lower surgical burden (fewer operative levels) and fewer comorbidities, except smoking. Furthermore, despite controlling for variables present in our WC cohort known to negatively affect outcomes after surgery (smoking, lower socioeconomic status, and belonging to the African American population), outcomes remained similar. Our study also reported significantly delayed RTW with the WC group, despite a statistically significant decreased readmission and reoperation rate observed in the same group. Unlike our results, prior studies comparing fusion rates between both groups have reported increased reoperation rates likely due to pseudarthrosis, which is commonly accelerated by smoking, a significant comorbidity in our WC group.11,33 However, we only reported reoperation rates up to 90 days, which is not enough time to determine pseudarthrosis that might warrant revision surgery and subsequently delayed RTW in the WC group, as reported by previous studies. Delayed RTW results in a significant socioeconomic burden, which is important considering an annual expenditure of more than $100 billion for treating LBP in the US.2

The reason for the increased correlation between adverse outcomes such as residual back and leg pain and WC status is still open to debate and is likely multifactorial. The WC patients in our study were more frequently employed even after propensity matching and thus perhaps demonstrated poorer outcomes due to increased injury severity typical of work envrionments,34 increased risk of opioid use,35 comorbidities related to mental illness,36 and other biopsychosocial factors (which may lead to increased pain perception). Other poor outcomes, notably more prolonged RTW rates, may also be caused by secondary gains such as exacerbated illness behavior promoting disability payments. WC coverage includes partial to full wage replacement offers that vary by state and WC claim type is provided until the worker returns to work following an injury. Such policies are open to manipulation and may enable employees to take longer than necessary to RTW because of secondary financial gain.

The creation of incentives for WC patients to RTW early after surgery can save costs by reducing the overall cost of WC claims and associated expenses of rehabilitation and lost wages, increase workplace productivity, and improve individual health outcomes by providing a sense of normalcy and routine that can have a positive impact on the individual’s overall mental and physical health. These may include: 1) financial incentives in terms of bonuses, additional paid time off, or reduced deductibles and copays for future medical expenses; 2) flexible work arrangements such as work from home or part-time work to allow employees to RTW while they are still recovering; 3) ergonomic equipment or modifications to the work environment for smoother transition back to work; and 4) recognition and awards for those who RTW early. It is important to note, however, that not all incentives may be appropriate for every employee or situation given the risk of reinjury or potential health hazards if the employee feels pressured to RTW early after surgery and to ignore doctors’ recommendations. It is vital for employers to communicate with the WC provider, medical professionals, and the affected employees to ensure the best course of action and establish that any incentives are balanced with adequate support and resources to help employees RTW safely and effectively.

Another factor that could contribute to a prolonged RTW is delayed claim resolutions, where complex, overly bureaucratic claim management could impede prompt RTW and overall patient satisfaction with the entire medical and surgical experience.2 The influence of underlying psychosocial determinants of health within WC claims has lately received more attention, according to a white paper by the Workers Compensation Research Institute.37 Stakeholders in WC understand the need for addressing psychosocial roadblocks to recovery. In 1994, Greenough et al. reported a significant association of psychological disturbances and depression with compensation claims, the former a strong negative predictor of postoperative RTW status in patients undergoing lumbar fusion.38 Regardless, to equalize outcomes between both groups and improve outcomes for the WC patient population, it is essential to recognize all of these biopsychosocial and medicolegal issues.39 Preoperative optimization, including opioid reduction techniques and mental well-being programs, as well as a thorough postoperative functional rehabilitation program, may help to mitigate these differences.40

Limitations of the Study

This study is not without limitations. First, it is limited by its retrospective design and might therefore suffer the inherent drawbacks of that design. Unfortunately, it is not possible to perform a randomized controlled trial of compensation status. Propensity-matched analysis of prospectively collected data is the next best alternative to control for confounding variables, which this study presents. Second, propensity matching is only as good as the variables included in the model. If there are important confounding variables that are not included in the matching process, such as biopsychosocial factors, pre- and postoperative opioid use, and preoperative symptom duration (information not present in the QOD), it may generate bias in the results. However, in the case of symptom duration, none of the patients in either group underwent surgery unless a standard 8 weeks of conservative therapy was unsuccessful. Third, in the centers that participate in the QOD, WC patients make up less than 10% of all patients, which may limit generalizability of the results. Yet, we do believe that this is the largest study to date evaluating outcomes in these WC patients, and should reflect the relationship between compensation status and lumbar surgery outcomes in the broader population. Lastly, the present study did not assess PROMs beyond 1 year. Subsequent higher-powered studies taking into account preoperative opioid use, mental health comorbidities, and other biopsychosocial factors, as well as assessing long-term PROMs in these patients, are necessary to generate discussion among peers and improve outcomes in WC patients.

Conclusions

Although lumbar decompression with or without fusion is quite effective, there is significantly diminished efficacy in WC patients. Our study revealed that WC patients had inferior quality of life, a protracted RTW, higher levels of residual disability and pain, and lower patient satisfaction. There is an urgent need for more in-depth studies identifying the root causes of these unfavorable outcomes to determine the precise societal impact that WC claims have on healthcare delivery in the context of lumbar spine surgery and to aid in maximizing outcomes in this patient population.

Disclosures

Dr. Bohl reported receiving intellectual property royalties from Dignity Health, personal consulting fees from Spine Wave, having an ownership interest and receiving royalties from SurgiSTUD, and receiving royalties and consulting fees from Mirus outside the submitted work.

Author Contributions

Conception and design: Hani, Monk, Pfortmiller, McGirt. Acquisition of data: Hani, Pfortmiller. Drafting the article: Hani, Monk. Critically revising the article: Stanley, Kim, Bohl, Holland, McGirt. Reviewed submitted version of manuscript: Holland, McGirt. Study supervision: McGirt. Administrative/technical/material support: Stanley, Bohl, Kim, Holland, McGirt. Statistical analysis: Pfortmiller. Approved the final version of the manuscript on behalf of all authors: Hani.

References

  • 1

    GBD 2017 Disease and Injury Incidence and Prevalence Collaborators. 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. 2018;392(10159):17891858.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Russo F, De Salvatore S, Ambrosio L, et al. Does workers’ compensation status affect outcomes after lumbar spine surgery? A systematic review and meta-analysis. Int J Environ Res Public Health. 2021;18(11):6165.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Gum JL, Glassman SD, Carreon LY. Is type of compensation a predictor of outcome after lumbar fusion? Spine (Phila Pa 1976). 2013;38(5):443448.

  • 4

    Hartvigsen J, Hancock MJ, Kongsted A, et al. What low back pain is and why we need to pay attention. Lancet. 2018;391(10137):23562367.

  • 5

    Deyo RA, Tsui-Wu YJ. Descriptive epidemiology of low-back pain and its related medical care in the United States. Spine (Phila Pa 1976). 1987;12(3):264268.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Leigh JP, Markowitz SB, Fahs M, Shin C, Landrigan PJ. Occupational injury and illness in the United States. Estimates of costs, morbidity, and mortality. Arch Intern Med. 1997;157(14):15571568.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Lippel K, Lotters F. Public insurance systems: a comparison of cause-based and disability-based income support systems. In: Loisel P, Anema J, eds. Handbook of Work Disability. Springer;2013:183-203.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Cvetanovich GL, Savin DD, Frank RM, et al. Inferior outcomes and higher complication rates after shoulder arthroplasty in workers’ compensation patients. J Shoulder Elbow Surg. 2019;28(5):875881.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Wagner ER, Woodmass JM, Chang MJ, Welp KM, Higgins LD, Warner JJP. The impact of workers’ compensation on recovery after biceps tenodesis. J Shoulder Elbow Surg. 2020;29(9):17831788.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Bhandari L, Bouri F, Ozyurekoglu T. Open versus arthroscopic treatment of chronic lateral epicondylitis and worker’s compensation. Arthrosc Sports Med Rehabil. 2020;2(6):e771e778.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Tabaraee E, Ahn J, Bohl DD, Elboghdady IM, Aboushaala K, Singh K. The impact of worker’s compensation claims on outcomes and costs following an anterior cervical discectomy and fusion. Spine (Phila Pa 1976). 2015;40(12):948953.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Janwantanakul P, Pensri P, Jiamjarasrangsi W, Sinsongsook T. Associations between prevalence of self-reported musculoskeletal symptoms of the spine and biopsychosocial factors among office workers. J Occup Health. 2009;51(2):114122.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Munce SE, Stansfeld SA, Blackmore ER, Stewart DE. The role of depression and chronic pain conditions in absenteeism: results from a national epidemiologic survey. J Occup Environ Med. 2007;49(11):12061211.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Klekamp J, McCarty E, Spengler DM. Results of elective lumbar discectomy for patients involved in the workers’. compensation system. J Spinal Disord. 1998;11(4):277282.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Penta M, Fraser RD. Anterior lumbar interbody fusion. A minimum 10-year follow-up. Spine (Phila Pa 1976). 1997;22(20):24292434.

  • 16

    McGirt MJ, Speroff T, Dittus RS, Harrell FE Jr, Asher AL. The National Neurosurgery Quality and Outcomes Database (N2QOD): general overview and pilot-year project description. Neurosurg Focus. 2013;34(1):E6.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Moses MJ, Tishelman JC, Stekas N, et al. Comparison of patient reported outcome measurement information system with Neck Disability Index and visual analog scale in patients with neck pain. Spine (Phila Pa 1976). 2019;44(3):E162E167.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Fairbank JC, Pynsent PB. The Oswestry Disability Index. Spine (Phila Pa 1976). 2000;25(22):29402952.

  • 19

    Faught RW, Church EW, Halpern CH, et al. Long-term quality of life after posterior cervical foraminotomy for radiculopathy. Clin Neurol Neurosurg. 2016;142:2225.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Kiselica D, Sibson B, Green-McKenzie J. Workers’ compensation: a historical review and description of a legal and social insurance system. Clin Occup Environ Med. 2004;4(2):v,237-247.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Bible JE, Spengler DM, Mir HR. A primer for workers’ compensation. Spine J. 2014;14(7):13251331.

  • 22

    Tribus CB, Corteen DP, Zdeblick TA. The efficacy of anterior cervical plating in the management of symptomatic pseudoarthrosis of the cervical spine. Spine (Phila Pa 1976). 1999;24(9):860864.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Franklin GM, Wickizer TM, Coe NB, Fulton-Kehoe D. Workers’ compensation: poor quality health care and the growing disability problem in the United States. Am J Ind Med. 2015;58(3):245251.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Gotten N. Survey of one hundred cases of whiplash injury after settlement of litigation. J Am Med Assoc. 1956;162(9):865867.

  • 25

    DePalma AF, Rothman RH, Levitt RL, Hammond NL III. The natural history of severe cervical disc degeneration. Acta Orthop Scand. 1972;43(5):392396.

  • 26

    Cheriyan T, Harris B, Cheriyan J, et al. Association between compensation status and outcomes in spine surgery: a meta-analysis of 31 studies. Spine J. 2015;15(12):25642573.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27

    Slosar PJ, Reynolds JB, Schofferman J, Goldthwaite N, White AH, Keaney D. Patient satisfaction after circumferential lumbar fusion. Spine (Phila Pa 1976). 2000;25(6):722726.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28

    Phan K, Davies S, Rao PJ, Mobbs RJ. Worker’s compensation status and outcomes following anterior lumbar interbody fusion: prospective observational study. World Neurosurg.2017;103:680685.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29

    Agazzi S, Reverdin A, May D. Posterior lumbar interbody fusion with cages: an independent review of 71 cases. J Neurosurg. 1999;91(2 suppl):186192.

  • 30

    Atlas SJ, Chang Y, Kammann E, Keller RB, Deyo RA, Singer DE. Long-term disability and return to work among patients who have a herniated lumbar disc: the effect of disability compensation. J Bone Joint Surg Am. 2000;82(1):415.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31

    Asch HL, Lewis PJ, Moreland DB, et al. Prospective multiple outcomes study of outpatient lumbar microdiscectomy: should 75 to 80% success rates be the norm?. J Neurosurg. 2002;96(1 suppl):3444.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32

    Montgomery AS, Cunningham JE, Robertson PA. The influence of no fault compensation on functional outcomes after lumbar spine fusion. Spine (Phila Pa 1976). 2015;40(14):11401147.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 33

    Khurana VG. Adverse impact of smoking on the spine and spinal surgery. Surg Neurol Int. 2021;12:118.

  • 34

    Sears JM, Bowman SM, Rotert M, Hogg-Johnson S. A new method to classify injury severity by diagnosis: validation using workers’ compensation and trauma registry data. J Occup Rehabil. 2015;25(4):742751.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 35

    Anderson JT, Haas AR, Percy R, Woods ST, Ahn UM, Ahn NU. Chronic opioid therapy after lumbar fusion surgery for degenerative disc disease in a workers’ compensation setting. Spine (Phila Pa 1976). 2015;40(22):17751784.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 36

    Kukreja S, Kalakoti P, Ahmed O, Nanda A. Predictors of reoperation-free survival following decompression-alone lumbar spine surgery for on-the-job injuries. Clin Neurol Neurosurg. 2015;135:4145.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 37

    A Primer on Behavioral Health Care in Workers’ Compensation. Workers Compensation Research Institute. August 16,2022.Accessed February 23, 2023. https://www.wcrinet.org/reports/a-primer-on-behavioral-health-care-in-workers-compensation

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 38

    Greenough CG, Taylor LJ, Fraser RD. Anterior lumbar fusion: results, assessment techniques and prognostic factors. Eur Spine J. 1994;3(4):225230.

  • 39

    The Best Workers’ Comp Claims Teams. Insurance Thought Leadership. August 8, 2018. Accessed February 24, 2023. https://www.insurancethoughtleadership.com/commercial-lines/best-workers-comp-claims-teams

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 40

    Mayer TG, Gatchel RJ, Brede E, Theodore BR. Lumbar surgery in work-related chronic low back pain: can a continuum of care enhance outcomes?. Spine J. 2014;14(2):263273.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • Collapse
  • Expand
Figure from Vedantam et al. (pp 28–39).
  • FIG. 1.

    A–D: Results for patients undergoing lumbar decompression only, preoperatively and at 3 months and 1 year postoperatively, for the ODI (A), EQ-5D (B), VAS back pain (C), and VAS leg pain (D) PROMs. Scores for each PROM were significantly improved at 3 months postoperatively and maintained at 12 months. Although baseline values were similar after propensity matching, improvements were significantly lower in WC patients than in non-WC patients. E: One-year patient satisfaction rates were significantly lower in WC patients than in non-WC patients. Figure is available in color online only.

  • FIG. 2.

    A–D: Results for patients undergoing lumbar decompression with fusion, preoperatively and at 3 months and 1 year postoperatively, for the ODI (A), EQ-5D (B), VAS back pain (C), and VAS leg pain (D) PROMs. Scores for each PROM were significantly improved at 3 months postoperatively and maintained at 12 months. Although baseline values were similar after propensity matching, improvements were significantly lower in WC patients than in non-WC patients. E: One-year patient satisfaction rates were significantly lower in WC patients than in non-WC patients. Figure is available in color online only.

  • FIG. 3.

    Kaplan-Meier survival curves for those undergoing only lumbar decompression show significantly delayed RTW in WC patients compared with non-WC patients. Figure is available in color online only.

  • FIG. 4.

    Kaplan-Meier survival curves for those undergoing lumbar decompression with fusion show significantly delayed RTW in WC patients compared with non-WC patients. Figure is available in color online only.

  • 1

    GBD 2017 Disease and Injury Incidence and Prevalence Collaborators. 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. 2018;392(10159):17891858.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Russo F, De Salvatore S, Ambrosio L, et al. Does workers’ compensation status affect outcomes after lumbar spine surgery? A systematic review and meta-analysis. Int J Environ Res Public Health. 2021;18(11):6165.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Gum JL, Glassman SD, Carreon LY. Is type of compensation a predictor of outcome after lumbar fusion? Spine (Phila Pa 1976). 2013;38(5):443448.

  • 4

    Hartvigsen J, Hancock MJ, Kongsted A, et al. What low back pain is and why we need to pay attention. Lancet. 2018;391(10137):23562367.

  • 5

    Deyo RA, Tsui-Wu YJ. Descriptive epidemiology of low-back pain and its related medical care in the United States. Spine (Phila Pa 1976). 1987;12(3):264268.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Leigh JP, Markowitz SB, Fahs M, Shin C, Landrigan PJ. Occupational injury and illness in the United States. Estimates of costs, morbidity, and mortality. Arch Intern Med. 1997;157(14):15571568.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Lippel K, Lotters F. Public insurance systems: a comparison of cause-based and disability-based income support systems. In: Loisel P, Anema J, eds. Handbook of Work Disability. Springer;2013:183-203.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Cvetanovich GL, Savin DD, Frank RM, et al. Inferior outcomes and higher complication rates after shoulder arthroplasty in workers’ compensation patients. J Shoulder Elbow Surg. 2019;28(5):875881.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Wagner ER, Woodmass JM, Chang MJ, Welp KM, Higgins LD, Warner JJP. The impact of workers’ compensation on recovery after biceps tenodesis. J Shoulder Elbow Surg. 2020;29(9):17831788.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Bhandari L, Bouri F, Ozyurekoglu T. Open versus arthroscopic treatment of chronic lateral epicondylitis and worker’s compensation. Arthrosc Sports Med Rehabil. 2020;2(6):e771e778.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Tabaraee E, Ahn J, Bohl DD, Elboghdady IM, Aboushaala K, Singh K. The impact of worker’s compensation claims on outcomes and costs following an anterior cervical discectomy and fusion. Spine (Phila Pa 1976). 2015;40(12):948953.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Janwantanakul P, Pensri P, Jiamjarasrangsi W, Sinsongsook T. Associations between prevalence of self-reported musculoskeletal symptoms of the spine and biopsychosocial factors among office workers. J Occup Health. 2009;51(2):114122.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Munce SE, Stansfeld SA, Blackmore ER, Stewart DE. The role of depression and chronic pain conditions in absenteeism: results from a national epidemiologic survey. J Occup Environ Med. 2007;49(11):12061211.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Klekamp J, McCarty E, Spengler DM. Results of elective lumbar discectomy for patients involved in the workers’. compensation system. J Spinal Disord. 1998;11(4):277282.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Penta M, Fraser RD. Anterior lumbar interbody fusion. A minimum 10-year follow-up. Spine (Phila Pa 1976). 1997;22(20):24292434.

  • 16

    McGirt MJ, Speroff T, Dittus RS, Harrell FE Jr, Asher AL. The National Neurosurgery Quality and Outcomes Database (N2QOD): general overview and pilot-year project description. Neurosurg Focus. 2013;34(1):E6.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Moses MJ, Tishelman JC, Stekas N, et al. Comparison of patient reported outcome measurement information system with Neck Disability Index and visual analog scale in patients with neck pain. Spine (Phila Pa 1976). 2019;44(3):E162E167.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Fairbank JC, Pynsent PB. The Oswestry Disability Index. Spine (Phila Pa 1976). 2000;25(22):29402952.

  • 19

    Faught RW, Church EW, Halpern CH, et al. Long-term quality of life after posterior cervical foraminotomy for radiculopathy. Clin Neurol Neurosurg. 2016;142:2225.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Kiselica D, Sibson B, Green-McKenzie J. Workers’ compensation: a historical review and description of a legal and social insurance system. Clin Occup Environ Med. 2004;4(2):v,237-247.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Bible JE, Spengler DM, Mir HR. A primer for workers’ compensation. Spine J. 2014;14(7):13251331.

  • 22

    Tribus CB, Corteen DP, Zdeblick TA. The efficacy of anterior cervical plating in the management of symptomatic pseudoarthrosis of the cervical spine. Spine (Phila Pa 1976). 1999;24(9):860864.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Franklin GM, Wickizer TM, Coe NB, Fulton-Kehoe D. Workers’ compensation: poor quality health care and the growing disability problem in the United States. Am J Ind Med. 2015;58(3):245251.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Gotten N. Survey of one hundred cases of whiplash injury after settlement of litigation. J Am Med Assoc. 1956;162(9):865867.

  • 25

    DePalma AF, Rothman RH, Levitt RL, Hammond NL III. The natural history of severe cervical disc degeneration. Acta Orthop Scand. 1972;43(5):392396.

  • 26

    Cheriyan T, Harris B, Cheriyan J, et al. Association between compensation status and outcomes in spine surgery: a meta-analysis of 31 studies. Spine J. 2015;15(12):25642573.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27

    Slosar PJ, Reynolds JB, Schofferman J, Goldthwaite N, White AH, Keaney D. Patient satisfaction after circumferential lumbar fusion. Spine (Phila Pa 1976). 2000;25(6):722726.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28

    Phan K, Davies S, Rao PJ, Mobbs RJ. Worker’s compensation status and outcomes following anterior lumbar interbody fusion: prospective observational study. World Neurosurg.2017;103:680685.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29

    Agazzi S, Reverdin A, May D. Posterior lumbar interbody fusion with cages: an independent review of 71 cases. J Neurosurg. 1999;91(2 suppl):186192.

  • 30

    Atlas SJ, Chang Y, Kammann E, Keller RB, Deyo RA, Singer DE. Long-term disability and return to work among patients who have a herniated lumbar disc: the effect of disability compensation. J Bone Joint Surg Am. 2000;82(1):415.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31

    Asch HL, Lewis PJ, Moreland DB, et al. Prospective multiple outcomes study of outpatient lumbar microdiscectomy: should 75 to 80% success rates be the norm?. J Neurosurg. 2002;96(1 suppl):3444.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32

    Montgomery AS, Cunningham JE, Robertson PA. The influence of no fault compensation on functional outcomes after lumbar spine fusion. Spine (Phila Pa 1976). 2015;40(14):11401147.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 33

    Khurana VG. Adverse impact of smoking on the spine and spinal surgery. Surg Neurol Int. 2021;12:118.

  • 34

    Sears JM, Bowman SM, Rotert M, Hogg-Johnson S. A new method to classify injury severity by diagnosis: validation using workers’ compensation and trauma registry data. J Occup Rehabil. 2015;25(4):742751.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 35

    Anderson JT, Haas AR, Percy R, Woods ST, Ahn UM, Ahn NU. Chronic opioid therapy after lumbar fusion surgery for degenerative disc disease in a workers’ compensation setting. Spine (Phila Pa 1976). 2015;40(22):17751784.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 36

    Kukreja S, Kalakoti P, Ahmed O, Nanda A. Predictors of reoperation-free survival following decompression-alone lumbar spine surgery for on-the-job injuries. Clin Neurol Neurosurg. 2015;135:4145.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 37

    A Primer on Behavioral Health Care in Workers’ Compensation. Workers Compensation Research Institute. August 16,2022.Accessed February 23, 2023. https://www.wcrinet.org/reports/a-primer-on-behavioral-health-care-in-workers-compensation

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 38

    Greenough CG, Taylor LJ, Fraser RD. Anterior lumbar fusion: results, assessment techniques and prognostic factors. Eur Spine J. 1994;3(4):225230.

  • 39

    The Best Workers’ Comp Claims Teams. Insurance Thought Leadership. August 8, 2018. Accessed February 24, 2023. https://www.insurancethoughtleadership.com/commercial-lines/best-workers-comp-claims-teams

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 40

    Mayer TG, Gatchel RJ, Brede E, Theodore BR. Lumbar surgery in work-related chronic low back pain: can a continuum of care enhance outcomes?. Spine J. 2014;14(2):263273.

    • PubMed
    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 1787 827 0
Full Text Views 844 524 277
PDF Downloads 436 231 33
EPUB Downloads 0 0 0