Atlas S J, Chang Y, Kammann E, Keller R B, Deyo R A, Singer D E
Massachusetts General Hospital, Boston 02114, USA.
J Bone Joint Surg Am. 2000 Jan;82(1):4-15. doi: 10.2106/00004623-200001000-00002.
Low-back problems are one of the most frequent reasons for disability compensation claims by workers. However, the effect of Workers' Compensation status on the long-term outcome for workers with sciatica has not been studied in detail, to our knowledge. Therefore, we believe that it is important to describe the long-term outcomes for patients who have herniation of a lumbar disc and sciatica according to the Workers' Compensation status at the time of the preoperative consultation.
We conducted a prospective, observational study of patients who had sciatica and were seeking care from specialist physicians in community-based practices throughout Maine. Among 440 eligible patients, 199 were receiving Workers' Compensation at the time of entry into the study (baseline) and 241 were not. Three hundred and twenty-six patients (74 percent) completed questionnaires at the time of a four-year follow-up. The outcomes that we assessed included disability compensation and work status as well as relief from symptoms, functional status, and quality of life.
Patients who were receiving Workers' Compensation at baseline were more likely to be young, male, and employed as laborers. They reported worse functional status; however, the clinical findings for these patients were similar to those for patients who were not receiving Workers' Compensation. Patients who had been receiving Workers' Compensation at baseline were more likely to be receiving disability benefits at the time of the four-year follow-up compared with those who had not (27 percent of 133 compared with 7 percent of 189; p<0.001); however, they were only slightly less likely to be working at the time of the four-year follow-up (80 percent of 133 compared with 87 percent of 190; p = 0.09). Operative management did not influence these comparisons, but it decreased symptoms and improved functional status. Patients who had been receiving Workers' Compensation at baseline also had significantly less relief from symptoms and improvement in quality of life than patients who had not been receiving Workers' Compensation (all p<0.001). In multivariate models, Workers' Compensation status at baseline was an independent predictor of whether the patient would be receiving disability benefits after four years (odds ratio, 3.5; 95 percent confidence interval, 1.7 to 7.6) but was not an independent predictor of whether the patient would be working on a job for pay at the time of the four-year follow-up (odds ratio, 0.6; 95 percent confidence interval, 0.3 to 1.2).
Even after adjustment for the initial treatment of the sciatica and for other clinical factors, patients who had been receiving Workers' Compensation at baseline were more likely to be receiving disability benefits and were less likely to report relief from symptoms and improvement in quality of life at the time of the four-year follow-up than patients who had not been receiving Workers' Compensation at baseline. Nonetheless, most patients returned to work regardless of their initial disability status, and those who had been receiving Workers' Compensation at baseline were only slightly less likely to be working after four years. Whether or not they had been receiving Workers' Compensation at baseline, patients who had been managed with an operation reported greater relief from symptoms and improvement in functional status at the time of the four-year follow-up compared with patients who had been managed nonoperatively, even though the outcomes with regard to disability and work status in these two groups were comparable.
腰背部问题是工人申请残疾赔偿最常见的原因之一。然而，据我们所知，工伤赔偿状况对坐骨神经痛工人长期预后的影响尚未得到详细研究。因此，我们认为，根据术前咨询时的工伤赔偿状况来描述腰椎间盘突出症合并坐骨神经痛患者的长期预后很重要。
我们对缅因州各地社区诊所中患有坐骨神经痛并寻求专科医生治疗的患者进行了一项前瞻性观察研究。在440名符合条件的患者中，199名在进入研究（基线）时正在接受工伤赔偿，241名未接受。326名患者（74%）在四年随访时完成了问卷调查。我们评估的结果包括残疾赔偿和工作状态，以及症状缓解情况、功能状态和生活质量。
基线时接受工伤赔偿的患者更可能年轻、为男性且从事体力劳动工作。他们报告的功能状态较差；然而，这些患者的临床检查结果与未接受工伤赔偿的患者相似。与未接受工伤赔偿的患者相比，基线时接受工伤赔偿的患者在四年随访时更可能领取残疾津贴（133名中的27% 对比189名中的7%；p<0.001）；然而，他们在四年随访时工作的可能性仅略低（133名中的80% 对比190名中的87%；p = 0.09）。手术治疗并未影响这些比较结果，但减轻了症状并改善了功能状态。与未接受工伤赔偿的患者相比，基线时接受工伤赔偿的患者症状缓解和生活质量改善也明显较少（所有p<0.001）。在多变量模型中，基线时的工伤赔偿状况是患者四年后是否领取残疾津贴的独立预测因素（比值比，3.5；95%置信区间，1.7至7.6），但不是四年随访时患者是否从事有薪工作的独立预测因素（比值比，0.6；95%置信区间，0.3至1.2）。
即使在对坐骨神经痛的初始治疗和其他临床因素进行调整后，与基线时未接受工伤赔偿的患者相比，基线时接受工伤赔偿的患者在四年随访时更可能领取残疾津贴，且报告症状缓解和生活质量改善的可能性较小。尽管如此，大多数患者无论其初始残疾状况如何都重返工作岗位，基线时接受工伤赔偿的患者在四年后工作的可能性仅略低。无论基线时是否接受工伤赔偿，与非手术治疗的患者相比，接受手术治疗的患者在四年随访时症状缓解更明显，功能状态改善更大，尽管这两组在残疾和工作状态方面的结果相当。
