Willems Paul, de Bie Rob, Oner Cumhur, Castelein René, de Kleuver Marinus
Department of Orthopaedics, Research School Caphri, Maastricht University Medical Center, Maastricht, the Netherlands.
BMJ Open. 2011 Dec 21;1(2):e000391. doi: 10.1136/bmjopen-2011-000391. Print 2011.
Objectives To assess the use of prognostic patient factors and predictive tests in clinical decision making for spinal fusion in patients with chronic low back pain. Design and setting Nationwide survey among spine surgeons in the Netherlands. Participants Surgeon members of the Dutch Spine Society were questioned on their surgical treatment strategy for chronic low back pain. Primary and secondary outcome measures The surgeons' opinion on the use of prognostic patient factors and predictive tests for patient selection were addressed on Likert scales, and the degree of uniformity was assessed. In addition, the influence of surgeon-specific factors, such as clinical experience and training, on decision making was determined. Results The comments from 62 surgeons (70% response rate) were analysed. Forty-four surgeons (71%) had extensive clinical experience. There was a statistically significant lack of uniformity of opinion in seven of the 11 items on prognostic factors and eight of the 11 items on predictive tests, respectively. Imaging was valued much higher than predictive tests, psychological screening or patient preferences (all p<0.01). Apart from the use of discography and long multisegment fusions, differences in training or clinical experience did not appear to be of significant influence on treatment strategy. Conclusions The present survey showed a lack of consensus among spine surgeons on the appreciation and use of predictive tests. Prognostic patient factors were not consistently incorporated in their treatment strategy either. Clinical decision making for spinal fusion to treat chronic low back pain does not have a uniform evidence base in practice. Future research should focus on identifying subgroups of patients for whom spinal fusion is an effective treatment, as only a reliable prediction of surgical outcome, combined with the implementation of individual patient factors, may enable the instalment of consensus guidelines for surgical decision making in patients with chronic low back pain.
目的 评估慢性下腰痛患者脊柱融合临床决策中患者预后因素及预测性检查的应用情况。
设计与背景 对荷兰脊柱外科医生进行全国性调查。
参与者 向荷兰脊柱协会的外科医生成员询问其对慢性下腰痛的手术治疗策略。
主要和次要结局指标 采用李克特量表询问外科医生对使用预后患者因素及预测性检查进行患者选择的看法，并评估一致性程度。此外，确定外科医生特定因素（如临床经验和培训）对决策的影响。
结果 分析了62位外科医生的意见（回复率70%）。44位外科医生（71%）有丰富的临床经验。在11项预后因素中的7项以及11项预测性检查中的8项上，意见缺乏统计学意义上的一致性。影像学检查比预测性检查、心理筛查或患者偏好更受重视（均p<0.01）。除了椎间盘造影和多节段长节段融合术的使用外，培训或临床经验的差异似乎对治疗策略没有显著影响。
结论 本次调查显示脊柱外科医生在预测性检查的评估和使用上缺乏共识。患者预后因素也未始终纳入其治疗策略中。在实践中，用于治疗慢性下腰痛的脊柱融合临床决策没有统一的证据基础。未来的研究应侧重于确定脊柱融合术对哪些患者亚组有效，因为只有可靠地预测手术结果并结合个体患者因素，才可能制定出慢性下腰痛患者手术决策的共识指南。
