Lumbar fusion surgery should not be the first line treatment for a majority of Ohio’s injured workers with back pain, according to a new rule. The Ohio Bureau of Workers’ Compensation implemented the guideline Jan.1, to curb unnecessary back surgeries and reduce the risk of opioid abuse. It is said to be the most restrictive rule of its kind in the workers’ compensation system.

The Ohio BWC is the largest injured worker fund in the nation, so getting this endorsement of non-surgical methods for most back pain is especially telling. As physical therapists, we applaud the Bureau’s efforts to protect the health of injured workers.

The Rule

“Effective January 1, 2018, reimbursement for lumbar fusion surgery for treatment of allowed conditions in a claim resulting from an allowed industrial injury or occupational disease shall be limited to claims in which current best medical practices as implemented by this rule are followed,” the revised rule language states.

In creating the rule change, the Bureau said that most injured workers with back pain must first undergo 60 days of ‘conservative care,’ before they can be approve for surgery. Conservative care is defined as:

• Physical reconditioning
• Avoidance of opioids, when possible
• Avoidance of provider catastrophizing the explanation of lumbar MRI findings.

The 60 day mandate would be waived and lumbar fusion surgery approved only for specific conditions, including; progressive functional neurological deficit, spinal fracture, tumor, infection, emergency/trauma care, and/or other catastrophic spinal pathology causally related to the injured worker's allowed conditions.

Notably missing from the list of exceptions are the majority of conditions we see with injured workers. The Bureau cites research on postoperative outcomes to make the point.

“Lumbar fusion for the diagnoses of disc degeneration, disc herniation, and/or radiculopathy in work comp setting is associated with significant increase in disability, opiate use, prolonged work loss, and poor return to work status.”

That statement is included in an appendix to the rule. The document, entitled What the BWC Wants You to Know About Lumbar Fusion Surgery is required reading by the injured worker, treating physician and the operating surgeon to gain approval for surgery.

In addition to 60 days of conservative care and signing the appendix, additional prerequisites for authorization of payment for lumbar fusion surgery are that the operating surgeon must have evaluated the injured worker on at least two occasions before requesting authorization for surgery and the injured worker must have undergone a comprehensive evaluation with coordination between the treating physician and the operating surgeon.

Making the Case

The rule has drawn some criticism for its potential to create hardships for those injured workers who could be best served through surgery. But the Bureau made a strong case for its position, noting the following from various studies of general lumbar fusion outcomes:

• The chance of an injured worker no longer being disabled 2 years after lumbar fusion is 32 percent.
• More than half of workers who received lumbar fusion through the Washington workers’ compensation program felt that both pain and functional recovery were no better or were worse after lumbar fusion.
• The use of spine stabilization hardware (metal devices) in Washington workers nearly doubled the chances of having another surgery

In a two year follow-up study in Ohio, the Bureau noted that back pain patients treated with fusion were able to return to work (activity) only 26 percent of the time, while workers treated non-surgically were able to return to work (activity) 67 percent of the time.

How PT Can Help

We often spend quite a bit of time with injured workers who have been advised to undergo surgery, but find with PT and time they can heal. Except in those rare instances when surgery is the only option, proper movement and exercise is the best remedy for back pain. Flexibility, stability and strengthening are important to increase mobility and range of motion. A combination of these exercises is most helpful.

Exercises that help strengthen the core — the muscles in the front and back of the spine, the transverse abdominis that support the spine, need to be worked. Planks are one of the best exercises to do that.

Improving flexibility in the lower extremities also helps. These involve the hip rotators, hamstrings and hip flexors.

One of the best but often overlooked ways of relieving back pain is by practicing good posture. Having a neutral spine relieves undo pressure.

Conclusion

The best tool to heal the body is usually the body itself. While there are instances where various medical procedures can expedite that process, the majority of injured workers with back pain benefit mostly from learning how to move properly and doing the right exercises.