title: Fusion versus nonoperative care for chronic low back pain: do psychological factors affect outcomes?
abstract: METHODS
  Systematic review.
  
  
  OBJECTIVE
  The objectives of this systematic review were to determine whether fusion is superior to conservative management in certain psychological subpopulations and to determine the most common psychological screening tests and their ability to predict outcome after treatment in patients with chronic lower back pain.
  
  
  BACKGROUND
  Many studies have documented the effects of various psychological disorders on outcomes in the treatment of lower back pain. The question of whether patients with certain psychological disorders would benefit more from conservative treatment than fusion is not clear. Furthermore, the most appropriate screening tools for assessing psychological factors in the presence of treatment decision making should be recommended.
  
  
  METHODS
  Systematic review of the literature, focused on randomized controlled trials to assess the heterogeneity of treatment effect of psychological factors on the outcomes of fusion versus nonoperative care of the treatment of chronic low back pain. In the analysis of psychological screening tests, we searched for the most commonly reported questionnaires and those that had been shown to predict lower back pain treatment outcomes.
  
  
  RESULTS
  Few studies comparing fusion to conservative management reported differences in outcome by the presence or absence of a psychological disorder. Among those that did, we observed the effect of fusion compared with conservative management was more favorable in patients without a personality disorder, neuroticism, or depression. The most commonly reported, validated psychological screening tests for lower back pain are the Beck Depression Inventory, the Fear Avoidance Belief Questionnaire, the Spielberger Trait Anxiety Inventory, the Zung Depression Scale, and the Distress Risk Assessment Method.
  
  
  CONCLUSIONS
  Psychological disorders affect chronic lower back pain treatment outcomes. Patients with a personality disorder appear to respond more favorably to conservative management and those without a personality disorder more favorably to fusion. Patients with higher depression and neuroticism scores may also respond more favorably to conservative management.
  
  
  CONCLUSIONS
  Recommendation 1: Chronic LBP patients with depression, neuroticism, and certain personality disorders should preferentially be treated nonoperatively. Strength of recommendation: Weak. Recommendation 2: Consider the use of a validated psychological screening questionnaire such as the BDI, FABQ, DRAM, ZDI or STAI, when treating patients with CLBP. Strength of recommendation: Weak.
authors.affiliation: Department of Orthopaedics, University of Utah, Salt Lake City, UT 84108, USA. michael.daubs@hsc.utah.edu
authors.forename: Michael D
authors.initials: MD
authors.lastname: Daubs
authors.forename: Daniel C
authors.initials: DC
authors.lastname: Norvell
authors.forename: Robert
authors.initials: R
authors.lastname: McGuire
authors.forename: Robert
authors.initials: R
authors.lastname: Molinari
authors.forename: Jeffrey T
authors.initials: JT
authors.lastname: Hermsmeyer
authors.forename: Daryl R
authors.initials: DR
authors.lastname: Fourney
authors.forename: J P
authors.initials: JP
authors.lastname: Wolinsky
authors.forename: Darrel
authors.initials: D
authors.lastname: Brodke
mesh_terms: D059350:Chronic Pain / Q000175:diagnosis / Q000523:psychology / Q000601:surgery / Q000628:therapy*; D019317:Evidence-Based Medicine; D006801:Humans; D017116:Low Back Pain / Q000175:diagnosis / Q000523:psychology / Q000601:surgery / Q000628:therapy*; D008603:Mental Health; D010147:Pain Measurement; D018579:Patient Selection; D017410:Practice Guidelines as Topic; D011237:Predictive Value of Tests; D011569:Psychiatric Status Rating Scales; D018570:Risk Assessment; D012307:Risk Factors; D013123:Spinal Fusion / Q000009:adverse effects; D011795:Surveys and Questionnaires; D016896:Treatment Outcome