title: Fusion versus nonoperative management for chronic low back pain: do sociodemographic factors affect outcome?
abstract: METHODS
  Systematic review.
  
  
  OBJECTIVE
  The objectives of this systematic review were to determine whether sociologic and demographic factors modify the effect of fusion versus nonoperative management in patients with chronic low back pain.
  
  
  BACKGROUND
  Chronic low back pain is among the most common symptoms leading patients to seek medical care and presents significant challenges in treatment decision making. This is due to the wide array of pathologic conditions causing back pain, the multitude of patient variables (i.e., litigation, psychologic issues, social issues) that are thought to influence the perception of back pain, and the wide variation in treatment response. Sociodemographic factors are thought to play a role in pain perception and treatment response, though this has been poorly assessed in the literature.
  
  
  METHODS
  Systematic review of the literature, focused on randomized controlled trials to assess the heterogeneity of treatment effect of sociodemographic factors on the outcomes of fusion versus nonoperative care of the treatment of chronic low back pain.
  
  
  RESULTS
  The only sociologic factors evaluated in randomized controlled trials adequate to assess heterogeneity of treatment effect are pending litigation, worker's compensation, sick leave, and heavy labor job type. Litigation patients, although thought to do poorly with treatment of chronic low back pain in general, responded more favorably to fusion than nonoperative care. Likewise, patients with lighter jobs and those patients who were not on sick leave did better with fusion than nonoperative care. No demographic factors were observed to respond more favorably to one treatment over the other.
  
  
  CONCLUSIONS
  Sociodemographic factors are not well studied in the literature, but are assumed to affect treatment outcomes. After rigorous review, few studies held up to the standards required for defining the comparative treatment effect of these factors. Pending litigation may negatively impact outcomes of patients with chronic low back pain; however, those who underwent fusion had better outcomes than those with nonoperative management in two European studies. There is no evidence to suggest that sociodemographic factors alone should preclude surgery. Well-constructed prospective randomized studies with predefined subgroup analyses are required to further understand the impact of sociodemographic factors in the treatment of chronic low back pain.
  
  
  CONCLUSIONS
  Sociodemographic factors should be considered when making treatment decisions for patients with chronic low back pain, but alone do not preclude fusion for chronic low back pain. Strength of recommendation: Weak.
authors.affiliation: Spine Surgery Fellowship, Cleveland Clinic, Euclid Avenue, Cleveland, OH 44130, USA. mrozt@ccf.org
authors.forename: Thomas E
authors.initials: TE
authors.lastname: Mroz
authors.forename: Daniel C
authors.initials: DC
authors.lastname: Norvell
authors.forename: Erika
authors.initials: E
authors.lastname: Ecker
authors.forename: Marcelo
authors.initials: M
authors.lastname: Gruenberg
authors.forename: Andrew
authors.initials: A
authors.lastname: Dailey
authors.forename: Darrel S
authors.initials: DS
authors.lastname: Brodke
mesh_terms: D059350:Chronic Pain / Q000175:diagnosis / Q000601:surgery / Q000628:therapy*; D019317:Evidence-Based Medicine; D006801:Humans; D017116:Low Back Pain / Q000175:diagnosis / Q000601:surgery / Q000628:therapy*; D010147:Pain Measurement; D018579:Patient Selection; D017410:Practice Guidelines as Topic; D018570:Risk Assessment; D012307:Risk Factors; D012959:Socioeconomic Factors; D013123:Spinal Fusion / Q000009:adverse effects; D016896:Treatment Outcome