Healthcare Professionals’ Decision-Making Regarding Lumbar Fusion Surgery or Conservative Care for Adults With Severe, Persistent Low Back Pain: An Australian Cross-Sectional Survey Using Case Vignettes

Abstract

Study Design Cross-sectional Survey. Objectives The objective of this study was to describe clinicians’ decision-making regarding suitability of patient cases for lumbar fusion surgery or conservative care and the level of equipoise to randomise participants into a randomised controlled trial (RCT). Methods An online survey distributed via Australian professional networks to clinicians involved in low back pain care, collected data on clinical discipline, clinical experience, practice setting and preferred care of five patient case vignettes (ranging in age, pain duration, BMI, imaging findings, neurological signs/symptoms). Clinicians were asked about preferred clinical care and willingness to randomise each case. Results Of 101 respondents (31 orthopaedic surgeons, 17 neurosurgeons, 50 allied health professionals (AHPs), 1 pain physician, 1 nurse), 44% worked in public health services only, 36.4% in both public and private, 19.2% in private only. 46.5% had over 20 years clinical experience. Conservative care was preferred for all cases (83.1%–90.9%). Surgeons preferred an anterior approach to lumbar fusion (range 40.6%–68.4%). On average 51.9% (range: 47%–55%) indicated willingness to randomise cases, with orthopaedic (61.5%) and neurosurgeons (64.9%) more willing than AHPs (44.4%). Willingness to randomise was highest in younger cases with shorter pain duration, no neurological symptoms/signs and localised degeneration, and lowest when cases had high BMI, longer pain duration, and inadequate conservative management. Willingness to randomise was higher in those in private (70.3%) vs public health care services (43.6%). Conclusions Over half of respondents reported willingness to randomise cases, indicating sufficient clinical equipoise for a future RCT.