BWC approves new surgery rule

Staff report

The Ohio Bureau of Workers’ Compensation (BWC) board of directors approved a rule June 23 discouraging surgery and opioid use in favor of conservative therapy for workers with lower back injuries.

Under BWC’s new spinal fusion rule, the agency requires those workers to first undergo at least 60 days of comprehensive conservative care before considering a surgical option. Conservative care includes physical therapy, chiropractic care and rest, anti-inflammatories, ice, and other non-surgical treatments.

“Our mission is to get injured workers back to work and back to life as soon as safely possible, and our research shows that rushing to surgery may not be the best path for workers with lower back injuries,” BWC Administrator/CEO Sarah Morrison said.

The rule follows several studies of BWC data by former BWC Chief Medical Officer Dr. Stephen T. Woods, researchers at Case Western University School of Medicine, and others that found fusion patients suffered considerably worse outcomes than non-fusion patients. Those outcomes included chronic opioid dependence, increased disability, and high rates of failed back syndrome, as well as additional surgery and new psychiatric co-morbidities. One study in the journal Orthopedics found nearly 77 percent of fusion patients did not return to work within two years.

“This is a look-before-you-leap rule,” said Woods, who specializes in physical medicine and rehabilitation. “We’re not saying injured workers can’t have surgery. We’re simply trying to educate patients and providers as much as possible about the risks involved and requiring other treatment options before choosing surgery. Our research, as well as research throughout the industry, suggests fusion surgery should be limited to patients only when it is clearly indicated.”

The number of lumbar fusion procedures performed on Ohio workers’ comp claimants dropped from 1,375 in 2002 to 563 in 2015, following trends nationwide. Even so, lower back injuries continue to be among the top injury types among Ohio workers each year.

The fusion rule’s goals are to: ensure the incorporation of best current clinical practices in the utilization of lumbar fusion surgery in the treatment of injured workers; ensure injured workers’ awareness of treatment options for allowed lumbar conditions and increase their awareness of potential outcomes; promote, at minimum, a two-month course of comprehensive conservative care for allowed lumbar conditions unless otherwise indicated, prior to consideration of lumbar fusion surgery; and provide criteria for consideration of lumbar fusion surgery when the injured worker’s condition has remained unchanged or worsened despite utilization of conservative care.

Exceptions to the rule include conditions that require more immediate intervention, such as spinal fractures, tumors, and infections, as well as progressive functional neurological deficits.

The rule does not expressly prohibit opioid use for pain management, but calls for “avoidance when possible.” Under BWC’s new opioid rule passed last year, physicians must follow best practice guidelines when prescribing the drugs or risk sanctions.

The spinal fusion rule now moves to the Joint Committee on Agency Rule Review, a bipartisan panel of state lawmakers. If approved there, it would become effective Jan. 1, 2018.

Staff report