As back injuries continue to be a top concern in workers compensation, states such as Ohio look to implement best practices that address long-term outcomes for injured workers.

A new rule from the Ohio Bureau of Workers’ Compensation aims to discourage lumbar fusion surgery and the use of opioids for workers with lower back injuries. The rule requires that workers undergo at least 60 days of comprehensive conservative care, including physical therapy, chiropractic care, rest, anti-inflammatories, ice and other nonsurgical remedies, before considering surgical options.

Conditions that require immediate intervention, such as spinal fractures, tumors, infections and functional neurological deficits, are exceptions to the rule, the bureau said.

This is standard practice, according to Dr. Richard Deyo, Kaiser Permanente professor of evidence-based family medicine and professor of medicine at Oregon Health and Science University in Portland. Most clinicians would recommend a course of nonsurgical therapy for most patients with back pain prior to considering surgery, he said.

“The most common situation in work-related back pain is simply that patients have pain and often little in the way of actual neurological injury — usually not fractures of the spine, but simply back pain — and in that situation, it makes a lot of sense to try aggressive nonsurgical therapy first,” Dr. Deyo said. “This is true for patients who have back pain alone, and even for patients who have a herniated disk in most cases. It’s worth waiting that length of time because patients will improve over that length in time without surgery.”

Employer groups such as The Ohio Manufacturers’ Association have expressed support for the rule, which in their view reinforces return to work and prevents potentially unnecessary surgical procedures.

“Our goal when it comes to the workers compensation system in Ohio is to make sure that our employees get the best medical treatment possible and get back to work as soon as possible,” said Rob Brundrett, Columbus, Ohio-based director of public policy services for The Ohio Manufacturers’ Association. “The rule change, speaking and working with the bureau ... their take is that this is best practices.” 

While Ohio’s specific waiting period for spinal fusion surgery may be unique, other states have taken other steps to discourage a rush to surgery and to promote conservative treatments prior to allowing fusion surgery for lower back injuries.

Washington, which like Ohio is a monopoly workers comp state where employers must buy workers comp insurance from a state-operated insurance fund rather than private insurers, encourages conservative care for back pain and injuries prior to authorizing lumbar fusion surgery except in cases of spinal fractures or dislocation, infection or deformities, according to guidelines published by the Washington State Department of Labor and Industries. Only after conservative care fails to improve symptoms does the agency allow lumbar fusion surgery.

The agency’s spinal fusion guidelines note that more than half of Washington workers who received lumbar fusion surgery through the state’s comp program reported that their pain and functional recovery were no better afterward, and that about two in three workers who received it remained disabled two years after surgery.

In 2016, Wyoming, another monopoly workers comp state, implemented a spine treatment protocol based on two spine studies sponsored by the Wyoming Legislature in 2011 and 2013. The protocol encourages six weeks of conservative treatment beginning within 48 hours of the injury, along with ongoing assessment of the patient’s progress and education of the injured worker. The protocol provides monetary incentives to both injured workers and providers for completing six weeks of conservative therapy and makes all treatment during the six-week protocol nonchargeable to employers.

The state’s action on spinal fusion surgeries was developed because the state observed higher rates of back injuries, related surgeries and medical costs than in other states, in part because of a greater percentage of workers in energy, construction and physical job functions, according to the agency’s website. The protocol is taken from evidence-based medical guidelines that show most back strains and sprains resolve within six weeks with conservative treatment.

Other states effectively require a waiting period by mandating physicians follow guidelines such as the Work Loss Data Institute’s Official Disability Guidelines when treating patients for occupational injuries.

At least 14 states require physicians to follow mandatory guidelines that address treatment for lumbar spine injuries, said Barry Lipton, practice leader and senior actuary at the Boca Raton, Florida-based National Council on Compensation Insurance Inc.

Some of these mandatory guidelines effectively create a waiting period for surgery even where not explicitly stated, Mr. Lipton said. Texas, for example, requires doctors to wait up to four weeks before ordering X-rays or MRIs in routine back injury cases that don’t raise red flags. Because this type of imaging would be required before a fusion surgery, a de facto waiting period is created, he said.

The idea behind imposing waiting periods for imaging is because most back injuries resolve on their own with conservative treatment and because imaging rarely changes prescribed treatment, Mr. Lipton said.