• Thomas E Mroz, Daniel C Norvell, Erika Ecker, Marcelo Gruenberg, Andrew Dailey, and Darrel S Brodke.
• Spine Surgery Fellowship, Cleveland Clinic, Euclid Avenue, Cleveland, OH 44130, USA. mrozt@ccf.org
• Spine. 2011 Oct 1;36(21 Suppl):S75-86.

Study DesignSystematic review.ObjectiveThe 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.Summary Of Background DataChronic 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.MethodsSystematic 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.ResultsThe 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.ConclusionSociodemographic 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.Clinical RecommendationsSociodemographic 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.

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