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Commentary and Perspective   |    
The Spine Patient Outcomes Research Trial (SPORT): A Continuing Return on InvestmentCommentary on an article by Jeffrey A. Rihn, MD, et al.: “The Influence of Obesity on the Outcome of Treatment of Lumbar Disc Herniation. Analysis of the Spine Patient Outcomes Research Trial (SPORT)”
Robert A. Hart, MD, MA1
1 Oregon Health & Science University, Portland, Oregon
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This article was chosen to appear electronically on November 28, 2012, in advance of publication in a regularly scheduled issue.



Disclosure: The author did not receive payments or services, either directly or indirectly (i.e., via his institution), from a third party in support of any aspect of this work. He, or his institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. The author has had another relationship, or has engaged in another activity, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2013 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2013 Jan 02;95(1):e5 1-2. doi: 10.2106/JBJS.L.01415
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Dr. Rihn and his coauthors are to be congratulated on their excellent publication titled “The Influence of Obesity on the Outcome of Treatment of Lumbar Disc Herniation. Analysis of the Spine Patient Outcomes Research Trial (SPORT).” This study represents a retrospective analysis of prospectively collected data from the Spine Patient Outcomes Research Trial (SPORT), focusing on patients with radiculopathy due to lumbar disc herniation and specifically on the influence of obesity on complication rates, reoperation rates, and patient-reported outcomes.
Although the original SPORT study was a randomized clinical trial, for this study, the authors have utilized an as-treated analysis, eliminating the design benefit of randomization. In addition, this is a retrospective analysis of data that were not initially collected with the intent to evaluate the effect of obesity on outcomes. Finally, several potential confounding variables, including sex, education and income levels, compensation claims, and medical comorbidities, differed at baseline between obese patients and nonobese patients.
Recognizing these limitations, the current study nonetheless represents the highest-level medical evidence yet presented, analyzing the effect of obesity in patients managed operatively and nonoperatively for lumbar disc herniation. Importantly, although obese patients did not share the same clinical benefit that nonobese patients did from either operative or nonoperative interventions, both groups showed significant improvements in clinical outcomes with operative treatment compared with nonoperative treatment for this condition. Other important conclusions were that complication and reoperation rates were similar between the two groups, despite the finding that operative times and length of hospitalization were slightly longer for obese patients.
Perhaps the most important aspect of this publication is its demonstration of the remarkable value returned on the financial investment and work effort in the SPORT study1-4. A brief PubMed search reveals that the total number of peer-reviewed publications derived from the SPORT database is approaching forty. Although the primary clinical reports of patient outcomes with lumbar disc herniation2, lumbar spinal stenosis3, and degenerative spondylolisthesis4 in themselves represent a landmark achievement, continuing subanalyses of the SPORT database have provided high-quality evidence, furthering our understanding of specific variables of importance in managing these patients. Indeed, the accomplishments of the SPORT investigators serve as a unique demonstration of the importance and impact of high-quality orthopaedic research. The current study represents the latest installment in this ongoing enterprise, and as such is a welcome addition to the orthopaedic literature.
Birkmeyer  NJ;  Weinstein  JN;  Tosteson  AN;  Tosteson  TD;  Skinner  JS;  Lurie  JD;  Deyo  R;  Wennberg  JE. Design of the Spine Patient Outcomes Research Trial (SPORT). Spine (Phila Pa 1976).  2002;27(  12):1361-72.[CrossRef][PubMed]
 
Weinstein  JN;  Tosteson  TD;  Lurie  JD;  Tosteson  AN;  Hanscom  B;  Skinner  JS;  Abdu  WA;  Hilibrand  AS;  Boden  SD;  Deyo  RA. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT): a randomized trial. JAMA.  2006;296(  20):2441-50.[CrossRef][PubMed]
 
Weinstein  JN;  Tosteson  TD;  Lurie  JD;  Tosteson  AN;  Blood  E;  Hanscom  B;  Herkowitz  H;  Cammisa  F;  Albert  T;  Boden  SD;  Hilibrand  A;  Goldberg  H;  Berven  S;  An  H; SPORT Investigators. Surgical versus nonsurgical therapy for lumbar spinal stenosis. N Engl J Med.  2008;358(  8):794-810.[CrossRef][PubMed]
 
Weinstein  JN;  Lurie  JD;  Tosteson  TD;  Hanscom  B;  Tosteson  AN;  Blood  EA;  Birkmeyer  NJ;  Hilibrand  AS;  Herkowitz  H;  Cammisa  FP;  Albert  TJ;  Emery  SE;  Lenke  LG;  Abdu  WA;  Longley  M;  Errico  TJ;  Hu  SS. Surgical versus nonsurgical treatment for lumbar degenerative spondylolisthesis. N Engl J Med.  2007;356(  22):2257-70.[CrossRef][PubMed]
 

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References

Birkmeyer  NJ;  Weinstein  JN;  Tosteson  AN;  Tosteson  TD;  Skinner  JS;  Lurie  JD;  Deyo  R;  Wennberg  JE. Design of the Spine Patient Outcomes Research Trial (SPORT). Spine (Phila Pa 1976).  2002;27(  12):1361-72.[CrossRef][PubMed]
 
Weinstein  JN;  Tosteson  TD;  Lurie  JD;  Tosteson  AN;  Hanscom  B;  Skinner  JS;  Abdu  WA;  Hilibrand  AS;  Boden  SD;  Deyo  RA. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT): a randomized trial. JAMA.  2006;296(  20):2441-50.[CrossRef][PubMed]
 
Weinstein  JN;  Tosteson  TD;  Lurie  JD;  Tosteson  AN;  Blood  E;  Hanscom  B;  Herkowitz  H;  Cammisa  F;  Albert  T;  Boden  SD;  Hilibrand  A;  Goldberg  H;  Berven  S;  An  H; SPORT Investigators. Surgical versus nonsurgical therapy for lumbar spinal stenosis. N Engl J Med.  2008;358(  8):794-810.[CrossRef][PubMed]
 
Weinstein  JN;  Lurie  JD;  Tosteson  TD;  Hanscom  B;  Tosteson  AN;  Blood  EA;  Birkmeyer  NJ;  Hilibrand  AS;  Herkowitz  H;  Cammisa  FP;  Albert  TJ;  Emery  SE;  Lenke  LG;  Abdu  WA;  Longley  M;  Errico  TJ;  Hu  SS. Surgical versus nonsurgical treatment for lumbar degenerative spondylolisthesis. N Engl J Med.  2007;356(  22):2257-70.[CrossRef][PubMed]
 
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These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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