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Lumbar fusion of variable value based on treating diagnosis, with significant complication rates
Clinical Question
What are the benefits and harms of lumbar fusion for degenerative low back pain?
Bottom line
Lumbar fusion for degnerative spinal disease appears to be most beneficial for patients undergoing the procedure for spondylolisthesis, but is of little clear benefit for patients with other indications, such as spinal stenosis or chronic back pain. And the risk of reoperation or complications is greater for patients with spinal stenosis who undergo fusion compared with those who have decompression alone. 1a-
Reference
Study design: Meta-analysis (other)
Funding: Unknown/not stated
Setting: Outpatient (specialty)
Synopsis
Spinal fusion is an expensive procedure of uncertain value that has high cost and regional variability in annual incidence. These authors performed a careful search of the literature to identify randomized trials (n = 19), cohort studies (n = 16 prospective and 15 retrospective), and registries (n = 15) that compared the outcomes of lumbar fusion, decompression, and/or nonoperative care for degenerative spine disease. They performed a comprehensive search to identify randomized trials and cohort studies with at least 2 arms, at least 2 participants per arm, and with at least 12 months of follow-up. Studies were generally at high risk of bias because of inadequate randomization, masking, and allocation concealment; this would tend to bias the studies in favor of active therapy. I'll focus here primarily on the results from the randomized trials. Regarding the Oswestry Disability Index (a 100-point scale), there was a statistically, but not clinically, significant 5-point improvement with fusion compared with nonoperative care for patients with chronic back pain, and a statistically and clinically significant 17-point improvement for those with spondylolisthesis as the indication. Results were similar for a visual analog scale measuring leg pain, with the improvement having statistical and clinical significance for patients with spondylolisthesis (2.2 points on a 10-point scale). Leg pain was largely evaluated in registry studies, and was not more improved by fusion than by decompression in patients with any indication. Patient satisfaction was greater for fusion compared with nonoperative care among patients with spondylolisthesis, but much less so for those with low back pain. There were no significant differences in risk of death, although confidence intervals were quite broad. Based mainly on registry and cohort studies, the risk of reoperation was greater for patients undergoing fusion than decompression if the indication was spinal stenosis (relative risk [RR] 1.17; 95% CI 1.06 - 1.28), but the opposite was true if spondylolisthesis was the indication (RR 0.75; 0.68 - 0.83). Finally, based on a mix of study designs, the risk of complications was greater for patients undergoing fusion than decompression alone (RR 1.70; 1.50 - 1.92).
Reviewer
Mark H. Ebell, MD, MS
Professor
University of Georgia
Athens, GA
Comments
Good poem
I have long felt that fusion is vastly overdone. Back pain alone is not an indication at all. Instability may be after all other options have been exhausted.
In the cervical spine disc replacement has a place in the appropriate candidate but is high risk in the lumbar region with present technology.
V. Useful information. Final decision neurosurgeon’s.
Il est bon de savoir que la fusion des vertébrés a le plus d´utilité dans le contexte de spondylolisthésie mais pour les simples sténoses, il vaut mieux ne faire que les décompressions.
I have not seen benefit of spinal stenosis in spondylosis with 5-6 mm dynamic instability but some mechanical radiculopathy with dynamic instability will have good result with limited and less invasive instrumented fusion. I think too may instrumented fusion is being done now I am looking forward for this kind of study .
I guess that Tiger Woods should have read this before embarking on his spinal surgery program.
I have found that the great majority, 90%, of my low back pain patients have sacroiliac joint dysfunction rather than lumbar spine pathology. With the appropriate examination and treatment, I can eliminate sacroiliac joint pain in 50% of those afflicted and relieve it in a further 30%. I will be presenting a poster to that effect at the Canadian pain Society meeting in May.
I am not the one who makes the decision about surgery or not...I want to send my patients for a surgical opinion in reasonable situations however.
It seems like patients with spondylolisthesis do best with surgery - this makes sense from what I have seen. It seems as if fusion might not be a good thing. Decompression seems to be the way to go.
I would like to see the same kind of review for epidural and facet joint injections...
Excellent