====== Lumbar fusion indications ======

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Due to uncertain evidence, lumbar [[fusion]] for degenerative indications is associated with the greatest measured practice variation of any surgical procedure.

====Systematic reviews====
===2017===
In 2017, a systematic review was conducted using PubMed, MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials (up to June 30, 2016). Comparative studies reporting validated measures of safety or efficacy were included. Treatment effects were calculated through DerSimonian and Laird random effects models.

The literature search yielded 65 studies (19 randomized controlled trials, 16 prospective cohort studies, 15 retrospective cohort studies, and 15 registries) enrolling a total of 302 620 patients. Disability, pain, and patient satisfaction following fusion, decompression-alone, or nonoperative care were dependent on surgical indications and study methodology. Relative to decompression-alone, the risk of reoperation following fusion was increased for spinal stenosis (relative risk [RR] 1.17, 95% confidence interval [CI] 1.06-1.28) and decreased for spondylolisthesis (RR 0.75, 95% CI 0.68-0.83). Among patients with spinal stenosis, complications were more frequent following fusion (RR 1.87, 95% CI 1.18-2.96). Mortality was not significantly associated with any treatment modality.

Positive clinical change was greatest in patients undergoing fusion for spondylolisthesis while complications and the risk of reoperation limited the benefit of fusion for spinal stenosis. The relative safety and efficacy of fusion for chronic low back pain suggests careful patient selection is required ([[PROSPERO]] International Prospective Register of Systematic Reviews number, CRD42015020153)
((Yavin D, Casha S, Wiebe S, Feasby TE, Clark C, Isaacs A, Holroyd-Leduc J,
Hurlbert RJ, Quan H, Nataraj A, Sutherland GR, Jette N. Lumbar Fusion for
Degenerative Disease: A Systematic Review and Meta-Analysis. Neurosurgery. 2017
Mar 17. doi: 10.1093/neuros/nyw162. [Epub ahead of print] PubMed PMID: 28327997.
)).

===2008===
The objective of this study was to evaluate lumbar fusion and nonsurgical interventions for various degenerative spine disorders using the Oswestry Disability Index (ODI) as a primary outcome measure in a systematic review. A secondary objective was to determine whether there is a difference in clinical outcomes based on the specific diagnosis.

Patients with low back pain of at least 12 weeks duration and older than 18 years, with prospectively collected ODI scores and at least a 12-month follow-up.

A MEDLINE, HealthSTAR, CINAHL, and Cochrane database search was done using the search strategy recommended by the Cochrane Back Review Group. Proceedings from annual meetings of various spine societies and reference lists from review articles and retrieved articles were evaluated for possible inclusion. Criteria for inclusion were prospective randomized clinical trials in patients with low back pain of at least 12 weeks duration and older than 18 years; with prospectively collected ODI scores and at least a 12-month follow-up. The methodological quality of the studies was assessed using the van Tulder criteria. Data extracted from each study included demographics, study design, diagnosis, baseline and change in ODI, and baseline and change in SF-36 Physical Composite Score (PCS). The data were pooled and analyzed based on the primary reported inclusion diagnosis: degenerative disc disease (DDD), chronic low back pain (CLBP), and spondylolisthesis; and treatment: fusion (unspecified, posterior, anterior, combined) and nonsurgical.

Twenty-five studies met the inclusion criteria. The distribution of sex and smokers was similar across diagnoses and treatments. Patients with spondylolisthesis were older than patients with DDD and CLBP. Patients with spondylolisthesis had the greatest ODI improvement followed by patients with DDD and CLBP. The three fusion types produced similar amounts of improvement in ODI. Nonsurgical patients did not improve as much but had a lower baseline ODI. Improvements in the SF-36 PCS were fairly consistent across diagnostic groups and treatment types.

Substantial improvement can be expected in patients treated with fusion, regardless of technique, when an established indication such as spondylolisthesis or DDD exists. CLBP patients are less disabled and experience less improvement
((Carreon LY, Glassman SD, Howard J. Fusion and nonsurgical treatment for
symptomatic lumbar degenerative disease: a systematic review of Oswestry
Disability Index and MOS Short Form-36 outcomes. Spine J. 2008
Sep-Oct;8(5):747-55. Epub 2007 Nov 26. Review. PubMed PMID: 18037354.
)).

===2005===
In 2005 Based on the medical evidence derived from the scientific literature on this topic, there does not appear to be evidence to support the hypothesis that fusion (with or without instrumentation) provides any benefit over decompression alone in the treatment of lumbar stenosis in patients in whom there is no evidence of preoperative deformity or instability. A single report provides Class II medical evidence and several papers provide Class III medical evidence suggesting that the addition of fusion to decompression in patients with lumbar stenosis and instability evidenced by movement on preoperative flexion-extension radiographs does improve outcome. There are also reports (Class III medical evidence) indicating that patients with lumbar stenosis, without deformity or instability, treated with wide decompression or facetectomy may suffer iatrogenic lumbar instability. Fusion in these patients may improve outcome. There is conflicting Class III medical evidence regarding the application of instrumentation in addition to PLF in patients treated for lumbar stenosis without deformity or preoperative instability
((Resnick DK, Choudhri TF, Dailey AT, Groff MW, Khoo L, Matz PG, Mummaneni P,
Watters WC 3rd, Wang J, Walters BC, Hadley MN; American Association of
Neurological Surgeons/Congress of Neurological Surgeons. Guidelines for the
performance of fusion procedures for degenerative disease of the lumbar spine.
Part 10: fusion following decompression in patients with stenosis without
spondylolisthesis. J Neurosurg Spine. 2005 Jun;2(6):686-91. PubMed PMID:
16028738.
))

However, fusion of the lumbar spine is sometimes avoided in these patients due to fears of increased [[complication]] rates with advanced age. Consequently, incomplete and inadequate decompression may potentially result
((Glassman SD, Carreon LY, Dimar JR, Campbell MJ, Puno RM, Johnson JR. Clinical outcomes in older patients after posterolateral lumbar fusion. Spine J. 2007;7(5):547–551.)).

Although the benefits and advantages of have been well established, the safety and efficacy of spinal fusion in the elderly population remains uncertain with conflicting data
((Carreon LY, Puno RM, Dimar JR II, Glassman SD, Johnson JR. Perioperative complications of posterior lumbar decompression and arthrodesis in older adults. J Bone Joint Surg Am. 2003;85-A(11):2089–2092.))
((Raffo CS, Lauerman WC. Predicting morbidity and mortality of lumbar spine arthrodesis in patients in their ninth decade. Spine (Phila Pa 1976). 2006;31(1):99–103.))
((Kilincer C, Steinmetz MP, Sohn MJ, Benzel EC, Bingaman W. Effects of age on the perioperative characteristics and short-term outcome of posterior lumbar fusion surgery. J Neurosurg Spine. 2005;3(1):34–39.))
((Cassinelli EH, Eubanks J, Vogt M, Furey C, Yoo J, Bohlman HH. Risk factors for the development of perioperative complications in elderly patients undergoing lumbar decompression and arthrodesis for spinal stenosis: an analysis of 166 patients. Spine (Phila Pa 1976). 2007;32(2):230–235.))
((Benz RJ, Ibrahim ZG, Afshar P, Garfin SR. Predicting complications in elderly patients undergoing lumbar decompression. Clin Orthop Relat Res. 2001(384):116–121.))
((Cloyd JM, Acosta FL Jr, Ames CP. Complications and outcomes of lumbar spine surgery in elderly people: a review of the literature. J Am Geriatr Soc. 2008;56(7):1318–1327.))
((Chou WY, Hsu CJ, Chang WN, Wong CY. Adjacent segment degeneration after lumbar spinal posterolateral fusion with instrumentation in elderly patients. Arch Orthop Trauma Surg. 2002;122(1):39–43.))
((Acosta FL, Cloyd JM, Aryan HE, Ames CP. Perioperative complications and clinical outcomes of multilevel circumferential lumbar spinal fusion in the elderly. J Clin Neurosci. 2009;16(1):69–73.)).

The role of fusion of lumbar motion segments for the treatment of intractable [[low back pain]] (LBP) from degenerative disc disease (DDD) without deformities or instabilities remains controversially debated. 

Characterizing indications for fusion based solely on primary ICD-9-CM codes extracted from large administrative databases does not accurately reflect the surgeon's indication. While these databases may accurately describe national rates of lumbar fusion surgery, the lack of fidelity in the source codes limits their role in accurately identifying indications for surgery. Studying relationships among indications, complications, and outcomes stratified solely by ICD-9-CM codes is not well founded
((Gologorsky Y, Knightly JJ, Chi JH, Groff MW. The Nationwide Inpatient Sample
database does not accurately reflect surgical indications for fusion. J Neurosurg
Spine. 2014 Oct 17:1-10. [Epub ahead of print] PubMed PMID: 25325170.)).