Lumbar fusion indications

• Advances in Endoscopic Lumbar Spine Surgery: A Comprehensive Review of the Techniques used for the Treatment of Lumbar Disc Herniations and Spinal Stenosis and Lumbar Spinal Fusion
• Optimizing TLIF Approach Selection: An Algorithmic Framework with Illustrative Cases
• Robotically assisted and minimally invasive pedicle screw placement at the lumbar spine
• Early Return to Play Following Conservative Treatment of a Lumbar Flexion-Distraction Injury in a Professional Soccer Player: A Case Report
• Is Minimally Invasive Superior to Traditional Open Technique for 2-Segmental Transforaminal Interbody Fusion in the Treatment of Lumbar Degenerative Disease?
• Identifying patients at risk of increased health utilization following lumbar spine surgery
• Intraoperative Venous Injury During Anterior Lumbar Interbody Fusion: Incidence, Risk Factors, and Complications
• Streamlining the Journey of Research Into Clinical Practice: Making Your Patients and Practice Flourish: When to Fuse? An Evidence Based Review of Treatment Strategies in Degenerative Spondylolisthesis

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

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) ¹⁾.

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 ²⁾.

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 ³⁾

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 ⁴⁾.

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 ^{5) 6) 7) 8) 9) 10) 11) 12)}.

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 ¹³⁾.