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Meta-Analysis
. 2005 Oct 19;2005(4):CD001352.
doi: 10.1002/14651858.CD001352.pub3.

Surgery for degenerative lumbar spondylosis

J N A Gibson  1 , G Waddell
Affiliations
Meta-Analysis

Surgery for degenerative lumbar spondylosis

J N A Gibson et al. Cochrane Database Syst Rev. .

Abstract

Background: Surgical investigations and interventions account for large health care utilisation and costs, but the scientific evidence for most procedures is still limited.

Objectives: Degenerative conditions affecting the lumbar spine are variously described as lumbar spondylosis or degenerative disc disease (which we regarded as one entity) and may be associated with back pain and associated leg symptoms, instability, spinal stenosis and/or degenerative spondylolisthesis. The objective of this review was to assess current scientific evidence on the effectiveness of surgical interventions for degenerative lumbar spondylosis.

Search strategy: We searched CENTRAL, MEDLINE, PubMed, Spine and ISSLS abstracts, with citation tracking from the retrieved articles. We also corresponded with experts. All data found up to 31 March 2005 are included.

Selection criteria: Randomised (RCTs) or quasi-randomised trials of surgical treatment of lumbar spondylosis.

Data collection and analysis: Two authors assessed trial quality and extracted data from published papers. Additional information was sought from the authors if necessary.

Main results: Thirty-one published RCTs of all forms of surgical treatment for degenerative lumbar spondylosis were identified. The trials varied in quality: only the more recent trials used appropriate methods of randomization, blinding and independent assessment of outcome. Most of the earlier published results were of technical surgical outcomes with some crude ratings of clinical outcome. More of the recent trials also reported patient-centered outcomes of pain or disability, but there is still very little information on occupational outcomes. There was a particular lack of long term outcomes beyond two to three years. Seven heterogeneous trials on spondylolisthesis, spinal stenosis and nerve compression permitted limited conclusions. Two new trials on the effectiveness of fusion showed conflicting results. One showed that fusion gave better clinical outcomes than conventional physiotherapy, while the other showed that fusion was no better than a modern exercise and rehabilitation programme. Eight trials showed that instrumented fusion produced a higher fusion rate (though that needs to be qualified by the difficulty of assessing fusion in the presence of metal-work), but any improvement in clinical outcomes is probably marginal, while there is other evidence that it may be associated with higher complication rates. Three trials with conflicting results did not permit any conclusions about the relative effectiveness of anterior, posterior or circumferential fusion. Preliminary results of two small trials of intra-discal electrotherapy showed conflicting results. Preliminary data from three trials of disc arthroplasty did not permit any firm conclusions.

Authors' conclusions: Limited evidence is now available to support some aspects of surgical practice. Surgeons should be encouraged to perform further RCTs in this field.

PubMed Disclaimer

Conflict of interest statement

Nil

Figures

1.1
1.1. Analysis
Comparison 1 DECOMPRESSION vs CONSERVATIVE, Outcome 1 Secondary surgery by 4 years.
1.2
1.2. Analysis
Comparison 1 DECOMPRESSION vs CONSERVATIVE, Outcome 2 Bad result at 10 years.
2.1
2.1. Analysis
Comparison 2 MULTIPLE LAMINOTOMY vs LAMINECTOMY, Outcome 1 No success: combined patient / surgeon rating.
2.2
2.2. Analysis
Comparison 2 MULTIPLE LAMINOTOMY vs LAMINECTOMY, Outcome 2 Spondylolisthesis progression.
3.1
3.1. Analysis
Comparison 3 LAMINECTOMY + FUSION ANY TYPE vs LAMINECTOMY, Outcome 1 Poor result 18‐24 months ‐ Surgeon rating.
3.2
3.2. Analysis
Comparison 3 LAMINECTOMY + FUSION ANY TYPE vs LAMINECTOMY, Outcome 2 Re‐operation 2‐4 years.
3.3
3.3. Analysis
Comparison 3 LAMINECTOMY + FUSION ANY TYPE vs LAMINECTOMY, Outcome 3 Spondylolisthesis progression.
3.4
3.4. Analysis
Comparison 3 LAMINECTOMY + FUSION ANY TYPE vs LAMINECTOMY, Outcome 4 No improvement in walking distance.
3.5
3.5. Analysis
Comparison 3 LAMINECTOMY + FUSION ANY TYPE vs LAMINECTOMY, Outcome 5 Good result at 18‐24 months.
3.6
3.6. Analysis
Comparison 3 LAMINECTOMY + FUSION ANY TYPE vs LAMINECTOMY, Outcome 6 No spondylolisthesis progression.
4.1
4.1. Analysis
Comparison 4 LAMINECTOMY PLUS MULTI‐LEVEL FUSION vs LAMINECTOMY, Outcome 1 Poor result as rated by patient ‐ at 2yrs.
4.2
4.2. Analysis
Comparison 4 LAMINECTOMY PLUS MULTI‐LEVEL FUSION vs LAMINECTOMY, Outcome 2 Poor result as rated by independent assessor ‐ at 2yrs.
4.3
4.3. Analysis
Comparison 4 LAMINECTOMY PLUS MULTI‐LEVEL FUSION vs LAMINECTOMY, Outcome 3 Re‐operation by 28mths.
5.1
5.1. Analysis
Comparison 5 LAMINECTOMY vs NO LAMINECTOMY (Isthmic spondylolisthesis), Outcome 1 No fusion at 4.5yrs.
5.2
5.2. Analysis
Comparison 5 LAMINECTOMY vs NO LAMINECTOMY (Isthmic spondylolisthesis), Outcome 2 No success ‐ Patient rating at 4.5yrs.
6.1
6.1. Analysis
Comparison 6 LAMINECTOMY PLUS ONE LEVEL FUSION (No instrumentation, spinal stenosis + degen spondylolisthesis vs LAMINECT, Outcome 1 Poor result as rated by surgeon ‐ at 36 mths (ave).
6.2
6.2. Analysis
Comparison 6 LAMINECTOMY PLUS ONE LEVEL FUSION (No instrumentation, spinal stenosis + degen spondylolisthesis vs LAMINECT, Outcome 2 Spondylolisthesis progression at 6 months.
6.3
6.3. Analysis
Comparison 6 LAMINECTOMY PLUS ONE LEVEL FUSION (No instrumentation, spinal stenosis + degen spondylolisthesis vs LAMINECT, Outcome 3 Re‐operation required within 4 years.
7.1
7.1. Analysis
Comparison 7 LUMBAR FUSION vs CONSERVATIVE (PHYSICAL) THERAPY, Outcome 1 Fair or Poor outcome (independent observer rated).
7.2
7.2. Analysis
Comparison 7 LUMBAR FUSION vs CONSERVATIVE (PHYSICAL) THERAPY, Outcome 2 Not back to work at 2 years.
7.3
7.3. Analysis
Comparison 7 LUMBAR FUSION vs CONSERVATIVE (PHYSICAL) THERAPY, Outcome 3 Unchanged / worse at two years (patient rating).
8.1
8.1. Analysis
Comparison 8 LUMBAR FUSION vs COGNITIVE EXERCISES (Degenerate disc), Outcome 1 Failure (patient rating) at 1 year.
8.2
8.2. Analysis
Comparison 8 LUMBAR FUSION vs COGNITIVE EXERCISES (Degenerate disc), Outcome 2 Failure (independent assessor) at 1 year.
9.1
9.1. Analysis
Comparison 9 INSTRUMENTED FUSION vs COGNITIVE EXERCISES (Post discectomy), Outcome 1 Failure (patient rating).
9.2
9.2. Analysis
Comparison 9 INSTRUMENTED FUSION vs COGNITIVE EXERCISES (Post discectomy), Outcome 2 Failure (Independent observer rating).
10.1
10.1. Analysis
Comparison 10 POSTERO‐LATERAL FUSION +/‐ INSTRUMENTATION vs EXERCISE THERAPY (Isthmic spondylolisthesis), Outcome 1 Sick leave post treatment.
10.2
10.2. Analysis
Comparison 10 POSTERO‐LATERAL FUSION +/‐ INSTRUMENTATION vs EXERCISE THERAPY (Isthmic spondylolisthesis), Outcome 2 Failure ‐ patient rating.
10.3
10.3. Analysis
Comparison 10 POSTERO‐LATERAL FUSION +/‐ INSTRUMENTATION vs EXERCISE THERAPY (Isthmic spondylolisthesis), Outcome 3 Failure ‐ Assessor rating.
11.1
11.1. Analysis
Comparison 11 INSTRUMENTED FUSION vs LAMINECTOMY (mixed, single/multi‐level), Outcome 1 Poor result as rated by patient ‐ at >2yrs.
11.2
11.2. Analysis
Comparison 11 INSTRUMENTED FUSION vs LAMINECTOMY (mixed, single/multi‐level), Outcome 2 Poor result at 2yrs ‐ surgeon rating.
11.3
11.3. Analysis
Comparison 11 INSTRUMENTED FUSION vs LAMINECTOMY (mixed, single/multi‐level), Outcome 3 Re‐operation at 28mths average.
11.4
11.4. Analysis
Comparison 11 INSTRUMENTED FUSION vs LAMINECTOMY (mixed, single/multi‐level), Outcome 4 Spondylolisthesis progression.
12.1
12.1. Analysis
Comparison 12 INSTRUMENTED POSTEROLATERAL FUSION vs GRAFT ONLY (mixed disease), Outcome 1 Fair/Poor outcome at 1 ‐ 2yr ‐ Surgeon rating.
12.2
12.2. Analysis
Comparison 12 INSTRUMENTED POSTEROLATERAL FUSION vs GRAFT ONLY (mixed disease), Outcome 2 2nd procedure by 2yrs.
12.3
12.3. Analysis
Comparison 12 INSTRUMENTED POSTEROLATERAL FUSION vs GRAFT ONLY (mixed disease), Outcome 3 No fusion at 2 yrs.
12.4
12.4. Analysis
Comparison 12 INSTRUMENTED POSTEROLATERAL FUSION vs GRAFT ONLY (mixed disease), Outcome 4 Poor clinical outcome.
12.5
12.5. Analysis
Comparison 12 INSTRUMENTED POSTEROLATERAL FUSION vs GRAFT ONLY (mixed disease), Outcome 5 Re‐operation at 5 years.
12.6
12.6. Analysis
Comparison 12 INSTRUMENTED POSTEROLATERAL FUSION vs GRAFT ONLY (mixed disease), Outcome 6 Pain score at 5 years.
13.1
13.1. Analysis
Comparison 13 INSTRUMENTED FUSION vs NON‐INSTRUMENTED FUSION (Isthmic spondylolisthesis), Outcome 1 Failure ‐ Patient rating at 2 yr.
13.2
13.2. Analysis
Comparison 13 INSTRUMENTED FUSION vs NON‐INSTRUMENTED FUSION (Isthmic spondylolisthesis), Outcome 2 Failure ‐ Assessor rating.
13.3
13.3. Analysis
Comparison 13 INSTRUMENTED FUSION vs NON‐INSTRUMENTED FUSION (Isthmic spondylolisthesis), Outcome 3 Failed fusion (definitely not solid).
14.1
14.1. Analysis
Comparison 14 INTERBODY FUSION + POSTEROLATERAL FUSION vs POSTERLATERAL FUSION, Outcome 1 Fusion failure.
14.2
14.2. Analysis
Comparison 14 INTERBODY FUSION + POSTEROLATERAL FUSION vs POSTERLATERAL FUSION, Outcome 2 Complications.
14.3
14.3. Analysis
Comparison 14 INTERBODY FUSION + POSTEROLATERAL FUSION vs POSTERLATERAL FUSION, Outcome 3 Not much better.
14.4
14.4. Analysis
Comparison 14 INTERBODY FUSION + POSTEROLATERAL FUSION vs POSTERLATERAL FUSION, Outcome 4 Re‐operation.
15.1
15.1. Analysis
Comparison 15 ALIF PLUS POSTEROLATERAL INSTRUMENTED vs ALIF plus INSTRUMENTED, Outcome 1 Fusion failure.
15.2
15.2. Analysis
Comparison 15 ALIF PLUS POSTEROLATERAL INSTRUMENTED vs ALIF plus INSTRUMENTED, Outcome 2 Re‐operation.
16.1
16.1. Analysis
Comparison 16 GRAF LIGAMENTOPLASTY vs ANTERIOR LUMBAR CAGED FUSION, Outcome 1 Re‐operation.
17.1
17.1. Analysis
Comparison 17 ANTERIOR THREADED CAGE vs FEMORAL RING FUSION, Outcome 1 Failure of fusion.
17.2
17.2. Analysis
Comparison 17 ANTERIOR THREADED CAGE vs FEMORAL RING FUSION, Outcome 2 Secondary procedure.
18.1
18.1. Analysis
Comparison 18 IDET vs SHAM, Outcome 1 No success (observer rated) ‐ at 8 weeks.
19.1
19.1. Analysis
Comparison 19 ANY FORM OF ELECTRICAL STIMULATION vs PLACEBO, Outcome 1 Failure of fusion with internal fixation.
19.2
19.2. Analysis
Comparison 19 ANY FORM OF ELECTRICAL STIMULATION vs PLACEBO, Outcome 2 Failure of fusion without internal fixation.
19.3
19.3. Analysis
Comparison 19 ANY FORM OF ELECTRICAL STIMULATION vs PLACEBO, Outcome 3 Poor clincical outcome.
20.1
20.1. Analysis
Comparison 20 X‐STOP INTERSPINOUS IMPLANT vs CONTROL, Outcome 1 Secondary surgery.
20.2
20.2. Analysis
Comparison 20 X‐STOP INTERSPINOUS IMPLANT vs CONTROL, Outcome 2 Moderate or severe pain.
21.1
21.1. Analysis
Comparison 21 CHARITE DISC REPLACEMENT vs BAK ANTERIOR INTERBODY FUSION, Outcome 1 Oswestry Disability Index at 2 years.
21.2
21.2. Analysis
Comparison 21 CHARITE DISC REPLACEMENT vs BAK ANTERIOR INTERBODY FUSION, Outcome 2 VAS‐pain.
21.3
21.3. Analysis
Comparison 21 CHARITE DISC REPLACEMENT vs BAK ANTERIOR INTERBODY FUSION, Outcome 3 Device failure.
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Update of

References

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Kitchel 2002 {published data only}
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Linovitz 2002 {published data only}
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References to studies excluded from this review

Boden 2002 {published data only}
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Christensen 2003 {published data only}
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Johnsson 2002 {published data only}
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Korovessis 2003 {published data only}
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Sanden 2002 {published data only}
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Transfeldt 2001 {published data only}
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von Strempel 1997 {published data only}
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References to studies awaiting assessment

Fairbank 2005 {published data only}
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References to ongoing studies

Clarke 2003 {published data only}
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Freeman 2005 {published data only}
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