An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spondylolisthesis

Watters, William C.; Bono, Christopher M.; Gilbert, Thomas; Kreiner, D. Scott; Mazanec, Daniel J.; Shaffer, William O.; Baisden, Jamie; Easa, John E.; Fernand, Robert; Ghiselli, Gary; Heggeness, Michael H.; Mendel, Richard C.; O’Neill, Conor; Reitman, Charles A.; Resnick, Daniel K.; Summers, Jeffrey T.; Timmons, Reuben B.; Toton, John F.

doi:10.1016/j.spinee.2009.03.016

Cited by 139 publications

(90 citation statements)

References 33 publications

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“…Two excluded review studies [25,45] did not use an accepted pooling method. For example, McGirt et al [25] included the comparative studies and the case series and analyzed both study designs in the same analysis.…”

Section: No Firm Conclusionmentioning

confidence: 99%

The evidence on surgical interventions for low back disorders, an overview of systematic reviews

et al. 2013

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Purpose Many systematic reviews have been published on surgical interventions for low back disorders. The objective of this overview was to evaluate the available evidence from systematic reviews on the effectiveness of surgical interventions for disc herniation, spondylolisthesis, stenosis, and degenerative disc disease (DDD). An earlier version of this review was published in 2006 and since then, many new, better quality reviews have been published. Methods A comprehensive search was performed in the Cochrane database of systematic reviews (CDSR), database of reviews of effectiveness (DARE) and Pubmed. Two reviewers independently performed the selection of studies, risk of bias assessment, and data extraction. Included are Cochrane reviews and non-Cochrane systematic reviews published in peer-reviewed journals. The following conditions were included: disc herniation, spondylolisthesis, and DDD with or without spinal stenosis. The following comparisons were evaluated: (1) surgery vs. conservative care, and (2) different surgical techniques compared to one another. The methodological quality of the systematic reviews was evaluated using AMSTAR. We report (pooled) analyses from the individual reviews. Results Thirteen systematic reviews on surgical interventions for low back disorders were included for disc herniation (n = 6), spondylolisthesis (n = 2), spinal stenosis (n = 4), and DDD (n = 4). Nine (69 %) were of high quality. Five reviews provided a meta-analysis of which two showed a significant difference. For the treatment of spinal stenosis, intervertebral process devices showed more favorable results compared to conservative treatment on the Zurich Claudication Questionnaire [mean difference (MD) 23.2 95 % CI 18.5-27.8]. For degenerative spondylolisthesis, fusion showed more favorable results compared to decompression for a mixed aggregation of clinical outcome measures (RR 1.40 95 % CI 1.04-1.89) and fusion rate favored instrumented fusion over non-instrumented fusion (RR 1.37 95 % CI 1.07-1.75). 123Eur Spine J ( ) 22:1936( -1949( DOI 10.1007( /s00586-013-2823 Conclusions For most of the comparisons, the included reviews were not significant and/or clinically relevant differences between interventions were identified. Although the quality of the reviews was quite acceptable, the quality of the included studies was poor. Future studies are likely to influence our assessment of these interventions.

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Section: No Firm Conclusionmentioning

confidence: 99%

The evidence on surgical interventions for low back disorders, an overview of systematic reviews

et al. 2013

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“…Degenerative lumbar spondylolisthesis has been investigated extensively from a management perspective, 41,56,58 and there is strong evidence to support surgical intervention. 47,58,59 However, it is not clear which surgery should be used to treat DLS, and there is no agreement on the role that instability should play in the treatment algorithm.…”

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confidence: 99%

“…47,58,59 However, it is not clear which surgery should be used to treat DLS, and there is no agreement on the role that instability should play in the treatment algorithm. It seems prudent to define symptomatic DLS in terms of stability to better target the optimal surgical technique and implant construct from an outcome and cost perspective.…”

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confidence: 99%

Defining the inherent stability of degenerative spondylolisthesis: a systematic review

Simmonds

Rampersaud

Dvorak

et al. 2015

SPI

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OBJECT A range of surgical options exists for the treatment of degenerative lumbar spondylolisthesis (DLS). The chosen technique inherently depends on the stability of the DLS. Despite a substantial body of literature dedicated to the outcome analysis of numerous DLS procedures, no consensus has been reached on defining or classifying the disorder with respect to stability or the role that instability should play in a treatment algorithm. The purpose of this study was to define grades of stability and to develop a guide for deciding on the optimal approach in surgically managing patients with DLS. METHODS The authors conducted a qualitative systematic review of clinical or biomechanical analyses evaluating the stability of and surgical outcomes for DLS for the period from 1990 to 2013. Research focused on nondegenerative forms of spondylolisthesis or spinal stenosis without associated DLS was excluded. The primary extracted results were clinical and radiographic parameters indicative of DLS instability. RESULTS The following preoperative parameters are predictors of stability in DLS: restabilization signs (disc height loss, osteophyte formation, vertebral endplate sclerosis, and ligament ossification), no disc angle change or less than 3 mm of translation on dynamic radiographs, and the absence of low-back pain. The validity and magnitude of each parameter’s contribution can only be determined through appropriately powered prospective evaluation in the future. Identifying these parameters has allowed for the creation of a preliminary DLS instability classification (DSIC) scheme based on the preoperative assessment of DLS stability. CONCLUSIONS Spinal stability is an important factor to consider in the evaluation and treatment of patients with DLS. Qualitative assessment of the best available evidence revealed clinical and radiographic parameters for the creation of the DSIC, a decision aid to help surgeons develop a method of preoperative evaluation to better stratify DLS treatment options.

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“…However, based on current evidence-based guidelines, those populations are not those that surgery should be offered to. 27 In contrast, surgical treatments for structural lowback diseases have been shown to be cost-effective and provide sustained improvement over time. A recent study by Glassman et al demonstrated that lumbar fusion is an effective, durable, and cost-effective treatment in a longterm 5-year follow-up.…”

Section: Discussionmentioning

confidence: 99%

Two-year comprehensive medical management of degenerative lumbar spine disease (lumbar spondylolisthesis, stenosis, or disc herniation): a value analysis of cost, pain, disability, and quality of life

Parker

Godil

Mendenhall³

et al. 2014

SPI

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Object Current health care reform calls for a reduction of procedures and treatments that are less effective, more costly, and of little value (high cost/low quality). The authors assessed the 2-year cost and effectiveness of comprehensive medical management for lumbar spondylolisthesis, stenosis, and herniation by utilizing a prospective single-center multidisciplinary spine center registry in a real-world practice setting. Methods Analysis was performed on a prospective longitudinal quality of life spine registry. Patients with lumbar spondylolisthesis (n = 50), stenosis (n = 50), and disc herniation (n = 50) who had symptoms persisting after 6 weeks of medical management and who were eligible for surgical treatment were entered into a prospective registry after deciding on nonsurgical treatment. In all cases, comprehensive medical management included spinal steroid injections, physical therapy, muscle relaxants, antiinflammatory medication, and narcotic oral agents. Two-year patient-reported outcomes, back-related medical resource utilization, and occupational work-day losses were prospectively collected and used to calculate Medicare fee–based direct and indirect costs from the payer and societal perspectives. The maximum health gain associated with medical management was defined as the improvement in pain, disability, and quality of life experienced after 2 years of medical treatment or at the time a patient decided to cross over to surgery. Results The maximum health gain in back pain, leg pain, disability, quality of life, depression, and general health state did not achieve statistical significance by 2 years of medical management, except for pain and disability in patients with disc herniation and back pain in patients with lumbar stenosis. Eighteen patients (36%) with spondylolisthesis, 11 (22%) with stenosis, and 17 (34%) with disc herniation eventually required surgical management due to lack of improvement. The 2-year improvement did not achieve a minimum clinically important difference in any outcome measure. The mean 2-year total cost (direct plus indirect) of medical management was $6606 for spondylolisthesis, $7747 for stenosis, and $7097 for herniation. Conclusions In an institution-wide, prospective, longitudinal quality of life registry that measures cost and effectiveness of all spine care provided, comprehensive medical management did not result in sustained improvement in pain, disability, or quality of life for patients with surgically eligible degenerative lumbar spondylolisthesis, stenosis, or disc herniation. From both the societal and payer perspective, continued medical management of patients with these lumbar pathologies in whom 6 weeks of conservative therapy failed was of minimal value given its lack of health utility and effectiveness and its health care costs. The findings from this real-world practice setting may more accurately reflect the true value and effectiveness of nonoperative care in surgically eligible patient populations.

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An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spondylolisthesis

Cited by 139 publications

References 33 publications

The evidence on surgical interventions for low back disorders, an overview of systematic reviews

The evidence on surgical interventions for low back disorders, an overview of systematic reviews

Defining the inherent stability of degenerative spondylolisthesis: a systematic review

Two-year comprehensive medical management of degenerative lumbar spine disease (lumbar spondylolisthesis, stenosis, or disc herniation): a value analysis of cost, pain, disability, and quality of life

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