Lumbar Fusion for Degenerative Disease: A Systematic Review and Meta-Analysis

Yavin, Daniel; Casha, Steven; Wiebe, Samuel; Feasby, Thomas E.; Clark, Callie; Isaacs, Albert M.; Holroyd‐Leduc, Jayna; Hurlbert, R. John; Quan, Hude; Nataraj, Andrew; Sutherland, Garnette R.; Jetté, Nathalie

doi:10.1093/neuros/nyw162

Cited by 119 publications

(90 citation statements)

References 89 publications

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“…showed that while decompression rates for lumbar spinal stenosis have doubled in the past decade in Australia, rates for decompression and fusion have quadrupled . Until recently, there were no RCT comparing fusion plus decompression to decompression alone for LSS; therefore, only the most recent review (from 2017 and rated as low quality), included evidence from an RCT (247 patients) . The review, which also included non‐randomised registry studies, reported no advantage of adding fusion to decompression for back pain or disability, and noted an increased rate of reoperation (RR 1.17, 95% CI 1.06–1.28, I 2 = 49.3%) and other complications (RR 1.87, 95% CI 1.18–2.96) in the fusion‐decompression group compared with decompression alone.…”

Section: Other Degenerative Conditionsmentioning

confidence: 99%

“…Complications from spinal fusion surgery for low back pain are common. One moderate-quality review 4 estimated the rate of early surgical complications to be 16% (95% CI [12][13][14][15][16][17][18][19][20]. A more recent low-quality review 13 estimated that complications such as infections, thrombosis, nerve root injury by pedicle screw and major bleeding are much greater with surgery (relative risk (RR) 22.11 (95% CI 5.99-81.60).…”

Section: Low Back Pain and Degenerative Disc Diseasementioning

confidence: 99%

“…Leg pain, one of the main indications for LSS surgery, showed no difference between groups at 24 months, with the single RCT and non-randomised registry studies reporting similar results. 15 Another RCT comparing the same interventions, published in 2016, showed fusion with decompression to provide better quality of life compared to decompression alone for LSS, but this study was restricted to cases with associated spondylolisthesis. Spine fusion for spondylolisthesis is covered below.…”

Section: Other Degenerative Conditionsmentioning

confidence: 99%

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Lumbar spine fusion: what is the evidence?

Harris

Traeger

Stanford

et al. 2018

Internal Medicine Journal

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Lumbar spine fusion is a common procedure associated with a high cost burden and risk of serious complications. We aimed to summarise systematic reviews on the effectiveness of lumbar spine fusion for most diagnoses. We found no high‐quality systematic reviews and the risk of bias of the randomised controlled trials in the reviews was generally high. The available evidence does not support a benefit from spine fusion compared to non‐operative alternatives for back pain associated with degeneration. The available evidence does not support a clinical benefit from spine fusion compared to non‐operative treatment or stabilisation without fusion for thoracolumbar burst fractures. Benefits of spine fusion compared to non‐operative treatment for isthmic spondylolisthesis are unclear (one trial at high risk of bias). Surgical intervention for metastatic carcinoma of the spine associated with spinal cord compromise improves mobility and neurological outcome (based on a single trial). Better evidence is required to determine more accurately the effectiveness of spine fusion surgery for all indications. Patients contemplating spinal fusion should be fully informed about the evidence base for their particular problem, including the relative potential benefits and harms of fusion compared with non‐operative treatments.

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Section: Other Degenerative Conditionsmentioning

confidence: 99%

Section: Low Back Pain and Degenerative Disc Diseasementioning

confidence: 99%

Section: Other Degenerative Conditionsmentioning

confidence: 99%

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Lumbar spine fusion: what is the evidence?

Harris

Traeger

Stanford

et al. 2018

Internal Medicine Journal

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“…[1][2][3] These procedures often require paraspinal muscle dissection, bone resection for the laminectomy, decortication for fusion bed preparation, and manipulation of vertebrae with instrumentation. Achieving adequate postoperative pain control in these patients is therefore critical and often involves a multimodal approach.…”

Section: Introductionmentioning

confidence: 99%

The Efficacy of Liposomal Bupivacaine in Lumbar Spine Surgery

Brown¹,

Weir²,

Shasti³

et al. 2018

Int J Spine Surg

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Background: Postoperative pain management in spine surgery holds unique challenges. The purpose of this study is to determine if the local anesthetic liposomal bupivacaine (LB) reduces the total opioid requirement in the first 3 days following posterior lumbar decompression and fusion (PLDF) surgery for degenerative spondylosis.Methods: Fifty patients underwent PLDF surgery in a prospective randomized control pilot trial between August 2015 and October 2016 and were equally allocated to either a treatment (LB) or a control (saline) group. Assessments included the 72-hour postoperative opioid requirement normalized to 1 morphine milligram equivalent (MME), visual analog scale (VAS), and hospital length of stay.Results: LB did not significantly alter the 72-hour postoperative opioid requirement compared to saline (11.6 vs. 13.4 MME, P ¼ .40). In a subgroup analysis, there was also no significant difference in opioid consumption among narcotic-naive patients with either LB or saline. Among narcotic tolerant patients, however, opioid consumption was higher with saline than LB (20.6 MME vs. 13.3 MME, P ¼ .048). Additionally, pre-and postoperative VAS scores and hospital length of stay were not significantly different with either LB or saline.Conclusions: In the setting of PLDF surgery, LB injections did not significantly reduce the consumption of opioids in the first 3 postoperative days, nor did the hospital length of stay or VAS pain scores, compared to saline. However, LB could be beneficial in reducing the consumption of opioids in narcotic-tolerant populations.Level of Evidence: 2.

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“…Almost 500 000 spinal fusions are performed annually in the United States to treat degenerative disc disease and other spinal pathologies . While mostly successful, evidence suggesting that reduced segmental mobility may accelerate degenerative changes at adjacent levels has driven interest in motion‐preserving approaches, such as total disc arthroplasty (TDA) . This class of implants can allow for some degree of flexion/extension, lateral bending, and axial rotation between adjacent vertebrae .…”

Section: Introductionmentioning

confidence: 99%

Load‐transfer in the human vertebral body following lumbar total disc arthroplasty: Effects of implant size and stiffness in axial compression and forward flexion

Bonnheim

Keaveny

2020

JOR Spine

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Adverse clinical outcomes for total disc arthroplasty (TDA), including subsidence, heterotopic ossification, and adjacent‐level vertebral fracture, suggest problems with the underlying biomechanics. To gain insight, we investigated the role of size and stiffness of TDA implants on load‐transfer within a vertebral body. Uniquely, we accounted for the realistic multi‐scale geometric features of the trabecular micro‐architecture and cortical shell. Using voxel‐based finite element analysis derived from a micro‐computed tomography scan of one human L1 vertebral body (74‐μm‐sized elements), a series of generic elliptically shaped implants were analyzed. We parametrically modeled three implant sizes (small, medium [a typical clinical size], and large) and three implant materials (metallic, E = 100 GPa; polymeric, E = 1 GPa; and tissue‐engineered, E = 0.01 GPa). Analyses were run for two load cases: 800 N in uniform compression and flexion‐induced anterior impingement. Results were compared to those of an intact model without an implant and loaded instead via a disc‐like material. We found that TDA implantation increased stress in the bone tissue by over 50% in large portions of the vertebra. These changes depended more on implant size than material, and there was an interaction between implant size and loading condition. For the small implant, flexion increased the 98th‐percentile of stress by 32 ± 24% relative to compression, but the overall stress distribution and trabecular‐cortical load‐sharing were relatively insensitive to loading mode. In contrast, for the medium and large implants, flexion increased the 98th‐percentile of stress by 42 ± 9% and 87 ± 29%, respectively, and substantially re‐distributed stress within the vertebra; in particular overloading the anterior trabecular centrum and cortex. We conclude that TDA implants can substantially alter stress deep within the lumbar vertebra, depending primarily on implant size. For implants of typical clinical size, bending‐induced impingement can substantially increase stress in local regions and may therefore be one factor driving subsidence in vivo.

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Lumbar Fusion for Degenerative Disease: A Systematic Review and Meta-Analysis

Cited by 119 publications

References 89 publications

Lumbar spine fusion: what is the evidence?

Lumbar spine fusion: what is the evidence?

The Efficacy of Liposomal Bupivacaine in Lumbar Spine Surgery

Load‐transfer in the human vertebral body following lumbar total disc arthroplasty: Effects of implant size and stiffness in axial compression and forward flexion

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