title: Circumferential fusion improves outcome in comparison with instrumented posterolateral fusion: long-term results of a randomized clinical trial.
abstract: METHODS
  Prospective randomized clinical study with a 5- to 9-year follow-up period.
  
  
  OBJECTIVE
  The aim of the present study was to analyze the long-term outcome with respect to functional disability, pain, and general health of patients treated by means of circumferential lumbar fusion in comparison with those treated by means of instrumented posterolateral lumbar fusion.
  
  
  BACKGROUND
  Circumferential fusion has become a common procedure in lumbar spinal fusion both as a primary and salvage procedure. However, the claimed advantages of circumferential fusion over conventional posterolateral fusion lack scientific documentation. (The primary report with a 2-year follow-up has been published in Spine in 2002.)
  
  
  METHODS
  From April 1996 to November 1999, a total of 148 patients (mean age, 45 years) with severe chronic low back pain were randomly selected for either posterolateral lumbar fusion (titanium Cotrel-Dubousset) or circumferential lumbar fusion (instrumented posterolateral fusion with anterior intervertebral support by a Brantigan cage). The primary outcome measure was the Dallas Pain Questionnaire (DPQ). The secondary outcome measures were the Oswestry Disability Index, the SF-36 instrument, and the Low Back Pain Rating Scale. All measures assessed the endpoint outcomes at 5 to 9 years after surgery.
  
  
  RESULTS
  The available response rate was 93%. The circumferential group showed a significantly better improvement (P < 0.05) in comparison with the posterolateral group with respect to all four DPQ categories: daily activities, work/leisure, anxiety/depression, and social interest. The Oswestry Disability Index supported these results (P < 0.01). General health, as assessed by means of the SF-36, also showed significantly better physical health (P < 0.01) in the circumferential group, whereas no significant difference was found with respect to mental health compared with the posterolateral group. The circumferential group experienced significantly less back pain (P < 0.05) in comparison with the posterolateral group. In regard to leg pain, no significant difference was found.
  
  
  CONCLUSIONS
  Circumferential lumbar fusion demands more extensive operative resources compared with posterolateral lumbar fusion. However, 5 to 9 years after surgery, the circumferentially fused patients had a significantly improved outcome compared with those treated by means of posterolateral fusion. These new results not only emphasize the superiority of circumferential fusion in the complex pathology of the lumbar spine but are also strongly supported in all of the validated questionnaires used in the study.
authors.affiliation: Spine Unit, Department of Orthopaedics, University Hospital of Aarhus, Aarhus, Denmark.
authors.forename: Tina S
authors.initials: TS
authors.lastname: Videbaek
authors.forename: Finn B
authors.initials: FB
authors.lastname: Christensen
authors.forename: Rikke
authors.initials: R
authors.lastname: Soegaard
authors.forename: Ebbe S
authors.initials: ES
authors.lastname: Hansen
authors.forename: Kristian
authors.initials: K
authors.lastname: Høy
authors.forename: Peter
authors.initials: P
authors.lastname: Helmig
authors.forename: Bent
authors.initials: B
authors.lastname: Niedermann
authors.forename: Søren P
authors.initials: SP
authors.lastname: Eiskjoer
authors.forename: Cody E
authors.initials: CE
authors.lastname: Bünger
mesh_terms: D000328:Adult; D000368:Aged; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D017116:Low Back Pain / Q000453:epidemiology / Q000601:surgery; D008159:Lumbar Vertebrae / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D013123:Spinal Fusion / Q000379:methods*; D013995:Time; D016896:Treatment Outcome