title: Effectiveness of spinal fusion versus structured rehabilitation in chronic low back pain patients with and without isthmic spondylolisthesis: a systematic review.
abstract: METHODS
  Systematic review.
  
  
  OBJECTIVE
  To determine if the presence of isthmic spondylolisthesis modifies the effect of treatment (fusion vs. multidimensional supervised rehabilitation) in patients with chronic low back pain (CLBP).
  
  
  BACKGROUND
  Results of spinal surgery for CLBP are variable. It is unclear whether patients with CLBP and isthmic spondylolisthesis have more success with surgery versus a multidimensional supervised rehabilitation program when compared with those with CLBP but without spondylolisthesis.
  
  
  METHODS
  A systematic search was conducted in MEDLINE and the Cochrane Collaboration Library for articles published through January 2011. Randomized controlled trials (RCTs) were included that compared spine fusion versus multidimensional supervised rehabilitation in patients with and without isthmic spondylolisthesis. Standardized mean differences (SMDs) and risk differences were calculated for common outcomes, and then compared to determine potential heterogeneity of treatment effect. The final strength of the body of literature was expressed as "high," "moderate," or "low" confidence that the evidence reflects the true effect.
  
  
  RESULTS
  No studies were found that directly compared the two subgroups. Three RCTs compared fusion with supervised nonoperative care in patients with CLBP without isthmic spondylolisthesis; one RCT evaluated these treatments in patients with isthmic spondylolisthesis. There were study differences in patient characteristics, type of fusion, the nature of the rehabilitation, outcomes assessed, and length of follow-up. The SMDs for pain in favor of fusion were modest at 2 years for those without isthmic spondylolisthesis, but large in favor of fusion for those with isthmic spondylolisthesis compared with rehabilitation. Similarly, the SMDs for function in patients without isthmic spondylolisthesis compared with rehabilitation was small at 2 years, but appreciably higher in favor of fusion in patients with isthmic spondylolisthesis.
  
  
  CONCLUSIONS
  The overall strength of evidence evaluating whether the presence of isthmic spondylolisthesis modifies the effect of fusion compared with rehabilitation patients with CLBP is "low." Fusion should be considered for patients with low back pain and isthmic spondylolisthesis who have failed nonoperative treatment.
  
  
  CONCLUSIONS
  We recommend considering fusion for patients with isthmic spondylolisthesis and lower back pain who have failed nonoperative treatment.
  
  
  CONCLUSIONS
  Weak.
authors.affiliation: Orthopaedic Surgery, Harvard Medical School, and Spine Service, Massachusetts General Hospital, Boston, MA 02114, USA kbwood@partners.org
authors.forename: Kirkham B
authors.initials: KB
authors.lastname: Wood
authors.forename: Peter
authors.initials: P
authors.lastname: Fritzell
authors.forename: Joseph R
authors.initials: JR
authors.lastname: Dettori
authors.forename: Robin
authors.initials: R
authors.lastname: Hashimoto
authors.forename: Teija
authors.initials: T
authors.lastname: Lund
authors.forename: Chris
authors.initials: C
authors.lastname: Shaffrey
mesh_terms: D059350:Chronic Pain / Q000175:diagnosis / Q000209:etiology / Q000534:rehabilitation / Q000601:surgery / Q000628:therapy*; D019317:Evidence-Based Medicine; D006801:Humans; D017116:Low Back Pain / Q000175:diagnosis / Q000209:etiology / Q000534:rehabilitation / Q000601:surgery / Q000628:therapy*; D010147:Pain Measurement; D018579:Patient Selection; D017410:Practice Guidelines as Topic; D018570:Risk Assessment; D012307:Risk Factors; D013123:Spinal Fusion / Q000009:adverse effects; D013168:Spondylolisthesis / Q000150:complications / Q000175:diagnosis / Q000534:rehabilitation / Q000601:surgery / Q000628:therapy*; D016896:Treatment Outcome