Lumbar Fusion for Degenerative Disease: A Systematic Review and Meta-Analysis.
BACKGROUND
Due to uncertain evidence, lumbar fusion for degenerative indications is associated with the greatest measured practice variation of any surgical procedure.


OBJECTIVE
To summarize the current evidence on the comparative safety and efficacy of lumbar fusion, decompression-alone, or nonoperative care for degenerative indications.


METHODS
A systematic review was conducted using PubMed, MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials (up to June 30, 2016). Comparative studies reporting validated measures of safety or efficacy were included. Treatment effects were calculated through DerSimonian and Laird random effects models.


RESULTS
The literature search yielded 65 studies (19 randomized controlled trials, 16 prospective cohort studies, 15 retrospective cohort studies, and 15 registries) enrolling a total of 302 620 patients. Disability, pain, and patient satisfaction following fusion, decompression-alone, or nonoperative care were dependent on surgical indications and study methodology. Relative to decompression-alone, the risk of reoperation following fusion was increased for spinal stenosis (relative risk [RR] 1.17, 95% confidence interval [CI] 1.06-1.28) and decreased for spondylolisthesis (RR 0.75, 95% CI 0.68-0.83). Among patients with spinal stenosis, complications were more frequent following fusion (RR 1.87, 95% CI 1.18-2.96). Mortality was not significantly associated with any treatment modality.


CONCLUSIONS
Positive clinical change was greatest in patients undergoing fusion for spondylolisthesis while complications and the risk of reoperation limited the benefit of fusion for spinal stenosis. The relative safety and efficacy of fusion for chronic low back pain suggests careful patient selection is required (PROSPERO International Prospective Register of Systematic Reviews number, CRD42015020153).
Division of Neurosurgery, Department of Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, Canada.|Department of Community Health Sciences, University of Calgary Cumming School of Medicine, Calgary, Canada.
Daniel
D
Yavin
Division of Neurosurgery, Department of Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, Canada.|The Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, Canada.
Steven
S
Casha
Department of Community Health Sciences, University of Calgary Cumming School of Medicine, Calgary, Canada.|The Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, Canada.|Division of Neurology, Department of Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, Canada.|The O'Brien Institute for Public Health, University of Calgary Cumming School of Medicine, Calgary, Canada.
Samuel
S
Wiebe
Department of Community Health Sciences, University of Calgary Cumming School of Medicine, Calgary, Canada.|The Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, Canada.|Division of Neurology, Department of Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, Canada.|The O'Brien Institute for Public Health, University of Calgary Cumming School of Medicine, Calgary, Canada.
Thomas E
TE
Feasby
Department of Community Health Sciences, University of Calgary Cumming School of Medicine, Calgary, Canada.
Callie
C
Clark
Division of Neurosurgery, Department of Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, Canada.
Albert
A
Isaacs
Department of Community Health Sciences, University of Calgary Cumming School of Medicine, Calgary, Canada.|The Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, Canada.|Department of Medicine, University of Calgary Cumming School of Medicine, Calgary, Canada.
Jayna
J
Holroyd-Leduc
Division of Neurosurgery, Department of Surgery, University of Arizona, Tucson, Arizona.
R John
RJ
Hurlbert
Department of Community Health Sciences, University of Calgary Cumming School of Medicine, Calgary, Canada.|The O'Brien Institute for Public Health, University of Calgary Cumming School of Medicine, Calgary, Canada.
Hude
H
Quan
Division of Neurosurgery, Department of Surgery, University of Alberta, Edmonton, Canada.
Andrew
A
Nataraj
Division of Neurosurgery, Department of Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, Canada.|The Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, Canada.
Garnette R
GR
Sutherland
Department of Community Health Sciences, University of Calgary Cumming School of Medicine, Calgary, Canada.|The Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, Canada.|Division of Neurology, Department of Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, Canada.|The O'Brien Institute for Public Health, University of Calgary Cumming School of Medicine, Calgary, Canada.
Nathalie
N
Jette
D019299:Decompression, Surgical / Q000379:methods; D006801:Humans; D017116:Low Back Pain / Q000175:diagnosis / Q000209:etiology / Q000601:surgery; D008159:Lumbar Vertebrae / Q000601:surgery*; D019636:Neurodegenerative Diseases / Q000150:complications / Q000175:diagnosis / Q000601:surgery*; D019635:Neurosurgical Procedures / Q000379:methods; D011446:Prospective Studies; D016032:Randomized Controlled Trials as Topic / Q000379:methods; D012086:Reoperation / Q000379:methods; D012189:Retrospective Studies; D024162:Second-Look Surgery / Q000379:methods; D013123:Spinal Fusion / Q000009:adverse effects / Q000379:methods*; D013130:Spinal Stenosis / Q000150:complications / Q000175:diagnosis / Q000601:surgery; D013168:Spondylolisthesis / Q000150:complications / Q000175:diagnosis / Q000601:surgery; D016896:Treatment Outcome
Decompression; Fusion; Low back pain; Lumbar spondylosis; Meta-analysis; Spinal stenosis; Spond-ylolisthesis