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Evidence for surgery in degenerative lumbar spine disorders

https://doi.org/10.1016/j.berh.2013.09.009Get rights and content

Abstract

We aimed to evaluate the available evidence on the effectiveness of surgical interventions for a number of conditions resulting in low back pain (LBP) or spine-related irradiating leg pain. We searched the Cochrane databases and PubMed up to June 2013. We included systematic reviews and randomised controlled trials (RCTs) on degenerative disc disease (DDD), herniated disc, spondylolisthesis and spinal stenosis due to degenerative osteoarthritis. We included comparisons between surgery and conservative care and between different techniques. The quality of the systematic reviews was evaluated using assessment of multiple systematic reviews (AMSTAR). Twenty systematic reviews were included which covered the following diagnoses: disc herniation (n = 9), spondylolisthesis (n = 2), spinal stenosis (n = 3), DDD (n = 4) and combinations (n = 2). For most of the comparisons, no significant and/or clinically relevant differences between interventions were identified. In general, surgery is only indicated for relief of leg pain in clear indications such as disc herniation, spondylolisthesis or spinal stenosis.

Introduction

The burden of low back pain (LBP) on patients and society is substantial and it ranks first as the disease with most years lived with disability [2] (see also chapter 1 in this edition). LBP has an estimated point prevalence of 10.2% [3] and a lifetime prevalence of up to 84% [4]. More than 80% of those who suffer from LBP seek medical attention [3]. Most episodes are temporary and resolve without treatment in about 25–58% of patients, even when specific causes, such as herniated discs, are present [6]. LBP is associated with high direct costs of health-care utilisation and indirect costs due to lost productivity [7]. While conservative therapy, including a wait-and-see policy, is the first step in the management of LBP, in the case of persistent pain and a clearly identified pain source, targeted injections or surgical intervention may be indicated.

The objective of this overview was to evaluate the available evidence from systematic reviews on the effectiveness of surgical interventions for a number of conditions, including degenerative disc disease (DDD), disc herniation, spondylolisthesis and spinal stenosis resulting in LBP or low back-related irradiating leg pain and/or paraesthesias. A secondary objective was to determine if the evidence was up to date.

Section snippets

Existing evidence for surgical interventions

We searched Cochrane databases and PubMed up to June 2013 to identify the available evidence on the effectiveness of surgical interventions for degenerative low back disorders. Systematic reviews and randomised controlled trials (RCTs) were included. We included studies on DDD, herniated disc, spondylolisthesis and spinal stenosis due to degenerative osteoarthritis. We included comparisons of surgery versus conservative care and of different surgical techniques compared to each other (see

Discogenic LBP, without disc herniation or spinal stenosis

Six reviews (four of high quality) dealt with discogenic LBP without disc herniation or spinal stenosis in the presence of degenerative changes in the disc [17], [19], [21], [22], [23], [*27]. Although there is controversy on DDD as a disease entity, we included studies that reported on DDD, excluding structural anatomical abnormalities of discs or vertebral elements.

Disc herniation with radiculopathy

Ten reviews (nine of high quality) dealt with spine-related irradiating leg pain due to herniated discs [9], [10], [14], [15], [16], [18], [19], [*20], [25], [26]. For patients with disc herniation there are two main questions to be answered. First, does the patient benefit from surgery, measured by improvement in function, relief of back pain or rather leg pain compared to conservative interventions? Second, which surgical technique provides us with the best outcomes? The choice of surgical

Low-grade isthmic spondylolisthesis (type II)

One older review [11] compared surgery with conservative treatment and surgical techniques to one another for low-grade adult isthmic spondylolisthesis with leg pain or LBP, or both. At that time, eight RCTs (376 patients), four observational prospective studies (148 patients) and 17 retrospective case series (648 patients) could be included. Seven randomised studies compared postero-lateral fusion (PLF) techniques to one another. Techniques that were compared included addition of

Degenerative spondylolisthesis (type III)

One high-quality review (Martin et al. [12]), which compared different surgical techniques to one another for degenerative spondylolisthesis, included four RCTs (180 patients) and nine observational studies (405 patients) that compared fusion versus decompression alone and instrumented fusion versus non-instrumented fusion. Spinal fusion was found to lead to a higher probability of improved clinical outcome than decompression with a pooled relative risk (RR) of 1.40 (95% CI 1.04–1.89).

Degenerative spinal stenosis

Five reviews (four of high quality) dealt with degenerative spinal stenosis [13], [19], [21], [*24], [28]; LBP was excluded in all studies.

Discussion

We identified 20 systematic reviews which examined the effectiveness of various surgical interventions for LBP or spine-related radiculopathy due to DDD, disc herniation, isthmic or degenerative spondylolisthesis and spinal stenosis. Most of the reviews that included low back-related disorders were aimed primarily at the treatment of leg pain. For these indications, surgery appears to result in better outcomes in the short term. The exception is DDD in the absence of disc herniation or spinal

Summary

For degenerative low back-related disorders that are accompanied by leg pain, surgical interventions appear to have a better short-term effect on the relief of pain than conservative care. There is no convincing evidence for clinically relevant differences that supports the choice for any of the surgical techniques. The evidence on isthmic and degenerative spondylolisthesis as well as surgical techniques for spinal stenosis should be updated. Evidence from 20 reviews demonstrates that for the

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