Review ArticleFusion and nonsurgical treatment for symptomatic lumbar degenerative disease: a systematic review of Oswestry Disability Index and MOS Short Form-36 outcomes
Introduction
There is increasing emphasis on the use of health-related quality of life outcome measures to determine the efficacy of treatment, particularly for diseases that are not life threatening but affect the patient's quality of life. In the treatment of degenerative spine disorders, the Medical Outcomes Study Short Form SF-36 (SF-36) [1] and the Oswestry Disability Index (ODI) [2] are widely used to measure treatment outcomes. The SF-36 is a generic measure of health-related quality of life, allowing comparison across disease and treatment groups, whereas the ODI is an outcome measure specific to lumbar degenerative disorders.
Numerous studies have been published reporting on the results of various treatment strategies for symptomatic lumbar degenerative disease. However, definite conclusions are difficult to draw because of differences in patient inclusion criteria, fusion technique, nonoperative treatment regimen, and clinical outcome measures used to determine success. The few randomized controlled trials (RCTs) directly comparing surgical and nonsurgical treatments have been criticized for the variations in nonsurgical and surgical regimens used within the studies and the substantial amount of crossovers [3], [4], [5], [6], [7]. Several systematic reviews on surgical and nonsurgical treatments for chronic low back pain (CLBP) have been published [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19]. However, none have analyzed a common patient-reported clinical outcome measure such as the ODI and the SF-36. The most recent systematic review presented data from a limited number of trials that only included patients with CLBP [11].
The objective of this study was to evaluate lumbar fusion and nonsurgical interventions for various symptomatic degenerative spine disorders using the ODI as a primary outcome measure in a systematic review. A secondary objective was to determine whether there is a difference in clinical outcomes based on the specific diagnosis.
Section snippets
Methods
A computer-aided search using that included MEDLINE, EMBASE, HealthSTAR, Cumulative Index to Nursing & Allied Health Literature, Cochrane Database of Systematic Reviews, ACP Journal Club, Database of Abstracts of Reviews of Effects, Cochrane Central Register of Controlled Trials, PsycINFO, and PsychLit from the beginning of the databases up to February 2007 was done using the search strategy (Table 1) recommended by the Back Review Group of the Cochrane Collaboration [20]. Proceedings
Surgical versus nonsurgical RCTs
Not all studies reported demographic or smoking information. However in those that did, the distribution of age and sex was similar across treatments (Table 3). There were more smokers in the study looking at postdiscectomy patients [3]. The mean baseline ODI was all within the severe disability category (mean=45.5, range 42.0–48.4). The mean change in ODI was higher in the surgical study groups (mean=18.3, range 8.9–24.5) compared with the nonsurgical study groups (mean=8.1, range 2.8–13.3).
Discussion
The results of this analysis of prospectively collected ODI and SF-36 PCS data highlight the difficulties in designing trials to determine the efficacy of treatments for symptomatic lumbar degenerative disease. First, many studies do not report the essential characteristics of their sample, limiting the degree to which results of these studies can be compared with other studies. Two articles met all inclusion criteria but did not report the specific diagnostic indication for treatment and had
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FDA approval status: This article does not discuss or include any applicable devices/drugs.
This study received funding from a commercial entity (Norton Hospital Healthcare), which may indirectly relate to the subject of this research.
Do not have a financial relationship that creates, or may be perceived as creating, a conflict related to this article (JMH, LYC).
The author SDG acknowledges a financial relationship (grant research and other support from Medtronic Sofamor Danek, and consultant for Medtronic Sofamor Danek), which may indirectly relate to the subject of this research.