Elsevier

The Spine Journal

Volume 8, Issue 5, September–October 2008, Pages 747-755
The Spine Journal

Review Article
Fusion and nonsurgical treatment for symptomatic lumbar degenerative disease: a systematic review of Oswestry Disability Index and MOS Short Form-36 outcomes

https://doi.org/10.1016/j.spinee.2007.06.013Get rights and content

Abstract

Background context

Although numerous studies have been published, controversy still exists regarding fusion and nonsurgical treatment for symptomatic degenerative lumbar spine conditions. 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.

Purpose

The objective of this study was to evaluate lumbar fusion and nonsurgical interventions for various degenerative spine disorders using the Oswestry Disability Index (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.

Study design/setting

Systematic review.

Patient sample

Patients with low back pain of at least 12 weeks duration and older than 18 years, with prospectively collected ODI scores and at least a 12-month follow-up.

Outcome measures

ODI and Short Form-36 (SF-36).

Methods

A MEDLINE, HealthSTAR, CINAHL, and Cochrane database search was done using the search strategy recommended by the Cochrane Back Review Group. Proceedings from annual meetings of various spine societies and reference lists from review articles and retrieved articles were evaluated for possible inclusion. Criteria for inclusion were prospective randomized clinical trials in patients with low back pain of at least 12 weeks duration and older than 18 years; with prospectively collected ODI scores and at least a 12-month follow-up. The methodological quality of the studies was assessed using the van Tulder criteria. Data extracted from each study included demographics, study design, diagnosis, baseline and change in ODI, and baseline and change in SF-36 Physical Composite Score (PCS). The data were pooled and analyzed based on the primary reported inclusion diagnosis: degenerative disc disease (DDD), chronic low back pain (CLBP), and spondylolisthesis; and treatment: fusion (unspecified, posterior, anterior, combined) and nonsurgical.

Results

Twenty-five studies met the inclusion criteria. The distribution of sex and smokers was similar across diagnoses and treatments. Patients with spondylolisthesis were older than patients with DDD and CLBP. Patients with spondylolisthesis had the greatest ODI improvement followed by patients with DDD and CLBP. The three fusion types produced similar amounts of improvement in ODI. Nonsurgical patients did not improve as much but had a lower baseline ODI. Improvements in the SF-36 PCS were fairly consistent across diagnostic groups and treatment types.

Conclusions

Substantial improvement can be expected in patients treated with fusion, regardless of technique, when an established indication such as spondylolisthesis or DDD exists. CLBP patients are less disabled and experience less improvement.

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).

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