Review: lumbar fusion versus nonsurgical treatment for chronic low back pain

[iSpine-Admin]

From: PubMed. Spine. 2006 Jan 15;31(2):245-9.

A review of the 2001 Volvo Award winner in clinical studies: lumbar fusion versus nonsurgical treatment for chronic low back pain: a multicenter randomized controlled trial from the Swedish lumbar spine study group
Kwon B, Katz JN, Kim DH, Jenis LG

Abstract
The current debate over the efficacy of lumbar fusion for low back pain has not been settled. Fritzell et al published a landmark paper entitled "Lumbar fusion versus nonsurgical treatment for chronic low back pain: a multicenter randomized controlled trial from the Swedish lumbar spine study group." Their goal was to provide objective evidence supporting lumbar fusion. While it was well designed and important to our knowledge base, it has limitations. We set out to review their work in an unbiased yet critical manner. Our goals are to summarize the strengths and weaknesses of the paper, place it in the context of current knowledge, and highlight its significance for present-day practice and research. From technical and study design perspectives, Fritzell et al were able to validate the use of lumbar fusion for the treatment of low back pain. However, their use of "usual nonoperative" care and nonspecific definition of low back pain precluded a truly genuine comparison of operative and nonoperative groups. We commend the Swedish lumbar spine study group and their remarkable efforts; they elevated the sophistication of spine research and spawned many more excellent works to help settle the ongoing controversy on the ideal treatment of low back pain.

Keywords: lumbar spine; artificial disc replacement; neurological complication; metaanalysis; LOW-BACK-PAIN; 2-YEAR FOLLOW-UP; INTERBODY FUSION; POSTEROLATERAL FUSION; CIRCUMFERENTIAL FUSION; BONE-GRAFT; IN-VITRO; SPINE; PROSTHESIS; NUCLEUS

[ans]

I wonder where things stand now w/newer fusion methods.

A comment:

A review of the 2001 volvo award winner in clinical studies : Lumbar fusion versus nosurgical treatment for chronic low back pain: A multicenter randomized controlled trial from the Swedish Lumbar Spine Study Group

[mmglobal]

ans,

My guess is that it's similar to where it was when these papers were published. I don't believe the answer is in the data. We still see people presenting 25% screw loosening with Dynesys, while others with large Dynesys experience present almost nil.

I believe that we can't sort out the biases in the numbers.

>> reported correctly?

>> cherry picking surgeons vs. those who take on the tough cases?

>> talent difference?

>> System / hardware differences?

Last night, I was speaking to someone who is considering XLIF fusion at L4-5. Where he lives, experience w/XLIF is quite limited, but starting to become availalbe. I told him that I'd rather have an excellent PLIF or TLIF than a bad XLIF.

I belive the same thing for fusions that I do for ADR. If you are a good candidate and get a good job done, it doesn't matter which system or approach is used. Obviously, there are some issues that will make us want to move towards techniques that are more promising, but new techniques may still have hidden issues. Most importantly, there are issues and potential problems that are not represented in the data. Interesting discussion,

Mark

[ans]

As usual, excellent points Mark. Thanks..