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Critical analysis of trends in lumbar fusion for degenerative disorders revisited: influence of technique on fusion rate and clinical outcomes

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Abstract

Purpose

Lumbar fusion for degenerative disorders is among the most common spine surgical procedures performed. The purpose of this study was to analyze fusion, complications, and clinical success for lumbar fusion performed with various surgical techniques as reported in the literature from 2000 to 2015 and compare with previous critical analysis of outcomes from 1980 to 2000.

Methods

A systematic review of the literature to identify all studies of adult lumbar fusion for degenerative disorders published between January 1, 2000, and August 31, 2015, was performed adhering to PRISMA guidelines. Studies were included if they enabled analysis of outcomes of individual fusion techniques.

Results

Data from 8599 patients extracted from 160 studies were recorded. Posterior and transforaminal lumbar interbody fusion (PLIF and TLIF) had significantly higher fusion rates compared to instrumented posterolateral fusion (PLF) (OR 3.20 and 2.46, respectively). Clinical success rate was statistically higher with MIS versus non-MIS fusion (OR 2.44). While methodological quality was higher in studies from 2000 to 2015 than prior decades, the outcomes of comparable procedures were about the same.

Conclusions

Lumbar fusions for degenerative disorders from 2000 to 2015 demonstrate a trend toward more interbody fusions and MIS techniques than prior decades. Clinical success with MIS appears more likely than with non-MIS fusions, despite equivalent fusion and complication rates. While these data are intriguing, they should be interpreted cautiously considering the level of heterogeneity of the studies available. Further, high-quality comparative studies are warranted to better understand the relative benefits of more complex interbody and MIS fusions for these conditions.

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References

  1. Deyo RA, Gray DT, Kreuter W et al (2005) United States trends in lumbar fusion surgery for degenerative conditions. Spine (Phila Pa 1976) 30:1441–1445

    Article  Google Scholar 

  2. Taylor VM, Deyo RA, Cherkin DC et al (1994) Low back pain hospitalization: recent United States trends and regional variations. Spine (Phila Pa 1976) 19:1207–1212

    Article  CAS  Google Scholar 

  3. Gray DT, Deyo RA, Kreuter W et al (2006) Population-based trends in volumes and rates of ambulatory lumbar spine surgery. Spine (Phila Pa 1976) 31:1957–1963

    Article  Google Scholar 

  4. Rajaee SS, Bae HW, Kanim LE et al (2012) Spinal fusion in the United States: analysis of trends from 1998 to 2008. Spine (Phila Pa 1976) 37(1):67–76

    Article  Google Scholar 

  5. Fischgrund JS, Mackay M, Herkowitz HN et al (1997) Degenerative lumbar spondylolisthesis with spinal stenosis: a prospective randomized study comparing decompressive laminectomy and arthrodesis with and without spinal instrumentation. Spine (Phila Pa 1976) 22:2807–2812

    Article  CAS  Google Scholar 

  6. Parker LM, Murrell SE, Boden SD et al (1996) The outcome of posterolateral fusion in highly selected patients with discogenic low back pain. Spine (Phila Pa 1976) 21:1909–1917

    Article  CAS  Google Scholar 

  7. Anderson DG, Sayadipour A, Shelby K et al (2011) Anterior interbody arthrodesis with percutaneous posterior pedicle fixation for degenerative conditions of the lumbar spine. Eur Spine J 20:1323–1330

    Article  PubMed  PubMed Central  Google Scholar 

  8. Ozgur BM, Aryan HE, Pimenta L et al (2006) Extreme lateral interbody fusion (XLIF): a novel surgical technique for anterior lumbar interbody fusion. Spine J 6:435–443

    Article  PubMed  Google Scholar 

  9. Weinstein JN, Lurie JD, Olson PR et al (2006) United States’ trends and regional variations in lumbar spine surgery: 1992–2003. Spine (Phila Pa 1976) 31:2707–2714

    Article  Google Scholar 

  10. Deyo R, Mirza S (2006) Trends and variations in the use of spine surgery. Clin Orthop Relat Res 443:139–146

    Article  PubMed  Google Scholar 

  11. Xu H, Tang H, Li Z (2009) Surgical treatment of adult degenerative spondylolisthesis by instrumented transforaminal lumbar interbody fusion in the Han nationality. J Neurosurg Spine 10:496–499

    Article  PubMed  Google Scholar 

  12. Boden SD, Zdebick TA, Sandhu HS et al (2000) The use of rhBMP-2 in Interbody fusion cages. Spine (Phila Pa 1976) 25:376–381

    Article  CAS  Google Scholar 

  13. Thirukumaran CP, Raudenbush B, Li Y et al (2016) National trends in the surgical management of adult lumbar isthmic spondylolisthesis: 1998 to 2011. Spine (Phila Pa 1976) 41(6):490–501

    Article  Google Scholar 

  14. Kepler CK, Vaccaro AR, Hilibrand AS et al (2014) National trends in the use of fusion techniques to treat degenerative spondylolisthesis. Spine (Phila Pa 1976) 39(19):1584–1589

    Article  Google Scholar 

  15. Yoshihara H, Yoneoka D (2015) National trends in the surgical treatment for lumbar degenerative disc disease: United States, 2000 to 2009. Spine J 15(2):265–271

    Article  PubMed  Google Scholar 

  16. Bono CM, Lee CK (2004) Critical analysis of trends in fusion for degenerative disc disease over the past 20 years: influence of technique on fusion rate and clinical outcome. Spine (Phila Pa 1976) 29(4):455–463

    Article  Google Scholar 

  17. Moher D, Liberati A, Tetzlaff J, The PRISMA Group et al (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ 339:b2535

    Article  PubMed  PubMed Central  Google Scholar 

  18. Bhalla A, Schoenfeld AJ, George J et al (2017) The influence of subgroup diagnosis on radiographic and clinical outcomes after lumbar fusion for degenerative disc disorders revisited: a systematic review of the literature. Spine J 17(1):143–149

    Article  PubMed  Google Scholar 

  19. Harbord RM, Egger M, Sterne JA (2006) A modified test for small-study effects in meta-analyses of controlled trials with binary endpoints. Stat Med 25(20):3443–3457

    Article  PubMed  Google Scholar 

  20. Fritz JM, Hebert J, Koppenhaver S et al (2009) Beyond minimally important change: defining a successful outcome of physical therapy for patients with low back pain. Spine (Phila Pa 1976) 34(25):2803–2809

    Article  Google Scholar 

  21. Gatchel RJ, Mayer TG (2010) Testing minimal clinically important difference: consensus or conundrum? Spine J 10(4):321–327

    Article  PubMed  Google Scholar 

  22. Ostelo RW, Deyo RA, Stratford P et al (2008) Interpreting change scores for pain and functional status in low back pain: towards international consensus regarding minimal important change. Spine (Phila Pa 1976) 33(1):90–94

    Article  Google Scholar 

  23. Glassman S, Gornet MF, Branch C et al (2006) MOS short form 36 and Oswestry Disability Index outcomes in lumbar fusion: a multicenter experience. Spine J 6(1):21–26

    Article  PubMed  Google Scholar 

  24. Liu XY, Qiu GX, Weng XS et al (2014) What is the optimum fusion technique for adult spondylolisthesis-PLIF or PLF or PLIF plus PLF? A meta-analysis from 17 comparative studies. Spine (Phila Pa 1976) 39(22):1887–1898

    Article  Google Scholar 

  25. Zhou ZJ, Zhao FD, Fang XQ et al (2011) Meta-analysis of instrumented posterior interbody fusion versus instrumented posterolateral fusion in the lumbar spine. J Neurosurg Spine 15(3):295–310

    Article  PubMed  Google Scholar 

  26. Liu X, Wang Y, Qiu G et al (2014) A systematic review with meta-analysis of posterior interbody fusion versus posterolateral fusion in lumbar spondylolisthesis. Eur Spine J 23(1):43–56

    Article  PubMed  Google Scholar 

  27. Putzier M, Hartwig T, Hoff EK et al (2016) Minimally invasive TLIF leads to increased muscle sparing of the multifidus muscle but not the longissimus muscle compared with conventional PLIF-a prospective randomized clinical trial. Spine J 16(7):811–819

    Article  PubMed  Google Scholar 

  28. Fan S, Hu Z, Zhao F et al (2010) Multifidus muscle changes and clinical effects of one-level posterior lumbar interbody fusion: minimally invasive procedure versus conventional open approach. Eur Spine J 19(2):316–324

    Article  PubMed  Google Scholar 

  29. Sidhu GS, Henkelman E, Vaccaro AR et al (2014) Minimally invasive versus open posterior lumbar interbody fusion: a systematic review. Clin Orthop Relat Res 472(6):1792–1799

    Article  PubMed  PubMed Central  Google Scholar 

  30. Sofianos DA, Briseno MR, Abrams J et al (2012) Complications of the lateral transpsoas approach for lumbar interbody arthrodesis: a case series and literature review. Clin Orthop Relat Res 470(6):1621–1632

    Article  PubMed  Google Scholar 

  31. Cummock MD, Vanni S, Levi AD et al (2011) An analysis of postoperative thigh symptoms after minimally invasive transpsoas lumbar interbody fusion. J Neurosurg Spine 15(1):11–18

    Article  PubMed  Google Scholar 

  32. Bhandari M, Morrow F, Kulkarni AV et al (2001) Meta-analyses in orthopaedic surgery: a systematic review of their methodologies. J Bone Joint Surg 83A:15–24

    Article  Google Scholar 

  33. Glassman SD, Carreon LY, Djurasovic M et al (2009) Lumbar fusion outcomes stratified by specific diagnostic indication. Spine J 9(1):13–21

    Article  PubMed  Google Scholar 

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Author information

Authors and Affiliations

  1. Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA

    Heeren Makanji, Andrew J. Schoenfeld & Christopher M. Bono

  2. Harbor-UCLA Medical Center, Los Angeles, CA, USA

    Amandeep Bhalla

Authors
  1. Heeren Makanji
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  2. Andrew J. Schoenfeld
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  3. Amandeep Bhalla
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  4. Christopher M. Bono
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Corresponding author

Correspondence to Christopher M. Bono.

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Conflict of interest

The authors declare that they have no conflict of interest.

Electronic supplementary material

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Appendix 1

Appendix 1

Electronic search terms

The following PubMed algorithm was used:

((“Spinal Stenosis/surgery”[Mesh] OR “Spinal Stenosis/therapy”[Mesh] OR “Spondylolisthesis/surgery”[Mesh] OR “Spondylolisthesis/therapy”[Mesh] OR “Low Back Pain/surgery”[Mesh] OR “Low Back Pain/therapy”[Mesh] OR

“Spondylosis/surgery”[Mesh] OR “Spondylosis/therapy”[Mesh]) OR “Scoliosis/surgery”[Mesh] OR “Scoliosis/therapy”[Mesh] OR “Intervertebral Disc Degeneration/surgery”[Mesh] OR “Intervertebral Disc Degeneration/therapy”[Mesh]) AND (“Spinal Fusion”[Mesh] OR “lumbar spinal fusion”[All Fields] OR “anterior lumbar fusion”[All Fields] OR “posterolateral fusion”[All Fields] OR “posterior interbody fusion”[All Fields] OR

(transforaminal[All Fields] AND interbody[All Fields])) NOT (“review”[Publication Type] OR “review literature as topic”[MeSH Terms] OR “review”[All Fields]) NOT (“guideline”[Publication Type] OR “guidelines as topic”[MeSH Terms] OR “guideline”[All Fields]) NOT (“meta-analysis”[Publication Type] OR “meta-analysis as topic”[MeSH Terms] OR “meta-analysis”[All Fields]) NOT (“case reports”[Publication Type] OR “case reports”[All Fields]) AND

((“2000/01/01”[PDAT] : “2014/10/10”[PDAT]) AND “humans”[MeSH Terms] AND English[lang])

An additional search was done through Web of Science using the following search algorithm:

TS = (“Spondylosis” OR “Scoliosis” OR “Intervertebral Disc Degeneration” OR “Degenerative disc”) AND TS = (“lumbar spinal fusion” OR “anterior lumbar fusion” OR “posterolateral fusion” OR “posterior interbody fusion” OR “transforaminal interbody” OR “axialif” OR “XLIF” OR “DLIF”) AND TS = (surgery OR therapy OR outcome*) AND DOCUMENT TYPES: (Article)

Timespan: 2000-2014. Indexes: SCI-EXPANDED, SSCI.

The articles in the Web of Science search, which were not found in the prior PubMed search, totaled 90. Next a search was done through the Scopus database. The following search algorithm was used:

TITLE-ABS-KEY (“Spondylosis” OR “Scoliosis” OR “Intervertebral Disc Degeneration” OR “Degenerative disc”) AND TITLE-ABS-KEY (“lumbar spinal fusion” OR “anterior lumbar fusion” OR “posterolateral fusion” OR “posterior interbody fusion” OR “transforaminal interbody” OR “axialif” OR “XLIF” OR “DLIF”) AND TITLE-ABS-KEY (surgery OR therapy OR outcome*) AND DOCTYPE (ar) AND SUBJAREA (mult OR medi OR nurs OR vete OR dent OR heal) AND PUBYEAR > 1999

A second Scopus query was also performed, specifically searching the titles and abstracts of articles published in core clinical journals, including Journal of Bone and Joint Surg American, Spine, The Spine Journal, Journal of Spinal Disorders and Techniques, Clinical Orthopaedics and Related Research, European Spine Journal, Journal of Neurosurgery: Spine, Neurosurgery, and Journal of Neurosurgery. The keywords ”degenerative,” “lumbar,” and “fusion” were used and the search algorithm is as follows:

TITLE-ABS-KEY(degenerative AND lumbar AND fusion) AND DOCTYPE(ar) AND SUBJAREA(MULT OR MEDI OR NURS OR VETE OR DENT OR HEAL) AND PUBYEAR > 1999 AND PUBYEAR < 2015 AND (LIMIT-TO(EXACTSRCTITLE,”Spine”) OR LIMIT-TO(EXACTSRCTITLE,”European Spine Journal”) OR LIMIT-TO(EXACTSRCTITLE,”Journal of Neurosurgery Spine”) OR LIMIT-TO(EXACTSRCTITLE,”Spine Journal”) OR LIMIT-TO(EXACTSRCTITLE,”Journal of Spinal Disorders and Techniques”) OR LIMIT-TO(EXACTSRCTITLE,”Neurosurgery”) OR LIMIT-TO(EXACTSRCTITLE,”Spine”) OR LIMIT-TO(EXACTSRCTITLE,”European Spine Journal”) OR LIMIT-TO(EXACTSRCTITLE,”Journal of Neurosurgery Spine”) OR LIMIT-TO(EXACTSRCTITLE,”Spine Journal”) OR LIMIT-TO(EXACTSRCTITLE,”Journal of Spinal Disorders and Techniques”) OR LIMIT-TO(EXACTSRCTITLE,”Neurosurgery”) OR LIMIT-TO(EXACTSRCTITLE,”Journal of Bone and Joint Surgery Series A”) OR LIMIT-TO(EXACTSRCTITLE,”Journal of Neurosurgery”) OR LIMIT-TO(EXACTSRCTITLE,”Clinics in Orthopedic Surgery”)) AND (LIMIT-TO(SUBJAREA,”MEDI”))

The articles from the Scopus searches, which were found in neither the Pubmed search nor the Web of Science searches, totaled 78.

Manual table of contents query for the following journals: Journal of Bone and Joint Surgery (American), Spine, The Spine Journal, Journal of Spinal Disorders and Techniques, Clinical Orthopaedics and Related Research, European Spine Journal, Journal of Neurosurgery: Spine, Neurosurgery, and Journal of Neurosurgery.

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Makanji, H., Schoenfeld, A.J., Bhalla, A. et al. Critical analysis of trends in lumbar fusion for degenerative disorders revisited: influence of technique on fusion rate and clinical outcomes. Eur Spine J 27, 1868–1876 (2018). https://doi.org/10.1007/s00586-018-5544-x

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  • DOI: https://doi.org/10.1007/s00586-018-5544-x

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