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Intervention Review

Surgery for degenerative lumbar spondylosis

  1. JNA Gibson Consultant Trauma and Orthopaedic Surgeon*,
  2. G Waddell

Editorial Group: Cochrane Back Group

Published Online: 20 APR 2005

DOI: 10.1002/14651858.CD001352.pub2

How to Cite

Gibson JNA, Waddell G. Surgery for degenerative lumbar spondylosis. The Cochrane Database of Systematic Reviews 2005, Issue 2. Art. No.: CD001352. DOI: 10.1002/14651858.CD001352.pub2.

Author Information

  1. The Royal Infirmary of Edinburgh, Lothian University Hospitals NHS Trust, Little France, Edinburgh, UK

*JNA Gibson, Consultant Trauma and Orthopaedic Surgeon, Lothian University Hospitals NHS Trust, The Royal Infirmary of Edinburgh, Little France, Edinburgh, EH16 4SU, UK. j.n.a.gibson@ed.ac.uk.

Publication History

  1. Published Online: 20 APR 2005

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This is not the most recent version of the article. View current version (19 OCT 2005)

 

Abstract

  1. Top of page
  2. Abstract
  3. Synopsis

Background

Surgical investigations and interventions account for large health care utilisation and costs, but the scientific evidence for most procedures is still limited.

Objectives

Degenerative conditions affecting the lumbar spine are variously described as lumbar spondylosis or degenerative disc disease (which we regarded as one entity) and may be associated with back pain and associated leg symptoms, instability, spinal stenosis and/or degenerative spondylolisthesis. The objective of this review was to assess current scientific evidence on the effectiveness of surgical interventions for degenerative lumbar spondylosis.

Search strategy

We searched CENTRAL, MEDLINE, PubMed, Spine and ISSLS abstracts, with citation tracking from the retrieved articles. We also corresponded with experts. All data found up to 31 March 2004 are included.

Selection criteria

Randomised (RCTs) or quasi-randomised trials of surgical treatment of lumbar spondylosis.

Data collection and analysis

Two authors assessed trial quality and extracted data from published papers. Additional information was sought from the authors if necessary.

Main results

Thirty-one published RCTs of all forms of surgical treatment for degenerative lumbar spondylosis were identified. The trials varied in quality: only the more recent trials used appropriate methods of randomization, blinding and independent assessment of outcome. Most of the earlier published results were of technical surgical outcomes with some crude ratings of clinical outcome. More of the recent trials also reported patient-centered outcomes of pain or disability, but there is still very little information on occupational outcomes. There was a particular lack of long term outcomes beyond two to three years. Seven heterogeneous trials on spondylolisthesis, spinal stenosis and nerve compression permitted limited conclusions. Two new trials on the effectiveness of fusion showed conflicting results. One showed that fusion gave better clinical outcomes than conventional physiotherapy, while the other showed that fusion was no better than a modern exercise and rehabilitation programme. Eight trials showed that instrumented fusion produced a higher fusion rate (though that needs to be qualified by the difficulty of assessing fusion in the presence of metal-work), but did not improve clinical outcomes, while there is other evidence that it may be associated with higher complication rates. Three trials with conflicting results did not permit any conclusions about the relative effectiveness of anterior, posterior or circumferential fusion. Preliminary results of two small trials of intra-discal electrotherapy showed conflicting results. Preliminary data from three trials of disc arthroplasty did not permit any firm conclusions.

Authors' conclusions

Limited evidence is now available to support some aspects of surgical practice. Surgeons should be encouraged to perform further RCTs in this field.

 

Synopsis

  1. Top of page
  2. Abstract
  3. Synopsis

Synopsis

Degeneration of the lumbar spine is described as lumbar spondylosis or degenerative disc disease and may lead to spinal stenosis (narrowing of the spinal canal), vertebral instability and/or malalignment, which may be associated with back pain and/or leg symptoms. This review considers the available evidence on the procedures of spinal decompression (widening the spinal canal or laminectomy), nerve root decompression (of one or more individual nerves) and fusion of adjacent vertebrae. There is moderate evidence that instrumentation can increase the fusion rate, but strong evidence that it does not improve clinical outcomes. The effectiveness of intra-discal electrotherapy (IDET) remains unproven. Only preliminary results are available on disc replacement and it is not possible to draw any conclusions on this subject.