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Surgery for degenerative lumbar spondylosis

  • Review
  • Intervention

Authors

  • JNA Gibson,

    Consultant Trauma and Orthopaedic Surgeon, Corresponding author
    1. The Royal Infirmary of Edinburgh, Lothian University Hospitals NHS Trust, Edinburgh, UK
    • JNA Gibson, Consultant Trauma and Orthopaedic Surgeon, Lothian University Hospitals NHS Trust, The Royal Infirmary of Edinburgh, Fairmilehead, Edinburgh, EH16 4SU, UK. j.n.a.gibson@ed.ac.uk.

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  • G Waddell,

  • IC Grant


Abstract

Background

Surgical investigations and interventions account for as much as one third of the health care costs for spinal disorders, but the scientific evidence for most procedures is still unclear.

Objectives

Degenerative conditions affecting the lumbar spine are variously described as lumbar spondylosis or degenerative disc disease (which we regarded as one entity) and are associated with back pain, instability, spinal stenosis and degenerative spondylolisthesis. The objective of this review was to assess the effects of surgical interventions for the treatment of degenerative lumbar spondylosis.

Search strategy

We searched the Cochrane Controlled Trials Register, Medline, Embase, Biosis, Dissertation Abstracts, Index to UK Thesis, and reference lists of the retrieved articles and we corresponded with experts. All data found up to 31/12/99 are included.

Selection criteria

Randomised or quasi-randomised trials of surgical treatment of lumbar spondylosis

Data collection and analysis

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

Main results

Sixteen published trials of all forms of surgical treatment for degenerative lumbar spondylosis have been identified. There were many serious weaknesses of trial design, including poor methods of randomisation, lack of blinding and lack of independent assessment of outcome which at times gave considerable potential for bias. Most of the published results were reporting on technical surgical outcomes with some crude ratings of clinical outcome, but few patient-centred outcomes of pain, disability or capacity for work. There was a particular lack of long-term outcomes. This review found no published trials comparing any form of surgery for degenerative lumbar spondylosis compared with natural history, placebo, or any form of conservative treatment. Ten trials randomly compared instrumented and non-instrumented fusion. 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 and there is evidence that it may be associated with higher complication rates. The few and heterogeneous trials on spondylolisthesis, spinal stenosis and nerve compression permitted very limited conclusions.

Authors' conclusions

There is no scientific evidence about the effectiveness of any form of surgical decompression or fusion for degenerative lumbar spondylosis compared with natural history, placebo, or conservative treatment.

Plain language summary

Synopsis

Evidence about the effeciveness of surgery for people with lumbar arthritis.

As ageing occurs many patients develop some wear of the discs lying between their lower lumbar vertebra. In consequence, the disc space narrows and stresses placed across the lower back are transmitted to the small intervertebral facet joints. These joints may then enlarge and press on the nerves leaving the spine from the lower canal, leading to conditions termed spinal stenosis and nerve root stenosis. This review considers the available evidence for the procedures of spinal decompression (widening the spinal canal or laminectomy), nerve root decompression (freeing a single nerve), and spinal fusion (joining the vertebra to diminish pain from the arthritic joints). The results reveal no clear evidence supporting decompression or fusion compared with natural history, placebo or conservative management of degenerate lumbar spondylosis. There is some evidence suggesting that instrumenting a spinal fusion will lead to a higher fusion rate, but there is no evidence that it makes any difference to clinical outcomes.

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