Comparison of therapies in lumbar degenerative disc disease: a network meta-analysis of randomized controlled trials

Abstract

Aim:To compare the efficacy and safety of total disc replacement, lumbar fusion, and conservative care in the treatment of single-level lumbar degenerative disc disease (DDD). Materials & methods: A network meta-analysis was conducted to determine the relative impact of lumbar DDD therapies on Oswestry Disability Index (ODI) success, back pain score, patient satisfaction, employment status, and reoperation. Odds ratios or mean differences and 95% credible intervals were reported. Results: Six studies were included (1417 participants). Overall, the activL total disc replacement device had the most favorable results for ODI success, back pain, and patient satisfaction. Results for employment status and reoperation were similar across therapies. Conclusion: activL substantially improves ODI success, back pain, and patient satisfaction compared with other therapies for single-level lumbar DDD. Degenerative disc disease (DDD) in the lumbar spine is a leading cause of pain and disability in adults and is the reason for over 90% of spinal surgeries performed [1,2]. Treatment for patients with symptomatic lumbar DDD always begins with rehabilitation and pain management [3]. For patients with functionally disabling discogenic low back pain that does not improve after conservative care, surgical options such as lumbar spine fusion and arthroplasty, which is the surgical reconstruction or replacement of a joint, may be considered. Unlike lumbar fusion, which is broadly indicated for several spinal disorders [4], arthroplasty is generally only indicated in patients with discogenic low back pain due to DDD between the fourth and fifth lumbar vertebrae (L4/L5) or fifth lumbar and first sacral vertebrae (L5/S1) that has been unresponsive to conservative care [5,6].Surgical approaches to the treatment of discogenic low back pain are associated with risks of procedure-and device-related complications and additional stress on other spinal segments, potentially leading to repeat surgeries or adjacent segment disease [7][8][9][10]. Since its commercial introduction over 10 years ago, arthroplasty continues to be an effective alternative to current therapies. In patients with lumbar DDD, evidence from randomized controlled trials (RCTs) and meta-analyses demonstrate greater success with arthroplasty than with lumbar fusion or conservative care and lower risk of adjacent segment disorder with arthroplasty than with lumbar fusion [11][12][13][14][15][16][17][18][19][20][21]. Advancements in the design and technology of total disc replacement (TDR) devices may further improve effectiveness and safety outcomes in arthroplasty [22]. First-generation TDR devices such as Charité and ProDisc-L offered a degree of motion preservation to protect against the increased mechanical stress imposed by lumbar fusion. The latest-generation device, the activL R Artificial Disc (Aesculap, Tuttlingen, Germany), advances motion-preserving technology to more closely align with the natural motion of the healthy human spine, thereby potentially further redu...

Final Long-Term Reporting from a Randomized Controlled IDE Trial for Lumbar Artificial Discs in Single-Level Degenerative Disc Disease: 7-Year Results

“…14 Long-term studies have also demonstrated that the likelihood of secondary surgery at adjacent spine segments is higher among patients who undergo fusion than among those who undergo lumbar TDR. 4, [15][16][17][18][19][20][21][22] A recent study showed no significant difference in adjacent segment degeneration rates at 8 years between patients who underwent lumbar TDR (42%) and those who continued with nonsurgical treatment (40%). 23 These data suggest that the progression of adjacent segment degeneration is part of the natural history of DDD but may be accelerated by lumbar fusion.…”

Comparison of Mid- to Long-term Follow-up of Patient-reported Outcomes Measures After Single-level Lumbar Total Disc Arthroplasty, Multi-level Lumbar Total Disc Arthroplasty, and the Lumbar Hybrid Procedure for the Treatment of Degenerative Disc Disease

“…There is considerable evidence on the benefits of TDA 10 , 15 ALIF 22 , 23 and hybrid 9 , 21 , 24 , 25 constructs in treating symptomatic DDD with comparison studies showing similar clinical outcomes. 11 , 17 , 23 , 26 – 28 However, there are few long-term studies comparing these procedures with each other.…”

The effect of mindfulness on the inflammatory, psychological and biomechanical domains of adult patients with low back pain: A randomized controlled clinical trial

“…The subset of symptomatic disc degeneration has affected 403 million new patients every year worldwide. The treatments of symptomatic disc degeneration vary from noninvasive (physical therapy, pain medication) to invasive surgical intervention [ 15 ]. Surgical approaches will be associated with risks of the surgery and may derive in repeated surgeries due to the increase in the stress received by the other segments.…”