Lumbar spine fusion: what is the evidence?

Abstract

Lumbar spine fusion is a common procedure associated with a high cost burden and risk of serious complications. We aimed to summarise systematic reviews on the effectiveness of lumbar spine fusion for most diagnoses. We found no high‐quality systematic reviews and the risk of bias of the randomised controlled trials in the reviews was generally high. The available evidence does not support a benefit from spine fusion compared to non‐operative alternatives for back pain associated with degeneration. The available evidence does not support a clinical benefit from spine fusion compared to non‐operative treatment or stabilisation without fusion for thoracolumbar burst fractures. Benefits of spine fusion compared to non‐operative treatment for isthmic spondylolisthesis are unclear (one trial at high risk of bias). Surgical intervention for metastatic carcinoma of the spine associated with spinal cord compromise improves mobility and neurological outcome (based on a single trial). Better evidence is required to determine more accurately the effectiveness of spine fusion surgery for all indications. Patients contemplating spinal fusion should be fully informed about the evidence base for their particular problem, including the relative potential benefits and harms of fusion compared with non‐operative treatments.

The Lancet Series call to action to reduce low value care for low back pain: an update

“…This is supported by a 2019 systematic review (14 studies) which found evidence that imaging is associated with higher medical costs, increased health care utilization and more work absence compared with nonimaged groups. 61 Despite little evidence to support its use for most back conditions, 43 and a 20% failure rate, 91 another US study estimated that $US12.8billion was spent on spinal fusion surgery in 2011, the highest aggregate hospital costs of any surgical procedure. 92…”

Musculoskeletal healthcare: Have we over‐egged the pudding?

“…For example, some in the back pain field dismiss the label non‐specific low back pain and instead argue for labels targeting a specific structure (disc, facet joint) or mechanism (eg instability) and the use of similarly targeted personalized therapies. The problem is that the diagnoses offered are nominal diagnoses that drive more invasive, costly and ineffective therapies without providing benefit . The resulting overuse is substantial: for example the most expensive surgical procedure (US$12.8 billion per annum) in the USA is spine fusion, a procedure that is most commonly performed for degenerative conditions for which there is good evidence of harm and poor evidence of benefit over cheaper and safer alternatives.…”

Care for low back pain: can health systems deliver?

“…magnetic resonance imaging) had increased over 21 years 7 . There is no robust evidence of benefit for spinal fusion surgery compared with non-surgical care for people with low back pain associated with spinal degeneration 8 . However, over the years 2004–2015, elective spinal fusion surgery in the United States increased by 62.3% (from 60.4 per 100 000 to 79.8 per 100 000), with hospital costs for this procedure exceeding 10 billion United States dollars (US$) in 2015 9 .…”