Randomized Clinical Trial of Lumbar Instrumented Fusion and Cognitive Intervention and Exercises in Patients with Chronic Low Back Pain and Disc Degeneration

Abstract

Study Design. Single blind randomized study. Objectives. To compare the effectiveness of lumbar instrumented fusion with cognitive intervention and exercises in patients with chronic low back pain and disc degeneration.Summary of Background Data. To the authors' best knowledge, only one randomized study has evaluated the effectiveness of lumbar fusion. The Swedish Lumbar Spine Study reported that lumbar fusion was better than continuing physiotherapy and care by the family physician.Patients and Methods. Sixty-four patients aged 25-60 years with low back pain lasting longer than 1 year and evidence of disc degeneration at L4 -L5 and/or L5-S1 at radiographic examination were randomized to either lumbar fusion with posterior transpedicular screws and postoperative physiotherapy, or cognitive intervention and exercises. The cognitive intervention consisted of a lecture to give the patient an understanding that ordinary physical activity would not harm the disc and a recommendation to use the back and bend it. This was reinforced by three daily physical exercise sessions for 3 weeks. The main outcome measure was the Oswestry Disability Index.Results. At the 1-year follow-up visit, 97% of the patients, including 6 patients who had either not attended treatment or changed groups, were examined. The Oswestry Disability Index was significantly reduced from 41 to 26 after surgery, compared with 42 to 30 after cognitive intervention and exercises. The mean difference between groups was 2.3 (Ϫ6.7 to 11.4) (P ϭ 0.33). Improvements inback pain, use of analgesics, emotional distress, life satisfaction, and return to work were not different. Fearavoidance beliefs and fingertip-floor distance were reduced more after nonoperative treatment, and lower limb pain was reduced more after surgery. The success rateaccording to an independent observer was 70% after surgery and 76% after cognitive intervention and exercises. The early complication rate in the surgical group was 18%.Conclusion. The main outcome measure showed equal improvement in patients with chronic low back pain and disc degeneration randomized to cognitive intervention and exercises, or lumbar fusion. Lumbar fusion rates have increased greatly over the past 20 years, but the rates vary from country to country. 1 Fusion rates appear to vary markedly among individual surgeons, among small and large geographic regions in the nation, and between the United States and England. 2 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. 3 The effect of using instruments, such as pedicle screws and cages, compared with pure osseous fusion has been compared in six randomized studies. 3 Only one of these studies reported a higher success rate in the instrumented group, but this was not a strictly randomized study, and the surgeon evaluated the outcome himself. The 1997 Volvo Award Winner concluded that lumbar posterolateral fusion with pedicle screw...

What is return to work? An investigation into the quantification of return to work

“…In total, 84% of participants achieved some employment since their injury and 74% were working at the time of the survey. These two methods of assessing work outcome have been employed in a number of studies (Trief et al 2000;Brox et al 2003;Price et al 2005), yet the utility of such isolated measures of performance without adjunct information (e.g. work maintenance) is questionable.…”

Does Wallis implant reduce adjacent segment degeneration above lumbosacral instrumented fusion?

“…Indications comprise degenerative disorders and spondylolisthesis (grades I, II) [20,24,49]. During the last years, lumbar fusion has been increasingly criticised [6], while clinical studies have shown similar long-term follow-up results with conservative treatment [8,14]. Side effects of lumbar fusion include ASD, pseudarthrosis, bone-graft morbidity, high rates of re-operation, implant failure, and sagittal spinal imbalancing.…”

Clinical and radiological outcome of anterior–posterior fusion versus transforaminal lumbar interbody fusion for symptomatic disc degeneration: a retrospective comparative study of 133 patients

“…The goal of a fusion of the lumbar spine is to obtain a primary solid arthrodesis so as to alleviate pain [10,11,14,15,19,22,31]. Different circumferential or ''360°'' fusion techniques have been described such as combined anteriorposterior fusion (APF), instrumented posterior lumbar interbody fusion (PLIF) and transforaminal lumbar interbody fusion (TLIF).…”