SPORT and the Canadian experience

Lumbar spine fusion for chronic low back pain due to degenerative disc disease: a systematic review

STUDY DESIGN

Systematic literature review.

OBJECTIVE

To categorize published evidence systematically for lumbar fusion for chronic low back pain (LBP) in order to provide an updated and comprehensive analysis of the clinical outcomes.

SUMMARY OF BACKGROUND DATA

Despite a large number of publications of outcomes of spinal fusion surgery for chronic LBP, there is little consensus on efficacy.

METHODS

A MEDLINE and Cochrane database search was performed to identify published articles reporting on validated patient-reported clinical outcomes measures (2 or more of visual analogue scale, Oswestry Disability Index, Short Form [36] Health Survey [SF-36] PCS, and patient satisfaction) with minimum 12 months of follow-up after lumbar fusion surgery in adult patients with LBP due to degenerative disc disease. Twenty-six total articles were identified and stratified by level of evidence: 18 level 1 (6 studies of surgery vs. nonoperative treatment, 12 studies of alternative surgical procedures), 2 level 2, 2 level 3, and 4 level 4 (2 prospective, 2 retrospective). Weighted averages of each outcomes measure were computed and compared with established minimal clinically important difference values.

RESULTS

Fusion cohorts included a total of 3060 patients. The weighted average improvement in visual analogue scale back pain was 36.8/100 (standard deviation [SD], 14.8); in Oswestry Disability Index 22.2 (SD, 14.1); in SF-36 Physical Component Scale 12.5 (SD, 4.3). Patient satisfaction averaged 71.1% (SD, 5.2%) across studies. Radiographical fusion rates averaged 89.1% (SD, 13.5%), and reoperation rates 12.5% (SD, 12.4%) overall, 9.2% (SD, 7.5%) at the index level. The results of the collective studies did not differ statistically in any of the outcome measures based on level of evidence (analysis of variance, P > 0.05).

CONCLUSION

The body of literature supports fusion surgery as a viable treatment option for reducing pain and improving function in patients with chronic LBP refractory to nonsurgical care when a diagnosis of disc degeneration can be made.

Introduction to and techniques of evidence-based medicine

STUDY DESIGN

: Literature review.

OBJECTIVE

: To outline the components and application of evidence-based medicine (EBM) with an emphasis on the critical components of conduct and appraisal of clinical research.

SUMMARY OF BACKGROUND DATA

: "Evidence-based medicine" is now a commonplace phrase representing the hallmark of excellence in clinical practice. EBM integrates a question, thoughtful comprehensive evaluation of the pertinent literature, with clinical experience and patient preference to make optimal patient care decisions. These decisions must be evaluated with objective outcome measures to ensure effectiveness. There have been some misconceptions around the application of EBM and that it is synonymous with randomized controlled trials (RCTs) or based purely on levels of evidence.

METHODS

: Narrative and review of literature.

CONCLUSION

: Clinicians must understand the importance of the research question, study design, and outcomes in order to apply the best available research to patient care. Treatment recommendations evolving from critical appraisal are not only based on levels of evidence, but the risk benefit ratio and cost. The true philosophy of EBM, however, is not for research to supplant individual clinical experience and the patient's informed preference, but to integrate them with the best available research. Healthcare professionals and administrators must grasp that EBM is not a RCT. They must realize that the question being asked and the research circumstances dictate the study design. Furthermore, they must not diminish the role of clinical expertise and informed patient preference in EBM.