In the July 2014 Journal of Neurosurgery: Spine issue, several spine surgeons contributed to the guideline updates for lumbar spinal fusion procedures.
JAANS: Spine initially published the "Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine" in 2005. In the updated guidelines, a team of experts used a five-tiered level of evidence strategy and replaced qualitative descriptors used in 2005 with "grades" to reflect medical evidence strength.
Here are key thoughts from the 16 updated guidelines:
1. Functional outcomes assessment — the guideline recommends using a "reliable, valid and responsive outcomes instrument" to assess functional outcome in lumbar spinal fusion patients. An example give is the Oswestry Disability Index. The abstract also notes pretreatment psychological state as a "major independent variable" that could impact the surgeon's ability to detect functional outcome change.
2. Economic outcomes — this guideline notes that hospital charges for surgical procedures should be converted to cost data for a cost-effectiveness analysis. Quality-adjusted life year data can be calculated using preference-based health-related quality-of-life instruments. There have been a few recent cost-effectiveness studies on lumbar spinal fusion, including a single study showing lumbar fusion for select patients can be "recommended from an economic perspective."
3. Radiographic assessment — the guidelines do not recommend static radiographs to identify successful arthrodesis. Non-invasive modalities of fusion assessment were shown to have poor potential in studies. They do recommend CT with fine-cut axial images and multiplanar views.
4. Radiographic outcome and function correlation — while there isn't conclusive evidence of the correlation between fusion and clinical outcome, evidence does suggest positive association between radiographic fusion presence and better clinical outcome, so the guidelines recommend strategies intended to enhance radiographic fusion potential during lumbar arthrodesis for degenerative disease.
5. Discography — the guidelines do not recommend discography as a standalone test for patient selection. However, the guideline does recommend discoblock considered as a diagnostic option.
6. Fusion for intractable low-back pain without stenosis or spondylolisthesis — this is controversial but evidence doesn't currently support a single alternative treatment. The guidelines recommend lumbar fusion for patients who are unable to manage pain with conservative care.
7. Fusion for lumbar disc herniation and radiculopathy — the guidelines do not recommend fusion for routine discectomies based on the evidence.
8. Fusion for lumbar stenosis with spondylolisthesis — the guidelines consider lumbar fusion appropriate to stabilize the spine and prevent delayed deterioration when stenosis is associated with spondylolisthesis. However, the guidelines cite "insufficient evidence" to recommending a standard approach to achieve a solid arthrodesis.
9. Fusion for stenosis without spondylolisthesis — the guidelines do not recommend fusion for patients with stenosis without deformity or instability.
10. Interbody techniques — evidence shows interbody techniques are associated with higher fusion rates in patients with degenerative spondylolisthesis with postoperative instability when compared with posterolateral fusion. The guidelines note posterolateral lumbar fusion is an option with posterior or anterior interbody lumbar fusion but does not recommend it due to increased potential risk and cost.
11. Pedicle screw fixation as an adjunct to posterolateral fusion — based on current evidence, the guidelines made no "definitive statement" on the efficacy of pedicle screw fixation to improve functional outcomes in posterolateral lumbar fusion patients undergoing surgery for chronic low-back pain.
12. Injection therapies, low back pain and lumbar fusion — there was some support for lumbar epidural injections for short-term relief in select chronic low back pain patients, but the guidelines note much of the medical literature does not support lumbar epidural injections for long-term relief of chronic back pain without radiculopathy. The guidelines do not recommend lumbar intraarticular facet injections for chronic low back pain.
13. Brace therapy — the guidelines recommend bracing as a treatment option for patients with subacute low back pain but does not recommend bracing following instrumented posterolateral fusion.
14. Electrophysiological monitoring — the guidelines neither support nor refute current evidence on electrophysiological monitoring. No evidence shows IOM can prevent nerve root injury, according to the guideline.
15. Bone graft extenders and substitutes — the guidelines suggest surgeons using bone morphogenetic proteins "should be aware of a growing body of literature demonstrating unique complications associated with the use of BMPs."
16. Bone growth stimulators — the use of direct current stimulation was recommended as an option for patients under 60 years old as an adjunct for lumbar fusion.
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