In Reply to the Letter to the Editor Regarding “Is Lumbar Fusion Necessary for Chronic Low Back Pain Associated with Degenerative Disk Disease? A Meta-Analysis”

The utilization of pedicle screw fixation as an adjunct to posterolateral lumbar fusion (PLF) has become routine, but demonstration of a definitive benefit remains problematic. The medical evidence indicates that the addition of pedicle screw fixation to PLF increases fusion rates when assessed with dynamic radiographs. More recent evidence, since publication of the 2005 Lumbar Fusion Guidelines, suggests a stronger association between radiographic fusion and clinical outcome, although, even now, no clear correlation has been demonstrated. Although several reports suggest that clinical outcomes are improved with the addition of pedicle screw fixation, there are conflicting findings from similarly classified evidence. Furthermore, the largest contemporary, randomized, controlled study on this topic failed to demonstrate a significant clinical benefit with the use of pedicle screw fixation in patients undergoing PLF for chronic low-back pain. This absence of proof should not, however, be interpreted as proof of absence. Several limitations continue to compromise these investigations. For example, in the majority of studies the sample size is insufficient to detect small increments in clinical outcome that may be observed with pedicle screw fixation. Therefore, no definitive statement regarding the efficacy of pedicle screw fixation as a means to improve functional outcomes in patients undergoing PLF for chronic low-back pain can be made. There appears to be consistent evidence suggesting that pedicle screw fixation increases the costs and complication rate of PLF. High-risk patients, including (but not limited to) patients who smoke, patients who are undergoing revision surgery, or patients who suffer from medical conditions that may compromise fusion potential, may appreciate a greater benefit with supplemental pedicle screw fixation. It is recommended, therefore, that the use of pedicle screw fixation as a supplement to PLF be reserved for those patients in whom there is an increased risk of nonunion when treated with only PLF.

Download Full-text

Reply to a letter to the editor regarding “Chronic low back pain, bacterial infection and treatment with antibiotics”

The Spine Journal ◽

10.1016/j.spinee.2021.03.036 ◽

2021 ◽

Vol 21 (7) ◽

pp. 1231-1232

Author(s):

Christopher J. Gilligan ◽

Steven P. Cohen ◽

Vincent A. Fischetti ◽

Joshua A. Hirsch ◽

Lloyd G. Czaplewski

Keyword(s):

Low Back Pain ◽

Back Pain ◽

Bacterial Infection ◽

Chronic Low Back Pain ◽

Low Back ◽

Letter To The Editor

Download Full-text

Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 8: Lumbar fusion for disc herniation and radiculopathy

Journal of Neurosurgery Spine ◽

10.3171/2014.4.spine14271 ◽

2014 ◽

Vol 21 (1) ◽

pp. 48-53 ◽

Cited By ~ 34

Author(s):

Jeffrey C. Wang ◽

Andrew T. Dailey ◽

Praveen V. Mummaneni ◽

Zoher Ghogawala ◽

Daniel K. Resnick ◽

...

Keyword(s):

Low Back Pain ◽

Back Pain ◽

Chronic Low Back Pain ◽

Lumbar Fusion ◽

Signs And Symptoms ◽

Herniated Disc ◽

Spinal Instability ◽

Low Back ◽

Low Level ◽

Disc Herniations

Patients suffering from a lumbar herniated disc will typically present with signs and symptoms consistent with radiculopathy. They may also have low-back pain, however, and the source of this pain is less certain, as it may be from the degenerative process that led to the herniation. The surgical alternative of choice remains a lumbar discectomy, but fusions have been performed for both primary and recurrent disc herniations. In the original guidelines, the inclusion of a fusion for routine discectomies was not recommended. This recommendation continues to be supported by more recent evidence. Based on low-level evidence, the incorporation of a lumbar fusion may be considered an option when a herniation is associated with evidence of spinal instability, chronic low-back pain, and/or severe degenerative changes, or if the patient participates in heavy manual labor. For recurrent disc herniations, there is low-level evidence to support the inclusion of lumbar fusion for patients with evidence of instability or chronic low-back pain.

Download Full-text

Intervertebral disc therapies for non-specific chronic low back pain: a systematic review and meta-analysis

Therapeutic Advances in Musculoskeletal Disease ◽

10.1177/1759720x211028001 ◽

2021 ◽

Vol 13 ◽

pp. 1759720X2110280

Author(s):

Camille Daste ◽

Stéphanie Laclau ◽

Margaux Boisson ◽

François Segretin ◽

Antoine Feydy ◽

...

Keyword(s):

Systematic Review ◽

Low Back Pain ◽

Back Pain ◽

Intervertebral Disc ◽

Chronic Low Back Pain ◽

Meta Analysis ◽

Activity Limitations ◽

Low Back ◽

Short Term

Objectives: We aim to evaluate the benefits and harms of intervertebral disc therapies (IDTs) in people with non-specific chronic low back pain (NScLBP). Methods: We conducted a systematic review and meta-analysis of randomized trials of IDTs versus placebo interventions, active comparators or usual care. EMBASE, MEDLINE, CENTRAL and CINHAL databases and conference abstracts were searched from inception to June 2020. Two independent investigators extracted data. The primary outcome was LBP intensity at short term (1 week–3 months), intermediate term (3–6 months) and long term (after 6 months). Results: Of 18 eligible trials (among 1396 citations), five assessed glucocorticoids (GCs) IDTs and were included in a quantitative synthesis; 13 assessed other products including etanercept ( n = 2), tocilizumab ( n = 1), methylene blue ( n = 2), ozone ( n = 2), chymopapaine ( n = 1), glycerol ( n = 1), stem cells ( n = 1), platelet-rich plasma ( n = 1) and recombinant human growth and differentiation factor-5 ( n = 2), and were included in a narrative synthesis. Standardized mean differences (95% CI) for GC IDTs for LBP intensity and activity limitations were −1.33 (−2.34; −0.32) and −0.76 (−1.85; 0.34) at short term, −2.22 (−5.34; 0.90) and −1.60 (−3.51; 0.32) at intermediate term and −1.11 (−2.91; 0.70) and −0.63 (−1.68; 0.42) at long term, respectively. Odds ratios (95% CI) for serious and minor adverse events with GC IDTs were 1.09 (0.25; 4.65) and 0.97 (0.49; 1.91). Conclusion: GC IDTs are associated with a reduction in LBP intensity at short term in people with NScLBP. Positive effects are not sustained. IDTs have no effect on activity limitations. Our conclusions are limited by high heterogeneity and a limited methodological quality across studies. Registration PROSPERO: CRD42019106336.

Download Full-text