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Effectiveness of Spinal Fusion Versus Structured Rehabilitation in Chronic Low Back Pain Patients With and Without Isthmic Spondylolisthesis: A Systematic Review

Wood, Kirkham B. MD*; Fritzell, Peter MD, PhD; Dettori, Joseph R. MPH, PhD; Hashimoto, Robin PhD; Lund, Teija MD§; Shaffrey, Chris MD

doi: 10.1097/BRS.0b013e31822ef8c5
Heterogeneity of Treatment Effects

Study Design. Systematic review.

Objective. To determine if the presence of isthmic spondylolisthesis modifies the effect of treatment (fusion vs. multidimensional supervised rehabilitation) in patients with chronic low back pain (CLBP).

Summary of Background Data. Results of spinal surgery for CLBP are variable. It is unclear whether patients with CLBP and isthmic spondylolisthesis have more success with surgery versus a multidimensional supervised rehabilitation program when compared with those with CLBP but without spondylolisthesis.

Methods. A systematic search was conducted in MEDLINE and the Cochrane Collaboration Library for articles published through January 2011. Randomized controlled trials (RCTs) were included that compared spine fusion versus multidimensional supervised rehabilitation in patients with and without isthmic spondylolisthesis. Standardized mean differences (SMDs) and risk differences were calculated for common outcomes, and then compared to determine potential heterogeneity of treatment effect. The final strength of the body of literature was expressed as “high,” “moderate,” or “low” confidence that the evidence reflects the true effect.

Results. No studies were found that directly compared the two subgroups. Three RCTs compared fusion with supervised nonoperative care in patients with CLBP without isthmic spondylolisthesis; one RCT evaluated these treatments in patients with isthmic spondylolisthesis. There were study differences in patient characteristics, type of fusion, the nature of the rehabilitation, outcomes assessed, and length of follow-up. The SMDs for pain in favor of fusion were modest at 2 years for those without isthmic spondylolisthesis, but large in favor of fusion for those with isthmic spondylolisthesis compared with rehabilitation. Similarly, the SMDs for function in patients without isthmic spondylolisthesis compared with rehabilitation was small at 2 years, but appreciably higher in favor of fusion in patients with isthmic spondylolisthesis.

Conclusion. The overall strength of evidence evaluating whether the presence of isthmic spondylolisthesis modifies the effect of fusion compared with rehabilitation patients with CLBP is “low.” Fusion should be considered for patients with low back pain and isthmic spondylolisthesis who have failed nonoperative treatment.

Clinical Recommendations. We recommend considering fusion for patients with isthmic spondylolisthesis and lower back pain who have failed nonoperative treatment. Recommendation: Weak.

A systematic review was conducted to study whether the presence of isthmic spondylolisthesis in chronic low back pain modified the outcome of fusion versus multidimensional supervised rehabilitation. Although the strength of evidence is “low,” there appears to be an effect favoring fusion among those with chronic low back pain and isthmic spondylolisthesis.

*Orthopaedic Surgery, Harvard Medical School, and Spine Service, Massachusetts General Hospital, Boston, MA;

Department of Orthopedic Surgery, Center for Clinical Research, Falun Hospital, Falun, Sweden;

Spectrum Research, Inc., Tacoma, WA;

§ORTON Orthopaedic Hospital, Invalid Foundation, Helsinki, Finland;

Neurological Surgery, School of Medicine, University of Virginia, Charlottesville, VA.

Address correspondence and reprint requests to Kirkham B. Wood, MD, Harvard Medical School and Massachusetts General Hospital, 55 Fruit St, Gray 502, Boston, MA 02114; E-mail:

Acknowledgment date: May 10, 2011. First Revision date: June 27, 2011. Acceptance date: July 21, 2011.

Analytic support for this work was provided by Spectrum Research, Inc

The manuscript submitted does not contain information about medical device(s)/drug(s).

AOSpine North America and Foundation funds were received to support this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript.

Author contributions: K.B.W., J.R.D., P.F.: study concept, data analysis and interpretation, manuscript preparation, and manuscript revision. T.L.: data interpretation and manuscript revision. R.H.: study concept, data analysis and interpretation, and manuscript preparation. C.S.: manuscript revision.

© 2011 Lippincott Williams & Wilkins, Inc.