Secondary Logo

Institutional members access full text with Ovid®

What Is the Clinical Relevance of Radiographic Nonunion After Single-Level Lumbar Interbody Arthrodesis in Degenerative Disc Disease?

A Meta-Analysis of the YODA Project Database

Noshchenko, Andriy, PhD; Lindley, Emily M., PhD; Burger, Evalina L., MD; Cain, Christopher M. J., MD; Patel, Vikas V., MA, MD

doi: 10.1097/BRS.0000000000001113

Study Design. Meta-analysis of 4 randomized controlled clinical trials (RCTs).

Objective. The aim of the study was to determine if patients with degenerative disc disease who achieve radiographic fusion after single-level lumbar interbody arthrodesis have better clinical outcomes than patients with radiographic pseudarthrosis at 12 and 24 months postoperative.

Summary of Background Data. The clinical relevance of successful fusion after lumbar arthrodesis with recombinant human bone morphogenetic protein-2 or iliac crest bone autograft has recently been questioned in the literature.

Methods. Individual patient-level data of 4 RCTs were obtained from the Yale University Open Data Access Project project and analyzed. Clinical outcomes (Oswestry Disability Index [ODI]; Numeric Rating Scales [NRSs] for back and leg pain) were compared between patients with radiographically confirmed fusion and those with radiographic nonunion 1 and 2 years postoperative. The results of each study were first analyzed separately, and then were pooled by meta-analysis. The GRADE approach was applied to evaluate the level of evidence.

Results. A total of 496 patients with clinical and radiographic data at 1- and 2-year follow-ups were identified. Of these, 5.5% (95% confidence interval: 3.7; 8.3) had radiographic nonunion which did not require reoperation. Patients with fusion had better improvements in ODI (P < 0.001) and NRS back pain scores (P < 0.001). The overall percentage of fused patients with ODI and NRS back pain scores that exceeded the criteria for minimal clinically important differences was also significantly higher than that of patients with nonunion (ODI, odds ratio [OR] = 2.7, P = 0.019; NRS back pain, OR = 3.5, P = 0.033). The predictive values of fusion for clinical outcomes, however, were poor, with low specificity and low negative predictive values.

Conclusion. The presence of radiographic fusion is clinically significant, as patients with fusion had better clinical outcomes at 1 and 2 years postoperative than those with nonunion; however, patient-centered clinical outcomes should also be taken into consideration as independent, complimentary variables when assessing treatment success.

Level of Evidence: 1

Department of Orthopedics, University of Colorado Anschutz Medical Campus, Aurora, CO.

Address correspondence and reprint requests to Andriy Noshchenko, PhD, Department of Orthopedics, University of Colorado Anschutz Medical Campus, 13001 E 17th Place, Mail Stop F432, Aurora, CO 80045; E-mail:

Received 6 April, 2015

Revised 17 July, 2015

Accepted 22 July, 2015

The device(s)/drug(s) is/are FDA-approved or approved by corresponding national agency for this indication.

No funds were received in support of this work.

Relevant financial activities outside the submitted work: consultancy, expert testimony, employment, grants, payment for lectures, patents, royalties, payment for development of educational presentations.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.