Decompression With and Without Fusion in the Treatment of Degenerative Lumbar Disease: A Systematic Review_Chinese Journal of Evidence-Based Medicine

Authors：

HUANG Weimin ¹ , BAI Jingping ² , XILIN Baoleri ² , LI Tongxiang ² , HE Zusheng ² ,  WU Taixiang ³

1.Xinjiang Jiangong Hospital, Urumqi 830002,China 2.The Affiliated Oncology Hospital of Xinjiang Medical University ,Urumqi 830054,China 3.Chinese Evidence-Based Medicine Centre/INCLEN CERTC, West China Hospital, Sichuan University, Chengdu 610041,China;

Corresponding author：

WU Taixiang, Email: txwutx@hotmail.com

Keywords：

Degenerative lumbar disease; Decompression; Fusion; Systematic review; Meta-analysis; RCT

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Objictive 　To evaluate the efficacy of decompression with and without fusion in the treatment of degenerative lumbar disease.
Methods 　We searched the Cochrane Library (Issue 1, 2006), MEDLINE (1966 to April, 2006), EMBASE (1984 to April, 2006), the China Biological Medicine Database (to Dec., 2005), VIP (1989 to April, 2006) and hand-searched several related journals for randomized controlled trials (RCTs) and quasi-randomized controlled trials (quasi-RCTs) involving the comparison of the outcomes between decompression with and without fusion in the treatment of degenerative lumbar disease. The quality of the included trials was assessed. RevMan 4.2.8 software was used for statistical analysis.
Results 　Seven studies involving 412 patients were included. The results of meta-analysis indicated that no statistically significant differences were observed between the two operative procedures in the cumulative clinical outcome (OR1.83, 95%CI 0.92, 3.41), incidence of postoperative leg pain (OR 1.04, 95%CI 0.48, 2.25), incidence of perioperative complications (OR 1.15, 95%CI 0.51, 2.60), incidence of re-operation (OR 0.68, 95%CI 0.30, 1.56) or pre and postoperative pain scores [Pre-op WMD 0.12, 95%CI (-0.44,0.68); Post-op WMD 0.08, 95%CI (-1.08,1.25)]. The only statistical significance was observed in the incidence of postoperative back pain (OR 0.25, 95%CI 0.14, 0.46). Four studies described the length of operation, the intraoperative blood loss, the duration of external fixation postoperative and the total cost in hospital, which revealed that decompression alone was superior to decompression plus fusion. Three studies described the relationships between the clinical outcome and the changes in segmental range of motion/disc height pre- and post-operatively, as well as the flexion-extension radiographs, which revealed that decompression plus fusion was superior to decompression alone.
Conclusions 　There are no significant differences between the two procedures in clinical outcomes, incidences of postoperative leg pain, re-operation and complications. Decompression with fusion leads to fewer patients suffering from postoperative lumbago than that of decompression alone. There is insufficient evidence to demonstrate that the radiographs may predict the clinical outcomes. More high quality, large-scale randomized controlled trials are required.

Citation： HUANG Weimin,BAI Jingping,XILIN Baoleri,LI Tongxiang,HE Zusheng,WU Taixiang. Decompression With and Without Fusion in the Treatment of Degenerative Lumbar Disease: A Systematic Review. Chinese Journal of Evidence-Based Medicine, 2006, 06(7): 484-493. doi: Copy

1.	Katz JN, Lipson SJ, Lew RA, et al. Lumbar laminectomy alone or with instrumented or noninstrumented arthrodesis in degenerative lumbar spinal stenosis. Patient selection, costs, and surgical outcomes. Spine, 1997; 22(10): 1123-1131.
2.	The Cochrane Collaboration.cochrane reviewers’ Handbook 4.2.3. http://www.cochraneeye.Org/documents/Cochrane%- 20Reviewers’%20Handbook%204.2.3.pdf.
3.	The Cochrane Collaboration.RevMan 4.2 User Guide. http://www.cc-ims.net/down load/revman/Documentation- /User%20guide.pdf.
4.	Grob D, Humke T, Dvorak J. Degenerative lumbar spinal stenosis. Decompression with and without arthrodesis. J Bone Joint Surg Am, 1995; 77(7): 1036-1041.
5.	Rompe JD, Eysel P, Hopf CH, et al. Surgical management of central lumbar spinal stenosis-results with decompressive laminectomy only and with concomitant instrumented fusion with the Cotrel-Dubousset-Instrumentation. Neuro-Orthopedics, 1995; 19(1): 17-31.
6.	Vaughan PA, Malcolm BW, Maistrelli GL. Results of L4-L5 Disc Excision Alone Versus Disc Excision and Fusion. Spine, 1988; 13(6): 690-695.
7.	Matsudaira K, Yamazaki T, Seichi A, et al. Spinal Stenosis in Grade I Degenerative Lumbar Spondylolisthsis: a Comparative Study of Outcomes Following Laminoplasty and Laminectomy with Instrumented Spinal fusion. J Orthop Sci, 2005; 10(3): 270-276.
8.	Takeshima T, Kambara K, Miyata S, et al. Clinical and radiographic evaluation of disc excision for lumbar disc herniation with and without posterolateral fusion. Spine, 2000; 25(4): 450-456.
9.	White AH, von Rogov P, Zucherman J, et al. Lumbar Laminectomy for Herniated Disc: A Prospective Controlled Comparison with Internal Fixation Fusion. Spine, 1987; 12(3): 305-307.
10.	Herkowitz HN, Kurz LT. Degenerative lumbar spondylolisthesis with spinal stenosis. A prospective study comparing decompression with decompression and intertransverse process arthrodesis. J Bone Joint Surg Am, 1991; 73(6): 802-808.
11.	Harris RI, Macnab I. Structural changes in the lumbar intervertebral discs; their relationship to low back pain and sciatica. J Bone Joint Surg Br, 1954; 36-B(2): 304-322.
12.	Kirkaldy-Willis WH, Farfan HF. Instability of the lumbar spine. Clin Orthop Relat Res, 1982; (165): 110-123.
13.	Spratt KF, Weinstein JN, Lehmann TR, et al. Efficacy of flexion and extension treatments incorporating braces for low-back pain patients with retrodisplacement, spondylolisthesis, or normal sagittal translation. Spine, 1993; 18(13): 1839-1849.
14.	Hanley EN, Matteri RE, Frymoyer JM. Accurate roentgenographic determination of lumbar flexion-extension. Clin Orthop Relat Res, 1976; (115): 145-148.
15.	Bjarke Christensen F, Stender Hansen E, Laursen M, et al. Long-Term Functional Outcome of Pedicle Screw Instrumentation as a Support for Posterolateral Spinal Fusion: Randomized Clinical Study With a 5-Year Follow-up. Spine, 2002; 27(12): 1269-1277.

1. Katz JN, Lipson SJ, Lew RA, et al. Lumbar laminectomy alone or with instrumented or noninstrumented arthrodesis in degenerative lumbar spinal stenosis. Patient selection, costs, and surgical outcomes. Spine, 1997; 22(10): 1123-1131.
2. The Cochrane Collaboration.cochrane reviewers’ Handbook 4.2.3. http://www.cochraneeye.Org/documents/Cochrane%- 20Reviewers’%20Handbook%204.2.3.pdf.
3. The Cochrane Collaboration.RevMan 4.2 User Guide. http://www.cc-ims.net/down load/revman/Documentation- /User%20guide.pdf.
4. Grob D, Humke T, Dvorak J. Degenerative lumbar spinal stenosis. Decompression with and without arthrodesis. J Bone Joint Surg Am, 1995; 77(7): 1036-1041.
5. Rompe JD, Eysel P, Hopf CH, et al. Surgical management of central lumbar spinal stenosis-results with decompressive laminectomy only and with concomitant instrumented fusion with the Cotrel-Dubousset-Instrumentation. Neuro-Orthopedics, 1995; 19(1): 17-31.
6. Vaughan PA, Malcolm BW, Maistrelli GL. Results of L4-L5 Disc Excision Alone Versus Disc Excision and Fusion. Spine, 1988; 13(6): 690-695.
7. Matsudaira K, Yamazaki T, Seichi A, et al. Spinal Stenosis in Grade I Degenerative Lumbar Spondylolisthsis: a Comparative Study of Outcomes Following Laminoplasty and Laminectomy with Instrumented Spinal fusion. J Orthop Sci, 2005; 10(3): 270-276.
8. Takeshima T, Kambara K, Miyata S, et al. Clinical and radiographic evaluation of disc excision for lumbar disc herniation with and without posterolateral fusion. Spine, 2000; 25(4): 450-456.
9. White AH, von Rogov P, Zucherman J, et al. Lumbar Laminectomy for Herniated Disc: A Prospective Controlled Comparison with Internal Fixation Fusion. Spine, 1987; 12(3): 305-307.
10. Herkowitz HN, Kurz LT. Degenerative lumbar spondylolisthesis with spinal stenosis. A prospective study comparing decompression with decompression and intertransverse process arthrodesis. J Bone Joint Surg Am, 1991; 73(6): 802-808.
11. Harris RI, Macnab I. Structural changes in the lumbar intervertebral discs; their relationship to low back pain and sciatica. J Bone Joint Surg Br, 1954; 36-B(2): 304-322.
12. Kirkaldy-Willis WH, Farfan HF. Instability of the lumbar spine. Clin Orthop Relat Res, 1982; (165): 110-123.
13. Spratt KF, Weinstein JN, Lehmann TR, et al. Efficacy of flexion and extension treatments incorporating braces for low-back pain patients with retrodisplacement, spondylolisthesis, or normal sagittal translation. Spine, 1993; 18(13): 1839-1849.
14. Hanley EN, Matteri RE, Frymoyer JM. Accurate roentgenographic determination of lumbar flexion-extension. Clin Orthop Relat Res, 1976; (115): 145-148.
15. Bjarke Christensen F, Stender Hansen E, Laursen M, et al. Long-Term Functional Outcome of Pedicle Screw Instrumentation as a Support for Posterolateral Spinal Fusion: Randomized Clinical Study With a 5-Year Follow-up. Spine, 2002; 27(12): 1269-1277.

Chinese Journal of Evidence-Based Medicine

Decompression With and Without Fusion in the Treatment of Degenerative Lumbar Disease: A Systematic Review

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