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The long-term effect of posterolateral fusion in adult isthmic spondylolisthesis: a randomized controlled study.
Spine J. 2005 Jan-Feb; 5(1):36-44.SJ

Abstract

BACKGROUND

Today there is some evidence-based medicine support for a positive short-term treatment effect of fusion in chronic low back pain in spondylolisthesis and in nonspecific degenerative lumbar spine disorders. The long-term effect is, however, unknown.

PURPOSE

To determine the long-term outcome of lumbar fusion in adult isthmic spondylolisthesis.

STUDY DESIGN

Prospective, randomized controlled study comparing a 1-year exercise program with instrumented and non-instrumented posterolateral fusion with average long-term follow-up of 9 years (range, 5-13).

PATIENT SAMPLE

111 patients aged 18 to 55 years with adult lumbar isthmic spondylolisthesis at L5 or L4 level of all degrees, and at least 1-year's duration of severe lumbar pain with or without sciatica.

OUTCOME MEASURES

Pain and functional disability was quantified by pain (VAS), the Disability Rating Index (DRI), the Oswestry Disability Index (ODI) work status, and global assessment of outcome by the patient into much better, better, unchanged or worse. Quality of life was assessed by the SF-36.

METHODS

The patients were randomly allocated to treatment with 1) a 1-year exercise program (n=34), 2) posterolateral fusion without pedicle screw instrumentation (n=37), or 3) posterolateral fusion with pedicle screw instrumentation (n=40). Long-term follow-up was obtained in 101 (91%) patients. Nine patients in the exercise group were eventually operated on.

RESULTS

Longitudinal analysis: At long-term follow-up pain and functional disability were significantly better than before treatment in both surgical groups. No significant differences were observed between instrumented and non-instrumented patients in any variable studied. In the exercise group the pain was significantly reduced but not the functional disability. Compared with the 2-year follow-up a significant increase in functional disability was observed, as measured by the DRI, but not the ODI, in the surgical group at long term. In the exercise group no significant changes were observed between the 2-year and the long-term follow-up. Cross-sectional analysis: Between the surgical and conservative group no significant differences were observed in any outcome measurement at long-term follow-up except for global assessment, which was significantly better for surgical patients. Of surgical patients 76% classified the overall outcome as much better or better compared with 50% of conservatively treated patients (p=0.015). Quality of life as estimated by the SF-36 at long term was not different between treatment groups in any of the eight domains studied but was considerably lower than for the normal population.

CONCLUSIONS

Posterolateral fusion in adult lumbar isthmic spondylolisthesis results ina modestly improved long-term outcome compared with a 1-year exercise program. Although the results show that some of the previously reported short-term improvement is lost at long term, patients with fusion still classify their global outcome as clearly better than conservatively treated patients. Furthermore, because the long-term outcome of the patients conservatively treated most likely reflects the natural course, one can also conclude that no considerable spontaneous improvement should be expected over time in adult patients with symptomatic isthmic spondylolisthesis. Substantial pain, functional disability and a reduced quality of life will in most patients most likely remain unaltered over many years.

Authors+Show Affiliations

Stockholm Söder Hospital, Department of Orthopedic Surgery, Stockholm Söder Hospital, 118 83 Stockholm, Sweden. per.ekman@sos.sll.seNo affiliation info availableNo affiliation info available

Pub Type(s)

Clinical Trial
Comparative Study
Journal Article
Randomized Controlled Trial
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

15653083

Citation

Ekman, Per, et al. "The Long-term Effect of Posterolateral Fusion in Adult Isthmic Spondylolisthesis: a Randomized Controlled Study." The Spine Journal : Official Journal of the North American Spine Society, vol. 5, no. 1, 2005, pp. 36-44.
Ekman P, Möller H, Hedlund R. The long-term effect of posterolateral fusion in adult isthmic spondylolisthesis: a randomized controlled study. Spine J. 2005;5(1):36-44.
Ekman, P., Möller, H., & Hedlund, R. (2005). The long-term effect of posterolateral fusion in adult isthmic spondylolisthesis: a randomized controlled study. The Spine Journal : Official Journal of the North American Spine Society, 5(1), 36-44.
Ekman P, Möller H, Hedlund R. The Long-term Effect of Posterolateral Fusion in Adult Isthmic Spondylolisthesis: a Randomized Controlled Study. Spine J. 2005 Jan-Feb;5(1):36-44. PubMed PMID: 15653083.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - The long-term effect of posterolateral fusion in adult isthmic spondylolisthesis: a randomized controlled study. AU - Ekman,Per, AU - Möller,Hans, AU - Hedlund,Rune, PY - 2004/01/12/received PY - 2004/05/14/accepted PY - 2005/1/18/pubmed PY - 2005/6/29/medline PY - 2005/1/18/entrez SP - 36 EP - 44 JF - The spine journal : official journal of the North American Spine Society JO - Spine J VL - 5 IS - 1 N2 - BACKGROUND: Today there is some evidence-based medicine support for a positive short-term treatment effect of fusion in chronic low back pain in spondylolisthesis and in nonspecific degenerative lumbar spine disorders. The long-term effect is, however, unknown. PURPOSE: To determine the long-term outcome of lumbar fusion in adult isthmic spondylolisthesis. STUDY DESIGN: Prospective, randomized controlled study comparing a 1-year exercise program with instrumented and non-instrumented posterolateral fusion with average long-term follow-up of 9 years (range, 5-13). PATIENT SAMPLE: 111 patients aged 18 to 55 years with adult lumbar isthmic spondylolisthesis at L5 or L4 level of all degrees, and at least 1-year's duration of severe lumbar pain with or without sciatica. OUTCOME MEASURES: Pain and functional disability was quantified by pain (VAS), the Disability Rating Index (DRI), the Oswestry Disability Index (ODI) work status, and global assessment of outcome by the patient into much better, better, unchanged or worse. Quality of life was assessed by the SF-36. METHODS: The patients were randomly allocated to treatment with 1) a 1-year exercise program (n=34), 2) posterolateral fusion without pedicle screw instrumentation (n=37), or 3) posterolateral fusion with pedicle screw instrumentation (n=40). Long-term follow-up was obtained in 101 (91%) patients. Nine patients in the exercise group were eventually operated on. RESULTS: Longitudinal analysis: At long-term follow-up pain and functional disability were significantly better than before treatment in both surgical groups. No significant differences were observed between instrumented and non-instrumented patients in any variable studied. In the exercise group the pain was significantly reduced but not the functional disability. Compared with the 2-year follow-up a significant increase in functional disability was observed, as measured by the DRI, but not the ODI, in the surgical group at long term. In the exercise group no significant changes were observed between the 2-year and the long-term follow-up. Cross-sectional analysis: Between the surgical and conservative group no significant differences were observed in any outcome measurement at long-term follow-up except for global assessment, which was significantly better for surgical patients. Of surgical patients 76% classified the overall outcome as much better or better compared with 50% of conservatively treated patients (p=0.015). Quality of life as estimated by the SF-36 at long term was not different between treatment groups in any of the eight domains studied but was considerably lower than for the normal population. CONCLUSIONS: Posterolateral fusion in adult lumbar isthmic spondylolisthesis results ina modestly improved long-term outcome compared with a 1-year exercise program. Although the results show that some of the previously reported short-term improvement is lost at long term, patients with fusion still classify their global outcome as clearly better than conservatively treated patients. Furthermore, because the long-term outcome of the patients conservatively treated most likely reflects the natural course, one can also conclude that no considerable spontaneous improvement should be expected over time in adult patients with symptomatic isthmic spondylolisthesis. Substantial pain, functional disability and a reduced quality of life will in most patients most likely remain unaltered over many years. SN - 1529-9430 UR - https://www.unboundmedicine.com/medline/citation/15653083/The_long_term_effect_of_posterolateral_fusion_in_adult_isthmic_spondylolisthesis:_a_randomized_controlled_study_ L2 - https://linkinghub.elsevier.com/retrieve/pii/S1529-9430(04)00485-1 DB - PRIME DP - Unbound Medicine ER -