Abstract # AM29ABS00808 Long Term Patient-Centered Clinical Outcomes of Lumbar Arthrodesis in Degenerative Disc Disease: A Systematic Review with Meta Analysis Noshchenko, Andriy; Lindley, Emily M.; Burger, Evalina L.; Cain, Christopher M.J.; Patel, Vikas V.

Introduction The effective treatment of lumbar spondylosis is a complex clinical and economic concern for patients and health care providers.

The purpose of this study Evaluate long-term patient-centered clinical outcomes after lumbar arthrodesis, with or without decompression for lumbar spondylosis Compare these outcomes to those of alternative treatments, including arthroplasty, decompression only and nonsurgical methods

Methods Comprehensive literature search: MEDLINE, EMBASE, the Cochrane Library, and other sources Selection of the publications Quality of the selected studies assessment (Cochrane Back Review Group scale) Data extraction Meta analysis of the combined data Level of evidence assessment (GRADE)

Methods: Selection criteria Study design: randomized controlled clinical trials (RCT) Diagnosis: lumbar degenerative disc disease with or without stenosis chronic back and/or leg pain spondylolisthesis grade I-II Patient age: >18 years old

Methods: Selection criteria Treatment: 1 or 2 level lumbar arthrodesis (ALIF, PLIF, TLIF, PLF, ALIF&PLF) 1 or 2 level lumbar arthroplasty decompression without arthrodesis conservative treatment Follow-up (months): 12 24 >24

Methods: Clinical outcomes Patient-centered clinical outcomes assessment by one or a few standardized scales such as: Oswestry Disability Index (ODI) European Quality of Life questionnaire (EQL) Roland Morris Disability Questionnaire (RMDQ) SF-36 physical scale (PCS) Visual Analog or Numeric Rating scale of back pain (VAS/NRS back pain) Visual Analog or Numeric Rating scale of leg pain (VAS/NRS leg pain) Dallas Pain Questionnaire (DPQ) Japanese Orthopedic Association Score (JOAS)

Methods: Measures of treatment effect  

Results: Literature search Of 1411 total citations, 38 RCTs of 5738 participants were included in the review [1-38] 37 RCTs were included in meta analysis

Results: Studies quality assessment Majority of studies (36) had moderate quality having score ranged from 6 to 9 of 12 by Cochrane Back Review Group scale, two studies had low quality with scores: 4, and 5 Risk of following types of biases were revealed: Type of bias Percent of studies Performance 100% Detection Selection 45% Attrition 18.4%

Results: Pooled treatment effect Questionnaires Follow-up, months Studies, number Patients, number Standardized difference in mean (Hedges’s g) 95% Cl P-value Heterogeneity Lumbar arthrodesis (1 or 2 levels) EQL; ODI; RMDQ; SF-36(PCS); NRS (back pain); NRS (leg pain); JOAS; DPQ 12-24 35 3574 1.0 ** 0.9; 1.2 <0.001 High (I2=90%) 36-108 11 1108 0.9 ** 0.7; 1.0 High (I2=78%) Non surgical treatment EQL; ODI; RMDQ; SF-36(PCS); NRS (back pain); NRS (leg pain); 7 535 0.5 * 0.3; 0.7 High (I2=63%) 48-72 3 299 0.2; 0.9 High (I2=75%) Lumbar decompression without arthrodesis EQL; RMDQ; SF-36(PCS); DPQ 2 427 0.7 * 0.6; 0.8 Low (I2=0%) 399 0.6 * 0.5; 0.7 Lumbar arthroplasty EQL; ODI; SF-36(PCS); NRS (back pain); NRS (leg pain) 1186 1.4 ** 1.2; 1.5 Moderate (I2=56%) 60 216 1.2; 1.6 Note: **, strong treatment effect; *, moderate treatment effect

Results: Comparative meta analysis Treatment Questionnaires Follow-up, months Studies, number Patients, number Standardized difference in mean (Hedges’s g) 95% Cl P-value Heterogeneity Lumbar arthrodesis versus non surgical treatment EQL; ODI; SF-36(PCS); NRS (back pain); NRS (leg pain) 12-24 7 1395 0.6 ** 0.3; 0.9 <0.001 High (I2=90%) 48-72 3 797 0.2 * -0.1; 1.5 0.125 Moderate (I2=58%) Lumbar arthrodesis with decompression versus decompression only EQL; RMDQ; SF-36(PCS); DPQ 2 845 0.1; 0.3 0.007 Low (I2=0%) 48-60 836 0.002 Lumbar arthrodesis versus lumbar arthroplasty EQL; ODI; SF-36(PCS); NRS (back pain); NRS (leg pain) 6 1521 -0.2 * -0.3;-0.1 60 399 -0.1 * -0.3; 0.2 0.625 Note: **, moderate difference; *, low difference

Discussion/Level of evidence Results Level of evidence (GRADE) Lumbar arthrodesis provide strong long term patient centered treatment effect in majority of patients with lumbar spondylosis suffered from chronic discogenic low back and leg pain, in particular after 3-6 months of unsuccessful conservative treatment Moderate One-two year postoperative patient centered clinical outcomes after lumbar arthrodesis significantly exceed the same outcomes after non surgical treatment, the difference is moderate One-six year postoperative patient centered clinical outcomes after decompression with lumbar arthrodesis significantly exceed the same outcomes after decompression without arthrodesis, however, the difference is low Low One-two year postoperative patient centered clinical outcomes after lumbar arthrodesis significantly inferior the same outcomes after lumbar arthroplasty, however, the difference is low

Conclusion Surgical stabilization of the lumbar spine is an effective treatment for lumbar spondylosis, in particular for patients with severe chronic low back pain that has been resistant to three or more months of conservative therapy

Thank You

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