1. 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.

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

3. 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

4. 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)

5. 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

6. 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): 24
>24

7. 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)

8. Methods: Measures of treatment effect

9. 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

10. 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%

11. 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 **
0.9; 1.2
<0.001
High (I2=90%)
36-108 11
1108 **
0.7; 1.0
High (I2=78%)
Non surgical treatment
EQL; ODI; RMDQ; SF-36(PCS);
NRS (back pain); NRS (leg pain); 7
535 *
0.3; 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 **
1.2; 1.5
Moderate (I2=56%) 60
216
1.2; 1.6
Note: **, strong treatment effect; *, moderate treatment effect

12. 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 **
0.3; 0.9
<0.001
High (I2=90%)
48-72 3
797 *
-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 *
-0.3;-0.1 60
399 *
-0.3; 0.2
0.625
Note: **, moderate difference; *, low difference

13. 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

14. 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

15. Thank You

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