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doi:10.1111/imj.14120

CLINICAL PERSPECTIVES

Lumbar spine fusion: what is the evidence?

Ian A. Harris ,1,2 Adrian Traeger,2 Ralph Stanford,3 Christopher G. Maher2 and Rachelle Buchbinder4,5
1
Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, UNSW, 2Sydney School of Public Health, The University of
Sydney, and 3Department of Orthopaedics, Prince of Wales Hospital, Sydney, New South Wales, and 4Monash Department of Clinical Epidemiology,
Cabrini Institute, and 5Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University,
Melbourne, Victoria, Australia

Key words Abstract

spinal fusion, back pain, surgery.
Correspondence
Ian Harris, Ingham Institute for Applied Medical
Research, 1 Campbell Street, Liverpool, NSW
2170, Australia.
Email: ianharris@unsw.edu.au
Received 7 July 2018; accepted
4 September 2018.
Lumbar spine fusion is a common procedure associated with a high cost burden and
risk of serious complications. We aimed to summarise systematic reviews on the effec-
tiveness of lumbar spine fusion for most diagnoses. We found no high-quality system-
atic reviews and the risk of bias of the randomised controlled trials in the reviews was
generally high. The available evidence does not support a benefit from spine fusion
compared to non-operative alternatives for back pain associated with degeneration.
The available evidence does not support a clinical benefit from spine fusion compared
to non-operative treatment or stabilisation without fusion for thoracolumbar burst frac-
tures. Benefits of spine fusion compared to non-operative treatment for isthmic spon-
dylolisthesis are unclear (one trial at high risk of bias). Surgical intervention for
metastatic carcinoma of the spine associated with spinal cord compromise improves
mobility and neurological outcome (based on a single trial). Better evidence is required
to determine more accurately the effectiveness of spine fusion surgery for all indica-
tions. Patients contemplating spinal fusion should be fully informed about the evidence
base for their particular problem, including the relative potential benefits and harms of
fusion compared with non-operative treatments.

Introduction disease, degenerative scoliosis and spinal canal stenosis.

Less commonly, lumbar fusion is used for spondylolisth-
The rate of lumbar spine fusion surgery has been
esis, traumatic conditions (fractures and dislocations)
increasing and is now occurring at a rate of 26 per
and tumours (most commonly metastases).
100 000 adults in Australia, with considerable regional
This review aims to summarise the evidence compar-
variation.1 Australian data from 2012/2013 place spine
ing lumbar spine fusion to non-operative treatments, or
fusion (in any spine region) as the fourth most costly
as an adjunct to other spinal procedures for any condi-
surgical procedure, behind knee replacement, hip
tion. The review will not include studies comparing spine
replacement and caesarean section, at an annual cost of
fusion to alternative surgical procedures, such as inter-
$650 million.2 The cost per procedure for spine fusion is
vertebral disc replacement (arthroplasty).
higher than other common procedures, a cost that is
We performed a review of reviews, including reviews
largely made up of medical, hospital and implant fees.
of randomised controlled trials (RCT) where possible,
Lumbar spine fusion is the most common type of spine
and chose the most recent and highest quality (based on
fusion and this is performed for several indications, most
A MeaSurement Tool to Assess systematic Reviews
commonly related to symptoms thought to arise from
(AMSTAR) 23) reviews to summarise. We searched Med-
degenerative conditions such as intervertebral disc
line for all articles with the medical subject heading
(MeSH) of spinal fusion. Restricting this search to
reviews resulted in 820 articles. These 820 titles and
Funding: No funding was received by any party for this work. abstracts were reviewed, others were added based on
A. Traeger is funded by a NHMRC Early Career Fellowship, references from these reviews and after dual review of
R. Buchbinder is funded by a NHMRC Senior Principal Research
Fellowship and C. G. Maher is funded by a NHMRC Principal
possible articles to include, 60 reviews were included.
Research Fellowship. The evidence from these reviews has been summarised
Conflict of interest: None. in sections according to the indication for surgery: low

1430 Internal Medicine Journal 48 (2018) 1430–1434

© 2018 Royal Australasian College of Physicians

back pain, other degenerative conditions, spondylolisth-
esis, trauma and tumour.
Low back pain and degenerative disc
disease
We located 33 reviews of fusion compared to non-
operative care for low back pain and/or degenerative
spine conditions. All of the systematic reviews we
located were low- to critically low-quality except for
three,4–6 which were moderate quality. Most of the sys-
tematic reviews published between 2005 and 2017
included the same set of four trials.7–10 Some of the later
reviews include small trials,11 which reported unusually
large effect sizes.
The most recent systematic review and network meta-
analysis was of critically low quality and included six
RCT (n = 609).12 A meta-analysis in that review found
lumbar fusion was not superior to an intensive, struc-
tured exercise and cognitive behavioural therapy pro-
gramme at reducing pain at 1 year (mean difference of
−3 points on a 100-point scale (95% confidence interval
(CI) −11.43 to 5.42), two RCT, n = 118, I2 54%) or dis-
ability at 1–2 years (mean difference of −1.71 points on
the 100-point Oswestry Disability Index (ODI) (95% CI
−5.73 to 2.31), three RCT, n = 399, I2 48%). There were
no meta-analyses assessing quality of life.
The authors of this review12 chose not to include one
outlying trial in their primary meta-analysis.7 This trial
reported positive results in favour of fusion surgery but
compared fusion to usual non-operative care, the failure
of which was one of the inclusion criteria.7 Wang et al.,13
on the other hand, did include this trial in their meta-
analysis comparing fusion with non-operative care for
patients with chronic low back pain thought to be disco-
genic, and also reported no benefit of fusion in reducing
disability (mean difference of −1.94 points on the ODI
(95% CI −6.02 to 2.14), six RCT, n = 889, I2 64%).
The most recent moderate quality review4 also con-
cluded that there was ‘fair’ evidence from four RCT (n =
767) that fusion is no more effective than intensive reha-
bilitation for chronic low back pain.4 None of the trials
included in reviews published after 2009 was of suffi-
ciently high quality to change this conclusion.
The two RCT that did find clinically meaningful bene-
fits of fusion compared to non-operative care for chronic
low back pain, one with a low risk of bias,7 and the other
with high risk of bias,11 had both used discography. It is
unclear whether selecting patients using discography
could improve the success of spinal fusion surgery for
patients with chronic low back pain.
Complications from spinal fusion surgery for low back
pain are common. One moderate-quality review4
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Lumbar fusion
estimated the rate of early surgical complications to be
16% (95% CI 12–20). A more recent low-quality
review13 estimated that complications such as infections,
thrombosis, nerve root injury by pedicle screw and
major bleeding are much greater with surgery (relative
risk (RR) 22.11 (95% CI 5.99–81.60).
Other degenerative conditions
Spine fusion is often performed for pain in the presence
of degenerative scoliosis, which affects the spine in
patients from middle age and should be distinguished
from congenital or idiopathic scoliosis, which is seen in
young patients and involves the thoracic spine. Our
search found no reviews of RCT or RCT comparing
fusion to any other treatment specifically for degenera-
tive scoliosis.
Lumbar spine stenosis (LSS) presenting with neuro-
genic claudication is a common condition in older people
and is often treated with surgical decompression. More
recently, spine fusion is being increasingly used in addi-
tion to decompression for this condition. Machado et al.
showed that while decompression rates for lumbar spinal
stenosis have doubled in the past decade in Australia,
rates for decompression and fusion have quadrupled.14
Until recently, there were no RCT comparing fusion plus
decompression to decompression alone for LSS; there-
fore, only the most recent review (from 2017 and rated
as low quality), included evidence from an RCT
(247 patients).15 The review, which also included non-
randomised registry studies, reported no advantage of
adding fusion to decompression for back pain or disabil-
ity, and noted an increased rate of reoperation (RR 1.17,
95% CI 1.06–1.28, I2 = 49.3%) and other complications
(RR 1.87, 95% CI 1.18–2.96) in the fusion-
decompression group compared with decompression
alone. The RCT reported a 2 point difference (95% CI −3
to 7) in the 100 point ODI change score at 24 months
favouring the decompression-only group. This difference
is less than any suggested minimum clinically important
differences.
Leg pain, one of the main indications for LSS surgery,
showed no difference between groups at 24 months,
with the single RCT and non-randomised registry studies
reporting similar results.15 Another RCT comparing the
same interventions, published in 2016, showed fusion
with decompression to provide better quality of life com-
pared to decompression alone for LSS, but this study was
restricted to cases with associated spondylolisthesis.
Spine fusion for spondylolisthesis is covered below.
Spine fusion is often recommended at the time of revi-
sion decompression surgery, often for recurrent disc her-
niation. One review, rated at critically low quality,
1431

Harris et al.
addressed the role of fusion for recurrent disc hernia-
tion.16 They concluded that there was no clinical advan-
tage to the addition of fusion to repeat decompression
for recurrent disc herniation; however, only one RCT17
(n = 45) was used in this review.
Instability associated with degenerative conditions is a
common indication for lumbar spine fusion. However,
we found no reviews or RCT addressing fusion surgery
specifically for spinal instability. Therefore, the value of
fusion surgery for radiographic instability is currently
uncertain.
Spondylolisthesis
Spondylolisthesis is the slippage of one vertebra upon
another, most commonly forward and most frequently
in the lumbar spine and is often not symptomatic. In
clinical practice, the most prevalent types are degenera-
tive and isthmic. Degenerative cases are due to loss of
integrity of facet joints and present in middle age and
later with any combination of back pain, lumbar radicu-
lopathy or neurogenic claudication due to accompanying
spinal canal stenosis. The underlying problem in isthmic
cases is a non-healing stress fracture of the pars interarti-
cularis acquired in childhood and may present at any
age from childhood to middle age with a combination of
back pain and lumbar radiculopathy due to foraminal
stenosis. Surgical management of degenerative spondy-
lolisthesis includes decompression of the spinal canal
with or without fusion, whereas for isthmic spondylo-
listhesis, fusion is always used with decompression of the
foramina. In each case, the use of spinal fixation is
discretionary.
A 2018 systematic review considered to be of low qual-
ity, identified four RCT that had investigated the value of
fusion over decompression alone for degenerative spon-
dylolisthesis.18 All four trials included participants with
spinal stenosis in addition to spondylolisthesis).19–22 One
trial also included participants without spondylolisthesis
but they were randomised separately, and results were
also presented separately.22
While the review authors considered all four trials to
be of high quality, one small trial (n = 50), was not ran-
domised (alternative allocation of participants),19 while
another small trial (n = 44), did not report their rando-
misation method, was at high risk of selection bias and
included non-randomised participants with instability in
the fusion with instrumentation group.20 In addition,
none of the trials blinded outcome assessment.
Overall, fusion added to decompression alone did not
yield importantly better outcomes than decompression
alone with respect to back or leg pain, disability, function
or satisfaction. While the overall complication rate did
1432
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not differ between groups, fusion was associated with
significantly longer operation time, greater blood loss
and longer hospital admission.
A single RCT has compared surgery (decompression
with or without fusion) to non-operative treatment for
degenerative spondylolisthesis with spinal stenosis.23
However, this trial did not report results for the fusion
arm separately.
Based on an overview of systematic reviews investi-
gating surgery for low back pain,24 of eight RCT investi-
gating fusion for isthmic spondylolisthesis, only one25
compared fusion to non-operative treatment. This trial,
judged to be at high risk of bias by Jacobs et al., included
111 participants aged 18–55 years with low back pain or
sciatica for at least 1 year and severe functional restric-
tion. Thirty-four participants were allocated to an exer-
cise programme and 77 received posterolateral fusion,
either with or without transpedicular fixation. Improve-
ments in pain and disability favoured the fusion group,
with a good outcome reported to have been achieved in
74% who received fusion compared with 43% in the
exercise group. However, back pain data were not pre-
sented separately so it is not known if fusion improved
leg or back pain or both.
Trauma
Spine trauma covers a broad spectrum, including
uncommon but highly unstable fractures and disloca-
tions. Commonly, fractures are assigned degrees of sta-
bility and surgery may be recommended based on the
degree of potential instability and the degree of any neu-
rological involvement.
A Cochrane review from 2008 noted that there were
no RCT comparing surgery to other treatments for acute
spinal cord injury.26 We were only able to locate reviews
pertaining to burst fractures, which usually occur around
the thoracolumbar junction, resulting from high energy
impact.
Three reviews compared instrumentation (the surgical
insertion of stabilising devices such as pedicle screws and
rods) alone to instrumentation and fusion using bone
graft.27–29 The two recent reviews both published in
201728,29 included data from five RCT (n = 266). Patient
age averaged less than 40 years in each study and aver-
age follow up ranged from 24 months to over 10 years.
Both reviews concluded that the addition of fusion
was not associated with significant improvement in clini-
cal outcomes such as pain, function and quality of life.
Treatment with fusion was associated with longer oper-
ating times and more blood loss and more complications,
but implant removal was more commonly required in
cases treated with internal fixation without fusion.
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Lumbar fusion

Surgical treatment is often directed at correcting and pre-
venting kyphotic deformity; however, there was no sig-
nificant difference in the degree of kyphotic correction
achieved, loss of kyphosis or final kyphotic angle
between the treatment groups.
A review (rated at low quality) compared fusion to
non-operative treatment (bracing) for thoracolumbar
burst fractures using data from two randomised trials
involving 87 patients with an average age of less than
40 years and an average follow up of over 3 years in
both trials.30 A pseudo-randomised trial and a prospec-
tive comparative (non-randomised) study were found,
but not included in the quantitative analysis.
Surgery was not associated with significant improve-
ment in pain, function or return to work at final follow-
up. Surgery was associated with an average of 6.2
degrees greater improvement in kyphosis from baseline
(95% CI −16.3 to 3.95, P = 0.23, I2 = 87%) but the
degree of kyphosis was not associated with pain or func-
tion at final follow up. Canal stenosis improved by a sim-
ilar amount in both groups, but the trials did not include
patients with neurological deficit. Surgery was associated
with a significant increase in complications (odds ratio =
6.4, 95% CI 1.7–24.6, P = 0.007, I2 = 0%) compared to
non-operative treatment.
There are no RCT to guide treatment of fracture types in
the lumbar spine other than thoracolumbar burst fractures.
Metastatic tumours of the spine
The role of surgery for metastatic disease of the spine is
to relieve pain and treat or prevent neurological loss of
function and so improve quality of life. This role is pallia-
tive, rather than aiming to improve overall survival. Sur-
gical treatment includes decompression of the spinal
cord and/or nerve roots and then stabilisation of the spi-
nal column by insertion of instrumentation, which may
or may not be accompanied by bone graft fusion.
A systematic review31 of the benefits of surgery in
metastatic disease of the spine identified a single RCT by
Patchell et al.32 that compared surgical decompression
and stabilisation followed by radiation therapy to the
excised tumour bed with radiation therapy alone. The
study included 101 adult patients with metastatic
carcinoma who presented with spinal cord compression
and examination findings of spinal cord compromise.
Surgical technique was at the discretion of the treating
surgeon based on patient and tumour characteristics.
More patients in the surgery group (42/50, 84%) than in
the radiotherapy group (29/51, 57%) achieved the pri-
mary outcome: ability to walk after treatment (odds ratio
= 6.2, 95% CI 2.0–19.8, P = 0.001). The study also found
improved survival time and neurological outcomes in
the surgical group.
Conclusion
Despite the high costs, risks and common nature of lum-
bar spine fusion surgery, the evidence base does not
include high quality systematic reviews. Furthermore,
the risk of bias of the RCT in the reviews is
generally high.
The available evidence does not support the hypothe-
sis that spine fusion confers a clinical benefit compared
to non-operative alternatives for low back pain associ-
ated with degeneration. Similarly, the available evidence
does not support the hypothesis that spine fusion confers
a clinical benefit compared to non-operative treatment
or stabilisation without fusion for thoracolumbar burst
fractures. Benefits of spine fusion compared to non-
operative treatment for isthmic spondylolisthesis are
unclear (one trial at high risk of bias). Surgical interven-
tion for metastatic carcinoma of the spine associated with
spinal cord compromise improves mobility and neuro-
logical outcome (based on a single trial).
Ideally spine fusion for spondylolisthesis, burst frac-
tures, back pain or degenerative conditions (degenerative
scoliosis, spinal stenosis, recurrent disc herniation or insta-
bility), should only be performed in the context of high
quality clinical trials until the true value for each of these
conditions is established. Until better quality evidence is
available, treatment will continue to be guided by expert
clinical opinion based on evidence at high risk of bias.
Patients contemplating spinal fusion should be fully
informed about the evidence base for their particular
problem, including the relative potential benefits and
harms of fusion compared with non-operative treatments.

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