Lumbar fusion versus nonoperative management for treatment of discogenic low back pain: a systematic review and meta-analysis of randomized controlled trials.

STUDY DESIGN: Systematic review and meta-analysis of randomized controlled trials (RCTs). OBJECTIVE: To evaluate the current evidence comparing lumbar fusion to nonoperative management for the treatment of chronic discogenic low back pain. BACKGROUND AND CONTEXT: Discogenic low back pain is a common and sometimes disabling condition. When the condition becomes chronic and intractable, spinal fusion may play a role. METHODS: A systematic review of the literature was conducted using the PubMed and CENTRAL databases. We included RCTs that compared lumbar fusion to nonoperative management for the treatment of adult patients with chronic discogenic low back pain. A meta-analysis was conducted to assess the improvement in back pain based on the Oswestry Disability Index (ODI). RESULTS: Five RCTs met our inclusion criteria. A total of 707 patients were divided into lumbar fusion (n=523) and conservative management (n=134). Although inclusion/exclusion criteria were relatively similar across studies, surgical techniques and conservative management protocols varied. The pooled mean difference in ODI (final ODI-initial ODI) between the nonoperative and lumbar fusion groups across all studies was -7.39 points (95% confidence interval: -20.26, 5.47) in favor of lumbar fusion, but this difference was not statistically significant (P=0.26). CONCLUSIONS: Despite the significant improvement in ODI in the lumbar fusion groups in 3 studies, pooled data revealed no significant difference when compared with the nonoperative group. Although there was an overall improvement of 7.39 points in the ODI in favor of lumbar fusion, it is unclear that this change in ODI would lead to a clinically significant difference. Prospective randomized trials comparing a specific surgical technique versus a structured physical therapy program may improve evidence quality. Until then, either operative intervention by lumbar fusion or nonoperative management and physical therapy remain 2 acceptable treatment methods for intractable low back pain.

Incidence of sacral fractures and in-hospital postoperative complications in the United States: an analysis of 2002-2011 data.

STUDY DESIGN: Retrospective study of an administrative database. OBJECTIVE: To estimate the incidence of sacral fractures in the United States and report short-term outcomes after their surgical management. SUMMARY OF BACKGROUND DATA: The incidence of sacral fractures in the United States is currently unknown, and these lesions have been associated with significant morbidity after their surgical management. METHODS: This study used the Nationwide Inpatient Sample database for the years 2002-2011. All patients with a primary discharge diagnosis of a sacral fracture with and without a neurological injury were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes. Patients with a diagnosis of osteoporosis or pathological fracture were excluded. A stepwise multivariate logistic regression analysis was performed to identify factors associated with an in-hospital complication. RESULTS: During the study period, 10,177 patients with a nonosteoporotic sacral fracture were identified, of whom 1002 patients underwent surgery. Between 2002 and 2011, the estimated incidence of sacral fractures increased from 0.67 per 100,000 persons to 2.09 (P < 0.001). Similarly, the rate of surgical treatment for sacral fractures increased from 0.05 per 100,000 persons in 2002 to 0.24 per 100,000 in 2011 (P < 0.001). Complications occurred in 25.95% of patients and remained steady over time (P = 0.992). Average length of stay significantly decreased from 11.93 days to 9.66 days in the 10-year period (P = 0.023). The independent factors associated with an in-hospital complication were congestive heart failure (odds ratio, 3.65; 95% confidence interval, 1.18-11.26), coagulopathy (odds ratio, 3.58; 95% confidence interval, 1.88-6.81), and electrolyte abnormalities (odds ratio, 3.28; 95% confidence interval, 2.14-5.02). CONCLUSION: During the examined 10-year period, both the incidence of nonosteoporotic sacral fractures and the surgical treatment of these lesions increased in the United States. Between 2002 and 2011, although patient comorbidity increased, in-hospital complication rates remained stable and length of stay significantly decreased over time. LEVEL OF EVIDENCE: 4.