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Daniel K. Resnick, Tanvir F. Choudhri, Andrew T. Dailey, Michael W. Groff, Larry Khoo, Paul G. Matz, Praveen Mummaneni, William C. Watters III, Jeffrey Wang, Beverly C. Walters and Mark N. Hadley

the frequency of lumbar fusion procedures in the 1980s. Davis 3 observed that the age-adjusted rate of hospitalization for lumbar surgery and lumbar fusion increased greater than 33% and greater than 60%, respectively, from 1979 to 1990. Lumbar fusion has been described as a treatment of symptomatic degenerative disc disease, spinal stenosis, spondylolisthesis, and degenerative scoliosis. Lumbar fusion has been performed to treat acute and chronic low-back pain, radiculopathy, and spinal instability. As practitioners have become caught up in the excitement of

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Daniel K. Resnick, Tanvir F. Choudhri, Andrew T. Dailey, Michael W. Groff, Larry Khoo, Paul G. Matz, Praveen Mummaneni, William C. Watters III, Jeffrey Wang, Beverly C. Walters and Mark N. Hadley

improving outcome with respect to back and leg pain is considered Class II despite the randomized design of the study because the difference in the improvement between the surgical groups in the primary outcome measure did not reach statistical significance. This information must be considered in light of the fact that similar measures of back and leg pain were not significantly different between treatment groups at other time points. Fritzell and colleagues 13, 14 performed a randomized, prospective, multicenter trial involving 294 patients with chronic low-back pain

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Daniel K. Resnick, Tanvir F. Choudhri, Andrew T. Dailey, Michael W. Groff, Larry Khoo, Paul G. Matz, Praveen Mummaneni, William C. Watters III, Jeffrey Wang, Beverly C. Walters and Mark N. Hadley

Recommendations Standard There is insufficient evidence to recommend a treatment standard. Guidelines There is insufficient evidence to recommend a treatment guideline. Options 1) Pedicle screw fixation is recommended as a treatment option for patients with low-back pain treated with PLF who are at high risk for fusion failure because the use of pedicle screw fixation improves fusion success rates. 2) Pedicle screw fixation as a routine adjunct to PLF in the treatment of patients with chronic low-back pain due to DDD is not recommended

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Daniel K. Resnick, Tanvir F. Choudhri, Andrew T. Dailey, Michael W. Groff, Larry Khoo, Paul G. Matz, Praveen Mummaneni, William C. Watters III, Jeffrey Wang, Beverly C. Walters and Mark N. Hadley

Therapeutic Recommendations Standards Facet injections are not recommended as longterm treatment for chronic low-back pain. Guidelines There is insufficient evidence to recommend a treatment guideline. Options The use of lumbar epidural injections or TPIs is not recommended as a treatment option for long-term relief of chronic low-back pain. The use of lumbar epidural injections, facet injections, or TPIs is recommended as a treatment option to provide temporary, symptomatic relief in selected patients with chronic low-back pain

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Daniel K. Resnick, Tanvir F. Choudhri, Andrew T. Dailey, Michael W. Groff, Larry Khoo, Paul G. Matz, Praveen Mummaneni, William C. Watters III, Jeffrey Wang, Beverly C. Walters and Mark N. Hadley

Recommendations Standards There is insufficient evidence to recommend a treatment standard. Guidelines The short-term use of a rigid lumbar support (1–3 weeks) is recommended as a treatment for low-back pain of relatively short duration (< 6 months). The use of a lumbar brace for patients with chronic low-back pain is not recommended because there is no pertinent medical evidence of any long-term benefit or evidence that brace therapy is effective in the treatment of patients with chronic (> 6 months) low-back pain. Options 1) Lumbar

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Daniel K. Resnick, Tanvir F. Choudhri, Andrew T. Dailey, Michael W. Groff, Larry Khoo, Paul G. Matz, Praveen Mummaneni, William C. Watters III, Jeffrey Wang, Beverly C. Walters and Mark N. Hadley

150) with weakness due to compression of lumbar nerve roots. Nine of the patients had complete normalization of DSEPs following decompression and had improved strength postoperatively. The other three patients had “variable improvement” in DSEPs and did not recover strength. Clearly, a chronically damaged nerve may not return to normal function even after adequate decompression. Therefore, although complete normalization of responses may be a positive predictor of improved function, the value of information provided by a “variable improvement” is less clear. Herron

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Daniel K. Resnick, Tanvir F. Choudhri, Andrew T. Dailey, Michael W. Groff, Larry Khoo, Paul G. Matz, Praveen Mummaneni, William C. Watters III, Jeffrey Wang, Beverly C. Walters and Mark N. Hadley

> 0.60. The SIP appeared to correlate  of sickness & dysfunction.  was completed for severity of sickness &  w/ the self-assessment of sickness & dysfunction  dysfunction.  (correlation > 0.50). Million, et al., 1982 I 19 patients w/ chronic LBP. Their functional disability External reliability was strong btwn & w/in observers The Million Scale is a reliable indicator of the severity  was studied using the Million Scale which was a  κ > 0.90. As a validity measure, the Million  of lumbago & is responsive in

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Daniel K. Resnick, Tanvir F. Choudhri, Andrew T. Dailey, Michael W. Groff, Larry Khoo, Paul G. Matz, Praveen Mummaneni, William C. Watters III, Jeffrey wang, Beverly C. Walters and Mark N. Hadley

. Christensen, et al., 2002 II 129 patients w/ chronic LBP & isthmic spondylolisthesis, The instrumented group had a 28% reop rate compared Medical outcome by reop & op time may be a responsive  primary degeneration, or secondary degeneration  w/ 14% for the noninstrumented group (p < 0.03). Op  indicator w/in 5 yrs of lumbar fusions w/  who underwent instrumented or noninstrumented  time 212 vs 127 min (p < 0.0001) w/ greater periop  instrumentation.  fusion. Outcome at 5 yrs was done using blood loss (p < 0

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Daniel K. Resnick, Tanvir F. Choudhri, Andrew T. Dailey, Michael W. Groff, Larry Khoo, Paul G. Matz, Praveen Mummaneni, William C. Watters III, Jeffrey Wang, Beverly C. Walters and Mark N. Hadley

Recommendations Standards There is insufficient evidence to recommend a treatment standard. Guidelines 1) It is recommended that MR imaging be used as a diagnostic test instead of discography for the initial evaluation of patients with chronic low-back pain. 2) It is recommended that MR imaging—documented disc spaces that appear to be normal not be considered for treatment as a source of low-back pain. 3) It is recommended that lumbar discography not be used as a stand-alone test on which treatment decisions are based for patients with low

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Daniel K. Resnick, Tanvir F. Choudhri, Andrew T. Dailey, Michael W. Groff, Larry Khoo, Paul G. Matz, Praveen Mummaneni, William C. Watters III, Jeffrey Wang, Beverly C. Walters and Mark N. Hadley

. Both of these trials are identified in Table 1 . A number of case series, cohort studies, and studies evaluating different fusion techniques were also identified and provide supportive scientific evidence. TABLE 1 Summary of studies involving patients with intractable, chronic low-back pain * Authors & Year Class Description Comment Fritzell, et al., 2001 I RCT of fusion vs conservative care in patients w/ CLBP. All Lumbar fusion is an effective treatment  3 fusion groups fared better on all outcome