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Michael G. Kaiser, Jason C. Eck, Michael W. Groff, William C. Watters III, Andrew T. Dailey, Daniel K. Resnick, Tanvir F. Choudhri, Alok Sharan, Jeffrey C. Wang, Praveen V. Mummaneni, Sanjay S. Dhall and Zoher Ghogawala

closely scrutinized, requiring that medical evidence justify the application of these procedures. In 2005, the first iteration of the “Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine” was published in the Journal of Neurosurgery: Spine. 5 This comprehensive compendium outlined 16 topics pertaining to the performance of lumbar fusion surgery for degenerative spinal disease, providing 50 recommendations based on a review of the medical literature published between 1966 and 2003. Given the time dependency of a literature

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Zoher Ghogawala, Daniel K. Resnick, William C. Watters III, Praveen V. Mummaneni, Andrew T. Dailey, Tanvir F. Choudhri, Jason C. Eck, Alok Sharan, Michael W. Groff, Jeffrey C. Wang, Sanjay S. Dhall and Michael G. Kaiser

Recommendations There is no evidence that conflicts with the previous recommendations published in the original version of the “Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine.” Grade B It is recommended that when assessing functional outcome in patients treated for low-back pain due to degenerative disease, a reliable, valid, and responsive outcomes instrument, such as the disease-specific Oswestry Disability Index (ODI), be used (Level II evidence). It is recommended that when assessing general

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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

Introduction to the Lumbar Fusion Guidelines As scientific understanding of the pathophysiology of degenerative disease of the lumbar spine has increased, the possibilities for correcting the underlying problem and the resulting improvement in clinical function have expanded exponentially. Fueled by advances in material technology and surgical technique, treatment of greater numbers of individuals suffering from lumbar spinal disease has proliferated. Using data from the National Hospital Discharge Survey, Deyo and colleagues 4 described a 200% increase 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

Recommendations Standards It is recommended that functional outcome be measured in patients treated for low-back pain due to degenerative disease of the lumbar spine by using reliable, valid, and responsive scales. Examples of these scales in the low-back pain population include the following: The Spinal Stenosis Survey of Stucki, Waddell—Main Questionnaire, RMDQ, DPQ, QPDS, SIP, Million Scale, LBPR Scale, ODI, the Short Form—12, the JOA system, the CBSQ, and the North American Spine Society Lumbar Spine Outcome Assessment Instrument. Guidelines

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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

purpose of this review is to examine the literature regarding the ability of various diagnostic techniques to assess fusion status after lumbar fusion is performed to treat degenerative disease. Search Criteria A computerized search of the database of the National Library of Medicine between 1966 and July 2003 was conducted using the search terms “lumbar spine fusion assessment,” “lumbar spine pseudoarthrosis,” or “lumbar spine fusion outcome.” The search was restricted to references in the English language involving humans. This yielded a total of 1076

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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

of lumbar fusion for degenerative lumbar spine disease as assessed by cost, complication rates, and rates of reoperation. These expenses of lumbar fusion must be contrasted with the return-to-work rate and the potential for improved productivity following treatment. These end points will be examined as economic outcome measures following lumbar fusion. Search Criteria A computerized search of the National Library of Medicine database of the literature published between 1966 and 2001 was performed. A search using the subject heading “lumbar fusion” yielded

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Alok Sharan, Michael W. Groff, Andrew T. Dailey, Zoher Ghogawala, Daniel K. Resnick, William C. Watters III, Praveen V. Mummaneni, Tanvir F. Choudhri, Jason C. Eck, Jeffrey C. Wang, Sanjay S. Dhall and Michael G. Kaiser

Recommendations There is no evidence that conflicts with the previous recommendations regarding electrophysiological monitoring published in the original version of the “Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine.” Grade I The use of direct screw stimulation evoked electromyography (EMG) responses, as a diagnostic modality during lumbar fusion surgery, is an option since evidence suggests that EMG monitoring can be highly sensitive in detecting breaches of the pedicle (one Level III study). The

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Sanjay S. Dhall, Tanvir F. Choudhri, Jason C. Eck, Michael W. Groff, Zoher Ghogawala, William C. Watters III, Andrew T. Dailey, Daniel K. Resnick, Alok Sharan, Praveen V. Mummaneni, Jeffrey C. Wang and Michael G. Kaiser

the National Library of Medicine between July 2003 and December 2011 was conducted using the search terms “lumbar spine fusion assessment,” “lumbar spine pseudoarthrosis,” or “lumbar spine fusion outcome.” (The spelling “pseudoarthrosis” was used in searching, but searching on this spelling also retrieves publications with the spelling “pseudarthrosis.”) The search was restricted to references in the English language involving humans. This yielded a total of 1076 references. The titles and abstracts of each of these references were reviewed. Papers not concerned

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Michael G. Kaiser, Jason C. Eck, Michael W. Groff, Zoher Ghogawala, William C. Watters III, Andrew T. Dailey, Daniel K. Resnick, Tanvir F. Choudhri, Alok Sharan, Jeffrey C. Wang, Sanjay S. Dhall and Praveen V. Mummaneni

Recommendations There is no evidence that conflicts with the previous recommendations regarding bone growth stimulation published in the original version of the “Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine.” 18 Grade C The routine use of DCS in patients over the age of 60 years is not recommended, as the evidence demonstrates no impact on fusion rates (single Level II study). For patients younger than 60 years of age, undergoing a lumbar fusion, the use of DCS is an option as studies have

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Tanvir F. Choudhri, Praveen V. Mummaneni, Sanjay S. Dhall, Jason C. Eck, Michael W. Groff, Zoher Ghogawala, William C. Watters III, Andrew T. Dailey, Daniel K. Resnick, Alok Sharan, Jeffrey C. Wang and Michael G. Kaiser

Recommendations There is no evidence that conflicts with the previous recommendations in the original version of the “Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine.” Grade A Following lumbar fusion surgery, static lumbar radiographs are not recommended as a stand-alone method to assess fusion status. Grade B Following instrumented posterolateral lumbar fusions (PLFs), CT imaging with fine-cut axial and multiplanar reconstruction views is recommended as a method to assess fusion status. When