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Tetsuo Hayashi, Michael D. Daubs, Akinobu Suzuki, Trevor P. Scott, Kevin H. Phan, Monchai Ruangchainikom, Shinji Takahashi, Keiichiro Shiba and Jeffrey C. Wang

MCs in the lumbar spine have been published, but most of them are focused on the relationship between MCs and low-back pain. 5 , 14 , 17 Some previous studies 1 , 8 , 15 demonstrated the relationship between nonfusion after surgery and MCs, and have reported on the instability related to bone marrow changes without using MCs. To our knowledge, no study has reported on the kinematics of MCs. In addition, few studies have reported on the relationship between MCs and degenerative disc disease. We hypothesized that lumbar MCs have some relationship to segmental

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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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Gun Keorochana, Cyrus E. Taghavi, Shiau-Tzu Tzeng, Yuichiro Morishita, Jeong Hyun Yoo, Kwang-Bok Lee, Jen-Chung Liao and Jeffrey C. Wang

D egenerative changes of the lumbar spine are a major cause of low-back pain and disability. 13 Previous studies have demonstrated the important role of disc degeneration and facet joint osteoarthritis, but they have usually ignored the contribution of the posterior spinal ligaments. Recent studies have highlighted the effect of disc degeneration on facet joint osteoarthritis and vice versa; 3 , 7 , 26 however, few studies have examined the degenerative processes and interactions of the ISL. 6 Significant degenerative changes also occur in spinal

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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

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

.01). Ability to maintain work at the preop status was 79% in the discectomy group & 86% in the fusion group at 6 yrs Results were similar at 6 mos, but fusion provided more stable relief of pain & maintenance of work function over prolonged follow-up. Matsunaga et al., 1993 IV A retrospective review of 82 pts (defined as laborers) who engaged daily in work that repeatedly put large amounts of stress on their lumbar spine & 28 athletes. 81 pts had discectomy alone (microdiscectomy in 30 & percutaneous discectomy in 51); 29 pts had discectomy & fusion. The groups had

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Jason C. Eck, Alok Sharan, Daniel K. Resnick, William C. Watters III, Zoher Ghogawala, Andrew T. Dailey, Praveen V. Mummaneni, Michael W. Groff, Jeffrey C. Wang, Tanvir F. Choudhri, 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 C It is recommended that discoblock be considered as a diagnostic option during the evaluation of a patient presenting with chronic low-back pain (single Level II study). It is recommended that lumbar discography not be used as a stand-alone test on which treatment decisions are based for patients with low-back pain with