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Circumferential shows significant advantages vs. posterolateral fusion

Anterior column cages may decrease disability and pain for patients with lumbar degeneration.

Issue: Issue 6 2006

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Circumferential fusion may provide significantly better function and less pain than posterolateral fusion for patients with severe lumbar conditions, according to Danish research.

Investigators at University Hospital of Aarhus analyzed postoperative surveys of more than 100 patients who were randomized to receive either circumferential lumbar fusion or posterolateral lumbar fusion (PLF) between 1996 and 1999. The researchers found that the circumferentially fused group had significantly better results on the Dallas Pain Questionnaire compared to the PLF cohort at 5 to 9 years postop (P<.05). Patients who underwent circumferential procedures also reported more pain relief (P<.05) and better SF-36 scores (P<.01).

The researchers reported in their abstract that the circumferential cohort had significantly better Oswestry Disability Index (ODI) scores (P<.01). “The take home message is, 5 to 9 years after, 18% in the circumferential group had severe disability,” said Finn B. Christensen, MD, a co-investigator of the study and orthopaedist at the hospital. Christensen presented the study results at the International Society for the Study of the Lumbar Spine annual meeting.

“Circumferential fusion demands more extensive operative resources — no doubt about it,” he said. “However, 5 to 9 years after surgery, circumferential patients had a significantly improved functional outcome compared to instrumented posterolateral fusion alone. These very new results, underline the superiority of circumferential fusion in the complex pathologies of the lumbar spine.”

Multiple questionnaires

Christensen and his colleagues sent questionnaire packets to 148 patients who underwent posterolateral fusion with a titanium Cotrel-Dubousset or a circumferential fusion with a Brantigan cage and posterolateral fusion. The patients had preoperative diagnoses of Grade 1 and 2 spondylosis, primary degeneration or secondary degeneration. The researchers classified secondary degeneration patients as those who had decompression surgery prior to fusion.

To determine the long-term pain and functional outcomes of circumferential fusion, the investigators distributed a questionnaire packet at 5 to 9 years after surgery. The packet included the Dallas Pain Questionnaire as the primary outcomes measure plus the Low Back Pain Rating scale, the ODI and the SF-36 scale. “The Dallas Pain Questionnaire has four categories; daily activity, work and leisure, anxiety and social interest or concern,” Christensen said.

Significant findings

Between 92% and 93% of the patients responded to the survey, he said. The researchers discovered that the circumferentially fused group reported significantly better outcomes on all four sections of the Dallas Pain Questionnaire. They also found similar results regarding low back pain. “They had highly significant less back pain at 5 to 9 years after [surgery] compared to the posterolateral fusion group,” Christensen said. “If we look at leg pain, we didn’t find any significant difference and that can be due to the fact that maybe some of the leg pain resolved perioperatively by decompression,” he said. Yet, Oswestry scores also showed significantly better function in the circumferential cohort. “The circumferential patient group had an ODI of 28,” Christensen said. “That’s actually very good.”

A sub-analysis of patients with spondylosis revealed that anterior support did not improve their postoperative outcomes. “However, when it came to anterior column cages, the first primary degeneration [group] seemed to gain quite a lot from anterior support from the column and the same is true for the patients that we defined with secondary degeneration,” Christensen said.

For more information:

• Videbaek TS, Christensen FB, Soegaard R, et al. Circumferential fusion improved long-term outcome in comparison to instrumented posterolateral fusion: A randomized clinical study with 5 to 9 years follow-up. Paper #62. Presented at the International Society for the Study of the Lumbar Spine 33rd Annual Meeting. June 14-17, 2006. Bergen, Norway.