Lumbar spine fusion: what is the evidence? Despite the high costs, risks and common nature of lumbar spine fusion surgery, the evidence base does not include high quality systematic reviews. Furthermore, the risk of bias of the RCT in the reviews is generally high. The available evidence does not support the hypothesis that spine fusion confers a clinical benefit compared to non‐operative alternatives for low back pain associated with degeneration. Similarly, the available evidence does not support the hypothesis that spine fusion confers a clinical benefit compared to non‐operative treatment or stabilisation without fusion for thoracolumbar burst fractures. Benefits of spine fusion compared to non‐operative treatment for isthmic spondylolisthesis are unclear (one trial at high risk of bias). Surgical intervention for metastatic carcinoma of the spine associated with spinal cord compromise improves mobility and neurological outcome (based on a single trial). Ideally spine fusion for spondylolisthesis, burst fractures, back pain or degenerative conditions (degenerative scoliosis, spinal stenosis, recurrent disc herniation or instability), should only be performed in the context of high quality clinical trials until the true value for each of these conditions is established. Until better quality evidence is available, treatment will continue to be guided by expert clinical opinion based on evidence at high risk of bias. Patients contemplating spinal fusion should be fully informed about the evidence base for their particular problem, including the relative potential benefits and harms of fusion compared with non‐operative treatments.
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