The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 81, Issue 5

Current Concepts Review | May 01, 1999

Current Concepts Review - Lumbar Arthrodesis for the Treatment of Back Pain*

EDWARD N. HANLEY, JR., M.D.†; STEPHEN M. DAVID, M.D.†, CHARLOTTE, NORTH CAROLINA

J Bone Joint Surg Am, 1999 May 01;81(5):716-30

5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case

Article

Comments (0)

text A A A

Extract

Lumbar arthrodesis is a commonly performed operative procedure for the treatment of low-back pain; however, the indications, techniques, and results remain controversial and unclear. The frequency of spinal arthrodesis for the treatment of back pain is increasing in the United States, as are criticism of the procedure and the study of available information on its outcomes. The concept of spinal arthrodesis is based on experience with other regions of the body in which arthrodesis has been used to treat painful joints by eliminating motion. Initially, spinal arthrodesis was used for the treatment of infectious conditions, deformity, and trauma of the spine. On the basis of these successful experiences and because of technical advances in imaging, operative procedures, implants, and bone-grafting, the indications for spinal arthrodesis have been expanded in an attempt to control pain attributed to abnormal or unstable motion between one vertebra and an adjacent vertebra or pain due to mechanical degeneration of the intervertebral disc.

Figures in this Article

Introduction

Much information on arthrodesis of the lumbar spine has been published, but most investigators have used nonstandardized criteria for inclusion of patients who were operated on for various diagnoses and whose outcomes were assessed with nonvalidated methods. Nevertheless, careful review of the available data may assist in determining which treatments are reasonable, which are unreasonable, and which are (or should be) considered investigational¹⁵⁵.

Under ideal circumstances, spinal arthrodesis should be performed only after a specific pathoanatomical diagnosis has been identified as being responsible for the patient's symptoms. In addition, the natural history of the diagnosis and the appropriate timing of operative intervention should be understood. By limiting abnormal motion or removing the intervertebral disc, lumbar spinal arthrodesis can potentially minimize or eliminate the source of pain. Procedures that result in minimum disruption of tissue and restore the normal biomechanics and physiological characteristics of the spine and that are safe, cost-effective, and not associated with adverse short or long-term effects should be considered for use in patients who are appropriate candidates for operative intervention.

An understanding of the etiology, diagnosis, and natural history of low-back pain and of the nonoperative and operative treatments that are available should guide the surgeon in selecting the best treatment for the patient.

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

†Department of Orthopaedic Surgery, Carolinas Medical Center, P.O. Box 32861, Charlotte, North Carolina 28232. E-mail address for Dr. Hanley: ehanley@carolinas.org.

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

†Department of Orthopaedic Surgery, Carolinas Medical Center, P.O. Box 32861, Charlotte, North Carolina 28232. E-mail address for Dr. Hanley: ehanley@carolinas.org.

Epidemiology and Economics

The large body of available information regarding the epidemiological characteristics of low-back pain has been summarized previously³. In industrialized societies, the prevalence of back pain over the course of a lifetime in the entire population is more than 70 percent. The incidence of back pain in the United States is 15 to 20 percent per year. Back pain is the most frequent cause of limitation of activity among individuals who are less than forty-five years old, and it is the second most common symptom necessitating a visit to a physician. Approximately 1 percent of the population in the United States is chronically disabled because of low-back pain⁷⁷, and an additional 1 percent is temporarily disabled⁷⁵. Each year, there are approximately 500,000 Workers' Compensation and personal-injury cases dealing with low-back pain. Most of the high cost incurred by society for the treatment of back pain is attributable to chronic, disabling pain⁷⁸.

The rate of operations on the back is higher in the United States than it is in other countries, and there are large variations among regions^{3,115,174,196,202}. The rate of lumbar arthrodesis increased by 200 percent between 1979 and 1987; this increase was greater than those for laminectomy (23 percent) and discectomy (75 percent). The rate of operations on the lower back increased an additional 100 percent, to twenty-six per 100,000, between 1987 and 1990¹⁹⁶.

Although it is impossible with current databases to give precise costs, it has been estimated that in the United States the direct and indirect cost of all conditions related to the spine ranges from thirty-eight to fifty billion dollars per year⁷⁹. The specific cost for the treatment of low-back pain is unknown, but it is obvious that the cost of diagnosis and treatment is a major health-care issue.

Etiology of Axial (Nonradicular) Low-Back Pain

Facet Joints

Degeneration of facet joints as a cause of low-back pain was first postulated in 1933⁸³, and the theory remains controversial. Nociceptive nerve fibers have been identified in facet-joint capsules and in synovial and pericapsular tissue^35,85,139. Numerous studies of anesthetic infiltration of the facet joints have been performed in an attempt to determine how abnormalities of these structures contribute to chronic low-back pain^{6,7,36,51,64,101,128,130,147,158,160,162,179}. Disappointing results have been reported with use of facet-joint injections as a therapeutic modality³⁵. It is believed that so-called facet syndrome is a much less common cause of low-back pain than are problems related to the intervertebral disc^6,58,111,136. In a recent small, prospective study, twenty-eight of ninety-one patients with chronic low-back pain who had at least 70 percent relief of symptoms after facet blocks (the analog-scale threshold for a decrease in symptoms that warrants consideration of operative treatment) subsequently were managed with a posterolateral spinal arthrodesis¹³⁶. The symptoms resolved in more than two-thirds of the patients postoperatively. However, other retrospective studies have not confirmed the predictive value of facet blocks for the success of lumbar arthrodesis^62,111.

Intervertebral Discs

Many authors have believed that a degenerated disc is the most likely source of chronic, disabling low-back pain (discogenic pain, internal disc disruption)^48,71. On the basis of this hypothesis, diagnostic studies such as discography and magnetic resonance imaging, and operative procedures such as excision of the disc and interbody arthrodesis, have been used extensively. However, studies also have demonstrated that degeneration of the disc may not be painful⁵⁴. Boden et al. studied the findings on magnetic resonance imaging in sixty-seven asymptomatic patients and found abnormalities in approximately one-third¹⁵.

The innervation of the intervertebral disc has been well characterized^{18,19,203,222}. The meningeal (sinuvertebral) nerve branches supply the posterior longitudinal ligament and the outer layers of the annulus fibrosus. The outer one-third of the annulus fibrosus is innervated with pain-transmitting free nerve-endings, and production of pain-related neuropeptides has been demonstrated⁴⁵. In addition, recent evidence suggests that severely degenerated lumbar discs have a more extensive innervation than do normal discs⁴⁵. Disruption of the annulus fibrosus during degeneration of the disc may cause stimulation of these pain pathways. Cartilage end-plates and underlying cancellous bone have been shown to have an increased density of sensory nerves and neuropeptides in patients who have degenerative disc disease, and these structures may transmit pain²⁹.

The pain response to tissue stimulation during procedures on the lumbar spine with use of local anesthesia has been reported^{65,106,123,161,165,192,214}. The findings suggest that direct stimulation of muscle and ligamentous tissue, often thought to be a cause of back pain, does not result in typical complaints of low-back pain. The outer layer of the annulus fibrosus has most often been implicated as the tissue causing axial low-back pain. Kuslich et al. found that the ligamentum flavum, epidural fat, posterior aspect of the dura, nucleus pulposus, laminae, and spinous processes were insensitive to mechanical stimulation in 193 patients¹²³. Stimulation of the central and lateral portions of the annulus fibrosus produced typical symptoms in slightly more than two-thirds of patients. The findings for the posterior longitudinal ligament were similar to those for the annulus fibrosus. The vertebral end plate was sensitive to stimulation in 61 percent of patients, and the facet-joint capsule was sensitive in 30 percent. Only direct pressure or stretch applied to the nerve root produced pain in the lower extremities. Pain in the buttocks could be reproduced only by simultaneous stimulation of the annulus fibrosus and the nerve root. Stimulation of fascia and muscle did not produce typical low-back pain.

Indirect evidence of a discogenic source of pain is also found in the literature on the cervical spine. Resolution of symptoms after excision of a cervical disc without interbody arthrodesis has been reported^148,182. These findings support the hypothesis that the disc is the source of pain and that continued loading after excision does not preclude a successful outcome. This theory also is supported by reports that continuing pain after successful posterior lumbar spinal arthrodesis can be relieved by excision of the disc and interbody arthrodesis²⁰⁸.

Degenerative Instability

A controversial indication for spinal arthrodesis is instability of one vertebra on an adjacent vertebra as a consequence of degenerative arthritis. This condition is thought to be uncommon²²⁵. One theory accounting for the success of this procedure is that selective arthrodesis of a single vertebra to an adjacent vertebra has a high probability of relieving symptoms if the diagnosis of abnormal motion can be made with certainty¹⁹⁴. The concept of eliminating motion in order to eradicate pain has been questioned by several authors who found no association between the outcome and the presence of a stable fusion, and a poor outcome has not been found to be associated with pseudarthrosis^8,69,72,89.

On the basis of observations of pathological specimens, Kirkaldy-Willis and Farfan concluded that degeneration of the lumbar spine occurs in three phases: dysfunction (progressive tearing of the annulus fibrosus, degeneration of the nucleus pulposus, and arthropathy of the facet joints), instability (laxity of the facet joints, ligaments, and discs), and restabilization (formation of osteophytes and hypertrophy of the facet joints)¹¹⁶. The natural history of instability was studied radiographically by Sato and Kikuchi, who reported restabilization in 20 percent of fifty patients after a minimum ten-year follow-up¹⁸⁴.

The American Academy of Orthopaedic Surgeons defined segmental instability as "an abnormal response to applied loads, characterized by motion in the motor segment beyond normal constraints."¹ In a patient who has an abnormal disc, subacute and repetitive mechanical overloading may result in abnormal motion that may cause pain. This concept of segmental instability, which does not indicate an exact source of pain, may be related to, but differs from, the diagnosis of so-called discogenic back pain (pain related to disc degeneration), for which demonstrable abnormal motion is not mandatory. Many classifications have been proposed in an attempt to identify a definitive etiology on the basis of biomechanical, clinical, and radiographic criteria^{74,76,175,213}. Frymoyer and Selby attempted to divide segmental instability into subtypes on the basis of the deformity that would produce symptoms if progression occurred⁷⁶. They also proposed tailoring a specific technique of arthrodesis to the type of instability as a means of reducing the rate of failure. Stokes and Frymoyer subsequently concluded that this classification could not be used with clinical success even when sophisticated radiographic studies were part of the evaluation process¹⁹⁴.

Many orthopaedists believe that there are patients with degenerative instability without spondylolisthesis or scoliosis who may respond to operative stabilization. Radiographic signs, such as the traction spur¹⁴⁰ and abnormal translational motion¹⁷¹, continue to be used as clinical criteria for this diagnosis. Additional studies have been performed with use of cadavera to more precisely quantify the magnitude of the motion that occurs¹⁷⁵ or to define the source of pain with use of facet blocks¹⁵⁹ or discometry⁹². Historically, some surgeons have advocated a trial of immobilization with use of a brace as a means of predicting which patients might benefit from intersegmental arthrodesis. However, biomechanical and radiographic studies have shown that lumbar orthoses have very little effect on motion between vertebrae even when a thigh extension is added. This treatment therefore has been abandoned by most clinicians^6,7,67,165. A trial of short-term external fixation has shown some promise in helping to determine which patients will benefit from arthrodesis¹²⁰, although this technique is impractical in most situations and has not gained widespread acceptance. Knutsson defined instability as "three millimeters or more of anterior translation on flexion/extension bending films."¹¹⁹ Other authors have attempted to define abnormal displacement more precisely^{5,16,59,73,132,168,175}. Spratt et al. analyzed the interobserver and intraobserver variability of these measurements and concluded that, at the third and fourth and the fourth and fifth lumbar vertebrae, a minimum of four millimeters of anterior displacement defined instability, and at the fifth lumbar and first sacral level, a minimum of five millimeters as seen on lateral bending radiographs was required¹⁹¹. The relationship between degeneration of the disc as seen on discography and angular instability (tilting of 15 degrees or more by one vertebra on an adjacent vertebra) as seen on lateral bending radiographs was studied, but no association was found¹⁹⁰. Others have noted that angular instability tends to resolve over time unless it is combined with translational instability, in which case it tends to persist¹⁸⁴.

Psychological Factors

In order to direct the best course of treatment for a patient who has persistent symptoms, an understanding of psychological factors and their relationship to low-back pain is important. Issues of secondary gain related to low-back pain include financial gain from disability insurance or Workers' Compensation and sick-role-related psychological gain. A range of disability and distress is commonly seen in patients who have comparable objective physical findings¹⁴⁴. The discrepancy between the nociceptive stimuli from abnormal tissues causing low-back pain and the behavioral and affective component has been referred to as desynchrony¹²⁷. It has been proposed that, in addition to the neurological and psychological responses, the reaction to pain is a taught behavior based on socialization¹⁰⁹. The effects of culture on low-back pain in a nonindustrialized, isolated community were examined in a community of Australian aborigines¹⁰⁹. Nearly half of the fifty-six adults had long-term back pain; however, because of their cultural beliefs, they chose not to make their pain public.

Rose et al. documented a positive effect of cognitive behavioral therapy, regardless of its duration or specific form, on patients' reports of pain, disability, self-esteem, and somatic awareness¹⁸⁰. There is an increasing body of literature demonstrating the beneficial role of cognitive behavioral programs in the treatment of chronic pain⁸¹. The diagnosis of chronic low-back pain has been accepted in our society, and industry, government, and traditional medical organizations have developed and supported programs and mechanisms that have the potential to be used for secondary gain; these include disability insurance, Workers' Compensation, and litigation after injury⁶⁷. The practitioner should be able to screen for the presence of psychological stress in a patient's life that may aggravate or cause back pain, and these factors should be addressed before major operative intervention is performed. Several validated psychometric instruments have been developed for use in the clinical setting^143,228.

The physician should be familiar with trained professionals and community resources, including counselors and self-help groups, that provide treatment choices to patients who have identifiable psychological stress. Several authors have advocated programs incorporating cognitive therapy with physical and vocational training and disability case management as an effective multimodal approach for patients in whom clear operative indications are lacking^98,152,173.

Diagnostic Studies

The use of plain radiographs to evaluate patients who have low-back symptoms is indicated when the symptoms have persisted for more than four to eight weeks and are associated with pain at night or at rest. These radiographs are used primarily to rule out infection, a malignant lesion, fracture, and inflammatory conditions. Negative results may help to reassure the patient that no major pathological condition is present¹¹⁴.

The greatest debate over the use of diagnostic studies to evaluate low-back pain concerns provocative discography. Several operative procedures have been developed and advocated for the treatment of lumbar pain diagnosed on discography. It is unclear how injection of the disc provokes pain, although various theories have been postulated. One such theory is that stimulation of nociceptive fibers in the innervated part of the annulus fibrosus^94,216 or the vertebral end plate or body^27,100 causes pain as the injection increases intradiscal pressure. Another theory is that injection leads to chemical stimulation that produces pain²¹¹. The use of provocative discography apparently was first reported in 1948 by Hirsch, who injected normal saline solution into lumbar discs in an effort to localize lesions¹⁰⁶. Lindblom apparently was the first investigator to inject contrast medium into the disc space, and he reported both normal and abnormal morphological characteristics¹³³. Colhoun et al. retrospectively reviewed the outcomes for 137 patients with low-back pain who had had spinal arthrodesis at levels for which discography demonstrated abnormal morphological characteristics and produced symptoms⁴³. At a mean of 3.6 years, 121 patients (88 percent) had a successful result compared with only thirteen (52 percent) of twenty-five who had had an arthrodesis without reproduction of the typical symptom. Simmons and Segil found discography to be accurate for the localization and planning of arthrodesis of symptomatic levels in 89 percent of 272 patients who had discogenic disease of the spine¹⁸⁶.

Less-than-optimum results also have been reported for patients who had an arthrodesis on the basis of discography. Wetzel et al. performed discography at seventy-seven levels in forty-eight patients who had low-back pain and found a positive response at sixty-three levels²¹². Posterolateral arthrodesis was performed at one level in eight patients, at two levels in twenty-six patients, at three levels in thirteen patients, and at four levels in one patient. Those authors reported a satisfactory outcome in 46 percent of the patients and a rate of union of 48 percent; however, as the number of levels that were operated on was not correlated with the discographic findings, interpretation of these results is difficult.

Opponents of discography often cite a study reported in 1968 by Holt¹⁰⁸. He found a 37 percent rate of false-positive results with regard to an association between the production of symptoms and abnormal morphological characteristics of the disc in thirty asymptomatic inmates of a correctional institution who had volunteered to participate in the study. A total of seventy-two segments were evaluated. These included the second and third lumbar vertebrae in one subject, the third and fourth lumbar vertebrae in twenty-seven, the fourth and fifth lumbar vertebrae in twenty-four, and the fifth lumbar and first sacral vertebrae in twenty. The validity of that study has been questioned. In a critical reassessment, Simmons et al. concluded that Holt's data "should no longer be used as scientific or authoritative evidence against the use of discography."¹⁸⁸ Major flaws that they identified included use of a study population consisting of so-called volunteer prison inmates whose reliability may be questionable, the high rate of failure of placement of the needle (twenty-three [77 percent] of thirty attempts at the fourth and fifth lumbar vertebrae and nineteen [63 percent] of thirty at the fifth lumbar and first sacral vertebrae were successful), and use of a contrast agent that is very irritating. Using superior radiographic equipment and nonirritating contrast medium, Milette and Melanson reported that discography was associated with only a 5 percent rate of false-positive results in a study of 320 normal discs¹⁵⁶. Walsh et al. described the results of discography in ten asymptomatic subjects who had had evaluation of a total of thirty segments (three segments per subject)²⁰⁶. No subject reported pain with injection, but five had abnormal findings at a single level.

The North American Spine Society Diagnostic and Therapeutic Committee, in a position statement on lumbar discography, noted that recent literature supports the use of discography in selected applications⁹⁵. For patients who have nonradicular low-back pain, these applications include determination of which disc level or levels have reproduction of the symptoms on noninvasive studies, in order to select the levels to be included in the arthrodesis, and localization of the discogenic sources of persistent pain after a previous unsuccessful procedure on the lumbar spine. Those authors believed that positive findings on discography alone should not be an indication for an operation, and they advocated the use of computed tomography after discography to further assess the morphological characteristics of the disc. The natural history of discogenic low-back pain that is diagnosed with discography has not been studied extensively. Smith et al. reported on thirty-six patients with severe, so-called discogram-concordant low-back pain (that is, pain that was reproduced by injection) who, for various reasons, did not have an arthrodesis when it was suggested to them¹⁸⁹. Although criticized as being flawed (in an editorial at the end of the article), this report indicated that, over time, most of these patients had a decrease in symptoms and resumed a fairly functional lifestyle.

The development of magnetic resonance imaging has provided a noninvasive method for evaluation of the morphological characteristics of the disc. Schneiderman et al. retrospectively studied 101 discs in thirty-two patients and found a 99 percent association between the findings on magnetic resonance imaging and those on discography¹⁸⁵. Other authors have shown that magnetic resonance imaging cannot be used preoperatively to predict the outcome of arthrodesis. Zucherman et al. reported on eighteen patients who had normal findings on magnetic resonance imaging and abnormal findings on discography; the abnormal results most often suggested a peripheral tear of the annulus fibrosus, with or without a small disc herniation²²⁷. Brightbill et al. reported on seven patients with chronic low-back pain who had normal findings on magnetic resonance imaging but abnormal findings on discography and a finding of internal disc disruption at the time of the operation²⁶.

Despite these findings, a morphological abnormality on magnetic resonance imaging in conjunction with a provocative pain response on discography might be predictive of which patients would benefit from operative stabilization. Gill and Blumenthal retrospectively reviewed the results in fifty-three patients with internal disc disruption at the fifth lumbar and first sacral vertebrae who had discogram-concordant pain and had had magnetic resonance imaging⁸⁶. Thirty-six months after an anterior arthrodesis, twenty-nine (74 percent) of thirty-nine patients who had abnormal findings on preoperative magnetic resonance imaging had a decrease in the symptoms compared with only seven of fourteen who had normal findings. Newman and Grinstead reported an 86 percent rate of success (thirty-one of thirty-six patients) two years after an anterior lumbar arthrodesis performed because of abnormal findings on discography and magnetic resonance imaging¹⁶³. Parker et al. noted less successful outcomes in twenty-three patients; nine patients (39 percent) had a clinically successful result, and eighteen (78 percent) had fusion¹⁷⁰.

Nonoperative Treatment

Extensive material concerning nonoperative treatment has been published and reviewed^56,201. In a recent review of randomized, controlled trials, van Tulder et al. identified only twenty-eight trials on intervention for acute back pain and twenty on intervention for chronic back pain that were considered to be of high quality²⁰¹. Those authors found strong evidence of the effectiveness of nonsteroidal anti-inflammatory drugs and muscle relaxants and of the ineffectiveness of exercise for the treatment of acute low-back pain. With regard to the treatment of chronic low-back pain, strong evidence, especially of short-term improvement, was reported for exercise, back school, and manipulation. Both the Agency for Health Care Policy and Research¹³ in the United States and the Clinical Standards Advisory Group Committee on Back Pain¹⁸¹ in the United Kingdom recommended use of acetaminophen, nonsteroidal anti-inflammatory drugs, muscle relaxants, manipulation, and active exercise for the treatment of acute low-back pain. The Quebec Task Force on Spinal Disorders¹⁷⁶ and the Clinical Standards Advisory Group Committee on Back Pain¹⁸¹ stated that the primary goal of treatment of chronic back pain is return to work or usual activities, with relief of pain being a secondary goal.

At least three randomized trials of bed rest for the treatment of acute low-back pain have been reported^52,70,215. The findings suggest that no more than a brief period of bed rest (two days) is advisable for most patients who have moderate symptoms. Additional bed rest may lead to deconditioning and the development of illness-related behavior. Many exercise programs, including those involving extension, flexion, a combination of flexion and extension, aerobic conditioning, and stretching, have been advocated for the treatment of low-back pain; however, the best regimen is not known⁵⁶. At least two large, randomized, controlled trials have failed to support the efficacy of flexion exercises^63,84, originally popularized by Williams²¹⁸. Although widely used and somewhat supported in the literature, randomized trials of extension-exercise regimens, such as those reported by Donelson et al.⁵⁷ and by McKenzie¹³⁸, have had problems related to classification and design, making the results difficult to interpret⁵⁶. The role of aerobic conditioning is not clear; however, one study predicted a lower risk of back problems among individuals who have higher levels of fitness³⁴. The use of traction for the treatment of low-back pain was not supported in at least seven randomized clinical trials^{46,129,150,151,167,209,210}. A comprehensive review of the literature on the use of acupuncture for the treatment of chronic pain concluded that the efficacy of this modality was unclear¹⁹⁹, and other studies have suggested that it is a form of placebo therapy⁵⁶. Several well controlled, randomized studies have failed to provide convincing evidence of the efficacy of transcutaneous electrical nerve stimulation^53,102,145. The Quebec Task Force on Spinal Disorders concluded that, despite the common use of braces and corsets, there is no substantial scientific evidence of their efficacy¹⁷⁶. A similar conclusion was reached regarding the use of electromyographic biofeedback¹⁷⁶. There is evidence that postural devices that maintain lumbar lordosis while the patient is sitting lead to a decrease in back pain and pain in the lower extremities²¹⁷.

Drug therapy is commonly used in clinical practice for the treatment of low-back pain. Although nonsteroidal anti-inflammatory drugs have been shown to be effective for the treatment of acute back pain^2,4,12,104, their effectiveness for chronic back pain is unclear. Narcotic agents may be useful for acute back pain, but their use is generally avoided for chronic back pain, although some authors have seen a role for them¹⁶⁹. Muscle relaxants appear to have some efficacy for the treatment of acute low-back pain^20,105.

The literature on spinal manipulation has been reviewed extensively²⁰¹. The effectiveness of this treatment is controversial, but there is some evidence to support its efficacy for the treatment of acute back pain¹⁴.

Functional restoration, work-hardening, and back-school programs for the treatment of chronic low-back pain have received much attention. Back school provides a structured educational program leading to behavioral modification and increased function in order to prevent and reduce future episodes of back pain. Cohen et al., in an overview of the literature, found insufficient evidence to recommend back school for patients who have low-back pain⁴², whereas other authors have found back school to be beneficial for those who have chronic back pain^{13,117,153,201}. Functional restoration and work-hardening programs focus on rehabilitation, with an emphasis on return to work and improved function despite continuing pain. Such programs are intensive (forty to fifty hours per week for three to four weeks), combining education, behavioral training, endurance and physical training, and work simulation, and they have shown some promise. However, properly performed studies of their results are lacking, and the programs are expensive^{57,98,157,197}. Pain centers vary widely with regard to their emphasis: some are oriented to a specific modality, others use a multidisciplinary approach, and still others deal with chronic pain. Therefore, the effectiveness of these programs has been difficult to assess⁶⁸.

Operative Treatment

Considerable controversy exists regarding specific operative treatment for low-back pain. Operative intervention usually is considered when nonoperative measures have been exhausted and disability and pain are still present. A moderate amount of experience has been accumulated with use of posterior arthrodesis alone, anterior disc excision and interbody arthrodesis, posterior lumbar disc excision and interbody arthrodesis, and circumferential stabilization procedures^{14,37,80,86,93,118,134,163,193,224}.

The use of arthrodesis for the treatment of low-back pain may be associated with morbidity. Deyo et al. reviewed the records of a group of Medicare patients who had had spinal procedures and reported nearly twice as many complications for those who had had an arthrodesis as for those who had not⁵⁵.

Posterolateral Arthrodesis

Of the several techniques that are available for spinal arthrodesis, posterolateral arthrodesis with use of autogenous bone graft with or without internal fixation has been the most commonly performed. In general, supporters of this technique accept the hypothesis that the fusion mass is sufficiently close to the center of vertebral motion to prevent movement that may stimulate a pain response.

Techniques for posterolateral spinal arthrodesis have been modified since they were first reported in 1911 by Hibbs¹⁰³. His technique of posterior arthrodesis involved use of graft from the spinous processes that was applied to the laminae as a local autogenous graft. This technique is now used rarely because it has been associated with a high rate of pseudarthrosis⁷¹.

Cleveland et al., in 1948, described use of a more laterally placed bone graft for the treatment of pseudarthrosis following a posterior spinal arthrodesis³⁹. Watkins popularized this technique in 1959, using a posterolateral approach to the spine and thus gaining direct access to the posterior articulations, the pars interarticularis, and the transverse processes²⁰⁷. Macnab and Dall reported on the anatomy and blood supply of the facet joints and transverse processes of the lumbar spine¹⁴¹. These observations provided a basis for the enhancement of fusion by facilitation of a maximum blood supply while minimizing blood loss during such procedures.

There are many variations of the techniques for posterior and posterolateral arthrodesis. McBride stressed the importance of the facet joint in 1949, when he described his results with use of an adjunctive morseled transfacet bone block for lumbosacral arthrodesis¹³⁷. This simple technique, which represents an attempt to eliminate intervertebral motion at the facet articulation, recently was questioned by Boden et al., who performed cadaver studies analyzing the axial and torsional stiffness associated with various techniques of arthrodesis¹⁷. Those authors concluded that disruption of the facet-joint capsule and placement of transfacet bone blocks as described by McBride resulted in loss of spinal stability as compared with use of posterior intertransverse-process arthrodesis alone.

Pedicle-Screw Instrumentation

The theoretical purpose of adding posterior instrumentation to a posterolateral arthrodesis is to increase the rate of fusion. Various systems for posterior stabilization, employing wire, hook, and pedicle-screw-based constructs, have been developed, and their efficacy has been supported in the literature^93,135,219. The best available evidence concerning pedicle-screw instrumentation was presented at the meeting of the United States Food and Drug Administration Orthopaedic and Rehabilitation Devices Advisory Panel that was held on July 22, 1994, in Gaithersburg, Maryland²²⁰. In a metaanalysis of the literature from 1970 through 1993, Mardjetko et al. reported the results of a review of twenty-five acceptable papers (comprising a total of 889 patients) on the subject of degenerative spondylolisthesis¹⁴⁶. Five of these studies included 101 patients who had had decompression and arthrodesis with pedicle-screw instrumentation, and four described the results for 138 patients who had been managed with what were referred to as control devices, such as Harrington rods, compression rods, and Luque rectangles with sublaminar wire fixation. The results indicated that "posterolateral spinal fusion rates are enhanced by adjunctive spinal instrumentation [p = 0.08] with no significant differences detectable between control devices and pedicle screw devices," with the number of patients studied (p = 0.19)¹⁴⁶. The complications related to the devices were similar, whereas the specific types of complications were unique to each device.

We believe that adjunctive spinal instrumentation increases the rate of fusion and that Food and Drug Administration class-II devices and pedicular instrumentation are comparable with regard to the rates of fusion, patient satisfaction, and complications. Yuan et al., in 1994, retrospectively analyzed the outcomes for patients with degenerative spondylolisthesis who had been managed with pedicle-screw fixation and compared the results with those for patients who had not had pedicle-screw instrumentation at the time of the operation²²³. A total of 2684 patients were included in the study, and 2177 (81 percent) had pedicle-screw fixation. There were two control groups, consisting of 456 patients who had an arthrodesis without instrumentation and fifty-one who had instrumentation with non-pedicle-screw devices. Intraoperative events related to the pedicle-screw fixation occurred infrequently, and the rate of breakage of the implant (0.2 percent) was extremely low. The rates of nerve-root, spinal cord, and vascular injuries also were low (less than 0.5 percent). Dural tears related to insertion of the screw were rare (prevalence, 0.1 percent), and the rates of tears that were not associated with placement of the screw were comparable between the groups that were managed with and without instrumentation. The rate of reoperation was higher in the patients who had pedicle-screw instrumentation than in those who did not (18 compared with 15 percent). Most of these procedures were related to removal of the device and reinstrumentation, and the rates of repeat arthrodesis were similar among the groups. At the time of the two-year follow-up evaluation, the patients who had been managed with pedicle-screw instrumentation had a significantly higher rate of fusion than the control group that had not had instrumentation (83 compared with 75 percent; p < 0.01). In addition, the patients who had had pedicle-screw instrumentation tended to have a more rapid rate of consolidation of the fusion and more often had maintenance of spinal alignment. They also had better clinical outcomes with regard to pain, function, and neurological recovery than did the patients in the control group that was managed without instrumentation. The rates of nondevice-related events, reoperation, and death were similar for the treatment groups. Yuan et al. concluded that the benefits of pedicle-screw use were substantially greater than the potential risks.

Zdeblick, in a prospective, randomized study of patients who had degenerative conditions of the lumbar spine, compared the results of posterolateral arthrodesis with and without segmental (pedicle-screw) instrumentation²²⁴. Superior results were found with use of rigid fixation. The rate of fusion for the patients who were managed with segmental instrumentation was 86 percent (sixty-two of seventy-two) compared with 64 percent (twenty-seven of forty-two) for those in whom no instrumentation was used.

Hall et al. described their experience with pedicle-screw instrumentation in 120 patients who had so-called degenerative disc disease⁹⁷. Various criteria had been used to select the patients, and 63 percent had had a previous operation on the lumbar spine. The arthrodesis included one level in thirty-two patients, two levels in forty-two, three in twenty-nine, four in eleven, and five levels or more in six. Results related to the number of levels included in an arthrodesis are difficult to analyze. The overall rate of clinical success at twenty-four months was 73 percent (seventy-eight of 107 patients), the rate of fusion was 91 percent (ninety-seven of 107), and the rate of intraoperative complications was 11 percent.

Lumbar Interbody Arthrodesis

Excision of the intervertebral disc followed by lumbar interbody arthrodesis for the treatment of back pain is not new. Originally developed for the treatment of tuberculosis, lumbar interbody arthrodesis with use of a posterior approach was reported by Jaslow¹¹² in 1946 and with use of an anterior approach, by Hodgson and Stock¹⁰⁷ in 1956. Cloward popularized this procedure for the treatment of axial low-back pain⁴⁰. Those who advocate this technique generally consider the disc to be the primary source of pain and use the terms discogenic pain, symptomatic annular tear, and internal disc disruption^48,71. Excision of the disc and interbody arthrodesis is thought to remove the source of pain and to prevent motion. The bone graft is placed closer to the center of vertebral motion, theoretically achieving greater stiffness when fusion has occurred. In addition, intervertebral height may be restored, and a smaller volume of bone graft may be used compared with that required for posterior techniques. The achievement of excellent vascularity of the arthrodesis bed has been reported as another advantage of this technique^71,107.

Posterior Lumbar Interbody Arthrodesis

A relatively common technique for interbody arthrodesis has been the posterior lumbar interbody procedure, which avoids the potential complications associated with the anterior approach. Jaslow reported using facetectomy and foraminotomy routinely to facilitate epidural hemostasis and complete removal of the disc¹¹². Excision of the disc was followed by decortication of the end plates. The results of posterior lumbar interbody arthrodesis are difficult to interpret with regard to validated patient-outcome measures as the available literature focuses on operative technique. Good and excellent results were reported for 93 percent of ninety-seven patients by Cloward⁴¹ and for 92 percent of fifty patients by Collis⁴⁴, whereas satisfactory clinical results were reported for 89 percent of sixty-two patients by Lee et al.¹²⁶, for 82 percent of 465 patients by Lin et al.¹³¹, and for 79 percent of 113 patients by Simmons¹⁸⁷. The rates of fusion among these series were similar (96 percent in the series of Cloward, 94 percent in that of Collis, 94 percent in that of Lee et al., 88 percent in that of Lin et al., and 90 percent in that of Simmons). Stonecipher and Wright reported a 100 percent rate of fusion in thirty-five patients with use of adjunctive facet-screw fixation with posterior lumbar interbody arthrodesis¹⁹⁵, and Yashiro et al. reported a 92 percent rate in fifty-eight patients who had been managed with adjunctive pedicle-screw segmental fixation²²¹. The clinical outcomes were difficult to determine in these latter two series.

Anterior Lumbar Interbody Arthrodesis

Burns apparently was the first to describe anterior lumbar interbody arthrodesis for the treatment of spondylolisthesis, in 1933³⁰. Crock reported use of this procedure for the treatment of internal disc disruption confirmed with discography⁴⁸. The advantages of anterior lumbar interbody arthrodesis include direct removal of the involved disc and avoidance of iatrogenic trauma associated with posterior paraspinal muscle dissection and partial denervation^47,90. Compared with posterior lumbar interbody arthrodesis, this technique allows a more complete excision of the disc (which is believed to be the primary cause of the pain). Anterior lumbar interbody arthrodesis requires excision of a large portion of the annulus fibrosus and the anterior longitudinal ligament. Concerns related to this technique include injury to the great vessels¹⁰ and the risk of injury to the presacral plexus, potentially resulting in retrograde ejaculation and sterility¹¹³.

Penta and Fraser¹⁷² recently reported that 68 percent of 108 patients had an outcome of fair or better after anterior lumbar interbody arthrodesis, according to the Low Back Outcome Score⁸⁸, at a minimum of ten years. The overall rate of fusion was 72 percent (91 percent for patients who had had a single-level arthrodesis and 51 percent for those who had had the procedure at multiple levels), which is similar to findings in other studies^{14,37,86,90,118,163,193}. A lower rate of success was reported by Knox and Chapman, who analyzed the results for twenty-two patients who had had an anterior lumbar interbody arthrodesis for the treatment of discogram-concordant pain¹¹⁸. Of the seventeen patients who had had a single-level arthrodesis, six had a good result, three had a fair result, and eight had a poor result. There were no excellent results; all five patients who had had the arthrodesis at two levels had a poor result.

In a recent study, Greenough et al.⁹⁰ prospectively reviewed the results of posterolateral lumbar arthrodesis with instrumentation in 135 patients and compared these outcomes with those from a similar study by Penta and Fraser¹⁷², who had performed an anterior interbody arthrodesis in 108 patients; both groups of investigators used the same outcome measure (the Low Back Outcome Score⁸⁸). Overall, there was a twofold difference in the outcome score (Wilcoxon rank-sum test, Fisher exact probability test, and chi-square test)⁹⁰, with anterior interbody arthrodesis yielding better results regardless of the patient's Workers' Compensation status.

Interbody Fusion Cages

Some authors have suggested that interbody arthrodesis is less successful if structural support is not provided for the intervertebral space. Autologous nonstructural cancellous bone graft, when used for the interbody technique, may migrate or collapse^87,110,112. In contrast to the potential disadvantages of structural corticocancellous autogenous graft and allograft, metal and carbon-fiber^22-25 implants filled with nonstructural cancellous bone have been found to provide immediate structural support and a biological substrate to promote fusion. As of late 1997, the Food and Drug Administration had granted approval to two companies for the marketing of titanium devices for interbody arthrodesis: the BAK device (Spine-Tech, Minneapolis, Minnesota) and the Ray-TFC device (Surgical Dynamics, Norwalk, Connecticut)^124,177. These devices were developed on the basis of studies by Bagby et al., who treated instability of the cervical spine in horses by distracting the intervertebral space and implanting a hollow, perforated cylinder filled with autogenous bone graft^9,50,205. Biomechanical and animal studies have supported use of these devices^{28,33,79,164,183,198}, which may be inserted with an anterior^142,149 or a posterior approach employing either an open or a laparoscopic technique.

The results of two large trials in which Investigational Device Exemption protocols developed by the Food and Drug Administration were used to evaluate these devices have been reported recently^124,177. As part of such a protocol, Ray prospectively followed 236 patients who had disabling low-back pain and had been managed with insertion of threaded titanium interbody-fusion cages (the Ray-TFC device) through a posterior approach¹⁷⁷. After a minimum of twenty-eight months, the rate of fusion was 94 percent (221 patients), and functional improvement, according to a validated outcome device, was excellent for 40 percent of the patients, good for 25 percent, fair for 21 percent, and poor for 14 percent. The rate of persistent complications after discharge from the hospital was less than 1 percent. Paralysis was not reported. A deep infection developed in two patients, and two patients needed a reoperation. Kuslich et al., in a similar trial, reported on 947 young and middle-aged patients who had had implantation of the BAK titanium device with use of either an open anterior approach (591 patients) or a posterior approach (356 patients)¹²⁴. At twelve months 680 patients were available for follow-up, and at twenty-four months 299 were available. There were no instances of paralysis, implant or procedure-related death, or deep infection. Major complications were reported in 2 percent of the patients, and migration of the implant necessitating reoperation occurred in 1 percent. Although the findings of that report were difficult to verify, those authors indicated that fusion occurred in 86 percent of 680 patients at twelve months and in 91 percent of 299 at twenty-four months. At the two-year follow-up evaluation, more than 85 percent of 299 patients reported a decrease in pain, and 91 percent had an improvement in function according to a nonvalidated analog scale. The operative approach and the number of levels included in the arthrodesis were not associated with the functional improvement score. The rate of return to work at twelve, twenty-four, and thirty-six months was 68 percent of 680 patients, 78 percent of 299 patients, and 91 percent of 143 patients, respectively.

The availability of these devices has had a major impact. Industry analysts stated that interbody fusion cages would account for 23 percent of the spinal implant market in the United States in 1997 compared with 3 percent in 1996¹⁵⁴.

Hacker compared the outcomes and costs of posterior lumbar interbody arthrodesis with use of the BAK device in fifty-four patients with those of a 360-degree arthrodesis (anterior lumbar interbody arthrodesis and posterolateral arthrodesis without instrumentation) for the treatment of disabling low-back pain in twenty-one patients⁹⁶. The patients who had been managed with a posterior lumbar arthrodesis had a more rapid return to work and more rapid closure of their Workers' Compensation claims as well as substantial cost-savings. The outcomes were similar for the two groups. Similar results have been reported with use of the Ray-TFC device¹⁷⁸.

Circumferential Arthrodesis

Circumferential spinal arthrodesis was first used for the treatment of trauma and deformity^{11,21,121,166,199}. The indications then were expanded to include failure of a previous operation on the lumbar spine⁸² and use as a primary procedure for the treatment of disabling low-back pain^61,122. The theoretical advantages of this procedure include elimination of all potential sources of pain in anterior and posterior structures as well as maximization of stability with a resulting increase in the rate of fusion. This hypothesis is supported by reports of back pain that persisted despite solid posterior fusion but was subsequently relieved after the addition of anterior discectomy and interbody arthrodesis²⁰⁸. Circumferential arthrodesis may be performed with use of a posterior approach alone or with use of a combined anterior and posterior approach, usually on the same day¹²². Linson and Williams, in a nonrandomized, retrospective study, compared the results of anterior lumbar arthrodesis in thirty-five patients with those of combined anterior and posterior arthrodesis in sixteen patients¹³⁴. At the fifteen to thirty-six-month follow-up evaluation, twenty-seven patients (77 percent) who had had an anterior lumbar arthrodesis had a good or excellent result compared with eleven who had had a combined procedure.

Intervertebral Disc Prosthesis

Implantation of a partial or total disc prosthesis is controversial and investigational. The underlying concept is removal of the disc to relieve pain, followed by implantation of a prosthesis to simulate the stability, mobility, and weight-bearing properties of the disc.

In addition to ensuring adequate material properties and patient outcomes over the long term, the difficulties and complications associated with operative implantation of a prosthetic device and revision or salvage procedures must be acceptable. The many devices that are currently under investigation^{31,32,49,60,99,125,200,204} may be divided into two basic groups: those used to replace all or part of the annulus fibrosus and nucleus pulposus of the disc, and those used to replace the nucleus pulposus only. Fernstrom retrospectively reported the results for 125 patients in whom 191 spherical alloy implants had been used to replace the nucleus pulposus⁶⁶. The goal was to restore normal weight-bearing to the annulus fibrosus and the facet joints and to restore disc height. Four to seven years after the operation, 88 percent of the prostheses had subsided into the vertebral end plates.

The results associated with the use of a dome and cup-shaped, low-friction gliding prosthesis in different stages of development have been reported by several authors^{32,38,49,91,226}. A satisfactory result was noted in more than 50 percent of patients with use of nonvalidated measures. Complications included migration or dislocation of the implant and fracture of the metal.

Conclusions

The available information on the diagnosis and treatment of low-back pain lacks objectivity, as most studies have been retrospective, uncontrolled, and predominantly focused on operative technique. Most investigators have used nonvalidated outcome measures that have reflected the biases of their proponents.

So-called facet disease and degenerative instability are extremely rare, and these diagnoses should seldom be used as indications for operative intervention. When they are present, stabilization with use of posterior instrumentation and arthrodesis is appropriate.

The pertinent issues revolve around the treatment of idiopathic and discogenic low-back pain. Major controversies center around which treatment is best when nonoperative measures have failed. Opponents of operative treatment believe that the outcomes of most or all procedures fall below the threshold needed to justify operative intervention, as only about 50 percent of patients have a successful result with regard to decreased pain, increased function, and ability to return to work. Proponents of operative treatment maintain that these patients have no other options, that some improvement in pain and function is important, and that operative intervention is therefore warranted. They believe that full relief of disability is too strict a criterion or goal.

We think that most patients who have acute or chronic idiopathic or discogenic low-back pain should be managed nonoperatively. Patients who have refractory pain with severe incapacity, and those who have imaging-confirmed morphological changes and concordant symptoms, may be managed successfully with anterior disc ablation and structural arthrodesis.

Some improvement occurs as a result of operative treatment in about 75 percent of patients, but major or complete relief of pain and recovery of function are seen in 50 percent or less. Each physician and each patient must assess these issues in a forthright manner and determine what is appropriate under the circumstances.

References

American Academy of Orthopaedic Surgeons: A Glossary on Spinal Terminology, p. 42. Chicago, American Academy of Orthopaedic Surgeons, 1981.

Amlie, E.; Weber, H.; and Holme, I.: Treatment of acute low-back pain with piroxicam: results of a double-blind placebo-controlled trial. Spine,12: 473-476, 1987.12473 1987 [PubMed]

Andersson, G. B. J.: The epidemiology of spinal disorders. In The Adult Spine: Principles and Practice, edited by J. W. Frymoyer. Ed. 2, vol. 1, pp. 93-141. Philadelphia, Lippincott-Raven, 1997.

Aoki, T.; Kuroki, Y.; Kageyama, T.; Irimajiri, S.; Mizushima, Y.; and Yamamoto, K.: Multicentre double-blind comparison of piroxicam and indomethacin in the treatment of lumbar diseases. European J. Rheumatol. and Inflam.,6: 247-252, 1983.6247 1983

Arkin, A. M.: The mechanism of rotation in combination with lateral deviation in the normal spine. J. Bone and Joint Surg.,32-A: 180-188, Jan. 1950.32-A180 1950

Axelsson, P.; Johnsson, R.; and Stromqvist, B.: Effect of lumbar orthosis on intervertebral mobility. A roentgen stereophotogrammetric analysis. Spine,17: 678-681, 1992.17678 1992 [PubMed]

Axelsson, P.; Johnsson, R.; and Stromqvist, B.: Lumbar orthosis with unilateral hip immobilization. Effect on intervertebral mobility determined by roentgen stereophotogrammetric analysis. Spine,18: 876-879, 1993.18876 1993 [PubMed]

Axelsson, P.; Johnsson, R.; Stromqvist, B.; Arvidsson, M.; and Herrlin, K.: Posterolateral lumbar fusion. Outcome of 71 consecutive operations after 4 (2—7) years. Acta Orthop. Scandinavica,65: 309-314, 1994.65309 1994

Bagby, G. W.: Arthrodesis by the distraction-compression method using a stainless steel implant. Orthopedics,11: 931-934, 1988.11931 1988 [PubMed]

Baker, J. K.; Reardon, P. R.; Reardon, M. J.; and Heggeness, M. H.: Vascular injury in anterior lumbar surgery. Spine,18: 2227-2230, 1993.182227 1993 [PubMed]

Banta, J. V.: Combined anterior and posterior fusion for spinal deformity in myelomeningocele. Spine,15: 946-952, 1990.15946 1990 [PubMed]

Berry, H.; Bloom, B.; Hamilton, E. B.; and Swinson, D. R.: Naproxen sodium, diflunisal, and placebo in the treatment of chronic back pain. Ann. Rheumat. Dis.,41: 129-132, 1982.41129 1982 [PubMed]

Bigos, S.; Bowyer, O.; and Braen, G.: Acute Low Back Problems in Adults. Clinical Practice Guideline No. 14. AHCPR Publication No. 95-0642. Rockville, Maryland, Agency for Health Care Policy and Research, Public Health Service, United States. Department of Health and Human Services, 1994.

Blumenthal, S. L.; Baker, J.; Dossett, A.; and Selby, D. K.: The role of anterior lumbar fusion for internal disc disruption. Spine,13: 566-569, 1988.13566 1988 [PubMed]

Boden, S. D.; Davis, D. O.; Dina, T. S.; Patronas, N. J.; and Wiesel, S. W.: Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. J. Bone and Joint Surg.,72-A: 403-408, March 1990.72-A403 1990

Boden, S. D., and Wiesel, S. W.: Lumbosacral segmental motion in normal individuals. Have we been measuring instability properly?. Spine,15: 571-576, 1990.15571 1990 [PubMed]

Boden, S. D.; Martin, C.; Rudolph, R.; Kirkpatrick, J. S.; Moeini, S. M. R.; and Hutton, W. C.: Increase of motion between lumbar vertebrae after excision of the capsule and cartilage of the facets. A cadaver study. J. Bone and Joint Surg.,76-A: 1847-1853, Dec. 1994.76-A1847 1994

Bogduk, N.; Tynan, W.; and Wilson, A. S.: The nerve supply to the human lumbar intervertebral discs. J. Anat.,132: 39-56, 1981.13239 1981 [PubMed]

Bogduk, N.: The innervation of the lumbar spine. Spine,8: 286-293, 1983.8286 1983 [PubMed]

Boyles, W. F.; Glassman, J. M.; and Soyka, J.: Management of acute musculoskeletal conditions: thoracolumbar strain or sprain. A double-blind evaluation comparing the efficacy and safety of carisoprodol with diazepam. Today's Therapeutic Trends, 1: 1, 1983.

Bradford, D. S., and Boachie-Adjei, O.: One-stage anterior and posterior hemivertebral resection and arthrodesis for congenital scoliosis. J. Bone and Joint Surg.,72-A: 536-540, April 1990.72-A536 1990

Brantigan, J. W.; Steffee, A. D.; and Geiger, J. M.: A carbon fiber implant to aid interbody lumbar fusion. Mechanical testing. Spine,16 (Supplement 6): 277-S282, 1991.16 (Supplement 6)277 1991

Brantigan, J. W., and Steffee, A. D.: A carbon fiber implant to aid interbody lumbar fusion. Two-year clinical results in the first 26 patients. Spine,18: 2106-2107, 1993.182106 1993 [PubMed]

Brantigan, J. W.; McAfee, P. C.; Cunningham, B. W.; Wang, H.; and Orbegoso, C. M.: Interbody lumbar fusion using a carbon fiber cage implant versus allograft bone. An investigational study in the Spanish goat. Spine,19: 1436-1444, 1994.191436 1994 [PubMed]

Brantigan, J. W.; Steffee, A. D.; and Lewis, M.: Lumbar interbody fusion using the Brantigan I/F cage for PLIF and the VSP pedicle screw system: two-year clinical results of the Food and Drug Administration clinical trial. Read at the International Meeting on Advanced Spine Techniques, Munich, Germany, June 21, 1996.

Brightbill, T. C.; Pile, N.; Eichelberger, R. P.; and Whitman, M., Jr.: Normal magnetic resonance imaging and abnormal discography in lumbar disc disruption. Spine,19: 1075-1077, 1994.191075 1994 [PubMed]

Brinckmann, P., and Horst, M.: The influence of vertebral body fracture, intradiscal injection, and partial discectomy on the radial bulge and height of human lumbar discs. Spine,10: 138-145, 1985.10138 1985 [PubMed]

Brodke, D. S.; Dick, J. C.; Kunz, D. N.; McCabe, R.; and Zdeblick, T. A.: Posterior lumbar interbody fusion. A biomechanical comparison, including a new threaded cage. Spine,22: 26-31, 1997.2226 1997 [PubMed]

Brown, M. F.; Hukkanen, M. V. J.; McCarthy, I. D.; Redfern, D. R. M.; Batten, J. J.; Crock, H. V.; Hughes, S. P. F.; and Polak, J. M.: Sensory and sympathetic innervation of the vertebral endplate in patients with degenerative disc disease. J. Bone and Joint Surg.,79-B(1): 147-153, 1997.79-B(1)147 1997

Burns, B. H.: An operation for spondylolisthesis. Lancet,1: 1233, 1933.11233 1933

Buttner-Janz, K.; Schellnack, K.; and Zippel, H.: Biomechanics of the SB Charite lumbar intervertebral disc endoprosthesis. Internat. Orthop.,13: 173-176, 1989.13173 1989

Buttner-Janz, K.: The Development of Artificial Disc. S. B. Charite. Hundley Associates, 1992.

Butts, M. K.; Kuslich, S. D.; and Bechtold, J. E.: Biomechanical analysis of a new method for spinal interbody fusion. Read at the Winter Annual Meeting of the American Society of Mechanical Engineers, Boston, Dec. 15, 1987.

Cady, L. D.; Bischoff, D. P.; O'Connell, E. R.; Thomas, P. C.; and Allan, J. H.: Strength and fitness and subsequent back injuries in firefighters. J. Occup. Med.,21: 269-272, 1979.21269 1979 [PubMed]

Carette, S.; Marcoux, S.; Truchon, R.; Grondin, C.; Gagnon, J.; Allard, Y.; and Latulippe, M.: A controlled trial of corticosteroid injections into facet joints for chronic low back pain. New England J. Med.,325: 1002-1007, 1991.3251002 1991

Carrera, G. F.: Lumbar facet joint injection in low back pain and sciatica: preliminary results. Radiology,137: 665-667, 1980.137665 1980 [PubMed]

Chow, S. P.; Leong, J. C.; Ma, A.; and Yau, A. C.: Anterior spinal fusion for deranged lumbar intervertebral disc. Spine,5: 452-458, 1980.5452 1980 [PubMed]

Cinotti, G.; David, T.; and Postacchini, F.: Results of disc prosthesis after a minimum follow-up period of 2 years. Spine,21: 995-1000, 1996.21995 1996 [PubMed]

Cleveland, M.; Bosworth, D. M.; and Thompson, F. R.: Pseudoarthrosis in the lumbosacral spine. J. Bone and Joint Surg.,30-A: 302-311, April 1948.30-A302 1948

Cloward, R. B.: The treatment of ruptured lumbar intervertebral discs by vertebral body fusion: indications, operative technique, after care. J. Neurosurg.,10: 154-168, 1953.10154 1953 [PubMed]

Cloward, R. B.: Spondylolisthesis: treatment by laminectomy and posterior interbody fusion. Review of 100 cases. Clin. Orthop.,154: 74-82, 1981.15474 1981 [PubMed]

Cohen, J. E.; Goel, V.; Frank, J. W.; Bombardier, C.; Peloso, P.; and Guillemin, F.: Group education interventions for people with low back pain. An overview of the literature. Spine,19: 1214-1222, 1994.191214 1994 [PubMed]

Colhoun, E.; McCall, I. W.; Williams, L.; and Cassar Pullicino, V. N.: Provocation discography as a guide to planning operations on the spine. J. Bone and Joint Surg.,70-B(2): 267-271, 1988.70-B(2)267 1988

Collis, J. S.: Total disc replacement: a modified posterior lumbar interbody fusion. Report of 750 cases. Clin. Orthop.,193: 64-67, 1985.19364 1985 [PubMed]

Coppes, M. H.; Marani, E.; Thomeer, R. T.; and Groen, G. J.: Innervation of "painful" lumbar discs. Spine,22: 2342-2349, 1997.222342 1997 [PubMed]

Coxhead, C. E.; Inskip, H.; Meade, T. W.; North, W. R.; and Troup, J. D.: Multicentre trial of physiotherapy in the management of sciatic symptoms. Lancet,1: 1065-1068, 1981.11065 1981 [PubMed]

Crock, H. V.: Anterior lumbar interbody fusion. Indications for its use and notes on surgical technique. Clin. Orthop.,165: 157-163, 1982.165157 1982 [PubMed]

Crock, H. V.: Internal disc disruption. A challenge to disc prolapse fifty years on. Spine,11: 650-653, 1986.11650 1986 [PubMed]

David, T.: Lumbar disc prosthesis. European Spine J.,1: 254-259, 1983.1254 1983

DeBowes, R. M.; Grant, B. D.; Bagby, G. W.; Gallina, A. M.; Sande, R. D.; and Ratzlaff, M. H.: Cervical vertebral interbody fusion in the horse: a comparative study of bovine xenografts and autografts supported by stainless steel baskets. Am. J. Vet. Res.,45: 191-199, 1984.45191 1984 [PubMed]

Destouet, J. M.; Gilula, L. A.; Murphy, W. A.; and Monsees, B.: Lumbar facet joint injection: indication, technique, clinical correlation, and preliminary results. Radiology,145: 321-325, 1982.145321 1982 [PubMed]

Deyo, R. A.; Diehl, A. K.; and Rosenthal, M.: How many days of bed rest for acute low back pain? A randomized clinical trial. New England J. Med.,315: 1064-1070, 1986.3151064 1986

Deyo, R. A.; Walsh, N. E.; Martin, D. C.; Schoenfeld, L. S.; and Ramamurthy, S.: A controlled trial of transcutaneous electrical nerve stimulation (TENS) and exercise for chronic low back pain. New England J. Med.,322: 1627-1634, 1990.3221627 1990

Deyo, R. A.; Cherkin, D.; Conrad, D.; and Volinn, E.: Cost, controversy, crisis: low back pain and the health of the public. Ann. Rev. Pub. Health,12: 141-156, 1991.12141 1991

Deyo, R. A.; Cherkin, D. C.; Loeser, J. D.; Bigos, S. J.; and Ciol, M. A.: Morbidity and mortality in association with operations on the lumbar spine. J. Bone and Joint Surg.,74-A: 536-543, April 1992.74-A536 1992

Deyo, R. A.: Nonoperative treatment of low back disorders: differentiating useful from useless therapy. In The Adult Spine: Principles and Practice, edited by J. W. Frymoyer. Ed. 2, vol. 2, pp. 1777-1793. Philadelphia, Lippincott-Raven, 1997.

Donelson, R.; Aprill, C.; Medcalf, R.; and Grant, W.: A prospective study of centralization of lumbar and referred pain. A predictor of symptomatic discs and anular competence. Spine,22: 1115-1122, 1997.221115 1997 [PubMed]

Dreyfuss, P. H.; Dreyer, S. J.; and Herring, S. A.: Lumbar zygapophysial (facet) joint injections. Spine,20: 2040-2047, 1995.202040 1995 [PubMed]

Dupuis, P. R.; Young-Hing, K.; Cassidy, J. D.; and Kirkaldy-Willis, W. H.: Radiologic diagnosis of degenerative lumbar spinal instability. Spine,10: 262-276, 1985.10262 1985 [PubMed]

Enker, P.; Steffee, A.; Mcmillin, C.; Keppler, L.; Biscup, R.; and Miller, S.: Artificial disc replacement. Preliminary report with a 3-year minimum follow-up. Spine,18: 1061-1070, 1993.181061 1993 [PubMed]

Enker, P., and Steffee, A. D.: Interbody fusion and instrumentation. Clin. Orthop.,300: 90-101, 1994.30090 1994 [PubMed]

Esses, S. I., and Moro, J. K.: The value of facet joint blocks in patient selection for lumbar fusion. Spine,18: 185-190, 1993.18185 1993 [PubMed]

Faas, A.; Chavannes, A. W.; van Eijk, J. T.; and Gubbels, J. W.: A randomized, placebo-controlled trial of exercise therapy in patients with acute low back pain. Spine,18: 1388-1395, 1993.181388 1993 [PubMed]

Fairbank, J. C.; Park, W. M.; McCall, I. W.; and O'Brien, J. P.: Apophyseal injection of local anesthetic as a diagnostic aid in primary low-back pain syndromes. Spine,6: 598-605, 1981.6598 1981 [PubMed]

Falconer, M. A.; McGeorge, M.; and Begg, A. C.: Observations on the cause and mechanism of symptom-production in sciatica and low-back pain. J. Neurol., Neurosurg., and Psychiat.,11: 13-26, 1948.1113 1948

Fernstrom, U.: Arthroplasty with intercorporal endoprosthesis in herniated disc and in painful disc. Acta Chir. Scandinavica,357 (Supplement): 154-159, 1966.357 (Supplement)154 1966

Fidler, M. W., and Plasmans, C. M. T.: The effect of four types of support on the segmental mobility of the lumbosacral spine. J. Bone and Joint Surg.,65-A: 943-947, Sept. 1983.65-A943 1983

Flor, H.; Fydrich, T.; and Turk, D. C.: Efficacy of multidisciplinary pain treatment centers: a meta-analytic review. Pain,49: 221-230, 1992.49221 1992 [PubMed]

Flynn, J. C., and Hoque, M. A.: Anterior fusion of the lumbar spine. End-result study with long-term follow-up. J. Bone and Joint Surg.,61-A: 1143-1150, Dec. 1979.61-A1143 1979

Fordyce, W. E.; Brockway, J. A.; Bergman, J. A.; and Spengler, D.: Acute back pain: a control-group comparison of behavioral vs traditional management methods. J. Behav. Med.,9: 127-140, 1986.9127 1986 [PubMed]

Fraser, R. D.: Interbody, posterior, and combined lumbar fusions. Spine,20 (Supplement 24): 167-S177, 1995.20 (Supplement 24)167 1995

Freebody, D.; Bendall, R.; and Taylor, R. D.: Anterior transperitoneal lumbar fusion. J. Bone and Joint Surg.,53-B(4): 617-627, 1971.53-B(4)617 1971

Frymoyer, J. W.; Hanley, E. N., Jr.; Howe, J.; Kuhlmann, D.; and Matteri, R. E.: A comparison of radiographic findings in fusion and nonfusion patients ten or more years following lumbar disc surgery. Spine,4: 435-440, 1979.4435 1979 [PubMed]

Frymoyer, J. W.: Symposium: the role of spine fusion for low-back pain. Conducted at the International Society for the Study of the Lumbar Spine, New Orleans, Louisiana, May 27, 1980.

Frymoyer, J. W.; Pope, M. H.; Clements, J. H.; Wilder, D. G.; MacPherson, B.; and Ashikaga, T.: Risk factors in low-back pain. J. Bone and Joint Surg.,65-A: 213-218, Feb. 1983.65-A213 1983

Frymoyer, J. W., and Selby, D. K.: Segmental instability. Rationale for treatment. Spine,10: 280-286, 1985.10280 1985 [PubMed]

Frymoyer, J. W., and Nachemson, A.: Natural history of low back disorders. In The Adult Spine: Principles and Practice, edited by J. W. Frymoyer. Vol. 2, pp. 1537-1550. New York, Raven Press, 1991.

Frymoyer, J. W.: Magnitude of the problem. In The Lumbar Spine, edited by S. W. Wiesel, J. N. Weinstein, H. Herkowitz, J. Dvorák, and G. Bell. Ed. 2, vol. 1, pp. 8-16. Philadelphia, W. B. Saunders, 1996.

Frymoyer, J. W., and Durett, C. L.: The economics of spinal disorders. In The Adult Spine: Principles and Practice, edited by J. W. Frymoyer. Ed. 2, vol. 1, pp. 143-150. Philadelphia, Lippincott-Raven, 1997.

Fujimaki, A.; Crock, H. V.; and Bedbrook, G. M.: The results of 150 anterior lumbar interbody fusion operations performed by two surgeons in Australia. Clin. Orthop.,165: 164-167, 1982.165164 1982 [PubMed]

Gatchel, R. J., and Turk, D.: Psychological Approaches to Pain Management: A Practitioner's Handbook. New York, Guilford, 1996.

Gertzbein, S. D.; Court-Brown, C. M.; Jacobs, R. R.; Marks, P.; Martin, C.; Stoll, J.; Fazl, M.; Schwartz, M.; and Rowed, D.: Decompression and circumferential stabilization of unstable spinal fractures. Spine,13: 892-895, 1988.13892 1988 [PubMed]

Ghormley, R. K.: Low back pain. With special reference to the articular facets, with presentation of an operative procedure. J. Am. Med. Assn.,101: 1773-1777, 1933.1011773 1933

Gilbert, J. R.; Taylor, D. W.; Hildebrand, A.; and Evans, C.: Clinical trial of common treatments for low back pain in family practice. British Med. J.,291: 791-794, 1985.291791 1985

Giles, L. G., and Harvey, A. R.: Immunohistochemical demonstration of nociceptors in the capsule and synovial folds of human zygapophyseal joints. British J. Rheumatol.,26: 362-364, 1987.26362 1987

Gill, K., and Blumenthal, S. L.: Functional results after anterior lumbar fusion at L5-S1 in patients with normal and abnormal MRI scans. Spine,17: 940-942, 1992.17940 1992 [PubMed]

Goel, V. K.; Kim, Y. E.; Lim, T. H.; and Weinstein, J. N.: An analytical investigation of the mechanics of spinal instrumentation. Spine,13: 1003-1011, 1988.131003 1988 [PubMed]

Greenough, C. G., and Fraser, R. D.: Assessment of outcome in patients with low-back pain. Spine,17: 36-41, 1992.1736 1992 [PubMed]

Greenough, C. G.; Taylor, L. J.; and Fraser, R. D.: Anterior lumbar fusion: results, assessment techniques and prognostic factors. European Spine J.,3: 225-230, 1994.3225 1994

Greenough, C. G.; Peterson, M. D.; Hadlow, S.; and Fraser, R. D.: Instrumented posterolateral lumbar fusion. Results and comparison with anterior interbody fusion. Spine,23: 479-486, 1998.23479 1998 [PubMed]

Griffith, S. L.; Shelokov, A. P.; Buttner-Janz, K.; LeMaire, J. P.; and Zeegers, W. S.: A multicenter retrospective study of the clinical results of the LINK SB Charite intervertebral prosthesis. The initial European experience. Spine,19: 1842-1849, 1994.191842 1994 [PubMed]

Grubb, S. A.; Lipscomb, H. J.; and Guilford, W. B.: The relative value of lumbar roentgenograms, metrizamide myelography, and discography in the assessment of patients with chronic low-back syndrome. Spine,12: 282-286, 1987.12282 1987 [PubMed]

Grubb, S. A., and Lipscomb, H. J.: Results of lumbosacral fusion for degenerative disc disease with and without instrumentation. Two- to five-year follow-up. Spine,17: 349-355, 1992.17349 1992 [PubMed]

Gunzburg, R.; Parkinson, R.; Moore, R.; Cantraine, F.; Hutton, W.; Vernon-Roberts, B.; and Fraser, B.: A cadaveric study comparing discography, magnetic resonance imaging, histology, and mechanical behavior of the human lumbar disc. Spine,17: 417-426, 1992.17417 1992 [PubMed]

Guyer, R. D., and Ohnmeiss, D. D.: Lumbar discography. Position statement from the North American Spine Society Diagnostic and Therapeutic Committee. Spine,20: 2048-2059, 1995.202048 1995 [PubMed]

Hacker, R. J.: Comparison of interbody fusion approaches for disabling low back pain. Spine,22: 660-666, 1997.22660 1997 [PubMed]

Hall, B. B.; Asher, M. A.; Zang, R. H.; and Quinn, L. M.: The safety and efficacy of the Isola spinal implant system for the surgical treatment of degenerative disc disease. A prospective study. Spine,21: 982-994, 1996.21982 1996 [PubMed]

Hazard, R. G.; Fenwick, J. W.; Kalisch, S. M.; Redmond, J.; Reeves, V.; Reid, S.; and Frymoyer, J. W.: Functional restoration with behavioral support. A one-year prospective study of patients with chronic low-back pain. Spine,14: 157-161, 1989.14157 1989 [PubMed]

Hedman, T. P.; Kostuik, J. P.; Fernie, G. R.; and Hellier, W. G.: Design of an intervertebral disc prosthesis. Spine,16 (Supplement 6): 256-S260, 1991.16 (Supplement 6)256 1991

100

Heggeness, M. H., and Doherty, B. J.: Discography causes end plate deflection. Spine,18: 1050-1053, 1993.181050 1993 [PubMed]

101

Helbig, T., and Lee, C. K.: The lumbar facet syndrome. Spine,13: 61-64, 1988.1361 1988 [PubMed]

102

Herman, E.; Williams, R.; Stratford, P.; Fargas-Babjak, A.; and Trott, M.: A randomized controlled trial of transcutaneous electrical nerve stimulation (CODETRON) to determine its benefits in a rehabilitation program for acute occupational low back pain. Spine,19: 561-568, 1994.19561 1994 [PubMed]

103

Hibbs, R. A.: An operation for progressive spinal deformities. A preliminary report of three cases from the service of the orthopaedic hospital. New York Med. J.,93: 1013-1016, 1911.931013 1911

104

Hickey, R. F.: Chronic low back pain: a comparison of diflunisal with paracetamol. New Zealand Med. J.,95: 312-314, 1982.95312 1982 [PubMed]

105

Hindle, T. H., III: Comparison of carisoprodol, butabarbital, and placebo in treatment of the low back syndrome. California Med.,117: 7-11, 1972.1177 1972 [PubMed]

106

Hirsch, C.: An attempt to diagnose the level of a disc lesion clinically by disc puncture. Acta Orthop. Scandinavica,18: 132-140, 1948.18132 1948

107

Hodgson, A. R., and Stock, F. E.: Anterior spinal fusion. A preliminary communication on the radical treatment of Pott's disease and Pott's paraplegia. British J. Surg.,44: 266-275, 1956.44266 1956

108

Holt, E. P., Jr.: The question of lumbar discography. J. Bone and Joint Surg.,50-A: 720-726, June 1968.50-A720 1968

109

Honeyman, P. T., and Jacobs, E. A.: Effects of culture on back pain in Australian aboriginals. Spine,21: 841-843, 1996.21841 1996 [PubMed]

110

Hutter, G. C.: Posterior intervertebral body fusion. A 25-year study. Clin. Orthop.,179: 86-96, 1983.17986 1983 [PubMed]

111

Jackson, R. P.: The facet syndrome. Myth or reality?. Clin. Orthop.,279: 110-121, 1992.279110 1992 [PubMed]

112

Jaslow, I. A.: Intercorporal bone graft in spinal fusion after disc removal. Surg., Gynec. and Obstet.,82: 215-218, 1946.82215 1946

113

Jeanneret, B.; Jovanovic, M.; and Magerl, F.: Percutaneous diagnostic stabilization for low back pain. Correlation with results after fusion operations. Clin. Orthop.,304: 130-138, 1994.304130 1994 [PubMed]

114

Kaplan, D. M.; Knapp, M.; Romm, F. J.; and Velez, R.: Low back pain and x-ray films of the lumbar spine: a prospective study in primary care. Southern Med. J.,79: 811-814, 1986.79811 1986 [PubMed]

115

Katz, J. N.: Lumbar spinal fusion. Surgical rates, costs, and complications. Spine,20 (Supplement 24): 78-S83, 1995.20 (Supplement 24)78 1995

116

Kirkaldy-Willis, W. H., and Farfan, H. F.: Instability of the lumbar spine. Clin. Orthop.,165: 110-123, 1982.165110 1982 [PubMed]

117

Klingenstiena, U.: Back schools/educational programs—a review. Crit. Rev. Phys. and Rehab. Med.,3: 155-171, 1991.3155 1991

118

Knox, B. D., and Chapman, T. M.: Anterior lumbar interbody fusion for discogram concordant pain. J. Spinal Disord.,6: 242-244, 1993.6242 1993 [PubMed]

119

Knutsson, F.: The instability associated with disc degeneration in the lumbar spine. Acta Radiol.,25: 593-609, 1944.25593 1944

120

Kostuik, J. P.; Harrington, I.; Alexander, D.; Rand, W.; and Evans, D.: Cauda equina syndrome and lumbar disc herniation. J. Bone and Joint Surg.,68-A: 386-391, March 1986.68-A386 1986

121

Kostuik, J. P.; Maurais, G. R.; Richardson, W. J.; and Okajima, Y.: Combined single stage anterior and posterior osteotomy for correction of iatrogenic lumbar kyphosis. Spine,13: 257-266, 1988.13257 1988 [PubMed]

122

Kozak, J. A., and O'Brien, J. P.: Simultaneous combined anterior and posterior fusion. An independent analysis of a treatment for the disabled low-back pain patient. Spine,15: 322-328, 1990.15322 1990 [PubMed]

123

Kuslich, S. D.; Ulstrom, C. L.; and Michael, C. J.: The tissue origin of low back pain and sciatica: a report of pain response to tissue stimulation during operations on the lumbar spine using local anesthesia. Orthop. Clin. North America,22: 181-187, 1991.22181 1991

124

Kuslich, S. D.; Ulstrom, C. L.; Griffith, S. L.; Ahern, J. W.; and Dowdle, J. D.: The Bagby and Kuslich method of lumbar interbody fusion. History, techniques, and 2-year follow-up results of a United States prospective, multicenter trial. Spine,23: 1267-1279, 1998.231267 1998 [PubMed]

125

Lee, C. K.; Langrana, N. A.; Alexander, H.; Clemow, A. J.; Chen, E. H.; Parsons, J. R.; and Yang, S. W.: Fiber-reinforced functional disc prosthesis. Read at the Annual Meeting of the Orthopaedic Research Society, Las Vegas, Nevada, Feb. 8, 1989.

126

Lee, C. K.; Vessa, P.; and Lee, J. K.: Chronic disabling low back pain syndrome caused by internal disc derangements. The results of disc excision and posterior lumbar interbody fusion. Spine,20: 356-361, 1995.20356 1995 [PubMed]

127

Lethem, J.; Slade, P. D.; Troup, J. D.; and Bentley, G.: Outline of a fear-avoidance model of exaggerated pain perception—I. Behav. Res. and Ther.,21: 401-408, 1983.21401 1983

128

Lewinnek, G. E., and Warfield, C. A.: Facet joint degeneration as a cause of low back pain. Clin. Orthop.,213: 216-222, 1986.213216 1986 [PubMed]

129

Lidstrom, A., and Zachrisson, M.: Physical therapy on low back pain and sciatica. An attempt at evaluation. Scandinavian J. Rehab. Med.,2: 37-42, 1970.237 1970

130

Lilius, G.; Harilainen, A.; Laasonen, E. M.; and Myllynen, P.: Chronic unilateral low-back pain. Predictors of outcome of facet joint injections. Spine,15: 780-782, 1990.15780 1990 [PubMed]

131

Lin, P. M.; Cautilli, R. A.; and Joyce, M. F.: Posterior lumbar interbody fusion. Clin. Orthop.,180: 154-168, 1983.180154 1983 [PubMed]

132

Lindahl, O.: Determination of the sagittal mobility of the lumbar spine. A clinical method. Acta Orthop. Scandinavica,37: 241-254, 1966.37241 1966

133

Lindblom, K.: Diagnostic puncture of intervertebral disks in sciatica. Acta Orthop. Scandinavica,17: 231-239, 1948.17231 1948

134

Linson, M. A., and Williams, H.: Anterior and combined anteroposterior fusion for lumbar disc pain. A preliminary study. Spine,16: 143-145, 1991.16143 1991 [PubMed]

135

Lorenz, M.; Zindrick, M.; Schwaegler, P.; Vrbos, L.; Collatz, M. A.; Behal, R.; and Cram, R.: A comparison of single-level fusions with and without hardware. Spine,16 (Supplement 8): 455-S458, 1991.16 (Supplement 8)455 1991

136

Lovely, T. J., and Rastogi, P.: The value of provocative facet blocking as a predictor of success in lumbar spine fusion. J. Spinal Disord.,10: 512-517, 1997.10512 1997 [PubMed]

137

McBride, E. D.: A mortised transfacet bone block for lumbosacral fusion. J. Bone and Joint Surg.,31-A: 385-393, April 1949.31-A385 1949

138

McKenzie, R. A.: Prophylaxis in recurrent low back pain. New Zealand Med. J.,89: 22-23, 1979.8922 1979 [PubMed]

139

McLain, R. F.: Mechanoreceptor endings in human cervical facet joints. Spine,19: 495-501, 1994.19495 1994 [PubMed]

140

Macnab, I.: The traction spur. An indicator of segmental instability. J. Bone and Joint Surg.,53-A: 663-670, June 1971.53-A663 1971

141

Macnab, I., and Dall, D.: The blood supply of the lumbar spine and its application to the technique of intertransverse lumbar fusion. J. Bone and Joint Surg.,53-B(4): 628-638, 1971.53-B(4)628 1971

142

Mahvi, D. M., and Zdeblick, T. A.: A prospective study of laparoscopic spinal fusion. Technique and operative complications. Ann. Surg.,224: 85-90, 1996.22485 1996 [PubMed]

143

Main, C. J.: The modified somatic perception questionnaire (MSPQ). J. Psychosom. Res.,27: 503-514, 1983.27503 1983 [PubMed]

144

Main, C. J.; Wood, P. L. R.; Hollis, S.; Spanswick, C. C.; and Waddell, G.: The distress and risk assessment method: a simple patient classification to identify distress and evaluate the risk of poor outcome. Spine,17: 42-52, 1992.1742 1992 [PubMed]

145

Marchand, S.; Charest, J.; Li, J.; Chenard, J.-R.; Lavignolle, B.; and Laurencelle, L.: Is TENS purely a placebo effect? A controlled study on chronic low back pain. Pain,54: 99-106, 1993.5499 1993 [PubMed]

146

Mardjetko, S. M.; Connolly, P. J.; and Shott, S.: Degenerative lumbar spondylolisthesis. A meta-analysis of the literature. Spine,19 (Supplement 20): 2256-S2265, 1994.19 (Supplement 20)2256 1994

147

Marks, R. C.; Houston, T.; and Thulbourne, T.: Facet joint injection and facet nerve block: a randomized comparison in 86 patients with chronic low back pain. Pain,49: 325-328, 1992.49325 1992 [PubMed]

148

Martins, A. N.: Anterior cervical discectomy with and without interbody bone graft. J. Neurosurg.,44: 290-295, 1976.44290 1976 [PubMed]

149

Mathews, H. H.; Evans, M. T.; Molligan, H. J.; and Long, B. H.: Laparoscopic discectomy with anterior lumbar interbody fusion. A preliminary review. Spine,20: 1797-1802, 1995.201797 1995 [PubMed]

150

Mathews, J. A., and Hickling, J.: Lumbar traction: a double-blind controlled study for sciatica. Rheumatol. and Rehab.,14: 222-225, 1975.14222 1975

151

Mathews, J. A.; Mills, S. B.; Jenkins, V. M.; Grimes, S. M.; Morkel, M. J.; Mathews, W.; Scott, C. M.; and Sittampalam, Y.: Back pain and sciatica: controlled trials of manipulation, traction, sclerosant and epidural injections. British J. Rheumatol.,26: 416-423, 1987.26416 1987

152

Mayer, T. G.; Gatchel, R. J.; Maher, H.; Kishino, N. D.; Keeley, J.; and Mooney, V.: A prospective two-year study of functional restoration in industrial low back injury. An objective assessment procedure. J. Am. Med. Assn.,258: 1763-1767, 1987.2581763 1987

153

Mellin, G.; Harkapaa, K.; Hurri, H.; and Jarvikoski, A.: A controlled study on the outcome of inpatient and outpatient treatment of low back pain. Part IV. Long-term effects on physical measurements. Scandinavian J. Rehab. Med.,22: 189-194, 1990.22189 1990

154

Mendenhall Associates, Inc.: 1997 spinal surgery update. Orthop. Network News,8(4): 1-9, 1997.8(4)1 1997

155

Michelson, J. D.; Clarke, H. J.; and Jinnah, R. H.: The effect of loading on tibiotalar alignment in cadaver ankles. Foot and Ankle,10: 280-284, 1990.10280 1990 [PubMed]

156

Milette, P. C., and Melanson, D.: A reappraisal of lumbar discography. J. Canadian Assn. Radiol.,33: 176-182, 1982.33176 1982

157

Mitchell, R. I., and Carmen, G. M.: The functional restoration approach to the treatment of chronic pain in patients with soft tissue and back injuries. Spine,19: 633-642, 1994.19633 1994 [PubMed]

158

Mooney, V., and Robertson, J.: The facet syndrome. Clin. Orthop.,115: 149-156, 1976.115149 1976 [PubMed]

159

Mooney, V.: Symposium: the role of spine fusion for low-back pain. Conducted at the International Society for the Study of the Lumbar Spine, New Orleans, Louisiana, May 27, 1980.

160

Moran, R.; O'Connell, D.; and Walsh, M. G.: The diagnostic value of facet joint injections. Spine,13: 1407-1410, 1988.131407 1988 [PubMed]

161

Murphey, F.: Chapter 1. Experience with lumbar disc surgery. Clin. Neurosurg.,20: 1-8, 1973.201 1973 [PubMed]

162

Murtagh, F. R.: Computed tomography and fluoroscopy guided anesthesia and steroid injection in facet syndrome. Spine,13: 686-689, 1988.13686 1988 [PubMed]

163

Newman, M. H., and Grinstead, G. L.: Anterior lumbar interbody fusion for internal disc disruption. Spine,17: 831-833, 1992.17831 1992 [PubMed]

164

Nibu, K.; Panjabi, M. M.; Oxland, T.; and Cholewicki, J.: Multidirectional stabilizing potential of BAK interbody spinal fusion system for anterior surgery. J. Spinal Disord.,10: 357-362, 1997.10357 1997 [PubMed]

165

Norton, P. L., and Brown, T.: The immobilizing efficiency of back braces. Their effect on the posture and motion of the lumbosacral spine. J. Bone and Joint Surg.,39-A: 111-138, Jan. 1957.39-A111 1957

166

O'Brien, J. P.; Yau, A. C. M. C.; Gertzbein, S.; and Hodgson, A. R.: Combined staged anterior and posterior correction and fusion of the spine in scoliosis following poliomyelitis. Clin. Orthop.,110: 81-89, 1975.11081 1975 [PubMed]

167

Pal, B.; Mangion, P.; Hossain, M. A.; and Diffey, B. L.: A controlled trial of continuous lumbar traction in the treatment of back pain and sciatica. British J. Rheumatol.,25: 181-183, 1986.25181 1986

168

Panjabi, M. M.; Thibodeau, L. L.; Crisco, J. J., III; and White, A. A., III: What constitutes spinal instability?. Clin. Neurosurg.,34: 313-339, 1988.34313 1988 [PubMed]

169

Pappagallo, M., and Campbell, J. N.: The pharmacologic management of chronic back pain. In The Adult Spine: Principles and Practice, edited by J. W. Frymoyer. Ed. 2, vol. 1, pp. 275-285. Philadelphia, Lippincott-Raven, 1997.

170

Parker, L. M.; Murrell, S. E.; Boden, S. D.; and Horton, W. C.: The outcome of posterolateral fusion in highly selected patients with discogenic low back pain. Spine,21: 1909-1917, 1996.211909 1996 [PubMed]

171

Penning, L., and Blickman, J. R.: Instability in lumbar spondylolisthesis: a radiologic study of several concepts. AJR: Am. J. Roentgenol.,134: 293-301, 1980.134293 1980 [PubMed]

172

Penta, M., and Fraser, R. D.: Anterior lumbar interbody fusion. A minimum 10-year follow-up. Spine,22: 2429-2434, 1997.222429 1997 [PubMed]

173

Polatin, P. B., and Gatchel, R. J.: Point of view. Spine,22: 2252-2253, 1997.222252 1997

174

Pople, I. K., and Griffith, H. B.: Prediction of an extruded fragment in lumbar disc patients from clinical presentations. Spine,19: 156-158, 1994.19156 1994 [PubMed]

175

Posner, I.; White, A. A., III; Edwards, W. T.; and Hayes, W. C.: A biochemical analysis of the clinical stability of the lumbar and lumbosacral spine. Spine,7: 374-389, 1982.7374 1982 [PubMed]

176

Quebec Task Force on Spinal Disorders: Scientific approach to the assessment and management of activity-related spinal disorders. A monograph for clinicians. Report of the Quebec Task Force on Spinal Disorders. Spine, 12 (Supplement 7), 1987.

177

Ray, C. D.: Threaded titanium cages for lumbar interbody fusions. Spine,22: 667-680, 1997.22667 1997 [PubMed]

178

Ray, C. D.: Threaded fusion cages for lumbar interbody fusions. An economic comparison with 360 degrees fusions. Spine,22: 681-685, 1997.22681 1997 [PubMed]

179

Raymond, J., and Dumas, J. M.: Intraarticular facet block: diagnostic test or therapeutic procedure?. Radiology,151: 333-336, 1984.151333 1984 [PubMed]

180

Rose, M. J.; Reilly, J. P.; Pennie, B.; Bowen-Jones, K.; Stanley, I. M.; and Slade, P. D.: Chronic low back pain rehabilitation programs: a study of the optimum duration of treatment and a comparison of group and individual therapy. Spine,22: 2246-2253, 1997.222246 1997 [PubMed]

181

Rosen, M.; Breen, A.; and Hamann, W.: Report of a Clinical Standards Advisory Group Committee on Back Pain. London, Her Majesty's Stationery Office, 1994.

182

Rosenorn, J.; Hansen, E. B.; and Rosenorn, M. A.: Anterior cervical discectomy with and without fusion. A prospective study. J. Neurosurg.,59: 252-255, 1983.59252 1983 [PubMed]

183

Sandhu, H. S.; Turner, S.; Kabo, J. M.; Kanim, L. E.; Liu, D.; Nourparvar, A.; Delamarter, R. B.; and Dawson, E. G.: Distractive properties of a threaded interbody fusion device. An in vivo model. Spine,21: 1201-1210, 1996.211201 1996 [PubMed]

184

Sato, H., and Kikuchi, S.: The natural history of radiographic instability of the lumbar spine. Spine,18: 2075-2079, 1993.182075 1993 [PubMed]

185

Schneiderman, G.; Flannigan, B.; Kingston, S.; Thomas, J.; Dillin, W. H.; and Watkins, R. G.: Magnetic resonance imaging in the diagnosis of disc degeneration: correlation with discography. Spine,12: 276-281, 1987.12276 1987 [PubMed]

186

Simmons, E. H., and Segil, C. M.: An evaluation of discography in the localization of symptomatic levels in discogenic disease of the spine. Clin. Orthop.,108: 57-69, 1975.10857 1975 [PubMed]

187

Simmons, J. W.: Posterior lumbar interbody fusion with posterior elements as chip grafts. Clin. Orthop.,193: 85-89, 1985.19385 1985 [PubMed]

188

Simmons, J. W.; Aprill, C. N.; Dwyer, A. P.; and Brodsky, A. E.: A reassessment of Holt's data on: "the question of lumbar discography.". Clin. Orthop.,237: 120-124, 1988.237120 1988 [PubMed]

189

Smith, S. E.; Darden, B. V.; Rhyne, A. L.; and Wood, K. E.: Outcome of unoperated discogram-positive low back pain. Spine,20: 1997-2000, 1995.201997 1995 [PubMed]

190

Soini, J.; Antti-Poika, I.; Tallroth, K.; Konttinen, Y. T.; Honkanen, V.; and Santavirta, S.: Disc degeneration and angular movement of the lumbar spine: comparative study using plain and flexion-extension radiography and discography. J. Spinal Disord.,4: 183-187, 1991.4183 1991 [PubMed]

191

Spratt, K. F.; Weinstein, J. N.; Lehmann, T. R.; Woody, J.; and Sayre, H.: Efficacy of flexion and extension treatments incorporating braces for low-back pain patients with retrodisplacement, spondylolisthesis, or normal sagittal translation. Spine,18: 1839-1949, 1993.181839 1993 [PubMed]

192

Spurling, R. G., and Grantham, E. G.: Neurologic picture of herniations of the nucleus pulposus in the lower part of the lumbar region. Arch. Surg.,40: 375-388, 1940.40375 1940

193

Stauffer, R. N., and Coventry, M. B.: Anterior interbody lumbar spine fusion: analysis of Mayo Clinic series. J. Bone and Joint Surg.,54-A: 756-768, June 1972.54-A756 1972

194

Stokes, I. A., and Frymoyer, J. W.: Segmental motion and instability. Spine,12: 688-691, 1987.12688 1987 [PubMed]

195

Stonecipher, T., and Wright, S.: Posterior lumbar interbody fusion with facet-screw fixation. Spine,14: 468-471, 1989.14468 1989 [PubMed]

196

Taylor, V. M.; Deyo, R. A.; Cherkin, D. C.; and Kreuter, W.: Low back pain hospitalization. Recent United States trends and regional variations. Spine,19: 1207-1213, 1994.191207 1994 [PubMed]

197

Teasell, R. W., and Harth, M.: Functional restoration. Returning patients with chronic low back pain to work—revolution or fad?. Spine,21: 844-847, 1996.21844 1996 [PubMed]

198

Tencer, A. F.; Hampton, D.; and Eddy, S.: Biomechanical properties of threaded inserts for lumbar interbody spinal fusion. Spine,20: 2408-2414, 1995.202408 1995 [PubMed]

199

Ter Riet, G.; Kleijnen, J.; and Knipschild, P.: Acupuncture and chronic pain: a criteria-based meta-analysis. J. Clin. Epidemiol.,43: 1191-1199, 1990.431191 1990 [PubMed]

200

Urbaniak, J. R.; Bright, D. S.; and Hopkins, J. E.: Replacement of intervertebral discs in chimpanzees by silicone-dacron implants: a preliminary report. J. Biomed. Mater. Res.,7: 165-186, 1973.7165 1973 [PubMed]

201

van Tulder, M. W.; Koes, B. W.; and Bouter, L. M.: Conservative treatment of acute and chronic nonspecific low back pain. A systematic review of randomized controlled trials of the most common interventions. Spine,22: 2128-2156, 1997.222128 1997 [PubMed]

202

Volinn, E.; Turczyn, K. M.; and Loeser, J. D.: Patterns in low back pain hospitalizations: implications for the treatment of low back pain in an era of health care reform. Clin. J. Pain,10: 64-70, 1994.1064 1994 [PubMed]

203

von Luschka, H.: Die Nerven des menschlichen Wirbelkanales. Tübingen, Germany, Laupp and Siebeck, 1850.

204

Vuono-Hawkins, M.; Zimmerman, M. C.; Lee, C. K.; Carter, F. M.; Parsons, J. R.; and Langrana, N. A.: Mechanical evaluation of a canine intervertebral disc spacer: in situ and in vivo studies. J. Orthop. Res.,12: 119-127, 1994.12119 1994 [PubMed]

205

Wagner, P. C.; Grant, B. D.; Bagby, G. W.; Gallina, A. M.; Sande, R. D.; and Ratzlaff, M.: Evaluation of cervical spinal fusion as a treatment in the equine "wobbler" syndrome. J. Vet. Surg.,8: 84-88, 1979.884 1979

206

Walsh, T. R.; Weinstein, J. N.; Spratt, K. F.; Lehmann, T. R.; Aprill, C.; and Sayre, H.: Lumbar discography in normal subjects. A controlled, prospective study. J. Bone and Joint Surg.,72-A: 1081-1088, Aug. 1990.72-A1081 1990

207

Watkins, M. B.: Posterolateral bone-grafting for fusion of the lumbar and lumbosacral spine. J. Bone and Joint Surg.,41-A: 388-395, April 1959.41-A388 1959

208

Weatherley, C. R.; Prickett, C. F.; and O'Brien, J. P.: Discogenic pain persisting despite solid posterior fusion. J. Bone and Joint Surg.,68-B(1): 142-143, 1986.68-B(1)142 1986

209

Weber, H.: Traction therapy in sciatica due to disc prolapse (does traction treatment have any positive effect on patients suffering from sciatica caused by disc prolapse?). J. Oslo City Hosp.,23: 167-176, 1973.23167 1973 [PubMed]

210

Weber, H.; Ljunggren, A. E.; and Walker, L.: Traction therapy in patients with herniated lumbar intervertebral discs. J. Oslo City Hosp.,34: 61-70, 1984.3461 1984 [PubMed]

211

Weinstein, J.; Claverie, W.; and Gibson, S.: The pain of discography. Spine,13: 1344-1348, 1988.131344 1988 [PubMed]

212

Wetzel, F. T.; LaRocca, S. H.; Lowery, G. L.; and Aprill, C. N.: The treatment of lumbar spinal pain syndromes diagnosed by discography. Lumbar arthrodesis. Spine,19: 792-800, 1994.19792 1994 [PubMed]

213

White, A. A., III; Panjabi, M. M.; Posner, I.; Edwards, W. T.; and Hayes, W. C.: Spinal instability: evaluation and treatment. In Instructional Course Lectures, American Academy of Orthopaedic Surgeons. Vol. 30, pp. 457-483. St. Louis, C. V. Mosby, 1981.

214

Wiberg, G.: Back pain in relation to the nerve supply of the intervertebral disc. Acta Orthop. Scandinavica,19: 211-221, 1950.19211 1950

215

Wiesel, S. W.; Cuckler, J. M.; Deluca, F.; Jones, F.; Zeide, M. S.; and Rothman, R. H.: Acute low-back pain. An objective analysis of conservative therapy. Spine,5: 324-330, 1980.5324 1980 [PubMed]

216

Wiley, J. J.; Macnab, I.; and Wortzman, G.: Lumbar discography and its clinical applications. Canadian J. Surg.,11: 280-289, 1968.11280 1968

217

Williams, M. M.; Hawley, J. A.; McKenzie, R. A.; and van Wijmen, P. M.: A comparison of the effects of two sitting postures on back and referred pain. Spine,16: 1185-1191, 1991.161185 1991 [PubMed]

218

Williams, P.: The Lumbosacral Spine; Emphasizing Conservative Management. New York, McGraw-Hill, 1965.

219

Wood, G. W., II; Boyd, R. J.; Carothers, T. A.; Mansfield, F. L.; Rechtine, G. R.; Rozen, M. J.; and Sutterlin, C. E., III: The effect of pedicle screw/plate fixation on lumbar/lumbosacral autogenous bone graft fusions in patients with degenerative disc disease. Spine,20: 819-830, 1995.20819 1995 [PubMed]

220

Yahiro, M. A.: Comprehensive literature review. Pedicle screw fixation devices. Spine,19 (Supplement 20): 2274-S2278, 1994.19 (Supplement 20)2274 1994

221

Yashiro, K.; Homma, T.; Hokari, Y.; Katsumi, Y.; Okumura, H.; and Hirano, A.: The Steffee variable screw placement system using different methods of bone grafting. Spine,16: 1329-1334, 1991.161329 1991 [PubMed]

222

Yoshizawa, H.; O'Brien, J. P.; Smith, W. T.; and Trumper, M.: The neuropathology of intervertebral discs removed for low-back pain. J. Pathol.,132: 95-104, 1980.13295 1980 [PubMed]

223

Yuan, H. A.; Garfin, S. R.; Dickman, C. A.; and Mardjetko, S. M.: A historical cohort study of pedicle screw fixation in thoracic, lumbar, and sacral spinal fusions. Spine,19 (Supplement 20): 2279-S2296, 1994.19 (Supplement 20)2279 1994

224

Zdeblick, T. A.: A prospective, randomized study of lumbar fusion. Preliminary results. Spine,18: 983-991, 1993.18983 1993 [PubMed]

225

Zdeblick, T. A.: The treatment of degenerative lumbar disorders. A critical review of the literature. Spine,20 (Supplement 24): 126-S137, 1995.20 (Supplement 24)126 1995

226

Zippel, H.: Charite modular. In Conception, Experience and Results in the Artificial Disc, pp. 69-78. Edited by M. Brock, H. M. Mayer, and K. Weigel. New York, Springer, 1991.

227

Zucherman, J.; Derby, R.; Hsu, K.; Picetti, G.; Kaiser, J.; Schofferman, J.; Goldthwaite, N.; and White, A.: Normal magnetic resonance imaging with abnormal discography. Spine,13: 1355-1359, 1988.131355 1988 [PubMed]

228

Zung, W. W. K.: A self-rating depression scale. Arch. Gen. Psychiat.,12: 63-70, 1965.1263 1965 [PubMed]

Topics

intervertebral disc ; pain ; lower back ; arthrodesis ; lumbar arthrodesis

First Page Preview

View Large

Username

Password

Access for Patients

Forgot Password?

Have a subscription to the print edition?

Not a Subscriber?

Buy this Article

Get online access for 30 days for $35

New to JBJS?

Subscribe to the online edition for 30 days for $75

Register for a FREE limited account to get full access to all CME activities, to comment on public articles, or to sign up for alerts.

Have a subscription to the print edition?

Current subscribers to The Journal of Bone & Joint Surgery in either the print or quarterly DVD formats receive free online access to JBJS.org.

Activate your online account now

Forgot your password?

Enter your username and email address. We'll send you a reminder to the email address on record.

Username:*

Email Address:*

Forgot your username or need assistance? Please contact customer service at subs@jbjs.org. If your access is provided
by your institution, please contact you librarian or administrator for username and password information. Institutional
administrators, to reset your institution's master username or password, please contact subs@jbjs.org

References

Accreditation Statement

These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.

CME Activities Associated with This Article

Submit a Comment

Please read the other comments before you post yours. Contributors must reveal any conflict of interest.
Comments are moderated and will appear on the site at the discretion of JBJS editorial staff.

* = Required Field

Comment Author(s) * (if multiple authors, separate names by comma)

Example: John Doe

Affiliation & Institution*

Comment Title*

Comment*

Cancel

Print
PDF
Email

Recipient(s) will receive an email with a link (good for 5 days) to 'Current Concepts Review - Lumbar Arthrodesis for the Treatment of Back Pain*'.
Your Name:*
Example: John Doe

Email Address:* CC Me:
Enter your valid email address. Example: jdoe@example.com

Recipient's Email Address:*

Separate multiple email address with semi-colons (up to 5).

Subject:* 's The Journal of Bone & Joint Surgery: 'Current Concepts Review - Lumbar Arthrodesis for the Treatment of Back Pain*'
Subject for your email.

Message:

(Optional, message will truncate at 1000 characters)

Processing your request... Please Wait...

Copyright © in the material you requested is held by The Journal of Bone & Joint Surgery, Inc. (unless otherwise noted). This email ability is provided as a courtesy, and by using it you agree that that you are requesting the material solely for personal, non-commercial use, and that it is subject to Journal of Bone & Joint Surgery, Inc.'s Terms of Use. The information provided in order to email this topic will not be used to send unsolicited email, nor will it be furnished to third parties. Please refer to The Journal of Bone & Joint Surgery Inc.'s Privacy Policy for further information.

Copyright © The Journal of Bone & Joint Surgery Inc. All rights reserved.
Share
Get Citation

EDWARD N. HANLEY, STEPHEN M. DAVID; Current Concepts Review - Lumbar Arthrodesis for the Treatment of Back Pain*. The Journal of Bone & Joint Surgery. 1999 May;81(5):716-30.

Download citation file:

RIS (Zotero)

EndNote

BibTex

Medlars

ProCite

RefWorks

Reference Manager

Copyright © The Journal of Bone and Joint Surgery, Inc.
Rights & Permissions
Article Alerts

Processing your request... Please Wait.
Submit a Comment