ISASS issues new lumbar fusion policy on degenerative disc disease

Jul 27 2011
The International Society for the Advancement of Spine Surgery (ISASS) has released a new policy on lumbar fusion surgery, clarifying whether it is appropriate for conditions such as degenerative disc disease, stenosis and herniated discs.

Lumbar fusion surgery is performed to treat some spinal conditions, and involves using a bone graft or artificial substitute to merge two or more vertebrae together. This can decrease back pain, but may result in a loss of mobility and flexibility, particularly if more than two vertebrae are fused.

The National Institutes of Health (NIH) states that herniated discs most often occur in the lumbar spine. Herniated discs can lead to sciatica by pressing on the sciatic nerve, which may cause low back pain and other pain symptoms. In some cases, a pinched nerve can cause numbness and loss of motor control in the leg.

According to the ISASS policy, which can be read on the organization's website, lumbar fusion is medically indicated as a treatment for recurrent disc herniation on the same level of the spine if a previous operation for disc herniation abated pain for a minimum of three months, and the patient is either in significant pain that precludes waiting or has found conservative therapies ineffective for 3 months.

The procedure isn't usually considered appropriate by the ISASS for initial disc herniation, stenosis, or for chronic low back pain that doesn't have a clear cause. The organization regards it as medically indicated for conditions like spondylolysis and in trauma cases.

The procedure is also considered medically indicated by the ISASS if a patient has degenerative disc disease at one or two levels, after 6 months of conservative therapies such as pain management and daily exercise have proven ineffective.

The ISASS statement points out that even if a patient has degeneration in multiple discs, it's possible that only one is the cause of back pain, and that lumbar fusion at more than two levels is "poorly studied".

For cases of degenerative disc disease in the elderly, or on multiple levels, the ISASS states that lumbar fusion should be evaluated on a case-by-case basis. The statement notes that the elderly with this disease usually have other conditions affecting them, but states that single-level lumbar fusion is appropriate as long as the patient meets the other degenerative disc disease criteria.

According to Becker's Orthopedic, Spine and Pain Management Review, the policy differs from guidelines laid out by other organizations, which suggest that fusion may not be the optimal surgical option for patients with degenerative disc disease. Despite stating that lumbar fusion is statistically effective for many patients with degenerative disc disease, the ISASS statement also makes it clear that surgery should only be considered after conservative medical management has failed.

According to the NIH, back pain treatments other than surgery can include heat and cold, bed rest, exercise and medications. The agency reports back pain to be the second most common neurological ailment in the United States, after headaches.