The treatment of lumbar adjacent segment pathology after a previous lumbar surgery: a systematic review.

STUDY DESIGN: Systematic review.

OBJECTIVE: To perform a systematic review, evaluating the best available evidence regarding the treatment of lumbar adjacent segment pathology (ASP) to facilitate clinical recommendations for treatment.

SUMMARY OF BACKGROUND DATA: It is unclear how nonoperative treatment of lumbar clinical ASP (CASP) compares with operative treatment, and it is also unclear if 1 type of operative treatment is superior to another in the treatment of lumbar CASP. Given that ASP occurs with a known frequency after fusion, it is important to understand outcomes for treatment based on the best available evidence.

METHODS: We conducted a systematic search in PubMed and the Cochrane Library for literature published through February 2012 for lumbar ASP. Our first goal was to identify studies comparing operative with nonoperative management of lumbar ASP. Our second goal was to identify studies comparing operative with operative management of lumbar CASP. Our third goal was to identify case series evaluating outcomes after the treatment of lumbar CASP. The overall body of evidence with respect to each clinical question was determined on the basis of precepts outlined by the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) working group and recommendations made by the Agency for Healthcare Research and Quality.

RESULTS: No studies comparing operative with nonoperative management or comparing operative with operative management of CASP were identified in the literature. Eight case series were identified for the treatment of CASP with decompression alone, decompression and fusion, or decompression and disc arthroplasty.

CONCLUSION: The strength of evidence supporting these clinical questions was insufficient based on GRADE criteria; therefore, conclusions are based on the best available evidence and clinical experience. Operative management for lumbar CASP should be considered after failure of nonoperative management. When considering the type of operative treatment for lumbar CASP, clinical judgment, radiographical appearance, and patient preference should guide operative intervention. If a patient's disability secondary to lumbar CASP is high enough, consideration should be given to operative treatment. All these recommendations are weak based on GRADE.

CONSENSUS STATEMENT: 1. Operative management for lumbar ASP should be considered after failure of nonoperative management of ASP. Strength of Statement: Weak. 2. When considering the type of operative treatment for the treatment of lumbar ASP, clinical judgment, radiographical appearance, and patient preference should guide operative intervention. Strength of Statement: Weak. 3. Although the level of evidence for the outcomes of the treatment of lumbar ASP is weak, there does seem to be some benefit from the surgical treatment of lumbar ASP. Thus, if the patient's disability secondary to lumbar ASP is high enough, consideration should be given to operative treatment. Strength of Statement: Weak.