Original Article
Surgical versus Nonsurgical Treatment for Lumbar Degenerative Spondylolisthesis
N Engl J Med 2007; 356:2257-2270May 31, 2007DOI: 10.1056/NEJMoa070302
- Abstract
Background
Management of degenerative spondylolisthesis with spinal stenosis is controversial. Surgery is widely used, but its effectiveness in comparison with that of nonsurgical treatment has not been demonstrated in controlled trials.
Methods
Surgical candidates from 13 centers in 11 U.S. states who had at least 12 weeks of symptoms and image-confirmed degenerative spondylolisthesis were offered enrollment in a randomized cohort or an observational cohort. Treatment was standard decompressive laminectomy (with or without fusion) or usual nonsurgical care. The primary outcome measures were the Medical Outcomes Study 36-Item Short-Form General Health Survey (SF-36) bodily pain and physical function scores (100-point scales, with higher scores indicating less severe symptoms) and the modified Oswestry Disability Index (100-point scale, with lower scores indicating less severe symptoms) at 6 weeks, 3 months, 6 months, 1 year, and 2 years.
Results
We enrolled 304 patients in the randomized cohort and 303 in the observational cohort. The baseline characteristics of the two cohorts were similar. The one-year crossover rates were high in the randomized cohort (approximately 40% in each direction) but moderate in the observational cohort (17% crossover to surgery and 3% crossover to nonsurgical care). The intention-to-treat analysis for the randomized cohort showed no statistically significant effects for the primary outcomes. The as-treated analysis for both cohorts combined showed a significant advantage for surgery at 3 months that increased at 1 year and diminished only slightly at 2 years. The treatment effects at 2 years were 18.1 for bodily pain (95% confidence interval [CI], 14.5 to 21.7), 18.3 for physical function (95% CI, 14.6 to 21.9), and −16.7 for the Oswestry Disability Index (95% CI, −19.5 to −13.9). There was little evidence of harm from either treatment.
Conclusions
In nonrandomized as-treated comparisons with careful control for potentially confounding baseline factors, patients with degenerative spondylolisthesis and spinal stenosis treated surgically showed substantially greater improvement in pain and function during a period of 2 years than patients treated nonsurgically. (ClinicalTrials.gov number, NCT00000409.)
Media in This Article
Figure 1
Exclusion, Enrollment, Randomization, and Follow-up of Trial Participants.Figure 2
Intention-to-Treat and As-Treated Results over Time for the Primary Outcome Measures of SF-36 Bodily Pain (Panels A and B), SF-36 Physical Function (Panels C and D), and the Oswestry Disability Index (Panels E and F).Article Activity
- Article
Degenerative spondylolisthesis is the slipping forward of one lumbar vertebra on another with an intact neural arch. It rarely occurs before the age of 50 years, and it disproportionately affects women, particularly black women, with a male:female ratio of approximately 1:6.1 Slippage most commonly occurs at the L4–L5 level and rarely exceeds 30% of vertebral width.1 Degenerative spondylolisthesis is generally asymptomatic, but it can be associated with symptomatic spinal stenosis.1
Spinal stenosis, the most common reason for lumbar surgery in adults over the age of 65, is a narrowing of the spinal canal with encroachment on the neural structures by surrounding bone and soft tissue. Patients typically present with neurogenic claudication — pain in the buttocks or legs with walking or standing that resolves with sitting or lumbar flexion. However, anatomical spinal stenosis is frequently detected by imaging studies in asymptomatic patients; thus, clinical correlation between symptoms and imaging is critical.2
Two studies have compared surgery with nonsurgical treatment for spinal stenosis, but both of these studies included patients with and those without degenerative spondylolisthesis.3-5 Several studies have compared surgical techniques in cohorts with degenerative spondylolisthesis; however, these studies had small samples with limited geographic participation and lacked nonsurgical controls and validated outcome measures.6-8 The optimal treatment strategy for symptomatic degenerative spondylolisthesis remains unclear.
The Spine Patient Outcomes Research Trial (SPORT) was designed to compare the effectiveness of surgical and nonsurgical treatment among participants with confirmed diagnoses of intervertebral disk herniation,9,10 spinal stenosis, and degenerative spondylolisthesis.11 Here we report the 2-year outcomes of patients with degenerative spondylolisthesis.
Methods
Study Design
The SPORT was conducted in 11 states at 13 medical centers in the United States that have multidisciplinary spine practices. The SPORT included both a randomized cohort and a concurrent observational cohort with identical selection criteria and outcomes assessment.12 The standardized protocol was approved by human subjects committees at each participating institution, and an independent data and safety monitoring board monitored the results of the trial. The principal investigator had full access to all the data in the study and takes responsibility for the accuracy and integrity of the data analysis. Additional background information has been published previously.9-11,13
Patient Population
All patients had neurogenic claudication or radicular leg pain with associated neurologic signs, spinal stenosis shown on cross-sectional imaging, and degenerative spondylolisthesis shown on lateral radiographs obtained with the patient in a standing position. The patients had had persistent symptoms for at least 12 weeks and had been confirmed as surgical candidates by their physicians. Patients with adjacent levels of stenosis were eligible; patients with spondylolysis and isthmic spondylolisthesis were not. The nature of nonsurgical care before enrollment was not prespecified but included physical therapy in 68% of patients, epidural injections in 55%, chiropractic treatment in 25%, antiinflammatory agents in 63%, and opioid analgesic agents in 30%.
Research nurses at each site identified potential participants and verified their eligibility. The patients were offered enrollment in either cohort and gave written informed consent after viewing videotapes explaining the expected benefits, risks, and uncertainties of the treatments.14,15 Participants in the randomized cohort received computer-generated random treatment assignments blocked according to center; those in the observational cohort chose their treatment with their physician. Enrollment began in March 2000 and ended in February 2005.
Study Interventions
The protocol surgery consisted of a standard posterior decompressive laminectomy with or without bilateral single-level fusion (iliac crest bone grafting with or without posterior pedicle-screw instrumentation).11 The nonsurgical protocol was usual care, recommended to include at least active physical therapy, education or counseling including instructions for exercising at home, and nonsteroidal antiinflammatory agents if tolerated.11,13
Study Measures
The primary end points were the Medical Outcomes Study 36-Item Short-Form General Health Survey (SF-36) bodily pain and physical function scores16-19 and the Oswestry Disability Index (American Academy of Orthopaedic Surgeons/Modems version)20 measured at 6 weeks and at 3, 6, 12, and 24 months after enrollment. Secondary outcomes included patient-reported improvement, satisfaction with current symptoms and care,21 the Stenosis Bothersomeness Index,22,23 and the Low Back Pain Bothersomeness Scale.3 The SF-36 scores range from 0 to 100, with higher scores indicating less severe symptoms; the Oswestry Disability Index ranges from 0 to 100, with lower scores indicating less severe symptoms; the Stenosis Bothersomeness Index ranges from 0 to 24, with lower scores indicating less severe symptoms; and the Low Back Pain Bothersomeness Scale ranges from 0 to 6, with lower scores indicating less severe symptoms.
Statistical Analysis
A sample size of 150 patients in each treatment group for the randomized cohort was determined as sufficient on the basis of a two-sided t-test with a power of 0.85 to detect a 10-point difference in the SF-36 bodily pain and physical function scores or a similar effect size in the Oswestry Disability Index. The sample size allowed for up to 20% of the data to be missing but did not account for any specific levels of nonadherence.
Initial analyses compared baseline characteristics of the patients between the randomized cohort and the observational cohort and between the treatment groups of the combined randomized cohort and the observational cohort. The extent of missing data and the percentage of patients undergoing surgery were calculated for each scheduled follow-up. Baseline predictors of time until surgical treatment in both cohorts (including treatment crossovers) were determined by a stepwise proportional-hazards regression model with an inclusion criterion of P<0.1 to enter and P>0.05 to exit. Predictors of missing follow-up visits at 1 year were determined by stepwise logistic regression with entry and exit criteria of P<0.1 and P>0.05, respectively.
Primary analyses compared surgical and nonsurgical treatments using changes from baseline at each follow-up time for SF-36 bodily pain and physical function and for the Oswestry Disability Index. The randomized cohort was initially analyzed on an intention-to-treat basis. However, because of the extent of crossover, subsequent analyses combined the randomized cohort and the observational cohort and were based on treatments actually received. In these as-treated analyses, the treatment indicator was a time-varying covariate, allowing for variable times to surgery. Before the time of surgery, all changes from baseline were included in the estimates of the nonsurgical treatment effect. After surgery, subsequent changes in outcomes were assigned to the surgical group with follow-up measured from the date of surgery. The randomized cohort and the observational cohort were each analyzed to produce separate as-treated estimates of treatment effect. These results were compared with the use of a Wald test to simultaneously test all follow-up visit times for differences in estimated treatment effects between the randomized and observational groups.24 Subsequent analyses combined the two cohorts.
To adjust for potential confounding effects, baseline variables associated with missing data or treatment received were included as covariates in longitudinal regression models.24 A random effect was specified to account for the correlation between the repeated measurements of individual patients. Computations were performed with the use of SAS software (PROC MIXED for continuous data with normal random effects and PROC GENMOD for binary and non-normal secondary outcomes). Statistical significance was defined as P<0.05 on the basis of a two-sided hypothesis test (SAS software, version 9.1). Data for these analyses were collected through October 3, 2006.
Results
Overall, 607 of 892 eligible participants were enrolled in the SPORT (304 in the randomized cohort and 303 in the observational cohort). A total of 601 patients (99%) completed at least one follow-up visit and were included in the analysis; between 83% and 95% of enrollees supplied data at each follow-up visit (Figure 1Figure 1
Exclusion, Enrollment, Randomization, and Follow-up of Trial Participants.).In the randomized cohort, 159 patients were assigned to surgery and 145 to nonsurgical treatment. Of those assigned to surgery, 57% underwent surgery by 1 year and 64% by 2 years. In the group assigned to nonsurgical care, 44% underwent surgery by 1 year and 49% by 2 years. In the observational cohort, 173 patients initially chose surgery and 130 initially chose nonsurgical care. Of those initially choosing surgery, 97% underwent surgery by 1 year, and one additional patient underwent surgery between 1 and 2 years from the time of enrollment. Of those initially choosing nonsurgical treatment, 17% underwent surgery by 1 year and 25% by 2 years. In both cohorts combined, 372 patients underwent surgery within the first 2 years and 235 received only nonsurgical treatment.
Patient Characteristics
Table 1Table 1
Characteristics of the Patients According to Study Cohort at Baseline. shows the baseline characteristics and clinical findings of participants in the randomized and the observational cohorts. The cohorts were remarkably similar; however, patients in the observational cohort had more L4–L5 involvement, less involvement of L3–L4, and less lateral recess stenosis.Summary statistics for the combined cohorts are also shown in Table 1 according to treatment received; the mean age was 66 years. Eighty-five percent of patients had neurogenic claudication, and 77% had associated dermatomal pain radiation. Most of the degenerative slips and associated stenoses were at L4–L5. On imaging, stenosis was graded as severe in 60% of patients, and 35% had multiple levels of stenosis.
At baseline, patients in the group undergoing surgery from the combined randomized and observational cohorts were younger and more likely to be receiving compensation (e.g., workers' compensation or social security) than those receiving nonsurgical treatment. They had worse pain, function, disability, and symptoms than patients in the nonsurgical group. Patients in the surgery group were more dissatisfied with their symptoms and at enrollment more often rated their symptoms as worsening. This observation highlights the need to control for baseline differences in the adjusted models. The final model controlled for the following covariates, selected as described in the Methods section: age, sex, work status, depression, osteoporosis, joint problems, duration of current symptoms, reflex deficit, number of moderate or severe stenotic levels, baseline score (for the SF-36, the Oswestry Disability Index, and the Stenosis Bothersomeness Index), and the center where the patient was treated. SF-36 and the Oswestry Disability Index scores were also adjusted for the baseline Stenosis Bothersomeness Index score.
Lateral radiographs obtained with the patient in a neutral standing position were available for independent review for 169 patients. The percentage of slip as measured by the method of Morgan and King25 ranged from 1 to 37% (median, 15%; interquartile range, 10 to 21%). Eighty-six percent of patients had grade 1 slip and 14% had grade 2.
Nonsurgical Treatments
Nonsurgical treatments used during the SPORT included physical therapy (42%), epidural steroid injections (45%), nonsteroidal antiinflammatory drugs (51%), and opioids (34%). Nonsurgical treatments were similar in the randomized cohort and the observational cohort, though more patients in the randomized cohort reported visits to a surgeon (44% vs. 34%, P=0.04), receiving injections (49% vs. 37%, P=0.02), and narcotics use (40% vs. 26%, P=0.007).
Surgical Treatment and Complications
The median surgical time was 199 minutes, with a mean blood loss of 589 ml (Table 2Table 2
Surgical Treatments and Complications.). There were no significant differences between the cohorts in rates of intraoperative blood replacement, but there was a difference in the postoperative transfusion rates (16% in the randomized cohort vs. 26% in the observational cohort, P=0.04). The most common surgical complication was dural tear (10%). The 2-year reoperation rate was 12%.Main Treatment Effects
The intention-to-treat analysis of the randomized cohort showed no statistically significant effects for the primary outcomes, on the basis of a global hypothesis test for differences in mean changes from baseline between the treatment groups including all time periods. Treatment effects at 2 years were 1.5 for SF-36 bodily pain (95% confidence interval [CI], –4.2 to 7.3; P=0.52), 1.9 for physical function (95% CI, –3.7 to 7.5; P=0.71), and 2.2 for the Oswestry Disability Index (95% CI, –2.3 to 6.8; P=0.68).
As-treated effects for the combined cohorts were statistically significant in favor of surgery for all primary and secondary outcomes (Table 3Table 3
Change Scores and Treatment Effects for Primary and Secondary Outcomes in the Randomized and Observational Cohorts Combined, According to Treatment Received. and Figure 2Figure 2Intention-to-Treat and As-Treated Results over Time for the Primary Outcome Measures of SF-36 Bodily Pain (Panels A and B), SF-36 Physical Function (Panels C and D), and the Oswestry Disability Index (Panels E and F).). Treatment effects were stable for 2 years and were significant for all time periods, with treatment effects at 2 years of 18.1 for SF-36 bodily pain (95% CI, 14.5 to 21.7), 18.3 for physical function (95% CI, 14.6 to 21.9), and −16.7 for the Oswestry Disability Index (95% CI, −19.5 to −13.9). The results of the intention-to-treat and the as-treated analyses of the randomized and the observational cohorts are compared in Figure 2. The as-treated treatment effects at 2 years were nearly identical in the randomized and the observational cohorts. For SF-36 bodily pain, the effect was 17.8 (95% CI, 12.5 to 23.0) in the randomized cohort as compared with 18.5 (95% CI, 13.4 to 23.6) in the observational cohort; for SF-36 physical function, the effect was 16.7 (95% CI, 11.4 to 22.1) in the randomized cohort as compared with 19.9 (95% CI, 14.8 to 24.9) in the observational cohort; and for the Oswestry Disability Index, the effect was −15.9 (95% CI, −20.2 to −11.7) in the randomized cohort as compared with −17.7 (95% CI, −21.6 to −13.7) in the observational cohort. The global hypothesis test comparing the treatment effects in the randomized and the observational cohorts over all time periods revealed no significant difference between the cohorts: P=0.29 for SF-36 bodily pain, P=0.28 for SF-36 physical function, and P=0.97 for the Oswestry Disability Index.Subgroup Analyses
Models fitted for selected subgroups were examined for evidence of modification of treatment efficacy. Participants less than 65 years old at baseline had larger treatment effects in favor of surgery at 3 months (21.3 vs. 14.6 for bodily pain, P=0.02) but not at 1 or 2 years. The treatment effect for a degenerative spondylolisthesis level of L3–L4 was larger than that for a level of L4–L5 (33.1 vs. 16.8 for SF-36 bodily pain, P=0.01) at 2 years but not at 3 months or 1 year. Participants with no more than a high-school education had smaller treatment effects for surgery at 3 months (12.8 vs. 20.5 for SF-36 bodily pain, P=0.02) and 2 years (11.5 vs. 21.6 for SF-36 bodily pain, P=0.01). Other subgroups (defined according to sex, smoking history, severity of symptoms at baseline, duration of symptoms, treatment preference, number of stenotic levels, severity of stenosis on imaging, number of coexisting conditions, and baseline SF-36 mental component summary score) did not show significant effect modification. These results should be considered cautiously, because the study was not designed or powered to examine subgroup differences.
Discussion
In patients with image-confirmed degenerative spondylolisthesis and symptoms persisting for at least 12 weeks, the intention-to-treat analysis found no significant advantage for surgery over nonsurgical care, but the analysis was severely limited by treatment crossover. As-treated analyses showed that surgery was superior to nonsurgical treatment in relieving symptoms and improving function. This treatment effect was seen as early as at the 6-week follow-up and persisted over 2 years. The nonsurgical-treatment group showed only moderate improvement over time. The smaller treatment effect for surgery seen in less-educated subjects is intriguing but unexplained and may be a chance finding in a post hoc subgroup.
The randomized and observational cohorts were remarkably similar at baseline. The only significant differences were small ones in level and location of stenosis on baseline imaging. The cohorts also had similar outcomes, with no significant differences between the treatment effects in the as-treated analyses. These similarities support the validity of the combined analysis presented here.
There was little evidence of harm from either treatment. Often patients fear they will get worse without surgery, but the patients receiving nonsurgical treatment, on average, showed moderate improvement in all outcomes. No patients undergoing surgical or nonsurgical treatment had cauda equina syndrome; 89% of surgical patients had no operative complications.
The characteristics of the participants in the SPORT were similar to those in previous studies of degenerative spondylolisthesis and mixed cohorts of patients with stenosis. The mean age of 66 years was similar to that in the cohorts reported by Herkowitz and Kurz8 (63.5 years), Fischgrund et al.7 (67 years), the Maine Lumbar Spine Study (MLSS)3 (66 years), Yukawa et al.26 (63 years), and Malmivaara et al.5 (63 years). At enrollment, 60% of the SPORT participants reported having had symptoms for more than 6 months, as did 60% of the participants in the MLSS. Baseline functional status in the SPORT was similar to that in the MLSS (mean SF-36 physical function scores, 34 and 35, respectively) and in the randomized trial by Malmivaara et al. (mean Oswestry Disability Index scores, 41.5 and 35.0, respectively).
The surgical outcomes in the SPORT were generally similar to those in previous surgical series. Herkowitz and Kurz8 reported absolute improvements of 33% for back pain and 55% for leg pain (6-point scales) at 3 years, similar to the changes of 31% and 41%, respectively (7-point scales), seen in the SPORT at 2 years. Also, the improvement at 1 year in the patients in the SPORT who were undergoing surgery for degenerative spondylolisthesis was similar to the outcomes of surgery in the MLSS mixed-stenosis (those with and those without degenerative spondylolisthesis) cohort. The improvement in the SF-36 bodily pain score was 32 in the SPORT and 43 in the MLSS, and the improvement in the SF-36 physical function score was 29 in the SPORT and 27 in the MLSS.3
The nonsurgical outcomes in the SPORT were similar to those in the study by Malmivaara et al.5 and in the MLSS.3 Malmivaara et al. reported absolute improvements in back pain at 2 years of 18% on an 11-point scale, as compared with 17% on a 7-point scale in the SPORT, and an improvement in leg pain of 16%, as compared with 17% in the SPORT. Similarly, at 1 year the MLSS reported an improvement of 12.0 points in SF-36 bodily pain, as compared with 12.7 in the SPORT. The nonsurgical functional outcomes, however, were better in the SPORT than in these previous studies. SF-36 physical function improved by 9.6 points in the SPORT nonsurgical group, as compared with 1.0 point in the MLSS, and the Oswestry Disability Index improved by −7.5 points in the SPORT, as compared with −4.5 points in the study by Malmivaara et al. The somewhat greater improvement in the SPORT may be related to the nonsurgical treatments received. The SPORT participants had higher rates of epidural steroid injections than did the MLSS participants (44% vs. 18%), similar rates of physical therapy, and much lower use of activity restriction (16% vs. 29%) and transcutaneous electrical nerve stimulation (2% vs. 14%). Differences in nonsurgical outcomes might also be due to differences in the underlying disease process in patients with degenerative spondylolisthesis as compared with a mixed stenosis population in the study by Malmivaara et al. and in the MLSS.
We can directly compare estimates of treatment effect in the SPORT with those in the MLSS and the study by Malmivaara et al. The estimated 1-year treatment effects for surgery in the SPORT were smaller than those in the MLSS (18.8 vs. 30.4 points for SF-36 bodily pain, and 19.4 vs. 25.5 points for SF-36 physical function). However, the MLSS did not adjust treatment effects for baseline differences between the treatment groups, which probably explains these discrepancies. The estimated 1-year treatment effects were similar in the SPORT and in the study by Malmivaara et al. (Oswestry Disability Index, −17.9 vs. −11.3, respectively; leg pain, 23% [7-point scale] vs. 15% [11-point scale], respectively; and back pain, 20% [7-point scale] vs. 21% [11-point scale], respectively.
The 1-year rate of reoperation for recurrent stenosis or spondylolisthesis was 0.6%, less than the rates reported by Malmivaara et al. (2%) and the MLSS (1.2%). The reoperation rate increased to 3% at 2 years. The perioperative mortality rate was 0.6%, which is less than the 1.3% seen in Medicare patients after fusion surgery for spondylolisthesis.27 The 2-year mortality rate was similar in both treatment groups and less than actuarial projections.
A limitation of this study is the marked degree of nonadherence to randomized treatment. The protocol stipulated that patients assigned to surgery have their surgery within 3 to 6 months after enrollment, a period thought to be appropriate in the clinical experience of the investigators. Although patients consented to this protocol, as in all clinical trials this consent could be changed at the request of the patient, and many chose to do so. This reduced the power of the intention-to-treat analysis to demonstrate a treatment effect. Although the as-treated analysis lost the strong protection from confounding conferred by randomization, these analyses were carefully controlled for important covariates and yielded results similar to previous studies.
Another limitation is the heterogeneity of the treatment interventions. The choice of nonsurgical therapies was at the discretion of the treating physician and the patient. However, with limited evidence regarding efficacy for most nonsurgical treatments for degenerative spondylolisthesis, creating a fixed protocol for nonsurgical treatment was neither clinically feasible nor generalizable. The nonsurgical treatments used were consistent with published guidelines.28,29 Similarly, the surgeries performed varied in terms of the presence, method, and extent of spinal fusion accompanying the decompression. We cannot make direct conclusions regarding the comparison between the effect of surgery and any specific nonsurgical treatment, nor do we directly compare the efficacy of nonsurgical treatment with one specific surgical technique.
The magnitudes of the mean changes reported here after surgery for degenerative spondylolisthesis are less than those reported for patients in a SPORT observational cohort undergoing surgery for intervertebral disk herniation. The mean change scores after 2 years were as follows: SF-36 bodily pain, 29.9 for degenerative spondylolisthesis versus 42.6 for intervertebral disk herniation; SF-36 physical function, 26.7 for degenerative spondylolisthesis versus 43.9 for intervertebral disk herniation; Oswestry Disability Index, −24.2 for degenerative spondylolisthesis versus 37.6 for intervertebral disk herniation.9,10 However, the treatment effects for surgery in the degenerative-spondylolisthesis group were larger than those in the study of intervertebral disk herniation (18.4 for bodily pain in the degenerative-spondylolisthesis group vs. 10.2 in the intervertebral-disk-herniation study) because of dramatic improvements in the nonsurgical group with intervertebral disk herniation not seen in the degenerative-spondylolisthesis group.
In these nonrandomized comparisons with careful control of potentially confounding baseline factors, patients with persistent neurogenic claudication from degenerative spondylolisthesis treated surgically showed substantially greater improvement in pain and function, as well as satisfaction, for 2 years. Characteristics of the patients and treatment outcomes were similar in the randomized and observational cohorts.
Supported by a grant (U01-AR45444-01A1) from the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) and the Office of Research on Women's Health; by the National Institutes of Health; by the National Institute of Occupational Safety and Health and the Centers for Disease Control and Prevention; and by a grant (P60-AR048094-01A1 to the Multidisciplinary Clinical Research Center in Musculoskeletal Diseases) and a Research Career Award (1 K23 AR 048138-01 to Dr. Lurie) from NIAMS. These sources had no role in the design or conduct of the study; in the collection, management, analysis, or interpretation of the data; or in the preparation, review, or approval of the manuscript.
Dr. Weinstein reports receiving consulting fees from United Healthcare and an honorarium as editor-in-chief of Spine. Dr. Lurie reports receiving consulting fees from the Pacific Business Group on Health. Dr. Birkmeyer reports receiving grant support from Blue Cross/Blue Shield of Michigan. Dr. Herkowitz reports receiving consulting fees and royalties from Medtronic Sofamor Danek. Dr. Cammisa reports owning equity in HealthPoint Capital Partners, K2M, Mazor Surgical Technologies, and Spinal Kinetics. Dr. Albert reports receiving consulting fees, lecture fees, and royalties from DePuy Spine and owning equity in K2M. Dr. Emery reports receiving departmental block grant support from Zimmer, Medtronic Sofamor Danek, and Synthes. Dr. Lenke reports receiving consulting fees and grant support from Medtronic Sofamor Danek and Biotek. Dr. Longley reports owning equity in Custom Spine. Dr. Errico reports receiving consulting fees from Stryker and Fastenetix; fellowship support from AOSpine, DePuy Spine, and Medtronic Sofamor Danek; and clinical research grant support from Stryker and Synthes. No other potential conflict of interest relevant to this article was reported.
We thank Tamara S. Morgan, Department of Orthopaedic Surgery, Dartmouth Medical School, for graphic design and production and for overall assistance to the SPORT.
Source Information
From the Departments of Orthopaedics (J.N.W., B.H., E.A.B., W.A.A.), Medicine (J.D.L., A.N.A.T.), and Community and Family Medicine (J.N.W., T.D.T., A.N.A.T.), Dartmouth Medical School, Lebanon, NH; the University of Michigan, Ann Arbor (N.J.O.B.); the Rothman Institute at Thomas Jefferson University, Philadelphia (A.S.H., T.J.A.); William H. Beaumont Hospital, Royal Oak, MI (H.H.); the Hospital for Special Surgery, New York (F.P.C.); the University Hospitals of Cleveland and Case Western Reserve University, Cleveland (S.E.E.); Washington University, St. Louis (L.G.L.); the Nebraska Foundation for Spinal Research, Omaha (M.L.); the Hospital for Joint Diseases, New York (T.J.E.); and the University of California at San Francisco, San Francisco (S.S.H.).
Address reprint requests to Dr. Weinstein at SPORT@dartmouth.edu.
Other investigators participating in the Spine Patient Outcomes Research Trial (SPORT) are listed in the Appendix.
Appendix
In addition to the authors, the following investigators participated in the Spine Patient Outcomes Research Trial (institutions are in order from highest to lowest enrollment): Dartmouth Medical School, Hanover, NH — J. Forman, B. Butler-Schmidt, J.J. Hebb, P. Bernini. R. Hazard, P. Ball, C. Murray, M. Splaine, D. Sengupta, H. Schmidek, R. Rose, C. Olson, P. McDonough, H. Magnasdottir; William Beaumont Hospital, Royal Oak, MI — G. Bradley, M. Lurie, L. Kurz, J. Fischgrund, D. Montgomery, E. Truumees; Rothman Institute at Thomas Jefferson Hospital, Philadelphia — C. Simon, T. Conliffe; Hospital for Special Surgery, New York — B. Green, J. Farmer, H. Sandhu; Nebraska Foundation for Spinal Research, Omaha — N. Fullmer, A.M. Fredericks, R. Woodward, J. Fuller, E. Phillips, J. McClellan, P. Bowman, T. Burd; Emory University–Emory Clinic, Atlanta — S. Boden, S. Lashley, H. Levy, D. Hubbell, M. Schaufele, J. Rhee, S.T. Yoon, S. Dreyer, J. Heller; Washington University, St. Louis — G. Stobbs, K. Bridwell, A. Margherita, K.D. Riew, B. Taylor, J. Metzler; University Hospitals of Cleveland and Case Western Reserve University, Cleveland — C. Furey, K. Higgins, J.X. Yoo, E.B. Marsolais, H. Bohlman; Hospital for Joint Diseases, New York — A. Lee, J. Bendo, J. Goldstein, J. Spivak, R. Perry, R. Schoenfeldt, R. Moskovich, J. Dryer; Kaiser Permanente, Oakland, CA — H. Goldberg, P. Malone, F. Massimino; University of California, San Francisco, San Francisco — P. Malone, S. Berven, T. Smith; Rush–Presbyterian–St. Luke's Medical Center, Chicago — G. Andersson, H. An, M. Hickey, E. Goldberg, F. Philips; Maine Spine and Rehabilitation, Scarborough — R. Keller, L. Thibodeau, J. Florman.
- References
References
1
Jacobsen S ,Sonne-Holm S ,Rovsing H ,Monrad H ,Gebuhr P . Degenerative lumbar spondylolisthesis: an epidemiological perspective: the Copenhagen Osteoarthritis Study. Spine 2007;32:120-125
CrossRef | Web of Science | Medline2
Boden SD ,Davis DO ,Dina TS ,Patronas NJ ,Wiesel S . Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects: a prospective investigation. J Bone Joint Surg Am 1990;72:403-408
Web of Science | Medline3
Atlas SJ ,Deyo RA ,Keller RB , et al. The Maine Lumbar Spine Study, Part III: 1-year outcomes of surgical and nonsurgical management of lumbar spinal stenosis. Spine 1996;21:1787-1794
CrossRef | Web of Science | Medline4
Atlas SJ ,Keller RB ,Robson D ,Deyo RA ,Singer DE . Surgical and nonsurgical management of lumbar spinal stenosis: four-year outcomes from the Maine Lumbar Spine Study. Spine 2000;25:556-562
CrossRef | Web of Science | Medline5
Malmivaara A ,Slatis P ,Heliovaara M , et al. Surgical or nonoperative treatment for lumbar spinal stenosis? A randomized controlled trial. Spine 2007;32:1-8
CrossRef | Web of Science | Medline6
Bridwell KH ,Sedgewick TA ,O'Brien MF ,Lenke LG ,Baldus C . The role of fusion and instrumentation in the treatment of degenerative spondylolisthesis with spinal stenosis. J Spinal Disord 1993;6:461-472
CrossRef | Medline7
Fischgrund JS ,Mackay M ,Herkowitz HN ,Brower R ,Montgomery DM ,Kurz LT . Degenerative lumbar spondylolisthesis with spinal stenosis: a prospective, randomized study comparing decompressive laminectomy and arthrodesis with and without spinal instrumentation. Spine 1997;22:2807-2812
CrossRef | Web of Science | Medline8
Herkowitz HN ,Kurz LT . Degenerative lumbar spondylolisthesis with spinal stenosis: a prospective study comparing decompression with decompression and intertransverse process arthrodesis. J Bone Joint Surg Am 1991;73:802-808
Web of Science | Medline9
Weinstein JN ,Lurie JD ,Tosteson TD , et al. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT) observational cohort. JAMA 2006;296:2451-2459
CrossRef | Web of Science | Medline10
Weinstein JN ,Tosteson TD ,Lurie JD , et al. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT): a randomized trial. JAMA 2006;296:2441-2450
CrossRef | Web of Science | Medline11
Birkmeyer NJ ,Weinstein JN ,Tosteson AN , et al. Design of the Spine Patient Outcomes Research Trial (SPORT). Spine 2002;27:1361-1372
CrossRef | Web of Science | Medline12
Tunis SR ,Stryer DB ,Clancy CM . Practical clinical trials: increasing the value of clinical research for decision making in clinical and health policy. JAMA 2003;290:1624-1632
CrossRef | Web of Science | Medline13
Cummins J ,Lurie JD ,Tosteson TD , et al. Descriptive epidemiology and prior healthcare utilization of patients in the Spine Patient Outcomes Research Trial's (SPORT) three observational cohorts: disc herniation, spinal stenosis, and degenerative spondylolisthesis. Spine 2006;31:806-814
CrossRef | Web of Science | Medline14
Phelan EA ,Deyo RA ,Cherkin DC , et al. Helping patients decide about back surgery: a randomized trial of an interactive video program. Spine 2001;26:206-211
CrossRef | Web of Science | Medline15
Weinstein JN . Partnership: doctor and patient: advocacy for informed choice vs. informed consent. Spine 2005;30:269-272
CrossRef | Web of Science | Medline16
McHorney CA ,Ware JE Jr ,Lu JF ,Sherbourne CD . The MOS 36-item Short-Form Health Survey (SF-36): III. Tests of data quality, scaling assumptions, and reliability across diverse patient groups. Med Care 1994;32:40-66
CrossRef | Web of Science | Medline17
Stewart AL ,Greenfield S ,Hays RD , et al. Functional status and well-being of patients with chronic conditions: results from the Medical Outcomes Study. JAMA 1989;262:907-913[Erratum, JAMA 1989;262:2542.]
CrossRef | Web of Science | Medline18
Ware JE Jr ,Sherbourne CD . The MOS 36-item Short-Form Health Survey. I. Conceptual framework and item selection. Med Care 1992;30:473-483
CrossRef | Web of Science | Medline19
Ware JE Jr, Snow KK, Kosinski M, Gandek B. SF-36 Health Survey: manual and interpretation guide. Boston: Nimrod Press, 1993.
20
Daltroy LH ,Cats-Baril WL ,Katz JN ,Fossel AH ,Liang MH . The North American Spine Society lumbar spine outcome assessment instrument: reliability and validity tests. Spine 1996;21:741-749
CrossRef | Web of Science | Medline21
Deyo RA ,Diehl AK . Patient satisfaction with medical care for low-back pain. Spine 1986;11:28-30
CrossRef | Web of Science | Medline22
Atlas SJ ,Deyo RA ,Patrick DL ,Convery K ,Keller RB ,Singer DE . The Quebec Task Force classification for spinal disorders and the severity, treatment, and outcomes of sciatica and lumbar spinal stenosis. Spine 1996;21:2885-2892
CrossRef | Web of Science | Medline23
Patrick DL ,Deyo RA ,Atlas SJ ,Singer DE ,Chapin A ,Keller RB . Assessing health-related quality of life in patients with sciatica. Spine 1995;20:1899-1908
CrossRef | Web of Science | Medline24
Fitzmaurice G, Laird NM, Ware JH. Applied longitudinal analysis. New York: Wiley, 2004.
25
Morgan FP ,King T . Primary instability of lumbar vertebrae as a common cause of low back pain. J Bone Joint Surg Br 1957;39:6-22
Web of Science | Medline26
Yukawa Y ,Lenke LG ,Tenhula J ,Bridwell KH ,Riew KD ,Blanke K . A comprehensive study of patients with surgically treated lumbar spinal stenosis with neurogenic claudication. J Bone Joint Surg Am 2002;84:1954-1959
Web of Science | Medline27
Deyo RA ,Ciol MA ,Cherkin DC ,Loeser JD ,Bigos SJ . Lumbar spinal fusion: a cohort study of complications, reoperations, and resource use in the Medicare population. Spine 1993;18:1463-1470
Web of Science | Medline28
Acute low back problems in adults: assessment and treatment. Bethesda, MD: Department of Health and Human Services, 1994. (AHCPR publication no. 95-0643.)
29
Degenerative spondylolisthesis. In: North American Spine Society phase III clinical guidelines for multidisciplinary spine care specialists. LaGrange, IL: North American Spine Society; 2000.
- Citing Articles (148)
Citing Articles
1
Jon D. Lurie, Rachel A. Moses, Anna N. A. Tosteson, Tor D. Tosteson, Eugene J. Carragee, John A. Carrino, Jay A. Kaiser, Richard J. Herzog. (2013) Magnetic Resonance Imaging Predictors of Surgical Outcome in Patients With Lumbar Intervertebral Disc Herniation. Spine 38:14, 1216-1225
2
Reginald Davis, Joshua D. Auerbach, Hyun Bae, Thomas J. Errico. (2013) Can low-grade spondylolisthesis be effectively treated by either coflex interlaminar stabilization or laminectomy and posterior spinal fusion? Two-year clinical and radiographic results from the randomized, prospective, multicenter US investigational device exemption trial. Journal of Neurosurgery: Spine1-11
3
Li-Yu Fay, Jau-Ching Wu, Tzu-Yun Tsai, Ching-Lan Wu, Wen-Cheng Huang, Henrich Cheng. (2013) Dynamic stabilization for degenerative spondylolisthesis: Evaluation of radiographic and clinical outcomes. Clinical Neurology and Neurosurgery 115:5, 535-541
4
Yossi Smorgick, Daniel K. Park, Kevin C. Baker, Jon D. Lurie, Tor D. Tosteson, Wenyan Zhao, Harry N. Herkowitz, Jeffrey S. Fischgrund, James N. Weinstein. (2013) Single- Versus Multilevel Fusion for Single-Level Degenerative Spondylolisthesis and Multilevel Lumbar Stenosis. Spine 38:10, 797-805
5
Ralph J Mobbs, Praveenan Sivabalan, Jane Li, Peter Wilson, Prashanth J Rao. (2013) Hybrid Technique for Posterior Lumbar Interbody Fusion: A Combination of Open Decompression and Percutaneous Pedicle Screw Fixation. Orthopaedic Surgery 5:2, 135-141
6
Stephen May, Christine Comer. (2013) Is surgery more effective than non-surgical treatment for spinal stenosis, and which non-surgical treatment is more effective? A systematic review. Physiotherapy 99:1, 12-20
7
Qi Yao, Shaobai Wang, Jae-Hyuk Shin, Guoan Li, Kirkham Burwick Wood. (2013) Lumbar Facet Joint Motion in Patients With Degenerative Spondylolisthesis. Journal of Spinal Disorders and Techniques 26:1, E19-E27
8
Jack E. Zigler, Rick B. Delamarter. (2013) Does 360° lumbar spinal fusion improve long-term clinical outcomes after failure of conservative treatment in patients with functionally disabling single-level degenerative lumbar disc disease? Results of 5-year follow-up in 75 postoperative patients. The International Journal of Spine Surgery
9
Jeremy Hobart, Catherine Gilkes, William Adams, Tim Germon. (2013) Interspinous spacers for lumbar foraminal stenosis: formal trials are justified. European Spine Journal
10
John J. You, S. Samuel Bederman, Sean Symons, Chaim M. Bell, Lingsong Yun, Andreas Laupacis, Y. Raja Rampersaud. (2013) Patterns of Care After Magnetic Resonance Imaging of the Spine in Primary Care. Spine 38:1, 51-59
11
Wendell B Lake, Nathaniel P Brooks, Daniel K Resnick. (2013) Comparative effectiveness research in spine surgery. Journal of Comparative Effectiveness Research 2:1, 45-51
12
Raymond J. Gardocki, Francis X. Camillo. Other Disorders of the Spine. In: Campbell's Operative Orthopaedics. Elsevier, 2013:1993-2050.e18.
13
Frank M. Phillips, Paul J. Slosar, Jim A. Youssef, Gunnar Andersson. (2013) Lumbar Spine Fusion for Chronic Low Back Pain due to Degenerative Disc Disease. Spine1
14
Jeffrey N. Katz, Christine E. Chaisson, Brian Cole, Ali Guermazi, David J. Hunter, Morgan Jones, Bruce A. Levy, Lisa A. Mandl, Scott Martin, Robert G. Marx, Clare Safran-Norton, Frank W. Roemer, Debra Skoniecki, Daniel H. Solomon, Kurt P. Spindler, John Wright, Rick W. Wright, Elena Losina. (2012) The MeTeOR Trial (Meniscal Tear in Osteoarthritis Research): Rationale and design features. Contemporary Clinical Trials 33:6, 1189-1196
15
Adam Pearson, Jon Lurie, Tor Tosteson, Wenyan Zhao, William Abdu, James N. Weinstein. (2012) Who Should Have Surgery for Spinal Stenosis? Treatment Effect Predictors in SPORT. Spine 37:21, 1791-1802
16
Luis M. Tumialán, Ryan P. Ponton, Anthony I. Riccio, Wayne M. Gluf. (2012) Rate of Return to Military Active Duty After Single Level Lumbar Interbody Fusion. Neurosurgery 71:2, 317-324
17
Joseph P. Gjolaj, Nathan H. Lebwohl, Adam L. Wollowick, Norele Cutrera, Marinus de Kleuver. (2012) Optimizing Outcomes in the Management of Degenerative Spondylolisthesis. Spine Deformity
18
Roger Chou, Richard A. Deyo, Jeffrey G. Jarvik. (2012) Appropriate Use of Lumbar Imaging for Evaluation of Low Back Pain. Radiologic Clinics of North America 50:4, 569-585
19
Basheal M. Agrawal, Nathaniel P. Brooks, Daniel K. Resnick. (2012) Wisconsin Spine Outcome Study–Pilot: preliminary data. Neurosurgical Focus 33:1, E15
20
Dueng-Yuan Hueng, Chia-Lin Tsai, Shih-Wei Hsu, Hsin-I Ma. (2012) Publication patterns of comparative effectiveness research in spine neurosurgery. Neurosurgical Focus 33:1, E9
21
Kalil G. Abdullah, Edward C. Benzel, Thomas E. Mroz. (2012) Comparative effectiveness research in spine surgery. Neurosurgical Focus 33:1, E2
22
Sami Tarnanen, Marko H. Neva, Hannu Kautiainen, Jari Ylinen, Liisa Pekkanen, Tiina Kaistila, Mirja Vuorenmaa, Arja Häkkinen. (2012) The early changes in trunk muscle strength and disability following lumbar spine fusion. Disability and Rehabilitation1-6
23
Raja Rampersaud, Kevin Macwan, Nizar N. Mahomed. (2012) Spinal Care in a Single-Payer System: The Canadian Example. Seminars in Spine Surgery 24:2, 117-122
24
Christopher K. Kepler, Jeffrey A. Rihn, Alexander R. Vaccaro, Todd J. Albert. (2012) Defining the Value of Spine Care to Society. Seminars in Spine Surgery 24:2, 94-102
25
David W. Polly, Charles Gerald T. Ledonio, Jonathan N. Sembrano, Robert A. Morgan. (2012) Defining Appropriate Spine Care for the Patient as well as Society. Seminars in Spine Surgery 24:2, 123-126
26
Kathryn J. McCarthy, Leah Y. Carreon, Steven D. Glassman. (2012) Spinal Care: What Measurements Should be Used to Define Value to Society?. Seminars in Spine Surgery 24:2, 112-116
27
William D. Smith, Ginger Christian, Sherrie Serrano, Kyle T. Malone. (2012) A comparison of perioperative charges and outcome between open and mini-open approaches for anterior lumbar discectomy and fusion. Journal of Clinical Neuroscience 19:5, 673-680
28
G. Barbanti Brodano, E. Mazzoni, M. Tognon, C. Griffoni, M. Manfrini. (2012) Human mesenchymal stem cells and biomaterials interaction: a promising synergy to improve spine fusion. European Spine Journal
29
Colleen M. Sitlani, Patrick J. Heagerty, Emily A. Blood, Tor D. Tosteson. (2012) Longitudinal structural mixed models for the analysis of surgical trials with noncompliance. Statistics in Medicinen/a-n/a
30
Ahmet Murat Müslüman, Tufan Cansever, Adem Yılmaz, Halit Çavuşoğlu, İsmail Yüce, Yunus Aydın. (2012) Midterm outcome after a microsurgical unilateral approach for bilateral decompression of lumbar degenerative spondylolisthesis. Journal of Neurosurgery: Spine 16:1, 68-76
31
Larry E. Miller, Jon E. Block. (2012) Interspinous Spacer Implant in Patients with Lumbar Spinal Stenosis: Preliminary Results of a Multicenter, Randomized, Controlled Trial. Pain Research and Treatment 2012, 1-10
32
Tuan V. Nguyen, Robert A. McGuire,. Degenerative Spondylolisthesis with Radicular Pain. In: Best Evidence for Spine Surgery: 20 Cardinal Cases. Elsevier, 2012:93-102.
33
Vincent J. Devlin, Paul Enker. When not to operate for spinal disorders. In: Spine Secrets Plus. Elsevier, 2012:157-159.
34
Robert H. Brophy, Matthew V. Smith, Christian Latterman, Morgan H. Jones, Emily K. Reinke, David C. Flanigan, Rick W. Wright, Brian R. Wolf. (2012) Multi-investigator collaboration in orthopedic surgery research compared to other medical fields. Journal of Orthopaedic Researchn/a-n/a
35
W. B. Rodgers, Jeffrey A. Lehmen, Edward J. Gerber, Jody A. Rodgers. (2012) Grade 2 Spondylolisthesis at L4-5 Treated by XLIF: Safety and Midterm Results in the “Worst Case Scenario”. The Scientific World Journal 2012, 1-7
36
Sami Tarnanen, Marko H Neva, Joost Dekker, Keijo Häkkinen, Kimmo Vihtonen, Liisa Pekkanen, Arja Häkkinen. (2012) Randomized controlled trial of postoperative exercise rehabilitation program after lumbar spine fusion: study protocol. BMC Musculoskeletal Disorders 13:1, 123
37
A.l.i. Bydon, Hormuzdiyar H. Dasenbrock, I.a.n. Suk. Posterior Lumbar Fusion by Open Technique. In: Schmidek and Sweet's Operative Neurosurgical Techniques. Elsevier, 2012:1899-1930.
38
Luis Marchi, Nitamar Abdala, Leonardo Oliveira, Rodrigo Amaral, Etevaldo Coutinho, Luiz Pimenta. (2012) Stand-Alone Lateral Interbody Fusion for the Treatment of Low-Grade Degenerative Spondylolisthesis. The Scientific World Journal 2012, 1-7
39
Hormuzdiyar H. Dasenbrock, Reza Yassari, Timothy F. Witham. Neurogenic Claudication-Operative Management (Decompression and Fusion). In: Evidence-Based Orthopedics. Wiley-Blackwell, 2011:686-693.
40
Chye Yew Ng, J. N. Alastair Gibson. (2011) An Aid to the Explanation of Surgical Risks and Complications. Spine 36:26, 2333-2345
41
Steven D. Glassman, Leah Y. Carreon, Paul A. Anderson, Daniel K. Resnick. (2011) A diagnostic classification for lumbar spine registry development. The Spine Journal 11:12, 1108-1116
42
Patrick R. Olson, Jon D. Lurie, John Frymoyer, Thomas Walsh, Wenyan Zhao, Tamara S. Morgan, William A. Abdu, James N. Weinstein. (2011) Lumbar Disc Herniation in the Spine Patient Outcomes Research Trial. Spine 36:26, 2324-2332
43
Kristen E. Radcliff, Jeff Rihn, Alan Hilibrand, Timothy DiIorio, Tor Tosteson, Jon D. Lurie, Wenyan Zhao, Alexander R. Vaccaro, Todd J. Albert, James N. Weinstein. (2011) Does the Duration of Symptoms in Patients With Spinal Stenosis and Degenerative Spondylolisthesis Affect Outcomes?. Spine 36:25, 2197-2210
44
Salin Kim, Soroush Mortaz Hedjri, Peter C. Coyte, Y. Raja Rampersaud. (2011) Cost-utility of lumbar decompression with or without fusion for patients with symptomatic degenerative lumbar spondylolisthesis. The Spine Journal
45
Carlo Ammendolia, Kent Stuber, Linda K de Bruin, Andrea D Furlan, Carol A Kennedy, Y. Raja Rampersaud, Ivan A Steenstra, Victoria Pennick. (2011) Non-Operative Treatment for Lumbar Spinal Stenosis with Neurogenic Claudication. Spine1
46
Anna N. A. Tosteson, Tor D. Tosteson, Jon D. Lurie, William Abdu, Harry Herkowitz, Gunnar Andersson, Todd Albert, Keith Bridwell, Wenyan Zhao, Margaret R. Grove, Milton C. Weinstein, James N. Weinstein. (2011) Comparative Effectiveness Evidence From the Spine Patient Outcomes Research Trial. Spine 36:24, 2061-2068
47
Y. Raja Rampersaud, Eugene K. Wai, Charles G. Fisher, Albert J.M. Yee, Marcel F.S. Dvorak, Joel A. Finkelstein, Rajiv Gandhi, Edward P. Abraham, Stephen J. Lewis, David I. Alexander, William M. Oxner, J.R. Davey, Nizar Mahomed. (2011) Postoperative improvement in health-related quality of life: a national comparison of surgical treatment for focal (one- to two-level) lumbar spinal stenosis compared with total joint arthroplasty for osteoarthritis. The Spine Journal 11:11, 1033-1041
48
James Kang, Howard An, Alan Hilibrand, S. Tim Yoon, Eoin Kavanagh, Scott Boden. (2011) Grafton® & Local Bone Has Comparable Outcomes to Iliac Crest Bone in Instrumented Single Level Lumbar Fusions. Spine1
49
Joseph S. Cheng, Michael J. Lee, Eric Massicotte, Bryan Ashman, Marcelo Gruenberg, Leslie E. Pilcher, Andrea C. Skelly. (2011) Clinical Guidelines and Payer Policies on Fusion for the Treatment of Chronic Low Back Pain. Spine 36, S144-S163
50
Peter G. Campbell, Sanjay Yadla, Jennifer Malone, Mitchell G. Maltenfort, James S. Harrop, Ashwini D. Sharan, John K. Ratliff. (2011) Complications related to instrumentation in spine surgery: a prospective analysis. Neurosurgical FOCUS 31:4, E10
51
Francisco M. Kovacs, Gerard Urrútia, José Domingo Alarcón. (2011) Surgery Versus Conservative Treatment for Symptomatic Lumbar Spinal Stenosis. Spine 36:20, E1335-E1351
52
Byung-Hyun Park, Kyung-Jin Song, Sun Jung Yoon, Ho Sung Park, Kyu Yun Jang, Lu Zhou, Sang Yong Lee, Kwang Bok Lee, Jung Ryul Kim. (2011) Acceleration of spinal fusion using COMP-angiopoietin 1 with allografting in a rat model. Bone 49:3, 447-454
53
Arno Bisschop, Margriet G. Mullender, Idsart Kingma, Timothy U. Jiya, Albert J. Veen, Jan C. Roos, Jaap H. Dieën, Barend J. Royen. (2011) The impact of bone mineral density and disc degeneration on shear strength and stiffness of the lumbar spine following laminectomy. European Spine Journal
54
S. Samuel Bederman, Charles D. Rosen, Nitin N. Bhatia, P. Douglas Kiester, Ranjan Gupta. (2011) Drivers of Surgery for the Degenerative Hip, Knee, and Spine: A Systematic Review. Clinical Orthopaedics and Related Research®
55
Owoicho Adogwa, Scott L. Parker, Brandon J. Davis, Oran Aaronson, Clinton Devin, Joseph S. Cheng, Matthew J. McGirt. (2011) Cost-effectiveness of transforaminal lumbar interbody fusion for Grade I degenerative spondylolisthesis. Journal of Neurosurgery: Spine 15:2, 138-143
56
F. S. Kleinstueck, T. F. Fekete, A. F. Mannion, D. Grob, F. Porchet, U. Mutter, D. Jeszenszky. (2011) To fuse or not to fuse in lumbar degenerative spondylolisthesis: do baseline symptoms help provide the answer?. European Spine Journal
57
Pär Slätis, Antti Malmivaara, Markku Heliövaara, Päivi Sainio, Arto Herno, Jyrki Kankare, Seppo Seitsalo, Kaj Tallroth, Veli Turunen, Paul Knekt, Heikki Hurri. (2011) Long-term results of surgery for lumbar spinal stenosis: a randomised controlled trial. European Spine Journal 20:7, 1174-1181
58
Ihsan Solaroglu, Ozerk Okutan, Ethem Beskonakli. (2011) The ATA and Its Surgical Importance. Spine 36:16, 1268-1272
59
Charles G. Fisher, Alexander R. Vaccaro, Peter G. Whang, Srinivas K. Prasad, Peter D. Angevine, Kishore Mulpuri, Kenneth C. Thomas, Alpesh A. Patel. (2011) Evidence-Based Recommendations for Spine Surgery. Spine 36:14, E897-E903
60
Charles H. Crawford, Jennifer Smail, Leah Y. Carreon, Steven D. Glassman. (2011) Health-Related Quality of Life after Posterolateral Lumbar Arthrodesis in Patients Seventy-Five Years of Age and Older. Spine 36:13, 1065-1068
61
Y. Raja Rampersaud, Randolph Gray, Steven J. Lewis, Eric M. Massicotte, Michael G. Fehlings. (2011) Cost-utility analysis of posterior minimally invasive fusion compared with conventional open fusion for lumbar spondylolisthesis. SAS Journal 5:2, 29-35
62
Susanne M. Simmerman, Phillip S. Sizer, Gregory S. Dedrick, Gail G. Apte, Jean-Michel Brismée. (2011) Immediate Changes in Spinal Height and Pain After Aquatic Vertical Traction in Patients With Persistent Low Back Symptoms: A Crossover Clinical Trial. PM&R 3:5, 447-457
63
Chin-wern Chan, Philip Peng. (2011) Failed Back Surgery Syndrome. Pain Medicine 12:4, 577-606
64
Po-Chou Liliang, Kang Lu, Cheng-Loong Liang, Yu-Duan Tsai, Kuo-Wei Wang, Han-Jung Chen. (2011) Sacroiliac Joint Pain after Lumbar and Lumbosacral Fusion: Findings Using Dual Sacroiliac Joint Blocks. Pain Medicine 12:4, 565-570
65
Adam M. Pearson, Kevin F. Spratt, James Genuario, William McGough, Katherine Kosman, Jon Lurie, Dilip K. Sengupta. (2011) Precision of Lumbar Intervertebral Measurements. Spine 36:7, 572-580
66
J. M. Winters, H. N. Herkowitz. (2011) Degenerative lumbar spondylolisthesis: evolution of treatment. ArgoSpine News & Journal 23:1, 3-9
67
S. Samuel Bederman, Peter C. Coyte, Hans J. Kreder, Nizar N. Mahomed, Warren J. McIsaac, James G. Wright. (2011) Whoʼs in the Driverʼs Seat? The Influence of Patient and Physician Enthusiasm on Regional Variation in Degenerative Lumbar Spinal Surgery. Spine 36:6, 481-489
68
Adam Pearson, Emily Blood, Jon Lurie, William Abdu, Dilip Sengupta, John Frymoyer Frymoyer, James Weinstein. (2011) Predominant Leg Pain Is Associated With Better Surgical Outcomes in Degenerative Spondylolisthesis and Spinal Stenosis. Spine 36:3, 219-229
69
Md Abu Bakar Siddiq, Suzon Al Hasan, Gautam Das, Amin Uddin A Khan. (2011) Interventional Pain Management in Rheumatological Diseases - A Three Years Physiatric Experience in a Tertiary Medical College Hospital in Bangladesh. The Korean Journal of Pain 24:4, 205
70
Gabriel C Tender, Larry E Miller, Jon E Block. (2011) Percutaneous pedicle screw reduction and axial presacral lumbar interbody fusion for treatment of lumbosacral spondylolisthesis: A case series. Journal of Medical Case Reports 5:1, 454
71
Adam Goode, Chad Cook, Christopher Brown, Robert Isaacs, Matthew Roman, William Richardson. (2011) Differences in Comorbidities on Low Back Pain and Low Back Related Leg Pain. Pain Practice 11:1, 42-47
72
Mitchell K Freedman, Alan S Hilibrand, Emily A Blood, Wenyan Zhao, Todd J Albert, Alexander Vacarro, Christina V Oleson, Tamara S. Morgan, James N Weinstein. (2011) The Impact of Diabetes On the Outcomes of Surgical and Nonsurgical Treatment of Patients in the Spine Patient Outcomes Research Trial (SPORT). Spine1
73
Nancy E. Epstein. Lumbar Spine Stenosis. In: Youmans Neurological Surgery. Elsevier, 2011:2923-2934.
74
Michael K. Rosner, Victoria A. Campbell. Treatment of Disk Disease of the Lumbar Spine. In: Youmans Neurological Surgery. Elsevier, 2011:2919-2922.
75
Zacharia Isaac, Jeffrey N Katz. Lumbar spine disorders. In: Rheumatology. Elsevier, 2011:659-681.e3.
76
Gordon R. Bell. Degenerative Spondylolisthesis. In: Rothman Simeone The Spine. Elsevier, 2011:1101-1115.
77
Peter G. Campbell, Amgad Hanna, James S. Harrop. Spinal Dural Injuries. In: Rothman Simeone The Spine. Elsevier, 2011:1720-1727.
78
William Blake Rodgers, Edward J. Gerber, Jody A. Rodgers. (2010) Lumbar Fusion in Octogenarians. Spine 35:Supplement, S355-S360
79
Guido B. Solinge, Albert J. Veen, Jaap H. Dieën, Idsart Kingma, Barend J. Royen. (2010) Anterior shear strength of the porcine lumbar spine after laminectomy and partial facetectomy. European Spine Journal 19:12, 2130-2136
80
Isaac O. Karikari, Robert E. Isaacs. (2010) Minimally Invasive Transforaminal Lumbar Interbody Fusion. Spine 35:Supplement, S294-S301
81
Charles A. Sansur, Davis L. Reames, Justin S. Smith, D. Kojo Hamilton, Sigurd H. Berven, Paul A. Broadstone, Theodore J. Choma, Michael James Goytan, Hilali H. Noordeen, Dennis Raymond Knapp, Robert A. Hart, Reinhard D. Zeller, William F. Donaldson, David W. Polly, Joseph H. Perra, Oheneba Boachie-Adjei, Christopher I. Shaffrey. (2010) Morbidity and mortality in the surgical treatment of 10,242 adults with spondylolisthesis. Journal of Neurosurgery: Spine 13:5, 589-593
82
Janna Friedly, Christopher Standaert, Leighton Chan. (2010) Epidemiology of Spine Care: The Back Pain Dilemma. Physical Medicine and Rehabilitation Clinics of North America 21:4, 659-677
83
Patrick J. Denard, Kathleen F. Holton, Jessica Miller, Howard A. Fink, Deborah M. Kado, Lynn M. Marshall, Jung U. Yoo. (2010) Back pain, neurogenic symptoms, and physical function in relation to spondylolisthesis among elderly men. The Spine Journal 10:10, 865-873
84
S. Samuel Bederman, Warren J. McIsaac, Peter C. Coyte, Hans J. Kreder, Nizar N. Mahomed, James G. Wright. (2010) Referral Practices for Spinal Surgery are Poorly Predicted by Clinical Guidelines and Opinions of Primary Care Physicians. Medical Care 48:9, 852-858
85
Michael O. Kelleher, Marcus Timlin, Oma Persaud, Yoga Raja Rampersaud. (2010) Success and Failure of Minimally Invasive Decompression for Focal Lumbar Spinal Stenosis in Patients With and Without Deformity. Spine 35:19, E981-E987
86
Steven J. Atlas. (2010) Point of View. Spine 35:19, 1818-1819
87
Daniel Omoto, S. Samuel Bederman, Albert J. M. Yee, Hans J. Kreder, Joel A. Finkelstein. (2010) How do validated measures of functional outcome compare with commonly used outcomes in administrative database research for lumbar spinal surgery?. European Spine Journal 19:8, 1369-1377
88
Mark G. Burnett, Sherman C. Stein, Ronald H. M. A. Bartels. (2010) Cost-effectiveness of current treatment strategies for lumbar spinal stenosis: nonsurgical care, laminectomy, and X-STOP. Journal of Neurosurgery: Spine 13:1, 39-46
89
Alexander R. Vaccaro, Charles G. Fisher, Kenneth C. Thomas, Peter D. Angevine, Kishore Mulpuri, Alpesh A. Patel, Srinivas K. Prasad, Peter G. Whang. (2010) Evidence-Based Recommendations for Spine Surgery. Spine1
90
Suat Erol Çelik, Sevinç Çelik, Kamber Göksu, Ayhan Kara, İrfan İnce. (2010) Microdecompressive Laminatomy With a 5-year Follow-up Period for Severe Lumbar Spinal Stenosis. Journal of Spinal Disorders & Techniques 23:4, 229-235
91
James N. Weinstein, Tor D. Tosteson, Jon D. Lurie, Anna Tosteson, Emily Blood, Harry Herkowitz, Frank Cammisa, Todd Albert, Scott D. Boden, Alan Hilibrand, Harley Goldberg, Sigurd Berven, Howard An. (2010) Surgical Versus Nonoperative Treatment for Lumbar Spinal Stenosis Four-Year Results of the Spine Patient Outcomes Research Trial. Spine1
92
Patrick J. Denard, Kathleen F. Holton, Jessica Miller, Howard A. Fink, Deborah M. Kado, Jung U. Yoo, Lynn M. Marshall. (2010) Lumbar Spondylolisthesis Among Elderly Men. Spine1
93
Alexander R. Vaccaro, Charles G. Fisher, Peter G. Whang, Alpesh A. Patel, Srinivas K. Prasad, Peter D. Angevine, Kishore Mulpari, Ken C. Thomas. (2010) Evidence-Based Recommendations for Spine Surgery. Spine 35:6, E178-E188
94
Peter C. Austin, Andrea Manca, Merrick Zwarenstein, David N. Juurlink, Matthew B. Stanbrook. (2010) A substantial and confusing variation exists in handling of baseline covariates in randomized controlled trials: a review of trials published in leading medical journals. Journal of Clinical Epidemiology 63:2, 142-153
95
Koichi Masuda, Jeffrey C. Lotz. (2010) New Challenges for Intervertebral Disc Treatment Using Regenerative Medicine. Tissue Engineering Part B: Reviews 16:1, 147-158
96
Alexander Richter, Christian Schütz, Michael Hauck, Henry Halm. (2010) Does an interspinous device (Coflex™) improve the outcome of decompressive surgery in lumbar spinal stenosis? One-year follow up of a prospective case control study of 60 patients. European Spine Journal 19:2, 283-289
97
Daniel K. Park, Howard S. An, Jon D. Lurie, Wenyan Zhao, Anna Tosteson, Tor D. Tosteson, Harry Herkowitz, Thomas Errico, James N. Weinstein. (2010) Does Multilevel Lumbar Stenosis Lead to Poorer Outcomes?. Spine 35:4, 439-446
98
Adam Pearson, Emily Blood, Jon Lurie, Tor Tosteson, William A. Abdu, Alan Hillibrand, Keith Bridwell, James Weinstein. (2010) Degenerative Spondylolisthesis Versus Spinal Stenosis. Spine 35:3, 298-305
99
Erin E. Krebs, Jon D. Lurie, Gilbert Fanciullo, Tor D. Tosteson, Emily A. Blood, Timothy S. Carey, James N. Weinstein. (2010) Predictors of Long-Term Opioid Use Among Patients With Painful Lumbar Spine Conditions. The Journal of Pain 11:1, 44-52
100
S Samuel Bederman, Nizar N. Mahomed, Hans J. Kreder, Warren J. McIsaac, Peter C. Coyte, James G. Wright. (2010) In the Eye of the Beholder. Spine 35:1, 108-115
101
Jeffrey C. Wang, Joseph S. Kim. Thoracolumbar Stenosis. In: Essential Orthopaedics. Elsevier, 2010:503-505.
102
Kerry H. Levin. Low Back Pain. In: Current Clinical Medicine. Elsevier, 2010:932-936.
103
Andrew P. White, Todd J. Albert. (2009) Evidence-Based Treatment of Lumbar Spinal Stenosis. Seminars in Spine Surgery 21:4, 230-237
104
Adam M. Pearson, James N. Weinstein. (2009) Pearls and Pitfalls in Evidence Based Medicine: What We've Learned About Outcomes Research in Spine Surgery. Seminars in Spine Surgery 21:4, 264-267
105
Sigurd H. Berven, Harry N. Herkowitz. (2009) Evidence-Based Medicine for the Spine: Degenerative Spondylolisthesis. Seminars in Spine Surgery 21:4, 238-245
106
William A. Abdu, Jon D. Lurie, Kevin F. Spratt, Anna N. A. Tosteson, Wenyan Zhao, Tor D. Tosteson, Harry Herkowitz, Michael Longely, Scott D. Boden, Sanford Emery, James N. Weinstein. (2009) Degenerative Spondylolisthesis. Spine 34:21, 2351-2360
107
John W. Frymoyer. (2009) Point of View. Spine 34:21, 2361
108
Charles G. Fisher, Ory Keynan, Stephen Ondra, Ziya Gokaslan. (2009) Introduction to Focus Issue in Spine Oncology. Spine 34:Supplement, S21-S25
109
Thomas Andersen, Finn B. Christensen, Carsten Ernst, Søren Fruensgaard, Jørgen Østergaard, Jens Langer Andersen, Sten Rasmussen, Bent Niedermann, Kristian Høy, Peter Helmig, Randi Holm, Bent Erling Lindblad, Ebbe Stender Hansen, Niels Egund, Cody Bünger. (2009) The Effect of Electrical Stimulation on Lumbar Spinal Fusion in Older Patients: A Randomized, Controlled, Multi-Center Trial. Spine 34:21, 2241-2247
110
Jeffrey G Jarvik, Bryan A Comstock, Michel Kliot, Judith A Turner, Leighton Chan, Patrick J Heagerty, William Hollingworth, Carolyn L Kerrigan, Richard A Deyo. (2009) Surgery versus non-surgical therapy for carpal tunnel syndrome: a randomised parallel-group trial. The Lancet 374:9695, 1074-1081
111
Brian T. Jankowitz, Dave S. Atteberry, Peter C. Gerszten, Patricia Karausky, Boyle C. Cheng, Ryan Faught, William C. Welch. (2009) Effect of fibrin glue on the prevention of persistent cerebral spinal fluid leakage after incidental durotomy during lumbar spinal surgery. European Spine Journal 18:8, 1169-1174
112
Jens Ivar Brox. (2009) The contribution of RCTs to quality management and their feasibility in practice. European Spine Journal 18:S3, 279-293
113
Paul S. Kalanithi, Chirag G. Patil, Maxwell Boakye. (2009) National Complication Rates and Disposition After Posterior Lumbar Fusion for Acquired Spondylolisthesis. Spine 34:18, 1963-1969
114
William C. Watters, Christopher M. Bono, Thomas J. Gilbert, D. Scott Kreiner, Daniel J. Mazanec, William O. Shaffer, Jamie Baisden, John E. Easa, Robert Fernand, Gary Ghiselli, Michael H. Heggeness, Richard C. Mendel, Conor O'Neill, Charles A. Reitman, Daniel K. Resnick, Jeffrey T. Summers, Reuben B. Timmons, John F. Toton. (2009) An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spondylolisthesis. The Spine Journal 9:7, 609-614
115
Eberhard Siebert, Harald Prüss, Randolf Klingebiel, Vieri Failli, Karl M. Einhäupl, Jan M. Schwab. (2009) Lumbar spinal stenosis: syndrome, diagnostics and treatment. Nature Reviews Neurology 5:7, 392-403
116
Harry N. Herkowitz. (2009) Degenerative lumbar spondylolisthesis: evolution of surgical management. The Spine Journal 9:7, 605-606
117
Steven P. Cohen, Nikolai Bogduk, Anthony Dragovich, Chester C. Buckenmaier, Scott Griffith, Connie Kurihara, JoLynne Raymond, Philip J. Richter, Necia Williams, Tony L. Yaksh. (2009) Randomized, Double-blind, Placebo-controlled, Dose-response, and Preclinical Safety Study of Transforaminal Epidural Etanercept for the Treatment of Sciatica. Anesthesiology 110:5, 1116-1126
118
Jwo-Luen Pao, Wein-Chin Chen, Po-Quang Chen. (2009) Clinical outcomes of microendoscopic decompressive laminotomy for degenerative lumbar spinal stenosis. European Spine Journal 18:5, 672-678
119
Roger Chou, Jamie Baisden, Eugene J. Carragee, Daniel K. Resnick, William O. Shaffer, John D. Loeser. (2009) Surgery for Low Back Pain. Spine 34:10, 1094-1109
120
Roger Chou, John D. Loeser, Douglas K. Owens, Richard W. Rosenquist, Steven J. Atlas, Jamie Baisden, Eugene J. Carragee, Martin Grabois, Donald R. Murphy, Daniel K. Resnick, Steven P. Stanos, William O. Shaffer, Eric M. Wall. (2009) Interventional Therapies, Surgery, and Interdisciplinary Rehabilitation for Low Back Pain. Spine 34:10, 1066-1077
121
Steven D. Glassman, Frank Schwab, Keith H. Bridwell, Christopher Shaffrey, William Horton, Serena Hu. (2009) Do 1-year outcomes predict 2-year outcomes for adult deformity surgery?. The Spine Journal 9:4, 317-322
122
Chad Cook. (2009) Sub-group Classification of Low Back Related Leg Pain: Is this the Catalyst Needed for Other Challenging Conditions?. Journal of Manual & Manipulative Therapy 17:2, 70-72
123
Mandi J. Lopez, Kevin R. McIntosh, Nakia D. Spencer, Jade N. Borneman, Ronald Horswell, Paul Anderson, Gang Yu, Lorrie Gaschen, Jeffrey M. Gimble. (2009) Acceleration of spinal fusion using syngeneic and allogeneic adult adipose derived stem cells in a rat model. Journal of Orthopaedic Research 27:3, 366-373
124
Steven D. Glassman, Leah Y. Carreon, Mladen Djurasovic, John R. Dimar, John R. Johnson, Rolando M. Puno, Mitchell J. Campbell. (2009) Lumbar fusion outcomes stratified by specific diagnostic indication. The Spine Journal 9:1, 13-21
125
John D. Markman, Jeremy C. Sinkin. LUMBAR SPINAL STENOSIS: CURRENT THERAPY AND FUTURE DIRECTIONS. In: Current Therapy in Pain. Elsevier, 2009:316-322.
126
Adam M. Pearson, Jon D. Lurie, Emily A. Blood, John W. Frymoyer, Heike Braeutigam, Howard An, Federico P. Girardi, James N. Weinstein. (2008) Spine Patient Outcomes Research Trial. Spine 33:25, 2759-2766
127
James N. Weinstein, Jon D. Lurie, Tor D. Tosteson, Anna N. A. Tosteson, Emily A. Blood, William A. Abdu, Harry Herkowitz, Alan Hilibrand, Todd Albert, Jeffrey Fischgrund. (2008) Surgical Versus Nonoperative Treatment for Lumbar Disc Herniation. Spine 33:25, 2789-2800
128
Jon D. Lurie, Sigurd H. Berven, Jennifer Gibson-Chambers, Tor Tosteson, Anna Tosteson, Serena S. Hu, James N. Weinstein. (2008) Patient Preferences and Expectations for Care. Spine 33:24, 2663-2668
129
Valentin Antoci Jr, Alan S Hilibrand. (2008) Nonspecific back pain: approach and management. Future Rheumatology 3:5, 485-492
130
T. Sugioka, Y. Hayashino, S. Konno, S. Kikuchi, S. Fukuhara. (2008) Predictive value of self-reported patient information for the identification of lumbar spinal stenosis. Family Practice 25:4, 237-244
131
RaʼKerry K Rahman, Douglas D Nowak, Daniel E Gelb, Kornelis A Poelstra, Steven C Ludwig. (2008) Lumbar spinal stenosis. Current Orthopaedic Practice 19:4, 351-356
132
Jordan M. Cloyd, Frank L. Acosta, Christopher P. Ames. (2008) Complications and Outcomes of Lumbar Spine Surgery in Elderly People: A Review of the Literature. Journal of the American Geriatrics Society 56:7, 1318-1327
133
Luke Brewster, Nathan Trueger, Carol Schermer, Alex Ghanayem, John Santaniello. (2008) Infraumbilical Anterior Retroperitoneal Exposure of the Lumbar Spine in 128 Consecutive Patients. World Journal of Surgery 32:7, 1414-1419
134
(2008) Using Evidence in Pain Practice: Part II: Interpreting and Applying Systematic Reviews and Clinical Practice Guidelines. Pain Medicine 9:5, 531-541
135
Gordon Li, Chirag G. Patil, Shivanand P. Lad, Chris Ho, Wendy Tian, Maxwell Boakye. (2008) Effects of Age and Comorbidities on Complication Rates and Adverse Outcomes After Lumbar Laminectomy in Elderly Patients. Spine 33:11, 1250-1255
136
Kurt Samson. (2008) Better Spinal Stenosis Outcomes with Surgery, Major Study Finds. Neurology Today 8:7, 1,20
137
Leonid Kalichman, David J. Hunter. (2008) Diagnosis and conservative management of degenerative lumbar spondylolisthesis. European Spine Journal 17:3, 327-335
138
Weinstein , James N. , Tosteson , Tor D. , Lurie , Jon D. , Tosteson , Anna N.A. , Blood , Emily , Hanscom , Brett , Herkowitz , Harry , Cammisa , Frank , Albert , Todd , Boden , Scott D. , Hilibrand , Alan , Goldberg , Harley , Berven , Sigurd , An , Howard , . (2008) Surgical versus Nonsurgical Therapy for Lumbar Spinal Stenosis. New England Journal of Medicine 358:8, 794-810
Free Full Text139
JN Alastair Gibson, Chye-Yew Ng. (2008) Is surgery more effective than nonsurgical treatment for the management of patients with degenerative spondylolisthesis?. Nature Clinical Practice Rheumatology 4:2, 68-69
140
Andrea D. Furlan, George Tomlinson, Alejandro (Alex) R. Jadad, Claire Bombardier. (2008) Examining Heterogeneity in Meta-Analysis. Spine 33:3, 339-348
141
Ji Hee Hong, Yong Chul Lee, Han Min Lee, Chul Hyung Kang. (2008) An Analysis of the Outcome of Transforaminal Epidural Steroid Injections in Patients with Spinal Stenosis or Herniated Intervertebral Discs. The Korean Journal of Pain 21:1, 38
142
Ji Hee Hong, Yong Chul Lee, Jin Mo Kim, Sung Ho Han, Eun Jee Park. (2008) Analysis of Factors Associated with the Therapeutic Duration of Transforaminal Epidural Steroid Injection in Lumbar Spinal Stenosis Patients. The Korean Journal of Pain 21:2, 136
143
Honorio T. Benzon. (2007) Studies on Diagnostic Injections and Surgery for Low Back Pain: Problems, Advances, and Opportunities. Anesthesia & Analgesia 105:6, 1523-1525
144
(2007) Surgical versus Nonsurgical Treatment for Back Pain. New England Journal of Medicine 357:12, 1255-1256
Free Full Text145
C. Faldini, S. Pagkrati, F. Acri, M. T. Miscione, D. Francesconi, S. Giannini. (2007) Surgical treatment of symptomatic degenerative lumbar spondylolisthesis by decompression and instrumented fusion. Journal of Orthopaedics and Traumatology 8:3, 128-133
146
&NA;. (2007) Whatʼs in the Literature?. Journal of Clinical Neuromuscular Disease 9:1, 277-284
147
Kurt Samson. (2007) Quicker Pain Relief with Back Surgery, But Waiting Works Too. Neurology Today 7:14, 22,27
148
Deyo , Richard A. , . (2007) Back Surgery — Who Needs It?. New England Journal of Medicine 356:22, 2239-2243
Full Text
- Letters
