Supplemental Digital Material



Supplemental Digital Material

Table 1. Detailed data from studies evaluating fusion and extension of fusion for the treatment of lumbar ASP.

|Author (year) |Population |Definition of ASP |Procedure |Risk factors |Results |Author’s |

|Study type (LoE) | | | | | |Conclusions |

|Chen (2001) |N = 39 |Radiographic abnormalities |Medial facetectomy and |NR |Success/failure: |Medial facetectomy reduced nerve |

| |Age: 61 (range, 47-74) years |were correlated with |instrumented posterolateral| |Successful fusion: 37/39 (94.9%) |root injury, neuropathic pain, |

|Case-series |Male: 23.1% |clinical symptoms |fusion | |Revision rate: 2/39 (5.1%) |and dural tear. |

| |F/U: 62 (range, 24-119) months |Spondylolisthesis or dynamic|Dorsale Kompressions | | | |

| |F/U rate: NR |instability with slippage |Spondylodes (DKS): 18/39 | |Results were categorized based on |Patients were satisfied with the |

| | |more than 4 mm and/or angle |(46.2%) | |modified Brodsky’s criteria. |result (76.7%), no P-value |

| | |change more than 10° on |Reduction Fixator I (RF): | | |given.. |

| |ASD: |flexion and extension |21/39 (53.8%) | |Satisfactory results: 30/39 (76.9%)| |

| |Previous surgery: 4.3 (1-9.3) |Radiographically | | |Excellent result: 9/39 (23.1%) |Authors did not compare outcomes |

| |years prior to ASD |demonstrated segmental | | |Good result: 21/39 (53.8%) |of different instrumentation used|

| |Interval between surgeries: 5.2 |instability | | | |in the fusion. |

| |(range, 1-11.5) years |Spinal stenosis confirmed by| | |Unsatisfactory results: 9/39 | |

| | |myelogram | | |(23.1%) | |

| | | | | |Fair result: 5/39 (12.8%) | |

| | | | | |Poor result: 4/39 (10.3%) | |

|Djurasovic (2011) |N = 42 |NR |Fusion approach: |Time since last surgery |Outcomes based on previously |Lumbar fusion as revision surgery|

| |Age: 59.7 ± 13.2 years | |Anterior spinal fusion |Workers’ compensation |published minimum clinically |yields modest levels of |

|Case-series |Male: 42.9% | |(ASF): 1/42 (2.4%) |Smoking |important difference (MCID) |improvement in health-related |

| |F/U: 24 months min | |Posterolateral fusion |Number of levels fused |thresholds: |quality of life measures. |

| |F/U rate: NR | |(PSF): 40/42 (95.2%) |Predominance of back | | |

| | | |Transforaminal interbody |pain compared to leg |Oswestry Disability Index: |Patients with ASP achieved low |

| | | |fusion (TLIF): 0/42 (0%) |pain |At 2 years 38% of ASP patients |rates of improvement. |

| |ASP: | |Circumferential |Whether patient felt |reached the MCID threshold of 12.8 | |

| |Interval between surgeries: 6.1 | |anteroposterior fusion |improvement from | | |

| |± 6.0 years | |(A/P): 1/42 (2.4%) |previous surgery |SF-36 PCS |Author did not compare outcomes |

| | | | |Narcotic use |At 2 years 40% of ASP patients |between patients with different |

| | | | |Number of prior |reached the MCID of 4.9 |fusions. |

| | | | |surgeries | | |

| | | | |Whether rediographs |Logistic regression analysis | |

| | | | |showed objective |determined which preoperative | |

| | | | |instability |factors predicted achievement of | |

| | | | | |MCID. | |

| | | | | |For ODI, patient reported | |

| | | | | |improvement from last surgery was | |

| | | | | |predictive (p = 0.019) | |

| | | | | |For SF-36 PCS, worker’s | |

| | | | | |compensation (P = 0.019) and the | |

| | | | | |preoperative use of strong | |

| | | | | |narcotics (P = 0.003) were | |

| | | | | |predictive of failure to reach MCID| |

|Whitecloud (1994) |N = 14 |Initial presentation of |Fusion with and without |Interval of less than 3 |Pseudoarthrosis rate: |Extension of a previous fusion |

| |Age: 52 (range, 35-75) years |progressive and |instrumentation: |years between surgeries.|Decreased from 80% to 17% through |requires transpedicular |

|Case-series |Male: 50% |functionally-limiting back |Uninstrumented |Advanced osteoporosis |use of instrumentation |instrumentation. |

| |F/U: 18.5 (range, 9-36) months |and leg pain after a |posterolateral fusion: 5/14| |Postoperative pain | |

| |F/U rate: NR |previous lumbosacral fusion.|(35.7%) | |relief: |All 3 patients with a poor result|

| | |Diagnostic studies |Instrumented posterolateral| |11/14 (78.6%) |had an interval of less than 3 |

| | |consistent with degenerative|fusion: 9/14 (64.3%) | | |years between surgeries (no |

| |ASP: |spinal/lateral recess | | |Outcomes*: |p-value/ p = NR). |

| |Interval between surgeries: 11.5|stenosis or segmental | | |Excellent: 0/14 (0%) | |

| |(range, 3-29) years |instability based on | | |Good: 5/14 (35.7%) |Advanced osteoporosis may lead to|

| | |radiographs, CT myelogram or| | |Fair: 6/14 (42.9%) |hardware pull out which results |

| | |MRI. | | |Poor: 3/14 (21.4%) |in arthrodesis failure (no |

| | | | | | |p-value). |

|Parker (2012) |N = 50 |Low-back and leg pain |Posterior fusion with |NR |All patient reported outcomes |Calculated MCIDs in the setting |

| |Age: 58.9 ± 10.9 years |localized to the adjacent |extension of the prior | |(PROs) improved 2 years |of revision lumbar surgery for |

|Case-series |Male: 40% |level after prior fusion |fusion construct and | |postoperatively (p = 55 than patients 48 months, 91 (range, | | | |increase in satisfaction (p = | |

| |50-228) | | | |0.035) | |

| | | | | |Adjacent level fusion outcomes had | |

| | | | | |equal or better outcomes than | |

| | | | | |initial fusion 31/38 (82%) | |

*Not a formal outcome measure, author took into account pain, medications required, and return to work

Table 2. Detailed data from studies evaluating decompression for the treatment of lumbar ASP.

|Author (year) |Population |Definition of ASP |Procedure |Risk factors |Results |Author’s |

|Study type (LoE) | | | | | |Conclusions |

|Schlegel |N = 58 |At least one of the |Decompression and fusion: |NR |Success rate: |The segment adjacent to the |

|(1996) |Age: 42.6 (range, 12-75) years |following criteria met in |14/37 (37.8%) | |Excellent result: 9/37 (24.3%) |adjacent segment is almost as |

| |Male: 37.9% |comparison with preoperative|Decompression only: 23/37 | |Good result: 17/37 (45.9%) |likely to break down, even after |

|Case-series |F/U: 3.1 years |radiographic, MRI, or |(62.2%) | |Fair result: 8/37 (21.6%) |a lengthy symptom free period. |

| |F/U rate: 37/58 (63.8%) |CT/myelographic findings at| | |Poor result: 2/37 (5.4%) | |

| | |a segment adjacent to a | | |Patient reported assessment based |Fusion in addition to |

| | |previously asymptomatic | | |on pain, functional outcome and |decompression of the adjacent |

| |ASP: |fusion | | |need for further surgery. |segment is often necessary. |

| |Interval between surgeries: 13.1|Severe back and leg pain | | | | |

| |years |Spinal stenosis | | |VAS: |Author did not compare outcomes |

| | |Disc herniation | | |Preoperative: |between patients with |

| | |Instability | | |Back pain score: 8.2 |decompression and fusion to |

| | | | | |Leg pain score: 7.2 |decompression alone. |

| | | | | |Postoperative: | |

| | | | | |Back pain score: 4.0 | |

| | | | | |Leg pain score: 2.3 | |

|Phillips |N = 33 |Symptomatic spinal stenosis |Decompression |Age |Success rate: |Surgery was effective at |

|(2000) |Age: 57 (range, 27-78) years |adjacent to a previously | |Sex |Satisfactory to perfect result*: |improving neural claudication |

| |Male: 34.6% |asymptomatic lumbar fusion | |Smoking history |15/26 (57.7%) |symptoms but continued low back |

|Case-series |F/U: 5 (range, 3-14) years | | |Number of prior lumbar |These patients had less |pain was associated with patient |

| |F/U rate: 26/33 (78.8%) | | |surgeries |postoperative back pain (p = 0.001)|dissatisfaction. |

| | | | |Preoperative back pain | | |

| | | | |Neurologic deficits |Greater functional abilities (p = | |

| |ASP: | | |Anatomic level or number|0.05) | |

| |Interval between surgeries: 94 | | |of levels operated on |Neutral result: 6/26 (23.1%) | |

| |months (range, 3-28) years | | | |Failed result: 5/26 (19.2%) | |

| | | | | |Low back pain at follow-up (p = | |

| | | | | |0.001) | |

| | | | | |Decreased functional abilities (p =| |

| | | | | |0.003) were predictive factors of | |

| | | | | |poor outcomes | |

| | | | | | | |

| | | | | |A larger interval between surgeries| |

| | | | | |predicted adjacent segment stenosis| |

| | | | | |involving more lumbar segments (p =| |

| | | | | |0.001). | |

*Not a formal outcome measure, author took into account pain, functional abilities, patient opinion of operative result, and use of medication.

Table 3. Detailed data from studies evaluating total disc arthroplasty for the treatment of lumbar ASP.

|Author (year) |Population |Definition of ASD |Procedure |Risk factors |Results |Author’s |

|Study type (LoE) | | | | | |Conclusions |

|Bertagnoli (2006) |N = 20 |Disabling low-back pain with|ProDisc lumbar total disc |NR |Improved VAS documented pain and |ProDisc lumbar total disc |

| |Age: 50 (range, 35-67) years |or without radicular |arthroplasty | |ODI scores at 3 and 24 months 16/18|arthroplasty is an effective |

|Case-series |Male: 50% |symptoms resulting from |One level: 16/18 (88.9%) | |(88.9%) |treatment alternative for |

| |Median F/U: 27 (range, 24-48) |L1-S1 DDD, confirmed by MR |Two level: 2/18 (11.1%) | |At 3 months p < 0.0001 for VAS and |symptomatic adjacent-segment |

| |months |imaging, CT scanning, and | | |ODI |lumbar DDD following remote |

| |F/U rate: 18/20 (90%) |discography | | |At 24 months p = 0.002 for ODI |fusion. |

| | | | | | | |

| | | | | |At 3 months compared to preop |Author did not compare outcomes |

| |ASP: | | | |score: |between patients with one or two |

| |Interval between surgeries: 4.5 | | | |VAS: 4.25 ± 0.40 (P < 0.0001) |level arthroplasty. |

| |years (range, 6-216 months) | | | |ODI: 42.00 ± 1.43 (P < 0.0001) | |

| | | | | | | |

| | | | | |Improvement at 24 months compared | |

| | | | | |to 3 months: | |

| | | | | |ODI: 13.00 ± 1.82 (P = 0.002) | |

| | | | | |VAS: 0.75 ± .53 (NS) | |

Level of Evidence Summary Table for Included Studies

|Methodological principle |Chen |Bertagnoli |Djurasovic |Parker |Whitecloud |Schlegel |Phillips |Glassman |

|Study design | | | | | | | | |

|Randomized controlled trial | | | | | | | | |

|Cohort Study | | | | | | | | |

|Case-series |√ |√ |√ |√ |√ |√ |√ |√ |

|Statement of concealed allocation† | | | | | | | | |

|Intention to treat† | | | | | | | | |

|Independent or blind assessment | |√ | |√ | | | | |

|Co-interventions applied equally |NA |NA |NA |NA |NA |NA |NA |NA |

|Complete follow-up of >80% | |√ | | | | | | |

|Adequate sample size | | | | | | | | |

|Controlling for possible confounding |NA |NA |NA |NA |NA |NA |NA |NA |

|Prospective study | |√ | |√ |√ | |√ | |

Evidence Level |IV |IV |IV |IV |IV |IV |IV |IV | |†Applies to Randomized controlled trials only

NA = not applicable for a case series

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