Supplemental Digital Material
Tables
Table 1. Level of Evidence grade for studies comparing fusion with multidimensional
supervised rehabilitation in CLBP patients with or without isthmic spondylolisthesis.
Methodological Principle
Brox
Fairbank Fritzell
Möller
Study design
Randomized controlled trial
Cohort Study
Case-series
Statement of concealed allocation*
Intention to treat*
Independent or blind assessment
Co-interventions applied equally
Complete follow-up of >80%
Adequate sample size
Controlling for possible confounding
Evidence Level

















†










I
I
II
II
*Applies to randomized controlled trials only
†Fritzell: while the intention to treat principle was used to analyze the differences between treatment groups, group
changers and drop outs were excluded from all reported data. Because we used the raw data to calculate SMDs and RDs, we
did not give credit.
Table 2. Results of studies comparing fusion with rehabilitation in patients with CLBP with and
without isthmic spondylolisthesis.
Fusion
Study
Outcome
N (%) or
pre and post score
Change score
(CS)*
Multidimensional supervised
rehabilitation
N (%) or
Change score
pre and post
(CS)*
scores
With isthmic spondylolisthesis
Möller (2000)/
Eckman (2005)
Disability Rating Index†
Pain (VAS)§
Patient-perceived outcome
(much better or better)
Clinician-perceived
outcome (much better or
better)
At-work
Pre: 48 ± 4.4‡
1 yr: 29 ± 5.9‡
2 yrs: 29 ± 5.8‡
9 yrs: 33 ± 5.6‡
Pre: 63 ± 4.7‡
1 yr: 35 ± 6.9‡
2 yrs: 37 ± 7.2‡
9 yrs: 40 ± 6.7‡
2 yrs: 74% (56/75)
9 yrs: 82%
2 yrs: 73% (55/75)
9 yrs: NR
Pre: 25% (19/77)
1 yr: 46%
2 yrs: 54% (41/75)
9 yrs: 51%
1 yr: 19
2 yrs: 19
9 yrs: 15
1 yr: 28
2 yrs: 26
9 yrs: 23
n/a
n/a
1 yr: 21%
2 yrs: 29%
9 yrs: 26%
Pre: 44 ± 6.2‡
1 yr: 45 ± 8.8‡
2 yrs: 44 ± 7.3‡
9 yrs: 38 ± 9.5‡
Pre: 65 ± 7.4‡
1 yr: 54 ± 9.7‡
2 yrs: 56 ± 7.7‡
9 yrs: 49 ± 10.4‡
2 yrs: 43% (13/31)
9 yrs: 66%
2 yrs: 23% (7/31)
9 yrs: NR
Pre: 38% (13/34)
1 yr: 48%
2 yrs: 55% (17/31)
9 yrs: 46%
1 yr: -1
2 yrs: 0
9 yrs: 6
1 yr: 11
2 yrs: 9
9 yrs: 16
n/a
n/a
1 yr: 10%
2 yrs: 17%
9 yrs: 8%
Without isthmic spondylolisthesis
Brox (2003)
ODI
General function score
Back pain (VAS)
Leg pain (VAS)
Emotional distress
Life satisfaction
Patients overall rating of
success
Physician overall rating of
success
Working full-time
Fairbank (2005)
ODI
ODI: Chronic back pain
pts only
SF-36 physical
SF-36 mental
Fritzell (2001)
Back pain (VAS)
Leg pain (VAS)
n = 35
Pre: 42.0 ± 11.0
1 yr: 26.4 ± 16.4
Pre: 35.9 ± 18.6
1 yr: 18.3 ± 17.3
Pre: 62.1 ± 14.5
1 yr: 39.4 ± 25.5
Pre: 43.5 ± 27.7
1 yr: 26.6 ± 28.1
Pre: 1.8 ± 0.5
1 yr: 1.5 ± 0.4
Pre: 5.4 ± 2.4
1 yr: 6.2 ± 2.4
1 yr: 71% (25/35)
1 yr: 69% (24/35)
Pre: 26% (9/35)
1 yr: 23% (8/35)
n = 138
Pre: 46.5 ± 14.6
2 yrs: 34.0 ± 21.1
n = NR
Pre: 46.7 ± 14.5
2 yrs: 33.3 ± 20.8
n =115
Pre: 19.4 ± 8.8
2 yrs: 28.8 ± 14.9
n = 115
Pre: 43.2 ± 10.9
2 yrs: 47.4 ± 12.2
n = 195
Pre: 64.2 ± 14.3
2 yrs: 43.2 ± 25.2**
n = 192
Pre: 35.3 ± 25.4
2 yrs: 29.0 ± 27.0**
1 yr: 0.8
n/a
n = 26
Pre: 43.0 ± 13.0
1 yr: 29.7 ± 19.6
Pre: 44.6 ± 13.7
1 yr: 22.6 ± 18.9
Pre: 64.1 ± 13.7
1 yr: 48.7 ± 24.0
Pre: 34.0 ± 19.3
1 yr: 35.5 ± 30.6
Pre: 1.9 ± 0.6
1 yr: 1.6 ± 0.5
Pre: 4.8 ± 2.0
1 yr: 6.6 ± 2.1
1 yr: 65% (17/26)
n/a
1 yr: 77% (20/26)
1 yr: 15.6
1 yr: 17.6
1 yr: 22.7
1 yr: 16.9
1 yr: 0.3
1 yr: -3%
2 yrs: 12.5
2 yrs: 13.4
2 yrs: 9.4
2 yrs: 4.2
2 yrs: 21.0
2 yrs: 6.3
Pre: 23% (6/26)
1 yr: 35% (9/26)
n = 146
Pre: 44.8 ± 14.8
2 yrs: 36.1 ± 20.6
n = NR
Pre: 45.4 ± 15.2
2 yrs: 37.2 ± 21.1
n =131
Pre: 20.0 ± 9.7
2 yrs: 27.6 ± 14.6
n = 131
Pre: 44.2 ± 12.6
2 yrs: 48.1 ± 12.6
n = 62
Pre: 62.6 ± 14.3
2 yrs: 58.3 ± 18.8**
n = 59
Pre: 35.6 ± 25.2
2 yrs: 42.6 ± 24.8**
1 yr: 13.3
1 yr: 22.0
1 yr: 15.4
1 yr: -1.5
1 yr: 0.3
1 yr: 1.8
n/a
n/a
1 yr: 12%
2 yrs: 8.7
2 yrs: 8.2
2 yrs: 7.6
2 yrs: 3.9
2 yrs: 4.3
2 yrs: -7.0
Fusion
Study
Outcome
ODI
MVAS
GFS
Zung
Return to work††
Patient-perceived rating
(% improved)‡‡
Physician-perceived rating
(excellent or good)
Physician-perceived rating
(excellent, good, or fair)
Willing to go through
again
N (%) or
pre and post score
n = 197
Pre: 47.3 ± 11.4
2 yrs: 35.7 ± 18.0**
n = 197
Pre: 63.7 ± 11.3
2 yrs: 45.6 ± 23.1**
n = 194
Pre: 49.1 ± 15.9
2 yrs: 34.1 ± 22.4**
n = 191
Pre: 39.1 ± 13.3
2 yrs: 31.4 ± 15.2**
2 yrs: 36% (57/160)**
Change score
(CS)*
Multidimensional supervised
rehabilitation
N (%) or
Change score
pre and post
(CS)*
scores
2 yrs: 7.7
n/a
n = 62
Pre: 48.4 ± 11.9
2 yrs: 45.6 ± 16.1**
n = 61
Pre: 65.5 ± 11.5
2 yrs: 60.4 ± 17.2**
n = 61
Pre: 47.6 ± 16.3
2 yrs: 45.5 ± 20.3**
n = 61
Pre: 39.4 ± 13.9
2 yrs: 36.7 ± 14.5**
2 yrs: 13% (6/48)**
2 yrs: 62.6% (122/195)**
n/a
2 yrs: 29.0% (18/62)**
n/a
2 yrs: 45.5% (91/200)**
n/a
2 yrs: 17.7% (11/62)**
n/a
2 yrs: 78.0% (156/200)**
n/a
2 yrs: 58.0% (36/62)**
n/a
2 yrs: 75.1% (145/193)**
n/a
2 yrs: 52.6% (30/57)**
n/a
2 yrs: 11.6
2 yrs: 18.1
2 yrs: 15.0
2 yrs: 2.8
2 yrs: 5.1
2 yrs: 2.1
2 yrs: 2.7
n/a
GFS: General Function Score; JOAS: Japanese Orthopedic Association Score; MVAS: Million Visual Analogue Score; n/a: not
applicable; NR: not reported; ODI: Oswestry Disability Index; VAS: Visual Analogue Scale
*Change score = post score – pre score; for outcome measures where a lower score represents a better outcome, the change
score is multiplied by -1 so that a positive score always represents improvement.
†Disability Rating Index (DRI): functional outcome score represents the mean of 12 VAS items: dressing, outdoor walking,
climbing stairs, sitting for longer time, standing bent over a sink, carrying a bag, making a bed, running, light work, heavy
work, lifting heavy objects, and participation in exercise or sports. Scores range from 0 (without difficulty) to 100 (impossible)
mm.
‡Standard deviation calculated using the mean and 95% confidence interval as reported in the study.
§Pain VAS reflects the overall pain index and does not distinguish between back and leg pain. The pain index was calculated
by taking the mean of the VAS for “pain right now” and that for “worst pain last week”. Scores range from 0 (no pain) to 100
(intolerable pain) mm.
**Data reported excluded group changers and dropouts (surgical: n = 201; nonsurgical: n = 63); although the authors included
group changers were included in the test for interaction (NR).
††Return to work calculated by subtracting the number of patients who stopped working from those who went back to work;
excludes patients who were on full time pension/ disability pension (surgical: n = 160; nonsurgical: n = 48).
‡‡Patient-rated improvement (“much better” or “better”) or no improvement (“unchanged” or “worse”) of back problems
Table 3. Articles excluded
Study
Reason for exclusion
Athiviraham 2007
Brox 2006, 2010
Chang 2005
1
degenerative spondylolisthesis and stenosis
2,3
prior surgery and or stenosis
4
stenosis with or without HNP
Ghogawala 2004
5
degenerative spondylolisthesis and stenosis
6
Herkowitz 1991
Maine Lumbar Spine Study Atlas 1996, 2000,
20057-9
Malmivaara 200710
degenerative spondylolisthesis and stenosis
degenerative spondylolisthesis and stenosis
Matsudaira 200512
degenerative spondylolisthesis and stenosis
no supervised rehabilitation, fusion versus
laminectomy or discectomy
degenerative spondylolisthesis and stenosis
Molinary 200113
results not stratified by subgroup
Malter 199811
Ohtori 2011
14
Weinstein 2007, 2008, 2010
1.
2.
3.
4.
5.
6.
7.
select population, no supervised rehabilitation
15-18
; Park 2010
19
degenerative spondylolisthesis and stenosis
Athiviraham A, Yen D. Is spinal stenosis better treated surgically or nonsurgically? Clin
Orthop Relat Res. May 2007;458:90-93.
Brox JI, Nygaard OP, Holm I, Keller A, Ingebrigtsen T, Reikeras O. Four-year follow-up
of surgical versus non-surgical therapy for chronic low back pain. Ann Rheum Dis. Sep
2010;69(9):1643-1648.
Brox JI, Reikeras O, Nygaard O, et al. Lumbar instrumented fusion compared with
cognitive intervention and exercises in patients with chronic back pain after previous
surgery for disc herniation: a prospective randomized controlled study. Pain. May
2006;122(1-2):145-155.
Chang Y, Singer DE, Wu YA, Keller RB, Atlas SJ. The effect of surgical and nonsurgical
treatment on longitudinal outcomes of lumbar spinal stenosis over 10 years. J. Am.
Geriatr. Soc. May 2005;53(5):785-792.
Ghogawala Z, Benzel EC, Amin-Hanjani S, et al. Prospective outcomes evaluation after
decompression with or without instrumented fusion for lumbar stenosis and degenerative
Grade I spondylolisthesis. J Neurosurg Spine. Oct 2004;1(3):267-272.
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. Jul 1991;73(6):802-808.
Atlas SJ, Deyo RA, Keller RB, et al. The Maine Lumbar Spine Study, Part II. 1-year
outcomes of surgical and nonsurgical management of sciatica. Spine (Phila Pa 1976).
Aug 1 1996;21(15):1777-1786.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
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 (Phila Pa 1976). Mar 1 2000;25(5):556-562.
Atlas SJ, Keller RB, Wu YA, Deyo RA, Singer DE. Long-term outcomes of surgical and
nonsurgical management of lumbar spinal stenosis: 8 to 10 year results from the maine
lumbar spine study. Spine (Phila Pa 1976). Apr 15 2005;30(8):936-943.
Malmivaara A, Slatis P, Heliovaara M, et al. Surgical or nonoperative treatment for
lumbar spinal stenosis? A randomized controlled trial. Spine (Phila Pa 1976). Jan 1
2007;32(1):1-8.
Malter AD, McNeney B, Loeser JD, Deyo RA. 5-year reoperation rates after different
types of lumbar spine surgery. Spine (Phila Pa 1976). Apr 1 1998;23(7):814-820.
Matsudaira K, Yamazaki T, Seichi A, et al. Spinal stenosis in grade I degenerative
lumbar spondylolisthesis: a comparative study of outcomes following laminoplasty and
laminectomy with instrumented spinal fusion. J. Orthop. Sci. May 2005;10(3):270-276.
Molinari RW, Gerlinger T. Functional outcomes of instrumented posterior lumbar
interbody fusion in active-duty US servicemen: a comparison with nonoperative
management. Spine J. May-Jun 2001;1(3):215-224.
Ohtori S, Koshi T, Yamashita M, et al. Surgical versus nonsurgical treatment of selected
patients with discogenic low back pain: a small-sized randomized trial. Spine (Phila Pa
1976). Mar 1 2011;36(5):347-354.
Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical versus nonsurgical treatment for
lumbar degenerative spondylolisthesis. N Engl J Med. May 31 2007;356(22):2257-2270.
Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical compared with nonoperative
treatment for lumbar degenerative spondylolisthesis. four-year results in the Spine Patient
Outcomes Research Trial (SPORT) randomized and observational cohorts. J Bone Joint
Surg Am. Jun 2009;91(6):1295-1304.
Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical versus nonsurgical therapy for
lumbar spinal stenosis. N Engl J Med. Feb 21 2008;358(8):794-810.
White AH, von Rogov P, Zucherman J, Heiden D. Lumbar laminectomy for herniated
disc: a prospective controlled comparison with internal fixation fusion. Spine (Phila Pa
1976). Apr 1987;12(3):305-307.
Park DK, An HS, Lurie JD, et al. Does multilevel lumbar stenosis lead to poorer
outcomes?: a subanalysis of the Spine Patient Outcomes Research Trial (SPORT) lumbar
stenosis study. Spine (Phila Pa 1976). Feb 15 2010;35(4):439-446.