The grades of recommendations (standards, guidelines, and options) and classes of evidence (I–III) are defined at the end of the "Major Recommendations" field.
Standards. There is insufficient evidence to recommend a treatment standard.
Guidelines. In the context of a single-level stand-alone anterior lumbar interbody fusion (ALIF) or ALIF with posterior instrumentation, the addition of a posterolareral fusion (PLF) is not recommended as it increases operating room time and blood loss without influencing the likelihood of fusion or the functional outcome.
Options. 1) It is recommended that both PLF and interbody fusion (posterolateral lumbar interbody fusion [PLIF], transformal LIF [TLIF], or ALIF) techniques be considered as treatment options for patients with low-back pain due to degenerative disc disease (DDD) at one or two levels. 2) Placement of an interbody graft is recommended as a treatment option to improve fusion rates and functional outcome in patients undergoing surgery for low-back pain due to DDD at one or two levels. The surgeon is cautioned that the marginal improvement in fusion rates and functional outcome with these techniques is associated with increased complication rates, particularly when combined approaches (that is, 360 degrees) are used. 3) The use of multiple approaches (anterior and posterior) to accomplish lumbar fusion is not recommended as a routine option for the treatment of patients with low-back pain without deformity.
Summary
The majority of reviewed medical evidence suggests that interbody techniques are associated with higher fusion rates compared with PLF when applied to patients with low-back pain due to DDD limited to one or two levels. The evidence is generally of poor quality and retrospective in nature. Conflicting evidence exists supporting the role of interbody graft placement for improvement of functional outcomes; however, there is no Class I or II evidence to suggest that the use of an interbody graft is associated with worse outcomes, and Class II evidence exists to suggest that outcomes are improved. Complication rates of interbody graft placement, particularly of circumferential procedures, are higher in most series. Many complications, however, are associated with pedicle screw fixation and not with interbody graft placement per se. In the context of a single-level stand-alone ALIF or ALIF with posterior instrumentation, there does not appear to be a substantial benefit to the addition of a PLF. The addition of a PLF to a construct that already includes an interbody graft is, however, associated with increased costs and complications. Therefore, although the addition of supplemental fixation (a 270 degree fusion) may be necessary for biomechanical reasons, it may not be appropriate to subject the patient to the morbidity of a full posterior exposure for placement of graft material.
Significant differences in clinical outcomes between the various interbody techniques have not been convincingly demonstrated. No general recommendation can therefore be made regarding the technique that should be used to achieve interbody fusion.
Definitions:
Grades of Recommendation
Standards Recommendations of the strongest type, based on Class I evidence reflecting a high degree of clinical certainty
Guidelines Recommendations based on Class II evidence reflecting a moderate degree of clinical certainty
Options Recommendations based on Class III evidence reflecting unclear clinical certainty
Classes of Evidence
Class I Evidence from one or more well-designed, randomized controlled clinical trials, including overviews of such trials
Class II Evidence from one or more well-designed comparative clinical studies, such as nonrandomized cohort studies, case-control studies, and other comparable studies, including less well-designed randomized controlled trials
Class III Evidence from case series, comparative studies with historical controls, case reports, and expert opinion as well as significantly flawed randomized controlled trials