Fusion of the lumbar spine. A consideration of the indications.

Low back pain (LBP) is a common complaint with various studies indicating a point prevalence of from 12% to 33%, a one-year prevalence from 22% to 65%, and lifetime prevalence from 11% to 84%. Most Western adults complaining of LBP do not seek professional treatment, but those with chronic spinal disorders have worse scores for measurement of physical function than those with most other conditions. Some may be candidates for lumbar spinal fusion. There are different opinions concerning the indications for this procedure, which is reflected in the considerable regional variation. Countries with high rates of back surgery also have similar levels of other discretionary procedures such as tonsillectomy and hysterectomy. In an Australian investigation, the rates of surgery of the lumbar spine varied from 25/100 000 to 92/100 000. In a regression model, only the rate of unemployment correlated negatively with the variation in the rate of lumbar spinal surgery and accounted for 11% of this. In another study on lumbar disc herniation, outcomes for patients who had been operated on by surgeons in areas with low rates of surgery were better than those in areas with high rates. These latter generally had less severe preoperative symptoms. We do not know to what extent factors such as genetics, occupation, access to health care, and the opinions of the general population about spinal fusion explain regional variation. The differing opinion of surgeons concerning the indications, however, appears to play an important role and the complexity of this process is high. This review focuses on the most common problems and indications, and does not claim completeness. Particularly, conditions such as tumours, infections, trauma, lumbar Scheuermann’s disease, kyphosis, severe lordosis, and degenerative scoliosis are not included. The indications for fusion