Introduction: Regional rates of surgical fusion of the lumbar spine vary more than any other surgical procedure.

Methods: The RAND/UCLA Appropriateness Method was used to identify degenerative indications for lumbar fusion. A North American expert panel of 13 physicians independently rated clinical scenarios for lumbar fusion. Panelists rated 1296 scenarios from 1 to 9 for their appropriateness for lumbar fusion. A meeting was then convened in a modified Delphi process and scenarios were again rated. The resulting criteria were applied in 150 patients who underwent elective instrumented lumbar fusion.

Results: Of the 1296 final scenarios, fusion was appropriate in 133 (10%), uncertain in 375 (29%), and inappropriate in 735 (57%). Disagreement occurred in the remaining 53 scenarios (4%). Of the appropriate indications, spondylolisthesis accounted for 98 (74%), spinal stenosis for 18 (14%), spondylosis for 9 (7%), and disc herniation for 8 (6%). Appropriate fusion was associated with mechanical low back pain (P<0.001) and radiologic signs of instability or sagittal imbalance (P<0.001). Of the 150 operated patients, fusion was appropriate in 72 (48%), uncertain in 70 (47%), and inappropriate in 8 (5%). In the 2 years after surgery, patients who underwent appropriate fusion required less cross-sectional imaging for persistent, worsening, or recurrent symptoms (adjusted hazard ratio [HR], 2.42; 95% confidence interval [CI], 1.31 to 4.48; P<0.01) and fewer spinal injections (adjusted HR, 2.53; 95% CI, 1.29 to 4.96; P<0.01). There was, however, no significant difference between groups in the probability of reoperation (P=0.84), rehospitalization (P=0.50), or use of prescription pain medication (P=0.23).

Conclusions: Criteria for the appropriate use of lumbar fusion for degenerative indications were identified (web-based decision tool accessible at www.appropriatelumbarfusion.com/site). In operated patients, appropriate fusion was associated with reduced healthcare demands. The criteria will require further validation and regular revision.

Patient Care: Criteria for the appropriate use of lumbar fusion for degenerative indications were identified by a multidisciplinary expert panel using the RAM. The recommendations are intended as a broadly applicable aid to decision making. By preventing costly procedures of limited value to patients, the appropriate use of lumbar fusion will improve care and promote responsible resource allocation.

Learning Objectives: By the conclusion of this session, participants should be able to: 1) Discuss the priority of exam findings and test results when selecting patients for fusion; 2) Describe the influence of appropriate fusion on subsequent measures of healthcare use; 3) Identify indications inappropriate for fusion.

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