STUDY DESIGN: Systematic review. OBJECTIVE: To determine if the presence of isthmic spondylolisthesis modifies the effect of treatment (fusion versus multidimensional supervised rehabilitation) in patients with chronic low back pain (CLBP). SUMMARY OF BACKGROUND DATA: Results of spinal surgery for CLBP are variable. It is unclear whether patients with CLBP and isthmic spondylolisthesis have more success with surgery versus a multidimensional supervised rehabilitation program when compared with those with CLBP but without spondylolisthesis. METHODS: A systematic search was conducted in Medline and the Cochrane Collaboration Library for articles published through January 2011. Randomized controlled trials (RCTs) were included that compared spine fusion versus multidimensional supervised rehabilitation in patients with and without isthmic spondylolisthesis. Standardized mean differences (SMDs) and risk differences were calculated for common outcomes, and then compared to determine potential heterogeneity of treatment effect. The final strength of the body of literature was expressed as "high", "moderate", or "low" confidence that the evidence reflects the true effect. RESULTS: No studies were found that directly compared the two subgroups. Three RCTs compared fusion with supervised nonoperative care in patients with CLBP without isthmic spondylolisthesis; one RCT evaluated these treatments in patients with isthmic spondylolisthesis. There were study differences in patient characteristics, type of fusion, the nature of the rehabilitation, outcomes assessed, and length of follow-up. The SMDs for pain in favor of fusion were modest at 2 years for those without isthmic spondylolisthesis, but large in favor of fusion for those with isthmic spondylolisthesis compared with rehabilitation. Similarly, the SMDs for function in patients without isthmic spondylolisthesis compared with rehabilitation was small at 2 years, but appreciably higher in favor of fusion in patients with isthmic spondylolisthesis. CONCLUSION: The overall strength of evidence evaluating whether the presence of isthmic spondylolisthesis modifies the effect of fusion compared with rehabilitation patients with CLBP is "low". Fusion should be considered for patients with low back pain and isthmic spondylolisthesis who have failed nonoperative treatment. CLINICAL RECOMMENDATIONS: We recommend considering fusion for patients with isthmic spondylolisthesis and lower back pain who have failed nonoperative treatment. RECOMMENDATION: Weak.
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