Decompression with or without concomitant fusion in lumbar stenosis due to degenerative spondylolisthesis: a systematic review

Decompression alone or decompression with fusion for lumbar spinal stenosis: five-year clinical results from a randomized clinical trial

Aims

We compared decompression alone to decompression with fusion surgery for lumbar spinal stenosis, with or without degenerative spondylolisthesis (DS). The aim was to evaluate if five-year outcomes differed between the groups. The two-year results from the same trial revealed no differences.

Methods

The Swedish Spinal Stenosis Study was a multicentre randomized controlled trial with recruitment from September 2006 to February 2012. A total of 247 patients with one- or two-level central lumbar spinal stenosis, stratified by the presence of DS, were randomized to decompression alone or decompression with fusion. The five-year Oswestry Disability Index (ODI) was the primary outcome. Secondary outcomes were the EuroQol five-dimension questionnaire (EQ-5D), visual analogue scales for back and leg pain, and patient-reported satisfaction, decreased pain, and increased walking distance. The reoperation rate was recorded.

Results

Five-year follow-up was completed by 213 (95%) of the eligible patients (mean age 67 years; 155 female (67%)). After five years, ODI was similar irrespective of treatment, with a mean of 25 (SD 18) for decompression alone and 28 (SD 22) for decompression with fusion (p = 0.226). Mean EQ-5D was higher for decompression alone than for fusion (0.69 (SD 0.28) vs 0.59 (SD 0.34); p = 0.027). In the no-DS subset, fewer patients reported decreased leg pain after fusion (58%) than with decompression alone (80%) (relative risk (RR) 0.71 (95% confidence interval (CI) 0.53 to 0.97). The frequency of subsequent spinal surgery was 24% for decompression with fusion and 22% for decompression alone (RR 1.1 (95% CI 0.69 to 1.8)).

Conclusion

Adding fusion to decompression in spinal stenosis surgery, with or without spondylolisthesis, does not improve the five-year ODI, which is consistent with our two-year report. Three secondary outcomes that did not differ at two years favoured decompression alone at five years. Our results support decompression alone as the preferred method for operating on spinal stenosis.

Degenerative lumbar spondylolisthesis: review of current classifications and proposal of a novel classification system

PURPOSE

To review existing classification systems for degenerative spondylolisthesis (DS), propose a novel classification designed to better address clinically relevant radiographic and clinical features of disease, and determine the inter- and intraobserver reliability of this new system for classifying DS.

METHODS

The proposed classification system includes four components: 1) segmental dynamic instability, 2) location of spinal stenosis, 3) sagittal alignment, and 4) primary clinical presentation. To establish the reliability of this system, 12 observers graded 10 premarked test cases twice each. Kappa values were calculated to assess the inter- and intraobserver reliability for each of the four components separately.

RESULTS

Interobserver reliability for dynamic instability, location of stenosis, sagittal alignment, and clinical presentation was 0.94, 0.80, 0.87, and 1.00, respectively. Intraobserver reliability for dynamic instability, location of stenosis, sagittal alignment, and clinical presentation were 0.91, 0.88, 0.87, and 0.97, respectively.

CONCLUSION

The UCSF DS classification system provides a novel framework for assessing DS based on radiographic and clinical parameters with established implications for surgical treatment. The almost perfect interobserver and intraobserver reliability observed for all components of this system demonstrates that it is simple and easy to use. In clinical practice, this classification may allow subclassification of similar patients into groups that may benefit from distinct treatment strategies, leading to the development of algorithms to help guide selection of an optimal surgical approach. Future work will focus on the clinical validation of this system, with the goal of providing for more evidence-based, standardized approaches to treatment and improved outcomes for patients with DS.

Evaluation of "appropriate use criteria" for surgical decision-making in lumbar degenerative spondylolisthesis. A controlled, multicentre, prospective observational study

INTRODUCTION

Selecting patients with lumbar degenerative spondylolisthesis (LDS) for surgery is difficult. Appropriate use criteria (AUC) have been developed to clarify the indications for LDS surgery but have not been evaluated in controlled studies.

METHODS

This prospective, controlled, multicentre study involved 908 patients (561 surgical and 347 non-surgical controls; 69.5 ± 9.7y; 69% female), treated as per normal clinical practice. Their appropriateness for surgery was afterwards determined using the AUC. They completed the Core Outcome Measures Index (COMI) at baseline and 12 months' follow-up. Multiple regression adjusting for confounders evaluated the influence of appropriateness designation and treatment received on the 12-month COMI and achievement of MCIC (≥ 2.2-point-reduction).

RESULTS

As per convention, appropriate (A) and uncertain (U) groups were combined for comparison with the inappropriate (I) group. For the adjusted 12-month COMI, the benefit of surgery relative to non-surgical care was not significantly greater for the A/U than the I group (p = 0.189). There was, however, a greater treatment effect of surgery for those with higher baseline COMI (p = 0.035). The groups' adjusted probabilities of achieving MCIC were: 83% (A/U, receiving surgery), 71% (I, receiving surgery), 50% (A/U, receiving non-surgical care), and 32% (I, receiving non-surgical care).

CONCLUSIONS

A/U patients receiving surgery had the highest chances of achieving MCIC, but the AUC were not able to identify which patients had a greater treatment effect of surgery relative to non-surgical care. The identification of other characteristics that predict a greater treatment effect of surgery, in addition to baseline COMI, is required to improve decision-making.

Symptomatic lumbar stenosis due to low-grade degenerative spondylolisthesis can effectively be treated with mere decompression

PURPOSE

Adding instrumented spondylodesis to decompression in symptomatic spinal stenosis with degenerative spondylolisthesis is subject of debate. The presence of spondylolisthesis due to degeneration is an indicator of severe facet joint and intervertebral disc degeneration, and this may fit increased instability of the spine. We aim to establish the incidence of degenerative spondylolisthesis in spinal stenosis surgical candidates and to evaluate the incidence of failure of decompressive surgery without concomitant spondylodesis as initial treatment.

METHODS

Medical files of all operated patients for spinal stenosis between 2007 and 2013 were evaluated. Demographic characteristics, pre-operative radiological characteristics (level of stenosis, presence, and grade of spondylolisthesis), surgical technique, incidence, and indication for reoperation were summarised, as well as the type of reoperation. Patient satisfaction was classified as 'satisfied' or 'unsatisfied' after initial and secondary surgery. The follow-up was 6 to 12 years.

RESULTS

Nine hundred thirty-four patients were included, and 253 (27%) had a spondylolisthesis. Seventeen percent of the spondylolisthesis patients receiving decompression were reoperated versus 12% of the stenosis patients (p=.059). Reoperation in the spondylolisthesis group concerned instrumented spondylodesis in 38 versus 10% in the stenosis group. The satisfaction percentage was comparable in the stenosis and the spondylolisthesis group two months after surgery (80 vs. 74%). Of the 253 spondylolisthesis patients, 1% initially received instrumented spondylodesis and 6% in a second operation.

CONCLUSION

Lumbar stenosis with and without (low-grade) degenerative spondylolisthesis can usually effectively be treated with mere decompression. Instrumented surgery in a second surgical procedure does not lead to less satisfaction with surgical outcomes.

Decompression alone versus decompression with instrumented fusion in the treatment of lumbar degenerative spondylolisthesis: a systematic review and meta-analysis of randomised trials

OBJECTIVE

To determine the efficacy of adding instrumented spinal fusion to decompression to treat degenerative spondylolisthesis (DS).

DESIGN

Systematic review with meta-analysis.

DATA SOURCES

MEDLINE, Embase, Emcare, Cochrane Library, CINAHL, Scopus, ProQuest Dissertations & Theses Global, ClinicalTrials.gov and WHO International Clinical Trials Registry Platform from inception to May 2022.

ELIGIBILITY CRITERIA FOR STUDY SELECTION

Randomised controlled trials (RCTs) comparing decompression with instrumented fusion to decompression alone in patients with DS. Two reviewers independently screened the studies, assessed the risk of bias and extracted data. We provide the Grading of Recommendations, Assessment, Development and Evaluation assessment of the certainty of evidence (COE).

RESULTS

We identified 4514 records and included four trials with 523 participants. At a 2-year follow-up, adding fusion to decompression likely results in trivial difference in the Oswestry Disability Index (range 0-100, with higher values indicating greater impairment) with mean difference (MD) 0.86 (95% CI -4.53 to 6.26; moderate COE). Similar results were observed for back and leg pain measured on a scale of 0 to 100, with higher values indicating more severe pain. There was a slightly increased improvement in back pain (2-year follow-up) in the group without fusion shown by MD -5·92 points (95% CI -11.00 to -0.84; moderate COE). There was a trivial difference in leg pain between the groups, slightly favouring the one without fusion, with MD -1.25 points (95% CI -6.71 to 4.21; moderate COE). Our findings at 2-year follow-up suggest that omitting fusion may increase the reoperation rate slightly (OR 1.23; 0.70 to 2.17; low COE).

CONCLUSIONS

Evidence suggests no benefits of adding instrumented fusion to decompression for treating DS. Isolated decompression seems sufficient for most patients. Further RCTs assessing spondylolisthesis stability are needed to determine which patients would benefit from fusion.

PROSPERO REGISTRATION NUMBER

CRD42022308267.

Comparison of 270-degree percutaneous transforaminal endoscopic decompression under local anesthesia and minimally invasive transforaminal lumbar interbody fusion in the treatment of geriatric lateral recess stenosis associated with degenerative lumbar spondylolisthesis

PURPOSE

Various lumbar decompression techniques have been used for the treatment of degenerative lumbar spondylolisthesis (DLS). Few studies have compared the clinical efficacy of percutaneous transforaminal endoscopic decompression (PTED) and minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) in the treatment of lateral recess stenosis associated with DLS (LRS-DLS) in geriatric patients. The objective of the study was to compare the safety and short-term clinical efficacy of 270-degree PTED under local anesthesia and MIS-TLIF in the treatment of LRS-DLS in Chinese geriatric patients over 60 years old.

MATERIALS AND METHODS

From January 2017 to August 2019, the data of 90 consecutive geriatric patients with single-level L4-5 LRS-DLS were retrospectively reviewed, including those in the PTED group (n = 44) and MIS-TLIF group (n = 46). The patients were followed up for at least 1 year. Patient demographics and perioperative outcomes were reviewed before and after surgery. The Oswestry Disability Index (ODI), visual analog scale (VAS) for leg pain, and modified MacNab criteria were used to evaluate the clinical outcomes. X-ray examinations were performed 1 year after surgery to assess the progression of spondylolisthesis in the PTED group and bone fusion in the MIS-TLIF group.

RESULTS

The mean patient ages in the PTED and MIS-TLIF groups were 70.3 years and 68.6 years, respectively. Both the PTED and MIS-TLIF groups demonstrated significant improvements in the VAS score for leg pain and ODI score, and no significant differences were found between the groups at any time point (P > 0.05). Although the good-to-excellent rate of the modified MacNab criteria in the PTED group was similar to that in the MIS-TLIF group (90.9% vs. 91.3%, P > 0.05), PTED was advantageous in terms of the operative time, estimated blood loss, incision length, drainage time, drainage volume, length of hospital stay, and complications.

CONCLUSIONS

Both PTED and MIS-TLIF led to favorable outcomes in geriatric patients with LRS-DLS. In addition, PTED caused less severe trauma and fewer complications. In terms of perioperative quality-of-life and clinical outcomes, PTED could supplement MIS-TLIF in geriatric patients with LRS-DLS.

Lumbar interbody fusion using oblique (OLIF) and lateral (LLIF) approaches for degenerative spine disorders: a meta-analysis of the comparative studies

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVE

Historically, posterior approaches to the lumbar spine have allowed surgeons to manage degenerative conditions affecting the lumbar spine. However, spinal muscles injury, post-surgical vertebral instability, cerebrospinal fluid (CSF) leakage, and failed back surgery syndrome (FBSS) represent severe complications that may occur after these surgeries. Lumbar interbody fusion using anterior (ALIF), oblique (OLIF), or lateral (LLIF) approaches may represent valuable surgical alternatives, in case fusion is indicated on single or multiple levels.

METHODS

The present study is a systematic review, conducted according to the PRISMA statement, of comparative studies on OLIF, and LLIF for degenerative spine disorders, and a meta-analysis of their clinical-radiological outcomes and complications.

RESULTS

After screening 1472 papers on PubMed, Scopus, and Cochrane Library, only 3 papers were included in the present study. 318 patients were included for data meta-analysis, 128 in OLIF group, and 190 in LLIF group. There were no significative differences in terms of surgical (intraoperative blood loss and surgical duration) and clinical (VAS-back, VAS-leg, and ODI scores) outcomes, or fusion rates at last follow-up (> 2 years). Significantly higher rates of abdominal complications, system failure, and vascular injuries were recorded in the OLIF group. Conversely, postoperative neurological symptoms and psoas weakness were significatively more common in LLIF group.

CONCLUSIONS

The meta-analysis suggests that OLIF and LLIF are both effective for lumbar degenerative disorders, although each of them presents specific complications and this should represent a relevant element in the surgical planning.

Decompression alone or decompression with fusion for lumbar spinal stenosis: a randomized clinical trial with two-year MRI follow-up

AIMS

The aims of this study were first, to determine if adding fusion to a decompression of the lumbar spine for spinal stenosis decreases the rate of radiological restenosis and/or proximal adjacent level stenosis two years after surgery, and second, to evaluate the change in vertebral slip two years after surgery with and without fusion.

METHODS

The Swedish Spinal Stenosis Study (SSSS) was conducted between 2006 and 2012 at five public and two private hospitals. Six centres participated in this two-year MRI follow-up. We randomized 222 patients with central lumbar spinal stenosis at one or two adjacent levels into two groups, decompression alone and decompression with fusion. The presence or absence of a preoperative spondylolisthesis was noted. A new stenosis on two-year MRI was used as the primary outcome, defined as a dural sac cross-sectional area ≤ 75 mm² at the operated level (restenosis) and/or at the level above (proximal adjacent level stenosis).

RESULTS

A total of 211 patients underwent surgery at a mean age of 66 years (69% female): 103 were treated by decompression with fusion and 108 by decompression alone. A two-year MRI was available for 176 (90%) of the eligible patients. A new stenosis at the operated and/or adjacent level occurred more frequently after decompression and fusion than after decompression alone (47% vs 29%; p = 0.020). The difference remained in the subgroup with a preoperative spondylolisthesis, (48% vs 24%; p = 0.020), but did not reach significance for those without (45% vs 35%; p = 0.488). Proximal adjacent level stenosis was more common after fusion than after decompression alone (44% vs 17%; p < 0.001). Restenosis at the operated level was less frequent after fusion than decompression alone (4% vs 14%; p = 0.036). Vertebral slip increased by 1.1 mm after decompression alone, regardless of whether a preoperative spondylolisthesis was present or not.

CONCLUSION

Adding fusion to a decompression increased the rate of new stenosis on two-year MRI, even when a spondylolisthesis was present preoperatively. This supports decompression alone as the preferred method of surgery for spinal stenosis, whether or not a degenerative spondylolisthesis is present preoperatively.Cite this article: Bone Joint J 2022;104-B(12):1343-1351.

Current treatment and decision-making factors leading to fusion vs decompression for one-level degenerative spondylolisthesis: survey results from members of the Lumbar Spine Research Society and Society of Minimally Invasive Spine Surgery

BACKGROUND

Degenerative spondylolisthesis (DS) is one of the most common pathologies spine surgeons treat. While a number of potential factors have been identified, there is no current consensus on which variables most impact the decision to fuse vs. decompress alone in this population.

PURPOSE

The purpose of this study was to describe current DS treatment practices and identify both the radiographic and clinical factors leading to the decision to fuse segments for one level DS.

STUDY DESIGN/SETTING

Descriptive cross-sectional survey.

PATIENT SAMPLE

Surveys were administered to members of Lumbar Spine Research Society and Society of Minimally Invasive Spine Surgery.

OUTCOME MEASURES

Surgeon demographics and treatment practices were reported. Radiographic and clinical parameters were ranked by each surgeon with regards to their importance.

METHODS

The primary analysis was limited to completed surveys. Baseline characteristics were summarized. Clinical and radiographic parameters were ranked and compared. Ranking of each clinical and radiographic parameters was reported using best and worst rank, mean rank position, and percentiles. The most important, top 3 most important, and top 5 most important parameters were ordered given each parameter's ranking frequency.

RESULTS

381 surveys were returned completed. With regards to fusion vs. decompression, 19.9% fuse all cases, 39.1% fuse > 75%, 17.8% fuse 50%-75%, and 23.2% fuse <25%. The most common decompressive technique was a partial laminotomy (51.4%), followed by full laminectomy (28.9%). 82.2% of respondents instrument all fusion cases. Instability (93.2%), spondylolisthesis grade (59.8%), and laterolisthesis (37.3%) were the most common radiographic factors impacting the decision to fuse. With regards to the clinical factors leading to fusion, mechanical low back pain (83.2%), activity level (58.3%), and neurogenic claudication (42.8%) were the top 3 clinical parameters.

CONCLUSIONS

There is little consensus on the treatment of DS, with society members showing substantial variation in treatment patterns with the majority utilizing fusion for treatment. The most common radiographic parameters impacting treatment are instability, spondylolisthesis grade, and laterolisthesis while mechanical low back pain, activity level, and neurogenic claudication are the most common clinical parameters.

Decompression alone or decompression and fusion in degenerative lumbar spondylolisthesis

BACKGROUND

Clinically, there are substantive practice variations in surgical management of degenerative lumbar spondylolisthesis. We aimed at evaluating whether decompression alone outcomes for patients with degenerative lumbar spondylolisthesis are comparable to those of decompression with fusion.

METHODS

In this meta-analysis, the Embase, PubMed, and Cochrane Library databases were searched from inception to February 16th, 2022. Randomised controlled trials (RCTs) and cohort studies comparing decompression alone with decompression and fusion for patients with degenerative lumbar spondylolisthesis were included in this study. There were no language limitations. Odds ratio (OR), mean difference (MD) and 95% confidence interval (CI) were used to report results in the random-effects model. Main outcomes included Oswestry disability index (ODI), pain, clinical satisfaction, complication and reoperation rates. The study protocol was published in PROSPERO (CRD42022310645).

FINDINGS

Thirty-three studies (6 RCTs and 27 cohort studies) involving 94 953 participants were included. Differences in post-operative ODI between decompression alone and decompression with fusion were not significant. A small difference for back (MD, 0.13; [95% CI, 0.08 to 0.18]; I ²:0.00%) and leg pain (MD, 0.30; [95% CI, 0.09 to 0.51]; I ²:48.35%) was observed on the 3rd post-operative month. The results did not reveal significant differences in leg pain and back pain between decompression alone and fusion groups on the 6th, 12th, and 24th post-operative months. Difference in clinical satisfaction between decompression alone and decompression with fusion were not significant from RCTs (OR, 0.26; [95% CI, 0.03 to 1.92]; I ²:83.27%). Complications (OR, 1.54; [95% CI, 1.16 to 2.05]; I ²:48.88%), operation time (MD, 83.39; [95% CI, 55.93 to 110.85]; I ²:98.75%), intra-operative blood loss (MD, 264.58; [95% CI, 174.99 to 354.16]; I ²:95.61%) and length of hospital stay (MD, 2.85; [95% CI, 1.60 to 4.10]; I ²:99.49%) were higher with fusion.

INTERPRETATION

Clinical effectiveness of decompression alone was comparable to that of decompression with fusion for degenerative lumbar spondylolisthesis. Decompression alone is recommended for patients with degenerative lumbar spondylolisthesis.

FUNDING

This work was supported by grants from the National Natural Science Foundation of China (No. 81871818), Tangdu Hospital Seed Talent Program (Fei-Long Wei), Natural Science Basic Research Plan in Shaanxi Province of China (No.2019JM-265) and Social Talent Fund of Tangdu Hospital (No.2021SHRC034).

Does fusion status following posterolateral lumbar fusion in the treatment for stable lumbar degenerative spondylolisthesis affect the long-term surgical outcomes? A propensity score-weighted analysis of consecutive patients

BACKGROUND

The surgical strategy of lumbar degenerative spondylolisthesis (LDS) is controversial, especially regarding whether or not fusion should be used. Although some reports have indicated that decompression combined with fusion may be better than decompression alone in the treatment of LDS, the effect of fusion status after uninstrumented posterolateral lumbar fusion (PLF) on the outcomes of patients with stable LDS remains unknown. This study aimed to evaluate the surgical outcomes of uninstrumented PLF for stable LDS and clarify whether radiographic fusion status could affect surgical outcomes.

METHODS

A total of 93 consecutive patients who had undergone single-level uninstrumented PLF for Meyerding grade I LDS without preoperative dynamic instability with a minimum follow-up period of 5 years were retrospectively studied. Patients were divided into two groups: nonunion (52 patients) and union (41 patients). The primary outcomes were the 5-year percent recovery of postoperative Japanese Orthopaedic Association (JOA) scores, Oswestry Disability Index (ODI), Visual analog scale (VAS) scores, and reoperation rate. The outcome scores were compared between the groups using the inverse probability weighting method using propensity scores.

RESULTS

The union and nonunion groups had comparable weighted means of the 5-year postoperative clinical score for the percent recovery of the JOA score (70.2% vs. 71.1%, P = 0.86), ODI (14.5 vs.14.6, P = 0.98), VAS of low back pain (20.3 vs. 18.7 mm, P = 0.72), and VAS of leg pain (24.0 vs. 19.4 mm, P = 0.43). The reoperation rate was 2.4% (one case of adjacent segment pathology) in the union group and 0% in the nonunion group (P = 0.44).

CONCLUSION

The fusion status following uninstrumented PLF had no significant effect on the 5-year postoperative clinical outcomes and reoperation rate in patients with Meyerding grade I LDS without dynamic instability.

Mid-term changes in spinopelvic sagittal alignment in lumbar spinal stenosis with coexisting degenerative spondylolisthesis or scoliosis after minimally invasive lumbar decompression surgery: minimum five-year follow-up

BACKGROUND CONTEXT

Recently, the number of patients with lumbar spinal stenosis (LSS) who present with a coexisting spinal deformity such as degenerative spondylolisthesis (DS) and scoliosis (DLS) has been increasing. Lumbar decompression without fusion can lead to a reactive improvement in the lumbar and sagittal spinopelvic alignment, even if a sagittal imbalance exists preoperatively. However, the mid- to long-term impact of the coexistence of DS and DLS on the change in sagittal spinopelvic alignment and clinical outcomes after decompression surgery remains unknown.

PURPOSE

This study aimed to investigate whether the coexistence of DS or DLS in patients with LSS is associated with differences in radiological and clinical outcomes after minimally invasive lumbar decompression surgery.

STUDY DESIGN/SETTING

A retrospective analysis of prospectively collected data.

PATIENT SAMPLE

A total of 169 patients who underwent minimally invasive lumbar decompression surgery and follow-up >5 years postoperatively.

OUTCOME MEASURES

Self-report measures: Low back pain (LBP) and/or leg pain and/or leg numbness visual analog scale (VAS) scores and the Japanese Orthopedic Association scores.

PHYSIOLOGIC MEASURES

Standing sagittal spinopelvic alignment.

METHODS

In total, 81 patients with LSS, 50 patients with LSS and DS (≥3 mm anterior slippage), and 38 patients with LSS and DLS (≥15° coronal Cobb angle) were included in the current study. Clinical and radiological outcome results before surgery and at 2 and 5 years after surgery were compared among the groups.

RESULTS

In patients with LSS with coexisting DS, the clinical outcomes at 2, and 5 years after surgery were similar to those of patients with only LSS. In patients with LSS with coexisting DLS, the VAS LBP and leg pain at 2 years after surgery was significantly higher (34.7 vs. 27.8, p=0.014; 27.8 vs. 14.7, p=0.028) and the achievement rate of the minimal clinically important difference in VAS LBP and leg pain was significantly lower than that of the LSS group (36.1% vs. 54.2%, p=0.036; 58.3% vs. 69.9%, p=0.10). The clinical outcomes except VAS leg numbness at 5 years after surgery were similar to those of patients with only LSS. The reoperation rate of the DS group was significantly lower than that of the LSS group (4.0% vs. 14.8%; p=0.01); however, the reoperation rate of the DLS group was comparable to that of the LSS group (15.8% vs. 14.8%; p=0.493). Lumbar lordosis (LL), sacral slope, pelvic tilt, and pelvic incidence-LL had significantly improved and been maintained for 5 years after the surgery in both the DS and the DLS groups. The sagittal vertical axis had improved at two-year follow-up; however, no significant difference was observed at the 5-year follow-up in both the DS, and the DLS groups.

CONCLUSIONS

Mid-term clinical outcomes in patients with LSS with and without deformity were comparable. Lumbar decompression without fusion can result in a reactive improvement in the lumbar and sagittal spinopelvic alignment, even with coexisting DS or DLS. Minimally invasive surgery could be considered for most patients with LSS.

Lumbar Spinal Stenosis with Degenerative Spondylolisthesis Treated with Decompression Alone. A Cohort of 346 Patients at a Large Spine Unit. Clinical Outcome, Complications and Subsequent Surgery

STUDY DESIGN

Cohort study.

OBJECTIVE

To study the clinical outcome, complications and subsequent surgery rate of DA for lumbar spinal stenosis (LSS) with DS.

SUMMARY OF BACKGROUND DATA

There is still no consensus regarding the treatment approach for LSS with DS.

METHODS

We performed a retrospectively designed cohort study on prospectively collected data from a single high productive spine surgical center. Results from the Swedish Spine Registry and a local register for complications were used for the analyses. Patients with LSS and DS (>3 mm) who underwent DA during January 2012 to August 2017 were included. Patient reported outcome measures at baseline and 2 years after surgery were analyzed. Complications within 30 days of surgery and all subsequent surgery in the lumbar spine were registered.

RESULTS

We identified and included 346 patients with completed 2-year follow-up registration. At 2-year follow-up there was a significant improvement in all outcome measures. The global assessment success rate for back and leg pain was 68.3% and 67.6% respectively. Forty-one patients had at least 1 intra- or postoperative complication (11.9%). Nine patients (2.6%), underwent subsequent surgery within 2 years of the primary surgery whereof 2 underwent fusion. During the whole period of data collection, that is, as of June 2020, 28 patients had undergone subsequent surgery (8.1%) whereas 8 of them had had 2 surgeries. Fifteen patients underwent fusion.

CONCLUSION

DA provides good clinical outcome at 2-year follow-up in patients with LSS and DS with low rate of intra- and postoperative complications and subsequent surgery. Our data supports the evidence that DA is effective and safe for LSS with DS.Level of Evidence: 3.

A novel minimally invasive technique of inter-spinal distraction fusion surgery for single-level lumbar spinal stenosis in octogenarians: a retrospective cohort study

Objective

Surgical treatment of lumbar spinal stenosis (LSS) in octogenarians (patients aged ≥ 80 years) has been a challenge. Inter-spinal distraction fusion (ISDF)—a minimally invasive procedure—was used for treating LSS in octogenarians. This retrospective cohort study aimed to investigate the clinical efficacy and safety of a minimally invasive ISDF technique for LSS in octogenarian patients.

Methods

From April 2015 to April 2019, octogenarian patients who underwent lumbar fusion surgery due to single-segment LSS were included. The patients were grouped into the ISDF group and posterior lumbar interbody fusion (PLIF) group based on the type of surgery. Clinical outcomes were evaluated using scores of the visual analog pain scale (VAS), Oswestry Disability Index (ODI), and Japanese Orthopedics Association (JOA) scale. Radiographs were assessed for the intervertebral angle (IA), lumbar lordosis (LL), and posterior disc height (PDH). After 2 years postoperatively, all patients underwent computed tomography (CT) to evaluate the fusion condition. Perioperative data and related complications were recorded.

Results

Sixty-two patients were included (mean age: 82.22 ± 1.95 years). The ISDF and the PLIF groups had 34 and 28 patients, respectively. The average follow-up time was 2.1 ± 0.25 years. There was no significant difference in VAS, ODI, JOA, and PDH scores between both groups preoperatively and at each postoperative time-point. The IA and LL showed significant differences between both groups after surgery (p < 0.05). The postoperative IA in the ISDF group were significantly lower than the preoperative values, while that in the PLIF group were markedly increased. The PLIF group had an increased LL compared with that preoperatively (p < 0.05), while the LL in the ISDF did not significantly change. The operative time, blood loss, hospital stay time, and the rate of perioperative complications of the ISDF group were significantly lower than those of the PLIF group (p < 0.05). There was no significant difference in the fusion rates between both groups.

Conclusion

ISDF surgery is a viable method for octogenarian patients with LSS that provides a similar clinical efficacy, shorter operative time, less blood loss, shorter hospital stay time, and fewer complications, compared to the PLIF surgery.

Finite analysis of stability between modified articular fusion technique, posterior lumbar interbody fusion and posteriorlateral lumbar fusion

Background

It is not clear whether modified facet fusion (MFF) is biomechanically different from traditional fusion techniques such as posterior lateral lumbar fusion (PLF) and posterior lumbar interbody fusion (PLIF).

Methods

In this study, a healthy adult Chinese male volunteer was selected to perform 3D reconstruction of CT image data and simulate the successful fusion of L4–5 MFF, PLF and PLIF, respectively. The motion range of L4–5 segments of the model was simulated under 6 working conditions, including forward flexion, extension, lateral flexion and rotation under normal physiological conditions, and the stability of the three fusion procedures in the pathological segments of the lumbar spine was compared.

Results

There was no difference in range of motion between MFF model and PLF or PLIF model (P < 0.05). Also, the stiffness of the PLFand the MFF model were comparable (P > 0.05), but were smaller than the PLIF model (P < 0.05).

Conclusions

MFF provides reliable stability at the lumbar fixation fusion level and does not differ significantly from PLF and PLIF in terms of range of motion.

Decompression with or without Fusion in Degenerative Lumbar Spondylolisthesis

BACKGROUND

In patients with lumbar spinal stenosis and degenerative spondylolisthesis, it is uncertain whether decompression surgery alone is noninferior to decompression with instrumented fusion.

METHODS

We conducted an open-label, multicenter, noninferiority trial involving patients with symptomatic lumbar stenosis that had not responded to conservative management and who had single-level spondylolisthesis of 3 mm or more. Patients were randomly assigned in a 1:1 ratio to undergo decompression surgery (decompression-alone group) or decompression surgery with instrumented fusion (fusion group). The primary outcome was a reduction of at least 30% in the score on the Oswestry Disability Index (ODI; range, 0 to 100, with higher scores indicating more impairment) during the 2 years after surgery, with a noninferiority margin of -15 percentage points. Secondary outcomes included the mean change in the ODI score as well as scores on the Zurich Claudication Questionnaire, leg and back pain, the duration of surgery and length of hospital stay, and reoperation within 2 years.

RESULTS

The mean age of patients was approximately 66 years. Approximately 75% of the patients had leg pain for more than a year, and more than 80% had back pain for more than a year. The mean change from baseline to 2 years in the ODI score was -20.6 in the decompression-alone group and -21.3 in the fusion group (mean difference, 0.7; 95% confidence interval [CI], -2.8 to 4.3). In the modified intention-to-treat analysis, 95 of 133 patients (71.4%) in the decompression-alone group and 94 of 129 patients (72.9%) in the fusion group had a reduction of at least 30% in the ODI score (difference, -1.4 percentage points; 95% CI, -12.2 to 9.4), showing the noninferiority of decompression alone. In the per-protocol analysis, 80 of 106 patients (75.5%) and 83 of 110 patients (75.5%), respectively, had a reduction of at least 30% in the ODI score (difference, 0.0 percentage points; 95% CI, -11.4 to 11.4), showing noninferiority. The results for the secondary outcomes were generally in the same direction as those for the primary outcome. Successful fusion was achieved with certainty in 86 of 100 patients (86.0%) who had imaging available at 2 years. Reoperation was performed in 15 of 120 patients (12.5%) in the decompression-alone group and in 11 of 121 patients (9.1%) in the fusion group.

CONCLUSIONS

In this trial involving patients who underwent surgery for degenerative lumbar spondylolisthesis, most of whom had symptoms for more than a year, decompression alone was noninferior to decompression with instrumented fusion over a period of 2 years. Reoperation occurred somewhat more often in the decompression-alone group than in the fusion group. (NORDSTEN-DS ClinicalTrials.gov number, NCT02051374.).

Classification and prognostic factors of residual symptoms after minimally invasive lumbar decompression surgery using a cluster analysis: a 5-year follow-up cohort study

PURPOSE

Residual symptoms indicating incomplete remission of lower leg numbness or low back pain may occur after spine surgery. The purpose was to elucidate the pattern of residual symptoms 5 years after minimally invasive lumbar decompression surgery using a cluster analysis.

METHODS

The study comprised 193 patients with lumbar spinal stenosis (LSS) (108 men, 85 women) ranging in age from 40 to 86 years (mean, 67.9 years). Each patient underwent 5-year follow-up. The Japanese Orthopedic Association score and visual analog scale scores for low back pain, leg pain, and leg numbness at 5 years were entered into the cluster analysis to characterize postoperative residual symptoms. Other clinical data were analyzed to detect the factors significantly related to each cluster.

RESULTS

The analysis yielded four clusters representing different patterns of residual symptoms. Patients in cluster 1 (57.0%) were substantially improved and had few residual symptoms of LSS. Patients in cluster 2 (11.4%) were poorly improved and had major residual symptoms. Patients in cluster 3 (17.6%) were greatly improved but had mild residual low back pain. Patients in cluster 4 (14.0%) were improved but had severe residual leg numbness. Prognostic factors of cluster 2 were a short maximum walking distance, motor weakness, resting lower leg numbness, cofounding scoliosis, and high sagittal vertical axis.

CONCLUSIONS

This is the first study to identify specific patterns of residual symptoms of LSS after decompression surgery. Our results will contribute to acquisition of preoperative informed consent and identification of patients with the best chance of postoperative improvement.

Lumbar spinal fusion of low-grade degenerative spondylolisthesis (Meyerding grade I and II): Do reduction and correction of the radiological sagittal parameters correlate with better clinical outcome?

INTRODUCTION

Lumbar and lumbosacral spinal fusion is an established procedure for the treatment of degenerative spondylolisthesis. However, the impact of reduction in the affected segment and of improvement in the radiological sagittal parameters on the clinical outcome remains unclear. Purpose of the study is to analyze the correlation between the radiological sagittal parameters and clinical outcome after lumbar spinal fusion in low-grade degenerative spondylolisthesis.

MATERIALS AND METHODS

In a monocentric prospective, clinical study, patients with low-grade degenerative spondylolisthesis of a single lumbar segment have been included. All patients received a lumbar spinal fusion according to the pathology of the treated segment. Patients attended clinical and radiological follow-up examination 1 and 2 years postoperatively. Clinical outcome was assessed using the Core Outcome Measurement Index (COMI), the Oswestry Disability Index (ODI) and the EuroQol 5D. The sagittal spinopelvic radiological parameters, sagittal rotation and anterior displacement of the affected segment and lumbar lordosis were assessed. The correlation between the sagittal radiological parameters and clinical outcome was analyzed using Spearman-Rho bi-serial test.

RESULTS

Sixty-two patients (35 female and 27 male) with an average age of 59.3 years were included in the study. All patients completed the follow-up examinations. Significant improvement in COMI, ODI and EuroQol 5D scores was shown in all follow-up examinations. Significant reduction in the anterior displacement was measured postoperatively, which was preserved during the follow-up. However, no correlation could be demonstrated between reduction in anterior displacement and improvement in clinical outcome. Nonetheless, correlation between correction of sagittal rotation and clinical outcome was shown.

CONCLUSIONS

Reduction in anterior displacement of the affected segment in the surgical treatment of low-grade degenerative spondylolisthesis does not have an impact on the clinical outcome.

Comparative Effectiveness of Microdecompression Alone vs Decompression Plus Instrumented Fusion in Lumbar Degenerative Spondylolisthesis

IMPORTANCE

Conflicting evidence and large practice variation are present in the surgical treatment of degenerative spondylolisthesis. More than 90% of surgical procedures in the United States include instrumented fusion compared with 50% or less in other countries.

OBJECTIVE

To evaluate whether the effectiveness of microdecompression alone is noninferior to decompression with instrumented fusion in a real-world setting.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter comparative effectiveness study with a noninferiority design assessed prospective data from the Norwegian Registry for Spine Surgery. From September 19, 2007, to December 21, 2015, 1376 patients at 35 Norwegian orthopedic and neurosurgical departments underwent surgery for lumbar spinal stenosis with degenerative spondylolisthesis without scoliosis. After excluding patients undergoing laminectomy alone, fusion without instrumentation, or surgery in more than 2 levels and those with a former operation at the index level, 794 patients were included in the analyses, regardless of missing or incomplete follow-up data, before propensity score matching. Data were analyzed from March 20 to October 30, 2018.

EXPOSURES

Microdecompression alone or decompression with instrumented fusion.

MAIN OUTCOMES AND MEASURES

A reduction from baseline of 30% or greater in the Oswestry Disability Index at 12-month follow-up.

RESULTS

After propensity score matching, 570 patients (413 female [72%]; mean [SD] age, 64.7 [9.5] years) were included for comparison, with 285 undergoing microdecompression (mean [SD] age, 64.6 [9.8] years; 205 female [72%]) and 285 undergoing decompression with instrumented fusion (mean [SD] age, 64.8 [9.2] years; 208 female [73%]). The proportion of each type of procedure varied between departments. However, changes in outcome scores varied within patients but not between departments. The proportion of patients with improvement in the Oswestry Disability Index of at least 30% was 150 of 219 (68%) in the microdecompression group and 155 of 215 (72%) in the instrumentation group. The 95% CI (-12% to 5%) for the difference of -4% was above the predefined margin of noninferiority (-15%). Microdecompression alone was associated with shorter operation time (mean [SD], 89 [44] vs 180 [65] minutes; P < .001) and shorter hospital stay (mean [SD], 2.5 [2.4] vs 6.4 [3.0] days; P < .001).

CONCLUSIONS AND RELEVANCE

Among patients with degenerative spondylolisthesis, the clinical effectiveness of microdecompression alone was noninferior to that of decompression with instrumented fusion. Microdecompression alone was also associated with shorter durations of surgery and hospital stay, supporting the suggestion that the less invasive procedure should be considered for most patients.

Percutaneous transforaminal full endoscopic decompression for the treatment of lumbar spinal stenosis

Background

One advantage of an endoscopic approach to treating lumbar spinal stenosis is preservation of spine stability and the adjacent anatomy, and there is a decrease in adjacent segment disc degeneration. The purpose of this study was to discuss the clinical efficacy of percutaneous transforaminal endoscopic decompression for the treatment of lumbar spinal stenosis (LSS).

Methods

This is a retrospective study. From September 2012 to June 2017, 45 patients who were diagnosed with LSS underwent the treatment of percutaneous transforaminal endoscopic decompression (PTED) and were followed up at 1 week, 3 months and 1 year postoperatively. Low back pain and leg pain were measured by Visual Analogue Scale scoring methods (VAS-back and VAS-leg), while functional outcomes were assessed by using the Oswestry Disability Index (ODI). All patients had one-level lumbar spinal stenosis.

Results

The most common type of stenosis was lateral recess stenosis (n = 22; 48.9%), followed by central stenosis (n = 13; 28.9%) and foraminal stenosis (n = 10: 22.2%). Regarding comparisons of VAS-back, VAS-leg, and ODI scores before and after operation, VAS and ODI scores significantly improved. The average leg VAS score improved from 7.01 ± 0.84 to 2.28 ± 1.43 (P < 0.001). The average ODI improved from 46.18 ± 10.11 to 14.40 ± 9.59 (P < 0.001). We also examined changes in ODI and VAS scores from baseline according to types of spinal stenosis, stenosis grade, spinal instability, and revision surgery in the same segment. The improvement percentage of leg VAS score was significantly less in patients with severe stenosis at both 3 months and 1 year postoperatively. The improvement percentages of ODI and leg VAS scores were significantly less in patients who had spinal instability and patients who had undergone revision surgery.

Conclusion

The PTED approach seems to give good results for the treatment of LSS. However, this approach may be less effective for LSS patients who have lumbar instability or require revision surgery in the same segment.

Critically Low Confidence in the Results Produced by Spine Surgery Systematic Reviews: An AMSTAR-2 Evaluation From 4 Spine Journals

STUDY DESIGN

A systematic cross-sectional survey of systematic reviews (SRs).

OBJECTIVE

To evaluate the methodological quality of spine surgery SRs published in 2018 using the updated AMSTAR 2 critical appraisal instrument.

METHODS

We identified the PubMed indexed journals devoted to spine surgery research in 2018. All SRs of spine surgical interventions from those journals were critically appraised for quality independently by 2 reviewers using the AMSTAR 2 instrument. We calculated the percentage of SRs achieving a positive response for each AMSTAR 2 domain item and assessed the levels of confidence in the results of each SR.

RESULTS

We identified 28 SRs from 4 journals that met our criteria for inclusion. Only 49.5% of the AMSTAR 2 domain items satisfied the AMSTAR 2 criteria. Critical domain items were satisfied less often (39.1%) compared with noncritical domain items (57.3%). Domain items most poorly reported include accounting for individual study risk of bias when interpreting results (14%), list and justification of excluded articles (18%), and an a priori establishment of methods prior to the review or registered protocol (18%). The overall confidence in the results was rated "low" in 2 SRs and "critically low" in 26.

CONCLUSIONS

The credibility of a SR and its value to clinicians and policy makers are dependent on its methodological quality. This appraisal found significant methodological limitations in several critical domains, such that the confidence in the findings of these reviews is "critically low."

Percutaneous transforaminal endoscopic decompression for lumbar spinal stenosis with degenerative spondylolisthesis in the elderly

OBJECTIVES

Percutaneous transforaminal endoscopic decompression (PTED) under local anesthesia is rarely performed for lumbar spinal stenosis (LSS) with degenerative lumbar spondylolisthesis (DLS) because of the limited field of vision, inherent instability, etc. The objective of this study was to describe the procedure of the PTED technique and to demonstrate the early clinical outcomes.

PATIENTS AND METHODS

From January 2017 to January 2019, 40 consecutive patients aged 60 and older were diagnosed with LSS with DLS in our institution and underwent PTED. All patient were followed up to 1 year postoperatively. The clinical outcomes were evaluated using the visual analogue scale (VAS), Oswestry Disability Index (ODI) and modified MacNab criteria.

RESULTS

The mean age was 70.2 ± 7.1 years. Follow-up ranged from 12 to 24 months. The mean ± SD values of the preoperative VAS leg pain and ODI scores were 7.5 ± 1.1 and 67.3 ± 9.3, respectively. The scores improved to 2.2 ± 1.1 and 20.7 ± 8.1 at 12 months postoperatively. The outcomes of the modified MacNab criteria showed that 87.5 % of patients obtained a good-to-excellent rate. The percent slippage of spondylolisthesis before surgery (10.8 ± 2.6 %) and at the end of follow-up (11.0 ± 2.4 %) was not significantly different. One patient had a dural tear and intracranial hypertension, and one patient had tibialis anterior weakness.

CONCLUSION

PTED under local anesthesia could be an effective treatment method for LSS with DLS in elderly patients. However, potential complications still require further evaluation.

Clinical outcomes of lumbar spinal surgery in patients 80 years or older with lumbar stenosis or spondylolisthesis: a systematic review and meta-analysis

PURPOSE

This systematic review and meta-analysis of all available evidence was performed to assess the safety and efficacy of surgery for lumbar stenosis and spondylolisthesis in patients 80 years or older versus those younger than 80 years.

METHODS

A search of the literature was conducted in PubMed/MEDLINE, EMBASE and the Cochrane Collaboration Library. Relevant studies comparing the clinical outcomes of lumbar surgery in octogenarians and younger patients were selected according to the eligibility criteria. The predefined endpoints were extracted and meta-analysed from the identified studies.

RESULTS

Data from 16 observational studies including 374,197 patients were included in the final analysis. The pooled data revealed that patients 80 years or older had a significantly higher incidence of overall complication, mortality, readmission and longer length of hospital stay than younger patients. There was a similar improvement in the clinical symptoms (Oswestry Disability Index and pain) of patients in the two groups. No significant differences in overall wound complication, reoperation rate, operative time and intraoperative blood loss were found between the groups.

CONCLUSIONS

Our results revealed that the clinical improvement in pain and disability did not significantly differ according to age, although the patients aged 80 years or older had increased incidences of mortality and complication than younger patients. Age alone is not a contraindication for lumbar surgery in very old patients. A careful preoperative evaluation, proper patient selection and appropriate surgical approach are important to achieve successful surgical outcomes. These slides can be retrieved under Electronic Supplementary Material.

Efficacy of percutaneous transforaminal endoscopic decompression treatment for degenerative lumbar spondylolisthesis with spinal stenosis in elderly patients

The efficacy of fusion combined with decompression for the treatment of spinal stenosis with degenerative lumbar spondylolisthesis (DLS) has been debated. Percutaneous transforaminal endoscopic decompression (PTED) under local anesthesia is an ultra-minimally invasive procedure. The present study aimed to evaluate whether PTED is an effective alternative therapy for spinal stenosis associated with DLS in elderly patients. PTED was performed in elderly patients exhibiting lumbar stenosis and low-grade (Meyerding grades I and II) DLS; these patients also exhibited leg-dominant symptoms and had tolerable or absent mechanical back pain. Administration of general anesthesia may be considerably hazardous in patients when combined with comorbid conditions that result from aging. Therefore, the present procedure was performed under local anesthesia. No obvious radiographic lumbar intervertebral instability was identified prior to surgery. Pre- and post-operative visual analogue scale (VAS) score, Oswestry Disability Index (ODI) and walking distance data were collected. The clinical global outcomes following surgery were evaluated using modified MacNab criteria. A total of 18 elderly patients underwent surgery using PTED techniques. The mean follow-up time was 27.7 months (range, 24-33 months) and the mean estimated blood loss was 18.33 ml (range, 10-35 ml). The mean pre-operative ODI, VAS score of the back and VAS score of the leg were 68.2±6.5, 2.8±1.4 and 6.6±1.2, respectively. All average scores improved post-operatively to 31.7±5.2, 1.5±0.6 and 1.7±0.8, respectively, at the latest follow-up. A statistically significant improvement was observed for all scores at 1 month and that the scores remained relatively stable after that. According to modified MacNab criteria, the good-to-excellent rate was 83.3%. Only 1 patient required micro-decompression surgery due to poor rating. The present study indicated that PTED may be an effective alternative therapeutic option for elderly patients with low-grade DLS associated with spinal stenosis. However, PTED techniques continue to evolve and further follow-up studies are required to determine the long-term outcomes of this treatment technique.

Manipulation for treatment of degenerative lumbar spondylolisthesis: A protocol of systematic review and meta-analysis

BACKGROUND

Degenerative lumbar spondylolisthesis (DLS) is one of the common orthopedic diseases which causes low back pain in patients, which seriously affects people's daily life and work. As a method of conservative treatment of this disease, manipulation is widely used in clinical practice. We will summarize the current published evidence of manipulation in the treatment of DLS, and evaluate the effectiveness and safety of manipulation through systematic review and meta-analysis, so as to provide more reliable evidence for future clinical practice.

METHODS

We will conduct a comprehensive search of the following 9 databases until January 2019: PubMed, Embase, Cochrane Library, ClinicalTrials.gov, Web of Science, Chinese National Knowledge Infrastructure, Chinese Science and Technique Journals Database, Wan Fang Database, and Chinese Biomedical Database. The 2 researchers will independently search, screen, extract data, and evaluate the quality of the literatures. The primary outcomes include clinical effectiveness, Japanese Orthopaedic Association scores, and the secondary outcomes include visual analog scale scores, symptom scores, and adverse events. Bias risk tools provided by Cochrane Collaboration will be used for literature quality assessment, and RevMan 5.3 software will be used for meta-analysis.

RESULTS

The results of this study will systematically evaluate the effectiveness and safety of manipulation intervention for people with DLS, especially in improving lumbar function scores and pain scores.

CONCLUSION

The systematic review of this study will summarize the current published evidence of manipulation for the treatment of DLS, which can further guide the promotion and application of it.

ETHICS AND DISSEMINATION

This study does not require ethical approval and the results will be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42019139933.

Endoscopic Ventral Decompression for Spinal Stenosis with Degenerative Spondylolisthesis by Partially Removing Posterosuperior Margin Underneath the Slipping Vertebral Body: Technical Note and Outcome Evaluation

BACKGROUND

Decompression alone is a treatment option in patients with lumbar spinal stenosis (LSS) and degenerative lumbar spondylolisthesis (DLS). This study aims to describe the procedure of percutaneous transforaminal endoscopic ventral decompression technique and to demonstrate the clinical outcomes.

METHODS

Two years of retrospective data were collected from 26 patients with predominant unilateral leg pain caused by LSS and low-grade DLS (Meyerding grades I and Ⅱ). All patients underwent endoscopic ventral decompression by removing the posterosuperior margin underneath the slipping vertebral body, combined with dorsal decompression without excessive resection of facet joints. The surgical outcomes were assessed using the visual analog scale (VAS), Oswestry Disability Index (ODI), modified MacNab criteria, and walking distance improvement evaluation.

RESULTS

The mean age of the 18 women and 8 men was 69.2 years. The mean preoperative ODI and VAS of the leg and the back scores were 64.7 ± 8.1, 7.0 ± 1.4, and 3.0 ± 1.2, respectively. All mean scores improved postoperatively to 31.4 ± 5.6, 2.4 ± 1.1, and 1.7 ± 1.1 at the final follow-up. In 88.5% of cases, patients' estimated walking distance improved. The outcomes of the modified MacNab criteria showed that 81.3% of patients obtained good-to-excellent rate. There were no statistically significant differences between the percent slip of spondylolisthesis before surgery and at the end of follow-up.

CONCLUSIONS

Based on the initial short-term follow-up results, transforaminal endoscopic ventral decompression by partially removing the posterosuperior margin underneath the slipping vertebral body, combined with dorsal decompression, might be an efficient alternative treatment for leg dominant symptoms in patients with LSS and low-grade DLS.

Management of symptomatic degenerative low-grade lumbar spondylolisthesis

Degenerative low-grade lumbar spondylolisthesis is the most common form of spondylolisthesis.

The majority of patients are asymptomatic and do not require surgical intervention.

Symptomatic patients present with a combination of lower back pain, radiculopathy and/or neurogenic claudication and may warrant surgery if non-operative measures fail.

There is widespread controversy regarding the indications for surgery and appropriate treatment strategies for patients with this type of spondylolisthesis.

This article provides a comprehensive evidence-based review of the available literature to support the management of degenerative low-grade spondylolisthesis.

Cite this article: EFORT Open Rev 2018;3:620-631. DOI: 10.1302/2058-5241.3.180020.

Does Concomitant Degenerative Spondylolisthesis Influence the Outcome of Decompression Alone in Degenerative Lumbar Spinal Stenosis? A Meta-Analysis of Comparative Studies

OBJECTIVE

To investigate whether the preoperative presence of degenerative spondylolisthesis (DS) worsens the outcome of patients undergoing decompression alone for degenerative lumbar stenosis.

METHODS

We conducted a comprehensive search in the PubMed, Embase, and Cochrane Library databases. All comparative studies were included in this meta-analysis. The literature search, data extraction, and quality assessment were conducted by 2 independent reviewers. The functional outcomes were clinical scores and reoperation rate. The radiologic outcomes were slippage rate and postoperative instability rate.

RESULTS

A total of 11 studies with 1081 cases, including 469 cases of degenerative lumbar stenosis with DS (DS group) and 612 degenerative lumbar stenosis without spondylolisthesis (noDS group), were enrolled in our meta-analysis. There were no significant differences between the 2 groups for functional outcomes in terms of Japanese Orthopedic Association score, Japanese Orthopedic Association recovery rate, Oswestry Disability Index score, visual analog scale back/leg, and reoperation rate after decompression alone. For the radiologic outcomes, slippage rate was found not changed significantly before and after minimally invasive decompression alone in the DS group and the postoperative instability rate did not differ significantly between the 2 groups after decompression alone by a minimally invasive method.

CONCLUSIONS

Our meta-analysis revealed that concomitant DS (Meyerding grade I-II) does not influence the outcome of decompression alone in degenerative lumbar spinal stenosis, especially when a minimally invasive procedure was performed and patients did not have predominant symptoms of mechanical back pain. The presence of DS should not be an indication for fusion surgery in degenerative lumbar spinal stenosis.

Minimally invasive decompression in patients with degenerative spondylolisthesis associated with lumbar spinal stenosis. Report of a surgical series and review of the literature

We reported the results of minimally invasive spinal decompression (MISD) in patients with degenerative spondylolisthesis (DS) associated with lumbar spinal stenosis (LSS) and performed a literature review in order to evaluate the clinical and radiological outcomes, the complications and reoperation rate of MISD procedures in these patients. Data of 28 patients submitted to MISD for DS associated to LSS were reviewed. We evaluated the Visual Analogue Scale (VAS) both for low back pain (LBP) and legs pain, the Oswestry Disability Index (ODI) and the degree of the slippage. A PubMed search of the English literature was conducted. Only papers with more than 10 patients and reporting explicitly data of patients with DS were included in the analysis. We found a statistically significant improvement of LBP, legs pain and ODI in our series. The degree of slippage was stable at follow-up (FU) with no need of reoperation. No major complications occurred. In our literature review, we were able to analyze the differences in ODI in 156 patients and the differences in Japanese Orthopedic Association (JOA) score in 218 patients. We observed a statistically significant improvement of ODI and JOA score at FU compared to pre-operative. The percentage of slippage, evaluated in 283 patients, was unchanged at FU compared to pre-operative. The overall complication rate was 1.6%. The overall reoperation rate was 4.5%. MISD procedures are safe and effective in patients with DS associated to LSS and are associated to low morbidity and significant improvement of disability without progression of slippage.