Is There a Role for Decompression Alone for Treating Symptomatic Degenerative Lumbar Spondylolisthesis?: A Systematic Review

A prospective study of lumbar facet arthroplasty in the treatment of degenerative spondylolisthesis and stenosis: cost-effective assessment from the Total Posterior Spine system (TOPSTM) IDE Study: 2-year model revision and sensitivity analyses based on 305 subjects

BACKGROUND CONTEXT

A previous cost-effectiveness analysis published in 2022 found that the Total Posterior Spine (TOPSTM) system was dominant over transforaminal lumbar interbody fusion (TLIF). This analysis required updating to reflect a more complete dataset and pricing considerations.

PURPOSE

To evaluate the cost-effectiveness of TOPSTM system as compared with TLIF based on an updated and complete FDA investigational device exemption (IDE) data set.

STUDY DESIGN/SETTING

Cost-utility analysis of the TOPSTM system compared to TLIF.

PATIENT SAMPLE

A multicenter, FDA IDE, randomized control trial (RCT) investigated the efficacy of TOPSTM compared to TLIF with a current population of n=305 enrolled and n=168 with complete 2-year follow-up.

OUTCOME MEASURES

Cost and quality adjusted life years (QALYs) were calculated to determine our primary outcome measure, the incremental cost-effectiveness ratio. Secondary outcome measures included: net monetary benefit as well at willingness-to-pay (WTP) thresholds.

METHODS

The primary outcome of cost-effectiveness is determined by incremental cost-effectiveness ratio. A Markov model was used to simulate the health outcomes and costs of patients undergoing TOPSTM or TLIF over a 2-year period. alternative scenario sensitivity analysis, one-way sensitivity analysis, and probabilistic sensitivity analysis were conducted to assess the robustness of the model results.

RESULTS

The updated base case result demonstrated that TOPSTM was immediately and longitudinally dominant compared with the control with an incremental cost-effectiveness ratio of -9,637.37 $/QALY. The net monetary benefit was correspondingly $2,237, both from the health system's perspective and at a WTP threshold of 50,000 $/QALY at the 2-year time point. This remained true in all scenarios tested. The Alternative Scenario Sensitivity Analysis suggested cost-effectiveness irrespective of payer type and surgical setting. To remain cost-effective, the cost difference between TOPSTM and TLIF should be no greater than $1,875 and $3,750 at WTP thresholds of $50,000 and 100,000 $/QALY, respectively.

CONCLUSIONS

This updated analysis confirms that the TOPSTM device is a cost-effective and economically dominant surgical treatment option for patients with lumbar stenosis and degenerative spondylolisthesis compared to TLIF in all scenarios examined.

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.

Decision-making Algorithm for the Surgical Treatment of Degenerative Lumbar Spondylolisthesis of L4/L5

STUDY DESIGN

A retrospective analysis of prospectively collected data.

OBJECTIVE

To report the decision-making process for decompression alone (DA) and decompression and fusion (DF) at a tertiary orthopedic center and compare the operative outcomes between both groups.

BACKGROUND

Controversy exists around the optimal operative treatment for DLS, either with DF or DA. Although previous studies tried to establish specific indications, clinical decision-making algorithms are needed.

MATERIALS AND METHODS

Patients undergoing spinal surgery for DLS at L4/5 were retrospectively analyzed. A survey of spine surgeons was performed to identify factors influencing surgical decision-making, and their association with the surgical procedure was tested in the clinical data set. We then developed a clinical score based on the statistical analysis and survey results. The predictive capability of the score was tested in the clinical data set with a receiver operating characteristic (ROC) analysis. To evaluate the clinical outcome, two years follow-up postoperative Oswestry Disability Index (ODI), postoperative low back pain (LBP) (Numeric Analog Scale), and patient satisfaction were compared between the DF and DA groups.

RESULTS

A total of 124 patients were included in the analysis; 66 received DF (53.2%) and 58 DA (46.8%). Both groups showed no significant differences in postoperative ODI, LBP, or satisfaction. The degree of spondylolisthesis, facet joint diastasis and effusion, sagittal disbalance, and severity of LBP were identified as the most important factors for deciding on DA or DF. The area under the curve of the decision-making score was 0.84. At a cutoff of three points indicating DF, the accuracy was 80.6%.

CONCLUSIONS

The two-year follow-up data showed that both groups showed similar improvement in ODI after both procedures, validating the respective decision. The developed score shows excellent predictive capabilities for the decision processes of different spine surgeons at a single tertiary center and highlights relevant clinical and radiographic parameters. Further studies are needed to assess the external applicability of these findings.

Japanese Orthopaedic Association (JOA) clinical practice guidelines on the management of lumbar spinal stenosis, 2021 - Secondary publication

BACKGROUND

The Japanese Orthopaedic Association (JOA) guideline for the management of lumbar spinal stenosis (LSS) was first published in 2011. Since then, the medical care system for LSS has changed and many new articles regarding the epidemiology and diagnostics of LSS, conservative treatments such as new pharmacotherapy and physical therapy, and surgical treatments including minimally invasive surgery have been published. In addition, various issues need to be examined, such as verification of patient-reported outcome measures, and the economic effect of revised medical management of patients with lumbar spinal disorders. Accordingly, in 2019 the JOA clinical guidelines committee decided to update the guideline and consequently established a formulation committee. The purpose of this study was to describe the formulation we implemented for the revision of the guideline, incorporating the recent advances of evidence-based medicine.

METHODS

The JOA LSS guideline formulation committee revised the previous guideline based on the method for preparing clinical guidelines in Japan proposed by the Medical Information Network Distribution Service in 2017. Background and clinical questions were determined followed by a literature search related to each question. Appropriate articles based on keywords were selected from all the searched literature. Using prepared structured abstracts, systematic reviews and meta-analyses were performed. The strength of evidence and recommendations for each clinical question was decided by the committee members.

RESULTS

Eight background and 15 clinical questions were determined. Answers and explanations were described for the background questions. For each clinical question, the strength of evidence and the recommendation were both decided, and an explanation was provided.

CONCLUSIONS

The 2021 clinical practice guideline for the management of LSS was completed according to the latest evidence-based medicine. We expect that this guideline will be useful for all medical providers as an index in daily medical care, as well as for patients with LSS.

Impacto dos parâmetros espinopélvicos pré-operatórios na correção de lordose segmentar após fusão intersomática lombar por via lateral de um nível

Objectives  The present study aimed to assess whether preoperative spinopelvic parameters can influence the gain of segmental lordosis after one level of lateral lumbar interbody fusion.

Methods  The following radiological parameters were measured in the X-rays: pelvic incidence, lumbar lordosis, pelvic tilt, L4S1 lordosis, index level segmental lordosis, intraoperative index segmental lordosis, pelvic mismatch (IP-LL), distal lordosis proportion, delta segmental lordosis, Pelvic Titlt (PT) > 20, actual sacral slope, and ideal sacral slope, and the correlation of these variables with the gain of segmental lordosis was investigated. Afterwards, an exploratory cluster analysis was performed to identify common characteristics between patients and segmental lordosis gain.

Results  The sample of the present study comprised 104 patients, of which 76% presented segmental lordosis gain. The most correlated parameters with the segmental lordosis gain were preoperative segmental lordosis (−0.50) and delta intraoperative lordosis (0.51). Moreover, patients in the high PI groups had a trend to gain more segmental lordosis ( p  < 0.05) and a reduced risk of losing segmental lordosis (Odds 6.08).

Conclusion  Patients with low-medium PI profiles presented higher odds of loss of segmental lordosis. However, the preoperative spinopelvic parameters alone do not seem to play a significant role in the fate of segmental lordosis gain.

Decompression without Fusion for Lumbar Spinal Stenosis at a Single Mobile Segment in Adults with Ankylosing Spondylitis: A Report of 2 Cases

CASE

This report details the cases of 2 older male patients with ankylosing spondylitis (AS) who presented with lumbar spinal stenosis at a single residual mobile segment and were treated with decompression without fusion. Both patients presented with severe symptoms in their lower limbs and opted to proceed with surgery.

CONCLUSION

With autofusion above and below their single, stable mobile segment, decompression without fusion was a safe and effective procedure. A Coflex device was implanted in 1 patient. After successful surgery, both patients experienced significantly decreased symptoms.

Instrumented Versus Noninstrumented Spinal Fusion for Degenerative Lumbar Spondylolisthesis: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVE

This systematic review compares radiographic and clinical outcomes between instrumented and noninstrumented posterolateral lumbar spine fusions for the treatment of degenerative lumbar spondylolisthesis.

SUMMARY OF BACKGROUND DATA

The optimal method of fusion for instability from degenerative lumbar spondylolisthesis remains to be an area of debate amongst spine surgeons. There are no prior comprehensive systematic review of comparative studies that compares outcomes between instrumented and noninstrumented posterolateral spine fusions for the treatment of degenerative lumbar spondylolisthesis.

MATERIALS AND METHODS

A systematic review was registered with PROSPERO and performed according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines using the PubMed, SCOPUS, and Ovid MEDLINE databases. All level I-III comparative studies published in the English language investigating the clinical outcomes between instrumented and noninstrumented posterolateral spine fusions for the treatment of degenerative lumbar spondylolisthesis were included.

RESULTS

Seven studies (672 patients, 274 noninstrumented, 398 instrumented) were analyzed. One randomized study was level I evidence, 2 randomized studies were level II, and 4 nonrandomized studies were level III. Mean follow-up ranged from 1.4 to 5.9 years. Instrumented patients had a higher rate of solid fusion (87.6% vs. 77.1%, P=0.023) and a lower rate of definitive pseudarthrosis (5.3% vs. 19.9%, P<0.001). However, there was no difference in overall functional improvement at final follow-up between the 2 treatment groups (75.0% vs. 81.7%, P=0.258). In addition, there was no difference in reoperation or complication rates.

CONCLUSIONS

For the treatment of degenerative lumbar spondylolisthesis, there are significantly higher rates of fusion among patients undergoing instrumented posterolateral fusion compared with noninstrumented posterolateral fusion. However, there is no difference in overall functional improvement, pain-related outcome scores, reoperation rates, or complication rates between the 2 treatment groups.

LEVEL OF EVIDENCE

Level III-systematic review of level I-III studies.

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.

To fuse or not to fuse: a survey among members of the German Spine Society (DWG) regarding lumbar degenerative spondylolisthesis and spinal stenosis

INTRODUCTION

Surgical treatment methods for degenerative spondylolisthesis (decompression versus decompression and fusion) have been critically debated. The medical care situation is almost unknown for either treatment. Therefore, the aim of the present study was to provide information regarding the use of parameters for decision-making and the employment of surgical techniques.

MATERIALS AND METHODS

A web-based survey was performed among members of the German-Spine-Society (DWG). Information regarding participant characteristics (specialty, age, DWG certification status, number of spine surgeries performed at the participant's institution each year, institutional status), estimates of the use of both treatment options, clinical and morphological decision-making criteria for additive fusion, and the surgical technique used was queried.

RESULTS

305 members (45% neurosurgeons/ 55% orthopedic or trauma surgeons) participated in the present study. The participants estimated that in 41.7% of the cases, decompression only was required, while 55.6% would benefit from additional fusion. Among the participants, 74% reported that low back pain was an important indicator of the need for fusion if the numerical rating scale for back pain was at least 6/10. The most commonly used decompression technique was minimally invasive unilateral laminotomy, whereas open approach-based interbody fusion with transpedicular fixation and laminotomy was the most frequently used fusion technique. Specialty, age, certification status, and institutional status had a partial effect on the responses regarding indications, treatment and surgical technique.

CONCLUSIONS

The present survey depicts the diversity of approaches to surgery for degenerative spondylolistheses in Germany. Considerable differences in treatment selection were observed in relation to the participants' educational level and specialty.

Decompression alone versus decompression with instrumental fusion the NORDSTEN degenerative spondylolisthesis trial (NORDSTEN-DS); study protocol for a randomized controlled trial

BACKGROUND

Fusion in addition to decompression has become the standard treatment for lumbar spinal stenosis with degenerative spondylolisthesis (DS). The evidence for performing fusion among these patients is conflicting and there is a need for further investigation through studies of high quality. The present protocol describes an ongoing study with the primary aim of comparing the outcome between decompression alone and decompression with instrumented fusion. The secondary aim is to investigate whether predictors can be used to choose the best treatment for an individual. The trial, named the NORDSTEN-DS trial, is one of three studies in the Norwegian Degenerative Spinal Stenosis (NORDSTEN) study.

METHODS

The NORDSTEN-DS trial is a block-randomized, controlled, multicenter, non-inferiority study with two parallel groups. The surgeons at the 15 participating hospitals decide whether a patient is eligible or not according to the inclusion and exclusion criteria. Participating patients are randomized to either a midline preserving decompression or a decompression followed by an instrumental fusion. Primary endpoint is the percentage of patients with an improvement in Oswestry Disability Index version 2.0 of more than 30% from baseline to 2-year follow-up. Secondary outcome measurements are the Zürich Claudication Questionnaire, Numeric Rating Scale for back and leg pain, Euroqol 5 dimensions questionnaire, Global perceived effect scale, complications and several radiological parameters. Analysis and interpretation of results will also be conducted after 5 and 10 years.

CONCLUSION

The NORDSTEN/DS trial has the potential to provide Level 1 evidence of whether decompression alone should be advocated as the preferred method or not. Further on the study will investigate whether predictors exist and if they can be used to make the appropriate choice for surgical treatment for this patient group.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02051374 . First Posted: January 31, 2014. Last Update Posted: February 14, 2018.

Effect of interbody fusion cage on clinical and radiological outcome of surgery in L4-L5 lumbar degenerative spondylolisthesis

Background

Lumbar degenerative spondylolisthesis (LDS) is a degenerative slippage of a lumbar vertebra relative to the adjacent vertebra below that can be clinically symptomatic. We aim to compare radiological and clinical outcome of surgery in L4-L5 LDS with or without applying the interbody fusion cage.

Methods

We studied 60 patients (mean age, 51.3±13.2 years; follow-up, 53.3±14.6 months) with L4-L5 LDS who had been treated by decompression, pedicle screw and rod instrumentation associated with posterolateral fusion (PLF) without and with transforaminal lumbar interbody fusion (TLIF) in equally divided groups A and B, respectively. Intraoperative parameters were recorded and outcome assessment carried out by visual analog scale (VAS), Oswestry Disability Index questionnaire (ODI), subjective satisfaction, radiologic union, and loss of reduction. We judged the differences by t-test and cross-tab.

Results

Using an interbody fusion cage was associated with a significant increase in intraoperative blood loss, operative time, and instrument cost. Improvement in VAS and ODI were significant but comparable. Satisfaction rate was higher in group A (P=0.52). Fusion rate and loss of correction were more favorable in group B but these differences were not significant.

Conclusions

In the surgical treatment of the patients with L4-L5 LDS, interbody fusion cage probably does not significantly improve the radiologic and clinical outcomes and may also be associated with more complication and morbidity.

ISSLS PRIZE IN BIOENGINEERING SCIENCE 2018: dynamic imaging of degenerative spondylolisthesis reveals mid-range dynamic lumbar instability not evident on static clinical radiographs

PURPOSE

Degenerative spondylolisthesis (DS) in the setting of symptomatic lumbar spinal stenosis is commonly treated with spinal fusion in addition to decompression with laminectomy. However, recent studies have shown similar clinical outcomes after decompression alone, suggesting that a subset of DS patients may not require spinal fusion. Identification of dynamic instability could prove useful for predicting which patients are at higher risk of post-laminectomy destabilization necessitating fusion. The goal of this study was to determine if static clinical radiographs adequately characterize dynamic instability in patients with lumbar degenerative spondylolisthesis (DS) and to compare the rotational and translational kinematics in vivo during continuous dynamic flexion activity in DS versus asymptomatic age-matched controls.

METHODS

Seven patients with symptomatic single level lumbar DS (6 M, 1 F; 66 ± 5.0 years) and seven age-matched asymptomatic controls (5 M, 2 F age 63.9 ± 6.4 years) underwent biplane radiographic imaging during continuous torso flexion. A volumetric model-based tracking system was used to track each vertebra in the radiographic images using subject-specific 3D bone models from high-resolution computed tomography (CT). In vivo continuous dynamic sagittal rotation (flexion/extension) and AP translation (slip) were calculated and compared to clinical measures of intervertebral flexion/extension and AP translation obtained from standard lateral flexion/extension radiographs.

RESULTS

Static clinical radiographs underestimate the degree of AP translation seen on dynamic in vivo imaging (1.0 vs 3.1 mm; p = 0.03). DS patients demonstrated three primary motion patterns compared to a single kinematic pattern in asymptomatic controls when analyzing continuous dynamic in vivo imaging. 3/7 (42%) of patients with DS demonstrated aberrant mid-range motion.

CONCLUSION

Continuous in vivo dynamic imaging in DS reveals a spectrum of aberrant motion with significantly greater kinematic heterogeneity than previously realized that is not readily seen on current clinical imaging.

LEVEL OF EVIDENCE

Level V data These slides can be retrieved under Electronic Supplementary Material.

Decompression Alone Versus Decompression and Fusion for Lumbar Degenerative Spondylolisthesis: A Meta-Analysis

OBJECTIVE

To compare the effectiveness and safety of decompression alone (D group) with decompression and fusion (DF group) for patients who were diagnosed with lumbar degenerative spondylolisthesis (LDS).

METHODS

Electronic databases were searched for relevant studies that compared decompression alone with decompression and fusion for LDS. Then, data extraction and quality assessment were conducted, and the extracted data were analyzed by using RevMan 5.3. We used the random effects model for studies that had heterogeneity between them, and for those without heterogeneity, the fixed model was used.

RESULTS

Four randomized controlled trials and 14 nonrandomized controlled studies involving 77,994 patients were included for this meta-analysis. Although the DF group was associated with a higher postoperative change score on a visual analog scale compared with the D group in terms of back (P = 0.02) and leg (P = 0.04), they failed to reach the minimum clinically important difference. Moreover, no significant differences were found in Oswestry Disability Index, European Quality of Life-5 Dimensions, Short-Form 36 physical and mental component summaries score, and patients' satisfaction (P > 0.05) between treatment groups. Complication rate and reoperation rate (P > 0.05) were similar in both groups. Data analysis also showed that the DF group was associated with longer operation time (P < 0.00001), more intraoperative blood loss (P < 0.00001), and longer length of hospital stay (P < 0.00001).

CONCLUSIONS

Among patients with LDS, decompression and fusion surgery did not yield better clinical outcomes than decompression alone surgery. Also, the complication rate and reoperation rate were comparable between treatment groups. However, patients who had undergone decompression alone had shorter operation time, less intraoperative blood loss, and shorter hospital stay.