Decompression Alone Compared to Decompression With Fusion in Patients With Lumbar Spondylolisthesis: Systematic Review, Meta-Analysis, and Meta-Regression

Outcomes of Primary vs. Revision TLIF Following Decompression Alone in Degenerative Spondylolisthesis: A Retrospective Propensity Score Matched Study

BACKGROUND

Degenerative grade 1 spondylolisthesis is associated with lumbar instability, typically addressed with decompression and fusion to prevent iatrogenic instability. The SLIP trial indicated that decompression-only patients benefit significantly from early reoperation for instability. Yet, it's unclear how these revision patients' outcomes compare to those undergoing primary fusion.

PURPOSE

To evaluate whether outcomes were inferior among patients receiving revision transforaminal lumbar interbody fusion(TLIF) after prior decompression in the setting of degenerative, grade 1 spondylolisthesis when compared to those undergoing primary TLIF for grade 1 spondylolisthesis.

STUDY DESIGN/SETTING

Retrospective cohort study.

PATIENT SAMPLE

Patients with grade 1 spondylolisthesis at L4-L5 or L5-S1 who underwent TLIF between 2018-2023 and had complete 1Y clinical follow-up and 6-month(6M) patient reported outcomes(PROs) were included.

OUTCOME MEASURES

PROs (ODI, PROMIS, SF-12, VAS Pain) and Clinical (Readmission and Reoperation at six-week(6W), 6M, and 1Y).

METHODS

No predictors for missing data were identified. Comparisons were made between primary fusion patients and those with prior decompression now undergoing revision TLIF. Bias was minimized via 2:1 propensity score matching (PSM) for age, comorbidities(CCI), slip percentage, slip translation, angular change, anterior and posterior disc height(ADH and PDH respectively), facet diastasis and cysts, and facet orientation-termed spondylolisthesis characteristics. Unmatched PROs and clinical outcomes were analyzed with a mixed-effects(ME) model and Chi-Squared test, while matched PROs and clinical outcomes employed an ME model and conditional logistic regression.

RESULTS

285 patients (55.4% female, mean age 60.80 ± 0.73, CCI of 2.10 ± 0.09, and 35.1% current/former smokers) were included. Spondylolisthesis slip was 13.11% ± 0.99% with mean translation in flexion/extension of 1.60 ± 0.19 mm. Compared to revision patients (N=42, 14.7%), primary fusion patients (N=243, 85.3%) were younger (59.70 ± 0.77 vs. 67.20 ± 1.76) and had a lower prevalence of active smoking (2.48% vs. 11.90%), but showed no differences in slip percentage (p=0.480), translation in flexion/extension (p=0.778), ADH(p=0.578), PDH(p=0.991), facet diastasis (p=0.132), facet cysts (p=0.550), or angular change across L3-S1. Preoperatively, PROs were comparable across all domains. At one-year postop, no differences were observed in back pain (p=0.430), leg pain (p=0.346), SF-12 PCS(p=0.976), MCS(p=0.737), PROMIS Score (p=0.063), or ODI(p=0.362). The PSM cohort, matched for age, CCI, and spondylolisthesis characteristics, showed standardized differences of less than 0.10 for all demographics, baseline PROs, and spondylolisthesis characteristics, aside angular change at L5-S1 (3.05 vs. 7.08, p=0.062). At one year postop, there were no differences in back pain (2.62 vs. 2.10, p=0.414), leg pain (2.15 vs. 1.48, p=0.270), SF-12 PCS (43.02 vs. 43.38, p=0.888), SF-12 MCS (51.31 vs. 52.80, p=0.553), PROMIS Score (45.69 vs. 44.81, p=0.630), and ODI (18.66 vs. 15.26, p=0.375). Finally, no significant differences were found in early (6W) or long-term (6M to 1Y) complications, with 98.1% primary and 90.5% revision patients complication-free at 6W, and 93.6% vs. 100.0%, respectively, from 6M to 1Y.

CONCLUSION

Following decompression alone for grade 1 spondylolisthesis, patients having revision TLIF after decompression exhibit patient-reported and clinical outcomes similar to those undergoing primary TLIF.

Decompression Alone vs Decompression and Fusion: Spin in Abstracts of Systematic Reviews and Meta-Analysis

STUDY DESIGN

Cross-sectional.

OBJECTIVES

Spin, a prevalent bias, can distort outcomes in well-validated research. Treatment of lumbar stenosis with spondylolisthesis through decompression alone (DA) vs decompression and fusion (DF) remains a controversial topic. We aimed to identify the prevalence of spin in meta-analyses and systematic reviews regarding DA vs DF in the treatment of spinal stenosis with concomitant degenerative spondylolisthesis.

METHODS

MEDLINE, Web of Science, and Google Scholar were searched for meta-analyses and systematic reviews comparing DA vs DF treatment of lumbar spinal stenosis accompanied by degenerative spondylolisthesis. Each study was evaluated for the nine most severe spin types. We also explored the association between spin and methodological quality of a systematic review using the revised A Measurement Tool to Assess Systematic Reviews appraisal tool.

RESULTS

The search yielded 1506 articles, of which 13 met inclusion. It was found that 46.2% (6/13) of the articles contained spin within the abstract. Of the nine most severe types, type 5 was found to be the most prevalent (4/13, 30.8%), followed by types 9 (2/13, 15.4%), 3 (1/13, 7.7%), 4 (1/13, 7.7%), and 6 (1/13, 7.7%). Spin types 1, 2, 7 and 8 were not found. According to AMSTAR-2, 53.8% (7/13) of the studies were appraised as "critically low" quality and 46.2% (6/13) as "low" quality.

CONCLUSION

This study demonstrated the presence of spin in 46.2% of abstracts pertaining to the treatment for spinal stenosis with degenerative spondylolisthesis. Spine surgeons should learn to recognize spin as they review articles before implementing them into practice.

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.

Decompression alone versus decompression with fusion in patients with lumbar spinal stenosis with degenerative spondylolisthesis: a systematic review and meta-analysis

INTRODUCTION

Surgical decompression is standard care in the treatment of degenerative spondylolisthesis in patients with symptomatic lumbar spinal stenosis, but there remains controversy over the benefits of adding fusion. The persistent lack of consensus on this matter and the availability of new data warrants a contemporary systematic review and meta-analysis of the literature.

METHODS

Multiple online databases were systematically searched up to October 2022 for randomized controlled trials (RCTs) and prospective studies comparing outcomes of decompression alone versus decompression with fusion for lumbar spinal stenosis in patients with degenerative spondylolisthesis. Primary outcome was the Oswestry Disability Index. Secondary outcomes included leg and back pain, surgical outcomes, and radiological outcomes. Pooled effect estimates were calculated and presented as mean differences (MD) with their 95% confidence intervals (CI) at two-year follow-up.

RESULTS

Of the identified 2403 studies, eventually five RCTs and two prospective studies were included. Overall, most studies had a low or unclear risk of selection bias and most studies were focused on low grade degenerative spondylolisthesis. All patient-reported outcomes showed low statistical heterogeneity. Overall, there was high-quality evidence suggesting no difference in functionality at two years of follow-up (MD - 0.31, 95% CI - 3.81 to 3.19). Furthermore, there was high-quality evidence of no difference in leg pain (MD - 1.79, 95% CI - 5.08 to 1.50) or back pain (MD - 2.54, 95% CI - 6.76 to 1.67) between patients undergoing decompression vs. decompression with fusion. Pooled surgical outcomes showed less blood loss after decompression only, shorter length of hospital stay, and a similar reoperation rate compared to decompression with fusion.

CONCLUSION

Based on the current literature, there is high-quality evidence of no difference in functionality after decompression alone compared to decompression with fusion in patients with degenerative lumbar spondylolisthesis at 2 years of follow-up. Further studies should focus on long-term comparative outcomes, health economic evaluations, and identifying those patients that may benefit more from decompression with fusion instead of decompression alone. This review was registered at Prospero (CRD42021291603).

Prospective, randomized controlled multicenter study of posterior lumbar facet arthroplasty for the treatment of spondylolisthesis

OBJECTIVE

The purpose of this study was to evaluate the safety and efficacy of a posterior facet replacement device, the Total Posterior Spine (TOPS) System, for the treatment of one-level symptomatic lumbar stenosis with grade I degenerative spondylolisthesis. Posterior lumbar arthroplasty with facet replacement is a motion-preserving alternative to lumbar decompression and fusion. The authors report the preliminary results from the TOPS FDA investigational device exemption (IDE) trial.

METHODS

The study was a prospective, randomized controlled FDA IDE trial comparing the investigational TOPS device with transforaminal lumbar interbody fusion (TLIF) and pedicle screw fixation. The minimum follow-up duration was 24 months. Validated patient-reported outcome measures included the Oswestry Disability Index (ODI) and visual analog scale (VAS) for back and leg pain. The primary outcome was a composite measure of clinical success: 1) no reoperations, 2) no device breakage, 3) ODI reduction of ≥ 15 points, and 4) no new or worsening neurological deficit. Patients were considered a clinical success only if they met all four measures. Radiographic assessments were made by an independent core laboratory.

RESULTS

A total of 249 patients were evaluated (n = 170 in the TOPS group and n = 79 in the TLIF group). There were no statistically significant differences between implanted levels (L4-5: TOPS, 95% and TLIF, 95%) or blood loss. The overall composite measure for clinical success was statistically significantly higher in the TOPS group (85%) compared with the TLIF group (64%) (p = 0.0138). The percentage of patients reporting a minimum 15-point improvement in ODI showed a statistically significant difference (p = 0.037) favoring TOPS (93%) over TLIF (81%). There was no statistically significant difference between groups in the percentage of patients reporting a minimum 20-point improvement on VAS back pain (TOPS, 87%; TLIF, 64%) and leg pain (TOPS, 90%; TLIF, 88%) scores. The rate of surgical reintervention for facet replacement in the TOPS group (5.9%) was lower than the TLIF group (8.8%). The TOPS cohort demonstrated maintenance of flexion/extension range of motion from preoperatively (3.85°) to 24 months (3.86°).

CONCLUSIONS

This study demonstrates that posterior lumbar decompression and dynamic stabilization with the TOPS device is safe and efficacious in the treatment of lumbar stenosis with degenerative spondylolisthesis. Additionally, decompression and dynamic stabilization with the TOPS device maintains segmental motion.