Randomized controlled trials for degenerative lumbar spondylolisthesis: which patients benefit from lumbar fusion? (original) (raw)

2016, Journal of Neurosurgery: Spine

P atients with lumbar stenosis often suffer from symptoms of radiculopathy and claudication. If nonoperative measures, including physical therapy and epidural steroid injections, fail to control their symptoms, patients may be offered surgery. The majority of patients with lumbar stenosis do not have spondylolisthesis, and when these patients undergo surgical treatment, it is typically decompression alone, based on previously published guidelines. 18,19 Some patients with lumbar stenosis also have spondylolisthesis, and this may be associated with a significant complaint of mechanical back pain. Patients with this constellation of findings may be offered lumbar decompression with or without fusion. Recently, conflicting studies have been published on the efficacy of decompression alone versus decompression with fusion for the treatment of symptomatic lumbar stenosis with spondylolisthesis. 5,7 Patients with degenerative Grade I or II spondylolisthesis are not all the same. 14 Some have mechanical low-back pain when there is axial load or stress on the lumbar spine, suggesting instability. Others have radiographic evidence of instability noted on dynamic plain lumbar radiographs. These nuances have been difficult to capture in prior published studies and make the generalization of study results difficult to apply to individual patients. The surgical options for treatment of lumbar stenosis with spondylolisthesis are reflected in prior lumbar guideline publications, which state that fusion should be considered in selected patients. 17,20 The past decade has seen a focus on the efficacy of spinal decompression with or without fusion surgery, based on patient-reported outcomes. In the coming decade there will be an additional emphasis on durability, cost effectiveness, and ultimately on the value of spinal surgery. This transition from a sole focus on the efficacy of surgical treatment to an analysis of cost-effectiveness or value has become an increasingly important priority. Our purpose is to examine the recently published randomized controlled trials that attempt to decipher the role of decompression with or without fusion for the treatment of symptomatic stenosis with spondylolisthesis and to assess the value of the addition of fusion to a decompression in the treatment paradigm. randomized controlled trials Recently, 2 new randomized controlled trials (RCTs) evaluated the utility of adding a fusion when performing a decompressive laminectomy for lumbar stenosis with Grade I lumbar spondylolisthesis: "A randomized, controlled trial of fusion surgery for lumbar spinal stenosis" (the Swedish Spinal Stenosis Study, clinicaltrials. gov registration number NCT01994512), by Försth et al., 5 and "Laminectomy plus fusion versus laminectomy alone