Fusion Surgery for Back — Is It Really Required?

Key Finding: Minimally Invasive Decompression Alone Effective for Some Patients

Patients with degenerative lumbar spondylolisthesis (DLS) with up to 25% listhesis can have similar improvements in disability and pain as patients without DLS after undergoing minimally invasive decompression without fusion, according to a review of 157 cases.

There was about an 11.5% reoperation rate in patients with and without DLS.

"The message is that perhaps we do not need to fuse patients who have a stable, low-grade spondylolisthesis and are undergoing decompression surgery for lumbar stenosis," said Langston Holly, MD, director of the UCLA Spine Center and vice chairman of the University of California, Los Angeles' Department of Neurosurgery. "The belief that fusion is necessary, due to concerns about worsening of the listhesis by the decompression, may not be valid in many patients, particularly if the decompression is performed with minimally invasive techniques. There's less disruption of the musculature, ligamentous and even bony supporting structures, with MIS than with an open approach."

Study Details

Lead investigator Raja Rampersaud, MD, medical director of the Back and Neck Specialty Program at Altum Health, University Health Network, in Toronto, Canada, and his colleagues published a paper in 2010 that showed MIS decompression can be successful for correcting lumbar spinal stenosis even in patients with spondylolisthesis (Spine 2010;25:E981-E987).

The team reviewed consecutive cases from January 2007 to June 2011 with at least two years of follow-up. Sixty-two of the 157 MIS-decompression patients had DLS and the other 95 did not. The criteria for MIS decompression alone were leg-dominant symptoms; no or tolerable mechanical back pain; up to 25% listhesis; stable listhesis; and anatomy favorable to MIS decompression.

Results

There were similar reductions in Oswestry Disability Index scores at two-year follow-up in patients with and without DLS, from an average of approximately 40 to 25. Furthermore, the leg pain levels fell from a mean of approximately 6.5 to a mean of approximately 3, and the back pain levels from a mean of 6 to 3.3.

During follow-up, seven of the 62 (11.3%) DLS patients underwent reoperation, as did 11 of the 95 (11.6%) non-DLS patients.

Cost Savings

"This validates the previous economic evaluation," concluded Dr. Rampersaud, referring to a study showing decompression without fusion is more cost-effective than instrumented fusion in patients with leg-dominant pain with stable grade 1 spondylolisthesis. "MIS decompression now represents up to 50% of my DLS surgery, resulting in significant cost savings."

The study was presented at the Canadian Spine Society's 2015 annual meeting. Source: Pain Medicine News.