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Archives of Orthopaedic and Trauma Surgery

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01-05-2017 | Orthopaedic Surgery

Effectiveness of decompression alone versus decompression plus fusion for lumbar spinal stenosis: a systematic review and meta-analysis

Authors: Wenli Chang, Peizhi Yuwen, Yanbing Zhu, Ning Wei, Chen Feng, Yingze Zhang, Wei Chen

Published in: Archives of Orthopaedic and Trauma Surgery | Issue 5/2017

Abstract

Introduction

The debate on efficacy of fusion added to decompression for lumbar spinal stenosis (LSS) is ongoing. No meta-analysis has compared the effectiveness of decompression versus decompression plus fusion in treating patients with LSS.

Methods

A literature search was performed in the Web of Science, PubMed, Embase, and Springer databases from 1970 to 2016. Relevant references were selected and the included studies were manually reviewed. We included trials evaluating decompression surgery compared to decompression plus fusion surgery in treating patients with LSS. The primary outcomes analyzed were back pain, leg pain, Oswestry Disability Index scores (ODI), the quality-of-life EuroQol-5 Dimensions (EQ-5D), duration of operation, intraoperative blood loss, length of hospital stay, major complications, walking ability, number of reoperation, and finally clinically excellent and good rates. Data analysis was conducted using the Review Manager 5.2 software.

Results

Fifteen studies involving 17,785 patients with LSS were included. The overall effect mean difference (MD) (95% CI) in the differences between pre- and post-operative back pain, leg pain, operative time, intraoperative blood loss, and length of stay were 0.04 (−0.36, 0.44), 0.69 (−0.38, 1.76), −2.04 (−3.12, −0.96), −3.96 (−6.64, −1.27) and −4.21 (−10.03, 1.62) (z = 0.18, 1.26, 3.71, 2.89 and 1.41, respectively; P = 0.86, 0.55, 0.0002, 0.004 and 0.16, respectively) in random effects models. The overall effect MD (95% CI) in ODI, EQ-5D, and walking ability were 0.43 (−1.15, 2.00), 0.01 (−0.01, 0.03) and 0.04 (−0.49, 0.57) (z = 0.52, 1.16 and 0.15, respectively; P = 0.59, 0.24 and 0.88, respectively) in fixed effects models. The overall effect odds ratio (OR) (95% CI) of major complications, number of reoperations, and clinically excellent and good rates between the two groups were 0.70 (0.60, 0.81), 1.04 (0.90, 1.19) and 0.31 (0.06, 1.59) (z = 4.63, 0.53 and 1.40, respectively; P < 0.00001, 0.60 and 0.16, respectively). Our study reveals no difference in the effectiveness between the two surgical techniques.

Conclusions

The additional fusion in the management of LSS yielded no clinical improvements over decompression alone within a 2-year follow-up period. But fusion resulted in a longer duration of operation, more blood loss, and a higher risk of complications. Therefore, the appropriate surgical protocol for LSS should be discussed further.

Verbiest H (1955) Further experiences on the pathological influence of a developmental narrowness of the bony lumbar vertebral canal. J Bone Jt Surg Br 37:576–583

Wiltse LL, Kirkaldy-Willis W, McIvor G (1976) The treatment of spinal stenosis. Clin Orthop Relat Res 115:83–91

Verbiest H (1977) Results of surgical treatment of idiopathic developmental stenosis of the lumbar vertebral canal. A review of twenty-seven years’ experience. J Bone Jt Surg Br 59:181–188

Grabias S (1980) Current concepts review. The treatment of spinal stenosis. J Bone Jt Surg Am 62:308–313CrossRef

Machado GC, Ferreira PH, Harris IA et al (2015) Effectiveness of surgery for lumbar spinal stenosis: a systematic review and meta-analysis. PLoS One 10:e0122800CrossRefPubMedPubMedCentral

Chang HS, Fujisawa N, Tsuchiya T et al (2014) Degenerative spondylolisthesis does not affect the outcome of unilateral laminotomy with bilateral decompression in patients with lumbar stenosis. Spine 39:400–408CrossRefPubMed

Mardjetko S, Connolly P, Shott S (1994) Degenerative lumbar spondylolisthesis: a meta-analysis of literature 1970–1993. Spine 19:2256–2265CrossRef

Carreon LY, Puno RM, Dimar JR 2nd et al (2003) Perioperative complications of posterior lumbar decompression and arthrodesis in older adults. J Bone Jt Surg Am 85:2089–2092CrossRef

Glassman SD, Carreon LY, Dimar JR et al (2007) Clinical outcomes in older patients after posterolateral lumbar fusion. Spine J 7:547–551CrossRefPubMed

10.

Cassinelli EH, Eubanks J, Vogt M et al (2007) Risk factors for the development of perioperative complications in elderly patients undergoing lumbar decompression and arthrodesis for spinal stenosis: an analysis of 166 patients. Spine 32:230–235CrossRefPubMed

11.

Raffo CS, Lauerman WC (2006) Predicting morbidity and mortality of lumbar spine arthrodesis in patients in their ninth decade. Spine 31:99–103CrossRefPubMed

12.

Nasca RJ (1989) Rationale for spinal fusion in lumbar spinal stenosis. Spine 14:451–454CrossRefPubMed

13.

Johnsson K-E, Redlund-Johnell I, Uden A et al (1989) Preoperative and postoperative instability in lumbar spinal stenosis. Spine 14:591–593CrossRefPubMed

14.

Getty C, Kirwan E, Sullivan M (1981) Partial undercutting facetectomy for bony entrapment of the lumbar nerve root. J Bone Jt Surg Br 63:330–335

15.

Gelalis ID, Arnaoutoglou C, Christoforou G et al (2010) Prospective analysis of surgical outcomes in patients undergoing decompressive laminectomy and posterior instrumentation for degenerative lumbar spinal stenosis. Acta Orthop Traumatol Turc 44:235–240CrossRefPubMed

16.

Grobler LJ, Robertson PA, Novotny JE et al (1993) Decompression for degenerative spondylolisthesis and spinal stenosis at L4–5: the effects on facet joint morphology. Spine 18:1475–1482CrossRefPubMed

17.

Ghogawala Z, Dziura J, Butler WE et al (2016) Laminectomy plus fusion versus laminectomy alone for lumbar spondylolisthesis. N Engl J Med 374:1424–1434CrossRefPubMed

18.

Forsth P, Olafsson G, Carlsson T et al (2016) A randomized, controlled trial of fusion surgery for lumbar spinal stenosis. N Engl J Med 374:1413–1423CrossRefPubMed

19.

Hansraj KK, O’Leary PF, Cammisa FP Jr et al (2001) Decompression, fusion, and instrumentation surgery for complex lumbar spinal stenosis. Clin Orthop Relat Res 384:18–25CrossRef

20.

Transfeldt EE, Topp R, Mehbod AA et al (2010) Surgical outcomes of decompression, decompression with limited fusion, and decompression with full curve fusion for degenerative scoliosis with radiculopathy. Spine 35:1872–1875CrossRefPubMed

21.

Amundsen T, Weber H, Nordal HJ et al (2000) Lumbar spinal stenosis: conservative or surgical management?: a prospective 10-year study. Spine 25:1424–1436CrossRefPubMed

22.

Burgstaller JM, Porchet F, Steurer J et al (2015) Arguments for the choice of surgical treatments in patients with lumbar spinal stenosis—a systematic appraisal of randomized controlled trials. BMC Musculoskelet Disord 16:1CrossRef

23.

Yone K, Sakou T, Kawauchi Y et al (1996) Indication of fusion for lumbar spinal stenosis in elderly patients and its significance. Spine 21:242–248CrossRefPubMed

24.

Herkowitz H, Kurz L (1991) Degenerative lumbar spondylolisthesis with spinal stenosis. J Bone Jt Surg 73:802–808CrossRef

25.

Harms J, Rolinger H (1981) A one-stager procedure in operative treatment of spondylolistheses: dorsal traction-reposition and anterior fusion. Z Orthop Ihre Grenzgeb 120:343–347CrossRef

26.

Suk S-I, Lee C-K, Kim W-J et al (1997) Adding posterior lumbar interbody fusion to pedicle screw fixation and posterolateral fusion after decompression in spondylolytic spondylolisthesis. Spine 22:210–219CrossRefPubMed

27.

Kleinstueck F, Fekete T, Mannion A et al (2012) To fuse or not to fuse in lumbar degenerative spondylolisthesis: do baseline symptoms help provide the answer? Eur Spine J 21:268–275CrossRefPubMed

28.

Martin CR, Gruszczynski AT, Braunsfurth HA et al (2007) The surgical management of degenerative lumbar spondylolisthesis: a systematic review. Spine 32:1791–1798CrossRefPubMed

29.

Lawhorne TW III, Girardi FP, Mina CA et al (2009) Treatment of degenerative spondylolisthesis: potential impact of dynamic stabilization based on imaging analysis. Eur Spine J 18:815–822CrossRefPubMedPubMedCentral

30.

Ekman P, Moller H, Shalabi A et al (2009) A prospective randomised study on the long-term effect of lumbar fusion on adjacent disc degeneration. Eur Spine J 18:1175–1186CrossRefPubMedPubMedCentral

31.

Hallett A, Huntley JS, Gibson JN (2007) Foraminal stenosis and single-level degenerative disc disease: a randomized controlled trial comparing decompression with decompression and instrumented fusion. Spine 32:1375–1380CrossRefPubMed

32.

Dailey A, Harrop JS, France JC (2010) High-energy contact sports and cervical spine neuropraxia injuries: what are the criteria for return to participation? Spine 35:S193–S201CrossRefPubMed

33.

Brodke DS, Annis P, Lawrence BD et al (2013) Reoperation and revision rates of 3 surgical treatment methods for lumbar stenosis associated with degenerative scoliosis and spondylolisthesis. Spine 38:2287–2294CrossRefPubMed

34.

McCullen GM, Bernini PM, Bernstein SH et al (1994) Clinical and roentgenographic results of decompression for lumbar spinal stenosis. J Spinal Disord 7:380–387CrossRefPubMed

35.

Brown MD, Wehman KF, Heiner AD (2002) The clinical usefulness of intraoperative spinal stiffness measurements. Spine 27:959–961CrossRefPubMed

36.

Matsudaira K, Yamazaki T, Seichi A et al (2005) Spinal stenosis in grade I degenerative lumbar spondylolisthesis: a comparative study of outcomes following laminoplasty and laminectomy with instrumented spinal fusion. J Orthop Sci 10:270–276CrossRefPubMed

37.

Radcliff K, Curry P, Hilibrand A et al (2013) Risk for adjacent segment and same segment reoperation after surgery for lumbar stenosis: a subgroup analysis of the Spine Patient Outcomes Research Trial (SPORT). Spine 38:531CrossRefPubMedPubMedCentral

38.

Tuli SM, Kapoor V, Jain AK et al (2011) Spinaplasty following lumbar laminectomy for multilevel lumbar spinal stenosis to prevent iatrogenic instability. Indian J Orthop 45:396–403CrossRefPubMedPubMedCentral

39.

Munting E, Roder C, Sobottke R et al (2015) Patient outcomes after laminotomy, hemilaminectomy, laminectomy and laminectomy with instrumented fusion for spinal canal stenosis: a propensity score-based study from the Spine Tango registry. Eur Spine J 24:358–368CrossRefPubMed

40.

Försth P, Michaëlsson K, Sandén B (2013) Does fusion improve the outcome after decompressive surgery for lumbar spinal stenosis? A two-year follow-up study involving 5390 patients. Bone Jt J 95:960–965CrossRef

41.

Kleinstueck FS, Fekete TF, Mannion AF et al (2012) To fuse or not to fuse in lumbar degenerative spondylolisthesis: do baseline symptoms help provide the answer? Eur Spine J 21:268–275CrossRefPubMed

42.

Sigmundsson FG, Jonsson B, Stromqvist B (2015) Outcome of decompression with and without fusion in spinal stenosis with degenerative spondylolisthesis in relation to preoperative pain pattern: a register study of 1624 patients. Spine J 15:638–646CrossRefPubMed

43.

Sigmundsson FG, Jonsson B, Stromqvist B (2014) Preoperative pain pattern predicts surgical outcome more than type of surgery in patients with central spinal stenosis without concomitant spondylolisthesis: a register study of 9051 patients. Spine 39:E199–E210CrossRefPubMed

44.

Aihara T, Toyone T, Aoki Y et al (2012) Surgical management of degenerative lumbar spondylolisthesis: a comparative study of outcomes following decompression with fusion and microendoscopic decompression. J Musculoskelet Res 15:1250020CrossRef

45.

Hu RW, Jaglal S, Axcell T et al (1997) A population-based study of reoperations after back surgery. Spine 22:2265–2270CrossRefPubMed

46.

Lad SP, Babu R, Ugiliweneza B et al (2014) Surgery for spinal stenosis: long-term reoperation rates, health care cost, and impact of instrumentation. Spine 39(12):978–987CrossRefPubMed

47.

Grob D, Humke T, Dvorak J (1995) Degenerative lumbar spinal stenosis. Decompression with and without arthrodesis. J Bone Jt Surg Am 77:1036–1041CrossRef

48.

Postacchini F, Cinotti G (1992) Bone regrowth after surgical decompression for lumbar spinal stenosis. J Bone Jt Surg Br 74:862–869

49.

Kim S, Mortaz Hedjri S, Coyte PC et al (2012) Cost-utility of lumbar decompression with or without fusion for patients with symptomatic degenerative lumbar spondylolisthesis. Spine J 12:44–54CrossRefPubMed

Title: Effectiveness of decompression alone versus decompression plus fusion for lumbar spinal stenosis: a systematic review and meta-analysis
Authors: Wenli Chang
Peizhi Yuwen
Yanbing Zhu
Ning Wei
Chen Feng
Yingze Zhang
Wei Chen
Publication date: 01-05-2017
Publisher: Springer Berlin Heidelberg
Published in: Archives of Orthopaedic and Trauma Surgery / Issue 5/2017
Print ISSN: 0936-8051
Electronic ISSN: 1434-3916
DOI: https://doi.org/10.1007/s00402-017-2685-z

At a glance: The STEP trials

Springer Medicine

Effectiveness of decompression alone versus decompression plus fusion for lumbar spinal stenosis: a systematic review and meta-analysis

Abstract

Introduction

Methods

Results

Conclusions

At a glance: The STEP trials

Springer Medicine

Abstract

Introduction

Methods

Results

Conclusions

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