Laminectomy With Fusion Is Associated With Greater Functional Improvement Compared With Laminectomy Alone for the Treatment of Degenerative Lumbar Spondylolisthesis

A Systematic Review and Meta-Analysis

Geet G. Shukla, BA; Sai S. Chilakapati, BS; Abhijith V. Matur, MD; Paolo Palmisciano, MD; Fatu Conteh, MD; Louisa Onyewadume, MD; Henry Duah, MPH; Azante Griffith, BS; Xu Tao, BS; Phillip Vorster, BS; Sahil Gupta, BS; Joseph Cheng, MD; Benjamin Motley, MD; Owoicho Adogwa, MD, MPH

Disclosures

Spine. 2023;48(12):874-884.

Abstract and Introduction

Abstract

Study Design: Systematic review and Meta-analysis.

Objective: To compare outcomes and complications profile of laminectomy alone versus laminectomy and fusion for the treatment of degenerative lumbar spondylolisthesis (DLS).

Summary of Background Data: Degenerative lumbar spondylolisthesis is a common cause of back pain and functional impairment. DLS is associated with high monetary (up to $100 billion annually in the US) and nonmonetary societal and personal costs. While nonoperative management remains the first-line treatment for DLS, decompressive laminectomy with or without fusion is indicated for the treatment-resistant disease.

Methods: We systematically searched PubMed and EMBASE for RCTs and cohort studies from inception through April 14, 2022. Data were pooled using random-effects meta-analysis. The risk of bias was assessed using the Joanna Briggs Institute risk of bias tool. We generated odds ratio and standard mean difference estimates for select parameters.

Results: A total of 23 manuscripts were included (n=90,996 patients). Complication rates were higher in patients undergoing laminectomy and fusion compared with laminectomy alone (OR: 1.55, P < 0.001). Rates of reoperation were similar between both groups (OR: 0.67, P = 0.10). Laminectomy with fusion was associated with a longer duration of surgery (Standard Mean Difference: 2.60, P = 0.04) and a longer hospital stay (2.16, P = 0.01). Compared with laminectomy alone, the extent of functional improvement in pain and disability was superior in the laminectomy and fusion cohort. Laminectomy with fusion had a greater mean change in ODI (−0.38, P < 0.01) compared with laminectomy alone. Laminectomy with fusion was associated with a greater mean change in NRS leg score (−0.11, P = 0.04) and NRS back score (−0.45, P < 0.01).

Conclusion: Compared with laminectomy alone, laminectomy with fusion is associated with greater postoperative improvement in pain and disability, albeit with a longer duration of surgery and hospital stay.

Introduction

Degenerative lumbar spondylolisthesis (DLS) is one of the main causes of low back pain and functional impairment. It is associated with high monetary (up to $100 billion annually in the United States) and nonmonetary societal and personal costs (depression, reduced productivity, emotional isolation, and health care resource utilization).^[1–3] DLS is characterized by horizontal displacement of 1 vertebra over an adjacent vertebra, arising from the accumulation of micro-instabilities from age-related osteoarthritis of lumbar facet joints.^[4–6] Clinical presentation can range from asymptomatic or incidental radiographic findings in lower grades of displacement to radicular or claudication symptoms from spinal root or thecal sac compression, respectively, with higher grades of displacement. Instability of the spinal segment, evidenced by abnormal translation during flexion and extension on x-ray, can lead to symptomatic neural compression. While nonoperative management remains the first-line therapy for mild to moderate DLS, surgery is indicated in more severe cases involving neurological deficits or debilitating refractory pain.^[7]

Two main surgical options exist: decompressive laminectomy alone and decompressive laminectomy with fusion. Decompressive laminectomy alone relieves compression of neural elements, whereas added fusion is thought to offer additional stability to adjacent vertebrae. However, controversy exists regarding the optimal surgical management strategy, and prior studies have been inconclusive. The Swedish Spinal Stenosis Study, a randomized control trial (RCT), demonstrated no differences in the improvement of disability burden or rate of reoperation at long-term follow-up.^[8] However, Spinal laminectomy versus instrumented pedicle screw fusion, an RCT, demonstrated improvement in quality of life and decreased reoperation rate in patients undergoing laminectomy with fusion.^[9] A lack of clear evidence limits efforts to standardize practice and minimize the financial and resource burden for health care providers.

Several prospective and randomized controlled studies with long-term follow-up after surgery have since been conducted investigating the comparative benefits of laminectomy alone and laminectomy with fusion.^[8–11] However, the conclusions of these studies were divergent, and interpretations varied significantly.^[12,13] In the context of this evidence, this systematic review and meta-analysis aim to comprehensively study the effectiveness and complications profile of laminectomy alone compared with laminectomy with fusion for the treatment of DLS. Agreeing with current North American Spine Society (NASS) guidelines that recommend laminectomy with fusion for the surgical management of DLS,^[14] we hypothesize that laminectomy with fusion is superior to laminectomy alone because it addresses both the neural compression as well as underlying instability of the spinal segment. Reliable estimates of the benefits of laminectomy with or without fusion are crucial to inform clinical decision-making and to improve outcomes in patients suffering from DLS.

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Abstract and Introduction
Methods
Results
Discussion
Conclusions
References
Sidebar

Table 1. Baseline Characteristics of Included Studies
Study	References	Year	Study design	Level of evidence	Sample size	Age—decompression w/fusion group	Age—decompression alone group	Female %	Follow-up time
1	Austevoll et al¹⁸	2017	Prospective cohort	IIb	520	66.3 (± 9.6)	66.7 (± 10)	73	12
2	Austevoll et al¹¹	2021	RCT	Ib	267	66.5 (± 7.9)	66.0 (± 7.4)	67	24
3	Badhiwala et al¹⁹	2021	Retrospective cohort	IIb	1804	62.7 (± 12.1)	64.4 (± 11.6)	64	1
4	Bisson et al²⁰	2021	Retrospective cohort	IIb	608	59.9 (± 11.3)	69.6 (± 11.5)	58	36
5	Chan et al²¹	2019	Retrospective cohort	IIb	143	62.1 (± 10.6)	72.3 (± 9.7)	55	24
6	Chan et al²²	2019	Retrospective cohort	IIb	426	60.7 (± 11.0)	69.9 (± 10.5)	59	12
7	Försth et al⁸	2016	RCT	Ib	135	68 (± 7)	67 (± 7)	79	24
8	Ghogawala et al²³	2004	Retrospective cohort	IIb	34	68.8 (± 8.0)	68.8 (± 8.0)	68	12
9	Ghogawala et al⁹	2016	RCT	Ib	66	66.7 (± 7.2)	66.5 (± 8.0)	80	48
10	Hayashi et al²⁴	2018	Prospective cohort	IIb	50	69.30 (± 7.2)	71.20 (± 8.0)	74	42
11	Hua et al²⁵	2021	Retrospective cohort	IIb	60	59.9 (± 8.6)	59.0 (± 7.9)	70	24
12	Inose et al¹⁰	2022	RCT	Ib60	63.5 (± 6.8)	63.4 (± 8.7)	53	60
13	Joelson et al²⁶	2022	Prospective cohort	IIb	372	63.9 (± 8.9)	69.4 (± 9.4)66	12
14	Kim et al²⁷	2018	Prospective cohortIIb	129	66.75 (± 8.77)	65.47 (± 9.03)	78	24
15	Kleinstueck et al²⁸	2012	Prospective cohort	IIb	213	67.4 (± 9.4)	73.0 (± 8.0)	73	12
16	Matsudaira et al²⁹	2005	Prospective cohort	IIb	37	67 (± 7)	68 (± 7)	65	24
17	Park et al³⁰	2012	Retrospective cohort	IIb	45	61.92 (± 19.6)	67.65 (± 19.6)	82	36
18	Pieters et al³¹	2019	Prospective cohort	IIb	9606	59.83 (± 14.1)	62.96 (± 14.6)	63	1
19	Sigmundsson et al³²	2015	Retrospective cohort	IIb	839	68.8 (± 8.7)	73.8 (± 9.3)	77	24
20	Ulrich et al³⁶	2022	Retrospective cohort	IIb	328	70.0 (± 7.4)	75.0 (± 8.3)	50	36
21	Ulrich et al³³	2017	Retrospective cohort	IIb	131	68.0 (± 7.8)	75.4 (± 7.6)	58	36
22	Vorhies et al³⁴	2018	Retrospective cohort	IIb	75024	61.00 (± 7.8)	69.00 (± 7.6)	62	60
23	Yagi et al³⁵	2018	Retrospective cohort	IIb	99	66.7 (± 7.1)	68.5 (± 9.3)	38	36

Table 2. Specific Inclusion Criteria and Surgical Parameters for Included Studies
Study	References	Year	Specific inclusion criteria	Type of fusion	Decompression/Laminectomy
1	Austevoll et al¹⁸	2017	Degenerative spondylolisthesis with spinal stenosis	No instrumentation, Posterolateral pedicle screw, or Pedicle screw + interbody fusion	Decompression
2	Austevoll et al¹¹	2021	MRI evidence of spinal stenosis and degenerative spondylolisthesis solely at the stenotic level of at least 3 mm	Posterolateral pedicle screw fixation	Decompression
3	Badhiwala et al¹⁹	2021	Functionally independent at baseline	Posterolateral fusion	Laminectomy
4	Bisson et al²⁰	2021	Meyerding grade I lumbar spondylolisthesis	Single-level fusion	Decompression
5	Chan et al²¹	2019	Meyerding Grade I, Single-segment, posteriorapproach surgery for grade 1 lumbar spondylolisthesis	Percutaneous screw fixation and placement of a Wiltse plane MIS intervertebral body graft (MIS TLIF)	Decompression
6	Chan et al²²	2019	Meyerding Grade 1 spondylolisthesis	TLIF	Laminectomy
7	Försth et al⁸	2016	Spondylolisthesis with spinal stenosis	Any	Decompression
8	Ghogawala et al²³	2004	Meyerding Grade 1 spondylolisthesis	Posterolateral instrumented fusion	Laminectomy
9	Ghogawala et al⁹	2016	Meyerding Grade I lumbar spondylolisthesis (3 to 14 mm) with lumbar stenosis and neurogenic claudication	Posterolateral instrumented fusion	Laminectomy
10	Hayashi et al²⁴	2018	Meyerding Grade 2 spondylolisthesis	Minimally invasive CBT-PLIF	Decompression
11	Hua et al²⁵	2021	Meyerding Grade 1 spondylolisthesis	Minimally invasive TLIF	Unilateral laminotomy w/Bilateral Decompression
12	Inose et al¹⁰	2022	>3 mm of spondylolisthesis of the L4 vertebra w/change of > 10 degrees of angulation or >4 mm of translation of the vertebrae between flexion and extension of the spine.	PLF with autogenous iliac bone graft and pedicle screw fixation	Decompression
13	Joelson et al²⁶	2022	Lumbar spinal stenosis w/degenerative spondylolisthesis, slip > 3 mm on the preoperative imaging studies	PLF, PLIF, TLIF	Decompression
14	Kim et al²⁷	2018	Meyerding Grade 1 spondylolisthesis	Circumferential fusion w/instrumentation using pedicle screws, posterolateral fusion with an autologous iliac bone graft, or posterior lumbar interbody fusion using a titanium cage filled with a local bone graft	Laminectomy
15	Kleinstueck et al²⁸	2012	First-time surgery at the level to be operated; maximum 3 levels to be operated in the lumbar or lumbosacral region of the spine	TLIF, PLIF, or posterolateral fusion	Decompression
16	Matsudaira et al²⁹	2005	Meyerding Grade 1 spondylolisthesis	Bilateral PLF with pedicle screw instrumentation	Decompression
17	Park et al³⁰	2012	Meyerding Grade 1, single-level spondylolisthesis	Interbody fusion with a polyester-ether-ketone (PEEK) cage and local bone and pedicle screw fixation	Left unilateral laminectomy
18	Pieters et al³¹	2019	None	Any	Decompression
19	Sigmundsson et al³²	2015	Single-level spondylolisthesis	Instrumented PLF	Decompression
20	Ulrich et al³⁶	2022	None	Implantation of pedicle screws with rods and intersomatic fusion and cage(s) at the affected disk level(s)	Decompression
21	Ulrich et al³³	2017	History of neurogenic claudication and lumbar spinal stenosis verified by MRI/CT; 1–2 adjacent levels of DLS	Implantation of pedicle screws with rods and intersomatic fusion and cage(s) at the affected disk level(s)	Decompression
22	Vorhies et al³⁴	2018	Primary or secondary diagnosis of degenerative spondylolisthesis	Any	Decompression
23	Yagi et al³⁵	2018	0–25% overhang of the vertebral body relative to the anteroposterior length of the body of the caudal vertebra in a lateral lumbar radiograph	PLIF or TLIF	Laminotomy

Y = study included only patients with this parameter, N = study excluded patients with this parameter.

Table 3. Patient Reported Outcome Measures for RCTs
Study	Type of PROM reporting	ODI L +F (CI/SD)	ODI L (CI/SD)	Significant?	Type of Pain Rating Scale	Leg Pain L +F (CI/SD)	Leg Pain L (CI/SD)	Significant?	Back Pain L +F (CI/SD)	Back Pain L (CI/SD)	Significant?	EQ-5D L +F (CI/SD)	EQ-5D L (CI/SD)	Significant?
Austevoll et al¹¹	Postop–Preop	−21.3 (−23.8 to −18.8)	−20.6 (−23.1 to −18.1)	No	NRS	−3.62 (−4.12 to −3.12)	−3.84 (−4.34 to −3.34)	No	−2.94 (−3.42 to −2.46)	−3.39 (−3.87 to −2.92)	No	0.34 (0.29 to 0.39)	0.26 (0.21 to 0.32)	No
Försth et al⁸	Last follow-up	25 ( ±19)	21 (±18)	P = 0.11	VAS	32 (±30)	29 (±31)	P = 0.6	36 (±29)	26 (±25)	P = 0.15	0.63 (±0.31)	0.69 (±0.28)	P = 0.2
Ghogawala et al⁹	Postop–Preop	−26.3	−17.9	P = 0.06	—	—	—	—	—	—	—	—	—	—
Inose et al¹⁰	Postop–Preop	—	—	—	VAS	—	—	—	−35.6 (−45.6 to -25.6)	−29.4 (−39.6 to −19.2)	P = 0.39	—	—	—

CI indicate confidence interval; EQ-5D, EuroQol 5-dimension scale; L, laminectomy alone; L+F, laminectomy with fusion; NRS, Numerical Rating Scale; ODI, Oswestry Disability Index; VAS, visual analog scale.