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Janis C. Kelly, Medscape
Patients whose lumbar spinal stenosis was treated with decompression surgery plus fusion ended up no less disabled than those who had decompression alone, but they did lose more blood, stay hospitalized longer, and have higher medical bills, according to two studies published in the April 14 issue of the New England Journal of Medicine.
Outcomes from these randomized controlled trials call into question the current enthusiasm for decompression plus fusion, now routinely performed in more than half of patients with surgically treated spinal stenosis in the United States (including 96% of those with degenerative spondylolisthesis).
Neither research group found that adding fusion improved scores on the Oswestry Disability
Index (ODI), a disease-
In an accompanying editorial, Wilco C. Peul, MD, PhD, and Wouter A. Moojen, MD, PhD, write, "The goal of surgery in lumbar spinal stenosis is to improve walking distance and to relieve pain by decompression of nerve roots. The addition of instrumented fusion — 'just to be sure' — for the treatment of the most frequent forms of lumbar spinal stenosis does not create any added value for patients and might be regarded as an overcautious and unnecessary treatment." Dr Peul and Dr Moojen are both from Leiden University Medical Center and Medical Center Haaglanden, The Hague, the Netherlands, and were not involved in either of the studies.
The aim of the first study, the Swedish Spinal Stenosis Study (SSSS), reported by Peter Försth, MD, PhD, from the Department of Surgical Science, Uppsala University, Sweden, and colleagues, was to determine whether combining fusion surgery with decompression surgery resulted in better clinical outcomes at 2 years than decompression surgery alone.
The trial included 247 patients with lumbar spinal stenosis at one or two adjacent vertebral levels who were randomly assigned either to decompression (laminectomy) alone or to decompression plus fusion surgery. About half of the patients also had degenerative spondylolisthesis, defined as presence of a vertebra that had slipped at least 3 mm past the vertebra below it.
Randomization was stratified for presence or absence of degenerative spondylolisthesis. The authors write, "Many spine surgeons view this sign of instability as a mandatory indication for fusion surgery."
The primary outcome in the Swedish study was the score on the ODI 2 years after surgery.
The researchers also assessed patient-
The second study was the Spinal Laminectomy versus Instrumental Pedicle Screw (SLIP) trial, reported by Zoher Ghogawala, MD, and colleagues in the United States. Dr Ghogawala is from the Alan L. and Jacqueline B. Stuart Spine Research Center, Lahey Hospital and Medical Center, Burlington, Massachusetts.
The SLIP researchers randomly assigned 66 patients, all of whom had symptomatic lumbar spinal stenosis and grade 1 degenerative spondylolisthesis, either to decompressive laminectomy alone or to laminectomy with posterolateral instrumented fusion. The authors note that in 2011, 465,000 spinal fusion procedures were performed in the United States, at a cost of $12.8 billion, the highest aggregate hospital costs of any surgical procedure performed in US hospitals.
Their study tested the hypothesis that lumbar laminectomy with instrumented fusion
(rigid pedicle screws affixed to titanium alloy rods) would produce better outcomes
on the SF-
Neither study showed a significant difference in disability (measured by the ODI)
associated with adding fusion to decompression surgery for spinal stenosis. In the
SSSS, the mean ODI at 2 years was 27 in the fusion group and 24 in the decompression-
Furthermore, in SSSS, adding fusion had no effect on disability score in the group of patients expected to be most likely to benefit: those with degenerative spondylolisthesis.
Dr Peul and Dr Moojen comment that in the SSSS study, decompression with fusion "was associated with higher costs [an additional $6800,] but did not provide improvement with respect to the primary outcome measure, the ODI, or to any other clinical outcome, including walking distance."
Researchers in the SLIP study report that their primary outcome, the SF-
Adjunct fusion was also associated with other problems. Length of hospital stay for fusion vs decompression alone was 4.2 vs 2.6 days in the SLIP study (P < .001) and 7.4 vs 4.1 days in the SSSS study (P < .001). In the SLIP patients, mean blood loss was 513.7 mL for fusion vs 83.4 mL for decompression alone (P < .001).
According to Dr Peul and Dr Moojen, Dr Ghogawala and colleagues were correct to conclude
that the difference in SF-
The editorialists conclude, "Given that the disease-
Study Reference: N Engl J Med. 2016;374:1413-
Fusion Adds Little to Laminectomy for Lumbar Stenosis
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