New meta-analysis indicates no benefit of adding instrumented fusion to decompression for stable degenerative spondylolisthesis

Radek Kaiser

There is no benefit of adding instrumented fusion to decompression for treating degenerative spondylolisthesis (DS), according to a recent systematic review and meta-analysis, the findings of which were published in the Journal of Neurology, Neurosurgery, and Psychiatry by Radek Kaiser (Charles University, Prague, Czech Republic) et al.

The aim of the research was to determine the efficacy of adding instrumented spinal fusion to decompression to treat DS.

Kaiser et al explain that the findings “provide clinicians and healthcare policy makers with a comprehensive assessment and high-quality evidence on the safety and efficacy of simple decompression as a superior option for patients with stable DS.

“This conclusion might be especially useful for patients in higher age groups who are likely to be better served by the lower morbidity associated with decompression alone,” they add.

The researchers collected data from the MEDLINE, Embase, Emcare, Cochrane Library, Cumulated Index to Nursing and Allied Health Literature, Scopus, ProQuest Dissertations and Theses Global, and WHO International Clinical Trials Registry Platform databases from inception to May 2022.

Randomised controlled trials (RCTs) comparing decompression with instrumented fusion to decompression alone in patients with DS were included. Two reviewers independently screened the studies, assessed the risk of bias and extracted data while the researchers provided the Grading of Recommendations, Assessment, Development and Evaluation assessment of the certainty of evidence (COE).

A total of 4,514 records were identified and included four trials with 523 participants. The evidence suggests that adding fusion to decompression is ineffective for most patients with spondylolisthesis. It likely results in no additional benefits regarding disability, pain and quality of life at a minimum follow-up of two years after surgery. Furthermore, fusion is linked to increased surgery-related complications (duration, blood loss, extended hospital stay) and costs while not decreasing the long-term complication and reoperation rate.

Speaking to Spinal News International, Kaiser said: “The added value of our review with meta-analysis, which distinguishes it from previous analyses, is that its design was discussed and validated by a national panel of experts in spine surgery with extensive experience in treating degenerative spinal conditions and evidence synthesis experts.

“We included only trials using pedicle screw fixation fusion, which has been established as the gold standard for spinal fusion because of its anchoring strength. We excluded historical studies comparing cases after other techniques of fixation or those using non-instrumented fusion due to its lower rate of solid fusion and higher rate of definitive pseudarthrosis and trials with pseudo-randomisation.

“Based on the careful examination of our meta-analysis using the GRADE approach, we can almost certainly state that future research is unlikely to change our confidence in the estimate of effect. Therefore, conclusions of our study should be considered strong enough to influence the clinical practice. We are aware of a limitation of our analysis, which is the lack of evidence for a difference in treatment between stable and unstable DS. Therefore, future trials should aim to determine which subgroups would benefit from adding fusion to decompression.”


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