Reoperations after decompression with or without fusion for L4–5 spinal stenosis with or without degenerative spondylolisthesis: a study of 6,532 patients in Swespine, the national Swedish spine register

Abstract

Background and purpose — There are different opinions on how to surgically address lumbar spinal stenosis with concomitant degenerative spondylolisthesis (DS). We investigated reoperation rates at the index and adjacent levels after L4–5 fusion surgery in a large cohort of unselected patients registered in Swespine, the national Swedish spine register. Patients and methods — 6,532 patients, who underwent surgery for L4–5 spinal stenosis with or without DS between 2007 and 2012, were followed up to 2017 to identify reoperations at the index and adjacent levels. The reoperation rates for decompression and fusion were compared with the reoperation rates for decompression only and for patients with or without DS. Patient-reported outcome data were collected preoperatively, and at 1 and 2 years after surgery and used to evaluate differences in outcome between index operations and reoperations. Results — For spinal stenosis with DS, the reoperation rate at the index level was 3.0% for decompression and fusion and 6.0% for decompression only. At the adjacent level, the corresponding numbers were 9.7% and 4.2% respectively. For spinal stenosis without DS, the reoperation rate at the index level was 3.7% for decompression and fusion and 6.2% after decompression only. At the adjacent level, the corresponding numbers were 8.1% and 3.8% respectively. For the reoperations at the adjacent level, there was no difference in patient-reported outcome between extended fusion or decompression only. Interpretation — Single-level lumbar fusion surgery is associated with an increased rate of reoperations at the adjacent level compared with decompression only. When reoperations at the index level are included there is no difference in reoperation rates between fusion and decompression only.

Decompression alone or decompression and fusion in degenerative lumbar spondylolisthesis

“…After removing duplicates and screening the titles and abstracts for the remaining articles, 81 full-text articles were evaluated. Ultimately, 33 studies (6 RCTs 7 , 8 , 19 , 20 , 21 , 22 and 27 cohort studies 11 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 ) involving 94 953 participants were included in this study.

Figure 1 Literature search and screening process.

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“…Our results are consistent with those of many previous studies. 9 , 10 , 23 , 25 , 42 With regards to the included studies, the common reasons for reoperation in decompression alone group were same-segment disease (including disc herniation and recurrent stenosis), while the main reasons for reoperation in the fusion group were implant-related problems and adjacent-segment stenosis and instability. 7 , 39 Long-term follow-up results showed that although spinal fusion accelerated the degeneration of adjacent segments, it had no effects on clinical outcomes.…”

Lumbar Spinal Stenosis with Degenerative Spondylolisthesis Treated with Decompression Alone. A Cohort of 346 Patients at a Large Spine Unit. Clinical Outcome, Complications and Subsequent Surgery

“…A negative consequence of fusion is that it accelerates the degenerative process in the segments proximal to the fusion construction, the so-called Adjacent Segment Disease (ASD) 35,36 . Past studies have found high percentage of ASD and reoperation rate after DF 37–39 . Risk factors for ASD after fusion have been shown to be LSS as the indication for fusion and high age 40 .…”

“…35,36 Past studies have found high percentage of ASD and reoperation rate after DF. [37][38][39] Risk factors for ASD after fusion have been shown to be LSS as the indication for fusion and high age. 40 Therefore, it is not uncommon for patients who have previously undergone fusion for LSS with DS, to present with new degeneration and stenosis of the proximal adjacent level.…”

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

“…In clinical practice, spine surgeons may presume that slippage and dynamic instability at the level of spondylolisthesis are better treated with fusion (2). However, there have been lingering controversies reported in several studies regarding these two surgical options (8,9). Previous studies have shown that superior clinical results were achieved when fusion was added to decompression in patients with LSS + DS (10,11).…”