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15 Articles in Volume 21, Issue #4
Advanced Practice Matters: Needs Assessment in Pain Management Training
Analgesics of the Future: Novel Capsaicin Formulation CNTX-4975
Ask the PharmD: How to Improve Medication Adherence in Chronic Pain Management
Behavioral Medicine: Applying Mindfulness-Based Stress Reduction for Comorbid Pain and PTSD
Case Report: Multimodal Management of Osteoarthritis
Commentary: The PCP's Role in Preventing Chronic Back Pain
Guest Editorial: Structural Racism in Pain Practice and How to Combat the “Hidden Curriculum”
Hypermobile Ehlers-Danlos Syndrome: An Update on Therapeutic Approaches for Pain Management
Male Clinicians as Allies in Women’s Leadership: What Your Female Peers Want You to Know
Meet the Women Changing Pain Medicine
Perspective: It’s Time to Advocate for Early Interventional Pain Management
Research Insights: Is Spinal Fusion Surgery Being Overused in Back Pain Care?
Tips from the Field: Treating Pain in an Under-Resourced State
Utilizing Music Therapy to Manage Chronic Pain
Woman to Woman: Leaders Share Advice for the Next Generation of Pain Medicine Clinicians

Research Insights: Is Spinal Fusion Surgery Being Overused in Back Pain Care?

Decompression with fusion for degenerative spondylolisthesis may be somewhat more effective for lumbar pain relief but can be more costly, come with greater complications, and require a lengthier recovery than laminectomy alone. Its wide use is being questioned.

Posterior lumbar decompression and fusion (PLDF), also known as instrumental spinal fusion, to treat symptomatic spinal stenosis associated with degenerative spondylolisthesis is one of the most common surgical procedures performed. In 2014, the hospital costs for elective PLDF totaled $12 billion, the highest aggregate costs of any surgical procedure in the United States.1 More than 90% of surgical procedures in the US include instrumented fusion in, compared to 50% or less in other countries.2

Degenerative spondylolisthesis is a forward slip of a vertebra over another caused by degeneration and instability of facet joints, as well as the degeneration of ligaments and intervertebral discs (Image: iStock).


Spondylolisthesis: A Quick Definition

Degenerative spondylolisthesis is a forward slip of a vertebra over another caused by degeneration and instability of facet joints, as well as the degeneration of ligaments and intervertebral discs. Most patients report symptoms similar to spinal stenosis, such as low back pain and pain that radiates down the leg.

See also, differentiating spondylosis and spondylitis from spondylolisthesis by the Advanced Spine Center and more about adhesive arachnoiditis.

Nonsurgical Treatment Approaches for Degenerative Spondylolisthesis

Nonsurgical treatment options for spondylolistheses include NSAIDs, muscle relaxants, physical therapy, home exercises, and core strengthening. However, surgery is considered when the patient experiences pain so severe that it inhibits their ability to sleep, walk, and/or function.

Decompression alone (ie, laminectomy) and decompression with instrumented fusion may provide similar clinical benefits to one another, but the greater invasiveness of lumbar fusion is associated with greater complications, healthcare use, and mortality, especially in older patients.3

Spinal Decompression With or Without Fusion

Lumbar decompression alone can be an effective treatment for spinal stenosis as it involves minimal dissection with the use of an operative microscope and allows for rapid postoperative mobilization. Studies have shown that most patients experience significant pain relief and functional improvement fairly quickly after this procedure.

What the Data Show on Lumbar Decompression for Lumbar Pain, Spine Degeneration

Since the early 1990s, however, when two studies found fusion and instrumented fusion to be significantly more effective than decompression alone,4,5 the fusion rate has climbed sharply, with most surgeries performed to treat degenerative spondylolisthesis using this method.2

Some patients may benefit from decompression alone, however. A 2016 systematic review of studies comparing decompression with instrumented fusion suggested similar outcomes with both procedures; however, with long-term follow-up, fusion may provide better long-term outcomes. The authors concluded that satisfactory outcomes can be achieved with decompression in selected patients and suggested that non-instrumented fusion may be an intermediate alternative for some patients.6

New Systematic Review Finds Decompression without Fusion May Be A Better Choice

More recently, Ivar M. Austevoll, MD, of the Haukeland University Hospital Orthopedic Clinic in Bergen, Norway, and colleagues, noted that the rise in instrumented fusion might be explained by industrial financial incentives. His team hypothesized that in real-world clinical practice, decompression alone works just as well as decompression with instrumented fusion. They also proposed that less invasive methods of decompression alone such as microdecompression, or microdiscectomy, in which only a small incision is made, could preserve potentially stabilizing structures of the spine.2

Rather than doing an RCT trial with strictly recruited patients and clinicians and enforced treatment allocation, their study was designed to provide knowledge about how treatments work in the real world. Their aim was to study patients recruited in daily clinical practice at several different hospitals with treatments chosen according to the surgeon and patient preferences.

Austevoll and his team screened 1,376 patients undergoing surgical procedures for lumbar spinal stenosis with degenerative spondylolisthesis from 2007 to 2015. Patients who underwent microdecompression alone had preservation of the midline (the spinous process and interspinous ligaments), and were treated with either unilateral laminotomy, bilateral laminotomy, or unilateral laminotomy and crossover decompression. Magnifying devices were used. Patients who underwent instrument fusion had a decompression with or without preservation of the midline structures and with or without visual enhancement, and additional posterior pedicle screw instrumentation with or without an intervertebral cage.2

Patients who achieved at least a 30% reduction in pain from baseline at the 12-month follow-up, as measured by the Oswestry Disability Index (ODI), version 2.0, were considered responders.

Of 794 patients who met study eligible criteria:

  • 476 (60%) underwent microdecompression alone
  •  318 (40%) underwent decompresision plus instrumented fusion

After propensity matching, 285 patients undergoing microdecompression alone and 285 undergoing decompression and instrumentation were included in the analysis.

After 12 months, 68% of patients in the microdecompression group and 72% of those in the instrumented fusion group achieved a clinically important improvement. There were no statistically significant differences in mean ODI scores. However, the microdecompression group had significantly higher scores for numeric rating scale (NRS) leg pain and NRS back pain, compared with the instrumented fusion group.

The duration of surgery and the length of hospital stay were significantly shorter for microdecompression alone than for instrumented fusion (P < .001 for both). In addition, the microdecompression group experienced fewer surgeon-reported perioperative complications that the fusion group (P = 0.003). However, patients undergoing microdecompression alone reported a significantly higher incidence of superficial wound infection than the fusion group during the first 3 months postoperatively.

Austevoll et al concluded that, based on results of their analysis study and those of previous pragmatic studies, the high rate of instrumented fusion in daily practice seems unreasonable.2,7,8 Their findings of shorter surgery times and hospital stays with microdecompression alone were also associated with acceptable clinical results at lower costs.2

“We consider the noninferior clinical effectiveness and the potential health economic benefits of microdecompression alone to surpass the procedure’s potential inferiority,” they wrote in their paper. “Although instrumented fusion was associated with somewhat more pain reduction...the somewhat higher perioperative complication rate showed disadvantages of instrumentation.”2

Patient Identification for Decompression with Fusion

Nevertheless, adding fusion to decompression may be the best option for certain subgroups – once they are identified. In general, candidates for fusion have severe, chronic pain for more than six months, and their condition is limited to one or two discs or vertebrae. Research is underway to provide Level 1 evidence of whether decompression alone should be advocated as the preferred method or not and whether predictors exist for making the appropriate choice for surgical treatment for patients with lumbar spinal stenosis with degenerative spondylolisthesis (NCT02051374).9 Patients will be followed for up to 10 years.

See also, our latest literature review on Axial Spondyloarthritis (axSpA): Early and Differential Diagnoses.

Last updated on: July 7, 2021
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