Back pain treatment: Has spinal fusion surgery been overused? – mahrgan

Compared with laminectomy alone, degenerative lumbar spondylolisthesis and fusion decompression may be more effective in relieving lumbar pain, but it costs more, has more complications, and requires a longer recovery time. Its widespread use has been questioned.

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

Degenerative spondylolisthesis is the forward slippage of the vertebrae caused by facet joint degeneration and instability, as well as ligament and intervertebral disc degeneration (picture source: iStock).

Spondylolisthesis: a quick definition

Degenerative spondylolisthesis is the forward sliding of the vertebrae caused by the degeneration and instability of the facet joints and the degeneration of the ligaments and intervertebral discs. Most patients report symptoms similar to spinal stenosis, such as low back pain and radiating pain in the lower extremities.

See also Advanced Spine Center distinguishing spondylopathy and spondylitis from spondylolisthesis And more information about adhesive arachnoiditis.

Non-surgical treatment of degenerative spondylolisthesis

Non-surgical treatment options for spondylolisthesis include non-steroidal anti-inflammatory drugs, muscle relaxants, physical therapy, home exercises, and core strengthening. However, when the patient’s pain is severe enough to affect their sleep, walking, and/or function, surgery is considered.

Separate decompression (ie laminectomy) and instrument fusion decompression may provide similar clinical benefits, but the greater invasiveness of lumbar fusion is associated with greater complications, health care use, and mortality, especially in the elderly In patients.3

Spinal decompression with or without fusion

Lumbar decompression alone can be an effective way to treat spinal stenosis because it involves the use of an operating microscope for minimal dissection and allows rapid movement after surgery. Studies have shown that most patients experience significant pain relief and functional improvement quite quickly after this operation.

Data of lumbar decompression for low back pain and spinal degeneration

However, since the early 1990s, when two studies found that fusion and instrument fusion were more effective than decompression alone,4,5 The fusion rate has risen sharply, and most surgeries use this method to treat degenerative spondylolisthesis.2

However, some patients may only benefit from decompression. A 2016 systematic review of studies comparing decompression and instrument fusion showed that the results of the two procedures were similar; however, with long-term follow-up, fusion may provide better long-term results. The authors conclude that decompression can achieve satisfactory results in selected patients and suggest that non-instrumental fusion may be an intermediate option for some patients.6

New systematic review finds that not using fusion decompression may be a better option

Recently, Ivar M. Austevoll, MD, of the Orthopedic Clinic at Haukeland University Hospital in Bergen, Norway, and colleagues pointed out that the rise of instrument fusion may be explained by industrial economic incentives. His team hypothesized that in real-world clinical practice, decompression alone is as effective as instrument fusion decompression. They also proposed that minimally invasive decompression methods such as minimally invasive decompression or microdiscectomy, with only a small incision, can preserve the potentially stable spinal structure.2

Their research is not to conduct RCT trials and mandatory assignment of treatments on strictly recruited patients and clinicians, but to provide knowledge about how treatments work in the real world. Their purpose is to study patients recruited in daily clinical practice in several different hospitals, and choose treatment methods according to the preferences of surgeons and patients.

Austevoll and his team screened 1,376 patients who underwent surgery for lumbar spinal stenosis with degenerative spondylolisthesis from 2007 to 2015. Patients who underwent micro decompression alone retained the midline (spinous process and interspinous ligament) and underwent unilateral laminectomy or bilateral laminectomy. Laminectomy, or unilateral laminectomy and cross decompression. A magnifying device is used. Patients undergoing instrumental fusion surgery underwent decompression with or without preservation of the midline structure and with or without visual enhancement, and an additional posterior pedicle screw with or without an intervertebral fusion cage fixed.2

During the 12-month follow-up, patients whose pain was reduced by at least 30% from baseline based on the Oswestry Disability Index (ODI) version 2.0 were considered responders.

Among the 794 patients who met the study eligibility criteria:

  • 476 (60%) people received light decompression alone
  • 318 (40%) underwent decompression plus instrument fusion

After propensity matching, 285 patients who received only minimal decompression and 285 patients who received decompression and device therapy were included in the analysis.

After 12 months, 68% of patients in the minimal decompression group and 72% in the device fusion group achieved clinically important improvements. There was no statistically significant difference in the average ODI score. However, compared with the device fusion group, the minimal decompression group scored significantly higher on the Numerical Rating Scale (NRS) leg pain and NRS back pain.

The operation time and hospitalization time of micro decompression alone are significantly shorter than that of instrument fusion.phosphorus <.001 for both). In addition, compared with the fusion group, the surgeons experienced in the minimal decompression group reported fewer perioperative complications.phosphorus = 0.003). However, in the first 3 months after surgery, patients who received minimal decompression alone reported a significantly higher incidence of superficial wound infections than the fusion group.

Austevoll et al. concluded that based on their analytical research results and previous practical research results, the high rate of instrumentation fusion in daily practice seems unreasonable.2,7,8 They found that only minimal decompression can shorten the operation time and hospital stay, which is also related to acceptable clinical results and lower costs.2

They wrote in the paper: “We believe that the non-inferior clinical effectiveness and potential health and economic benefits of micro-decompression alone outweigh the potential disadvantages of the procedure.” “Although device fusion is associated with more pain reduction… …The perioperative complication rate is slightly higher, but it shows the shortcomings of the device.”2

Fusion decompression patient identification

However, for some subgroups, adding fusion based on decompression may be the best option-once they are identified. Generally speaking, candidates for fusion have severe chronic pain for more than six months, and their condition is limited to one or two intervertebral discs or vertebrae. Research is ongoing to provide level 1 evidence to demonstrate whether decompression alone should be promoted as the preferred method and whether there are predictors to make appropriate surgical treatment options for patients with lumbar spinal stenosis and degenerative spondylolisthesis (NCT02051374).9 The patient will be followed for up to 10 years.

See also our latest literature review Axial spondyloarthritis (axSpA): early and differential diagnosis.

Last update date: July 7, 2021

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