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- Title
Comparative Effectiveness of Microdecompression Alone vs Decompression Plus Instrumented Fusion in Lumbar Degenerative Spondylolisthesis.
- Authors
Austevoll, Ivar Magne; Gjestad, Rolf; Solberg, Tore; Storheim, Kjersti; Brox, Jens Ivar; Hermansen, Erland; Rekeland, Frode; Indrekvam, Kari; Hellum, Christian
- Abstract
This comparative effectiveness study evaluates whether the effectiveness of microdecompression alone is noninferior to decompression with instrumented fusion in a real-world setting among patients with lumbar degenerative spondylolisthesis. Key Points: Question: How do outcomes compare between microdecompression and decompression with instrumented fusion for patients undergoing surgery for degenerative spondylolisthesis? Findings: In this comparative effectiveness study including 285 pairs of propensity score–matched patients, 150 of 219 patients (68%) in the microdecompression group and 155 of 215 patients (72%) in the instrumented fusion group achieved an improvement in Oswestry Disability Index of at least 30%, a clinically meaningful noninferior difference. Microdecompression was associated with shorter operation time and shorter length of hospital stay. Meaning: The findings suggest that microdecompression alone should be considered as an option for most patients undergoing surgery for spinal stenosis with degenerative spondylolisthesis. Importance: Conflicting evidence and large practice variation are present in the surgical treatment of degenerative spondylolisthesis. More than 90% of surgical procedures in the United States include instrumented fusion compared with 50% or less in other countries. Objective: To evaluate whether the effectiveness of microdecompression alone is noninferior to decompression with instrumented fusion in a real-world setting. Design, Setting, and Participants: This multicenter comparative effectiveness study with a noninferiority design assessed prospective data from the Norwegian Registry for Spine Surgery. From September 19, 2007, to December 21, 2015, 1376 patients at 35 Norwegian orthopedic and neurosurgical departments underwent surgery for lumbar spinal stenosis with degenerative spondylolisthesis without scoliosis. After excluding patients undergoing laminectomy alone, fusion without instrumentation, or surgery in more than 2 levels and those with a former operation at the index level, 794 patients were included in the analyses, regardless of missing or incomplete follow-up data, before propensity score matching. Data were analyzed from March 20 to October 30, 2018. Exposures: Microdecompression alone or decompression with instrumented fusion. Main Outcomes and Measures: A reduction from baseline of 30% or greater in the Oswestry Disability Index at 12-month follow-up. Results: After propensity score matching, 570 patients (413 female [72%]; mean [SD] age, 64.7 [9.5] years) were included for comparison, with 285 undergoing microdecompression (mean [SD] age, 64.6 [9.8] years; 205 female [72%]) and 285 undergoing decompression with instrumented fusion (mean [SD] age, 64.8 [9.2] years; 208 female [73%]). The proportion of each type of procedure varied between departments. However, changes in outcome scores varied within patients but not between departments. The proportion of patients with improvement in the Oswestry Disability Index of at least 30% was 150 of 219 (68%) in the microdecompression group and 155 of 215 (72%) in the instrumentation group. The 95% CI (–12% to 5%) for the difference of −4% was above the predefined margin of noninferiority (–15%). Microdecompression alone was associated with shorter operation time (mean [SD], 89 [44] vs 180 [65] minutes; P <.001) and shorter hospital stay (mean [SD], 2.5 [2.4] vs 6.4 [3.0] days; P <.001). Conclusions and Relevance: Among patients with degenerative spondylolisthesis, the clinical effectiveness of microdecompression alone was noninferior to that of decompression with instrumented fusion. Microdecompression alone was also associated with shorter durations of surgery and hospital stay, supporting the suggestion that the less invasive procedure should be considered for most patients.
- Subjects
LUMBAR vertebrae surgery; COMBINED modality therapy; COMPARATIVE studies; MEDICAL cooperation; RESEARCH; SPINAL fusion; SPONDYLOLISTHESIS; TREATMENT effectiveness; SURGICAL decompression; DATA analysis software; DESCRIPTIVE statistics
- Publication
JAMA Network Open, 2020, Vol 3, Issue 9, pe2015015
- ISSN
2574-3805
- Publication type
Article
- DOI
10.1001/jamanetworkopen.2020.15015