Re-evaluating established principles—should decompression replace fusion as the go-to for degenerative lumbar spondylolisthesis?


Blog DLS

Degenerative lumbar spondylolisthesis (DLS) is one of the major causes of lower back pain in adult and elderly patients. Fusion is generally seen as the standard surgical treatment. But could it be time to re-evaluate? At the Global Spine Congress 2023 in Prague, Stipe Ćorluka, an associate member of the AO Spine Knowledge Forum Degenerative, will argue that it could make more sense to focus on decompression instead.

Ask around a little among spine surgeons what they consider to be the best surgical procedure for low-grade cases of degenerative lumbar spondylolisthesis (DLS), and what you will hear may contradict what you thought was an established fact. In fact, it is reasonably likely that you will be told about fusion procedures with very poor patient outcomes on the one hand, while on the other hand you will probably hear about very good results after decompression surgery alone.

This, of course, is all very much anecdotal and is not solid scientific evidence. Still, it is odd. After all, fusion surgery is seen by many as the gold standard for the surgical treatment of low-grade DLS. On closer inspection, however, there are a few reasons that can make you wonder why. As a procedure, fusion is much more physically disruptive than decompression. It is also associated with more blood loss, longer hospital stays, and higher overall treatment costs.

Questioning conventional wisdom for low-grade degenerative lumbar spondylolisthesis

Most importantly, however, fusion inevitably causes a loss of motion in the affected segment of the spine. Although it is true that this is exactly the desired outcome—unstable vertebrae can be stabilized by permanently joining them together—the resulting impairment in motion can also have rather negative effects on patient quality of life.

When we met in Las Vegas last year for our regular meeting of the AO Spine Knowledge Forum Degenerative (KF Degen), we discovered that many of us had heard anecdotes like the one I outlined at the start. So collectively, we started to wonder: Shouldn’t we reconsider whether fusion should really be the go-to technique for low-grade DLS? Shouldn’t we instead aim to resort to fusion only in cases where there is absolutely no alternative? Wouldn’t it make much more sense to put simpler procedures in the spotlight that preserve motion, and based on our collective treasure trove of anecdotes, could decompression possibly assume that role?

Easier and more qualified decisions for management of degenerative spine disorders

It quickly became clear to us that there is currently no clear scientific consensus on the best surgical treatment for low-grade DLS. So, we asked how can we as spine surgeons be expected to make an informed decision on which procedure to go for when confronted with the condition? The simple answer is as follows: We cannot. There are frankly not enough clear conclusions based on high-quality studies to help us choose the most appropriate way forward in each individual case.

Focus group of AO Spine KF Degen is in the process of systematically reviewing the literature in order to identify the risk factors for failure in decompression only procedures. In the next phase of our project, we will do the same for fusion procedures. 

Fortunately, as members of the KF Degen, we have access to vast knowledge and data resources. Among them is DegenPRO, an international multi-center prospective registry for the treatment of degenerative spine disorders. The database contains comprehensive information on thousands of degenerative spine patients, including treatment outcomes for various surgical procedures. Among them, there are also cases of DLS, and after our review of the literature, we will be able to identify poor outcomes after surgery for DLS. We hope to be able to identify risk factors as well, so that in the future we can better predict patient suitability for either surgical technique.

Our basic premise is: can we say for certain that a significant portion of DLS patients with decompression surgery only will have the same or better outcomes than they would if they had fusion surgery? Our hope is to eventually give spine surgeons a better set of criteria to allow them to make easier and more qualified decisions on the appropriate procedure.

Diverse approaches, one goal: best treatment and outcomes for spine patients

I believe that KF Degen is an ideal platform to answer questions related to the DLS treatment strategy. We are a diverse group from all around the world with members of all ages, backgrounds, and specialties. We have very different philosophies, and the standards of care in our respective home countries can vary greatly. Still, we all share the same goals: we want to contribute to the discipline, make long-term improvements to treatment outcomes, and thereby improve quality of life for as many patients as possible.

I am proud and happy to be an associate member of the KF Degen. It provides a stage on which to share ideas with a large group of colleagues, some of whom are eminent authorities in the field. I am also thankful for the opportunity to present our research project at this year’s Global Spine Congress in Prague. It will allow me to discuss our approach with some of the biggest names in our field and hear their thoughts.

About the author:

Stipe Ćorluka, MD, is orthopedic and trauma spinal surgeon at the largest spinal surgery centre in the Southeastern Europe which is the Spinal Surgery Division of the Traumatology Department at the the University Hospital Centre Sestre Milosrdnice and also practices in the Arithera Special Hospital, both in Zagreb, Croatia. He is one of the leading spinal surgeons in Croatia and the region. In his professional work, Ćorluka's focus is on degenerative spinal conditions and diseases, spinal injuries, and tumors of the spine. He performs more than 200 surgical procedures on the spine every year on the cervical, thoracic, and lumbar spine. For his work, patients awarded him the title of Best Doctor in 2022. Ćorluka is an associate member of the AO Spine Knowledge Forum Degenerative and actively participates in several of the group's studies. 

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The articles included in the AO Spine Blog represent the opinion of individual authors exclusively and not necessarily the opinion of AO Spine or AO Foundation.