Degenerative Spondylolisthesis—What We Know, What We Don’t, and Where We Go From Here
fusion, this has yet to be demonstrated in a comparative study. Until such a study is performed, the currently observed wide variation in practice is likely to continue.
To guide treatment decision-making and identify groups that might benefit from a specific type of treatment, subgroup analyses and prediction models can be helpful. The SPORT investigation is essentially the only large-scale study that has evaluated outcomes predictors for DS, with previous studies combining patients with DS with those with SpS in their analyses of outcomes predictors. Other authors have suggested that patients with SpS who have predominant low back pain (LBP) improved less with surgery than did those with predominant leg pain.5,19
As such, the SPORT DS data were
analyzed to determine the effect of predominant pain location on surgical and non-operative outcomes.20
This analysis demonstrated that patients
with predominant leg pain improved significantly more with surgery than did those with predominant LBP across all primary outcome measures at one and two years following surgery. A similar, but less consistent, trend was seen for non-operative outcomes. In addition, the treatment effect of surgery (TE), the difference in surgical and non-operative change scores, tended to be higher for patients with predominant leg pain. These data can be useful in counseling patients about expected outcomes based on their predominant pain location and suggest that patients with predominant leg pain can expect to improve more with surgery. However, the patients with predominant LBP still improved significantly more with surgery than with non-operative treatment, suggesting that surgery also remains the preferred treatment for this group. The radiographic SPORT data were also evaluated to determine whether listhesis grade, disk height and hypermobility on flexion, and extension radiographs predicted outcomes.21 Somewhat surprisingly, patients with hypermobility on pre-operative flexion–extension X-rays, defined as translation greater than 4mm or rotation >10º, improved more with non-operative care compared with those without hypermobility. Given that this hypermobile group has been described as ‘unstable’ in the past, this group was not expected to improve more with non-operative care compared with the ‘stable’ group.22
Surgical
outcomes were similar regardless of listhesis grade, disk height, and mobility. Although the hypermobile group did improve significantly more with surgery compared with non-operative treatment on most outcome
1. Vogt MT, Rubin D, Valentin RS, et al. Lumbar olisthesis and lower back symptoms in elderly white women. The Study of Osteoporotic Fractures, Spine, 1998;23(23):2640–7.
2. Deyo RA, Mirza SK, Martin BI, et al. Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults, JAMA, 2010;303(13):1259–65.
3. Weinstein JN, Lurie JD, Tosteson TD, et al., Surgical versus nonsurgical treatment for lumbar degenerative spondylolisthesis, N Engl J Med, 2007;356(22):2257–70.
4. Pearson A, Blood E, Lurie J, et al., Degenerative spondylolisthesis versus spinal stenosis: does a slip matter? Comparison of baseline characteristics and outcomes (SPORT), Spine, 2010;35(3):298–305.
5. Atlas SJ, Deyo RA, Keller RB, et al., The Maine Lumbar Spine Study, Part III. 1-year outcomes of surgical and nonsurgical management of lumbar spinal stenosis, Spine, 1996;21(15):1787–94, discussion 94–5.
6. Atlas SJ, Keller RB, Robson D, et al., Surgical and nonsurgical management of lumbar spinal stenosis: four-year outcomes from the maine lumbar spine study, Spine, 2000;25(5):556–62.
7. Atlas SJ, Keller RB, Wu YA, et al., Long-term outcomes of surgical and nonsurgical management of lumbar spinal stenosis: 8 to 10 year results from the maine lumbar spine study, Spine, 2005;30(8):936–43.
8. Malmivaara A, Slatis P, Heliovaara M, et al., Surgical or nonoperative treatment for lumbar spinal stenosis? A randomized controlled trial, Spine, 2007;32(1):1–8.
9. Weinstein JN, Tosteson TD, Lurie JD, et al., Surgical versus
measures, the results of this study suggest that hypermobility should not be a contra-indication to non-operative care. Unfortunately, SPORT was not able to compare surgical outcomes among patients with hypermobility undergoing different types of surgical treatment (i.e. decompression alone, uninstrumented posterolateral fusion, instrumented posterolateral fusion, or 360º fusion) owing to the small size of these subgroups. Some authors have suggested that patients with hypermobility might benefit from instrumented fusion; however, no comparative data exist comparing instrumented and uninstrumented fusion for these patients.23
Where We Go from Here
The above discussion highlights what we do and do not know about the treatment of DS. Based on the evidence, surgical treatment has been shown to lead to better outcomes than non-operative treatment for patients who meet strict indications for surgery (i.e. duration of symptoms greater than 12 weeks, neurologic findings on physical exam, and imaging demonstrating DS causing stenosis). Fusion should be added to decompression to prevent progressive listhesis and recurrent symptoms, and future research should be performed to compare results between traditional decompression with fusion and more modern anatomy- preserving decompression without fusion. No strong evidence exists to dictate the most appropriate fusion technique, although what evidence does exist suggests that the addition of instrumentation does not lead to improved clinical outcomes, at least in the short term. The science of outcomes prediction in DS remains rudimentary, although we do know that patients with predominant leg pain tend to improve more with surgery compared with those with predominant LBP. Future research should attempt to answer the following questions: does a less destructive decompression without fusion lead to similar outcomes as a traditional decompression and fusion; does the addition of instrumentation or interbody fusion lead to better long-term outcomes compared with uninstrumented fusion; can certain subgroups be defined for which specific treatments are more appropriate; and can a model be created to predict outcomes based on individual characteristics? Although marked progress has been made during the past two decades to create an evidence base for the treatment of DS, there is still much work that needs to be carried out to determine the right treatment for each individual DS patient. n
nonoperative treatment for lumbar spinal stenosis four-year results of the Spine Patient Outcomes Research Trial, Spine, 2010;35(14):1329–38.
10. Tosteson TD, Hanscom B, Blood EA, et al., Statistical methods for cross-over in the SPORT lumbar disc herniation trial, Presented at: International Society for the Study of the Lumbar Spine Annual Meeting, Hong Kong, 2007.
11. Flum DR, Interpreting surgical trials with subjective outcomes: avoiding UnSPORTsmanlike conduct, JAMA, 2006;296(20):2483–5.
12. Herkowitz HN, Kurz LT, Degenerative lumbar spondylolisthesis with spinal stenosis. A prospective study comparing decompression with decompression and intertransverse process arthrodesis, J Bone Joint Surg Am, 1991;73(6):802–8.
13. Martin CR, Gruszczynski AT, Braunsfurth HA, et al., The surgical management of degenerative lumbar spondylolisthesis: a systematic review, Spine, 2007;32(16):1791–8.
14. Rampersaud YR, Wai E, Abraham E, et al., Health related quality of life following decompression copmared to decompression and fusion for degenerative spondylolisthesis: a Canadian multicenter trial, Can J Surg, 2010;53(Suppl.):S26–48.
15. Ghogawala Z, Benzel EC, Amin-Hanjani S, et al., Prospective outcomes evaluation after decompression with or without instrumented fusion for lumbar stenosis and degenerative Grade I spondylolisthesis, J Neurosurg Spine, 2004;1(3):267–72.
16. Fischgrund JS, Mackay M, Herkowitz HN, et al., 1997 Volvo Award winner in clinical studies. Degenerative lumbar spondylolisthesis with spinal stenosis: a prospective,
randomized study comparing decompressive laminectomy and arthrodesis with and without spinal instrumentation, Spine, 1997;22(24):2807–12.
17. Kornblum MB, Fischgrund JS, Herkowitz HN, et al., Degenerative lumbar spondylolisthesis with spinal stenosis: a prospective long-term study comparing fusion and pseudarthrosis, Spine, 2004;29(7):726–33, discussion 33–4.
18. Abdu WA, Lurie JD, Spratt KF, et al., Degenerative spondylolisthesis: does fusion method influence outcome? Four-year results of the spine patient outcomes research trial, Spine, 2009;34(21):2351–60.
19. Kleinstuck FS, Grob D, Lattig F, et al., The influence of preoperative back pain on the outcome of lumbar decompression surgery, Spine, 2009;34(11):1198–203.
20. Pearson A, Blood E, Lurie J, et al., Predominant leg pain is associated with better surgical outcomes in degenerative spondylolisthesis and spinal stenosis: results from the Spine Patient Outcomes Research Trial (SPORT), Spine, 2011;36(3):219–29
21. Pearson AM, Lurie JD, Blood EA, et al., Spine patient outcomes research trial: radiographic predictors of clinical outcomes after operative or nonoperative treatment of degenerative spondylolisthesis, Spine, 2008;33(25):2759–66.
22. Frymoyer JW, Selby DK, Segmental instability. Rationale for treatment, Spine, 1985;10(3):280–6.
23. Yone K, Sakou T, Usefulness of Posner’s definition of spinal instability for selection of surgical treatment for lumbar spinal stenosis, J Spinal Disord, 1999;12(1):40–4.
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