To fuse or not to fuse: The elderly patient with lumbar stenosis and low-grade spondylolisthesis. Systematic review and meta-analysis of randomised controlled trials.

ABSTRACT

BACKGROUND: The optimum surgical intervention for elderly patients with lumbar spinal stenosis (LSS) and low-grade degenerative-spondylolisthesis (LGDS) has been extensively debated. We conducted a systematic review and meta-analysis of randomised-controlled-trials (RCTs) comparing the effectiveness of decompression-alone against the gold-standard approach of decompression-with-fusion (D + F) in elderly patients with LSS and LGDS. METHODS: A systematic literature search was performed on published databases from inception to October-2021. English-language RCTs of elderly patients (mean age over-65) with LSS and LGDS, who had undergone DA or D + F were included. The quality and weight of evidence was assessed, and a meta-analysis performed. RESULTS: Six RCTs (n = 531; mean age 66.2 years; 57.8% female) were included. There was no difference in visual-analogue-scale (VAS) scores of back-pain (BP) or leg-pain (LP) at mean follow-up of 27.4 months between both DA and D + F groups (BP mean-difference (MD)0.24, 95%CI -0.38-0.85; LP MD0.39, 95%CI -0.34-1.11). No difference in disability, measured by Oswestry-Disability-Index scores, was found between both groups (MD0.50, 95%CI -3.31-4.31). However, patients in DA group had less hospital complications and fewer adverse events (total-surgical-complications OR0.57, 95%CI 0.36-0.90), despite a higher rate of worsening DS (OR3.49, 95%CI 1.05-11.65). No difference in BP or LP was found in subgroup-analysis of open-laminectomy compared to posterolateral-fusion (PLF) (BP MD -0.24, 95%CI -1.80-1.32; LP MD0.80, 95%CI -0.95-2.55). CONCLUSIONS: DA is not inferior to D + F in elderly patients with LSS and LGDS. DA carries a lower risk of hospital complications and fewer adverse events, however, surgeons should weigh these findings with the increased risk of DS progressing post-operatively.