Surgical Management of Spinal Stenosis - To Fuse or Not To Fuse? Save

Three articles (2 studies, 1 commentary) in this week's issue of NEJM tackle the issue of whether fusion adds anything to long-term outcomes in those undergoing decompression for lumbar spinal fusion.

In one study, 247 patients with lumbar spinal stenosis between 50 and 80 years old had either decompression surgery plus fusion surgery (fusion group) or decompression surgery alone (decompression-alone group).  At the end of 2 years, there was no significant difference between the groups. Results were similar between patients with and those without spondylolisthesis.

Among the patients who had 5 years of follow-up and were eligible for inclusion in the 5-year analysis, there were no significant differences between the groups in clinical outcomes at 5 years.

In another study of 66 patients, there were modest benefits with the addition of fusion. Among patients with degenerative grade I spondylolisthesis, the addition of lumbar spinal fusion to laminectomy was associated with slightly greater but clinically meaningful improvement in overall physical health–related quality of life than laminectomy alone.  (Citation source http://buff.ly/1VslFzG 

The accompanying editorial reviews the subject and the norms in current surgical approach. Overall, these two studies suggest there is little value in adding fusion to decompression surgery. In both studies, standard bony decompression was compared with decompression plus instrumented fusion among patients who had stenosis that was limited to a maximum of two lumbar levels and did not involve spinal instability, which is the most common form of spinal stenosis. Both show stenosis surgery should be limited to decompression when no overt instability is present, and that fusion is no longer the best practice and its use should be restricted to patients who have proven spinal instability, vertebral destruction caused by trauma, tumors, infections, or spinal deformities.  http://buff.ly/1SDMtWB