Single level fusion provides equivalent outcomes to multilevel fusion for treating degenerative spondylolisthesis

Image: PD

Key Study Points:

1)     Decompression with single level fusion or multilevel fusion provided similar functional outcomes in patients with multilevel stenosis and single level degenerative spondylolisthesis.

2)     Operative time and intraoperative blood loss were significantly higher in the multilevel fusion group.

Primer:  Degenerative spondylolisthesis (DS) is the forward translation of a vertebral body over the vertebral body below it. It is caused by arthritis and remodeling of the spinal facet joints.  Although most DS is asymptomatic, it often presents with concurrent degenerative changes such as multilevel spinal stenosis which can cause radicular pain symptoms.  Operative treatment has been shown to provide superior outcomes to non-operative treatment, with those procedures that include fusion providing superior outcomes due to the increased segmental stability afforded.  Some surgeons treat patients via multilevel decompression with single level fusion while others employ multilevel decompression with multilevel fusion.  Multilevel fusion avoids the possibility of future adjacent segment degeneration, but comes at the cost of increased operative time, increased blood loss, and increased cost.  This study is the first to systematically compare the clinical outcomes of single and multilevel fusion for the treatment of DS with multilevel stenosis.

Background reading:

1. Degenerative Lumbar Spondylolisthesis: Trends in Management(JAAOS)
2. Degenerative spondylolisthesis. Predisposing factors(JBJS)

This [retrospective] study: enrolled 207 patients who presented with single level degenerative spondylolisthesis and multilevel stenosis.  130 patients were treated with multilevel decompression and single level fusion and 77 patients had multilevel decompression with multilevel fusion.  The primary outcomes of pain and physical function were assessed by the SF-36 and Oswestry Disability Index at 1, 2, 3, and 4 years.

No difference was seen in baseline pain and disability scores, however patients presenting with asymmetric depressed reflexes or lateral recess stenosis were more likely to receive a multi-level fusion.  No differences in primary outcomes were found when comparing single level and multi-level fusion for the treatment of DS with multilevel stenosis.  Operative time (250min  vs. 187min) and intraoperative blood loss (784mL vs 623mL) were both significantly higher in the multilevel fusion group.  Interestingly, no significant difference was found in either blood replacement volume or complication rate.

In sum: For patients suffering from DS with concurrent stenosis, decompression with single level fusion provides equivalent functional outcomes to decompression with multilevel fusion.  In light of this, the decreased operative time, blood loss, and cost associated with single level fusion enhances the appeal of this technique.

Lack of randomization and variability in surgeon decision making are possible limitations of this study.  Additionally, it is a subgroup analysis of the original data and the follow-up period is relatively short term.  Although longer follow up may be warranted to confirm these results, this study remains the first to systematically compare these surgical techniques for the treatment of DS with multi-level stenosis.

Click to read the article in Spine

By [CC] and [AH]

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