OBJECTIVE: To determine the efficacy of adding instrumented spinal fusion to decompression to treat degenerative spondylolisthesis (DS). DESIGN: Systematic review with meta-analysis. DATA SOURCES: MEDLINE, Embase, Emcare, Cochrane Library, CINAHL, Scopus, ProQuest Dissertations & Theses Global, ClinicalTrials.gov and WHO International Clinical Trials Registry Platform from inception to May 2022. ELIGIBILITY CRITERIA FOR STUDY SELECTION: Randomised controlled trials (RCTs) comparing decompression with instrumented fusion to decompression alone in patients with DS. Two reviewers independently screened the studies, assessed the risk of bias and extracted data. We provide the Grading of Recommendations, Assessment, Development and Evaluation assessment of the certainty of evidence (COE). RESULTS: We identified 4514 records and included four trials with 523 participants. At a 2-year follow-up, adding fusion to decompression likely results in trivial difference in the Oswestry Disability Index (range 0-100, with higher values indicating greater impairment) with mean difference (MD) 0.86 (95% CI -4.53 to 6.26; moderate COE). Similar results were observed for back and leg pain measured on a scale of 0 to 100, with higher values indicating more severe pain. There was a slightly increased improvement in back pain (2-year follow-up) in the group without fusion shown by MD -5·92 points (95% CI -11.00 to -0.84; moderate COE). There was a trivial difference in leg pain between the groups, slightly favouring the one without fusion, with MD -1.25 points (95% CI -6.71 to 4.21; moderate COE). Our findings at 2-year follow-up suggest that omitting fusion may increase the reoperation rate slightly (OR 1.23; 0.70 to 2.17; low COE). CONCLUSIONS: Evidence suggests no benefits of adding instrumented fusion to decompression for treating DS. Isolated decompression seems sufficient for most patients. Further RCTs assessing spondylolisthesis stability are needed to determine which patients would benefit from fusion. PROSPERO REGISTRATION NUMBER: CRD42022308267.

Czech Health Research Council Prague Czech Republic

Czech National Centre for Evidence Based Healthcare and Knowledge Translation Institute of Biostatistics and Analyses Masaryk University Faculty of Medicine Brno Czech Republic

Department of Neurosurgery and Neurooncology 1st Faculty of Medicine Charles University Prague Czech Republic

Department of Neurosurgery Faculty of Medicine and Dentistry Palacky University Olomouc Czech Republic

Department of Neurosurgery Faculty of Medicine Masaryk University Brno Czech Republic

Department of Neurosurgery Na Homolce Hospital Prague Czech Republic

Department of Neurosurgery Regional Hospital Liberec Liberec Czech Republic

Department of Orthopaedic Surgery Faculty of Medicine Masaryk University Brno Czech Republic

Department of Spinal Surgery 1st Faculty of Medicine Charles University Prague Czech Republic

Institute of Health Information and Statistics of the Czech Republic Prague Czech Republic

Military University Hospital Prague Prague Czech Republic

Motol University Hospital Prague Czech Republic

University Hospital Brno Brno Czech Republic

University Hospital Olomouc Olomouc Czech Republic

See more in PubMed

Wang YXJ, Káplár Z, Deng M, et al. . Lumbar degenerative spondylolisthesis epidemiology: a systematic review with a focus on gender-specific and age-specific prevalence. J Orthop Translat 2017;11:39–52. 10.1016/j.jot.2016.11.001 PubMed DOI PMC

Schulte TL, Ringel F, Quante M, et al. . Surgery for adult spondylolisthesis: a systematic review of the evidence. Eur Spine J 2016;25:2359–67. 10.1007/s00586-015-4177-6 PubMed DOI

Weinstein JN, Lurie JD, Tosteson TD, et al. . Surgical versus nonsurgical treatment for lumbar degenerative spondylolisthesis. N Engl J Med 2007;356:2257–70. 10.1056/NEJMoa070302 PubMed DOI PMC

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 (Phila Pa 1976) 2008;33:2759–66. 10.1097/BRS.0b013e31818e2d8b PubMed DOI PMC

Dijkerman ML, Overdevest GM, Moojen WA, et al. . Decompression with or without concomitant fusion in lumbar stenosis due to degenerative spondylolisthesis: a systematic review. Eur Spine J 2018;27:1629–43. 10.1007/s00586-017-5436-5 PubMed DOI

Pranata R, Lim MA, Vania R, et al. . Decompression alone compared to decompression with fusion in patients with lumbar spondylolisthesis: systematic review, meta-analysis, and meta-regression. Int J Spine Surg 2022;16:71–80. 10.14444/8179 PubMed DOI PMC

Liang H-F, Liu S-H, Chen Z-X, et al. . Decompression plus fusion versus decompression alone for degenerative lumbar spondylolisthesis: a systematic review and meta-analysis. Eur Spine J 2017;26:3084–95. 10.1007/s00586-017-5200-x PubMed DOI

Wu J, Zhang J, Xu T, et al. . The necessity or not of the addition of fusion to decompression for lumbar degenerative spondylolisthesis patients: a PRISMA compliant meta-analysis. Medicine (Baltimore) 2021;100:e24775. 10.1097/MD.0000000000024775 PubMed DOI PMC

Martin BI, Mirza SK, Spina N, et al. . Trends in lumbar fusion procedure rates and associated hospital costs for degenerative spinal diseases in the United States, 2004 to 2015. Spine (Phila Pa 1976) 2019;44:369–76. 10.1097/BRS.0000000000002822 PubMed DOI

Pieters TA, Li YI, Towner JE, et al. . Comparative analysis of decompression versus decompression and fusion for surgical management of lumbar spondylolisthesis. World Neurosurg 2019;125:e1183–8. 10.1016/j.wneu.2019.01.275 PubMed DOI

Chen B, Lv Y, Wang Z-C, et al. . Decompression with fusion versus decompression in the treatment of lumbar spinal stenosis: a systematic review and meta-analysis. Medicine (Baltimore) 2020;99:e21973. 10.1097/MD.0000000000021973 PubMed DOI PMC

Koenig S, Jauregui JJ, Shasti M, et al. . Decompression versus fusion for grade I degenerative spondylolisthesis: a meta-analysis. Global Spine J 2019;9:155–61. 10.1177/2192568218777476 PubMed DOI PMC

Martin CR, Gruszczynski AT, Braunsfurth HA, et al. . The surgical management of degenerative lumbar spondylolisthesis: a systematic review. Spine (Phila Pa 1976) 2007;32:1791–8. 10.1097/BRS.0b013e3180bc219e PubMed DOI

Wei F-L, Zhou C-P, Gao Q-Y, et al. . Decompression alone or decompression and fusion in degenerative lumbar spondylolisthesis. EClinicalMedicine 2022;51:101559. 10.1016/j.eclinm.2022.101559 PubMed DOI PMC

Higgins JPT, Cochrane Collaboration . Cochrane handbook for systematic reviews of interventions. 2nd ed. Hoboken, NJ: Wiley-Blackwell, 2020.

Page MJ, McKenzie JE, Bossuyt PM, et al. . The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. 10.1136/bmj.n71 PubMed DOI PMC

Santesso N, Glenton C, Dahm P, et al. . Grade guidelines 26: informative statements to communicate the findings of systematic reviews of interventions. J Clin Epidemiol 2020;119:126–35. 10.1016/j.jclinepi.2019.10.014 PubMed DOI

Matz PG, Meagher RJ, Lamer T, et al. . Guideline summary review: an evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spondylolisthesis. Spine J 2016;16:439–48. 10.1016/j.spinee.2015.11.055 PubMed DOI

Bramer WM, Giustini D, de Jonge GB, et al. . De-duplication of database search results for systematic reviews in endnote. J Med Libr Assoc 2016;104:240–3. 10.3163/1536-5050.104.3.014 PubMed DOI PMC

Sterne JAC, Savović J, Page MJ, et al. . RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ 2019;366:l4898. 10.1136/bmj.l4898 PubMed DOI

McGuinness LA, Higgins JPT. Risk-of-bias visualization (robvis): an R package and shiny web APP for visualizing risk-of-bias assessments. Res Synth Methods 2021;12:55–61. 10.1002/jrsm.1411 PubMed DOI

Schünemann H, Brożek J, Guyatt G, et al. . GRADE handbook for grading quality of evidence and strength of recommendations: the GRADE working group. 2013. Available: guidelinedevelopment.org/handbook

Asher AL, Kerezoudis P, Mummaneni PV, et al. . Defining the minimum clinically important difference for grade I degenerative lumbar spondylolisthesis: insights from the quality outcomes database. Neurosurg Focus 2018;44:E2. 10.3171/2017.10.FOCUS17554 PubMed DOI

Austevoll IM, Hermansen E, Fagerland MW, et al. . Decompression with or without fusion in degenerative lumbar spondylolisthesis. N Engl J Med 2021;385:526–38. 10.1056/NEJMoa2100990 PubMed DOI

Inose H, Kato T, Sasaki M, et al. . Comparison of decompression, decompression plus fusion, and decompression plus stabilization: a long-term follow-up of a prospective, randomized study. Spine J 2022;22:747–55. 10.1016/j.spinee.2021.12.014 PubMed DOI

Inose H, Kato T, Yuasa M, et al. . Comparison of decompression, decompression plus fusion, and decompression plus stabilization for degenerative spondylolisthesis: a prospective, randomized study. Clin Spine Surg 2018;31:E347–52. 10.1097/BSD.0000000000000659 PubMed DOI PMC

Ghogawala Z, Dziura J, Butler WE, et al. . Laminectomy plus fusion versus laminectomy alone for lumbar spondylolisthesis. N Engl J Med 2016;374:1424–34. 10.1056/NEJMoa1508788 PubMed DOI

Försth P, Ólafsson G, Carlsson T, et al. . A randomized, controlled trial of fusion surgery for lumbar spinal stenosis. N Engl J Med 2016;374:1413–23. 10.1056/NEJMoa1513721 PubMed DOI

Forsth P, Carlsson T, Sanden B, et al. . No long time benefit from fusion in decompressive surgery for lumbar spinal stenosis: 5 year-results from the swedish spinal stenosis study, a multicenter rct of 233 patients. Eur Spine j 2017;26:S287. 10.1007/s00586-017-5224-2 DOI

Grotle M, Småstuen MC, Fjeld O, et al. . Lumbar spine surgery across 15 years: trends, complications and reoperations in a longitudinal observational study from Norway. BMJ Open 2019;9:e028743. 10.1136/bmjopen-2018-028743 PubMed DOI PMC

Lehr AM, Delawi D, van Susante JLC, et al. . Long-term (> 10 years) clinical outcomes of instrumented posterolateral fusion for spondylolisthesis. Eur Spine J 2021;30:1380–6. 10.1007/s00586-020-06671-6 PubMed DOI

Alvin MD, Lubelski D, Abdullah KG, et al. . Cost-utility analysis of instrumented fusion versus decompression alone for grade I L4-L5 spondylolisthesis at 1-year follow-up: a pilot study. Clin Spine Surg 2016;29:E80–6. 10.1097/BSD.0000000000000103 PubMed DOI

Okuda S, Yamashita T, Matsumoto T, et al. . Adjacent segment disease after posterior lumbar interbody fusion: a case series of 1000 patients. Global Spine J 2018;8:722–7. 10.1177/2192568218766488 PubMed DOI PMC

Bridwell KH, Sedgewick TA, O’Brien MF, et al. . The role of fusion and instrumentation in the treatment of degenerative spondylolisthesis with spinal stenosis. J Spinal Disord 1993;6:461–72. 10.1097/00002517-199306060-00001 PubMed DOI

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;73:802–8. 10.2106/00004623-199173060-00002 PubMed DOI

Cho W, Cho SK, Wu C. The biomechanics of pedicle screw-based instrumentation. J Bone Joint Surg Br 2010;92:1061–5. 10.1302/0301-620X.92B8.24237 10.1302/0301-620X.92B8.24237 PubMed DOI

Dantas F, Dantas FLR, Botelho RV. Effect of interbody fusion compared with posterolateral fusion on lumbar degenerative spondylolisthesis: a systematic review and meta-analysis. Spine J 2022;22:756–68. 10.1016/j.spinee.2021.12.001 PubMed DOI

Hirase T, Ling JF, Haghshenas V, et al. . Instrumented versus noninstrumented spinal fusion for degenerative lumbar spondylolisthesis: a systematic review. Clin Spine Surg 2022;35:213–21. 10.1097/BSD.0000000000001266 PubMed DOI

Sharif S, Shaikh Y, Bajamal AH, et al. . Fusion surgery for lumbar spinal stenosis: WFNS spine committee recommendations. World Neurosurg X 2020;7:100077. 10.1016/j.wnsx.2020.100077 PubMed DOI PMC

Spina N, Schoutens C, Martin BI, et al. . Defining instability in degenerative spondylolisthesis: surgeon views. Clin Spine Surg 2019;32:E434–9. 10.1097/BSD.0000000000000874 PubMed DOI PMC

Schroeder GD, Kepler CK, Kurd MF, et al. . Rationale for the surgical treatment of lumbar degenerative spondylolisthesis. Spine (Phila Pa 1976) 2015;40:E1161–6. 10.1097/BRS.0000000000001116 PubMed DOI

Kepler CK, Vaccaro AR, Hilibrand AS, et al. . National trends in the use of fusion techniques to treat degenerative spondylolisthesis. Spine (Phila Pa 1976) 2014;39:1584–9. 10.1097/BRS.0000000000000486 PubMed DOI

Glennie RA, Bailey CS, Abraham E, et al. . Variation in surgical treatment of degenerative spondylolisthesis in Canada: surgeon assessment of stability and impact on treatment. Eur Spine J 2021;30:3709–19. 10.1007/s00586-021-06928-8 PubMed DOI

Gille O, Challier V, Parent H, et al. . Degenerative lumbar spondylolisthesis: cohort of 670 patients, and proposal of a new classification. Orthop Traumatol Surg Res 2014;100:S311–5. 10.1016/j.otsr.2014.07.006 PubMed DOI

John J, Mirahmadizadeh A, Seifi A. Association of insurance status and spinal fusion usage in the united states during two decades. J Clin Neurosci 2018;51:80–4. 10.1016/j.jocn.2018.02.013 PubMed DOI

Hasegawa K, Kitahara K, Shimoda H, et al. . Lumbar degenerative spondylolisthesis is not always unstable: clinicobiomechanical evidence. Spine (Phila Pa 1976) 2014;39:2127–35. 10.1097/BRS.0000000000000621 PubMed DOI

Herkowitz HN, Sidhu KS. Lumbar spine fusion in the treatment of degenerative conditions: current indications and recommendations. J Am Acad Orthop Surg 1995;3:123–35. 10.5435/00124635-199505000-00002 PubMed DOI

Pisano AJ, Butler JS, Sebastian A, et al. . Does surgically managed grade I degenerative lumbar spondylolisthesis require fusion? Clin Spine Surg 2019;32:133–6. 10.1097/BSD.0000000000000684 PubMed DOI

Austevoll IM, Hermansen E, Fagerland M, et al. . Decompression alone versus decompression with instrumental fusion the NORDSTEN degenerative spondylolisthesis trial (NORDSTEN-DS); study protocol for a randomized controlled trial. BMC Musculoskelet Disord 2019;20:7. 10.1186/s12891-018-2384-0 PubMed DOI PMC

Kepler CK, Hilibrand AS, Sayadipour A, et al. . Clinical and radiographic degenerative spondylolisthesis (cards) classification. Spine J 2015;15:1804–11. 10.1016/j.spinee.2014.03.045 PubMed DOI

Volovici V, Vogels VI, Dammers R, et al. . Neurosurgical evidence and randomized trials: the fragility index. World Neurosurg 2022;161:224–9. 10.1016/j.wneu.2021.12.096 PubMed DOI