Lumbar Decompression Is Safe and Effective for Grade 1 Spondylolisthesis, Study Shows

Highlight From the 33rd Annual Meeting of the North American Spine Society (NASS 2018)

Peer Reviewed

Lumbar decompression is safe and effective for Grade 1 spondylolisthesis-related spinal stenosis in patients with relative pre-operative stability, according to a retrospective review of prospectively collect data from a single center presented by Reginald Q. Knight, MD, MHA, at the NASS 2018 Meeting held September 26-29 in Los Angeles, CA.

“Degenerative conditions of the lumbar spine occur frequently in our population, and quite often require surgical intervention after exhaustive non-operative treatments,” said Dr. Knight, who is an orthopaedic spine surgeon and Director of the Bassett Spine Care Institute in Cooperstown, NY. “Spondylolisthesis due to the translation is often associated with spinal stenosis, and is often considered to be unstable requiring fusion.”

“Minimally invasive spinal surgical techniques have long been touted as being stability-maintaining procedures, and we look to incorporate that in our practice as much as possible,” Dr. Knight explained. In this study, Dr. Knight and colleagues examined whether minimally invasive surgery (MIS) techniques for lumbar decompression can be used safely and effectively in the outpatient setting in select patients with spondylolisthesis.

The researchers extracted data from 24 patients with Grade 1 spondylolisthesis and compared outcomes with 58 patients who did not have spondylolisthesis from a database of 384 L4-L5 lumbar decompressions performed at the same rural academic medical center over a 7-year period.

“All patients underwent lumbar decompression at L4-L5 for symptoms of neurogenic claudication with back pain and leg pain as prominent symptoms,” Dr. Knight explained. Patients were refractory to non-operative care including physical therapy and injections, he said.

Patient-reported functional outcomes included the Visual Analog Scale (VAS), Oswestry Disability Index (ODI), and Patient Health Questionnaire-9 (PHQ-9), which were measured pre-operatively and at 1, 4, 10, and 24 months post-operatively.

Lumbar Decompression Linked to Significant Improvements
Significant improvement in back and leg pain on the VAS as well as improvement in ODI scores were found in both groups at all time intervals compared with pre-operative assessment (Figures 1A-1D).

“We noticed the typical U-shaped patient reported outcomes that we see at 24 months, with a slight return or increase in symptoms but with significantly improvement found over pre-operative levels,” Dr. Knight told the audience at NASS 2018.
Figure 1A. VAS back painFigure 1A. VAS back pain. Figure Source: Reginald Q. Knight, MD, MHA.Figure 1B. VAS leg painFigure 1B. VAS leg pain. Figure Source: Reginald Q. Knight, MD, MHA.Figure 1C. ODIFigure 1C. ODI. Figure Source: Reginald Q. Knight, MD, MHA.Figure 1D. PHQ-9Figure 1D. PHQ-9. Figure Source: Reginald Q. Knight, MD, MHA.Figures 1A-1D. Patient-reported functional outcomes significantly improved in patients with and without spondylolisthesis who underwent L4-L5 lumbar decompression. Source: Knight R, et al. Presented at: North American Spine Society (NASS) 33rd Annual Meeting. September 27, 2018, Los Angeles, CA.

Patients with spondylolisthesis were significantly older (72.4 vs. 55.9 years; P=0.0001), had longer length of stay (0.4 days vs. 0.1; P=0.007), lower body mass index (27.6 vs. 30.6; P=0.0295), and experienced less fluoroscopy time (9.9 vs. 14.1 seconds; P=0.0118) than patients without spondylolisthesis.

Re-operations were found in 5 patients without spondylolisthesis (8.6%; 4 re-decompressions and 1 fusion) at a mean of 22.4 months post-operatively, compared with 1 patient in the spondylolisthesis group (4.2%) who underwent fusion at 27 months post-operatively.

“We always hear about facet cysts as being indications for instability,” Dr. Knight explained. “Eleven out of 82 patients in this study had facet cysts, including 8 patients in the non-spondylolisthesis group; thus, not everybody with facet cysts developed spondylolisthesis,” Dr. Knight said.

The 1 patient with spondylolisthesis who later underwent fusion had a facet cyst, he noted. The case involved a 68-year-old man who was negative for Modic changes suggestive of edema or swelling of the implants, and had lack of motion at L4-L5 on flexion and extension of the lumbar spine. Sagittal T2-weighted MRI showed a bulging disc, left facet cyst, and decompression through the tube. Following fusion, the patient was able to resume normal activities, including golf, and was satisfied with the treatment.

“In conclusion, lumbar decompression for Grade 1 spondylolisthesis related to primary complaints of neurogenic claudication can be performed safely without fusion in many cases,” Dr. Knight concluded. “You will note that these cases were largely what we would consider in our clinical practices to be stable spondylolisthesis. Thus, wide MIS decompressions can be done in the outpatient setting, and patient reported functional outcomes are not compromised by this technique,” he said.

Disclosure
Dr. Knight has no relevant disclosures.

Updated on: 12/04/18
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Pre-Operative Planning Reduces Complication Risk in Adult Spinal Deformity Surgery
Reginald Q. Knight, MD, MHA
Director
Bassett Spine Care Institute
Cooperstown, NY
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