Minimally Invasive Decompression Lowers Reoperation Rates

Study earns the CNS 2017 Paper of the Year award in the Spine & Peripheral Nerve subspecialty

Researchers comparing secondary fusion rates after open versus minimally invasive decompression for patients with lumbar spinal stenosis and low-grade degenerative spondylolisthesis found minimally invasive surgery (MIS) yielded better patient outcomes. The findings, originally published March 2017 in Neurosurgery, earned one of the Congress of Neurological Surgeons’ (CNS) 2017 Paper of the Year awards.

The study questions one of the long-held beliefs of many spine surgeons: When patients need surgery for lumbar spinal stenosis and spondylolisthesis, they will benefit most of a decompression and fusion procedure.

batch of blue balls marked negative with one green positive sign ballResearchers comparing secondary fusion rates after open versus minimally invasive decompression for patients with lumbar spinal stenosis and low-grade degenerative spondylolisthesis found minimally invasive surgery yielded better patient outcomes. This approach originated decades ago and is based on study findings that employed traditional open surgery, says Roger Härtl, MD, who authored this current research.

“Over the past 10 to 15 years, surgeons have increasingly understood the potential benefits of less invasive and minimally invasive spinal surgery,” Dr. Härtl says. “One of the main benefits is that minimally invasive surgery avoids unnecessary injury and damage to stabilizing structures, such as muscles, tendons and bones. Therefore, a minimally invasive approach for decompression of lumbar spinal stenosis can frequently be done without having to stabilize or fuse the spine.”

And, a minimally invasive approach may have better outcomes for the patient—as the findings of this study suggest.

“Significant Differences Between the Groups”
The authors performed a systematic review and meta-analysis of secondary fusion rates following open versus minimally invasive decompression in patients with lumbar spinal stenosis associated with degenerative spondylolisthesis.

The authors reviewed 37 studies (19 with open laminectomy, 18 with minimally invasive unilateral laminotomy) published between 1983 and 2015. A total of 1156 patients were included in the review. The primary end point was secondary fusion rate, but the authors also noted total reoperation rate, postoperative progression of listhetic slip, and patient satisfaction.

outcomes of open laminectomy vs minimally invasive unilateral laminectomyOutcomes of open laminectomy vs minimally invasive unilateral laminectomy.“The significance of our study was certainly surprising,” Dr. Härtl says. “We would not have expected to find such significant differences between the groups.”

The findings further support the wide-reaching benefits of MIS. As MIS gains popularity, it may have significant implications not only for patients but also for health care in general, particularly because of the prevalence of degenerative spinal disease in the elderly population, Dr. Härtl says.

“First, of course, MIS reduces tissue injury and complications associated with this operation,” Dr. Härtl says. “Patients leave the hospital earlier and return to their normal activities sooner.”

Dr. Härtl also noted that MIS results in significantly lower costs to the health care system because expensive spinal instrumentation is not required, patients leave the hospital earlier, and there is a decreased risk of infections and other complications that associated with open fusion surgery.

Findings Reveal Challenges to Spine Surgeons
Dr. Härtl says the literature review illuminated two challenges faced by spine surgeons.

First, future studies need to address the challenge of patient selection. While fusion should not be viewed as an automatic course of action for patients with lumbar spinal stenosis with degenerative spondylolisthesis, it may be appropriate in some cases.

“There's certainly a subset of patients who will benefit of fusion surgery,” Dr. Härtl says. “The challenge to the clinician currently is to identify these patients based on preoperative radiographic features or clinical presentation. More work is needed to better identify this patient group.”

With the burgeoning popularity of MIS techniques, the second challenge is the growing need to train spine surgeons in MIS.

“We are actively involved in this by organizing MIS courses here in New York and elsewhere,” he says.

The First-Ever CNS Paper of the Year Awards
The work of Dr. Härtl and his colleagues is among the 10 winners of CNS’ inaugural Paper of the Year awards, which recognize the top papers from each neurological subspecialty published in Neurosurgery. This study won in the Spine & Peripheral Nerve category.

Papers published in Neurosurgery between June 2016 and June 2017 were eligible to earn this year’s award.

“We are incredibly lucky to have the brightest minds in neurosurgery submitting their original papers to Neurosurgery,” said Dr. Nelson Oyesiku, Editor-in-Chief of Neurosurgery, in a CNS news release. “It was difficult to limit ourselves to only 10 awardees. We’re confident the selected papers are changing our field, and we’re proud to spotlight them at the CNS Annual Meeting.”

The winning papers, which all underwent a scrupulous review process, will be recognized at the 2017 CNS Annual Meeting in Boston on October 7-11. Several authors will deliver oral presentation about their research and answer audience questions.

Updated on: 02/08/18
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