Comparison of minimally invasive decompression alone versus minimally invasive short-segment fusion in the setting of adult degenerative lumbar scoliosis: a propensity score–matched analysis

Murray Echt Department of Surgery, Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire;

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Adewale A. Bakare Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois;

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Jesus R. Varela Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois;

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Andrew Platt Department of Orthopaedics, The Daniel and Jane Och Spine Hospital, NewYork-Presbyterian, Columbia University Medical Center, New York, New York;

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Mohammed Abdul Sami Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois;

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Joseph Molenda WellSpan Neurosurgery, York Hospital, York, Pennsylvania; and

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Mena Kerolus Department of Neurosurgery, Piedmont Healthcare, Atlanta Brain and Spine, Atlanta, Georgia

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Richard G. Fessler Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois;

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OBJECTIVE

Patients with degenerative lumbar scoliosis (DLS) and neurogenic pain may be candidates for decompression alone or short-segment fusion. In this study, minimally invasive surgery (MIS) decompression (MIS-D) and MIS short-segment fusion (MIS-SF) in patients with DLS were compared in a propensity score–matched analysis.

METHODS

The propensity score was calculated using 13 variables: sex, age, BMI, Charlson Comorbidity Index, smoking status, leg pain, back pain, grade 1 spondylolisthesis, lateral spondylolisthesis, multilevel spondylolisthesis, lumbar Cobb angle, pelvic incidence minus lumbar lordosis, and pelvic tilt in a logistic regression model. One-to-one matching was performed to compare perioperative morbidity and patient-reported outcome measures (PROMs). The minimal clinically important difference (MCID) for patients was calculated based on cutoffs of percentage change from baseline: 42.4% for Oswestry Disability Index (ODI), 25.0% for visual analog scale (VAS) low-back pain, and 55.6% for VAS leg pain.

RESULTS

A total of 113 patients were included in the propensity score calculation, resulting in 31 matched pairs. Perioperative morbidity was significantly reduced for the MIS-D group, including shorter operative duration (91 vs 204 minutes, p < 0.0001), decreased blood loss (22 vs 116 mL, p = 0.0005), and reduced length of stay (2.6 vs 5.1 days, p = 0.0004). Discharge status (home vs rehabilitation), complications, and reoperation rates were similar. Preoperative PROMs were similar, but after 3 months, improvement was significantly higher for the MIS-SF group in the VAS back pain score (−3.4 vs −1.2, p = 0.044) and Veterans RAND 12-Item Health Survey (VR-12) Mental Component Summary (MCS) score (+10.3 vs +1.9, p = 0.009), and after 1 year the MIS-SF group continued to have significantly greater improvement in the VAS back pain score (−3.9 vs −1.2, p = 0.026), ODI score (−23.1 vs −7.4, p = 0.037), 12-Item Short-Form Health Survey MCS score (+6.5 vs −6.5, p = 0.0374), and VR-12 MCS score (+7.6 vs −5.1, p = 0.047). MCID did not differ significantly between the matched groups for VAS back pain, VAS leg pain, or ODI scores (p = 0.38, 0.055, and 0.072, respectively).

CONCLUSIONS

Patients with DLS undergoing surgery had similar rates of significant improvement after both MIS-D and MIS-SF. For matched patients, tradeoffs were seen for reduced perioperative morbidity for MIS-D versus greater magnitudes of improvement in back pain, disability, and mental health for patients 1 year after MIS-SF. However, rates of MCID were similar, and the small sample size among the matched patients may be subject to patient outliers, limiting generalizability of these results.

ABBREVIATIONS

ALIF = anterior lumbar interbody fusion; CCI = Charlson Comorbidity Index; DLS = degenerative lumbar scoliosis; LLIF = lateral lumbar interbody fusion; MCID = minimal clinically important difference; MCS = Mental Component Summary; MIS = minimally invasive surgery; MIS-D = MIS decompression; MIS-SF = MIS short-segment fusion; MISDEF2 = minimally invasive spinal deformity surgery revision 2; ODI = Oswestry Disability Index; PI-LL = pelvic incidence minus lumbar lordosis; PROM = patient-reported outcome measure; PT = pelvic tilt; SF-12 = 12-Item Short-Form Health Survey; SMD = standardized mean difference; TLIF = transforaminal lumbar interbody fusion; VAS = visual analog scale; VR-12 = Veterans RAND 12-Item Health Survey.

OBJECTIVE

Patients with degenerative lumbar scoliosis (DLS) and neurogenic pain may be candidates for decompression alone or short-segment fusion. In this study, minimally invasive surgery (MIS) decompression (MIS-D) and MIS short-segment fusion (MIS-SF) in patients with DLS were compared in a propensity score–matched analysis.

METHODS

The propensity score was calculated using 13 variables: sex, age, BMI, Charlson Comorbidity Index, smoking status, leg pain, back pain, grade 1 spondylolisthesis, lateral spondylolisthesis, multilevel spondylolisthesis, lumbar Cobb angle, pelvic incidence minus lumbar lordosis, and pelvic tilt in a logistic regression model. One-to-one matching was performed to compare perioperative morbidity and patient-reported outcome measures (PROMs). The minimal clinically important difference (MCID) for patients was calculated based on cutoffs of percentage change from baseline: 42.4% for Oswestry Disability Index (ODI), 25.0% for visual analog scale (VAS) low-back pain, and 55.6% for VAS leg pain.

RESULTS

A total of 113 patients were included in the propensity score calculation, resulting in 31 matched pairs. Perioperative morbidity was significantly reduced for the MIS-D group, including shorter operative duration (91 vs 204 minutes, p < 0.0001), decreased blood loss (22 vs 116 mL, p = 0.0005), and reduced length of stay (2.6 vs 5.1 days, p = 0.0004). Discharge status (home vs rehabilitation), complications, and reoperation rates were similar. Preoperative PROMs were similar, but after 3 months, improvement was significantly higher for the MIS-SF group in the VAS back pain score (−3.4 vs −1.2, p = 0.044) and Veterans RAND 12-Item Health Survey (VR-12) Mental Component Summary (MCS) score (+10.3 vs +1.9, p = 0.009), and after 1 year the MIS-SF group continued to have significantly greater improvement in the VAS back pain score (−3.9 vs −1.2, p = 0.026), ODI score (−23.1 vs −7.4, p = 0.037), 12-Item Short-Form Health Survey MCS score (+6.5 vs −6.5, p = 0.0374), and VR-12 MCS score (+7.6 vs −5.1, p = 0.047). MCID did not differ significantly between the matched groups for VAS back pain, VAS leg pain, or ODI scores (p = 0.38, 0.055, and 0.072, respectively).

CONCLUSIONS

Patients with DLS undergoing surgery had similar rates of significant improvement after both MIS-D and MIS-SF. For matched patients, tradeoffs were seen for reduced perioperative morbidity for MIS-D versus greater magnitudes of improvement in back pain, disability, and mental health for patients 1 year after MIS-SF. However, rates of MCID were similar, and the small sample size among the matched patients may be subject to patient outliers, limiting generalizability of these results.

In Brief

The clinical outcomes of patients with degenerative scoliosis undergoing decompression alone or short-segment fusion were compared using propensity score matching. For matched patients, a tradeoff was seen for reduced perioperative morbidity for decompression versus greater improvement in back pain, disability, and mental health 1 year after short-segment fusion. In the first propensity score–matched comparison of MISDEF2 (minimally invasive spinal deformity surgery revision 2) class I patients, future directions are provided to further refine treatment algorithms.

With increased life expectancy and a growing elderly population, degenerative lumbar scoliosis (DLS) is becoming increasingly more prevalent.1 Unlike idiopathic scoliosis, DLS is characterized by a midlumbar curve with minimal compensatory thoracic curve, hypolordosis, rotatory deformity at the apex, coronal/sagittal subluxation, and stenosis.2 Radiculopathy and neurogenic claudication in the setting of DLS are common because of the presence of both central lateral recess and foraminal stenosis.3 Significant variability in radiological findings, presenting symptoms, heterogeneous patient populations, and diverse surgical training experiences creates controversy as to the best strategies to manage the condition.46 Patients satisfied with their current health and quality of life are advised to continue with nonoperative treatment; however, surgery may be a preferred approach if symptoms progress over time.7

Some patients require deformity correction as part of their surgical treatment strategy, while others have primary complaints related to spinal stenosis in the setting of a mild DLS.8,9 Mummaneni et al. presented an updated 4-level treatment algorithm, the minimally invasive spinal deformity surgery revision 2 (MISDEF2) algorithm, to aid spine surgeons in decision-making for DLS based on specific criteria.10 Glassman et al. also presented appropriate use criteria for DLS.11 Both papers provide a thorough overview of the decision-making process to select an appropriate level of intervention given the patient’s primary symptoms and radiographic findings.

Patients with primary complaints of neurogenic leg pain in the setting of a mild DLS may be considered in MISDEF2 class I and candidates for less-invasive surgery without deformity correction. The assumption that these smaller curves require in situ stabilization to allow adequate decompression and prevent curve progression has been challenged by recent case series, especially when employing minimally invasive techniques.1216 However, there are few reports that directly compare decompression alone with short-segment fusion in DLS, and there are no available cohort-matched controlled studies.

In this propensity score matched–analysis, patients with DLS undergoing minimally invasive surgery (MIS) decompression (MIS-D) or MIS short-segment fusion (MIS-SF) are compared.

Methods

This was a single-surgeon retrospective comparative study of patients with DLS undergoing MIS-D versus MIS-SF performed by the senior author (R.G.F.). Patients who underwent surgical intervention between January 2014 and December 2018 were included in the analysis on a continuous basis over this time period. Preoperative evaluations included detailed neurological physical examinations, dynamic and static radiographs of the lumbosacral spine, and lumbosacral MRI or CT. Patients were candidates for surgery if they presented with painful motor or sensory radiculopathy and/or mechanical back pain that failed to respond to nonoperative treatment such as nonsteroidal anti-inflammatory medication, injections, or physical therapy. Inclusion criteria consisted of adult patients (> 18 years old) with DLS, defined as a lumbar coronal Cobb angle > 10°, who underwent either MIS-D or MIS-SF (≤ 3 levels) via transforaminal lumbar interbody fusion (TLIF), lateral lumbar interbody fusion (LLIF), or anterior lumbar interbody fusion (ALIF) were included. Patients with progression of idiopathic scoliosis, mobile spondylolisthesis, infection, tumor, or > 3 levels of treated disease were excluded. The review was approved by the Rush University Medical Center Institutional Review Board.

Decision-making by the senior author (R.G.F.) was made on a case-by-case basis in conjunction with patient preference. Decompression alone was offered through minimally invasive tubular access with decompression performed based on laterality of symptoms (i.e., unilateral hemilaminectomy and foraminotomy for unilateral symptoms vs a unilateral approach for bilateral decompression for bilateral symptoms). The decision on whether decompression alone versus fusion was largely made according to the patient’s preference as well as presence of a listhesis, concern that the extent of decompression might lead to instability of a segment, patient age, and comorbidities. Patients with signs of dynamic instability were not offered decompression alone and thus were excluded from analysis on this basis. Regarding the method of MIS-SF, the minimally invasive interbody selection algorithm by Mummaneni et al. provides a thorough systematic framework.17 In brief, preference was for LLIF or ALIF, depending on the level of the iliac crest and vascular anatomy, in cases in which there was a desire for segmental lordosis restoration. Foraminal stenosis related to the concavity of the main or fractional curve was also addressed with indirect decompression via ALIF or LLIF. However, a TLIF was chosen for cases of severe central stenosis requiring direct decompression or in cases in which the anatomy was not favorable for anterior or lateral access. When the symptomatic level was unclear, the patient underwent a series of selective nerve root blocks to determine if an approach could be narrowed down to one or two segments.

The propensity to undergo MIS-D was calculated using 13 variables: sex, age, BMI, Charlson Comorbidity Index (CCI), smoking status, complaint of neurogenic leg pain, complaint of mechanical back pain, and the 6 radiographic factors: grade 1 spondylolisthesis, lateral spondylolisthesis, multilevel spondylolisthesis, major lumbar coronal Cobb angle, pelvic incidence minus lumbar lordosis (PI-LL), and pelvic tilt (PT) in a logistic regression model. These variables were chosen based on availability and as proven factors affecting approach selection in the treatment of adult spinal deformity.18 One-to-one matching was performed for patients who underwent MIS-D with those who had the same propensity score but received MIS-SF to compare perioperative morbidity and patient-reported outcome measures (PROMs). This was performed using an optimal algorithm with caliper width specified as 0.10. Standardized coefficients with 95% confidence intervals and standardized mean differences (SMDs) were reported for all variables. Although there are no universally agreed on criteria to determine the threshold of the SMD, an SMD less than 0.2 is considered acceptably balanced with approximately 85% overlap between distributions.1922 Patient satisfaction scores were not collected, but the minimal clinically important difference (MCID) for patients was calculated based on cutoffs of percentage change from baseline: 42.4% for Oswestry Disability Index (ODI), 25.0% for visual analog scale (VAS) low-back pain, and 55.6% for VAS leg pain.23 All statistical analyses were performed using XLSTAT software, version 2021.5.1 (Addinsoft). The Student t-test was used for continuous variables, and the chi-square test was used for categorical variables. To assess predictors of reoperation, ANCOVA for both quantitative and qualitative covariates was performed for variables with p < 0.20 on univariate analysis; p < 0.05 was considered significant.

Results

A total of 162 charts were collected, and 113 patients met criteria to be included in the propensity score calculation. One-to-one matching resulted in 31 pairs of MIS-D and MIS-SF cases (Fig. 1). Standardized coefficients of each variable in the logistic regression model used to compute the propensity score associated to each participant are shown in Fig. 2. The three highest coefficients with an absolute value greater than 0.2 included a lack of mechanical back pain (0.242) with a propensity for a patient to undergo MIS-D, or presence of a single-level spondylolisthesis (0.263) or multiple levels of spondylolisthesis (0.403) with a propensity for the patient to undergo MIS-SF. Distances of propensity scores between matched pairs, defined under the caliper width of < 0.10, ranged from 0 to 0.096 with an average of 0.033. Figure 3 presents the distribution of propensity scores before and after matching, demonstrating that adequate matching was achieved based on the logit propensity score.

FIG. 1.
FIG. 1.

Flowchart of cases through selection of analysis. AIS = adolescent idiopathic scoliosis.

FIG. 2.
FIG. 2.

Standardized coefficients of variables. Back pain = complaint of mechanical back pain; leg pain = complaint of neurogenic leg pain; spondy = spondylolisthesis. Figure is available in color online only.

FIG. 3.
FIG. 3.

Scatterplots (A) and histograms (B) depicting propensity score distributions for the matched and unmatched MIS-D and MIS-SF groups. Figure is available in color online only.

Baseline comparison of demographic and radiographic factors revealed that significantly more patients undergoing MIS-SF had grade 1 spondylolisthesis (63% vs 28%, p = 0.0003) and multilevel spondylolisthesis (12% vs 0%, p = 0.015) (Table 1). Prior to matching, 6 of 13 covariates were unbalanced (SMD > 0.2) and included female sex, smoking status, leg pain, back pain, grade 1 spondylolisthesis, lateral listhesis, and multilevel spondylolisthesis. After propensity score matching, all demographic and radiographic factors were similar (p > 0.5), but one of the 13 covariates remained unbalanced (prevalence of leg pain, SMD = −0.257).

TABLE 1.

Unadjusted and propensity score–matched demographic and radiographic factors

UnadjustedPropensity Score Matched
MIS-D (n = 46)MIS-SF (n = 67)p ValueSMDMIS-D (n = 31)MIS-SF (n = 31)p ValueSMD
Demographics
 Female sex17 (37)37 (55.2)0.0560.37113 (41.9)15 (48.4)0.610.129
 Age, yrs68.3680.87−0.003268.266.90.54−0.0174
 BMI, kg/m228.628.30.66−0.011228.328.30.9960.00117
 CCI3.12.90.6−0.09893.02.90.87−0.0395
 Smoker4 (8.7)3 (4.5)0.36−0.171 (3.2)2 (6.5)0.550.154
 Leg pain46 (100)63 (94)0.092−0.35731 (100)30 (96.8)0.31−0.257
 Back pain 34 (73.9)57 (85)0.140.27728 (90.3)27 (87.1)0.69−0.101
Radiographic factors
 Grade 1 spondylolisthesis13 (28.2)42 (62.7)0.0003*0.73911 (35.5)11 (35.5)>0.990
 Lateral listhesis23 (50)24 (35.8)0.1330.2913 (41.9)14 (45.2)0.80.0666
 Multilevel spondylolisthesis0 (0)8 (11.9)0.015*0.520 (0)0 (0)NANA
 Major lumbar coronal Cobb angle, °18.9 16.80.28−0.032817.315.50.39−0.0264
 PI-LL, °20.719.70.78−0.003719.922.90.480.0112
 PT, °23.123.80.730.0082323.10.96 0.00106

NA = not applicable.

Values are presented as the number of patients (%) or mean unless stated otherwise.

p < 0.05.

SMD < 0.2.

In both unadjusted and propensity score–matched comparisons, perioperative morbidity was significantly reduced for the MIS-D group, including shorter operative duration (unadjusted: 94 vs 215 minutes, p < 0.0001; matched: 91 vs 204 minutes, p < 0.0001), decreased blood loss (unadjusted: 25 vs 205 mL, p = 0.022; matched: 22 vs 116 mL, p = 0.0005), and reduced length of hospital stay (unadjusted: 2.5 vs 4.9 days, p < 0.0001; matched: 2.6 vs 5.1 days, p = 0.0004) (Table 2). In the unadjusted comparison, MIS-D patients were more likely to be discharged home than to acute rehabilitation compared with MIS-SF patients (home: 95.7% vs 77.6%, p = 0.011; acute rehabilitation: 0% vs 11.9%, p = 0.015). Discharge status (home vs acute rehabilitation) was similar after matching. Discharge to a subacute rehabilitation/nursing facility, 30-day surgical complications, and reoperation for any reason were similar in both unadjusted and propensity score–matched comparisons. Among patients after MIS-SF, the most common complications were postoperative urinary retention (n = 6, 9.0%), ileus (n = 5, 7.5%), delirium (n = 2, 3.0%), pulmonary embolus (n = 1, 1.5%), and iliopsoas hematoma (n = 1, 1.5%). The most common reoperation was additional fusion for symptomatic adjacent-segment degeneration (n = 5, 7.5%), followed by 3 unplanned decompressions after inadequate indirect decompression via ALIF or LLIF (4.5%), and 1 return to the operating room for wound dehiscence (1.5%). Among unmatched MIS-SF patients, 12 underwent ALIF, 20 underwent LLIF, and 34 underwent TLIF, and among matched MIS-SF patients 8 underwent ALIF, 8 underwent LLIF, and 15 underwent TLIF. Complications were most common after ALIF (33.3%), followed by TLIF (20.6%) and least common with LLIF (4.5%). The most common complication after MIS-D was also postoperative urinary retention (n = 4, 8.7%), followed by unintended durotomy (n = 3, 6.5%), and delirium (n = 1, 2.2%); 7 patients (15.2%) subsequently underwent fusion, and 3 (6.5%) required revision decompression at the index level.

TABLE 2.

Unadjusted and propensity score–matched comparisons of perioperative morbidity

UnadjustedPropensity Score Matched
MIS-D (n = 46)MIS-SF (n = 67)p ValueMIS-D (n = 31)MIS-SF (n = 31)p Value
Op duration, mins94215<0.0001*91204<0.0001*
EBL, mL252050.022*221160.0005*
LOS, days2.54.9<0.0001*2.65.10.0004*
Discharge status
 Home44 (95.7)52 (77.6)0.011*29 (93.5)27 (87.1)0.3903
 Acute rehab0 (0)8 (11.9)0.015*0 (0)3 (9.7)0.076
 Subacute rehab/nursing facility2 (4.3)6 (9.0)0.352 (6.5)1 (3.2)0.55
30-day complication8 (17.4)15 (22.4)0.525 (16.1)8 (25.8)0.35
Reop, any10 (21.7)9 (13.4)0.256 (19.4)4 (12.9)0.49

EBL = estimated blood loss; LOS = length of stay.

Values are presented as the number of patients (%) unless stated otherwise.

p < 0.05.

Preoperative PROMs did not differ significantly between the two groups in unadjusted or matched cohorts. In the unadjusted comparison, there was a greater improvement for the MIS-SF group in the VAS back pain score after 1 year (−3.8 vs −3.0, p = 0.027) (Table 3). MCID did not differ significantly between unadjusted groups for VAS leg pain, VAS back pain, or ODI score (p = 0.41, 0.37, and 0.73, respectively). After propensity score matching, improvement was significantly higher for the MIS-SF group in VAS back pain (−3.4 vs −1.2, p = 0.044) and Veterans RAND 12-Item Health Survey (VR-12) Mental Component Summary (MCS) (+10.3 vs +1.8, p = 0.009) scores at the 3-month follow-up. At 1 year, the MIS-SF group continued to demonstrate significantly greater improvement in the VAS back pain score (−3.9 vs −1.2, p = 0.026), ODI score (−23.1 vs −7.4, p = 0.03), 12-Item Short-Form Health Survey (SF-12) MCS score (+6.5 vs −6.5, p = 0.037), and VR-12 MCS score (+7.6 vs −5.1, p = 0.047) (Table 4). MCID did not differ significantly between the matched groups for the VAS back pain and ODI (p = 0.38 and 0.072, respectively) scores but did approach significance for VAS leg pain (p = 0.055).

TABLE 3.

Unadjusted comparison of mean changes in patient-reported outcomes

MeasurePreopp Value3 mosp Value1 yrp Value
MIS-DMIS-SFMIS-DMIS-SFMIS-DMIS-SF
VAS back pain5.86.50.19−2.1−3.10.097−3.0−3.8 0.027*
VAS leg pain5.55.50.99−2.2−2.80.19−3.4−3.30.84
ODI38.440.50.61−9.7−9.60.54−14.8−19.60.087
SF-12 MCS51.548.40.22.55.10.13−0.575.10.12
SF-12 PCS2930.10.554.63.50.677.78.90.43
SRS-30 satisfaction w/ mgmt2.32.50.371.31.10.931.53.10.18
SRS-30 function3.03.10.940.310.100.320.561.80.17
SRS-30 mental health3.83.80.90.340.110.40.190.250.51
SRS-30 pain2.93.00.730.630.610.70.70.820.35
SRS-30 self-image3.03.10.450.420.390.940.430.670.32
SRS-30 total3.13.20.60.460.400.97 0.5150.720.25
VR-12 MCS52.150.10.382.85.40.110.725.70.13
VR-12 PCS31.331.30.995.54.80.998.710.20.37
VR6D0.580.580.91 0.065 0.0630.870.088 0.300.21

Mgmt = management; PCS = Physical Component Summary; SRS-30 = Scoliosis Research Society–30; VR6D = Veterans RAND 6D.

p < 0.05.

TABLE 4.

Propensity score–matched comparison of mean changes in patient-reported outcomes

MeasurePreopp Value3 mosp Value1 yrp Value
MIS-DMIS-SFMIS-DMIS-SFMIS-DMIS-SF
VAS back pain5.46.50.15−1.2−3.40.044*−1.2−3.90.026*
VAS leg pain5.35.90.5−1.3−30.24−2.4−40.26
ODI36.943.90.16−8.3−10.50.74−7.4−23.10.03*
SF-12 MCS5246.20.080.59.30.01*−6.56.50.037*
SF-12 PCS28.728.90.9264.70.793.5110.25
SRS-30 satisfaction w/ mgmt2.52.70.521.91.00.940.51.60.10
SRS-30 function3.12.90.350.480.360.740.163.10.27
SRS-30 mental health3.73.80.920.33 0.0880.54−0.10.20.6
SRS-30 pain2.93.00.350.50.530.910.231.10.098
SRS-30 self-image2.93.10.330.50.40.73 0.0330.850.13
SRS-30 total3.13.20.70.470.480.940.072 0.9120.078
VR-12 MCS52.647.70.111.810.30.009*−5.17.60.047*
VR-12 PCS30.930.20.786.26.30.983.112.90.17
VR6D 0.58 0.560.37 0.0640.110.320.0120.560.3

p < 0.05.

Among the 18 patients who required either additional fusion or revision decompression, only current smoking status was found to be significantly associated on univariate analysis and on ANCOVA (rate for smokers: 22.2% vs nonsmokers: 3.2%; p = 0.002 and 0.003, respectively). Other variables including MIS-D versus MIS-SF, female sex, age, CCI, BMI, leg pain, back pain, grade 1 spondylolisthesis, lateral listhesis, multilevel spondylolisthesis, major lumbar Cobb angle, PT, PI-LL, surgery duration, and estimated blood loss were not significantly associated with either an additional fusion or revision decompression.

Discussion

There remains controversy regarding the preferred treatment modality for patients with degenerative scoliosis and refractory pain. The question of whether patients with spinal stenosis and DLS who undergo decompression require an accompanying fusion, and how extensive, remains difficult to answer. The marked heterogeneity of patients’ imaging and primary complaints complicates decision-making. Patients fitting into the lowest class of the MISDEF2 category may be selected for either MIS-D or MIS-SF. However, individual decisions will largely be based on surgeon experience and patient preference. Further understanding of the outcomes for similar patients undergoing selective interventions in the setting of a larger deformity remains critical. To compare the results of MIS-D or MIS-SF for patients with mild DLS, a propensity score–matched analysis was created to provide a more homogeneous cohort. We found patients who are similar with regard to the outlined variables, and thereby may be equally selected for MIS-D or MIS-SF, may benefit from surgeon counseling toward choosing a concomitant fusion despite an upfront cost of increased perioperative morbidity.

However, well-selected patients may still have substantial improvement after MIS-D. In the unadjusted MIS-D cohort, MCID was reached by 66.7% for VAS leg pain and 51.6% for ODI scores. This result is similar to reported satisfaction rates in the literature, ranging from 50% to 80%.24 This less-invasive approach avoiding instrumentation consistently minimized perioperative morbidity, including decreased operative time, blood loss, and length of stay in the hospital. Minamide et al. presented similar outcomes after microendoscopic decompression surgery as largely successful, but more severe deformity was predictive of poor outcomes.16 Specifically, preoperative Cobb angle > 30°, PI-LL > 35°, and VAS score for low-back pain > 7 were associated with significantly worse outcomes and potential progression of the deformity. Likewise, our results support the conclusion that patients not well suited for decompression alone had a greater magnitude of improvement when fusion was performed, even when contained to a short segment.

While not directly comparing results, Transfeldt et al. reported outcomes of the 3 major approaches for DLS with radiculopathy, including decompression alone, decompression and limited fusion, and decompression plus full curve fusion.13 Patients undergoing decompression alone were significantly older than the other two cohorts and also had the lowest blood loss, shortest hospital stay, fewest complications, and least need for revisions. However, even though there was an improvement in ODI scores in patients undergoing decompression alone, it had the lowest ranking under the question, "Would you have the same treatment again?" This confounding result may be related to our results; for a certain number of patients, the magnitude of improvement was not felt to be worth undergoing surgery, even if it was significantly less invasive. As with patients in our cohort with a lateral listhesis on imaging, Transfeldt et al. also found that patients with rotatory listhesis did well with decompression alone. However, it is important to note that presence of a lateral listhesis in our series was mild and not severe, which has been shown to be an independent predictor of disability requiring realignment.25

Previous studies also favored fusion for patients with DLS but because of the perceived high revision rate and subsequent need for fusion after decompression alone.26 However, in our current analysis, the only significant difference in clinical outcomes was seen in terms of PROMs; the reoperation rates remained similar in both unadjusted and propensity score–matched comparisons. Thus, the risks of revision surgery with decompression alone versus fusion may be overestimated. Kleinstueck et al. reported revision surgery rates of patients with DLS as 7% after decompression alone, 15% after short-segment fusion, and 28% after long-segment fusion.15 However, these incidences vary throughout the literature; Liu et al. also compared secondary operations after decompression alone, short-segment fusions (< 3 segments), and long-segment fusions and found the rates to be 33.3%, 8%, and 3%, respectively.27 Contrasting results like these may imply significant variation with regard to patient selection, operative technique, and postoperative management. However, even without a clear distinction between reoperation risk, for similar patients selecting between MIS-D and MIS-SF, the smaller improvement in PROMs seen after 1 year may outweigh benefits of a shorter recovery period after MIS-D.

In univariate and multivariate analyses, only current smoking was associated with additional surgery. While smoking has not been previously identified as a risk factor for revision surgery in this specific patient population, it is a known independent risk factor for revision surgery following lumbar discectomy, decompression, and 1- and 2-level fusion.2830 All patients who smoked preoperatively were counseled extensively regarding the increased risks of complications according to evidence-based guidelines.31 In a systematic review of decompression alone in the setting of DLS, other risk factors for additional surgery included preoperative severe lumbar coronal Cobb angle (mean 29.6°), increased preoperative PT (mean 28.3°), preoperative PI-LL (mean 35.5°), and poor facet preservation (approximately 50%) on the approach side of the concavity.24 In another systematic review of prognostic factors for curve progression in untreated DLS, Faraj et al. found that the majority of prognostic factors were limited, conflicting, or inconsistent.32 As such, risk factors other than current smoking may not be directly applicable to each individual patient, and shared decision-making with the patient considering their chief complaints and goals of surgery are paramount.

Furthermore, there is a known high rate of revision surgery following full curve correction.33,34 In a large prospective multicenter adult spinal deformity database, the authors found a 17% risk of reoperation, including instrumentation failure as the most common reason.35 Pellisé et al. analyzed the two largest multicenter data sets available, and, even with significant improvement in surgeon experience and medical management, the most recent 2-year reintervention rate was 16%.36 Clearly, the patients in the study by Pellisé et al. had a greater degree of spinal deformity and are not readily comparable to the patients represented in the current analysis. However, trends in the improvement of reoperation and other quality metrics coincided with trends in decreased surgical invasiveness, including a decrease in the mean number of fused segments, pelvic fixation, and three-column osteotomies. Future work may assess whether there is a small subset of these patients amenable to even less-invasive operations.37

Decision-making on surgical approach is a multifactorial process based on more factors than the 13 variables used in this propensity score–matched analysis. However, we believe that our analysis approximates various considerations as best as possible given the inherent limitations to a retrospective comparison. Figure 4 represents an illustrative example of a matched pair of patients, where one underwent an ALIF at L5–S1 and the other underwent minimally invasive unilateral decompression on the left at L4–5 and L5–S1. The patient who underwent an ALIF was a 60-year-old male who was a nonsmoker and had a CCI of 4 and BMI of 23. The patient had complaints of back and right leg pain, and an ALIF was chosen due to primarily right-sided foraminal stenosis at L5–S1 in the fractional curve with close approximation of the pedicles. The patient underwent selective nerve root blocks and had the most relief with an L5 injection. Thus, because of the severe foraminal stenosis in the fractional curve, it was felt that it would be best to treat the condition through indirect decompression via an ALIF. This patient was matched with a 77-year-old male, with a CCI of 3 and BMI of 28, who had left leg pain and mechanical back pain found to have a grade 1 L4–5 spondylolisthesis with a main lumbar coronal Cobb angle of 21°, PT of 13°, and PI-LL of 19°. In this case, direct decompression was selected for both lateral recess and foraminal stenosis because of a combination of disc bulge and hypertrophy of the ligamentum flavum and facet hypertrophy worse on the left from L4 to S1. Both short-segment fusion via MIS TLIFs and decompression alone were offered, and the patient preferred to undergo decompression alone and avoid fusion. Decompression was performed via a unilateral tubular approach for left-sided L4–S1 minimally invasive hemilaminectomies, medial facetectomies, and foraminotomies. Postoperatively, neither patient had complications, and both were discharged home after 3 versus 2 days in the hospital (MIS-SF vs MIS-D, respectively). The first patient (i.e., the one who underwent ALIF) had significant improvement in his VAS back pain (−7), VAS leg pain (−8), and ODI (−34%) scores at 1 year. The second patient had initial improvement at the 3-month follow-up in VAS back pain (–4), VAS leg pain (−6), and ODI (−14%) scores. However, after 1 year, the patient experienced recurrence of right-sided radiculopathy with new VAS back pain, VAS leg pain, and ODI scores of 7, 9, and 59, respectively. The patient decided on nonoperative treatment before ultimately selecting to undergo revision decompression approximately 4 years after his initial surgery, with good relief on last follow-up.

FIG. 4.
FIG. 4.

Lateral (A) and anteroposterior (B) scoliosis radiographs obtained in a 60-year-old male with grade 1 L5–S1 spondylolisthesis, L1–4 coronal Cobb angle of 22°, PT of 20°, and PI-LL of 9° who underwent an ALIF. Lateral (C) and anteroposterior (D) radiographs obtained in a matched 77-year-old male with grade 1 L4–5 spondylolisthesis, L1–4 coronal Cobb angle of 21°, PT of 13°, and PI-LL of 19° who underwent L4–S1 MIS-D and unilateral foraminotomies.

Of note, the propensity score matching, calculated as the probability of undergoing MIS-SF versus MIS-D using the logit method and adjusting for relevant confounders, had a high matching rate of 49% of MIS-SF patients and 65% of MIS-D patients. This rate appears impressive but is similar to other propensity score matching using an optimal matching algorithm such as the recently published propensity score–matched study by Badhiwala et al. that matched 62% of patients (186 of 300 patients).38 Optimal matching was selected over the greedy nearest-neighbor algorithm since it minimizes the average within-pair difference in propensity scores while maximizing the number of matched pairs. In contrast, greedy nearest-neighbor matching selects a treated and untreated subject whose propensity score lies closest to each other, but at the cost of the number of matched pairs.39 The higher match rate as seen in this propensity score matching using an optimal match may have led to slightly more statistical imbalance between covariates. Although SMD is the most commonly used measure to assess balance between cohorts, it should be interpreted with caution.40 Although the SMD remained imbalanced after matching for prevalence of neurogenic leg pain, this does not necessarily equate to clinical confounding. For instance, a difference in leg pain prevalence of 4%, or 1 patient, is not likely to be clinically meaningful. Furthermore, by excluding additional patients to further balance covariates, the sample size of the study population after propensity score matching will be reduced along with the power to detect statistical significance. Thus, nonsignificance after a statistically balanced propensity score matching would be likely due to reduced sample size rather than improved balance, especially in a smaller baseline unadjusted cohort of only 113 patients. Additionally, an even smaller sample size will also further increase the influence of any outliers.

Future steps may include machine learning algorithms using larger multicenter prospective databases. These simulated study methods may better account for interaction between variables without requiring a limited number believed to be prognostically important.40

Limitations of this study include its retrospective nature and its small sample size, which may be subject to the influence of patient outliers. Propensity score matching only accounts for the 13 confounders identified. Residual bias from uncontrolled confounding variables is possible, specifically factors that may be significant but were not available, such as that full-length preoperative scoliosis radiographs and measurement of sagittal vertical axis as well as preoperative MRI findings were generally not available for independent review and comparison. Patient-reported satisfaction scores were also not available for outcomes comparison. Each patient was counseled extensively, and decisions were individualized to each patient based on a multitude of factors. Additionally, the drawbacks of an increasingly detailed list of variables to consider in propensity score matching will eventually severely restrict the number of one-to-one matched pairs.

Further limitations include the decision to include three surgical approaches for MIS-SF (TLIF, ALIF, and LLIF). While this may create inconsistencies with regard to surgical intervention, all three approaches are commonly used in cases of degenerative lumbar scoliosis with comparable results.41 Unfortunately, comparing outcomes of each intervention would be underpowered and was decided to remain out of the scope of this analysis. Postoperative radiographic outcomes were not compared. Although this was of interest, postoperative standing radiographs were not routinely obtained for patients after MIS-D. While postoperative alignment was not available in our cohort, it is already well known that patients with positive sagittal alignment after surgery have poor outcomes.13 Additional limitations are the clinical outcomes limited to only 1 year after surgery and we cannot comment on outcomes after 5–10 years or provide commentary for patient counseling beyond 1-year results. Finally, while a single-surgeon and single-institution experience decreases many surgeon- and institution-specific confounders, it does limit the generalizability of these results. The strengths of this study include its direct comparison of potential MISDEF2 class I patients who may be candidates for decompression alone or short-segment fusion and performing the first cohort-matched controlled study of this population. Future work to assess these subsets of patients with DLS amenable to less-invasive operations is needed to further refine treatment algorithms.

Conclusions

Patients with DLS undergoing MIS-D or MIS-SF had similar rates of significant improvement. The benefit of MIS-D was consistently reduced perioperative morbidity, including decreased operative time, reduced blood loss, and shorter length of stay. For matched patients, a tradeoff was seen for reduced perioperative morbidity for MIS-D versus a greater magnitude of improvement in back pain, disability, and mental health for patients 1 year after MIS-SF. However, rates of MCID were similar, and the small sample size among the matched patients may be subject to patient outliers limiting generalizability of these results. Future work to assess these subsets of patients with DLS amenable to less-invasive operations is needed to further refine treatment algorithms.

Acknowledgments

We thank Mr. Eric Geng for his contributions to the review of statistical methods used herein.

Disclosures

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Author Contributions

Conception and design: Echt, Bakare, Platt, Molenda, Kerolus, Fessler. Acquisition of data: Echt, Bakare, Varela, Abdul Sami, Molenda. Analysis and interpretation of data: Echt, Molenda, Kerolus. Drafting the article: Echt, Molenda. Critically revising the article: Echt, Bakare, Platt, Molenda, Fessler. Reviewed submitted version of manuscript: Echt, Bakare, Molenda, Fessler. Approved the final version of the manuscript on behalf of all authors: Echt. Statistical analysis: Echt, Molenda. Administrative/technical/material support: Fessler. Study supervision: Molenda, Fessler.

Supplemental Information

Previous Presentations

Portions of this work were presented at the International Society for the Advancement of Spine Surgery (ISASS) 22nd Annual Conference, Paradise Island, Bahamas, June 2, 2022.

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  • Collapse
  • Expand
Figure from Semonche et al. (pp 419–426).
  • FIG. 1.

    Flowchart of cases through selection of analysis. AIS = adolescent idiopathic scoliosis.

  • FIG. 2.

    Standardized coefficients of variables. Back pain = complaint of mechanical back pain; leg pain = complaint of neurogenic leg pain; spondy = spondylolisthesis. Figure is available in color online only.

  • FIG. 3.

    Scatterplots (A) and histograms (B) depicting propensity score distributions for the matched and unmatched MIS-D and MIS-SF groups. Figure is available in color online only.

  • FIG. 4.

    Lateral (A) and anteroposterior (B) scoliosis radiographs obtained in a 60-year-old male with grade 1 L5–S1 spondylolisthesis, L1–4 coronal Cobb angle of 22°, PT of 20°, and PI-LL of 9° who underwent an ALIF. Lateral (C) and anteroposterior (D) radiographs obtained in a matched 77-year-old male with grade 1 L4–5 spondylolisthesis, L1–4 coronal Cobb angle of 21°, PT of 13°, and PI-LL of 19° who underwent L4–S1 MIS-D and unilateral foraminotomies.

  • 1

    Jimbo S, Kobayashi T, Aono K, Atsuta Y, Matsuno T. Epidemiology of degenerative lumbar scoliosis: a community-based cohort study. Spine (Phila Pa 1976). 2012;37(20):17631770.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Epstein JA, Epstein BS, Jones MD. Symptomatic lumbar scoliosis with degenerative changes in the elderly. Spine (Phila Pa 1976). 1979;4(6):542547.

  • 3

    Fu KMG, Rhagavan P, Shaffrey CI, Chernavvsky DR, Smith JS. Prevalence, severity, and impact of foraminal and canal stenosis among adults with degenerative scoliosis. Neurosurgery. 2011;69(6):11811187.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Al Jammal OM, Delavar Ã, Maguire K, et al. National trends in the surgical management deformity patients. Spine (Phila Pa 1976). 2019;44(23):13691378.

  • 5

    Berven SH, Kamper SJ, Germscheid NM, et al. An international consensus on the appropriate evaluation and treatment for adults with spinal deformity. Eur Spine J. 2018;27(3):585596.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Kang J, Hosogane N, Ames C, et al. Diversity in surgical decision strategies for adult spine deformity treatment: The effects of neurosurgery or orthopedic training background and surgical experience. Neurospine. 2018;15(4):353361.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Kelly MP, Lurie JD, Yanik EL, et al. Operative versus nonoperative treatment for adult symptomatic lumbar scoliosis. J Bone Joint Surg Am. 2019;101(4):338352.

  • 8

    Aebi M. The adult scoliosis. Eur Spine J. 2005;14(10):925948.

  • 9

    Ledonio CGT, Polly DW Jr, Crawford CH III, et al. Adult degenerative scoliosis surgical outcomes: a systematic review and meta-analysis. Spine Deform. 2013;1(4):248258.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Mummaneni PV, Park P, Shaffrey CI, et al. The MISDEF2 algorithm: an updated algorithm for patient selection in minimally invasive deformity surgery. J Neurosurg Spine. 2019;32(2):221228.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Glassman SD, Berven SH, Shaffrey CI, Mummaneni PV, Polly DW. Commentary: Appropriate use criteria for lumbar degenerative scoliosis: Developing evidence-based guidance for complex treatment decisions. Neurosurgery. 2017;80(3):E205E212.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Kato M, Namikawa T, Matsumura A, Konishi S, Nakamura H. Radiographic risk factors of reoperation following minimally invasive decompression for lumbar canal stenosis associated with degenerative scoliosis and spondylolisthesis. Global Spine J. 2017;7(6):498505.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Transfeldt EE, Topp R, Mehbod AA, Winter RB. Surgical outcomes of decompression, decompression with limited fusion, and decompression with full curve fusion for degenerative scoliosis with radiculopathy. Spine (Phila Pa 1976). 2010;35(20):18721875.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Kelleher MO, Timlin M, Persaud O, Rampersaud YR. Success and failure of minimally invasive decompression for focal lumbar spinal stenosis in patients with and without deformity. Spine (Phila Pa 1976). 2010;35(19):E981E987.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Kleinstueck FS, Fekete TF, Jeszenszky D, Haschtmann D, Mannion AF. Adult degenerative scoliosis: comparison of patient-rated outcome after three different surgical treatments. Eur Spine J. 2016;25(8):26492656.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Minamide A, Yoshida M, Iwahashi H, et al. Minimally invasive decompression surgery for lumbar spinal stenosis with degenerative scoliosis: predictive factors of radiographic and clinical outcomes. J Orthop Sci. 2017;22(3):377383.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Mummaneni PV, Hussain I, Shaffrey CI, et al. The minimally invasive interbody selection algorithm for spinal deformity. J Neurosurg Spine. 2021;34(5):741748.

  • 18

    Park P, Than KD, Mummaneni PV, et al. Factors affecting approach selection for minimally invasive versus open surgery in the treatment of adult spinal deformity: analysis of a prospective, nonrandomized multicenter study. J Neurosurg Spine. 2020;33(5):601606.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Austin PC. An introduction to propensity score methods for reducing the effects of confounding in observational studies. Multivariate Behav Res. 2011;46(3):399424.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Cepeda S, Castaño-León AM, Munarriz PM, et al. Effect of decompressive craniectomy in the postoperative expansion of traumatic intracerebral hemorrhage: a propensity score-based analysis. J Neurosurg. 2019;132(5):16231635.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Stuart EA. Matching methods for causal inference: a review and a look forward. Stat Sci. 2010;25(1):121.

  • 22

    Andrade C. Mean difference, standardized mean difference (SMD), and their use in meta-analysis: as simple as it gets. J Clin Psychiatry. 2020;81(5):20f13681.

  • 23

    Nakarai H, Kato S, Kawamura N, et al. Minimal clinically important difference in patients who underwent decompression alone for lumbar degenerative disease. Spine J. 2022;22(4):549560.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Echt M, De la Garza Ramos R, Geng E, et al. Decompression alone in the setting of adult degenerative lumbar scoliosis and stenosis: a systematic review and meta-analysis. Global Spine J. 2023;13(3):861872.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

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