Revision surgery following minimally invasive decompression for lumbar spinal stenosis with and without stable degenerative spondylolisthesis: a 5- to 15-year reoperation survival analysis

Nizar Moayeri MD, PhD1 and Y. Raja Rampersaud MD, FRCSC2,3
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  • 1 Department of Neurology and Neurosurgery, University Medical Center Utrecht, The Netherlands;
  • | 2 J. Bernard Gosevitz Chair in Arthritis Research at UHN, Department of Orthopaedic Surgery, Toronto Western Hospital, Schroeder Arthritis Institute, University Health Network (UHN), Toronto; and
  • | 3 University of Toronto, Toronto, Ontario, Canada
Open access

OBJECTIVE

Minimally invasive decompression (MID) is an effective procedure for lumbar spinal stenosis (LSS). Long-term follow-up data on reoperation rates are lacking. The objective of this retrospective cohort study was to evaluate reoperation rates in patients with LSS who underwent MID, stratified for degenerative lumbar spondylolisthesis (DLS), with a follow-up between 5 and 15 years.

METHODS

All consecutive patients with LSS who underwent MID between 2002 and 2011 were included. All patients had neurogenic claudication from central and/or lateral recess stenosis, without or with up to 25% of slippage (grade I spondylolisthesis), and no obvious dynamic instability on imaging (increase in spondylolisthesis by ≥ 5 mm demonstrated on supine-to-standing or flexion-extension imaging). Reoperation rates defined as any operation on the same or adjacent level were assessed. Revision decompression alone was considered if the aforementioned clinical and radiographic criteria were met; otherwise, patients underwent a minimally invasive posterior fusion.

RESULTS

A total of 246 patients (mean age 66 years) were included. Preoperative spondylolisthesis was present in 56.9%. The mean follow-up period was 8.2 years (range 5.0−14.9 years). The reoperation rates in patients with and without spondylolisthesis were 15.7% and 15.1%, respectively; fusion was required in 7.1% and 7.5%, with no significant difference (redecompression only, p = 0.954; fusion, p = 0.546). For decompression only, the mean times to reoperation were 3.9 years (95% CI 1.8−6.0 years) for patients with DLS and 2.8 years (95% CI 1.3−4.2 years) for patients without DLS; for fusion, the mean times to reoperation were 3.1 years (95% CI 1.0−5.3 years) and 3.1 years (95% CI 1.1−5.1 years), respectively.

CONCLUSIONS

In highly selected patients with stable DLS and leg-dominant pain from central or lateral recess stenosis, the long-term reoperation rate is similar between DLS and non-DLS patients undergoing MIS decompression.

ABBREVIATIONS

DLS = degenerative lumbar spondylolisthesis; LSS = lumbar spinal stenosis; MID = minimally invasive decompression.

OBJECTIVE

Minimally invasive decompression (MID) is an effective procedure for lumbar spinal stenosis (LSS). Long-term follow-up data on reoperation rates are lacking. The objective of this retrospective cohort study was to evaluate reoperation rates in patients with LSS who underwent MID, stratified for degenerative lumbar spondylolisthesis (DLS), with a follow-up between 5 and 15 years.

METHODS

All consecutive patients with LSS who underwent MID between 2002 and 2011 were included. All patients had neurogenic claudication from central and/or lateral recess stenosis, without or with up to 25% of slippage (grade I spondylolisthesis), and no obvious dynamic instability on imaging (increase in spondylolisthesis by ≥ 5 mm demonstrated on supine-to-standing or flexion-extension imaging). Reoperation rates defined as any operation on the same or adjacent level were assessed. Revision decompression alone was considered if the aforementioned clinical and radiographic criteria were met; otherwise, patients underwent a minimally invasive posterior fusion.

RESULTS

A total of 246 patients (mean age 66 years) were included. Preoperative spondylolisthesis was present in 56.9%. The mean follow-up period was 8.2 years (range 5.0−14.9 years). The reoperation rates in patients with and without spondylolisthesis were 15.7% and 15.1%, respectively; fusion was required in 7.1% and 7.5%, with no significant difference (redecompression only, p = 0.954; fusion, p = 0.546). For decompression only, the mean times to reoperation were 3.9 years (95% CI 1.8−6.0 years) for patients with DLS and 2.8 years (95% CI 1.3−4.2 years) for patients without DLS; for fusion, the mean times to reoperation were 3.1 years (95% CI 1.0−5.3 years) and 3.1 years (95% CI 1.1−5.1 years), respectively.

CONCLUSIONS

In highly selected patients with stable DLS and leg-dominant pain from central or lateral recess stenosis, the long-term reoperation rate is similar between DLS and non-DLS patients undergoing MIS decompression.

ABBREVIATIONS

DLS = degenerative lumbar spondylolisthesis; LSS = lumbar spinal stenosis; MID = minimally invasive decompression.

In Brief

The authors retrospectively determined the long-term revision rate 5-15 years (mean 8.2 years) after minimally invasive decompression (MID) for lumbar spinal stenosis in 246 consecutive patients with (n = 140) and those without degenerative grade I spondylolisthesis (DS). For stable DS (< 5-mm motion) and leg-dominant symptoms due to central or lateral recess stenosis, the long-term reoperation rates including adjacent segments were 15.7% and 15.1%, respectively, in patients with and without spondylolisthesis. Durable surgical survival is achievable with MID alone in selected DS patients.

Lumbar spinal stenosis (LSS) is the most common indication for spinal surgery in people older than 65 years,1 with an estimated prevalence of 5.7% in the general population.2 It is often associated with multiple imaging findings, of which spondylolisthesis deserves special attention due to the ongoing debate about the need for fusion.3 Depending on the clinical population, age, and screening method, degenerative lumbar spondylolisthesis (DLS) is seen in about 15% to 40% of patients with LSS.4–6 Surgery is only warranted if adequate trials of nonsurgical care, such as medications, physiotherapy, spinal injections, lifestyle modification, and multidisciplinary rehabilitation, do not sufficiently address symptoms caused by neurogenic claudication with varying degrees of back pain.7

Both traditional open laminectomy and less-invasive techniques such as minimally invasive laminotomies have been shown to be effective for LSS decompression.8–10 However, conventional open laminectomies violate stabilizing midline bony and ligamentous structures and may cause spondylolisthesis or exacerbate preexisting spondylolisthesis.11,12 Minimally invasive decompression (MID) through tubular or similar retractors is an alternative procedure for decompression of LSS, which avoids detachment of the paraspinal muscles and preserves posterior stabilizing ligamentous and bony spinal structures,8,9,13–15 resulting in less postoperative instability as indicated by biomechanical studies.16–19

Current recommendations on the surgical treatment of degenerative spondylolisthesis include decompression and fusion.20,21 As demonstrated in the SPORT trial, decompression and fusion remains the most commonly performed procedure in LSS with degenerative spondylolisthesis.22 More recent reports suggest similar functional improvement and reoperation rates after MID in patients with LSS and DLS after short- to midterm follow-up.8,9,14,23 However, long-term follow-up data are lacking. Therefore, we conducted a retrospective analysis of a prospectively collected cohort to evaluate the long-term reoperation rates in patients with and without low-grade stable degenerative spondylolisthesis and LSS who had undergone MID with a minimum 5-year follow-up.

Methods

Patient Selection

Institutional review board approval was obtained from the review board committee of the University Health Network at Toronto Western Hospital, Toronto, Ontario, for subanalysis of a prospective cohort study. We retrospectively reviewed all consecutive patients who underwent MID using tubular retractors for symptomatic LSS with or without degenerative spondylolisthesis grade 1 between 2002 and 2011. Patients with a history of previous lumbar surgery were excluded. All patients presented with typical neurogenic claudication signs and symptoms of LSS (e.g., significant leg-dominant pain related to standing or walking that was relieved by postural change and/or rest) with no to tolerable mechanical low-back pain. LSS was radiographically confirmed by MRI or myelography with postmyelography CT scans when MRI was contraindicated. Patients underwent decompression alone if they had leg-dominant symptoms as noted above, attributable to central and/or lateral recess stenosis, with up to 25% of slippage (grade I spondylolisthesis) and no obvious dynamic instability on imaging. Radiographic dynamic instability was defined as an increase in spondylolisthesis by 5 mm or more demonstrated on supine to standing or flexion-extension imaging as previously described.24,25 Patients with dominant leg symptoms consistent with the existing nerve root (confirmed by a selective nerve root block if clinically unclear) of the surgical segment(s) with correlative foraminal stenosis underwent fusion with foraminal height distraction using a transforaminal interbody fusion technique.26

Surgical Technique

The minimally invasive procedure is described in detail elsewhere.23 In brief, surgery was performed using an operating microscope and tubular retractor system (16 or 18 mm) through a 20-mm parasagittal longitudinal incision (MetRx, Medtronic). We performed a unilateral laminotomy for ipsilateral decompression, followed by medial angulation of the tube and undercutting the base of the spinous process, which allowed us to partially remove the contralateral hypertrophied medial facet after flavectomy from within the spinal canal. If there was a clinical and radiological predominant side for bilateral symptoms, the incision was typically performed on the more dominant side.

If LSS was present at more than one level, we performed the decompression at each level, sparing the laminae between. All operations were performed by a single experienced spine surgeon or under his direct supervision. Patients were typically discharged home on the same surgical day (90%), except for patients with significant medical comorbidities requiring monitoring in the postoperative phase.

Follow-Up

To minimize the risk of missing data regarding any lumbar reoperation performed elsewhere, after our routine follow-up period of 5 years, we contacted all patients and requested additional surgical and radiographic data in case they underwent reoperation elsewhere. Based on the single-payer healthcare delivery model in Ontario with associated limited access to spine surgeons, assessment by other surgeons is uncommon (i.e., patients are redirected back to their original surgeon because of long respective waiting lists). Revision surgery was performed if significant pain or spine-related symptoms (e.g. sensorimotor claudication without pain) recurred from the decompressed lumbar level or adjacent level along with evidence of continued lumbar stenosis on MRI or myelography with postmyelography CT scans during follow-up. Revision decompression alone and/or adjacent-segment decompression alone was considered using the same MID technique if there was a leg-dominant symptom presentation and no radiological dynamic instability (as defined above) was shown; otherwise, patients underwent a minimally invasive posterior instrumented fusion with transforaminal interbody fusion and percutaneous pedicle screw instrumentation at revision.26

Statistical Analysis

Revision rates were calculated for the entire group and stratified for concomitant preoperative spondylolisthesis. Kaplan-Meier survival graphs for revision surgery (decompression alone with or without posterior fusion) were calculated and plotted for patients with or without spondylolisthesis. Possible risk factors based on patient’s (baseline) characteristics for developing dynamic instability after the initial minimally invasive decompression, including age, sex, BMI, level and segment(s) of lumbar stenosis, and presence of degenerative spondylolisthesis, were assessed using uni- and multivariate logistic regression. All categorical variables were assessed using the chi-square test. Continuous variables were assessed using the independent t-test or Wilcoxon t-test; p < 0.05 was considered significant.

Results

Demographic Data

Between 2002 and 2011, all consecutive patients with LSS who underwent an MID for one or more lumbar levels were included. The total number of consecutive patients along with the inclusion and exclusion criteria are shown in Fig. 1. A total of 246 patients, of whom 45.5% were females, with a mean age of 66 years (20−88 years) at the time of the initial surgery were included; 134 patients (54.1%) were 65 years of age or older. The mean overall BMI was 28.3 ± 4.2 (range 20.7−41.4). Patients in DLS group were slightly older than those without DLS. Table 1 summarizes patient demographics stratified for DLS in the current series.

FIG. 1.
FIG. 1.

Flowchart of excluded and included consecutive patients.

TABLE 1.

Patient demographics stratified for preexisting DLS with degenerative stenosis

w/o DLSw/ DLSp Value
No. of patients106 (43.1)140 (56.9)
Sex
 Female36 (14.6)76 (30.9)
 Male70 (28.5)64 (26.0)
Mean age ± SD, yrs63.7 ± 11.168.0 ± 10.10.003
Mean BMI ± SD29.1 ± 4.227.7 ± 4.20.084
Mean baseline ODI41450.205
Mean baseline VAS leg 6.8 6.80.983
Mean baseline VAS back6.06.10.634
Level of decompression
 L2–334
 L3–42221
 L4–54373
 L5–S121
 Combined3641
No. of decompressed levels
 17198
 22731
 >2811

ODI = Oswestry Disability Index; VAS = visual analog scale.

Values represent the number of patients (%) unless stated otherwise. Boldface type indicates statistical significance.

No significant difference was seen in the preoperative Oswestry Disability Index or visual analog score for leg and back pain between patients with and those without DLS (Table 1). Preoperative spondylolisthesis at the level of spinal stenosis was present in 56.9% of patients. The majority of patients (68.7%) underwent one-level decompression, followed by 23.6%, 6.1%, and 1.6% for 2, 3, and 4 levels, respectively. The most common decompressed level was L4–5 (47.2%), followed by L3–4 (17.5%), L2–3 (2.8%), L5–S1 (1.2%) and a combination of two or more levels (31.3%).

Reoperation Rate

Of the 246 patients, 220 (89.4%) were available for long-term follow-up assessment 5 to 14.9 years after surgery (mean 8.2 years); 26 patients (10.6%) could not be reached after the 5-year follow-up and therefore their analyzed follow-up period remained at 5 years. During this period, 38 patients underwent subsequent surgery, accounting for an overall reoperation rate of 15.4%. After stratifying for DLS, the reoperation rates were 15.7% (22/140 patients) and 15.1% (16/106 patients), respectively, for DLS and non-DLS patients. Postoperative symptoms or instability not meeting the criteria noted above and thus requiring fusion was seen in 10 (7.1%) of 104 patients with DLS and 8 (7.5%) of 106 patients without DLS. In both same-level and adjacent-level reoperations, DLS did not play a significant role as a risk factor for future reoperation, as shown in Fig. 2. In addition, except for a slightly overrepresentation of older patients in the DLS group, none of the baseline and surgical characteristics shown in Table 1 appeared to be significant as a risk factor for reoperation or fusion. Due to the small number of revision cases for DLS and non-DLS patients, no meaningful predictive analysis could be conducted and is thus not reported.

FIG. 2.
FIG. 2.

Distribution of all patients who underwent surgery stratified for DLS, decompression alone, and fusion. Based on the criteria requiring a fusion (see Follow-Up in Methods), if there was a need for reoperation attributed to the adjacent level and a fusion was required, the previously decompressed level with or without DLS was included in the fusion. Figure is available in color online only.

The mean times to revision surgery in patients with and without DLS were 3.9 years (95% CI 1.8–6.0 years) and 2.8 years (95% CI 1.3−4.2 years), respectively, for decompression only, and 3.1 years (95% CI 1.0−5.3 years) and 3.1 years (95% CI 1.1−5.1 years), respectively, for fusion. The distribution of time to revision surgery (both decompression only and fusion) in patients with and without DLS did not differ significantly (log-rank test, p < 0.318). Kaplan-Meier survival plots of the revision operation and rate (decompression only or fusion) at the index or adjacent level(s) are shown in Fig. 3.

FIG. 3.
FIG. 3.

Kaplan-Meier survival plots of the revision operation and rate stratified for re-decompression only (left) or fusion (right). Figure is available in color online only.

Discussion

Many studies have reported short- to moderate-term results of unilateral and bilateral laminotomy for decompression of LSS as a less-invasive surgical option. Our current series is a 5- to 15-year survival analysis of reoperation rates after minimally invasive lumbar decompression in patients with neurogenic claudication from central and/or lateral recess stenosis with and without stable (as defined above: < 5 mm of motion) grade I degenerative spondylolisthesis. Overall, the long-term reoperation rate at a mean of 8 years in this series was similar between those with (15.7%) and those without (15.1%) degenerative spondylolisthesis. In addition, the type of revision (decompression alone vs decompression and fusion) was also similar between the groups. Surprisingly, progression of spondylolisthesis after MID in patients with preexisting DLS necessitating a fusion at the same level as the index decompression procedure only occurred in 2.1% of DLS patients. Same-level reoperations were performed in 6.9% of all patients, more than half (56.9%) of whom had DLS. The mean time for reoperation surgery (decompression only or with fusion) was 3.1 years for both groups.

In the present series, the 15.4% incidence of overall surgery-related reoperation for clinically significant restenosis at the operated levels, progressive stenosis at adjacent segment(s), or spinal instability (de novo or secondary) falls within the range of incidences reported in the literature (10% to 23%) for decompression with or without fusion in patients with LSS, with follow-up between 3 and 10 years.11,27–30 It has been stipulated that factors such as laminar bone regrowth and progressive mechanical disruption of the lumbar spine integrity and postoperative instability could contribute to the failure in long-term follow-up.31 Bone regrowth in a surgical defect after posterior decompression in LSS has been reported to occur in 44% to 94% of patients.31,32 In this series, we also included adjacent-segment reoperations (8.5%) as part of the overall reoperation rate to account for the patient’s perspective. However, in the absence of a fusion and with an anatomy preserving decompression alone, these additional surgeries are likely more representative of the natural history of LSS (i.e., spine osteoarthritis).

In our series, the reoperation (decompression alone) rate at the same level as the index procedure was 3.7% (9/246), regardless of the presence of DLS. This is generally similar to or lower than most rates reported for minimally invasive tubular retractor laminectomy in the literature, with a mean reoperation rate of 8.1% (range 1.2%–15%) and mean follow-up period of 25 months (range 9–42 months), as shown in Table 2.8,9,13,15,23 An overall explanation could be better preservation of the spinal integrity (bony and soft tissue) with the unilateral laminotomy for bilateral decompression, with minimal postoperative bone regrowth.32 As a progressive degenerative disease, LSS often affects the entire lumbar spine, with degenerative changes still present after decompressive surgery. This may explain the long-term reoperation rate of 8.5% for stenosis and/or lumbar disc herniation of segments other than those that were surgically treated in the current series. Stenosis and disc herniation at adjacent levels might occur irrespective of the selected operative technique for decompression of LSS. However, it is known that fusion of one or more segments could change the biomechanics of the adjacent levels and cause accelerated degeneration. However, the clinical significance and whether this would result in higher number of reoperations remains to be elucidated.

TABLE 2.

Comparison of reoperation rates (decompression only or fusion) in minimally invasive tubular decompression, as reported in the literature

Authors & YearNo. of CasesFU DurationTotal Reop RateReop w/ Fusion Rate
Parikh et al., 200815609 mos3.4%NA
Kim et al., 201285742 mos15%7%
Müslüman et al., 201298424 mos1.2%0%
Palmer & Davison, 2012135427 mosNA2%
Alimi et al., 2015238428 mos12.9%3.5%

FU = follow-up; NA = not applicable.

Revision surgery with spinal fusion for primary concerns at the same level as the index procedure was necessary in 3.3% of all patients in the present series (2.1% and 4.7% in DLS and non-DLS patients, respectively). There was no increased significant difference in rate of fusion between patients with preexisting DLS and those without. Our data are comparable with reoperation fusion rates reported in the literature, with a mean rate of 3.1% (range 0%–7%) and mean follow-up period of 30 months (range 24–42 months).8,9,13,23 In patients without preoperative spondylolisthesis, rates of progressive postoperative spondylolisthesis up to 31% and for those with a preoperative listhesis up to 100% (30%–100%) have been reported.11,33–35 Therefore, a substantially higher incidence of postoperative spinal instability and associated reoperation rate (range 7%–24%) has been reported in laminectomy and bilateral laminotomy series for both DLS and non-DLS patients.11,27,30,34,36

It must be noted that reoperation is not a binary decision based on presence or absence of postoperative instability. This is reflected in the wide variation of reported reoperation rates that reflects the reality that reoperation rates will be driven by three key factors: patient factors (e.g., symptoms and choice), surgeon factors (e.g., radiographic, clinical, and surgical technique), and regional health system factors (e.g., limited resources vs incentives to perform more surgery). For example, in the two recent decompression versus decompression and fusion trials for DLS, the reoperation rate (mean 6.5 years) reported by Försth et al. in Sweden was 21% for decompression alone compared with 22% for decompression and fusion, whereas the reoperation rate at 4 years in the US series by Ghogawala et al. was 34% for decompression alone compared with 14% for fusion.37,38 In both series, laminectomies were used for decompression. Thus, it is possible that the lower rate of reoperation in the current series was related to the use of the midline-preserving MID technique. However, differences in patient selection and surgeon and system biases are also likely contributory. In the current series, a single surgeon’s criteria (see Methods) were used to select patients for decompression alone in DLS patients. Comparatively, these criteria are closest to the criteria noted in the study by Ghogawala et al.38 In their study, all patients with grade I lumbar spondylolisthesis (degree of spondylolisthesis, 3 to 14 mm) with lumbar stenosis and neurogenic claudication with or without lumbar radiculopathy were eligible for inclusion. Patients were excluded “if radiography revealed lumbar instability (motion of >3 mm at the level of listhesis, as measured on flexion–extension radiographs of the lumbar spine), if they were judged by the enrolling surgeon to have lumbar instability because of a history of mechanical low back pain with axial loading of the spine, if they had had previous lumbar spinal surgery….”38 In the study by Försth et al., patients with “pseudoclaudication in one or both legs and back pain (score on visual-analogue scale >30)” and a minimum of 3 mm of listhesis were included.37 These patients are likely more heterogeneous than those enrolled in the study by Ghogawala et al. or the current series. With the specific patient and radiographic selection criteria outlined, our long-term results suggest that a durable outcome as it relates to reoperation is feasible after decompression alone for selected DLS patients. In particular, a midline preserving approach to decompression may further reduce the reoperation rates in decompression alone and provide further evidence of noninferiority of decompression alone for appropriately selected patients. To establish this proposition in a higher level of evidence, a pragmatic randomized multicenter controlled trial is currently being led by the senior author in Canada (https://clinicaltrials.gov/ct2/show/NCT02348645).

Our results present the longest follow-up interval of LSS patients stratified for DLS treated with MID. Persistent inclusion criteria, clinical homogeneity of the patient population, reliability and consistency of MID surgical technique (performed or supervised by one single spine surgeon), together with clear and reproducible outcome criteria, reflect the strength of the present study. However, these strengths also negatively affect the study’s generalizability and limit its reproducibility, especially in a setting where one single spine surgeon was involved. Additionally, as is the case for every retrospective analysis, there is an inherent risk of recall, misclassification, and information bias. Loss to follow-up might bias the clinical results; however, the follow-up rate in this series was almost 90%. Moreover, relying on dynamic radiological imaging to assess spinal instability might underestimate actual preoperative instability and failure to assess postoperative surgery-induced spinal instability. As has been stipulated in the literature, the degree of radiologically confirmed decompression and evidence of instability are poorly related to the surgical outcome.11,37–39 Moreover, we did not assess for one or more radiological parameters that may have significant effect to the need of fusion in the future (such as, but not limited to, pelvic parameters, regional and global sagittal alignment, disc height, facet angle, or specific distance of slippage). For the purpose of this particular study, we excluded these parameters because we only aimed to study the effect of spondylolisthesis in this heterogeneous cohort in combination with the MID, which we believe has little effect on the general biomechanical status of the lumbar region. Furthermore, these specific radiographic parameters, although clinically considered by the senior author, are not used above and beyond the criteria outlined in Methods for decision-making to consider decompression alone in the DLS patients. Nonetheless, in a separate study in a small series of more recent DLS patients, the senior author has assessed the correlation to progression of radiographic slip and Oswestry Disability Index after decompression alone. In that study, the mean baseline slip was 17.2% (SD 8%) in patients undergoing surgery with the same selection criteria as in the current article.39

Conclusions

In highly selected patients with stable DLS and leg-dominant pain due to central or lateral recess stenosis, the long-term reoperation rate is similar between DLS and non-DLS patients undergoing MID.

Disclosures

Dr. Rampersaud: consultant and royalties from Medtronic.

Author Contributions

Conception and design: both authors. Acquisition of data: both authors. Analysis and interpretation of data: both authors. Drafting the article: Moayeri. Critically revising the article: both authors. Reviewed submitted version of manuscript: both authors. Approved the final version of the manuscript on behalf of both authors: Rampersaud. Statistical analysis: Moayeri. Administrative/technical/material support: Rampersaud. Study supervision: Rampersaud.

References

  • 1

    Deyo RA. Treatment of lumbar spinal stenosis: a balancing act. Spine J. 2010;10(7):625627.

  • 2

    Yabuki S, Fukumori N, Takegami M, Onishi Y, Otani K, Sekiguchi M, et al. Prevalence of lumbar spinal stenosis, using the diagnostic support tool, and correlated factors in Japan: a population-based study. J Orthop Sci. 2013;18(6):893900.

    • Search Google Scholar
    • Export Citation
  • 3

    Lurie J, Tomkins-Lane C. Management of lumbar spinal stenosis. BMJ. 2016;352:h6234.

  • 4

    Ishimoto Y, Yoshimura N, Muraki S, Yamada H, Nagata K, Hashizume H, et al. Association of lumbar spondylolisthesis with low back pain and symptomatic lumbar spinal stenosis in a population-based cohort: the Wakayama Spine Study. Spine (Phila Pa 1976). 2017;42(11):E666E671.

    • Search Google Scholar
    • Export Citation
  • 5

    Ong KL, Auerbach JD, Lau E, Schmier J, Ochoa JA. Perioperative outcomes, complications, and costs associated with lumbar spinal fusion in older patients with spinal stenosis and spondylolisthesis. Neurosurg Focus. 2014;36(6):E5.

    • Search Google Scholar
    • Export Citation
  • 6

    Segebarth B, Kurd MF, Haug PH, Davis R. Routine upright imaging for evaluating degenerative lumbar stenosis: incidence of degenerative spondylolisthesis missed on supine MRI. J Spinal Disord Tech. 2015;28(10):394397.

    • Search Google Scholar
    • Export Citation
  • 7

    Sengupta DK, Herkowitz HN. Lumbar spinal stenosis. Treatment strategies and indications for surgery. Orthop Clin North Am. 2003;34(2):281295.

    • Search Google Scholar
    • Export Citation
  • 8

    Kim S, Mortaz Hedjri S, Coyte PC, Rampersaud YR. Cost-utility of lumbar decompression with or without fusion for patients with symptomatic degenerative lumbar spondylolisthesis. Spine J. 2012;12(1):4454.

    • Search Google Scholar
    • Export Citation
  • 9

    Müslüman AM, Cansever T, Yılmaz A, Çavuşoğlu H, Yüce İ, Aydın Y. Midterm outcome after a microsurgical unilateral approach for bilateral decompression of lumbar degenerative spondylolisthesis. J Neurosurg Spine. 2012;16(1):6876.

    • Search Google Scholar
    • Export Citation
  • 10

    Slätis P, Malmivaara A, Heliövaara M, Sainio P, Herno A, Kankare J, et al. Long-term results of surgery for lumbar spinal stenosis: a randomised controlled trial. Eur Spine J. 2011;20(7):11741181.

    • Search Google Scholar
    • Export Citation
  • 11

    Fox MW, Onofrio BM, Onofrio BM, Hanssen AD. Clinical outcomes and radiological instability following decompressive lumbar laminectomy for degenerative spinal stenosis: a comparison of patients undergoing concomitant arthrodesis versus decompression alone. J Neurosurg. 1996;85(5):793802.

    • Search Google Scholar
    • Export Citation
  • 12

    Mardjetko SM, Connolly PJ, Shott S. Degenerative lumbar spondylolisthesis. A meta-analysis of literature 1970-1993. Spine (Phila Pa 1976).1994;19(20)(suppl):2256S2265S.

    • Search Google Scholar
    • Export Citation
  • 13

    Palmer S, Davison L. Minimally invasive surgical treatment of lumbar spinal stenosis: two-year follow-up in 54 patients. Surg Neurol Int. 2012;3:41.

    • Search Google Scholar
    • Export Citation
  • 14

    Pao JL, Chen WC, Chen PQ. Clinical outcomes of microendoscopic decompressive laminotomy for degenerative lumbar spinal stenosis. Eur Spine J. 2009;18(5):672678.

    • Search Google Scholar
    • Export Citation
  • 15

    Parikh K, Tomasino A, Knopman J, Boockvar J, Härtl R. Operative results and learning curve: microscope-assisted tubular microsurgery for 1- and 2-level discectomies and laminectomies. Neurosurg Focus. 2008;25(2):E14.

    • Search Google Scholar
    • Export Citation
  • 16

    Abumi K, Panjabi MM, Kramer KM, Duranceau J, Oxland T, Crisco JJ. Biomechanical evaluation of lumbar spinal stability after graded facetectomies. Spine (Phila Pa 1976).1990;15(11):11421147.

    • Search Google Scholar
    • Export Citation
  • 17

    Cardoso MJ, Dmitriev AE, Helgeson M, Lehman RA, Kuklo TR, Rosner MK. Does superior-segment facet violation or laminectomy destabilize the adjacent level in lumbar transpedicular fixation? An in vitro human cadaveric assessment. Spine (Phila Pa 1976). 2008;33(26):28682873.

    • Search Google Scholar
    • Export Citation
  • 18

    Delank KS, Gercek E, Kuhn S, Hartmann F, Hely H, Röllinghoff M, et al. How does spinal canal decompression and dorsal stabilization affect segmental mobility? A biomechanical study. Arch Orthop Trauma Surg. 2010;130(2):285292.

    • Search Google Scholar
    • Export Citation
  • 19

    Hamasaki T, Tanaka N, Kim J, Okada M, Ochi M, Hutton WC. Biomechanical assessment of minimally invasive decompression for lumbar spinal canal stenosis: a cadaver study. J Spinal Disord Tech. 2009;22(7):486491.

    • Search Google Scholar
    • Export Citation
  • 20

    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(6):802808.

    • Search Google Scholar
    • Export Citation
  • 21

    Kreiner DS, Shaffer WO, Baisden JL, Gilbert TJ, Summers JT, Toton JF, et al. An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spinal stenosis (update). Spine J. 2013;13(7):734743.

    • Search Google Scholar
    • Export Citation
  • 22

    Weinstein JN, Lurie JD, Tosteson TD, Hanscom B, Tosteson AN, Blood EA, et al. Surgical versus nonsurgical treatment for lumbar degenerative spondylolisthesis. N Engl J Med. 2007;356(22):22572270.

    • Search Google Scholar
    • Export Citation
  • 23

    Alimi M, Hofstetter CP, Pyo SY, Paulo D, Härtl R. Minimally invasive laminectomy for lumbar spinal stenosis in patients with and without preoperative spondylolisthesis: clinical outcome and reoperation rates. J Neurosurg Spine. 2015;22(4):339352.

    • Search Google Scholar
    • Export Citation
  • 24

    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.

    • Search Google Scholar
    • Export Citation
  • 25

    Simmonds AM, Rampersaud YR, Dvorak MF, Dea N, Melnyk AD, Fisher CG. Defining the inherent stability of degenerative spondylolisthesis: a systematic review. J Neurosurg Spine. 2015;23(2):178189.

    • Search Google Scholar
    • Export Citation
  • 26

    Aleem IS, Rampersaud YR. Elderly patients have similar outcomes compared to younger patients after minimally invasive surgery for spinal stenosis. Clin Orthop Relat Res. 2014;472(6):18241830.

    • Search Google Scholar
    • Export Citation
  • 27

    Rompe JD, Eysel P, Zöllner J, Nafe B, Heine J. Degenerative lumbar spinal stenosis. Long-term results after undercutting decompression compared with decompressive laminectomy alone or with instrumented fusion. Neurosurg Rev. 1999;22(2-3):102106.

    • Search Google Scholar
    • Export Citation
  • 28

    Tsai RY, Yang RS, Bray RS Jr. Microscopic laminotomies for degenerative lumbar spinal stenosis. J Spinal Disord. 1998;11(5):389394.

  • 29

    Tuite GF, Stern JD, Doran SE, Papadopoulos SM, McGillicuddy JE, Oyedijo DI, et al. Outcome after laminectomy for lumbar spinal stenosis. Part I: Clinical correlations. J Neurosurg. 1994;81(5):699706.

    • Search Google Scholar
    • Export Citation
  • 30

    Javid MJ, Hadar EJ. Long-term follow-up review of patients who underwent laminectomy for lumbar stenosis: a prospective study. J Neurosurg. 1998;89(1):17.

    • Search Google Scholar
    • Export Citation
  • 31

    Postacchini F, Cinotti G. Bone regrowth after surgical decompression for lumbar spinal stenosis. J Bone Joint Surg Br. 1992;74(6):862869.

    • Search Google Scholar
    • Export Citation
  • 32

    Chen Q, Baba H, Kamitani K, Furusawa N, Imura S. Postoperative bone re-growth in lumbar spinal stenosis. A multivariate analysis of 48 patients. Spine (Phila Pa 1976).1994;19(19):21442149.

    • Search Google Scholar
    • Export Citation
  • 33

    Jönsson B. Vertebral slipping after decompression for spinal stenosis. Acta Orthop Scand Suppl. 1993;251:7677.

  • 34

    Nakai O, Ookawa A, Yamaura I. Long-term roentgenographic and functional changes in patients who were treated with wide fenestration for central lumbar stenosis. J Bone Joint Surg Am. 1991;73(8):11841191.

    • Search Google Scholar
    • Export Citation
  • 35

    Thomas NW, Rea GL, Pikul BK, Mervis LJ, Irsik R, McGregor JM. Quantitative outcome and radiographic comparisons between laminectomy and laminotomy in the treatment of acquired lumbar stenosis. Neurosurgery. 1997;41(3):567575.

    • Search Google Scholar
    • Export Citation
  • 36

    Katz JN, Lipson SJ, Chang LC, Levine SA, Fossel AH, Liang MH. Seven- to 10-year outcome of decompressive surgery for degenerative lumbar spinal stenosis. Spine (Phila Pa 1976).1996;21(1):9298.

    • Search Google Scholar
    • Export Citation
  • 37

    Försth P, Ólafsson G, Carlsson T, Frost A, Borgström F, Fritzell P, et al. A randomized, controlled trial of fusion surgery for lumbar spinal stenosis. N Engl J Med. 2016;374(15):14131423.

    • Search Google Scholar
    • Export Citation
  • 38

    Ghogawala Z, Dziura J, Butler WE, Dai F, Terrin N, Magge SN, et al. Laminectomy plus fusion versus laminectomy alone for lumbar spondylolisthesis. N Engl J Med. 2016;374(15):14241434.

    • Search Google Scholar
    • Export Citation
  • 39

    Ravinsky RA, Crawford EJ, Reda LA, Rampersaud YR. Slip progression in degenerative lumbar spondylolisthesis following minimally invasive decompression surgery is not associated with increased functional disability. Eur Spine J. 2020;29(4):896903.

    • Search Google Scholar
    • Export Citation
  • View in gallery

    Flowchart of excluded and included consecutive patients.

  • View in gallery

    Distribution of all patients who underwent surgery stratified for DLS, decompression alone, and fusion. Based on the criteria requiring a fusion (see Follow-Up in Methods), if there was a need for reoperation attributed to the adjacent level and a fusion was required, the previously decompressed level with or without DLS was included in the fusion. Figure is available in color online only.

  • View in gallery

    Kaplan-Meier survival plots of the revision operation and rate stratified for re-decompression only (left) or fusion (right). Figure is available in color online only.

  • 1

    Deyo RA. Treatment of lumbar spinal stenosis: a balancing act. Spine J. 2010;10(7):625627.

  • 2

    Yabuki S, Fukumori N, Takegami M, Onishi Y, Otani K, Sekiguchi M, et al. Prevalence of lumbar spinal stenosis, using the diagnostic support tool, and correlated factors in Japan: a population-based study. J Orthop Sci. 2013;18(6):893900.

    • Search Google Scholar
    • Export Citation
  • 3

    Lurie J, Tomkins-Lane C. Management of lumbar spinal stenosis. BMJ. 2016;352:h6234.

  • 4

    Ishimoto Y, Yoshimura N, Muraki S, Yamada H, Nagata K, Hashizume H, et al. Association of lumbar spondylolisthesis with low back pain and symptomatic lumbar spinal stenosis in a population-based cohort: the Wakayama Spine Study. Spine (Phila Pa 1976). 2017;42(11):E666E671.

    • Search Google Scholar
    • Export Citation
  • 5

    Ong KL, Auerbach JD, Lau E, Schmier J, Ochoa JA. Perioperative outcomes, complications, and costs associated with lumbar spinal fusion in older patients with spinal stenosis and spondylolisthesis. Neurosurg Focus. 2014;36(6):E5.

    • Search Google Scholar
    • Export Citation
  • 6

    Segebarth B, Kurd MF, Haug PH, Davis R. Routine upright imaging for evaluating degenerative lumbar stenosis: incidence of degenerative spondylolisthesis missed on supine MRI. J Spinal Disord Tech. 2015;28(10):394397.

    • Search Google Scholar
    • Export Citation
  • 7

    Sengupta DK, Herkowitz HN. Lumbar spinal stenosis. Treatment strategies and indications for surgery. Orthop Clin North Am. 2003;34(2):281295.

    • Search Google Scholar
    • Export Citation
  • 8

    Kim S, Mortaz Hedjri S, Coyte PC, Rampersaud YR. Cost-utility of lumbar decompression with or without fusion for patients with symptomatic degenerative lumbar spondylolisthesis. Spine J. 2012;12(1):4454.

    • Search Google Scholar
    • Export Citation
  • 9

    Müslüman AM, Cansever T, Yılmaz A, Çavuşoğlu H, Yüce İ, Aydın Y. Midterm outcome after a microsurgical unilateral approach for bilateral decompression of lumbar degenerative spondylolisthesis. J Neurosurg Spine. 2012;16(1):6876.

    • Search Google Scholar
    • Export Citation
  • 10

    Slätis P, Malmivaara A, Heliövaara M, Sainio P, Herno A, Kankare J, et al. Long-term results of surgery for lumbar spinal stenosis: a randomised controlled trial. Eur Spine J. 2011;20(7):11741181.

    • Search Google Scholar
    • Export Citation
  • 11

    Fox MW, Onofrio BM, Onofrio BM, Hanssen AD. Clinical outcomes and radiological instability following decompressive lumbar laminectomy for degenerative spinal stenosis: a comparison of patients undergoing concomitant arthrodesis versus decompression alone. J Neurosurg. 1996;85(5):793802.

    • Search Google Scholar
    • Export Citation
  • 12

    Mardjetko SM, Connolly PJ, Shott S. Degenerative lumbar spondylolisthesis. A meta-analysis of literature 1970-1993. Spine (Phila Pa 1976).1994;19(20)(suppl):2256S2265S.

    • Search Google Scholar
    • Export Citation
  • 13

    Palmer S, Davison L. Minimally invasive surgical treatment of lumbar spinal stenosis: two-year follow-up in 54 patients. Surg Neurol Int. 2012;3:41.

    • Search Google Scholar
    • Export Citation
  • 14

    Pao JL, Chen WC, Chen PQ. Clinical outcomes of microendoscopic decompressive laminotomy for degenerative lumbar spinal stenosis. Eur Spine J. 2009;18(5):672678.

    • Search Google Scholar
    • Export Citation
  • 15

    Parikh K, Tomasino A, Knopman J, Boockvar J, Härtl R. Operative results and learning curve: microscope-assisted tubular microsurgery for 1- and 2-level discectomies and laminectomies. Neurosurg Focus. 2008;25(2):E14.

    • Search Google Scholar
    • Export Citation
  • 16

    Abumi K, Panjabi MM, Kramer KM, Duranceau J, Oxland T, Crisco JJ. Biomechanical evaluation of lumbar spinal stability after graded facetectomies. Spine (Phila Pa 1976).1990;15(11):11421147.

    • Search Google Scholar
    • Export Citation
  • 17

    Cardoso MJ, Dmitriev AE, Helgeson M, Lehman RA, Kuklo TR, Rosner MK. Does superior-segment facet violation or laminectomy destabilize the adjacent level in lumbar transpedicular fixation? An in vitro human cadaveric assessment. Spine (Phila Pa 1976). 2008;33(26):28682873.

    • Search Google Scholar
    • Export Citation
  • 18

    Delank KS, Gercek E, Kuhn S, Hartmann F, Hely H, Röllinghoff M, et al. How does spinal canal decompression and dorsal stabilization affect segmental mobility? A biomechanical study. Arch Orthop Trauma Surg. 2010;130(2):285292.

    • Search Google Scholar
    • Export Citation
  • 19

    Hamasaki T, Tanaka N, Kim J, Okada M, Ochi M, Hutton WC. Biomechanical assessment of minimally invasive decompression for lumbar spinal canal stenosis: a cadaver study. J Spinal Disord Tech. 2009;22(7):486491.

    • Search Google Scholar
    • Export Citation
  • 20

    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(6):802808.

    • Search Google Scholar
    • Export Citation
  • 21

    Kreiner DS, Shaffer WO, Baisden JL, Gilbert TJ, Summers JT, Toton JF, et al. An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spinal stenosis (update). Spine J. 2013;13(7):734743.

    • Search Google Scholar
    • Export Citation
  • 22

    Weinstein JN, Lurie JD, Tosteson TD, Hanscom B, Tosteson AN, Blood EA, et al. Surgical versus nonsurgical treatment for lumbar degenerative spondylolisthesis. N Engl J Med. 2007;356(22):22572270.

    • Search Google Scholar
    • Export Citation
  • 23

    Alimi M, Hofstetter CP, Pyo SY, Paulo D, Härtl R. Minimally invasive laminectomy for lumbar spinal stenosis in patients with and without preoperative spondylolisthesis: clinical outcome and reoperation rates. J Neurosurg Spine. 2015;22(4):339352.

    • Search Google Scholar
    • Export Citation
  • 24

    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.

    • Search Google Scholar
    • Export Citation
  • 25

    Simmonds AM, Rampersaud YR, Dvorak MF, Dea N, Melnyk AD, Fisher CG. Defining the inherent stability of degenerative spondylolisthesis: a systematic review. J Neurosurg Spine. 2015;23(2):178189.

    • Search Google Scholar
    • Export Citation
  • 26

    Aleem IS, Rampersaud YR. Elderly patients have similar outcomes compared to younger patients after minimally invasive surgery for spinal stenosis. Clin Orthop Relat Res. 2014;472(6):18241830.

    • Search Google Scholar
    • Export Citation
  • 27

    Rompe JD, Eysel P, Zöllner J, Nafe B, Heine J. Degenerative lumbar spinal stenosis. Long-term results after undercutting decompression compared with decompressive laminectomy alone or with instrumented fusion. Neurosurg Rev. 1999;22(2-3):102106.

    • Search Google Scholar
    • Export Citation
  • 28

    Tsai RY, Yang RS, Bray RS Jr. Microscopic laminotomies for degenerative lumbar spinal stenosis. J Spinal Disord. 1998;11(5):389394.

  • 29

    Tuite GF, Stern JD, Doran SE, Papadopoulos SM, McGillicuddy JE, Oyedijo DI, et al. Outcome after laminectomy for lumbar spinal stenosis. Part I: Clinical correlations. J Neurosurg. 1994;81(5):699706.

    • Search Google Scholar
    • Export Citation
  • 30

    Javid MJ, Hadar EJ. Long-term follow-up review of patients who underwent laminectomy for lumbar stenosis: a prospective study. J Neurosurg. 1998;89(1):17.

    • Search Google Scholar
    • Export Citation
  • 31

    Postacchini F, Cinotti G. Bone regrowth after surgical decompression for lumbar spinal stenosis. J Bone Joint Surg Br. 1992;74(6):862869.

    • Search Google Scholar
    • Export Citation
  • 32

    Chen Q, Baba H, Kamitani K, Furusawa N, Imura S. Postoperative bone re-growth in lumbar spinal stenosis. A multivariate analysis of 48 patients. Spine (Phila Pa 1976).1994;19(19):21442149.

    • Search Google Scholar
    • Export Citation
  • 33

    Jönsson B. Vertebral slipping after decompression for spinal stenosis. Acta Orthop Scand Suppl. 1993;251:7677.

  • 34

    Nakai O, Ookawa A, Yamaura I. Long-term roentgenographic and functional changes in patients who were treated with wide fenestration for central lumbar stenosis. J Bone Joint Surg Am. 1991;73(8):11841191.

    • Search Google Scholar
    • Export Citation
  • 35

    Thomas NW, Rea GL, Pikul BK, Mervis LJ, Irsik R, McGregor JM. Quantitative outcome and radiographic comparisons between laminectomy and laminotomy in the treatment of acquired lumbar stenosis. Neurosurgery. 1997;41(3):567575.

    • Search Google Scholar
    • Export Citation
  • 36

    Katz JN, Lipson SJ, Chang LC, Levine SA, Fossel AH, Liang MH. Seven- to 10-year outcome of decompressive surgery for degenerative lumbar spinal stenosis. Spine (Phila Pa 1976).1996;21(1):9298.

    • Search Google Scholar
    • Export Citation
  • 37

    Försth P, Ólafsson G, Carlsson T, Frost A, Borgström F, Fritzell P, et al. A randomized, controlled trial of fusion surgery for lumbar spinal stenosis. N Engl J Med. 2016;374(15):14131423.

    • Search Google Scholar
    • Export Citation
  • 38

    Ghogawala Z, Dziura J, Butler WE, Dai F, Terrin N, Magge SN, et al. Laminectomy plus fusion versus laminectomy alone for lumbar spondylolisthesis. N Engl J Med. 2016;374(15):14241434.

    • Search Google Scholar
    • Export Citation
  • 39

    Ravinsky RA, Crawford EJ, Reda LA, Rampersaud YR. Slip progression in degenerative lumbar spondylolisthesis following minimally invasive decompression surgery is not associated with increased functional disability. Eur Spine J. 2020;29(4):896903.

    • Search Google Scholar
    • Export Citation

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