Re-evaluating established principles—should decompression replace fusion as the go-to for degenerative lumbar spondylolisthesis?

Degenerative lumbar spondylolisthesis (DLS) is one of the major causes of lower back pain in adult and elderly patients. Fusion is generally seen as the standard surgical treatment. But could it be time to re-evaluate? At the Global Spine Congress 2023 in Prague, Stipe Ćorluka, an associate member of the AO Spine Knowledge Forum Degenerative, will argue that it could make more sense to focus on decompression instead.

Ask around a little among spine surgeons what they consider to be the best surgical procedure for low-grade cases of degenerative lumbar spondylolisthesis (DLS), and what you will hear may contradict what you thought was an established fact. In fact, it is reasonably likely that you will be told about fusion procedures with very poor patient outcomes on the one hand, while on the other hand you will probably hear about very good results after decompression surgery alone.

This, of course, is all very much anecdotal and is not solid scientific evidence. Still, it is odd. After all, fusion surgery is seen by many as the gold standard for the surgical treatment of low-grade DLS. On closer inspection, however, there are a few reasons that can make you wonder why. As a procedure, fusion is much more physically disruptive than decompression. It is also associated with more blood loss, longer hospital stays, and higher overall treatment costs.

Questioning conventional wisdom for low-grade degenerative lumbar spondylolisthesis

Most importantly, however, fusion inevitably causes a loss of motion in the affected segment of the spine. Although it is true that this is exactly the desired outcome—unstable vertebrae can be stabilized by permanently joining them together—the resulting impairment in motion can also have rather negative effects on patient quality of life.

When we met in Las Vegas last year for our regular meeting of the AO Spine Knowledge Forum Degenerative (KF Degen), we discovered that many of us had heard anecdotes like the one I outlined at the start. So collectively, we started to wonder: Shouldn’t we reconsider whether fusion should really be the go-to technique for low-grade DLS? Shouldn’t we instead aim to resort to fusion only in cases where there is absolutely no alternative? Wouldn’t it make much more sense to put simpler procedures in the spotlight that preserve motion, and based on our collective treasure trove of anecdotes, could decompression possibly assume that role?

Easier and more qualified decisions for management of degenerative spine disorders

It quickly became clear to us that there is currently no clear scientific consensus on the best surgical treatment for low-grade DLS. So, we asked how can we as spine surgeons be expected to make an informed decision on which procedure to go for when confronted with the condition? The simple answer is as follows: We cannot. There are frankly not enough clear conclusions based on high-quality studies to help us choose the most appropriate way forward in each individual case.