Surgery in degenerative spondylolisthesis: does fusion improve outcome in subgroups? A secondary analysis from a randomized trial (NORDSTEN trial)

• Published in: The spine journal 2023-11, Vol.23 (11), p.1613-1622
• Main Authors: Hellum, Christian, Rekeland, Frode, Småstuen, Milada Cvancarova, Solberg, Tore, Hermansen, Erland, Storheim, Kjersti, Brox, Jens Ivar, Furunes, Håvard, Franssen, Eric, Weber, Clemens, Brisby, Helena, Grundnes, Oliver, Algaard, Knut Robert Hector, Böker, Tordis, Banitalebi, Hasan, Indrekvam, Kari, Austevoll, Ivar Magne
• Format: Article
• Language: English
• Subjects: back-pain; Decompression; Degenerative; diagnosis; Fusion; instability; instrumentation; lumbar spinal stenosis; mri; Neurosciences; Neurosciences & Neurology; Neurovetenskaper; Orthopedics; Ortopedi; Predictor; radiographic predictors; selection; Spinal stenosis; Spondylolisthesis; stability; Subgroup; Surgery
• ISSN: 1529-9430; 1878-1632; 1878-1632
• DOI: 10.1016/j.spinee.2023.06.386

•More preoperative leg pain and less comorbidity associated with improved outcome.•Baseline variables did not modify the treatment effect.•Instability criteria cannot be recommended as selection criteria for fusion surgery. Patients with spinal stenosis and degenerative spondylolisthesis are treated surgically with decompression alone or decompression with fusion. However, there is debate regarding which subgroups of patients may benefit from additional fusion. To investigate possible treatment effect modifiers and prognostic variables among patients operated for spinal stenosis and degenerative spondylolisthesis. A secondary exploratory study using data from the Norwegian Degenerative Spondylolisthesis and Spinal Stenosis (NORDSTEN-DS) trial. Patients were randomized to decompression alone or decompression with instrumented fusion. The sample in this study consists of 267 patients from a randomized multicenter trial involving 16 hospitals in Norway. Patients were enrolled from February 12, 2014, to December 18, 2017. The study did not include patients with degenerative scoliosis, severe foraminal stenosis, multilevel spondylolisthesis, or previous surgery. The primary outcome was an improvement of ≥ 30% on the Oswestry Disability Index score (ODI) from baseline to 2-year follow-up. When investigating possible variables that could modify the treatment effect, we analyzed the treatment arms separately. When testing for prognostic factors we analyzed the whole cohort (both treatment groups). We used univariate and multiple regression analyses. The selection of variables was done a priori, according to the published trial protocol. Of the 267 patients included in the trial (183 female [67%]; mean [SD] age, 66 [7.6] years), complete baseline data for the variables required for the present analysis were available for 205 of the 267 individuals. We did not find any clinical or radiological variables at baseline that modified the treatment effect. Thus, none of the commonly used criteria for selecting patients for fusion surgery influenced the chosen primary outcome in the two treatment arms. For the whole cohort, less comorbidity (American Society of Anesthesiologists Classification [ASA], OR = 4.35; 95% confidence interval (CI [1.16–16.67]) and more preoperative leg pain (OR = 1.23; CI [1.02–1.50]) were significantly associated with an improved primary outcome. In this study on patients with degenerative spondylolisthesis, neither previously defined instability