To fuse or not to fuse: the elderly patient with lumbar stenosis and low-grade spondylolisthesis. Systematic review and meta-analysis of randomised controlled trials

Background
The optimum surgical intervention for elderly patients with lumbar spinal stenosis (LSS) and low-grade degenerative-spondylolisthesis(LGDS) has been extensively debated. We conducted a systematic review and meta-analysis of randomised-controlled-trials (RCTs) comparing the effectiveness of decompression-alone against the gold-standard approach of decompression-with-fusion (D+F) in elderly patients with LSS and LGDS.

Methods
A systematic literature search was performed on published databases from inception to October-2021. English-language RCTs of elderly patients (mean age over-65) with LSS and LGDS, who had undergone DA or D+F were included. The quality and weight of evidence was assessed, and a meta-analysis performed.

Results

Six RCTs (n=531; mean age: 66.2 years; 57.8% female) were included. There was no difference in visual-analogue-scale (VAS) scores of back-pain (BP) or leg-pain (LP) at mean follow-up of 27.4 months between both DA and D+F groups (BP: mean-difference (MD)0.24, 95%CI: -0.38-0.85; LP MD:0.39, 95%CI: -0.34-1.11). No difference in disability, measured by Oswestry-Disability-Index scores, was found between both groups (MD:0.50, 95%CI: -3.31- 4.31). However, patients in DA group had less hospital complications and fewer adverse events (total-surgical-complications OR:0.57, 95%CI: 0.36-0.90), despite a higher rate of
worsening DS (OR:3.49, 95%CI: 1.05-11.65). No difference in BP or LP was found in subgroup-analysis of open-laminectomy compared to posterolateral-fusion(PLF) (BP: MD: -0.24, 95%CI: -1.80-1.32; LP MD:0.80, 95%CI: -0.95-2.55).

Conclusions
DA is not inferior to D+F in elderly patients with LSS and LGDS. DA carries a lower risk of hospital complications and fewer adverse events, however, surgeons should weigh these findings with the increased risk of DS progressing post-operatively.