Decompression Versus Decompression and Fusion in Lumbar Degenerative Stenosis/Spondylolisthesis
Location
LSU Health NO Center for Advanced Learning and Simulation (CALS)
Document Type
Event
Start Date
20-6-2026 8:15 AM
End Date
20-6-2026 8:45 AM
Publication Date
June 2026
Description
Introduction: Degenerative spondylolisthesis (DS) is among the most common spinal conditions with a prevalence of 2.1% in men and 8.1% in women. DS involves forward displacement of one lumbar vertebra over another due to degeneration. Surgical management of symptomatic DS refractory to conservative care remains controversial, specifically whether decompression alone is sufficient versus decompression combined with fusion. This review evaluates and compares clinical outcomes, complication profiles, and cost-effectiveness of these two surgical strategies.
Methods: A narrative review of the current literature was performed, including randomized controlled trials (RCTs), systematic reviews, and prospective/retrospective cohort studies. Key RCTs included the Swedish Spinal Stenosis Trial (Forsth et al., 2016; n=247), NORDSTEN-DS (Austevoll et al., 2021; n=267), the SLIP trial (Ghogawala et al., 2016; n=66), and Inose et al. (2022; n=85). Outcomes included PROMs (ODI, ZCQ, EQ-5D, SF-36, VAS), reoperation rates, operative metrics (EBL, LOS, operative time), complications (SSI, pseudoarthrosis, adjacent segment disease, delayed instability), and cost-effectiveness analyses. This narrative review did not require IRB approval or informed consent.
Results: Multiple multicenter RCTs demonstrated decompression alone to be noninferior to decompression and fusion in primary PROMs (ODI, ZCQ, EQ-5D) at 2- and 5-year follow-up (Swedish Spinal Stenosis Trial; NORDSTENDS), with significantly lower EBL, operative time, LOS, and index costs. The US-based SLIP trial found fusion superior in SF-36 scores at 2 and 4 years, but decompression alone carried a 34% reoperation rate versus 14% with fusion. Fusion was associated with a 33% increased SSI risk, and adjacent segment disease occurred at 23%/year with 30% requiring intervention within 10 years. MIS techniques reduced SSI rates approximately sevenfold versus open. Radiographic predictors of delayed instability after isolated decompression include motion >1.25 mm, disc height >6.5 mm, facet angle >50°, and slippage >13%. Decompression is more cost-effective at index; fusion becomes more cost-effective at 2–4 years (cost/QALY: $115,600 at 2 years → $64,300 at 4 years, SPORT registry).
Discussion: Current evidence supports decompression alone as noninferior for carefully selected patients, particularly older/comorbid patients with stable DS and primarily radicular symptoms. Decompression and fusion is indicated for dynamic instability (motion >1.25 mm, disc height >6.5 mm, facet angle >50°, slippage >13%), sagittal malalignment, high-grade slip, or biologic nonunion risk. Interbody fusion should be added for focal kyphosis or joint effusion on MRI. Discrepancies between the SLIP trial and European RCTs likely reflect heterogeneous patient selection and operative technique rather than a true difference in efficacy. MIS approaches show promise in reducing delayed instability. Limitations include variable instability assessment protocols across trials. Ongoing RCTs (SLIP II) are expected to further clarify selection criteria.
Significance/Clinical Relevance: If the aims of this review are achieved, orthopedic spine surgeons will be better equipped to make individualized, evidence-based surgical decisions for patients with lumbar degenerative spondylolisthesis, potentially reducing unnecessary fusion procedures, associated complications, and revision surgery costs.
Recommended Citation
Dong, Katherine MD, "Decompression Versus Decompression and Fusion in Lumbar Degenerative Stenosis/Spondylolisthesis" (2026). Dept. of Orthopaedics: Robert D. D’Ambrosia Lectureship & Research Day. 2.
https://digitalscholar.lsuhsc.edu/ortho_rd/2026/chief/2
Decompression Versus Decompression and Fusion in Lumbar Degenerative Stenosis/Spondylolisthesis
LSU Health NO Center for Advanced Learning and Simulation (CALS)
Introduction: Degenerative spondylolisthesis (DS) is among the most common spinal conditions with a prevalence of 2.1% in men and 8.1% in women. DS involves forward displacement of one lumbar vertebra over another due to degeneration. Surgical management of symptomatic DS refractory to conservative care remains controversial, specifically whether decompression alone is sufficient versus decompression combined with fusion. This review evaluates and compares clinical outcomes, complication profiles, and cost-effectiveness of these two surgical strategies.
Methods: A narrative review of the current literature was performed, including randomized controlled trials (RCTs), systematic reviews, and prospective/retrospective cohort studies. Key RCTs included the Swedish Spinal Stenosis Trial (Forsth et al., 2016; n=247), NORDSTEN-DS (Austevoll et al., 2021; n=267), the SLIP trial (Ghogawala et al., 2016; n=66), and Inose et al. (2022; n=85). Outcomes included PROMs (ODI, ZCQ, EQ-5D, SF-36, VAS), reoperation rates, operative metrics (EBL, LOS, operative time), complications (SSI, pseudoarthrosis, adjacent segment disease, delayed instability), and cost-effectiveness analyses. This narrative review did not require IRB approval or informed consent.
Results: Multiple multicenter RCTs demonstrated decompression alone to be noninferior to decompression and fusion in primary PROMs (ODI, ZCQ, EQ-5D) at 2- and 5-year follow-up (Swedish Spinal Stenosis Trial; NORDSTENDS), with significantly lower EBL, operative time, LOS, and index costs. The US-based SLIP trial found fusion superior in SF-36 scores at 2 and 4 years, but decompression alone carried a 34% reoperation rate versus 14% with fusion. Fusion was associated with a 33% increased SSI risk, and adjacent segment disease occurred at 23%/year with 30% requiring intervention within 10 years. MIS techniques reduced SSI rates approximately sevenfold versus open. Radiographic predictors of delayed instability after isolated decompression include motion >1.25 mm, disc height >6.5 mm, facet angle >50°, and slippage >13%. Decompression is more cost-effective at index; fusion becomes more cost-effective at 2–4 years (cost/QALY: $115,600 at 2 years → $64,300 at 4 years, SPORT registry).
Discussion: Current evidence supports decompression alone as noninferior for carefully selected patients, particularly older/comorbid patients with stable DS and primarily radicular symptoms. Decompression and fusion is indicated for dynamic instability (motion >1.25 mm, disc height >6.5 mm, facet angle >50°, slippage >13%), sagittal malalignment, high-grade slip, or biologic nonunion risk. Interbody fusion should be added for focal kyphosis or joint effusion on MRI. Discrepancies between the SLIP trial and European RCTs likely reflect heterogeneous patient selection and operative technique rather than a true difference in efficacy. MIS approaches show promise in reducing delayed instability. Limitations include variable instability assessment protocols across trials. Ongoing RCTs (SLIP II) are expected to further clarify selection criteria.
Significance/Clinical Relevance: If the aims of this review are achieved, orthopedic spine surgeons will be better equipped to make individualized, evidence-based surgical decisions for patients with lumbar degenerative spondylolisthesis, potentially reducing unnecessary fusion procedures, associated complications, and revision surgery costs.