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Randomised controlled trial(s)
Fusion in degenerative spondylolisthesis becomes controversial…again
  1. James Weinstein1,
  2. Adam Pearson2
  1. 1 The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire, USA
  2. 2 Department of Orthopaedics, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
  1. Correspondence to : Professor James Weinstein, The Dartmouth Institute for Health Policy and Clinical Practice, 35 Centerra Pkwy, Lebanon, NH 03766, USA; James.N.Weinstein{at}Hitchcock.org

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Context

The role of fusion in degenerative spondylolisthesis (DS) was hotly debated in the 1990s, until two studies were performed suggesting that patients undergoing fusion in addition to laminectomy had better outcomes and less progression of listhesis than patients undergoing laminectomy alone.1 ,2 These were single centre studies that used rudimentary randomisation techniques and generally subjective, surgeon-reported outcomes. While relatively high-quality studies for the time, they would be viewed as no better than level 2 evidence today. Based largely on the results of these studies and the explosion of new devices, laminectomy and fusion became the standard treatment for DS, and over 95% of patients with DS undergoing surgery in the USA now undergo a fusion with some type of instrumentation.3 More recently, the role of fusion has been questioned, especially as less invasive decompressive techniques have been developed.4 As a result, two recent randomised controlled trials were performed comparing laminectomy to laminectomy and fusion.

Methods

Forsth et al 5 reported the results of the Swedish Spinal Stenosis Study (SSSS), which included 247 patients, 135 of whom had DS. The trial was performed at seven sites across Sweden, with patient enrolment from 2006 to 2012. They randomised patients to either decompression alone (D) or decompression and fusion (DF). All patients with DS underwent a midline laminectomy, and …

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