Lumbar Degenerative Spondylolisthesis: Posterolateral Fusion Is Sufficient

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1 Lumbar Degenerative Spondylolisthesis: Posterolateral Fusion Is Sufficient Stephen Ryu, MD FACS Department of Neurosurgery Palo Alto Medical Foundation Deputy Chief of Neurosurgery Stanford University Hospital Consulting Professor Department of Electrical Engineering Stanford University IEP Fellow Course 21 November 2015 San Diego, CA

2 Disclosures Consultant Nuvasive Stryker LDR

3 Posterolateral Fusion for Lumbar Anterior subluxation of one vertebral body on another Most common at L4-5 and L5-S1 Due to progressive degeneration of facets at the segment without a pars defect

4 Posterolateral Fusion for Lumbar Spinal stenosis Neurogenic claudication Radiculopathy Cauda equina

5 Surgery for Lumbar 10-20% fail conservative management Absolute indications: Cauda equina syndrome Progressive debilitating weakness Relative indications: Radiculopathy Neurogenic claudication Radiographically documented instability

6 Fusion Surgery for Lumbar Greater than Grade 2 spondylolisthesis After multiple discectomies Gross instability Clear established mechanical back pain Bilateral >50% facetectomies But these are NOT the most of your patients.

7 Posterolateral Fusion for Lumbar 1. Evidence supports posterolateral instrumented fusion to increase fusion rate 2. Evidence does not support better clinical outcomes with instrumentation 3. Evidence does not support anything beyond posterolateral fusion with instrumentation Evidence supports increased costs and complications with additional surgery

8 Spine Surgery Then Forge what you learned Here is TRUTH!

9 Spine Surgery Then Fusion Rate 60-70% Clinical Improvement 60-70%

10 Spine Surgery Then Fusion Rate 60-70% Clinical Improvement 60-70% Spine Surgery Today Fusion Rate 90+% Clinical Improvement 60-70%

11 Surgery for Lumbar JBJS patients Fusions did much better 36% pseudoarthrosis

12 Surgery for Lumbar Spine 2000 Clinical outcome superior at 1 and 2 year

13 Surgery for Lumbar Spine patients Fused patients had better clinical outcomes 86% vs 56%

14 Fusion Surgery for Lumbar Degenerative Lumbar Spondylolisthesis With Spinal Stenosis: A Prospective, Randomized Study Comparing Decompressive Laminectomy and Arthrodesis With and Without Spinal Instrumentation Spine 1997 Fischgrund JS, et. al. 68 patients fusion without and with instrumentation Clinical outcome: 85% vs 76% Fusion rate: 45% vs 82%

15 Fusion Surgery for Lumbar The Effect of Pedicle Screw Instrumentation on Functional Outcome and Fusion Rates in Posterolateral Lumbar Spinal Fusion: A Prospective, Randomized Clinical Study Spine 1997 Thomsen K, et. al. Significantly better clinical outcomes with instrumentation BUT increased surgery time, reoperation rate, nerve injury, and blood loss did not justify instrumentation

16 Fusion Surgery for Lumbar The Cochrane Review 2005 Surgery for lumbar spondylosis Any improvement with fusion in clinical outcomes is probably marginal Moderate evidence that instrumentation can increase the fusion rate* Bridwell 1993 and Zdeblic 1996 studies suspiciously good results No difference in outcomes for anterior, posterior, and combined surgeries with respect to clinical outcomes Significant costs and complications

17 Fusion Surgery for Lumbar

18 Fusion Surgery for Lumbar

19 Fusion Surgery for Lumbar

20 Why fuse?

21 2014 NASS Guidelines for Lumbar

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26 Posterolateral Fusion for Lumbar Evidence supports posterolateral instrumented fusion to increase fusion rate Evidence does not support better clinical outcomes with instrumentation Evidence does not support anything beyond posterolateral fusion with instrumentation Evidence supports increased costs and complications with additional surgery SO WHY DO MORE?!.. $$$$$$$.. ;)

27 Thank You!