Adding Lumbar Fusion to Laminectomy Improves Long-Term Quality of Life

MedicalResearch.com Interview with:

Zoher Ghogawala MD FACS Department of Neurosurgery Lahey Hospital and Medical Center Burlington, MA 01805

Dr. Zoher Ghogawala

Zoher Ghogawala MD FACS
Department of Neurosurgery
Lahey Hospital and Medical Center
Burlington, MA 01805

MedicalResearch.com: What is the background for this study?

Dr. Ghogawala: There is enormous practice variation around the utilization of lumbar spinal fusion in the United States and across the world.  In the United States, lumbar spinal fusion utilization has increased to 465,000 hospital-based procedures in 2011 according to a report from the AHRQ (published in 2014).  Spinal fusion accounts now for the highest aggregate hospital cost (12.8 billion dollars in 2011) of any surgical procedure performed in US hospitals.  What is problematic is that there are no top tier studies that address the question of whether or not adding a lumbar spinal fusion when performing a simple decompression is necessary or helpful.  The question is whether we perform too many fusions in the United States.

The SLIP study is the first class I study that demonstrates that the addition of a lumbar fusion when performing a lumbar laminectomy to decompress spinal nerves improves health-related quality of life for patients suffering from low back pain and sciatica from lumbar stenosis with spondylolisthesis – a very common cause of low back pain caused by nerve compression associated with one spinal bone being slightly out of alignment. 

MedicalResearch.com: What are the main findings?

Dr. Ghogawala:

1)  Adding a lumbar fusion when performing a lumbar laminectomy results in superior health-related quality of life at 2,3, and 4 years after surgery.

2)  Patients with fusion obtained durable results but 14% required re-operation for problems adjacent to their fusion over the 4 year study period.

3)  Lumbar laminectomy alone provided good results for 70% of patients.  There was less blood loss and faster recovery for these patients.  On the other hand, the outcomes were less durable.  One in three patients who underwent a lumbar laminectomy alone required re-operation within 4 years because their back became unstable.  These patients underwent fusion and their health-related quality of life improved.

MedicalResearch.com: What should clinicians and patients take away from your report?

Dr. Ghogawala: The most important concept is that surgeons and patients should use the data provided by the SLIP study to make educated decisions about whether or not to add fusion to laminectomy.  Overall, patients with fusion had superior results in terms of improved health-related quality of life over 4 years.  However, fusion was associated with higher blood loss and longer recovery time.  For those patients who underwent fusion, 14% still required another operation within 4 years.  Lumbar laminectomy was associated with satisfactory outcome in 70% of patients.  The results were not as durable – 34% underwent a subsequent operation to fuse the spine where the laminectomy was performed.  Those patients who underwent a second operation had excellent outcomes.  Different patients with different priorities will make different decisions based on the SLIP study results.  I think that older patients with osteoporosis and other major health conditions should probably be treated more conservatively – a lumbar laminectomy alone might suffice in these patients.  On the other hand, younger healthier patients will more likely choose to have fusion performed in order to enjoy longer-lasting improvements following surgery.

MedicalResearch.com: What recommendations do you have for future research as a result of this study?

Dr. Ghogawala:
1)  Formal Comparative Economic Analysis that includes out-patient health costs, loss of productivity, and costs of re-operations.

It would be tempting, in the spirit of lowering hospital costs, to conclude that fewer fusions should be performed for patients with lumbar stenosis and spondylolisthesis.  This type of policy might actually result greater health costs.  Future research should focus on the comparative economic analysis of the decision to fuse the spine up front when performing a laminectomy for patients with stenosis with spondylolisthesis versus doing a laminectomy alone followed by a second operation to fuse the spine in ~1/3 patients.  Those patients who developed delayed instability pain following a simple laminectomy might actually have higher health costs with loss of productivity, higher physical rehab costs, possible spinal injections costs, etc. before the second operation, with its associated costs and recovery time.

2)  Improved Radiographic Imaging

The SLIP study demonstrates that 70% of patients will do well with a simple laminectomy alone.  Our current radiology assessments do not allow us to predict who needs a fusion and who does not need a fusion.  We need better radiology studies that can assess strain patterns in the bone and measure where back pain is actually coming from.  Today, spinal surgeons understand how to diagnose that treat nerve compression, but we do not understand how best to diagnose and treat mechanical low back pain.

MedicalResearch.com: Is there anything else you would like to add?

Response: I believe that the SLIP study and other high quality RCTs should be used to empower patients and their treating physicians.  All stakeholders need information provided by high quality clinical studies.  Performing unncessary fusions should be limited for a number of reasons.  For example, it is pretty clear from the literature that simple lumbar stenosis without deformity or spondylolisthesis can and should be treated with simple surgical decompression.  On the other hand, patients who have spondylolisthesis with stenosis should be counseled by physicians and surgeons about the relative benefits and risks associated with laminectomy alone versus laminectomy with lumbar fusion.  Patients should have the right to choose along with their doctors among rational options understanding that all surgical choices have different outcomes and risks.

Spinal fusion is often attacked in our society as being costly without clear benefits.  The SLIP study shows that certain patients clearly benefit from fusion when it performed appropriately.  Future research will continue to refine the optimal population suitable for spinal fusion.  This approach will lower costs and improve health-related quality of life for more patients in our society.

MedicalResearch.com: Thank you for your contribution to the MedicalResearch.com community.

Citation:

Laminectomy plus Fusion versus Laminectomy Alone for Lumbar Spondylolisthesis

Zoher Ghogawala, M.D., James Dziura, Ph.D., William E. Butler, M.D., Feng Dai, Ph.D., Norma Terrin, Ph.D., Subu N. Magge, M.D., Jean-Valery C.E. Coumans, M.D., J. Fred Harrington, M.D., Sepideh Amin-Hanjani, M.D., J. Sanford Schwartz, M.D., Volker K.H. Sonntag, M.D., Fred G. Barker, II, M.D., and Edward C. Benzel, M.D.

N Engl J Med 2016; 374:1424-1434
April 14, 2016 DOI: 10.1056/NEJMoa1508788

Note: Content is Not intended as medical advice. Please consult your health care provider regarding your specific medical condition and questions.

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