Debate explores open vs MIS treatment for lytic spondylolisthesis and stenosis

Treatments for patients with lytic spondylolisthesis, stenosis and the general health outcomes were the focus of two surgeons’ presentations.

The treatment options for a patient with lytic spondylolisthesis and stenosis are many, and the benefits of minimally invasive treatments and open decompression can vary depending on the surgeon.

At a meeting, David A. Wong, MD, MSc, FRCS(C), and P. Justin Tortolani, MD, presented their opinions on the best treatment for lytic spondylolisthesis and stenosis in a debate focused on general health outcomes from the treatments, cost efficiency, ease of treatment and a number of other factors involved in the procedures.

Two treatments, two opinions

Wong, who is a Spine Surgery Today Editorial Board member, discussed some of the positives of minimally invasive surgery for decompression and fusion for these two spine conditions. An interbody procedure, he said, generally results in better fusion rates and angulation postoperatively.

“For lytic spondylolisthesis, minimally invasive surgery is a great option, absolutely. Keep an eye on the sagittal alignment, analyze the stenosis, and be careful with the bone morphogenetic protein during the procedure,” he said.

David A. Wong

However, Tortolani said open decompression and fusion remains “the gold standard” for lytic spondylolisthesis and stenosis. It results in essentially the same health outcomes as its minimally invasive counterpart, but is a cheaper and easier procedure to complete.

“The best methods support simplicity over complexity,” he said.

Tortolani explained minimally invasive techniques must show superiority in order to justify the complications sometime associated with the learning curve and the worse neurologic outcomes. But there are three technical advantages to open procedures, which he said are better visibility, more versatility and the fact it is easier to teach and learn the open surgery, which is the gold standard.

Minimally invasive is best

Wong cited a retrospective study by Yung Park, MD, and colleagues in which 66 patients with spondylolisthesis and degenerative segmental instability underwent minimally invasive transforaminal lumbar interbody fusion (TLIF). In that study, there were 23 cases of low-grade spondylolytic spondylolisthesis, 24 cases of degenerative spondylolisthesis and 19 cases of degenerative segmental instability.

The results of the study demonstrated the fusion rates and clinical outcomes were similar in all three patient subgroups he said. Additionally, VAS and Oswestry Disability Index (ODI) outcome scores were similar in the three subgroups.

“With a laminectomy there was a trend to poor clinical outcomes,” he said. This highlighted the fact that in many cases an indirect decompression, which is often via a minimally invasive approach, is adequate.

Results of the Park study support minimally invasive surgery (MIS) for the treatment of lytic spondylolisthesis and stenosis, Wong said,

Open treatment better

While the results of MIS in these cases may be favorable, according to Tortolani, open decompression and fusion remain the best techniques to use for cases of lytic spondylolisthesis and stenosis.

The goal of every surgery is the same and a straightforward technique is a sensible one, Tortolani said. He said all aspects of the two procedures need to be taken into account for a fair comparison. Beyond general health outcomes, it is essential to evaluate lifetime incremental cost utility, ease of the procedure and the patient’s potential complications.

However Tortolani said that because it is less safe and a much more complex procedure, TLIF should not be used at all for lytic spondylolisthesis. For degenerative, non-lytic spondylolisthesis, he discussed the prospective, level-2 studies in the literature, none of which used randomization in which operating room time was better in the open cases, estimated blood loss was better in the MIS groups, and there was a 2 day to 3 day difference in length of stay. Despite a few outliers, the fusion rates are basically identical, he said.

A learning curve with MIS

In what he called the “best” study done in this area, investigators comparing preoperative VAS, ODI and other findings to those at 6 months to 2 years found no differences in the MIS and open results.

The learning curve for minimally invasive interbody surgery is steep, Tortolani said. On average, it takes about 44 procedures for a surgeon to be proficient with the technique, and the MIS uses pedicle screws. That tends to make it more expensive than an open procedure, Tortolani said.

Patients are concerned about radiation exposure and the MIS procedure, in these cases, exposes a patient to three to 10 times more radiation than an open procedure, according to Tortolani – by Robert Linnehan

References:

Park Y. Asian Spine J. 2011;doi:10.4184/asj.2011.5.4.228.
Tortolani PJ. Presentation #16.
Wong DA. Presentation #15. Both presented at: Federation of Spine Associations Specialty Day Meeting; March 15, 2014; New Orleans.

For more information:

P. Justin Tortolani, MD, can be reached at Medstar Union Memorial Hospital, 3333 N. Calvert St., Suite 400, Baltimore, MD 21204; email: justintortolani@gmail.com.
David A. Wong, MD, MSc, FRCS(C) can be reached at the Denver Spine Surgeons, 7800 E. Orchard Rd., Greenwood Village, CO 80111; email: ddaw@denverspine.com.

Disclosures: Tortolani receives royalties from Globus Medical. He is a paid speaker, paid consultant, and receives research support from Globus Medical. He is a paid consultant for Integra. Wong is a speaker for Anulex and a paid consultant for Allosource, Anulex, and United Healthcare. He holds stock in Denver Integrated Imaging North, Huron Shores Investments LLC and Neurotech/CervIOM. He completes research support for Anulex. He receives royalties from Wolters Kluwer Health – Lippincott Williams and Wilkins. He sits on a boards for Journal of Bone and Joint Surgery, Neurosurgery, Orthopedics Today, Spine Surgery Today, Spine, and the Spine Journal. He is a board member for the International Society for the Study of the Lumbar Spine and the North American Spine Society.