Use of decompression with fusion for lumbar stenosis increased from 2016 to 2019

Todd J. Albert, MD

Importantly, and not highlighted by the authors, was that both New England Journal of Medicine landmark studies demonstrated noninferiority. Noninferiority can lead to a conclusion that it is equally safe and effective to do a laminectomy and fusion as it is to do a laminectomy alone for this diagnosis. Notably, the authors do not reference the Spine Patient Outcomes Research Trial studies of the early 2000s which demonstrated long-term excellent and cost-effective results of surgical treatment for degenerative spondylolisthesis (most done with fusion) compared to nonoperative treatment. In addition, omitted was reference to studies from Harry N. Herkowitz, MD, and colleagues in the 1990s demonstrating superiority of laminectomy and fusion over laminectomy alone in this same pathological condition. While demographics, insurance status and geographic location were highlighted by the authors, surgeon experience and prior literature suggesting greater patient challenges, lesser outcomes and a significant increase in complications when performing revision of a failed decompression alone for degenerative spondylolisthesis were not. The finding of the noted randomized clinical trials suggesting no specific downside to performing a laminectomy and fusion vs. a laminectomy alone in degenerative spondylolisthesis and the potential protection against failure over the long-term utilizing fusion in degenerative spondylolisthesis offer a possible explanation for the increase in fusion after 2016 and subtleties of the studies in the New England Journal of Medicine that did not change the perspective of surgeons given their knowledge, experience and prior literature.