Abstract
Recent published RCTs have created uncertainty around the appropriate utilization of lumbar fusion when performing a laminectomy for symptomatic lumbar degenerative spondylolisthesis. SLIP II is an RCT that aims to determine if spinal expert review might help to optimize patient experience and outcome for patients with degenerative lumbar spondylolisthesis.
To determine if use of a surgical expert review panel might improve surgical outcome for patients with symptomatic degenerative lumbar spondylolisthesis.
Multicenter prospective RCT at 14 sites.
A total of 273 patients with Grade I degenerative lumbar spondylolisthesis enrolled in an RCT (SLIP II) and with 1-year follow-up.
EuroQol 5-D Owestery Disability Index NASS patient satisfaction index
We performed a multicenter prospective RCT at 14 sites. Patients (ages 18-85) with symptomatic lumbar stenosis with degenerative spondylolisthesis were enrolled. Patients were randomized to either receive an expert panel review of their case or not. Spinal expert review consisted of 10-15 surgeons' review of patient imagines and history regarding appropriateness of fusion that was shared with both treating surgeon and patient. Patients had surgical treatment at the discretion of the treating surgeon. Analysis focused upon whether outcomes differed when surgery aligned with the majority of the panel experts or not. Analysis also focused on whether super majority consensus on treatment was associated with superior outcomes or not. Outcome assessments (EQ-5D and ODI) were assessed preoperatively, 3 months, 6 months, and 1 year. NASS patient satisfaction was also assessed at 1 year.
Fourteen sites randomized 575 patients. Analysis was performed on 273 patients who had one-year follow-up available. Of these, 146 underwent review and 127 no review. Mean age was 66 years (57% female). Baseline characteristics were comparable. Fusion was performed on 210 (77%) of patients. For patients randomized to an expert review – fusion was recommended in 112/146 (77%) cases. Fusion was associated with significantly improved outcomes regardless of panel recommendation. ODI and EQ-5D outcomes for patients treated with decompression alone versus decompression and fusion were not different at one-year; ODI (20-point change vs 22-point change, respectively [p=0.594]) and EQ-5D (0.25 change vs 0.23 change, respectively [p=0.799]). A super majority (>80% consensus among experts) recommended fusion 54% of the time and decompression alone 15% of the time. Super majority recommendation for fusion aligned with actual surgery performed in 92% of cases. NASS patient satisfaction was graded at 1 (treatment met my expectations) in 83% of patients who had super majority review favoring fusion as compared to 65% of other cases (P=0.12). Supermajority recommendation for fusion was associated with 24.7-point ODI change vs 17.3-point ODI change (p= 0.024) and 0.28 change in Eq5D vs 0.19 change in Eq5D (p=0.026).
Expert panel review does not reduce the number of fusion operations performed but is associated with a trend toward improved patient satisfaction at one year after surgery. Super majority vote for fusion was associated with superior patient reported outcomes.
This abstract does not discuss or include any applicable devices or drugs.