Abstract
The appropriate utilization of lumbar fusion when performing laminectomy for lumbar spondylolisthesis is uncertain. The objective was to determine whether the use of a surgical expert review panel recommending fusion might improve patient selection, possibly reducing surgical failures.
Randomized clinical trial of patients with symptomatic degenerative lumbar stenosis with spondylolisthesis enrolled from 14 North American hospitals was conducted with patients randomized to receive an expert panel review of their case or not. Spinal expert review consisted of 10 to 15 surgeons' review of patient images and clinical data with voting on the appropriateness of fusion. Primary outcome was the percentage of patients who failed to improve their 1-year EuroQol-5 Dimension (EQ-5D) score. Secondary analysis focused on whether a supermajority (>80% consensus) of spinal experts recommending fusion might reduce operative failures. The trial (SLIP II) was registered at ClinicalTrials.gov (NCT03570801).
Between November 1, 2017, and June 30, 2022, 663 patients were randomized (mean age 65.6 years; [59.6%] female) and 523 of 574 patients (91%; who had surgery) were included in the 1-year analysis. Final follow-up was on March 5, 2024. Among the 523 patients, 270 underwent review and 253 had no review. The overall surgical failure rate (using EQ-5D) did not differ between the review groups, 16.7% vs 17.4% (no review: difference 0.7%; 95% CI, -8% to 6%; P = .92). However, with supermajority recommending fusion, the proportion of patients who failed to improve EQ-5D score after surgery was 8.4% (review group) vs 18.4% (nonreview group: difference 10%; 95% CI, 2%-18%; P = .03). Supermajority recommendation for fusion was associated with 0.296 vs 0.240 EQ-5D change in the nonreview group (difference 0.056, 95% CI, 0.002-0.108; P = .04).
Among patients with grade I degenerative lumbar spondylolisthesis, an expert panel review with a supermajority favoring fusion was associated with a greater improvement in health-related quality of life and fewer surgical failures.