The surgical management of degenerative lumbar spondylolisthesis: a systematic review.

STUDY DESIGN Systematic review. OBJECTIVE To identify whether there is an advantage to instrumented or noninstrumented spinal fusion over decompression alone for patients with degenerative lumbar spondylolisthesis. SUMMARY OF BACKGROUND DATA The operative management of degenerative spondylolisthesis includes spinal decompression with or without instrumented or noninstrumented spinal fusion. Evidence on the operative management of degenerative spondylolisthesis is still divisive. METHODS Relevant RCT and comparative observational studies between 1966 and June 2005 were identified. Abstracted outcomes included clinical outcome, reoperation rate, and solid fusion status. Analyses were separated into: 1) fusion versus decompression alone and 2) instrumented fusion versus noninstrumented fusion. RESULTS Thirteen studies were included. The studies were generally of low methodologic quality. A satisfactory clinical outcome was significantly more likely with fusion than with decompression alone (relative risk, 1.40; 95% confidence interval, 1.04-1.89; P < 0.05). The use of adjunctive instrumentation significantly increased the probability of attaining solid fusion (relative risk, 1.37; 95% confidence interval, 1.07-1.75; P < 0.05), but no significant improvement in clinical outcome was recorded (relative risk, 1.19; 95% confidence interval, 0.92-1.54). There was a nonsignificant trend toward lower repeat operations with fusion compared with both decompression alone and instrumented fusion. CONCLUSION Spinal fusion may lead to a better clinical outcome than decompression alone. No conclusion about the clinical benefit of instrumenting a spinal fusion could be made. However, there is moderate evidence that the use of instrumentation improves the chance of achieving solid fusion.