BACKGROUND

Degenerative lumbar spondylolisthesis is one of the most common pathologies addressed by surgeons. Recently, data demonstrated improved outcomes with fusion in conjunction with laminectomy compared to laminectomy alone. However, given not all degenerative spondylolistheses are clinically comparable, the best treatment option may depend on multiple parameters. Specifically, the impact of spinopelvic alignment on patient reported and clinical outcomes following fusion versus decompression for grade I spondylolisthesis has yet to be explored.

PURPOSE

This study assessed two-year clinical outcomes and one-year patient reported outcomes following laminectomy with concomitant fusion versus laminectomy alone for management of grade I degenerative spondylolisthesis and stenosis. The present study is the first to examine the effect of spinopelvic alignment on patient-reported and clinical outcomes following decompression alone versus decompression with fusion.

STUDY DESIGN/SETTING

Retrospective sub-group analysis of observational, prospectively collected cohort study.

PATIENT SAMPLE

679 patients treated with laminectomy with fusion or laminectomy alone for grade I degenerative spondylolisthesis and comorbid spinal stenosis performed by orthopaedic and neurosurgeons at three medical centers affiliated with a single, tertiary care center.

OUTCOME MEASURES

The primary outcome was the change in Patient-Reported Outcome Measurement Information System (PROMIS), Global Physical Health (GPH), and Global Mental Health (GMH) scores at baseline and post-operatively at 4-6 and 10-12 months postoperatively. Secondary outcomes included operative parameters (estimated blood loss and operative time), and two-year clinical outcomes including reoperations, duration of postoperative physical therapy, and discharge disposition.

METHODS

Radiographs/MRIs assessed stenosis, spondylolisthesis, pelvic incidence, lumbar lordosis, sacral slope, and pelvic tilt; from this data, two cohorts were created based on pelvic incidence minus lumbar lordosis (PILL), denoted as “high” and “low” mismatch. Patients underwent either decompression or decompression with fusion; propensity score matching (PSM) and coarsened exact matching (CEM) were used to create matched cohorts of “cases” (fusion) and “controls” (decompression). Binary comparisons used McNemar test; continuous outcomes used Wilcoxon rank-sum test. Between-group comparisons of changes in PROMIS GPH and GMH scores were analyzed using mixed-effects models; analyses were conducted separately for patients with high and low pelvic incidence-lumbar lordosis (PILL) mismatch.

RESULTS

49.9% of patients (339) underwent lumbar decompression with fusion, while 50.1% (340) received decompression. In the high PLL mismatch cohort at 10-12 months postoperatively, fusion-treated patients reported improved PROs, including GMH (26.61 vs. 20.75, p<0.0001) and GPH (23.61 vs. 18.13, p<0.0001). They also required fewer months of outpatient physical therapy (1.61 vs. 3.65, p<0.0001) and had lower 2-year reoperation rates (12.63% vs. 17.89%, p=0.0442) compared to decompression-only patients. In contrast, in the low PLL mismatch cohort, fusion-treated patients demonstrated worse endpoint PROs (GMH: 18.67 vs. 21.52, p<0.0001; GPH: 16.08 vs. 20.74, p<0.0001). They were also more likely to require skilled nursing/rehabilitation centers (6.86% vs. 0.98%, p=0.0412) and extended outpatient physical therapy (2.47 vs. 1.34 months, p<0.0001) and had higher 2-year reoperation rates (25.49% vs. 14.71%,p=0.0152).

CONCLUSIONS

Lumbar laminectomy with fusion was superior to laminectomy in health–related quality of life and reoperation rate at two years postoperatively only for patients with sagittal malalignment, represented by high PILL mismatch. In contrast, the addition of fusion for patients with low-grade spondylolisthesis, spinal stenosis, and spinopelvic harmony (low PILL mismatch) resulted in worse quality of life outcomes and reoperation rates.

中文翻译：

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是否应根据脊柱骨盆排列对腰椎管狭窄症和 I 级腰椎滑脱患者进行区别对待？一项回顾性的、为期两年的、倾向匹配的、比较单个卫生系统内多个地点的患者报告的结果测量和临床结果

背景

退行性腰椎滑脱是外科医生最常见的病症之一。最近，数据表明与单独的椎板切除术相比，融合联合椎板切除术的结果有所改善。然而，鉴于并非所有退行性脊椎滑脱在临床上都具有可比性，最佳治疗选择可能取决于多个参数。具体而言，对于 I 级脊椎滑脱患者，脊柱骨盆对线对融合与减压后患者报告和临床结果的影响尚待探索。

目的

这项研究评估了两年的临床结果和一年的患者报告的结果，这些结果是椎板切除术伴随融合与单独椎板切除术治疗 I 级退行性脊椎滑脱和狭窄后的结果。本研究首次检查了脊柱骨盆对齐对单独减压与融合减压后患者报告和临床结果的影响。

研究设计/设置

观察性、前瞻性收集的队列研究的回顾性亚组分析。

患者样本

679 名患者在附属于一个三级医疗中心的三个医疗中心由骨科和神经外科医生对 679 名患者进行椎板切除融合术或单纯椎板切除术治疗 I 级退行性脊椎滑脱和并发椎管狭窄。

结果测量

主要结果是患者报告的结果测量信息系统 ( PROMIS )、全球身体健康 (GPH) 和全球心理健康 (GMH) 评分在基线和术后 4-6 个月和术后 10-12 个月的变化。次要结果包括手术参数（估计失血量和手术时间）和两年临床结果，包括再次手术、术后物理治疗持续时间和出院处置。

方法

X 光片/MRI 评估狭窄、脊椎滑脱、骨盆发生率、腰椎前凸、骶骨倾斜和骨盆倾斜；根据该数据，根据骨盆发病率减去腰椎前凸 (PILL) 创建了两个队列，表示为“高”和“低”不匹配。患者接受减压或融合减压；倾向得分匹配(PSM) 和粗化精确匹配 (CEM) 用于创建“病例”（融合）和“对照”（减压）的匹配队列。二进制比较使用 McNemar 检验；连续结果使用 Wilcoxon 秩和检验。使用混合效应模型分析 PROMIS GPH 和 GMH 分数变化的组间比较；分别对高低骨盆发生率-腰椎前凸 (PILL) 不匹配的患者进行了分析。

结果

49.9% 的患者 (339) 接受了腰椎减压融合术，而 50.1% (340) 接受了减压。在术后 10-12 个月的高 PLL 不匹配队列中，接受融合治疗的患者报告了改善的 PRO，包括 GMH（26.61 对 20.75，p<0.0001）和 GPH（23.61 对 18.13，p<0.0001）。与仅接受减压的患者相比，他们还需要更少的门诊物理治疗月数（1.61 对 3.65，p<0.0001）并且 2 年再手术率更低（12.63% 对 17.89%，p=0.0442）。相反，在低 PLL 不匹配队列中，接受融合治疗的患者表现出更差的终点 PRO（GMH：18.67 与 21.52，p<0.0001；GPH：16.08 与 20.74，p<0.0001）。他们也更有可能需要熟练的护理/康复中心（6.86% 对 0.98%，p=0.0412）和延长门诊物理治疗（2.47 对 1.34 个月，p<0.

结论

腰椎椎板切除融合术在与健康相关的生活质量和术后两年的再手术率方面优于椎板切除术，仅适用于矢状面排列不齐的患者，以高 PILL 不匹配为代表。相比之下，对轻度脊椎滑脱、椎管狭窄和脊柱骨盆和谐（低 PILL 不匹配）患者进行融合会导致更差的生活质量结果和再手术率。