The authors analyze national trends in surgical treatment for lumbar degenerative spondylolisthesis (DS) with stenosis from 2010 to 2021 using a national insurance database [1]. They report a significant shift toward decompression with fusion as the dominant surgical approach by 2016, despite randomized trials showing no clear superiority over decompression alone [2,3]. Factors such as younger age, fewer comorbidities, obesity, surgeon training, and regional practices appear to drive this preference. Notably, fusion was associated with slightly lower 30-day complication rates and reduced revision surgeries compared to decompression alone, though the clinical significance of these findings is debatable [4]. The study’s retrospective design and reliance on coding data limit detailed insights into radiographic parameters, functional outcomes, and reasons for revision surgeries. Nevertheless, it provides a valuable snapshot of real-world practice patterns, raising important questions about regional differences in surgical trends. For example, comparing these findings from the United States with practices in Asia or Europe, where cultural, economic, and healthcare system differences play a role, could inform the development of globally applicable treatment guidelines and improve patient outcomes.
The decision to perform fusion in cases of DS largely depends on whether the segment has been restabilized. Additionally, factors such as the patient’s age, overall condition, sagittal and coronal balance, and the presence of osteoporosis play crucial roles in determining the appropriate surgical technique. In cases of instability, decompression alone could worsen segmental instability after removing posterior elements, making fusion a more favorable option. With the recent advancements in various endoscopic surgical techniques, promising outcomes from decompression procedures have been reported even in cases of foraminal stenosis. However, achieving adequate decompression often necessitates the removal of significant structural elements, raising the question of whether stability can be maintained postforaminal decompression in DS. This aspect warrants detailed discussion to optimize surgical outcomes.
In summary, this study provides a comprehensive analysis of evolving surgical trends for lumbar DS in the United States, highlighting the predominance of decompression with fusion despite ongoing debates about its superiority over decompression alone. The findings emphasize the importance of tailoring surgical approaches to individual patient factors, such as age, comorbidities, and anatomical stability, while also addressing the broader implications of surgical decision-making, including revision rates and complication profiles. The authors emphasize the need for balanced discussions within the spine community to refine treatment strategies, integrate emerging techniques like endoscopic decompression, and account for long-term considerations such as adjacent segment degeneration [5,6]. This study is a significant contribution to the ongoing discourse on optimizing care for this complex and prevalent spinal condition.
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