This RCT (n=247) tested whether adding fusion to decompression improves outcomes in lumbar spinal stenosis, with or without degenerative spondylolisthesis. Patients aged 50-80 with stenosis at one or two levels were randomized 1:1 to decompression plus fusion vs decompression alone. The primary outcome was Oswestry Disability Index score at 2 years.
For decades, degenerative spondylolisthesis was treated as a near-mandatory indication for fusion — 96% of such patients in the US received it. The reasoning was intuitive: if a vertebra is slipping, stabilize it. This trial, published alongside a companion RCT by Ghogawala et al. in the same NEJM issue, delivered the first high-quality randomized evidence to challenge that assumption.
When you see a patient with neurogenic claudication and spondylolisthesis on imaging, decompression alone is a defensible first operation. This paper is why routine add-on fusion for stenosis with spondylolisthesis is no longer evidence-based practice.
The equivalent reoperation rates (22% vs 21%) are particularly important: fusion did not reduce the likelihood of returning to the OR, undermining the prophylactic rationale for the added procedure.
The one clinical nuance worth knowing: the companion Ghogawala trial showed a modest SF-36 physical component advantage for fusion in spondylolisthesis patients, but that trial had a much higher reoperation rate in the decompression-alone arm (34% vs 14%), which the Försth authors argue confounded those results.
This RCT (n=247) tested whether adding fusion to decompression improves outcomes in lumbar spinal stenosis, with or without degenerative spondylolisthesis. Patients aged 50-80 with stenosis at one or two levels were randomized 1:1 to decompression plus fusion vs decompression alone. The primary outcome was Oswestry Disability Index score at 2 years.
For decades, degenerative spondylolisthesis was treated as a near-mandatory indication for fusion — 96% of such patients in the US received it. The reasoning was intuitive: if a vertebra is slipping, stabilize it. This trial, published alongside a companion RCT by Ghogawala et al. in the same NEJM issue, delivered the first high-quality randomized evidence to challenge that assumption.
When you see a patient with neurogenic claudication and spondylolisthesis on imaging, decompression alone is a defensible first operation. This paper is why routine add-on fusion for stenosis with spondylolisthesis is no longer evidence-based practice.
The equivalent reoperation rates (22% vs 21%) are particularly important: fusion did not reduce the likelihood of returning to the OR, undermining the prophylactic rationale for the added procedure.
The one clinical nuance worth knowing: the companion Ghogawala trial showed a modest SF-36 physical component advantage for fusion in spondylolisthesis patients, but that trial had a much higher reoperation rate in the decompression-alone arm (34% vs 14%), which the Försth authors argue confounded those results.