An orthopedic surgeon performs spinal decompression surgery on a patient with degenerative lumbar spondylolisthesis. The surgical setting shows advanced medical equipment with precision instruments. The patient's spine is shown during surgery, with vertebrae highlighted, showing pressure relief on spinal nerves. Surgical team in focus, intense yet calm atmosphere.
Degenerative lumbar spondylolisthesis, a condition where one vertebra slips over another, is often treated through either spinal decompression or fusion surgery. The Nordsten-DS trial, a five-year follow-up study, compared these two approaches. Researchers aimed to determine if decompression alone could yield similar outcomes to the more invasive fusion surgery.
“The results of this trial are critical,” said Dr. Christian Hellum. “We need evidence-based guidance for surgical decisions that don’t overburden patients.”
Decompression involves relieving pressure on the spinal nerves by removing bone or tissue, while fusion involves permanently connecting two or more vertebrae. Traditionally, fusion is believed to offer better long-term stability, but it comes with increased surgical complexity, risk, and recovery time.
The Five-Year Outcome: Surprising Results
The Nordsten-DS trial enrolled patients with symptomatic lumbar spondylolisthesis, who were randomized to either decompression alone or decompression with fusion. After five years, the researchers found that both groups showed significant improvement in pain and functionality. However, there was no major difference in outcomes between the two procedures.
Dr. Jens Ivar Brox, one of the lead researchers, highlighted the key finding: “Decompression alone seems to offer comparable results without the added risks and complications that fusion surgery entails.”
The study’s statistical analysis supported the conclusion that decompression alone was non-inferior to fusion surgery in improving patient outcomes. This finding has the potential to reshape how lumbar spondylolisthesis is treated globally, especially for patients who may not be suited for complex fusion surgery.
Surgery Without Fusion: A Less Invasive Path Forward?
Orthopedic surgery is often invasive, requiring months of recovery. Fusion surgery, while effective, limits mobility and increases the risk of adjacent segment disease, where nearby vertebrae degenerate faster due to the immobilization of fused segments.
Decompression, by comparison, spares the spine’s natural flexibility and may result in a quicker recovery. Dr. Kjersti Storheim stated, “For patients, particularly those who are older or have underlying conditions, avoiding fusion could reduce both the immediate surgical risks and long-term complications.”
The Nordsten-DS study involved over 400 patients and carefully measured outcomes through patient-reported measures of pain, physical function, and overall satisfaction. Both treatment groups showed substantial improvements in all these measures, but the decompression group had a slightly lower complication rate.
Implications for Future Practice
The implications of this study could be far-reaching for clinical practice. As fusion surgeries are often more expensive and carry greater risks, the option of decompression alone offers a compelling alternative.
Dr. Ivar Magne Austevoll, the corresponding author, commented: “For many patients, especially those with mild to moderate spondylolisthesis, fusion may not be necessary. We’re seeing a clear shift toward more conservative approaches, which prioritize patient safety and cost-effectiveness.”
The Nordsten-DS trial may set a new standard for how spinal surgery is approached. Moving forward, clinicians could consider decompression as the first-line surgical treatment for specific cases of degenerative lumbar spondylolisthesis, potentially sparing many patients from the invasiveness of fusion surgery. However, more research is needed to understand the long-term durability of decompression in more severe cases.
Citation:
Kgomotso EL, Hellum C, Fagerland MW, et al. Decompression alone or with fusion for degenerative lumbar spondylolisthesis (Nordsten-DS): five year follow-up of a randomised, multicentre, non-inferiority trial. BMJ. 2024;386.
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