What to consider in degenerative spondylolisthesis: posterolateral fusion or transforaminal interbody fusion

© AME Medical Journal. All rights reserved. AME Med J 2017;2:142 amj.amegroups.com Degenerative spondylolisthesis (DS) usually happens at lower lumbar levels (more commonly at L4–5) with the degree of slip is Meyerding classification type 1 or 2. Rarely DS has Meyerding type 3 or more slip. DS is usually a combination of facet hypertrophy and thickening of ligamentum flavum that leads to spinal stenosis. Therefore, majority of DS patients usually presents to a surgeon with symptoms of spinal stenosis. In that sense, the treatment for DS is hotly debated in literature. Different articles clearly mention superiority of decompression and fixation (DF) over decompression alone (D) in such cases (1). Decompression alone can improve clinical symptoms of patients with DS; however, symptoms can recur in few years requiring another surgery. Therefore, according to the current consensus, DF is often indicated while treating DS with lumbar stenosis (2-4). When it comes to the DF and what is to be done is still unclear. There are two main ways for DF: pedicle screw fixation and posterolateral fusion (PLF) and pedicle screw fixation and posterior/transforaminal lumbar interbody fusion (PLIF/TLIF). Literatures do not prove superiority of PLF over TLIF or vice a versa in cases of DS. In an article by Kepler et al. reported a significant decrease in the number of patients undergoing isolated decompression in patients with DS between 1999 and 2011, and an increase in the number of patients undergoing decompression with an interbody fusion (5). Reviewing the published articles, one thing is understood that there are very few highlevel prospective randomized studies demonstrating better results with TLIF when compared with PLF in patients of DS. They give the credit of improved results to a solid bone fusion associated with TLIF, which is often used as an oversimplified rationale to support the increased cost and complications in relation with TLIF (6). In a recent study published by Schroeder et al, worldwide survey opinion was taken for cases of single level DS in a questionnaire from 223 surgeons. The survey included orthopedic and neurosurgeons both from US and non-US countries. Spine surgeons believe that the treatment for DS depends upon various factors when deciding decompression alone versus decompression and instrumentations such as demographics, pathology, associated instability, presence of low back pain and patients’ age etc. They also have pointed out socioeconomic impact as TLIF drastically increases the cost of surgery when compared with PLF. Thus, the general consensus is to tailor the treatment according to patient (7). If we compare the neurological complications between PLF versus TLIF, it has been noted higher neurological complications in TLIF group in form of CSF leak, nerve damage or root sleeve injuries. Additionally, TLIF has increased overall cost of the surgery as well when compared with PLF (8,9). On the other hand, a recent meta-analysis published by McAnany et al. showed no significant difference in developing postoperative complications Editorial