A stratified analysis of multilevel direct decompression of degenerative lumbar central stenosis: Is fusion needed in the elderly?

Background: Surgical decompression of degenerative lumbar central stenosis, in older patients, has been shown to provide improved outcomes compared to conservative treatment. However, in elderly patients lacking instability, there still lacks a consensus on whether fusion is needed following decompression and whether the argument extends to cases involving multiple levels. Methods: Patients ≥ 65 years of age undergoing 2-4 multilevel laminectomies were included in the study. Intervertebral displacement was measured as the sagittal translation of each vertebral segment from L1 to S1 from flexion-extension films. Analyses of surgical and clinical outcomes were performed between decompression alone (MD) and decompression with fusion (MDF) groups through independent sample t-tests and Chi-square analyses. Propensity-score analysis was conducted to match patients from each group based on the number of levels decompressed and intervertebral stability. Results: After groups were propensity-matched based on the number of levels of decompressed and baseline intervertebral displacement (L1-S1), differences were no longer found in baseline characteristics between groups. Estimated blood loss, operative time, and length of stay were all significantly lower in the MD group (all P < 0.001), with a lower rate of postoperative complications (7.7% vs. 30.8%, P = 0.075). At 1 year, MD and MDF groups experienced equivalent clinical outcomes, including radiculopathy, revision, and patient-reported measures. Conclusion: Our data suggest that in elderly patients with similar baseline traits, multilevel decompression without fusion can provide improved perioperative outcomes with noninferior results at 1 year compared to with fusion.