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.