Management for degenerative lumbar spondylolisthesis: a network meta-analysis and systematic review basing on randomized controlled trials

Abstract

Background: Consensus on the various interventions for degenerative lumbar spondylolisthesis (DLS) remains unclear.

Materials and methods: The authors searched PubMed, Embase, Cochrane Library, Web of Science, and major scientific websites until 01 November 2023, to screen eligible randomized controlled trials (RCTs) involving the treatment of DLS. The seven most common DLS interventions [nonsurgical (NS), decompression only (DO), decompression plus fusion without internal fixation (DF), decompression plus fusion with internal fixation (DFI), endoscopic decompression plus fusion (EDF), endoscopic decompression (ED), and circumferential fusion (360F)] were compared. The primary (pain and disability) and secondary (complications, reoperation rate, operation time, blood loss, length of hospital stay, and satisfaction) outcomes were analyzed.

Results: Data involving 3273 patients in 16 RCTs comparing the efficacy of different interventions for DLS were reported. In terms of improving patient pain and dysfunction, there was a significant difference between surgical and NS. EDF showed the greatest improvement in short-term and long-term dysfunction (probability, 7.1 and 21.0%). Moreover, EDF had a higher complication rate (probability 70.8%), lower reoperation rate (probability, 20.2%), and caused greater blood loss (probability, 82.5%) than other surgical interventions. Endoscopic surgery had the shortest hospitalization time (EDF: probability, 42.6%; ED: probability, 3.9%). DF and DFI had the highest satisfaction scores.

Conclusions: Despite the high complication rate of EDF, its advantages include improvement in pain, lower reoperation rate, and shorter hospitalization duration. Therefore, EDF may be a good option for patients with DLS as a less invasive surgical approach.

Figure 1

Flowchart of study selection and design.

Figure 2

Network plots of comparison-based network meta-analyses in terms of complication (A), reoperation (B), short-term ODI (C) and hospital stay (D) for DLS. Each circular node represents a type of intervention. The circle size is proportional to the total number of patients. The width of the lines is proportional to the number of studies. performing head-to-head comparisons in the same study.

Figure 3

The SUCRA plots of different interventions to rank probability and ascertain the efficacies in terms of complication (A), reoperation (B), short-term ODI (C) and hospital stay (D) for DLS. The larger the SUCRA value, the larger the value of outcome indicator. SUCRA, surface under the cumulative ranking.

Figure 4

Complication (A), reoperation (A) and SF-36 (B) based network meta-analysis (NMA) in the consistency model. Data are ORs (95% CIs) in the column-defining treatment compared with the row-defining treatment; significant results are in bold. OR, odds ratio; Cis, credible intervals; SF-36, short form-36.

Figure 5

Forest plot for complication (A), reoperation (B), short-term ODI (C) and hospital stay (D) from network meta-analysis of mixed comparisons. Covering OR or WMD values, 95% CIs, 95% Prl. OR, odds ratio; Cis, credible intervals; Prl, prediction intervals; WMD, weighted mean difference.

Figure 6

Funnel plot of complication (A) and reoperation (B) for DLS based network meta-analysis (NMA) in the consistency model.