Introduction
Degenerative lumbar spondylolisthesis (DLS) is one of the most common lumbar disorders, which may require surgical care in case of severe symptoms and/or neurologic deficits. While open decompression and fusion have traditionally been the mainstay of treatment, the use of minimally invasive surgery (MIS) is being increasingly adopted in the field, with promising results. This study examines the global trends in the adoption of open surgery versus MIS for the management of single-level L4-L5 DLS.
Methods
An online cross-sectional survey conducted by the AO Spine Knowledge Forums Degenerative targeted AOSpine members from July to September 2023. Respondents were presented with three clinical scenarios of grade 1 L4-L5 DLS, characterized by varying levels of stenosis and instability. Briefly, case 1 was an elderly man with central stenosis without instability, case 2 was a young female with bilateral foraminal stenosis and instability, and case 3 was a middle-aged female with unilateral foraminal stenosis and mild instability. The survey collected data on surgeon demographics and preferences for open or MIS techniques for each case. Statistical analyses, including Chi-squared tests and logistic regression, were used to evaluate the relationships between surgical preferences and surgeon characteristics.
Results
A total of 943 surgeons participated, with 479 completing the survey. Open surgery was the predominant choice across all three scenarios (58.8%, 57.3%, and 42.4%, respectively), especially in cases involving central and bilateral foraminal stenosis. MIS was the second most common preference, favored in cases with unilateral foraminal stenosis and mild instability (38.8%). Overall, 38.7% and 24.0% utilized open and MIS approaches in all three cases, respectively, whereas the remaining surgeons chose different techniques based on the single case. In case 1, the use of MIS was significantly less common among surgeons aged between 55 and 64 years (OR: 0.33, 95% CI: 0.22-0.94, p=0.041) and in practice for 11-15 years (OR: 0.41, 95% CI: 0.18-0.94, p=0.038). MIS was also notably more popular among neurosurgeons (OR: 1.73, 95% CI: 1.12-2.70, p=0.014). In case 2, surgeons aged between 55-64 years were less likely to perform MIS (OR: 0.30, 95% CI: 0.10-0.87, p=0.030), which was more commonly preferred by neurosurgeons (OR: 2.59, 95% CI: 1.66-4.09, p<0.0001) and less utilized among participants who did not complete a fellowship (OR: 0.50, 95% CI: 0.28-0.89, p=0.012). In case 3, only surgeons aged between 55 and 64 years were less likely to utilize MIS (OR: 0.34, 95% CI: 0.12-0.92, p=0.038).
Discussion
Open surgery remains the preferred treatment for DLS, particularly in complex cases, despite growing acceptance of MIS techniques. Regional and demographic variations in surgical preferences underscore the need for tailored clinical guidelines and standardized training programs to enhance patient outcomes. Future studies should investigate the long-term effectiveness of these approaches and the role of emerging technologies in shaping surgical decision-making.