Minimally Invasive Surgery Versus Open Surgery Spinal Fusion for Spondylolisthesis

A Systematic Review and Meta-analysis

Victor M. Lu, MD; Panagiotis Kerezoudis, MD; Hannah E. Gilder, BS; Brandon A. McCutcheon, MD, MPP; Kevin Phan, BS; Mohamad Bydon, MD


Spine. 2017;42(3):E177-E185. 

In This Article

Abstract and Introduction


Study Design. Systematic review and meta-analysis.

Objective. Compare minimally invasive surgery (MIS) and open surgery (OS) spinal fusion outcomes for the treatment of spondylolisthesis.

Summary of Background Data. OS spinal fusion is an interventional option for patients with spinal disease who have failed conservative therapy. During the past decade, MIS approaches have increasingly been used, with potential benefits of reduced surgical trauma, postoperative pain, and length of hospital stay. However, current literature consists of single-center, low-quality studies with no review of approaches specific to spondylolisthesis only.

Methods. This first systematic review of the literature regarding MIS and OS spinal fusion for spondylolisthesis treatment was performed using the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines for article identification, screening, eligibility, and inclusion. Electronic literature search of Medline/PubMed, Cochrane, EMBASE, and Scopus databases yielded 2489 articles. These articles were screened against established criteria for inclusion into this study.

Results. A total of five retrospective and five prospective articles with a total of 602 patients were found. Reported spondylolisthesis grades were I and II only. Overall, MIS was associated with less intraoperative blood loss (mean difference [MD], −331.04 mL; 95% confidence interval [CI], −490.48 to −171.59; P < 0.0001) and shorter length of hospital stay (MD, −1.74 days; 95% CI, −3.04 to −0.45; P = 0.008). There was no significant difference overall between MIS and OS in terms of functional or pain outcomes. Subgroup analysis of prospective studies revealed MIS had greater operative time (MD, 19.00 minutes; 95% CI, 0.90 to 37.10; P = 0.04) and lower final functional scores (weighted MD, −1.84; 95% CI, −3.61 to −0.07; P = 0.04) compared with OS.

Conclusion. Current data suggests spinal fusion by MIS is a safe and effective approach to treat grade I and grade II spondylolisthesis. Moreover, although prospective trials associate MIS with better functional outcomes, longer-term and randomized trials are warranted to validate any association found in this study.


Spondylolisthesis is the displacement of a vertebral body that can present as mechanical low back pain, radiculopathy, or neurogenic claudication. Etiologies include spondylolysis (isthmic spondylolisthesis) and degeneration (degenerative spondylolisthesis). For patients with spondylolisthesis refractory to conservative therapy, surgical intervention represent an alternative option with studies[1–4] demonstrating the potential benefit of surgery in improving quality of life.

Traditionally, surgical approaches for degenerative and isthmic spondylolisthesis involve open surgery (OS) with direct decompression and instrumented fusion to address the instability associated with vertebral slip. Fusion techniques vary and include transforaminal lumbar interbody fusion (TLIF), posterior lumbar interbody fusion (PLIF), lateral interbody fusion, anterior lumbar interbody fusion, and posterior lumbar fusion (PLF).

Within the last decade, minimally invasive surgery (MIS) techniques have emerged. MIS proponents emphasize the benefits of minimizing postoperative pain and function, shortening recovery, reducing blood loss, minimizing soft tissue damage, and maintaining paraspinal structural integrity while minimizing scar tissue.[5] These benefits are particularly relevant for spondylolisthesis, where an open approach may further destabilize support structures such as the facet joints, ligamentous structures, and musculature.

Many studies have focused on comparing perioperative, functional, and pain outcomes between MIS and OS in treating general lumbar degenerative diseases (including spondylolisthesis, disc disease, and spinal stenosis). Systematic evidence has investigated MIS versus OS in this group of conditions for spinal fusion,[6–9] laminectomy,[10,11] discectomy,[12] and pedicle screw fixation.[13] However, to the best of our knowledge, no review of spondylolisthesis has analyzed perioperative, functional, and pain outcomes between MIS and OS. Thus, the aim of this study was to compare outcomes of spondylolisthesis treated either by MIS or by OS and contextualize the results with respect to general lumbar degenerative diseases.