Evidence-Based Recommendations for Spine Surgery

Alexander R. Vaccaro, MD, PhD, MBA; Charles G. Fisher, MD; Srinivas K. Prasad, MD; Alpesh A. Patel, MD, FACS; John Chi, MD, MPH; Kishore Mulpuri, MBBS, MHSc; Kenneth C. Thomas, MD, MHSc; Peter G. Whang, MD, FACS


Spine. 2020;45(21):E1441-E1448. 

In This Article

Recommendation Regarding Impact on Clinical Practice

Overdevest et al report the long-term results of a prospective, multicenter, randomized controlled trial evaluating a large series of subjects assigned to undergo lumbar discectomy performed using an open technique or through a tubular retractor. At 5 years, there were no significant differences between the functional and clinical outcomes of these two cohorts, suggesting that a tubular discectomy may not be superior to the analogous open procedure. While there is still a great deal of enthusiasm for these types of operations, this study indicates that tubular discectomy may not actually give rise to many of the advantages which are frequently attributed to such novel "minimally invasive" strategies. Thus, we believe that these findings may give surgeons pause as they decide whether to adopt these procedures but do not justify any major changes in clinical practice.

Arts MP, Wolfs JFC, Kuijlen JMA, et al. Minimally invasive surgery versus open surgery in the treatment of lumbar spondylolisthesis: study protocol of a multicenter, randomised controlled trial (MISOS trial). BMJ Open 2017;7:e017882

Lumbar instability resulting in symptoms of neural element compression with or without axial back pain is a well-accepted indication for surgical intervention when patients fail to respond to conservative measures. While certain stable deformities may be managed with a decompression alone,[12] an arthrodesis including posterior fixation and possibly interbody support may need to be performed in cases where there appears to be frank instability. Traditionally, these procedures have been performed using an open approach which typically requires extensile skin incisions and iatrogenic injury to the surrounding paraspinal musculature which may contribute to the development of persistent pain, hinder rehabilitation, and increase the risk of other complications (e.g., postoperative infection). In an attempt to avoid many of the inherent disadvantages of these conventional surgeries, minimally invasive strategies for the treatment of spinal conditions have become more prevalent. By adhering to certain principles such as limiting muscle dissection and preserving other supporting structures of the spinal column, it is possible that minimally invasive spine surgery (MISS) may bring about improvements in clinical and functional outcomes. Nevertheless, there is a dearth of high-quality studies assessing the efficacy of minimally invasive lumbar fusion for lumbar spondylolisthesis and still no compelling Level 1 evidence validating its superiority relative to open surgery.[13–15] In an attempt to address these deficiencies in the published literature, Arts et al[16] sought to elucidate the protocol of a proposed investigation which is intended to directly compare the results of these two fusion techniques for patients with lumbar instability.