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. 2025 Aug 26;20(8):e0330926. doi: 10.1371/journal.pone.0330926

Decompression with interbody fusion versus decompression alone for degenerative lumbar diseases: A meta-analysis

Yuxian Chen 1, Shenglin Lei 2, Wei Lin 1, Yilin Huang 3, Pinying Cheng 4, Shuling Gu 5, Dongping Wang 1,*
Editor: Tadashi Ito6
PMCID: PMC12380314  PMID: 40857261

Abstract

Objective

To appraise the clinical effectiveness and complications of two surgical approaches, namely decompression alone (DA) versus decompression with interbody fusion (DF), in managing degenerative lumbar diseases (DLD).

Methods

As of July 1, 2024, an exhaustive search identified all randomized controlled studies and cohort studies comparing DA and DF in DLD management. Relevant data were extracted using strict criteria, and study quality was assessed via the Newcastle-Ottawa Scale and Cochrane Collaboration’s tool. The extracted outcomes encompassed a range of measures, including operative duration, intraoperative hemorrhage, hospitalization length, time to ambulation, short form 12 physical component score (SF12-PCS), low back pain visual analog scale (VAS) score, leg pain VAS score, Oswestry disability index (ODI), Japanese orthopedic association (JOA) score, EuroQol five dimensions (EQ-5D), incidence of complications, reoperation rate, and Odom’s criteria.

Results

A total of 35 articles were included in this study, involving 12,030 patients. Of these, 7,442 patients were in the DA group, while 4,588 were in the DF group. Operative duration was shorter (MD = −89.09, 95%CI −92.71, −85.47, P < 0.00001), intraoperative hemorrhage was less (MD = −242.26, 95%CI −252.16, −232.36, P < 0.00001), hospitalization length was shorter (MD = −2.36, 95%CI −2.59, −2.14, P < 0.00001), and time to ambulation was reduced (MD = −10.49, 95%CI −12.52, −8.46, P < 0.00001) in the DA group than in the DF group. At the final follow-up for ODI, the DF group demonstrated statistically superior outcomes compared to the DA group (MD = 1.28, 95%CI 0.35, 2.21, P = 0.007). Data revealed no significant differences in SF12-PCS, JOA score, back pain VAS score, leg pain VAS score, final follow-up EQ-5D, reoperation rates, complication rates, and Odom’s criteria (P > 0.05).

Conclusion

When treating DLD, DA offers more favorable outcomes in terms of operative duration, intraoperative hemorrhage, hospitalization length, and time to ambulation. These findings suggest that DA should be considered the preferred surgical approach for most DLD patients, unless specific indications for fusion exist. Clinicians should tailor decisions to each surgery’s specifics to optimize patient outcomes.

Trial registration

PROSPERO registration number: CRD42024580975.

Introduction

Degenerative lumbar diseases (DLD) are prevalent chronic health issues, predominantly affecting the elderly but increasingly observed in younger populations [1]. These conditions are typically marked by lower back and leg pain, along with impaired physical function, resulting in long-term discomfort and a substantial financial burden on patients [2,3].

Degenerative lumbar disc herniation (DLDH), degenerative lumbar spinal stenosis (DLSS), and degenerative lumbar spondylolisthesis (DLS) are the three most common types of DLD. Previous studies have shown DLDH leads to sciatica with an annual prevalence of 1–5%, while the lifetime prevalence can reach up to 43% [4]. Furthermore, according to radiological criteria, 21% of individuals over the age of 60 are diagnosed with DLSS [5]. DLS occurs when one vertebra slips over another, potentially causing central canal stenosis and instability. It affects approximately 4.1% of the general population and is rare before the age of 50 [6]. Conservative treatment is generally recommended for patients without significant neurological deficits, as it often leads to symptom relief. However, surgical intervention may be necessary when pain intensifies, new neurological deficits develop, or if conservative treatment proves ineffective after three months.

Recently, decompression alone (DA) and decompression with interbody fusion (DF) are established surgical interventions extensively employed in clinical settings for treating DLD [7]. Despite their acceptance, comparative studies on the effectiveness of DA versus DF reveal inconsistent outcomes, thereby perpetuating uncertainty regarding the optimal surgical approach for individual patients [8–10]. Consequently, both patients and healthcare providers face challenges in determining the most appropriate option between DA and DF.

This investigation endeavors to consolidate extant research, assessing the comparative effectiveness and safety profiles of DA and DF, with the objective of informing forthcoming surgical decisions in the context of DLD management.

Methods

Registration ID

This meta-analysis was conducted in accordance with the PRISMA guidelines and was registered in the PROSPERO database under registration number CRD42024580975 [11]. The PRISMA checklist is available in S1 File.

Literature search strategy

English databases, including the Cochrane Library, PubMed, Web of Science, and Embase, were systematically searched using keywords such as fusion, decompression, lumbar spinal stenosis, lumbar disc herniation, lumbar spinal canal stenosis, intervertebral disk displacement, spondylolisthesis, and olisthesis. The search spanned from the inception of each database to July 1, 2024. The search strategy is provided in the S2 File.

Inclusion and exclusion criteria

The inclusion criteria were as follows: 1) patients undergoing DA (partial laminectomy and decompression of compressed structures, such as protruding disc fragments, hypertrophic ligaments, and ossified small joint surfaces) or DF (decompression and insertion of pedicle screws between adjacent vertebrae for fixation, with selective implantation of bone grafts using any approach) for the management of DLD; 2) outcomes included operative duration, intraoperative hemorrhage, hospitalization length, time to ambulation, short form 12 physical component score (SF12-PCS), low back pain visual analog scale (VAS) score, leg pain VAS score, Oswestry disability index (ODI), Japanese orthopedic association (JOA) score, EuroQol five dimensions (EQ-5D), incidence of complications, reoperation rate, and Odom’s criteria; 3) literature types included randomized controlled trials (RCTs), retrospective studies, and prospective studies with at least 6 months of postoperative follow-up.

The exclusion criteria were as follows: 1) patients with combined lumbar spinal infectious diseases, tumor diseases, and bleeding diseases; 2) non-primary lumbar surgeries; 3) reviews, conferences, expert opinions, case reports, animal experiments, and unavailable literature; 4) non-English language publications; 5) studies lacking complete outcome data.

Statistics extraction and collection

Two researchers independently screened literature and extracted data based on predefined criteria. Collected baseline characteristics included author, year, country, study design, disease type, sample size, mean age, and follow-up duration. Outcome measures matched the inclusion criteria. Data were standardized: operative time (minutes), blood loss (milliliters), hospital stay and ambulation time (days), and VAS score for back and leg pain (0–10, with 10 being most severe). Results included patients rated as excellent or good by Odom’s criteria. Discrepancies encountered during the data extraction process were addressed by an independent senior researcher.

Quality assessment

Two investigators independently assessed bias risk, followed by cross-validation for consistency. The Newcastle Ottawa Scale (NOS) was employed to appraise cohort studies, encompassing aspects of study design, comparability, and exposure [12]. Each study could attain a maximum score of nine points, categorized into low-quality (0–3 points), moderate-quality (4–6 points), and high-quality (7–9 points) classifications. The Cochrane Collaboration’s tool [13] was utilized in evaluating RCTs. In instances where discrepancies arose during the quality assessment, they were reconciled by a third senior researcher.

Statistical analysis

A meta-analysis of observational indicators was performed using Review Manager 5.4 software. For continuous variables, such as ODI and JOA, the mean difference (MD) was used as the effect measure. For dichotomous variables, such as complications and reoperation, the odds ratio (OR) was employed as the effect measure. All effect measures were provided with a 95% confidence interval (CI). Heterogeneity analysis among studies was appraised using the I2 statistic. If I2 < 50%, heterogeneity was considered low, and the fixed effect model was chosen. If I2 > 50%, heterogeneity was considered significant, and a random-effects model was selected. Subgroup analysis was conducted to identify potential sources of heterogeneity, and sensitivity analysis was performed to minimize heterogeneity as much as possible. When heterogeneity was high, sensitivity analysis was conducted by excluding studies one by one until it dropped below 50%. If heterogeneity remained high, a random-effects model or subgroup analysis was applied. Bias for each study was assessed using funnel plots.

Results

Literature search results and literature screening flow

From an initial pool of 8,062 records sourced across four databases using predefined search terms, 2,575 duplicates were identified and removed. Applying our inclusion criteria, we screened titles and abstracts to exclude a further 5,364 records. Subsequent full-text examination of the remaining 123 articles resulted in the selection of 35 eligible studies [8–10,14–45], involving a total of 12,030 patients (Fig 1). This cohort comprised 7,442 patients in the DA group and 4,588 in the DF group. A summary of the fundamental characteristics for these 35 studies is presented in Table 1.

Fig 1. Flow diagram of study selection.

Fig 1

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Table 1. Characteristics of the included literature.

NO Author (year) Country Study Design Disease type DA/DF
Females (N) Gender (N) Age (years) Follow-up (months)
1 Aleksandra, 2014 Poland Retrospective DLSS NR 50/50 51.28 ± 12.08/57.74 ± 9.22 120
2 Austevoll, 2016 Norway Retrospective DLSS, DLS NR 260/260 66.7 ± 10.0/66.3 ± 9.6 12
3 Austevoll, 2021 Norway RCT DLS 92/88 133/129 66.0 ± 7.4/66.5 ± 7.9 24
4 Austevoll, 2020 Norway Prospective DLS 205/208 285/285 64.6 ± 9.8/64.8 ± 9.2 12
5 Bovonratwet, 2022 America Retrospective DLS 46/67 79/109 72.3 ± 11.2/61.7 ± 12.4 12
6 Chan, 2018 America Retrospective DLSS 41/211 84/342 69.9 ± 10.5/60.7 ± 11.0 12
7 Chan, 2019 America Retrospective DLS 39/40 71/72 72.3 ± 9.7/62.1 ± 10.6 24
8 Dave, 2019 India Retrospective DLDH, DLSS 12/5 37/27 48.16 ± 11.12/51.29 ± 12.44 86.21 ± 7.47/79.55 ± 6.21
9 Försth, 2013 Sweden Retrospective DLSS 2239/818 4259/1131 70 ± 10/67 ± 10 24
10 Försth, 2016 Sweden RCT DLSS, DLS 85/70 120/113 66.6 ± 7.4/67.2 ± 7.9 24
11 Ghogawala, 2016 America RCT DLS 27/26 35/31 66.5 ± 8.0/66.7 ± 7.2 48
12 Hua, 2020 China Retrospective DLSS 20/48 32/80 56.7 ± 9.1/ 58.8 ± 10.5 24
13 Hua, 2021 China Retrospective DLSS, DLS 16/26 24/36 59.0 ± 7.9/59.9 ± 8.6 24
14 Inose, 2022 Japan RCT DLS 12/20 29/31 63.4 ± 8.7/63.5 ± 6.8 144
15 Kim, 2015 Korea Prospective DLFS 16/21 25/30 73.12 ± 6.75/70.00 ± 5.62 12
16 Kim, 2018 Korea Prospective DLS 53/47 68/61 65.47 ± 9.03/66.75 ± 8.77 24
17 Kleinstueck, 2012 Switzerland Prospective DLS 33/122 56/157 73.0 ± 8.0/67.4 ± 9.4 12
18 Kuo, 2019 Canada Retrospective DLS 105/312 164/437 68.5 ± 9.6/69.2 ± 9.6 60
19 Kurogochi, 2023 Japan Retrospective DLS NR 47/63 71.8 ± 7.8/71.5 ± 6.8 12
20 Lenga, 2024 Germany Retrospective DLSS, DLS 170/44 327/89 82.5 ± 2.5/81.7 ± 1.4 36
21 Lin, 2019 China Retrospective DLDH 9/4 33/16 57 ± 15.2/51.3 ± 12.4 51.2 ± 33/37.4 ± 19.6
22 Park, 2012 Korea Retrospective DLS 15/22 20/25 67.7 ± 7.3/61.9 ± 8.0 54.9 ± 7/69.4 ± 5.25
23 Shafiekhani, 2024 America Prospective DLSS 21/21 38/38 53.77 ± 5.069/55.8 ± 8.215 12
24 Shahi, 2024 America Retrospective DLS 53/85 87/146 73.0 ± 9.9/63.8 ± 10.4 24
25 Shahi, 2024 (2) America Retrospective DLDH 51/35 120/80 63.34 ± 16.77/53.13 ± 15.33 24
26 Son, 2013 Korea Retrospective DLSS 15/18 31/29 72.8 ± 6.8/69.4 ± 3.8 69.6 ± 20.4/62.4 ± 37.2
27 Staartjes, 2018 Switzerland Prospective DLS 29/26 51/51 52.7 ± 8.4/53.5 ± 11.1 21.7 ± 4.8
28 Sun, 2014 China Prospective DLDH NR 38/42 30.3 ± 7.3/34.9 ± 4.7 12
29 Thomas, 2019 Canada Prospective DLSS 65/57 199/107 65.5 ± 11.6/63.2 ± 9.9 24
30 Tozawa, 2022 Japan Retrospective DLS 10/23 18/24 70.4 ± 8.7/70.2 ± 9.1 24
31 Tu, 2021 China Retrospective DLSS 9/6 15/13 68.466 ± 4.033/67.307 ± 4.750 12
32 Tye, 2016 America Retrospective DLSS 68/46 227/137 49.9 ± 10.3/48.7 ± 8.3 36
33 Ulrich, 2017 Switzerland Retrospective DLSS 53/23 85/46 75.4 ± 7.6/68.0 ± 7.8 36
34 Yagi, 2018 Japan Retrospective DLS 22/16 59/40 68.5 ± 9.3/66.7 ± 7.1 36
35 Yi, 2020 China Retrospective DLSS 105/128 236/261 60.0 ± 16.5/63.0 ± 14.8 24
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DA: Decompression alone; DF: Decompression with interbody fusion; RCT: Randomized controlled trial; DLDH: Degenerative lumbar disc herniation; DLSS: Degenerative lumbar spinal stenosis; DLFS: Degenerative lumbar foraminal stenosis; DLS: Degenerative lumbar spondylolisthesis; NR: Not reported.

Evaluation of the quality of the studies

The literature review encompassed 8 prospective [10,24–26,32,36–38] and 23 retrospective [14,16–22,27–31,33–35,39–45] investigations. Assessment via the NOS classified all studies as possessing moderate to high methodological quality, as detailed in Table 2. Furthermore, 4 RCTs [8,9,15,23] underwent quality appraisal through the Cochrane Collaboration’s instrument within Review Manager version 5.4 (Figs 2 and 3).

Table 2. Study evaluation using modified Newcastle-Ottawa Scale.

Author Study design Comparability Exposure Scores Quality rating
Case
definition		 Case
representativeness		 Selection
of
Controls		 Definition
of
Controls		 Comparability
of cases and
controls		 Ascertainment
of exposure		 Same
methods of
ascertainment
for cases and
controls		 Non-response
rate
Aleksandra, 2014 1 1 1 0 1 1 1 1 7 High quality
Austevoll, 2016 1 1 1 0 2 1 0 1 7 High quality
Austevoll, 2020 1 1 1 1 2 1 1 1 9 High quality
Bovonratwet, 2022 1 1 1 0 2 1 1 1 8 High quality
Chan, 2018 1 1 1 0 1 1 1 1 7 High quality
Chan, 2019 1 1 1 0 2 1 1 0 7 High quality
Dave, 2019 1 1 1 0 2 0 1 1 7 High quality
Försth, 2013 1 1 1 0 2 1 1 1 8 High quality
Hua, 2020 1 1 1 0 2 1 1 1 8 High quality
Hua, 2021 1 1 1 0 2 0 1 1 7 High quality
Kim, 2015 1 1 1 1 2 1 0 1 8 High quality
Kim, 2018 1 1 1 1 1 0 1 1 7 High quality
Kleinstueck, 2012 1 1 1 1 2 0 0 1 7 High quality
Kuo, 2019 1 1 1 0 2 1 1 1 8 High quality
Kurogochi, 2023 1 1 1 0 2 1 0 1 7 High quality
Lenga, 2024 1 1 1 0 2 1 0 1 7 High quality
Lin, 2019 1 1 1 0 1 0 1 1 6 Moderate quality
Park, 2012 1 1 1 0 2 0 1 1 7 High quality
Shafiekhani, 2024 1 1 1 1 2 0 0 1 7 High quality
Shahi, 2024 1 1 1 0 2 1 0 1 7 High quality
Shahi, 2024 (2) 1 1 1 0 2 0 0 1 6 Moderate quality
Son, 2013 1 1 1 0 2 0 1 1 7 High quality
Staartjes, 2018 1 1 1 1 2 0 1 1 8 High quality
Sun, 2014 1 1 1 1 1 1 0 1 7 High quality
Thomas, 2019 1 1 1 1 2 1 1 1 9 High quality
Tozawa, 2022 1 1 1 0 2 0 1 1 7 High quality
Tu, 2021 1 1 1 0 1 0 1 1 6 Moderate quality
Tye, 2016 1 1 1 0 2 1 1 1 8 High quality
Ulrich, 2017 1 1 1 0 1 1 1 1 7 High quality
Yagi, 2018 1 1 1 0 2 0 1 1 7 High quality
Yi, 2020 1 1 1 0 2 0 1 1 7 High quality
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Fig 2. Risk of bias graph.

Fig 2

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Fig 3. Risk of bias summary.

Fig 3

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Meta‑analysis

Twenty studies [8–10,16–18,21–23,25,29,32,37,38,40,41,45] reported operative durations. The meta-analysis exhibited substantial heterogeneity among these studies (I2 = 98%). After conducting a sensitivity analysis and excluding thirteen studies, this heterogeneity decreased substantially to I2 = 32%. Subsequently, Meta-analysis demonstrated that the DA group had significantly shorter operative duration compared to controls (MD = −89.09, 95%CI −92.71, −85.47, P < 0.00001) (Fig 4).

Fig 4. Forest plot of operation time.

Fig 4

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Eighteen studies [8,9,16–18,21–23,25,29,32,35–41] submitted intraoperative hemorrhage. The results exhibited significant heterogeneity among the included studies (I2 = 99%). After conducting a sensitivity analysis and removing eleven studies, the heterogeneity was substantially reduced (I2 = 46%). Meta-analysis revealed that the DA group experienced significantly less intraoperative hemorrhage (MD = −242.26, 95%CI −252.16, −232.36, P < 0.00001) (Fig 5).

Fig 5. Forest plot of intraoperative blood loss.

Fig 5

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Twenty studies [8–10,16–18,21–23,25,28,32,35–41,45] provided data on hospitalization length. The results showed significant heterogeneity among the included studies (I2 = 97%). After conducting a sensitivity analysis and excluding nine studies, the heterogeneity was substantially reduced (I2 = 18%). The meta-analysis presented that the DA group had a significantly shorter hospitalization length (MD = −2.36, 95%CI −2.59, −2.14, P < 0.00001) (Fig 6).

Fig 6. Forest plot of hospital length stay.

Fig 6

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Three studies [21,22,40] provided data on the time to ambulation. The results revealed high heterogeneity among the included studies (I2 = 97%). A sensitivity analysis and the removal of one study significantly reduced this heterogeneity (I2 = 0%). The meta-analysis presented that the DA group had significantly shorter time to ambulation (MD = −10.49, 95%CI −12.52, −8.46, P < 0.00001) (Fig 7).

Fig 7. Forest plot of time to ambulation.

Fig 7

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Five studies [16,33,34,39,45] provided both preoperative and final follow-up data for the SF12-PCS. Subgroup analyses revealed low heterogeneity in all groups (I2 < 50%). No significant differences were observed in the SF12-PCS between the DA and DF groups (P > 0.05) (Fig 8).

Fig 8. Forest plot of SF12-PCS.

Fig 8

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Fourteen articles [8,16,19–24,28,33–35,37,40] provided data on low back pain VAS score. Among these, fourteen, eight, and fifteen articles reported preoperative, early postoperative, and final follow-up data respectively. A significant difference was found in preoperative low back pain VAS score between the DA and DF groups (MD = −0.49, 95%CI −0.70, −0.28, P < 0.00001). Subgroup analysis presented heterogeneity was substantial in the early postoperative and final follow-up subgroups, as well as in the total dataset (I2 > 50%). No significant differences were observed in low back pain VAS score between the DA and DF groups (P > 0.05) (Fig 9).

Fig 9. Forest plot of back VAS score.

Fig 9

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A total of eleven studies [8,16,19–22,28,33,35,37,41] provided data on leg pain VAS score, with eleven, six, and eleven studies reporting preoperative, early postoperative, and final follow-up measurements, respectively. The overall heterogeneity was minimal (I2 = 2%). Subgroup analysis displayed no difference was found in leg pain VAS score between the DA and DF groups (P > 0.05) (Fig 10).

Fig 10. Forest plot of leg VAS score.

Fig 10

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Twenty-one articles [8,10,14,16–18,20–22,24,25,28,31,33–35,37,39,40,44,45] offered data on ODI. Specifically, twenty-one, twelve, and twenty-one articles reported preoperative, early postoperative, and final follow-up data, respectively. Total heterogeneity test result was evident (I2 = 81%). There were no significant differences between the two groups before surgery and early postoperatively (P > 0.05). However, the DF group demonstrated statistically superior outcomes compared to the DA group at the final follow-up (MD = 1.28, 95%CI 0.35, 2.21, P = 0.007) (Fig 11).

Fig 11. Forest plot of ODI.

Fig 11

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Three studies [28,37,41] provided preoperative and final follow-up data for the JOA. The total heterogeneity test result was high (I2 = 64%). Subgroup analysis revealed no difference was found in JOA between the DA and DF groups (P > 0.05) (Fig 12).

Fig 12. Forest plot of JOA.

Fig 12

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Five studies [8,17,18,20,39] provided EQ-5D for both preoperative and final follow-up assessments. A significant difference was evident in the preoperative EQ-5D between the DA and DF groups (MD = 0.03, 95%CI 0.01, 0.05, Р = 0. 002), but not in the final follow-up. The total heterogeneity across these studies was minimal (I2 = 30%). Subgroup analysis further indicated a significant difference in EQ-5D between these groups (MD = 0.02, 95%CI 0.01, 0.03, Р = 0.001) (Fig 13). Given the significant preoperative differences, the interpretation of these results requires caution.

Fig 13. Forest plot of EQ-5D.

Fig 13

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Fourteen studies [9,10,14,15,19,21,26,27,29,35,36,41,43,45] submitted incidence of complications. The results revealed significant heterogeneity among the included studies (I2 = 63%). After conducting a sensitivity analysis and removing one study, the heterogeneity was substantially reduced (I2 = 28%). There were no significant differences between the two groups (P > 0.05) (Fig 14).

Fig 14. Forest plot of complication rates.

Fig 14

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Fourteen articles [15–18,23,27,29,32,33,35,36,42,43,45] reported on reoperation rates, enrolling 1,629 and 1,909 patients in two groups respectively. The results indicated found low heterogeneity among the included studies (I2 = 44%). Meta-analysis revealed no significant difference in reoperation rates between the DA and DF groups (P > 0.05) (Fig 15).

Fig 15. Forest plot of reoperation rates.

Fig 15

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Three studies [30,31,35] employed Odom’s criteria. The results indicated significant heterogeneity among the included literature (I2 = 52%). A sensitivity analysis and the exclusion of one study significantly reduced this heterogeneity (I2 = 0%). Meta-analysis demonstrated no significant difference in Odom’s criteria between the DA and DF groups (P > 0.05) (Fig 16).

Fig 16. Forest plot of Odom’s criteria.

Fig 16

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Publication bias was assessed using funnel plots based on low back pain VAS score, leg pain VAS score, ODI, and complication rates as key metrics. The largely symmetrical appearance of the funnel plots suggested a low likelihood of publication bias (Fig 17).

Fig 17. Funnel plots of outcome indicators.

Fig 17

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A low back pain VAS score; B leg pain VAS score; C ODI; D complication rates.

Discussion

The meta-analysis revealed that the DA group exhibited significantly reduced surgical duration, decreased intraoperative hemorrhage, shorter hospitalization length, and earlier resumption of ambulation compared to the DF group (P < 0.05). Yang et al.‘s study on lumbar spinal stenosis, encompassing 21 RCTs and 3,636 patients, reached similar conclusions [46]. Furthermore, this meta-analysis concluded that there were no significant differences in the results of SF12-PCS, back VAS score, leg VAS score, ODI, JOA, Odom’s criteria, and reoperation rates between the DA and DF groups (P > 0.05). The results align with Wu et al.’s study on DLS, which included only RCTs [47]. Another study on DLS indicated that early postoperative low back pain VAS score slightly favored the DF group [48]. However, no significant difference was observed at the final follow-up [48]. Although the EQ-5D showed a slight advantage for the DA group, this was influenced by significant preoperative differences (P < 0.05). Postoperative results showed no significant difference (P > 0.05). A similar trend in dorsal VAS score suggests potential biases in the included literature. The difference in ODI at the final follow-up was minor and lacked clinical significance. However, it reached statistical significance, possibly attributable to the large sample size.

When DLD is subdivided into different diseases, slight variations in results emerge. Byvaltsev et al. [49] conducted a single-center retrospective study on intervertebral disc disease, finding that the DA group exhibited better early outcomes for ODI, whereas the DF group demonstrated superior results at the final follow-up. Another study involving 29,066 patients with lumbar spinal stenosis reported no significant differences in SF12-PCS, back and leg VAS score or ODI [50]. Kaiser et al.‘s study on DLS showed comparable treatment outcomes and quality of life between the two groups [51]. However, omitting fusion may marginally reduce back pain while slightly increasing the reoperation rate compared to DF. Pranata et al. [52] observed that the DF group exhibited advantages in ODI, back VAS score, and leg VAS score, whereas the DA group performed better in terms of operative time, hospital stay, and intraoperative blood loss. A two-year study on DLS patients found that instability characteristics did not result in superior clinical outcomes for the DF group [53]. Additionally, Gadjradj et al.’s study on lumbar spondylolisthesis with stenosis reported no significant differences in back and leg VAS scores or reoperation rates between the groups [54].

This meta-analysis categorized ODI into preoperative, early postoperative (< 1 year), and final follow-up (≥ 1 year) periods through subgroup analysis. However, heterogeneity remained unchanged, indicating that follow-up time was not the source. To reduce heterogeneity, we suggest improving clinical trial design by standardizing follow-up times. Shen et al. [55] categorized ODI into two subgroups, Caucasians and Mongolians, and concluded that racial differences did not account for the heterogeneity. A study of 6 RCTs and 27 cohort studies with 94,953 patients found no significant difference in ODI at 3, 6, 12, and 24 months [48]. Subgroup analysis of clinical satisfaction showed that trial type (RCT or cohort study) did not impact the results. This meta-analysis used sensitivity analysis to exclude multiple studies for the four outcome indicators: operation time, intraoperative bleeding, hospitalization time, and time to ambulation, aiming to reduce heterogeneity and improve reliability. However, excluding these studies did not affect the outcomes.

Moreover, the findings revealed no significant difference in complication rates between the two groups (P > 0.05). A previous study concluded that there was no significant difference in postoperative complications after treatment for DLSS [55]. A RCT on lumbar spinal stenosis found that the DF group had a higher frequency of proximal adjacent segment stenosis postoperatively but a lower incidence of re-stenosis at the surgical segment [56]. Regardless of preoperative spondylolisthesis, the DA group exhibited increased vertebral slippage postoperatively [56]. A similar study, comprising six RCTs on elderly patients, found a higher rate of lumbar spondylolisthesis progression in the DA group but fewer in-hospital complications and adverse events [57]. A multicenter 5-year RCT on DLS showed a higher dural tear rate in the fusion group [58]. They demonstrated adverse events occurred in 13% of the DA group and 19% of the DF group, with no significant difference. Another study on first-grade spondylolisthesis revealed fewer complications but higher reoperation rate in the DA cohort [59].

Compared to other studies, the advantages of DA—reduced operative time, shorter hospitalization, and less blood loss—are consistently observed, though its efficacy may vary slightly across conditions. Given these benefits, DA appears cost-effective for most patients without specific contraindications. DF may be preferable for DLDH patients presenting with cauda equina syndrome or massive central disc herniation [19,30]. Based on the Michigan State University classification, Li et al. [60] recommended percutaneous endoscopic lumbar discectomy for three DLDH subtypes and transforaminal fusion for four others. Shafiekhani et al. [32] proposed DA for mild to moderate DLSS and DF for severe cases. Shahi et al. [34] recommended DF for patients with spinal instability, isthmic spondylolisthesis, severe disc collapse with foraminal stenosis, the need for realignment, or resection of more than 50% of the facet joint. Similarly, the World Federation of Neurosurgical Societies advised fusion for symptomatic unstable spondylolisthesis and bilateral facet resection exceeding 50% [61]. Two surveys of spine surgeons identified instability, spondylolisthesis grade, lateral translation, hypermobility, mechanical low back pain, and high activity demands as key factors influencing fusion decisions [62,63]. DF may stabilize painful segments and prevent progression in severe dynamic instability or high-risk cases. Dijkerman et al. [64] suggested fusion for high-grade spondylolisthesis or low-grade cases with foraminal stenosis or instability. These findings underscore the importance of assessing spinal stability in both DLS and DLSS. Various posture-based imaging techniques assist in evaluating intervertebral stability [65,66]. In DLS patients with sagittal facet malalignment and significant effusion, fusion may be appropriate [36]. Tools such as the Jakarta Instability Score and the Degenerative Lumbar Spondylolisthesis Instability Classification further support surgical decision-making, particularly for Type III DLS patients with instability who may benefit from fusion [67,68].

The advantages of DF remain indistinct at present, and its overuse has been observed. Our results indicated that DF did not offer additional benefits in treating DLD. Despite its frequent clinical use, DF is sometimes applied unnecessarily. A Canadian prospective study on DLS revealed that DF was used to treat stable, potentially unstable, and unstable cases in 59%, 77%, and 100% of cases, respectively [69]. Data from the American College of Surgeons National Surgical Quality Improvement Program (2005–2015) showed that 90.6% of spondylolisthesis patients opted for fusion surgery [70]. Sastry et al. [71] indicated that the proportion of DF procedures for treating DLSS and DLS in the United States increased from 67.4% in 2016 to 90.4% in 2019, while DA procedures declined from 32.6% to 9.6% over the same period. Kaiser et al. [51] found that not all patients undergoing DF had unstable characteristics, suggesting that 4% to 24% of patients requiring surgery for DLS could be candidates for simple decompression. This highlights the need for clinicians to exercise caution when selecting DF as a surgical option.

Limitations

The primary limitation lies in the quality and language of the included literature, which is exclusively in English. Additionally, the diverse regions represented may reflect varying technical capabilities. Data analysis is limited by potential biases from high attrition rates in long-term follow-ups and small sample sizes in short-term studies. Sensitivity analysis excluded several articles, which could introduce bias and reduce the sample size. High heterogeneity in the subgroup analysis may impact the results. The follow-up times for subgroup analysis were imprecise, with recent postoperative indicators including markers such as three and six months. Long-term postoperative indicators include markers beyond one year, such as at one, two, and six years. Other limitations include variations due to time and technological advances. This study focused on primary surgeries, excluding secondary surgeries where fusion is commonly used. The question of whether fusion should be the first treatment option for DLS remains controversial. Finally, the inclusion criteria for DLD are too broad, and future studies should focus on more specific disease subtypes.

Conclusion

Meta-analysis results revealed the DA group and the DF group exhibit comparable clinical effectiveness and patient satisfaction levels. The DA group demonstrated advantages in terms of shorter operative duration, reduced intraoperative hemorrhage, decreased hospitalization length, and quicker time to postoperative ambulation. The difference in ODI at the final follow-up was minor and lacked clinical significance. However, it reached statistical significance, possibly attributable to the large sample size. These findings suggest that DA should be considered the preferred surgical approach for most DLD patients, unless specific indications for fusion exist. Future studies should aim to delineate which patient subsets derive greater benefits from decompression combined with fusion procedures.

Supporting information

S1 File. PRISMA checklist.

(DOCX)

pone.0330926.s001.docx (33.1KB, docx)
S2 File. Search strategy.

(DOCX)

pone.0330926.s002.docx (15.3KB, docx)
S3 File. Raw data set.

(DOCX)

pone.0330926.s003.docx (41KB, docx)

Data Availability

All relevant data are within the paper and its Supporting Information files.

Funding Statement

The author(s) received no specific funding for this work.

References

  • 1.Wan ZY, Zhang J, Shan H, Liu TF, Song F, Samartzis D, et al. Epidemiology of Lumbar Degenerative Phenotypes of Children and Adolescents: A Large-Scale Imaging Study. Global Spine J. 2023;13(3):599–608. doi: 10.1177/21925682211000707 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Ma Y, Huang P, Tu Z, Yao Z, Wang Z, Luo Z, et al. Associations between facet tropism and vertebral rotation in patients with degenerative lumbar disease. Eur J Med Res. 2021;26(1):149. doi: 10.1186/s40001-021-00622-7 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3.Waldrop R, Cheng J, Devin C, McGirt M, Fehlings M, Berven S. The Burden of Spinal Disorders in the Elderly. Neurosurgery. 2015;77(Suppl 4):S46–50. doi: 10.1227/NEU.0000000000000950 [DOI] [PubMed] [Google Scholar]
  • 4.Kögl N, Petr O, Löscher W, Liljenqvist U, Thomé C. Lumbar Disc Herniation—the Significance of Symptom Duration for the Indication for Surgery. Dtsch Arztebl Int. 2024;121(13):440–8. doi: 10.3238/arztebl.m2024.0074 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5.Kalff R, Ewald C, Waschke A, Gobisch L, Hopf C. Degenerative lumbar spinal stenosis in older people: current treatment options. Dtsch Arztebl Int. 2013;110(37):613–23; quiz 624. doi: 10.3238/arztebl.2013.0613 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6.Steiger F, Becker HJ, Standaert CJ, Balague F, Vader JP, Porchet F, et al. Surgery in lumbar degenerative spondylolisthesis: indications, outcomes and complications. A systematic review. Eur Spine J. 2014;23(5):945–73. doi: 10.1007/s00586-013-3144-3 [DOI] [PubMed] [Google Scholar]
  • 7.Reid PC, Morr S, Kaiser MG. State of the union: a review of lumbar fusion indications and techniques for degenerative spine disease. J Neurosurg Spine. 2019;31(1):1–14. doi: 10.3171/2019.4.SPINE18915 [DOI] [PubMed] [Google Scholar]
  • 8.Försth P, Ólafsson G, Carlsson T, Frost A, Borgström F, Fritzell P, et al. A Randomized, Controlled Trial of Fusion Surgery for Lumbar Spinal Stenosis. N Engl J Med. 2016;374(15):1413–23. doi: 10.1056/NEJMoa1513721 [DOI] [PubMed] [Google Scholar]
  • 9.Ghogawala Z, Dziura J, Butler WE, Dai F, Terrin N, Magge SN, et al. Laminectomy plus Fusion versus Laminectomy Alone for Lumbar Spondylolisthesis. N Engl J Med. 2016;374(15):1424–34. doi: 10.1056/NEJMoa1508788 [DOI] [PubMed] [Google Scholar]
  • 10.Austevoll IM, Gjestad R, Solberg T, Storheim K, Brox JI, Hermansen E, et al. Comparative Effectiveness of Microdecompression Alone vs Decompression Plus Instrumented Fusion in Lumbar Degenerative Spondylolisthesis. JAMA Netw Open. 2020;3(9):e2015015. doi: 10.1001/jamanetworkopen.2020.15015 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 11.Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ. 2009;339:b2535. doi: 10.1136/bmj.b2535 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 12.Norris JM, Simpson BS, Ball R, Freeman A, Kirkham A, Parry MA, et al. A Modified Newcastle-Ottawa Scale for Assessment of Study Quality in Genetic Urological Research. Eur Urol. 2021;79(3):325–6. doi: 10.1016/j.eururo.2020.12.017 [DOI] [PubMed] [Google Scholar]
  • 13.Higgins JPT, Altman DG, Gøtzsche PC, Jüni P, Moher D, Oxman AD, et al. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ. 2011;343:d5928. doi: 10.1136/bmj.d5928 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 14.Austevoll IM, Gjestad R, Brox JI, Solberg TK, Storheim K, Rekeland F, et al. The effectiveness of decompression alone compared with additional fusion for lumbar spinal stenosis with degenerative spondylolisthesis: a pragmatic comparative non-inferiority observational study from the Norwegian Registry for Spine Surgery. Eur Spine J. 2017;26(2):404–13. doi: 10.1007/s00586-016-4683-1 [DOI] [PubMed] [Google Scholar]
  • 15.Austevoll IM, Hermansen E, Fagerland MW, Storheim K, Brox JI, Solberg T, et al. Decompression with or without Fusion in Degenerative Lumbar Spondylolisthesis. N Engl J Med. 2021;385(6):526–38. doi: 10.1056/NEJMoa2100990 [DOI] [PubMed] [Google Scholar]
  • 16.Bovonratwet P, Samuel AM, Mok JK, Vaishnav AS, Morse KW, Song J, et al. Minimally Invasive Lumbar Decompression Versus Minimally Invasive Transforaminal Lumbar Interbody Fusion for Treatment of Low-Grade Lumbar Degenerative Spondylolisthesis. Spine (Phila Pa 1976). 2022;47(21):1505–14. doi: 10.1097/BRS.0000000000004432 [DOI] [PubMed] [Google Scholar]
  • 17.Chan AK, Bisson EF, Bydon M, Glassman SD, Foley KT, Potts EA, et al. A comparison of minimally invasive transforaminal lumbar interbody fusion and decompression alone for degenerative lumbar spondylolisthesis. Neurosurg Focus. 2019;46(5):E13. doi: 10.3171/2019.2.FOCUS18722 [DOI] [PubMed] [Google Scholar]
  • 18.Chan AK, Bisson EF, Bydon M, Glassman SD, Foley KT, Potts EA, et al. Laminectomy alone versus fusion for grade 1 lumbar spondylolisthesis in 426 patients from the prospective Quality Outcomes Database. J Neurosurg Spine. 2018;30(2):234–41. doi: 10.3171/2018.8.SPINE17913 [DOI] [PubMed] [Google Scholar]
  • 19.Dave BR, Samal P, Sangvi R, Degulmadi D, Patel D, Krishnan A. Does the Surgical Timing and Decompression Alone or Fusion Surgery in Lumbar Stenosis Influence Outcome in Cauda Equina Syndrome?. Asian Spine J. 2019;13(2):198–209. doi: 10.31616/asj.2018.0168 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 20.Försth P, Michaëlsson K, Sandén B. Does fusion improve the outcome after decompressive surgery for lumbar spinal stenosis?: A two-year follow-up study involving 5390 patients. Bone Joint J. 2013;95-B(7):960–5. doi: 10.1302/0301-620X.95B7.30776 [DOI] [PubMed] [Google Scholar]
  • 21.Hua W, Wang B, Ke W, Wu X, Zhang Y, Li S, et al. Comparison of lumbar endoscopic unilateral laminotomy bilateral decompression and minimally invasive surgery transforaminal lumbar interbody fusion for one-level lumbar spinal stenosis. BMC Musculoskelet Disord. 2020;21(1):785. doi: 10.1186/s12891-020-03820-2 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 22.Hua W, Wang B, Ke W, Xiang Q, Wu X, Zhang Y, et al. Comparison of Clinical Outcomes Following Lumbar Endoscopic Unilateral Laminotomy Bilateral Decompression and Minimally Invasive Transforaminal Lumbar Interbody Fusion for One-Level Lumbar Spinal Stenosis With Degenerative Spondylolisthesis. Front Surg. 2021;7:596327. doi: 10.3389/fsurg.2020.596327 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 23.Inose H, Kato T, Sasaki M, Matsukura Y, Hirai T, Yoshii T, et al. Comparison of decompression, decompression plus fusion, and decompression plus stabilization: a long-term follow-up of a prospective, randomized study. Spine J. 2022;22(5):747–55. doi: 10.1016/j.spinee.2021.12.014 [DOI] [PubMed] [Google Scholar]
  • 24.Kim HJ, Jeong JH, Cho HG, Chang BS, Lee CK, Yeom JS. Comparative observational study of surgical outcomes of lumbar foraminal stenosis using minimally invasive microsurgical extraforaminal decompression alone versus posterior lumbar interbody fusion: a prospective cohort study. Eur Spine J. 2015;24(2):388–95. doi: 10.1007/s00586-014-3592-4 [DOI] [PubMed] [Google Scholar]
  • 25.Kim SI, Ha KY, Kim YH, Kim YH, Oh IS. A Comparative Study of Decompressive Laminectomy and Posterior Lumbar Interbody Fusion in Grade I Degenerative Lumbar Spondylolisthesis. Indian J Orthop. 2018;52(4):358–62. doi: 10.4103/ortho.IJOrtho_330_16 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 26.Kleinstueck FS, Fekete TF, Mannion AF, Grob D, Porchet F, Mutter U, et al. To fuse or not to fuse in lumbar degenerative spondylolisthesis: do baseline symptoms help provide the answer? Eur Spine J. 2012;21(2):268–75. doi: 10.1007/s00586-011-1896-1 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 27.Kuo CC, Merchant M, Kardile MP, Yacob A, Majid K, Bains RS. In Degenerative Spondylolisthesis, Unilateral Laminotomy for Bilateral Decompression Leads to Less Reoperations at 5 Years When Compared to Posterior Decompression With Instrumented Fusion: A Propensity-matched Retrospective Analysis. Spine (Phila Pa 1976). 2019;44(21):1530–7. doi: 10.1097/BRS.0000000000003121 [DOI] [PubMed] [Google Scholar]
  • 28.Kurogochi D, Uehara M, Yui M, Ikegami S, Oba H, Mimura T, et al. Comparison of spinous process-splitting laminectomy versus posterolateral fusion for lumbar degenerative spondylolisthesis. Eur Spine J. 2023;32(2):447–54. doi: 10.1007/s00586-022-07298-5 [DOI] [PubMed] [Google Scholar]
  • 29.Lenga P, Gülec G, Bajwa AA, Issa M, Oskouian RJ, Chapman JR, et al. Lumbar Decompression versus Decompression and Fusion in Octogenarians: Complications and Clinical Course With 3-Year Follow-Up. Global Spine J. 2024;14(2):687–96. doi: 10.1177/21925682221121099 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 30.Lin TY, Wang YC, Chang CW, Wong CB, Cheng YH, Fu TS. Surgical Outcomes for Upper Lumbar Disc Herniation: Decompression Alone versus Fusion Surgery. J Clin Med. 2019;8(9):1435. doi: 10.3390/jcm8091435 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 31.Park JH, Hyun SJ, Roh SW, Rhim SC. A comparison of unilateral laminectomy with bilateral decompression and fusion surgery in the treatment of grade I lumbar degenerative spondylolisthesis. Acta Neurochir (Wien). 2012;154(7):1205–12. doi: 10.1007/s00701-012-1394-1 [DOI] [PubMed] [Google Scholar]
  • 32.Shafiekhani P, Hajimohammadebrahim-Ketabforoush M, Jajin EA, Zandpazandi S, Shahmohammadi M. Clinical Outcomes Following Decompression of Central Canal and Lateral Recess Simultaneous Stenosis, with a Focus on Multilevel Stenosis: A Randomized Comparison of Microscopic Bilateral Laminotomy versus Total Laminectomy with Posterior Spinal Fusion. World Neurosurg. 2024;187:e257–63. doi: 10.1016/j.wneu.2024.04.072 [DOI] [PubMed] [Google Scholar]
  • 33.Shahi P, Singh S, Morse K, Maayan O, Subramanian T, Araghi K, et al. Impact of age on comparative outcomes of decompression alone versus fusion for L4 degenerative spondylolisthesis. Eur Spine J. 2024;33(10):3749–59. doi: 10.1007/s00586-024-08336-0 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 34.Shahi P, Subramanian T, Maayan O, Singh N, Araghi K, Singh S, et al. Outcomes of Minimally Invasive Decompression Alone Versus Fusion for Predominant Back Pain. HSS J. 2025;21(1):42–8. doi: 10.1177/15563316231223503 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 35.Son S, Kim WK, Lee SG, Park CW, Lee K. A comparison of the clinical outcomes of decompression alone and fusion in elderly patients with two-level or more lumbar spinal stenosis. J Korean Neurosurg Soc. 2013;53(1):19–25. doi: 10.3340/jkns.2013.53.1.19 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 36.Staartjes VE, Schröder ML. Effectiveness of a Decision-Making Protocol for the Surgical Treatment of Lumbar Stenosis with Grade 1 Degenerative Spondylolisthesis. World Neurosurg. 2018;110:e355–61. doi: 10.1016/j.wneu.2017.11.001 [DOI] [PubMed] [Google Scholar]
  • 37.Sun Z, Li W, Chen Z, Guo Z, Qi Q, Zeng Y, et al. Decompression alone versus decompression with instrumented fusion for young patients with single-level lumbar disc herniation: a short-term prospective comparative study. Chin Med J (Engl). 2014;127(11):2037–42. doi: 10.3760/cma.j.issn.0366-6999.20122204 [DOI] [PubMed] [Google Scholar]
  • 38.Thomas K, Faris P, McIntosh G, Manners S, Abraham E, Bailey CS, et al. Decompression alone vs. decompression plus fusion for claudication secondary to lumbar spinal stenosis. Spine J. 2019;19(10):1633–9. doi: 10.1016/j.spinee.2019.06.003 [DOI] [PubMed] [Google Scholar]
  • 39.Tozawa K, Matsubayashi Y, Kato S, Doi T, Taniguchi Y, Kumanomido Y, et al. Surgical outcomes between posterior decompression alone and posterior decompression with fusion surgery among patients with Meyerding grade 2 degenerative spondylolisthesis: a multicenter cohort study. BMC Musculoskelet Disord. 2022;23(1):902. doi: 10.1186/s12891-022-05850-4 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 40.Truszczyńska A, Rąpała K, Łukawski S, Trzaskoma Z, Tarnowski A, Drzal-Grabiec J, et al. Evaluation of functional outcomes in individuals 10 years after posterior lumbar interbody fusion with corundum implants and decompression: a comparison of 2 surgical techniques. Med Sci Monit. 2014;20:1400–6. doi: 10.12659/MSM.890545 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 41.Tu P, Cao S, Jiang C, Yan CC. A comparative study of Lumbar Decompression and Fusion with Internal Fixation versus Simple Decompression in elderly patients with two-segment Lumbar Spinal Stenosis. Pak J Med Sci. 2021;37(1):256–60. doi: 10.12669/pjms.37.1.2287 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 42.Tye EY, Anderson J, Haas A, Percy R, Woods ST, Ahn N. Decompression Versus Decompression and Fusion for Degenerative Lumbar Stenosis in a Workers’ Compensation Setting. Spine (Phila Pa 1976). 2017;42(13):1017–23. doi: 10.1097/BRS.0000000000001970 [DOI] [PubMed] [Google Scholar]
  • 43.Ulrich NH, Burgstaller JM, Pichierri G, Wertli MM, Farshad M, Porchet F, et al. Decompression Surgery Alone Versus Decompression Plus Fusion in Symptomatic Lumbar Spinal Stenosis: A Swiss Prospective Multicenter Cohort Study With 3 Years of Follow-up. Spine (Phila Pa 1976). 2017;42(18):E1077–86. doi: 10.1097/BRS.0000000000002068 [DOI] [PubMed] [Google Scholar]
  • 44.Yagi M, Fujita N, Okada E, Tsuji O, Nagoshi N, Tsuji T, et al. Comparisons of direct costs, outcomes, and cost-utility of decompression surgery with fusion versus decompression alone for degenerative lumbar spondylolisthesis. J Orthop Sci. 2018;23(4):653–7. doi: 10.1016/j.jos.2018.04.001 [DOI] [PubMed] [Google Scholar]
  • 45.Yi W, Tang Y, Yang D, Huang W, Liu H, Sun Z, et al. Microendoscopic discectomy versus minimally invasive transforaminal lumbar interbody fusion for lumbar spinal stenosis without spondylolisthesis. Medicine (Baltimore). 2020;99(24):e20743. doi: 10.1097/MD.0000000000020743 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 46.Yang LH, Liu W, Li J, Zhu WY, An LK, Yuan S, et al. Lumbar decompression and lumbar interbody fusion in the treatment of lumbar spinal stenosis: A systematic review and meta-analysis. Medicine (Baltimore). 2020;99(27):e20323. doi: 10.1097/MD.0000000000020323 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 47.Wu J, Zhang J, Xu T, Pan Y, Cui B, Wei W, et al. The necessity or not of the addition of fusion to decompression for lumbar degenerative spondylolisthesis patients: A PRISMA compliant meta-analysis. Medicine (Baltimore). 2021;100(14):e24775. doi: 10.1097/MD.0000000000024775 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 48.Wei FL, Zhou CP, Gao QY, Du MR, Gao HR, Zhu KL, et al. Decompression alone or decompression and fusion in degenerative lumbar spondylolisthesis. EClinicalMedicine. 2022;51:101559. doi: 10.1016/j.eclinm.2022.101559 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 49.Byvaltsev VA, Kalinin AA, Shepelev VV, Pestryakov YY, Jubaeva BA. Minimally invasive decompression alone versus fusion surgery for acute lumbar disk herniation combined incomplete cauda equina syndrome. Clin Neurol Neurosurg. 2023;225:107589. doi: 10.1016/j.clineuro.2023.107589 [DOI] [PubMed] [Google Scholar]
  • 50.Chen B, Lv Y, Wang ZC, Guo XC, Chao CZ. Decompression with fusion versus decompression in the treatment of lumbar spinal stenosis: A systematic review and meta-analysis. Medicine (Baltimore). 2020;99(38):e21973. doi: 10.1097/MD.0000000000021973 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 51.Kaiser R, Kantorová L, Langaufová A, Slezáková S, Tučková D, Klugar M, et al. Decompression alone versus decompression with instrumented fusion in the treatment of lumbar degenerative spondylolisthesis: a systematic review and meta-analysis of randomised trials. J Neurol Neurosurg Psychiatry. 2023;94(8):657–66. doi: 10.1136/jnnp-2022-330158 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 52.Pranata R, Lim MA, Vania R, Bagus Mahadewa TG. Decompression Alone Compared to Decompression With Fusion in Patients With Lumbar Spondylolisthesis: Systematic Review, Meta-Analysis, and Meta-Regression. Int J Spine Surg. 2022;16(1):71–80. doi: 10.14444/8179 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 53.Hellum C, Rekeland F, Småstuen MC, Solberg T, Hermansen E, Storheim K, et al. Surgery in degenerative spondylolisthesis: does fusion improve outcome in subgroups? A secondary analysis from a randomized trial (NORDSTEN trial). Spine J. 2023;23(11):1613–22. doi: 10.1016/j.spinee.2023.06.386 [DOI] [PubMed] [Google Scholar]
  • 54.Gadjradj PS, Basilious M, Goldberg JL, Sommer F, Navarro-Ramirez R, Mykolajtchuk C, et al. Decompression alone versus decompression with fusion in patients with lumbar spinal stenosis with degenerative spondylolisthesis: a systematic review and meta-analysis. Eur Spine J. 2023;32(3):1054–67. doi: 10.1007/s00586-022-07507-1 [DOI] [PubMed] [Google Scholar]
  • 55.Shen J, Wang Q, Wang Y, Min N, Wang L, Wang F, et al. Comparison Between Fusion and Non-Fusion Surgery for Lumbar Spinal Stenosis: A Meta-analysis. Adv Ther. 2021;38(3):1404–14. doi: 10.1007/s12325-020-01604-7 [DOI] [PubMed] [Google Scholar]
  • 56.Karlsson T, Försth P, Skorpil M, Pazarlis K, Öhagen P, Michaëlsson K, et al. Decompression alone or decompression with fusion for lumbar spinal stenosis: a randomized clinical trial with two-year MRI follow-up. Bone Joint J. 2022;104-B(12):1343–51. doi: 10.1302/0301-620X.104B12.BJJ-2022-0340.R1 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 57.Abdel-Fattah AR, Bell F, Boden L, Ferry J, McCormick C, Ross M, et al. To fuse or not to fuse: The elderly patient with lumbar stenosis and low-grade spondylolisthesis. Systematic review and meta-analysis of randomised controlled trials. Surgeon. 2023;21(1):e23–31. doi: 10.1016/j.surge.2022.02.008 [DOI] [PubMed] [Google Scholar]
  • 58.Kgomotso EL, Hellum C, Fagerland MW, Solberg T, Brox JI, Storheim K, et al. Decompression alone or with fusion for degenerative lumbar spondylolisthesis (Nordsten-DS): five year follow-up of a randomised, multicentre, non-inferiority trial. BMJ. 2024;386:e079771. doi: 10.1136/bmj-2024-079771 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 59.Koenig S, Jauregui JJ, Shasti M, Jazini E, Koh EY, Banagan KE, et al. Decompression Versus Fusion for Grade I Degenerative Spondylolisthesis: A Meta-Analysis. Global Spine J. 2019;9(2):155–61. doi: 10.1177/2192568218777476 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 60.Li H, Xiao C, Pan H, Yang H, Lei Y, Wang H, et al. Surgical Strategy for Lumbar Disc Herniation based on the MSU Classification: Percutaneous Endoscopic Lumbar Discectomy versus Transforaminal Lumbar Interbody Fusion: A 5-year Retrospective Study. Orthop Surg. 2024;16(8):1963–73. doi: 10.1111/os.14145 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 61.Sharif S, Shaikh Y, Bajamal AH, Costa F, Zileli M. Fusion Surgery for Lumbar Spinal Stenosis: WFNS Spine Committee Recommendations. World Neurosurg X. 2020;7:100077. doi: 10.1016/j.wnsx.2020.100077 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 62.Morse KW, Steinhaus M, Bovonratwet P, Kazarian G, Gang CH, Vaishnav AS, et al. Current treatment and decision-making factors leading to fusion vs decompression for one-level degenerative spondylolisthesis: survey results from members of the Lumbar Spine Research Society and Society of Minimally Invasive Spine Surgery. Spine J. 2022;22(11):1778–87. doi: 10.1016/j.spinee.2022.07.095 [DOI] [PubMed] [Google Scholar]
  • 63.Rangwalla K, Filley A, El Naga A, Gendelberg D, Baldwin A, Maziad A, et al. Degenerative lumbar spondylolisthesis: review of current classifications and proposal of a novel classification system. Eur Spine J. 2024;33(5):1762–72. doi: 10.1007/s00586-023-07818-x [DOI] [PubMed] [Google Scholar]
  • 64.Dijkerman ML, Overdevest GM, Moojen WA, Vleggeert-Lankamp CLA. Decompression with or without concomitant fusion in lumbar stenosis due to degenerative spondylolisthesis: a systematic review. Eur Spine J. 2018;27(7):1629–43. doi: 10.1007/s00586-017-5436-5 [DOI] [PubMed] [Google Scholar]
  • 65.Morita T, Yoshimoto M, Emori M, Iesato N, Fukushi R, Takashima H, et al. Safe, simple, and valid position for obtaining flexion-extension radiographs to assess instability in patients with lumbar spondylolisthesis: one specific instruction can make a difference. J Neurosurg Spine. 2024;42(2):133–9. doi: 10.3171/2024.7.SPINE24349 [DOI] [PubMed] [Google Scholar]
  • 66.Moradi F, Bagheri SR, Ataee M, Alimohammadi E. Can magnetic resonance imaging findings effectively diagnose the instability observed on radiographs in patients with degenerative lumbar spinal stenosis? J Orthop Surg Res. 2024;19(1):459. doi: 10.1186/s13018-024-04963-x [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 67.Saleh I, Hutami WD, Librianto D, Prasetyo M, Rahyussalim AJ, Hendriarto A, et al. The Development of New Scoring System to Define the Presence of Instability and the Need of Fusion in Degenerative Lumbar Spinal Stenosis - Jakarta Instability Score. Global Spine J. 2025;15(1):241–50. doi: 10.1177/21925682241262713 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 68.Leinweber KA, Baltic SP, Lyons KW, Mariaux F, Mannion AF, Werth PM, et al. Evaluation of the degenerative lumbar spondylolisthesis instability classification (DSIC) system as a guide to surgical technique selection. Eur Spine J. 2025;34(5):1985–94. doi: 10.1007/s00586-025-08770-8 [DOI] [PubMed] [Google Scholar]
  • 69.Glennie RA, Bailey CS, Abraham E, Manson N, Casha S, Thomas K, et al. Variation in surgical treatment of degenerative spondylolisthesis in Canada: surgeon assessment of stability and impact on treatment. Eur Spine J. 2021;30(12):3709–19. doi: 10.1007/s00586-021-06928-8 [DOI] [PubMed] [Google Scholar]
  • 70.Pieters TA, Li YI, Towner JE, Schmidt T, Vates GE, Pilcher W, et al. Comparative Analysis of Decompression Versus Decompression and Fusion for Surgical Management of Lumbar Spondylolisthesis. World Neurosurg. 2019;125:e1183–8. doi: 10.1016/j.wneu.2019.01.275 [DOI] [PubMed] [Google Scholar]
  • 71.Sastry RA, Chen J-S, Shao B, Weil RJ, Chang K-E, Maynard K, et al. Patterns in Decompression and Fusion Procedures for Patients With Lumbar Stenosis After Major Clinical Trial Results, 2016 to 2019. JAMA Netw Open. 2023;6(7):e2326357. doi: 10.1001/jamanetworkopen.2023.26357 [DOI] [PMC free article] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

S1 File. PRISMA checklist.

(DOCX)

pone.0330926.s001.docx (33.1KB, docx)
S2 File. Search strategy.

(DOCX)

pone.0330926.s002.docx (15.3KB, docx)
S3 File. Raw data set.

(DOCX)

pone.0330926.s003.docx (41KB, docx)

Data Availability Statement

All relevant data are within the paper and its Supporting Information files.

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