J Orthop. 2025 May 27;68:175-184. doi: 10.1016/j.jor.2025.05.059. eCollection 2025 Oct.
ABSTRACT
INTRODUCTION: Spinal fusion is a common treatment for degenerative or isthmic lumbar spondylolisthesis (LS) in adult patients, where vertebral slippage can lead to significant neurological impairment. However, debate exists regarding the exact fixation method, as fusion and complication rates may differ via instrumented fusion (IF) or uninstrumented fusion (UIF). Therefore, the purpose of this study is to investigate the high-level literature for the fusion and complication rates associated with IF versus UIF to guide decision-making.
METHODS: This systematic review and meta-analysis utilized PubMed, SCOPUS, and Web of Science through September 15th, 2024, to assess the fusion and complication rates associated with IF versus UIF for LS. Inclusion criteria included randomized controlled trials (RCTs) only. The primary outcomes were rates of fusion, reoperation, and complication rates. Statistical analysis included relative risk (RR) with 95 % confidence intervals (CI) along with trial sequential analysis (TSA) and assessment of fragility index (FI).
RESULTS: A total of five RCTs were included in this study out of the 799 articles initially retrieved. Included patients (n = 286; 72.02 % female) had a mean age of 60.97 years and underwent either IF (n = 150) or UIF (n = 136) for LS with a mean follow-up of 2.31 years. Roughly 26.92 % of patients had isthmic LS (n = 77) and 73.08 % of patients had degenerative LS (n = 209) with 98.91 % of patients (n = 182/184) having a grade 1 or 2 LS. Patients who underwent IF had a statistically significant higher rate of fusion as compared to patients who underwent UIF for LS (90.7 % versus 48.5 %; RR: 1.96; 95 % CI: [1.23, 3.13]; p = 0.005) with robust evidence (FI: 11 patients). However, there was no statistically significant difference in reoperation rates (10.4 % versus 2.7 %; RR: 1.05; 95 % CI: [0.97,1.13]; p = 0.264) or total complication rates (7.3 % versus 2.4 %; RR: 0.90; 95 % CI: [0.90, 1.02]; p = 0.228) between patients who underwent IF versus UIF for LS. TSA for all primary outcomes demonstrated a Z-curve that did not cross the required information size, suggesting more research is needed for definitive conclusions on this topic. Qualitatively, two RCTs reported greater operative time (OT) and estimated blood loss (EBL) for IF as compared to UIF for LS.
CONCLUSION: Among adult patients with LS, IF resulted in a robust and statistically significant higher fusion rate as compared to UIF, although more research is needed for definitive conclusions. However, there was no statistically significant difference in reoperation or total complication rates for IF versus UIF for LS.
PMID:40530324 | PMC:PMC12167837 | DOI:10.1016/j.jor.2025.05.059
