Patterns and preferences of fusion selections in the treatment of lumbar spondylolisthesis among spine surgeons

Introduction: Lumbar degenerative spondylolisthesis is a common clinical condition that spine surgeons across the globe treat routinely. Patients with symptomatic lumbar spondylolisthesis may present with significant variations of clinical presentation and radiographic findings that impact surgeons- treatment decisions. Age-related and other medical and anatomical considerations may alter surgeons- surgical strategies. The current study aims to understand how often surgeons decide to fuse in lumbar spondylolisthesis based on differences in clinical, radiographical, and patient factors. Additionally, the study aims to reveal patterns and preferences of various fusion types from surgeons worldwide. Material and Methods: Three lumbar spondylolisthesis cases were electronically presented to AOSpine international members to study surgeons- preferences for treatment considerations. Case 1 included an elderly patient with mainly radiculopathy and severe central stenosis without dynamic instability, case 2 included a younger patient with mechanical back pain and radiculopathy with severe central and neuroforaminal stenosis and significant instability on dynamic xrays, and case 3 had an older patient with back pain and radiculopathy with instability on dynamic x-rays without severe central stenosis. Data collected includes demographics, training background, years of experience, and treatment decisions based on various radiographical findings, including segmental measures and global and spinopelvic parameters. The survey was distributed online to over 6000 AO Spine members between July 27 , September 8, 2023. 943 responded, and 479 completed the survey. Responses to questions about decision-making parameters and surgical technique preferences in treating grade 1 L4-5 spondylolisthesis were collected and analyzed. Comparative analysis was performed using the Pearson Chi-Squared Test. Results: In all cases, fusionwas the preferred treatment among all surveyed surgeons. Even without dynamic instability and mainly radiculopathy, 75.2% responded that they would fuse. Selection of fusion methods were distributed widely across all cases, ranging from 0.3% to 20.2% in case 1 with radiculopathy without dynamic instability, 0.5% to 17% in case 2 with back pain, and radiculopathy associated with dynamic instability with severe central and neuroforaminal stenosis, and 0.2% to 21.8% in case 3 with back pain and radiculopathy associated with dynamic instability without central or neuroforaminal stenosis. Overall, posterolateral fusion with direct decompression was the most common procedure among surveyed surgeons in patients with severe central stenosis without dynamic instability, followed by MIS transforaminal interbody fusion and posterior lumbar interbody fusion (PLIF). On the other hand, anterior and lateral approaches for fusion are less commonly chosen across all three cases. Dynamic instability was associated with increased utilization of anterior lumbar interbody fusion and lateral transpsoas or pre-psoas interbody fusions. There were no significant differences between orthopedics vs. neurosurgery, fellowship vs. no fellowship, academic/university practices vs. private practices, or \textless 15 years experience vs. \textgreater 15 years experience in selecting their surgical approaches. Conclusion: Fusion remains the most preferred procedure for treating lumbar degenerative spondylolisthesis by spine surgeons around the globe, and most surgeons favor posterolateral fusion with direct decompression in spondylolisthesis, followed by MIS TLIF and PLIF. There were no significant differences in the selection of fusion methods by subspecialty, fellowship status, practice setting, and years of experience.