Review Article

Global Spine Journal

2023, Vol. 13(3) 861–872
Decompression Alone in the Setting of Adult © The Author(s) 2022
Article reuse guidelines:
Degenerative Lumbar Scoliosis and Stenosis: sagepub.com/journals-permissions
DOI: 10.1177/21925682221127955
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A Systematic Review and Meta-Analysis

Murray Echt, MD1 , Rafael De la Garza Ramos, MD2 , Eric Geng, BA3 ,
Ula Isleem, MD3 , Julia Schwarz, BS3, Steven Girdler, MD3, Andrew Platt, MD1 ,
Adewale A Bakare, MD1, Richard G Fessler, MD, PhD1 , and Samuel K Cho, MD3

Abstract
Study Design: Systematic review and meta-analysis.
OBJECTIVESSurgical decompression alone for patients with neurogenic leg pain in the setting of degenerative lumbar scoliosis
(DLS) and stenosis is commonly performed, however, there is no summary of evidence for outcomes.
Methods: A systematic search of English language medical literature databases was performed for studies describing outcomes
of decompression alone in DLS, defined as Cobb angle >10˚, and 2-year minimum follow-up. Three outcomes were examined:
1) Cobb angle progression, 2) reoperation rate, and 3) ODI and overall satisfaction. Data were pooled and weighted averages
were calculated to summarize available evidence.
Results: Across 15 studies included in the final analysis, 586 patients were examined. Average preoperative and postoperative
Cobb angles were 17.6˚ (Range: 12.7 - 25˚) and 18.0 (range 14.1 - 25˚), respectively. Average change in Cobb angle was an
increase of 1.8˚. Overall rate of reoperation ranged from 3 to 33% with an average of 9.7%. Average ODI before surgery, after
surgery, and change in scores were 56.4%, 27.2%, and an improvement of 29% respectively. Average from 8 studies that
reported patient satisfaction was 71.2%.
Conclusions: Current literature on decompression alone in the setting of DLS is sparse and is not high quality, limited to
patients with small magnitude of lumbar coronal Cobb angle, and heterogenous in the type of procedure performed. Based on
available evidence, select patients with DLS who undergo decompression alone had minimal progression of Cobb angle,
relatively low reoperation rate, and favorable patient-reported outcomes.

Keywords
degenerative lumbar scoliosis, decompression, laminectomy, radiculopathy

Introduction 1
Department of Neurological Surgery, Rush University Medical Center,
Chicago, IL, USA
Degenerative lumbar scoliosis (DLS) is a prevalent condition 2
Department of Neurological Surgery, Montefiore Medical Center/Albert
amongst the growing elderly population.1 Unlike idiopathic Einstein College of Medicine, Bronx, NY, USA
scoliosis, DLS is characterized by a mid-lumbar curve with 3
Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New
minimal compensatory thoracic curve, hypolordosis, rotatory York, NY, USA
deformity at the apex, coronal/sagittal subluxation, and ste-
Corresponding Author:
nosis.2 Radiculopathy and neurogenic claudication in the Murray Echt, Department of Neurological Surgery, Rush University
setting of DLS are common due to the presence of both Medical Center, 1725 W. Harrison St., Suite 855, Chicago, IL 60612, USA.
central, lateral recess, and foraminal stenosis.3 Significant Email: murrayecht@gmail.com

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862 Global Spine Journal 13(3)

variability in radiological findings, presenting symptoms, and Data Extraction

a heterogeneous patient population creates controversy on the
best strategies to manage the condition.4,5 Abstracts were screened by 2 reviewers, ME and JS, using the
Surgical management options include decompression inclusion and exclusion criteria stated above. In cases of
alone, decompression with limited fusion, and decompression disagreement, a third independent reviewer was involved to
with multilevel fusion for the goal of scoliosis correction.6 The make the final decision. The inclusion and exclusion of studies
use of decompression alone for radiculopathy or neurogenic was performed according to the latest version of the Preferred
claudication in the setting of DLS with stenosis is Reporting Items for Systematic Reviews and Meta-Analyses
controversial.7–9 Proponents of limited surgical intervention (PRISMA) 2020 Statement (www.prisma-statement.org). The
through simple decompression alone, cite advantages in select bias of each study was evaluated with the criteria recom-
patients, particularly in the elderly and frail.10 Opponents of mended by the Cochrane Back Review Group, and studies
this approach suggest that if a scoliotic deformity contributes were considered to have an overall low risk of bias when at
to the clinical presentation then fusion is necessary to ade- least 6 of the individual criteria were determined to have a low
quately decompress the neural elements and prevent the risk of bias.12
progression of deformity.8,9 Although decompression alone Levels of evidence were assigned based on the North
procedures may limit upfront costs, a failure to stop the American Spine Society guidelines. Three outcomes were
progression of deformity may lead to revision surgeries and examined: (1) radiological Cobb angle progression, (2) re-
increased costs long-term.11 operation rate including the need for fusion, and (3) patient-
This systematic review and meta-analysis assesses the reported outcome measures including Oswestry Disability
functional and radiological outcomes of decompression alone Index (ODI), Visual Analog Scale (VAS) for leg and back
in patients with DLS. pain, and overall satisfaction. Data were pooled to summarize
the available evidence. A qualitative review of risk factors for
progression of scoliosis after decompression was performed.
Materials and Methods
Literature Search Strategy Statistical Analysis
The Preferred Reporting Items for Systematic Reviews and Weighted means were calculated for demographic variables,
Meta-Analyses (PRISMA) guidelines were followed for the spinal measurements, and outcome measures. Studies were
present systematic review. Electronic searches were per- weighted according to their reported sample size. Calculations
formed using Ovid Medline, PubMed, Cochrane Central were performed using Python 3.8.3 and the publicly available
Register of Controlled Trials (CCTR), Cochrane Database of package Pandas 1.0.5.
Systematic Reviews (CDSR), and Database of Abstracts of
Review of Effectiveness (DARE), from their dates of in-
Results:
ception to February 2021. The final search string was: “lumbar
scoliosis” OR “degenerative scoliosis” OR “adult spinal de- Search results are summarized in the PRISMA flow diagram
formity” AND “decompression.” The reference lists of all shown in Figure 1. Our search returned 483 results from the
retrieved articles were reviewed for further identification of search of online databases. Two additional references were
potentially relevant studies. added after the bibliography review of included studies. After
the removal of 217 duplicates, 266 records were screened for
eligibility based on title and abstract. After screening, 39 full-
Eligibility Criteria text versions of the remaining studies were collected and
All studies undergoing full-text screening were included if the further assessed for eligibility. Of these 39 studies, 15 were
following criteria were met: (1) published prior to February, found to meet inclusion criteria for analysis. Of the 24 articles
2021; (2) peer-reviewed, original, and written in the English excluded, 12 were review articles offering expert opinion, 4
language or full-English translation available; (3) reported on had insufficient follow-up time, and 8 did not separate out-
clinical and/or radiographic outcomes of lumbar decom- come results for patients that did or did not have degenerative
pression alone in patients with de novo or degenerative lumbar lumbar scoliosis or from patients that underwent fusion.
scoliosis, defined as Cobb angle >10˚, no known history of
adolescent idiopathic scoliosis, and with 2 year minimum
Included Studies and Patient Demographics
follow-up; (4) format of a randomized controlled trial, non-
randomized trial, case series (≥ 2 patients), case-control study, Of the 15 studies listed in Table 1, 3 were prospective, non-
or cohort study. Abstracts, case reports, conference presen- randomized cohort studies (level III)13–15 and 12 were ret-
tations, editorials, reviews, and expert opinions were ex- rospective reviews and case series (level IV).16–27 In com-
cluded. No ethics approval was required for this study with all parative studies only patients who received decompression
data obtained from a review of the literature. alone were included further in analysis. Four studies presented
Echt et al. 863

Figure 1. PRISMA Diagram.

results with a minimally invasive technique of bilateral de- Radiographic Outcomes

compression via a unilateral approach or minimally invasive
lumbar laminectomy.13,17,19,21 2 studies presented results with Table 3 details the radiographic outcomes of included
an endoscopic approach.15,22 The other 12 studies presented studies. Nine of the included studies reported both pre-
open laminectomy and foraminotomies. operative and postoperative segmental Cobb angles
Across the 15 studies, 586 patients are represented with whereas 5 studies included only preoperative values.
demographics listed in Table 2. Follow-up ranged from 2 to 6 Hosogane et al divided outcomes into 2 groups based on
years with an average of 3.2 years. The mean age of patients was radiographic curve progression of more than 5 degrees
70.8 years old (range 54 to 77 years old). Three papers did not (Group 1) or less than 5 degrees (Group 2). 23 The average
specify gender, but among the others 59.5% of patients were Cobb angle before surgery was 17.6 degrees (range 12.7
female. Eleven papers specified the number of levels decom- to 25 degrees), and post-operatively 18.0 degrees (range
pressed with an average of 1.7. All fifteen studies described 14.1 to 25 degrees) on last follow-up. The average change
decompression only within the lumbar spine, however only 4 in Cobb angle in studies that included both preoperative
studies included at what level the decompression was and postoperative values was 1.8 degrees. Among these
performed.13,15,17,22 Among these 4 studies, the L4-5 level studies the average follow-up period was
represented the most common region for decompression. 3.6 years. 14,17,19,20,23–27
864 Global Spine Journal 13(3)

Table 1. Included studies and level of evidence.

First Author Year Study Period Study Design Surgical technique Level of Evidence

Liu 2009 2001-2006 R OP IV

Kelleher 2010 2002-2006 R MIS IV
Matsumura 2010 NR R MIS IV
Transfeldt 2010 1999-2005 R OP IV
Daubs 2012 1996-2003 R OP IV
Hosogane 2013 2005-2010 R OP IV
Kleinstueck 2016 2005-2011 R OP IV
Kato 2017 2007-2011 Pro MIS III
Minamide 2017 2008-2013 R MIS IV
Gadiya 2019 2006-2016 R OP IV
Brodke 2013 2004-2009 R OP IV
Hatta 2018 2003-2007 R OP IV
Masuda 2018 2005-2013 Pro OP III
Jin 2020 2015-2018 R Endoscopic IV
Wu 2020 2015-2017 Pro Endoscopic III
NR = not reported, R = Retrospective, Pro = prospective, OP = open posterior, MIS = minimally invasive surgery (bilateral decompression via a unilateral
approach), value in [] represents range if provided, standard deviation value provided after (±) if available.

Table 2. Patient Demographics.

First- Patient, Follow-up Average Mean Age Gender (% Number of Levels

author n (Years) (Years) male) Decompressed Lumbar Level Decompressed

Liu 15 5.7 [2.5-7] 54.7 [43-67] 42 NR NR

Kelleher 28 3 [2-5.7] 68 [ 40-89] 52 1.4 NR
Matsumura 25 3.6 [2-7.4] 69.6 [53-82] 40 1.8 L3-4 – 18; L4-5 – 22; NS Lumbar
segment – 5
Transfeldt 21 4.75 [2.0-8.1] 77 [52-85] NR NR NR
Daubs 16 4.6 75.6 ± 6 NR 1.9 NR
Hosogane 50 2.8 70.2 ± 5.8 36 1.7 NR
Kleinstueck 81 2 75.8 ± 7.4 33 2.2 ± 0.8 NR
Kato 37 2.0 [2-2.1] 70.7 ± 7.7 51 1.5 L3-4 – 1; L4-5 – 17; L5-S1 – 1; L2-3-4 –
3 ; L3-4-5 – 15
Minamide 122 2.4 70.4 ± 8 47 NR NR
Gadiya 51 4 ± 1.5 63.9 ± 7.2 39 NR NR
Brodke 24 5.25 [2-7.9] 69 ± 9.2 NR NR NR
Hatta 20 5.94 [5-8.3] 71.2 [61-82] 20 2.0 NR
Masuda 25 5.5 [3.5-8] 73 [61 -86] 56 1.4 NR
Jin 46 2.76 73.5 ± 8.1 28 1.4 L1-2 – 3; L2-3 – 3; L3-4 – 10; L4-5 – 37;
L5-S1 – 13
Wu 25 2 72.6 ± 10.5 40 1.7 ± 0.6 L2-3 – 2; L3-4 – 20; L4-5 – 20; L5-S1 –
1
NR = not reported, NS = not specified, value in [] represents range if provided, standard deviation value provided after (±) if available

Four of the included studies reported preoperative and Clinical Outcomes

postoperative lumbar lordosis with or without describing
pelvic incidence whereas 3 studies included only preoperative The most used validated outcome measure was the ODI,
values.14,20,24,25 The average pre-operative lordosis was 32.0 which was tracked in 6 studies listed in Table 4.15,16,20–22,25
degrees and post-operative lordosis was 25.2 degrees. The The average ODI before surgery, after surgery, and change in
average change in lumbar lordosis was a negative (-) 2.2 score was 28.2, 13.6, and -29% respectively. This represents
degrees. Among the studies that included the lumbar lordosis, an overall shift from severe to moderate disability. Five studies
the average follow-up period was 4.9 years. included preoperative VAS for both back and leg pain with an
Echt et al. 865

Table 3. Radiographic Outcomes

Cobb Angle (degrees) Lumbar Lordosis (degrees)

First Author Preop Postop Change Preop Postop Change

Liu 15.3 ±3.7 19.9 ± 6.1 4.6 28.7 24.4 -4.3

Kelleher 13.9 [10-32] NR NR NR NR NR
Matsumura 12.7 14.1 1.4 NR NR NR
Transfeldt 25 NR NR 46 NR NR
Daubs 16 18 2 NR NR NR
Hosogane
Group 1 16.1 ± 11.2 24.6 ± 10.4 8.5 ± 4.8 33.5 ± 17.5 NR NR
Group 2 17.2 ± 6.0 19.0 ± 6.6 2.0 ± 1.9 36.9 ± 13.7 NR NR
Kleinstueck 20.4 ±10 NR NR NR NR NR
Kato 13.8 [10-18] NR NR NR NR NR
Minamide 16.3 ±7.1 17.8 ± 9.9 1.5 NR NR NR
Gadiya 20.8 ± 5.1 21.9 ± 5.7 1.1 30.2 ± 7.9 27.5 ± 7.1 -2.7
Brodke 14 ±3.6 14 ±5.9 0 ±3.5
Hatta 14.9 ±5.5 17.8 ±6.5 2.9 19.7 ±12.6 17.2 ±13.8 -2.5
Masuda 14 ±2.9 14.3 ±6.4 0.3 27.5 ±13.4 27.8 0.3
Jin 24.5 ± 8.2 NR NR 31.6 ±16.1 NR NR
Wu NR NR NR NR NR NR

NR = not reported, value in [] represents range if provided, standard deviation value provided after (±) if available

Table 4. Clinical Outcomes

ODI VAS Back Pain VAS Leg Pain

First Author Preop Score Postop Score Change in Score (%) Preop Postop Preop Postop Patient Satisfaction

Liu 22.7 ± 3.9 16.2 ± 4.1 12.9 NR NR NR NR NR

Kelleher 25.9 13.4 24.9 NR NR NR NR 80%
Matsumura NR NR NR NR NR NR NR NR
Transfeldt 19.8 15.8 7.9 NR NR NR NR 73%
Daubs NR NR NR NR NR NR NR 50%
Hosogane
Group 1 NR NR NR NR NR NR NR NR
Group 2 NR NR NR NR NR NR NR NR
Kleinstueck NR NR NR 5.1±2.9 NR 6.9±2.2 NR 79%
Kato NR NR NR 5.0±2.5 4.1±2.3 7.0±2.6 2.3±3.0
Minamide NR NR NR 5.6±2.8 3.5±3.0 NR NR 60%
Gadiya 30.4 ±5.9 16.4 ± 4.5 27.9 ±12.4 4.9±1.9 6.0±1.2 5.8±1.1 2.6±1.2 NR
Brodke NR NR NR NR 85%
Hatta NR NR NR NR NR NR NR NR
Masuda NR NR NR NR NR NR NR NR
Jin 31 ± 4.3 11.5 ± 5.9 39 4.0±1.2 3.0±1.4 8.2±0.6 1.9±0.4 78%
Wu 31.4 ± 7.4 8.5 ± 7.7 45.7 7.0±2.0 2.0±1.8 7.6±1.4 1.6±1.7 80%
NR = not reported, standard deviation value provided after (±) if available.
ODI = Oswestry Disability Index
VAS = Visual Analog Scale

average VAS back pain of 5.2 and VAS leg pain of pain of 2.2.13,15,22,25 8 studies reported generic patient sat-
7.0.13,15,18,22,25 The average ratio of preoperative VAS leg isfaction with surgery with a mean of
pain to VAS back pain was 1.4 (range 1.1 to 2.1). Four studies 71.2%.15,16,18,19,21,22,26,27
included postoperative outcomes for both VAS back and leg Complications and revisions were described and listed in
pain resulting in an average VAS back pain of 3.8 and VAS leg Table 5. The complication rate was 8% across 7 studies, and
866 Global Spine Journal 13(3)

Table 5. Complication and Revision Rates

First Author Complications Reoperation Rate of revision fusion Rate of revision decompression

Liu NS 33.3% 33.3% 0%

Kelleher 12% 25% NR NR
Matsumura NR 8% 8% 0%
Transfeldt 10.00% 10% 0% 10%
Daubs 7% 25% 18.8% 6.3%
Hosogane
Group 1 NR 10% 0% 10%
Group 2 NR 10% 2.60% 7.7%
Kleinstueck 12% 7% 2.50% 1.2%
Kato 0% 8.1% 8.10% 0%
Minamide NR 3.3% 3.30% 0%
Gadiya NR 3.9% NR NR
Brodke 8% 8.3% NR NR
Hatta NR 30.0% NR NR
Masuda 0% 8% 4% 4%
Jin NR NR NR NR
Wu NR NR NR NR
NR = not reported

most commonly included wound infection, epidural hema- follow-up period, decompression level, apical vertebral ro-
toma, and durotomy.13,14,16,18,21,26,27 Overall rate of reoper- tation, Cobb angle at decompression level, lumbar lordosis,
ation was 9.7% reported in 13 of the 15 included T10-L2 sagittal angle, rotatory subluxation >5mm, Cobb
publications.13,14,16–21,23–27 9 of these studies further de- angle of main curve, pelvic tilt angle, and
scribed the type of revision surgery including need for fusion spondylolisthesis >5mm.23 However, in both their univariate
vs revision decompression, averages were 4.3% vs 2.4% and multivariate logistic regression analysis no variable
respectively.13,14,16–20,23,26 Among these 9 studies, the aver- reached statistical significance.
age follow-up period was 2.8 years. Minamide et al found that patients with preoperative Cobb
angle over 20 degrees were more likely to have curve pro-
gression more than 5 degrees than patients with preoperative
Risk Factors for Progression of Scoliosis and Revision Cobb angle less than 20 degrees (40 vs 15%, P < .05) as well
Surgery or Poor Outcomes as a higher rate of additional fusion (13 vs 1%, P < .05).19
Four studies further specified risk factors for Cobb angle They also evaluated risk factors for poor outcomes based on
progression, revision surgery, and poor outcomes. Matsumura Japanese Orthopaedic Association (JOA) score, and demon-
et al reported 2 patients requiring additional fusion, of which 1 strated that gender, preoperative severe lumbar coronal Cobb
was due to poor facet preservation leading to curve pro- angle (mean; 29.6 ± 7.9o), increased preoperative pelvic tilt
gression.17 They further postulated that the approach side may (mean; 28.3 ± 11.5 o) and preoperative mismatch of pelvic
influence facet preservation, and when using the convex incidence minus lumbar lordosis (mean; 35.5 ± 21.2 o) were
approach there was around 80% of the facet preserved and no significant (P < .05).
curve progression. In contrast, the concave approach led to Transfeldt et al performed a logistic regression analysis for
approximately 50% facet preservation, which may have led to probable risk factors for less than successful outcomes and
curve progression and poor clinical outcome in the 2 reported demonstrated 2 significant factors, a sacrum to curve apex
patients. Conversely, Hosogane et al found that Cobb angle fusion, and a positive sagittal malalignment greater than
progression did not affect outcomes. They compared patients 4.0 cm after surgery.16 Rotatory olisthesis was not found to be
that demonstrated Cobb angle progression over 5 degrees a significant factor.
(Group 1) and no progression (Group 2), and reported equal
rates of reoperation of 10% for both groups.23
Hosogane et al also performed analysis of 15 variables to
Discussion
determine risk factors for progression of the lumbar curve, Degenerative lumbar scoliosis with associated stenosis re-
including vertebral osteophyte on the concave or convex side, mains a challenging spinal pathology without a standard
decompression method (fenestration vs laminectomy vs spi- surgical treatment algorithm based on high-quality evidence.28
nous process splitting), age, disc degeneration, L-5 tilt angle, This is due to limited evidence as the majority of studies (12
Echt et al. 867

out of 15) included in this systematic review were retro- Previous studies favored fusion for patients with DLS due
spective case series, level IV evidence. In addition, the to the perceived high revision rate for decompression alone.8
complexity of the pathology along with a highly variable There is, however, also a high rate of complications and re-
amount of patient comorbidities, functional status, and both vision surgery following short-segment fusion or full curve
surgeon and patient preferences add to the convolution of correction with the reported incidence varying between
decision making for surgery.6 An increasing number of studies.38,39 Reoperation risk from a large prospective mul-
complex reconstructive surgery being performed for DLS has ticenter adult spinal deformity database report a 17% risk of
raised concerns about the high rate of complications and reoperation, including instrumentation failure as the most
revision surgery as well as the higher total cost, especially in common reason for a return to surgery.40 Pellise et al recently
elderly patients.29 Limiting surgical morbidity to the least analyzed the 2 largest multicenter data sets available, and,
invasive approach via decompressing areas of stenosis alone even with significant improvements in surgeon experience and
has become favored in select patient populations.30 However, medical management, the most recent 2 year major compli-
the durability of this approach has not yet received a full cation rate was 23% and reintervention rate was 16%.41
appraisal of the literature.31 In this systematic review, for the Clearly, the patients in this study have a greater degree of
first time the radiographic and clinical outcomes of decom- spinal deformity and are not readily comparable to the patients
pression alone in the setting of DLS over an average 3-year represented in this systematic review. However, trends in the
period are described. improvement of quality metrics coincided with trends in
Radiographically, the degree of scoliosis as measured by decreased surgical invasiveness, including a decrease in mean
Cobb angle progressed at a rate of approximately 2 degrees per number of fused segments, pelvic fixation, and three-column
2-year follow-up after surgery. This rate is equivalent to the osteotomies. Similarly, Deyo et al found in a retrospective
rate of progression seen with natural history as reported by cohort analysis of Medicare claims of procedures performed
Pritchett and Bortell of an average 3 degrees per year over a 5 for older patients with spinal stenosis trends of increasing
year period.32 Of note, the patient population in their study had frequency of complex fusions and decreasing frequency of
a higher average preoperative Cobb angle of 24 degrees decompression alone were associated with a rise in major
compared with the weighted mean of 17.6 degrees seen across complications, 30-day mortality, and costs.42 As such, further
the selected studies presented here. Thus, among the well- work must be done to identify appropriate cases for decom-
selected patients included in the above publications, with mild pression alone in DLS, and to compare effectiveness to more
to moderate degenerative lumbar curves, there was a low complex and potentially higher risk short-segment fusion or
magnitude of progression following decompression alone. full curve corrections.
Although mild hypolordosis and positive sagittal malalign- Brodke et al provided a direct comparison between lam-
ment were present among the included patients, this finding inectomy without fusion vs laminectomy and fusion by ex-
did not significantly worsen in the reported results following cluding patients from the study if the deformity precluded the
decompression alone. Buckland et al demonstrated patients option for either treatment.27 The radiographical parameters
with DLS permit mild to moderate sagittal malalignment varied minimally with mean preoperative Cobb angle of 14
without recruiting compensatory mechanisms to achieve degrees for both groups. Their results demonstrate that lam-
neural decompression, however ultimately the drive for up- inectomy and fusion had a higher rate of reoperation due to
right posture becomes the priority seen by the adoption of symptomatic adjacent segment pathology, whereas lam-
increased pelvic tilt.33 inectomy alone had the highest rate of progression free sur-
Current trends include finding minimally invasive surgery vival. Thus, when considering surgical options there must be
(MIS) alternatives for DLS.34,35 A prior meta-analyses focusing an analysis between the rate of re-developing stenotic
on MIS approaches to DLS by Dangelmajer et al compared symptoms or instability in decompression alone vs the rate of
twelve studies in the MIS group, including 8 studies utilizing pseudarthrosis and adjacent segment complications in fusion
extreme lateral interbody fusion (XLIF) and 4 studies utilizing procedures. Additionally, proceeding to full curve correction
decompression alone, against thirty-five studies in the open is less invasive following previous decompression alone than
surgery and fusion group with or without osteotomy.36 Another after a previous in-situ short-segment fusion.43
meta-analysis by Wang et al also compared various surgical Studies that included patients treated by all 3 methods were
treatments for DLS, including 9 studies that performed de- specifically described as distinct patient populations not in-
compression alone.37 3 of these studies, however, incorporated tended for direct comparison.16,18,26 This current review is
dynamic stabilization instrumentation as part of the decom- therefore unable to decide which surgical technique is best for
pression alone group. Thus, both systematic reviews did not DLS, however demonstrates that decompression alone is an
yield more than 6 studies that performed decompression alone effective intervention in the well selected patient groups
because of a limited search and broad comparisons. As such, this represented herein. Mummaneni et al presented an updated 4-
current systematic review builds upon the previous works by level treatment algorithm, the MISDEF2 algorithm, to aid
adjusting a focus solely to assessing the outcomes of the least spine surgeons in fitting patients into specific criteria.44
invasive approach available – decompression alone. Glassman et al also presented appropriate use criteria for
868 Global Spine Journal 13(3)

lumbar degenerative scoliosis.45 Both papers provide a more factors may not be directly applicable to an individual patient.
thorough overview of the decision-making process to select an Thus, shared decision making with the patient and considering
appropriate level of intervention given the patient’s primary their chief complaints and goals of surgery are paramount.
symptoms and radiographic findings. However, both papers Studies that measured the intensity of leg to back pain
relied on panels of experts that methodically determined demonstrated the importance of an absence of severe back
appropriateness of an intervention for a specific clinical pain (VAS <8), as predominant axial back pain is strongly
scenario. Our results after a systematic review of the literature correlated with potential instability or sagittal
offers further evidence-based support for these expert rec- imbalance.13,15,22,25 Further work may define more strict
ommendations. It is important to note smaller deformities with criteria based on the ratio of leg pain to back pain.
small coronal Cobb angle less than 20 degrees and normal Other factors to consider are foraminal stenosis due to
sagittal alignment are a common presentation seen in clinical severe disc wedging resulting from approximation of the
practice. Yet, the decision to offer decompression alone for pedicles will be better suited via interbody fusion allowing for
these patients is primarily based off expert opinion and has not indirect decompression in the cranial-caudal dimension. In
been well studied, as demonstrated by the low level of evi- addition, the finding of a mobile spondylolisthesis coexisting
dence available. Thus, most importantly this systematic re- with DLS is a contraindication to decompression alone and
view demonstrates a need for these patients with mild to necessitates at least a limited fusion.14 Phan et al demonstrated
moderate DLS to be enrolled in large, multicenter prospective that these patients with mild DLS and focal deformities or
comparison studies with greater follow-up periods. instability may be more amenable to a short vs long segment
Risk factors for poor patient-reported outcomes included fusion.47
preoperative severe lumbar coronal Cobb angle (mean; 29.6 ± As the number of older and elderly patients with DLS
7.9o), increased preoperative pelvic tilt (mean 28.3) preop- increases so does the prevalence of osteoporosis in spinal
erative mismatch of pelvic incidence minus lumbar lordosis surgery.48,49 Decreased bone mineral density was previously
(mean 35.5), and poor facet preservation (approximately 50%) thought to be a significant risk factor for progression seen in
on the approach side of the concavity.17,19 However, a patient the natural history of DLS, with regional malalignment re-
that falls outside these parameters is represented in Figure 2 sulting in asymmetric compression fractures and accelerating
with a severe T12-L4 curve of 33 degrees but relatively the progression of deformity.50,51 However, recent studies
balanced without significant coronal offset or sagittal mala- have demonstrated no correlation between bone mineral
lignment. Figure 3 demonstrates a MIS decompression with density and curve progression in DLS, including both mea-
follow-up full-length x-rays demonstrating a stable deformity. surements on dual-energy x-ray absorptiometry scans and
Faraj et al performed a systematic review of prognostic factors Hounsfield units.46,52–54 Osteoporosis and bone mineral
for curve progression in DLS, and found that the majority of density have, on the other hand, consistently demonstrated to
prognostic factors were limited, conflicting, or inconsistent.46 be a major risk factor for instrumentation failure and proximal
As such, the authors demonstrated that many of these risk junctional failure.55–58 Unfortunately, none of the current

Figure 2. A 68 year-old woman presenting with primarily left greater than right radiating leg pain due to cranial disc extrusion and spinal
stenosis at L4-5 seen on sagittal T2-weighted MRI (A), axial cuts shown at the level behind the L4 body and L4-5 disc space, respectively (B &
C), and a severe T12-L4 curve of 33 degrees on standing AP lumbar x-ray (D).
Echt et al. 869

Figure 3. demonstrates a minimally invasive tubular decompression (A) with 1-year follow-up full-length AP and Lateral x-rays (B)
demonstrating a stable deformity without progression.

studies listed herein are stratified by bone mineral density Duration of follow-up was another profound limitation,
measurements, and thus no conclusions can be made regarding particularly in DLS where the natural history is slow and
its effect on decompression alone in DLS. This is a major greater time intervals are needed. The longest average follow-
potential area of study. up period was shy of 6 years, and the minimum was 2-year
follow-up. If significant destabilization after decompression
Limitations alone occurred presumably deterioration will be seen within
the first 2 years. However, if the durability of a procedure is
Limitations of this study include the inability to directly under analysis, then future studies with long-term follow-up of
compare results between decompression alone, short-segment, 10-years is required.
and long-segment fusions. While several reports include pa- Additionally, while all included studies report only patients
tients treated by all 3 methods, they were specifically de- with adult degenerative, or de novo, scoliosis were included, it
scribed as different patient populations not meant for is possible that some patients were actually untreated ado-
comparison. The ability to provide a meta-analysis comparing lescent idiopathic scoliosis (AIS) with superimposed degen-
outcomes was thus limited by the methods of the included erative changes. This is an important factor since DLS and
papers. adult progression of AIS are distinct in their treatment and
The other main limitation to this analysis is the low level of prognosis. However, patients with adult progression of AIS
evidence in all the included studies, and the indications for are typically easy to differentiate by the presence of higher
decompression alone, the surgical techniques, and outcome degrees of curvature and younger age of presentation. The
measures varied significantly. Thus, the reported case series included patients reported by each study demonstrated lesser
are susceptible to bias in their results. It is also difficult to draw degrees of curvature and older age making this possible
final conclusions from small sample sizes which was made confounding factor less likely.
more complex by heterogeneity of levels, approach side at the While the analysis is limited to compiling the available data
convexity vs concavity, limited radiographic follow-up, and for decompression alone for DLS, it provides for the first time
no standard reported outcome measures. Importantly, lumbar a compilation of the literature regarding the radiographic and
lordosis and pelvic tilt were poorly reported, and it is not clinical outcomes of decompression alone in the setting of
known if the decompressions were primarily in the fractional DLS over an average 3-year period. This results in a consistent
curve or at the concavity of the mid-lumbar curve. However, demonstration of a relatively low rate of deformity progres-
all studies reported decompressions only in the lumbar spine, sion and need for revision surgery in carefully selected pa-
and not remote from the degenerative lumbar scoliosis. tients. Perhaps most compelling to advocate for a
870 Global Spine Journal 13(3)

decompression only approach in these case series is to reflect 2. Epstein JA, Epstein, Epstein BS, Jones MD. Symptomatic
its already accepted use in current clinical practices. In ad- lumbar scoliosis with degenerative changes in the elderly. Spine
dition, risk factors for Cobb angle progression, revision (Phila Pa 1976). 1979;4(6):542-547. doi:10.1097/00007632-
surgery, and poor outcomes revealed in the included studies 197911000-00017
represent important considerations for clinical evaluation and 3. Liu H, Ishihara H, Kanamori M, Kawaguchi Y, Ohmori K,
for future study. The weighted averages described herein may Kimura T. Characteristics of nerve root compression caused by
provide a baseline, but most importantly demonstrates a need degenerative lumbar spinal stenosis with scoliosis. Spine J.
for future large, multicenter prospective comparison studies 2003;3(6):524-529. doi:10.1016/j.spinee.2003.07.006
with greater follow-up periods. 4. Gupta MC. Degenerative scoliosis: Options for surgical man-
agement. Orthop Clin North Am. 2003;34(2):269-279. doi:10.
1016/S0030-5898(03)00029-4
Conclusions 5. Tribus CB. Degenerative lumbar scoliosis: evaluation and
Current literature on decompression alone in the setting of management. J Am Acad Orthop Surg. 2003;11(3):174-183. doi:
DLS is sparse and is not high quality, limited to patients with 10.5435/00124635-200305000-00004
small magnitude of lumbar coronal Cobb angle, and heter- 6. Kim YJ, Hyun SJ, Cheh G, Cho SK, Rhim SC. Decision making
ogenous in the type of procedure performed. Based on algorithm for adult spinal deformity surgery. J Korean Neurosurg
available evidence, well-selected patients with DLS who Soc. 2016;59(4):327-333. doi:10.3340/jkns.2016.59.4.327
undergo decompression alone had minimal progression of 7. Houten JK, Nasser R. Symptomatic progression of degenerative
Cobb angle, relatively low reoperation rate, and favorable scoliosis after decompression and limited fusion surgery for
patient-reported outcomes. A low complication rate and du- lumbar spinal stenosis. J Clin Neurosci. 2013;20(4):613-615.
rable outcomes may be expected for selected patients with doi:10.1016/j.jocn.2012.06.002
predominant symptoms related to stenosis in the presence of 8. Berven S, DiGiorgio A. The Case for Deformity Correction in
mild degenerative scoliosis, but further study is needed. the Management of Radiculopathy with Concurrent Spinal
Deformity. Neurosurg Clin N Am. 2017;28(3):341-347. doi:10.
Declaration of Conflicting Interests 1016/j.nec.2017.03.002
9. Frazier DD, Lipson SJ, Fossel AH, Katz JN. Associations be-
The author(s) declared the following potential conflicts of interest
tween spinal deformity and outcomes after decompression for
with respect to the research, authorship, and/or publication of this
spinal stenosis. Spine (Phila Pa 1976). 1997;22(17):2025-2029.
article: Dr. Richard Fessler receives consulting fees from DePuy-
doi:10.1097/00007632-199709010-00017
Synthes and Benvenue. Dr. Samuel Cho receives consulting fees
10. Weidenbaum M. Considerations for focused surgical intervention
from Globus, Zimmer, and Medtronic. The other authors have no
in the presence of adult spinal deformity. Spine (Phila Pa 1976).
conflict of interest to disclose.
2006;31(19 suppl L.):139-143. doi:10.1097/01.brs.0000231964.
43289.10
Funding 11. Indrakanti SS, Weber MH, Takemoto SK, Hu SS, Polly D, Berven
The author(s) received no financial support for the research, au- SH. Value-based care in the management of spinal disorders: A
thorship, and/or publication of this article. systematic review of cost-utility analysis. Clin Orthop Relat Res.
2012;470(4):1106-1123. doi:10.1007/s11999-011-2141-2
ORCID iDs 12. Furlan AD, Pennick V, Bombardier C, van Tulder M,
Murray Echt  https://orcid.org/0000-0002-4504-4918 Editorial Board CBRG. 2009 updated method guidelines for
Rafael De la Garza Ramos  https://orcid.org/0000-0002-5536- systematic reviews in the Cochrane Back Review Group.
2514 Spine (Phila Pa 1976). 2009;34(18):1929-1941. doi:10.1097/
Eric Geng  https://orcid.org/0000-0003-0736-3245 BRS.0b013e3181b1c99f
Ula Isleem  https://orcid.org/0000-0002-3965-3071 13. Kato M, Namikawa T, Matsumura A, Konishi S, Nakamura H.
Andrew Platt  https://orcid.org/0000-0002-2514-2705 Radiographic Risk Factors of Reoperation Following Minimally
Richard G Fessler  https://orcid.org/0000-0002-7432-0950 Invasive Decompression for Lumbar Canal Stenosis Associated
With Degenerative Scoliosis and Spondylolisthesis. Glob Spine
Supplemental Material J. 2017;7(6):498-505. doi:10.1177/2192568217699192
14. Masuda K, Higashi T, Yamada K, Sekiya T, Saito T. The surgical
Supplemental material for this article is available online. outcome of decompression alone versus decompression with
limited fusion for degenerative lumbar scoliosis. J Neurosurg
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