Patient outcomes: One-stage vs. two-stage lumbar surgery for symptomatic low-grade spondylolisthesis: A quality outcomes database study

Objective: Controversy exists regarding treatment of symptomatic low-grade spondylolisthesis (LGS). Both one- and two-stage fusions are commonly performed, but it is unclear if one approach is superior. We aim to compare the satisfaction rates and patient-reported outcomes (PROs) in patients with LGS undergoing one- versus two-stage lumbar spine surgery.

Methods: The Quality Outcomes Database was queried for patients with Grades I and II spondylolisthesis who underwent one- (n = 3223) or two-stage (n = 325), 1-2 level lumbar fusion. Demographics, comorbidities, symptom burden, and PROs were extracted and compared. Outcomes included Visual Analogue Scale (VAS) for back and leg pain, Oswestry Disability Index (ODI), Quality-Adjusted Life Year (QALY), and satisfaction index. Minimal clinically important difference (MCID) values for VAS back pain, VAS leg pain, ODI, and QALY were 1.6, 1.7, 14.3, and 0.2, respectively. Patients with pre-existing scoliosis or kyphosis, missing data, and revision procedures were excluded. Categorical variables were compared with a Chi-square test; continuous variables were assessed for normality with a Shapiro Wilk test and compared with a Mann-Whitney U or Student's t-test.

Results: No significant differences were noted for baseline characteristics, except for a lower mean age, percentage of female patients, and prevalence of osteoporosis in the two-stage cohort (58 ± 12.4 vs 62 ± 11.6 years; 50 % vs 62 %; 3.0 % vs 7.1 %, respectively; p < 0.01). The average surgery length was longer in the two-stage cohort (p < 0.01). A significantly higher percentage of patients returned to baseline activities within 3 months postoperatively following one-stage procedures (43 % vs. 29 %, p < 0.01), irrespective of whether they had Grade 1 or Grade 2 spondylolisthesis. Comparable proportions of patients achieved the MCID for PROs, with no significant differences in satisfaction indices observed at 3, 12, and 24 months postoperatively, regardless of preoperative spondylolisthesis grade.

Conclusions: Patients receiving one and two-stage procedures for symptomatic LGS had similar rates of satisfaction and PROs. More research is necessary to define the benefits of two-stage approaches given their increased time, cost, and risk profile.