Indirect Lumbar Decompression Combined With or Without Additional Direct Posterior Decompression: A Systematic Review

Abstract

Study Design: Systematic review. Objective: Indirect decompression via lateral lumbar interbody fusion (LLIF) can ameliorate central and foraminal lumbar stenosis. In severe central stenosis, additional posterior direct decompression is utilized. The aim of this review is to synthesize existing literature on these 2 techniques and identify significant differences in outcomes between isolated indirect decompression via LLIF and combined indirect decompression supplemented with direct posterior decompression. Methods: A database search algorithm was utilized to query MEDLINE, COCHRANE, and EMBASE to identify literature reporting adult decompression study groups that involved an oblique or lateral fusion approach through September 2020. Improvement in outcomes measures and complication rates were pooled and tested for significance. Results: A total of 110 publications were assessed with 15 studies meeting inclusion criteria, including 557 patients and 1008 levels. Mean age was 63.1 years with BMI of 27.5 kg/m2. For the combined indirect and direct decompression cohort, lumbar lordosis (LL) increased 133.9%, from 22.8o to 48.7o, while the indirect decompression cohort LL increased 8.9%, from 41.9o to 45.5o. Difference in LL improvement between cohorts was insignificant ( P > .05). Oswestry Disability Index (ODI) decreased from 36.5 to 19.4 in the combined indirect and direct decompression cohort, and from 44.4 to 23.1 in the indirect decompression cohort. ODI reduction was insignificant ( P = .053). Conclusions: Prior studies of both indirect decompression as well as combined indirect and direct decompression of lumbar spine stenosis are limited by small samples, heterogeneous populations, and lack of direct comparisons. Both procedures result in improved function and pain postoperatively with direct decompression restoring more lordosis in patients with worse preoperative alignment.

Pearls and Pitfalls of Oblique Lateral Interbody Fusion: A Comprehensive Narrative Review

“…Additional posterior direct decompression can be performed in conjunction with indirect decompression, particularly in cases with severe stenosis or a sequestered disc [ 34 , 35 ]. In a recent systemic review, Manzur et al [ 36 ] compared clinical outcomes between isolated indirect decompression and combined indirect and direct decompression. In this study, the isolated indirect decompression group tended to have a more significant improvement in the Oswestry Disability Index (ODI; 21.3% vs. 17.1%, p=0.053).…”

Novel Combination of Lateral Interbody Fusion and Endoscopic Ipsi-Contra Decompression for Severe Stenosis From Lumbar Spondylolisthesis: A Case Report

“…One approach, the direct lateral lumbar interbody fusion (DLIF) achieves indirect decompression via ligamentotaxis, reduces morbidity and improves recovery. However, lateral approach effectiveness varies with factors like spondylolisthesis grade, age, anatomy, and faces limitation in patients with severe radicular symptoms at rest [ 4 , 5 ]. Literature suggests that indirect decompression with pedicle screw fixation can increase vertebral canal cross-sectional area, yet patients with severe central stenosis may require a more robust direct decompression [ 6 , 7 ].…”