Skip to content

Decompression versus fusion

TL;DR — Degenerative spondylolisthesis is not an automatic indication for fusion. In NORDSTEN-DS, decompression alone was noninferior to decompression plus instrumented fusion at two years (Austevoll 2021, PMID 34347953) and remained noninferior at five years (Kgomotso 2024, PMID 39111800). The Swedish Spinal Stenosis Study found no outcome advantage from added fusion with or without spondylolisthesis (Försth 2016, PMID 27074066). Fusion remains relevant for selected deformity or clinically meaningful instability, but definitions are inconsistent.

The causal question

Fusion aims to prevent painful or progressive instability created by disease or decompression. It adds operative time, blood loss, implant complications and adjacent-segment exposure, so benefit must exceed decompression alone on patient-important outcomes.

Swedish trial

Försth and colleagues randomized patients with lumbar stenosis, stratified by degenerative spondylolisthesis, to decompression alone or decompression plus fusion and found no better clinical outcome with fusion (Försth 2016, PMID 27074066). Five-year clinical results continued to show no meaningful advantage (Karlsson 2024, PMID 38945544).

SLIP trial

A smaller US trial in stable grade-I degenerative spondylolisthesis reported some quality-of-life advantage and fewer reoperations with fusion (Ghogawala 2016, PMID 27074067). Its size, selection, outcome hierarchy and reoperation definitions help explain why it sits in tension with larger pragmatic trials.

NORDSTEN-DS

At two years, decompression alone met the prespecified noninferiority criterion versus decompression plus fusion (Austevoll 2021, PMID 34347953). At five years, noninferiority persisted and subsequent operations were not sufficiently different to reverse the interpretation (Kgomotso 2024, PMID 39111800).

What counts as instability

Static slip magnitude, flexion–extension translation, facet orientation/effusion, predominant mechanical back pain, deformity and extent of facet removal are proposed signals. None alone is a universally validated treatment-effect modifier (Bydon 2019, PMID 31078230). Instability must predict extra benefit from fusion, not merely coexist with it.

Evidence synthesis

Systematic reviews generally find similar patient-reported outcomes with more perioperative burden for fusion, while acknowledging heterogeneity and selective crossover (Gadjradj 2023, PMID 36609887) (Shen 2018, PMID 29357326). Network rankings cannot repair incompatible indications.

Decision rule

Defaulting to decompression alone is evidence-consistent for many stable cases. Fusion becomes a separate hypothesis requiring documented deformity/instability, anticipated destabilizing resection, prior failed decompression or another reconstructive objective. Consent should explain the trial disagreement rather than reduce it to surgeon preference.

Decision table

Trial/evidence Population Main inference
Swedish trial Stenosis ± spondylolisthesis No added clinical benefit from fusion
SLIP Stable grade-I spondylolisthesis Some QOL/reoperation signal; small trial
NORDSTEN-DS, 2 years Degenerative spondylolisthesis Decompression noninferior
NORDSTEN-DS, 5 years Same cohort Noninferiority sustained
Meta-analysis Mixed definitions Similar outcomes; greater fusion burden
Unresolved subgroup True dynamic/deformity instability Treatment-effect modifier not validated

Evidence map

The table records the page-specific live PubMed retrieval set; inclusion here maps evidence, not endorsement of every intervention.

PMID Year Design Contribution to this page
34347953 2021 randomized trial Decompression with or without Fusion in Degenerative Lumbar Spondylolisthesis (Austevoll 2021, PMID 34347953)
39111800 2024 randomized trial Decompression alone or with fusion for degenerative lumbar spondylolisthesis (Nordsten-DS): five year … (Kgomotso 2024, PMID 39111800)
27074066 2016 randomized trial A Randomized, Controlled Trial of Fusion Surgery for Lumbar Spinal Stenosis (Försth 2016, PMID 27074066)
38945544 2024 randomized trial Decompression alone or decompression with fusion for lumbar spinal stenosis: five-year clinical result… (Karlsson 2024, PMID 38945544)
27074067 2016 randomized trial Laminectomy plus Fusion versus Laminectomy Alone for Lumbar Spondylolisthesis (Ghogawala 2016, PMID 27074067)
31078230 2019 review Degenerative Lumbar Spondylolisthesis: Definition, Natural History, Conservative Management, and Surgi… (Bydon 2019, PMID 31078230)
36609887 2023 meta-analysis Decompression alone versus decompression with fusion in patients with lumbar spinal stenosis with dege… (Gadjradj 2023, PMID 36609887)
29357326 2018 meta-analysis Fusion or Not for Degenerative Lumbar Spinal Stenosis: A Meta-Analysis and Systematic Review (Shen 2018, PMID 29357326)
36453042 2022 clinical/observational study No need to add fusion to lumbar decompression for stenosis (Azizpour 2022, PMID 36453042)
41476308 2025 meta-analysis Decompression, decompression plus fusion and decompression plus dynamic stabilization for degenerative… (Guo 2025, PMID 41476308)
35075090 2022 review Degenerative Spondylolisthesis: A Narrative Review (Akkawi 2022, PMID 35075090)
40291940 2025 review Surgical and non-surgical management of spondylolisthesis: a comprehensive review (Nedelea 2025, PMID 40291940)
18399601 2008 review Spondylolisthesis and spondylolysis (Hu 2008, PMID 18399601)
932080 1976 clinical/observational study Degenerative spondylolisthesis (Fitzgerald 1976, PMID 932080)
36083346 2022 clinical/observational study [Lumbar spinal stenosis] (Birkenmaier 2022, PMID 36083346)
1253475 1976 clinical/observational study Degenerative spondylolisthesis (Cauchoix 1976, PMID 1253475)
2649568 1989 review Degenerative spondylolisthesis (Bolesta 1989, PMID 2649568)
40484475 2025 review Decompression Versus Decompression Fusion in Lumbar Degenerative Stenosis/Spondylolisthesis (Dong 2025, PMID 40484475)
29248779 2018 meta-analysis Decompression Alone Versus Decompression and Fusion for Lumbar Degenerative Spondylolisthesis: A Meta-… (Chen 2018, PMID 29248779)
38251455 2024 clinical/observational study Lumbar Decompression With and Without Fusion for Lumbar Stenosis With Spondylolisthesis: A Cost Utilit… (Sastry 2024, PMID 38251455)
35503342 2022 review Diagnosis and Management of Lumbar Spinal Stenosis: A Review (Katz 2022, PMID 35503342)
23680830 2013 randomized trial Decompression and Coflex interlaminar stabilization compared with decompression and instrumented spina… (Davis 2013, PMID 23680830)
30611229 2019 randomized trial Decompression alone versus decompression with instrumental fusion the NORDSTEN degenerative spondyloli… (Austevoll 2019, PMID 30611229)
40498575 2025 guideline/consensus AO Spine Clinical Practice Recommendations for the Surgical Management of Degenerative Spondylolisthes… (Martin 2025, PMID 40498575)
33674366 2021 randomized trial MIS-TLIF versus O-TLIF for single-level degenerative stenosis: study protocol for randomised controlle… (Leonova 2021, PMID 33674366)
27745582 2016 review [Lumbar spinal stenosis] (Andresen 2016, PMID 27745582)
38444008 2024 cohort study Clinical effects of arthroscopic-assisted uni-portal spinal surgery and unilateral bi-portal endoscopy… (Wang 2024, PMID 38444008)
33627893 2021 clinical/observational study Degenerative Lumbar Spinal Stenosis (Hennemann 2021, PMID 33627893)
17445736 2007 review Lumbar spinal stenosis (Chad 2007, PMID 17445736)
35489687 2023 cohort study Effect of decompression surgery for lumbar spinal stenosis on aerobic capacities during a 6-min walk t… (Gouteron 2023, PMID 35489687)
35334560 2022 review Microendoscopic Lumbar Posterior Decompression Surgery for Lumbar Spinal Stenosis: Literature Review (Suzuki 2022, PMID 35334560)
36763556 2023 clinical/observational study Revision surgery after previous spinal decompression and fusion for lumbar spinal stenosis (Lebedev 2023, PMID 36763556)
36268217 2022 review Comparison of posterior decompression techniques and conventional laminectomy for lumbar spinal stenosis (Zhang 2022, PMID 36268217)
27683714 2016 clinical/observational study A novel strategy of non-fusion instrumentation with coflex interlaminar stabilization after decompress… (Nomura 2016, PMID 27683714)

Interpretation rules

  • Anatomical narrowing is necessary but not sufficient for a symptomatic stenosis diagnosis.
  • Lumbar claudication, lumbar radiculopathy, cervical myelopathy and imaging-only compression are analyzed separately.
  • Absolute changes, confidence intervals and responder proportions outrank within-group significance.
  • Comparator choice determines the question a trial can answer.
  • Reoperation, falls, delirium and recovery burden are outcomes, not footnotes.
  • Subgroup claims require an interaction or externally validated treatment-effect model.
  • Older age is not a contraindication; reserve, goals and modifiable vulnerability are assessed directly.
  • Absence of deterioration in a cohort does not guarantee individual stability.
  • Evidence is research knowledge, not individualized medical advice.

Open questions

  • Which prespecified instability or deformity phenotype modifies the effect of adding fusion to decompression? (Austevoll 2021, PMID 34347953)
  • Which causes of subsequent surgery differ between strategies at five years, rather than reoperation being treated as one composite event? (Kgomotso 2024, PMID 39111800)
  • Does any fusion benefit emerge after the interval in which its added operating time, bleeding, hospitalization and cost are already apparent? (Försth 2016, PMID 27074066)

References

  1. Austevoll IM, et al. Decompression with or without Fusion in Degenerative Lumbar Spondylolisthesis. The New England journal of medicine. 2021;385:526-538. PMID 34347953
  2. Kgomotso EL, et al. Decompression alone or with fusion for degenerative lumbar spondylolisthesis (Nordsten-DS): five year follow-up of a randomised, multicentre, non-inferiority trial. BMJ (Clinical research ed.). 2024;386:e079771. PMID 39111800
  3. Försth P, et al. A Randomized, Controlled Trial of Fusion Surgery for Lumbar Spinal Stenosis. The New England journal of medicine. 2016;374:1413-23. PMID 27074066
  4. Karlsson T, et al. Decompression alone or decompression with fusion for lumbar spinal stenosis: five-year clinical results from a randomized clinical trial. The bone & joint journal. 2024;106-B:705-712. PMID 38945544
  5. Ghogawala Z, et al. Laminectomy plus Fusion versus Laminectomy Alone for Lumbar Spondylolisthesis. The New England journal of medicine. 2016;374:1424-34. PMID 27074067
  6. Bydon M, et al. Degenerative Lumbar Spondylolisthesis: Definition, Natural History, Conservative Management, and Surgical Treatment. Neurosurgery clinics of North America. 2019;30:299-304. PMID 31078230
  7. Gadjradj PS, et al. Decompression alone versus decompression with fusion in patients with lumbar spinal stenosis with degenerative spondylolisthesis: a systematic review and meta-analysis. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society. 2023;32:1054-1067. PMID 36609887
  8. Shen J, et al. Fusion or Not for Degenerative Lumbar Spinal Stenosis: A Meta-Analysis and Systematic Review. Pain physician. 2018;21:1-8. PMID 29357326
  9. Azizpour K, et al. No need to add fusion to lumbar decompression for stenosis. The bone & joint journal. 2022;104-B:1281-1283. PMID 36453042
  10. Guo C, et al. Decompression, decompression plus fusion and decompression plus dynamic stabilization for degenerative lumbar spondylolisthesis: a network meta-analysis. Journal of orthopaedic surgery and research. 2025;21:73. PMID 41476308
  11. Akkawi I, et al. Degenerative Spondylolisthesis: A Narrative Review. Acta bio-medica : Atenei Parmensis. 2022;92:e2021313. PMID 35075090
  12. Nedelea DG, et al. Surgical and non-surgical management of spondylolisthesis: a comprehensive review. Journal of medicine and life. 2025;18:196-207. PMID 40291940
  13. Hu SS, et al. Spondylolisthesis and spondylolysis. Instructional course lectures. 2008;57:431-45. PMID 18399601
  14. Fitzgerald JA, et al. Degenerative spondylolisthesis. The Journal of bone and joint surgery. British volume. 1976;58:184-92. PMID 932080
  15. Birkenmaier C, et al. [Lumbar spinal stenosis]. Orthopadie (Heidelberg, Germany). 2022;51:943-952. PMID 36083346
  16. Cauchoix J, et al. Degenerative spondylolisthesis. Clinical orthopaedics and related research. 1976:122-9. PMID 1253475
  17. Bolesta MJ, et al. Degenerative spondylolisthesis. Instructional course lectures. 1989;38:157-65. PMID 2649568
  18. Dong K, et al. Decompression Versus Decompression Fusion in Lumbar Degenerative Stenosis/Spondylolisthesis. The Orthopedic clinics of North America. 2025;56:223-239. PMID 40484475
  19. Chen Z, et al. Decompression Alone Versus Decompression and Fusion for Lumbar Degenerative Spondylolisthesis: A Meta-Analysis. World neurosurgery. 2018;111:e165-e177. PMID 29248779
  20. Sastry RA, et al. Lumbar Decompression With and Without Fusion for Lumbar Stenosis With Spondylolisthesis: A Cost Utility Analysis. Spine. 2024;49:847-856. PMID 38251455
  21. Katz JN, et al. Diagnosis and Management of Lumbar Spinal Stenosis: A Review. JAMA. 2022;327:1688-1699. PMID 35503342
  22. Davis RJ, et al. Decompression and Coflex interlaminar stabilization compared with decompression and instrumented spinal fusion for spinal stenosis and low-grade degenerative spondylolisthesis: two-year results from the prospective, randomized, multicenter, Food and Drug Administration Investigational Device Exemption trial. Spine. 2013;38:1529-39. PMID 23680830
  23. Austevoll IM, et al. Decompression alone versus decompression with instrumental fusion the NORDSTEN degenerative spondylolisthesis trial (NORDSTEN-DS); study protocol for a randomized controlled trial. BMC musculoskeletal disorders. 2019;20:7. PMID 30611229
  24. Martin CT, et al. AO Spine Clinical Practice Recommendations for the Surgical Management of Degenerative Spondylolisthesis: When to Decompress Alone and When to Fuse. Global spine journal. 2025;15:3046-3054. PMID 40498575
  25. Leonova ON, et al. MIS-TLIF versus O-TLIF for single-level degenerative stenosis: study protocol for randomised controlled trial. BMJ open. 2021;11:e041134. PMID 33674366
  26. Andresen AK, et al. [Lumbar spinal stenosis]. Ugeskrift for laeger. 2016;178. PMID 27745582
  27. Wang F, et al. Clinical effects of arthroscopic-assisted uni-portal spinal surgery and unilateral bi-portal endoscopy on unilateral laminotomy for bilateral decompression in patients with lumbar spinal stenosis: a retrospective cohort study. Journal of orthopaedic surgery and research. 2024;19:167. PMID 38444008
  28. Hennemann S, et al. Degenerative Lumbar Spinal Stenosis. Revista brasileira de ortopedia. 2021;56:9-17. PMID 33627893
  29. Chad DA. Lumbar spinal stenosis. Neurologic clinics. 2007;25:407-18. PMID 17445736
  30. Gouteron A, et al. Effect of decompression surgery for lumbar spinal stenosis on aerobic capacities during a 6-min walk test: A preliminary cohort study. Annals of physical and rehabilitation medicine. 2023;66:101673. PMID 35489687
  31. Suzuki A, et al. Microendoscopic Lumbar Posterior Decompression Surgery for Lumbar Spinal Stenosis: Literature Review. Medicina (Kaunas, Lithuania). 2022;58. PMID 35334560
  32. Lebedev VB, et al. Revision surgery after previous spinal decompression and fusion for lumbar spinal stenosis. Zhurnal voprosy neirokhirurgii imeni N. N. Burdenko. 2023;87:70-76. PMID 36763556
  33. Zhang Y, et al. Comparison of posterior decompression techniques and conventional laminectomy for lumbar spinal stenosis. Frontiers in surgery. 2022;9:997973. PMID 36268217
  34. Nomura H. A novel strategy of non-fusion instrumentation with coflex interlaminar stabilization after decompression for lumbar spinal stenosis. Journal of spine surgery (Hong Kong). 2016;2:149-53. PMID 27683714