Decision-making Algorithm for the Surgical Treatment of Degenerative Lumbar Spondylolisthesis of L4/L5

Study Design.A retrospective analysis of prospectively collected data.To report the decision-making process for decompression alone (DA) and decompression and fusion (DF) at a tertiary orthopedic center and compare the operative outcomes between both groups.Controversy exists around the optimal operative treatment for DLS, either with DF or DA. Although previous studies tried to establish specific indications, clinical decision-making algorithms are needed.Patients undergoing spinal surgery for DLS at L4/5 were retrospectively analyzed. A survey of spine surgeons was performed to identify factors influencing surgical decision-making, and their association with the surgical procedure was tested in the clinical data set. We then developed a clinical score based on the statistical analysis and survey results. The predictive capability of the score was tested in the clinical data set with a receiver operating characteristic (ROC) analysis. To evaluate the clinical outcome, two years follow-up postoperative Oswestry Disability Index (ODI), postoperative low back pain (LBP) (Numeric Analog Scale), and patient satisfaction were compared between the DF and DA groups.A total of 124 patients were included in the analysis; 66 received DF (53.2%) and 58 DA (46.8%). Both groups showed no significant differences in postoperative ODI, LBP, or satisfaction. The degree of spondylolisthesis, facet joint diastasis and effusion, sagittal disbalance, and severity of LBP were identified as the most important factors for deciding on DA or DF. The area under the curve of the decision-making score was 0.84. At a cutoff of three points indicating DF, the accuracy was 80.6%.The two-year follow-up data showed that both groups showed similar improvement in ODI after both procedures, validating the respective decision. The developed score shows excellent predictive capabilities for the decision processes of different spine surgeons at a single tertiary center and highlights relevant clinical and radiographic parameters. Further studies are needed to assess the external applicability of these findings.Degenerative lumbar spondylolisthesis (DLS) is among the most common degenerative spine diseases in older people. It is often associated with mechanical lower back pain, radiculopathy, and neurological claudication resulting in spinal stenosis.1 Surgical treatment is often recommended in symptomatic patients for whom conservative treatment failed.2,3 In the past decades, spinal decompression, in combination with instrumented fusion, has been used predominantly to treat DLS.4,5 More recently, several studies have shown that decompression alone (DA) can also lead to satisfactory outcomes while being less invasive.6-10 Adding instrumentation to decompression presents disadvantages: increased surgical time, blood loss, and surgical costs.11,12DA has been described as an alternative to fusion and an effective procedure, especially for patients without segmental hypermobility on dynamic lumbar radiographs.13,14 In this context, it is a clinical challenge to identify the subgroup of patients who may benefit from an isolated decompression. Various factors might be considered when deciding whether to fuse, including patient demographics, symptom presentation, and radiographic parameters.15 The individual characteristics of each patient and the complex interactions of different factors make proper indication for surgery a challenging task. Despite several systematic reviews and meta-analyses, the indication to perform a DA or decompression with fusion remains controversial. 16,17 Thus, evidence-based decision-making or scoring systems are needed to guide the treatment of DLS.This study assesses factors associated with the decision to perform DA or decompression and fusion (DF) surgery based on patients who underwent spinal surgery for DLS at a tertiary orthopedic center. We further aimed to develop a predictive score that reflects the decision-making process at our institution. Since the decision for DA or DF is influenced by the biomechanical differences of each lumbar level and special considerations are necessary for multilevel DLS, we only analyzed the most frequent group (L4/L5), as there were a limited number of DLS cases at other levels and multilevel DLS in our cohort.Study Design.A retrospective analysis of prospectively collected data.To report the decision-making process for decompression alone (DA) and decompression and fusion (DF) at a tertiary orthopedic center and compare the operative outcomes between both groups.Controversy exists around the optimal operative treatment for DLS, either with DF or DA. Although previous studies tried to establish specific indications, clinical decision-making algorithms are needed.Patients undergoing spinal surgery for DLS at L4/5 were retrospectively analyzed. A survey of spine surgeons was performed to identify factors influencing surgical decision-making, and their association with the surgical procedure was tested in the clinical data set. We then developed a clinical score based on the statistical analysis and survey results. The predictive capability of the score was tested in the clinical data set with a receiver operating characteristic (ROC) analysis. To evaluate the clinical outcome, two years follow-up postoperative Oswestry Disability Index (ODI), postoperative low back pain (LBP) (Numeric Analog Scale), and patient satisfaction were compared between the DF and DA groups.A total of 124 patients were included in the analysis; 66 received DF (53.2%) and 58 DA (46.8%). Both groups showed no significant differences in postoperative ODI, LBP, or satisfaction. The degree of spondylolisthesis, facet joint diastasis and effusion, sagittal disbalance, and severity of LBP were identified as the most important factors for deciding on DA or DF. The area under the curve of the decision-making score was 0.84. At a cutoff of three points indicating DF, the accuracy was 80.6%.The two-year follow-up data showed that both groups showed similar improvement in ODI after both procedures, validating the respective decision. The developed score shows excellent predictive capabilities for the decision processes of different spine surgeons at a single tertiary center and highlights relevant clinical and radiographic parameters. Further studies are needed to assess the external applicability of these findings.Degenerative lumbar spondylolisthesis (DLS) is among the most common degenerative spine diseases in older people. It is often associated with mechanical lower back pain, radiculopathy, and neurological claudication resulting in spinal stenosis.1 Surgical treatment is often recommended in symptomatic patients for whom conservative treatment failed.2,3 In the past decades, spinal decompression, in combination with instrumented fusion, has been used predominantly to treat DLS.4,5 More recently, several studies have shown that decompression alone (DA) can also lead to satisfactory outcomes while being less invasive.6-10 Adding instrumentation to decompression presents disadvantages: increased surgical time, blood loss, and surgical costs. 11,12DA has been described as an alternative to fusion and an effective procedure, especially for patients without segmental hypermobility on dynamic lumbar radiographs.13,14 In this context, it is a clinical challenge to identify the subgroup of patients who may benefit from an isolated decompression. Various factors might be considered when deciding whether to fuse, including patient demographics, symptom presentation, and radiographic parameters.15 The individual characteristics of each patient and the complex interactions of different factors make proper indication for surgery a challenging task. Despite several systematic reviews and meta-analyses, the indication to perform a DA or decompression with fusion remains controversial.16,17 Thus, evidence-based decision-making or scoring systems are needed to guide the treatment of DLS.This study assesses factors associated with the decision to perform DA or decompression and fusion (DF) surgery based on patients who underwent spinal surgery for DLS at a tertiary orthopedic center. We further aimed to develop a predictive score that reflects the decision-making process at our institution. Since the decision for DA or DF is influenced by the biomechanical differences of each lumbar level and special considerations are necessary for multilevel DLS, we only analyzed the most frequent group (L4/L5), as there were a limited number of DLS cases at other levels and multilevel DLS in our cohort.Study Design.A retrospective analysis of prospectively collected data.To report the decision-making process for decompression alone (DA) and decompression and fusion (DF) at a tertiary orthopedic center and compare the operative outcomes between both groups.Controversy exists around the optimal operative treatment for DLS, either with DF or DA. Although previous studies tried to establish specific indications, clinical decision-making algorithms are needed.Patients undergoing spinal surgery for DLS at L4/5 were retrospectively analyzed. A survey of spine surgeons was performed to identify factors influencing surgical decision-making, and their association with the surgical procedure was tested in the clinical data set. We then developed a clinical score based on the statistical analysis and survey results. The predictive capability of the score was tested in the clinical data set with a receiver operating characteristic (ROC) analysis. To evaluate the clinical outcome, two years follow-up postoperative Oswestry Disability Index (ODI), postoperative low back pain (LBP) (Numeric Analog Scale), and patient satisfaction were compared between the DF and DA groups.A total of 124 patients were included in the analysis; 66 received DF (53.2%) and 58 DA (46.8%). Both groups showed no significant differences in postoperative ODI, LBP, or satisfaction. The degree of spondylolisthesis, facet joint diastasis and effusion, sagittal disbalance, and severity of LBP were identified as the most important factors for deciding on DA or DF. The area under the curve of the decision-making score was 0.84. At a cutoff of three points indicating DF, the accuracy was 80.6%.The two-year follow-up data showed that both groups showed similar improvement in ODI after both procedures, validating the respective decision. The developed score shows excellent predictive capabilities for the decision processes of different spine surgeons at a single tertiary center and highlights relevant clinical and radiographic parameters. Further studies are needed to assess the external applicability of these findings. Degenerative lumbar spondylolisthesis (DLS) is among the most common degenerative spine diseases in older people. It is often associated with mechanical lower back pain, radiculopathy, and neurological claudication resulting in spinal stenosis.1 Surgical treatment is often recommended in symptomatic patients for whom conservative treatment failed.2,3 In the past decades, spinal decompression, in combination with instrumented fusion, has been used predominantly to treat DLS.4,5 More recently, several studies have shown that decompression alone (DA) can also lead to satisfactory outcomes while being less invasive.6-10 Adding instrumentation to decompression presents disadvantages: increased surgical time, blood loss, and surgical costs.11,12DA has been described as an alternative to fusion and an effective procedure, especially for patients without segmental hypermobility on dynamic lumbar radiographs.13,14 In this context, it is a clinical challenge to identify the subgroup of patients who may benefit from an isolated decompression. Various factors might be considered when deciding whether to fuse, including patient demographics, symptom presentation, and radiographic parameters.15 The individual characteristics of each patient and the complex interactions of different factors make proper indication for surgery a challenging task. Despite several systematic reviews and meta-analyses, the indication to perform a DA or decompression with fusion remains controversial.16,17 Thus, evidence-based decision-making or scoring systems are needed to guide the treatment of DLS.This study assesses factors associated with the decision to perform DA or decompression and fusion (DF) surgery based on patients who underwent spinal surgery for DLS at a tertiary orthopedic center. We further aimed to develop a predictive score that reflects the decision-making process at our institution. Since the decision for DA or DF is influenced by the biomechanical differences of each lumbar level and special considerations are necessary for multilevel DLS, we only analyzed the most frequent group (L4/L5), as there were a limited number of DLS cases at other levels and multilevel DLS in our cohort.Study Design.A retrospective analysis of prospectively collected data.To report the decision-making process for decompression alone (DA) and decompression and fusion (DF) at a tertiary orthopedic center and compare the operative outcomes between both groups.Controversy exists around the optimal operative treatment for DLS, either with DF or DA. Although previous studies tried to establish specific indications, clinical decision-making algorithms are needed.Patients undergoing spinal surgery for DLS at L4/5 were retrospectively analyzed. A survey of spine surgeons was performed to identify factors influencing surgical decision-making, and their association with the surgical procedure was tested in the clinical data set. We then developed a clinical score based on the statistical analysis and survey results. The predictive capability of the score was tested in the clinical data set with a receiver operating characteristic (ROC) analysis. To evaluate the clinical outcome, two years follow-up postoperative Oswestry Disability Index (ODI), postoperative low back pain (LBP) (Numeric Analog Scale), and patient satisfaction were compared between the DF and DA groups.A total of 124 patients were included in the analysis; 66 received DF (53.2%) and 58 DA (46.8%). Both groups showed no significant differences in postoperative ODI, LBP, or satisfaction. The degree of spondylolisthesis, facet joint diastasis and effusion, sagittal disbalance, and severity of LBP were identified as the most important factors for deciding on DA or DF. The area under the curve of the decision-making score was 0.84. At a cutoff of three points indicating DF, the accuracy was 80.6%.The two-year follow-up data showed that both groups showed similar improvement in ODI after both procedures, validating the respective decision. The developed score shows excellent predictive capabilities for the decision processes of different spine surgeons at a single tertiary center and highlights relevant clinical and radiographic parameters. Further studies are needed to assess the external applicability of these findings.Degenerative lumbar spondylolisthesis (DLS) is among the most common degenerative spine diseases in older people. It is often associated with mechanical lower back pain, radiculopathy, and neurological claudication resulting in spinal stenosis.1 Surgical treatment is often recommended in symptomatic patients for whom conservative treatment failed.2,3 In the past decades, spinal decompression, in combination with instrumented fusion, has been used predominantly to treat DLS.4,5 More recently, several studies have shown that decompression alone (DA) can also lead to satisfactory outcomes while being less invasive.6-10 Adding instrumentation to decompression presents disadvantages: increased surgical time, blood loss, and surgical costs.11,12DA has been described as an alternative to fusion and an effective procedure, especially for patients without segmental hypermobility on dynamic lumbar radiographs.13,14 In this context, it is a clinical challenge to identify the subgroup of patients who may benefit from an isolated decompression. Various factors might be considered when deciding whether to fuse, including patient demographics, symptom presentation, and radiographic parameters.15 The individual characteristics of each patient and the complex interactions of different factors make proper indication for surgery a challenging task. Despite several systematic reviews and meta-analyses, the indication to perform a DA or decompression with fusion remains controversial.16,17 Thus, evidence-based decision-making or scoring systems are needed to guide the treatment of DLS.This study assesses factors associated with the decision to perform DA or decompression and fusion (DF) surgery based on patients who underwent spinal surgery for DLS at a tertiary orthopedic center. We further aimed to develop a predictive score that reflects the decision-making process at our institution. Since the decision for DA or DF is influenced by the biomechanical differences of each lumbar level and special considerations are necessary for multilevel DLS, we only analyzed the most frequent group (L4/L5), as there were a limited number of DLS cases at other levels and multilevel DLS in our cohort.Study Design.A retrospective analysis of prospectively collected data.To report the decision-making process for decompression alone (DA) and decompression and fusion (DF) at a tertiary orthopedic center and compare the operative outcomes between both groups.Controversy exists around the optimal operative treatment for DLS, either with DF or DA. Although previous studies tried to establish specific indications, clinical decision-making algorithms are needed.Patients undergoing spinal surgery for DLS at L4/5 were retrospectively analyzed. A survey of spine surgeons was performed to identify factors influencing surgical decision-making, and their association with the surgical procedure was tested in the clinical data set. We then developed a clinical score based on the statistical analysis and survey results. The predictive capability of the score was tested in the clinical data set with a receiver operating characteristic (ROC) analysis. To evaluate the clinical outcome, two years follow-up postoperative Oswestry Disability Index (ODI), postoperative low back pain (LBP) (Numeric Analog Scale), and patient satisfaction were compared between the DF and DA groups.A total of 124 patients were included in the analysis; 66 received DF (53.2%) and 58 DA (46.8%). Both groups showed no significant differences in postoperative ODI, LBP, or satisfaction. The degree of spondylolisthesis, facet joint diastasis and effusion, sagittal disbalance, and severity of LBP were identified as the most important factors for deciding on DA or DF. The area under the curve of the decision-making score was 0.84. At a cutoff of three points indicating DF, the accuracy was 80.6%.The two-year follow-up data showed that both groups showed similar improvement in ODI after both procedures, validating the respective decision. The developed score shows excellent predictive capabilities for the decision processes of different spine surgeons at a single tertiary center and highlights relevant clinical and radiographic parameters. Further studies are needed to assess the external applicability of these findings.Degenerative lumbar spondylolisthesis (DLS) is among the most common degenerative spine diseases in older people. It is often associated with mechanical lower back pain, radiculopathy, and neurological claudication resulting in spinal stenosis.1 Surgical treatment is often recommended in symptomatic patients for whom conservative treatment failed.2,3 In the past decades, spinal decompression, in combination with instrumented fusion, has been used predominantly to treat DLS.4,5 More recently, several studies have shown that decompression alone (DA) can also lead to satisfactory outcomes while being less invasive.6-10 Adding instrumentation to decompression presents disadvantages: increased surgical time, blood loss, and surgical costs.11,12DA has been described as an alternative to fusion and an effective procedure, especially for patients without segmental hypermobility on dynamic lumbar radiographs.13,14 In this context, it is a clinical challenge to identify the subgroup of patients who may benefit from an isolated decompression. Various factors might be considered when deciding whether to fuse, including patient demographics, symptom presentation, and radiographic parameters.15 The individual characteristics of each patient and the complex interactions of different factors make proper indication for surgery a challenging task. Despite several systematic reviews and meta-analyses, the indication to perform a DA or decompression with fusion remains controversial.16,17 Thus, evidence-based decision-making or scoring systems are needed to guide the treatment of DLS.This study assesses factors associated with the decision to perform DA or decompression and fusion (DF) surgery based on patients who underwent spinal surgery for DLS at a tertiary orthopedic center. We further aimed to develop a predictive score that reflects the decision-making process at our institution. Since the decision for DA or DF is influenced by the biomechanical differences of each lumbar level and special considerations are necessary for multilevel DLS, we only analyzed the most frequent group (L4/L5), as there were a limited number of DLS cases at other levels and multilevel DLS in our cohort.Study Design.A retrospective analysis of prospectively collected data.To report the decision-making process for decompression alone (DA) and decompression and fusion (DF) at a tertiary orthopedic center and compare the operative outcomes between both groups.Controversy exists around the optimal operative treatment for DLS, either with DF or DA. Although previous studies tried to establish specific indications, clinical decision-making algorithms are needed.Patients undergoing spinal surgery for DLS at L4/5 were retrospectively analyzed. A survey of spine surgeons was performed to identify factors influencing surgical decision-making, and their association with the surgical procedure was tested in the clinical data set. We then developed a clinical score based on the statistical analysis and survey results. The predictive capability of the score was tested in the clinical data set with a receiver operating characteristic (ROC) analysis. To evaluate the clinical outcome, two years follow-up postoperative Oswestry Disability Index (ODI), postoperative low back pain (LBP) (Numeric Analog Scale), and patient satisfaction were compared between the DF and DA groups.A total of 124 patients were included in the analysis; 66 received DF (53.2%) and 58 DA (46.8%). Both groups showed no significant differences in postoperative ODI, LBP, or satisfaction. The degree of spondylolisthesis, facet joint diastasis and effusion, sagittal disbalance, and severity of LBP were identified as the most important factors for deciding on DA or DF. The area under the curve of the decision-making score was 0.84. At a cutoff of three points indicating DF, the accuracy was 80.6%.The two-year follow-up data showed that both groups showed similar improvement in ODI after both procedures, validating the respective decision. The developed score shows excellent predictive capabilities for the decision processes of different spine surgeons at a single tertiary center and highlights relevant clinical and radiographic parameters. Further studies are needed to assess the external applicability of these findings.Degenerative lumbar spondylolisthesis (DLS) is among the most common degenerative spine diseases in older people. It is often associated with mechanical lower back pain, radiculopathy, and neurological claudication resulting in spinal stenosis.1 Surgical treatment is often recommended in symptomatic patients for whom conservative treatment failed.2,3 In the past decades, spinal decompression, in combination with instrumented fusion, has been used predominantly to treat DLS.4,5 More recently, several studies have shown that decompression alone (DA) can also lead to satisfactory outcomes while being less invasive.6-10 Adding instrumentation to decompression presents disadvantages: increased surgical time, blood loss, and surgical costs.11,12DA has been described as an alternative to fusion and an effective procedure, especially for patients without segmental hypermobility on dynamic lumbar radiographs.13,14 In this context, it is a clinical challenge to identify the subgroup of patients who may benefit from an isolated decompression. Various factors might be considered when deciding whether to fuse, including patient demographics, symptom presentation, and radiographic parameters.15 The individual characteristics of each patient and the complex interactions of different factors make proper indication for surgery a challenging task. Despite several systematic reviews and meta-analyses, the indication to perform a DA or decompression with fusion remains controversial.16,17 Thus, evidence-based decision-making or scoring systems are needed to guide the treatment of DLS.This study assesses factors associated with the decision to perform DA or decompression and fusion (DF) surgery based on patients who underwent spinal surgery for DLS at a tertiary orthopedic center. We further aimed to develop a predictive score that reflects the decision-making process at our institution. Since the decision for DA or DF is influenced by the biomechanical differences of each lumbar level and special considerations are necessary for multilevel DLS, we only analyzed the most frequent group (L4/L5), as there were a limited number of DLS cases at other levels and multilevel DLS in our cohort.Study Design.A retrospective analysis of prospectively collected data.To report the decision-making process for decompression alone (DA) and decompression and fusion (DF) at a tertiary orthopedic center and compare the operative outcomes between both groups.Controversy exists around the optimal operative treatment for DLS, either with DF or DA. Although previous studies tried to establish specific indications, clinical decision-making algorithms are needed.Patients undergoing spinal surgery for DLS at L4/5 were retrospectively analyzed. A survey of spine surgeons was performed to identify factors influencing surgical decision-making, and their association with the surgical procedure was tested in the clinical data set. We then developed a clinical score based on the statistical analysis and survey results. The predictive capability of the score was tested in the clinical data set with a receiver operating characteristic (ROC) analysis. To evaluate the clinical outcome, two years follow-up postoperative Oswestry Disability Index (ODI), postoperative low back pain (LBP) (Numeric Analog Scale), and patient satisfaction were compared between the DF and DA groups.A total of 124 patients were included in the analysis; 66 received DF (53.2%) and 58 DA (46.8%). Both groups showed no significant differences in postoperative ODI, LBP, or satisfaction. The degree of spondylolisthesis, facet joint diastasis and effusion, sagittal disbalance, and severity of LBP were identified as the most important factors for deciding on DA or DF. The area under the curve of the decision-making score was 0.84. At a cutoff of three points indicating DF, the accuracy was 80.6%.The two-year follow-up data showed that both groups showed similar improvement in ODI after both procedures, validating the respective decision. The developed score shows excellent predictive capabilities for the decision processes of different spine surgeons at a single tertiary center and highlights relevant clinical and radiographic parameters. Further studies are needed to assess the external applicability of these findings.Degenerative lumbar spondylolisthesis (DLS) is among the most common degenerative spine diseases in older people. It is often associated with mechanical lower back pain, radiculopathy, and neurological claudication resulting in spinal stenosis. 1 Surgical treatment is often recommended in symptomatic patients for whom conservative treatment failed.2,3 In the past decades, spinal decompression, in combination with instrumented fusion, has been used predominantly to treat DLS.4,5 More recently, several studies have shown that decompression alone (DA) can also lead to satisfactory outcomes while being less invasive.6-10 Adding instrumentation to decompression presents disadvantages: increased surgical time, blood loss, and surgical costs.11,12DA has been described as an alternative to fusion and an effective procedure, especially for patients without segmental hypermobility on dynamic lumbar radiographs.13,14 In this context, it is a clinical challenge to identify the subgroup of patients who may benefit from an isolated decompression. Various factors might be considered when deciding whether to fuse, including patient demographics, symptom presentation, and radiographic parameters.15 The individual characteristics of each patient and the complex interactions of different factors make proper indication for surgery a challenging task. Despite several systematic reviews and meta-analyses, the indication to perform a DA or decompression with fusion remains controversial.16,17 Thus, evidence-based decision-making or scoring systems are needed to guide the treatment of DLS.This study assesses factors associated with the decision to perform DA or decompression and fusion (DF) surgery based on patients who underwent spinal surgery for DLS at a tertiary orthopedic center. We further aimed to develop a predictive score that reflects the decision-making process at our institution. Since the decision for DA or DF is influenced by the biomechanical differences of each lumbar level and special considerations are necessary for multilevel DLS, we only analyzed the most frequent group (L4/L5), as there were a limited number of DLS cases at other levels and multilevel DLS in our cohort.Study Design.A retrospective analysis of prospectively collected data.To report the decision-making process for decompression alone (DA) and decompression and fusion (DF) at a tertiary orthopedic center and compare the operative outcomes between both groups.Controversy exists around the optimal operative treatment for DLS, either with DF or DA. Although previous studies tried to establish specific indications, clinical decision-making algorithms are needed.Patients undergoing spinal surgery for DLS at L4/5 were retrospectively analyzed. A survey of spine surgeons was performed to identify factors influencing surgical decision-making, and their association with the surgical procedure was tested in the clinical data set. We then developed a clinical score based on the statistical analysis and survey results. The predictive capability of the score was tested in the clinical data set with a receiver operating characteristic (ROC) analysis. To evaluate the clinical outcome, two years follow-up postoperative Oswestry Disability Index (ODI), postoperative low back pain (LBP) (Numeric Analog Scale), and patient satisfaction were compared between the DF and DA groups.A total of 124 patients were included in the analysis; 66 received DF (53.2%) and 58 DA (46.8%). Both groups showed no significant differences in postoperative ODI, LBP, or satisfaction. The degree of spondylolisthesis, facet joint diastasis and effusion, sagittal disbalance, and severity of LBP were identified as the most important factors for deciding on DA or DF. The area under the curve of the decision-making score was 0.84. At a cutoff of three points indicating DF, the accuracy was 80.6%.The two-year follow-up data showed that both groups showed similar improvement in ODI after both procedures, validating the respective decision. The developed score shows excellent predictive capabilities for the decision processes of different spine surgeons at a single tertiary center and highlights relevant clinical and radiographic parameters. Further studies are needed to assess the external applicability of these findings.Degenerative lumbar spondylolisthesis (DLS) is among the most common degenerative spine diseases in older people. It is often associated with mechanical lower back pain, radiculopathy, and neurological claudication resulting in spinal stenosis.1 Surgical treatment is often recommended in symptomatic patients for whom conservative treatment failed.2,3 In the past decades, spinal decompression, in combination with instrumented fusion, has been used predominantly to treat DLS.4,5 More recently, several studies have shown that decompression alone (DA) can also lead to satisfactory outcomes while being less invasive.6-10 Adding instrumentation to decompression presents disadvantages: increased surgical time, blood loss, and surgical costs.11,12DA has been described as an alternative to fusion and an effective procedure, especially for patients without segmental hypermobility on dynamic lumbar radiographs.13,14 In this context, it is a clinical challenge to identify the subgroup of patients who may benefit from an isolated decompression. Various factors might be considered when deciding whether to fuse, including patient demographics, symptom presentation, and radiographic parameters.15 The individual characteristics of each patient and the complex interactions of different factors make proper indication for surgery a challenging task. Despite several systematic reviews and meta-analyses, the indication to perform a DA or decompression with fusion remains controversial.16,17 Thus, evidence-based decision-making or scoring systems are needed to guide the treatment of DLS.This study assesses factors associated with the decision to perform DA or decompression and fusion (DF) surgery based on patients who underwent spinal surgery for DLS at a tertiary orthopedic center. We further aimed to develop a predictive score that reflects the decision-making process at our institution. Since the decision for DA or DF is influenced by the biomechanical differences of each lumbar level and special considerations are necessary for multilevel DLS, we only analyzed the most frequent group (L4/L5), as there were a limited number of DLS cases at other levels and multilevel DLS in our cohort.Study Design.A retrospective analysis of prospectively collected data.To report the decision-making process for decompression alone (DA) and decompression and fusion (DF) at a tertiary orthopedic center and compare the operative outcomes between both groups.Controversy exists around the optimal operative treatment for DLS, either with DF or DA. Although previous studies tried to establish specific indications, clinical decision-making algorithms are needed.Patients undergoing spinal surgery for DLS at L4/5 were retrospectively analyzed. A survey of spine surgeons was performed to identify factors influencing surgical decision-making, and their association with the surgical procedure was tested in the clinical data set. We then developed a clinical score based on the statistical analysis and survey results. The predictive capability of the score was tested in the clinical data set with a receiver operating characteristic (ROC) analysis. To evaluate the clinical outcome, two years follow-up postoperative Oswestry Disability Index (ODI), postoperative low back pain (LBP) (Numeric Analog Scale), and patient satisfaction were compared between the DF and DA groups.A total of 124 patients were included in the analysis; 66 received DF (53.2%) and 58 DA (46.8%). Both groups showed no significant differences in postoperative ODI, LBP, or satisfaction. The degree of spondylolisthesis, facet joint diastasis and effusion, sagittal disbalance, and severity of LBP were identified as the most important factors for deciding on DA or DF. The area under the curve of the decision-making score was 0.84. At a cutoff of three points indicating DF, the accuracy was 80.6%.The two-year follow-up data showed that both groups showed similar improvement in ODI after both procedures, validating the respective decision. The developed score shows excellent predictive capabilities for the decision processes of different spine surgeons at a single tertiary center and highlights relevant clinical and radiographic parameters. Further studies are needed to assess the external applicability of these findings.Degenerative lumbar spondylolisthesis (DLS) is among the most common degenerative spine diseases in older people. It is often associated with mechanical lower back pain, radiculopathy, and neurological claudication resulting in spinal stenosis.1 Surgical treatment is often recommended in symptomatic patients for whom conservative treatment failed.2,3 In the past decades, spinal decompression, in combination with instrumented fusion, has been used predominantly to treat DLS.4,5 More recently, several studies have shown that decompression alone (DA) can also lead to satisfactory outcomes while being less invasive.6-10 Adding instrumentation to decompression presents disadvantages: increased surgical time, blood loss, and surgical costs.11,12DA has been described as an alternative to fusion and an effective procedure, especially for patients without segmental hypermobility on dynamic lumbar radiographs.13,14 In this context, it is a clinical challenge to identify the subgroup of patients who may benefit from an isolated decompression. Various factors might be considered when deciding whether to fuse, including patient demographics, symptom presentation, and radiographic parameters.15 The individual characteristics of each patient and the complex interactions of different factors make proper indication for surgery a challenging task. Despite several systematic reviews and meta-analyses, the indication to perform a DA or decompression with fusion remains controversial.16,17 Thus, evidence-based decision-making or scoring systems are needed to guide the treatment of DLS.This study assesses factors associated with the decision to perform DA or decompression and fusion (DF) surgery based on patients who underwent spinal surgery for DLS at a tertiary orthopedic center. We further aimed to develop a predictive score that reflects the decision-making process at our institution. Since the decision for DA or DF is influenced by the biomechanical differences of each lumbar level and special considerations are necessary for multilevel DLS, we only analyzed the most frequent group (L4/L5), as there were a limited number of DLS cases at other levels and multilevel DLS in our cohort.