Comparison of early clinical efficacy of percutaneous endoscopic transforaminal lumbar decompression and single-level lumbar intervertebral fusion in the treatment of lumbar degenerative spondylolisthesis with lumbar spinal stenosis

doi:10.21203/rs.3.rs-4941763/v1

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Research Article

Comparison of early clinical efficacy of percutaneous endoscopic transforaminal lumbar decompression and single-level lumbar intervertebral fusion in the treatment of lumbar degenerative spondylolisthesis with lumbar spinal stenosis

https://doi.org/10.21203/rs.3.rs-4941763/v1

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Background

The clinical efficacy of decompression alone with and without fusion in the treatment of lumbar degenerative spondylolisthesis (LDS) with lumbar spinal stenosis (LSS) remains controversial, and this article compares the efficacy of percutaneous transforaminal lumbar discectomy (PTED) with that of lumbar decompression fusion in the treatment of LDS with LSS.

Method

From August 2018 to December 2020, 54 consecutive patients were diagnosed with LSS with DLS at our institution, 26 were treated with PTED, and 28 underwent single-segment lumbar fusion surgery. All patients were followed up for at least 1 year after surgery. Clinical outcomes were assessed using the Visual Analog Scale (VAS), Oswestry Disability Index (ODI), and modified Macnab’s criteria.

Results

The mean age was 65.81 ± 8.04 years in the PTED group and 63.29 ± 4.60 years in the decompression fusion group. At 1 year postoperatively, the VAS and ODI scores of patients in both groups showed significant improvement compared with the preoperative scores (p < 0.05), with no significant difference between the two groups eventually. At 3 and 6 months postoperatively, the ODI values of patients in both groups were statistically significant (p < 0.05), and the postoperative recovery was faster in the PTED group than in the decompression fusion group. According to the modified Macnab criteria, the excellent rates were 92.31% and 92.86% in the PTED group and the decompression fusion group, respectively. And the operative time, blood loss, postoperative hospital stay, off-bed time and complication rate were significantly shorter in the PTED group. There was no significant difference in preoperative radiological parameters between the two groups. At the last follow-up, there was no significant difference in the slippage rate between the two groups.

Conclusion

The advantages of the PTED group over the decompression fusion group are faster postoperative recovery, less bleeding, and less trauma.There was no significant difference in the short-term clinical outcomes between the two groups, and the long-term outcomes and complications still need to be further explored and validated.

The word spondylolisthesis is derived from Greek, and the adjacent vertebral body slides relatively anteriorly or posteriorly due to vertebral degeneration.¹Degenerative spondylolisthesis(DS) is one of the most commonly observed disorders of the spine and the term was cited by Newman and Stone in the 1950s.² Lumbar degenerative spondylolisthesis（LDS） is a common clinical degenerative change, usually accompanied by lumbar spinal stenosis（LSS）, and is also one of the most common causes of lumbar pain.³LDS is common in middle-aged and elderly women. Generally, the incidence of L4-5 is higher than that of L5-S1 and L3-4, and grade I spondylolisthesis is more common.^3-4 Patients usually present with intermittent claudication or radicular symptoms due to lumbar spinal stenosis, and many patients already have prolonged chronic low back pain(CLBP) before the onset of leg symptoms.^5-7

Since Kambin introduced discectomy ⁸ in 1973, percutaneous endoscopic lumbar discectomy (PELD) has become an increasingly accepted minimally invasive surgical procedure for the majority of the population. Although laminectomy incision and decompression surgery is the "gold standard" for the treatment of LSS ⁷，however, its complications and inability to be used in elderly people with co-morbidities are the biggest drawbacks. In contrast, percutaneous transforaminal endoscopic lumbar discectomy (PTED) has a higher success rate in the treatment of lumbar spinal stenosis in the elderly, with no significant difference in efficacy compared with the young, mild complications, and Surgery remains effective in elderly patients with comorbidities.⁹

Vorhies et al followed 75,024 patients with LDS over a 5-year period and found that decompression alone and fusion did not significantly correlate with reoperation rates within five years, and the data showed that decompression alone did not increase the risk of recurrence and worsening spondylolisthesis grade.¹⁰ The efficacy of transforaminal lumbar decompression without fusion for LDS with LSS remains controversial，as the reported by Li et al.,¹¹ Increasing intervertebral fusion may not gain greater benefits .By P.et al reported that decompression alone did not increase the risk of lumbar instability in patients with a preoperative diagnosis of spondylolisthesis^{4, 12}. At the same time, fusion combined with decompression is a traditional treatment for LDS with LSS, and the addition of pedicle screw internal fixation is to ensure that the stability of the lumbar spine can still be maintained without fusion of the lumbar spine.^{1-2, 10, 12} In addition, fusion surgery requires general anesthesia for the patient, which does not seem to be a good management for the elderly with comorbidities, but PTED can be operated under local anesthesia and can communicate synchronously with the patient.¹³ In this study, we compared the postoperative clinical efficacy of PTED and fusion surgery in the treatment of patients with mild spondylolisthesis and lumbar spinal stenosis, and explored whether decompression alone can achieve the same effect as fusion surgery, as well as the necessity of fusion surgery.

Patients:

This study was a retrospective study approved by the Ethics Committee of the Affiliated Hospital of Chengde Medical College, Hebei Province, China, to evaluate the efficacy of PTED with fusion surgery in patients with DLS and LSS. From August 2018 to December 2020, 780 cases of lumbar degenerative diseases were treated with PTED in the Department of Minimally Invasive Spinal Surgery, Chengde Hospital (Hebei, China). Fifty-eight patients were diagnosed with low-grade DLS (Meryeding grade I) and LSS, 28 patients in the PTED group, and 28 patients in the short-segment fusion group. DLS was diagnosed by X-ray, and the site of stenosis or compression was indicated by CT and MRI. Flexion-Extension x Spine was used to determine the instability of the x Spine. Patients with previous lumbar surgery, trauma, tumor, or infection were excluded.

Inclusion criteria:

i）Low-grade LDS（Meyerding grade I）with LSS，without lumbar isthmus fracture ；ii）neurogenic claudication with unilateral or bilateral leg symptoms；iii）Failure to respond to conservative treatment for 3 months or signs of symptomatic aggravation； iv）Patients with chronic lower back pain.

Exclusion Criteria:

i）X-ray flexion-extension radiograph of the lumbar spine showing no lumbar instability；ii）History of lumbar surgery and trauma；iii）No deformities of the lumbar spine such as scoliosis, pronation or kyphosis；iv）. Pathological changes in the lumbar spine, such as lumbar fractures, tumors, and infectious lesions.

Surgical procedure

PTED group

(1).Positioning and anesthesia

After the patient was admitted to the lateral decubitus position, the body surface projection of the slipped vertebral space was located by fluoroscopy, a vertical line was made to the posterior midline, and 9-12 cm above the intersection point was selected as the needle insertion point. Routine iodophor disinfection was performed 3 times in the operation area, and sterile towels were draped. A total of 20 mL2% lidocaine combined with 30 mL1:200,000 epinephrine was used during the procedure. The surgeon inserted a puncture needle obliquely along the needle insertion point in the direction of the superior facet of the slipped lower vertebral body. After successful fluoroscopic positioning, the surgeon pushed the puncture needle into the spinal canal, and fluoroscopy determined that the contrast needle was located at the posterosuperior margin of the L5 vertebral body, and the patient had no discomfort.

(2).Foraminoplasty

An incision of approximately 1 cm is made in the skin at the point of needle insertion, and a soft tissue channel is established by inserting dilating cannulae in a stepwise fashion over the aiming needle. The bone tissue channel was established by sequentially drilling part of the bone ventral to the superior articular eminence with a No. 6-8 bone drill. After the working channel was established, an endoscope was inserted along the trocar, and a bipolar shaper was used throughout the procedure for hemostasis.

(3).Decompression

Endoscopic resection of the ipsilateral ligamentum flavum, posterior longitudinal ligament, and scar tissue with a medullary forceps shows the compressed nerve roots as well as the scar, the ventral side of the capsule is filled with herniated disc tissue or hyperplastic bone, the herniated nucleus pulposus is removed with a nucleus pulposus removal forceps, and the bone at the posterior edge of the slipped segment of the vertebral body is removed with a microosteotome. Decompression was completed when the nerve root was naturally drooping, the blood filling of the surface tube was good, the dura mater was not compressed and fluctuated well. Intraoperative bleeding points were carefully managed, and the surgical cavity was irrigated with normal saline throughout.

Fusion group

The patient was placed under general anesthesia in the prone position by static suction, and the surgical field was routinely disinfected. a longitudinal skin incision, approximately 10 cm in length, was made centered on the spinous process of the responsible segment. the lumbar structure of the slipped segment was located under fluoroscopy, the responsible pedicle was located with a guide pin, and pedicle screws were placed along the route of the guide pin, followed by the insertion of connecting rods and reinforcing screws. Based on preoperative imaging, the articular eminence and lamina of the responsible segment are selectively removed and adequately decompressed. The disc responsible for the segment is then removed, the intervertebral space is opened, and an intervertebral fusion cage is inserted through the foraminal approach with intervertebral bone and posterior lateral bone grafting to reduce irritation of the dura and nerve roots. Moderate support or compression will be applied to restore local alignment, and the slipped segment will be restored to normal physiologic curvature after surgery.

Efficacy evaluation

We followed each patient for at least 1 year, and all patients underwent single-level lumbar surgery. The postoperative clinical efficacy was mainly evaluated by the visual analog scale (VAS) score of back pain and leg pain; the patient disability index (ODI) score at 1 week, 1 month, 3 months, 6 months and 12 months after operation; the excellent and good rate of Macnab’s criteria.¹¹ These data scores were obtained by questionnaire. Clinical assessment also included postoperative radiographic findings, symptom recurrence rate, postoperative complications, time to ambulation, and length of hospital stay.

Statistical analysis

Statistical calculations were performed using the SPSS26 program (IBM, Armonk, USA). Basic admission information, perioperative observation indexes and clinical recovery efficacy of the two groups of patients were analyzed using chi-square test, Student's t-test and Mann-Whitney U test. The significance level was defined as p<0.05.

3.1 Preoperative demographic characteristics and outcomes

The preoperative demographic characteristics and results are shown in Table 1. the mean follow-up was at least 12 months (12–36 months). 6 men and 20 women in the PTED group and 7 men and 21 women in the fusion group participated in this study. the mean age was 65.81 ± 8.04 years in the PTED group; 63.29 ± 4.60 years in the fusion group. The most common co-morbidities in patients were cardiovascular disease, with 30.77% and 25.0% in the two groups, respectively; followed by endocrinologic disease, with 7.69% and 7.14% in the two groups, respectively. 42.31% of patients in the PTED group had co-morbidities; compared to 35.71% in the fusion group. Imaging evaluation showed that the patients had spinal slips distributed at L3-4, L4-5, and L5-S1.

3.2 Perioperative information and complication

Perioperative information and complications are shown in Fig. 2. PTED group was significantly shorter than fusion group in operation time (76.92 ± 7.76 vs 121.07 ± 12.94), blood loss (24.03 ± 5.48 vs 200.00 ± 68.04), total hospital stay (9.65 ± 4.16 vs 13.43 ± 4.98), postoperative hospital stay (6.62 ± 3.71 vs 8.96 ± 3.65) and postoperative off-bed time (2.58 ± 1.77 vs 6.86 ± 2.99) (P < 0.05). At PTED, 1 patient had recurrence of symptoms and received a second fusion 2 months after surgery, 2 patients had residual numbness of the lower limb, and 1 had transient sensory disturbance of the lower limb and intraoperative tear. In fusion group, 1 patient had incision infection, 2 had transient sensory disturbance of lower limb, 3 had residual numbness of lower limb, 1 had dural tear during operation, and 1 had reoperation.

3.3 Clinical results

VAS and ODI scores for both groups were 3 and 2. There was no significant difference in the mean preoperative VAS back pain score between the PTED decompression and fusion group (6.85 ± 0.78 and 7.03 ± 0.92, respectively), which decreased to 2.27 ± 0.92 and 2.14 ± 1.08 at 1 year after surgery, and there was no significant difference from 3 months to 1 year after surgery, which was significantly better than that before surgery (P < 0.05). The mean preoperative VAS leg pain scores for the PTED fusion group were 7.08 ± 0.84 and 7.32 ± 0.72, respectively, decreasing to 2.23 ± 1.03 and 2.32 ± 0.90 at 1 year postoperatively. The mean preoperative ODI scores between the two groups were 68.38 ± 5.09 and 70.43 ± 5.69, which were not significantly different. The ODI at 3 and 6 months after surgery was statistically significant (p < 0.05), and the postoperative recovery rate was significantly faster in the PTED group than in the decompression fusion group. There was no significant difference between the two groups at 1 year after surgery(p<0.05). The preoperative and postoperative ODI values were statistically significant in both groups. As shown in Table 4 and Fig. 1, the excellent/good rates in the PTED and decompression fusion groups were 92.31% and 92.86%, respectively, according to the modified Macnab criteria.

Lumbar degenerative spondylolisthesis(LDS) is usually accompanied by lumbar spinal stenosis༈LSS༉ and is one of the causes of lower limb neuropathic claudication and lumbar pain in most patients. Degeneration of lumbar structures such as intervertebral discs, facet joints, and vertebral bodies becomes a potential factor in lumbar spondylolisthesis. For a significant proportion of patients with spondylolisthesis in clinical practice, surgical treatment is required if conservative treatment is ineffective. The choice of two surgical methods, decompression alone and decompression combined with fusion, remains controversial among the majority of scholars.^{10, 14–19} Some scholars believe that decompression alone treatment of lumbar spondylolisthesis will be accompanied by lumbar instability and the risk of recurrence, because these are real phenomena after surgery.¹⁶ In contrast, some scholars believe that decompression combined with fusion is unnecessary and increases the economic expenditure of patients.^{15, 18}Now, lumbar fusion with or without instrumentation is regarded as the "gold standard" procedure for LDS.¹⁵ At the same time ,percutaneous transforaminal endoscopic discectomy (PTED) is one of the safe and effective surgical methods for the treatment of lumbar spondylolisthesis and lumbar spinal stenosis.²⁰

The cause of lumbar spinal stenosis(LSS) is due to disc herniation, periprosthetic bone formation, intervertebral tubercle hyperplasia and ligamentum flavum hypertrophy, all of which can lead to compression of the cauda equina and nerve roots. LSS is mainly characterized by clinical symptoms such as pain in the lower back and legs, neurological sensory deficits, and intermittent claudication.⁵ Patients with lumbar spondylolisthesis are usually associated with lumbar spinal stenosis. Patients with lumbar spinal slippage usually have concomitant lumbar spinal stenosis. The slippage may not be the cause of the patient's clinical symptoms, and the patient's clinical symptoms are adequately relieved or even asymptomatic after lumbar spinal decompression. ^{15, 17}

PTED has good efficacy in the decompression level of lumbar degenerative diseases and has good efficacy in the treatment of lumbar degenerative spondylolisthesis with stenosis.²⁰ PTED has advantages over open fusion such as minimally invasive, less bleeding, shorter operative time, and quicker getting out of bed after surgery.²¹ Decompression combined with interbody fusion surgery reduces the risk of postoperative instability and reoperation of the lumbar spine. To prevent intervertebral nonunion and pseudoarthrosis formation, lumbar internal fixation is an excellent option that adds solidity to lumbar spine fusion.²² At the same time, the addition of fusion as well as internal fixation at the time of lumbar decompression increases the operating time, intraoperative bleeding, long hospital stay, risk of infection and huge financial expenses to the detriment of prolonging the patient's postoperative recovery time.^{19, 23} There is no standardized treatment for degenerative lumbar spondylolisthesis with lumbar spinal stenosis.

Pieters et al.²⁴ performed a prospective comparative analysis of decompression alone (907 cases) versus decompression fusion (8699 cases) in the treatment of degenerative lumbar spondylolisthesis with lumbar spinal stenosis. They compared the short-term outcomes of decompression alone versus decompression combined with fusion for lumbar spondylolisthesis. The rate of unplanned return to surgery was higher in the fusion group than in the decompression alone group. Rates of both minor and serious adverse events were higher in the fusion group than in the decompression alone group. There were no significant differences in mortality, prolonged hospital stay, or readmission within one month. Chen et al.¹⁵ conducted a meta-analysis of 18 studies totaling 77,994 patients comparing the clinical outcomes of simple decompression (7878 patients) and fusion decompression (70,116 patients) in the treatment of lumbar spondylolisthesis with spinal stenosis. They concluded and suggested that fusion decompression did not produce better clinical outcomes than simple decompression. In patients without degenerative instability in flexion and extension, they concluded that no significant difference in clinical outcomes could be obtained with decompression alone compared with decompression fusion. Wang et al.¹⁷ performed a meta-analysis of 1081 patients with mild lumbar degenerative slippage with lumbar spinal stenosis. They found that lumbar spine slippage did not affect the outcome of decompression, and that minimally invasive surgery reduced the risk of postoperative lumbar instability and worsening of slippage by reducing damage to bone, ligaments, and paravertebral muscles. Whether lumbar fusion and internal fixation are necessary when patients do not have predominantly lower back pain still deserves to be explored by a wide range of scholars.

Because elderly patients may have various comorbidities, such as cardiovascular, endocrine and pulmonary diseases are risk factors for general anesthesia. PTED allows simultaneous communication with patients under local anesthesia and timely intraoperative feedback from patients, while avoiding the suppression of aging and sensitive organs by general anesthetic drugs. At the same time, general anesthesia has a negative effect on the metabolism and psychology of elderly patients, which is obviously a result we do not want to see.¹³ Unfortunately, when the posterior edge of the vertebral body is removed with a microosteotome, the higher volume of bleeding leads to poor surgical visualization and increases the risk of dural tears as well as intracranial hypertension. When intracranial hypertension occurs, ending the procedure as soon as possible is the best option.²⁰ Fan et al. investigated 738 patients with unilateral lateral saphenous and foraminal stenosis and found that PTED possessed more complications than lumbar discs in the treatment of lumbar spinal stenosis, such as risk of dural tears, recurrent lumbar stenosis, persistent lower back pain, and infection. Due to the limited space available for endoscopic manipulation, dural tears tend to occur in areas close to the neural canal and are generally less traumatic and do not require special management. If the tear is large it will require open suture management. Bony growth of the vertebral body, hypertrophy of the ligamentum flavum and small joint growth are all risk factors for recurrence of lumbar spinal stenosis, when open fusion is one of the common options for surgeons.²⁵ PTED is safe and effective for central lumbar stenosis. It is important to decompress the ventral side of the spinal canal sufficiently during surgery to avoid any residual herniated and enlarged tissue and to prevent recurrence of symptoms after surgery.²⁶

Försth et al. suggested that decompression fusion surgery was not superior to decompression alone in the treatment of LDS with or without LSS.²⁷ Meanwhile, Ghogawala and Försth et al. noted that stable degenerative anterior spinal displacement can be adequately treated by decompression alone, and that the ideal treatment for unstable degenerative anterior spinal displacement remains unclear despite a 34% revision surgery rate. Lumbar spondylolisthesis and lumbar instability are two different and easily confused concepts.²⁸ Any suggestion that a stable slip will progress to an unstable slip may mislead medical scholars. A new set of criteria for indications for postoperative instability and revision surgery should be developed among physicians. In the face of this, it is inevitable that the rate of reoperation in patients will be reduced, but the outcome of reoperation may not be as ideal as expected and may be more costly in terms of medical care, significantly reducing the patient's quality of life. More importantly, operators should also inform patients about the risks of revision surgery and possible postoperative sequelae before surgery.^28–30

In our study, there was no significant difference in the postoperative clinical outcomes between the decompression-only group and the fusion group, and the percentage of satisfied patients in both groups reached more than 90%. This shows that the simple decompression group is not necessarily worse than the fusion group. In the PTED treatment group, the time for patients to return to normal motor function after surgery was significantly shorter than that in the fusion group. The short postoperative soft tissue growth and recovery time, mild pain, and lack of concern about the risks of general anesthesia for patients with comorbidities due to the small incisions in the PTED group are clearly central to the surgeon's concerns. Whether there is a difference in long-term efficacy between the decompression alone and decompression fusion groups remains ambiguous, which requires a long-term research study to verify our conclusions.

Limitations

Our disadvantage is the short follow-up period and the small number of patients followed up. Although decompression alone is effective in the short term and does not differ from decompression fusion, long-term postoperative effectiveness and safety are still lacking. The analysis we did this time was retrospective and needs to be further validated by prospective studies. Comprehensive and practical scoring criteria help in the accurate assessment of patients' postoperative recovery and the prognosis of lumbar stability and recurrence risk.

PTED can achieve the same excellent results as fusion decompression surgery in the short term, but long-term clinical outcomes still require extensive data validation. The need for fusion for LDS with LSS may not be necessary in the short term, but the long-term safety and reoperation rates still need to be explored. PTED provides a better platform for minimally invasive spine surgery by reducing the cost of surgery to the patient while having the advantages of less trauma, less bleeding, and faster postoperative recovery.

Ethics approval and consent to participate

This research was approved by the ethics committee of Afliated Hospital of Chengde Medical University. Written informed consent were obtained from all the participants. All procedures were performed in accordance with relevant guidelines. The research was conducted in compliance with the Declaration of Helsinki.

Consent for publication

The methods of this study were conducted in strict accordance with world health-related guidelines and guidelines. The study was approved by the Ethics Committee of the Affiliated Hospital of Chengde Medical University, Hebei, China, and informed consent was obtained and written consent was signed by all patients and their families.

Acknowledgements

We would like to thank all the participants in the studies.

Authors’ contributions

Zhezhe Zhang wrote the main manuscript text, Zuxue Zhang completed the collection of medical records and postoperative follow-up information, Pengfei Li Tables 1-4 as well as Figures 1-4, Youxin Song revised the manuscript, and all authors reviewed the manuscript.

Funding

None.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Conflicts of interest

The authors report no conflicts of interest related to this manuscript

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Table 1

Demographic Data
Items	PTED	Fusion	P value
Member	26	28	P>0.05
Gender			P>0.05
Male	6	7
Female	20	21
Age(years)	66.50 ± 8.46	61.50 ± 7.33	P>0.05
Affected segment			P>0.05
L3-L4	1	0
L4-5	21	28
L5-S1	4	0
Comorbidities
cardiovascular	8(30.77%)	7(25.00%)
cerebrovascular	0(0.00%)	1(3.57%)
endocrinologic	2(7.69%)	2(7.14%)
pulmonary	1(3.85%)	0(0.00%)
others	7(26.92%)	5(17.86%)
Percentage of comorbidities	11(42.31%)	10(35.71)

Table 2

Perioperative information and complication
Outcome measure	PTED	Fusion	P
Operation time(min)	76.92 ± 7.76	121.07 ± 12.94	P<0.01
Intraoperative hemorrhage(ml)	24.03 ± 5.48	200.00 ± 68.04	P<0.01
Time to ambulation (d)	2.58 ± 1.77	6.86 ± 2.99	P<0.01
Postoperative hospital stay(d)	6.62 ± 3.71	8.96 ± 3.65	P<0.05
Length in hospital(d)	9.65 ± 4.16	13.43 ± 4.98	P<0.05
Major complication
Residual numbness	2(7.69%)	3(10.71%)
Transient dysesthesia	1(3.85%)	2(7.14%)
Dural tear	2(7.69%)	1(3.57%)
Wound infection	0(0.00%)	1(3.57%)
Revision surgery	1(3.85%)	1(3.57%)

TABLE 3 Clinical results comparison between patients in two groups.

Item	PTED(n=26)	fusion(n=28)	P value
VAS-back Preoperative Postoperative 3m	6.85±0.78 3.81±0.57	7.03±0.92 4.18±0.98	P＞0.05 P＞0.05
Postoperative 6m	2.65±0.85	2.60±1.03	P＞0.05
Postoperative 1y	2.27±0.92	2.14±1.08	P＞0.05
P	P＜0.05	P＜0.05
VAS-leg Preoperative Postoperative 3m Postoperative 6m Postoperative 1y P	7.08±0.84 3.54±0.86 2.46±0.95 2.23±1.03 P＜0.05	7.32±0.72 3.93±0.77 2.68±0.98 2.32±0.90 P＜0.05	P＞0.05 P＞0.05 P＞0.05 P＞0.05
ODI
Preoperative Postoperative 3m	68.38±5.09 35.62±4.35	70.43±5.69 39.93±6.41	P＞0.05 P＜0.05
Postoperative 6m Postoperative 1y P	26.85±4.24 20.77±4.90 P＜0.05	30.64±5.79 21.86±7.16 P＜0.05	P＜0.05 P＞0.05

Table 4

Comprehensive outcome according to Macnab’s criteria
Outcome	PTED	Fusion
Excellent	18(69.32%)	21(75%)
Good	6(23.08)	5(17.86%)
Fair	1(3.8%)	1(3.57%)
bad	1(3.8%)	1(3.57%)

No competing interests reported.

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Comparison of early clinical efficacy of percutaneous endoscopic transforaminal lumbar decompression and single-level lumbar intervertebral fusion in the treatment of lumbar degenerative spondylolisthesis with lumbar spinal stenosis

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1. Introduction

2. Materials and methods

3. Results

3.1 Preoperative demographic characteristics and outcomes

3.2 Perioperative information and complication

3.3 Clinical results

Discussion

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