The NORDSTEN Study - Degenerative Spondylolisthesis (NORDSTEN/DS)
Lumbar Degenerative Spondylolisthesis (LDS) is a slippage of one vertebra over another caused by degeneration of facet joints, ligaments and intervertebral discs. Most patients suffer from symptoms related to spinal stenosis, such as radiating pain to the lower extremities, and typically increased pain in the lower limbs when walking upright and decreased when bending forward.
There is a moderate grade of evidence for whether patients will achieve better outcome after surgery when decompression is followed by fusion. In theory, fusion following decompression should give more stability to the operated level, thus less pain and less progression of the olisthesis. On the other hand, fusion procedures, in general, are associated with more severe complications and postoperative mortality than decompression alone.
In summary, there is still insufficient evidence for performing fusion in addition to decompression for patients with LDS. The investigators are planning a trial where the main aim is to detect whether the intervention-related difference in outcome between decompression alone (DA) and decompression followed by fusion with instrumentation (DF) is large enough to justify the use of the fusion procedure. The proposed trial is a randomized, controlled, multicentre, non- inferiority trial with two parallel groups, with 15 participating Norwegian hospitals. The main analysis will be performed 2 years after surgery with long-term follow-up planned at 5 and 10 years postoperatively.
Lumbar Degenerative Spondylolisthesis
Procedure: Decompression alone
Procedure: Decompression followed by fusion with instrumentation
|Study Design:||Allocation: Randomized
Endpoint Classification: Efficacy Study
Intervention Model: Parallel Assignment
Masking: Single Blind (Outcomes Assessor)
Primary Purpose: Treatment
|Official Title:||Degenerative Lumbar Spondylolisthesis: Is Only Decompression Good Enough? A Prospective Randomized Clinical Multi- Institutional Trial|
- The Oswestry Disability Index [ Time Frame: Prior to operation and 3 months, 1 year, 2 years, 5 years and 10 years postoperatively. ] [ Designated as safety issue: No ]
The Oswestry Disability Index (ODI) version 2.0 will be used as primary outcome measure. ODI is widely used by physicians treating patients with back-related symptoms and has been translated and validated for applications with Norwegian patients. It is a self-reported instrument comprising 10 sections where the patient is supposed to mark the most appropriate item. ODI scores range from 0 to 100, where 100 is the greatest impairment.
The change in ODI from baseline to follow- up will be computed. An individual cutoff value for ODI- improvement will be used to dichotomize the patients in a success group and in a non- success group. This threshold value is planned to be estimated based on data from patients registered in the Norwegian registry for Spine Surgery The change in ODI from before operation to follow up will also be computed and reported as means.
- Zürich Claudication Questionnaire (ZCQ): [ Time Frame: Prior to operation and 3 months, 1 year, 2 years, 5 years and 10 years postoperatively. ] [ Designated as safety issue: No ]
Zürich Claudication Questionnaire is also known as the Swiss Spinal Stenosis Questionaire, and is a self-completed disorder-specific functional score consisting of three domains: symptom severity, physical function and patient satisfaction. The questionnaire is translated and validated for use on Norwegian patients suffering from degenerative lumbar spinal stenosis.
The change in ZCQ from baseline to follow- up will be computed. An individual cutoff value will be used to dichotomize the patients in a success group and in a non- success group.
- Numeric Rating Scale (NRS) for back- and leg pain [ Time Frame: Prior to operation and 3 months, 1 year, 2 years, 5 years and 10 years postoperatively. ] [ Designated as safety issue: No ]NRS is a PRO that assesses self-reported pain the patients experienced in the last week from 0 (no pain) to 10 (the worst pain imaginable), on a horizontal 10 centimeter scale. The change in NRS from baseline to follow- up will be computed separately for leg and back pain.
- Euroquol 5 dimensions questionnaire (EQ-5D) [ Time Frame: Prior to operation, 3 months, 1 year, 2 years, 5 years and 10 years postoperatively. ] [ Designated as safety issue: No ]EQ-5D is a generic PRO that is self-completed and comprises 5 questions relating to mobility, self-care, usual activity, pain/discomfort, and anxiety/depression. It is one of the most frequent used questionnaires in determining cost- effectiveness in health economic evaluation. We will consider doing such an evaluation as part of the secondary outcome analysis.
- Global Perceived Effect (GPE) scale: [ Time Frame: 3 months, 1 year, 2 years, 5 years and 10 years postoperatively. ] [ Designated as safety issue: No ]Patient- rated satisfaction with treatment and treatment outcome will be assessed using single question with seven-point descriptive scaling.
- Number of participants with adverse effects (complications) [ Time Frame: During the hospital stay (average 2-3 days) and up to 10 years postoperatively. ] [ Designated as safety issue: No ]A research coordinator will record complications consecutively during the hospital stay. These may include infections, hematoma, neurological deficits due to the operation, CSF leakage and other major adverse effects. Later complications such as wound infections and hardware failure, will be recorded by the self- questionnaires.
- Number of participants needing a reoperation. [ Time Frame: From operation time and up to 10 years. ] [ Designated as safety issue: No ]Any new operation in the primary operated level during the follow- up period will be recorded as a reoperation.
- Radiological findings [ Time Frame: MRI: Prior to operation. Skeletal x-rays:Prior to operation, at 3 month follow- up and at 2 year follow- up. CT scan: At 2 year follow- up. ] [ Designated as safety issue: Yes ]
The following radiological procedures will be performed:
- MRI of the lumbar spine, including T1 and T2 sequences in the axial and sagittal plane.
- Standard images; frontal and lateral view of L1 to S1 in standing position.
- Ex/flex- images; lateral view of L1 to S1 with respectively maximal flexion and maximal extension
- CT scan: To compute the fusion rate. "Union" is classified as bony continuity between the fused vertebrae in both the coronal and sagittal view.
|Study Start Date:||February 2014|
|Estimated Study Completion Date:||December 2026|
|Estimated Primary Completion Date:||December 2026 (Final data collection date for primary outcome measure)|
Active Comparator: Decompression alone
Posterior approach with decompression will be performed. The decompression will be done after microsurgical principles, and the midline structures will be preserved. The surgeons will either use microscope or magnifying glasses.
|Procedure: Decompression alone|
Active Comparator: Decompression followed by fusion with instrumentation
Posterior approach with decompression will be performed, followed by posterolateral pedicle screw fixation with or without an additional cage. The surgeons will either use microscope or magnifying glasses.
|Procedure: Decompression followed by fusion with instrumentation|
Show Detailed Description
Please refer to this study by its ClinicalTrials.gov identifier: NCT02051374
|Contact: Ivar Magne Austevoll, MDfirstname.lastname@example.org|
|Contact: Christian Hellum, MD, PhD||+47 email@example.com|
|Kysthospitalet i Hagevik, Orthopeadic Clinic, Haukeland University Hospital||Recruiting|
|Bergen, Hagevik, Norway, 5217|
|Contact: Ivar Magne Austevoll, MD +47 56565800 firstname.lastname@example.org|
|Contact: Kari Indrekvam, MD, Dr.Med +4756565800 email@example.com|
|Principal Investigator: Ivar Magne Austevoll, MD|
|Study Chair:||Christian Hellum, MD, PhD||Orthopeadic Clinic, Oslo University Hospital|
|Principal Investigator:||Ivar Magne Austevoll, Md||Kysthospitalet i Hagevik, Orthopeadic Clinic, Haukeland University Hospital|