Endoscopic lumbar spinal hybrid surgery in the treatment of multiple-level lumbar degenerative spondylolisthesis and spinal stenosis

Elderly patients frequently suffer from multi-level degenerative lumbar spondylolisthesis/stenosis, particularly heavy labor workers, farmers, and obese individuals. The gold standard of treatment is surgical fusion following failure of conservative management; however, long-segment fusion wounds can cause premature adjacent segment disease. Owing to improved techniques and equipment, endoscopic spine surgery, lumbar spine fusion, laminectomy, or discectomy can be performed with a single or biportal spinal endoscope. We attempted to use these endoscopic techniques to decrease the fusion level in long-segment degenerative lumbar spines. Our strategy was to only fuse the most severe central and foraminal spondylolisthesis levels and arrange for endoscopic decompression only (without fusion) in other central stenosis spondylolisthesis levels. From September 2019 to May 2021, we enrolled 14 patients (average age 72 [9 females, 5 males]) with long-segment (>3 segments) low-grade spondylolisthesis and spinal stenosis who required spinal fusion after failed conservative treatment. We performed anterior lumbar interbody fusion or endoscopic-transforaminal lumbar interbody fusion for spondylolisthesis with central and foraminal stenosis levels only, particularly those involving the lowest segment; the endoscopic unilateral approach and bilateral decompressions were performed for other cephalic spondylolisthesis with central stenosis levels. At the 1-year after hybrid operation, the patient's daily function and neurologic pain have significant improvement. No major complications occurred during follow-up. There was no significant lumbar lordosis change, vertebral slip distance progression or range of motion change, even in vertebrae adjacent to the fusion level. Performing multiple levels of endoscopic decompression above the fusion level is a reliable alternative technique that does not negatively impact spine structural stability.