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Strøm J, Nielsen CV, Jørgensen LB, Andersen NT, Laursen M. A web-based platform to accommodate symptoms of anxiety and depression by featuring social interaction and animated information in patients undergoing lumbar spine fusion: a randomized clinical trial. Spine J 2019; 19:827-839. [PMID: 30500464 DOI: 10.1016/j.spinee.2018.11.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 11/26/2018] [Accepted: 11/26/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND Approximately one-third of patients undergoing spine surgery have symptoms of anxiety and depression that correlate with pain, disability, and lower health-related quality of life. The use of web-based informative strategies before surgery and principles from cognitive behavioral therapy, have been applied in other patient groups, facilitating mobility and encouraging beneficial coping behavior. PURPOSE To examine the effect of a web-based Spine Platform featuring Interaction and Information by Animation (w-SPIINA) on symptoms of anxiety and depression, pain, disability, and health-related quality of life. STUDY DESIGN A single-center, two-arm, randomized controlled trial PATIENT SAMPLE: One hundred fourteen consecutive patients scheduled for instrumented lumbar spine fusion due to degenerative disc disease or spondylolisthesis. OUTCOME MEASURES Primary outcome was the change in self-reported Hospital Anxiety and Depression Scale (HADS) scores from baseline to 3-month follow-up. Secondary outcomes were change in HADS 1-day before surgery 2days and 6 months after and changes in self-reported disability measured on the Oswestry disability index (ODI), quality of life (EQ-5D-5L questionnaire), and the low back pain rating scale (LBPRS) 2days and 3 and 6 months after surgery. METHOD Patients were randomized to either a control group receiving a standard information regimen or an intervention group gaining access to w-SPIINA in addition to the standard regimen. The independent charity Helsefonden contributed $45,000, the Health Research Fund of the Regional Hospital Central Jutland contributed $10,000, and the Toyota foundation contributed $10,000 to remunerate a dedicated investigator. The authors have no conflict of interest to declare. RESULTS There was no statistically significant difference within the w-SPIINA group and the control group regarding changes in HADS at 3-month follow-up (p≥.37). Approximately 40% reached minimum clinically important difference (MCID) in the w-SPIINA group on the HADS at 3 months. In the control group 50% reached MCID on anxiety subscale and 35% on the depression subscale at 3 months. No statistically significant differences were found between groups with regard to the overall outcomes at any of the predefined time points. CONCLUSION Providing patients with access to w-SPIINA in addition to a standard information regimen had no additional effect on HADS and patient-reported outcomes1day before, 2days, 3 or 6 months after surgery. However, a high compliance and degree of interaction with w-SPIINA indicates that this mode of web-based support could be applicable in this group of patients.
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Abstract
RATIONALE Gout occurs mainly in joints, but rarely in the spine. In the spine, urate crystals can cause intervertebral space instability but rarely lead to retrolisthesis. Here, we present an extremely rare disease with gout invaded the intervertebral disc with lumbar retrolisthesis. PATIENT CONCERNS A 61-years male patient with gout history has suffered from severe low back pain and intermittent claudication. Physical examination showed the level of muscle strength of his left first toe was 3/5. Images illustrated a destruction of the intervertebral space, and a retrolisthesis at L4/5 interspace and the dural sac obviously compressed. DIAGNOSES Combining with lab examinations, imaging examinations, and histopathological results, the patient was diagnosed with gouty arthritis associated with lumbar spinal stenosis, L4-5 spondylodiscitis and L4 vertebral body retrolisthesis. INTERVENTION The patient underwent posterior decompression, reduction, and interbody fusion, and then received an aggressive postoperative rehabilitation program. OUTCOMES The patient's low back pain was significantly alleviated after the operation. Postoperative X-ray shows the internal fixation was well placed and the sequence of spine was reconstructed. 12 weeks later, the lower limb symptoms of the patients were obviously improved, his muscle strength of the left first toe was 4/5, Japanese Orthopaedic Association (JOA) score was 19 and the improvement rate was 61.5%. LESSONS Gouty spondylodiscitis can cause intervertebral space instability. Sagittal imbalance and degeneration of disc with decreasing of segmental disc height are considered as the main factors of retrolisthesis. The appearance may lead to misdiagnose a patient with gout history with a destruction of the intervertebral space. Surgery is a compromise method for gouty spondylodiscitis patients with urgent neurological symptoms.
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Kong L, Tian W, Cao P, Wang H, Zhang B, Shen Y. Predictive factors associated with neck pain in patients with cervical disc degeneration: A cross-sectional study focusing on Modic changes. Medicine (Baltimore) 2017; 96:e8447. [PMID: 29069048 PMCID: PMC5671881 DOI: 10.1097/md.0000000000008447] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
The predictive factors associated with neck pain remain unclear. We conducted a cross-sectional study to assess predictive factors, especially Modic changes (MCs), associated with the intensity and duration of neck pain in patients with cervical disc degenerative disease.We retrospectively reviewed patients in our hospital from January 2013 to December 2016. Severe neck pain (SNP) and persistent neck pain (PNP) were the 2 main outcomes, and were assessed based on the numerical rating scale (NRS). Basic data, and also imaging data, were collected and analyzed as potential predictive factors. Univariate analysis and multiple logistic regression analysis were performed to assess the predictive factors for neck pain.In all, 381 patients (193 males and 188 females) with cervical degenerative disease were included in our study. The number of patients with SNP and PNP were 94 (24.67%) and 109 (28.61%), respectively. The NRS of neck pain in patients with type 1 MCs was significantly higher than type 2 MCs (4.8 ± 0.9 vs 3.9 ± 1.1; P = .004). The multivariate logistic analysis showed that kyphosis curvature (odds ratio [OR] 1.082, 95% confidence interval [CI] 1.044-1.112), spondylolisthesis (OR 1.339, 95% CI 1.226-1.462), and annular tear (OR 1.188, 95% CI 1.021-1.382) were factors associated with SNP, whereas kyphosis curvature (OR 1.568, 95% CI 1.022-2.394), spondylolisthesis (OR 1.486, 95% CI 1.082-2.041), and MCs (OR 1.152, 95% CI 1.074-1.234) were associated with PNP.We concluded that kyphosis curvature, spondylolisthesis, and annular tear are associated with SNP, whereas kyphosis curvature, spondylolisthesis, and MCs are associated with PNP. This study supports the view that MCs can lead to a long duration of neck pain.
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Cheng X, Zhang K, Sun X, Zhao C, Li H, Ni B, Zhao J. Clinical and radiographic outcomes of bilateral decompression via a unilateral approach with transforaminal lumbar interbody fusion for degenerative lumbar spondylolisthesis with stenosis. Spine J 2017; 17:1127-1133. [PMID: 28416439 DOI: 10.1016/j.spinee.2017.04.011] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Revised: 02/11/2017] [Accepted: 04/10/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Laminectomy with posterior lumbar interbody fusion (PLIF) has been shown to achieve satisfactory clinical outcomes, but it leads to potential adverse consequences associated with extensive disruption of posterior bony and soft tissue structures. PURPOSE This study aimed to compare the clinical and radiographic outcomes of bilateral decompression via a unilateral approach (BDUA) with transforaminal lumbar interbody fusion (TLIF) and laminectomy with PLIF in the treatment of degenerative lumbar spondylolisthesis (DLS) with stenosis. STUDY DESIGN This is a prospective cohort study. PATIENT SAMPLE This study compared 43 patients undergoing BDUA+TLIF and 40 patients undergoing laminectomy+PLIF. OUTCOME MEASURES Visual analog scale (VAS) for low back pain and leg pain, Oswestry Disability Index (ODI), and Zurich Claudication Questionnaire (ZCQ) score. METHODS The clinical outcomes were assessed, and intraoperative data and complications were collected. Radiographic outcomes included slippage of the vertebra, disc space height, segmental lordosis, and final fusion rate. This study was supported by a grant from The National Natural Science Foundation of China (81572168). RESULTS There were significant improvements in clinical and radiographic outcomes from before surgery to 3 months and 2 years after surgery within each group. Analysis of leg pain VAS and ZCQ scores showed no significant differences in improvement between groups at either follow-up. The mean improvements in low back pain VAS and ODI scores were significantly greater in the BDUA+TLIF group than in the laminectomy+PLIF group. No significant difference was found in the final fusion rate at 2-year follow-up. The BDUA+TLIF group had significantly less blood loss, shorter length of postoperative hospital stay, and lower complication rate compared with the laminectomy+PLIF group. CONCLUSIONS When compared with the conventional laminectomy+PLIF procedure, the BDUA+TLIF procedure achieves similar and satisfactory effects of decompression and fusion for DLS with stenosis. The BDUA+TLIF procedure appears to be associated with less postoperative low back discomfort and quicker recovery.
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Jiang H, Yang Q, Jiang J, Zhan X, Xiao Z. Association between COL11A1 (rs1337185) and ADAMTS5 (rs162509) gene polymorphisms and lumbar spine pathologies in Chinese Han population: an observational study. BMJ Open 2017; 7:e015644. [PMID: 28583914 PMCID: PMC5623369 DOI: 10.1136/bmjopen-2016-015644] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVES A previous study identified a significant association between several single nucleotide polymorphisms (SNPs) and lumbar disc degeneration (LDD) in Indians. To validate the association between these SNPs and specific lumbar spine pathologies, we performed a case-control study in Chinese Han population. DESIGN An observational study. SETTING University Hospital in Nanning, China. PARTICIPANTS This study included 428 patients with LDD and 400 normal controls. OUTCOME MEASURES Patients with LDD were classified into four subgroups, including disc herniation only (subgroup 1), discopathies or/and osteochondrosis associated with disc herniation (subgroup 2), spinal stenosis or/and spondylolisthesis (subgroup 3) and degenerative scoliosis (subgroup 4). This study was conducted by examining two aspects: environmental factors and SNP genotyping. The environmental factors were evaluated with a questionnaire survey including questions about body mass index, smoking habits, the physical demands of their job and exposure to vibrations. Rs1337185, rs5275, rs5277, rs7575934, rs3213718 and rs162509 were genotyped using a PCR-based invader assay. RESULTS The physical workload was significantly higher in patients with lumbar spine pathologies than in the normal controls (p=0.035). The genotype and allele frequencies of rs1337185 and rs162509 were significantly different between the patients with LDD and the normal controls. In rs1337185, a significant association was found between the C allele (risk allele) and the presence of disc herniation (OR=1.80; 95% CI 1.21 to 2.68; p=0.003, adjusted p=0.012) and the presence of spinal stenosis and spondylolisthesis (OR=1.92; 95% CI 1.29 to 2.89; p=0.001, adjusted p=0.004). In rs162509, the G allele represented 1.58-fold increased risk to suffer from disc herniation (OR=1.58; 95% CI 1.20 to 2.09; p=0.001, adjusted p=0.004). CONCLUSION The SNPs rs1337185 in COL11A1 and rs162509 in ADAMTS5 are associated with susceptibility to LDD. The C allele of rs1337185 is risky for patients who are affected by lumbar pathologies such as disc herniation, stenosis and spondylolisthesis. The G allele of rs16250 represents a risk factor for the development of disc herniation.
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Fedorchuk C, Lightstone DF, McRae C, Kaczor D. Correction of Grade 2 Spondylolisthesis Following a Non-Surgical Structural Spinal Rehabilitation Protocol Using Lumbar Traction: A Case Study and Selective Review of Literature. J Radiol Case Rep 2017; 11:13-26. [PMID: 29299090 DOI: 10.3941/jrcr.v11i5.2924] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Objective Discuss the use of non-surgical spinal rehabilitation protocol in the case of a 69-year-old female with a grade 2 spondylolisthesis. A selective literature review and discussion are provided. Clinical Features A 69-year-old female presented with moderate low back pain (7/10 pain) and severe leg cramping (7/10 pain). Initial lateral lumbar x-ray revealed a grade 2 spondylolisthesis at L4-L5 measuring 13.3 mm. Interventions and Outcomes The patient completed 60 sessions of Mirror Image® spinal exercises, adjustments, and traction over 45 weeks. Post-treatment lateral lumbar x-ray showed a decrease in translation of L4-L5 from 13.3 mm to 2.4 mm, within normal limits. Conclusions This case provides the first documented evidence of a non-surgical or chiropractic treatment, specifically Chiropractic BioPhysics®, protocols of lumbar spondylolisthesis where spinal alignment was corrected. Additional research is needed to investigate the clinical implications and treatment methods.
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Blizzard DJ, Sheets CZ, Seyler TM, Penrose CT, Klement MR, Gallizzi MA, Brown CR. The Impact of Lumbar Spine Disease and Deformity on Total Hip Arthroplasty Outcomes. Orthopedics 2017; 40:e520-e525. [PMID: 28358974 DOI: 10.3928/01477447-20170327-03] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Accepted: 02/20/2017] [Indexed: 02/03/2023]
Abstract
Concomitant spine and hip disease in patients undergoing total hip arthroplasty (THA) presents a management challenge. Degenerative lumbar spine conditions are known to decrease lumbar lordosis and limit lumbar flexion and extension, leading to altered pelvic mechanics and increased demand for hip motion. In this study, the effect of lumbar spine disease on complications after primary THA was assessed. The Medicare database was searched from 2005 to 2012 using International Classification of Diseases, Ninth Revision, procedure codes for primary THA and diagnosis codes for preoperative diagnoses of lumbosacral spondylosis, lumbar disk herniation, acquired spondylolisthesis, and degenerative disk disease. The control group consisted of all patients without a lumbar spine diagnosis who underwent THA. The risk ratios for prosthetic hip dislocation, revision THA, periprosthetic fracture, and infection were significantly higher for all 4 lumbar diseases at all time points relative to controls. The average complication risk ratios at 90 days were 1.59 for lumbosacral spondylosis, 1.62 for disk herniation, 1.65 for spondylolisthesis, and 1.53 for degenerative disk disease. The average complication risk ratios at 2 years were 1.66 for lumbosacral spondylosis, 1.73 for disk herniation, 1.65 for spondylolisthesis, and 1.59 for degenerative disk disease. Prosthetic hip dislocation was the most common complication at 2 years in all 4 spinal disease cohorts, with risk ratios ranging from 1.76 to 2.00. This study shows a significant increase in the risk of complications following THA in patients with lumbar spine disease. [Orthopedics. 2017; 40(3):e520-e525.].
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Vanti C, Ferrari S, Villafañe JH, Berjano P, Monticone M. Responsiveness and minimum important change of the Oswestry Disability Index in Italian subjects with symptomatic lumbar spondylolisthesis. J Orthop Traumatol 2017; 18:145-150. [PMID: 28210872 PMCID: PMC5429257 DOI: 10.1007/s10195-017-0446-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Accepted: 01/23/2017] [Indexed: 11/25/2022] Open
Abstract
Background This study aims to investigate the responsiveness and the minimum important change of the Italian version of the Oswestry Disability Index (ODI-I) in subjects with symptomatic specific low back pain associated with lumbar spondylolisthesis (SPL). Materials and methods One hundred and fifty-one patients with symptomatic SPL completed the ODI-I, a 0–100 numerical rating scale (NRS), and performed the prone and supine bridge tests. The global perception of effectiveness was measured with a 7-point Likert scale. Responsiveness was assessed by distribution methods (minimum detectable change [MDC], effect size [ES], standardized response mean [SRM]) and anchor-based methods (ROC curves). Results The MDC was 4.23, the ES was 0.95 and the SRM was 1.25. ROC analysis revealed an area under the curve of 0.76 indicating moderate discriminating capacity. The best cut-off point for the dichotomous outcome was 7.5 (sensitivity 90.3%, specificity 56.7%). . Conclusions The ODI-I proved to be responsive in detecting changes after conservative treatment in subjects with lumbar SPL. Level of evidence II.
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Morell SM, McCarthy RE, Ocal E. Segmental spinal dysgenesis: a report of early surgical intervention and outcome in a 14-month-old child. Childs Nerv Syst 2017; 33:381-384. [PMID: 27613633 DOI: 10.1007/s00381-016-3224-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Accepted: 08/15/2016] [Indexed: 11/25/2022]
Abstract
Segmental spinal dysgenesis is a rare spinal deformity that is the result of failure of formation resulting in some cases spondyloptosis and neurological dysfunction usually at the thoracolumbar junction. There is little known concerning surgical intervention and timing in these patients. The goal of this case report is to present a case involving 14 months old diagnosed with segmental spinal dysgenesis with stenosis at the thoracolumbar junction soon after birth, treated with definitive posterior spinal fusion and subsequent follow-up.
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Takeshima Y, Hanakita J, Takahashi T, Nakase H. Multiple Osseous Loose Bodies Associated with Lumbar Isthmic Spondylolisthesis. World Neurosurg 2016; 95:623.e1-623.e4. [PMID: 27353557 DOI: 10.1016/j.wneu.2016.06.073] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Revised: 06/16/2016] [Accepted: 06/17/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND Multiple osseous loose bodies in the lumbar spine have never been reported. We describe a rare surgical case of multiple osseous loose bodies associated with lumbar isthmic spondylolisthesis. CASE DESCRIPTION A 74-year-old man who experienced left foot numbness and bilateral gluteal pain was diagnosed with lumbar spondylolisthesis 7 years previously and managed conservatively. He reported recurrence of the left foot numbness 6 months previously, at which time aggressive (rather than conservative) therapy became a consideration. Radiographs of the lumbar spine revealed L5 isthmic spondylolisthesis with dynamic instability at L5/S1. Magnetic resonance imaging of the lumbar spine revealed multiple mass lesions dorsally located in the lumbar canal. Computed tomography myelography demonstrated multiple osseous materials near the isthmic portion at the L5 level where compression of the dural sac by the lesions induced lumbar canal stenosis. The patient underwent posterior decompression surgery that enabled total removal of the osseous lesions. Intraoperative findings revealed osseous lesions located in the fibrocartilage material and no connection of the lytic portion at the L5 level or ligamentum flavum. Postoperative course of the patient was uneventful as his neurological symptoms improved. CONCLUSIONS We described the first instance of multiple loose bodies in the spinal canal with lumbar canal stenosis. It is presumed that long standing minor trauma due to dynamic instability with a trend of hyperossification induced secondary synovial osteochondromatosis forming multiple loose bodies.
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Försth P, Ólafsson G, Carlsson T, Frost A, Borgström F, Fritzell P, Öhagen P, Michaëlsson K, Sandén B. A Randomized, Controlled Trial of Fusion Surgery for Lumbar Spinal Stenosis. N Engl J Med 2016; 374:1413-23. [PMID: 27074066 DOI: 10.1056/nejmoa1513721] [Citation(s) in RCA: 509] [Impact Index Per Article: 63.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND The efficacy of fusion surgery in addition to decompression surgery in patients who have lumbar spinal stenosis, with or without degenerative spondylolisthesis, has not been substantiated in controlled trials. METHODS We randomly assigned 247 patients between 50 and 80 years of age who had lumbar spinal stenosis at one or two adjacent vertebral levels to undergo either decompression surgery plus fusion surgery (fusion group) or decompression surgery alone (decompression-alone group). Randomization was stratified according to the presence of preoperative degenerative spondylolisthesis (in 135 patients) or its absence. Outcomes were assessed with the use of patient-reported outcome measures, a 6-minute walk test, and a health economic evaluation. The primary outcome was the score on the Oswestry Disability Index (ODI; which ranges from 0 to 100, with higher scores indicating more severe disability) 2 years after surgery. The primary analysis, which was a per-protocol analysis, did not include the 14 patients who did not receive the assigned treatment and the 5 who were lost to follow-up. RESULTS There was no significant difference between the groups in the mean score on the ODI at 2 years (27 in the fusion group and 24 in the decompression-alone group, P=0.24) or in the results of the 6-minute walk test (397 m in the fusion group and 405 m in the decompression-alone group, P=0.72). Results were similar between patients with and those without spondylolisthesis. Among the patients who had 5 years of follow-up and were eligible for inclusion in the 5-year analysis, there were no significant differences between the groups in clinical outcomes at 5 years. The mean length of hospitalization was 7.4 days in the fusion group and 4.1 days in the decompression-alone group (P<0.001). Operating time was longer, the amount of bleeding was greater, and surgical costs were higher in the fusion group than in the decompression-alone group. During a mean follow-up of 6.5 years, additional lumbar spine surgery was performed in 22% of the patients in the fusion group and in 21% of those in the decompression-alone group. CONCLUSIONS Among patients with lumbar spinal stenosis, with or without degenerative spondylolisthesis, decompression surgery plus fusion surgery did not result in better clinical outcomes at 2 years and 5 years than did decompression surgery alone. (Funded by an Uppsala institutional Avtal om Läkarutbildning och Forskning [Agreement concerning Cooperation on Medical Education and Research] and others; Swedish Spinal Stenosis Study ClinicalTrials.gov number, NCT01994512.).
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Ghogawala Z, Dziura J, Butler WE, Dai F, Terrin N, Magge SN, Coumans JVCE, Harrington JF, Amin-Hanjani S, Schwartz JS, Sonntag VKH, Barker FG, Benzel EC. Laminectomy plus Fusion versus Laminectomy Alone for Lumbar Spondylolisthesis. N Engl J Med 2016; 374:1424-34. [PMID: 27074067 DOI: 10.1056/nejmoa1508788] [Citation(s) in RCA: 504] [Impact Index Per Article: 63.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The comparative effectiveness of performing instrumented (rigid pedicle screws affixed to titanium alloy rods) lumbar spinal fusion in addition to decompressive laminectomy in patients with symptomatic lumbar grade I degenerative spondylolisthesis with spinal stenosis is unknown. METHODS In this randomized, controlled trial, we assigned patients, 50 to 80 years of age, who had stable degenerative spondylolisthesis (degree of spondylolisthesis, 3 to 14 mm) and symptomatic lumbar spinal stenosis to undergo either decompressive laminectomy alone (decompression-alone group) or laminectomy with posterolateral instrumented fusion (fusion group). The primary outcome measure was the change in the physical-component summary score of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36; range, 0 to 100, with higher scores indicating better quality of life) 2 years after surgery. The secondary outcome measure was the score on the Oswestry Disability Index (range, 0 to 100, with higher scores indicating more disability related to back pain). Patients were followed for 4 years. RESULTS A total of 66 patients (mean age, 67 years; 80% women) underwent randomization. The rate of follow-up was 89% at 1 year, 86% at 2 years, and 68% at 4 years. The fusion group had a greater increase in SF-36 physical-component summary scores at 2 years after surgery than did the decompression-alone group (15.2 vs. 9.5, for a difference of 5.7; 95% confidence interval, 0.1 to 11.3; P=0.046). The increases in the SF-36 physical-component summary scores in the fusion group remained greater than those in the decompression-alone group at 3 years and at 4 years (P=0.02 for both years). With respect to reductions in disability related to back pain, the changes in the Oswestry Disability Index scores at 2 years after surgery did not differ significantly between the study groups (-17.9 in the decompression-alone group and -26.3 in the fusion group, P=0.06). More blood loss and longer hospital stays occurred in the fusion group than in the decompression-alone group (P<0.001 for both comparisons). The cumulative rate of reoperation was 14% in the fusion group and 34% in the decompression-alone group (P=0.05). CONCLUSIONS Among patients with degenerative grade I spondylolisthesis, the addition of lumbar spinal fusion to laminectomy was associated with slightly greater but clinically meaningful improvement in overall physical health-related quality of life than laminectomy alone. (Funded by the Jean and David Wallace Foundation and others; SLIP ClinicalTrials.gov number, NCT00109213.).
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Tian Y, Liu X. Clinical outcomes of two minimally invasive transforaminal lumbar interbody fusion (TLIF) for lumbar degenerative diseases. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2016; 26:745-51. [PMID: 26943871 DOI: 10.1007/s00590-016-1755-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 02/17/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND There are two modified TLIF, including MIS-TLIF and TLIF through Wiltse approach (W-TLIF). Although both of the two minimally invasive surgical procedures can be effective in the treatment for lumbar degenerative diseases, no comparative analysis has been made so far regarding their clinical outcomes. OBJECTIVE To compare the clinical outcomes of MIS-TLIF and W-TLIF for the treatment for single-segment degenerative lumbar diseases. METHODS Ninety-seven patients with single-segment degenerative lumbar disorders were included in this study. Forty-seven underwent MIS-TLIF surgery (group A). For group B, fifty patients underwent W-TLIF. The Japanese Orthopedic Association (JOA) score, the visual analog scale (VAS) of low back pain (LBP) and leg pain, MRI score and atrophy rate of CSA, interbody fusion rate were assessed during the postoperative follow-up. RESULTS Incision length, blood loss, operative time, CPK, and postoperative incision pain VAS were better in group A (P < 0.05). The seconds of intraoperative fluoroscopy in groups A and B were 76 ± 9 and 7 ± 2, respectively (P < 0.05). In group B, The blood loss and CPK at L5-S1 were significantly higher than those at L4-5. Postoperative JOA scores, VAS of leg pain, and fusion rate were statistically the same between the two groups. VAS of LBP, MRI score, and atrophy rate of CSA was better in group A than in group B (P < 0.05). CONCLUSION Both methods are effective in the treatment for lumbar degenerative disease. MIS-TLIF has less blood loss, shorter surgical incision, and less lower postoperative back pain, while W-TLIF is less expensive for hospital stay with lower exposure to X-rays.
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Chandra V, Singh RK. Anterior lumbar inter-body fusion with instrumentation compared with posterolateral fusion for low grade isthmic-spondylolisthesis. Acta Orthop Belg 2016; 82:23-30. [PMID: 26984651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
UNLABELLED Spondylolisthesis presenting as low back pain is not an uncommon condition. Many of such patients are treated conservatively. For those that require surgical management, various treatment options are in vogue e.g. Postero-lateral fusion (PLF) with decompression or posterior fusion with instrumentation and anterior lumbar inter-body fusion (ALIF). Each technique has produced satisfactory outcome with benefits and disadvantages. AIM OF THE STUDY To compare the outcome of surgical management of low grade spondylolisthesis with two treatments modalities--Postero-lateral fusion (PLF) and Anterior lumbar inter-body fusion (ALIF) with posterior instrumentation in similar patient profile. SETTINGS AND DESIGN Prospective study to compare the results of two surgical treatment modalities. MATERIAL AND METHODS The selected group of patients for surgery based on definite criteria was operated by the same surgeon by two modalities: Postero-lateral fusion with decompression and Anterior Lumbar Inter-body fusion with posterior instrumentation. The outcomes were compared. STATISTICAL ANALYSIS USED Analysis of variance (ANOVA) test. RESULTS Follow up was done at twelve weekly intervals up to 2 years. Both groups showed good recovery in pain as seen in Visual analogue scale (VAS) and Oswestry low back pain scoring. Intra-operative bleeding was observed to be higher in Postero-lateral fusion group. Average length of hospital stay for the patients of PLF group was 6.6 days (Range: 4-7 days) as compared to 12.5 days (Range: 10-16 days) in case of ALIF group. Treatment cost was found to be higher in patients who undergone ALIF with instrumentation. CONCLUSIONS ALIF with posterior instrumentation in low grade isthmic spondylolisthesis provides satisfactory outcome in patients requiring surgical treatment. The results of pain relief and disability index are comparable to time tested posterolateral fusion. ALIF shows a tendency to faster pain relief and return to activity with less intraoperative blood requirement in low grade isthmic spondylolisthesis.
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Matsudaira K, Hara N, Oka H, Kunogi J, Yamazaki T, Takeshita K, Atsushi S, Tanaka S. Predictive Factors for Subjective Improvement in Lumbar Spinal Stenosis Patients with Nonsurgical Treatment: A 3-Year Prospective Cohort Study. PLoS One 2016; 11:e0148584. [PMID: 26863214 PMCID: PMC4749385 DOI: 10.1371/journal.pone.0148584] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 01/19/2016] [Indexed: 11/19/2022] Open
Abstract
Objective To assess the predictive factors for subjective improvement with nonsurgical treatment in consecutive patients with lumbar spinal stenosis (LSS). Materials and Methods Patients with LSS were enrolled from 17 medical centres in Japan. We followed up 274 patients (151 men; mean age, 71 ± 7.4 years) for 3 years. A multivariable logistic regression model was used to assess the predictive factors for subjective symptom improvement with nonsurgical treatment. Results In 30% of patients, conservative treatment led to a subjective improvement in the symptoms; in 70% of patients, the symptoms remained unchanged, worsened, or required surgical treatment. The multivariable analysis of predictive factors for subjective improvement with nonsurgical treatment showed that the absence of cauda equina symptoms (only radicular symptoms) had an odds ratio (OR) of 3.31 (95% confidence interval [CI]: 1.50–7.31); absence of degenerative spondylolisthesis/scoliosis had an OR of 2.53 (95% CI: 1.13–5.65); <1-year duration of illness had an OR of 3.81 (95% CI: 1.46–9.98); and hypertension had an OR of 2.09 (95% CI: 0.92–4.78). Conclusions The predictive factors for subjective symptom improvement with nonsurgical treatment in LSS patients were the presence of only radicular symptoms, absence of degenerative spondylolisthesis/scoliosis, and an illness duration of <1 year.
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Abstract
Lumbar spinal stenosis (LSS) affects more than 200,000 adults in the United States, resulting in substantial pain and disability. It is the most common reason for spinal surgery in patients over 65 years. Lumbar spinal stenosis is a clinical syndrome of pain in the buttocks or lower extremities, with or without back pain. It is associated with reduced space available for the neural and vascular elements of the lumbar spine. The condition is often exacerbated by standing, walking, or lumbar extension and relieved by forward flexion, sitting, or recumbency. Clinical care and research into lumbar spinal stenosis is complicated by the heterogeneity of the condition, the lack of standard criteria for diagnosis and inclusion in studies, and high rates of anatomic stenosis on imaging studies in older people who are completely asymptomatic. The options for non-surgical management include drugs, physiotherapy, spinal injections, lifestyle modification, and multidisciplinary rehabilitation. However, few high quality randomized trials have looked at conservative management. A systematic review concluded that there is insufficient evidence to recommend any specific type of non-surgical treatment. Several different surgical procedures are used to treat patients who do not improve with non-operative therapies. Given that rapid deterioration is rare and that symptoms often wax and wane or gradually improve, surgery is almost always elective and considered only if sufficiently bothersome symptoms persist despite trials of less invasive interventions. Outcomes (leg pain and disability) seem to be better for surgery than for non-operative treatment, but the evidence is heterogeneous and often of limited quality.
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Andrade NS, Ashton CM, Wray NP, Brown C, Bartanusz V. Systematic review of observational studies reveals no association between low back pain and lumbar spondylolysis with or without isthmic spondylolisthesis. 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 2015; 24:1289-95. [PMID: 25833204 DOI: 10.1007/s00586-015-3910-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Revised: 03/23/2015] [Accepted: 03/26/2015] [Indexed: 11/27/2022]
Abstract
PURPOSE The hypothesis that spondylolysis (SL) and/or isthmic spondylolisthesis (IS) cause low back pain (LBP) is widely accepted representing surgical indication in symptomatic cases. If SL/IS cause LBP, individuals with these conditions should be more prone to LBP than those without SL/IS. Therefore, the goal of the study was to assess whether the published primary data demonstrate an association between SL/IS and LBP in the general adult population. METHODS Systematic review of published observational studies to identify any association between SL/IS and LBP in adults. The methodological quality of the cohort and case-control studies was evaluated using the Newcastle-Ottawa scale. RESULTS Fifteen studies met inclusion criteria (one cohort, seven case-control, seven cross-sectional). Neither the cohort study nor the two highest-quality case-control studies detected an association between SL/IS and LBP; the same is true for the remaining studies. CONCLUSIONS There is no strong or consistent association between SL/IS and LBP in epidemiological studies of the general adult population that would support a hypothesis of causation. It is possible that SL/IS coexist with LBP, and observed effects of surgery and other treatment modalities are primarily due to benign natural history and nonspecific treatment effects. We conclude that traditional surgical practice for the adult general population, in which SL/IS is assumed to be the cause of non-radicular LBP whenever the two coexist, should be reconsidered in light of epidemiological data accumulated in recent decades.
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Sigmundsson FG, Jönsson B, Strömqvist B. Outcome of decompression with and without fusion in spinal stenosis with degenerative spondylolisthesis in relation to preoperative pain pattern: a register study of 1,624 patients. Spine J 2015; 15:638-46. [PMID: 25450653 DOI: 10.1016/j.spinee.2014.11.020] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Revised: 10/14/2014] [Accepted: 11/21/2014] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Patients with spinal stenosis with concomitant degenerative spondylolisthesis (DS) and predominant back pain (PBP) have been shown to have inferior outcome after surgery. Studies comparing outcome according to preoperative pain predominance and treatment received are lacking. PURPOSE The purpose was to study if adding spinal fusion to the decompression in DS affects outcome in patients with PBP (back pain [BP] Visual Analog Scale [VAS] more than or equal to leg pain [LP] VAS) compared with predominant leg pain (PLP) (BP VAS less than LP VAS). PATIENT SAMPLE The Swedish Spine Register was used and included 1,624 patients operated for DS at the L4-L5 level. OUTCOME MEASURES Self-reported measures were used, including a VAS for BP and LP, the EuroQol-5D (EQ-5D), and the physical and mental component summaries of the Short-Form 36 to estimate health-related quality of life and the Oswestry disability index (ODI) to estimate function. METHODS Inclusion criterion was single-level DS operated on with either decompression only (D) or decompression and instrumented posterolateral fusion (DF). Based on preoperative LP and BP scores, the patients were assigned to one of the two groups: LP predominance or BP predominance. The patients completed the outcome protocol at 1- and 2-year follow-ups. Statistical analysis was performed using linear regression adjusting for multiple potential confounders. RESULTS In the adjusted outcome at the 1-year follow-up, patients with PLP reported a 7.9-mm more improvement on the VAS for BP with fusion, compared with D (95% confidence interval [CI], 0.7-15.2), p=.03. Despite more change in the fused group, the reported BP levels remained similar in the D versus decompressed and fused at the 1-year follow-up (28 vs. 24, p=.77). The patients with PBP benefited from adding fusion in terms of BP 7.1 (95% CI, 0.3-13.9, p=.04), LP 8.8 (2-15.7, p=.01), the ODI 5.7 (1.6-9.9, p=.006), and the EQ-5D 0.09 (1.7-0.02, p=.02) at the 1-year follow-up as the DF group reported greater change in the outcome compared with the D group. At the 2-year follow-up, no significant differences were found between D and decompressed and fused in either the LP or the PBP groups. CONCLUSIONS Patients with PBP operated with DF report better outcomes in terms of pain, function, and health-related quality of life than patients with D. Although these differences are significant on a group level, they may fail to reach minimal clinical significant difference. Patients with PLP report significantly more improvement in terms of BP with DF compared with D, but because of baseline differences in preoperative BP, these improvements may not be explained by the added fusion per se. At the 2-year follow-up, no significant differences were observed between the D and DF patients in either the PBP or PLP groups, but greater loss to follow-up in the DF groups could potentially bias these findings.
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Kaftandziev I, Trpeski S, Filipce V, Arsovski O, Hasani I, Nikolov L, Kaev A. Operative treatment of degenerative lumbar spine spondylolisthesis. Pril (Makedon Akad Nauk Umet Odd Med Nauki) 2015; 36:129-135. [PMID: 26076782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
INTRODUCTION Management of degenerative lumbosacral spondylolisthesis with spinal stenosis is still controversial. Surgery is widely used, as well as non-surgical treatment. AIM To evaluate the clinical results and functional outcome after operative treatment in Grade II and III lumbar spine spondylolisthesis. MATERIAL AND METHODS Twelve patients with symptoms and image-confirmed degenerative spondylolisthesis entered the study. Mean patient age was 57 years. Spondylolisthesis Grade II or III, segment L4-L5 or L5-S1 were evaluated. All patients underwent similar protocols. Operative treatment was decompressive laminectomy, posterior one segment fixation, and fusion with autologous bone grafting. Functional outcome measures were Visual Analog Scale (VAS, 10-point scale) and Oswestry Disability Index (ODI, 100-percent scale) after 6 and 12 months. RESULTS Patient follow-up was 12 months. Preoperatively, 7 patients had severe disability according to ODI, 4 had moderate disability. VAS measured 6 and 7 points in 6 patients, lowest score of 4 points and the highest score of 9. After 6 months, ODI showed 5 patients had minimal and 7 had moderate disability; 2 patients had 0 points on the VAS, 2 had a score of 1, 4 had a score of 2, highest score of 4 points. Treatment outcome effects after 1 year were 9 patients with minimal disability, 3 with moderate; VAS - 2 patients with O points, 3 with 1 point, 4 with 2 points. CONCLUSION Patients with degenerative spondylolisthesis and spinal stenosis treated surgically showed substantially greater improvement in pain and functional outcome during a period of 1 year.
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Jasper GP, Francisco GM, Telfeian AE. Transforaminal endoscopic discectomy with foraminoplasty for the treatment of spondylolisthesis. Pain Physician 2014; 17:E703-E708. [PMID: 25415785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND Lumbar degenerative spondylolisthesis is a common entity and occurs mainly in elderly patients. The trend in surgery has been to offer decompression with instrumented fusion based on patient-based outcome data and the inherent instability of the condition. OBJECTIVES Transforaminal endoscopic discectomy and foraminotomy is an ultra-minimally invasive outpatient surgical option available to patients that does not require general anesthesia and does not involve the same amount of destabilizing facet joint removal as a traditional laminectomy and medial facetectomy. The purpose of this study was to assess the benefit of tranforaminal endoscopic discectomy and foraminotomy in patients with lumbar 4-5 (L4-L5) and lumbar 5-sacral 1 (L5-S1) spondylolisthesis and lumbar radiculopathy. METHODS After Institutional Review Board Approval, charts from 21 consecutive patients with L4-L5 or L5-S1 spondylolisthesis and complaints of lower back and radicular pain who underwent endoscopic procedures between 2007 and 2012 were reviewed. RESULTS The average pain relief one year postoperatively was reported to be 71.9%, good results as defined by MacNab. The average pre-operative VAS score was 8.48, indicated in our questionnaire as severe and constant pain. The average one year postoperative VAS score was 2.30, indicated in our questionnaire as mild and intermittent pain. LIMITATIONS This is a retrospective study and only offers one year follow-up data for patients with spondylolisthesis undergoing endoscopic spine surgery for treatment of lumbar radiculopathy. CONCLUSIONS Endoscopic discectomy is a safe and effective alternative to open back surgery. The one year follow-up data presented here appears to indicate that an ultra-minimally invasive approach to the treatment of lumbar radiculopathy in the setting of spondylolisthesis that has a low complication rate, avoids general anesthesia, and is outpatient might be worth studying in a prospective, longer term way. IRB approval: Meridian Health: IRB Study # 201206071J.
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Crostelli M, Mazza O. Comments about Zou Z, Song Y, Cai Q, Kong Q. Spontaneous resolution of scoliosis associated with lumbar spondylolisthesis. Spine J 2013;13:e7-e10. Spine J 2014; 14:1082-3. [PMID: 24184642 DOI: 10.1016/j.spinee.2013.10.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Revised: 10/04/2013] [Accepted: 10/19/2013] [Indexed: 02/03/2023]
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Assad APL, Abreu AS, Seguro LPC, Guedes LKN, Lima FR, Pinto ALDS. Spondyloptosis in athlete. REVISTA BRASILEIRA DE REUMATOLOGIA 2014; 54:234-236. [PMID: 25054602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2012] [Accepted: 11/30/2012] [Indexed: 06/03/2023] Open
Abstract
The adolescent athletes are at greater risk of low back pain and structural spine injuries. Spondylolysis is responsible for the majority of back pain cases in young athletes, rarely occurring in adults. We report a case of a 13-year-old judo female athlete, who came to our service with 5 months of progressive low back pain during training which was initially attributed to mechanical causes, without any further investigation by imaging methods. At admission, the patient had lumbar deformity, antalgic posture and bilaterally positive unipodalic lumbar hyperextension maneuver. After a research which showed spondyloptosis, the patient underwent surgery. In this article, we discuss, based on this case report, the diagnostic approach to low back pain in young athletes, since the complaint of chronic back pain can be a marker of a structural lesion that may be permanent and bring irreversible functional loss.
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Smorgick Y, Mirovsky Y, Fischgrund JS, Baker KC, Gelfer Y, Anekstein Y. Radiographic predisposing factors for degenerative spondylolisthesis. Orthopedics 2014; 37:e260-4. [PMID: 24762153 DOI: 10.3928/01477447-20140225-58] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2013] [Accepted: 11/25/2013] [Indexed: 02/03/2023]
Abstract
This study was a retrospective radiographic study involving analysis of computed tomography scans obtained for patients with degenerative spondylolisthesis of the L4-L5 segment and a control group. The purpose of the study was to identify radiological predisposing factors for degenerative spondylolisthesis of the L4-L5 segment. The authors reviewed all computed tomography scans (N=3370) performed at their institution between January 2005 and December 2008. Eighty-four patients with degenerative spondylolisthesis were identified and compared with a control group regarding facet joint orientation, the presence of sacralization of the L5 vertebra, the presence of major degenerative changes in the L5-S1 disk space, and the location of the intercrestal line. There was a statistically significant difference between the 2 groups regarding facet joint orientation, with more sagittal facet joints in the degenerative spondylolisthesis group (56° and 54° in the right and left facets, respectively, in the study group, and 46° and 42° in the right and left facets, respectively, in the control group) (P<.001). There was no statistically significant difference between the 2 groups regarding the presence of sacralization of the L5 vertebra, the presence of major degenerative changes in the L5-S1 disk space, and the location of the intercrestal line relative to the lumbar spine. There is an association between sagittal orientation of the facet joints at the L4-L5 segment and degenerative spondylolisthesis at the same level.
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Babbi L, Terzi S, Bandiera S, Barbanti Brodano G. Spina bifida occulta in high grade spondylolisthesis. EUROPEAN REVIEW FOR MEDICAL AND PHARMACOLOGICAL SCIENCES 2014; 18:8-14. [PMID: 24825035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
A 14-year-old boy presented with symptomatic high-grade dysplastic type spondylolisthesis, with a presence of spina bifida occulta, not diagnosed by plain radiographs, but confirmed on preoperative CT and MR. Circumferential fusion with partial reduction of L5/S1 was performed. Awareness of the coexistence of spondylolisthesis and spina bifida by an accurate preoperative planning is paramount to avoid iatrogenic damage to neural elements during surgery.
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Stulík J, Adámek S, Barna M, Kaspříková N, Polanecký O, Kryl J. [Axial lumbar interbody fusion: prospective monocentric study]. ACTA CHIRURGIAE ORTHOPAEDICAE ET TRAUMATOLOGIAE CECHOSLOVACA 2014; 81:203-211. [PMID: 24945389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
PURPOSE OF THE STUDY The aim of this prospective study was to evaluate clinical and radiographic results in the patients who underwent L5-S1 fixation using the technique of percutaneous lumbar interbody fusion (AxiaLIF). MATERIAL The study comprised 23 patients, 11 women and 12 men, who ranged from age of 21 to 63 years, with an average of 48.2 years. In all patients surgical posterior stabilisation involving the L5-S1 segment had previously been done. The initial indications for surgery were L5-S1 spondylolisthesis in 20 and L5-S1 spondylosis and stenosis in three patients. METHODS The AxiaLIF technique for L5-S1 fixation was indicated in overweight patients and in those after repeated abdominal or retroperitoneal surgery. A suitable position and shape of the sacrum or lumbosacral junction was another criterion. The patients were evaluated between 26 and 56 months (average, 40.4 months) after primary surgery and, on the basis of CT and radiographic findings, bone union and lumbosacral junction stability were assessed. The clinical outcome was investigated using the ODI and VAS systems and the results were statistically analysed by the Wilcoxon test for paired samples with statistical significance set at a level of 0.05. RESULTS The average VAS value was 6.6 before surgery and, after surgery, 5.2 at three months, 4.2 at six months, 3.1 at one year, 2.9 at two years and 2.1 at three years (n=18). At two post-operative years, improvement in the VAS value by 56.1% was recorded. The average pre-operative ODI value was 25.1; the post-operative values were 17.0 at six months, 12.3 at one year, 10.6 at two years and 8.2 at three years (n=18). At two years after surgery the ODI value improved by 57.8%. To the question concerning their willingness to undergo, with acquired experience, surgery for the same diagnosis, 21 patients (91.3%) gave an affirmative answer. Neither screw breakage nor neurovascular damage or rectal injury was found. CT scans showed complete interbody bone fusion in 22 of the 23 patients (95.6%), In one patient the finding was not clear. Also, posterolateral fusion was achieved in all but one patients (95.6%). A stable L5-S1 segment was found in all patients at all follow-up intervals. The improvement in both VAS and ODI values was statistically significant. DISCUSSION In addition to indications usual in degenerative disc disease, overweight patients, those who had repeated trans- or retroperitoneal surgery in the L5-S1 region or who underwent long posterior fixation to stabilise the caudal margin of instrumentation are indicated for the AxiaLIF procedure. The clinical results of our study are in agreement with the conclusions of other studies and are similar to the outcomes of surgery using other types of fusion or dynamic stabilisation for this diagnosis. The high rate of fusion in our group is affected by use of a rigid transpedicular fixator together with posterolateral arthrodesis. On the other hand, no negative effects of only synthetic bone applied to interbody space were recorded. CONCLUSIONS The percutaneous axial pre-sacral approach to the L5-S1 interbody space with application of a double-treaded screw is another option for the management of this much strained segment. The technique is useful particularly when contraindications for conventional surgical procedures are present in patients with anatomical anomalies, in overweight patients or in those who have had repeated surgery in the region. Clinical outcomes and the success rate for L5-S1 bone fusion are comparable with conventional techniques. Complications are rare but their treatment is difficult.
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