Transforaminal endoscopic discectomy with foraminoplasty for the treatment of spondylolisthesis

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.

Spondyloptosis in athlete

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.

Radiographic predisposing factors for degenerative spondylolisthesis

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.

Spina bifida occulta in high grade spondylolisthesis

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.

[Axial lumbar interbody fusion: prospective monocentric study]

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.

[Surgery for degenerative spondylolisthesis of the lumbar spine using intra-articular fusion. A prospective study]

PURPOSE OF THE STUDY

The aim of the study is to present our surgical method of treating degenerative spondylolisthesis, which includes radical bilateral laminectomy to relieve compression on the spinal cord, transpedicular fixation of the segment and arthrodesis by bilateral intra-articular fusion.

MATERIAL AND METHODS

This surgery was indicated in patients with grade I or grade II of degenerative sponylolisthesis with a 4-mm or more slippage. Our prospectively studied group consisted of 46 patients (17 men, 29 women; average age, 64.2 years; range, 39-84 years). Before surgery and at 1 year after the procedure, the intensity of axial pain and that of radicular pain were each assessed using the visual Analogue Scale (VAS). Difficulty in performing daily living activities was measured by the Oswestry Disability Index (ODI). The surgical procedure included laminectomy, partial medial facetectomy, foraminotomy to relieve pressure on the spinal nerve roots and transpedicular fixation to provide stability. Using a cutter, cartilage was separated off the cortical bone and, in order to facilitate fusion, bone cavities thus produced were filed with corticospongious grafts harvested from the removed vertebral arch with Kerrison forceps. At 1-year follow-up, dynamic X-ray was used to evaluate spine alignment and, on a CT scan, the degree of intra-articular fusion was assessed. Fusion was achieved when bone density measurement showed more than 350 Hounsfield Units (HU). For the measurements, the authors used their own modified method by means of a Region of Interest (ROI) analysis. The clinical and radiographic results were statistically evaluated.

RESULTS

At 1 year after surgery, lumbar flexion-extension bending X-ray films revealed stability of the treated segments in all patients (100%). CT examination showed bone density higher than 350 HU at both joints, i.e., complete bone fusion, also in all 46 patients. The mean post-operative ODI score was significantly lower than its mean pre-operative value (23.6 vs 55.4), which was improvement by 57.4%. The differences in pre- and post-operative VAS scores were also statistically significant. The mean VAS score for low back pain decreased from 7.61 to 1.74, i.e., improvement by 77.1%, and the mean vAS score for radicular pain dropped from 6.98 to 1.24, i.e., improvement by 82.2%. Assessed by Odom's outcome criteria, the results were excellent in 26 patients and very good in 20 patients, and they were not related to age, gender or the spinal level treated. Any complications associated with the operative procedure or wound healing and requiring repeated surgical treatment were not recorded.

DISCUSSION

The surgical technique described here has advantages over other methods in reliable achieving nerve decompression, joint fusion and spinal stability at low costs and short operative time. In addition, it avoids the necessity of harvesting bone from the iliac crest.

CONCLUSIONS

At 1-year follow-up all patients showed better health conditions, with improvement in average scores for the ODI by 57%, for low back pain by 77% and for radicular and claudication pain by 82%. The technique of intra-articular fusion for treatment of degenerative spondylolisthesis resulted in solid bone fusion and spinal stability in all patients.

The significance of facet joint cross-sectional area on magnetic resonance imaging in relationship to cervical degenerative spondylolisthesis

BACKGROUND CONTEXT

Characteristic changes of the facet joints, including synovial cysts, facet joint hypertrophy, and facet joint effusions, on magnetic resonance imaging (MRI) and computed tomography have been associated with lumbar degenerative spondylolisthesis. The cervical facets have not been examined for associations with cervical degenerative spondylolisthesis similar to those seen in the lumbar spine.

PURPOSE

To define abnormalities of the facet joints seen on supine MRI that correlate with cervical spondylolisthesis seen on upright radiographs.

STUDY DESIGN

Retrospective radiographic review of consecutive patients with a universally applied standard.

PATIENT SAMPLE

A total of 204 consecutive patients from a single institution, with both an MRI and upright radiographs, were reviewed.

OUTCOME MEASURES

Sagittal plane displacement on upright lateral radiographs was compared with MRI. The total area of the facet joint and the amount of facet joint asymmetry were measured on an axial MRI.

METHODS

The data were analyzed to determine a significant association between the cervical degenerative spondylolisthesis and the following: facet joint asymmetry, increased total area of the facet joint, and age.

RESULTS

Degenerative spondylolisthesis was seen in 26 patients at C3-C4 and in 27 patients at C4-C5. Upright radiographs identified significantly more degenerative spondylolisthesis than MRIs at levels C3-C4 and C4-C5, 26 versus 6 (p<.001) at C3-C4 and 27 versus 11 (p<.001) at C4-C5. Patients with degenerative spondylolisthesis were more likely to be older, have a larger total facet area, and more facet asymmetry at C3-C4 and C4-C5 (p<.05).

CONCLUSIONS

Supine MRIs underestimate sagittal displacement compared with upright lateral radiographs. Asymmetric facet hypertrophy at C3-C4 and C4-C5 is associated with degenerative spondylolisthesis on upright lateral films even in the absence of anterolisthesis on supine MRIs.

Spontaneous resolution of scoliosis associated with lumbar spondylolisthesis

BACKGROUND CONTEXT

Scoliosis in association with spondylolisthesis is a common phenomenon. According to the traditional opinion, scoliosis should be managed depending on its classification and flexibility. Recently, Crostelli and Mazza proposed a new opinion toward this topic. They advocate that spondylolisthesis-associated scoliosis, especially severe scoliosis, should be considered as idiopathic scoliosis and must be treated with the same principles used in the treatment of idiopathic scoliosis. According to their viewpoints, more scoliotic curves in association with spondylolisthesis need to be treated, either surgically or conservatively.

PURPOSE

To describe the spontaneous correction of a severe case of scoliosis by internal fixation of the spondylolisthesis.

STUDY DESIGN

Case report of a patient with scoliosis developing in association with high-grade lumbar spondylolisthesis.

METHODS

A 12-year-old girl presented with a 2-year history of spinal curvature. She did not have low back or leg pain. The scoliotic deformity corrected readily in the supine position. Radiographs revealed 88% slippage of L5 on S1 in addition to a long section curve of the spine with the main 50° curve at the thoracic level. The spondylolisthesis was repaired with segmental instrumentation and circumferential fusion of L5 and S1.

RESULTS

The scoliosis showed spontaneous resolution gradually after lumbosacral fusion and reached a complete correction 2 years after surgery.

CONCLUSIONS

The relationship between scoliosis and spondylolisthesis is complex. If scoliosis is considered to be caused by spondylolisthesis, surgery for the latter condition might be the only required intervention for the patient. Unnecessary operation for scoliosis should be avoided.

Management of high-grade spondylolisthesis

Management of high-grade spondylolisthesis (HGS) remains challenging and is associated with significant controversies. The best surgical procedure remains debatable. Although the need for instrumentation is generally agreed upon, significant controversies still surround the role of reduction and anterior column support in the surgical management of HGS. Complications with operative management of HGS can be significant and often dictate the selection of surgical approach. This review highlights the pathophysiology, classification, clinical presentation, and management controversies of HGS, in light of recent advances in our understanding of the importance of sagittal spinopelvic alignment and technologic advancements.

[Sacral insufficiency, unexpected clinical entity as a cause of low back pain. Report of two cases]

BACKGROUND

sacral insufficiency fractures are a cause of debilitating pain in the elderly. These fractures were first described as a clinical entity in 1982. The bone in these patients is structurally weakened and often associated with diseases such as osteoporosis, cancer and immunological processes. This translates into back and pelvic pain unrelated to trauma. These fractures are usually caused by fatigue in most cases. Bone scans and MRI are the imaging studies with the most sensitivity for detecting sacral insufficiency.

CLINICAL CASES

two patients with sacral insufficiency fractures who were studied by MRI and bone scan, in whom the diagnosis of sacral insufficiency was made, were treated by sacroplasty.

CONCLUSIONS

sacral insufficiency is an underdiagnosed disease, caused by wide range of diseases, mainly osteoporosis. The studies of choice for diagnosis are MRI and bone scans. Techniques, such as percutaneous sacroplasty, produce significant improvements in pain scores and seem a suitable alternative for managing this disease.

Conservative treatment with spontaneous stabilization of Grade II isthmic spondylolisthesis L5/S1 in a forty-four-year old woman, with a six-year follow-up: a case report

Spondylolisthesis is a pathological condition caused by the slipping of a vertebral body, compared to the underlying structure, following structural and/or degenerative changes to the spine. Studies have attempted evidence to the connection between the natural history of spondylolisthesis, the degree and progression of the slip factor, as well as the pain and disability. Studies have reported a high level of heterogeneity of these factors in different patients as well as difficulty in predicting behaviour. It has been suggested that vertebral instability, independent of the slip factor, could be considered the most important factor to be treated conservatively or surgically. Furthermore, it appears that some patients may manifest complete disk degeneration over time, with vertebral bodies shifting closer and spontaneous stabilisation. This case study reports a forty-four-year old woman, with isthmic spondylolisthesis, where the spine surgeon recommended physiotherapy for conservative treatment, with a prognosis of possible spontaneous stabilization. The case was followed for six years, both clinically and radiologically. Treatment was based on a specific stabilising training program (motor control), immediately aimed to improve the disability and pain factors while waiting for a possible spontaneous stabilisation, that the latest radiological exams revealed with an attempt of arthrodesis. The Oswestry Disability Index (ODI) and the Roland Morris Disability Questionnaire (RMDQ) to measure disability, and the Numeric Rating Scale (NRS) to measure pain, were carried out at the beginning, during and at the end of treatment. They were compared with the radiographic material documenting the evolution of the spondylolisthesis over time. This case study appears to confirm that the hypothesis that a specific aimed approach of rehabilitation may improve the disability and pain levels without compromising the process of spontaneous arthrodesis. The evolution was documented radiographically and clinically over a six-year period.

Comparison of Dynesys posterior stabilization and posterior lumbar interbody fusion for spinal stenosis L4L5

The aim of this prospective randomized study was to compare the radiological and clinical outcome after treatment of lumbar spinal stenosis L4L5 with or without spondylolisthesis, with either posterior lumbar interbody fusion (PLIF) (26 patients) or Dynesys posterior stabilization (27 patients). Demographic characteristics were comparable in both groups. Dynesys stabilization resulted in significantly higher preservation of motion at the index level (p < 0.001), and significantly less (p < 0.05) hypermobility at the adjacent segments. Oswestry Disability Index (ODI) and VAS for back and leg pain improved significantly (p < 0.05) with both methods, but there was no significant difference between groups. Operation time, blood loss, and length of hospital stay were all significantly (p < 0.001) less in the Dynesys group. The latter benefits may be of particular importance for elderly patients, or those with significant comorbidities. Complications were comparable in both groups. Dynesys posterior stabilization was effective for treating spinal stenosis L4L5 with or without spondylolisthesis.

[Posterior interbody fusion versus improved transforaminal lumbar interbody fusion in segmental spinal fixation for aged spondylolisthesis with lumbar spinal canal stenosis]

OBJECTIVE

To assess the clinical and radiographic outcomes of posterior lumbar fixation and posterior interbody fusion or improved transforaminal lumbar interbody fusion for Meyerding grade II/III spondylolisthesis so as to address the suitability of a dynamic stabilization.

METHODS

A total of 28 consecutive patients underwent posterior lumbar fixation and posterior interbody fusion or improved transforaminal lumbar interbody fusion for Meyerding grade II/III spondylolisthesis. Among them, 13 patients underwent posterior interface fusion (PLIF) and pedicle screw fixation. And improved transforaminal lumbar interbody fusion (ITLIF) and placement of the same system were performed in 15 patients. Their clinical, economic, functional, and radiographic data were recorded both pre- and postoperatively.

RESULTS

The average changes of economic and functional scores on the Prolo scale were 1.36 and 1.48 respectively. In patients with posterior interbody fusion; the average preoperative vertebral slippage was 46.9% (range: 25 - 75%) versus 14.6% (range: 15 - 25%) postoperatively. In patients with ITLIF, the average changes in economic and functional scores were 1.75 and 1.63 respectively. And the average preoperative vertebral slippage was 45.2% (range: 28 - 78%) compared with 26.3% (range: 14 - 28%) postoperatively. When two fusion techniques were compared, an overall superior reliability and resistance of systems was associated with the ITLIF procedure. But their clinical outcomes did not differ greatly (P > 0.05).

CONCLUSIONS

The application of a segmental pedicle screw fixation is both feasible and efficacious.

Radiofrequency neurotomy for treatment of low back pain in patients with minor degenerative spondylolisthesis

BACKGROUND

Degenerative spondylolisthesis is one of the major causes for low back pain. Morphological abnormalities of the zygapophysial joints are a predisposing factor in the development of degenerative spondylolisthesis. Therefore, radiofrequency neurotomy seems to be a rational therapy.

OBJECTIVES

To determine if radiofrequency neurotomy is effective for patients with low back pain and degenerative spondylolisthesis.

STUDY DESIGN

Retrospective practice audit.

SETTING

Single spine center

METHODS

Charts of all patients with degenerative spondylolisthesis who underwent treatment with radiofrequency neurotomy during a time period of 3 years were reviewed. Only patients with magnetic resonance imaging confirming the diagnosis were included. Patients with a lumbar spine operation in their history, patients with neurological deficits, and patients with a follow-up less than 3 months were excluded. Patients were treated with lumbar radiofrequency neurotomy. Positive treatment response was defined as at least a 50% reduction in pain. A radiofrequency neurotomy was only performed after positive diagnostic medial branch blocks.

RESULTS

During a time period of 3 years, 1,490 patients were treated with lumbar radiofrequency neurotomy. Forty of these patients with degenerative spondylolisthesis were included. A significant pain reduction was achieved in 65 % of the patients.

LIMITATIONS

This audit is retrospective and observational, and therefore does not represent a high level of evidence. However, to our knowledge, since this information has not been previously reported and no specific nonoperative treatment for lumbar pain in patients with degenerative spondylolisthesis exists, it appears to be the best available research upon which to recommend treatment and to plan higher quality studies.

CONCLUSION

Zygapophysial joints are a possible source of pain in patients with spondylolisthesis. Radiofrequency neurotomy is a rational, specific nonoperative therapy in addition to other nonoperative therapy methods with a success rate of 65%. This is the first study to determine the effect of radiofrequency neurotomy in patients with minor degenerative spondylolisthesis.

Mid-term clinical results of minimally invasive decompression and posterolateral fusion with percutaneous pedicle screws versus conventional approach for degenerative spondylolisthesis with spinal stenosis

INTRODUCTION

In order to minimize perioperative invasiveness and improve the patients' functional capacity of daily living, we have performed minimally invasive lumbar decompression and posterolateral fusion (MIS-PLF) with percutaneous pedicle screw fixation for degenerative spondylolisthesis with spinal stenosis. Although several minimally invasive fusion procedures have been reported, no study has yet demonstrated the efficacy of MIS-PLF in degenerative spondylolisthesis of the lumbar spine. This study prospectively compared the mid-term clinical outcome of MIS-PLF with those of conventional PLF (open-PLF) focusing on perioperative invasiveness and patients' functional capacity of daily living.

MATERIALS AND METHODS

A total of 80 patients received single-level PLF for lumbar degenerative spondylolisthesis with spinal stenosis. There were 43 cases of MIS-PLF and 37 cases of open-PLF. The surgical technique of MIS-PLF included making a main incision (4 cm), and neural decompression followed by percutaneous pedicle screwing and rod insertion. The posterolateral gutter including the medial transverse process was decorticated and iliac bone graft was performed. The parameters analyzed up to a 2-year period included the operation time, intra and postoperative blood loss, Oswestry-Disability Index (ODI), Roland-Morris Questionnaire (RMQ), the Japanese Orthopaedic Association score, and the visual analogue scale of low back pain. The fusion rate and complications were also reviewed.

RESULTS

The average operation time was statistically equivalent between the two groups. The intraoperative blood loss was significantly less in the MIS-PLF group (181 ml) when compared to the open-PLF group (453 ml). The postoperative bleeding on day 1 was also less in the MIS-PLF group (210 ml) when compared to the open-PLF group (406 ml). The ODI and RMQ scores rapidly decreased during the initial postoperative 2 weeks in the MIS-PLF group, and consistently maintained lower values than those in the open-PLF group at 3, 6, 12, and 24 months postoperatively. The fusion rate was statistically equivalent between the two groups (98 vs. 100%), and no major complications occurred.

CONCLUSION

The MIS-PLF utilizing a percutaneous pedicle screw system is less invasive compared to conventional open-PLF. The reduction in postoperative pain led to an increase in activity of daily living (ADL), demonstrating rapid improvement of several functional parameters. This superiority in the MIS-PLF group was maintained until 2 years postoperatively, suggesting that less invasive PLF offers better mid-term results in terms of reducing low back pain and improving patients' functional capacity of daily living. The MIS-PLF utilizing percutaneous pedicle screw fixation serves as an alternative technique, eliminating the need for conventional open approach.

Mini-open versus open decompression and fusion for lumbar degenerative spondylolisthesis with stenosis

The outcome of less invasive surgical techniques in comparison to traditional surgical techniques has been the source of debate. In this retrospective study, 51 patients who had undergone posterior lumbar fusion along with bilateral decompression were enrolled. Twenty-one patients underwent fusion using a standard, midline open technique (open group) and 30 patients underwent fusion using a mini-open technique, with a small, central incision for the decompression and bilateral paramedian incisions for the posterolateral fusion and placement of cannulated pedicle screws (mini-open group). Surgical variables were compared between the 2 groups. Patients in both groups experienced significant improvements in leg pain at 12 months, with a reduction in visual analog scale scores from 7.6 to 2.4 in the open group, and 7.8 to 2.3 in the mini-open group. There were no statistical differences between the groups in the magnitude of improvement of either the visual analog scale or Oswestry Disability Index scores. Operative times, blood loss, and length of hospitalization failed to show statistically significant differences between the groups, although there was a trend toward less blood loss and shorter hospitalization in the mini-open group. Fusion results and complications were similar between the 2 groups. Both techniques resulted in similarly statistically significant improvements in pain and clinical function.

Spondylolisthesis mimicking the progression of dissection in a case of chronic Stanford type B aortic dissection

Aortic dissection is an acute lethal cardiovascular condition. A 67-year-old hypertensive woman was admitted to our Emergency Department with an abrupt onset of tearing pain in the interscapular area. A thoracic computed tomography scan with contrast showed chronic type B aortic dissection. The patient was transferred to intensive care and medical therapy was initiated. Upon spread of the pain to the lumbar area, the dissection was thought to have progressed. The patient, being hemodynamically stable, was examined using ultrasonography, and the dissection did not show any progression. In the neurological examination for the lumbar pain, the lumbar processus spinosus was found to be sensitive, and the sciatic nerve stretch test was positive at 30 degrees. Magnetic resonance imaging revealed spondylolisthesis and a centrally located disc herniation at the L3-4 level. No operation for the dissection was planned, but discectomy and fusion surgery was scheduled. Since the patient refused surgery, she was discharged with medical therapy. Our aim in this report was to emphasize the importance of spondylolisthesis mimicking the progression of dissection in the differential diagnosis of a chronic type B aortic dissection case.

Cervical myelopathy due to degenerative spondylolisthesis

OBJECTIVE

To investigate clinical-radiological features of cervical myelopathy due to degenerative spondylolisthesis (DSL).

METHODS

A total of 448 patients were operated for cervical myelopathy at Nishitaga National Hospital between 2000 and 2003. Of these patients, DSL at the symptomatic disc level was observed in 22 (4.9%) patients. Clinical features were investigated by medical records, and radiological features were investigated by radiographs.

RESULTS

Disc levels of DSL were C3/4 in 6 cases and C4/5 in 16 cases. Distance of anterior slippage was 2 to 5 mm (average 2.9 mm) in flexion position. Space available for the spinal cord (SAC) was 11 to 15 mm (average 12.8 mm) in flexion position and 11 to 18 mm (average 14.6 mm) in extension position; 11 cases were reducible and 11 cases were irreducible in extension position. Myelograms demonstrated compression of spinal cord by the ligamentum flavum in extension position. Compression of spinal cord was not demonstrated in flexion position. C5-7 lordosis angle was lower than control. C5-7 range of motion (ROM) was reduced compared to controls. These alterations were statistically significant.

CONCLUSIONS

DSL occurs in the mid-cervical spine. Lower cervical spine demonstrated restricted ROM and lower lordosis angle. Pathogenesis of cervical myelopathy due to DSL is compression of spinal cord by the ligamentum flavum in extension position and not by reduced SAC in flexion position.

Predominant leg pain is associated with better surgical outcomes in degenerative spondylolisthesis and spinal stenosis: results from the Spine Patient Outcomes Research Trial (SPORT)

STUDY DESIGN

As-treated analysis of the Spine Patient Outcomes Research Trial.

OBJECTIVE

To compare baseline characteristics and surgical and nonoperative outcomes in degenerative spondylolisthesis (DS) and spinal stenosis (SpS) patients stratified by predominant pain location (i.e., leg vs. back).

SUMMARY OF BACKGROUND DATA

Evidence suggests that DS and SpS patients with predominant leg pain may have better surgical outcomes than patients with predominant low back pain (LBP).

METHODS

The DS cohort included 591 patients (62% underwent surgery), and the SpS cohort included 615 patients (62% underwent surgery). Patients were classified as leg pain predominant, LBP predominant, or having equal pain according to baseline pain scores. Baseline characteristics were compared between the 3 predominant pain location groups within each diagnostic category, and changes in surgical and nonoperative outcome scores were compared for 2 years. Longitudinal regression models including baseline covariates were used to control for confounders.

RESULTS

Among DS patients at baseline, 34% had predominant leg pain, 26% had predominant LBP, and 40% had equal pain. Similarly, 32% of SpS patients had predominant leg pain, 26% had predominant LBP, and 42% had equal pain. DS and SpS patients with predominant leg pain had baseline scores indicative of less severe symptoms. Leg pain predominant DS and SpS patients treated surgically improved significantly more than LBP predominant patients on all primary outcome measures at 1 and 2 years. Surgical outcomes for the equal pain groups were intermediate to those of the predominant leg pain and LBP groups. The differences in nonoperative outcomes were less consistent. Conclusion. Predominant leg pain patients improved significantly more with surgery than predominant LBP patients. However, predominant LBP patients still improved significantly more with surgery than with nonoperative treatment.

[Treatment of degenerative spondylolisthesis of the lumbosacral spine by decompression and dynamic transpedicular stabilisation]

PURPOSE OF THE STUDY

The aim of the study was to present the effect and advantages of surgical decompression and dynamic transpedicular stabilisation in patients with degenerative spondylolisthesis of the lumbosacral spine.

MATERIAL AND METHODS

This prospective study involved patients undergoing dynamic transpedicular stabilisation using Isolock or Isobar TTL (Scient X, France) systems. Between June 2003 and June 2009, 65 patients were treated and followed-up. They were aged 35 to 75 years (average, 57.17 years), and there were 32 men and 33 women. Follow-up ranged from 1 to 6 years. Based on indications for surgery they fell into two groups. Group 1 included 52 patients with grade I or II degenerative spondylolisthesis or retrolisthesis. Group 2 (control) consisted of 13 patients with degenerative disc disease or failed back surgery syndrome. The disorder had always been manifested by combined axial and radicular symptoms. Treatment included posterior decompression of nerve structures by laminectomy in conjunction with semi-rigid stabilisation, without fusion. Followup clinical (VAS, ODI), neurological and radiographic examinations were carried out at 6 weeks, 6 months and 1 to 6 years after surgery. The VAS and ODI results of both groups were statistically analysed and compared.

RESULTS

During follow-up the ODI values decreased by 54 % (from 58.4 % to 26.8 %) and VAS values by 62 % (from 7.9 to 3.0) as compared with the pre-operative values, and this was statistically significant. When both groups were compared, the VAS values decreased significantly (by 5.61) in Group 1, as compared with Group 2 (decrease by 3.54).

DISCUSSION

In the treatment of pseudospondylolisthesis, the semi-rigid stabilisation with spinal decompression, as presented here, is a convenient alternative to simple decompression without fixation or to various forms of instrumented or non-instrumented arthrodesis. A disadvantage associated with arthrodesis is a higher risk of ASD development; dynamic systems do not allow for reduction of spondylolisthesis and involve a change in sagittal spinal balance, and simple decompression carries the risk of slip progression and recurrent problems.

CONCLUSIONS

The authors demonstrated that decompression combined with semi-rigid stabilisation had a very good effect on the clinical state of patients with degenerative spondylolisthesis (retrolisthesis) at medium-term follow-up. The procedure was less effective in other indications. Semi-rigid stabilisation with Isobar TTL or Isolock systems prevented the progression of anterolisthesis or retrolisthesis; none of the patients experienced instrumentation failure. Neither symptomatic restenosis nor disc herniation was found in the instrumented segment. Semi-rigid stabilisation can, if necessary, be converted to fusion or disc replacement.

Diastematomyelia - a diagnostic and therapeutic problem. Case study

BACKGROUND

Diastematomyelia is a type of dysraphism with a double or bifid spinal cord divided by an osseous septum. This defect often co-occurs with other developmental disorders of the skull or the atlanto-occipital junction. The course may be benign or aggressive. 2.

CASE REPORTS

We describe two female patients treated in the Rehabilitation Clinic and the Orthopaedic Department at the Medical University of Lublin in the years 2004 - 2009. The first patient was diagnosed at the age of 20 years to have diastematomyelia at the L3 level and spina bifida occulta at L1- S5 and at the C1 arch. In the other patient, diastematomyelia at the L3 level and spondylolisthesis at L5-S1 were found at the age of 14 years. Initially both patients were treated for lumbosacral radicular syndromes. Physiotherapy intensified the pain. The patient with diastematomyelia and L5-S1 spondylolisthesis had L5-S1 segment stabilization performed at the age of 16. The pain subsided after the surgery. The other patient was instructed to stop rehabilitation, follow a balanced lifestyle, and refrain from physical work, which eliminated the pain.

DISCUSSION

Managing a patient with diastematomyelia demands caution. Diagnosis of this defect requires a thorough cause-and-effect analysis of the presenting signs and symptoms of spinal dysfunction. The treatment should be dependent on local pain intensity (which is often not directly associated with the disorder) and on the degree of neurological dysfunction. 5.

CONCLUSIONS

1. A thorough clinical evaluation with spinal imaging prior to elective surgery for scoliosis and other spine deformities should be a standard procedure undertaken in order to avoid complications. 2. The treatment for diastematomyelia should depend on the intensity of local pain and on the level of neurological dysfunction. 3. Broadly understood rehabilitation is not always effective, often increasing the pain and/or neurological complaints.

Diabetes mellitus as a risk factor for the development of lumbar spinal stenosis

BACKGROUND

Diabetes mellitus is a multi-organ disorder affecting many types of connective tissues, including bone and cartilage. Certain skeletal changes are more prevalent in diabetic patients than in non-diabetic individuals. A possible association of diabetes mellitus and lumbar spinal stenosis has been raised.

OBJECTIVES

To compare the prevalence of diabetes mellitus in patients with spinal stenosis, degenerative disk disease or osteoporotic vertebral fractures.

METHODS

A cross-sectional analysis was performed of 395 consecutive patients diagnosed with spinal stenosis, degenerative disk disease or osteoporotic vertebral fractures. All the patients were examined by one senior author in the outpatient orthopedic clinic of a large general hospital between June 2004 and January 2006 and diagnosed as having lumbar spinal stenosis (n=225), degenerative disk disease (n=124), or osteoporotic vertebral fractures (n=46).

RESULTS

The prevalence of diabetes mellitus in the three groups (spinal stenosis, osteoporotic fracture, degenerative disk disease) was 28%, 6.5% and 12.1%, respectively, revealing a significantly higher prevalence in the spinal stenosis group compared with the others (P=0.001). The higher prevalence of diabetes in the stenotic patients was unrelated to the presence of degenerative spondylolisthesis.

CONCLUSIONS

There is an association between diabetes and lumbar spinal stenosis. Diabetes mellitus may be a predisposing factor for the development of lumbar spinal stenosis.

Noninstrumented facet fusion in patients undergoing lumbar laminectomy for degenerative spondylolisthesis

The purpose of this retrospective study was to evaluate the radiographic and clinical efficacy of uninstrumented facet fusion in elderly patients undergoing lumbar laminectomy for spinal stenosis due to a single-level degenerative spondylolisthesis. Several studies have clearly demonstrated the beneficial effects of concomitant spinal fusion with laminectomy in degenerative spondylolisthesis. Controversy, however, persists regarding the virtues of fusion in this patient population. This study included 62 patients with a single-level grade I or II degenerative spondylolisthesis who underwent laminectomy and uninstrumented facet fusion for unremitting symptoms of spinal stenosis. Group 1 (39 patients) had a fixed degenerative spondylolisthesis with no measurable translation on flexion/extension radiographs, while group 2 (23 patients) had a mobile degenerative spondylolisthesis with preoperative translation. Postoperatively, the 62 listhetic levels were analyzed for radiographic signs of instability on flexion/extension radiographs for a minimum of 24 months. Clinical outcome was assessed in each patient at the time of final follow-up. In group 1 (patients with no preoperative translation), 64% of the index listhetic facet fusion levels had < or = 2 mm of motion on postoperative flexion/extension radiographs, while the other 36% had > 2 mm to < or = 15 mm of motion. Ninety-six percent of patients with < or = 2 mm of postoperative motion were "much better" after surgery, whereas only 50% of patients with > 10 mm of postoperative motion had similar results. Similar trends were also observed in group 2 with 52% of levels having < or = 2 mm motion and patient "much better" outcomes being observed with less motion postoperatively. The overall postoperative radiographic stabilization rate and improved patient outcomes were higher in group 1 than in group 2. In patients undergoing laminectomy for a grade I or II fixed or mobile degenerative spondylolisthesis, concomitant facet fusion decreases motion and stabilizes the spine via a bony fusion or a stable pseudarthrosis. In general, patients with less motion on postoperative flexion/extension radiographs had a better clinical outcome than those with more motion.