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Lee HR, Cho JH, Lee DH, Seok SY, Hwang CJ, Lee CS. Exploring the impact of mild-to-moderate foraminal stenosis at L5-S1 on clinical outcomes following L4-5 posterior lumbar interbody fusion. Spine J 2024; 24:820-830. [PMID: 38219839 DOI: 10.1016/j.spinee.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 11/11/2023] [Accepted: 12/27/2023] [Indexed: 01/16/2024]
Abstract
BACKGROUND CONTEXT Patients scheduled for L4-5 PLIF often have FS at L5-S1. However, data on the clinical and radiographic outcomes of cases with mild-to-moderate L5-S1 FS are lacking, which may affect clinical outcomes or require additional surgery after L4-5 fusion. PURPOSE To evaluate the clinical and radiographic outcomes of L4-5 PLIF in patients with and without mild-to-moderate L5-S1 FS, with a primary focus on the association between L5-S1 FS and postoperative clinical outcomes including back pain, leg pain, and scores on the oswestry disability index (ODI) and EuroQol 5-dimension (EQ-5D). STUDY DESIGN Retrospective comparative study. PATIENT SAMPLE A retrospective review of patients who underwent L4-5 PLIF from 2014 to 2018. The patients were divided according to the presence of mild-to-moderate FS at L5-S1. OUTCOME MEASURES Clinical assessment included the pain visual analog scale (VAS), ODI, and EQ-5D score. Radiographic assessments included spinopelvic parameters and grades for central and foraminal stenosis. METHODS Clinical outcomes were assessed using validated outcome measures at preoperative, 6-month, 12-month, and 36-month follow-up visits. Radiographic evaluations were performed using preoperative and postoperative radiographs. Foraminal stenosis was assessed qualitatively using MRI with a grading system from none to severe and quantitatively by measuring changes in the foraminal area on CT. RESULTS Among 186 patients, 55 were categorized as the FS group and 131 as the non-FS group. The FS group was older (p=0.039) and had more severe central stenosis at L5-S1 (p=0.007) as well as more severe FS at both L4-5 and L5-S1 (both p<0.001). Preoperative disc height (p<0.001), C7-S1 sagittal vertical axis (p=0.003), lumbar lordosis (p=0.005), and pelvic incidence-lumbar lordosis mismatch (p=0.026) were more aggravated in the FS group. The FS group showed inferior clinical outcomes at the final follow-up in terms of back pain (p=.010) and ODI score (p=.003). CONCLUSION The presence of mild-to-moderate FS at L5-S1 was associated with more aggravated sagittal balance in terms of smaller preoperative disc height, larger sagittal vertical axis, smaller lumbar lordosis, and larger pelvic incidence-lumbar lordosis mismatch. Patients with L5-S1 FS also had poorer clinical outcomes including back pain and ODI score after L4-5 PLIF. Patients with L5-S1 FS need to be carefully examined before L4-5 fusion considering their adverse outcomes due to underlying degenerative changes.
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Affiliation(s)
- Hyung Rae Lee
- Department of Orthopedic Surgery, Korea University Medical Center, Anam Hospital, 73 Goryeodae-ro Seongbuk-gu, Seoul 02841, Republic of Korea
| | - Jae Hwan Cho
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.
| | - Dong-Ho Lee
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Sang Yun Seok
- Department of Orthopedic Surgery, Daejeon Eulji Medical Center, 95, Dunsanseo-ro, Seo-gu, Daejeon, Republic of Korea
| | - Chang Ju Hwang
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Choon Sung Lee
- St. Peter's Hospital, 2633, Nambusunhwan-ro, Gangnam-gu, Seoul, Republic of Korea
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Daniels AH, Balmaceno-Criss M, McDonald CL, Singh M, Knebel A, Kuharski MJ, Daher M, Alsoof D, Lafage R, Lafage V, Diebo BG. Segmental Sagittal Alignment in Lumbar Spinal Fusion: A Review of Evidence-Based Evaluation of Preoperative Measurement, Surgical Planning, Intraoperative Execution, and Postoperative Evaluation. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01153. [PMID: 38690883 DOI: 10.1227/ons.0000000000001179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 03/05/2024] [Indexed: 05/03/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Maintaining and restoring global and regional sagittal alignment is a well-established priority that improves patient outcomes in patients with adult spinal deformity. However, the benefit of restoring segmental (level-by-level) alignment in lumbar fusion for degenerative conditions is not widely agreed on. The purpose of this review was to summarize intraoperative techniques to achieve segmental fixation and the impact of segmental lordosis on patient-reported and surgical outcomes. METHODS In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, PubMed, Embase, Cochrane, and Web of Science databases were queried for the literature reporting lumbar alignment for degenerative lumbar spinal pathology. Reports were assessed for data regarding the impact of intraoperative surgical factors on postoperative segmental sagittal alignment and patient-reported outcome measures. Included studies were further categorized into groups related to patient positioning, fusion and fixation, and interbody device (technique, material, angle, and augmentation). RESULTS A total of 885 studies were screened, of which 43 met inclusion criteria examining segmental rather than regional or global alignment. Of these, 3 examined patient positioning, 8 examined fusion and fixation, 3 examined case parameters, 26 examined or compared different interbody fusion techniques, 5 examined postoperative patient-reported outcomes, and 3 examined the occurrence of adjacent segment disease. The data support a link between segmental alignment and patient positioning, surgical technique, and adjacent segment disease but have insufficient evidence to support a relationship with patient-reported outcomes, cage subsidence, or pseudoarthrosis. CONCLUSION This review explores segmental correction's impact on short-segment lumbar fusion outcomes, finding the extent of correction to depend on patient positioning and choice of interbody cage. Notably, inadequate restoration of lumbar lordosis is associated with adjacent segment degeneration. Nevertheless, conclusive evidence linking segmental alignment to patient-reported outcomes, cage subsidence, or pseudoarthrosis remains limited, underscoring the need for future research.
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Affiliation(s)
- Alan H Daniels
- Department of Orthopedics Surgery, Rhode Island Hospital, Brown University, Providence, Rhode Island, USA
| | - Mariah Balmaceno-Criss
- Department of Orthopedics Surgery, Rhode Island Hospital, Brown University, Providence, Rhode Island, USA
| | - Christopher L McDonald
- Department of Orthopedics Surgery, Rhode Island Hospital, Brown University, Providence, Rhode Island, USA
| | - Manjot Singh
- Department of Orthopedics Surgery, Rhode Island Hospital, Brown University, Providence, Rhode Island, USA
| | - Ashley Knebel
- Department of Orthopedics Surgery, Rhode Island Hospital, Brown University, Providence, Rhode Island, USA
| | - Michael J Kuharski
- Department of Orthopedics Surgery, Rhode Island Hospital, Brown University, Providence, Rhode Island, USA
| | - Mohammad Daher
- Department of Orthopedics Surgery, Rhode Island Hospital, Brown University, Providence, Rhode Island, USA
| | - Daniel Alsoof
- Department of Orthopedics Surgery, Rhode Island Hospital, Brown University, Providence, Rhode Island, USA
| | - Renaud Lafage
- Department of Orthopedic Surgery, Lenox Hill Northwell, New York, New York, USA
| | - Virginie Lafage
- Department of Orthopedic Surgery, Lenox Hill Northwell, New York, New York, USA
| | - Bassel G Diebo
- Department of Orthopedics Surgery, Rhode Island Hospital, Brown University, Providence, Rhode Island, USA
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Leng Y, Tang C, Liao Y, Tang Q, Ma F, Pu X, He B, Wang Q, Zhong D. Correlation Between Sacral Slope and Pedicle Morphology of the Fourth Lumbar Vertebra in Degenerative Lumbar Spondylolisthesis. Global Spine J 2024; 14:583-592. [PMID: 35921499 PMCID: PMC10802538 DOI: 10.1177/21925682221117151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Retrospective Radiographic Review. OBJECTIVES The purpose of this study was to investigate the correlation between the sacral slope (SS) and pedicle morphological parameters of the fourth lumbar vertebra in degenerative lumbar spondylolisthesis (DLS). METHODS Our study included 134 patients with L4-5 DLS. We used preoperative multi-slice spiral computed tomography to measure a range of pedicle morphological parameters, and the SS and percentage of slip distance (SDP) of the L4 vertebra were measured on preoperative standing neutral lumbar radiography. Patients were divided into three groups based on their degree of SS: the low sacral slope (LSS) group with SS values of <35°, the mean sacral slope (MSS) group with SS of 35°-45°, and the high sacral slope (HSS) group with SS > 45°. RESULTS As the SS increased across groups, the pedicles of L4 became longer and thinner and the pedicle camber angle was smaller. The SDP, pedicle length parameters were positively correlated with the SS, while pedicle width, height, and camber angle were negatively correlated with the SS in the three groups. CONCLUSIONS SS had an impact on the degree of spondylolisthesis and on pedicle morphological parameters in patients with DLS, with greater slope resulting in greater impact. The progression of DLS occurred due to the increasing forward shear force of the vertebra being greater than the reverse resistance. The pedicle at the slip level adaptively remodeled, becoming slenderer and tilting inward due to the long-term traction of the two opposing forces.
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Affiliation(s)
- Yebo Leng
- Department of Orthopaedics, The Affiliated Hospital of Southwest Medical University, Lu Zhou, China
| | - Chao Tang
- Department of Orthopaedics, The Affiliated Hospital of Southwest Medical University, Lu Zhou, China
| | - Yehui Liao
- Department of Orthopaedics, The Affiliated Hospital of Southwest Medical University, Lu Zhou, China
| | - Qiang Tang
- Department of Orthopaedics, The Affiliated Hospital of Southwest Medical University, Lu Zhou, China
| | - Fei Ma
- Department of Orthopaedics, The Affiliated Hospital of Southwest Medical University, Lu Zhou, China
| | - Xiamin Pu
- Department of Cardiology, The Affiliated Hospital of Southwest Medical University, Lu Zhou, China
| | - Baoqiang He
- Department of Orthopaedics, The Affiliated Hospital of Southwest Medical University, Lu Zhou, China
| | - Qing Wang
- Department of Orthopaedics, The Affiliated Hospital of Southwest Medical University, Lu Zhou, China
| | - Dejun Zhong
- Department of Orthopaedics, The Affiliated Hospital of Southwest Medical University, Lu Zhou, China
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Jing X, Gong Z, Zhang N, Xu Z, Qiu X, Li F, Liu W, Hu Q, Chen Q. Comparison of Intraoperative Endplate Injury between Mini-Open Lateral Lumbar Interbody Fusion (LLIF) and Transforaminal Lumbar Interbody Fusion (TLIF) and Analysis of Risk Factors: A Retrospective Study. J INVEST SURG 2023; 36:2285787. [PMID: 38010393 DOI: 10.1080/08941939.2023.2285787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 11/14/2023] [Indexed: 11/29/2023]
Abstract
OBJECTIVE The study aimed to compare the incidence of intraoperative endplate injury in patients who underwent Transforaminal interbody fusion (TLIF) and mini-open lumbar interbody fusion (LLIF) surgery. The independent risk factors related to endplate injury in LLIF procedure were analyzed. METHODS A total of 199 patients who underwent LLIF (n = 106) or TLIF (n = 93) surgery from June 2019 to September 2021 were reviewed. The endplate injury was assessed by postoperative sagittal CT scan. A binary logistic analysis model were used to identify independent risk factors related to LLIF endplate injury based on univariate analysis. RESULTS There was an obvious difference in the occurrence of intraoperative endplate injury between LLIF (42/106, 39.6%) and TLIF group (26/93, 28%), although it did not reach the significant level. L1 CT value (OR = 0.985, 95% CI = 0.972-0.998), cage position (OR = 3.881, 95% CI = 1.398-10.771) and height variance (OR = 1.263, 95% CI = 1.013-1.575) were independent risk factors for endplate injury in LLIF procedure. According to the cage settlement patterns, there 5 types of A to E. The severity of the facet joint degeneration was positively related to the occurrence of endplate injury. CONCLUSIONS The incidence of intraoperative endplate injury is higher in LLIF than in TLIF procedures. Low bone quantity, cage posterior position and larger height variance are risk factors to induce endplate injury in LLIF surgery. The facet joint degeneration may be related to severe endplate injuries and even fractures.
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Affiliation(s)
- Xiaowei Jing
- Department of Orthopedic Surgery, The Fourth Affiliated Hospital Zhejiang University School of Medicine, Yiwu, Zhejiang, China
| | - Zhiyuan Gong
- Department of Orthopedic Surgery, The Fourth Affiliated Hospital Zhejiang University School of Medicine, Yiwu, Zhejiang, China
| | - Ning Zhang
- Department of Orthopedic Surgery, The Second Affiliated Hospital Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Zhengkuan Xu
- Department of Orthopedic Surgery, The Second Affiliated Hospital Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Xiaowen Qiu
- Department of Orthopedic Surgery, The Fourth Affiliated Hospital Zhejiang University School of Medicine, Yiwu, Zhejiang, China
| | - Fangcai Li
- Department of Orthopedic Surgery, The Second Affiliated Hospital Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Wei Liu
- Department of Orthopedic Surgery, The Fourth Affiliated Hospital Zhejiang University School of Medicine, Yiwu, Zhejiang, China
| | - Qingfeng Hu
- Department of Orthopedic Surgery, The Fourth Affiliated Hospital Zhejiang University School of Medicine, Yiwu, Zhejiang, China
| | - Qixin Chen
- Department of Orthopedic Surgery, The Second Affiliated Hospital Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
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Loubeyre J, Ferrero E, Jmal MM, Guigui P, Khalifé M. Surgical treatment of degenerative lumbar spondylolisthesis: Effect of TLIF and slip reduction on sagittal alignment. Orthop Traumatol Surg Res 2023; 109:103541. [PMID: 36608900 DOI: 10.1016/j.otsr.2022.103541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 08/08/2022] [Accepted: 10/12/2022] [Indexed: 01/05/2023]
Abstract
INTRODUCTION The surgical treatment of lumbar degenerative spondylolisthesis (LDS) remains controversial. The aim of this study was to determine the effect of adding transforaminal lumbar interbody fusion (TLIF) to posterolateral fusion (PLF) on the local lordosis, sagittal alignment and potential complications. The second aim was to evaluate the effect of slip reduction on the same parameters. HYPOTHESIS The initial hypothesis was that TLIF provides better correction of the local lordosis and that reducing the slip improves the global sagittal balance. METHODS In this retrospective, single-center study, patients who had been operated on for LSD at one or two levels by laminectomy and PLF, with or without a TLIF cage, were included. Data collected consisted of age, sex, number of levels fused and whether or not a TLIF cage was used. Fusion was defined as the absence of indirect nonunion signs on radiographs at 2 years postoperative. The occurrence and time frame of any complications and the need for reoperation were documented. Lateral radiographs of the entire spine were analyzed preoperatively, in the early postoperative period (3 to 6 months) and at a minimum follow-up of 2 years. The following parameters were measured: pelvic parameters, C7 sagittal tilt (C7ST), spinosacral angle (SSA), maximum lumbar lordosis (LL), lordosis at slipped level (LS), slip percentage. The analysis compared patients treated by PLF and TLIF and determined the impact of slip reduction. RESULTS One hundred and three patients were included in the study (71% women). The mean follow-up was 38 months. The mean age was 69 years. Seventy-seven patients (75%) underwent PLF. Comparing the preoperative and early postoperative data identified 5.4% better spondylolisthesis reduction in the TLIF group than the PLF group (-8.9±9.5% vs -3.5±7.6%; p=0.04) that was not maintained at the final follow-up. The fusion rate was comparable between groups: 94% in APL and 89% in TLIF (p=0.7). The overall complication rate was 46% in the TLIF group versus 33% in the PLF group (p=0.35). A comparison based on whether or not the slip was reduced found significant improvement in the reduction group of the SSA by more than 6° (6.8°±6° vs 0.5°±7.4°; p=0.04). The fusion rate was 91% in the reduced group and 95% in the non-reduced group (p=0.81); the complication rate was 44% versus 28% in the non-reduced group (p=0.10). CONCLUSION This study shows that slip reduction helps to improve the sagittal alignment by increasing the SSA when treating LDS. Posterolateral fusion and TLIF produce comparable radiographic outcomes at 2 years postoperative in the segmental lordosis, slip reduction, global sagittal alignment and fusion rate. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Jeanne Loubeyre
- Service de chirurgie orthopédique, hôpital européen Georges-Pompidou, 20, rue Leblanc, 75015 Paris, France; Université Paris-Cité, Paris, France
| | - Emmanuelle Ferrero
- Service de chirurgie orthopédique, hôpital européen Georges-Pompidou, 20, rue Leblanc, 75015 Paris, France; Université Paris-Cité, Paris, France
| | - Mohamed Mokhtar Jmal
- Service de chirurgie orthopédique, hôpital européen Georges-Pompidou, 20, rue Leblanc, 75015 Paris, France; Université Paris-Cité, Paris, France
| | - Pierre Guigui
- Service de chirurgie orthopédique, hôpital européen Georges-Pompidou, 20, rue Leblanc, 75015 Paris, France; Université Paris-Cité, Paris, France
| | - Marc Khalifé
- Service de chirurgie orthopédique, hôpital européen Georges-Pompidou, 20, rue Leblanc, 75015 Paris, France; Université Paris-Cité, Paris, France.
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Lee HR, Cho JH, Lee DH, Seok SY, Hwang CJ, Lee CS. Risk Factors for the Aggravation of Sagittal Balance After L5-S1 Posterior Lumbar Interbody Fusion. World Neurosurg 2023; 175:e653-e661. [PMID: 37030480 DOI: 10.1016/j.wneu.2023.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Accepted: 04/02/2023] [Indexed: 04/09/2023]
Abstract
OBJECTIVE To identify the risk factors for the aggravation of sagittal alignment after single-level L5-S1 PLIF. METHODS Eighty-six patients who underwent L5-S1 PLIF were divided into 2 groups according to the postoperative changes in the segmental angle (SA; group I: increase; group D: decrease). The 2 groups were compared in terms of demographic, clinical, and radiological outcomes. Multivariate logistic regression analysis was performed to identify the risk factors for aggravation of sagittal alignment. RESULTS Of the study patients, 39 (45%) were categorized as group I and 47 (55%) as group D. The demographic and clinical parameters were not significantly different between the 2 groups. Group D showed postoperative deteriorations in the local sagittal parameters, including lumbar lordosis (LL; P = 0.034), sacral slope (P = 0.012), and pelvic tilt (P = 0.003). In contrast, group I showed improved LL after surgery (P = 0.021). Large preoperative values of lumbosacral angle (LSA; odds ratio [OR], 1.287; P = 0.001), SA (OR, 1.448; P < 0.001), and flexion LSA (OR, 1.173; P = 0.011) were independent risk factors for the aggravation of sagittal balance. CONCLUSIONS Surgeons treating patients with large preoperative SA, LSA, and flexion LSA at L5-S1 level should be cautious of the possible aggravation of sagittal balance after L5-S1 PLIF and may consider different surgical approaches such as anterior or oblique lumbar interbody fusion.
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Affiliation(s)
- Hyung Rae Lee
- Department of Orthopedic Surgery, Uijeongbu Eulji Medical Center, Uijeongbusi, Gyeonggido, Republic of Korea
| | - Jae Hwan Cho
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
| | - Dong-Ho Lee
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang Yun Seok
- Department of Orthopedic Surgery, Daejeon Eulji Medical Center, Daejeonsi, Republic of Korea
| | - Chang Ju Hwang
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Choon Sung Lee
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Mohanty S, Barchick S, Kadiyala M, Lad M, Rouhi AD, Vadali C, Albayar A, Ozturk AK, Khalsa A, Saifi C, Casper DS. Should patients with lumbar stenosis and grade I spondylolisthesis be treated differently based on spinopelvic alignment? A retrospective, two-year, propensity matched, comparison of patient-reported outcome measures and clinical outcomes from multiple sites within a single health system. Spine J 2023; 23:92-104. [PMID: 36064091 DOI: 10.1016/j.spinee.2022.08.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 08/16/2022] [Accepted: 08/26/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Degenerative lumbar spondylolisthesis is one of the most common pathologies addressed by surgeons. Recently, data demonstrated improved outcomes with fusion in conjunction with laminectomy compared to laminectomy alone. However, given not all degenerative spondylolistheses are clinically comparable, the best treatment option may depend on multiple parameters. Specifically, the impact of spinopelvic alignment on patient reported and clinical outcomes following fusion versus decompression for grade I spondylolisthesis has yet to be explored. PURPOSE This study assessed two-year clinical outcomes and one-year patient reported outcomes following laminectomy with concomitant fusion versus laminectomy alone for management of grade I degenerative spondylolisthesis and stenosis. The present study is the first to examine the effect of spinopelvic alignment on patient-reported and clinical outcomes following decompression alone versus decompression with fusion. STUDY DESIGN/SETTING Retrospective sub-group analysis of observational, prospectively collected cohort study. PATIENT SAMPLE 679 patients treated with laminectomy with fusion or laminectomy alone for grade I degenerative spondylolisthesis and comorbid spinal stenosis performed by orthopaedic and neurosurgeons at three medical centers affiliated with a single, tertiary care center. OUTCOME MEASURES The primary outcome was the change in Patient-Reported Outcome Measurement Information System (PROMIS), Global Physical Health (GPH), and Global Mental Health (GMH) scores at baseline and post-operatively at 4-6 and 10-12 months postoperatively. Secondary outcomes included operative parameters (estimated blood loss and operative time), and two-year clinical outcomes including reoperations, duration of postoperative physical therapy, and discharge disposition. METHODS Radiographs/MRIs assessed stenosis, spondylolisthesis, pelvic incidence, lumbar lordosis, sacral slope, and pelvic tilt; from this data, two cohorts were created based on pelvic incidence minus lumbar lordosis (PILL), denoted as "high" and "low" mismatch. Patients underwent either decompression or decompression with fusion; propensity score matching (PSM) and coarsened exact matching (CEM) were used to create matched cohorts of "cases" (fusion) and "controls" (decompression). Binary comparisons used McNemar test; continuous outcomes used Wilcoxon rank-sum test. Between-group comparisons of changes in PROMIS GPH and GMH scores were analyzed using mixed-effects models; analyses were conducted separately for patients with high and low pelvic incidence-lumbar lordosis (PILL) mismatch. RESULTS 49.9% of patients (339) underwent lumbar decompression with fusion, while 50.1% (340) received decompression. In the high PLL mismatch cohort at 10-12 months postoperatively, fusion-treated patients reported improved PROs, including GMH (26.61 vs. 20.75, p<0.0001) and GPH (23.61 vs. 18.13, p<0.0001). They also required fewer months of outpatient physical therapy (1.61 vs. 3.65, p<0.0001) and had lower 2-year reoperation rates (12.63% vs. 17.89%, p=0.0442) compared to decompression-only patients. In contrast, in the low PLL mismatch cohort, fusion-treated patients demonstrated worse endpoint PROs (GMH: 18.67 vs. 21.52, p<0.0001; GPH: 16.08 vs. 20.74, p<0.0001). They were also more likely to require skilled nursing/rehabilitation centers (6.86% vs. 0.98%, p=0.0412) and extended outpatient physical therapy (2.47 vs. 1.34 months, p<0.0001) and had higher 2-year reoperation rates (25.49% vs. 14.71%,p=0.0152). CONCLUSIONS Lumbar laminectomy with fusion was superior to laminectomy in health-related quality of life and reoperation rate at two years postoperatively only for patients with sagittal malalignment, represented by high PILL mismatch. In contrast, the addition of fusion for patients with low-grade spondylolisthesis, spinal stenosis, and spinopelvic harmony (low PILL mismatch) resulted in worse quality of life outcomes and reoperation rates.
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Affiliation(s)
- Sarthak Mohanty
- Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Stephen Barchick
- University of Pennsylvania, Department of Orthopaedics; 3737 Market St, Philadelphia, PA, 19104, USA
| | - Manasa Kadiyala
- Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Meeki Lad
- New Jersey Medical School; Rutgers University; 185 W S Orange Ave, Newark, NJ, 07103, USA
| | - Armaun D Rouhi
- Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Chetan Vadali
- University of Pennsylvania, Department of Orthopaedics; 3737 Market St, Philadelphia, PA, 19104, USA
| | - Ahmed Albayar
- University of Pennsylvania Department of Neurosurgery; 3737 Market St, Philadelphia, PA, 19104, USA
| | - Ali K Ozturk
- University of Pennsylvania Department of Neurosurgery; 3737 Market St, Philadelphia, PA, 19104, USA
| | - Amrit Khalsa
- University of Pennsylvania, Department of Orthopaedics; 3737 Market St, Philadelphia, PA, 19104, USA
| | - Comron Saifi
- Houston Methodist Hospital, Department of Orthopedics & Sports Medicine; 6445 Main St. 2500, Houston, TX, 77030, USA
| | - David S Casper
- University of Pennsylvania, Department of Orthopaedics; 3737 Market St, Philadelphia, PA, 19104, USA.
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Bredow J, Meyer C, Oikonomidis S, Kernich C, Kernich N, Hofstetter CP, Heck VJ, Eysel P, Prasse T. Long-term Radiological and Clinical Outcome after Lumbar Spinal Fusion Surgery in Patients with Degenerative Spondylolisthesis: A Prospective 6-Year Follow-up Study. Orthop Surg 2022; 14:1607-1614. [PMID: 35711118 PMCID: PMC9363728 DOI: 10.1111/os.13350] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 05/16/2022] [Accepted: 05/18/2022] [Indexed: 11/30/2022] Open
Abstract
Objective To assess which radiological alignment parameters are associated with a satisfactory long‐term clinical outcome after performing lumbar spinal fusion for treating degenerative spondylolisthesis. Methods This single‐center prospective study assessed the relation between radiological alignment parameters measured on standing lateral lumbar spine radiographs and the patient‐reported outcome using four different questionnaires (COMI, EQ‐5D, ODI and VAS) as primary outcome measures (level of evidence: II). The following spinopelvic alignment parameters were used: gliding angle, sacral inclination, anterior displacement, sagittal rotation, lumbar lordosis, sacral slope, pelvic tilt and pelvic incidence. Furthermore, the length of stay and perioperative complications were documented. Only cases from 2013 to 2015 of low‐grade degenerative lumbar spondylolisthesis (Meyerding grades I and II) were considered. The patients underwent open posterior lumbar fusion surgery by pedicle screw instrumentation and cage insertion. The operative technique was either a posterior lumbar interbody fusion (PLIF) or a transforaminal lumbar interbody fusion (TLIF) performed by three different senior orthopedic surgeons. Exclusion criteria were spine fractures, minimally invasive techniques, underlying malignant diseases or acute infections, previous or multisegmental spine surgery as well as preoperative neurologic impairment. Of 89 initially contacted patients, 17 patients were included for data analysis (11 males, six females). Results The data of 17 patients after mono‐ or bisegmental lumbar fusion surgery to treat low‐grade lumbar spondylolisthesis and with a follow‐up time of least 72 months were analyzed. The mean age was 66.7 ± 11.3 years. In terms of complications two dural tears and one intraoperative bleeding occurred. The average body mass index (BMI) was 27.6 ± 4.4 kg/m2 and the average inpatient length of stay was 12.9 ± 3.8 days (range: 8–21). The long‐term clinical outcome correlated significantly with the change of the pelvic tilt (rs = −0.515, P < 0.05) and the sagittal rotation (rs = −0.545, P < 0.05). The sacral slope was significantly associated with the sacral inclination (rs = 0.637, P < 0.01) and the pelvic incidence (rs = 0.500, P < 0.05). In addition, the pelvic incidence showed a significant correlation with the pelvic tilt (rs = 0.709, P < 0.01). The change of the different clinical scores over time also correlated significantly between the different questionnaires. Conclusions The surgical modification of the pelvic tilt and the sagittal rotation are the two radiological alignment parameters that can most accurately predict the long‐term clinical outcome after lumbar interbody fusion surgery.
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Affiliation(s)
- Jan Bredow
- Department of Orthopedics and Trauma Surgery, Krankenhaus Porz am Rhein, University of Cologne, Cologne, Germany
| | - Carolin Meyer
- Center for Spinal Surgery, Helios Klinikum Bonn/Rhein-Sieg, Bonn, Germany
| | - Stavros Oikonomidis
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Orthopedics and Trauma Surgery, Cologne, Germany
| | - Constantin Kernich
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Orthopedics and Trauma Surgery, Cologne, Germany
| | - Nikolaus Kernich
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Orthopedics and Trauma Surgery, Cologne, Germany
| | | | - Vincent J Heck
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Orthopedics and Trauma Surgery, Cologne, Germany
| | - Peer Eysel
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Orthopedics and Trauma Surgery, Cologne, Germany
| | - Tobias Prasse
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Orthopedics and Trauma Surgery, Cologne, Germany.,University of Washington, Department of Neurological Surgery, Seattle, Washington, USA
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Tan R, Lv X, Wu P, Li Y, Dai Y, Jiang B, Ren B, Lv G, Wang B. Learning Curve and Initial Outcomes of Full-Endoscopic Posterior Lumbar Interbody Fusion. Front Surg 2022; 9:890689. [PMID: 35574552 PMCID: PMC9096087 DOI: 10.3389/fsurg.2022.890689] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 04/11/2022] [Indexed: 11/13/2022] Open
Abstract
Study DesignThis was a retrospective cohort study.ObjectiveWe evaluated the feasibility, safety, and accuracy of full-endoscopic posterior lumbar interbody fusion (FE-PLIF) by assessing the learning curve and initial clinical outcomes.Summary of Background DataLow back pain is one of the crucial medical conditions worldwide. FE-PLIF has been reported to be a minimally invasive method to treat mechanical low back pain, but there lacks a thorough evaluation on this new technique.MethodsThe patients were divided into three groups in the order of operating date, implying that Group A consisted of the initial 12 cases, Group B the subsequent 12 cases, and Group C the last 12 cases. The data of patients were reviewed for gender, age, preoperative symptoms, satisfaction, as well as clinical outcomes demonstrated by visual analog scale (VAS). The operative time and intraoperative fluoroscopy were recorded to demonstrate the learning curve and the extent of radiographic exposure. Statistical significance was set at a p < 0.05 (two-sided).ResultsThe patients enrolled in this study were followed up at an average of 1.41 ± 0.24 years. Overall, patients were satisfied with the surgery. The average number of intraoperative fluoroscopy was 6.97 ± 0.74. A significant improvement was observed in the VAS of both lumbar pain and leg pain. The overall fusion rate was 77.7%. Complications were reported in two patients in Group A, one in Group B, and none in Group C. The average operative time showed a trend of gradual decline. The learning curve was characterized using a cubic regression analysis as y = –27.07x + 1.42x2–0.24x3 + 521.84 (R2 = 0.617, p = 0.000).ConclusionsFE-PLIF is an effective and safe method for treating low back pain caused by short-segmental degenerative diseases. The learning curve of this technique is steep at the initial stage but acceptable and shows great potential for improvement.
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