Circumferential minimally invasive approach for low-grade isthmic spondylolisthesis: A clinical and radiological study of 43 patients

Surgical management of isthmic spondylolisthesis: A comparative study of postoperative outcomes between ALIF and TLIF

INTRODUCTION

Circumferential fusion by the anterior (ALIF) or transforaminal (TLIF) approach combined with posterior instrumentation is currently used for the surgical treatment of low-grade isthmic spondylolisthesis. But few studies have compared the clinical and radiological outcomes of various interbody fusion techniques. The objective of this study was to compare the clinical and radiological results at 2 years postoperative of two fusion techniques-TLIF versus ALIF plus posterior instrumentation-for low-grade isthmic spondylolisthesis in adults.

MATERIALS AND METHODS

This was an observational multicenter study done at nine French healthcare facilities specialized in spine surgery. The inclusion criteria were minimum age of 18 years, grade 1-3 isthmic spondylolisthesis, ALIF+posterior fixation (ALIF+PS) or TLIF, minimum follow-up of 2 years. Clinical and radiological evaluations were done preoperatively and at 2 years of follow-up. A lumbar CT scan was done at 1 year postoperative to evaluate fusion.

RESULTS

The cohort consisted of 89 patients (50 women, 39 men) with a mean age of 47.7±12.3 (18-79) years. The patients in the ALIF groups (n=71) had a significantly longer hospital stay than those in the TLIF group (n=18): 5.7 days versus 4.6 days (p=.04). However, their medical leave from work was significantly shorter: 31.0 weeks versus 40.7 (p=.003). Lumbar pain VAS diminished faster in the ALIF groups, with a significantly larger drop than the TLIF group in the first 3 months postoperative. Only the increase in lumbar disc lordosis was larger in the ALIF group: 11.7°±12.0° versus 6.0°±11.7° (p=.036). There was a significant correlation between the increase in global lordosis and reduction in lumbar VAS at 2 years postoperative (ρ=-0.3295; p=.021).

CONCLUSION

ALIF+PS provides a faster relief of postoperative low back pain than TLIF but there are no significant clinical differences between techniques at 2 years of follow-up. Despite better restoration of disc lordosis in the ALIF+PS group, there was no difference in the restoration of global lordosis.

LEVEL OF EVIDENCE

III; multicenter comparative study.

High-grade L5-S1 spondylolisthesis with lumbosacral kyphosis: Long-term results of non-instrumented circumferential arthrodesis in children, adolescents

INTRODUCTION

The choice of surgical technique for high-grade spondylolisthesis (HGS) associated with lumbosacral kyphosis remains controversial. Are non-instrumented techniques still relevant, what with the multiplicity and modernity of patient-specific instrumentation?

HYPOTHESIS

Our hypothesis was that a non-instrumented circumferential arthrodesis performed after a period of gradual reduction of HGS, associated with lumbosacral kyphosis, provided satisfactory long-term functional and radiographic results in children and adolescents while minimizing the risk of complications.

MATERIALS AND METHODS

Thirty-one L5-S1 HGS associated with a lumbosacral kyphosis operated by non-instrumented circumferential arthrodesis after a period of traction and suspension were included in our study. The first stage of this technique consisted of a gradual reduction using traction followed by immobilization in the corrected position. The second stage involved a posterior, followed by an anterior, surgical procedure and a spica cast immobilization for 4 months. The mean age at surgery was 13.9±2.3 years (6-18) and the mean follow-up was 10.3±4.5 years (2.1-17.8).

RESULTS

The overall complication rate was 26% (n=8/31): 13% neurologic complications, 10% bone fusion defects and 3% skin complications. The reoperation rate was 13% (n=4/31). The mean ODI (/50) was 3±4.6 (0-22) and the SRS-30 126.7±15 (72-143). The Taillard index decreased by 25% (p<.001) and remained stable throughout the follow-up period (p=.65). The lumbosacral angle was corrected by 13.5% (p=.03) and the correction was maintained throughout the follow-up period (p=.71). At the last follow-up, the lumbosacral angle was significantly correlated with a low ODI score and a high SRS-30 score (p<.05).

CONCLUSION

Even though this technique achieved a smaller reduction of the lumbosacral angle, it reduced by at least a factor of three the incidence of neurologic complications and resulted in satisfactory functional outcomes when compared to instrumented and intraoperative correction series.

LEVEL OF EVIDENCE

IV.

Isthmic spondylolisthesis treated with circumferential arthrodesis (ALIF and posterior fixation): correction, fusion and indirect decompression

There is no consensus regarding the choice of the surgical technique for isthmic spondylolisthesis treatment, although they all aim to a common goal, achieving fusion at the index level while restoring an appropriate lordosis and remove potential radicular compression. Analyze outcome of circumferential arthrodesis (CA) with ALIF (Anterior Lumbar Interbody Fusion) and pedicle screw fixation for the treatment of all-grade isthmic spondylolisthesis, with indirect neurological decompression. Retrospective study of isthmic spondylolisthesis treated with CA, with one-year follow-up. Clinical scores were collected at one year: VAS-L, VAS-R and ODI. Pelvic parameters, L4-S1 lordosis and at index and adjacent levels, and lumbo-sacral angle (LSA) were measured pre- and post-operatively and at last follow-up. Foraminal surface and diameters were measured pre- operatively and at follow-up on CT-Scan. Level of evidence: IV. 87 patients were included. Mean VAS-L was 2.3, mean VAS-R was 1, and mean ODI was 13.8%. 10% of the patients presented a high-grade spondylolisthesis and 50% a grade II. Mean lordosis at index level shifted from 6° to 18°, L4-S1 lordosis increased from 37 to 45° and LSA shifted from 116 to 125° (p<0.001). The foraminal surface increased from 50mm 2 to 70mm 2 at last follow-up mostly through the supero-inferior diameter, shifting from 7.4mm to 9.5mm (p<0.001). In LSA<90° group, mean correction was 20° at index level, 13° at L4-S1 and 21° for LSA versus 11°, 8° and 8° respectively in LSA>90° group (p<0.001). Fusion rate was estimated at 96.5%. One infection, 5 sympathetic dysfunctions, one retrograde ejaculation, one iliac vein injury, one incisional hernia, one lateral femoral cutaneous nerve injury and two adjacent syndromes have been noted. CA is an efficient technique for the treatment of isthmic spondylolisthesis of all grades, with an acceptable rate of complications. It allows a restoration of the regional lordosis as well as a foraminal widening, avoiding additional decompression.

Circumferential fusion with open versus percutaneous posterior fusion for lumbar isthmic spondylolisthesis

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To investigate the clinical and radiographic differences between patients who underwent anterior lumber interbody fusion (ALIF) with either open or percutaneous posterior fusion for lumbar isthmic spondylolisthesis.

SUMMARY OF BACKGROUND DATA

Circumferential fusion for isthmic spondylolisthesis is commonly performed with superior clinical outcomes, fusion rates, and restoration of sagittal balance when compared to posterior fusion alone. The outcomes comparing traditional open versus percutaneous posterior fusion in this setting have not been fully evaluated.

METHODS

A retrospective review of patients who underwent ALIF with either traditional open or percutaneous posterior fusion for isthmic spondylolisthesis between 2014 and 2019 was conducted. Patient demographics, surgical characteristics, and radiographic and clinical outcomes were compared between groups.

RESULTS

A total of 79 patients were included in the final analysis, with 49 in the Open group and 30 in the Percutaneous group. No differences were found with regard to demographic factors between groups including sex, body mass index (BMI), diabetic status, and smoking status. The percutaneous group had less estimated blood loss (EBL, 69.2 mL) and shorter length of stay (3.06 days) compared to the open group (446 mL, p = 0.017; 3.98 days, p = 0.003). Both groups demonstrated significant improvement in all clinical outcome measures after surgery (PCS-12, MCS-12, ODI, VAS Back, and VAS Leg scores). The percutaneous group achieved greater ∆VAS Back (Open = 3.55, Perc = 5.17; p = 0.045) and also had a significantly greater improvements in recovery ratio for VAS Back (Open: 0.43, Perc: 0.73; p = 0.037) and ODI (Open: 0.40, Perc = 0.67; p = 0.031). Regression analysis demonstrated percutaneous surgery to be significant predictor of superior improvement in VAS Back scores (β = 1.957, p = 0.027).

CONCLUSION

ALIF with percutaneous posterior fusion affords greater improvement in back pain and disability when compared to ALIF with open posterior fusion for isthmic spondylolisthesis.

LEVEL OF EVIDENCE

III.

A Technical Nuance to Avoid Lumbar Five Radiculopathy with Anterior Lumbar Fusion and Posterior Instrumentation

The anterior lumbar interbody fusion (ALIF) is a well-established procedure used to treat a multitude of spinal pathologies. When performed at the L5-S1 level, the ALIF is often supplemented with posterior pedicle screw and rod fixation. Because the interbody device can restore disk and foraminal height, one benefit of the ALIF procedure is indirect neural decompression in the spinal canal and neural foramina. If the contour of the posterior rod is not matched to the exact position of the tulip heads on the pedicle screws, spondylolisthesis can be introduced, leading to foraminal stenosis and nerve compression. This concern is particularly germane when the posterior instrumentation is placed percutaneously without any direct foraminal decompression. In this report, we describe a patient who had an L4-S1 ALIF, resulting in new L5-S1 retrolisthesis and worsening L5 radiculopathy. Technical nuances and avoidance strategies are discussed.

How I do it: mini invasive transforaminal lumbar interbody fusion

BACKGROUND

Minimally invasive approaches for lumbar fusion are aimed at reducing soft tissue injury in order to minimize surgical morbidity and facilitate recovery.

METHOD

Applied to lumbar fusion, such an approach is described as a mini-open transforaminal lumbar interbody fusion (TLIF). Important anatomical landmarks are reviewed. Indications, advantages, and limitations are discussed, and a step-by-step description of the procedure is presented.

RESULTS

Decompression, fixation, and bone grafting can be achieved efficiently through this approach with lesser blood loss, shorter hospital stay, reduced rate of general complications, and infections as well as a lower readmission rate.

CONCLUSION

The mini-open TLIF technique, as presented here, is a safe and efficient procedure to achieve lumbar fusion with a reduced rate of complications related to surgery.

Back pain outcomes after minimally invasive anterior lumbar interbody fusion: a systematic review

OBJECTIVE

Minimally invasive anterior lumbar interbody fusion surgery (MIS ALIF) is a technique that restores disc height and lumbar lordosis through a smaller exposure and less soft-tissue trauma compared to open approaches. The mini-open and laparoscopic assistance techniques are two main forms of MIS ALIF. The authors conducted a systematic review that sought to critically summarize the literature on back pain following MIS ALIF.

METHODS

In March 2020, the authors searched the PubMed, Web of Science, and Cochrane Library databases for studies describing back pain visual analog scale (VAS) outcomes after MIS ALIF. The following exclusion criteria were applied to studies evaluated in full text: 1) the study included fewer than 20 patients, 2) the mean follow-up duration was shorter than 12 months, 3) the study did not report back pain VAS score as an outcome measure, and 4) MIS ALIF was not studied specifically. The methodology for the included studies were evaluated for potential biases and assigned a level of evidence.

RESULTS

There were a total of 552 patients included from 13 studies. The most common biases were selection and interviewer bias. The majority of studies were retrospective. The mean sample size was 42.3 patients. The mean follow-up duration was approximately 41.8 months. The mean postoperative VAS reduction was 5.1 points. The mean VAS reduction for standalone grafts was 5.9 points, and 5.0 points for those augmented with posterior fixation. The most common complications included bladder or urinary dysfunction, infection, and hardware-related complications.

CONCLUSIONS

This was a systematic review of back pain outcomes following MIS ALIF. Back pain VAS score was reduced postoperatively across all studies. The complication rates were low overall. MIS ALIF is safe and effective at reducing back pain in appropriate patient populations.

Simultaneous surgical interventions in spinal surgery: a review of the literature and clinical caso for spondylolisthesis of the lumbar spine

The article presents the first clinical case of surgical treatment of a patient with spondylolysis spondylolisthesis using a combination of minimally invasive surgical techniques and simultaneous operation. This intervention has significantly reduced the level of vertebral pain syndrome, improve the functional status in the postoperative period, effectively eliminate pathological mobility, provide early activation, to carry out a full rehabilitation in the shortest possible time and can be an operation of choice in patients with lumbar spondylolysis spondylolisthesis. Conflict of interest: the authors state no conflict ofinterest Funding: the study was performed with no extermal funding