Fusion in situ versus reduction for spondylolisthesis treatment: grading the evidence through a meta-analysis

Minimally invasive versus mini-open transforaminal lumbar interbody fusion in managing low-grade degenerative spondylolisthesis

DATA BACKGROUND

Because the traditional open-TLIF approach has several drawbacks, minimally invasive surgery (MIS) approaches for TLIF (MISTLIF) have been developed to speed up recovery after surgery and minimize pressure on the para-spinal muscles, necessitating a cost-utility analysis for comparison in healthcare reforms.

OBJECTIVES AND AIM OF THE WORK

This study aimed to compare the radiological and clinical parameters between mini-open TLIF and minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) surgery in patients with single-level lumbar degenerative spondylolisthesis.

HYPOTHESIS

This study hypothesizes that both minimally invasive and mini-open methods using sublaminar trimming laminoplasty (SLTL) (while preserving midline structures) and interbody cages have comparable mid- and long-term clinical and radiological outcomes.

METHODS

Retrospective analyses were performed on 120 patients who underwent single-level TLIF procedures with a minimum of two years of follow-up utilizing either the mini-open (n = 60) or MIS (n = 60) technique. Records of the operation's time frame, intraoperative fluoroscopy, blood loss, postoperative drainage volume, duration of bed rest, and complications were recorded. The Oswestry Disability Index (ODI) and visual analog scale (VAS) scores for both groups were utilized to assess improvements in clinical scores, and t tests were employed to statistically compare the outcomes. For comparison, radiological parameters, including lumbar lordosis, pelvic incidence (PI), and localized lordosis at the index level, were measured preoperatively, postoperatively, and at the final follow-up. To assess postoperative interbody fusion, the Bridwell grading system was used.

RESULTS

In the Mini-open TLIF group, the average follow-up time was 24.91 ± 5.7 months, while in the MIS-TLIF group, the average follow-up time was 25.15 ± 4.2 months. In the MIS-TLIF group, the mean operation and radiological time were longer. However, compared to the Mini-open TLIF group, the MISTLIF group experienced less blood loss and a shorter hospital stay. The MIS-TLIF group outperformed the Open-TLIF group in terms of the VAS score for back pain and the ODI at less than 6 months following surgery, and the differences were statistically significant. However, at the final follow-up, there were no statistically significant differences in the VAS score for the back between the two groups, but the ODI score was significantly greater in the MIS-TLIF group. Both groups' lumbar lordosis and focal lordosis significantly improved at the index level, with the Mini-open-TLIF group showing more focal lordosis. The interbody fusion rate did not significantly differ between the two groups.

CONCLUSION

MIS-TLIF and mini-open-TLIF can be surgically effective in treating single-level degenerative lumbar spine spondylolisthesis.

Clinical and radiological outcomes of gradual reduction and circumferential fusion of high-grade spondylolisthesis in adolescents: a prospective cohort study of 29 young patients

AIM

The objective of this study was to evaluate the safety and efficacy of a novel technique of formal reduction and circumferential fusion for pediatric high-grade spondylolisthesis (HGS).

PURPOSE

The safety and efficacy of formal reduction for high-grade spondylolisthesis (HGS) has never been thoroughly examined. This study reports the outcomes of 29 children with HGS who underwent a procedure of gradual reduction and circumferential fusion.

METHODS

29 children (13 males, 16 females) were recruited between 2006 and 2010. Radiographic measurements (including % of slip, lumbosacral angle-LSA, pelvic incidence-PI, pelvic tilt-PT, sacral slope-SS, and proximal femoral angle-PFA) and quality of life assessment (SRS-22 questionnaire) were prospectively obtained at baseline and at the last post-operative follow-up (> 2 years post-op). Radiological measurements were used to classify patients according to the Spine Deformity Study Group (SDSG) classification.

RESULTS

Mean baseline slip % was 69.9 ± 16.5%. There were 13 patients with a balanced pelvic (SDSG Type 4) and 16 with an unbalanced pelvis (SDSG Type 5 and 6). On average, a reduction of 45.5 ± 15.3% (range 20-86%) was achieved safely with no major complication. In particular, of the 29 patients, only 3 had a L5 radiculopathy postoperatively that was self-resolved at follow-up. From a radiological standpoint, we observed a mean improvement of LSA from 80.3 ± 17.9° to 91.7 ± 13.6°. We also observed a statistically significant improvement in global HRQOL, and in the function and body image domains.

CONCLUSION

This prospective study suggests that formal reduction of HGS followed by circumferential fusion is safe when using a standardized surgical technique based on gradual reduction. Performing this intervention could also help improve QOL in some patients.

Can minimally invasive transforaminal lumbar interbody fusion achieve a better clinical and radiological outcome than traditional open technique in isthmic spondylolisthesis?

BACKGROUND

Spondylolisthesis is a prevalent condition in the lumbar spine that can cause low back pain, leg pain, neurogenic claudication, and impact health-related quality of life in symptomatic individuals.

AIM

to assess the results of minimally invasive TLIF (MIS-TLIF) versus open-TLIF and the impact of correcting spino-pelvic parameters on the Health-Related Quality of Life (HRQoL) in patients with low-grade isthmic spondylolisthesis. The primary objective was to compare the effectiveness of both methods in correcting spinopelvic parameters. The secondary objectives involved comparing clinical improvement, operating time, blood loss, complications, and postoperative hospital stays between the two procedures.

PATIENTS AND METHODS

Seventy-two patients with low-grade isthmic spondylolisthesis were enrolled in this retrospective cohort-control study, with a minimum follow-up period of 18 months. Disability was assessed using the Oswestry Disability Index (ODI), while back and leg discomfort were rated using the Visual Analogue Scale (VAS) for each patient. The measurements comprised the sacral slope (SS), pelvic tilt (PT), pelvic incidence (PI), and Meyerding slip grades. We measured lumbar lordosis (LL), and segmental lordosis.

RESULTS

The seventy-two patients were 60 female and 12 males. There was no statistically significant difference in the duration of operation between the two groups. In the MIS group, there was a notable reduction in blood loss, higher radiation exposure, and a shorter hospital stay (P < 0.001). The back VAS showed more favorable outcomes in the MIS-TLIF, while the leg VAS showed better results in the Open-TLIF in the early outcome. Both procedures significantly reduced leg and back pain VAS scores and ODI, with no notable difference between the two groups at the final follow-up. Post-surgery, the pelvic incidence (PI) and lumbar lordosis (LL) matched properly in all patients, showing a rise in LL and sacral slope along with a decrease in pelvic tilt.

CONCLUSION

Both open-TLIF and MIS-TLIF are effective methods for correcting spino-pelvic parameters and improving HRQoL in patients with low-grade isthmic spondylolisthesis. The rapid improvement in back pain experienced by these patients favored the use of MIS-TLIF. However, the cost-effectiveness of this approach must be carefully evaluated.

Clinical effectiveness of reduction and fusion versus in situ fusion in the management of degenerative lumbar spondylolisthesis: a systematic review and meta-analysis

PURPOSE

To compare the clinical effectiveness of reduction and fusion with in situ fusion in the management of patients with degenerative lumbar spondylolisthesis (DLS).

METHODS

The systematic review was conducted following the PRISMA guidelines. Relevant studies were identified from PubMed, Embase, Scopus, Cochrane Library, ClinicalTrials.gov, and Google Scholar. The inclusion criteria were: (1) comparative studies of reduction and fusion versus in situ fusion for DLS patients, (2) outcomes reported as VAS/NRS, ODI, JOA score, operating time, blood loss, complication rate, fusion rate, or reoperation rate, (3) randomized controlled trials and observational studies published in English from the inception of the databases to January 2023. The exclusion criteria included: (1) reviews, case series, case reports, letters, and conference reports, (2) in vitro biomechanical studies and computational modeling studies, (3) no report on study outcomes. The risk of bias 2 (RoB2) tool and the Newcastle-Ottawa scale was conducted to assess the risk of bias of RCTs and observational studies, respectively.

RESULTS

Five studies with a total of 704 patients were included (375 reduction and fusion, 329 in situ fusion). Operating time was significantly longer in the reduction and fusion group compared to in situ fusion group (weighted mean difference 7.20; 95% confidence interval 0.19, 14.21; P = 0.04). No additional significant intergroup differences were noted in terms of other outcomes analyzed.

CONCLUSION

While the reduction and fusion group demonstrated a statistically longer operating time compared to the in situ fusion group, the clinical significance of this difference was minimal. The findings suggest no substantial superiority of lumbar fusion with reduction over without reduction for the management of DLS.

Minimally Invasive Decompression With Noninstrumented Facet Fusion Versus Minimally Invasive Transforaminal Lumbar Interbody Fusion for Stenosis Associated With Grade 1 Lumbar Degenerative Spondylolisthesis

STUDY DESIGN

Retrospective matched cohort study.

SUMMARY OF BACKGROUND DATA

With a growing interest in minimally invasive spine surgery (MIS), the question of which technique is the most advantageous for patients with low-grade degenerative lumbar spondylolisthesis (DLS) still remains unclear.

OBJECTIVE

To compare patient-reported outcomes, perioperative morbidity, and rates of reoperation between MIS decompression with either unilateral noninstrumented facet fusion (MIS-F) or with transforaminal interbody fusion (MIS-T) for grade 1 DLS.

METHODS

Twenty patients who underwent MIS-T and 20 patients with MIS-F were matched based on age, sex, and preoperative ODI, VAS back, and VAS leg. All patients had DLS with at least 4 millimeters of translation on standing radiographs. Exclusion criteria included prior level surgery, multilevel instability, disk impinging on the exiting nerve root, spondylolisthesis from significant facet arthropathy, or foraminal compromise from disk collapse. ODI, VAS back, VAS leg, and patient satisfaction measured by the North American Spine Society questionnaire were tracked at 3, 6, 12, and 24 months postoperatively. Minimum clinically important differences and substantial clinical benefits were calculated.

RESULTS

MIS-F and MIS-T resulted in decreased ODI at 3, 6, and 12 months following the index procedure. Sixty percent of MIS-F and 83% of MIS-T patients reached minimum clinically important difference at 1 year postoperatively; however, using the threshold of 30% ODI reduction from baseline, 67% of MIS-F and 83% MIS-T ( P = 0.25) achieved this goal. Forty-three percent of MIS-F and 59% of MIS-T patients met substantial clinical benefits. Satisfaction at 1 year, measured by a score of 1 or 2 on the North American Spine Society questionnaire, was 64% for MIS-F and 83% for MIS-T.

CONCLUSIONS

MIS-F and MIS-T are effective treatment options for spinal stenosis associated with low-grade DLS. Both techniques result in comparable patient-reported outcomes and satisfaction up to 2 years and have similar long-term reoperation rates. More evidence is required to delineate optimal selection characteristics for MIS-F versus MIS-T.

Beneficial influence of single-stage posterior surgery for the treatment of lumbar brucella spondylitis combined with spondylolisthesis

We aimed to evaluate the clinical efficacy of the single-stage posterior surgical treatment for patients of lumbar brucella spondylitis combined with spondylolisthesis. In this study, we performed a retrospective analysis of 16 patients with lumbar brucellosis spondylitis combined with spondylolisthesis from January 2015 to January 2019. All patients underwent single-stage posterior lumbar debridement, reduction, interbody fusion, and instrumentation. Preoperative and postoperative of the visual analog scale (VAS), the Oswestry disability index (ODI), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) were compared. In addition, the spondylolisthesis reduction rate, reduction loss rate, interbody fusion rate, and complication rate were recorded. VAS, ODI, ESR, and CRP were conducted with repeated analysis of variance data at different follow-ups. The postoperative follow-up was 12-36 months, with an average of (25.0 ± 8.1) months. VAS, ODI, ESR, and CRP were significantly better at 2-week and 1-year follow-up than preoperative results (P = 0.000, respectively). In addition, 1 year after the operation, VAS, ODI, ESR, and CRP showed a significant improvement (P = 0.000, respectively). The average spondylolisthesis reduction in 2 weeks after operation was (91.2 ± 6.7)%, and the median reduction loss rate in 1 year after operation was 8.0 (5.0, 9.8)%. At the last follow-up, all patients achieved interbody fusion, no loosening and fracture of instrumentation were found, and no recurrence happened. Single-stage posterior operation for lumbar debridement, reduction, interbody fusion, and instrumentation is beneficial for treating lumbar brucellosis spondylitis combined with spondylolisthesis. Furthermore, the reconstruction of spinal stability may relieve pain, heal lesions, and improve patients' living.

Spondylolysis

Spondylolysis is a bony defect of the pars interarticularis and most often results from repetitive stress. Although spondylolysis is usually asymptomatic, symptomatic spondylolysis is the most common cause of identifiable back pain in children and adolescent athletes. A thorough history and physical exam, as well as appropriate imaging studies are helpful in diagnosis. General first-ine therapy for spondylolysis is conservative and consists of rest from sports, core strengthening, as well as spinal bracing. Patients who have failed conservative therapy may consider surgical repair. This article aims to review the epidemiology, pathophysiology, presentation, and treatment options of spondylolysis.

Spondylolisthesis

Spondylolisthesis refers to the anterior, lateral, or posterior slippage of a superior vertebral disc over the adjacent inferior disc, and is often separated into categories based on the causative etiology. Spondylolisthesis is often asymptomatic but may present with low back pain and neurogenic claudication which is worsened with spinal extension and activity. A detailed history and physical exam, along with appropriate imaging tests are useful in making the diagnosis. Conservative therapy is first-line and includes pain management with physical therapy. Patients who fail conservative therapy may consider surgical decompression, stabilization, and fusion. This review aims to discuss the epidemiology, pathophysiology, presentation, and treatment options of spondylolisthesis.