Double-level isthmic spondylolisthesis treated with posterior lumbar interbody fusion with cage

L3-L4/L4-L5 Type II-A spondylolisthesis: A case report

INTRODUCTION AND IMPORTANCE

Double level isthmic spondylolisthesis at L3-L4/L4-L5 is exceedingly rare with only a few documented cases in the literature, but to our knowledge no detailed case reports have been written.

CASE PRESENTATION

49 year old male with L3-4, L4-5 isthmic spondylolisthesis with neurologic symptoms and failed conservative management treated with L3-4, L4-5 Gill laminectomy, transforaminal interbody fusion with bone grafting and L3-5 posterior instrumented fusion.

CLINICAL DISCUSSION

While rare, this condition can be successfully treated with posterior decompression and instrumented interbody fusion similar to single level spondylolisthesis. Surgeons should feel confident that they can achieve a good outcome for patients and feel comfortable offering this procedure.

CONCLUSION

This case report may offer guidance for surgeons in the future as it explores the successful treatment of double level isthmic spondylolisthesis at L3-L4/L4-5 from initial presentation to final post-operative follow-up where the patient had complete resolution of symptoms.

Comparison of Fusion Rate and Clinical Outcomes in Minimally Invasive and Conventional Posterior Fusion for Lumbar Degenerative Disease: A Network Meta-Analysis

BACKGROUND

The fusion rate, clinical efficacy, and complications of minimally invasive fusion surgery and open fusion surgery in the treatment of lumbar degenerative disease are still unclear.

METHODS

We conducted a literature search using PubMed, Embase, Cochrane Library, CNKI, and WANFANG databases.

RESULTS

This study included 38 retrospective studies involving 3097 patients. Five intervention modalities were considered: unilateral biportal endoscopic-lumbar interbody fusion (UBE-LIF), percutaneous endoscopic-lumbar interbody fusion (PE-LIF), minimally invasive-transforaminal lumbar interbody fusion (MIS-TLIF), transforaminal lumbar interbody fusion (TLIF), and posterior lumbar interbody fusion (PLIF). Quality assessment indicated that each study met acceptable quality standards. PE-LIF demonstrated reduced low back pain (Odds Ratio = 0.50, Confidence Interval: 0.38-0.65) and lower complication rate (Odds Ratio = 0.46, Confidence Interval: 0.25-0.87) compared to PLIF. However, in indirect comparisons, PE-LIF showed the lowest fusion rates, with the ranking as follows: UBE-LIF (83.2%) > MIS-TLIF (59.6%) > TLIF (44.3%) > PLIF (39.8%) > PE-LIF (23.1%). With respect to low back pain relief, PE-LIF yielded the best results, with the order of relief as follows: PE-LIF (96.4%) > MIS-TLIF (64.8%) > UBE-LIF (62.6%) > TLIF (23.0%) > PLIF (3.2%). Global and local consistency tests showed satisfactory results, and heterogeneity tests indicated good stability.

CONCLUSIONS

Compared to conventional open surgery, minimally invasive fusion surgery offered better scores for low back pain and Oswestry Disability Index, lower complication rates, reduced bleeding, and shorter hospital stays. However, minimally invasive fusion surgery did not show a significant advantage in terms of fusion rate and had a longer operative time.

Efficacy of transforaminal lumbar interbody fusion in the treatment of double-level lumbar spondylolisthesis with sagittal imbalance

OBJECTIVE

To analyze the clinical efficacy of transforaminal lumbar interbody fusion (TLIF) in the treatment of continuous double-level lumbar spondylolisthesis with sagittal imbalance.

METHODS

The clinical data of 36 patients with double-level spondylolisthesis treated with TLIF were included and divided into L3/L4 double spondylolisthesis group and L4/L5 double spondylolisthesis group according to the site of spondylolisthesis. The sagittal parameters of the patients were measured by standing anteroposterior and lateral X-rays of the whole spine, and the visual analogue scale (VAS) for lumbar and lower limb pain, Japanese Orthopaedic Association (JOA), and Oswestry Disability Index (ODI) were recorded. The imaging parameters and clinical parameters of the patients before surgery, after surgery, and at the last follow-up were compared and statistically analyzed.

RESULTS

A total of 36 patients were included in the study and all had sagittal imbalance. Among them, there were 21 cases of L3 and L4 spondylolisthesis, 6 males and 15 females, with an average age of 64.7 ± 9.4 years; there were 15 cases of L4 and L5 spondylolisthesis, 4 males and 11 females, with an average age of 66.5 ± 8.0 years. 36 patients completed the operation, the operation time was 190.28 ± 6.12 min, and intraoperative blood loss was 345 ± 11 ml. Compared with preoperative, there were significant differences in SVA, TPA, T1-SPi, LL, PT, SS, PI-LL, SD, SA, and SP between patients after surgery and at the last follow-up (P < 0.05). Compared with preoperative, VAS score, JOA score, and ODI index of waist and lower limbs were significantly improved after the operation and at the last follow-up, and there was a significant difference (P < 0.05).

CONCLUSION

TLIF can effectively relieve the symptoms of patients with continuous double-level lumbar spondylolisthesis, restore lumbar lordosis and sagittal spinal sequence, and improve the quality of life of patients.

Effect of MED-TLIF Combined with Percutaneous Pedicle Screw Fixation on Function and Spinal Pelvic Parameters in Patients with Lumbar Spondylolisthesis

Background

Lumbar spondylolisthesis is a common clinical spinal lesion. The upper vertebral body of the patient is displaced relative to the lower vertebral body, causing spinal instability and nerve compression. The clinical manifestations are low back and leg pain, abnormal lower limb sensation, and intermittent rupture. In severe cases, cauda equina syndrome and paraplegia may occur. Minimally invasive spinal surgery has developed rapidly in recent years and become the preferred treatment for lumbar spondylolisthesis.

Objective

The aim of this study is to investigate the clinical effect of minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) combined with percutaneous pedicle screw fixation in the treatment of lumbar spondylolisthesis under microscope.

Methods

The clinical and surgical data of 106 patients with lumbar spondylolisthesis treated in our hospital were selected and divided into research group (56 cases) according to surgical methods (MIS-TLIF combined with percutaneous pedicle screw fixation). The other 50 patients were treated with traditional open percutaneous intervertebral foramen fusion (control group). The surgical trauma-related indicators, visual analog pain scale (VAS) scores before and after surgery, modified Japanese Orthopedic Association low back pain score (JOA), bone graft fusion effect, spinal pelvic parameters, and surgical complications of the two groups were statistically analyzed in detail.

Results

The incision length, intraoperative blood loss, operation time, and hospitalization time in the research group were lower than those in the control group, and the differences were statistically significant (P < 0.05). There was no significant difference in the VAS score and JOA score between the two groups before operation (P > 0.05). The VAS score and JOA score of the research group were lower than those of the control group on the first day after operation (P < 0.05). There was no significant difference in the VAS score and JOA score between the two groups at 1 month and 3 months after operation (P > 0.05). Six months, 12 months, and 18 months after operation, the bone graft fusion rates in the research group were 42.86%, 73.21%, and 94.64%, respectively, and those in the control group were 40.00%, 68.00%, and 92.00%, respectively, with no significant difference (P > 0.05). There was no significant difference in PI, PT, SS, LL, TK, LSJA, and SVA between the two groups before and 6 months after operation (P > 0.05). At 6 months after operation, the PT and TK values of the two groups were higher than those before operation (P < 0.05), and the SS, LL, LSJA, and SVA values of the two groups were lower than those before operation (P < 0.05). The complication rate of the research group was 3.57%, which was lower than 18.00% of the control group, and the difference was statistically significant (P < 0.05).

Conclusion

MIS-TLIF combined with percutaneous pedicle screw fixation in the treatment of lumbar spondylolisthesis has the same effect as traditional open surgery and has the same correction effect for spinal pelvic parameters, but it has the advantages of less trauma and fewer complications.

Fusion rate and influence of surgery-related factors in lumbar interbody arthrodesis for degenerative spine diseases: a meta-analysis and systematic review

The aim of this meta-analysis and systematic review is to summarize and critically analyze the influence of surgery-related factors in lumbar interbody fusion for degenerative spine diseases. A systematic review of the literature was carried out with a primary search being performed on Medline through PubMed. The 2009 PRISMA flowchart and checklist were taken into account. Sixty-seven articles were included in the analysis: 48 studies were level IV of evidence, whereas 19 were level III. All interbody fusion techniques analyzed have proved to reach a good fusion rate. An overall mean fusion rate of 93% (95% CI 92-95%, p < 0.001) was estimated pooling the selected studies. The influence of sagittal parameters and cages features in fusion rate was not clear. Autograft is considered the gold standard material. The use of synthetic bone substitutes and biological factors alone or combined with bone graft have shown conflicting results. Low level of evidence studies and high heterogeneity (χ² = 271.4, df = 72, p < 0.001; I² = 73.5%, τ² = 0.05) in data analysis could result in the risk of bias. Further high-quality studies would better clarify these results in the future.

rhBMP in lumber fusion for lumbar spondylolisthesis: A systematic review and meta-analysis

PURPOSE

To compare the efficacy and safety of recombinant human bone morphogenetic protein (rhBMP) and iliac crest autograft in the fusion treatment of lumbar spondylolisthesis.

METHODS

The studies using randomized controlled trials to compare the rhBMP with iliac crest autograft in the treatment of lumbar spondylolisthesis were retrieved from Embase, Pubmed, ProQuest dissertations & theses (PQDT), China national knowledge infrastructure (CNKI), Chinese Biomedical Database, Wanfang Data, Cochrane Library (from March 1998 to March 2018). Postoperative fusion rate, clinical success rate, postoperative intervertebral height, complications, operation time, blood loss and duration of hospitalization were chosen as the outcome indicators. Methodological quality of the trials was critically assessed, and relevant data were extracted. Statistical software Revman 5.3 was used for data-analysis.

RESULTS

Eleven articles were included in the meta-analysis. The results showed that, comparing the efficacy of rhBMP with iliac crest autograft, statistical significance was found in the 24-month fusion rate post operation [95% CI (1.38, 24.70), p = 0.02] and operation time [95% CI (-14.22, -2.08), p = 0.008]. There is not sufficient evidence for statistical differences in the remaining indicators.

CONCLUSION

The current literature shows rhBMP is a safe and effective grafting material in the treatment of lumbar spondylolisthesis. Further evidence is dependent on the emergence of more randomized controlled trials with higher quality and larger sample sizes in the future.