Expectations for Postoperative Improvement in Health-Related Quality of Life in Young Patients With Lumbosacral Spondylolisthesis: A Prospective Cohort Study

A Surgical Treatment Algorithm for Restoring Pelvic Balance and Health-related Quality of Life in High-grade Lumbosacral Spondylolisthesis: Prospective Multicenter Cohort of 61 Young Patients

STUDY DESIGN

Retrospective multicenter cohort-study.

OBJECTIVE

We propose an evidence-based surgical algorithm for achieving normal pelvic balance while optimizing health-related quality of life (HRQoL) in high-grade spondylolisthesis.

SUMMARY OF BACKGROUND DATA

The principles of surgical treatment for young patients with high-grade L5-S1 spondylolisthesis remain unclear. There is a growing body of evidence supporting the central role of pelvic balance in the postural control and biomechanics of subjects with high-grade spondylolisthesis.

METHODS

This retrospective study assessed a multicenter cohort of 61 patients with high-grade L5-S1 spondylolisthesis. Classification and regression tree analysis was used to identify objective criteria associated with pelvic balance and HRQoL after surgery.

RESULTS

The most important predictor of a postoperative balanced pelvis was a postoperative L5 incidence ≤63.5 degrees. With postoperative L5 incidence ≤63.5 degrees,a residual slip percentage 9% and performing an L5-S1 posterior lumbar interbody fusion (PLIF)/transforaminal lumbar interbody fusion (TLIF) increased the likelihood of achieving a balanced pelvis postoperatively. When L5 incidence was 63.5 degrees,a balanced pelvis was most likely achieved with fusion limited to L5 proximally, residual slip percentage ≤40%, and residual lumbosacral angle 98 degrees. Predictors of postoperative HRQoL were the preoperative HRQoL score, L5 incidence and slip percentage.

CONCLUSIONS

A surgical algorithm is proposed to achieve normal pelvic balance, while optimizing HRQoL. The first step during surgery is to assess L5 incidence and if L5 incidence is <65 degrees, the next step depends on the pelvic balance. With a preoperative balanced pelvis, it is important not to reduce completely the slip percentage by leaving a slip percentage ≥10%. When the preoperative pelvis is unbalanced, a TLIF/PLIF at L5-S1 is recommended to facilitate correcting the angular deformity at L5-S1. If L5 incidence is ≥65 degrees,a TLIF/PLIF at L5-S1 should be performed to correct the angular deformity at L5-S1, and fusion should ideally end at L5 proximally, in addition to performing gradual reduction of the slip percentage. If fusion up to L4 is required, a lumbosacral angle ≥100 degrees is key.

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.

Health-Related Quality of Life Outcomes of Instrumented Circumferential Spinal Fusion for Pediatric Spondylolisthesis: A Comparison With Age and Sex Matched Healthy Controls

STUDY DESIGN

A prospective study on the clinical, radiographic, and the health-related quality of life (HRQOL) outcomes in adolescents with spondylolisthesis undergoing instrumented circumferential spinal fusion compared with age and sex matched controls.

OBJECTIVE

To determine the outcomes of pediatric spondylolisthesis patients minimum 2 years after surgery and to compare their HRQOL with age and sex matched controls.

SUMMARY OF BACKGROUND DATA

There is limited evidence of the HRQOL of adolescent spondylolisthesis patients after surgery and no studies comparing it with healthy controls.

METHODS

Twenty-six consecutive adolescents (mean age 14.7 yr, range 10-18 yr) undergoing instrumented reduction with intercorporeal spinal fusion for spondylolisthesis (11 low-grade, 15 high-grade) by a single orthopedic surgeon were included to this study cohort and matched by age and sex with two controls. The HRQOL was measured with Scoliosis Research Society-24 (SRS-24) questionnaire before surgery, 6 months and 2 years after the surgery.

RESULTS

The mean (SD) vertebral slip in the low-grade patients was 25% (13%) and 67% (15%) in the high-grade patients and 6% (7%) and 21% (25%) postoperatively, respectively (P ≤ 0.041 for both comparisons). Three (12%) patients developed a non-union during follow-up. None of the patients developed a persistent neurologic deficit, but two (8%) patients presented with chronic postsurgical pain persisting 24 months. Seven (27%) of the patients had reoperations for any reason during the follow-up. Pain and activity domains of the SRS-24 improved significantly from preoperative to 2-year follow-up (P ≤ 0.007 for both). SRS pain, self-image, function domains, and total score were significantly worse as compared with the 52 controls (P ≤ 0.020 for all comparisons).

CONCLUSION

Risk of non-union is relatively low after instrumented spinal reduction in adolescents with spondylolisthesis. HRQOL improves significantly after instrumented reduction and circumferential spinal fusion in adolescents with spondylolisthesis, but remains at statistically lower level than in the controls.

LEVEL OF EVIDENCE

2.

Regional Variance in Disability and Quality-of-Life Outcomes After Surgery for Grade I Degenerative Lumbar Spondylolisthesis: A Quality Outcomes Database Analysis

OBJECTIVE

Regional differences in outcomes after spine surgery are poorly understood. We assessed disability and quality-of-life outcomes by geographic region in the United States using the NeuroPoint Alliance Quality Outcomes Database.

METHODS

We queried the prospective Quality Outcomes Database patient registry to identify patients who underwent elective 1- or 2-level lumbar surgery for grade I degenerative spondylolisthesis from July 2014 through June 2016. Primary outcome measures included Oswestry Disability Index (ODI) and EuroQOL-5D (EQ-5D) reported at 24 months postoperatively. Differences in EQ-5D and ODI were compared across geographic regions of the United States (Northeast, Midwest, South, West).

RESULTS

We identified 608 patients from 12 centers who underwent surgery. Of these, 517 (85.0%) had ODI data and 492 (80.9%) had EQ-5D data at 24 months. Southern states had the largest representation (304 patients; 5 centers), followed by Northeastern (114 patients; 3 centers), Midwestern (96 patients; 2 centers), and Western (94 patients; 2 centers) states. Baseline ODI scores were significantly different among regions, with the South having the greatest baseline disability burden (Northeast: 40.9 ± 16.9, South: 51.2 ± 15.8, Midwest: 40.9 ± 17.8, West: 45.0 ± 17.1, P < 0.001). The change in ODI at 24 months postoperatively was significantly different among regions, with the South showing the greatest ODI improvement (Northeast: -21.1 ± 18.2, South: -26.5 ± 20.2, Midwest: -18.2 ± 22.9, West: -21.7 ± 19.6, P < 0.001). All regions had ≥60% achievement of the minimum clinically important difference in ODI at 24 months postoperatively. No regional differences were observed for EQ-5D.

CONCLUSION

Significant regional variation exists for disability outcomes, but not quality of life, at 24 months after spinal surgery for grade I degenerative spondylolisthesis.

Long-term quality of life and posttraumatic stress following elective cardiac surgery: preliminary findings of a 5-year follow-up study

BACKGROUND

Heart surgery is a major stressful event that can have a significant negative effect on patients' quality of life (QoL) and may cause long-term posttraumatic stress reactions. The aim of this pilot study was to estimate the longitudinal change and predictors of health-related quality of life (HRQOL) dynamics and identify factors associated with PTS at 5-year follow-up (T2) after elective cardiac surgery and associations with pre-surgery (T1) QoL.

MATERIALS AND METHODS

Single-centre prospective study was conducted after Regional Bioethics Committee approval. Adult consecutive patients undergoing elective cardiac surgery were included. HRQOL was measured using the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) questionnaire before (T1) and 5-years after (T2) cardiac surgery. Posttraumatic stress was assessed using the International Trauma Questionnaire.

RESULTS

The pilot study revealed a significant positive change at 5-year follow-up in several domains of SF-36: physical functioning (PF), energy/fatigue (E/F), and social functioning (SF). Prolonged postoperative hospital stay was associated with change in SF (p < 0.01), E/F (p < 0.05) and emotional well-being (p < 0.05). The percentage of patients that had the posttraumatic stress disorder (PTSD) at T2 was 12.2%. Posttraumatic stress symptoms were associated with longer hospitalization after surgery (p < 0.01).

CONCLUSIONS

HRQOL improved from baseline to five years postoperatively. Patients with lower preoperative HRQOL scores tended to have a more significant improvement of HRQOL five years after surgery. A prolonged postoperative hospital stay had a negative impact on postoperative social functioning, energy/fatigue, and emotional well-being. Increased levels of PTSD were found in cardiac surgery patients following five years after the surgery.