Lumbar degenerative disease after oblique lateral interbody fusion: sagittal spinopelvic alignment and its impact on low back pain

Comparison of short-segment and long-segment fixation in treatment of degenerative scoliosis and analysis of factors associated with adjacent spondylolisthesis

The bleeding time and amount in the short-segment group were shorter than in the long-segment group, and the bleeding volume was less than in the long-segment group. The Japanese Orthopaedic Association low back pain score, Oswestry Dysfunction Index, and lumbar spine stiffness disability index score of the two groups were significantly improved preoperatively, postoperatively, and at 6 months, 1 year, and 2 years post-operation. The differences were statistically significant at different time points within the groups. Neurological function improved to varying degrees postoperatively. The Cobb angle was significantly higher in both groups (P < 0.05). Adjacent vertebral disease occurred in 10 of 64 patients with short-segment fixation, with a prevalence of 15.6%. Preoperative pelvic tilt angle, preoperative pelvic projection angle (PPA), preoperative degree of matching of PPA to LL (PI-LL), and preoperative coronal Cobb angle were higher in patients with adjacent vertebral disease. There were varying degrees of improvement in low back pain and spinal function after short-segment decompression and fusion internal fixation. However, the patients are generally elderly and at risk of persistent low back pain and accelerated degeneration of adjacent segments.

Predicting adequate segmental lordosis correction in lumbar spinal stenosis patients undergoing oblique lumbar interbody fusion: a focus on the discontinuous segment

PURPOSE

To identify the factors associated with a correction of the segmental angle (SA) with a total change greater than 10° in each level following minimally invasive oblique lumbar interbody fusion (MIS-OLIF).

METHODS

Patients with lumbar spinal stenosis who underwent single- or two-level MIS-OLIF were reviewed. Segments with adequate correction of the SA >10° after MIS-OLIF in immediate postoperative radiograph were categorized as discontinuous segments (D segments), whereas those without such improvement were assigned as continuous segments (C segments). Clinical and radiological parameters were compared, and multivariate logistic regression analysis was performed to identify factors associated with SA correction >10° after MIS-OLIF.

RESULTS

Of 211 segments included, 38 segments (18.0%) were classified as D segments. Compared with C segments, D segments demonstrated a significantly smaller preoperative SA (mean ± standard deviation [SD], - 1.1° ± 6.7° vs. 6.6° ± 6.3°, p < 0.001), larger change of SA (mean ± SD, 13.5° ± 3.4° vs. 3.1° ± 3.9°, p < 0.001), and a higher rate of presence of facet effusion (76.3% vs. 48.6%, p = 0.002). Logistic regression revealed preoperative SA (odds ratio (OR) [95% confidence interval (CI)]:0.733 [0.639-0.840], p < 0.001) and facet effusion (OR [95% CI]:14.054 [1.758-112.377], p = 0.027) as significant predictors for >10° SA correction after MIS-OLIF.

CONCLUSION

Preoperative kyphotic SA and facet effusion can predict SA correction >10° following MIS-OLIF. For patients with lordotic SA and no preoperative facet effusion, supplemental procedures, such as anterior column release or posterior osteotomy, should be prepared for additional lumbar lordosis correction required for remnant global sagittal imbalance after MIS-OLIF.

Segmental Sagittal Alignment in Lumbar Spinal Fusion: A Review of Evidence-Based Evaluation of Preoperative Measurement, Surgical Planning, Intraoperative Execution, and Postoperative Evaluation

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.

Sagittal Alignment in the Degenerative Lumbar Spine: Surgical Planning

➤ Sagittal alignment of the spine has gained attention in the field of spinal deformity surgery for decades. However, emerging data support the importance of restoring segmental lumbar lordosis and lumbar spinal shape according to the pelvic morphology when surgically addressing degenerative lumbar pathologies such as degenerative disc disease and spondylolisthesis.➤ The distribution of caudal lordosis (L4-S1) and cranial lordosis (L1-L4) as a percentage of global lordosis varies by pelvic incidence (PI), with cephalad lordosis increasing its contribution to total lordosis as PI increases.➤ Spinal fusion may lead to iatrogenic deformity if performed without attention to lordosis magnitude and location in the lumbar spine.➤ A solid foundation of knowledge with regard to optimal spinal sagittal alignment is beneficial when performing lumbar spinal surgery, and thoughtful planning and execution of lumbar fusions with a focus on alignment may improve patient outcomes.

Prevalence of global spinal malalignment and the influence on LBP and HR-QOL in a healthy, nonelderly population. A cross sectional analysis, including bone mineral density, skeletal muscle mass index, and back muscle extensor strength

Background

In healthy, nonelderly populations, prevalence of 3 modifiers of global spinal malalignment (GS-MalAlign) (PT ≧20°, PI-LL≧10°, SVA≧40 mm) remains unknown. The clinical significance has not been determined. The purposes are to disclose the prevalence of the 3 modifiers of GS-MalAlign, and evaluate the influence on LBP, and HR-QOL related to bone mineral density (BMD), skeletal muscle mass index (SMI), and back muscle extensors strength (BMES) in a healthy, nonelderly population.

Methods

A mono-centric, cross-sectional survey. Three hundred and 2 participants (18< age <65 years) without ADL disturbance were consecutively enrolled. Sagittal parameters of the spine and the pelvis were measure on whole spine radiograms. BMD and SMI were determined using DEXA. BMES was defined as a maximum extension force at the T4 to T7 level and measured by a strain-gauge dynamotor. LBP was checked through interview. HR-QOL was ascertained by score of Medical Outcome Study Short-Form 36-Health Survey (SF-36v2).

Results

The final analysis could be done in 84 females and 179 males. PT≧20°, PI-LL≧10°, and SVA≧40 mm were found in 12% (31/263), 11% (31/263), and 6% (16/263), and each mean value was 25.0 ± 4.0°, 15.3 ± 5.9°, and 52.7 ± 12.2 mm (Mean ± S.D.). Prevalence of LBP was significantly higher in the participants with PI-LL≧10° than with PI-LL<10°; 43% (12/28) versus 21% (49/235) (p<.05). PI-LL≧10° only had an association with LBP (OR: 3.0435, 95% CI, 1.1378-8.141, p<.05). Four 2% of participants (4/263) associated with all 3 modifiers had LBP and a significantly lower mental component summary score of SF-36v2 (p<.05).

Conclusions

Some of individuals are associated with GS-MalAlign even in healthy, nonelderly populations. There is a possibility that PI-LL ≧10° results in LBP within a degree of no ADL disturbance, and it is speculated that coexistence of all 3 modifiers of GS-MalAlign would lead to a poor mental HR-QOL.

Oblique lateral interbody fusion (OLIF) compared with unilateral biportal endoscopic lumbar interbody fusion (ULIF) for degenerative lumbar spondylolisthesis: a 2-year follow-up study

BACKGROUND

Oblique lumbar interbody fusion (OLIF) has been proven to be an effective method of indirect decompression for the treatment of Degenerative Lumbar Spondylolisthesis (DLS). However, its superiority over Unilateral biportal endoscopic Lumbar Interbody Fusion (ULIF) has not been reported yet. The current study aimed to compare the clinical and radiological outcomes of OLIF and ULIF in patients with DLS.

METHODS

A total of 107 patients were included in this study, divided into two groups according to the surgical methods with 45 patients treated by OLIF combined with anterolateral single screwrod fixation, and 62 patients treated by ULIF. To compare the perioperative parameters (blood loss, operation time, and postop hospitalization) and clinical (the Visual Analog Scale (VAS) scores of the low back pain and leg pain and the Oswestry Disability Index (ODI)) and radiological (disk height (DH), lumbar lordosis (LL), segmental lordosis (SL), the cross-sectional area (CSA) of the spinal canal) results of the two surgical approaches to evaluate their efficacy.

RESULTS

Compared with the ULIF group, the blood loss and operation time in the OLIF-AF group were significantly reduced, and the Postop hospitalization was comparable. The VAS scores in both groups were significantly improved compared to preop; however, the VAS score of low back pain in the OLIF-AF group was superior to that in ULIF group throughout the follow-up period (P < 0.05). The improvements in DH, LL, and Segmental angle were significantly lower in the ULIF group, and the expansion rate of CSA in the OLIF-AF group was superior to that in the ULIF group, but the difference was not statistically significant. The fusion rate in OLIF-AF group was significantly higher than that in ULIF group within 6 mo postop, and there was no significant difference at the last follow-up. The incidence of complications was comparable between the two groups, and there was no statistical difference.

CONCLUSIONS

Both OLIF-AF and ULIF achieved good short-term results in the treatment of DLS, and both surgical approaches are desirable. However, OLIF-AF has advantages over ULIF in terms of postoperative restoration of lumbar sagittal parameters and earlier intervertebral fusion. Long-term follow-up and larger clinical studies are needed to confirm this result.

Characteristics of the paravertebral muscle in adult degenerative scoliosis with PI-LL match or mismatch and risk factors for PI-LL mismatch

Objective

Pelvic incidence (PI) minus the lumbar lordosis (LL) angle (PI-LL) correlates with function and disability. It is associated with paravertebral muscle (PVM) degeneration and is a valuable tool for surgical planning of adult degenerative scoliosis (ADS). This study aims to explore the characteristics of PVM in ADS with PI-LL match or mismatch and to identify the risk factors for PI-LL mismatch.

Methods

A total of 67 patients with ADS were divided into PI-LL match and mismatch groups. The visual analog scale (VAS), symptom duration, and Oswestry disability index (ODI) were used to assess patients’ clinical symptoms and quality of life. The percentage of fat infiltration area (FIA%) of the multifidus muscle at the L1-S1 disc level was measured by using MRI with Image-J software. Sagittal vertical axis, LL, pelvic tilt (PT), PI, sacral slope, and the asymmetric and average degeneration degree of the multifidus were recorded. Logistic regression analysis was done to identify the risk factors for PI-LL mismatch.

Results

In the PI-LL match and mismatch groups, the average FIA% of the multifidus on the convex side was less than that on the concave side (P &lt; 0.05). There was no statistical difference of asymmetric degeneration degree of the multifidus between the two groups (P &gt; 0.05). In the PI-LL mismatch group, the average degeneration degree of the multifidus, VAS, symptom duration, and ODI were significantly higher than that in the PI-LL match group, respectively (32.22 ± 6.98 vs. 26.28 ± 6.23 (%), 4.33 ± 1.60 vs. 3.52 ± 1.46, 10.81 ± 4.83 vs. 6.58 ± 4.23 (month), 21.06 ± 12.58 vs. 12.97 ± 6.49, P &lt; 0.05). The average degeneration degree of the multifidus muscle was positively correlated with the VAS, symptom duration, and ODI, respectively (r = 0.515, 0.614, and 0.548, P &lt; 0.05). Sagittal plane balance, LL, PT, and the average degeneration degree of the multifidus were the risk factors for PI-LL mismatch (OR: 15.447, 95% CI: 1.274–187.269; OR: 0.001, 95% CI: 0.000–0.099; OR: 107.540, 95% CI: 5.195–2,225.975; OR: 52.531, 95% CI: 1.797–1,535.551, P &lt; 0.05).

Conclusion

The PVM on the concave side was larger than that on the convex side in ADS irrespective of whether PI-LL matched or not. PI-LL mismatch could aggravate this abnormal change, which is an important cause of pain and disability in ADS. Sagittal plane imbalance, decreased LL, higher PT, and larger average degeneration degree of the multifidus were independent risk factors for PI-LL mismatch.

Relationship between lumbar lordosis, pelvic parameters, PI-LL mismatch and outcome after short fusion surgery for lumbar degenerative disease. Literature review, rational and presentation of public study protocol: RELApSE study (registry for evaluation of lumbar artrodesis sagittal alignEment)

Background

Vertebral arthrodesis for degenerative pathology of the lumbar spine still remains burdened by clinical problems with significant negative results. The introduction of the sagittal balance assessment with the evaluation of the meaning of pelvic parameters and spinopelvic (PI-LL) mismatch offered new evaluation criteria for this widespread pathology, but there is a lack of consistent evidence on long-term outcome.

Methods

The authors performed an extensive systematic review of literature, with the aim to identify all potentially relevant studies about the role and usefulness of the restoration or the assessment of Sagittal balance in lumbar degenerative disease. They present the study protocol RELApSE (NCT05448092 ID) and discuss the rationale through a comprehensive literature review.

Results

From the 237 papers on this topic, a total of 176 articles were selected in this review. The analysis of these literature data shows sparse and variable evidence. There are no observations or guidelines about the value of lordosis restoration or PI-LL mismatch. Most of the works in the literature are retrospective, monocentric, based on small populations, and often address the topic evaluation partially.

Conclusions

The RELApSE study is based on the possibility of comparing a heterogeneous population by pathology and different surgical technical options on some homogeneous clinical and anatomic-radiological measures aiming to understanding the value that global lumbar and segmental lordosis, distribution of lordosis, pelvic tilt, and PI-LL mismatch may have on clinical outcome in lumbar degenerative pathology and on the occurrence of adjacent segment disease.

Comparison of sagittal spinal alignment on standing plain x-rays and supine MRI in degenerative lumbar disease

Background

The purpose of the present study is to examine the possible correlation between standing plain x-rays and supine magnetic resonance imaging (MRI) for evaluating spinal sagittal alignment in degenerative lumbar disease (DLD).

Methods

The characteristics and images of 64 patients with DLD were reviewed retrospectively. The thoracolumbar junction kyphosis (TJK), lumbar lordosis (LL) and sacral slope (SS) were measured on lateral plain x-rays and by MRI. Inter- and intra-observer reliability was tested using intra-class correlation coefficients.

Results

The results suggested that TJK measurements obtained from MRI tended to underestimate the radiographic measures by 2°, whereas SS measurements obtained from MRI tended to overestimate the radiographic measures by 2°. The LL measurements obtained from MRI were approximately equal to the radiographic measures, and the x-ray and MRI measurements were linearly related.

Conclusions

In conclusion, supine MRI can be directly translated into sagittal alignment angle measurements obtained from standing x-rays with an acceptable degree of accuracy. This can avoid the impaired view caused by the overlapping ilium, while reducing the patient's exposure to radiation.

Comparing the medium-term outcomes of lumbar interbody fusion via transforaminal and oblique approach in treating lumbar degenerative disc diseases

BACKGROUND CONTEXT

Oblique lumbar interbody fusion (OLIF) has been proven to be effective in treating lumbar degenerative disorders (LDDs) via indirect decompression. However, its superiority over transforaminal lumbar interbody fusion (TLIF) remains questionable, especially in terms of medium-term follow-up.

PURPOSE

To compare the medium-term clinical and radiological outcomes of TLIF and OLIF in treating patients with LDDs.

STUDY DESIGN

Retrospective comparative study.

PATIENT SAMPLE

Fifty-two patients treated by TLIF and forty-six patients treated by OLIF.

OUTCOME MEASURES

Clinical records including the visual analog scale (VAS) score of the lower back and leg and the Oswestry Disability Index (ODI). Radiological records including disk height (DH), lumbar lordosis (LL), segmental lordosis (SL), the cross-sectional area (CSA) of the spinal canal, and fusion rate. Surgical-related information and complications were also recorded.

METHODS

A retrospective review was performed on patients who were surgically managed for LDDs at L4-5 between 2015 and 2017 and completed at least 4 years of follow-up. A total of 98 patients were analyzed, with 46 patients treated by OLIF combined with anterolateral single screw-rod fixation (OLIF-AF group), and 52 patients treated by TLIF (TLIF group). Parameters including postoperative outcomes and perioperative complications were compared with evaluate the efficacy of the two approaches.

RESULTS

There was significantly less bleeding, surgical duration, and hospitalization in the OLIF-AF group than in the TLIF group. Significant improvements in the clinical score were achieved in both groups. However, the VAS score of the lower back was significantly higher in the TLIF group than in the OLIF-AF group throughout the whole follow-up period. Significantly higher expansion of the CSA was found in the TLIF group than in the OLIF-AF group. However, the improvements in DH, LL, and SL were significantly lower in the TLIF group. The fusion rate was significantly higher in the OLIF-AF group than in the TLIF group within 6 months postoperatively, and there was no significant difference between the two groups at the final record. No significant difference was found in the rate of overall complications between the two groups (25.0% vs. 23.9%, p=.545). The intraoperative complication rate in the TLIF group (13.5%) was slightly higher than that in the OLIF-AF group (6.5%) (p=.257). There was no significant difference in the incidence of adjacent segment disorder (ASD) between the two groups (7.7% vs. 10.9%, p=.422). Cage subsidence was slightly lower in the TLIF group (5.8%) than in the OLIF-AF group (13.0%) (p=.298).

CONCLUSIONS

Both the TLIF and OLIF-AF approaches demonstrated good medium-term outcomes in treating LDDs. Compared with TLIF, OLIF-AF showed advantages in postoperative recovery, improvement of intervertebral space and lumbar sagittal balance, and early intervertebral fusion but was associated with inferior spinal canal decompression efficacy. The two approaches shared comparable overall complication rates. However, OLIF-AF tended to have fewer intraoperative complications, and a higher incidence of subsidence.

Oblique Lateral Interbody Fusion versus Transforaminal Lumbar Interbody Fusion in Degenerative Lumbar Spondylolisthesis: A Single-Center Retrospective Comparative Study

Objective

To compare the efficacy of oblique lateral interbody fusion (OLIF) and transforaminal lumbar interbody fusion (TLIF) in single-level degenerative lumbar spondylolisthesis (DLS).

Methods

A retrospective analysis of patients who underwent single-level DLS surgery in our department from 2015 to 2018 was performed. According to the surgical method, the enrolled patients were divided into two groups, namely, the OLIF group who underwent OLIF combined with percutaneous pedicle screw fixation (PPSF) and the TLIF group. Clinical outcomes included operation time, operation blood loss, postoperative drainage, hospital stay, visual analog scale (VAS) score, Oswestry disability index (ODI), and complications, and imaging outcomes included upper vertebral slip, intervertebral space height (ISH), intervertebral foramen height (IFH), intervertebral space angle (ISA), lumbar lordosis (LL), and bone fusion rate. All outcomes were recorded and analyzed.

Results

A total of 65 patients were finally included, and there were 28 patients and 37 patients in the OLIF group and the TLIF group, respectively. The OLIF group showed shorter operation time, less blood loss, less postoperative drainage, and shorter hospital stay than the TLIF group (P < 0.05). The ISH, IFH, ISA, and LL were all larger in the OLIF group at postoperative and last follow-up (P < 0.05), but the degree of upper vertebral slip was found no difference between the two groups (P > 0.05). The bone graft fusion rate of OLIF group and TLIF group at 3 months, 6 months, and last follow-up was 78.57%, 92.86%, and 100% and 70.27%, 86.49%, and 97.30%, respectively, and no significant differences were found (P > 0.05). Compared with the TLIF group, the OLIF group showed a superior improvement in VAS and ODI at 1 month, 3 months, and 6 months postoperative (P < 0.05), but no differences were found at 12 months postoperative and the last follow-up (P > 0.05). There was no significant difference in complications between the two groups, with 4 patients and 6 patients in the OLIF group and TLIF group, respectively (P > 0.05).

Conclusions

Compared with TLIF, OLIF showed the advantages of less surgical invasion, better decompression effect, and faster postoperative recovery in single-level DLS surgery.

The effect of preoperative degenerative spondylolisthesis on postoperative outcomes of degenerative lumbar spinal stenosis: A single-center cohort study protocol

BACKGROUND

Most degenerative lumbar spinal stenosis (DLSS) patients primitively received the conservative treatment to control symptoms. In order to develop an optimal surgical treatment strategy, it is very significant to understand how the degenerative lumbar spondylolisthesis (DS) affects the effect of decompression in the DLSS. Thus, the aim of this current study was to explore whether the concomitant DS would affect the effect of decompression alone in the patients with DLSS.

METHODS

The current study was carried out at our hospital and it was approved through our institutional review committee of General Hospital of Ningxia Medical University. During the period from January 2015 to December 2017, in our study, we identified consecutive patients who received the minimally invasive laminectomy to treat the DLSS. The inclusion criterion included radicular leg pain or neurogenic claudication with the neurological symptoms associated with DLSS syndrome, magnetic resonance imaging of the lumbar spine reveals at least 1 level of serious stenosis, the conservative treatment failed for at least 3 months, and patients agreed to provide the postoperative details. The major outcomes of this present research was Oswestry Disability Index. Secondary outcomes of this current study involved visual analog score, short form-36, surgical revision rate as well as complications.

RESULTS

We assumed that previous DS possessed a negative effect on the postoperative results of the DLSS patients.

TRIAL REGISTRATION

researchregistry5943.