Health-related quality of life and sagittal balance at two to 25 years after posterior transfixation for high-grade dysplastic spondylolisthesis

Restoration of Spinopelvic Alignment After Reduction of High-grade Spondylolisthesis: Myth or Reality? A Systematic Review of the literature and Meta-analysis

STUDY DESIGN

Systematic review and meta-analysis of literature.

OBJECTIVE

The aim of the presented study is to assess whether the reduction of high-grade spondylolisthesis (HGS) through the correction of lumbosacral kyphosis leads to a decrease in the sagittal spinopelvic compensatory mechanisms.

SUMMARY OF BACKGROUND DATA

HGS is as an anterior translation of a vertebra, >50%. It is also characterized by a kyphotic deformity of the affected level. This combination of translation and kyphosis leads to compensatory mechanisms on the sagittal plane [pelvic retroversion, increased lumbar lordosis (LL), reduction in thoracic kyphosis (TK)].

METHODS

A systematic search of electronic databases was conducted. Inclusion criteria were diagnosis of HGS (Meyerding >II, Slip% >50%), partial or complete reduction surgery (with a significant decrease in Slip%), and report of spinopelvic parameters (pelvic incidence, pelvic tilt, or sacral slope). Clinical and radiographic outcomes were extracted and summarized. Meta-analyses were performed to estimate the differences between preoperative and postoperative spinopelvic alignment measures. P<0.05 was considered significant.

RESULTS

Eighteen studies were included. PT showed a statistically significant decrease of -2.1217 (95% CI: -3.4803 to -0.7630), while SS showed a significant increase of 4.8349 (95% CI: 2.7462-6.9236). Conversely, both LL and TK showed nonsignificant changes, -4.7043 (95% CI: -10.4535 to 1.0449) and 6.3881 (95% CI: -0.8344 to 13.6106), respectively. VAS significantly decreased by -3.1950 (95% CI: -4.9462 to -1.4439).

CONCLUSIONS

The meta-analysis showed mild, yet statistically significant, decrease of PT and an increase in SS after HGS reduction. Conversely, nonstatically significant decrease in LL and an increase in TK occurred. The clinical significance of these results remains questionable.

LEVEL OF EVIDENCE

Level IV.

Long-Term Health-Related Quality of Life (QOL) after Paediatric Spinal Deformity Surgery and Comparison with the General Population

QOL questionnaires assess patients' perception on surgical outcomes. We reviewed 1354 patients with spinal deformity. Four hundred and twenty-eight patients had >10 years of follow-up. The SRS-22r questionnaire was completed before surgery, at 6/12/24 months, 5-10 years and >10 years postoperatively. Patients with >10 years of follow-up completed the EQ-5D VAS/index and the VAS for back/leg pain. We used QOL data reporting in the general population of 20-29 and 30-39 years of age to compare against our patient cohort. Among the patients, 993 had AIS, 80 congenital scoliosis, 102 syndromic or secondary scoliosis, 105 Scheuermann kyphosis and 40 low-grade and 34 high-grade spondylolisthesis. SRS-22r total and domain scores improved from preoperative to follow-up in all diagnosis categories. At >10 years after surgery, patients with congenital scoliosis and Scheuermann kyphosis had better SRS-22r total/domain and EQ-5D (index/VAS) scores along with lower VAS back/leg pain scores compared to the other groups. Patients with congenital scoliosis and Scheuermann kyphosis had comparable SRS-22r total/domain, EQ-5D (index/VAS) and VAS back/leg pain scores to the general population in the 20-29 year category and better scores than the 30-39 year group. Patients with AIS, syndromic/secondary scoliosis and low/high-grade spondylolisthesis had reduced SRS-22r total/domain and EQ-5D (index/VAS) scores and higher VAS back/leg pain scores compared to the 20-29 year group but comparable scores to the 30-39 year group. Patients with spinal deformity reported improved QOL and high satisfaction after surgery which was maintained at >10 years of follow-up. Patients with congenital scoliosis and Scheuermann kyphosis had better QOL outcomes (comparable to the general population of similar age) as opposed to other types of scoliosis or lumbosacral spondylolisthesis.

Management of High-Grade Dysplastic Spondylolisthesis

The Meyerding classification grades the degree of slippage in the sagittal plane on lateral standing neutral imaging: 0% to 25% Grade I, 25% to 50% Grade II, 50% to 75% Grade III, 75% to 100% Grade IV, and greater than 100% Grade V (Spondyloptosis). Grades I and II are considered low-grade and Grades III-V are considered high-grade. There are several etiologies of spondylolisthesis. A classification system of the most common causes: Type I - Dysplastic, Type II - Isthmic (including subtypes: A - Lytic, B - Elongation, and C - Acute fracture), Type III - Degenerative, Type IV - Traumatic, Type V - Pathologic, and Type VI - Iatrogenic. Dysplastic spondylolisthesis is a type of spondylolisthesis that occurs at L5-S1 when dysplastic lumbosacral anatomy is present, and is associated with high-grade slip and spina bifida occulta.

High-grade dysplastic spondylolisthesis: surgical technique and case series

PURPOSE

The aim of the present study is to evaluate the results of our all posterior-one stage surgical technique for the reduction and fusion of high-grade high-dysplastic spondylolisthesis.

METHODS

Patients over 11 years old with high-grade spondylolisthesis treated by reduction and circumferential fusion with a posterior-only approach were reviewed. Data about operative time, blood loss, length of stay, intra- and postoperative complications were collected. Meyerding grade (M), lumbar lordosis (LL), thoracic kyphosis (TK), pelvic incidence (PI), pelvic tilt (PT), lumbosacral angle (LSA), slip angle (SLIP), lumbar index (LI) and severity index were measured on preoperative and last follow-up. Sagittal vertical axis (SVA) was used to assess sagittal balance.

RESULTS

Of the 14 included patients, L5-S1 arthrodesis was performed in 12 cases, and L4-S1 was performed in 2 cases. Average surgical time was 275 ± 65 min; average blood loss was 635 ± 375 mL. Average length of stay of was 3.9 ± 1.5 days. The SLIP angle improves from 33.8° ± 7.3° to 6.4° ± 2.5°, (p = 0.002); the lumbosacral angle improves from 68.8° ± 18.6° to 100.7° ± 13.2°, (p = 0.01); and the SVA decreased from 49.4 ± 22.1 mm to 34.4 ± 8.6 mm (p = 0.02). No significant changes were observed in PI, PT and SS. Thoracic kyphosis (TK) and lumbar lordosis (LL) did not change significantly. At last follow-up, no patient had surgical site infection or mechanical complications; no pseudoarthrosis was observed. No revision surgery was performed.

CONCLUSION

Although technically demanding, reduction and fusion with one stage all posterior approach prove to be a safe and effective.

Spontaneous improvement of olisthetic scoliosis in children following lumbosacral fusion for high-grade spondylolisthesis: A report of four new cases and systematic review of the literature

Background

The study aim was to present four new well-documented cases of spontaneous improvement of olisthetic scoliosis and to analyze well-documented cases from the literature.

Methods

Surgical log search and systematic review were conducted. Inclusion criteria were (1) age less than 18 years, (2) symptomatic high-grade (≥50%) spondylolisthesis, (3) scoliosis ≥20o, (4) primary surgical treatment via lumbosacral fusion, (5) complete x-rays, and (6) minimum 1-year radiographic follow-up or until curve resolution.

Results

A total of 13 patients with average age of 13.9 years were included in the study, 4 from the authors' surgical logs and 9 from the literature. Slip percentage of L5-S1 ranged from 51% to 95%. Olisthetic curve magnitude averaged 34.6° (range: 20°-45°) with majority (8/13) demonstrating long thoracic curves with lateral trunk shift. All but one of these were apex right with rightward trunk shift. The remainder of the curves were isolated lumbar curves, with an apex left morphology without trunk shift. Eleven of the 13 patients showed curve improvement following isolated lumbosacral fusion. Three patients experienced a decrease in curve magnitude of 12°-28° and eight patients enjoyed complete resolution (≤10°) of their scoliosis.

Conclusion

The current study summarizes 13 well-documented cases of olisthetic scoliosis (4 new cases and 9 from the literature) that associated with symptomatic high-grade spondylolisthesis. All were treated via a primary posterior lumbosacral fusion strategy. Eleven of the 13 curves showed spontaneous improvement (8 complete resolution of scoliosis) following their lumbosacral surgery.

Level of evidence

Therapeutic level IV.