Evidence-based surgical management of spondylolisthesis: reduction or arthrodesis in situ

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.

Epidemiology of Spondylolisthesis: A Nationwide Study From 2001 to 2016 in the Italian Population

STUDY DESIGN

Epidemiological study.

OBJECTIVE

This study aimed to evaluate the annual incidence of spondylolisthesis requiring surgery in Italy and the epidemiological characteristics of the patients.

BACKGROUND

The health care system continues to incur considerable costs as a result of low-back pain. Segmental instability of the lumbar spine has attracted significant interest from researchers as a potential mechanism leading to mechanical low back pain.

MATERIALS AND METHODS

The Italian Ministry of Health's National Hospital Discharge Reports database in the 2001-2016 period was considered.

RESULTS

A total of 55,804 hospital admissions for spondylolisthesis were performed in Italy. The cumulative incidence was 6.8 interventions for every 100,000 Italian adult residents. The highest amount of procedures was recorded in the 65-69 years of age group. The overall patient's age was 56.8 ± 15.1 years. The 62.2% of patients were females. The average hospital stay length was 8.1 ± 7.3 days. On average, older patients require more days of hospital stay. Over the study period, it was observed a decreasing trend in the average number of days of hospital stay. The main primary diagnoses included were "acquired spondylolisthesis" [International Classification of Diseases (ICD) code: 738.4; 57.8%] and "spondylolisthesis" (ICD code: 756.12; 42.2%). By far, the main primary procedure performed was "lumbar and lumbosacral fusion of the anterior column, posterior technique" (ICD code: 81.08; 60.3%).

CONCLUSIONS

Spondylolisthesis is a problem in Italy and a leading cause requiring spine surgery. Females were the majority of patients requiring surgery for spondylolisthesis. However, for younger age groups, males showed superior or equal need for spine surgery. The socioeconomic impact of spondylolisthesis in Italy is relevant, affecting patients still in the working population. The increasing trend of spine surgery for spondylolisthesis in Italy may be attributable to the widespread diffusion of modern diagnostic and surgical technologies.

LEVEL OF EVIDENCE

Level II.

Short-term and mid-term evaluation of three types of minimally invasive lumbar fusion surgery for treatment of L4/L5 degenerative spondylolisthesis

This was a single-centre retrospective study. Minimally invasive techniques for transforaminal lumbar interbody fusion (MIS-TLIF), oblique lumbar interbody fusion (OLIF), and percutaneous endoscopic transforaminal lumbar interbody fusion (Endo-TLIF) have been extensively used for lumbar degenerative diseases. The present study analyses the short-term and mid-term clinical effects of the above three minimally invasive techniques on L4/L5 degenerative spondylolisthesis. In this retrospective study, 98 patients with L4/L5 degenerative spondylolisthesis received MIS-TLIF, 107 received OLIF, and 114 received Endo-TLIF. All patients were followed up for at least one year. We compared patient data, including age, sex, body mass index (BMI), Oswestry disability index (ODI), visual analogue scale of low back pain (VAS-B), visual analogue scale of leg pain (VAS-L), surgical time, blood loss, drainage volume, hospital stay, complications, and neurological status. Moreover, we performed imaging evaluations, including lumbar lordosis angle (LLA), disc height (DH) and intervertebral fusion status. No significant differences were noted in age, sex, BMI, preoperative ODI, preoperative VAS-B, preoperative VAS-L, preoperative LLA, or preoperative DH. Patients who underwent OLIF had significantly decreased blood loss, a lower drainage volume, and a shorter hospital stay than those who underwent MIS-TLIF or Endo-TLIF (P < 0.05). The VAS-B in the OLIF group significantly decreased compared with in the MIS-TLIF and Endo-TLIF groups at 6 and 12 months postoperatively (P < 0.05). The VAS-L in the Endo-TLIF group significantly decreased compared with that in the MIS-TLIF and OLIF groups at 6 months postoperatively (P < 0.05). The ODI in the OLIF group was significantly better than that in the MIS-TLIF and Endo-TLIF groups at 6 months postoperatively (P < 0.05). No statistically significant differences in the incidence of complications and healthcare cost were found among the three groups. Follow-up LLA and DH changes were significantly lower in the OLIF group than in the other groups (P < 0.05). The intervertebral fusion rate was significantly higher in the OLIF group than in the other groups at 6 and 12 months postoperatively (P < 0.05). In conclusion, while MIS-TLIF, OLIF, and Endo-TLIF techniques can effectively treat patients with L4/5 degenerative spondylolisthesis, OLIF has more benefits, including less operative blood loss, a shorter hospital stay, a smaller drainage volume, efficacy for back pain, effective maintenance of lumbar lordosis angle and disc height, and a higher fusion rate. OLIF should be the preferred surgical treatment for patients with L4/5 degenerative spondylolisthesis.

Surgical versus nonsurgical management of lumbar degenerative spondylolisthesis based on spinal canal cross-sectional area

Disability and pain associated with lumbar degenerative spondylolisthesis (LDS) result in a significant burden on both the healthcare costs and patients' quality of life. Currently, there exists controversy regarding employment of either nonsurgical management (NSM) or surgical management (SM) in a clinical setting. Spinal canal cross-sectional area (SCA) has been an important morphological parameter for the analysis of LDS. However, there is lack of research about the comparative value of NSM and SM according to SCA. Moreover, previous research have not yet evaluated the clinical most suitable cutoff values of SCA. The objective of this research was to evaluate the effective of NSM and SM for LDS using SCA as an objective morphological parameter. The axial T2 magnetic resonance imaging images were obtained from each patient. We collected SCA samples from 149 patients with LDS. 72 patients underwent SM and the rest did NSM. We measured SCA at the L4/5 LDS on magnetic resonance imaging using a picture archiving and communications system. We measured SCA at the intervertebral disk posterior border, turning down to reach the facet joint side on the opposite edge at the L4/5 level. The average SCA value was 114.34 ± 48.11 mm2 in the NSM group and 69.88 ± 27.87 mm2 in the SM group. Therefore, the SM group had considerably lower SCA (P < .001). In view of the effectiveness of SCA as a prediction factor of surgical option, Receiver Operating Characteristic curve analysis show the optimal cutoff value for SCA as 83.21 mm2, with 70.8% sensitivity, 71.4% specificity, and an area under the curve of 0.80 (95% CI, 0.73-0.87). The narrower the SCA, the higher the probability of SM. Thus, it is proposed that to evaluate surgical decision making, the pain physician should carefully inspect the SCA.

Is Full-Endoscopic Transforaminal Lumbar Interbody Fusion Superior to Open Transforaminal Lumbar Interbody Fusion for Single-Level Degenerative Lumbar Spondylolisthesis? A Retrospective Study

BACKGROUND

 In this study, we evaluate the clinical efficacy and safety of full-endoscopic transforaminal lumbar interbody fusion (TLIF) for treatment of single-level lumbar degenerative spondylolisthesis.

METHODS

 Fifty-three patients were divided into two groups according to the surgical techniques: Full endoscopic (Endo)-TLIF (n = 25) and TLIF (n = 28). Clinical efficacy was evaluated pre- and postoperatively. The operation time, operative blood loss, postoperative amount of serum creatine phosphokinase (CPK), postoperative drainage volume, postoperative hospital stay time, total cost, and operative complications were also recorded.

RESULTS

 Compared with the TLIF group, the Endo-TLIF group had similar intraoperative blood loss, less postoperative increased CPK, less postoperative drainage volume, and shorter postoperative hospital stay, but longer operative time and higher total cost. The postoperative visual analog scale (VAS) scores of back and leg pain and Oswestry Disability Index (ODI) scores significantly improved compared with the preoperative scores in both two groups; more significant improvement of postoperative VAS scores of back pain and ODI scores were shown in the Endo-TLIF group at the 1-month follow-up (p < 0.05). No difference was found in the intervertebral fusion rate between the two groups.

CONCLUSION

 The Endo-TLIF has similar clinical effect compared with the TLIF for the treatment of lumbar degenerative spondylolisthesis. It also has many surgical advantages such as less muscle trauma, less postoperative back pain, and fast functional recovery of the patient. However, steep learning curve, longer operative time, and higher total cost may be the disadvantages that limit this technique. Also, the Endo-TLIF treatment of patients with bilateral lateral recess stenosis is considered a relative contraindication.

How I do it? Uniportal full-endoscopic transforaminal lumbar interbody fusion with a complete reduction for L5 isthmic grade 2 spondylolisthesis

BACKGROUND

Endoscopic transforaminal lumbar interbody fusion (endo-TLIF) with bilateral percutaneous pedicle screw fixation is an emerging option for low-grade spondylolisthesis. However, uniportal full endo-TLIF with a complete reduction for high-grade spondylolisthesis is challenging.

METHODS

We attempted uniportal endo-TLIF for L5 isthmic grade 2 spondylolisthesis with a complete reduction, and have described the procedures, with a discussion of the indications, limitations, potential complications, and ways to avoid complications.

CONCLUSION

We had successfully completed a perfect reduction of L5 isthmic grade 2 spondylolisthesis via uniportal endo-TLIF with bilateral pedicle screw fixation. Uniportal endo-TLIF is suitable for isthmic grade 2 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.

Minimally Invasive Surgery for Managing Grade IV and V Spondylolisthesis

Surgical treatment of high-grade spondylolisthesis is controversial and aims at restoring the spinopelvic sagittal balance through complete or partial reduction of the listhesis. Nerve decompression and interbody fusion are necessary for patients presenting with neurological deficit, severe pain, lower limb asymmetry, or deformities. We present the case and the results of a patient with high-grade spondylolisthesis, in whom minimally invasive management was performed. A narrative review in this topic is also provided. We performed a literature review of high-grade spondylolisthesis to compare our technique to current surgical alternatives. We included articles from PubMed, Embase, Scopus, Ovid, and Science Direct published between 1963 and 2022 that were written in English, German, and Spanish. The terms used were the following: "high grade spondylolisthesis," "spondyloptosis," "surgical management," "interbody fusion," and "arthrodesis." In all, 485 articles were displayed, from which we filtered 112 by title and abstract. At the end, 75 references were selected for the review. Different interbody fusion techniques can be used to correct the lumbosacral kyphosis and restore the spinopelvic parameters. A complete reduction of the listhesis is not always required. The surgical procedure carried out in our patient corresponds to the first known case of minimally invasive circumferential arthrodesis with iliac screws and sacral fixation in a high-grade dysplastic spondylolisthesis. This approach guarantees the correction of the lumbosacral kyphosis and a complete reduction of the listhesis. Further studies are required to determine whether the results of this case can be extrapolated to other patients with high-grade spondylolisthesis.

Stem cells and discogenic back pain

BACKGROUND

Chronic low back pain, common from the sixth decade, negatively impacts the quality of life of patients and health care systems. Recently, mesenchymal stem cells (MSCs) have been introduced in the management of degenerative discogenic pain. The present study summarizes the current knowledge on the effectiveness of MSCs in patients with discogenic back pain.

SOURCES OF DATA

We performed a systematic review of the literature following the PRISMA guidelines. We searched PubMed and Google Scholar database, and identified 14 articles about management of chronic low back pain with MSCs injection therapy. We recorded information on type of stem cells employed, culture medium, clinical scores and MRI outcomes.

AREAS OF AGREEMENT

We identified a total of 303 patients. Ten studies used bone marrow stem cells. In the other four studies, different stem cells were used (of adipose, umbilical, or chondrocytic origin and a pre-packaged product). The most commonly used scores were Visual Analogue Scale and Oswestry Disability Index.

AREAS OF CONTROVERSY

There are few studies with many missing data.

GROWING POINTS

The studies analysed demonstrate that intradiscal injections of MSCs are effective on discogenic low-back pain. This effect may result from inhibition of nociceptors, reduction of catabolism and repair of injured or degenerated tissues.

AREAS TIMELY FOR DEVELOPING RESEARCH

Further research should define the most effective procedure, trying to standardize a single method.

Transdiscal instrumentation in single-level lumbosacral fusion for high-grade isthmic pediatric spondylolisthesis: Technical note and review of the literature

Pediatric spondylolisthesis is a common cause of back pain in children, typically managed conservatively with bracing and non-steroidal anti-inflammatory drugs. When posterolateral fusion is performed for refractory pain, pseudarthrosis and implant failure may occur, necessitating reoperation. To improve patient outcomes, there is a need for alternative surgical techniques to effectively manage high-grade isthmic slips. Here, the authors report the case of a child with Meyerding grade III anterolisthesis of L5 on S1 who was treated with a single-level, instrumented fusion using bilateral S1-L5 transdiscal screws, supported with L5-S1 posterolateral instrumentation and arthrodesis. Postoperatively, there was improvement in the patient's symptoms with good clinical and radiographic outcomes. The patient continues to be symptom free with radiographic evidence of hardware stability and bony fusion across the segment. The authors detail a novel surgical technique in children as well as a review of lumbosacral transdiscal screw fixation. Further evidence is required to definitively establish the safety, outcomes, and biomechanical strength of this technique.

Surgical management of high-grade paediatric spondylolisthesis: meta-analysis and systematic review

PURPOSE

There is currently no consensus on the management of high-grade spondylolisthesis (HGS) in paediatric populations. The objective of this analysis is to compare the outcomes of reduction followed by fusion (RFF) or in situ fusion (ISF) in paediatric patients.

METHODS

Using major databases, a systematic literature search was performed. Primary studies comparing ISF with RFF in paediatric and adolescent patients were identified. Study data including patient-reported outcomes, complications, and spinopelvic parameters were collected and analysed.

RESULTS

Seven studies were included, comprising 97 ISF and 131 RFF. Average patient age was 14.4 ± 2.1 years and follow up was 8.2 ± 5.1 years. Patients undergoing RFF compared to patients undergoing ISF alone were less likely to develop pseudarthrosis (RR 0.51, 95% CI, [0.26, 0.99], p = 0.05). On average, RFF led to 11.97º more reduction in slip angle and 34.8% more reduction in sagittal translation (p < 0.00001) compared to ISF. There was no significant difference between patient satisfaction and pain at follow up. Neurologic complications and reoperation rates were not significantly different.

CONCLUSIONS

Both RFF and ISF are effective techniques for managing HGS. Performing a reduction followed by fusion reduces the likelihood of pseudarthrosis in paediatric patients. The difference between risk of neurologic complications, need for reoperation, patient satisfaction, and pain outcomes did not reach statistical significance. Correlation with patient-reported outcomes still needs to be further explored. LEVEL 3 EVIDENCE: Meta-analysis of Level 3 studies.

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.

Vertebral Slip Morphology in Dysplastic Spondylolisthesis as a Criterion for the Choice of the L5/S1 Support (ALIF, PLIF, Fibular Graft) in Surgical Treatment

Dysplastic spondylolisthesis is a severe pathological condition, based on dysplastic changes in the lumbosacral part of the spine, that causes the asymmetry of the lumbosacral junction. The appropriate therapeutic algorithm remains controversial. As the gold standard, the surgical reposition of the slipped vertebra and 360° fusion of the affected spinal segment is preferred. Thirty-two patients were operated on between the years 2005 and 2018. Different techniques of 360° fusion, based on the severity of the displacement of the affected vertebral segment, were used. Herein, the advantages and disadvantages of different techniques of interbody fusion are discussed. The slippage and retention after reduction in the vertebrae are evaluated prior to the operation, postoperatively, one year after the surgery, and during follow-up, which was 7 years on average (minimum 2 years for a follow-up). Complications associated with the surgery are evaluated, in addition to the operation time, blood loss, spinopelvic parameters, and patient satisfaction with the surgery. All surgical techniques improved the slippage compared to preoperative conditions. The retention of the reposition was not changed significantly in postoperative controls. The incidence of neurological complications reached 12.5%. Surgical treatment is the only treatment option that successfully addressed the pathological principle of dysplastic spondylolisthesis. All of the surgical methods used led to restoring the symmetry of the lumbar spine, and to the improvement in both radiological parameters and the alleviation of subjective difficulties. The aim of this article is to summarize surgical methods in patients having dysplastic spondylolisthesis with a slip of more than 25%, who were operated on, and to determine the optimal treatment algorithm according to the severity of the slip.

Scoliosis in dysplastic spondylolisthesis: a clinical survey of 50 young patients

Background

Dysplastic spondylolisthesis is a rare spinal deformity that occurs mainly in young patients. Although its sagittal parameters had been well stated, coronal abnormalities in these patients were poorly studied. The purposes of this study were: (1) to investigate the prevalence of scoliosis in dysplastic spondylolisthesis;(2) to assess scoliosis resolution or persistence after surgery; and (3) to propose a modified classification of scoliosis associated with dysplastic spondylolisthesis.

Methods

Fifty patients (average age 14.9 ± 5.6 years) diagnosed with dysplastic spondylolisthesis who underwent surgical treatment were followed up and their data were analyzed. Standing posteroanterior and lateral full spine radiographs were used to measure the coronal and sagittal parameters. Patients with scoliosis, which was defined as a coronal Cobb angle greater than 10°, were divided into three groups according to their curve characteristics: “independent” scoliosis (IS) group, spasm scoliosis (SS) group, and olisthetic scoliosis (OS) group. SS and OS were spondylolisthesis-induced scoliosis. The radiographic parameters and patient-reported outcomes were collected before and after surgery and compared between groups.

Results

The average slip percentage was 62.8% ± 23.1% and the average follow-up time was 51.5 ± 36.4 months (range 3–168 months). Twenty-eight of the 50 (56%) dysplastic spondylolisthesis patients showed scoliosis, of which 8 were IS (24.7° ± 15.2°), 11 were SS (13.9° ± 3.0°), and 9 were OS (12.9° ± 1.9°). By the last follow-up, no scoliosis resolution was observed in the IS group whereas all SS patients were relieved. Of the nine patients with OS, four (44.4%) had scoliosis resolution after surgery.

Conclusion

Distinguishing different types of scoliosis in dysplastic spondylolisthesis patients may help surgeons to plan treatment and understand prognosis. For patients with significant scoliosis, whether “independent” or spondylolisthesis-induced, treatment of spondylolisthesis should be performed first and scoliosis should be observed for a period of time and treated according to the corresponding principles.

Comparative analysis of the effects of OLIF and TLIF on adjacent segments after treatment of L4 degenerative lumbar spondylolisthesis

Background

The fusion of the lumbar spine may lead to the degeneration of the adjacent segments. In this study, the effects of OLIF and TLIF on adjacent segments after treatment of L4 degenerative lumbar spondylolisthesis (DLS) were compared and analysed.

Methods

This was a retrospective analysis of the medical records of consecutive patients treated with OLIF or TLIF for L4DLS. They were divided into the OLIF group and TLIF group based on different treatment methods. Cage height, segmental lordosis (SL), lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT), and sacral slope (SS) were compared between the two groups, and the postoperative biomechanical changes were analysed by establishing the disc angle (DA). The clinical outcomes were analysed by comparing the visual analogue scale (VAS), Oswestry Disability Index (ODI) and incidence of adjacent segment disease (ASDis) between the two groups. The intervertebral disc height (IDH), intervertebral foramen height (IDH), intervertebral foramen area (IFA), sliding distance (SD), and angular displacement (AD) in L3-4 and L5-S1 were compared between the two groups. The incidence of aggravated disc degeneration (ADD), the incidence of aggravated zygapophyseal joint degeneration (AJD) and the incidence of adjacent segment degeneration (ASDeg) were compared between the two groups for radiological degeneration.

Results

At the last follow-up, there was one case of ASDis in the OLIF group (2.78%) and two cases in the TLIF group (5.56%). At the last follow-up, compared with the preoperative values, IDH, IFH, and IFA of the adjacent segments above and below L4-5 decreased in both groups (P < 0.05); the SD and AD increased in both groups (P < 0.05). The cage height and L4-5 IDH in the OLIF group were significantly higher than those in the TLIF group (P < 0.05). SL, LL, PT, SS, and L5- S1DA were significantly improved in the OLIF group compared with the TLIF group (P < 0.05). The incidence of L3-4ASDeg in the two groups was higher than that of L5-S1. The incidence of ASDeg and the incidence of L5-S1ADD in the OLIF group were lower than those in the TLIF group, but the incidence of L5-S1AJD was higher than that in the TLIF group.

Conclusion

L4DLS after OLIF and TLIF treatment will cause adjacent segment degeneration, and L3-4 degeneration is more obvious than L5-S1 degeneration. OLIF has more advantages in restoring lumbar sagittal balance. Compared with TLIF, OLIF can weaken the degeneration of the L5-S1 disc and increase the degeneration of the L5-S1 zygapophyseal joints.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-022-03084-7.

Surgical outcomes with anatomic reduction of high-grade spondylolisthesis revisited: an analysis of 101 patients

OBJECTIVE

The ideal strategy for high-grade L5-S1 isthmic spondylolisthesis (HGS) remains controversial. Critical questions include the impact of reduction on clinical outcomes, rate of pseudarthrosis, and postoperative foot drop. The scope of this study was to delineate predictors of radiographic and clinical outcome factors after surgery for HGS and to identify risk factors of foot drop.

METHODS

This was a single-center analysis of patients who were admitted for HGS, defined as grade III or greater L5 translation according to the Meyerding (MD) classification. Complete postoperative reduction was defined as MD grade I or less and L5 slip < 20%. Forty-six patients completed health-related quality-of-life questionnaires (Oswestry Disability Index, Physical Component Summary of SF-36, and visual analog scale) and ≥ 2 years' follow-up (average 105 months). A 540° approach was used in 61 patients, a 360° approach was used in 40, and L5 corpectomy was used in 17. Radiographic analysis included measures of global spinopelvic balance (e.g., pelvic incidence [PI], lumbar lordosis) and measurement of lumbosacral kyphosis angle (LSA), L4 slope (L4S), L5 slip (%), and postoperative increase of L5-S1 height.

RESULTS

The authors included 101 patients with > 1 year of clinical and radiographic follow-up. The mean age was 26 years. Average preoperative MD grade was 3.8 and average L5 slip was 81%; complete reduction was achieved in 55 and 42 patients, respectively, according to these criteria. At follow-up, LSA correlated with all clinical outcomes (r ≥ 0.4, p < 0.05). Forty patients experienced a major complication. Risk was increased in patients with greater preoperative deformity (i.e., LSA) (p = 0.04) and those who underwent L5 corpectomy (p < 0.01) and correlated with greater deformity correction. Thirty-one patients needed revision surgery, including 17 for pseudarthrosis. Patients who needed revision surgery had greater preoperative deformity (i.e., MD grade and L5 slip) (p < 0.01), greater PI (p = 0.02), and greater postoperative L4S (p < 0.01) and were older (p = 0.02), and these patients more often underwent L5 corpectomy (p < 0.01). Complete reduction was associated with lower likelihood of pseudarthrosis (p = 0.08) and resulted in better lumbar lordosis correction (p = 0.03). Thirty patients had foot drop, and these patients had greater MD grade and L5 slip (p < 0.01) and greater preoperative LSA (p < 0.01). These patients with foot drop more often required L5 corpectomy (p < 0.01). Change in preoperative L4S (p = 0.02), LSA (p < 0.01), and L5-S1 height (p = 0.02) were significantly different between patients with foot drop and those without foot drop. A significant risk model was established that included L4S change and PI as independent variables and foot drop as a dependent variable (82% negative predictive value and 71% positive predictive value, p < 0.01).

CONCLUSIONS

Multivariable analysis identified factors associated with foot drop, major complications, and need for revision surgery, including degree of deformity (MD grade and L5 slip) and correction of LSA. Functional outcome correlated with LSA correction.

Efficacy and Safety of Oblique Lumbar Interbody Fusion Versus Transforaminal Lumbar Interbody Fusion for Degenerative Lumbar Spondylolisthesis: A Systematic Review and Meta-Analysis

OBJECTIVE

We critically evaluated the efficacy and safety of oblique lumbar interbody fusion (OLIF) versus transforaminal lumbar interbody fusion (TLIF) for degenerative lumbar spondylolisthesis (DLS).

METHODS

PubMed, Embase, Cochrane Library, the Web of Science Core Collection, Chinese Biomedical Literature, China National Knowledge Infrastructure, Wanfang Digital Periodicals, and Chinese Science and Technology Periodicals were searched from their inception to February 2021. Randomized controlled trials and retrospective or prospective cohort studies (CSs) comparing OLIF and TLIF for DLS were included. A meta-analysis was conducted, if possible.

RESULTS

Ten studies were included in the statistical analysis. The pooled results of the CSs showed no statistically significant differences (P > 0.05) in pain relief at 3 or 6 months of follow-up and functional improvement at 1 or 3 months of follow-up in DLS patients between those who had undergone OLIF versus TLIF. The pooled results of the CSs showed that OLIF could significantly improve the degree of lumbar lordosis, foraminal height, and disc height and decrease the intraoperative blood loss, postoperative drainage volume, operative duration, bed rest time, and hospital length of stay (P < 0.05) compared with TLIF. The incidence of adverse events was not significantly different statistically between OLIF and TLIF.

CONCLUSIONS

The results from the present study suggest that pain relief and functional improvement were not significantly different between OLIF and TLIF. Nevertheless, the use of OLIF might improve radiological outcomes and reduce intraoperative blood loss, postoperative drainage volume, operative duration, bed rest duration, and hospital length of stay compared with TLIF. Additional high-quality randomized controlled trials are still required to confirm these findings.

Biomechanical analysis of reduction technique for lumbar spondylolisthesis: anterior lever versus posterior lever reduction method

BACKGROUND

Reduction of lumbar spondylolisthesis during spinal fusion surgery is important for improving the fusion rate and restoring the sagittal alignment. Despite the variety of reduction methods, the fundamental mechanics of lumbar spondylolisthesis reduction remain unclear. This study aimed to investigate the biomechanical behavior while performing spondylolisthesis reduction with the anterior and posterior lever reduction method.

METHODS

We developed an L4-L5 spondylolisthesis model using sawbones. Two spine surgeons performed the simulated reduction with a customized Cobb elevator. The following data were collected: the torque and angular motion of Cobb, displacement of vertebral bodies, change of lordotic angle between L4 and L5, total axial force and torque applied on the model, and force received by adjacent disc.

RESULTS

Less torque value (116 N-cm vs. 155 N-cm) and greater angular motion (53o vs. 38o) of Cobb elevator were observed in anterior lever reduction. Moreover, the total axial force received by the entire model was greater in the posterior lever method than that in the anterior lever method (40.8 N vs. 16.38 N). Besides, the displacement of both vertebral bodies was greater in the anterior lever method.

CONCLUSIONS

The anterior lever reduction is a more effort-saving method than the posterior lever reduction method. The existing evidence supports the biomechanical advantage of the anterior reduction method, which might be one of the contributing factors to successfully treating high-grade lumbar spondylolisthesis with short-segment instrumentation.

Long term outcome and fusion rate of transdiscal fixation for L5-S1 high grade spondylolisthesis

OBJECTIVE

High grade spondylolisthesis (HGS) is a quite rare entity and many techniques are available to address this condition. In 1994 Abdu et al. proposed a transdiscal fixation approach that achieved a good clinical outcome. We analyse outcome and fusion achieved in patients treated by transdiscal fixation after 1-year follow-up.

METHODS

We reviewed patients operated through transdiscal fixation since 2014 with a follow-up of at least 1 year, and compared preoperative and postoperative clinical measures (ODI, VAS and EQ-5D) and postoperative complications. Also, we analyzed the degree of fusion on CT scan with Lenke and Birdwell criteria.

RESULTS

Twelve patients were included in the study with a mean follow-up of 49.4 months (range 12.8-84.1 months). Three cases presented a Meyerding grade IV spondylolisthesis and 9 cases grade III. At 1-year follow-up mean postoperative ODI, VAS and EQ5D scores improved (ODI 13.2 (range 0-30) vs 49.83 (range 15-71.1); p = .005). Equally this improvement was seen in the last follow-up (ODI 9.28 (range 0-35) vs 49.83 (range 15-71.1); p = .005). CT scan showed fusion grade A in 5 patients (41.6%), another 5 as grade B (41.6%) in Lenke classification. According to the Birdwell criteria 4 patients were classified as grade I (33.3%), 7 patients grade II (58.3%). None showed complications postoperatively or radiolucency in follow-up.

CONCLUSIONS

Transdiscal fixation shows a good clinical outcome that is maintained throughout a long time period and provides a reliable and suitable fusion.

Management of degenerative spondylolisthesis: development of appropriate use criteria

BACKGROUND CONTEXT

Outcomes of treatment in care of patients with spinal disorders are directly related to patient selection and treatment indications. However, for many disorders, there is absence of consensus for precise indications. With the increasing emphasis on quality and value in spine care, it is essential that treatment recommendations and decisions are optimized.

PURPOSE

The purpose of the North American Spine Society Appropriate Use Criteria was to determine the appropriate (ie reasonable) multidisciplinary treatment recommendations for patients with degenerative spondylolisthesis across a spectrum of more common clinical scenarios.

STUDY DESIGN

A Modified Delphi process was used.

METHODS

The methodology was based on the Appropriate Use Criteria development process established by the Research AND Development Corporation. The topic of degenerative spondylolisthesis was selected by the committee, key modifiers determined, and consensus reached on standard definitions. A literature search and evidence analysis were completed by one work group simultaneously as scenarios were written, reviewed, and finalized by another work group. A separate multidisciplinary rating group was assembled. Based on the literature, provider experience, and group discussion, each scenario was scored on a nine-point scale on two separate occasions, once without discussion and then a second time following discussion based on the initial responses. The median rating for each scenario was then used to determine if indications were rarely appropriate (1 - 3), uncertain (4-6), or appropriate (7-9). Consensus was not mandatory.

RESULTS

There were 131 discrete scenarios. These addressed questions on bone grafting, imaging, mechanical instability, radiculopathy with or without neurological deficits, obesity, and yellow flags consisting of psychosocial and medical comorbidities. For most of these, appropriateness was established for physical therapy, injections, and various forms of surgical intervention. The diagnosis of spondylolisthesis should be determined by an upright x-ray. Scenarios pertaining to bone grafting suggested that patients should quit smoking prior to surgery, and that use of BMP should be reserved for patients who had risk factors for non-union. Across all clinical scenarios, physical therapy (PT) had an adjusted mean of 7.66, epidural steroid injections 5.76, and surgery 4.52. Physical therapy was appropriate in most scenarios, and most appropriate in patients with back pain and no neurological deficits. Epidural steroid injections were most appropriate in patients with radiculopathy. Surgery was generally more appropriate for patients with neurological deficits, higher disability scores, and dynamic spondylolisthesis. Mechanical back pain and presence of yellow flags tended to be less appropriate, and obesity in general had relatively little influence on decision making. Decompression alone was more strongly considered in the presence of static versus dynamic spondylolisthesis. On average, posterior fusion with or without interbody fusion was similarly appropriate, and generally more appropriate than stand-alone interbody fusion which was in turn more appropriate than interspinous spacers.

CONCLUSIONS

Multidisciplinary appropriate treatment criteria were generated based on the Research AND Development methodology. While there were consistent and significant differences between surgeons and non-surgeons, these differences were generally very small. This document provides comprehensive evidence-based recommendations for evaluation and treatment of degenerative spondylolisthesis. The document in its entirety will be found on the North American Spine Society website (https://www.spine.org/Research-Clinical-Care/Quality-Improvement/Appropriate-Use-Criteria).

L5 Radiculopathy After Formal Reduction of High-Grade SDSG Type 5 and 6 L5-S1 Isthmic Spondylolisthesis with 2-Year Follow-Up

BACKGROUND

Surgery is the main treatment for patients with high-grade L5-S1 isthmic spondylolisthesis, which can result in neurologic complications, but little is known about its clinical course. The present study evaluated the presence of L5 radiculopathy in high-grade L5-S1 spondylolisthesis in adults in pre- and postoperative periods and after a 2-year follow-up.

METHODS

A series of 16 patients who underwent reduction and instrumented fusion for high-grade 5 and 6 spondylolisthesis between 2018 and 2019 were retrospectively evaluated in the pre- and postoperative periods as well as after 6 weeks, 3 months, 6 months, and 1 and 2 years of follow-up. Clinical and surgical data on possible neurological complications of L5 radiculopathy were prospectively collected.

RESULTS

The age was 20.1 ± 12.0 years, and preoperative L5-S1 slip was 89.0%. Five patients presented motor deficit in the preoperative period. In the immediate postoperative period, 9 patients (56%) experienced motor deficits or worsening of the preoperative condition. At the 6-week follow-up, only 1 patient showed resolution of the motor deficit. Three patients presented healed motor deficits after 3 months, and 1 patient demonstrated a healed L5 motor radiculopathy after 6 months. At the 1-year follow-up, only 1 patient exhibited an L5 radiculopathy motor deficit, and at the 2-year follow-up, none of the patients exhibited an L5 radiculopathy motor deficit.

CONCLUSION

L5 radiculopathy was frequent in the preoperative period and increased after reduction and instrumented fusion of high-grade L5-S1 spondylolisthesis in the postoperative period and in the 6-week follow-up. Three and 6 months after the surgery, there were consecutive motor improvements. After 2 years of follow-up, no patients showed neurological deficit of L5 radiculopathy.

LEVEL OF EVIDENCE

2.

CLINICAL RELEVANCE

This is the first study reporting a reduction in complications of L5 neurological motor deficit over a 2-year follow-up in high-grade L5-S1 spondylolisthesis in young adults.

Lumbosacral Spondylolysis and Spondylolisthesis

Repetitive stress on the lumbosacral spine during sporting activity places the athletic patient at risk of developing symptomatic pars defect. Clinical history, physical examination, and diagnostic imaging are important to distinguish spondylolysis from other causes of lower back pain. Early pars stress reaction can be identified with advanced imaging, before the development of cortical fracture or vertebral slip progression to spondylolisthesis. Conservative management is first-line for low-grade injury with surgical intervention indicated for refractory symptoms, severe spondylolisthesis, or considerable neurologic deficit. Prompt diagnosis and management of spondylolysis leads to good outcomes and return to competition for most athletes.

What is the Optimal Surgical Method for Achieving Correction and Avoiding Neurological Complications in Pediatric High-grade Spondylolisthesis?

BACKGROUND

Controversy persists in the treatment of high-grade spondylolisthesis (HGS). Surgery is recommended in patients with intrusive symptoms and evidence debates the competing strategies. This study compares the radiologic outcomes and postoperative complications at a minimum of 2 years follow-up for patients with HGS treated with instrumented fusion with partial reduction (IFIS) with those treated with reduction, decompression, and instrumented fusion (RIF). We hypothesize that IFIS leads to a lower rate of complication and revision surgery than RIF.

METHODS

A retrospective comparative methodology was used to analyze consecutive HGS treated surgically between 2006 and 2017. Patients diagnosed with ≥grade 3 spondylolisthesis treated with arthrodesis before the age of 18 years with a minimum of 2 years follow-up were included. Patients were excluded if surgery did not aim to achieve arthrodesis or was a revision procedure. Cases were identified through departmental and neurophysiological records.

RESULTS

Thirty patients met the inclusion criteria. Mean follow-up was 4 years. Ten patients underwent IFIS and the remaining 20 underwent RIF. The 2 groups showed no difference in demographics, grade of slip, deformity or presenting symptoms. Of 10 treated with IFIS, the SA reduced by a mean of 10 degrees and C7 sagittal vertical line changed by 31 mm. In the RIF cohort, SA reduced by 16 degrees and C7 sagittal vertical line reduced by 26 mm. PT was unchanged in both groups. In IFIS cohort, 2 patients showed postoperative weakness, resolved by 2 years. None required revision surgery. In the RIF group, 4 sustained dural tears and 1 a laminar fracture, 7 showed postoperative weakness or dysaesthesia, 3 of which had not resolved by 2 years. Eight patients underwent unplanned further surgery, 3 for pseudarthrosis.

CONCLUSIONS

RIF and IFIS show similar radiologic outcomes. RIF shows a higher rate of unplanned return to surgery, pseudarthrosis and persisting neurological changes.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

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

Aims

High-grade dysplastic spondylolisthesis is a disabling disorder for which many different operative techniques have been described. The aim of this study is to evaluate Scoliosis Research Society 22-item (SRS-22r) scores, global balance, and regional spino-pelvic alignment from two to 25 years after surgery for high-grade dysplastic spondylolisthesis using an all-posterior partial reduction, transfixation technique.

Methods

SRS-22r and full-spine lateral radiographs were collected for the 28 young patients (age 13.4 years (SD 2.6) who underwent surgery for high-grade dysplastic spondylolisthesis in our centre (Scottish National Spinal Deformity Service) between 1995 and 2018. The mean follow-up was nine years (2 to 25), and one patient was lost to follow-up. The standard surgical technique was an all-posterior, partial reduction, and S1 to L5 transfixation screw technique without direct decompression. Parameters for segmental (slip percentage, Dubousset’s lumbosacral angle) and regional alignment (pelvic tilt, sacral slope, L5 incidence, lumbar lordosis, and thoracic kyphosis) and global balance (T1 spino-pelvic inclination) were measured. SRS-22r scores were compared between patients with a balanced and unbalanced pelvis at final follow-up.

Results

SRS-22r domain and total scores improved significantly from preoperative to final follow-up, except for the mental health domain that remained the same. Slip percentage improved from 75% (SD 15) to 48% (SD 19) and lumbosacral angle from 70° (SD 11) to 101° (SD 11). Preoperatively, 35% had global imbalance, and at follow-up all were balanced. Preoperatively, 63% had an unbalanced pelvis, and at final follow-up this was 32%. SRS-22r scores were not different in patients with a balanced or unbalanced pelvis. However, postoperative pelvic imbalance as measured by L5 incidence was associated with lower SRS-22r self-image and total scores (p = 0.029).

Conclusion

In young patients with HGDS, partial reduction and transfixation improves local lumbosacral alignment, restores pelvic, and global balance and provides satisfactory long-term clinical outcomes. Higher SRS-22r self-image and total scores were observed in the patients that had a balanced pelvis (L5I < 60°) at two to 25 years follow-up.

Cite this article: Bone Jt Open 2021;2(3):163–173.

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.

Comparison of unilateral and bilateral polymethylmethacrylate-augmented cannulated pedicle screw fixation for the management of lumbar spondylolisthesis with osteoporosis

Background

Cannulated pedicle screw (CPS) augmented by polymethylmethacrylate (PMMA) can achieve satisfactory clinical efficacy in the treatment of lumbar spondylolisthesis with osteoporosis. However, accurate application of CPSs will help to avoid the difficulty of screw revision and reduce the incidence of PMMA-related complications. This study aimed to investigate the mid-term efficacy of CPS compared to unilateral and bilateral applications in this common lumbar degenerative disease.

Methods

May 2011 and May 2018, 50 patients with lumbar spondylolisthesis with osteoporosis who underwent posterior fixation and fusion using traditional pedicle screws or CPSs were included in the study. Patients were divided into two groups based on the application: the unilateral PMMA-augmented CPS group (UC, n = 29) and the bilateral PMMA-augmented CPS group (BC, n = 21). Operation time, blood loss, average hospitalization time, PMMA leakage, and other complications were recorded. The visual analog scale (VAS) and Oswestry disability index (ODI) scores were used to evaluate symptom recovery. Radiographic results were compared for intervertebral fusion and screw loosening.

Results

There were no significant differences in the baseline data of the two groups.

The VAS and ODI scores improved significantly after surgery (P < 0.05), with no significant differences between the groups (P > 0.05). The operation time and blood loss in the UC group were significantly lower than those in the BC group (P < 0.05). However, the loss of intervertebral disk height and Taillard index did not differ significantly between the groups. The rates of PMMA leakage in the UC and BC groups were 7.0% and 11.9%, respectively (P < 0.05). Bony fusion was achieved in all groups without screw loosening at the last follow-up. Only one patient experienced superficial infection in both groups, while cerebrospinal fluid leakage was observed in two patients in the BC group.

Conclusions

Unilateral application of PMMA-augmented CPS may provide adequate clinical safety and effectiveness in the surgical treatment of lumbar spondylolisthesis with osteoporosis.

Efficacy and radiographic analysis of oblique lumbar interbody fusion in treating lumbar degenerative spondylolisthesis with sagittal imbalance

The aim of this study was to evaluate the effectiveness of OLIF (oblique lumbar interbody fusion) in the treatment of lumbar degenerative spondylolisthesis with sagittal imbalance. Fifty-nine patients were included in our analysis. Included patients were divided into 2 groups according to the surgical techniques: PLIF (posterior lumbar interbody fusion) (n = 31) and OLIF + PSF (OLIF combined with posterior spinal fixation) (n = 28). Perioperative radiographic parameters, complications, and clinical outcome from each group were assessed and compared. The operation time for both groups was 165.1 min in the OLIF group and 182.1 min in the PLIF group (P < 0.05). The intraoperative blood loss was 190.6 ml in the OLIF group and 356.3 ml in the PLIF group (P < 0.05). The number of intraoperative and postoperative complications for both groups was 7 in the OLIF group and 11 in the PLIF group. Significant clinical improvement was observed in VAS scores and ODI when comparing preoperative evaluation and final follow-up. The preoperative SVA (the distance from the posterosuperior corner of S1body to the C7 plumb line), PI (pelvic incidence), LL (lumbar lordosis), PI-LL mismatch, DH (disc height), and lumbar Cobb angles of both groups were similar. The postoperative and final follow-up SVA, LL, PI-LL mismatch, and disc height were improved in both groups, and a statistical difference was found between both groups (P < 0.05). An improvement of SVA, LL, PI-LL mismatch, and disc height at the OLIF group was better than that found at the PLIF group. An improvement in radiographic and clinical outcomes for the OLIF group was better than that seen for the PLIF group. Then, OLIF had a more curative effect in lumbar degenerative spondylolisthesis with sagittal imbalance.

Lumbar spinal fusion of low-grade degenerative spondylolisthesis (Meyerding grade I and II): Do reduction and correction of the radiological sagittal parameters correlate with better clinical outcome?

INTRODUCTION

Lumbar and lumbosacral spinal fusion is an established procedure for the treatment of degenerative spondylolisthesis. However, the impact of reduction in the affected segment and of improvement in the radiological sagittal parameters on the clinical outcome remains unclear. Purpose of the study is to analyze the correlation between the radiological sagittal parameters and clinical outcome after lumbar spinal fusion in low-grade degenerative spondylolisthesis.

MATERIALS AND METHODS

In a monocentric prospective, clinical study, patients with low-grade degenerative spondylolisthesis of a single lumbar segment have been included. All patients received a lumbar spinal fusion according to the pathology of the treated segment. Patients attended clinical and radiological follow-up examination 1 and 2 years postoperatively. Clinical outcome was assessed using the Core Outcome Measurement Index (COMI), the Oswestry Disability Index (ODI) and the EuroQol 5D. The sagittal spinopelvic radiological parameters, sagittal rotation and anterior displacement of the affected segment and lumbar lordosis were assessed. The correlation between the sagittal radiological parameters and clinical outcome was analyzed using Spearman-Rho bi-serial test.

RESULTS

Sixty-two patients (35 female and 27 male) with an average age of 59.3 years were included in the study. All patients completed the follow-up examinations. Significant improvement in COMI, ODI and EuroQol 5D scores was shown in all follow-up examinations. Significant reduction in the anterior displacement was measured postoperatively, which was preserved during the follow-up. However, no correlation could be demonstrated between reduction in anterior displacement and improvement in clinical outcome. Nonetheless, correlation between correction of sagittal rotation and clinical outcome was shown.

CONCLUSIONS

Reduction in anterior displacement of the affected segment in the surgical treatment of low-grade degenerative spondylolisthesis does not have an impact on the clinical outcome.

High-Grade Spondylolisthesis in Adults: Current Concepts in Evaluation and Management

Background

Information regarding the treatment of high-grade spondylolisthesis (HGS) in adults has been previously described; however, previous descriptions of the evaluation and surgical management of HGS do not represent more recent and now established approaches. The purpose of the current review is to discuss current concepts in the evaluation and management of patients with HGS.

Methods

Literature review.

Results

HGS is diagnosed in up to 11.3% of adults with spondylolisthesis and typically presents as nonspecific lower back pain. Regarding evaluation, a thorough history and physical examination should be performed, which may help predict the presence of HGS. Diagnostic imaging, and specifically the use of spino-pelvic parameters, are now commonly implicated in guiding treatment course and prognosis. When surgical intervention is indicated, surgical approaches include in situ fusion variations, reduction and partial reduction with fusion, and vertebrectomy. Although the majority of studies suggest improvements with these approaches, the literature is limited by a low level of evidence with regards to the superiority of one technique when compared with others.

Conclusions

HGS is a unique cause of low back pain in adults that carries considerable morbidity, but rarely presents with neurologic symptoms. Although the definitions, classifications, and methods of diagnosis of this spinal deformity have been established and accepted, the ideal surgical management of this deformity remains highly debated. Fusion in situ techniques are often technically easier to perform and provide lower risk of neurologic complications, whereas reduction and fusion techniques offer greater restoration of global spino-pelvic balance. Preoperative spino-pelvic parameters may have utility in assisting in procedural selection; however, future, higher-quality and longer-term studies are warranted to determine the optimal surgical intervention among the widely available techniques currently used, and to better define the indications for these interventions.

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

PURPOSE

During surgical procedure on lumbar spondylolisthesis, the role of reducing slip remains controversial. The purpose of the present study was to compare fusion in situ with reduction in clinical and radiographic outcomes.

METHODS

A literature research was performed at PubMed, Embase, Web of Science, and Cochrane Library. After screening by two authors, ten articles were brought into this meta-analysis finally, and the quality was evaluated by the modified Newcastle-Ottawa Scale (NOS). Isthmic, moderate, and serious spondylolisthesis were all analyzed separately. Sensitivity analyses were performed for high-quality studies, and the publication bias was evaluated by the funnel plot.

RESULTS

Most criteria did not have statistical differences between reduction and fusion in situ groups. However, in reduction group, the union rate was significantly higher (P=0.008), the slippage was much improved (P<0.001) and the hospital stay was much shorter comparing to no-reduction group (P<0.001). Subgroup analysis (containing moderate and serious slip, or isthmic spondylolisthesis) and sensitivity analysis were all consistent with original ones, and the funnel plot indicated no obvious publication bias in this meta-analysis.

CONCLUSIONS

Both reduction and fusion in situ for lumbar spondylolisthesis were related with good clinical results. Reduction led to higher rate of fusion, better radiographic slippage, and shorter hospital stay. After sufficient decompression, reduction did not incur additional risk of neurologic impairment compared with fusion in situ.

Family Caregiver Strain and Challenges When Caring for Orthopedic Patients: A Systematic Review

Background: Caregivers represent the core of patients’ care in hospital structures, in the process of care and self-care after discharge. We aim to identify the factors that affect the strain of caring for orthopedic patients and how these factors are related to the quality of life of caregivers. We also want to evaluate the role of caregivers in orthopedic disease, focusing attention on the patient–caregiver dyad. Methods: A comprehensive search on PubMed, Cochrane, CINAHL and Embase databases was conducted. This review was reported following PRISMA statement guidance. Studies were selected, according to inclusion and exclusion criteria, about patient–caregiver dyads. For quality assessment, we used the MINORS and the Cochrane Risk of BIAS assessment tool. Results: 28 studies were included in the systematic review; in these studies, 3034 dyads were analyzed. Caregivers were not always able to bear the difficulties of care. An improvement in strain was observed after behavioral interventions from health-care team members; Conclusions: The role of the caregiver can lead to a deterioration of physical, cognitive and mental conditions. The use of behavioral interventions increased quality of life, reducing the strain in caregivers of orthopedic patients. For this reason, it is important to consider the impact that orthopedic disease has on the strain of the caregiver and to address this topic.

Reduction versus In Situ Fusion for Adult High-Grade Spondylolisthesis: A Systematic Review and Meta-Analysis

BACKGROUND

Surgical management of high-grade spondylolisthesis is controversial. Both reduction and in situ fusion are available options, but it remains unclear which approach provides better outcomes. We conducted a systematic review and meta-analysis of studies reporting outcomes following reduction or in situ fusion for adult high-grade spondylolisthesis.

METHODS

PubMed, Embase, Web of Science, and Cochrane databases were last searched on June 24, 2019. We identified 1236 studies after excluding duplicates. After screening, 15 studies were included in the meta-analysis. Random-effects models were used to pool effect estimates.

RESULTS

A total of 188 patients were analyzed. Compared with reduction, in situ fusion had a higher mean estimated blood loss (584 mL vs. 451 mL) and a clinically higher incidence of neurologic (48% vs. 15%), pseudarthrosis (13% vs. 8%), and infectious (20% vs. 10%) complications; however, these differences were not statistically significant. Reduction was associated with a clinically higher incidence of overall complications (32% vs. 25%) and dural tears (22% vs. 7%). Reduction provided better pain relief (mean difference [MD] = 5.24 vs. 4.77) and greater change in pelvic tilt (MD = 5.33 vs. 2.60); however, these differences were not statistically significant. Patients who underwent reduction had significantly greater decline in Oswestry Disability Index scores (MD = 55.7 vs. 11.5; P_interaction < 0.01) and greater change in slip angle (MD = 25.0 vs. 11.4; P_interaction = 0.01).

CONCLUSIONS

In management of adult high-grade spondylolisthesis, both approaches appeared to be safe and effective. Reduction appeared to offer better disability relief and spinopelvic parameter correction than in situ fusion.

Minimally invasive anterior and lateral transpsoas approaches for closed reduction of grade II spondylolisthesis: initial clinical and radiographic experience

OBJECTIVE Minimally invasive anterior and lateral approaches to the lumbar spine are increasingly used to treat and reduce grade I spondylolisthesis, but concerns still exist for their usage in the management of higher-grade lesions. The authors report their experience with this strategy for grade II spondylolisthesis in a single-surgeon case series and provide early clinical and radiographic outcomes. METHODS A retrospective review of a single surgeon's cases between 2012 and 2016 identified all patients with a Meyerding grade II lumbar spondylolisthesis who underwent minimally invasive lateral lumbar interbody fusion (LLIF) or anterior lumbar interbody fusion (ALIF) targeting the slipped level. Demographic, clinical, and radiographic data were collected and analyzed. Changes in radiographic measurements, Oswestry Disability Index (ODI), and visual analog scale (VAS) scores were compared using the paired t-test and Wilcoxon signed rank test for continuous and ordinal variables, respectively. RESULTS The average operative time was 199.1 minutes (with 60.6 ml of estimated blood loss) for LLIFs and 282.1 minutes (with 106.3 ml of estimated blood loss), for ALIFs. Three LLIF patients had transient unilateral anterior thigh numbness during the 1st week after surgery, and 1 ALIF patient had transient dorsiflexion weakness, which was resolved at postoperative week 1. The mean follow-up time was 17.6 months (SD 12.5 months) for LLIF patients and 10 months (SD 3.1 months) for ALIF patients. Complete reduction of the spondylolisthesis was achieved in 12 LLIF patients (75.0%) and 7 ALIF patients (87.5%). Across both procedures, there was an increase in both the segmental lordosis (LLIF 5.6°, p = 0.002; ALIF 15.0°, p = 0.002) and overall lumbar lordosis (LLIF 2.9°, p = 0.151; ALIF 5.1°, p = 0.006) after surgery. Statistically significant decreases in the mean VAS and the mean ODI measurements were seen in both treatment groups. The VAS and ODI scores fell by a mean value of 3.9 (p = 0.002) and 19.8 (p = 0.001), respectively, for LLIF patients and 3.8 (p = 0.02) and 21.0 (p = 0.03), respectively, for ALIF patients at last follow-up. CONCLUSIONS Early clinical and radiographic results from using minimally invasive LLIF and ALIF approaches to treat grade II spondylolisthesis appear to be good, with low operative blood loss and no neurological deficits. Complete reduction of the spondylolisthesis is frequently possible with a statistically significant reduction in pain scores.

Grade II Spondylolisthesis: Reverse Bohlman Procedure with Transdiscal S1-L5 and S2 Alar Iliac Screws Placed with Robotic Guidance

BACKGROUND

Grade II spondylolisthesis remains a complex surgical pathology for which there is no consensus regarding optimal surgical strategies. Surgical strategies vary regarding extent of reduction, use of instrumentation/interbody support, and anterior versus posterior approaches with or without decompression. Here we provide the first report on the efficacy of robotic spinal surgery systems in support of the treatment of grade II spondylolisthesis.

METHODS

Using 2 illustrative cases, we provide a technical report describing how robotic spinal surgery platform can be used to treatment grade II spondylolisthesis with a novel instrumentation strategy.

RESULTS

We describe how the "reverse Bohlman" technique to achieve a large anterior fusion construct spanning the pathological level and buttressed by the adjacent level above, coupled with a novel, high-fidelity posterior fixation scheme with transdiscal S1-L5 and S2 alar iliac (S2AI) screws placed in a minimally invasive fashion with robot guidance allows for the best chance of fusion in situ.

CONCLUSIONS

The reverse Bohlman technique coupled with transdiscal S1-L5 and S2AI screw fixation accomplishes the surgical goals of creating a solid fusion construct, avoiding neurologic injury with aggressive reduction, and halting the progression of anterolisthesis. The use of robot guidance allows for efficient placement of these difficult screw trajectories in a minimally invasive fashion.

High-Grade Lumbar Spondylolisthesis

Most high-grade spondylolistheses are resultant from isthmic spondylolisthesis, as complete discontinuity of the pars is typically necessary to allow for this degree of anterior vertebral translation, although can occur less commonly in other scenarios. Higher-grade slips can affect the global sagittal balance of the patient and often result in altered gait patterns and compensatory posturing. Management usually entails surgical decompression and fusion with instrumentation. The addition of anterior column support carries many advantages, including greater surface area for fusion, dynamic compression load sharing at the lumbosacral junction, and a powerful adjunct for deformity correction.

[Spondylolisthesis in the growing spine]

BACKGROUND

Spondylolisthesis (Greek for sliding vertebra) in children is usually the result of a defect (=lysis) or an elongation of the interarticular portion. The cause can be a congenital dysplasia of the dorsal stabilizing structures or pressure of the facet on the interarticular portion. This is a consequence of lumbar lordosis which is necessary for an upright posture.

TREATMENT

The treatment depends on the symptoms and the risk of progression. This is related to the sliding distance, the degree of secondary dysplasia of the vertebral bodies and the sagittal profile, which is considered in the Mac-Thiong classification. For low-grade olistheses, conservative therapy is an option; for a symptomatic lysis without disc degeneration, pars repair should be considered. In higher-grade olistheses, repositioning and spondylodesis are usually recommended. Repositioning improves the fusion rate and sagittal profile, but increases the risk of nerve root damage, so complete repositioning should not be forced.

Biomechanical evaluation of traditional posterior versus anterior spondylolisthesis reduction in a cadaveric grade I slip model

OBJECTIVE

Posterior reduction with pedicle screws is often used for stabilization of unstable spondylolisthesis to directly reduce misalignment or protect against micromotion while fusion of the affected level occurs. Optimal treatment of spondylolisthesis combines consistent reduction with a reduced risk of construct failure. The authors compared the reduction achieved with a novel anterior integrated spacer with a built-in reduction mechanism (ISR) to the reduction achieved with pedicle screws alone, or in combination with an anterior lumbar interbody fusion (ALIF) spacer, in a cadaveric grade I spondylolisthesis model.

METHODS

Grade I slip was modeled in 6 cadaveric L5-S1 segments by creation of a partial nucleotomy and facetectomy and application of dynamic cyclic loading. Following the creation of spondylolisthesis, reduction was performed under increasing axial loads, simulating muscle trunk forces between 50 and 157.5 lbs, in the following order: bilateral pedicle screws (BPS), BPS with an anterior spacer (BPS+S), and ISR. Percent reduction and reduction failure load-the axial load at which successful reduction (≥ 50% correction) was not achieved-were recorded along with the failure mechanism. Corrections were evaluated using lateral fluoroscopic images.

RESULTS

The average loads at which BPS and BPS+S failed were 92.5 ± 6.1 and 94.2 ± 13.9 lbs, respectively. The ISR construct failed at a statistically higher load of 140.0 ± 27.1 lbs. Reduction at the largest axial load (157.5 lbs) by the ISR device was tested in 67% (4 of 6) of the specimens, was successful in 33% (2 of 6), and achieved 68.3 ± 37.4% of the available reduction. For the BPS and BPS+S constructs, the largest axial load was 105.0 lbs, with average reductions of 21.3 ± 0.0% (1 of 6) and 32.4 ± 5.7% (3 of 6) respectively.

CONCLUSIONS

While both posterior and anterior reduction devices maintained reduction under gravimetric loading, the reduction capacity of the novel anterior ISR device was more effective at greater loads than traditional pedicle screw techniques. Full correction was achieved with pedicle screws, with or without ALIF, but under significantly lower axial loads. The anterior ISR may prove useful when higher reduction forces are required; however, additional clinical studies will be needed to evaluate the effectiveness of anterior devices with built-in reduction mechanisms.

Restoration of normal pelvic balance from surgical reduction in high-grade spondylolisthesis

PURPOSE

To investigate the effectiveness of surgical reduction in high-grade spondylolisthesis in maintaining or restoring a normal pelvic balance, as related to the QoL.

METHODS

It is a retrospective analysis of prospectively collected data of 60 patients (17 males, 43 females) aged 15 ± 3.1 years who underwent surgery for high-grade spondylolisthesis and were followed for a minimum of 2 years after surgery. Patients with a residual high-grade slip following surgery were referred to the postoperative high-grade (PHG) group, while patients with a residual low-grade slip were referred to the postoperative low-grade (PLG) group. Pelvic balance was assessed from pelvic tilt and sacral slope, in order to identify patients with a balanced pelvis or unbalanced pelvis. The SRS-22 questionnaire was completed before surgery and at last follow-up.

RESULTS

Postoperatively, there were 36 patients with a balanced pelvis and 24 patients with an unbalanced pelvis. The improvement in QoL was better in patients with a postoperative balanced pelvis. There were 14 patients in the PHG group and 46 patients in the PLG group. Four of seven patients (57%) in the PHG group and 21 of 26 patients (81%) in the PLG group with a preoperative balanced pelvis maintained a balanced pelvis postoperatively (P = 0.1). None of the patients in the PHG group and 11 of 20 patients (55%) in the PLG group improved from an unbalanced to a balanced pelvis postoperatively (P < 0.05).

CONCLUSIONS

Surgical reduction in high- to low-grade slip is more effective in maintaining and restoring a normal pelvic balance postoperatively. These slides can be retrieved under Electronic Supplementary Material.

Surgical Treatment of Developmental Spondylolisthesis: Contemporary Series With a Two-Surgeon Team

STUDY DESIGN

Retrospective case series.

OBJECTIVES

To report operative outcomes of contemporary surgical treatment of spondylolisthesis in the pediatric population.

SUMMARY OF BACKGROUND DATA

Surgical treatment of developmental spondylolisthesis is controversial, with limited data on complication and reoperation rates.

METHODS

A retrospective study followed pediatric patients with either L5-S1 high-grade spondylolisthesis (HGS) or L5-S1 symptomatic low-grade spondylolisthesis (LGS) for a minimum of two years. All patients underwent a contemporary, single-stage decompression, partial reduction, and posterior instrumented fusion (DRPF) or in situ stabilization by a combined orthopedic and neurosurgeon team at a single institution during 2005-2015. Clinical examination and radiographic data were collected preoperatively and at discharge, 1 year, 2 years, and terminal visit (defined as the last follow-up at >2 years).

RESULTS

Thirty-four patients (79% HGS), mean (±standard deviation) age at surgery 13.5 (±3.3) years, were followed for 4.8 (±2.3) years. The patients who underwent DRPF (n = 26) had mean lumbosacral angle increase from 79.8° (±20.8) to 92.5° (±16.1) (p < .001) and mean listhesis reduce from 63.2% (±21.9) to 26.0% (±20.1) (p < .001). Preoperatively, 18 (53%) had neurologic symptoms. At one- and two-year follow-up, new or residual neurologic symptoms were present in four patients (12%) (p < .001). Postoperative symptoms were not significantly related to amount of reduction. Sixteen (47%) underwent reoperation at an average of 24.8 months, 10 for planned prominent instrumentation removal, and 6 for true complications.

CONCLUSIONS

Surgical reduction and decompression of spondylolisthesis in the pediatric population restores spinopelvic alignment. We found no evidence that a greater amount of reduction was associated with a higher incidence of postoperative complications. However, patients should be advised that prominent instrumentation may require future removal. Although previous reports suggest complication rates and permanent neurologic sequelae in up to 20% after operative treatment of spondylolisthesis, our results suggest that a contemporary approach with a two-surgeon team may provide improved results.

LEVEL OF EVIDENCE

Level IV.

The Challenge of Creating Lordosis in High-Grade Dysplastic Spondylolisthesis

High-grade dysplastic spondylolisthesis (HGDS) is a subset of L5-S1 spondylolisthesis that occurs due to dysmorphic anatomy at the lumbosacral junction, often resulting in sagittal imbalance. Enhanced understanding of global sagittal alignment has led many to preferentially treat HGDS with reduction and fusion to restore sagittal balance. The purpose of this article is to review published surgical techniques for obtaining sagittal correction in HGDS and to evaluate the current evidence regarding the associated surgical complications.

Current Use of Evidence-Based Medicine in Pediatric Spine Surgery

Evidence-based medicine (EBM) is a process of decision-making aimed at making the best clinical decisions as they relate to patients' health. The current use of EBM in pediatric spine surgery is varied, based mainly on the availability of high-quality data. The use of EBM is limited in idiopathic scoliosis, whereas EBM has been used to investigate the treatment of pediatric spondylolysis. Studies on early onset scoliosis are of low quality, making EBM difficult in this condition. Future focus and commitment to study quality in pediatric spinal surgery will likely increase the role of EBM in these conditions.

Modified Lumbosacral Angle and Modified Pelvic Incidence as New Parameters for Management of Pediatric High-grade Spondylolisthesis

STUDY DESIGN

Retrospective clinical study.

OBJECTIVE

We aimed to introduce new parameters that can better describe the pelvic morphology and lumbosacral segmental deformity in children with high-grade spondylolisthesis of the L5 vertebra: modified pelvic incidence (mPI) and modified lumbosacral angle (mLSA). Also, we aimed to establish the mLSA as a convenient, reliable measurement method and criteria to evaluate the reduction of L5 vertebral slippage.

SUMMARY OF BACKGROUND DATA

Numerous parameters and methods exist to evaluate segmental deformity and reduction of L5 vertebral slippage, but no definitive standard for accurately and conveniently describing lumbosacral kyphosis and degree of reduction exists.

METHODS

A total of 24 children with high-grade spondylolisthesis (S group) and 152 children without spondylolisthesis (non-S group) underwent standard lateral radiography of the spine in our hospital between June 2009 and June 2014. We compared mPI and mLSA between the S and non-S groups. The agreement and repeatability of mPI and mLSA were also assessed. Preoperative and postoperative Japanese Orthopaedic Association (JOA) and Scoliosis Research Society (SRS)-22 scores were compared to assess clinical outcomes in the S group. The correlations between modified parameter applications and clinical outcomes were also assessed.

RESULTS

While mPI did not differ between groups, mLSA differed significantly. In the non-S group, mLSA was lordotic (25.51±6.41 degrees). In the S group, mLSA was kyphotic (25.85±5.17 degrees) before surgery and lordotic (20.74±7.04 degrees) postoperatively. The agreement and repeatability of mPI and mLSA were good, and clinical outcomes of the S group were satisfactory. Positive correlations were found between modified parameter applications and the improvement rates of JOA scores.

CONCLUSIONS

mPI and mLSA can better describe the pelvic morphology and local deformity of pediatric high-grade L5 spondylolisthesis, and mLSA can serve as a useful index for correcting lumbosacral kyphosis, rebalancing the sagittal spinal profile and predicting clinical outcomes.

Risk Factors Associated With Failure to Reach Minimal Clinically Important Difference in Patient-reported Outcomes Following Minimally Invasive Transforaminal Lumbar Interbody Fusion for Spondylolisthesis

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

To determine risk factors associated with failure to reach the minimal clinically important difference (MCID) in patient-reported outcomes (PROs) for patients undergoing minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) for spondylolisthesis.

SUMMARY OF BACKGROUND DATA

The MCID of PROs are often utilized to determine the benefit of spinal procedures. However, negative predictive factors for reaching MCID in patients surgically treated for lumbar spondylolisthesis have been difficult to elucidate.

MATERIALS AND METHODS

A prospectively maintained surgical database of patients who were diagnosed with lumbar spondylolisthesis and surgically treated with a single level MIS TLIF from 2010 to 2016 was reviewed. Patients with incomplete PRO survey data or <6-month follow-up were excluded from the analysis. MCID for visual analogue scale (VAS) back, VAS leg, and Oswestry Disability Index (ODI) was obtained from established values in the literature. All risk factors were then assessed for association with failure to reach MCID using bivariate and multivariate regression adjusting for preoperative characteristics.

RESULTS

A total of 165, 76, and 73 patients treated with MIS TLIF for spondylolisthesis had complete PRO data for VAS back, VAS leg, and ODI, respectively, and were thus included in the analysis for the respective PRO. Overall, 75.76%, 71.05%, and 61.64% of patients treated with a single level MIS TLIF for spondylolisthesis reached MCID for VAS back, VAS leg, and ODI, respectively. On multivariate analysis, patients were less likely to achieve MCID for VAS back following surgical treatment if they received workers' compensation (P<0.001). No other measured factors were noted to independently correlate with MCID achievement.

CONCLUSIONS

The results of this study suggest that a majority of patients with spondylolisthesis achieve MCID for commonly measured PROs following MIS TLIF for spondylolisthesis. However, worker's compensation insurance status may serve as a negative predictive factor for reaching MCID.

Correlation Between Lumbopelvic and Sagittal Parameters and Health-Related Quality of Life in Adults With Lumbosacral Spondylolisthesis

STUDY DESIGN

Secondary analysis of prospective, multicenter data.

OBJECTIVE

To evaluate impact of sagittal parameters on health-related quality of life (HRQoL) in adults with lumbosacral spondylolisthesis.

METHODS

Adults with unoperated lumbosacral spondylolisthesis were identified in the Spinal Deformity Study Group database. Pearson's correlations were calculated between SF-12 (Short Form-12)/Scoliosis Research Society-30 (SRS-30) scores and radiographic parameters (C7 sagittal vertical axis [SVA] deviation, T1 pelvic angle, pelvic tilt [PT], pelvic incidence, sacral slope, slip angle, Meyerding slip grade, Labelle classification). Main effects linear regression models measured association between individual health status measures and individual radiographic predictor variables.

RESULTS

Forty-five patients were analyzed (male, 15; female, 30; average age 40.5 ± 18.7 years; 14 low-grade, 31 high-grade). For low-grade slips, SVA had strong negative correlations with SF-12 mental component score (MCS), SRS-30 appearance, mental, and satisfaction domains (r = -0.57, r = -0.60, r = -0.58, r = -0.53, respectively; P < .05). For high-grade slips, slip angle had a moderate negative correlation with SF-12 MCS (r = -0.36; P = .05) and SVA had strong negative correlations with SF-12 physical component score (PCS), SRS-30 appearance and activity domains (r = -0.48, r = -0.48, r = -0.45; P < .05) and a moderate negative correlation with SRS-30 total (r = -0.37; P < .05). T1 pelvic angle had a moderate negative correlation with SF-12 PCS and SRS-30 appearance (r = -0.37, r = -0.36; P ≤ .05). For every 1° increase in PT, there was a 0.04-point decrease in SRS appearance, 0.05-point decrease in SRS activity, 0.06-point decrease in SRS satisfaction, and 0.04-point decrease in SRS total score (P < .05).

CONCLUSION

Lumbosacral spondylolisthesis in adults negatively affects HRQoL. Multiple radiographic sagittal parameters negatively affect HRQoLs for patients with low- and high-grade slips. Improvement of sagittal parameters is an important goal of surgery for adults with lumbosacral spondylolisthesis.