Biomechanical response of decompression alone in lower grade lumbar degenerative spondylolisthesis--A finite element analysis

BACKGROUND

Previous studies have demonstrated the clinical efficacy of decompression alone in lower-grade spondylolisthesis. A higher rate of surgical revision and a lower rate of back pain relief was also observed. However, there is a lack of relevant biomechanical evidence after decompression alone for lower-grade spondylolisthesis.

PURPOSE

Evaluating the biomechanical characteristics of total laminectomy, hemilaminectomy, and facetectomy for lower-grade spondylolisthesis by analyzing the range of motion (ROM), intradiscal pressure (IDP), annulus fibrosus stress (AFS), facet joints contact force (FJCF), and isthmus stress (IS).

METHODS

Firstly, we utilized finite element tools to develop a normal lumbar model and subsequently constructed a spondylolisthesis model based on the normal model. We then performed total laminectomy, hemilaminectomy, and one-third facetectomy in the normal model and spondylolisthesis model, respectively. Finally, we analyzed parameters, such as ROM, IDP, AFS, FJCF, and IS, for all the models under the same concentrate force and moment.

RESULTS

The intact spondylolisthesis model showed a significant increase in the relative parameters, including ROM, AFS, FJCF, and IS, compared to the intact normal lumbar model. Hemilaminectomy and one-third facetectomy in both spondylolisthesis and normal lumbar models did not result in an obvious change in ROM, IDP, AFS, FJCF, and IS compared to the pre-operative state. Moreover, there was no significant difference in the degree of parameter changes between the spondylolisthesis and normal lumbar models after undergoing the same surgical procedures. However, total laminectomy significantly increased ROM, AFS, and IS and decreased the FJCF in both normal lumbar models and spondylolisthesis models.

CONCLUSION

Hemilaminectomy and one-third facetectomy did not have a significant impact on the segment stability of lower-grade spondylolisthesis; however, patients with LDS undergoing hemilaminectomy and one-third facetectomy may experience higher isthmus stress on the surgical side during rotation. In addition, total laminectomy changes the biomechanics in both normal lumbar models and spondylolisthesis models.

Differences in imaging and clinical characteristics are associated with higher rates of decompression-fusion versus decompression-alone in women compared to men for lumbar degenerative spondylolisthesis

PURPOSE

The goals were to ascertain if differences in imaging/clinical characteristics between women and men were associated with differences in fusion for lumbar degenerative spondylolisthesis.

METHODS

Patients had preoperative standing radiographs, CT scans, and intraoperative fluoroscopic images. Symptoms and comorbidity were obtained from patients; procedure (fusion-surgery or decompression-alone) was obtained from intraoperative records. With fusion surgery as the dependent variable, men and women were compared in multivariable logistic regression models with clinical/imaging characteristics as independent variables. The sample was dichotomized, and analyses were repeated with separate models for men and women.

RESULTS

For 380 patients (mean age 67, 61% women), women had greater translation, listhesis angle, lordosis, and pelvic incidence, and less diastasis and disc height (all p ≤ 0.03). The rate of fusion was higher for women (78% vs. 65%; OR 1.9, p = 0.008). Clinical/imaging variables were associated with fusion in separate models for men and women. Among women, in the final multivariable model, less comorbidity (OR 0.5, p = 0.05), greater diastasis (OR 1.6, p = 0.03), and less anterior disc height (OR 0.8, p = 0.0007) were associated with fusion. Among men, in the final multivariable model, opioid use (OR 4.1, p = 0.02), greater translation (OR 1.4, p = 0.0003), and greater diastasis (OR 2.4, p = 0.0002) were associated with fusion.

CONCLUSIONS

There were differences in imaging characteristics between men and women, and women were more likely to undergo fusion. Differences in fusion within groups indicate that decisions for fusion were based on composite assessments of clinical and imaging characteristics that varied between men and women.

Minimally invasive decompression alone versus fusion surgery for acute lumbar disk herniation combined incomplete cauda equina syndrome

STUDY DESIGN

Retrospective single center study.

BACKGROUND

Cauda equine syndrome (CES), which caused by acute lumbar disc herniation (LDH), often requires urgent surgical treatment. Currently, there is no standard defining the type of surgery, and approaches to the treatment of patients are based on the experience of the surgeon.

PURPOSE

to compare the clinical efficacy of minimally invasive decompression alone (Decompression alone group) and transforaminal lumbar interbody fusion (Fusion group) in the treatment of the incomplete CES, caused by acute LDH.

PATIENTS AND METHODS

89 patients with acute incomplete CES associated with LDH either underwent decompression alone and fusion surgery from January 2005 to January 2020 in single-center, and data were collected and retrospectively analyzed. The patients were divided into 2 groups according to the operation technics: the Decompression alone group (n = 46) and the Fusion group (n = 43). The perioperative clinical data (neurological deficit, control of the urinary bladder sphincter, ODI scale, SF-36) was used to assess the efficacy of the respective surgical methods before operation and with a minimum follow-up 24 months.

RESULTS

Verified statistical significance more bleeding, longer surgery time and hospital stay, in the Fusion group than in the Decompression alone group. The postoperative clinical data dramatic improved after Decompression alone and Fusion surgery. At early postoperative period registered better clinical outcomes according to ODI, SF-36 after Decompression alone surgery, but at minimum follow-up 24 months verified better in the Fusion group. The number of revision interventions in the Decompression alone group was 28.3% (n = 13), in Fusion group - 9.3% (n = 4) (p = 0.02).

CONCLUSIONS

The prevalence of acute incomplete CES due to LDH in our series was registered in 1.02% of patients (124 of 12087). In the Fusion group, in the long-term period, there were better clinical outcomes and fewer revision surgical interventions compared with Decompression alone.

High preoperative expectations and postoperative fulfillment of expectations two years after decompression alone and decompression plus fusion for lumbar degenerative spondylolisthesis

BACKGROUND CONTEXT

Fulfillment of expectations is a patient-centered outcome that has not been assessed based on fusion status for lumbar degenerative spondylolisthesis (LDS).

PURPOSE

To compare preoperatively cited expectations and 2-year postoperative fulfillment of expectations between patients undergoing decompression alone (no-fusion) vs. decompression plus fusion (fusion) for LDS.

STUDY DESIGN

Longitudinal cohort.

PATIENT SAMPLE

357 patients.

OUTCOME MEASURES

Postoperative version of Lumbar Spine Surgery Expectations Survey, Oswestry Disability Index (ODI), satisfaction with surgery.

METHODS

Preoperatively patients completed the 20-item Expectations Survey measuring amount of 'improvement expected' for symptoms, physical function, and psychosocial well-being (score range 0-100); two years postoperatively patients completed the follow-up Survey measuring 'improvement received'. The proportion of expectations fulfilled was calculated as 'improvement received' divided by 'improvement expected' (<1 some expectations fulfilled, >1 expectations surpassed). Patients also completed the ODI, SF-12 mental health subscale, satisfaction with surgery, and measures of comorbidity and psychosocial status, including social support (i.e. help at home) and prior orthopedic surgery (i.e. hip/knee arthroplasty).

RESULTS

Patients' mean age was 67 years, 61% were women, 82% had single-level LDS, 73% had fusion, and mean follow-up was 26.2 months. Compared to patients with no-fusion, patients with fusion had more pain, spinal instability, use of opioids, disability, and greater preoperative Expectations Survey scores (69 vs 74, p=.008). The proportion of expectations fulfilled postoperatively was high and similar for both groups (.82 vs. .79, p=.40), but more variable for fusion (IQR .32 vs. .40). In multivariable analysis with the proportion as the dependent variable, fulfilled expectations was associated with better mental well-being (coeff=1.1, 95% CI 0.6-1.7, p=.0001) and more social support (coeff=3.3, 95% CI 1.1-5.6, p=.004) and unfulfilled expectations was associated with prior arthroplasty (coeff=-8.6, 95% CI -15.4-(-1.9), p=.01) and subsequent lumbar surgery (coeff=-15.6, 95% CI -25.2-(-6.0), p=.002). Similar associations were found for change in ODI and satisfaction.

CONCLUSIONS

Patients had high preoperative expectations of surgery with greater expectations for decompression-fusion compared to decompression-alone. Although more variable for the fusion group, both groups had high proportions of expectations fulfilled. This study highlights the spectrum of clinical and psychosocial variables that impacts fulfillment of expectations for both decompression-alone and decompression-fusion for LDS surgery.

Percutaneous endoscopic unilateral laminotomy and bilateral decompression under 3D real-time image-guided navigation for spinal stenosis in degenerative lumbar kyphoscoliosis patients: an innovative preliminary study

BACKGROUND

The aim of this study is to introduce a new method of percutaneous endoscopic decompression under 3D real-time image-guided navigation for spinal stenosis in degenerative kyphoscoliosis patients without instability or those who with multiple comorbidities. Decompression alone using endoscope for kyphoscoliosis patient is technical demanding and may result in unnecessary bone destruction leading to further instability. The O-arm/StealthStation system is popular for its ability to provide automated registration with intraoperative, postpositioning computed tomography (CT) which results in superior accuracy in spine surgery.

METHODS

In this study, we presented four cases. All patients were over seventy years old female with variable degrees of kyphoscoliosis and multiple comorbidities who could not endure major spine fusion surgery. Percutaneous endoscopic unilateral laminotomy and bilateral decompression under 3D real-time image-guided navigation were successfully performed. Patients' demographics, image study parameters, and outcome measurements including pre- and post-operative serial Visual analog scale (VAS), and Oswestry Disability Index (ODI) were well documented. The follow-up time was 1 year.

RESULTS

Pre- and post-operative MRI showed average dural sac cross sectional area (DSCSA) improved from 81.62 (range 67.34-89.07) to 153.27 (range 127.96-189.73). Preoperative neurological symptoms including radicular leg pain improved postoperatively. The mean ODI (%) were 85 (range 82.5-90) at initial visit, 35.875 (range 25-51) at 1 month post-operatively, 26.875 (range 22.5-35) at 6 months post-operatively and 22.5 (range 17.5-30) at 12 months post-operatively (p < 0.05). The mean VAS score were 9 (range 8-10) at initial visit, 2.25 (range 2-3) at 1 month post-operatively, 1.75 (range 1-2) at 6 months post-operatively and 0.25 (range 0-1) at 12 months post-operatively (p < 0.05). There was no surgery-related complication.

CONCLUSIONS

To the best of our knowledge, this is the first preliminary study of percutaneous endoscopic laminotomy under O-arm navigation with successful outcomes. The innovative technique may serve as a promising solution in treating spinal stenosis patients with lumbar kyphoscoliosis and multiple comorbidities.

Surgical Treatment of Lumbar Spondylolisthesis in the Elderly

By 2060, population projections estimate the number of individuals older than 65 will double. Prevalence of degenerative spondylolisthesis is reported as 4.1%-11.1% within the general population. Given the growing older population, the need for evidence-based guidance is essential. Regarding benefit derived from decompression alone versus decompression plus fusion for degenerative spondylolisthesis, the consensus is that all patients do not require a fusion; however, clarity around clearly identifying this cohort is lacking. Nevertheless, instrumented fusion is an effective strategy in the elderly. Numerous options exist, and individual patient characteristics as well as surgeon experience should be evaluated when planning surgery.

The Case for Deformity Correction in the Management of Radiculopathy with Concurrent Spinal Deformity

The management of adult deformity varies significantly. Options range from nonoperative care to limited decompression to decompression with limited or extensive fusion. The appropriate surgical management is the approach that optimizes the likelihood of improvement in health-related quality of life, while limiting risks of complications and costs. Decompression alone is unreliable in the setting of significant deformity contributing to radiculopathy. Decompression with limited fusion is most appropriate for patients with age-appropriate global alignment of the spine, and decompression with more extensive fusion is most appropriate for patients with progressive deformity or with global sagittal or coronal malalignment.