Instrumented L5-S1 interbody graft with IFUSE implant using the reverse Bohlman technique

BACKGROUND

In case of high sacral slope, anterior lumbosacral fusions can be performed by retroperitoneal or transperitoneal approach using a reversed Bohlman technique with an autologous corticocancellous fibular graft. The use of a trans-lumbosacral implant can avoid the iatrogenic effects but currently, there is no implant specifically designed for this fusion technique. Could the IFUSE implant from SI BONE replace a fibular graft to avoiding the iatrogenic effect induced by sampling during a Reverse Bohlman technique?

PATIENTS AND METHODS

We present the case of a 38-year-old woman with L5S1 interbody pseudarthrosis after posterior fixation for grade 2 L5-S1 spondylolisthesis with isthmic lysis of L5, and that of a 69-year-old woman who underwent a posterior T4 fusion to the pelvis for degenerative scoliosis. Both required a trans-lumbosacral instrumented fusion via an anterior approach using the reverse Bohlman technique. Surgical technique was described.

RESULTS

There were no perioperative or postoperative complications. At 6 months, the patients reported a decrease in lumbar and radicular symptomatology. There were no infectious, neurological or vascular complications. CT-scans confirmed the good position and stability of the IFUSE implant.

DISCUSSION

We present an innovative interbody grafting technique adapted to spines with high pelvic incidence. The surgical technique is safe, minimally invasive, and reduces surgical iatrogeny. The short and medium-term results are positive but require longer-term follow-up and a larger cohort.

The clinical and radiographic degenerative spondylolisthesis classification and its predictive value

INTRODUCTION

The clinical and radiographic degenerative spondylolisthesis (CARDS) classification is a new classification that has been introduced for degenerative spondylolisthesis (DS). It has four categories. Our study aimed to analyse the functional and radiographic outcome following DS surgery based on the preoperative CARDS classification.

METHODS

A retrospective study of the prospectively collected Australian Spine Registry database was performed. Data on demographics, patient reported outcome measures including the Oswestry Disability Index (ODI) and EQ-5D-3 L scores, and changes in radiographic measurements were analysed. Based on the preoperative findings all x-rays were classified applying the CARDS classification.

RESULTS

Between 2018 and 2021 a total of 54-patients were identified as having had surgery for DS at L4/5. The mean age was 65.3 ± 11.3years and females were predominantly affected (61%). Most cases were of CARDS type C (46%), followed by type B (29%). CARDS type A and D were observed in 18% and 6% respectively. Preoperatively, the L4/5 lordosis was 19.8 ± 6.3° and lumbar lordosis 43.9 ± 12.8°. Postoperatively the L4/5 lordosis alignment changed significantly to 23.5 ± 8.8° (p < 0.05). Preoperatively, the CARDS classification was 34.8 ± 17.4 (type A), 40.5 ± 11.0 (type B), 43.8 ± 12.9 and 50.0 ± 14.4 for type D (Pearson-coefficient 0.284, p = 0.041). Postoperatively this changed to 22.7 ± 16.1, 28.7 ± 21.2, 12.5 ± 13.1, and 6.5 ± 2.1 respectively. Similar improvements were observed for the EQ-5D-3 L.

CONCLUSION

This study shows that the CARDS classification correlates with preoperative functional scores as well as helping to predict response to surgery. CARDS will likely assist in operative planning and prognostication.

LEVEL OF EVIDENCE

III, therapeutic and prognostic study.

Return to Play Criteria After Adult Lumbar Spinal Fractures: A Review of Current Literature and Expert Recommendations

PURPOSE OF REVIEW

Understanding the management of lumbar spinal fractures and return to play (RTP) criteria is an essential component of care for adult athletes. Appropriate management of lumbar spinal fractures must balance minimizing time away from physical activity while also minimizing risk of reinjury. The purpose of this review is to summarize current recommendations on lumbar spinal fracture management and RTP guidelines and to provide expert opinion on areas of discrepancy in the field.

RECENT FINDINGS

There is a paucity of high-level evidence on the management and return to play criteria for adult lumbar spine fractures in athletes. Much of the data and recommendations are based on expert opinion and studies in pediatric or osteoporotic patients, which may not be applicable to adult athletes. These data presented here may be used to aid patient-physician conversations and provide guidance on expectations for patients, coaches, and athletic trainers. In general, we recommend that patients be free of lumbar pain, neurologically intact, and have full strength and motion of the lumbar spine and lower extremities before returning to play. Adequate protective equipment is recommended to be worn at all times during practice and play.

Closed Reduction for the Treatment of Traumatic Thoracolumbar Spondylolisthesis

OBJECTIVE

Thoracolumbar traumatic spondylolisthesis is a relatively rare phenomenon and has poor prognosis due to serious spinal cord or cauda equina injuries. In such cases, closed reduction is a method for restoring the vertebral sequence and may play an important role in the treatment process, although whether it is actually feasible for patients with this condition requires further investigation. The present study included 9 patients with serious thoracolumbar traumatic spondylolisthesis to determine the advantages of closed reduction over total reduction through open surgery.

METHODS

Data from 9 patients (cases 1-9), diagnosed with severe thoracolumbar traumatic spondylolisthesis between June 2012 and August 2023, were retrospectively reviewed. Five patients were treated with closed reduction in an emergency department and subsequently underwent delayed internal fixation surgery at least 48 hours after the injury, and 4 with similar serious injuries underwent emergency surgery. The incidence of complications and recovery of the spinal cord or cauda equina were compared between groups.

RESULTS

There were no significant differences in demographic characteristics or adverse events between the 2 groups. The reduction group had a shorter surgical duration and less blood loss than the surgery group. Although patients in the surgery group may have experienced more pain, there were no significant differences between the groups in Oswestry Disability Index or Japanese Orthopaedic Association scores. Thus, regardless of whether closed reduction was chosen, patients experienced a similar quality of life for a relatively prolonged period.

CONCLUSIONS

Closed reduction may be feasible for serious thoracolumbar traumatic spondylolisthesis, although the safety of this method requires further research.

Pacific Spine and Pain Society (PSPS) Evidence Review of Surgical Treatments for Lumbar Degenerative Spinal Disease: A Narrative Review

INTRODUCTION

Interventional treatment options for the lumbar degenerative spine have undergone a significant amount of innovation over the last decade. As new technologies emerge, along with the surgical specialty expansion, there is no manuscript that utilizes a review of surgical treatments with evidence rankings from multiple specialties, namely, the interventional pain and spine communities. Through the Pacific Spine and Pain Society (PSPS), the purpose of this manuscript is to provide a balanced evidence review of available surgical treatments.

METHODS

The PSPS Research Committee created a working group that performed a comprehensive literature search on available surgical technologies for the treatment of the degenerative spine, utilizing the ranking assessment based on USPSTF (United States Preventative Services Taskforce) and NASS (North American Spine Society) criteria.

RESULTS

The surgical treatments were separated based on disease process, including treatments for degenerative disc disease, spondylolisthesis, and spinal stenosis.

CONCLUSIONS

There is emerging and significant evidence to support multiple approaches to treat the symptomatic lumbar degenerative spine. As new technologies become available, training, education, credentialing, and peer review are essential for optimizing patient safety and successful outcomes.

Clinical Efficacy of Unilateral Dual-channel Endoscopic Lumbar Interbody Fusion for Lumbar Spondylolisthesis with Spinal Scoliosis

OBJECTIVES

Scoliosis associated with spondylolisthesis is a common phenomenon. Recent research has reported that scoliosis can spontaneously disappear after lumbar spinal fusion surgery. Researchers have advocated that, for scoliosis associated with vertebral slippage, surgery for the latter may be the only necessary intervention, while unnecessary surgery for scoliosis should be avoided. So we propose that minimally invasive techniques can achieve treatment effects similar to those of open surgery. Therefore, in this study, we aimed to investigate the clinical efficacy of unilateral dual-channel endoscopic lumbar interbody fusion (ULIF) for treating lumbar spondylolisthesis with spinal scoliosis.

METHODS

This study retrospectively analyzed patients with lumbar spondylolisthesis and spinal scoliosis who underwent ULIF between September 2021 and September 2023. Measurements of the Cobb angle, lumbar lordosis (LL) angle, sacral slope (SS), slip percentage (SP), slip angle (SA), L1 plumb line-S1 distance (LASD), and average intervertebral height (AIH) were taken preoperatively, immediately following surgery, 3 months after surgery, and at the final follow-up. The visual analogue scale (VAS), Oswestry disability index (ODI), and Japanese Orthopaedic Association (JOA) scoring systems were used to assess clinical results. The surgical efficacy was evaluated by comparing these parameters before and after surgery. Comparison of indicators within the same group was conducted using one-way repeated-measures analysis of variance or paired sample t-tests, whereas between-group differences were compared using an independent t-test.

RESULTS

This study included 31 individuals who underwent surgery and completed follow-up. The follow-up period did not show a significant loss of corrective angles. Furthermore, the Cobb angle, SP, SA, and LASD significantly decreased after surgery, whereas the LL angle, SS, and AIH significantly increased (all p < 0.05). SP did not differ between the immediate postoperative period and the 3-month and final follow-up periods (p > 0.05). However, other parameters significantly improved during the follow-up period at all time points, except from 3 months to the final follow-up period (p > 0.05). Throughout the follow-up period, the lower back and leg pain VAS, ODI, and JOA scores considerably improved compared with the preoperative levels (p < 0.05).

CONCLUSION

ULIF effectively treated lumbar spondylolisthesis with scoliosis, thereby reducing the degree of slip and scoliosis. By performing surgical reduction, fusion, and fixation only on the slipped segment, ULIF also had a corrective effect on the spinal lateral curvature, thereby avoiding the need for unnecessary scoliosis surgery. Moreover, the short-term efficacy was satisfactory, but the long-term efficacy requires further study.

Microendoscopic Tailored Spine Decompression as a Less-Invasive, Stability-Preserving Surgical Option to Instrumented Correction in Complex Spine Deformities: A Preliminary Multicenter Experience

OBJECTIVES

The aim of this study was to explore the effectiveness of a less-invasive posterior spine decompression in complex deformities. We studied the potential advantages of the microendoscopic approach, supplemented by the piezoelectric technique, to decompress both sides of the vertebral canal from a one-sided approach to preserve spine stability, ensuring adequate neural decompression.

METHODS

A series of 32 patients who underwent a tailored stability-preserving microendoscopic decompression for lumbar spine degenerative disease was retrospectively analyzed. The patients underwent selective bilateral decompression via a monolateral approach, without the skeletonization of the opposite side. For omo- and the contralateral decompression, we used a microscopic endoscopy-assisted approach, with the assistance of piezosurgery, to work safely near the exposed dura mater. Piezoelectric osteotomy is extremely effective in bone removal while sparing soft tissues.

RESULTS

In all patients, adequate decompression was achieved with a high rate of spine stability preservation. The approach was essential in minimizing the opening, therefore reducing the risk of spine instability. Piezoelectric osteotomy was useful to safely perform the undercutting of the base of the spinous process for better contralateral vision and decompression without damaging the exposed dura. In all patients, a various degree of neurologic improvement was observed, with no immediate spine decompensation.

CONCLUSIONS

In selected cases, the tailored microendoscopic monolateral approach for bilateral spine decompression with the assistance of piezosurgery is adequate and safe and shows excellent results in terms of spine decompression and stability preservation.

Bilateral vertebral artery injury leads to brain death following traumatic brain injury: a case report

BACKGROUND

Vertebral artery injury is a rare condition in trauma settings. In the advanced stages, it causes death.

CASE

A 31-year-old Sundanese woman with cerebral edema, C2-C3 anterolisthesis, and Le Fort III fracture after a motorcycle accident was admitted to the emergency room. On the fifth day, she underwent arch bar maxillomandibular application and debridement in general anesthesia with a hyperextended neck position. Unfortunately, her rigid neck collar was removed in the high care unit before surgery. Her condition deteriorated 72 hours after surgery. Digital subtraction angiography revealed a grade 5 bilateral vertebral artery injury due to cervical spine displacement and a grade 4 left internal carotid artery injury with a carotid cavernous fistula (CCF). The patient was declared brain death as not improved cerebral perfusion after CCF coiling.

CONCLUSIONS

Brain death due to cerebral hypoperfusion following cerebrovascular injury in this patient could be prevented by early endovascular intervention and cervical immobilisation.

Imaging predictors of progression of lumbar spondylolysis to spondylolisthesis: a systematic review

BACKGROUND CONTEXT

Isthmic spondylolisthesis (IS) is defined as the anterior translation of one lumbar vertebra relative to the next caudal segment as a result of a unilateral or bilateral fracture of the pars interarticularis. These fractures are interchangeably known as "pars defects" or "spondylolysis." Many risk factors have been proposed to explain the progression of a spondylolytic defect to IS, however, none are validated.

PURPOSE

This systematic review provides an overview of various radiological and imaging parameters that can help predict the risk of progression of a spondylolytic defect into IS.

STUDY DESIGN

Systematic review.

METHODS

Medline, Embase and Cochrane online database were searched. The various correlations between imaging features with observed spondylolisthesis prevalence or severity or spondylolysis rates of spondylolisthesis were evaluated to provide a list of imaging risk factors to predict IS. Significance of the correlations in the original article was recorded to enable comparison of the collected evidence of separate image features.

RESULTS

All searches combined generated a total of 431 results of which 26 articles were included into this study. Of the 22 potential risk factors identified, 5 were found to be statistically insignificant, 8 were found to be significant and 9 had mixed results. The following features were found to be significant risk factors in at least on study: disc degeneration, transverse process width, pelvic incidence, pelvic tilt, sacral slope, lumbar lordosis, lumbar index, thoracic kyphosis, facet joint angle above the level of defect, facet joint degeneration, facet tropism, multifidus size, lateral erector spinae size, mesenteric fat thickness, subcutaneous fat thickness and soft tissue calcification.

CONCLUSION

Our research suggests that only disc degeneration had moderately strong evidence with consistent significant associations with development of IS in patients with spondylolysis. Transverse process width, pelvic incidence, pelvic tilt, sacral slope, lumbar lordosis, lumbar index, thoracic kyphosis, facet joint angle above the level of defect, facet joint degeneration, facet tropism, multifidus size, lateral erector spinae size, mesenteric fat thickness, subcutaneous fat thickness and soft tissue calcification had some evidence. All other radiological factors had weak evidence. The results of this study can be used to improve early clinical decision making for patients with spondylolysis.

Thoracolumbar junction translation injury in a patient with ankylosing spondylitis, a case report

INTRODUCTION

The thoracic spine is stable because of kyphotic alignment, rib cage, and costovertebral joints. Any compression or kyphosis in the thoracic spine always causes spinal cord injury.

CLINICAL CASE

A 47-year-old male with complaints of back pain 1 day prior to admission, after he sustained a motorbike crush and landed on his back. The pain, radiates to both limbs, associated with severe spasms, numbness, and weakness in his lower extremities, however no incontinence. No other associated injuries were reported. 25 years ago he had a history of tuberculosis of the spine with progressive deformity of the back, he was treated medically without surgery. On examinations: Gibbus at T11-L1, with hyper-pigmented post-inflammatory skin and an easily palpable spine, power 1/5 right and 2/5 left lower limbs, Sensation and bulbocarvenosus reflex were intact. Upper limbs were neurologically intact. All laboratory investigations including FBP, ESR, Electrolytes, renal and liver function tests were all within normal range. After radiological imaging, a final diagnosis of Spinal Cord Injury, ASIA C. AO classification type T12-L1:C/T9-L1:A4/N3/M2 was made. He was kept on a thoracolumbar corset 6 weeks after being initiated on spine protocol. He was discharged 8 weeks this time patient had no back pain but no improvement was noted neurologically. After a year of thoracolumbar corset and physiotherapy, he reported no more back pain, no numbness to lower limbs, and power 3/5 right and 4/5 left lower limbs, with intact sensation. However, no changes were observed radiologically.

CLINICAL DISCUSSION

Due to the instability of fracture-dislocation, surgical treatment is recommended to realign the spine but for this case with back deformity and fractured vertebra bodies, it is best not to temper with reduction and fixation as it would further worsen the neurological deficit of the patient, during maneuvers while doing the reduction.

CONCLUSION

Fracture-dislocation of the thoracic spine can impact the physical and mental well-being of the patients. Surgical fixation and instrumentation are ideal but in cases where surgical intervention would further impair the neurological function of the patient conservative management is the goal.

Intraoperative Cone-Beam Computed Tomography Navigation Versus 2-Dimensional Fluoroscopy in Single-Level Lumbar Spinal Fusion: A Comparative Analysis

OBJECTIVE

Several studies have advocated for the higher accuracy of transpedicular screw placement under cone-beam computed tomography (CBCT) compared to conventional 2-dimensional (2D) fluoroscopy. The superiority of navigation systems in perioperative and postoperative outcomes remains a topic of debate. This study aimed to compare operative time, screw placement time and accuracy, total radiation dose, perioperative and postoperative outcomes in patients who underwent transpedicular screw fixation for degenerative lumbar spondylolisthesis (DLS) using intraoperative CBCT navigation versus 2D fluoroscopy.

METHODS

A retrospective analysis was conducted on patients affected by single-level DLS who underwent posterior lumbar instrumentation with transpedicular screw fixation using surgical CBCT navigation (NV group) or 2D fluoroscopy-assisted freehand technique (FH group). Demographics, screw placement time and accuracy, operative time, total radiation dose, intraoperative blood loss, screw revision rate, complications, and length of stay (LOS) were assessed.

RESULTS

The study included a total of 30 patients (NV group: n = 15; FH group: n = 15). The mean screw placement time, operative time, and LOS were significantly reduced in the NV group compared to the FH group (p < 0.05). The total radiation dose was significantly higher in the NV group (p < 0.0001). No significant difference was found in terms of blood loss and postoperative complications.

CONCLUSION

This study suggests that intraoperative CBCT-navigated single-level lumbar transpedicular screw fixation is superior in terms of mean screw placement time, operative time, and LOS compared to 2D fluoroscopy, despite a higher intraoperative radiation exposure.

Forearm bone mineral density predicts screw loosening after lumbar fusion similar to lumbar Hounsfield unit value in patients with lumbar spondylolisthesis

Preoperative bone density assessment is necessary to predict screw loosening. The forearm BMD is a useful predictor of BMD-related complications after lumbar operation. Our results show that the forearm BMD is as effective a predictor of screw loosening as the lumbar average HU value. Measurement of the forearm BMD may be a useful adjunct in predicting screw loosening following lumbar fusion.

PURPOSE

To determine the relationship between forearm bone mineral density (BMD) and the risk of pedicle screw loosening in patients with lumbar spondylolisthesis.

METHODS

We retrospectively evaluated 270 patients who underwent posterior lumbar interbody fusion for lumbar spondylolisthesis. The patients were divided into two groups on the basis of the with or without loose screws: the loosening group and the non-loosening group. The patient's gender, age, BMI, smoking and diabetes histories, and the operative segment were recorded as the basic information. The Hounsfield unit (HU) value for the BMD of the L1-4 lumbar was measured using computed tomography. The patient's distal one-third of the length of the radius and ulna of the non-dominant forearm was chosen as the site for dual-energy X-ray (DXA) bone density testing.

RESULTS

The rate of screw loosening was 13% at a minimum 12 months follow-up. Average forearm BMD (0.461 ± 0.1 vs 0.577 ± 0.1, p < 0.001) and mean HU value (L1-4) (121.1 ± 27.3 vs 155.6 ± 32.2, p < 0.001) were lower in the screw loosening group than those in the non-loosening group. In multivariate logistic regression analysis, the forearm BMD (OR 0.840; 95%CI 0.797-0.886) and HU value (L1-4) (OR 0.952; 95%CI 0.935-0.969) were independent risk factor for screw loosening. The area under the curve (AUC) for the forearm BMD and HU value for prediction of pedicle screw loosening was 0.802 and 0.811. The forearm BMD cut-off for predicting pedicle screw loosening was 0.543 (sensitivity, 0.800; specificity, 0.864).

CONCLUSIONS

The forearm BMD was an independent risk factor for loosening of the lumbar pedicle screws. The forearm BMD was a valid predictor of pedicle screw loosening in patients undergoing lumbar fusion, as was the CT HU value.

Significance of Facet Fluid Index in Anterior Cervical Degenerative Spondylolisthesis

STUDY DESIGN

Retrospective cohort study.

PURPOSE

To correlate cervical facet fluid characteristics to radiographic spondylolisthesis, determine if facet fluid is associated with instability in cervical degenerative spondylolisthesis, and examine whether vertebral levels with certain facet fluid characteristics and spondylolisthesis are more likely to be operated on.

OVERVIEW OF LITERATURE

The relationship between facet fluid and lumbar spondylolisthesis is well-documented; however, there is a paucity of literature investigating facet fluid in degenerative cervical spondylolisthesis.

METHODS

Patients diagnosed with cervical degenerative spondylolisthesis were identified from a hospital's medical records. Demographic and surgical characteristics were collected through a structured query language search and manual chart review. Radiographic measurements were made on preoperative MRIs for all vertebral levels diagnosed with spondylolisthesis and adjacent undiagnosed levels between C3 and C6. The facet fluid index was calculated by dividing the facet fluid measurement by the width of the facet. Bivariate analysis was conducted to compare facet characteristics based on radiographic spondylolisthesis and spondylolisthesis stability.

RESULTS

We included 154 patients, for whom 149 levels were classified as having spondylolisthesis and 206 levels did not. The average facet fluid index was significantly higher in patients with spondylolisthesis (0.26±0.07 vs. 0.23±0.08, p <0.001). In addition, both fluid width and facet width were significantly larger in patients with spondylolisthesis (p <0.001 each). Cervical levels in the fusion construct demonstrated a greater facet fluid index and were more likely to have unstable spondylolisthesis than stable spondylolisthesis (p <0.001 each).

CONCLUSIONS

Facet fluid index is associated with cervical spondylolisthesis and an increased facet size and fluid width are associated with unstable spondylolisthesis. While cervical spondylolisthesis continues to be an inconclusive finding, vertebral levels with spondylolisthesis, especially the unstable ones, were more likely to be included in the fusion procedure than those without spondylolisthesis.

Factors influencing slippage after microsurgical single level lumbar spinal decompression surgery - Are the psoas and multifidus muscles involved?

PURPOSE

Patients with lumbar spinal stenosis (LSS) require microsurgical decompression (MSD) surgery; however, MSD is often associated with postoperative instability at the operated level. Paraspinal muscles support the spinal column; lately, paraspinal volume has been used as a good indicator of sarcopenia. This study aimed to determine preoperative radiological factors, including paraspinal muscle volume, associated with postoperative slippage progression after MSD in LSS patients.

METHODS

Patients undergoing single-level (L3/4 or L4/5) MSD for symptomatic LSS and followed-up for ≥ 5 years in our institute were reviewed retrospectively to measure preoperative imaging parameters focused on the operated level. Paraspinal muscle volumes (psoas muscle index [PMI] and multifidus muscle index [MFMI]) defined using the total cross-sectional area of each muscle/L3 vertebral body area in the preoperative lumbar axial CT) were calculated. Postoperative slippage in the form of static translation (ST) ≥ 2 mm was assessed on the last follow-up X-ray.

RESULTS

We included 95 patients with average age and follow-up periods of 69 ± 8.2 years and 7.51 ± 2.58 years, respectively. PMI and MFMI were significantly correlated with age and significantly larger in male patients. Female sex, preoperative ST, dynamic translation, sagittal rotation angle, facet angle, pelvic incidence, lumbar lordosis, and PMI were correlated with long-term postoperative worsening of ST. However, as per multivariate analysis, no independent factor was associated with postoperative slippage progression.

CONCLUSION

Lower preoperative psoas muscle volume in LSS patients is an important predictive factor of postoperative slippage progression at the operated level after MSD. The predictors for postoperative slippage progression are multifactorial; however, a well-structured postoperative exercise regimen involving psoas muscle strengthening may be beneficial in LSS patients after MSD.

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.

Utility of intraoperative neurophysiological monitoring in detecting motor and sensory nerve injuries in pediatric high-grade spondylolisthesis

BACKGROUND CONTEXT

Intraoperative neuromonitoring (IONM) during surgical correction of spinal deformity has been shown to reduce iatrogenic injury in pediatric and adult populations. Although motor-evoked potentials (MEP), somatosensory-evoked potentials (SSEP), and electromyography (EMG) have been shown to be highly sensitive and specific in detecting spinal cord and nerve root injuries, their utility in detecting motor and sensory nerve root injury in pediatric high-grade spondylolisthesis (HGS) remains unknown.

PURPOSE

We aim to assess the diagnostic accuracy and therapeutic impact of unimodal and multimodal IONM in the surgical management of HGS.

STUDY DESIGN/SETTING

Retrospective cohort study.

PATIENT SAMPLE

Pediatric patients undergoing posterior spinal fusion (PSF) for treatment of HGS.

OUTCOME MEASURES

Data on patient demographics, spinopelvic and spondylolisthesis parameters, and the presence of pre-and postoperative neurological deficits were collected.

METHODS

Intraoperative MEP, SSEP, and EMG alerts were recorded. Alert criteria were defined as a change in amplitude of more than 50% for MEP and/or SSEP, with or without change in latency, and more than 10 seconds of sustained EMG activity. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were calculated for each modality and the combination of MEP and SSEP. The 95% confidence intervals (CIs) were calculated using the exact (Clopper-Pearson) method.

RESULTS

Fifty-four pediatric patients with HGS undergoing PSF between 2003 and 2021 in a single tertiary center were included. Seventy-two percent (39/54) of patients were female; the average age of patients was 13.7±2.3 years. The sensitivity of MEP in detecting new postoperative neurologic deficit was 92.3% (95% CI [64.0-99.8]), SSEP 77.8% (95% CI [40.0-97.2]), EMG 69.2% (95% CI [38.6-90.9]), and combination MEP and SSEP 100% (95% CI [73.5-100]). The specificity of MEP was 80.0% (95% CI [64.4-91.0]), SSEP 95.1% (95% CI [83.5-99.4]), EMG 65.9% (95% CI [49.4-79.9]), and combination MEP and SSEP 82.9% (95% CI [67.9-92.9]). The accuracy of SSEP was 92.0% (95% CI [80.8%-97.8%]), and the combination of MEP and SSEP was 86.8% (95% CI [74.7%-94.5%]). Twelve (22.2%) patients had a new motor or sensory deficit diagnosed immediately postoperatively. Nine patients made a full recovery, and 3 had some neurologic deficit on final follow-up.

CONCLUSION

Unimodal IONM using SSEP and MEP alone were accurate in diagnosing sensory and motor nerve root injuries, respectively. The diagnostic accuracy in predicting motor and sensory nerve injuries in pediatric HGS improved further with the use of multimodal IONM (combining MEP and SEP). We recommend the utilization of multimodal IONM in all HGS PSF surgeries.

Prone Transpsoas Lateral Interbody Fusion (PTP LIF) with Anterior Docking: Preliminary functional and radiographic outcomes

Background

Disadvantages of lateral interbody fusion (LIF) through a direct, transpsoas approach include difficulties associated with lateral decubitus positioning and limited sagittal correction without anterior longitudinal ligament release or posterior osteotomy. Prior technical descriptions advocate anchoring or docking the retractor into the posterior to middle aspect of the disc space.

Methods

72 patients who underwent 116 total levels of Prone Transpsoas (PTP) LIF with anterior docking with a single surgeon between December 2021 and May 2023 were included. Patient characteristics, perioperative data, as well as postoperative functional and radiographic outcomes were recorded. Subgroup analysis was performed for patients who underwent single-level PTP LIF with single-level percutaneous fixation (SLP). Patients in the SLP subgroup did not undergo direct decompression, release, or osteotomy.

Results

N=41 (56.9%) of cases included the L4-5 level. No vascular, bowel, or other visceral complications occurred. No patients developed a permanent motor deficit. Both the total cohort and the SLP group demonstrated statistically significant improvements in functional outcomes including Oswestry Disability Index (ODI) and Visual Analog Scale (VAS) as well as all radiographic parameters measured. Mean total operative time (incision to completion of closure for lateral and posterior fusion) in the SLP group was 104.3 minutes with a significant downward trend with increasing surgeon experience. The SLP group demonstrated a 9.9° increase in segmental lordosis (SL), a 7.5° increase in lumbar lordosis (LL), 5.3° reduction in pelvic tilt (PT), and a decrease in pelvic incidence - lumbar lordosis mismatch (PI-LL) from 11.0° preoperatively to 3.9°, postoperatively (p<.01).

Conclusions

PTP LIF with anterior docking may address shortcomings associated with traditional lateral interbody fusion by producing safe and reproducible access with improved restoration of segmental lordosis and optimization of spinopelvic parameters.

Reduction of adolescent grade IV L5-S1 spondylolisthesis with anterior joystick manipulation during a combined anterior and posterior surgical approach: A case report

Background

High-grade isthmic spondylolisthesis poses a clinical challenge in the pediatric and adolescent population. Current surgical management using posterior-based approaches may lead to incomplete reduction and restoration of listhesis, disc height, and lordosis. Combined anterior and posterior approach addresses these issues but has been infrequently reported, mainly in the treatment of low-grade isthmic spondylolisthesis. Neither offers good disc space visualization and control of spinal alignment during reduction.

Case Description

A healthy 17-year-old female presented with 9 months of progressively worsening lower back pain radiating down the left lower extremity and 3 inches of height loss. Diagnosis of grade IV L5-S1 spondylolisthesis was made using plain radiographs, CT, and MRI. Management with combined anterior and posterior fusion, involving the manual manipulation of segments using an anterior pedicle screw joystick, was pursued.

Outcome

Satisfactory alignment, solid arthrodesis, no complications, and improved patient reported outcomes.

Conclusions

Combined anterior and posterior fusion with anterior joystick manipulation allowed for full reduction of grade IV spondylolisthesis and restoration of disc/foraminal height and L5-S1 segmental lordosis without neurological complication. Although less commonly performed in children and adolescents, this surgical approach can assist in restoring optimal alignment in isthmic spondylolisthesis.

MRI-based measurements of spondylolisthesis and kyphosis in degenerative cervical myelopathy

BACKGROUND

To provide normative data and to determine accuracy and reliability of preoperative measurements of spondylolisthesis and kyphosis on supine static magnetic resonance imaging (MRI) of patients with degenerative cervical myelopathy.

METHODS

T2-weighted midsagittal images of the cervical spine were in 100 cases reviewed twice by one junior observer, with an interval of 3 months, and once by a senior observer. The spondylolisthesis slip (SSlip, mm) and the modified K-line interval (mK-line INT, mm) were assessed for accuracy with the standard error of measurement (SEm) and the minimum detectable change (MDC). Intraobserver and interobserver reliability levels were determined using the intraclass correlation coefficient (ICC).

RESULTS

The SEm was 0.5 mm (95% CI 0.4-0.6) for spondylolisthesis and 0.6 mm (95% CI 0.5-0.7) for kyphosis. The MDC, i.e., the smallest difference between two examinations that can be detected with statistical certainty, was 1.5 mm (95% CI 1.2-1.8) for spondylolisthesis and 1.6 mm (95% CI 1.3-1.8) for kyphosis. The highest reliability levels were seen between the second observation of the junior examiner and the senior observer (ICC = 0.80 [95% CI 0.70-0.87] and ICC = 0.96 [95% CI 0.94-0.98] for SSlip and mK-line INT, respectively).

CONCLUSIONS

This study provides normative values of alignment measurements of spondylolisthesis and kyphosis in DCM patients. It further shows the importance of taking measurement errors into account when defining cut-off values for cervical deformity parameters and their potential clinical application in surgical decision-making.

Surgery in degenerative spondylolisthesis: does fusion improve outcome in subgroups? A secondary analysis from a randomized trial (NORDSTEN trial)

BACKGROUND CONTEXT

Patients with spinal stenosis and degenerative spondylolisthesis are treated surgically with decompression alone or decompression with fusion. However, there is debate regarding which subgroups of patients may benefit from additional fusion.

PURPOSE

To investigate possible treatment effect modifiers and prognostic variables among patients operated for spinal stenosis and degenerative spondylolisthesis.

DESIGN

A secondary exploratory study using data from the Norwegian Degenerative Spondylolisthesis and Spinal Stenosis (NORDSTEN-DS) trial. Patients were randomized to decompression alone or decompression with instrumented fusion.

PATIENT SAMPLE

The sample in this study consists of 267 patients from a randomized multicenter trial involving 16 hospitals in Norway. Patients were enrolled from February 12, 2014, to December 18, 2017. The study did not include patients with degenerative scoliosis, severe foraminal stenosis, multilevel spondylolisthesis, or previous surgery.

OUTCOME MEASURES

The primary outcome was an improvement of ≥ 30% on the Oswestry Disability Index score (ODI) from baseline to 2-year follow-up.

METHODS

When investigating possible variables that could modify the treatment effect, we analyzed the treatment arms separately. When testing for prognostic factors we analyzed the whole cohort (both treatment groups). We used univariate and multiple regression analyses. The selection of variables was done a priori, according to the published trial protocol.

RESULTS

Of the 267 patients included in the trial (183 female [67%]; mean [SD] age, 66 [7.6] years), complete baseline data for the variables required for the present analysis were available for 205 of the 267 individuals. We did not find any clinical or radiological variables at baseline that modified the treatment effect. Thus, none of the commonly used criteria for selecting patients for fusion surgery influenced the chosen primary outcome in the two treatment arms. For the whole cohort, less comorbidity (American Society of Anesthesiologists Classification [ASA], OR = 4.35; 95% confidence interval (CI [1.16-16.67]) and more preoperative leg pain (OR = 1.23; CI [1.02-1.50]) were significantly associated with an improved primary outcome.

CONCLUSIONS

In this study on patients with degenerative spondylolisthesis, neither previously defined instability criteria nor other pre-specified baseline variables were associated with better clinical outcome if fusion surgery was performed. None of the analyzed variables can be applied to guide the decision for fusion surgery in patients with degenerative spondylolisthesis. For both treatment groups, less comorbidity and more leg pain were associated with improved outcome 2 years after surgery.

TRIAL REGISTRATION

NORDSTEN-DS ClinicalTrials.gov, NCT02051374.

Adolescent idiopathic scoliosis with concomitant spondylolysis: choice of fusion levels and evaluation of the outcomes obtained leaving the lytic level not instrumented

PURPOSE

7% of adolescent idiopathic scoliosis (AIS) patients also present with a pars defect. To date, there are no available data on the results of fusion ending proximal to a spondylolysis in the setting of AIS. The aim of this study was to analyze the outcomes of posterior spinal fusion (PSF) in this patient cohort, to investigate if maintaining the lytic segment unfused represents a safe option.

METHODS

Retrospective review of all patients who received PSF for AIS, presented with a spondylolysis or spondylolisthesis and had a min. 2-year follow-up. Demographic data, instrumented levels, and preoperative radiographic data were collected. Mechanical complications, coronal or sagittal parameters, amount of slippage, and pain levels were evaluated.

RESULTS

Data from 22 patients were available (age 14.4 ± 2.5 years), 18 Lenke 1-2 and 4 Lenke 3-6. 5 patients (24%) had an isthmic spondylolisthesis, all Meyerding I. The mean preoperative Cobb angle of the instrumented curves was 58 ± 13°. For 18 patients, the lowest instrumented vertebra (LIV) was the last touched vertebra (LTV); for 2, LIV was distal to the LTV; for 2, LIV was one level proximal to the LTV. The number of segments between the LIV and the lytic vertebra ranged from 1 to 6. At the last follow-up, no complications were observed. The residual curve below the instrumentation measured 8.5 ± 6.4°, the lordosis below the instrumented levels was 51.4 ± 13°. The magnitude of the isthmic spondylolisthesis remained constant for all included patients. Three patients reported minimal occasional low back pain.

CONCLUSION

The LTV can be safely used as LIV when performing PSF for the management of AIS in patients with L5 spondylolysis.

Clinical, Radiographic and Fusion Comparison of Oblique Lumbar Interbody Fusion (OLIF) stand-alone and OLIF with posterior pedicle screw fixation in patients with degenerative spondylolisthesis

PURPOSE

To compare the outcomes and characteristics of oblique lumbar interbody fusion stand-alone (OLIF-SA) and OLIF with posterior pedicle screw fixation (OLIF-PPS) in the treatment of Grade I or Grade II degenerative lumbar spondylolisthesis.

PATIENTS AND METHODS

Between January 2019 and May 2022, 139 patients with degenerative spondylolisthesis were treated with OLIF-SA (n = 85) or OLIF-PPS (n = 54). The clinical and radiographic records were reviewed.

RESULTS

The clinical and radiographic outcomes were similar in both groups. The operative time and intraoperative blood loss in the OLIF-SA group were lower than those in the OLIF-PPS group (P < 0.05). However, the OLIF-PPS group had significantly better disc height (DH) and postoperative forward spondylolisthesis distance (FSD) improvement at 6 months (P < 0.05). The OLIF-PPS group had a significantly lower cage subsidence value than the OLIF-SA group (P < 0.05). Improvement of the lumbar lordotic angle (LA) and fusion segmental lordotic angle (FSA) in the OLIF-PPS group was significantly better than that in the OLIF-SA group (P < 0.05). In terms of fusion types, the OLIF-SA group tended to undergo fusion from the edge of the vertebral body. Fusion in the OLIF-PPS group began more often in the bone graft area of the central cage of the vertebral body. The fusion speed of the OLIF-SA group was faster than that of the OLIF-PPS group.

CONCLUSION

OLIF-SA has the advantages of a short operative time, less intraoperative blood loss, and reduced financial burden, while PPS has incomparable advantages in the reduction of spondylolisthesis, restoration of lumbar physiological curvature, and long-term maintenance of intervertebral DH. In addition, the SA group had a unique vertebral edge fusion method and faster fusion speed.

Rehabilitation after lumbar spine surgery in adults: a systematic review with meta-analysis

BACKGROUND

The role of rehabilitation after surgery in patients with low back pain is well recognized. The aim of this systematic review is to summarize and update the existing evidence according to the type of clinical condition and rehabilitation approach.

METHODS

This systematic review included RCTs on the effectiveness of rehabilitation after surgery for lumbar disc herniation, spinal stenosis, and spondylolisthesis. We searched the literature for randomized controlled trials indexed in MEDLINE, Embase, CINHAL, CENTRAL, Scopus, PEDro, and Web of Science databases, up to April 15, 2023. We used Cochrane Risk of Bias 2.0 tool to assess each study. We conducted a quantitative synthesis when population, intervention, control, and outcome were sufficiently homogeneous; otherwise, we conducted a qualitative analysis.

RESULTS

Forty-five studies (3.036 subjects) were included and analyzed according to the population considered: lumbar stenosis (1 trial), spondylolisthesis (3 trials), and disc herniation (41 trials). Regarding lumbar stenosis, a supervised active exercise program appears to improve outcomes related to pain, disability, and quality of life both in the short- and mid-term (1 study, n = 60). Concerning spondylolisthesis, kinesiophobia is reduced in the home exercises group compared to usual care, at 3-months follow-up (3 studies, n = 98). For disk herniation, supervised exercises are better than non-supervised exercises to reduce pain (MD -1.14; 95% CIs -1.65, -0.62; 5 trials, n = 250) and disability (SMD -0.70; 95% CIs -1.14, -0.26; 4 trials, n = 175). Supervised exercises are better than advice in reducing pain (SMD -0.91; 95% CIs -1.61, -0.21; 5 trials, n = 341) and disability (SMD -0.80; 95% CIs -1.59, -0.01; 4 trials, n = 261), in the short-term. Supervised exercises are equal to no treatment in reducing pain and disability, at 3 and 6 months after intervention (2 trials, n = 166). These results are supported by a very low to low quality of evidence.

CONCLUSIONS

Our research suggests that supervised exercise may be effective in improving patient's pain and disability after lumbar surgery, but RCTs regarding lumbar spinal stenosis and lumbar spondylolisthesis are still scarce, with significant heterogeneity of proposed interventions.

Anterolateral versus posterior minimally invasive lumbar interbody fusion surgery for spondylolisthesis: comparison of outcomes from a global, multicenter study at 12-months follow-up

BACKGROUND CONTEXT

Several minimally invasive lumbar interbody fusion techniques may be used as a treatment for spondylolisthesis to alleviate back and leg pain, improve function and provide stability to the spine. Surgeons may choose an anterolateral or posterior approach for the surgery however, there remains a lack of real-world evidence from comparative, prospective studies on effectiveness and safety with relatively large, geographically diverse samples and involving multiple surgical approaches.

PURPOSE

To test the hypothesis that anterolateral and posterior minimally invasive approaches are equally effective in treating patients with spondylolisthesis affecting one or two segments at 3-months follow-up and to report and compare patient reported outcomes and safety profiles between patients at 12-months post-surgery.

DESIGN

Prospective, multicenter, international, observational cohort study.

PATIENT SAMPLE

Patients with degenerative or isthmic spondylolisthesis who underwent 1- or 2-level minimally invasive lumbar interbody fusion.

OUTCOME MEASURES

Patient reported outcomes assessing disability (ODI), back pain (VAS), leg pain (VAS) and quality of life (EuroQol 5D-3L) at 4-weeks, 3-months and 12-months follow-up; adverse events up to 12-months; and fusion status at 12-months post-surgery using X-ray and/or CT-scan. The primary study outcome is improvement in ODI score at 3-months.

METHODS

Eligible patients from 26 sites across Europe, Latin America and Asia were consecutively enrolled. Surgeons with experience in minimally invasive lumbar interbody fusion procedures used, according to clinical judgement, either an anterolateral (ie, ALIF, DLIF, OLIF) or posterior (MIDLF, PLIF, TLIF) approach. Mean improvement in disability (ODI) was compared between groups using ANCOVA with baseline ODI score used as a covariate. Paired t-tests were used to examine change from baseline in PRO for both surgical approaches at each timepoint after surgery. A secondary ANCOVA using a propensity score as a covariate was used to test the robustness of conclusions drawn from the between group comparison.

RESULTS

Participants receiving an anterolateral approach (n=114) compared to those receiving a posterior approach (n=112) were younger (56.9 vs 62.0 years, p <.001), more likely to be employed (49.1% vs 25.0%, p<.001), have isthmic spondylolisthesis (38.6% vs 16.1%, p<.001) and less likely to only have central or lateral recess stenosis (44.9% vs 68.4%, p=.004). There were no statistically significant differences between the groups for gender, BMI, tobacco use, duration of conservative care, grade of spondylolisthesis, or the presence of stenosis. At 3-months follow-up there was no difference in the amount of improvement in ODI between the anterolateral and posterior groups (23.2 ± 21.3 vs 25.8 ± 19.5, p=.521). There were no clinically meaningful differences between the groups on mean improvement for back- and leg-pain, disability, or quality of life until the 12-months follow-up. Fusion rates of those assessed (n=158; 70% of the sample), were equivalent between groups (anterolateral, 72/88 [81.8%] fused vs posterior, 61/70 [87.1%] fused; p=.390).

CONCLUSIONS

Patients with degenerative lumbar disease and spondylolisthesis who underwent minimally invasive lumbar interbody fusion presented statistically significant and clinically meaningful improvements from baseline up to 12-months follow-up. There were no clinically relevant differences between patients operated on using an anterolateral or posterior approach.

Surgical management of isthmic spondylolisthesis: A comparative study of postoperative outcomes between ALIF and TLIF

INTRODUCTION

Circumferential fusion by the anterior (ALIF) or transforaminal (TLIF) approach combined with posterior instrumentation is currently used for the surgical treatment of low-grade isthmic spondylolisthesis. But few studies have compared the clinical and radiological outcomes of various interbody fusion techniques. The objective of this study was to compare the clinical and radiological results at 2 years postoperative of two fusion techniques-TLIF versus ALIF plus posterior instrumentation-for low-grade isthmic spondylolisthesis in adults.

MATERIALS AND METHODS

This was an observational multicenter study done at nine French healthcare facilities specialized in spine surgery. The inclusion criteria were minimum age of 18 years, grade 1-3 isthmic spondylolisthesis, ALIF+posterior fixation (ALIF+PS) or TLIF, minimum follow-up of 2 years. Clinical and radiological evaluations were done preoperatively and at 2 years of follow-up. A lumbar CT scan was done at 1 year postoperative to evaluate fusion.

RESULTS

The cohort consisted of 89 patients (50 women, 39 men) with a mean age of 47.7±12.3 (18-79) years. The patients in the ALIF groups (n=71) had a significantly longer hospital stay than those in the TLIF group (n=18): 5.7 days versus 4.6 days (p=.04). However, their medical leave from work was significantly shorter: 31.0 weeks versus 40.7 (p=.003). Lumbar pain VAS diminished faster in the ALIF groups, with a significantly larger drop than the TLIF group in the first 3 months postoperative. Only the increase in lumbar disc lordosis was larger in the ALIF group: 11.7°±12.0° versus 6.0°±11.7° (p=.036). There was a significant correlation between the increase in global lordosis and reduction in lumbar VAS at 2 years postoperative (ρ=-0.3295; p=.021).

CONCLUSION

ALIF+PS provides a faster relief of postoperative low back pain than TLIF but there are no significant clinical differences between techniques at 2 years of follow-up. Despite better restoration of disc lordosis in the ALIF+PS group, there was no difference in the restoration of global lordosis.

LEVEL OF EVIDENCE

III; multicenter comparative study.

Traumatic irreducible non-Hangman's type bilateral C2-C3 high-grade facet dislocation: technical nuance

Majority of C2-C3 vertebral dislocations occur as in combination with bilateral pars fractures, also known as Hangman's fractures. Isolated C2-C3 facet dislocation without any associated C2 fracture is a very rare injury. One such case has been presented in this report. A 29-year male was involved in a road traffic accident (RTA) after which he developed midline neck pain. Following a minor neck manipulation at a hair salon 15 days after the RTA, his neck pain worsened and he developed quadriparesis. Imaging at the time of admission showed bilateral high-grade C2-C3 facet dislocations without any associated fracture of C2 vertebra. Due to non-reduction of the dislocation with skeletal traction, surgery was contemplated. Intraoperatively, the C2-C3 joint spaces were opened but only partial reduction could be achieved. Complete reduction was achieved only after opening of the C1-C2 joints was performed. Later, C2-C4 screw-rod constructs were placed. Patient achieved good outcome with resolution of symptoms. This report concludes that, in cases of delayed presentation of irreducible C2-C3 bilateral facet dislocations and non-reducibility by skeletal traction, opening of the C1-2 joints may need to be performed in addition to the C2-C3 joint spaces, in order to achieve complete reduction.

Surgical treatment of degenerative lumbar spondylolisthesis: Effect of TLIF and slip reduction on sagittal alignment

INTRODUCTION

The surgical treatment of lumbar degenerative spondylolisthesis (LDS) remains controversial. The aim of this study was to determine the effect of adding transforaminal lumbar interbody fusion (TLIF) to posterolateral fusion (PLF) on the local lordosis, sagittal alignment and potential complications. The second aim was to evaluate the effect of slip reduction on the same parameters.

HYPOTHESIS

The initial hypothesis was that TLIF provides better correction of the local lordosis and that reducing the slip improves the global sagittal balance.

METHODS

In this retrospective, single-center study, patients who had been operated on for LSD at one or two levels by laminectomy and PLF, with or without a TLIF cage, were included. Data collected consisted of age, sex, number of levels fused and whether or not a TLIF cage was used. Fusion was defined as the absence of indirect nonunion signs on radiographs at 2 years postoperative. The occurrence and time frame of any complications and the need for reoperation were documented. Lateral radiographs of the entire spine were analyzed preoperatively, in the early postoperative period (3 to 6 months) and at a minimum follow-up of 2 years. The following parameters were measured: pelvic parameters, C7 sagittal tilt (C7ST), spinosacral angle (SSA), maximum lumbar lordosis (LL), lordosis at slipped level (LS), slip percentage. The analysis compared patients treated by PLF and TLIF and determined the impact of slip reduction.

RESULTS

One hundred and three patients were included in the study (71% women). The mean follow-up was 38 months. The mean age was 69 years. Seventy-seven patients (75%) underwent PLF. Comparing the preoperative and early postoperative data identified 5.4% better spondylolisthesis reduction in the TLIF group than the PLF group (-8.9±9.5% vs -3.5±7.6%; p=0.04) that was not maintained at the final follow-up. The fusion rate was comparable between groups: 94% in APL and 89% in TLIF (p=0.7). The overall complication rate was 46% in the TLIF group versus 33% in the PLF group (p=0.35). A comparison based on whether or not the slip was reduced found significant improvement in the reduction group of the SSA by more than 6° (6.8°±6° vs 0.5°±7.4°; p=0.04). The fusion rate was 91% in the reduced group and 95% in the non-reduced group (p=0.81); the complication rate was 44% versus 28% in the non-reduced group (p=0.10).

CONCLUSION

This study shows that slip reduction helps to improve the sagittal alignment by increasing the SSA when treating LDS. Posterolateral fusion and TLIF produce comparable radiographic outcomes at 2 years postoperative in the segmental lordosis, slip reduction, global sagittal alignment and fusion rate.

LEVEL OF EVIDENCE

IV.

A New Technique for Lumbar Spondylolisthesis Reduction Using T-Shaped Tools

STUDY DESIGN

Retrospective study.

PURPOSE

To introduce a simple technique to facilitate lumbar spondylolisthesis reduction during posterior lumbar interbody fusion (PLIF).

OVERVIEW OF LITERATURE

Spondylolisthesis reduction has been conducted in various ways, but most of them require special complicated tools.

METHODS

T-shaped levering tool was newly designed. This study included 23 patients who underwent PLIF for lumbar spondylolisthesis treatment using newly designed T-shaped tools and followed up for >2 years. Demographic, clinical, and surgical data, which had been routinely collected in a database, were analyzed. The degree of listhesis was measured on lateral radiographs by the Taillard method.

RESULTS

The authors could achieve lumbar spondylolisthesis reduction without difficulty using newly designed T-shaped tools. Immediate postoperative lateral radiographs revealed a reduced preoperative slip of 36.9%±9.6% to 1.2%±1.9%, showing a correction rate of 96.7%. The final follow-up radiographs revealed the mean final slip of 2.6%±2.7%, showing a correction rate of 93.0%.

CONCLUSIONS

This technique allowed lumbar spondylolisthesis reduction without difficulty.

Sagittal alignment in operative degenerative lumbar spondylolisthesis: a scoping review

Background

The benefit of surgical intervention over conservative treatment for degenerative lumbar spondylolisthesis (DLS) patients with neurologic symptoms is well-established. However, it is currently unclear what breadth of available evidence exists on regional and global sagittal alignment in DLS surgery. As such, the purpose of the current study is to conduct a scoping review to map and synthesize the DLS literature regarding the current radiographic assessment of sagittal spinal alignment in DLS surgery.

Methods

A comprehensive search of the MEDLINE, EMBASE and Cochrane databases from January 1971 to January 2023 was performed for all DLS studies examining sagittal spinal alignment parameters with DLS surgery according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Review (PRISMA-ScR) protocol.

Results

From 2,222 studies, a total of 109 studies were included, representing 10,730 patients with an average age of 63.0 years old and average follow-up of 35.1 months postoperatively. Among included studies, 93 (85%), were largely published in the last decade and predominantly represented retrospective cohorts 70 (64%) or case series 22 (20%). A common theme among the reporting of radiographic parameters in the included investigations was the assessment of the magnitude and/or maintenance of a radiographic change postoperatively, with 92 (84%) studies reporting these findings. The majority of studies focused on index DLS level [33 (30%) studies] or lumbar spine radiographic imaging [33 (30%) studies] only. Thirty-seven (34%) studies reported spinopelvic parameters, with only 13 (12%) of included studies assessing 36-inch standing lateral radiographs and overall alignment.

Conclusions

There is increasing prevalence of investigations assessing sagittal spinal alignment parameters in DLS surgery. Although, there is an increasing prevalence of studies investigating sagittal spinal alignment parameters in DLS surgery the quality of the currently available literature on this topic is of overall low evidence and largely retrospective in nature. Additionally, there is limited analysis of global sagittal spinal alignment in DLS suggesting that future investigational emphasis should prioritize longitudinally followed large prospective cohorts or multi-centre randomized controlled trials. Attempts at standardizing the radiographic and functional outcome reporting techniques across multi-centre investigations and prospective cohorts will allow for more robust, reproducible analyses of significance to be conducted on DLS patients.

Saving Stabilizing Structure Treatment With Bilateral-Contralateral Decompression for Spinal Stenosis in Degenerative Spondylolisthesis Using Unilateral Biportal Endoscopy

OBJECTIVE

This study aimed to evaluate the treatment of spinal stenosis with spondylolisthesis using bilateral-contralateral unilateral biportal endoscopic (UBE) decompression to minimize facet joint damage.

METHODS

We retrospectively evaluated 42 patients with grade 1 spondylolisthesis who underwent bilateral-contralateral UBE decompression between July 2018 and September 2019. To identify segmental instability, static and dynamic images from preoperative and postoperative procedures and final follow-up radiographs were reviewed. Lateral radiograph slippage ratio, sagittal motion, and facet joint preservation were evaluated. Clinical assessments were conducted using the visual analogue scale (VAS), Oswestry Disability Index (ODI), and modified MacNab criteria.

RESULTS

The average final follow-up period was 26.5 ± 1.3 months. The average preoperative slip percentage was 15.70% ± 5.25%, which worsened to 18.80% ± 5.41% at the final follow-up (p < 0.005). The facet joint preservation rate was 95.6% ± 4.1% on the contralateral side. Improvements in the VAS scores (leg pain: from 7.9 ± 2.2 to 3.1 ± 0.7; p < 0.005; back pain: from 7.2 ± 3.0 to 2.8 ± 1.0; p < 0.005) were observed at the final follow-up. The mean preoperative ODI was 26.19 ± 3.42, which improved to 9.6 ± 1.0 (p < 0.005). Thirteen patients exhibited delayed focal segmental instability following decompression. Despite the absence of symptoms or improvement with conservative treatment in the majority of patients with delayed instability, two patients required fusion surgery to address the instability. Additionally, 2 patients developed facet synovial cysts, while 2 experienced spinous process fractures.

CONCLUSION

Bilateral decompression with a contralateral UBE approach could be an effective and alternative treatment method to reduce instability in spinal stenosis with grade 1 spondylolisthesis.

Simultaneous Single-Position Lateral Lumbar Interbody Fusion Surgery and Unilateral Percutaneous Pedicle Screw Fixation for Spondylolisthesis

OBJECTIVE

To evaluate the clinical and radiological efficacy of a combine of lateral single screw-rod and unilateral percutaneous pedicle screw fixation (LSUP) for lateral lumbar interbody fusion (LLIF) in the treatment of spondylolisthesis.

METHODS

Sixty-two consecutive patients with lumbar spondylolisthesis who underwent minimally invasive (MIS)-TLIF with bilateral pedicle screw (BPS) or LLIF-LSUP were retrospectively studied. Segmental lordosis angle (SLA), lumbar lordosis angle (LLA), disc height (DH), slipping percentage, the cross-sectional areas (CSA) of the thecal sac, screw placement accuracy, fusion rate and foraminal height (FH) were used to evaluate radiographic changes postoperatively. Visual analogue scale (VAS) and Oswestry Disability Index (ODI) were used to evaluate the clinical efficacy.

RESULTS

Patients who underwent LLIF-LSUP showed shorter operating time, less length of hospital stay and lower blood loss than MIS-TLIF. No statistical difference was found between the 2 groups in screw placement accuracy, overall complications, VAS, and ODI. Compared with MIS-TLIF-BPS, LLIF-LSUP had a significant improvement in sagittal parameters including DH, FH, LLA, and SLA. The CSA of MIS-TLIF-BPS was significantly increased than that of LLIF-LSUP. The fusion rate of LLIF-LSUP was significantly higher than that of MIS-TLIF-BPS at the follow-up of 3 months postoperatively, but there was no statistical difference between the 2 groups at the follow-up of 6 months, 9 months, and 12 months.

CONCLUSION

The overall clinical outcomes and complications of LLIF-LSUP were comparable to that of MIS-TLIF-BPS in this series. Compared with MIS-TLIF-BPS, LLIF-LSUP for lumbar spondylolisthesis represents a significantly shorter operating time, hospital stay and lower blood loss, and demonstrates better radiological outcomes to maintain lumbar lordosis, and reveal an overwhelming superiority in the early fusion rate.

High-grade dysplastic spondylolisthesis: surgical technique and case series

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Utility of Seated Lateral Radiographs in the Diagnosis and Classification of Lumbar Degenerative Spondylolisthesis

STUDY DESIGN

Retrospective cohort study.

PURPOSE

Our goal was to determine which radiographic images are most essential for degenerative spondylolisthesis (DS) classification and instability detection.

OVERVIEW OF LITERATURE

The heterogeneity in DS requires multiple imaging views to evaluate vertebral translation, disc space, slip angle, and instability. However, there are several restrictions on frequently used imaging perspectives such as flexion-extension and upright radiography.

METHODS

We assessed baseline neutral upright, standing flexion, seated lateral radiographs, and magnetic resonance imaging (MRI) for patients identified with spondylolisthesis from January 2021 to May 2022 by a single spine surgeon. DS was classified by Meyerding and Clinical and Radiographic Degenerative Spondylolisthesis classifications. A difference of >10° or >8% between views, respectively, was used to characterize angular and translational instability. Analysis of variance and paired chi-square tests were utilized to compare modalities.

RESULTS

A total of 136 patients were included. Seated lateral and standing flexion radiographs showed the greatest slip percentage (16.0% and 16.7%), while MRI revealed the lowest (12.2%, p <0.001). Standing flexion and lateral radiographs when seated produced more kyphosis (4.66° and 4.97°, respectively) than neutral upright and MRI (7.19° and 7.20°, p <0.001). Seated lateral performed similarly to standing flexion in detecting all measurement parameters and categorizing DS (all p >0.05). Translational instability was shown to be more prevalent when associated with seated lateral or standing flexion than when combined with neutral upright (31.5% vs. 20.2%, p =0.041; and 28.1% vs. 14.6%, p =0.014, respectively). There were no differences between seated lateral or standing flexion in the detection of instability (all p >0.20).

CONCLUSIONS

Seated lateral radiographs are appropriate alternatives for standing flexion radiographs. Films taken when standing up straight do not offer any more information for DS detection. Rather than standing flexion-extension radiographs, instability can be detected using an MRI, which is often performed preoperatively, paired with a single seated lateral radiograph.

A Comparison of Radiographic Alignment between Bilateral and Unilateral Interbody Cages in Patients Undergoing Transforaminal Lumbar Interbody Fusion

STUDY DESIGN

Retrospective cohort study.

PURPOSE

To compare radiographic outcomes between unilateral and bilateral cage placement in transforaminal lumbar interbody fusions (TLIF) and to determine if the rate of fusion at the 1-year postoperative point was different in patients who received bilateral versus unilateral cages.

OVERVIEW OF LITERATURE

There is no clear evidence to dictate whether bilateral or unilateral cages promote superior radiographic or surgical outcomes in TLIF.

METHODS

Patients >18 years old who underwent primary one- or two-level TLIFs at our institution were identified and propensitymatched in a 3:1 fashion (unilateral:bilateral). Patient demographics, surgical characteristics, and radiographic outcomes, including vertebral endplate obliquity, segmental lordosis, subsidence, and fusion status, were compared between groups.

RESULTS

Of the 184 patients included, 46 received bilateral cages. Bilateral cage placement was associated with greater subsidence (1.06±1.25 mm vs. 0.59±1.16 mm, p=0.028) and enhanced restoration of segmental lordosis (5.74°±14.1° vs. -1.57°±10.9°, p=0.002) at the 1-year postoperative point, while unilateral cage placement was associated with an increased correction of endplate obliquity (-2.02°±4.42° vs. 0.24°±2.81°, p<0.001). Bilateral cage placement was significantly associated with radiographic fusion on bivariate analysis (89.1% vs. 70.3%, p=0.018) and significantly predicted radiographic fusion on multivariable regression analysis (estimate, 1.35; odds ratio, 3.87; 95% confidence interval, 1.51-12.05; p=0.010).

CONCLUSIONS

Bilateral interbody cage placement in TLIF procedures was associated with restoration of lumbar lordosis and increased fusion rates. However, endplate obliquity correction was significantly greater for patients who received a unilateral cage.

Age, pelvic incidence, facet joint angle and pedicle-facet angle as correlative factors for isthmic spondylolisthesis: a retrospective case control study

BACKGROUND

Isthmic spondylolisthesis (IS) is a common clinical disease with a high incidence rate. However, most current researches explain the clear pathogenesis from a single perspective. The aim of our study was to explore the relationships between multiple parameters in patients and find the potential risk factors of this disease.

METHODS

Our study retrospectively included 115 patients who were diagnosed with isthmic spondylolisthesis and the same number of individuals without spondylolisthesis. The following parameters were measured or collected: age, pelvic incidence (PI), facet joint angle (FJA) and pedicle-facet angle (P-F angle). The radiographic files were imported into Mimics Medical 20.0 and all collected data were analyzed using SPSS, version 26.0, statistical software.

RESULTS

The age was higher in IS group than in control group. PI was also higher in the IS group (50.99 ± 7.67) than in the control group (43.77 ± 9.30) significantly (P = 0.009). There was significant difference in cranial and average FJA tropism in L3-L4 level (P = 0.002, P = 0.006, respectively) and in L4-L5 level (P < 0.001). P-F angle of L4-L5 level showed significantly larger in IS group than in control group (P = 0.007).The logistic regression analysis showed a larger age, a greater L3-L4 cranial FJA tropism, and a greater L4-L5 cranial FJA tropism were potential predictors of IS, with an OR of 1.07, 1.28, and 1.39 respectively. The thresholds of the predictors were 60 years, 5.67°, and 8.97° according to the ROC curve. The linear regression equation was established: degree of slippage (%) = 0.220*age - 0.327* L3-4 cranial FJA tropism - 0.346* L4-5 average FJA tropism (F = 3.460, P = 0.011, r = 0.659).

CONCLUSIONS

Our study revealed that isthmic spondylolisthesis may be related to multiple factors rather than a single factor. Age, PI, PJA and P-F angle are potentially associated with spondylolisthesis.

Evaluation and Treatment of the Child with Acute Back Pain

Back pain is common, in up to 30% of children, increasing with age. Eighty percent is benign, mechanical type, improving within 2 weeks of conservative care. Required for those not improving is in-depth evaluation, including MRI, laboratory, and peer consultations. Spondylolysis and spondylolisthesis comprise almost 10% of pediatric back pain, often caused by lumbar hyperextension activities and treated conservatively in most cases. Osteoid osteomas and osteoblastomas constitute the most common benign spinal tumors in childhood. Aggressive and malignant tumors of the spine are rare but when present require tertiary care referral and a comprehensive oncology team for optimal life-sustaining outcomes.

Full-endoscopic foraminotomy in low-grade degenerative and isthmic spondylolisthesis: a patient-specific tailored approach

PURPOSE

To describe the surgical technique and methodology to successfully plan and execute an endoscopic foraminotomy in patients with isthmic or degenerative spondylolisthesis, according to each patient's unique characteristics.

METHODS

Thirty patients with degenerative or isthmic spondylolisthesis (SL) with radicular symptoms were included from March 2019 to September 2022. Treating physician registered patients' baseline and imaging characteristics, as well as preoperative back pain VAS, leg pain VAS and ODI. Subsequently, authors treated the included patients with an endoscopic foraminotomy according to a "patient-specific" tailored approach.

RESULTS

Nineteen patients (63.33%) had isthmic SL and 11 patients (36.67%) had degenerative SL. 75.86% of the cases had a Meyerding Grade 1 listhesis. One of the transforaminal foraminotomies with lateral recess decompression in degenerative SL had to be aborted because of intense osseous bleeding. Of the remaining 29 patients, one patient experienced recurrence of the sciatica pain that required subsequent reintervention and fusion. No other intraoperative or post-operative complications were observed. None of the patients developed post-operative dysesthesia. In 86.67% of the patients, the foraminotomy was implemented using a transforaminal approach. In the remaining 13.33% of the cases, an interlaminar contralateral approach was used. Lateral recess decompression was performed in half of the cases. Mean follow-up time was 12.69 months, reaching a maximum of 40 months in some patients. Outcome variables such as VAS for leg and back pain, as well as ODI, showed statistically significant reduction since the 3-month follow-up visit.

CONCLUSION

In the presented case series, endoscopic foraminotomy achieved satisfactory outcomes without sacrificing segmental stability. The proposed patient-specific "tailored" approach allowed to successfully design and execute the surgical strategy to perform an endoscopic foraminotomy through transforaminal or interlaminar contralateral approaches.

Reduction of spondylolisthesis and restoration of lumbar lordosis after anterior lumbar interbody fusion (ALIF)

BACKGROUND

Anterior lumbar interbody fusion (ALIF) is a well-established surgical treatment option for various diseases of the lumbar spine, including spondylolisthesis. This study aimed to evaluate the postoperative correction of spondylolisthesis and restoration of lumbar and segmental lordosis after ALIF.

METHODS

Patients with spondylolisthesis who underwent ALIF between 2013 and 2019 were retrospectively assessed. We assessed the following parameters pre-and postoperatively (6-months follow-up): Visual Analogue Scale (VAS) for pain, Oswestry Disability Index (ODI), lumbar lordosis (LL), segmental lordosis (SL), L4/S1 lordosis, and degree of spondylolisthesis.

RESULTS

96 patients were included. In 84 cases (87.50%), additional dorsal instrumentation was performed. The most frequent diagnosis was isthmic spondylolisthesis (73.96%). VAS was reduced postoperatively, from 70 to 40, as was ODI (50% to 32%). LL increased from 59.15° to 64.45°, as did SL (18.95° to 28.55°) and L4/S1 lordosis (37.90° to 44.00°). Preoperative spondylolisthesis was 8.90 mm and was reduced to 6.05 mm postoperatively. Relative spondylolisthesis was 21.63% preoperatively and 13.71% postoperatively. All clinical and radiological improvements were significant (all p < 0.001). No significant difference considering the lordosis values nor spondylolisthesis was found between patients who underwent ALIF surgery without dorsal instrumentation and patients who received additional dorsal instrumentation. Venous laceration was the most frequent complication (10.42%).

CONCLUSIONS

With ALIF, good clinical results and safe and effective reduction of spondylolisthesis and restoration of lordosis can be achieved. Additional dorsal instrumentation does not significantly affect postoperative lordosis or spondylolisthesis. Individual vascular anatomy must be reviewed preoperatively before considering ALIF.

Laminoplasty is relevant for degenerative cervical spondylolisthesis when there is little risk of postoperative excessive kyphosis during neck flexion

BACKGROUND

Elderly patients with degenerative cervical myelopathy frequently have severe symptoms due to spondylolisthesis. The effectiveness of laminoplasty for degenerative cervical spondylolisthesis (DCS) is an important question.

OBJECTIVE

The aim of this study is to elucidate factors associated with the outcome of laminoplasty for DCS.

METHOD

Eighty-nine patients with cervical spondylotic myelopathy (CSM) who underwent laminoplasty without instrumented posterior fusion were enrolled. Positive spondylolisthesis was defined as more than 2 mm during neck flexion or extension, from this, 46 DCS cases and 43 non-DCS cases were classified. Radiological parameters, including cervical alignment, balance, range of motion, and slippage along with the Japanese Orthopedic Association (JOA) score, were obtained before and 1 year after surgery. Factors associated with good surgical outcomes for DCS were analyzed using multivariate logistic analysis.

RESULTS

There were no significant differences in background and preoperative JOA score, but the DCS group recovery rate was significantly less (42% vs 53%). Multivariate logistic analysis revealed only the postoperative C2-7 angle during neck flexion was associated with a favorable outcome for DCS (P = 0.0039, Odds ratio: 1.49, 95% CI: 1.14-1.94). Multivariate regression analysis positively correlated the preoperative C2-7 angle in neutral and during flexion with the postoperative C2-7 angle during flexion.

CONCLUSION

The major factor related to poor outcome was the magnitude of postoperative kyphotic C2-7 angle during neck flexion. Slippage was not directly related to outcome and postoperative cervical alignment. Caution is recommended for surgeons performing laminoplasty on patients with risk factors for postoperative excessive kyphotic C2-7 angle during flexion.

A Review of the Main Classifications of Lumbar Spondylolisthesis

OBJECTIVE

This study was conducted to review the main classifications and to present author's recommendations.

METHODS

Review of English language medical literature.

RESULTS

In recent decades, classification systems of lumbar spondylolisthesis have been proposed based on many factors, from essential causes to combinations of imaging features and clinical manifestations; the latter type of system is more clinically practical. We have systematically listed the main types of classification systems in chronological order to make it easier for clinicians to find the type of diagnosis and treatment suitable for their patients and develop an appropriate treatment plan.

CONCLUSIONS

Classification systems for lumbar spondylolisthesis have been proposed that have been based on the study of the essential causes or the combination of imaging features and clinical manifestations; the latter type of system is more clinically practical. We still have much work to do in exploring a more applicable classification of lumbar spondylolisthesis.

Decompression alone versus decompression with fusion in patients with lumbar spinal stenosis with degenerative spondylolisthesis: a systematic review and meta-analysis

INTRODUCTION

Surgical decompression is standard care in the treatment of degenerative spondylolisthesis in patients with symptomatic lumbar spinal stenosis, but there remains controversy over the benefits of adding fusion. The persistent lack of consensus on this matter and the availability of new data warrants a contemporary systematic review and meta-analysis of the literature.

METHODS

Multiple online databases were systematically searched up to October 2022 for randomized controlled trials (RCTs) and prospective studies comparing outcomes of decompression alone versus decompression with fusion for lumbar spinal stenosis in patients with degenerative spondylolisthesis. Primary outcome was the Oswestry Disability Index. Secondary outcomes included leg and back pain, surgical outcomes, and radiological outcomes. Pooled effect estimates were calculated and presented as mean differences (MD) with their 95% confidence intervals (CI) at two-year follow-up.

RESULTS

Of the identified 2403 studies, eventually five RCTs and two prospective studies were included. Overall, most studies had a low or unclear risk of selection bias and most studies were focused on low grade degenerative spondylolisthesis. All patient-reported outcomes showed low statistical heterogeneity. Overall, there was high-quality evidence suggesting no difference in functionality at two years of follow-up (MD - 0.31, 95% CI - 3.81 to 3.19). Furthermore, there was high-quality evidence of no difference in leg pain (MD - 1.79, 95% CI - 5.08 to 1.50) or back pain (MD - 2.54, 95% CI - 6.76 to 1.67) between patients undergoing decompression vs. decompression with fusion. Pooled surgical outcomes showed less blood loss after decompression only, shorter length of hospital stay, and a similar reoperation rate compared to decompression with fusion.

CONCLUSION

Based on the current literature, there is high-quality evidence of no difference in functionality after decompression alone compared to decompression with fusion in patients with degenerative lumbar spondylolisthesis at 2 years of follow-up. Further studies should focus on long-term comparative outcomes, health economic evaluations, and identifying those patients that may benefit more from decompression with fusion instead of decompression alone. This review was registered at Prospero (CRD42021291603).

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.

Transdiscal Screw Fixation in L5-S1 Adult Spondylolisthesis: Technical Note and Midterm Outcomes of a Case Series

BACKGROUND

Spondylolisthesis changes the pelvic morphology and sagittal spinopelvic alignment with abnormality compared to individuals with similar pelvic morphology. There are many treatment options including a combination of decompression and fusion. In spondylolisthesis patients with high-grade spondylolisthesis, bone to bone contact (closed intradiscal space), and high-grade disc degeneration with disc collapse, fusion is challenging.

METHODS

From 2011 through 2020, an analysis of L5-S1 spondylolisthesis patients who had L5-S1 transdiscal screw fixation with a minimum follow-up of 2 years was performed. Radiological evaluation and clinical measures were compared preoperatively and postoperatively. Postoperative complications were analyzed. Also, L5-S1 degree fusion was analyzed using a computed tomography scan.

RESULTS

Eight patients of L5-S1 spondylolisthesis with a mean follow-up of 69 (25-122) months. All patients were female; the average age was 58 (43-78) years. 4 patients presented with high-grade spondylolisthesis (Meyerding grade III). Among the patients, 3 patients were undergoing revision surgery. Only 5 patients had interbody fusion for their adjacent levels. In the postoperative follow-up, none of the patients had neurological deficits. Radiological evaluations of L5-S1 level showed fusion in all patients. Only 1 patient had rod failure and was advised for revision surgery.

CONCLUSIONS

L5-S1 transdiscal screw fixation may provide a satisfactory rigid fixation and fusion at the L5-S1 level in cases of spondylolisthesis. This technique requires a surgeon's experience. Despite the challenge of this technique, it can provide a safe option for acquiring rigid stabilization.

Disc Height Narrowing Could Not Stabilize the Mobility at the Level of Cervical Spondylolisthesis: A Retrospective Study of 83 Patients with Cervical Single-Level Spondylolisthesis

STUDY DESIGN

A retrospective study at a single academic institution.

PURPOSE

We aimed to understand the pathogenesis of cervical spondylolisthesis by analyzing whether narrowing of the disc height stabilizes the slipped disc level according to the degenerative cascade.

OVERVIEW OF LITERATURE

According to Kirkaldy-Willis' degenerative cascade, the narrowing of the disc height at slipped level contributes to intervertebral stability in lumbar spondylolisthesis. Conversely, the pathogenesis of cervical spondylolisthesis is unknown due to a scarcity of reports on the condition.

METHODS

The images of 83 patients with cervical single-level spondylolisthesis were studied. We looked at 52 slipped levels for anterior slippage and 31 for posterior slippage. The imaging parameters included slippage in the neutral, flexed, and extended positions, axial facet joint orientation, sagittal facet slope, global cervical alignment, C2-C7 angle, C2-C7 sagittal vertical axis, range of motion (ROM), and slipped disc angle ROM.

RESULTS

With the narrowing of the intervertebral disc height, slippage in the flexed position of both anterior and posterior spondylolisthesis increased. However, in both anterior and posterior spondylolisthesis, disc height narrowing did not show stability. The narrowing of the intervertebral disc height was found to be a risk factor for a translation of slippage of 1.8 mm or more in flexionextension motion in anterior spondylolisthesis in multivariate regression analysis.

CONCLUSIONS

Narrowing the intervertebral disc height did not stabilize the translation of slippage in flexion-extension motion in cervical spondylolisthesis. Instead, narrowing of the disc height was associated with a translation of slippage of 1.8 mm or more in flexion-extension motion in cases of anterior slippage. Therefore, we discovered that degenerative cascade stabilization for cervical spondylolisthesis was difficult to achieve.

Foraminoplasty with Partial Pediculectomy in Degenerative Spondylolisthesis Cases with Nerve Compression

BACKGROUND

Degenerative spondylolisthesis refers to a forward displacement of a vertebra relative to the underlying vertebra. Patients with radicular pain and/or neurogenic claudication are considered suitable candidates for surgical intervention. The aim of this study was to present clinical results of dynamic stabilization applied after pediculectomy and neural foramen enlargement in patients with degenerative spondylolisthesis and normal spinal sagittal balance.

MATERIALS AND METHODS

All patients who underwent pediculectomy and dynamic stabilization for lumbar degenerative spondylolisthesis were retrospectively identified. Diagnosis was made with detailed neurological and radiological imaging examinations for the anatomical location of the pain. Demographic data, visual analog scale scores, and quality-of-life scores were obtained.

RESULTS

Patients included 3 (33.3%) men and 6 (66.7%) women with a mean age of 61.3 ± 13.0 years (range, 46-80 years) at initial symptom onset. Grade 1 degenerative spondylolisthesis was present in 5 (55.6%) patients, and grade 2 was present in 4 (44.4%) patients. Pathology was detected in L4-5 in 4 patients (44.4%) and L5-S1 in 5 patients (55.6%). In all patients, at the 3-month follow-up, statistically significant decrease in visual analog scale and Oswestry Disability Index scores was observed. At the last follow-up, no implant-related complications requiring revision were observed.

CONCLUSIONS

In patients without any pathology in the sagittal balance, the optimal physiological treatment modality can be created by applying posterior dynamic stabilization together with pediculectomy to support the posterior tension band.

Prospective Cohort Study with a 2-Year Follow-up of Clinical Results, Fusion rate, and Muscle Bulk for Uniportal Full Endoscopic Posterolateral Transforaminal Lumbar Interbody Fusion

Study Design

Retrospective cohort study.

Purpose

Postoperative evaluation of the cross-sectional area of paraspinal muscle and clinical findings in patients who had interlaminar route uniportal full endoscopic posterolateral transforaminal lumbar interbody fusion (EPTLIF) after 2 years.

Overview of Literature

There are limited short-term follow-up studies on efficacy, safety, and physiological changes with a 2-year follow-up. There is no study on paraspinal muscle cross-sectional area change in patients who had undergone uniportal EPTLIF.

Methods

We evaluated patients who underwent EPTLIF with a minimum 24-month follow-up. Clinical parameters of the Visual Analog Scale (VAS) and Oswestry Disability Index (ODI) were measured at the preoperative, 1-week postoperative mark, postoperative 3-month mark, and final follow-up. Preoperative and 1-year postoperative magnetic resonance imaging measurement of preoperative and postoperative Kjaer grade, right and left psoas muscle mass area, and right and left paraspinal muscle mass area was performed.

Results

EPTLIF with a minimum 24-month follow-up of 35 levels was included. The complication rate was 6%, and the mean Bridwell's fusion grade was 1.37 (1-2). There was statistically significant improvement at 1 week, 3 months, and 2 years in VAS (4.11±1.23, 4.94±1.30, and 5.46±1.29) and in ODI (40.34±10.06, 46.69±9.14, and 49.63±8.68), respectively (p <0.05). Successful operation rate with excellent and good MacNab's criteria at 2 years was 97%. There was an increment of statistically significant bilateral psoas muscle cross-sectional area, right side (70.03±149.1 mm²) and left side (67.59±113.2 mm²) (p <0.05).

Conclusions

Uniportal EPTLIF achieved good fusion and improved clinical outcomes with favorable paraspinal musculature bulk at the 2-year follow-up.

Lumbar interbody fusion using oblique (OLIF) and lateral (LLIF) approaches for degenerative spine disorders: a meta-analysis of the comparative studies

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVE

Historically, posterior approaches to the lumbar spine have allowed surgeons to manage degenerative conditions affecting the lumbar spine. However, spinal muscles injury, post-surgical vertebral instability, cerebrospinal fluid (CSF) leakage, and failed back surgery syndrome (FBSS) represent severe complications that may occur after these surgeries. Lumbar interbody fusion using anterior (ALIF), oblique (OLIF), or lateral (LLIF) approaches may represent valuable surgical alternatives, in case fusion is indicated on single or multiple levels.

METHODS

The present study is a systematic review, conducted according to the PRISMA statement, of comparative studies on OLIF, and LLIF for degenerative spine disorders, and a meta-analysis of their clinical-radiological outcomes and complications.

RESULTS

After screening 1472 papers on PubMed, Scopus, and Cochrane Library, only 3 papers were included in the present study. 318 patients were included for data meta-analysis, 128 in OLIF group, and 190 in LLIF group. There were no significative differences in terms of surgical (intraoperative blood loss and surgical duration) and clinical (VAS-back, VAS-leg, and ODI scores) outcomes, or fusion rates at last follow-up (> 2 years). Significantly higher rates of abdominal complications, system failure, and vascular injuries were recorded in the OLIF group. Conversely, postoperative neurological symptoms and psoas weakness were significatively more common in LLIF group.

CONCLUSIONS

The meta-analysis suggests that OLIF and LLIF are both effective for lumbar degenerative disorders, although each of them presents specific complications and this should represent a relevant element in the surgical planning.

A New Interlaminar/Interspinous and Facet-Joint Stabilization System in Lumbar Degenerative Disk Disease: 2 Years of Results

INTRODUCTION

In lumbar degenerative disk diseases (DDDs), we include a wide range of lumbar pathologies. Lumbar spinal stenosis with or without spondylolisthesis is a common cause of lower-limb pain in elderly patients. The surgical treatment of lumbar DDD consists of the decompression of the neural structures or the decompression and fusion of the involved motion segment. Unfortunately, rigid spinal implants followed by fusion cause increased stresses on the neighboring spinal segments, often leading to adjacent segment degeneration. The aim of this paper is to present a new system for interlaminar/interspinous and facet-joint stabilization and fusion.

MATERIAL AND METHODS

From March 2018 to June 2021, 175 patients with severe lumbar back and/or leg pain were operated on with this device after the failure of conservative treatment for a minimum of 6 months. For this study, we considered 75 available patients with a minimum follow-up time of 24 months. Patients rated their back pain and leg pain on a visual analog scale (VAS) after surgery and at the last follow-up; also, the postoperative consumption of analgesic drugs was investigated. Finally, patients were asked whether they would undergo this kind of surgery again or recommend it. The device is designed to promote a better and more efficient intervertebral fusion: Bone Ingrowth technology allows the system to achieve the best response from the bone tissue.

RESULTS

All procedures were performed without any complications. A reoperation was required in five cases (6.7%) because of implant failure. In one case, a spinous process and unilateral articular process fracture occurred. In four cases, a subcutaneous ISCHIA (one case) or FILICUDI (three cases) pullout was observed. Significant improvements following lumbar surgery were observed when evaluating the postoperative VAS values, analgesic drug consumption levels, and patients' satisfaction ratings. Evident fusion was seen in 58 of 75 patients (77.3%).

CONCLUSIONS

Our interspinous/interlaminar and facet-joint implant solution, associated with bone grafting, provided vertebral fusion in most stenotic patients with Grade I DS undergoing bilateral microdecompression (BMD) or bilateral decompression via the unilateral approach (BDUA). A higher number of patients and a longer follow-up will certainly be required to completely validate these new devices, but this minimally invasive surgery (MIS) is currently very encouraging and satisfactory.

Spondylolysis and Isthmic Spondylolisthesis: A Guide to Diagnosis and Management

INTRODUCTION

Spondylolysis and isthmic spondylolisthesis are commonly implicated as organic causes of low back pain in this population. Many patients involved in sports that require repetitive hyperextension of the lumbar spine like diving, weightlifting, gymnastics and wrestling develop spondylolysis and isthmic spondylolisthesis. While patients are typically asymptomatic in mild forms, the hallmark of symptoms in more advanced disease include low back pain, radiculopathy, postural changes and rarely, neurologic deficits.

METHODS

We conducted a narrative review of the literature on the clinical presentation, diagnosis, prognosis and management of spondylolysis and isthmic spondylolisthesis.

RESULTS

A comprehensive physical exam and subsequent imaging including radiographs, CT and MRI play a role in the diagnosis of this disease process. While the majority of patients improve with conservative management, others require operative management due to persistent symptoms.

CONCLUSION

Due to the risk of disease progression, referral to a spine surgeon is recommended for any patient suspected of having these conditions. This review provides information and guidelines for practitioners to promote an actionable awareness of spondylolysis and isthmic spondylolisthesis.

Long-Term Clinical and Imaging Results of Oblique Lateral Interbody Fusion for Degenerative Lumbar Spondylolisthesis: A Systematic Review and Meta-Analysis

The efficacies and safety of oblique lateral interbody fusion (OLIF) for degenerative lumbar spondylolisthesis (DLS) remains controversial, and long-term clinical efficacies in particular need to be explored. This study is designed accordingly, therefore, we searched PubMed, Embase, Scopus, Web of Science, Cochrane Library, ProQuest, OVID, and SinoMed for literature, regardless of publication date or language. Taking 12 months after operation as the shortest limit, the outcome measures were extracted, including visual analog scale (VAS), Oswetry dysfunction index (ODI), Japanese Orthopaedic Association (JOA) score, intervertebral disk height (IDH), foraminal height (FH), lumbar lordosis (LL), segment lordosis (SL), slip ratio, and incidence of surgical complications. Meta-analysis was performed by RevMan 5.4 and Stata 16.0, and results were expressed with MD and 95% CI, and two-sided p-values with p < 0.05 being statistically significant. In total, 17 clinical studies (n = 689 patients) were screened, with an average patient age of 63.4 years. Our study revealed that VAS decreased by 4.55 (low back pain) and 5.46 (leg pain) points, respectively. And ODI score decreased by an average of 33.82% while JOA score increased by an average of 11.56 points. In terms of imaging indicators, mean IDH and FH increased by 4.18 and 4.91 mm, mean LL and SL improved by 9.22° and 2.46°, respectively. Besides, mean slip ratio decreased by 10.45%. The incidence of complications was statistically analyzed in 18 studies, with a rate of 4%-54% and an overall incidence of 19%. To sum up, our study was the first to focus on the long-term efficacies of OLIF treatment for DLS, and to provide further clinical evidence. However, long-term follow-up multicenter randomized controlled trials are still needed for further evaluation.