A possible correlation between facet orientation and development of degenerative cervical spinal stenosis

BACKGROUND

Previous studies have demonstrated the relationship between sagittal facet orientation and cervical degenerative spondylolisthesis. However, the associations between facet orientation and cervical spinal stenosis (CSS) have rarely been studied.

METHODS

One hundred twenty patients with CSS (CSS group) and 120 healthy participants (control group) were consecutively enrolled. The cervical facet angles and anteroposterior diameter (A-P diameter) of spinal canal at each subaxial cervical levels were measured using axial magnetic resonance imaging. The intersection angle of the midsagittal line of the vertebra to the facet line represents the orientation of the facet joint.

RESULTS

The facet angles on the right side at C2- C3 and C3-C4 in CSS group and at C2- C3 in control group had significantly higher values than those of the other sides. Besides, the facet angles and A-P diameter of spinal canal in CSS group were significantly smaller than those in control group at all levels (p < 0.05).

CONCLUSIONS

Our study demonstrated that patients with CSS have smaller axial cervical facet joint angles compared to the healthy individuals. Further studies are needed to elicit the specific underlying mechanism between sagittalization of the cervical facet joints and the pathology of CSS.

Does intervertebral disc degeneration in adolescent idiopathic scoliosis correlate with patient-reported pain scores? A review of 968 cases

PURPOSE

Report the rate and severity of degenerative disc disease (DDD) in non-surgical adolescent idiopathic scoliosis (AIS) patients and correlate these findings with patient-reported symptomatology scores. Additionally, to quantify the rate of concurrent pathological radiological findings in this group.

METHODS

This was a retrospective chart review study at a single tertiary centre. AIS patients aged 10-16 who had received a whole spine MRI between September 2007 and January 2019 and who had not received surgical intervention to their spine were included. MRI scan reports were screened to extract those who had evidence of DDD. These were then reviewed by a blinded second reviewer who graded every disc using the Pfirrmann grading system. SRS-22 scores were extracted for patients when available.

RESULTS

In total, 968 participants were included in the study. Of these, 93 (9.6%) had evidence of DDD, which was Pfirrmann grade ≥ 3 in 28 (2.9%). The most commonly affected level was L5/S1 (59.1% of DDD cases). A total of 55 patients (5.7%) had evidence of syringomyelia, 41 (3.4%) had evidence of spondylolisthesis (all L5/S1), 14 (1.4%) had bilateral L5 pars defects, and 5 (0.5%) had facet joint degeneration. Spondylolisthesis and bilateral pars defects were more common in patients with DDD identified on MRI scan (p < 0.001 and p = 0.04, respectively). Function (p = 0.048) and pain (p = 0.046) scores were worse in patients with DDD.

CONCLUSION

We present a baseline for the rate and severity of DDD in the non-operative AIS cohort. This should assist in decision-making and counselling of patients prior to surgery.

LEVEL OF EVIDENCE

III.

Transforaminal lumbar interbody fusion with a tantalum cage: lumbar lordosis redistribution and sacral slope restoration with a modified posterior technique

BACKGROUND

Transforaminal lumbar interbody fusion (TLIF), a commonly used procedure in spine surgery, has the advantage of a lower incidence of nerve lesions compared to the posterior lumbar interbody fusion (PLIF) technique. The intersomatic arthrodesis has always been carried out with a single tantalum cage normally used for PLIF. Tantalum is a metal that is particularly used in orthopedic surgery. It has a modulus of elasticity similar to marrow and leads to high primary stability of the implant.

MATERIALS AND METHODS

Our study was a retrospective monocentric observational study evaluating clinical and radiological outcomes of tantalum cages in a modified TLIF technique with posterior instrumentation and autologous and/or homologous posterolateral bone grafting. The aim of the study was to evaluate clinical outcomes and the increase in or redistribution of lumbar lordosis. The intersomatic arthrodesis was always carried out with a single tantalum cage normally used for PLIF to reduce the neurological risk. We retrospectively studied 105 patients who were treated with a modified unilateral TLIF approach by two surgeons between 2013 and 2018. We evaluated the Oswestry Disability Index (ODI), Visual Analogue Scale (VAS) for back pain, global lumbar lordosis, lordosis of L4-sacrum, segmental lordosis of functional motion units that underwent arthrodesis, pelvic tilt, pelvic incidence, and the sacral slope in 77 patients. All patients were suffering from grade III or IV Pfirrmann, instability, or foraminal post-laminectomy stenosis and/or grade I-II degenerative spondylolisthesis or low-grade isthmic spondylolisthesis. They had no significant sagittal imbalance, with a sagittal vertical axis (SVA) of < 5 mm. The average follow-up duration was 30 months.

RESULTS

We achieved excellent clinical results, with only four cases of failure (5.2%). Moreover, we noticed a statistically significant redistribution of lumbar lordosis, with an average percentage increase in L4-S1 lordosis equal to 19.9% (P < 0.001), an average increase in the L4-S1/Lumbar lordosis (LL) ratio from 0.53 to 0.63 (P < 0.001), and a mean percentage increase in sacral slope equal to 7.6% (P < 0.001).

CONCLUSION

Thanks to the properties of tantalum, our modified single-portal TLIF technique is a valid surgical solution to obtain a solid arthrodesis and restore the correct lumbar lordosis distribution while reducing neurological complications and the number of failures.

LEVEL OF EVIDENCE

4 Trial registration statement: retrospective observational study, no trial registration.

Female Sex and Supine Proximal Lumbar Lordosis Are Associated With the Size of the LLIF "Safe Zone" at L4-L5

STUDY DESIGN

Retrospective chart review.

OBJECTIVE

Identify demographic and sagittal alignment parameters that are independently associated with femoral nerve position at the L4-L5 disk space.

SUMMARY OF BACKGROUND DATA

Iatrogenic femoral nerve or lumbar plexus injury during lateral lumbar interbody fusion (LLIF) can result in neurological complications. The LLIF "safe zone" is the anterior half to two third of the disk space. However, femoral nerve position varies and is inconsistently identifiable on magnetic resonance imaging. The safe zone is also narrowest at L4-L5.

METHODS

An analysis of patients with symptomatic lumbar spine pathology and magnetic resonance imaging with a visibly identifiable femoral nerve evaluated at a single large academic spine center from January 1, 2017, to January 8, 2020, was performed. Exclusion criteria were transitional anatomy, severe hip osteoarthritis, coronal deformity with cobb >10 degrees, > grade 1 spondylolisthesis at L4-L5 and anterior migration of the psoas.Standing and supine lumbar lordosis (LL) and its proximal (L1-L4) and distal (L4-S1) components were measured. Femoral nerve position on sagittal imaging was then measured as a percentage of the L4 inferior endplate. A stepwise multivariate linear regression of sagittal alignment and LL parameters was then performed. Data are written as estimate, 95% CI.

RESULTS

Mean patient age was 58.2±14.7 years, 25 (34.2%) were female and 26 (35.6%) had a grade 1 spondylolisthesis. Mean femoral nerve position was 26.6±10.3% from the posterior border of L4. Female sex (-6.6, -11.1 to -2.1) and supine proximal lumbar lordosis (0.4, 0.1-0.7) were independently associated with femoral nerve position.

CONCLUSIONS

Patient sex and proximal LL can serve as early indicators of the size of the femoral nerve safe zone during a transpsoas LLIF approach at L4-L5.

A Readability Analysis of Online Spondylolisthesis and Spondylolysis Patient Resources Among Pediatric Hospital Web Pages: A US-Based Study

INTRODUCTION

With the increasing use of the internet for health information, it is essential to prioritize resources that match the reading level of patients and parents. Limited health literacy is a notable issue in the United States, creating a financial burden and negatively affecting patient outcomes. This study aimed to assess the availability and readability of pediatric hospital web pages concerning two prevalent spine conditions in children, spondylolisthesis and spondylolysis, specifically examining whether the available resources meet the recommended sixth grade reading level.

METHODS

A total of 179 pediatric hospital web pages were assessed for their availability and readability of spondylolisthesis and spondylolysis patient information. The web pages' readability was assessed using five readability formulae. Descriptive statistics and Student t-tests were performed on the collected scores with significance set at P < 0.05.

RESULTS

Among the analyzed hospitals, 40.2% had no information on spondylolisthesis or spondylolysis, 20.1% mentioned treating these conditions, 7.8% had < 100 dedicated words, and only 31.8% had dedicated web pages with more than 100 words on these conditions. The average reading grade level for the evaluated web pages was 12.0, indicating a high school education level is required for comprehension. None of the web pages were written below the recommended sixth grade reading level.

DISCUSSION

The readability of the limited resources was markedly higher than the recommended reading level. In addition, this study emphasizes the need for enhanced accessibility and readability of online patient information from pediatric hospitals to improve parental comprehension and informed decision-making. Physicians should consider identifying online resources that they consider of high quality and acceptable readability to support better patient understanding and outcomes.

Reduction of cervicothoracic spondyloptosis in an ambulatory patient: when traction fails

INTRODUCTION

Cervical spondyloptosis is a rare complication of high-energy trauma which often results in significant patient morbidity and mortality. The authors present a case of spondyloptosis of C7 over T1 with minimal radicular symptoms and otherwise complete spinal cord sparing. This case highlights the surgical challenges faced with cervical spondyloptosis and the techniques used when traction fails.

CASE PRESENTATION

A 21-year-old man with no significant past medical history presented after a high-speed motor vehicle collision with cervicothoracic pain and mild hand grip weakness in addition to numbness of the fourth and fifth digits bilaterally (American Spinal Injury Association Impairment Scale Grade D). Computed tomography imaging revealed spondyloptosis of C7 over T1, a fracture of the C2 vertebral body, and a burst fracture of C3. To relieve spinal cord compression and restore sagittal realignment, closed reduction was attempted, however this resulted in perching of the bilateral C7-T1 facets, leading to an open posterior approach. The patient underwent C7 laminectomy, bilateral C7-T1 facetectomy, and manual reduction using a Mayfield skull clamp followed by C2-T3 fixation. Postoperatively, pain was diminished, sensory disturbances were resolved and the patient was otherwise neurologically stable.

DISCUSSION

There is a role for closed traction for reduction of cervical spondyloptosis, however, its role is debated especially when the patient is predominately neurologically intact. In this setting, the spine surgeon may be required to change traction and operative strategies in order to minimize potentially harmful manipulation while restoring sagittal realignment and stabilizing the spine for preservation of neurological function.

Estradiol is a key candidate for treating Ankylosing Spondylolisthesis with Traditional Chinese Medicine

Some Traditional Chinese Medicine (TCM) has shown anti-inflammatory and immunosuppressive effects on Ankylosing Spondylitis (AS) treatment. Wan Bikang (WBK) and Wan Biqing (WBQ) are two traditional empirical formulas for AS. However, the mechanism of their effects on AS is largely unknown. This study deciphered the underlying common molecular mechanisms of these TCM treatments for AS. The ultra-high-performance liquid chromatography-triple/time-of-flight mass spectrometry (UHPLC-Q-TOF-MS/MS) assays were employed to detect herbal ingredients. Target proteins of herbal ingredients were identified by ChEMBL Database. To infer the relationships between ingredients and AS-related proteins, network pharmacology was employed. Protein-protein interaction (PPI) network and core target analyses were carried out with tools Cytoscape and STRING. To find out the molecular basis and target of AS, molecular docking and an in vitro experiment were also conducted. It is found that estradiol may participate in the treatment of AS via the inhibition of inflammatory factors, and Estrogen Receptor 1 (ESR1) appears to be a key target. This research offers insight into the therapeutic mechanism of TCM formulas for AS and furthers our understanding of TCM pharmacology.

Periradicular corticosteroid infiltration for radicular pain - comparison of Diprophos and Depomedrone and ozone effects

OBJECTIVES

To determine the treatment effect of corticosteroids in periradicular therapy (PRT) for radicular pain and to compare different types of corticosteroids and ozone. We also examined the effect in different indication groups for periradicular therapy for each type of treatment agent.

BACKGROUND

Various studies have examined the therapeutic value of periradicular infiltration using treatment agents consisting of local anesthetic and corticosteroids or ozone application for radicular pain. This is the first study to compare different types of corticosteroids and ozone.

METHODS

Eligible patients with radicular pain who failed conservative management were divided into five indication groups and prospectively followed to assess the PRT effect of corticosteroids or ozone application. PRT was performed under computer tomography (CT) monitoring. A set of three PRT applications in three weeks was applied and the outcome was evaluated using a visual analogue score for back and leg pain. The in-group and between-group treatment effect was tested using the Wilcoxon signed-rank test and the Kruskal-Wallis H-test with Dunn's post-hoc tests, respectively. The dependency between treatment effectiveness and indication for each group was tested using the Kruskal-Wallis H-test and Dunn's post-hoc tests.

RESULTS

We prospectively followed 150 patients, randomized into three groups of 50 patients each. The follow-up rate was 100%. All three treatment agents showed a statistically significant treatment effect (P<0.001). The statistically significant effect was higher in betamethasone (Diprophos) versus methylprednisolone (Depomedrone) (P=0.019) and Diprophos versus ozone (P<0.001). Diprophos also showed the highest decrease of VAS after therapy versus VAS prior to therapy (median decrease = 4) compared to Depomedrone and ozone (median decrease = 3 and 2, respectively). The statistically significant outcome was better with the indication of spondylolisthesis and disc herniation (P=0.019) indication for the Diprophos group and between spinal stenosis and spondylolisthesis (P=0.022) and spondylolisthesis and disc herniation (P=0.016) for the ozone group.

CONCLUSION

Clinical improvement occurred in all three groups but Diprophos showed the statistically best treatment effect compared to Depomedrone and ozone. Disc herniation resulting in radicular pain had a statistically significant better effect in comparison with spondylolisthesis in the Diprophos and ozone groups, but the ozone group showed heterogeneity depending on treatment effect and indication.

[Preliminary results of biportal endoscopic lumbar interbody fusion, decompression and pedicle screw insertion assisted with endoscopic technique for lumbar spinal stenosis combined with spondylolisthesis or instability]

Objectives: To evaluate the preliminary clinical outcomes of biportal endoscopic lumbar interbody fusion (BE-LIF), decompression and pedicle screw insertion assisted with endoscopic technique for lumbar spinal stenosis combined with spondylolisthesis or instability. Methods: The data of 9 patients with single-level lumbar spinal stenosis who underwent BE-LIF, decompression and pedicle screw insertion assisted with biportal endoscopy in Xinjiang Production and Construction Corps Hospital from March 1st 2022 to April 30th 2022 were analyzed retrospectively. The visual analogue scales (VAS) for pain in back and legs, and the Oswestry disability index (ODI) of all the patients were collected before operation, on the third day after operation and at the last follow-up. Moreover, the operation time, intra-operation blood loss, radiation shots for pedicle screw insertion, post-operation drainage and ambulation time were recorded. The screw position was checked with CT after the operation. Results: All the patients were female with a mean age of (70.3±8.4) years (ranged 56-84 years); the patients were followed-up for 12-16 weeks. All 9 patients had good clinical results. The VAS scores for back pain on the third day after operation and at the last follow-up were both significantly lower than that preoperatively[(2.9±0.6), (1.8±0.4) vs (6.4±1.1) points, both P<0.05]. The VAS scores for leg pain on the third day after operation and at the last follow-up were both significantly lower than that preoperatively[(1.9±0.3), (1.4±0.5) vs (7.3±1.6) points, P<0.05]. The ODI scores at last follow-up was significantly lower than that before the operation ((24.0%±6.5% vs 55.7%±12.8%, P<0.05). The intra-operative blood loss was (177±103) ml, the drainage amounts post-operation was (122±56) ml, the operation time was (207.8±32.7)min, the ambulation time was (2.3±0.5) days. The total radiation shots for pedicle screw insertion were 20-42 times, the average radiation shots per screw was (6.9±1.5) times. No severe complications or adverse events occurred. No nerve root injury or dural tear occurred in the operation, and no revision surgery needed. Conclusions: The pedicle screw insertion assisted with biportal endoscopic technique can decrease the radiation exposure with good feasibility and safety during the BE-LIF. The BE-LIF combined with the pedicle screw insertion assisted with biportal endoscopy is an effective and safe surgery for lumbar spinal stenosis with good early results.

Comparison of alignment and spondylolysis fracture angle in bilateral and unilateral spondylolysis

OBJECTIVES

Spondylolysis occurs bilaterally or unilaterally and bilateral spondylolysis increases the risk of developing isthmic spondylolisthesis. The characteristics of the lumbar lordosis angle (LLA), sacral slope angle (SSA), and spondylolysis fracture angle (SFA) in bilateral spondylolysis compared with those in unilateral spondylolysis have not been clarified. The purpose of this study was to compare the LLA, SSA, and SFA of bilateral and unilateral spondylolysis.

MATERIALS AND METHODS

Thirty-eight patients with lumbar spondylolysis who visited our clinic for an initial visit and 15 age-matched patients with a chief complaint of low back pain were included as controls. Computed tomography films were used to classify all spondylolysis patients into two groups: those with bilateral fractures (bilateral) and those with unilateral fractures (unilateral). The LLA and SSA were measured using lateral X-ray films and the SFA was measured using computed tomography films.

RESULTS

The LLA was significantly higher in all spondylolysis patients than in the control group (p = .026). There was no significant difference in SSA between the spondylolysis and control groups (p = .28). The LLA was significantly higher in the bilateral group than in the unilateral group (p = .018). There was no significant difference in SSA between the bilateral and unilateral groups (p = .15). The SFA was significantly lower in the bilateral group than in the unilateral group (p = .024).

CONCLUSIONS

This study suggests that physical therapy for spondylolysis may be considered bilaterally and unilaterally.

A Systematic Review and Meta-Analysis of the Facet Joint Orientation and Its Effect on the Lumbar

Facet tropism is recognized as the difference in the positioning of the facet joints in association with each other in the sagittal plane. This guides to an imbalanced biomechanical force over the facet joints and the intervertebral disc during rotation and other physiological activities. A systematic review and meta-analysis of Web of Science, EMBASE, PubMed, Cochrane Library, SCOPUS, and CINHAL from 2004 to 2021 to recognize the related research studies was performed. The data for meta-analysis were obtained from multiple studies to get the combined effect of the facet tropism on the lumbar disc herniation (LDH) and the degenerative lumbar spondylolisthesis (LDS). 117 articles were incorporated in the systematic review, where 41 studies were selected for meta-analysis, out of which 7 studies were found eligible as per the inclusion criteria. When degenerative lumbar spondylolisthesis was compared with the normal group, 95% CI was observed at 1.94 (1.59, 2.28). There was a comparison of disc herniation with the normal group in L4/L5, with a 95% CI of 0.60 (0.05, 1.14). The L5/S1 disc herniation was compared with the normal group and was found to be 0.21 (-0.48, 0.90). Therefore, it was observed that facet tropism is related to lumbar disc herniation and degenerative lumbar spondylolisthesis. Our meta-analysis demonstrated a unique link between the facet tropism and the lumbar disk degeneration along with degenerative lumbar spondylolisthesis.

Clinical and Patient-reported Outcomes After Posterior Versus Transforaminal Lumbar Interbody Fusion-A Propensity Score-matched Cohort Study on 422 Patients with 2-year Follow-up

STUDY DESIGN

This was a dual-center study over an eight-year period on patients undergoing single level fusion surgery with either posterior- (PLIF) or transforaminal lumbar interbody fusion (TLIF). We analyzed prospectively collected pre- and postoperative data from the national Danish surgical spine database (DaneSpine).

OBJECTIVE

The aim of this study was to compare clinical and patient-reported outcome (PRO) 2 years after TLIF or PLIF in patients with symptomatic lumbar mechanical disc degeneration.

SUMMARY OF BACKGROUND DATA

PLIF and TLIF are well-described techniques for treating lumbar mechanical disc degeneration but whether the theoretical differences between the two techniques translate to different clinical outcomes is unknown.

METHODS

The primary outcome was Oswestry Disability Index (ODI) score at 2-year follow-up. Secondary outcome measures were scores on the European Quality of Life-5 Dimensions (EQ-5D) and visual analog scale (VAS) and the rate of intraoperative complications. To minimize baseline differences between the groups, propensity-score matching was employed in a 1:1 fashion, balancing the groups on preoperative factors including age, sex, back and leg pain, ODI, EQ-5D, and previous spine surgery.

RESULT

The matched cohort included 211 patients in each cohort. There was no significant difference between the groups in the mean score on the ODI at two years (PLIF: 33 ± 20 vs. TLIF: 35 ± 20, P = 0.328). We found no statistically significant differences in EQ-5D score (0.54 ± 0.35 vs. 0.51 ± 0.34, P = 0.327), VAS score for back pain (47 ± 32 vs. 48 ± 29, P = 0.570) or leg pain (42 ± 33 vs. 41 ± 32, P = 0.936) between the PLIF and TLIF groups, respectively, at 2-year follow-up. Dural tears occurred in 9.5% in the PLIF group and 1.9% in the TLIF group (P = 0.002) corresponding to a relative risk of 5.0 (95% CI 1.7-14.4).

CONCLUSION

We found no significant difference in PRO at 2-year follow-up between PLIF and TLIF for the treatment of lumbar disc degeneration. PLIF is associated with a five times higher risk of dural tears.Level of Evidence: 3.

Trans-isthmic pars interarticularis screw fixation under CT and fluoroscopic guidance: technical success and clinical outcome in patients with symptomatic low-grade lumbar isthmic lysis

OBJECTIVES

To assess the technical success of trans-isthmic screw fixation with simultaneous CT and fluoroscopic guidance in patients with symptomatic low-grade isthmic spondylolisthesis.

METHODS

Fifty patients (28 women and 22 men; mean age ± standard deviation: 50 years ± 18.9) presenting with symptomatic low back pain with isthmic spondylolisthesis refractory to medical management were treated by means of trans-isthmic pars interarticularis percutaneous screw fixation. The procedure was performed under local anesthesia with double CT and fluoroscopic guidance. Primary outcome was technical success of the procedure, which was assessed with a post-procedure CT using the same success criteria as surgical screw placement with regard to entry point, trajectory, and screw tip. Secondary outcome was pain decrease assessed by the Visual Analog Scale (VAS).

RESULTS

Ninety-nine procedures were performed in 50 patients and 99 screws were inserted. Postoperative CT assessment showed satisfactory screw placement in 96 cases, reflecting a technical success rate of 96.9%. No complications occurred during or after the procedure. Pain assessment showed a pain decrease of VAS score from a median of 7 (min 5, max 10; MAD 1.4) to 2 (p < 0.0001) (min 0, max 7, MAD 1.7) with a mean follow-up of 39 months.

CONCLUSION

Trans-isthmic screw fixation performed under CT and fluoroscopic guidance presents a high technical success and appears as a safe procedure and effective procedure in patients with symptomatic low-grade isthmic lysis.

KEY POINTS

• Trans-isthmic pars interarticularis percutaneous screw insertion is feasible under double CT and fluoroscopic guidance by a radiologist with a high technical success. • This technique can be performed under local anesthesia only. • In patients with chronic low back pain, isthmic screwing allows long-term pain improvement.

Comparative Demographics and Outcomes of Minimally Invasive Transforaminal Lumbar Interbody Fusion in Chinese, Malays, and Indians

STUDY DESIGN

This study carried out a retrospective review of prospectively collected registry data.

OBJECTIVE

This study aimed to determine whether (1) utilization rates; (2) demographics and preoperative statuses; and (3) clinical outcomes differ among Chinese, Malays, and Indians undergoing minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF).

SUMMARY OF BACKGROUND DATA

There is a marked racial disparity in spine surgery outcomes between white and African American patients. Comparative studies of ethnicity have mostly been carried out in American populations, with an underrepresentation of Asian ethnic groups. It is unclear whether these disparities exist among Chinese, Malays, and Indians.

METHODS

A prospectively maintained registry was reviewed for 753 patients who underwent primary MIS-TLIF for degenerative spondylolisthesis between 2006 and 2013. The cohort was stratified by race. Comparisons of demographics, functional outcomes, and patient satisfaction were performed preoperatively and 1 month, 3 months, 6 months, and 2 years postoperatively.

RESULTS

Compared with population statistics, there was an overrepresentation of Chinese (6.6%) and an underrepresentation of Malays (5.0%) and Indians (3.5%) who underwent MIS-TLIF. Malays and Indians were younger and had higher body mass index at the time of surgery compared with Chinese. After adjusting for age, sex, and body mass index, Malays had significantly worse back pain and Indians had poorer Short-Form 36 Physical Component Summary compared with Chinese preoperatively. Chinese also had a better preoperative Oswestry Disability Index compared with the other races. Although significant differences remained at 1 month, there was no difference in outcomes up to 2 years postoperatively, except for a lower Physical Component Summary in Indians compared with Chinese at 2 years. The rate of minimal clinically important difference attainment, satisfaction, and expectation fulfillment was also comparable. At 2 years, 87.0% of Chinese, 76.9% of Malays, and 91.7% of Indians were satisfied.

CONCLUSION

The variations in demographics, preoperative statuses, and postoperative outcomes between races should be considered when interpreting outcome studies of lumbar spine surgery in Asian populations.

LEVEL OF EVIDENCE

Level III-nonrandomized cohort study.

Association between the appropriateness of surgery, according to appropriate use criteria, and patient-rated outcomes after surgery for lumbar degenerative spondylolisthesis

INTRODUCTION

Treatment failures in spine surgery are often attributable to poor patient selection and the application of inappropriate treatment. We used published appropriate use criteria (AUC) to evaluate the appropriateness of surgery in a large group of patients operated for lumbar degenerative spondylolisthesis (LDS) and to evaluate its association with outcome.

METHODS

This was a retrospective analysis of prospectively collected outcome data from patients operated in our Spine Centre, 2005-2012. Appropriateness of surgery was judged based on the AUC. Patients had completed the multidimensional Core Outcome Measures Index (COMI) before surgery and at 3 months' and 1, 2 and 5 years' follow-up (FU).

RESULTS

In total, 448 patients (69.8 ± 9.6 years; 323 (72%) women) were eligible for inclusion and the AUC could be applied in 393 (88%) of these. Surgery was considered appropriate (A) in 234 (59%) of the patients, uncertain/equivocal (U) in 90 (23%) and inappropriate (I) in 69 (18%). A/U patients had significantly (p < 0.05) greater improvements in COMI than I patients at each FU time point. The minimal clinically important change (MCIC) score for COMI was reached by 82% A, 76% U and 54% I patients at 1-year FU (p < 0.001, I vs A and U); the odds of achieving MCIC were 3-4 times greater in A/U patients than in I patients.

CONCLUSIONS

The results suggest a relationship between appropriateness of surgery for LDS and the improvements in COMI score after surgery. The findings require confirmation in prospective studies that also include a control group of non-operated patients.

Non-discogenic low back pain treated with oxygen-ozone: outcome in selected applications

Low back pain and sciatica are highly debilitating conditions affecting all socioeconomic groups at an increasingly early age. They are caused by different often concomitant spinal disorders: disc or facet joint disease, spondylolysis (with or without listhesis), vertebral body and interapophyseal arthrosis, spinal stenosis, radicular and synovial cysts and, more rarely, infections and primary or metastatic cancer. Treatment of low back pain and/or sciatica requires an accurate diagnosis based on thorough history-taking and physical examination followed by appropriate imaging tests, namely computed tomography, and/or magnetic resonance scans in addition to standard and morphodynamics X-rays of the spine. In recent years, several reports have demonstrated the utility of oxygen-ozone therapy in reducing the size of herniated discs. The present study reports on the outcome of oxygen-ozone treatment in 576 patients with non-discogenic low back pain caused by degenerative disease of the posterior vertebral compartment (facet synovitis, Baastrup syndrome, spondylolysis and spondylolisthesis, facet degeneration).

Microendoscopic discectomy versus minimally invasive transforaminal lumbar interbody fusion for lumbar spinal stenosis without spondylolisthesis

Micoendoscopic discectomy (MED) and minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) has become alternatives of the traditional open decompression surgery alone and decompression plus fusion surgery in the treatment of lumbar spinal stenosis (LSS). To date, there is no study focusing on the comparison of clinical outcomes after MED and MIS-TLIF for LSS without spondylolisthesis.Four hundred ninety-seven patients who underwent MED (236 cases) or MIS-TLIF (261 cases) for LSS without spondylolisthesis were included in this study. Perioperative outcomes (hospital stay, operation time and blood loss), cost, functional scores (Oswestry Disability Index, 12-item short form health survey) with a 24-month follow-up visit, complication and reoperation condition within 24 months after surgery were recorded and assessed.No significant difference of clinical outcomes over time was observed between these 2 surgical approaches. Compared with MIS-TLIF, MED was associated with greater satisfaction at 1-month time point postoperatively, whereas this effect was equalized at 3-month time point postoperatively. MED brought advantages in shorter hospital stay, shorter operation time, less blood loss, and less cost over MIS-TLIF.There was no significant difference in 24-month function scores over time between MED group and MIS-TLIF group. Compared with MIS-TLIF, MED could result in a better perioperative effect and less cost.

Transforaminal Endoscopic Lumbar Decompression for Isthmic Spondylolisthesis: Technique Description and Clinical Outcome

OBJECTIVES

To describe a transforaminal endoscopic spinal decompression technique for treating adult patients with isthmic spondylolisthesis and report preliminary surgical and radiological results.

BACKGROUND

Spondylolisthesis is prevalent in the general population. Surgical approaches for symptomatic spondylolisthesis that is refractory to conservative treatment vary. Direct repair of pars fractures and spinal nerve decompression with or without fusion have been reported with varied clinical results. The de facto gold standard, "fusion," is often associated with high complication rates and costs, and may not be necessary for many patients whose spine is relatively stable.

METHODS

Transforaminal endoscopic lumbar decompression (TFELD) was performed to resect fractured bone or bone fragments and inflamed tissue compressing the exiting nerve root in 2 patients with isthmic spondylolisthesis (grade 1 in one patient and grade 2 in another). We describe the technique step-by-step and assess the Oswestry Disability Index and pain scores for back and leg pain before and after surgery.

RESULTS

Radiographic images demonstrated spondylolisthesis with L5 pars fracture. The fractured bone and bone fragment were intraoperatively visible in the gap between facets and fractured pars in patients with isthmic spondylolisthesis. The core pathology of the patients was fractured bone and bone fragment coupled with scar or inflamed tissue compressing the exiting L5 nerve roots. After the bone fragments and scar tissue were removed using TFELD, the patients' back and leg pain was significantly reduced, and physical function was restored.

CONCLUSION

For patients with spondylolisthesis-associated low back and leg pain without spinal instability, TFELD is a safe and effective surgical treatment option.

[Comparative study on effectiveness of modified-transforaminal lumbar interbody fusion and posterior lumbar interbody fusion surgery in treatment of mild to moderate lumbar spondylolisthesis in middle-aged and elderly patients]

OBJECTIVE

To compare the effectiveness of modified transforaminal lumbar interbody fusion (modified-TLIF) and posterior lumbar interbody fusion (PLIF) for mild to moderate lumbar spondylolisthesis in middle-aged and elderly patients.

METHODS

The clinical data of 106 patients with mild to moderate lumbar spondylolisthesis (Meyerding classification≤Ⅱ degree) who met the selection criteria between January 2015 and January 2017 were retrospectively analysed. All patients were divided into modified-TLIF group (54 cases) and PLIF group (52 cases) according to the different surgical methods. There was no significant difference in preoperative clinical data of gender, age, disease duration, sliding vertebra, Meyerding grade, and slippage type between the two groups ( P>0.05). The intraoperative blood loss, operation time, postoperative drainage volume, postoperative bed time, hospital stay, and complications of the two groups were recorded and compared. The improvement of pain and function were evaluated by the visual analogue scale (VAS) score and Japanese Orthopedic Association (JOA) score at preoperation, 1 week, and 1, 6, 12 months after operation, and last follow-up, respectively. The effect of slip correction was evaluated by slip angle and intervertebral altitude at preoperation and last follow-up, and the effectiveness of fusion was evaluated according to Suk criteria.

RESULTS

All patients were followed up, the modified-TLIF group was followed up 25-36 months (mean, 32.7 months), the PLIF group was followed up 24-38 months (mean, 33.3 months). The intraoperative blood loss, operation time, postoperative drainage volume, postoperative bed time, and hospital stay of the modified-TLIF group were significantly less than those of the PLIF group ( P<0.05). The VAS score and JOA score of both groups were significantly improved at each time point after operation ( P<0.05); the scores of the modified-TLIF group were significantly better than those of the PLIF group at 1 and 6 months after operation ( P<0.05). The slip angle and intervertebral altitude of both groups were obviously improved at last follow-up ( P<0.05), and there was no significant difference between the two groups at preoperation and last follow-up ( P>0.05). At last follow-up, the fusion rate of the modified-TLIF group and the PLIF group was 96.3% (52/54) and 98.1% (51/52), respectively, and no significant difference was found between the two groups ( χ 2=0.000, P=1.000). About complications, there was no significant difference between the two groups in nerve injury on the opposite side within a week, incision infection, and pulmonary infection ( P>0.05). No case of nerve injury on the operation side within a week or dural laceration occurred in the modified-TLIF group, while 8 cases (15.4%, P=0.002) and 4 cases (7.7%, P=0.054) occurred in the PLIF group respectively.

CONCLUSION

Modified-TLIF and PLIF are effective in the treatment of mild to moderate lumbar spondylolisthesis in middle-aged and elderly patients. However, modified-TLIF has relatively less trauma, lower blood loss, lower drainage volume, lower incidence of dural laceration and nerve injury, which promotes enhanced recovery after surgery.

[The Facet Wedge: a minimally invasive technique for posterior segmental intra-articular fusion]

OBJECTIVE

Minimally invasive posterior segmental instrumentation and intra-articular fusion with the Facet Wedge device.

INDICATIONS

All fusion indications in degenerative disc disease without significant translational instability, postnucleotomy syndrome, spondylarthrosis, discitis.

CONTRAINDICATIONS

Translatory instabilities, status after decompression with partial facet joint resection, spondylolysis in the affected segment.

SURGICAL TECHNIQUE

Through a 3 cm skin incision, blunt transmuscular approach to the corresponding facet joint L1/2 to L5/S1. Opening of the joint capsule and visualisation of the intra-articular space. Cartilage removal and intra-articular implantation of the Facet Wedge device. Fixation of the implant by means of two angle-stable screws inserted in the corresponding facet joint parts.

POSTOPERATIVE MANAGEMENT

Early mobilisation under thomboprophylaxis. Wearing a trunk-stabilizing brace for up to 12 weeks, depending on the type and extent of the procedure. No restrictions regarding walking distance, standing and sitting immediately postoperatively after pain.

RESULTS

In all, 27 patients (mean age 51.2 years, range 30-76 years) were enrolled in the prospective nonrandomized study from 02/2015 to 9/2017 with a total of 31 treated segments. In 23 cases a ventrodorsal surgical technique was used, in 4 cases a purely dorsal procedure with interposition of an intervertebral cage. Follow-up was 2 years. The Oswestry Score (ODI) improved from an average of 40.6% preoperatively to 16.6% postoperatively. The visual analog scale (VAS) for back pain improved from an average of 6.7 points preoperatively to 2.1 points 2 years postoperatively. During this observation period, 2 implant-specific complications were observed. One Facet Wedge had to be revised due to misplacement with early loosening. In another case, loss of correction occurred in a preoperatively existing first-degree spondylolisthesis with revision to a dorsal screw-rod system.

An histopathological description

INTRODUCCIÓN

Los cambios en el ligamento flavum (LF) relacionados con la degeneración son secundarios al proceso de envejecimiento o a la inestabilidad mecánica. Estudios anteriores han indicado que LF con envejecimiento muestra pérdida de fibras elásticas y aumento del contenido de colágeno, la pérdida de elasticidad puede hacer que el LF se pliegue en el canal espinal, disminuyendo su espacio.

MATERIAL Y MÉTODOS

Se incluyeron 67 pacientes operados de estenosis lumbar espinal (LSS), hernia de disco lumbar (LDH) y espondilolistesis degenerativa (LDS). Se obtuvieron muestras de LF de pacientes que tenían LSS (39), LDH (22) y LDS (6). Se examinaron especímenes con respecto a metaplasia condroide, calcificación, fragmentación de fibras de colágeno, degeneración quística, apariencia fibrilar e hipercelularidad.

RESULTADOS

Los cambios histopatológicos más frecuentes fueron la hialinización y la fragmentación de las fibras de colágeno (34%), neovascularización en 40.3%, y la disposición irregular de las fibras elásticas es el cambio más frecuente con 56.7% del total de muestras. Existe una diferencia en la presencia de cambios en el LF, de acuerdo con el diagnóstico, siendo estadísticamente significativo para la fragmentación de las fibras de colágeno (p = 0.045), la degeneración quística (p = 0.001), la apariencia fibrilar (p = 0.007) y la hipercelularidad (p = 0.005) todos ellos, siendo más frecuentes en el grupo LDS. El grupo LHD presentó fragmentación de las fibras de colágeno en 45.5% (p = 0.045) y la apariencia fibrilar en 4.5% (p = 0.009).

CONCLUSIONES

No hay evidencia de hipertrofia celular en los análisis histopatológicos, el engrosamiento del LF se puede ver por abultamiento del mismo, seguido de colapso del segmento de movimiento.

Automatic Lumbar Spondylolisthesis Measurement in CT Images

Lumbar spondylolisthesis is one of the most common spinal diseases. It is caused by the anterior shift of a lumbar vertebrae relative to subjacent vertebrae. In current clinical practices, staging of spondylolisthesis is often conducted in a qualitative way. Although meyerding grading opens the door to stage spondylolisthesis in a more quantitative way, it relies on the manual measurement, which is time consuming and irreproducible. Thus, an automatic measurement algorithm becomes desirable for spondylolisthesis diagnosis and staging. However, there are two challenges. 1) Accurate detection of the most anterior and posterior points on the superior and inferior surfaces of each lumbar vertebrae. Due to the small size of the vertebrae, slight errors of detection may lead to significant measurement errors, hence, wrong disease stages. 2) Automatic localize and label each lumbar vertebrae is required to provide the semantic meaning of the measurement. It is difficult since different lumbar vertebraes have high similarity of both shape and image appearance. To resolve these challenges, a new auto measurement framework is proposed with two major contributions: First, a learning based spine labeling method that integrates both the image appearance and spine geometry information is designed to detect lumbar vertebrae. Second, a hierarchical method using both the population information from atlases and domain-specific information in the target image is proposed for most anterior and posterior points positioning. Validated on 258 CT spondylolisthesis patients, our method shows very similar results to manual measurements by radiologists and significantly increases the measurement efficiency.

[MINIMALLY INVASIVE SURGERY FOR DIRECT REPAIR OF LUMBAR SPONDYLOLYSIS BY UTILIZING INTRAOPERATIVE NAVIGATION AND MICROENDOSCOPIC TECHNIQUES]

OBJECTIVE

To analyze the effectiveness of direct screw repair for lumbar spondylolysis by using intraoperative O-arm based navigation and microendoscopic techniques.

METHODS

Between February 2012 and May 2014, 11 consecutive patients with lumbar spondylolysis were treated with Buck's procedure by the aid of intraoperative O-arm based navigation and minimally invasive approach. The debridement and autograft of pars interarticularis defects was performed under microendoscopy. There were 7 males and 4 females, with an average age of 28.4 years (range, 19 - 47 years) and an average disease duration of 10.5 months (range, 8-23 months); no nerve symptoms or signs of lower limb was observed. The radiological examinations showed single level bilateral lumbar spondylolysis without obvious disc degeneration, lumbar instability, or spondylolisthesis. Isthmic injury located at L4 in 2 cases and at L5 in 9 cases. Of 11 patients, 7 were rated as grade 2 disc degeneration, and 4 as grade 3 disc degeneration according to the modified Pfirrmann classification system. The operation time, intraoperative blood loss, and complications were recorded. The fluoroscopic examinations were performed to assess defect repair and screw position. Visual analogue scale (VAS) score was used to evaluate the improvement of low back pain.

RESULTS

The average operation time was 147.6 minutes (range, 126-183 minutes). The average blood loss was 54.9 mL (range, 40-85 mL). Primary healing of incision was obtained. There was no complication of nerve root injury, dural tear, or infection. Three patients had pain at donor site postoperatively, and pain disappeared within 3 weeks. The average follow-up duration was 15.7 months (range, 10-23 months). VAS score of low back pain was significantly decreased from preoperative 7.1 ± 2.3 to 1.8 ± 0.4 at last follow-up (t = 13.42, P = 0.01). Of 22 isthmic bone grafting, bilateral isthmic bony fusion was achieved in 7 patients and unilateral isthmic bony fusion in 3 patients at 6-10 months (mean, 7.9 months). One patient failed bilateral isthmic bony fusion, and had bony resorption.

CONCLUSION

Debridement, autograft, and percutaneous intralaminar screw fixation by microendoscopy and O-arm based navigation may provide safe and effective treatment for spondylolysis. Minimally invasive direct repair can obtain satisfactory effectiveness.

[Vertebral in vivo motion of adjacent segments in patients with degenerative spondylolisthesis]

OBJECTIVE

To observe the in vivo vertebral motion of adjacent segments in patients with degenerative spondylolisthesis (DS) during functional weight-bearing activities.

METHODS

A total of 15 symptomatic L4 DS patients (mean age 54.4 years) and 15 asymptomatic volunteers (mean age 53.4 years) were recruited. The vertebral segment motion of each subject was reconstructed with three-dimensional computed tomography and solid modeling software. In vivo lumbar vertebral motion during functional postures (flexion-extension, left-right twisting and left-right bending) was observed with dual fluoroscopic imaging. Coordinate systems were established at the vertebral center of L3-S1 to obtain the intervertebral range of motion (ROM) at L3/4, L4/5 and L5/S1 in DS and normal groups.

RESULTS

The motion pattern at L3/4 with DS was altered. During left-right bending, the rotation along sagittal axis was significantly larger than normal group (4.4° ± 2.8° vs 2.1° ± 1.7°, P < 0.05). During left-right twisting, the rotation along vertical axis was significantly larger than normal group (4.3° ± 2.8° vs 2.1° ± 1.3°, P < 0.05). During flexion to extension, the rotation along frontal axis was larger than DS group (3.9° ± 3.3° vs 3.2° ± 2.5°). However the difference was insignificant. The motion pattern at L4/5 and L5/S1 with DS had no significant difference with normal group.

CONCLUSION

The slipped segments of degenerative spondylolisthesis are stable. However, the ROM of cranial segment increases.

[Application of posterior spinal canal reconstruction in surgery of intraspinal tumor]

OBJECTIVE

To apply H-shaped allogeneic bone graft combined with spinous process replantation for posterior spinal canal reconstruction after removal of intraspinal tumors, and observe its effectiveness.

METHODS

A total of 48 cases of thoracic and lumbar intraspinal tumors were recruited between February 2006 and May 2012, including 35 males and 13 females with a mean age of 29.5 years (range, 17-48 years). The disease duration was 3-16 months (mean, 10.5 months). Intraspinal tumors located at T5,6 in 3 cases, at T10 in 7 cases, at T12, L1 in 13 cases, at L3 in 10 cases, and at L4-S1 in 15 cases. There were 18 cases of epidural meningioma, 2 cases of epidural lipoma, 3 cases of extramedullary neurological tumors, 10 cases of extramedullary meningioma, 6 cases of extramedullary schwannoma, 6 cases of intramedullary ependymoma, and 3 cases of intramedullary astrocytoma. All patients underwent H-shaped allogeneic bone graft combined with spinous process replantation for posterior spinal canal reconstruction after removal of intraspinal tumor by posterior laminectomy. The Oswestry disability index (ODI) was used to assess postoperative symptom improvement, and the Frankel grade of spinal cord injury to evaluate the extent of nerve damage and recovery.

RESULTS

After operation, 8 cases had cerebrospinal fluid leakage, and 4 cases had yellowish exudate, and they were all cured after appropriate treatment; primary healing of wound was obtained in the other cases, without postoperative complication. Forty-eight patients were followed up 18-72 months (mean, 38 months). CT showed all the graft bones healed and posterior spinal canal was well reconstructed without iatrogenic spinal stenosis formation. X-ray film showed no vertebral instability or spondylolisthesis, and no shifting of reconstructed vertebrae. MRI showed no recurrence except 1 case. The symptoms were improved significantly after operation; the ODI score at last follow-up (16.69 ± 2.53) was significantly lower (t = 0.89, P = 0.00) than that at preoperation (47.83 ± 7.25). The results of symptom improvement were excellent in 36 cases, good in 10 cases, fair in 1 case, and poor in 1 case; the excellent and good rate was 95.83%. At last follow-up, Frankel grade was improved significantly (Z = 13.32, P = 0.00) when compared with preoperative grade except 1 recurrent patient.

CONCLUSION

The application of the H-shaped allogeneic bone graft combined with spinous process replantation can well reconstruct the posterior spinal canal, and also can effectively avoid iatrogenic spinal stenosis, so it is worthy of promoting in the clinical treatment of intraspinal tumor surgery.

A case report

A 15-year-old teenager with Type 1 Neurofibromatosis presented with grade 4 spondylolisthesis over T12/L1 junction resulting paraparesis (Frankel D). Radiograph showed a Cobb angle of 88 degrees. Computed tomography scan showed dysplastic vertebral bodies, pedicles and facet joints of T11, T12 and L1 vertebra with complete T12/L1 facets dislocation. Magnetic resonance imaging confirmed presence of spinal cord compression. He underwent posterior instrumentation and posterolateral fusion (T8 to L4) using hybrid instrumentation. Extensive corticotomy of the posterior elements was followed by the use of large amount of bone graft. Post operatively, his neurology improved markedly back to normal. Radiographs showed a good correction of the deformity. He was immobilized in a thoracolumbar orthosis for six months. A solid posterior fusion was achieved at six months follow up. At 36-month follow up, he remained asymptomatic. This case report illustrates a successful treatment of a grade 4 thoracolumbar spondylolisthesis secondary to neurofibromatosis with posterior spinal fusion alone.

Part 7: intractable low-back pain without stenosis or spondylolisthesis

Class I medical evidence exists in support of the use of lumbar fusion as a treatment standard for carefully selected patients with low-back pain intractable to the best medical management. There is Class III medical evidence that suggests that a course of intensive cognitive and physical therapy may be an efficacious treatment option for the treatment of patients with chronic disabling low-back pain.

Part 10: fusion following decompression in patients with stenosis without spondylolisthesis

Based on the medical evidence derived from the scientific literature on this topic, there does not appear to be evidence to support the hypothesis that fusion (with or without instrumentation) provides any benefit over decompression alone in the treatment of lumbar stenosis in patients in whom there is no evidence of preoperative deformity or instability. A single report provides Class II medical evidence and several papers provide Class III medical evidence suggesting that the addition of fusion to decompression in patients with lumbar stenosis and instability evidenced by movement on preoperative flexion-extension radiographs does improve outcome. There are also reports (Class III medical evidence) indicating that patients with lumbar stenosis, without deformity or instability, treated with wide decompression or facetectomy may suffer iatrogenic lumbar instability. Fusion in these patients may improve outcome. There is conflicting Class III medical evidence regarding the application of instrumentation in addition to PLF in patients treated for lumbar stenosis without deformity or preoperative instability.

Finite element methods in spine biomechanics research

The finite element method has been used in spine biomechanics research for nearly a quarter of a century. Recent developments have made it possible to simulate a variety of clinically relevant situations in an increasingly realistic manner, elevating the finite element method into a fully complementary partnership with experimental approaches for the investigation of clinical problems in the spine. These new developments are presented in a historical context to evaluate their potential impact on future spine biomechanics research.

[Spondyl-olisthesis more than a problem of etymology (author's transl)]

The term "spondylolisthesis" is derived from the Greek word "olisthánein" = to slip. It denotes the forward displacement of one vertebra over another. The English expression denoting slipping of the bones of a joint or of vertebrae is "olisthy" or "olisthe".

Dislocation, subluxation or listhesis?

The lack of a generally accepted set of terms to describe traumatic vertebral displacements as shown by different interpretations of the terms 'subluxation' and 'dislocation' is discussed. The need for clear and precise terminology for clinical and research purposes is stressed. Causes for confusion in terminology are briefly outlined. Terminology separately describing displacement of vertebral bodies and apophyseal joints is suggested.