Adult Isthmic Spondylolisthesis Research Articles

Enhancing endoscopic foraminal decompression in adult isthmic spondylolisthesis: the potential influence of lateral recess isthmic spur and our case series of an innovative craniocaudal interlaminar approach via unilateral biportal endoscopic spinal surgery

BackgroundThe NASS guideline cannot recommend any of the surgical treatment options toward adult isthmic spondylolisthesis (AIS) since 2014. After the introduction of endoscopic decompression, instead of treating the spondylolysis itself, treatment can specifically target the refractory radicular pain developed during the degeneration progress without devastating the peripheral soft tissue. However, we noticed that endoscopic transforaminal decompression seems to be less effective in AIS compared to other types of degenerative spondylolisthesis. Thus, we came up with a novel craniocaudal interlaminar approach, utilizing the proximal adjacent interlaminar space to perform bilateral decompression and observed the pathoanatomy of pars defect directly and tried to identify the cause of decompression failure.MethodsFrom January 2022 to June 2022, 13 patients with AIS underwent endoscopic decompression via the endoscopic craniocaudal interlaminar approach and were followed up for at least 6 months. Visual Analogue Scale, Oswestry Disability Index and MacNab scores were recorded to monitor patients’ clinical recovery. All endoscopic procedures were recorded and reviewed to illustrate the pathoanatomy.ResultsFour patients required minor revision via the same technique. One of them required it due to incomplete isthmic spur resection, two due to neglected disc protrusion, and the other due to root subpedicular kinking in higher grade anterolisthesis. All patients’ clinical condition improved significantly subsequently. After reviewing the endoscopic video, we have observed that the hook-like, ragged spur originating from the isthmic defect extends beyond the region around the foramen. Instead, it extends proximally into the adjacent lateral recess, resulting in impingement along the fracture edge above the index foramen and, in some cases, even in the extraforaminal area.ConclusionsThe broad spanning isthmic spur extending to the proximal adjacent lateral recess might be the reason why the transforaminal approach yielded less satisfactory results due to the incomplete decompression result from approach related restriction. Our study demonstrated an optimistic outcome by applying decompression from the upper level. Therefore, we propose that the craniocaudal interlaminar approach might be a better route for decompression in adult isthmic spondylolisthesis.

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

IntroductionCircumferential 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 methodsThis 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. ResultsThe 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). ConclusionALIF+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 evidenceIII; multicenter comparative study.

Adult Isthmic Spondylolisthesis: A Radiographic and Outcomes Analysis Comparing Circumferential Fusions Versus TLIF Procedures.

This was a retrospective cohort study. The objective of this study was to compare radiographic and patient-reported outcome measures (PROMs) between circumferential fusions and transforaminal lumbar interbody fusion (TLIF) for adult isthmic spondylolisthesis (IS). Definitive management of adult IS typically requires decompression and fusion. Multiple fusion techniques have been described, but literature is sparse in identifying the optimal technique. Patients with IS undergoing single-level or 2-level circumferential fusion or TLIF with a minimum 1-year follow-up were included. Patient demographics, surgical characteristics, and PROMs were extracted from patients' electronic medical records. Descriptive statistics and multivariate regression analysis compared outcomes with significance set at P -value <0.05. A total of 78 circumferential fusions (48 open decompression and fusions and 30 circumferential fusions utilizing posterior percutaneous instrumentation) and 50 TLIF procedures were included. Length of stay was significantly longer when comparing circumferential procedures (3.56±0.96 d) versus TLIFs (2.88±1.14 d) ( P =0.002). The circumferential fusion group resulted in greater postoperative improvement in segmental lordosis [anterior/posterior (A/P): 6.45, TLIF: -1.99, P <0.001], posterior disk height (A/P: 12.6 mm, TLIF: 8.9 mm, P <0.001), and ∆disk height (A/P: 7.7 mm, TLIF: 3.6 mm, P <0.001). Both groups significantly improved in all PROMs ( P <0.001). While the circumferential fusion group had a significantly higher rate of perioperative surgical complications (12.82% vs. 2.00%, P =0.049), there was no difference in the rate of 30-day readmissions ( P =0.520) or revision surgeries between techniques ( P =0.057). Circumferential fusions are associated with improvements in radiographic outcomes compared with TLIFs, but this is at the expense of longer hospital length of stay and increased risk for perioperative complications. The surgical technique did not result in superior postoperative PROMs or differences in readmissions or revisions.

Rehabilitation to improve outcomes of lumbar fusion surgery: a systematic review with meta-analysis.

To evaluate the effectiveness of rehabilitation strategies on disability, pain, pain-related fear, and return-to-work in patients undergoing lumbar fusion surgery for degenerative conditions or adult isthmic spondylolisthesis. Six electronic databases were systematically searched for randomized controlled trials (RCTs) evaluating the effect of rehabilitation (unimodal or multimodal). The estimated effect size was calculated for interventions with homogeneous content using a random-effects model. Certainty of evidence was assessed by GRADE. In total, 18 RCTs, including 1402 unique patients, compared specific rehabilitation to other rehabilitation strategies or usual care. Most described indications were degenerative disc disease and spondylolisthesis. All rehabilitation interventions were delivered in the postoperative period, and six of them also included a preoperative component. Intervention dose and intensity varied between studies (ranging from one session to daily sessions for one month). Usual care consisted mostly of information and postoperative mobilization. At short term, low quality of evidence shows that exercise therapy was more effective for reducing disability and pain than usual care (standardized mean difference [95% CI]: -0.41 [-0.71; -0.10] and -0.36 [-0.65; -0.08], four and five studies, respectively). Multimodal rehabilitation consisted mostly of exercise therapy combined with cognitive behavioral training, and was more effective in reducing disability and pain-related fear than exercise therapy alone (-0.31 [-0.49; -0.13] and -0.64 [-1.11; -0.17], six and four studies, respectively). Effects disappeared beyond one year. Rehabilitation showed a positive tendency towards a higher return-to-work rate (pooled relative risk [95% CI]: 1.30 [0.99; 1.69], four studies). There is low-quality evidence showing that both exercise therapy and multimodal rehabilitation are effective for improving outcomes up to six months after lumbar fusion, with multimodal rehabilitation providing additional benefits over exercise alone in reducing disability and pain-related fear. Additional high-quality studies are needed to demonstrate the effectiveness of rehabilitation strategies in the long term and for work-related outcomes.

English

BACKGROUND Operative treatment and fusion for isthmic spondylolisthesis can be achieved by various fusion techniques such as posterolateral fusion (PLF), anterior lumbar interbody fusion (ALIF), posterior lumbar interbody fusion (PLIF), transforaminal lumbar interbody fusion (TLIF) and circumferential fusion. The purpose of this study is to evaluate the clinical outcome and radiological correction achieved after TLIF and assess the correlation between them if any. METHODS This is a retrospective cohort study analysing 30 cases of adult isthmic spondylolisthesis who failed conservative treatment and were then treated with transforaminal lumbar interbody fusion between 2011 and 2013. The clinical follow-up was done with the modified Oswestry disability index (ODI) and visual pain analogue score (VPAS). For the radiological follow-up radiographs were taken and several radiographic parameters were noted and analysed. RESULTS The mean of the Oswestry disability index scores in all patients decreased from 67.73 to 13.1 at final follow up. Similarly, visual pain analogue score reduced from mean 8.43 to 1.76 at final follow up. The average anterolisthesis was significantly reduced from the preoperative 27.1 ± 14 % to 7.1 ± 5 % at final follow-up radiographs (P < 0.001). Segmental lordosis increased from a mean of 11.5 degrees to 15.7 degrees. The difference in slip angle was significant from preoperative -4.87 ± 4.8 degrees and - 7.23 ± 4.63 degrees on the initial postoperative and - 7.2 ± 4.57 degrees at final follow-up radiographs (P = 0.14 and 0.13 respectively). CONCLUSIONS Thus, adult isthmic spondylolisthesis can be safely and effectively treated by TLIF with significant clinical relief and decrease in disability. TLIF procedure in isthmic spondylolisthesis is capable of reducing the sagittal translation and restoring disc height. Also, sagittal alignment and lordosis can be restored to a large extent. KEYWORDS Spondylolisthesis, Pelvic Incidence, Sagittal Balance, TLIF

Transforaminal lumbar interbody fusion versus posterolateral fusion for the treatment of low-grade isthmic spondylolisthesis in adults

Background Isthmic spondylolisthesis means slippage of one vertebra relative to the next caudal vertebra as a result of an abnormality in the pars interarticularis. Isthmic spondylolisthesis has three subtypes: subtype A in which there is stress fracture of the pars (spondylolysis), subtype B in which the pars is elongated, and subtype C in which there is acute fracture of the pars. Isthmic spondylolisthesis is the most common cause of low back pain in adolescents. Spinal fusion is the mainstay of the surgical treatment of low-grade isthmic spondylolisthesis. Spinal fusion can be achieved by posterolateral fusion (PLF) or circumferential fusion. The three basic techniques for circumferential fusion include anterior lumbar interbody fusion, posterior lumbar interbody fusion, and transforaminal lumbar interbody fusion (TLIF). Patients and methods Fifty patients with low-grade isthmic spondylolisthesis managed with spinal fusion at the Zagazig University Hospital. Patients were divided into two groups: group I included patients managed by TLIF and group II included patients managed by PLF. The mean age of patients was 34.6 years (range: 26–43 years) in group I and 36.8 years (range: 28–46) in group II. Sex distribution was nine males and 16 females in group I and seven males and 18 females in group II. Exclusion criteria included patients with high-grade spondylolisthesis, traumatic spondylolisthesis, degenerative spondylolisthesis, neoplastic spondylolisthesis, patients with acute or chronic infection, and congenital malformation. Results No patients were dropped in the follow-up. In both groups, the mean visual analog scale (VAS) for back pain and leg pain and the Oswestry disability index (ODI) showed statistically significant difference between the values obtained preoperatively and the values obtained at the 1-year follow-up visit. In comparison between both groups for the change in the VAS for back and leg pain and ODI score, group I gave a significant difference regarding the change in the VAS for back pain compared to group II. However, the change in the VAS for leg pain and ODI was not statistically significant. Conclusion Both TLIF and PLF are effective options for the treatment of low-grade isthmic spondylolisthesis in adults. However, TLIF gives better clinical outcome, so it is considered a better option.

Back Dominant Pain Has Equal Outcomes to Radicular Dominant Pain Following Posterior Lumbar Fusion in Adult Isthmic Spondylolisthesis: A CSORN Study.

Study Design:Retrospective Cohort Study.Objectives:This study aimed to determine how the surgeon-determined and patient-rated location of predominant pain influences patient-rated outcomes at 1-year after posterior lumbar fusion in adult isthmic spondylolisthesis.Methods:We retrospectively reviewed consecutive patients prospectively enrolled in the Canadian Spine Outcomes and Research Network national registry between 2009 and 2017 that underwent posterior lumbar fusion for isthmic spondylolisthesis. Using longitudinal mixed-model repeated-measures analysis the change from baseline in patient-reported outcome measures (PROMs) at 1 year after surgery was compared between surgeon-determined groups (back vs. radicular) and between patient-rated pain groups (back, leg, and equal) derived from preoperative pain scores on the numerical rating scale (NRS).Results:83/252 (33%) patients had a surgeon-determined chief complaint of back pain, while 103 (41%) patients rated their back pain as the predominant pain location, and 78 (31%) rated their back and leg pain to be equal. At baseline patients in the surgeon-determined radicular group had worse NRS-leg pain than those in the back-pain group but equal NRS-back pain. At baseline patients in the patient-rated equal pain group had similar back pain compared to the patient-rated back pain group and similar leg pain compared to the patient-rated leg pain group. All PROMs improved post-operatively and were not different between the 2 groups at 1 year.Conclusions:Our study found no difference in outcome, irrespective of whether a surgeon determines the patient’s primary pain complaint back or radicular dominant, or the patient rates pain in one location greater than another.

Direct Pars Defect Tubular Decompression and TLIF for the Treatment of Low-Grade Adult Isthmic Spondylolisthesis: Surgical Challenges and Nuances of a Muscle-Sparing Minimally Invasive Approach.

We present an illustrative report on the use of a minimally invasive, muscle-sparing, direct pars defect decompression with transforaminal lumbar interbody fusion (TLIF) and instrumentation for the treatment of low-grade adult isthmic spondylolysis with spondylolisthesis and discuss the surgical challenges and nuances associated with the technique.

61. ALIF vs TLIF for isthmic spondylolisthesis: differences in radiographic outcomes

BACKGROUND CONTEXT Patients with a diagnosis of isthmic spondylolisthesis have higher sacral slope, pelvic tilt, pelvic incidence and lumbar lordosis compared to patients without isthmic spondylolisthesis. Several fusion techniques have been used to treat isthmic spondylolisthesis in adults, including anterior lumbar interbody fusion (ALIF) and transforaminal interbody fusion (TLIF). Compared to other fusion techniques, ALIF has shown better sagittal alignment outcomes, particularly restoration of segmental lordosis. PURPOSE The purpose of this study was to evaluate which fusion technique provides the better radiological outcome for adult lumbar isthmic spondylolisthesis. STUDY DESIGN/SETTING This study was a retrospective analysis of prospectively collected data from a single, high-volume academic medical center. PATIENT SAMPLE Patients who underwent lumbar fusion for isthmic spondylolisthesis from 2014 to 2019 were included in the analysis. Surgery was indicated after failure of conservative treatment to address radiculopathy and/or neurogenic claudication. Patients were excluded if they were under 18 years of age at the time of surgery, presented with a tumor or infection, or underwent revision surgery. OUTCOME MEASURES Preoperative and postoperative radiographic parameters were collected including sacral slope, pelvic tilt, pelvic incidence, lumbar lordosis, segmental lumbar lordosis, and the vertebral slip percentage. METHODS Patient and surgical characteristics including age, gender, smoking status, body mass index (BMI), Charlson Comorbidity Index (CCI), number of levels decompressed and number of levels fused were collected. Preoperative and final radiographic outcomes were obtained from an institutional electronic medical record. For analysis, patients were divided into two groups based on surgical technique: combined anterior fusion with posterior stabilization (ALIF-PLDF) or anterior and posterior fusion through a posterior approach (TLIF). RESULTS A total of 101 patients were included in final analysis, with 52 patients in the ALIF-PLDF group and 49 patients in the TLIF group. Mean age was greater in the TLIF group (p=0.017). Patients in the TLIF group were more likely to have a history of smoking (p=0.008), to have a greater CCI score (p=0.003), and to have higher number of levels decompressed. On analysis of radiographic parameters, preoperative sacral slope was higher in in the ALIF-PLDF group than the TLIF group (p=0.071). Postoperative overall lumbar lordosis was lower in the TLIF group (p=0.036). Postoperative segmental lumbar lordosis and the delta value for segmental lumbar lordosis were both lower in the TLIF group (p=0.030 and p=0.001). The TLIF group had a significant increase in PI-LL mismatch (p=0.032). Both groups had significant decrease in vertebral slip percent (p CONCLUSIONS Our data highlights that patients undergoing ALIF have a significant increase in segmental lordosis from their preoperative baseline. Interestingly, patients undergoing TLIF have significantly less postoperative change in segmental lumbar lordosis when compared to ALIF. When treating patients with isthmic spondylolisthesis, the ALIF approach has benefits not only in its capacity to restore segmental lordosis, but also by providing significant reduction in vertebral body slip. Our results suggest that, when compared to the TLIF approach, ALIF may be associated with better outcomes in terms of critical radiographic parameters. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

P45. Radiological features of slip progression in adult patients with isthmic spondylolisthesis

BACKGROUND CONTEXT Lumbar spondylolysis is generally recognized as a stress fracture of pars interarticularis occurring in childhood and adolescence. Non-union after pars fracture in the spinal motion segment may lead to isthmic spondylolisthesis. Various factors such as disc degeneration and sagittal radiological parameters contributing to slip progression in adult isthmic spondylolisthesis have been discussed. In the relationship between L5 isthmic spondylolisthesis and deformities of the sacral table, it was reported that the mechanism of vertebral slippage was different between immature and mature spine in animal studies. There are two types of isthmic spondylolisthesis which occur before and after skeletal maturity: adolescent slip with sacral deformities and adult slip without sacral deformities. However, in these two types of isthmic spondylolisthesis, there are no reports that have clarified whether there is a difference in the slip progression radiologically. PURPOSE Purpose of this study is to clarify the predictive risk factors contributing to progression of vertebral slippage in adults diagnosed with isthmic spondylolisthesis and treated conservatively. STUDY DESIGN/SETTING This is a retrospective study using 29 adult patients with isthmic spondylolisthesis. PATIENT SAMPLE Patients who were 20 to 59 years old and diagnosed with isthmic spondylolisthesis by ICD-9 and ICD-10 between 2007 and 2017 were included in this study through a Northwestern Medicine Enterprise Data Warehouse search. Patients who were diagnosed with dysplastic, traumatic, degenerative or pathologic spondylolisthesis, patients who have lumbar scoliosis, patients who have past medical history of spine surgery were excluded. OUTCOME MEASURES Slip progression and slip progression percent during follow-up. METHODS We evaluated their plain radiographs of the lumbar spine which were followed up for more than 3 years and analyzed factors affected the slip progression. RESULTS Patients’ mean age was 41.6 (± 7.9) years old. The follow-up period was 68.6 (± 20.8) months. Slip and slip% were 6.7 (± 4.1) mm, 15.5 (± 10.2) % at initial X-ray, and 10.0 (± 4.6) mm, 22.7 (± 10.6) % at final X-ray respectively. All of them progressed anterior slip during the follow-up period (P CONCLUSIONS All patients who were followed-up conservatively progressed anterior slip in this study cohort. However, the degree of their slip was not correlated with the sacral deformity or other factors described in the previous reports compared to normal group. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

56. Minimally invasive pedicle screws provide similar clinical outcomes to open posterior fusion in the management of adult isthmic spondylolisthesis

BACKGROUND CONTEXT In adult patients undergoing anterior lumbar interbody fusion (ALIF) for the treatment of isthmic spondylolisthesis, the literature shows that posterior percutaneous pedicle screw fixation leads to shorter hospital stays, less time under anesthesia, and less intraoperative blood loss compared to open posterior fusion. However, there is conflicting evidence on whether patients undergoing posterior percutaneous fixation experience similar clinical outcomes as those undergoing open posterior fusion. PURPOSE The purpose of this study was to determine the impact of minimally invasive posterior surgery on clinical outcomes following lumbar spinal fusion for isthmic spondylolisthesis. STUDY DESIGN/SETTING This study was a retrospective analysis of prospectively collected data from a single, high-volume academic medical center. PATIENT SAMPLE Analysis of patients who underwent lumbar fusion for isthmic spondylolisthesis from 2014 to 2019 was conducted. Surgery was indicated after failure of conservative treatment to address lumbar radiculopathy and/or neurogenic claudication. OUTCOME MEASURES Patient-reported outcome measures (PROMs) were recorded at preoperative and postoperative clinical visits, and included the Visual Analog Scale back pain (VAS back) and leg pain (VAS leg), the Short-Form 12 Mental Component Score (MCS-12) and Physical Component Score (PCS-12), and the Oswestry Disability Index (ODI). Secondary measures included estimated blood loss (EBL) and length of stay (LOS). METHODS Patient and surgical characteristics including age, gender, body mass index (BMI), Charlson Comorbidity Index (CCI), number of levels decompressed and number of levels fused were recorded. Preoperative and final PROMs were obtained from an institutional query. For analysis, patients were divided into two groups based on surgical approach: ALIF with percutaneous pedicle screws (Percutaneous) and ALIF with open posterior fusion (Open). Multivariate linear regression was performed to correlate surgical approach and outcomes. RESULTS A total of 61 patients were included, with 20 patients in the Percutaneous group and 41 patients in the Open group. Patients undergoing open surgery had greater intraoperative EBL (p=0.013) and longer LOS (p=0.034). Otherwise, there were no significant differences in patient characteristics. Patients in both the Percutaneous and the Open groups had significant improvement in VAS back scores (p=0.001, p CONCLUSIONS Our results suggest that patients undergoing minimally invasive posterior fusion and patients undergoing open posterior fusion for adult isthmic spondylolisthesis have similar improvement of PROMs from preoperative to final assessment. Additionally, open surgery is significantly correlated with less improvement in VAS leg scores than minimally invasive approaches and was associated with significantly higher intraoperative blood loss and hospital length of stay. This study underscores the importance of considering surgical approach as a prognostic factor. Furthermore, the results provide additional information that can be used by physicians in preoperative discussions with patients regarding expectations of postoperative improvements in pain. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

271. Surgical technique and patient-reported outcomes in adult isthmic spondylolisthesis

BACKGROUND CONTEXT Combined anterior lumbar interbody fusion (ALIF) with posterior lumbar decompression and fusion (PLDF), and transforaminal lumbar interbody fusion (TLIF) are two procedures recommended to improve clinical outcomes in adult patients with isthmic spondylolisthesis. However, there is debate whether TLIF provides superior clinical outcomes to ALIF combined with PLDF, specifically regarding patient-reported outcome measures (PROMs). PURPOSE The purpose of this study was to compare PROMs between combined ALIF-PLDF and TLIF techniques following lumbar spinal fusion for adult isthmic spondylolisthesis. STUDY DESIGN/SETTING This study was a retrospective analysis of prospectively collected data from a single, high-volume academic medical center. PATIENT SAMPLE Patients who underwent lumbar fusion for isthmic spondylolisthesis from 2014 to 2019 were included in the analysis. Surgery was indicated after failure of conservative treatment to address radiculopathy and/or neurogenic claudication. OUTCOME MEASURES Patient-reported outcome measures were collected at preoperative and postoperative clinical visits. Metrics recorded include the visual analog scale for back pain (VAS back) and leg pain (VAS leg), the Short-Form 12 Mental Component Score (MCS-12) and Physical Component Score (PCS-12), and the Oswestry Disability Index (ODI). Secondary measures included estimated blood loss (EBL) and hospital length of stay (LOS). METHODS Patient and surgical characteristics including age, gender, body mass index (BMI), Charlson Comorbidity Index (CCI), number of levels decompressed and number of levels fused were recorded. Preoperative and final patient-reported outcome measures were obtained from an institutional query. For analysis, patients were divided into two groups based on surgical technique: combined anterior fusion with posterior stabilization (ALIF-PLDF) or anterior and posterior fusion through a posterior approach (TLIF). Multivariate linear regression was performed to correlate surgical approach and PROMs. RESULTS A total of 125 patients were included in final analysis, with 62 patients in the ALIF-PLDF group and 63 patients in the TLIF group. Patients undergoing ALIF-PLDF were more likely to be older (p=0.041) and have shorter LOS (p=0.009), while patients in the TLIF group had significantly more smoking history (p=0.007), more comorbid conditions (p=0.003), and higher number of levels decompressed (p=0.003). Patients in both the ALIF-PLDF group and the TLIF group had significant improvements in VAS back scores (p CONCLUSIONS Our results indicate that patients with isthmic spondylolisthesis treated with ALIF-PLDF approaches show significant improvements in all evaluated PROMs from initial preoperative visit to final follow-up, whereas similar patients treated with a TLIF approach have significant improvements in all PROMs except MCS-12. Our data further suggest that TLIF is more likely to be chosen for older, chronically ill patients, and those undergoing decompression at a higher number of levels. Despite these baseline differences, PROMs are similar between both fusion methods. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

High grade isthmic spondylolisthesis – A case series illustrating three different operative instrumented fusion techniques

Adult isthmic spondylolisthesis most commonly occurs at the L5-S1 level. In adults a high-grade slip degree is rare comprising less than 1% of cases. Progressive axial lumbar backache characterizes the early stage of the disease which over time commonly complicates with the development of a super-imposed L5 radiculopathy. These are difficult cases to manage and the attending spinal surgeon must have an understanding of several different surgical options. These options include conservative treatment in those who are mildly symptomatic, decompression alone with its inherent tendency to facilitate further slip, decompression and fusion without instrumentation, decompression and fusion with instrumentation, and if so the extent of the construct both cranially and caudally. Another important consideration is whether, or not, reduction is necessary or whether fusion in situ will suffice. Regarding the surgical approach some surgeons regard an anterior approach, to perform an anterior release, as necessary if reduction is to be achieved. Others consider nerve root decompression and posterior spinal fusion in situ as the technique of choice. Others advocate a combined anterior and posterior surgical approach.We report a case series of three adult female patients with high grade isthmic spondylolisthesis complicated by L5 nerve root compression. Each patient was successfully managed with a different instrumented fusion technique. Our case series serves to highlight several of the specific surgical nuances pertaining to the management of high-grade isthmic spondylolisthesis and as such is valuable to the attending spinal surgeon who may infrequently encounter patient with the high-grade form of this disease.

Long-term outcome after spinal fusion for isthmic spondylolisthesis in adults

BACKGROUND CONTEXTData on the long-term outcome after fusion for isthmic spondylolisthesis are scarce. PURPOSETo study patient-reported outcomes and adjacent segment degeneration (ASD) after fusion for isthmic spondylolisthesis and to compare patient-reported outcomes with a control group. STUDY DESIGN/SETTINGA prospective study including a cross-sectional control group. PATIENT SAMPLEPatients with isthmic spondylolisthesis underwent posterior lumbar interbody fusion (PLIF) (n=86) or posterolateral fusion (PLF) (n=77). Patient-reported outcome data were available for 73 patients in the PLIF group and 71 in the PLF group at a mean of 11 (range 5–16) years after baseline. Seventy-seven patients in the PLIF group and 54 in the PLF group had radiographs at a mean of 14 (range 9–19) years after baseline. One hundred thirty-six randomly selected persons from the population served as controls for the patient-reported outcomes. OUTCOME MEASURESPatient-reported outcomes include the following: global outcome, Oswestry Disability Index, Disability Rating Index, and Short Form 36. The ASD was determined from radiographs using the University of California Los Angeles (UCLA) grading scale. METHODS: The chi-square test or analysis of covariance (ANCOVA) was used for group comparisons. The ANCOVA was adjusted for follow-up time, smoking, Meyerding slippage grade, teetotaler (yes/no) and, if available, the baseline level of the dependent variable. RESULTSThere were no significant patient-reported outcome differences between the PLIF group and the PLF group. The prevalence of ASD was 42% (32/77) in the PLIF group and 26% (14/54) in the PLF group (p=.98). The patient-reported outcome data indicated lower physical function and more pain in individuals with surgically treated isthmic spondylolisthesis compared to the controls. CONCLUSIONSPLIF and PLF groups had similar long-term patient-reported and radiological outcomes. Individuals with isthmic spondylolisthesis have lower physical function and more pain several years after surgery when compared to the general population.

Wednesday, September 26, 2018 10:35 AM – 12:00 PM Understanding Lumbar Stenosis/Spondylolisthesis: 10. Comparing surgical outcomes between back pain dominant and leg pain dominant chief complaint for adult isthmic spondylolisthesis: a CSORN ambispective study

BACKGROUND CONTEXT Fusion for isthmic spondylolisthesis is a commonly performed lumbosacral surgery. Patients will present with either a chief complaint that is back dominant pain or leg dominant pain. It is well recognized by spinal surgeons, that patients requiring lumbar surgery for a complaint that is predominantly leg pain, (radicular or neurogenic claudication) will have superior postoperative outcomes than those with a predominant complaint of low back pain. This has been well described for the common surgical indications of lumbar disc herniation requiring discectomy and lumbar spinal stenosis requiring laminectomy for example. However, unlike these lumbar pathologies, lytic spondylolisthesis is associated with mal-alignment secondary to inherent instability which may be a cause of low back pain that would be more amendable to surgical treatment using a fusion procedure. PURPOSE To compare patient-rated outcomes between the patients with a chief complaint of low back pain versus radicular pain who were treated with a posterior fusion for isthmic spondylolisthesis. STUDY DESIGN/SETTING Ambispective study from the Canadian Spine Outcome and Research Network (CSORN). PATIENT SAMPLE Patients were identified form the Canadian Spine Society registry who underwent a posterior fusion for isthmic spondylolisthesis between 2013 and 2016. CSORN prospectively enrolls patients with spinal pathologies requiring surgical treatment from 16 tertiary care academic hospitals across Canada. Inclusion criteria for this study included: 18 years of age or older, minimum of 1 year follow-up, surgeon-determined chief complaint of either back dominant or radicular pain, and completed preoperative and postoperative patient-rated outcome measures for leg pain and back pain. OUTCOME MEASURES Patient-rated outcome measures included the Numeric Pain Rating Scale (NPRS) for back pain and leg pain, Oswestry Disability Index (ODI), SF-12 Physical Component Summary score (PCS) and Mental Component Summary score (MCS). METHODS Patients were classified into radicular pain (RP) or low back pain (LBP) groups according to their chief complaint which determined by the treating surgeon at the time of patient enrollment into the registry. Statistical analysis was performed on SPSS. Unpaired t-test, chi-square test or Fisher's exact test were used for comparison of patient characteristics and outcome scores between RP and LBP groups. Statistical significance was defined as P RESULTS A total of 136 patients were included according to the inclusion criteria. Seventy-six patients were female (56%). Eighty-seven (64%) patients had a chief complaint of RP and 49 (36%) patients had a chief complaint of LBP. There was no statistical significant difference in baseline demographics, except for mean BMI which was 28.9+/−6 for RP and 26.7+/−5.9 for LBP (p=.043). There was no statistical significant difference in preoperative back pain NPRS, ODI, PCS, or MCS between the two groups. The initial leg pain NPRS was significantly higher for the RP cohort (7.6+/−1.7) compared to the LBP cohort (5.9+/−2.6) (p=.00001).There was no difference in surgical parameters between groups. NPRS for leg and back pain, ODI, and PCS all significantly improved at 1-2 year follow-up. There was no difference between the RP and LBP cohorts in outcome measures. At 1-2 years following surgery, most patients were satisfied with treatment (85.9% RP vs. 88.5% LBP; p=.72). CONCLUSIONS The results of this study demonstrate that patients with a chief complaint of low back pain are expected to have similarly good outcomes as patients with a chief complaint of radicular pain following posterior spinal fusion for lytic spondylolisthesis. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Comparison of Simple Lumbar Inter Body Fusion with Circumferential Fusion for Treatment of Isthmic Spondylolisthesis

Purpose: Spondylolisthesis is a common cause of surgery in patients with lower back pain. Although inter body fusion and circumferential fusion are a relatively common surgical method for the treatment of spondylolisthesis, we retrospectively compared surgical reduction or fusion in situ with simple lumbar inter body fusion (PLIF/TLIF) and circumferential fusion (PLF+TLIF/PLIF) for adult isthmic spondylolisthesis in terms of surgical invasiveness, clinical and radio graphical outcomes, and complications. Methods: From January 2013 to June 2015, 84 adult patients with isthmic spondylolisthesis who underwent surgical treatment in our department were randomized to simple lumbar inter body fusion (PLIF/TLIF) group (group 1, n=45) and circumferential fusion (PLF+TLIF/PLIF) group (group 2, n=39), and followed up for average 28.6 months (range 24-54 months). All patients of both groups had low back pain as their predominant symptom, with varying degree of radicular pain and neurological symptoms. The data collected retrospectively for analysis were: duration of symptoms, levels of fusion, revision surgery, clinical and radiographic results after surgery, and complications. Result: All the 84 patients compared in two surgical approaches for IS were included in this retrospective studies. In our analysis, for the surgical management of isthmic spondylolisthesis, we indicated that both approaches lumbar inter body fusion (PLIF/TLIF) and circumferential fusion (PLF+TLIF/PLIF) have equal significant, greater fusion rates with successful clinical outcomes

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The standard surgical treatment for adult isthmic spondylolisthesis consists of various techniques of arthrodesis supplemented with instrumentation. However, the superiority of this strategy has not been irrefutably proved. Considering the risk associated with the instrumentation surgery, examining a less invasive approach is justified.We describe a series of 9 patients with adult isthmic spondylolisthesis, in whom we microsurgically decompressed the responsible nerve root in the intervertebral foramen through the posterolateral intermuscular approach. Technical details specific to isthmic spondylolisthesis were reviewed. The 2-year outcome was assessed with Short Form 36 and visual analog scale scores.The mean age of the patients was 68 ± 7 years (standard deviation [SD]). The mean slip rate of spondylolisthesis measured on the preoperative lumbar radiography was 20% ± 12% (SD). All patients successfully underwent the procedure without complications. All the examined scores remained significantly better than the preoperative values 2 years after surgery; the mean visual analog scale score decreased from 7.8 ± 2.8 (SD) preoperatively to 2.8 ± 1.4 (SD) at 2 years (P = 0.008), average physical score of Short Form 36 improved from 33.1 ± 9.7 to 52.5 ± 9.4 (P = 0.001), and the bodily pain score improved from 28.0 ± 13.5 to 55.1 ± 9.7 (P = 0.001).Microsurgical decompression through the posterolateral intermuscular approach was effective in producing good 2-year outcome in patients with adult isthmic spondylolisthesis. This procedure may be considered as a less invasive alternative in the surgical treatment of adult isthmic spondylolisthesis.

Outcomes of autograft alone versus PEEK+ autograft interbody fusion in the treatment of adult lumbar isthmic spondylolisthesis

ObjectivesBone resulting from a complete resection of the posterior arch can be cut into an autograft bone that contains the facet joint structure and morselised bone for interbody fusion. However, whether a strut autograft that contains this trimmed facet joint can produce the same clinical and radiographic outcomes as a cage for interbody fusion remains unclear. The aim of this study was to compare the outcomes of a local facet joint autograft alone to those of polyetheretherketone (PEEK)+autograft for posterior lumbar interbody fusion (PLIF) in the treatment of adult isthmic spondylolisthesis. Patients and methodsA retrospective analysis was performed on 84 patients with single lumbar isthmic spondylolisthesis who were treated with a local facet joint autograft alone (group A; n=44) or PEEK+autograft (group B; n=40) in PLIF with a minimum follow-up period of 24 months. Pain and disability were assessed using the visual analogue scale, Oswestry disability index and Kirkaldy-Willis criteria. In the radiological evaluation, disc height, slippage reduction, and fusion status were examined. Postoperative complications were also monitored. ResultsAt the last follow-up examination, 84.1% (37/44) of the patients in group A and 82.5% (33/40) of the patients in group B had a good outcome, and there were no significant differences between the two groups. Boh Methods led to significant improvements in disc height, and while PEEK+autograft produced a smaller loss in disc height, the difference was insignificant. The improvements in slippage and the fusion and complication rates between the two groups were similar. ConclusionThere were no significant differences in the clinical outcomes or radiographic improvements of both fusion methods in the treatment of adult isthmic spondylolisthesis. An autograft excised from a complete posterior arch containing a facet joint for interbody fusion is effective and affordable for treating isthmic spondylolisthesis.

Comparison of Simple Lumbar Interbody Fusion with CircumferentialFusion for Treatment of Isthmic Spondylolisthesis

Purpose: Spondylolisthesis is a common cause of surgery in patients with lower back pain. Although interbody fusion and circumferential fusion are a relatively common surgical method for the treatment of spondylolisthesis, we retrospectively compared surgical reduction or fusion in situ with simple lumbar interbody fusion (PLIF/TLIF) and circumferential fusion (PLF+TLIF/PLIF) for adult isthmic spondylolisthesis in terms of surgical invasiveness, clinical and radiographical outcomes, and complications. Methods: From January 2013 to June 2015, 84 adult patients with isthmic spondylolisthesis who underwent surgical treatment in our department were randomized to simple lumbar interbody fusion (PLIF/TLIF) group (group 1, n=45) and circumferential fusion (PLF+TLIF/PLIF) group (group 2, n=39), and followed up for average 28.6 months (range 24–54 months). All patients of both groups had low back pain as their predominant symptom, with varying degree of radicular pain and neurological symptoms. The data collected retrospectively for analysis were: duration of symptoms, levels of fusion, revision surgery, clinical and radiographic results after surgery, and complications. Results: All the 84 patients compared in two surgical approaches for IS were included in this retrospective studies. In our analysis, for the surgical management of isthmic spondylolisthesis, we indicated that both approaches lumbar interbody fusion (PLIF/TLIF) and circumferential fusion (PLF+TLIF/PLIF) have equal significant, greater fusion rates with successful clinical outcomes. Conclusion: Our clinical experience along with statistic findings indicates that in conclusion, there was no significant difference was found between simple interbody fusion (PLIF/TLIF) compared to circumferential fusion (PLF+TLIF/PLIF). Moreover, both techniques led to similar surgical outcomes and complication during follow-up. Thus, these results suggest that both procedures are equally effective for the treatment of isthmic spondylolisthesis.

Correlation between correction of pelvic balance and clinical outcomes in mid- and low-grade adult isthmic spondylolisthesis.

Pelvic balance is a version of the pelvis defined by pelvic orientation parameters of PT and SS. Two distinct versions of pelvis are defined: (1) balanced characterized by a relatively low PT and high SS, and (2) unbalanced with relatively high PT and low SS meaning excessive retroversion of the pelvis. It was proved for patients with a high-grade spondylolisthesis that rebalancing of the pelvis can positively affect clinical outcomes. Little is known about the impact of such rebalancing in low-grade isthmic spondylolisthesis. To determine whether clinical outcomes correlated with rebalancing of the pelvis after surgical correction of mid- and low-grade adult isthmic spondylolisthesis. One hundred and three adult patients with a mid- and low-grade isthmic slip were the participants. Clinical outcomes were assessed at least 2years after the surgery with the use of the Oswestry Disability Index (ODI) and a back pain visual analogue scale. Statistical analysis was used to identify differences in clinical outcomes between patients (1) with a balanced and unbalanced pelvis postoperatively, (2) who regained and did not regain pelvic balance postoperatively, (3) who maintained and lost pelvic balance postoperatively, and (4) with reduced and increased postoperative PT. There were no significant differences in clinical outcomes between patients with a balanced and unbalanced pelvis postoperatively regardless of whether they lost, maintained, or regained pelvic balance after the surgery (Student's t test for independent variables or the non-parametric Mann-Whitney U, p value=0.05). No correlation (Spearman's rank correlation) was found between postoperative reduction of PT and postoperative: (1) level of back pain (r=-0.10, p=0.3063), (2) degree of reduction in back pain (r=0.03, p=0.7927), (3) ODI scores (r=-0.18, p=0.0696), and (4) degree of reduction in ODI scores (r=0.13, p=0.1893). Radiological improvement of pelvic balance after surgical correction of mid- and low-grade isthmic spondylolisthesis did not correlate with clinical outcomes.