Cases Of Degenerative Spondylolisthesis Research Articles

Clinical study on real-time three-dimensional CT navigation-guided full-endoscopic lumbar interbody fusion

To analyze the technical notes, effectiveness, and current issues of real-time three-dimensional CT navigation-guided full-endoscopic lumbar interbody fusion. Between April 2020 and October 2021, a total of 27 patients received real-time three-dimensional CT navigation-guided full-endoscopic lumbar interbody fusion. There were 18 males and 9 females with an average age of 63.2 years (range, 48-84 years). There were 6 cases of lumbar spinal stenosis, 1 case of lumbar instability, 9 cases of lumbar spinal stenosis with instability, 3 cases of degenerative spondylolisthesis, 6 cases of isthmus spondylolisthesis, and 2 cases of recurrent lumbar disc herniation. All patients showed neurological symptoms before operation (ipsilateral symptom for 15 cases and bilateral symptom for 12 cases). The symptom duration was 1-300 months (median, 24 months). The operations were performed via transforaminal approach in 8 cases, trans-facet joint approach in 18 cases, and combined approaches in 1 case. A total of 32 levels were fused, including 23 single-level cases, 3 two-level cases, and 1 three-level case. Lumbar fusion segment was L 2, 3 in 1 case, L 3, 4 in 4 cases, L 4, 5 in 20 cases, and L 5, S 1 in 7 cases. The operation time, intraoperative estimated blood loss (IEBL), and perioperative complications were recorded. The improvement of intervertebral space height at fusion level was measured, and the accuracy of percutaneous pedicle screw (PPS) and Cage placement was also evaluated based on CT images performed at 1 week postoperatively. Visual analogue scale (VAS) score for both low back pain and leg pain, Japanese Orthopaedic Association (JOA) score, and Oswestry disability index (ODI) were evaluated before operation, at 1 week postoperatively, and at last follow-up. Satisfaction to effectivenss were assessed by patients using modified MacNab criteria at last follow-up. The operation time was ranged from 255 to 805 minutes (mean, 424.9 minutes). IEBL was 150-290 mL (mean, 219.3 mL). All patients received follow-up with the duration from 4 to 22 months (mean, 12.4 months). At 1 week postoperatively and last follow-up, VAS scores of low back pain and leg pain, JOA score, and ODI were significantly improved when compared with those before operation ( P<0.05). At last follow-up, the clinical indicators were similar in comparison with those at 1 week postoperatively ( P>0.05). There were 26 patients and 1 patient who respectively ranked excellent and mild in terms of effectiveness according to the modified MacNab criteria, with the excellent and good rate of 96.3%. There was 1 patient who suffered from incomplete injury of L 5 nerve root and partial neurological function recovered after 3-month conservative treatments. There were 118 implanted PPSs, and 116 of them were implanted under navigation. There were 33 Cages that were implanted under navigation. The accuracy of PPS and Cage placement was 99.1% and 97.0% respectively based on CT performed at 1 week postoperatively. The postoperative intervertebral space height was significantly increased in comparison with that before operation ( P<0.05). During follow-up, mild Cage subsidence was observed in 1 patient, whereas no fixation loosing was found. Real-time three-dimensional CT navigation-guided full-endoscopic lumbar interbody fusion has great safety and effectiveness with satisfactory preliminary clinical results. Design and further improvement of surgical equipment and instruments are expected to resolve the current technical difficulties.

Comparison of adjacent segment degeneration following single-segment minimally invasive and open transforaminal lumbar interbody fusion

Objective To compare the incidence of adjacent segment degeneration (ASDeg) and clinical outcomes of minimally invasive versus traditional transforaminal lumbar interbody fusion (TLIF) in the treatment of L 4,5 single-segment lumbar spinal stenosis (LSS) and explore the risk factors of ASDeg. Methods All of 115 patients with LSS who were treated by the same group of doctors from 2009 to 2013, with a minimum follow-up of 5 years. Thirty-eight patients underwent minimally invasive trans-foraminal lumbar interbody fusion (MIS-TLIF) and 77 patients underwent traditional TLIF. Standing radiographs at the preopera-tive period and the final follow-up were assessed. Radiological parameters included lumbar lordosis (LL), fused segment angle (FSA), disc height (DH) and range of motion (ROM). Babu classification was used to identify facet joint violation (FJV) in patients at 5-year follow-up. Clinical outcomes were assessed according to visual analog scale (VAS) score, Japanese Orthopaedic Associa-tion (JOA) score and Oswestry Disability Index (ODI). Student's t-test, Chi-square test, and non-parametric test were used as the main statistical methods. Results The mean age of MIS-TLIF group was 58.2±8.8 years, and that of TLIF group was 54.7±11.2 years, and there was no significant difference between the two groups. The mean follow-up time was 64.5±3.8 months in the MIS-TLIF group and 63.9±3.3 months in the TLIF group, and there was no significant difference between the two groups. There were 17 cases of degenerative spondylolisthesis in MIS-TLIF group (44.7%) and 35 cases of degenerative spondylolisthesis in TLIF group (45.5%), and there was no significant difference between the two groups. There was no significant difference in DH and ROM of L3,4, L4,5, L5S1 between the two groups before operation. There was no significant difference in VAS, JOA and ODI scores between the two groups before operation. The VAS, JOA and ODI scores were significantly improved at the last follow-up compared with those before operation. After 5-year follow-up, 56 cases (48.7%) had ASDeg. The incidence of ASDeg was 31.6% in MIS-TLIF group and 57.1% in TLIF group, and there was statistical differences between the two groups (χ2=6.656, P <0.01). Among them, 32 cases only had upper segment ASDeg (6 cases in MIS-TLIF group, 26 cases in TLIF group), 19 cases only had lower segment ASDeg (6 cases in MIS-TLIF group, 13 cases in TLIF group), and 5 cases had both upper and lower ASDeg (5 cases in the TLIF group). The DH of adjacent segments decreased after operation, but the loss of DH in MIS-TLIF group was smaller than that in TLIF group, including L3,4 segments (-4.9%±6.4% vs-8.7%±7.2%, t=-2.761, P <0.01), L5S1 segment (-4.7%±9.8% vs-10.5%±11.7%, t=-2.623, P <0.01). The ROM of adjacent segments increased in both groups, but the increase of ROM in MIS-TLIF group was smaller than that in TLIF group, including L 3,4 segments (1.1°±1.8° vs 2.3°±2.5°, t=-3.122, P <0.01), L5S1 segment (0.9°± 1.9 ° vs 1.8°±1.9 °, t=-2.353, P <0.01). The incidence of FJV was 54.2% in patients with ASDeg in MIS-TLIF group and 47.7% in patients with ASDeg in TLIF group. Chi-square analysis showed that FJV was related to ASDeg in both groups (χ2=3.869, P < 0.05). Conclusion Both of the two surgical methods have good clinical effects on L 4,5 single-segment LSS. The incidence of AS-Deg after MIS-TLIF is lower than that of TLIF. FJV is a risk factor for ASDeg. Key words: Lumbar vertebrae; Spinal stenosis; Spinal fusion; Surgical procedures, minimally invasive; Postoperative complications

Reliability and Clinical Utility of the CARDS Classification for Degenerative Spondylolisthesis

Retrospective cohort study. The objective of this study is to determine the reliability and clinical utility of the of the proposed CARDS classification for degenerative spondylolisthesis. The Clinical and Radiographic Degenerative Spondylolisthesis (CARDS) classification system was recently proposed as an alternative to the Meyerding system for classifying degenerative spondylolisthesis (DS). Unlike Meyerding, CARDS considers other relevant radiographic findings such as disk space collapse and segmental kyphosis to stratify DS into 4 radiographically discreet types. Currently, no studies have been conducted to assess the clinical utility of the CARDS system. A total of 78 consecutive surgical patients with L4-L5 DS were rated as CARDS types A through D and Fleiss' κ for interobserver agreement was calculated. Then, demographics as well as preoperative and postoperative outcome scores (ODI, SF-12 mental and physical, VAS) were collected. The Kruskal-Wallis test was used to detect significant differences amongst CARDS types. An unpaired t test was used to compare individual CARDS types with all other subtypes combined. Grading showed: 4 type A, 19 type B, 45 type C, and 8 type D (k=0.63). There was a statistically significant difference in preoperative back pain (P=0.046) between groups. CARDS type D had the highest mean back pain scores (8.8) of all subtypes which was significantly higher than mean back pain for all other subtypes combined (P=0.016). CARDS D showed the largest degree of improvement in all outcome measures. There was a trend towards an increased improvement in ODI (P=0.074) and SF-12 MCS (P=0.095) in the CARDS D subtype relative to the rest of the cohort. The CARDS classification system represents a reliable method for classifying cases of DS. Our results indicate that kyphotic segmental alignment (CARDS D) may be a less common, yet clinically distinct subset of DS characterized by worse preoperative back pain. CARDS type D cases may also show a greater degree of improvement in multiple outcome measures following surgical intervention.

An International Multicenter Study Assessing the Role of Ethnicity on Variation of Lumbar Facet Joint Orientation and the Occurrence of Degenerative Spondylolisthesis in Asia Pacific: A Study from the AOSpine Asia Pacific Research Collaboration Consortium.

Study Design A multinational, multiethnic, cross-sectional image-based study was performed in 33 institutions, representing 10 countries, which were part of the AOSpine Asia Pacific Research Collaboration Consortium. Objective Lumbar facet joint orientation has been reported to be associated with the development of degenerative spondylolisthesis (DS). The role of ethnicity regarding facet joint orientation remains uncertain. As such, the following study was performed across a wide-ranging population base to assess the role of ethnicity in facet joint orientation in patients with DS in the Asia Pacific region. Methods Lateral standing X-rays and axial magnetic resonance imaging scans were obtained for patients with lumbar DS. The DS parameters and facet joint angulations were assessed from L3–S1. Sex, age, body mass index (BMI), and ethnicity were also noted. Results The study included 371 patients with known ethnic origin (mean age: 62.0 years; 64% males, 36% females). The mean BMI was 25.6 kg/m2. The level of DS was most prevalent at L4–L5 (74.7%). There were 28.8% Indian, 28.6% Japanese, 18.1% Chinese, 8.6% Korean, 6.5% Thai, 4.9% Caucasian, 2.7% Filipino, and 1.9% Malay patients. Variations in facet joint angulations were noted from L3 to S1 and between patients with and without DS (p < 0.05). No differences were noted with regards to sex and overall BMI to facet joint angulations (p > 0.05); however, increasing age was found to increase the degree of angulation throughout the lumbar spine (p < 0.05). Accounting for age and the presence or absence of DS at each level, no statistically significant differences between ethnicity and degree of facet joint angulations from L3–L5 were noted (p > 0.05). Ethnic variations were noted in non-DS L5–S1 facet joint angulations, predominantly between Caucasian, Chinese, and Indian ethnicities (p < 0.05). Conclusions This study is the first to suggest that ethnicity may not play a role in facet joint orientation in the majority of cases of DS in the Asia-Pacific region. Findings from this study may facilitate future comparative studies in other multiethnic populations. An understanding of ethnic variability may assist in identifying those patients at risk of postsurgical development or progression of DS. This study also serves as a model for large-scale multicenter studies across different ethnic groups and cultural boundaries in Asia.

Motion Characteristics of the Vertebral Segments with Lumber Degenerative Spondylolisthesis in Elderly Patients

Background Data: Spondylolisthesis refers to the forward displacement of one vertebra relative to another. Whether degenerative spondylolisthesis (DS) leads to instability was controversial in the literature. DS was conventionally considered to be instable but some papers have reported that there was no evidence that the range of motions (ROMs) of the vertebrae with DS were increased compared with normal vertebrae. Purpose: The aim of the work was to study motor characteristics of the vertebral segments with lumber degenerative spondylolisthesis in elderly patients aftersurgical management. Study Design: This is a prospective study. Patients and Methods: Thirty patients (age more than 55 years) with lumbar DS and failed conservative measures for at least three months before surgical treatmentwere included. Vertebral kinematics obtained using dynamic plain X. ray; also MRI and/or CT scan of lumbosacral spine were done. During functional postures, vertebral instability was studied. All cases operated upon from May 2013 toDecember 2013 in the Neurosurgery Department of Banha University hospital and followed up 6 months for at least. Patients were grouped into 2 groups according to vertebral instability: Group A (fifteen cases ) and Group B (fifteen cases) chosen without privilege to sex , or weight, but suffering from midline low back pain and/ or claudication that were proven to be attributed to spondylolisthesis. Clinical follow-up: done immediately, at 3 and 6 months intervals. The evaluation included the Japanese Orthopedic Association (JOA). Preoperative and last postoperative standing were done to measure the degree of slip and percentage of slip. Results: Adequate lumbar decompression alone in cases of Group A (with noevident range of motion) showed good outcome with less complications when compared with cases of Group B(showing instability) treated with decompression with posterolateral instrumented fusion using bilateral pedicle screw fixation.Conclusion: Lumbar DS is a degenerative disease of lumbar spine results in neural compression but does not result necessarily in vertebral instability, some cases of lumbar DS may need only neural decompression as re-stabilization process may have occurred but other cases show instability which required decompression with instrumented fusion. (2014ESJ082)

Hybrid technique of cortical bone trajectory and pedicle screwing for minimally invasive spine reconstruction surgery: a technical note.

The pedicle screw (PS) system is widely used for spinal reconstruction. Recently, screw insertion using the cortical bone trajectory (CBT) technique has been reported to provide increased holding strength of the vertebra, even in an osteoporotic spine. CBT is also beneficial due to its low invasiveness. We have been performing hybrid reconstruction with CBT at the cranial level and PS at the caudal level based on the concept of minimal invasiveness. We applied this hybrid technique to 6 cases of degenerative spondylolisthesis. Surgery was completed with a small skin incision of around 5-6 cm, which is shorter than that of the conventional PS procedure. The mean percent slippage before surgery was 19.8%, and this was reduced to 3.9% after surgery and almost maintained 3 months after surgery. Furthermore, no major surgical complications were observed. Here, we introduce the minimally invasive hybrid technique of CBT-PS. Surgeons should be aware of the procedure as an option for minimally invasive lumbar spine reconstructive surgery.

Morbidity and mortality in the surgical treatment of 10,242 adults with spondylolisthesis

Object This is a retrospective review of 10,242 adults with degenerative spondylolisthesis (DS) and isthmic spondylolisthesis (IS) from the morbidity and mortality (M&amp;M) index of the Scoliosis Research Society (SRS). This database was reviewed to assess complication incidence, and to identify factors that were associated with increased complication rates. Methods The SRS M&amp;M database was queried to identify cases of DS and IS treated between 2004 and 2007. Complications were identified and analyzed based on age, surgical approach, spondylolisthesis type/grade, and history of previous surgery. Age was stratified into 2 categories: &gt; 65 years and ≤ 65 years. Surgical approach was stratified into the following categories: decompression without fusion, anterior, anterior/posterior, posterior without instrumentation, posterior with instrumentation, and interbody fusion. Spondylolisthesis grades were divided into low-grade (Meyerding I and II) versus high-grade (Meyerding III, IV, and V) groups. Both univariate and multivariate analyses were performed. Results In the 10,242 cases of DS and IS reported, there were 945 complications (9.2%) in 813 patients (7.9%). The most common complications were dural tears, wound infections, implant complications, and neurological complications (range 0.7%–2.1%). The mortality rate was 0.1%. Diagnosis of DS had a significantly higher complication rate (8.5%) when compared with IS (6.6%; p = 0.002). High-grade spondylolisthesis correlated strongly with a higher complication rate (22.9% vs 8.3%, p &lt; 0.0001). Age &gt; 65 years was associated with a significantly higher complication rate (p = 0.02). History of previous surgery and surgical approach were not significantly associated with higher complication rates. On multivariate analysis, only the grade of spondylolisthesis (low vs high) was in the final best-fit model of factors associated with the occurrence of complications (p &lt; 0.0001). Conclusions The rate of total complications for treatment of DS and IS in this series was 9.2%. The total percentage of patients with complications was 7.9%. On univariate analysis, the complication rate was significantly higher in patients with high-grade spondylolisthesis, a diagnosis of DS, and in older patients. Surgical approach and history of previous surgery were not significantly correlated with increased complication rates. On multivariate analysis, only the grade of spondylolisthesis was significantly associated with the occurrence of complications.

P165. Characterizing Radiographic Changes in 102 Consecutive Cases of Degenerative Spondylolisthesis

P165. Characterizing Radiographic Changes in 102 Consecutive Cases of Degenerative Spondylolisthesis

Diagnosis and conservative management of degenerative lumbar spondylolisthesis.

Degenerative spondylolisthesis (DS) is a disorder that causes the slip of one vertebral body over the one below due to degenerative changes in the spine. Lumbar DS is a major cause of spinal canal stenosis and is often related to low back and leg pain. We reviewed the symptoms, prognosis and conservative treatments for symptoms associated with DS. PubMed and MEDLINE databases (1950-2007) were searched for the key words "spondylolisthesis", "pseudospondylolisthesis", "degenerative spondylolisthesis", "spinal stenosis", "lumbar spine", "antherolisthesis", "posterolisthesis", "low back pain", and "lumbar instability". All relevant articles in English were reviewed. Pertinent secondary references were also retrieved. The prognosis of patients with DS is favorable, however, those who suffer from neurological symptoms such as intermittent claudication or vesicorectal disorder, will most probably experience neurological deterioration if they are not operated upon. Nonoperative treatment should be the initial course of action in most cases of DS, with or without neurologic symptoms. Treatment options include use of analgesics and NSAIDs to control pain; epidural steroid injections, and physical methods such as bracing and flexion strengthening exercises. An up-to-date knowledge on diagnosis and prevention of lumbar DS can assist in determination of future research goals. Additional studies are required to establish treatment protocols for the conservative treatment of DS.

Pedicle screw insertion: computed tomography versus fluoroscopic image guidance

Computed tomography image-guided surgery (CTGS) clearly improves the accuracy of pedicle screw insertion. Recent reports claim that a fluoroscopy-guided system (FGS) offered high accuracy and easy application. However, the superiority of either technique remains unclear in clinical application. This study compares the accuracy of pedicle screws installed using CTGS with that of screws installed using FGS. Seventy-four screws inserted using FGS in 13 patients and 76 screws inserted using CTGS in 11 patients were compared. The study population included ten cases of vertebral fracture, five cases of degenerative spondylolisthesis, three cases of spondylolytic spondylolisthesis, two cases of tuberculous spondylitis, two cases of failed earlier back surgery and two case of ankylosing spondylitis with pseudarthrosis. The installed vertebral levels ranged from T8 to S1. Screw positions were assessed with postoperative radiographs and computed tomography. Sixty-nine (93.2%) screws were correctly placed in the FGS group, and seventy-three (96.1%) screws were correctly placed in the CTGS group (P=0.491). The results indicated that both image-guided systems offer high accuracy. However, the fluoroscope image-guided system could be considered the primary tool for lower thoracic and lumbosacral pedicle placement because it enables real-time navigation and does not require a preoperative CT scan.

Treatment of lumbar spinal stenosis with a total posterior arthroplasty prosthesis: implant description, surgical technique, and a prospective report on 29 patients

Total disc replacement is an alternative to lumbar fusion, but patients with spinal stenosis, spondylolisthesis, and facet arthropathy are often excluded from this procedure because increased adjacent-segment motion can exacerbate dorsal spondylotic changes. In such cases of degenerative spondylolisthesis with stenosis, decompression and fusion remain the gold standard of treatment. To avoid attendant loss of motion at the treated segment, the TOPS system is a novel total posterior arthroplasty prosthesis that allows for an alternative dynamic, multiaxial, three-column stabilization and motion preservation. The purpose of this study is to report preliminary surgical data and clinical outcomes in patients treated with the TOPS lumbar total posterior arthroplasty system. Twenty-nine patients were enrolled in a nonrandomized, multicenter, prospective pilot study outside the US. All patients had spinal stenosis and/or spondylolisthesis at L4-5 due to facet arthropathy. Radiographs and scores on outcome measures including the visual analog scale (VAS) for pain, Oswestry Disability Index (ODI), Short Form-36, and Zurich Claudication Questionnaire were prospectively recorded before surgery and at 6-week, 3-month, 6-month, and 1-year intervals after surgery. Prior to instrumentation, a bilateral total facetectomy and laminectomy at L4-5 or L3-4 was performed via a standard midline posterior approach. After decompression, the TOPS screws were inserted into four pedicles to achieve maximal purchase with triangulating bicortical trajectories. An appropriately sized TOPS arthroplasty implant was then applied. The mean surgical time was 3.1 hours, and patients' clinical status improved significantly following treatment with the TOPS device. The mean ODI score decreased compared with baseline by 41% at 1 year, and the 100-mm VAS score declined by 76 mm over the same time period. Radiographic analysis showed that lumbar motion was maintained, disc height was preserved, and no evidence of screw loosening was found. No device malfunctions or migrations and no device-related adverse events were reported during the study. The TOPS total posterior arthroplasty system represents a novel, dynamic, posterior arthroplasty device that provides multiaxial stability in flexion, extension, rotation, and lateral bending after total facetectomy and neural decompression. The surgical data indicate that it can be safely applied via a traditional approach with low surgical morbidity and excellent 1-year functional and radiographic outcomes in patients with degenerative spondylolisthesis accompanied by stenosis and back pain.

Treatment of lumbar spinal stenosis with a total posterior arthroplasty prosthesis: implant description, surgical technique, and a prospective report on 29 patients

Posterior dynamic stabilization (PDS) devices promise to relieve pain by altering the transmission of any abnormal loads across degenerative discs. These devices can function as an adjunct in the presence of anterior and posterior total disc replacement (TDR). Clinical reports on currently available PDS devices are reviewed and their applicability to TDR is discussed. Products being developed that incorporate posterior TDR prostheses with PDS devices are also reviewed. The PDS devices described can be used in conjunction with anterior TDR at the time of the initial surgery or at a later date. Posterior TDR prostheses used in conjunction with PDS devices will have a role in the marketplace in the future.

Sagittal plane configuration of the sacrum in spondylolisthesis.

A radiographic study of the sagittal sacral deformity in spondylolisthesis. To characterize and classify the pathoanatomy of sagittal sacral deformation in spondylolisthesis. Spondylolisthesis has been extensively described and reviewed in the literature. Deformity of the entire sacrum in spondylolisthesis potentially could affect the natural history, treatment options, and outcome. The sagittal contour of the entire human sacrum has never been quantitatively studied in spondylolisthesis. A literature search was performed and data was gathered retrospectively on patients with spondylolisthesis at the authors' institution. Cases of degenerative spondylolisthesis were excluded. Specifically those patients with L5-S1 spondylolisthesis were studied. The authors studied standing lateral radiographs and performed statistical analysis to understand morphologic relations. A broad range of global sacral kyphosis (37-188 degrees ) exists in spondylolisthesis. Increasing sacral kyphosis is significantly associated with increasing percent slip, sacral horizontal angle, Neuman's classification, lumbar lordosis, and lumbar index. A simple classification of the spectrum of sacral deformity in the sagittal plane is presented. The entire sacrum in spondylolisthesis can develop a significant kyphotic deformity in the sagittal plane, and this is associated with other abnormalities found in the lumbosacral spine. Sacral deformity is a significant factor in the assessment of the sagittal contour of the patient with L5-S1 spondylolisthesis.

腰部脊柱管狭窄症の観血的治療経験

Low back pain accompanied with degenerative lumbar spine is an important problem as well as cauda equina syndrome for lumbar spinal canal stenosis. The purpose of the surgical intervention is to decompress the neural stractures without spoiling stability of the lumbar spine. In point of this purpose, Wedge's osteotomy is one of the ideal methods for laminectomy. Multiple fenestration at the narrow interlaminar segments is a new method.We treated nineteen cases of the lumbar spinal canal stenosis surgically from 1982 o 1986 in our hospital. Central laminectomy was done in one case, Modified Wedge's osteotomy in eleven cases, multiple fenestration in five cases, anterior interbody fusion in two cases. Posterior spinal fusion was done in three cases of laminectomy, and in all cases of multiple fenestration. Harrignton distraction rod was employed in two cases, Harrignton compression rod in one case, and L-type rod in two cases.Good results were obtained concerning involvement of the cauda equina. But one case accompanied with cervical spondylotic myelopathy and one case with thoracic spinal cord tumor developed left paraparesis as sequelae due to spinal cord involvement. Low back pain was deteriorated postoperatively in two cases of laminectomy without fusion.One was a case of degenerative spondylolisthesis. In another one, postoperative stress ulcar occurred and long period of rest in bed was required.Instrumentation gave stability to the spinal column immediately after surgery and was able to make postoperative care easy.

腰椎変性すべり症における手術症例の検討

腰椎変性すべり症における手術症例の検討