Degenerative Spondylolisthesis Patients Research Articles

What are the differences in paraspinal muscle morphometry among degenerative spondylolisthesis patients, isthmic spondylolisthesis patients, and healthy individuals? A propensity score matching analysis

PurposeTo compare the morphometry of paraspinal muscles in patients with degenerative spondylolisthesis (DS), isthmic spondylolisthesis (IS), and healthy individuals.MethodsThirty-seven pairs of DS patients were selected using propensity score matching with IS patients, while 37 healthy individuals matched for age, sex, and BMI were selected as controls. The relative cross-sectional area (rCSA), and relative functional cross-sectional area (rfCSA) of paraspinal muscles were measured, and the degree of fatty infiltration (FI) was calculated. Based on occupational differences, the patients were also divided into worker and farmer groups, and the same measurements were taken on them.ResultsAt the L3/L4 level, the multifidus (MF) FI was greater in the DS and IS groups than in the control group, the erector spinae (ES) rfCSA was higher in the IS group than in the DS and control groups. At the L4/L5 level, MF rfCSA was smaller in the DS and IS groups than in the control group; ES rfCSA was higher in the IS group than in the DS and control groups. At the L5/S1 level, MF rfCSA was smaller in the DS and IS groups than in the control group; ES rfCSA was higher in the IS group than in the DS group. At the L3/L4, L4/L5 level, MF rfCSA were higher in the worker group than in the farmer group (p < 0.05).ConclusionThe morphological changes in paraspinal muscles in patients with DS were dominated by selective atrophy of the MF, while in patients with IS, the morphological changes in paraspinal muscle showed selective atrophy of the MF accompanied by compensatory hypertrophy of the ES. The surgeon should consider the morphological differences in paraspinal muscle between different types of lumbar spondylolisthesis when establishing the appropriate surgical program.

277 Clinical Outcome With and Without Adherence to Evidence-based Medicine Guidelines for Lumbar Degenerative Spondylolisthesis Fusion Patients

INTRODUCTION: Degenerative lumbar spondylolisthesis (DS) patients are treated with instrumented fusion, following EBM guidelines, and typically have excellent clinical outcomes. However, not all lumbar fusion procedures adhere to EBM guidelines, typically due to a lack of prospective data. METHODS: This study compared outcomes of lumbar fusion procedures for degenerative spondylolisthesis in two groups: 125 patients treated according to EBM guidelines and 21 patients without EBM literature support. ODI scores were collected pre- and post-surgery and categorized into SCB, MCID, no MCID, or no change/worsening. Statistical analysis included χ2, Fisher exact, and t-student tests. Multivariate logistic regression analyzed the odds of achieving MCID after six months of follow-up. RESULTS: The study included a total of 146 lumbar fusion patients, with the majority (125/146) adhering to EBM guidelines (EBM concordant) while a smaller proportion (21/146) did not (EBM discordant). The EBM concordant group demonstrated a statistically significant improvement in ODI scores compared to the EBM discordant group (p = 0.02). Compliance with EBM guidelines was associated with higher odds of achieving MCID, with an odds ratio of 2.93 and a confidence interval of 1.128-7.58 (p = 0.027). In the EBM concordant group, 42% of patients achieved SCB, and 64.8% showed MCID, whereas in the EBM discordant group, only 14% achieved SCB, and 38.1% showed MCID. These findings suggest that adherence to EBM guidelines in lumbar fusion procedures may lead to better clinical outcomes for patients. CONCLUSIONS: Patients whose lumbar fusions met the EBM criteria exhibited better self-reported outcomes at six months compared to those who did not meet the requirements. In order to strengthen EBM-guided patient care, an expanded knowledge base is needed.

Outcomes in Lumbar Fusion Patients Stratified by the Clinical and Radiographic Degenerative Spondylolisthesis (CARDS) Classification System.

Background and objective The Meyerding classification system remains the most common classification system for spondylolisthesis based on the percentages of vertebral translation. However, the majority of patients with degenerative disease fall into Grade 1, limiting its utility in this subset of patients. The Clinical and Radiographic Degenerative Spondylolisthesis (CARDS) classification system provides a simple radiographic framework for classifying degenerative lumbar spondylolisthesis (DLS) patients by incorporating disc height, kyphosis, and anterior translation. The purpose of this study was to evaluate how clinical characteristics, treatments, and outcomes vary across different CARDSgroups in patients undergoing one- or two-level lumbar fusion for DLS. Methods The patients were classified into one of the following four CARDS groups - Type A: advanced disc space collapse with no evidence of kyphosis; Type B: partially preserved disc space with less than 5.0 mm of translation; Type C: partially preserved disc space with greater than 5.0 mm of translation; and Type D: kyphotic alignment. Univariate analyses were performed to compare demographics, symptoms, clinical outcomes, and Patient-Reported Outcomes Measurement Information System (PROMIS) physical (PH) and mental health (MH) scores across groups. Results Ninety-one patients were included in the study. Based on the CARDS classification, there were three (3%) Type A patients, 25 (28%) Type B, 58 (64%) Type C, and five (5%) Type D. No significant differences in baseline demographics, symptom duration, or PROMIS scores were observed across groups. Interbody utilization varied, ranging from 19% in CARDS C (n=11) to 60% in CARDS B (n=15) and D (n=3) patients (p=0.005). Thirty-day clinical outcomes were similar across groups. At an average follow-up of 8.9 months, improvements in PROMIS PH and MH scores and rates of clinically significant improvement were similar across groups. Conclusions Based on our findings, patients undergoing lumbar fusion for DLS present with similar demographic and clinical characteristicsand experience similar clinical and patient-reported outcomes when stratified using the CARDS classification system. Posterolateral fusion (PLF) can be effective for various radiographic presentations of DLS. Further research is warranted to assess the utility of CARDS in preoperative planning.

Severe Preoperative Disability Is Associated With Greater Mental Health Improvements Following Surgery for Degenerative Spondylolisthesis: A Cohort Matched Analysis.

To evaluate preoperative disability's influence on patient-reported outcomes (PROs) following surgery for degenerative spondylolisthesis (DS). DS patients who underwent surgical intervention were retrospectively identified from a single-surgeon spine registry. Cohorts based on Oswestry Disability Index (ODI) < 41 (milder disability) and ≥ 41 (severe disability) were created. Demographic differences were accounted for with 1:1 propensity score matching. For the matched sample, perioperative and PRO data were additionally collected. PROs assessed included mental health, physical function, pain, and disability. Pre- and up to 2-year postoperative PROs were utilized. Average time to final follow-up was 15.7 ± 8.8 months. Improvements in PROs and minimal clinically important difference (MCID) rates were calculated. Continuous variables were compared through Student t-test and categorical variables were compared through chi-square tests. Altogether, 214 patients were included with 77 in the milder disability group. The severe disability group had worse postoperative day (POD) 1 pain scores and longer hospital stays (p ≤ 0.038, both). The severe disability group reported worse outcomes pre- and postoperatively (p < 0.011, all), but had greater average improvement in 12-item Short Form health survey mental composite score (SF-12 MCS), 9-Item Patient Health Questionnaire (PHQ-9), visual analogue scale (VAS)-back, and ODI by 6 weeks (p ≤ 0.037, all) and PHQ-9, VAS-back and ODI by final follow-up (p ≤ 0.015, all). The severe disability cohort was more likely to achieve MCID for SF-12 MCS, PHQ-9, and ODI (p ≤ 0.003, all). Patients with greater baseline disability report higher POD 1 pain and discharge later than patients with milder disability. While these patients report inferior physical/mental health before and after surgery, they report greater improvements in mental health and disability postoperatively.

Analysis of the causes of cage subsidence after oblique lateral lumbar interbody fusion

To observe the cage subsidence after oblique lateral interbody fusion (OLIF) for lumbar spondylosis, summarize the characteristics of the cage subsidence, analyze causes, and propose preventive measures. The data of 144 patients of lumbar spine lesions admitted to our hospital from October 2015 to December 2018 were retrospectively analyzed. There were 43 males and 101 females, and the age ranged from 20 to 81 years old, with an average of (60.90±10.06) years old. Disease types:17 patients of lumbar intervertebral disc degenerative disease, 12 patients of giant lumbar disc herniation, 5 patients of discogenic low back pain, 33 patients of lumbar spinal stenosis, 26 patients of lumbar degenerative spondylolisthesis, 28 patients of lumbar spondylolisthesis with spondylolisthesis, 11 patients of adjacent vertebral disease after lumbar internal fixation, 7 patients of primary spondylitis in the inflammatory outcome stage, and 5 patients of lumbar degenerative scoliosis. Preoperative dual-energy X-ray bone mineral density examination showed 57 patients of osteopenia or osteoporosis, and 87 patients of normal bone density. The number of fusion segments:124 patients of single-segment, 11 patients of two-segment, 8 patients of three-segment, four-segment 1 patient. There were 40 patients treated by stand-alone OLIF, and 104 patients by OLIF combined with posterior pedicle screw. Observed the occurrence of fusion cage settlement after operation, conducted monofactor analysis on possible risk factors, and observed the influence of fusion cage settlement on clinical results. All operations were successfully completed, the median operation time was 99 min, and the median intraoperative blood loss was 106 ml. Intraoperative endplate injury occurred in 30 patients and vertebral fracture occurred in 5 patients. The mean follow-up was (14.57±7.14) months from 6 to 30 months. During the follow-up, except for the patients of primary lumbar interstitial inflammation and some patients of lumbar spondylolisthesis with spondylolisthesis, the others all had different degrees of cage subsidence. Cage subsidence classification:119 patients were normal subsidence, and 25 patients were abnormal subsidence (23 patients were gradeⅠ, and 2 patients were gradeⅡ). There was no loosening or rupture of the pedicle screw system. The height of the intervertebral space recovered from the preoperative average (9.48±1.84) mm to the postoperative average (12.65±2.03) mm, and the average (10.51±1.81) mm at the last follow-up. There were statistical differences between postoperative and preoperative, and between the last follow-up and postoperative. The interbody fusion rate was 94.4%. The low back pain VAS decreased from the preoperative average (6.55±2.2 9) to the last follow-up (1.40±0.82), and there was statistically significant different. The leg pain VAS decreased from the preoperative average (4.72±1.49) to the final follow-up (0.60±0.03), and the difference was statistically significant (t=9.13, P<0.000 1). The ODI index recovered from the preoperative average (38.50±6.98)% to the latest follow-up (11.30±3.27)%, and there was statistically significant different. The complication rate was 31.3%(45/144), and the reoperation rate was 9.72%(14/144). Among them, 8 patients were reoperated due to fusion cage subsidence or displacement, accounting for 57.14%(8/14) of reoperation. The fusion cage subsidence in this group had obvious characteristics. The monofactor analysis showed that the number of abnormal subsidence patients in the osteopenia or osteoporosis group, Stand-alone OLIF group, 2 or more segments fusion group, and endplate injury group was higher than that in the normal bone mass group, OLIF combined with pedicle screw fixation group, single segment fusion group, and no endplate injury group, and the comparison had statistical differences. Cage subsidence is a common phenomenon after OLIF surgery. Preoperative osteopenia or osteoporosis, Stand-alone OLIF, 2 or more segments of fusion and intraoperative endplate injury may be important factors for postoperative fusion cage subsidence. Although there is no significant correlation between the degree of cage subsidence and clinical symptoms, there is a risk of cage migration, and prevention needs to be strengthened to reduce serious complications caused by fusion of cage subsidence, including reoperation.

Comprehensive Assessment of Indirect Decompression Through Lateral Lumbar Interbody Fusion for Degenerative Lumbar Spinal Stenosis: A Japanese Orthopedic Association Back Pain Evaluation Questionnaire-Based Analysis.

A retrospective study. This study aimed to comprehensively evaluate the clinical outcomes of lateral lumbar interbody fusion (LLIF) as an indirect decompression technique for degenerative spondylolisthesis (DS) and concomitant degenerative lumbar spinal stenosis (DLSS) patients. We utilized the Japanese Orthopedic Association Back Pain Evaluation Questionnaire (JOABPEQ) to assess treatment success and its impact on patient's quality of life (QOL). We included 124 patients who underwent LLIF. Pre- and postoperative JOABPEQ evaluations indicated treatment success. Subgroup analysis categorized patients' perceptions of surgery as beneficial or non-beneficial. 89% of patients (110/124) reported satisfaction with LLIF. Lateral lumbar interbody fusion achieved successful indirect decompression, increasing canal diameter and central canal area. Significant improvements occurred across all JOABPEQ domains, notably for low back pain, lumbar function, walking ability, social life function, and mental health. Patients who perceived the surgery as beneficial experienced fewer postoperative complications, lower numeric rating scale scores for pain relief, and greater functional outcome improvements compared to non-beneficial patients. Our findings highlight the utility of JOABPEQ as a valuable and sensitive tool for assessing treatment effectiveness and patient-reported outcomes in DS and concomitant DLSS patients. Patients undergoing LLIF. The results affirm the favorable outcomes of LLIF as a surgical option for DLSS patients and emphasize the importance of considering patient perspectives when evaluating overall treatment success. The study provides valuable insights into the impact of indirect decompression on patients' QOL, supporting the effectiveness of LLIF as a minimally invasive technique for DLSS and DS management.

Clinical and radiographic outcomes of oblique lumbar interbody fusion with anterolateral screw and rod instrumentation in osteopenia patients: a retrospective study

PurposeThe purpose of this paper is to evaluate the clinical and radiographic outcomes of oblique lumbar interbody fusion (OLIF) to perform in L4/5 degenerative lumbar spondylolisthesis (DLS) patients who diagnosed with osteopenia.MethodsFrom December 2018 to 2021 March, 94 patients were diagnosed with degenerative spondylolisthesis underwent OLIF and divided into two groups with different bone mineral density. Anterolateral screw and rod instrumentation was applied in two groups. The primary outcomes were VAS, JOA and ODI. The secondary outcomes included disc height (DH), cross-sectional height of the intervertebral foramina (CSH), cross-sectional area of the dural sac (CSA), lumbar lordorsis (LL), pelvic titlt (PT), pelvic incidence (PI) and sacrum slop (SS).ResultsAll patients finished at least 1 years follow-up with 21.05 ± 4.42 months in the group A and 21.09 ± 4.28 months in the group B. The clinical symptoms were evaluated by VAS, JOA and ODI and 94 patients showed good outcomes at final follow-up (P < 0.05), with significant increases in DH, CSH and CSA. In group A, DH increased from 8.54 ± 2.48 to 11.11 ± 2.63 mm, while increased from 8.60 ± 2.29 to 11.23 ± 1.88 were recorded in group B. No statistical difference was found in DH between the two groups (P > 0.05). The cage subsidence was 1.14 ± 0.83 mm in group A and 0.87 ± 1.05 mm in group B (P > 0.05). There was no significant difference in the adjusted parameters of spino-pelvic between two groups (P > 0.05).ConclusionOblique lumbar interbody fusion with anterolateral screw and rod instrumentation is feasible to be performed in osteopenia patients who diagnosed with degenerative spondylolisthesis.

Sagittal alignment in operative degenerative lumbar spondylolisthesis: a scoping review.

The benefit of surgical intervention over conservative treatment for degenerative lumbar spondylolisthesis (DLS) patients with neurologic symptoms is well-established. However, it is currently unclear what breadth of available evidence exists on regional and global sagittal alignment in DLS surgery. As such, the purpose of the current study is to conduct a scoping review to map and synthesize the DLS literature regarding the current radiographic assessment of sagittal spinal alignment in DLS surgery. A comprehensive search of the MEDLINE, EMBASE and Cochrane databases from January 1971 to January 2023 was performed for all DLS studies examining sagittal spinal alignment parameters with DLS surgery according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Review (PRISMA-ScR) protocol. From 2,222 studies, a total of 109 studies were included, representing 10,730 patients with an average age of 63.0 years old and average follow-up of 35.1 months postoperatively. Among included studies, 93 (85%), were largely published in the last decade and predominantly represented retrospective cohorts 70 (64%) or case series 22 (20%). A common theme among the reporting of radiographic parameters in the included investigations was the assessment of the magnitude and/or maintenance of a radiographic change postoperatively, with 92 (84%) studies reporting these findings. The majority of studies focused on index DLS level [33 (30%) studies] or lumbar spine radiographic imaging [33 (30%) studies] only. Thirty-seven (34%) studies reported spinopelvic parameters, with only 13 (12%) of included studies assessing 36-inch standing lateral radiographs and overall alignment. There is increasing prevalence of investigations assessing sagittal spinal alignment parameters in DLS surgery. Although, there is an increasing prevalence of studies investigating sagittal spinal alignment parameters in DLS surgery the quality of the currently available literature on this topic is of overall low evidence and largely retrospective in nature. Additionally, there is limited analysis of global sagittal spinal alignment in DLS suggesting that future investigational emphasis should prioritize longitudinally followed large prospective cohorts or multi-centre randomized controlled trials. Attempts at standardizing the radiographic and functional outcome reporting techniques across multi-centre investigations and prospective cohorts will allow for more robust, reproducible analyses of significance to be conducted on DLS patients.

A systematic review and meta-analysis of risk factors for reoperation after degenerative lumbar spondylolisthesis surgery

BackgroundConsidering the high reoperation rate in degenerative lumbar spondylolisthesis (DLS) patients undergoing lumbar surgeries and controversial results on the risk factors for the reoperation, we performed a systematic review and meta-analysis to explore the reoperation rate and risk factors for the reoperation in DLS patients undergoing lumbar surgeries.MethodsLiterature search was conducted from inception to October 28, 2022 in Pubmed, Embase, Cochrane Library, and Web of Science. Odds ratio (OR) was used as the effect index for the categorical data, and effect size was expressed as 95% confidence interval (CI). Heterogeneity test was performed for each outcome effect size, and subgroup analysis was performed based on study design, patients, surgery types, follow-up time, and quality of studies to explore the source of heterogeneity. Results of all outcomes were examined by sensitivity analysis. Publication bias was assessed using Begg test, and adjusted using trim-and-fill analysis.ResultsA total of 39 cohort studies (27 retrospective cohort studies and 12 prospective cohort studies) were finally included in this systematic review and meta-analysis. The overall results showed a 10% (95%CI: 8%-12%) of reoperation rate in DLS patients undergoing lumbar surgeries. In surgery types subgroup, the reoperation rate was 11% (95%CI: 9%-13%) for decompression, 10% (95%CI: 7%-12%) for fusion, and 9% (95%CI: 5%-13%) for decompression and fusion. An increased risk of reoperation was found in patients with obesity (OR = 1.91, 95%CI: 1.04–3.51), diabetes (OR = 2.01, 95%CI: 1.43–2.82), and smoking (OR = 1.51, 95%CI: 1.23–1.84).ConclusionsWe found a 10% of reoperation rate in DLS patients after lumbar surgeries. Obesity, diabetes, and smoking were risk factors for the reoperation.

488 Prospective Evaluation of Racial Disparities in Surgical Treatment Of Degenerative Spondylolisthesis Using PROMIS Pain Interference And Physical Function Scores

INTRODUCTION: Spine surgery for degenerative spondylolisthesis is indicated in patients who remain symptomatic despite a course of nonsurgical therapy. Patient’s report of pain interference and physical function are key indicators for intervention. We know that Black and indigenous patients of color have poorer outcomes in back pain. This study aims to identify trends in intervention for degenerative spondylolisthesis based on race and patient-reported outcomes. METHODS: A prospective cohort study of degenerative spondylolisthesis patients seen in Harvard Medical School-affiliated clinics from 2015 to 2022 and who completed the routinely collected PROMIS patient-reported outcome measures (PROMs): Physical Function (PF) and pain Interference (PI). PROMIS scores are standardized to the U.S. population (mean score = 50). Regression analyses were performed to determine factors associated with treatment assignment. RESULTS: In this study, 22 374 patients (mean Age, 66.91(14.22); Female, 64%; BIPOC, 3019 (13%)) completed PROMs at baseline. Medicaid coverage was more prevalent among BIPOC (13% vs. 3.1%; P &lt; 0.001) who were less likely to receive an interventional treatment (351/ 3,019 (12%) vs. 3,021 / 19,355 (16%); P &lt; 0.001) despite a significantly higher pain interference score (62.32 (8.37) vs. 61.51 (8.35); P &lt; 0.001). White race was associated with higher odds of receiving surgical treatment than BIPOC after adjusting for age, comorbidities, medical coverage, physical function, and pain interference at baseline (OR = 1.20; 95 CI, 1.15-1.26; P &lt; 0.001). CONCLUSIONS: Despite higher pain interference scores, BIPOC patients were less likely to be offered spine surgery for degenerative spondylolisthesis, indicating that race is a predictor of spine surgery after accounting for comorbidities, physical function, and disability at diagnosis.

Letter to the Editor concerning "Magnetic Resonance Imaging Proxies for Segmental Instability in Degenerative Lumbar Spondylolisthesis Patients" by Elmose et al.

Tsukamoto, Masatsugu MD, PhD; Morimoto, Tadatsugu MD, PhD, MD; Hirata, Hirohito MD, PhD; Yoshihara, Tomohito MD, PhD; Mawatari, Masaaki MD, PhD Author Information

Response to "Letter to the Editor Regarding: Magnetic Resonance Imaging Proxies for Segmental Instability in Degenerative Lumbar Spondylolisthesis Patients".

Forbech Elmose, Signe MDa; Oesterheden Andersen, Mikkel MDa; Sigmundsson, Freyr Gauti MD, PhDb; Yacat Carreon, Leah MD, MSca Author Information

Clinical Outcomes with and without Adherence to Evidence-Based Medicine Guidelines for Lumbar Degenerative Spondylolisthesis Fusion Patients.

Degenerative lumbar spondylolisthesis (DS) patients are treated with instrumented fusion, following EBM guidelines, and typically have excellent clinical outcomes. However, not all lumbar fusion procedures adhere to EBM guidelines, typically due to a lack of prospective data. This retrospective study compared outcomes of DS lumbar fusion patients treated according to EBM guidelines (EBM concordant) to lumbar fused patients with procedures that did not have clear EBM literature that supported this treatment, the goal being to examine the value of present EBM to guide clinical care. A total of 125 DS patients were considered EBM concordant, while 21 patients were EBM discordant. Pre- and postsurgical ODI scores were collected. Clinical outcomes were stratified into substantial clinical benefit (SCB ΔODI >10 points), minimal clinical importance benefit (MCID ΔODI ≥ 5 points), no MCID (ΔODI < 5 points), and a group that showed no change or worsening ODI. Fisher's exact and χ2 tests for categorical variables, Student's t-test for continuous variables, and descriptive statistics were used. Statistical tests were computed at the 95% level of confidence. Analysis of 125 degenerative spondylolisthesis patients was performed comparing preoperative and postoperative (6 months) ODI scores. ODI improved by 8 points in the EBM concordant group vs. 2.1 points in the EBM discordant group (p = 0.002). Compliance with EBM guidelines was associated with an odds ratio (OR) of 2.93 for achieving MCID ([CI]: 1.12-7.58, p = 0.027). Patients whose lumbar fusions met EBM criteria had better self-reported outcomes at six months than those who did not meet the requirements. A greater knowledge set is needed to help further support EBM-guided patient care.

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

Surgical decompression is standard care in the treatment of degenerative spondylolisthesis in patients with symptomaticlumbar spinal stenosis, but there remains controversy over the benefits of adding fusion. The persistent lack of consensus on this matter and the availability of new data warrants a contemporary systematic review and meta-analysis of the literature. Multiple online databases were systematically searched up to October 2022 for randomized controlled trials (RCTs) and prospective studies comparing outcomes of decompression alone versus decompression with fusion for lumbar spinal stenosis in patients with degenerative spondylolisthesis. Primary outcome was the Oswestry Disability Index. Secondary outcomes included leg and back pain, surgical outcomes, and radiological outcomes. Pooled effect estimates were calculated and presented as mean differences (MD) with their 95% confidence intervals (CI) at two-year follow-up. Of the identified 2403 studies, eventually five RCTs and two prospective studies were included. Overall, most studies had a low or unclear risk of selection bias and most studies were focused on low grade degenerative spondylolisthesis. All patient-reported outcomes showed low statistical heterogeneity. Overall, there was high-quality evidence suggesting no difference in functionality at two years of follow-up (MD - 0.31, 95% CI - 3.81 to 3.19). Furthermore, there was high-quality evidence of no difference in leg pain (MD - 1.79, 95% CI - 5.08 to 1.50) or back pain (MD - 2.54, 95% CI - 6.76 to 1.67) between patients undergoing decompression vs. decompression with fusion. Pooled surgical outcomes showed less blood loss after decompression only, shorter length of hospital stay, anda similar reoperation ratecompared to decompression with fusion. Based on the current literature, there is high-quality evidence of no difference in functionality after decompression alone compared to decompression with fusion in patients with degenerative lumbar spondylolisthesis at 2years of follow-up. Further studies should focus on long-term comparative outcomes, health economic evaluations, and identifying those patients that may benefit more from decompression with fusion instead of decompression alone. This review was registered at Prospero (CRD42021291603).

121. The influence of frailty in spine surgery populations is highly variable: an analysis of 57,027 patients from the NSQIP database undergoing surgery for degenerative cervical myelopathy or lumbar spondylolisthesis

<h3>BACKGROUND CONTEXT</h3> Frailty is an emerging concept in risk prediction for spine surgery, but how the influence of frailty affects different populations of patients with different index pathologies has not been established. <h3>PURPOSE</h3> To compare the effect of frailty in predicting 30-day outcomes after surgery in two common patient populations: degenerative cervical myelopathy (DCM) and degenerative spondylolisthesis (DS). <h3>STUDY DESIGN/SETTING</h3> Statistical analysis of prospectively-collected registry data. <h3>PATIENT SAMPLE</h3> Patients included in the National Safety and Quality Improvement (NSQIP) database 2010-2018 undergoing a surgical procedure with a diagnosis of DCM or DS. <h3>OUTCOME MEASURES</h3> (1) Major complication (pneumonia, deep vein thrombosis (DVT), pulmonary embolism, myocardial infarction, cardiac arrest, wound infection or dehiscence, stroke, and sepsis) within 30 days, and (2) mortality, reoperation, readmission within 30 days, length of stay and discharge destination. <h3>METHODS</h3> Patients with a diagnosis of DCM or DS undergoing surgery were selected from an assimilated database of the NSQIP registry in the years 2010-2018 inclusive using the corresponding ICD-9/-10 codes. The 5-point modified frailty index (MFI-5) was then calculated for all patients using a score of 0 (Not-Frail), 1 (Pre-Frail) 2 (Frail) or 3 or more (Severely Frail). Simple demographics, including age, type of approach, number of levels, co-morbidities, fusion or nonfusion surgery and frailty distribution were compared using descriptive statistics for parametric and nonparametric data. Univariate analysis was used to define the odds ratio (OR) or beta coefficient (BC, continuous variables) of major complication, mortality, readmission, reoperation, length of hospital stay and discharge destination stratified by frailty, and then compared between DCM and DS cohorts. A multivariable model adjusting for age, gender and frailty was then used to test any significant effect seen. <h3>RESULTS</h3> A total of 41,369 patients underwent surgery for DCM compared to 15,658 patients who underwent surgery for DS. DCM patients (mean age 56.6[56.5-56.7]) were younger than DS patients (mean age 62.5[62.31-69.70]; p <0.001). In the DCM group, 80% underwent anterior approach, 17% posterior and 3% combined. In the DS group, 27.7% underwent posterior decompression alone compared to 72.3% with instrumented fusion. The DCM group had a higher proportion of non-frail patients (45%) compared to the DS group (36.8%), and the distribution of frailty was significantly different between cohorts (p <0.001). OR of a major complication was greater in the DCM patients compared to DS patients, for all strata of frailty (2.40[2.06-2.80] vs 1.75[1.38-2.24] for pre-frail, 3.80[3.22-4.48] vs 2.02[1.50-2.69] for frail, and 11.63[9.44-14.33] vs 2.68[1.51-4.75] for severely frail patients; p <0.001 for each). Frailty demonstrated a larger effect on the mortality in DCM patients compared to DS patients (OR for pre-frail 4.89[2.72-8.79] vs 5.34[1.21-23.69], OR for severely frail 27.70[14.29-53.69] vs 9.15[0.83-101.20]). This was also true for length of hospital stay and discharge to non-home destination. The effect of frailty on reoperation or readmission was equivalent. On multivariable analysis, DCM patients demonstrated significantly greater OR of major complication (1.35[1.20-1.52]; p <0.001), mortality (3.02[1.89-4.83] but a shorter length of hospital stay (BC -0.33[-0.42 - -0.24]; p <0.001). <h3>CONCLUSIONS</h3> This study shows the influence of frailty amongst patients undergoing surgery for DCM and DS populations is not equivalent. In DCM populations, frailty has a greater effect size for metrics such as major complication or mortality compared to DS patients, but the opposite is true for length of hospital stay. Further work is required to define the key elements of frailty assessment in these discrete populations. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

66. Can classification systems and baseline radiographic findings guide surgical technique selection for degenerative spondylolisthesis?

<h3>BACKGROUND CONTEXT</h3> The role of fusion in degenerative spondylolisthesis (DS) is controversial. The Clinical and Radiographic Degenerative Spondylolisthesis (CARDS) and Degenerative Spondylolisthesis Instability Classification (DSIC) systems were developed to assist surgeons in surgical technique selection based on individual patient characteristics. These systems have not been clinically validated. Additionally, it is unclear if baseline radiographic findings such as slip magnitude, angular and translational motion, and facet effusion are useful in guiding technique selection. <h3>PURPOSE</h3> The purpose of this study was to determine if outcomes vary with different surgical techniques across the CARDS and DSIC categories and with certain baseline radiographic findings. <h3>STUDY DESIGN/SETTING</h3> Prospective cohort study performed at one Swiss and one American spine center. <h3>PATIENT SAMPLE</h3> A total of 508 degenerative spondylolisthesis patients undergoing surgical treatment. <h3>OUTCOME MEASURES</h3> Core Outcomes Measure Index (COMI) at 3 months and 12 months postoperatively. <h3>METHODS</h3> DS patients undergoing surgery were enrolled at two institutions in Switzerland and the United States, and classified according to the CARDS and DSIC systems. MRIs were analyzed for Pfirrmann grade, disc height loss, presence of Schmorl's nodes, Modic changes, central and foraminal stenosis severity, magnitude of listhesis, magnitude of facet joint effusion, and facet joint angle. Dynamic radiographs were analyzed for magnitude of listhesis, disc height, bony apposition, kyphosis, translation, and intervertebral rotation. The Core Outcomes Measure Index (COMI) was completed at baseline, 3 months, and 12 months postoperatively. Due to small numbers in some subgroup analyses, patients treated with decompression alone or decompression with uninstrumented fusion were combined for analysis (uninstrumented group) as were patients treated with decompression and posterolateral instrumented fusion or decompression with posterolateral and interbody instrumented fusion (instrumented group). Unadjusted analyses and mixed effect models compared COMI scores between the two surgery technique groups (uninstrumented vs instrumented), stratified by CARDS and DSIC category and radiographic characteristics over time. Reoperation rates were also compared between the surgery technique groups stratified by CARDS and DSIC category. <h3>RESULTS</h3> A total of 508 patients were enrolled in the study, 460 had sufficient data to be classified according to CARDS, 459 could be classified according to DSIC, and 490 had radiographic images available for analysis. Seven percent were classified as CARDS A, 28% as CARDS B, 48% as CARDS C, and 17% as CARDS D (CARDS A most "stable", CARDS D least "stable"). 2% were classified as DSIC 1, 80% as DSIC 2, and 17% as DSIC 3 (DSIC 1 most "stable, DSIC 3 least "stable"). One hundred thrity-three patients (26%) underwent decompression alone, 30 (6%) underwent decompression and uninstrumented fusion, 42 (8%) underwent decompression and posterolateral instrumented fusion, and 303 (60%) underwent decompression with posterolateral and interbody instrumented fusion. Patients in the least "stable" categories tended to be less likely to be treated with an uninstrumented technique (CARDS D 19% and DSIC 3 21% vs 32% for the other categories, p=0.10 for CARDS, p=0.02 for DSIC). There were no significant differences in 3- or 12-month COMI scores between surgical technique groups stratified by CARDS or DSIC category in the unadjusted or adjusted analyses. In the unadjusted analyses, there was a trend toward less improvement in 12-month COMI change score in the CARDS D patients in the uninstrumented group compared to the instrumented group (-3.01 vs -3.88, p=0.10). Reoperation rates were not significantly different between the surgical technique groups stratified by CARDS and DSIC category. There were no significant differences between the surgical technique groups across the different radiographic characteristics. There was a nonsignificant trend toward more improvement in the instrumented group in patients with severe foraminal stenosis and larger facet joint effusions. <h3>CONCLUSIONS</h3> In general, outcomes for uninstrumented and instrumented surgical techniques were similar across the DSIC and CARDS categories. There was a trend toward less improvement in the CARDS D patients treated with uninstrumented techniques, suggesting that in patients with kyphosis (the defining feature of the CARDS D category) better outcomes may be associated with instrumentation. Baseline radiographic findings were generally not associated with different outcomes across the surgical technique groups. The major limitation of this study was the low numbers in the CARDS D (n=15) and DSIC 3 (n=17) uninstrumented groups, likely due to surgeons choosing to avoid uninstrumented techniques in these patients. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Magnetic Resonance Imaging Proxies for Segmental Instability in Degenerative Lumbar Spondylolisthesis Patients.

Retrospective cohort study. The aim was to investigate whether findings on magnetic resonance imaging (MRI) can be proxies (MRIPs) for segmental instability in patients with degenerative lumbar spinal stenosis (LSS) and/or degenerative spondylolisthesis (LDS) L4/L5. LDS has a heterogeneous nature. Some patients have a dynamic component of segmental instability associated with LDS. Studies have shown that MRI can show signs of instability. Patients with LSS or LDS at L4/L5 undergoing decompressive surgery±fusion from 2010 to 2017, with preoperative standing lateral spine radiographs and supine lumbar MRI and enrolled in Danish national spine surgical database, DaneSpine. Instability defined as slip of >3mm on radiographs. Patients divided into two groups based upon presence of instability. Outcome measures: radiograph: sagittal slip (mm). MRIPs for instability: sagittal slip >3mm, facet joint angle (°), facet joint effusion (mm), disk height index (%), and presence of vacuum phenomena. Optimal thresholds for MRIPs was determined by receiver operating characteristic (ROC) curves and area under the curve (AUC). Logistic regression to investigate association between instability and MRIPs. Two hundred thirty-two patients: 47 stable group and 185 unstable group. The two groups were comparable with regard to baseline patient-reported outcome measures. Thresholds for MRIPs: bilateral facet joint angle ≥46°; bilateral facet effusion ≥1.5mm and disk height index ≥13%. Logistic regression showed statistically significant association with MRIPs except vacuum phenomena, ROC curve AUC of 0.951. By absence of slip on MRI logistic regression showed statistically significant association between instability on radiograph and the remaining MRIPs, ROC curve AUC 0.757. Presence of MRIPs for instability showed statistically significant association with instability and excellent ability to predict instability on standing radiograph in LSS and LDS patients. Even in the absence of slip on MRI the MRIPs had a good ability to discriminate presence of instability.

Degenerative Lumbar Spondylolisthesis Patients With Movement-related Low Back Pain Have Less Postoperative Satisfaction After Decompression Alone.

Retrospective analysis of prospectively collected multicenter observational data. The aim was to examine the preoperative factors affecting postoperative satisfaction following posterior lumbar interbody fusion (PLIF) and microendoscopic muscle-preserving interlaminar decompression (ME-MILD) in patients with degenerative lumbar spondylolisthesis (DLS). The technique involved in DLS surgery may either be decompression alone or decompression-fixation. Poor performance may occur after either of these surgical treatments. The author hypothesized that evaluating the correlation between preoperative quality of life and postoperative performance would aid in determining the optimal procedure. This study included 138 patients who underwent surgery for 1-level mild DLS. The authors performed PLIF for 79 patients and ME-MILD for 59 patients. When the satisfaction subscale of the Zurich Claudication Questionnaire exceeded 2 points, postoperative satisfaction was considered poor. The clinical characteristics were investigated. Responses to preoperative health-related quality of life questionnaires, such as the Japanese Orthopedic Association Back Pain Evaluation Questionnaire (JOABPEQ), short form-36 health survey (SF-36), and visual analog scale, were compared between the satisfied and unsatisfied groups. In the PLIF group, no endogenous factors influenced postoperative satisfaction. The ME-MILD cohort's satisfied and unsatisfied patients differed significantly in terms of preoperative lumbar spine dysfunction ( P <0.001) items of the JOABPEQ, role physical ( P =0.03), and role emotional ( P =0.03) items of the SF-36. A strong correlation ( r =-0.609 P =0.015) was found between preoperative lumbar spine dysfunction and postoperative satisfaction. In the ME-MILD group, preoperative lumbar spine function was correlated with postoperative satisfaction. Decompression alone may be ineffective in cases with decreased lumbar spine function prior to surgery. The degree of low back pain on movement should be considered before selecting the surgical method. 3.

Postural stability, body composition and functional ability of the lower extremity in patients with lumbar degenerative spondylolisthesis

Although patients accessing rehabilitation services had been reported to have better functional ability of the lower limbs, postural stability, and low cardiovascular disease risk factors, updated data from developing countries is however vital for clinical practices. Hence, the aim of this study was to present the association between lower extremity functional ability (LEFA), stability, and body composition profiles in rehabilitative lumbar degenerative spondylolisthesis (LDS) patients considering age and gender. One hundred and twenty-four participants (45 females, 79 males), with a mean age of 56.45±11.13 years, volunteered for the study. Weight, height body fat percent (BFP), visceral fat, body mass index (BMI), resting systolic and diastolic blood pressure, and resting heart rate were measured while functional ability and stability tests were conducted on the participants. 53.4% were at least overweight; LEFA was below average, stability of both dominant and nondominant legs was very poor, blood pressure and heart rate were high. Women had high total body fat and visceral fat. Significant differences were observed in BMI (p=0.044) and BFP (p=0.035) based on age classification as well as BMI (p=0.000), BFP (p=0.000) and visceral fat (p=0.000) by gender. Overweight, high blood pressure, poor LEFA, and postural stability are crucial comorbidities of Ghanaian LDS patients in this study. Educationally and pragmatically comprehensive healthy lifestyle interventions of regular exercise regimes, adequate and quality nutrition, and occupational stress reduction would play major complementary roles in chiropractic treatment.

What's New in Spine Surgery.

What's New in Spine Surgery.