Degenerative Spondylolisthesis Research Articles

Laminectomy Adjacent to Instrumented Fusion Increases Adjacent Segment Disease.

Retrospective cohort. To determine if performing a simultaneous laminectomy at an unfused level adjacent to an instrumented fusion increases the risk of adjacent segment disease(ASD). Laminectomy adjacent to instrumented fusion has uncertain outcomes. The increased mechanical forces at the unfused laminectomy may lead to more ASD. Few studies have examined the development of ASD with regards to laminectomy performed adjacent to instrumented fusions. 789 patients underwent instrumented lumbar fusion and laminectomy at the same level(s) (n=676) or with an additional adjacent level laminectomy (n=113) with a minimum of 2-year follow-up. Diagnoses were degenerative spondylosis (n=241), degenerative spondylolisthesis (n=485) and isthmic spondylolisthesis (n=63) in addition to central stenosis. Primary outcome measures included development of ASD, time to development of ASD, revision surgery, and time to revision surgery. The adjacent laminectomy group developed ASD at a significantly greater rate of 57.5% (n=65), compared with 35.2% (n=238) of the non-adjacent laminectomy group (P<0.001). Revision surgery rate was also greater in the adjacent laminectomy group (22.1% v 13.5%, P<0.001). There was no difference in time to revision surgery (31.1 v 32.6mo, P=0.71) or time to ASD development (31.2 v 32.3mo, P=0.72). ODI and VAS scores did not differ, nor did patient baseline demographics including sex, BMI, Charleston Comorbidity Index, and tobacco use. The exception was the adjacent laminectomy group average age was 67.6 while the non-adjacent laminectomy group average age was 62.3 (P<0.001). However, age was not found to be an independent predictor of ASD development (P=0.44). Surgeons should be cautious when performing a laminectomy adjacent to an instrumented fusion, as this increases the rate of ASD as well as revision surgery.

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.

Comparing OLIF Combined with Lateral Screw Fixation Versus Minimally Invasive TLIF for Treating Single-Level Degenerative Lumbar Spondylolisthesis: A Retrospective Cohort Study.

The present study aimed to compare the clinical and radiological outcomes of oblique lumbar interbody fusion (OLIF) combined with lateral screw fixation and minimally invasive transforaminal lumbar interbody fusion (Mis-TLIF) for the treatment of single-level degenerative lumbar spondylolisthesis (DLS). Data regarding clinical and radiological outcomes for single-level DLS treated using OLIF combined with lateral screw fixation or Mis-TLIF between November 2017 and June 2020 were retrospectively analyzed. Seventy-five patients with single-level DLS (≥ 2 years' follow-up) were included and divided into 2 groups according to surgical method: OLIF (n=33); and Mis-TLIF (n=42). Operative time, intraoperative blood loss, and length of hospital stay were significantly lower in the OLIF group than that in the Mis-TLIF group. There were no significant differences in preoperative low back pain (LBP), leg pain (LP) visual analog scale (VAS) scores, and Oswestry Disability Index (ODI) between the two groups, although the OLIF group had significantly lower LBP VAS scores at 1, 3, and 6 months postoperatively. Additionally, the LP VAS score was significantly lower in the Mis-TLIF group than that in the OLIF group at 1 month postoperatively, and the ODI of the OLIF group at 3 months postoperatively was significantly lower than that of the Mis-TLIF group. There was no significant difference in the preoperative and postoperative lumbar lordosis angles between the two groups, whereas the postoperative surgical segmental lordosis angle and disc height (1, 6, 12, and 24 months) in the OLIF group were significantly higher than those in the Mis-TLIF group. Additionally, there was no significant difference in complication rates between the two groups (OLIF, 18.2% versus Mis-TLIF, 11.9%; p=0.520). Conclusion OLIF combined with lateral screw fixation yielded better clinical and radiological outcomes than Mis-TLIF in patients with single-level DLS.

Association Between Vertebral Endplate Defects and Patient-reported Symptoms: An Immunohistochemical Study Investigating the COX-2/PGE-2/EP-4 Axis

Background ContextVertebral endplate defects are often implicated in degenerative disc disorders, yet their connection to patient-reported symptoms remains unclear. COX-2 and PGE-2 are known for their roles in inflammation and pain, with EP-4 receptor involvement in pain signaling. Examining their expression in vertebral endplate tissues may provide insights into pathomechanism of low back pain. PurposeTo investigate the association between endplate defects and patient-reported symptoms and to further clarify the role of the COX-2/PGE-2/EP-4 axis in the pathogenesis of chronic low back pain. Study Design/SettingRetrospective study Patient SampleA total of 71 patients who had undergone single-level L4/5 or L5/S1 modified laminectomy decompression preserving proximal upper laminae and transforaminal lumbar interbody fusion surgery were included in this study, including 18 patients diagnosed with lumbar disc herniation, 19 with lumbar disc herniation accompanied by degenerative lumbar spinal stenosis, and 34 with degenerative spondylolisthesis. Outcome MeasuresDemographic data, Pfirrmann grade, Modic changes, endplate defect score, visual analog scale (VAS) for back and leg pain, and Oswestry Disability Index (ODI) before surgery, 3-month and 6-month follow-up, and the percentage of immune-positive cells (COX-2, PGE-2, and EP-4) in endplate tissue sections. MethodsPatients were divided into Defect and Non-defect groups according to endplate morphology on lumbar MR. All intraoperative endplate specimens were immediately fixed in 10% formaldehyde, and then embedded in paraffin 3 days later for tissue sections. The outcome measures were compared between the Defect group and Non-defect group. Data were analyzed using independent t-tests and χ² tests. Pearson's rank correlation test was used to assess correlations between patient-reported symptoms and the percentage of immune-positive cells in the groups. Multivariable logistic regression models using the forward stepwise likelihood ratio method were used to identify the factors that were independently associated with endplate defects. ResultsThe age of Defect group was significantly higher than that of Non-defect group (52.5±7.7 vs. 57.2±9.1. P=0.024). There were no significant differences in gender, diagnosis, BMI, comorbidities, or surgical level between the two groups. Modic changes (Type Ⅱ/Type Ⅲ) were more common in patients of Defect group than Non-defect group (38.5% vs. 11.1%, P<0.001), and so was disc degeneration (Pfirrmann grade Ⅳ/Ⅴ) (69.2% vs. 33.3%, P<0.001). Defect group had significantly higher VAS-Back (6.5±2.0 vs. 4.9±1.6, P<0.001) and ODI scores (62.9±10.7 vs. 45.2±14.8, P<0.001) than Non-defect group, while there was no significant differences between the two groups during the 3 and 6-month follow-up after surgery. Histologically, Defect group was characterized by upregulation of COX-2, PGE-2, and EP-4 in endplate tissue sections. Both in Defect and Non-defect groups, VAS-Back showed moderate positive correlations with the expressions of COX-2 (r=0.643; r=0.558, p both<0.001), PGE-2 (r=0.611; r=0.640, p both<0.001), and EP-4 (r=0.643; r=0.563, p both<0.001). Multivariate regression analyses reveled that percentage of COX-2-positive cells was associated with endplate defects (OR=1.509, 95%CI [1.048∼2.171], P=0.027), as well as percentage of PGE-2-positive (OR=1.291, 95%CI [1.106∼1.508], P=0.001) and EP-4-positive cells (OR=1.284, 95%CI [1.048∼2.171], P=0.003). ConclusionsPatients with endplate defects had worse quality of life, more severe disc degeneration and Modic changes, and up-regulated COX-2/PGE-2/EP-4 axis expression in cartilage endplates in patients with defected endplates. Inflammatory factors may significantly contribute to the onset and progression of chronic low back pain in patients with endplate defects, consequently impacting patient-reported symptoms.

406 Long-term Outcomes of Lumbar Facet Arthroplasty versus Spinal Fusion in the Treatment of Degenerative Spondylolisthesis and Stenosis

INTRODUCTION: Facet arthroplasty is a proposed alternative to lumbar fusion for treating degenerative lumbar spondylolisthesis and stenosis. Facet arthroplasty provides stabilization and preserves range of motion. METHODS: Patient-reported outcomes (PROMS), including Oswestry disability index (ODI), visual analog pain scales (VAS), and Zurich claudication questionnaires (ZCQ), were assessed at baseline and at multiple timepoints postoperatively. Flexion/extension range of motion (ROM) were radiographically evaluated at baseline, 12 months, and 24 months. Data were analyzed following an intention-to-treat model. RESULTS: A total of 299 patients were included (TOPS = 206, TLIF = 93). There were no significant differences at baseline. At 2 years, the TOPS group had a significantly greater proportion of patients report =30% improvement for ODI (93.8% versus 74.3%, p = 0.004) and =20-point improvement for VAS back (84.4% versus 61.8%, p = 0.014). At 1 year, TOPS group had a significantly greater proportion of patients report clinically significant improvements in all ZCQ categories (91.6% versus 78.5%, p = 0.012). In patients &lt;65 years, the TOPS group had significantly improved PROMS compared to TLIF at 2 years; however, these differences were not observed in patients =65 years old. The TOPS groups preserved significantly more ROM at 12 (2.8° 95% CI [1.87; 3.74], p &lt; 0.0001) and 24 (2.99° 95% CI [1.82; 4.15], p &lt; 0.0001) months postoperatively compared to TLIF. ROM was similarly preserved in patients aged &lt;64 and =65. The rate of adverse events did not differ significantly between groups (65.2% TOPS versus 61.5% TLIF). CONCLUSIONS: Facet arthroplasty preserves significantly more ROM and leads to improved PROMS compared to TLIF, particularly in younger patients. In older patients, the procedure improved outcomes significantly from baseline.

The Relationship Between Paraspinal Muscle Atrophy and Degenerative Lumbar Spondylolisthesis at the L4/5 Level

Background/ContextDegenerative lumbar spondylolisthesis (DLS) is a prevalent spinal condition that can result in significant disability. DLS is thought to result from a combination of disc and facet joint degeneration, as well as various biological, biomechanical, and behavioral factors. One hypothesis is the progressive degeneration of segmental stabilizers, notably the paraspinal muscles, contributes to a vicious cycle of increasing slippage. PurposeTo examine the correlation between paraspinal muscle status on MRI and severity of slippage in patients with symptomatic DLS. Study Design/ settingRetrospective cross-sectional study at an academic tertiary care center. Patient SamplePatients who underwent surgery for DLS at the L4/5 level between 2014-2016 were included. Those with multilevel DLS or insufficient imaging were excluded. Outcome MeasuresThe percentage of relative slippage (RS) at the L4/5 level evaluated on standing lateral radiographs. Muscle morphology measurements including functional cross-sectional area (fCSA), body height normalized functional cross-sectional area (HI) of Psoas, erector spinae (ES) and multifidus muscle (MF) and fatty infiltration (FI) of ES and MF were measured on axial MR. Disc degeneration and facet joint arthritis were classified according to Pfirrmann and Weishaupt, respectively. MethodsDescriptive and comparative statistics, univariable and multivariable linear regression models were utilized to examine the associations between RS and muscle parameters, adjusting for confounders sex, age, BMI, segmental degeneration, and back pain severity and symptom duration. ResultsThe study analyzed 138 out of 183 patients screened for eligibility. The median age of all patients was 69.5 years (IQR 62 to 73), average BMI was 29.1 (SD ± 5.1) and average preoperative ODI was 46.4 (SD ± 16.3). Patients with Meyerding-Grade 2 (M2, N=25) exhibited higher Pfirrmann scores, lower MFfCSA and MFHI, and lower BMI, but significantly more fatty infiltration in the MF and ES muscles compared to those with Meyerding Grade 1 (M1). Univariable linear regression showed that each cm2 decrease in MFfCSA was associated with a 0.9%-point increase in RS (95%CI -1.4 to - 0.4, p<0.001), and each cm2/m2 decrease in MFHI was associated with an increase in slippage by 2.2%-points (95%CI -3.7 to -0.7, p=0.004). Each 1%-point rise in ESFI and MFFI corresponded to 0.17%- (95%CI 0.05 - 0.3, p=0.01) and 0.20%-point (95%CI 0.1 – 0.3 p<0.001) increases in relative slippage, respectively. Notably, after adjusting for confounders, each cm2 increase in PsoasfCSA and cm2/m2 in PsoasHI was associated with an increase in relative slippage by 0.3% (95%CI 0.1 - 0.6, p = 0.004) and 1.1%-points (95%CI 0.4 -1.7, p= 0.001). While MFfCSA tended to be negatively associated with slippage, this did not reach statistical significance (p = 0.105). However, each 1%-point increase in MFFI and ESFI corresponded to increases of 0.15% points (95%CI 0.05 – 0.24, p= 0.002) and 0.14% points (95%CI 0.01 - 0.27, p= 0.03) in relative slippage, respectively. ConclusionThis study found a significant association between paraspinal muscle status and severity of slippage in DLS. Whereas, higher degeneration of the ES and MF correlate with a higher degree of slippage, the opposite was found for the psoas. These findings suggest that progressive muscular imbalance between posterior and anterior paraspinal muscles could contribute to the progression of slippage in DLS.

Spine

The April 2024 Spine Roundup360 looks at: Lengthening behaviour of magnetically controlled growing rods in early-onset scoliosis: a multicentre study; LDL, cholesterol, and statins usage cause pseudarthrosis following lumbar interbody fusion; Decision-making in the treatment of degenerative lumbar spondylolisthesis of L4/L5; Does the interfacing angle between pedicle screws and support rods affect clinical outcomes after posterior thoracolumbar fusion?; Returning to the grind: how workload influences recovery post-lumbar spine surgery; Securing the spine: a leap forward with s2 alar-iliac screws in adult spinal deformity surgery.

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

Several studies have advocated for the higher accuracy of transpedicular screw placement under cone-beam computed tomography (CBCT) compared to conventional 2-dimensional (2D) fluoroscopy. The superiority of navigation systems in perioperative and postoperative outcomes remains a topic of debate. This study aimed to compare operative time, screw placement time and accuracy, total radiation dose, perioperative and postoperative outcomes in patients who underwent transpedicular screw fixation for degenerative lumbar spondylolisthesis (DLS) using intraoperative CBCT navigation versus 2D fluoroscopy. A retrospective analysis was conducted on patients affected by single-level DLS who underwent posterior lumbar instrumentation with transpedicular screw fixation using surgical CBCT navigation (NV group) or 2D fluoroscopy-assisted freehand technique (FH group). Demographics, screw placement time and accuracy, operative time, total radiation dose, intraoperative blood loss, screw revision rate, complications, and length of stay (LOS) were assessed. The study included a total of 30 patients (NV group: n = 15; FH group: n = 15). The mean screw placement time, operative time, and LOS were significantly reduced in the NV group compared to the FH group (p < 0.05). The total radiation dose was significantly higher in the NV group (p < 0.0001). No significant difference was found in terms of blood loss and postoperative complications. This study suggests that intraoperative CBCT-navigated single-level lumbar transpedicular screw fixation is superior in terms of mean screw placement time, operative time, and LOS compared to 2D fluoroscopy, despite a higher intraoperative radiation exposure.

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

Interventional treatment options for the lumbar degenerative spine have undergone a significant amount of innovation over the last decade. As new technologies emerge, along with the surgical specialty expansion, there is no manuscript that utilizes a review of surgical treatments with evidence rankings from multiple specialties, namely, the interventional pain and spine communities. Through the Pacific Spine and Pain Society (PSPS), the purpose of this manuscript is to provide a balanced evidence review of available surgical treatments. The PSPS Research Committee created a working group that performed a comprehensive literature search on available surgical technologies for the treatment of the degenerative spine, utilizing the ranking assessment based on USPSTF (United States Preventative Services Taskforce) and NASS (North American Spine Society) criteria. The surgical treatments were separated based on disease process, including treatments for degenerative disc disease, spondylolisthesis, and spinal stenosis. There is emerging and significant evidence to support multiple approaches to treat the symptomatic lumbar degenerative spine. As new technologies become available, training, education, credentialing, and peer review are essential for optimizing patient safety and successful outcomes.

ChatGPT versus NASS clinical guidelines for degenerative spondylolisthesis: a comparative analysis.

Clinical guidelines, developed in concordance with the literature, are often used to guide surgeons' clinical decision making. Recent advancements of large language models and artificial intelligence (AI) in the medical field come with exciting potential. OpenAI's generative AI model, known as ChatGPT, can quickly synthesize information and generate responses grounded in medical literature, which may prove to be a useful tool in clinical decision-making for spine care. The current literature has yet to investigate the ability of ChatGPT to assist clinical decision making with regard to degenerative spondylolisthesis. The study aimed to compare ChatGPT's concordance with the recommendations set forth by The North American Spine Society (NASS) Clinical Guideline for the Diagnosis and Treatment of Degenerative Spondylolisthesis and assess ChatGPT's accuracy within the context of the most recent literature. ChatGPT-3.5 and 4.0 was prompted with questions from the NASS Clinical Guideline for the Diagnosis and Treatment of Degenerative Spondylolisthesis and graded its recommendations as "concordant" or "nonconcordant" relative to those put forth by NASS. A response was considered "concordant" when ChatGPT generated a recommendation that accurately reproduced all major points made in the NASS recommendation. Any responses with a grading of "nonconcordant" were further stratified into two subcategories: "Insufficient" or "Over-conclusive," to provide further insight into grading rationale. Responses between GPT-3.5 and 4.0 were compared using Chi-squared tests. ChatGPT-3.5 answered 13 of NASS's 28 total clinical questions in concordance with NASS's guidelines (46.4%). Categorical breakdown is as follows: Definitions and Natural History (1/1, 100%), Diagnosis and Imaging (1/4, 25%), Outcome Measures for Medical Intervention and Surgical Treatment (0/1, 0%), Medical and Interventional Treatment (4/6, 66.7%), Surgical Treatment (7/14, 50%), and Value of Spine Care (0/2, 0%). When NASS indicated there was sufficient evidence to offer a clear recommendation, ChatGPT-3.5 generated a concordant response 66.7% of the time (6/9). However, ChatGPT-3.5's concordance dropped to 36.8% when asked clinical questions that NASS did not provide a clear recommendation on (7/19). A further breakdown of ChatGPT-3.5's nonconcordance with the guidelines revealed that a vast majority of its inaccurate recommendations were due to them being "over-conclusive" (12/15, 80%), rather than "insufficient" (3/15, 20%). ChatGPT-4.0 answered 19 (67.9%) of the 28 total questions in concordance with NASS guidelines (P = 0.177). When NASS indicated there was sufficient evidence to offer a clear recommendation, ChatGPT-4.0 generated a concordant response 66.7% of the time (6/9). ChatGPT-4.0's concordance held up at 68.4% when asked clinical questions that NASS did not provide a clear recommendation on (13/19, P = 0.104). This study sheds light on the duality of LLM applications within clinical settings: one of accuracy and utility in some contexts versus inaccuracy and risk in others. ChatGPT was concordant for most clinical questions NASS offered recommendations for. However, for questions NASS did not offer best practices, ChatGPT generated answers that were either too general or inconsistent with the literature, and even fabricated data/citations. Thus, clinicians should exercise extreme caution when attempting to consult ChatGPT for clinical recommendations, taking care to ensure its reliability within the context of recent literature.

[Spondylolisthesis].

Spondylolisthesis is afrequent disease that is found in 20% of the adult population and is particularly accompanied by lumbar back pain. Degenerative spondylolisthesis develops in adulthood and is most often found in the L4/5 segment, in contrast to nondegenerative spondylolisthesis which is most often situated in the L5/S1 segment. Prior to every treatment the heterogeneous disease pattern has to be classified according to the severity grade of the olisthesis and to the Spinal Deformity Study Group (SDSG) classification. High-grade spondylolisthesis should preferably be surgically treated and low-grade spondylolisthesis should preferably be treated conservatively. In approximately 50% of all recently acquired spondylolistheses healing of the lysis can be achieved by a consequently carried out conservative treatment.

Management for degenerative lumbar spondylolisthesis: a network meta-analysis and systematic review basing on randomized controlled trials.

Consensus on the various interventions for degenerative lumbar spondylolisthesis (DLS) remains unclear. We searched PubMed, Embase, Cochrane Library, Web of Science, and major scientific websites until Nov 01, 2023, to screen eligible randomized controlled trials (RCTs) involving the treatment of DLS. The seven most common DLS interventions (non-surgical [NS], decompression only [DO], decompression plus fusion without internal fixation [DF], decompression plus fusion with internal fixation [DFI], endoscopic decompression plus fusion [EDF], endoscopic decompression [ED], and circumferential fusion [360F]) were compared. The primary (pain and disability) and secondary (complications, reoperation rate, operation time, blood loss, length of hospital stay, and satisfaction) outcomes were analyzed. Data involving 3,273 patients in 16 RCTs comparing the efficacy of different interventions for DLS were reported. In terms of improving patient pain and dysfunction, there was a significant difference between surgical and NS. EDF showed the greatest improvement in short-term and long-term dysfunction (probability, 7.1% and 21.0%). Moreover, EDF had a higher complication rate (probability 70.8%), lower reoperation rate (probability, 20.2%), and caused greater blood loss (probability, 82.5%) than other surgical interventions. Endoscopic surgery had the shortest hospitalization time (EDF: probability, 42.6%; ED: probability, 3.9%). DF and DFI had the highest satisfaction scores. Despite the high complication rate of EDF, its advantages include improvement in pain, lower reoperation rate, and shorter hospitalization duration. Therefore, EDF may be a good option for patients with DLS as a less invasive surgical approach.

Practice for the treatment of noncontiguous double-level lumbar spinal stenosis with degenerative spondylolisthesis and Scoliosis with Endo-LIF.

Practice for the treatment of noncontiguous double-level lumbar spinal stenosis with degenerative spondylolisthesis and Scoliosis with Endo-LIF.

Cervical sagittal parameters in degenerative cervical spondylolisthesis versus degenerative cervical kyphosis with myeloradiculopathy treated by anterior cervical discectomy and fusion.

Adult spinal deformity, especially sagittal imbalance, is affecting health-related quality-of-life (HRQOL) scores. There is a lack of emphasis in the comparison of cervical sagittal parameters in patients with degenerative cervical spondylolisthesis and degenerative cervical kyphosis. The aim of study is to determine the preoperative and postoperative cervical sagittal parameters in myeloradiculopathic patients with degenerative cervical spondylolisthesis and degenerative cervical kyphosis treated by anterior cervical discectomy and fusion (ACDF). A retrospective medical records and radiographic study of 30 adult patients were reviewed. Fifteen patients with degenerative cervical spondylolisthesis and 15 patients with degenerative cervical kyphosis have been performed ACDF from 2010-2020. We measured the preoperative and postoperative cervical sagittal parameters: C0-C2 angle, C1-C2 angle, C2-C7 angle, C2-C7 sagittal vertical axis (SVA), T1 slope, neck tilt angle and thoracic inlet angle. Minimum follow-up period was at least 2 years. Patients in degenerative cervical kyphosis group have C2-C7 angle less than degenerative cervical spondylolisthesis group (-14.88±7.32 vs. 9.60±13.60), leading to increase the mismatch between T1 slope and C2-C7 angle in kyphotic group and hyperlordosis of C0-C2 angle and C1-C2 angle (31.13±7.68, 37.88±5.08) compare with spondylolisthesis group (13±10.20, 24.60±10.70). Whereas patients with degenerative cervical spondylolisthesis have C2-C7 SVA (33.22±13.92) more than kyphosis group (13.70±13.60). After surgery, there is significant increase of the C2-C7 angle in the kyphosis group compare before and after surgery (-14.88±7.32 vs. 4.10±11.80). While the spondylolisthesis group has no significantly different parameters compare to before surgery. However, the postoperative cervical sagittal parameters of all patients are within the normal thresholds (T1-Slope minus C2-C7 lordosis <15° and C2-C7 SVA <40 mm). The study demonstrates the difference of sagittal parameters between degenerative cervical spondylolisthesis and kyphosis before and after surgery. ACDF not only provides neural decompressive procedure, but also corrects the regional cervical sagittal parameters.

Differences in the surgical management of degenerative lumbar spondylolisthesis based on self-reported sex: analysis of the CSORN prospective DLS study.

Surgical treatment of degenerative lumbar spondylolisthesis (DLS) reliably improves patient-reported quality of life; however, patient population heterogeneity, in addition to other factors, ensures ongoing equipoise in choosing the ideal surgical treatment. Surgeon preference for fusion or decompression alone influences surgical treatment decision-making. Meanwhile, at presentation, patient-reported outcome measures (PROMs) differ considerably between females and males. The aims of this study were to determine whether there exists a difference in the rates of decompression and fusion versus decompression alone based on patient-reported sex, and to determine if widely accepted indications for fusion justify any observed differences or if surgeon preference plays a role. This study is a retrospective cohort analysis of patients enrolled in the Canadian Spine Outcomes Research Network (CSORN) DLS study, a multicentered Canadian prospective study, investigating the surgical management and outcome of DLS. Decompression and fusion rates, patient characteristics, preoperative PROMs, and radiographic measures were compared between males and females before and after propensity score matching. In the unmatched cohort, female patients were more likely to undergo decompression and fusion than male patients. Females were more likely to have the recognized indications for fusion, including kyphotic disc angle, higher spondylolisthesis grade and slip percentage, and patient-reported back pain. Other radiographic findings associated with the decision to fuse, including facet effusion, facet distraction, or facet angle, were not more prevalent in females. After propensity score matching for demographic and radiographic characteristics, similar proportions of male and female patients underwent decompression and fusion and decompression alone. Although it remains unclear who should or should not undergo fusion, in addition to surgical decompression of DLS, female patients undergo fusion at a higher rate than their male counterparts. After matching baseline radiographic factors indicating fusion, this analysis showed that the decision to fuse was not biased by sex differences. Rather, the higher proportion of females undergoing fusion is largely explained by the radiographic and clinical indications for fusion, suggesting that specific clinical and anatomical features of this condition are indeed different between sexes.

Comparison of facet fusion rates and clinical outcomes between cortical bone trajectory screw and percutaneous pedicle screw fixation for degenerative lumbar spondylolisthesis

BACKGROUND CONTEXTCortical bone trajectory (CBT) screws have been introduced as an alternative technique for pedicle screw (PS) insertion because they have greater contact with the cortex and a greater uniaxial pullout load than traditional PS. CBT screwing can also minimize muscle dissection. However, CBT screws and traditional PSs have not yet been compared in terms of fusion rates and clinical outcomes for particular operative procedures. PURPOSEThis study aimed to assess the fusion rate and clinical outcomes of facet fusion (FF) fixed with CBT screws (CBT-FF) and to compare them with those of FF fixed with percutaneous PS (PPS-FF). STUDY DESIGNRetrospective study. PATIENT SAMPLERecords of 68 patients who underwent CBT-FF for single-level degenerative lumbar spondylolisthesis (DLS) with at least 1 year of follow-up were retrospectively reviewed. The control group comprised 143 patients who underwent PPS-FF under the same conditions. OUTCOME MEASURESComputed tomography was performed to confirm fusion. Therapeutic effectiveness was assessed as a clinical outcome using the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ), Roland-Morris Disability Questionnaire (RMDQ), and visual analog scale (VAS) preoperatively and 1 year postoperatively. The rate of revision surgery was also calculated. Intraoperative blood loss was measured. METHODSFusion rate, clinical outcomes, revision surgery rate, and intraoperative blood loss of CBT-FF and PPS-FF were compared. RESULTSThe CBT-FF and PPS-FF fusion rates were 91.2% and 90.1%, respectively. The JOABPEQ category scores demonstrated therapeutic effectiveness in 74.5% and 77.1% of the patients for low back pain; the corresponding proportions for walking ability were 84.7% and 89.3%, respectively. No significant differences in therapeutic effectiveness were observed for any category, including the RMDQ and VAS scores for buttock and lower limb pain. Three patients required revision surgery for adjacent segment disease between 6 months and 3.5 years after CBT-FF (revision surgery rate, 4.4%), whereas the revision surgery rate for PPS-FF was 6.3% (9/143 cases). Average intraoperative blood loss was significantly less in the CBT-FF group than in the PPS-FF group. CONCLUSIONSBoth procedures were equally useful in terms of fusion rate and clinical outcomes for DLS management.

The clinical and radiographic degenerative spondylolisthesis classification and its predictive value.

The clinical and radiographic degenerative spondylolisthesis (CARDS) classification is a new classification that has been introduced for degenerative spondylolisthesis (DS). It has four categories. Our study aimed to analyse the functional and radiographic outcome following DS surgery based on the preoperative CARDS classification. A retrospective study of the prospectively collected Australian Spine Registry database was performed. Data on demographics, patient reported outcome measures including the Oswestry Disability Index (ODI) and EQ-5D-3L scores, and changes in radiographic measurements were analysed. Based on the preoperative findings all x-rays were classified applying the CARDS classification. Between 2018 and 2021 a total of 54-patients were identified as having had surgery for DS at L4/5. The mean age was 65.3 ± 11.3years and females were predominantly affected (61%). Most cases were of CARDS type C (46%), followed by type B (29%). CARDS type A and D were observed in 18% and 6% respectively. Preoperatively, the L4/5 lordosis was 19.8 ± 6.3° and lumbar lordosis 43.9 ± 12.8°. Postoperatively the L4/5 lordosis alignment changed significantly to 23.5 ± 8.8° (p < 0.05). Preoperatively, the CARDS classification was 34.8 ± 17.4 (type A), 40.5 ± 11.0 (type B), 43.8 ± 12.9 and 50.0 ± 14.4 for type D (Pearson-coefficient 0.284, p = 0.041). Postoperatively this changed to 22.7 ± 16.1, 28.7 ± 21.2, 12.5 ± 13.1, and 6.5 ± 2.1 respectively. Similar improvements were observed for the EQ-5D-3L. This study shows that the CARDS classification correlates with preoperative functional scores as well as helping to predict response to surgery. CARDS will likely assist in operative planning and prognostication. III, therapeutic and prognostic study.

Evaluation of "appropriate use criteria" for surgical decision-making in lumbar degenerative spondylolisthesis. A controlled, multicentre, prospective observational study.

Selecting patients with lumbar degenerative spondylolisthesis (LDS) for surgery is difficult. Appropriate use criteria (AUC) have been developed to clarify the indications for LDS surgery but have not been evaluated in controlled studies. This prospective, controlled, multicentre study involved 908 patients (561 surgical and 347 non-surgical controls; 69.5 ± 9.7y; 69% female), treated as per normal clinical practice. Their appropriateness for surgery was afterwards determined using the AUC. They completed the Core Outcome Measures Index (COMI) at baseline and 12 months' follow-up. Multiple regression adjusting for confounders evaluated the influence of appropriateness designation and treatment received on the 12-month COMI and achievement of MCIC (≥ 2.2-point-reduction). As per convention, appropriate (A) and uncertain (U) groups were combined for comparison with the inappropriate (I) group. For the adjusted 12-month COMI, the benefit of surgery relative to non-surgical care was not significantly greater for the A/U than the I group (p = 0.189). There was, however, a greater treatment effect of surgery for those with higher baseline COMI (p = 0.035). The groups' adjusted probabilities of achieving MCIC were: 83% (A/U, receiving surgery), 71% (I, receiving surgery), 50% (A/U, receiving non-surgical care), and 32% (I, receiving non-surgical care). A/U patients receiving surgery had the highest chances of achieving MCIC, but the AUC were not able to identify which patients had a greater treatment effect of surgery relative to non-surgical care. The identification of other characteristics that predict a greater treatment effect of surgery, in addition to baseline COMI, is required to improve decision-making.

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

BackgroundPrevious studies have demonstrated the relationship between sagittal facet orientation and cervical degenerative spondylolisthesis. However, the associations between facet orientation and cervical spinal stenosis (CSS) have rarely been studied.MethodsOne hundred twenty patients with CSS (CSS group) and 120 healthy participants (control group) were consecutively enrolled. The cervical facet angles and anteroposterior diameter (A-P diameter) of spinal canal at each subaxial cervical levels were measured using axial magnetic resonance imaging. The intersection angle of the midsagittal line of the vertebra to the facet line represents the orientation of the facet joint.ResultsThe facet angles on the right side at C2- C3 and C3-C4 in CSS group and at C2- C3 in control group had significantly higher values than those of the other sides. Besides, the facet angles and A-P diameter of spinal canal in CSS group were significantly smaller than those in control group at all levels (p < 0.05).ConclusionsOur study demonstrated that patients with CSS have smaller axial cervical facet joint angles compared to the healthy individuals. Further studies are needed to elicit the specific underlying mechanism between sagittalization of the cervical facet joints and the pathology of CSS.

The Influence of Spinous Process Union on Clinical Outcomes After Spinous Process Osteotomy for Lumbar Spinal Stenosis After 2 Years: A Secondary Analysis From the NORDSTEN-Study.

Lumbar spinal stenosis is a prevalent and increasingly important cause of low back pain, leg pain, and walking impairment. Minimally invasive decompressive techniques such as spinous process (SP) osteotomy have become more common in recent years. The main aim of this study was to investigate the proportion of complete SP union and whether complete radiological healing after the osteotomy is associated with superior clinical outcome after 2 years. In this retrospective cohort study, 149 patients were included from the Spinal Stenosis Trial, a part of the NORwegian Degenerative spondylolisthesis and spinal STENosis study. Computed tomography imaging was performed 2 years postoperatively. The number of osteotomies and the number of SP unions were recorded. Patients were divided into groups based on the degree of union: nonunion, partial union, and complete union. Rate of success (>30% improvement in Oswestry Disability Index [ODI]) and mean change in ODI were the primary outcome measures. We compared the differences between baseline and follow-up between the Degree of Union groups. The study included 102 of 149 eligible patients. Ten patients (9.8%) were classified as having nonunion, 15 (14.7%) as having partial union, and 77 (75.5%) as having complete union. Of the 155 osteotomies, there were 122 classified as union (77%). The success rate was 74%, with no influence of SP union. The mean change in the ODI was -20.1 (95% CI -37.0, 14.2) with no influence of SP union. We found no influence of SP union, classified by computed tomography, on clinical outcome 2 years after SP osteotomy in patients with lumbar spinal stenosis. Supplying useful information about SPO to assist surgeons in the choice of decompressive technique.