Degree Of Spondylolisthesis Research Articles

Shannon entropy and fuzzy C-means weighting for AI-based diagnosis of vertebral column diseases

Degenerative vertebral column diseases are becoming increasingly common and computer-aided decision-making and diagnosis systems are gaining popularity. In this paper, we propose a machine learning decision-making model based on noninvasive panoramic radiographs to tackle the problem of automated diagnosis of two common vertebral column diseases; disc prolapse and spondylolisthesis. We collected raw data from real X-ray images of 422 subjects (i.e., 201 disc prolapse, 111 spondylolisthesis, and 110 healthy). We used five biomechanical parameters as input to the model representing the pelvic incidence, pelvic tilt, lumbar lordosis angle, sacral slope, and degree spondylolisthesis. To obtain more meaningful features, we preprocessed each vertebral column dataset by weighting every vertebral feature using a set of weights computed based on Shannon entropy and the fuzzy C-means clustering algorithm. Then, the new weighted set of features was fed to an artificial neural network classifier. Our proposed method was able to classify the subjects into three classes with 99.5% overall accuracy. This reflects a strong ability to predict the patient vertebral column dysfunction using the biomechanical attributes and with an accuracy satisfying clinical requirements. This approach represents a feasible system that facilitates the diagnosis of vertebral column disorders. It can help the physician to take the correct decision very early, which will prevent the development of the pathology into a chronic level and reduce the need for surgical treatment.

NeuroSpine Surgery Research Group (NSURG) Classification System for Grading Lumbar Synovial Cysts.

To classify facet joint cysts (FJC) which will assist in identification of patient groups to best fit with a particular intervention. Sagittal T2 -weighted magnetic resonance images (MRI) of these patients are used to measure cyst size, while axial T2 -weighted MRI are used to determine the percentage of the vertebral canal occupied by the cyst. The degree of spondylolisthesis is also measured through standing X-rays or sagittal MRI. The proposed grading system is as follows. Grade I includes cysts that occupy less than 25% of the canal diameter that usually present with unilateral radiculopathy. Grade II includes cysts that occupy less than 50% of the canal diameter and may present with radiculopathy, with or without claudicant symptoms. Grade III cysts may present with radiculopathy and claudication with bilateral leg symptoms, along with facetogenic pain symptoms. Grades IV and V include potential instability as defined by greater than 15% spondylolisthesis in addition to either less than or greater than 50% canal stenosis. With higher grade cysts, presentation may include: facetogenic back pain, radiculopathy and claudicant pain in variable degrees of severity. The optimal classification system grades FJC from I to V on the basis of canal compression and degree of spondylolisthesis. Prospective studies are required to confirm the validity of this grading scale for long-term use.

Laminectomy plus Fusion versus Laminectomy Alone for Lumbar Spondylolisthesis

BackgroundThe comparative effectiveness of performing instrumented (rigid pedicle screws affixed to titanium alloy rods) lumbar spinal fusion in addition to decompressive laminectomy in patients with symptomatic lumbar grade I degenerative spondylolisthesis with spinal stenosis is unknown.MethodsIn this randomized, controlled trial, we assigned patients, 50 to 80 years of age, who had stable degenerative spondylolisthesis (degree of spondylolisthesis, 3 to 14 mm) and symptomatic lumbar spinal stenosis to undergo either decompressive laminectomy alone (decompression-alone group) or laminectomy with posterolateral instrumented fusion (fusion group). The primary outcome measure was the change in the physical-component summary score of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36; range, 0 to 100, with higher scores indicating better quality of life) 2 years after surgery. The secondary outcome measure was the score on the Oswestry Disability Index (range, 0 to 100, with higher scores indicating more disability related to back pain). Patients were followed for 4 years.ResultsA total of 66 patients (mean age, 67 years; 80% women) underwent randomization. The rate of follow-up was 89% at 1 year, 86% at 2 years, and 68% at 4 years. The fusion group had a greater increase in SF-36 physical-component summary scores at 2 years after surgery than did the decompression-alone group (15.2 vs. 9.5, for a difference of 5.7; 95% confidence interval, 0.1 to 11.3; P=0.046). The increases in the SF-36 physical-component summary scores in the fusion group remained greater than those in the decompression-alone group at 3 years and at 4 years (P=0.02 for both years). With respect to reductions in disability related to back pain, the changes in the Oswestry Disability Index scores at 2 years after surgery did not differ significantly between the study groups (−17.9 in the decompression-alone group and −26.3 in the fusion group, P=0.06). More blood loss and longer hospital stays occurred in the fusion group than in the decompression-alone group (P<0.001 for both comparisons). The cumulative rate of reoperation was 14% in the fusion group and 34% in the decompression-alone group (P=0.05).ConclusionsAmong patients with degenerative grade I spondylolisthesis, the addition of lumbar spinal fusion to laminectomy was associated with slightly greater but clinically meaningful improvement in overall physical health–related quality of life than laminectomy alone. (Funded by the Jean and David Wallace Foundation and others; SLIP ClinicalTrials.gov number, NCT00109213.)

Treatment of degenerative lumbar spondylolisthesis by using minimally invasive transforaminal lumbar interbody fusion and percutaneous pedicle screw fixation

Objective To discuss clinical therapeutic effects of minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) combined with percutaneous pedicle screw fixation for degenerative lumbar spondylolisthesis (DLS). Methods A total of 32 DLS patients treated by MIS-TLIF and percutaneous pedicle screw fixation from January 2013 to September 2015 in Xuanwu Hospital, Capital Medical University were retrospectively reviewed. Visual Analogue Scale (VAS), Oswestry Disability Index (ODI) and Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) scores were assessed and compared between preoperation and one week, 3 months after operation and in the last follow-up. Lumbar lordosis angle, coronal Cobb angle, coronal and sagittal body shifting, complication, the degree of spondylolisthesis (Meyerding classification) and the rate of spondylolisthesis were measured according to preoperative and postoperative spinal X-ray examination. Fusion rate was evaluated according to X-rays or CT in the last follow-up, and MRI was used to assess the degree of decompression. Results Thirty-two patients were under test with mean operation time 160 min, intraoperative blood loss 120 ml, postoperative hospital stay 7.22 d and follow-up 10.83 months. Decompression and fusion levels ranged from L2-S1 and interbody fusion was performed in 32 patients and 41 levels were fused. Compared with preoperation, the VAS and ODI scores were significantly increased at one week, 3 months after operation and in the last follow-up ( P = 0.000, for all), while SF-36 score ( P = 0.002, 0.000, 0.000), lumbar lordotic angle ( P = 0.000, for all), coronal Cobb angle ( P = 0.000, for all) and slippage rate ( P = 0.000, for all) were significantly decreased. The fusion rate was 92.22%, and the improvement rate of ODI was (80.51 ± 6.02)% in the last follow-up. There were 3 cases appeared complications, including one case of infection and 2 cases of cerebrospinal fluid (CSF) fistula, and were cured after treatment. Neurological defects, internal fixation failure, breakage of pedicle screw or titanium rod, or Cage displacement were not found in 32 cases. There was no death. Conclusions MIS-TLIF combined with percutaneous pedicle screw fixation is an effective technique for treatment of DLS patients, with less injury, less intraoperative blood loss, low complication incidence rate, good scoliosis correction and definite therapeutic effects, even this method needs more operation time, longer learning curve and more radiation. DOI: 10.3969/j.issn.1672-6731.2016.03.003

Cervical degenerative spondylolisthesis: analysis of facet orientation and the severity of cervical spondylolisthesis

Background ContextPrevious studies have shown an association between the degree of cervical degenerative spondylolisthesis (DS) and spinal cord conditions of the cervical spine. However, there is no information available on the association between the severity of cervical DS and the orientation of the cervical facet joints. This study examined the association between the severity of cervical DS and facet tropism. PurposeThis study aimed to retrospectively explore the relationship between facet tropism and cervical DS and the effect of facet tropism on cervical DS. Study DesignA retrospective review of radiographic and magnetic resonance imaging (MRI) findings in patients with or without cervical DS was carried out. Patient SampleA total of 200 patients from a single institution who underwent both MRI and radiography were reviewed. Outcome MeasuresThe facet angles at the C3–C4, C4–C5, and C5–C6 levels based on axial MRI in the two groups and the slippage degree at C4–C5 based on neutral lateral radiographs in the experimental group were measured and calculated. MethodsOne hundred patients with only C4–C5 level cervical DS who were treated in our hospital from January 2005 to August 2011 were selected as the experimental group. One hundred age- and sex-matched spinal disease-free patients were selected as the control group from patients who presented for physical examinations. Comparative analysis of the obtained parameters was performed to determine significant differences between the examined levels in the two groups and to investigate the association between cervical DS and facet tropism. ResultsFacet tropism at C4–C5 was significantly greater than that at C3–C4 and C5–C6 in the experimental group (C4–C5 vs. C3–C4, p<.001; C4–C5 vs. C5–C6, p<.001), but there were no significant differences between the examined levels in the control group (p=.075). Facet tropism at C4–C5 in the moderate spondylolisthesis patients was significantly greater than that in the severe spondylolisthesis patients (p=.036), but facet tropism severity did not vary with the degree of spondylolisthesis in the experimental group (p=.108). ConclusionsThis study revealed that facet tropism is universally present at the C3–C4, C4–C5, and C5–C6 levels and that the greatest degree of facet tropism exists in spondylolisthesis-affected levels. Although there was no significant correlation between facet tropism severity and the degree of spondylolisthesis, facet tropism was found to increase the risk of the development of spondylolisthesis. This finding suggested that facet tropism may play a significant role in cervical DS.

HIGH DEGREE SPONDYLOLISTHESIS IN ADULTS: MONOSEGMENTAL REDUCTION AND FIXATION

Objective:To evaluate a method to reduce high degree spondylolisthesis in adults with monosegmental fixing preserving the adjacent level and the improvement of sagittal balance.Methods:A prospective study, with 12 adult patients with high degree spondylolisthesis (III and IV) in adults who underwent surgery by the same team. We included 7 women and 5 men with a mean age of 37 years and lombosciatalgy that had no improvement with conservative treatment. The surgical technique used was total or partial reduction by Spondylolisthesis Reduction Instrument (SRI) system, with instrumentation only in the affected level, thus sparing the adjacent level, associated with 360ofusion.Results:The L5-S1 level was involved in nine patients, L4-L5 in two, and VT-S1 in one patient. The isthmic type predominated in nine patients, followed by dysplastic type in two, and one iatrogenic spondylolisthesis. These patients were assessed by the Oswestry scale, which showed a preoperative average of 59% and postoperative average of 12.4% (P&lt;0.05). A significant improvement in the average slip angle from 54.66% to 9.5% (35% to 0%) was found. No major complications such as infection, neurological damage or material breaks were observed.Conclusion:The reduction of high degree listhesis instrumenting only the affected level produces good results, with good control of pain and functional improvement of patients. However, a larger follow-up is required to better evaluation.

Minimally Invasive Transforaminal Lumbar Interbody Fusion for Spondylolisthesis: Comparison Between Isthmic and Degenerative Spondylolisthesis

Minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) is a common surgical option for degenerative spondylolisthesis (DS). However, its effectiveness for isthmic spondylolisthesis (IS) is still controversial. No current studies have directly compared perioperative and postoperative results including various radiological parameters between IS and DS after MIS TLIF. The purpose of this study is to compare the clinical and radiological results between isthmic and degenerative spondylolisthesis after MIS TLIF. This is a retrospective study of 41 patients who underwent MIS TLIF for single-segment, grade 1 or 2 IS (n = 18) and DS (n = 23). The same surgical techniques and procedure were applied to both groups. Perioperative outcomes (operation time, blood loss, hospital stay, complications); clinical outcomes (visual analog scale [VAS], Oswestry Disability Index [ODI]); radiological parameters (disk height, degree of spondylolisthesis, slip angle, lumbar lordosis, segmental lordosis, sacropelvic parameters: pelvic incidence, sacral slope, pelvic tile); and fusion rates using computed tomography scanning were compared between groups at 1 year postoperatively. There were no significantly different perioperative results between groups. Mean VAS and ODI scores improved significantly postoperatively in both groups but were not significantly different between groups at each follow-up point. Radiological parameters were not significantly different between groups except disk height and degree of spondylolisthesis. The disk heights were increased postoperatively (IS: 6.79-9.22 mm; DS: 8.18-8.97 mm) in both groups, and there were significant differences preoperatively. In addition, disk height restoration was greater for IS than DS (2.43 mm vs. 0.79 mm, P = 0.01). However, postoperative disk heights were not significantly different between groups. The degree of spondylolisthesis was significantly different between groups both preoperatively (16.77% vs. 11.33%, P < 0.01) and postoperatively (9.79% vs. 3.78%, P < 0.01). However, slip reduction was no different between groups (6.97 vs. 7.56%, P = 0.74). Fusion rates were not significantly different between groups. MIS TLIF resulted in similar clinical outcomes when used to treat both isthmic and degenerative spondylolisthesis. Although disk height restoration was more effective for IS than DS, other radiological parameters including fusion rate were no different between groups. For both isthmic and degenerative spondylolisthesis, MIS TLIF can be a safe and effective surgical option.

Sensitivity of magnetic resonance imaging in the diagnosis of mobile and nonmobile L4–L5 degenerative spondylolisthesis

Background contextLumbar degenerative spondylolisthesis (LDS) is often diagnosed by conventional supine magnetic resonance imaging (MRI). Numerous studies have shown, however, that the degree of spondylolisthesis can be reduced or disappears when the patient is supine as compared with standing lateral and flexion-extension (SLFE) radiographs. PurposeTo compare the sensitivity of supine MRI with SLFE radiographs in patients with L4–L5 LDS. Study designA retrospective imaging study. Patient sampleIncluded patients diagnosed with L4–L5 LDS with both SLFE films and supine MRI. MethodsLumbar degenerative spondylolisthesis was defined radiographically as a slip greater than 4.5 mm. Mobile LDS was defined as a difference of greater than 3% in slip percentage between lateral radiographs and sagittal MRIs. Additional measurements included L4–L5 facet effusion diameter on axial MRIs. Measurements were performed by two independent examiners. The kappa coefficient was used to assess the interobserver agreement. ResultsOf 103 patients assessed, 68% were women and the average age was 66 years. Lumbar degenerative spondylolisthesis was seen on 101 (98%) lateral films and 80 (78%) MRIs. Average slip was 10.0 mm for lateral standing radiographs and 6.6 mm on MRI (p<.0001). Fifty (48%) patients were identified with mobile LDS. The positive predictive value of facet joint effusion for mobile LDS increased from 52% for effusions greater than 1 mm to 100% for effusions greater than 3.5 mm. ConclusionsThis study found that MRI had a sensitivity of 78% for detecting L4–L5 LDS compared with 98% for lateral standing films. We also identified facet effusion size as a marker to predict mobile LDS. These findings suggest that, particularly in the setting of facet effusions, the complete workup of patients in whom LDS is possible should include standing radiographs.

Spine Hypermobility in Sports

ABSTRACT Spondylolysis and 1st degree spondylolisthesis are one of the common conditions causing low back pain in athletes. Treatment options are very variable and often controversial. Misdiagnosis and inappropriate treatment increases risk of reoccurrence in such conditions. It may also cause decrease in an athlete's performance if not treated well. Conservative management includes functional rehabilitation and anti-lordotic bracing. Therapy medium if given in right manner will have positive therapeutic effects. If conservative management fails to show any improvement, surgical stabilization with spinal fusion may be considered. How to cite this article Wicker A. Spine Hypermobility in Sports. J Postgrad Med Edu Res 2013;47(2):90-93.

True synovial cysts of the lumbar spine: an epiphenomenon of instability of the functional spine unit?

Dear Editor, We read with great interest the paper of Landi et al. titled: “Microsurgical excision without fusion as a safe option for resection of synovial cyst of the lumbar spine: long-term follow-up in mono-institutional experience.” published in Neurosurg Rev, 2012 Apr; 35(2):245–53 [16]. In this report, the authors present their series of 18 patients with synovial cysts who have been operated from 1995 to 2007. After excluding three patients who presented spinal instability at the preoperative assessment, the surgical procedure performed in all other 15 patients was restricted to surgical resection of the synovial cyst without fusion. According to their results, no patient presented signs of instability at the 2year follow-up as evaluated by dynamic x-rays. With basis on such data, the authors defend that, once excluded preoperative instability, the majority of the patients with lumbar synovial cysts can be optimally treated with surgical resection of the synovial cyst and partial arthrectomy (usually restricted to 1/3 of the involved facet) without fusion. Although these are the general lines upon which we base our surgical decision in the daily clinical practice, some special remarks about the present study are opportune. Although the authors found a very low incidence of preoperative instability (around 20 % of the patients with synovial cysts), other series have found much higher rates (up to 65 % in some series) [15] despite the fact that, similarly to the study of Landi et al., usually less than 10 % of the patients received upfront fusion [4, 22], In fact, two previous series reported the presence of at least some degree of spondylolisthesis in plain x-rays in up to 55 % of the patients [18, 20]. Even if such patients may occasionally present no motion in flexion/extension preoperative x-rays, they present a very high risk of developing symptomatic instability after a surgical procedure for resection of the synovial cyst which involves a partial facetectomy and, therefore, also a high likelihood of requiring fusion at the long-term; the reason for which they should be closely followed. Regarding the nomenclature of synovial cysts arising from (or adjacent to) the lumbar zygapophyseal joint, the literature presents a broad range of variation. The first report of such lesion dates from 1880 by von Gruker [12]. Vosschulte and Borger were the first to report associated nerve root compression secondary to a cyst adjacent to the facet articulations in 1950 [28]. Historically, the term juxta-facet cyst was first used by Kao et al. to describe cysts located adjacent to the facets joints or arising from the ligamentum flavum [14]. As the authors mention, from a morphological standpoint, such cysts can be basically subdivided in “synovial”, “ganglion”, “ligamentum flavum,” and “posterior longitudinal ligament cysts” (Fig. 1). True synovial cysts have a synovial lining membrane which communicates with the facet joint. Ganglion cysts, in opposition, have no synovial lining and develop from mucinous degeneration of the periarticular tissue and usually contain proteinaceous fluid. Ligamentum flavum and posterior longitudinal ligament cysts usually contain clear or xanthochromic fluid and also present no real communication with the facet joint [22]. Although some authors have previously defended that such anatomopathological differentiation does not bear any clinical significance, as one cyst type could evolve into the other and, ultimately, all of them would receive the same treatment, we truly believe that it is possible, in a significant proportion of the cases, to subclassify such entities after a T. A. Mattei (*) Department of Neurosurgery, University of Illinois College of Medicine at Peoria, 530 NE Glen Oak, #7430, Peoria, IL 61637, USA e-mail: tobias.a.mattei@osfhealthcare.org

Spontaneous reduction of spondylolisthesis during growth

Isthmic spondylolisthesis is a common cause of low back pain in children. It is associated with a defect in the pars interarticularis of the vertebra. The treatment depends on the clinical course and degree of spondylolisthesis. Low-grade isthmic spondylolisthesis usually shows a benign course without significant progression and therefore, conservative treatment is advised. Although isthmic pars defect can heal, initial existing degree of slippage persists. A complete reversion of deformity was never described yet. We present the case of a 7½-year-old girl with symptomatic grade 2 isthmic spondylolisthesis according to the Meyerding classification. Without any specific therapy, there was a radiologically documented near total reversion of slippage and total relief of clinical symptoms during 8 years of follow-up. Computed tomography scan after this period showed persisting pars interarticularis defect without signs of healing. This case report indicates that during growth, spontaneous reversion of vertebral slip in isthmic spondylolisthesis can occur, even without healing of the pars defect.

Das interspinöse Implantat „InSWing®“ an der Lendenwirbelsäule

Interspinous stabilization and, if desired, posterior spreading of the functional spinal unit (FSU). Symptomatic spinal stenosis with or without concomitant degeneration of the lumbar spine above L5/S1. Relative Indications: Mass prolapse of the lumbar intervertebral disc, for stabilization of the FSU together with removal of the prolapse/sequester. Symptomatic recurrent stenosis after stand-alone decompression surgery, for prevention of re-stenosis in the same segment. Topping-off during fusion surgery for a more physiological introduction of loads into the adjacent segment. Lack of operability and sustainance of anaesthesia of the patient - this may also include severe psychiatric/psychological disorders, adipositas permagna, and severe osteoporosis. Insufficient posterior structures such as spondylolysis, more than first degree spondylolisthesis. Severe bony stenosis (if implant is used without additional decompressive surgery!). Preoperatively known, intraoperatively discovered and/or induced instability of the FSU. Too close distance of the implant towards dural sac, particularly in case of dural tears, fistulae or overt inflammation. Interspinous unfolding of the PEEK-based implant via small midline incision, from one deliberately chosen access side with preservation of the supraspinous ligament and with optional tension-band fixation around both spinous processes in contact with the implant. 6 weeks restriction of lifting plus advocation of isometric physiotherapy without large motion amplitudes for warranting of a stable encapsulation of the implant via ligamentary remodelling. Sports activities not before that time period. The author prefers administration of a light brace for that time, yet the latter does not seem mandatory. Proven safe, unilateral, little invasive, and versatile procedure with advantages over well-established other market-available implants.

Which lumbar interbody fusion technique is better in terms of level for the treatment of unstable isthmic spondylolisthesis?

The purpose of this study was to investigate and compare clinical and radiographic outcomes of 2 kinds of lumbar interbody fusion (LIF) for the treatment of adult low-grade isthmic spondylolisthesis at L4-5 and L5-S1 levels. The medical records and radiographs of 86 patients who underwent anterior LIF (ALIF) (L4-5, 42 patients; L5-S1, 44 patients) and 42 patients who underwent transforaminal LIF (TLIF) (L4-5, 22 patients; L5-S1, 20 patients) between 2001 and 2004 were retrospectively reviewed. Clinical results were investigated using the visual analog scale (VAS) and Oswestry Disability Index (ODI) scores, and using radiographic measurements, including disc height (DH), degree of spondylolisthesis, segmental lordosis, whole lumbar lordosis (WL), sacral slope (SS), and pelvic tilt; the L-1 axis S-1 distance (LASD) and pelvic incidence were also obtained. In both groups, VAS and ODI scores had significantly improved at both treatment levels. Statistical analysis showed no significant difference in postoperative VAS scores between groups at the L4-5 level and in postoperative VAS/ODI scores at the L5-S1 level. However, ODI scores were better in the TLIF than in the ALIF group at the L4-5 level. In terms of radiological changes, there were no significant differences between the 2 groups at the L4-5 level; however, at the L5-S1 level, radiographic results indicated that ALIF was superior to TLIF in its capacity to restore DH, WL, SS, and LASD. The radiological evidence of fusion shows no intergroup difference and no interlevel difference. Considering the clinical and radiological outcomes in both groups, the authors recommend that instrumented mini-TLIF is preferable at the L4-5 level, whereas instrumented mini-ALIF might be preferable at the L5-S1 level for the treatment of unstable isthmic spondylolisthesis.

Repositioning injuries of nerve root L5 after surgical treatment of high degree spondylolistheses and spondyloptosis--in vitro studies

Temporary or persistent paralysis of the fifth lumbar nerve root have been frequently reported as complications following reposition of high degree spondylolisthesis. According to an outcome analysis of sixty-four patients, we found an increased incidence of motor damages after reduction of Meyerding degree four anterolisthesis or spondyloptosis. There were no signs of intradural root compression or nerve injury tracable. In order to detect extraforaminal strictures, the anatomic course of the lumbosacral plexus and its relation to neighbouring structures, especially pelvivertebral connective tissue junctions were recorded in cadavric measurements. Beside an number of variations in origin and course of the iliolumbar ligament complex, we observed a junction between os sacrum and the anterior part of the fifth lumbar vertebrae in 14/30 specimen, constantly running anterior to the fifth lumbar nerve root. In addition the nerve was fixed to the sacral periostium a few centimeters distal this crossing in about 20% of all cases. Pathophysiological effects were measured in reposition trials, using a continuous pressure monitoring system. A reposition of more than 20 mm resulted in a perineural pressure > 30 mmHg. This caused a nerve fiber deformation at the edge of the compressed nerve segment. Increased pressure leads to a nodular displacement of perineural fat as well as intraneural fascicles.

Secondary vascular disease in spondylolisthesis

The topographic relation of the spine to the great vessels let to the expectation that spondylolisthesis may lead to mechanical irritation of the cauda equina as well as of the great vessels. The angiological examination of 223 patients with spondylolisthesis of the lumbar spine shows that the changes in the anatomy of the great vessels are less significant than expected after experiments involving artificial dislocations of the spine in cadavers. In vivo arterial function is not altered even in true spondyloptosis. Pelvic veins on the other hand show considerable compression and diminished flow in third and fourth degree spondylolisthesis of L5 over S1 as well as in second degree spondylolishtesis of L4 over L5. These patients seem to be disposed to venous disorders involving varices and thrombosis. If therefore a high venous pressure is found and a ventral fusion proposed it should be discussed to combine the procedure with a decompression of the veins.

Condutas usuais entre os reumatologistas brasileiros: levantamento nacional

OBJETIVO: avaliar condutas tomadas pelos reumatologistas de todo Brasil frente a situações clínicas comuns na prática do dia-a-dia. MÉTODO: cenários clínicos fictícios sobre várias doenças reumáticas foram montados, com perguntas objetivas acerca do tratamento. Os questionários foram enviados aos 831 sócios com títulos de especialistas pela Sociedade Brasileira de Reumatologia (SBR), com envelope selado para envio das respostas. RESULTADOS: a taxa média de devolução dos questionários foi de apenas 21,4%. A média de idade (DP) dos reumatologistas respondedores foi de 42,7 anos (DP=11,7), com tempo médio de formados de 19,8 anos (DP=10,1). No cenário clínico sobre artrite reumatóide (AR) de início recente em atividade, a maioria dos colegas (84,7%) tratava inicialmente o paciente com prednisona ou prednisolona. As drogas modificadoras da doença mais escolhidas foram metotrexato (84,2%) e cloroquina (63,8%). Quatro médicos (2,8%) escolheram os agentes biológicos (infliximabe e etanercepte) como droga de primeira escolha no tratamento inicial da doença. A profilaxia para osteoporose induzida pelo corticóide com suplementação de cálcio e vitamina D só foi orientada por 61,2% e 46,5% dos reumatologistas, respectivamente. No cenário clínico de um paciente com lúpus eritematoso sistêmico (LES), a grande maioria dos colegas optou pelo tratamento com corticóide oral (93,7%), cloroquina (92,5%) e fotoproteção (93,7%). Na presença de nefrite lúpica caracterizada com preservação da função renal e níveis pressóricos normais, a conduta mais escolhida foi pulsoterapia de corticóide (47,7%) ou prednisona oral em altas doses. Pulsoterapia de ciclofosfamida foi escolhida por 34,6% dos reumatologistas. No cenário sobre lombalgia aguda mecânico-postural, sem sinais de alarme, 55,4% dos colegas não solicitavam nenhum exame na abordagem inicial e as drogas mais escolhidas para o tratamento foram: antiinflamatórios não-hormonais (AINHs) (89,3%), relaxante muscular (72,9%), fisioterapia (33,3%). O repouso no leito foi orientado por 31,6% dos especialistas. Num caso de lombalgia crônica com raio X recente mostrando espondilolistese grau 1 e discoartrose, 39,6% dos reumatologistas não solicitavam nenhum exame adicional, enquanto 26,2% e 24,4% solicitavam tomografia computadorizada (TC) e ressonância nuclear magnética (RNM), respectivamente. As condutas mais indicadas nesse caso foram: fisioterapia (75,1%), relaxante muscular (48,5%), RPG (45,6%), exercícios físicos (41%), AINH seletivo da Cox-2 (40,5%), amitriptilina (35,3%), analgésicos opióides (34,7%). Outros cenários de artrose de joelho e ombro doloroso foram apresentados. CONCLUSÕES: a baixa taxa de devolução dos questionários pode refletir uma prática ainda não-incorporada na nossa cultura. O perfil dos reumatologistas respondedores é muito semelhante entre as regiões. A maioria das condutas escolhidas está de acordo com as melhores evidências disponíveis, refletindo uma homogeneidade de abordagem terapêutica entre os reumatologistas. Embora este estudo traga importantes dados sobre a prática reumatológica, pode não ser representativo da população de reumatologistas brasileiros, tendo em vista o baixo percentual de respondedores.

TREATMENT OF SPONDYLOLISTHESIS WITH A DEVICE FOR EXTERNAL TRANSPEDICULAR SPINAL FIXATION

Objectives. To analyze issues of surgical treatment of complicated spondylolisthesis in the lumbar spine. Materials and Methods. Forty-five patients at the age of 14 to 62 years were operated on with a device for external transpedicular fixation. All patients underwent clinical, radiological and physiologic examinations. To characterize the degree of spondylolisthesis the Meyerding classification was used. Grade I and II dislocations were treated by laminectomy of a displaced vertebra, excision of scars and mobilization of a dural sack, discectomy at a pathologic level involving both end plates of the adjacent vertebral bodies, impacting of 2 autografts (of the bone excised during laminectomy) into a disc space, and placement of a device for external transpedicular fixation. For Grade III and IV the second stage was performed after instrumentation and maximum possible reduction of dislocation. The procedure included anterior fusion of displaced and adjacent vertebrae in the achieved position either with autografts of the illiac crest or with porous nickel titanium implants through trans- or extraperitoneal approach. Results. Achieved results of application of the device for external transpedicular fixation in patients with spondylolisthesis enable to consider clinically justified a partial or total reduction of a displaced vertebra followed by neurologic status monitoring and radiological control during the post-operative period. Use of porous nickel titanium implant accelerates the formation of a bony block and decreases the time of surgery, as there is no need for autograft preparation.

P68. Surgical outcomes for degenerative spondylolisthesis in relation to slip severity

BACKGROUND CONTEXT: The presence of degenerative spondylolisthesis is a well-established indication for surgical fusion at the time of surgical decompression for associated spinal stenosis. The degree of spondylolisthesis and its relation to clinical outcomes following decompression and fusion have not been addressed.

Patient outcome after resection of lumbar juxtafacet cysts.

Retrospective review of patients who underwent lumbar juxtafacet cyst resection with questionnaire follow-up. Determine the long-term outcome after resection of lumbar juxtafacet cysts. Juxtafacet cysts are uncommon causes of radicular pain and are often associated with significant spinal degenerative disease. Previous studies have not focused on the outcome of patients who have undergone resection. Charts of 29 patients who underwent lumbar juxtafacet resection were reviewed and an outcomes questionnaire was sent to each. Thirty-three lumbar juxtafacet cysts were resected from 29 patients. Cysts, 31 (94%) from facets and 2 (6%) from the ligamentum flavum, most commonly arose at the L4-L5 level (51%). Twelve patients (41%) were found to have some degree of spondylolisthesis before surgery, while 26 patients (90%) had facet arthropathy. Two patients (7%) underwent concurrent resection and fusion. Recurrence occurred in 3%. Three patients (9%) had subsequent lumbar spine operations, including 2 fusions (6%). Incidental durotomy was the most common surgical complication occurring in 3 cases (9%). Twenty-four patients (83%) responded to follow-up questionnaire or phone interview. Mean length of follow-up was 24 months (4-64 months). Twenty patients (83%) reported improvement in pain, and 16 (67%) reported an improved level of function. All respondents reported some degree of improvement in their condition after surgery. Juxtafacet cysts are an uncommon cause of radiculopathy. Surgical resection is the treatment of choice with low rates of complications, recurrences, and residual complaints.

Long-term follow-up of patients with grade-III and IV spondylolisthesis. Treatment with and without posterior fusion.

The outcome in eleven patients in whom Grade-III and IV spondylolisthesis was treated non-operatively (Group I) was compared with that in twenty-one patients in whom the same degrees of spondylolisthesis were treated by posterior interlaminar fusion (Group II). At an average eighteen-year follow-up of the eleven patients in Group I, four (36 per cent) were asymptomatic, six (55 per cent) had mild symptoms, and only one had significant symptoms. Five (45 per cent) had one or more neurological findings, but none were incontinent. All of the patients in this group led an active life, and all had required only minor adjustments in their life-style. At an average twenty-four-year follow-up of the twenty-one patients in Group II, twelve (57 per cent) were asymptomatic, eight (38 per cent) had mild symptoms, and only one had significant symptoms. Nine (50 per cent) of the eighteen patients who had a physical examination had one or more neurological findings. Roentgenographically demonstrated failure of fusion did not adversely affect the results, and the patients remained asymptomatic despite the development of pseudarthrosis in one patient and bending of the fusion mass in three (14 per cent). In situ arthrodesis provides acceptable results for the patient who has Grade-III or IV spondylolisthesis and pain that interferes with life-style and that is unresponsive to non-operative treatment. In the skeletally immature patient, in situ fusion is recommended for disturbances of gait secondary to tight hamstrings and when the spondylolisthesis progresses.