Focal Lordosis Research Articles

Posterior lumbar interbody fusion for aged patients with degenerative spondylolisthesis: is intentional surgical reduction essential?

Background contextSurgical reduction and posterior lumbar interbody fusion (PLIF) is commonly used to recover segmental imbalance in degenerative spondylolisthesis. However, whether intentional reduction of the slipped vertebra during PLIF is essential in aged patients with degenerative spondylolisthesis remains controversial. PurposeWe compared the outcomes of surgical reduction and fusion in situ among aged patients who underwent PLIF for degenerative spondylolisthesis. Study designA prospective randomized clinical trial on the surgical treatment of degenerative spondylolisthesis patients aged older than 70 years. Patient sampleBetween January 2006 and December 2009, 73 patients aged 70 years or older with single-level degenerative spondylolisthesis requiring surgical treatment were included in this study. Outcome measuresClinical outcomes were assessed using the visual analog scale, Oswestry Disability Index, and Japanese Orthopedic Association scores. Radiographic outcomes included percentage of vertebral slippage, focal lordosis, and disc height. MethodsThe 73 patients were randomly assigned to two groups treated using surgical reduction (Group A, n=36) and fusion in situ (Group B, n=37). Both groups were followed up for an average of 33.2 months (range, 24–54 months). The clinical and radiographic outcomes were compared between the two groups. ResultsSurgical complications were similar in the two groups. The average operative time and blood loss during surgery did not insignificantly differ (p>.05) between the two groups. Spondylolisthesis, disc height, and focal lordosis were significantly improved postoperatively in both groups. There was no obvious difference in clinical outcomes, as assessed using the visual analog scale, Oswestry Disability Index, and Japanese Orthopedic Association scores, although the radiographic outcomes were considerably better in Group A than in Group B. ConclusionsPosterior lumbar interbody fusion with pedicle screws fixation, with or without intraoperative reduction, provides good outcomes in the surgical treatment of aged patients with degenerative spondylolisthesis. Better radiological outcomes by intentional reduction do not necessarily indicate better clinical outcomes.

Anterior Elongation as a Minimally Invasive Alternative for Sagittal Imbalance—A Case Series

Degenerative and iatrogenic conditions may lead to flat back or even to kyphotic deformity, and sagittal imbalance can cause significant clinical impairment. Minor imbalance cases are usually treated with conservative care. Among currently popular surgical techniques for the correction of sagittal imbalance are posterior-based procedures, which are associated with access-related risks (mostly neurological) and postoperative morbidity risks. This study aims to report a minimally invasive lateral approach using hyperlordotic cages in the treatment of mild sagittal imbalance. Radiological correction, clinical improvement, and safety will be analyzed. Eight patients (mean age 71.8years, SD 7.8; mean BMI 27.5, SD 2.3) with symptomatic sagittal imbalance were retrospectively reviewed. Eight cases were treated by anterior interbody fusion with lordotic cages. A minimally invasive lateral retroperitoneal approach was used in the surgical procedures, with or without percutaneous pedicle screw supplementation. No major complications occurred and just one case needed revision for direct decompression. Clinical outcomes Visual Analog Scale score changed from 88 at preoperative visit to 51 at 1-week visit, and Oswestry Disability Index score decreased from 82 at preoperative visit to 44 at 6-week visit. The 6-month radiological assessment revealed improvement in spinopelvic parameters: Focal lordosis improved from 2.3° ± 7.7 to 27.1° ± 6.7. Sagittal vertical alignment improved from 11.7 ± 5.3 to 6.2 ± 4.0cm. Preoperative sacral slope improved from 20.1° ± 5.8 to 29.4° ± 10.3 and preoperative pelvic tilt improved from 35.2° ± 5.2 to 23.8° ± 4.3. Short-term results indicate that the minimally invasive lateral approach can be applied to the treatment of mild sagittal imbalance, with special advantage in elderly patients or those in which posterior approaches are relatively contraindicated.

Limited decompression, fixation, and fusion for degenerative scoliosis with vertebral stenosis

Objective To evaluate the efficiency of limited decompression, fixation, and fusion for degenerative scoliosis with vertebral stenosis. Methods From January 2001 to January 2008, 36 patients with degenerative scoliosis with vertebral stenosis were treated in our hospital. There were 2 males and 34 females. The age was from 51 to 76 years with an average of 62.3 years. X-ray, CT, MR examination were performed preoperatively for all the cases, 5 cases underwent myelography. Preoperative Cobb's angle, focal lordosis, the distance between C_7 plumb line(C_7PL) and upper edge of S_1 vertebral body (SVA), and the distance between C_7PL and center sacral vertical line(CSVL) were 24.0°±10.2°, 22.6°±11.2°, (7.8±6.6) cm and (6.9±5.8) cm respectively. Limited decompression, pedicle screw internal fixation and fusion were carried out for patients, VAS and SF-36 scored system were used to evaluate surgery effects. Results The mean followup period was 2.4 years (range, 1.2-4 years) and no patients were lost during follow-up. The mean surgery time was 130 min (range, 115-164 min) with an average bleeding amount of 625 ml (range, 450-870 ml). Compared to preoperation, Cobb's angle (10.6°±8.5°, 8.9°±5.3°), focal lordosis (25.6°±14.3°, 31.8°±13.4°), SVA[(0.5±3.4) cm, (-1.2±2.7) cm], and CSVL [(2.9±1.4) cm, (1.7±1.2) cm] were significantly improved at postoperation and final follow-up through statistics of SPSS 13.0 software. Loss of correction happened in one case. No collapse of the disc height occurred, neither did nerve root injuries nor fracture of the fixation system. Conclusion Limited decompression, pedicle screw fixation and fusion are testified efficient for degenerative scoliosis with vertebral stenosis, individualized surgery design should be made according to clinical symptoms, signs and imaging features to expect a satisfactory result. Key words: Lumbar vertebrae; Spinal stenosis; Scoliosis

Spinal Osteotomy in Ankylosing Spondyloarthritis

The role of surgical correction of sagittal plane deformity in cases of lytic spondylolisthesis remains controversial. While some early evidence is emerging of the possible short- and long-term benefits of restoring spinal balance, many surgeons have been concerned about the associated risks. The insert-and-rotate posterior lumbar interbody fusion (PLIF) technique, first described by Jaslow in 1946, may enable surgeons to safely and effectively correct sagittal balance through a single posterior approach.To determine whether the focal kyphosis and subluxation associated with a lytic lumbosacral spondylolisthesis can be safely and effectively corrected using a single-stage posterior distraction/reduction technique and insert-and-rotate interbody fusion spacers.A prospective, single cohort, observational study of the clinical outcomes and retrospective radiological review, in a series of 18 consecutive patients with lytic spondylolisthesis Grades I to IV, operated between September 2000 and December 2002.Mean age of 50.2 years (range, 15.5 to 77.8 years). Principal indication for surgery was relief of radicular pain secondary to foraminal stenosis in 16 of 18 patients, and back pain was the principal symptom in 2 patients. Mean preoperative slip was 30.2% (range, 9% to 78%). Mean preoperative focal lordosis was 10.6 degrees (range, −12 to 33 degrees).Minimum 12-month follow-up was available on all patients except one, who died of unrelated causes after his 6-month visit. Patients completed Visual Analogue Pain Score (VAS), Low Back Outcome Score (LBOS), Short Form (SF)-12 and patient satisfaction questionnaires. Pre- and postoperative measurements of the percentage slip and lumbar lordosis of the involved segments were available on 13 patients.Decompressive laminectomy was followed by reduction of the spondylolisthesis with the aid of intervertebral disc space spreaders and supplementary pedicle screw instrumentation. The vertebral bodies were supported with bilateral intervertebral lordotic spacers made from carbon fiber, titanium mesh or polyether-ether-ketone (Medtronic Sofamor Danek, Memphis, TN). These were inserted on their sides and rotated 90 degrees before placing bone graft to either side of them, within the disc space.Mean follow-up was 17.3 months. Mean preoperative measures of VAS and LBOS of 5.0±2.3 and 29.3±16.4, respectively, improved to 2.9±3.0 (p=.01) and 42.6±20.1 (p=.005) at last follow-up. Fifteen of 18 patients (83.3%) considered their outcome to be good or excellent. Mean preoperative slip reduced from 30.2% to 6.2% (p=.001). Mean focal lordosis improved from 10.6 to 18.1 degrees (p=.02). Lumbar lordosis (L1–S1) did not change, but the lordosis of the lumbar segments above the fusion reduced from 46.8 to 34.9 degrees (p=.02). There were no serious implant or procedural complications. Postoperatively, there was a delayed and temporary weakness of ankle dorsiflexion in a patient with Grade IV spondylolisthesis.This series suggests that PLIF using an insert-and-rotate technique can yield satisfactory clinical outcomes and substantial deformity correction using a posterior only approach and with low levels of serious or permanent complications. Longer-term clinical outcome and comparative studies are required regarding the importance of the restoration of spinal balance.

Posterior lumbar interbody fusion for lytic spondylolisthesis: restoration of sagittal balance using insert-and-rotate interbody spacers

Background context The role of surgical correction of sagittal plane deformity in cases of lytic spondylolisthesis remains controversial. While some early evidence is emerging of the possible short- and long-term benefits of restoring spinal balance, many surgeons have been concerned about the associated risks. The insert-and-rotate posterior lumbar interbody fusion (PLIF) technique, first described by Jaslow in 1946, may enable surgeons to safely and effectively correct sagittal balance through a single posterior approach. Purpose To determine whether the focal kyphosis and subluxation associated with a lytic lumbosacral spondylolisthesis can be safely and effectively corrected using a single-stage posterior distraction/reduction technique and insert-and-rotate interbody fusion spacers. Study design/setting A prospective, single cohort, observational study of the clinical outcomes and retrospective radiological review, in a series of 18 consecutive patients with lytic spondylolisthesis Grades I to IV, operated between September 2000 and December 2002. Patient sample Mean age of 50.2 years (range, 15.5 to 77.8 years). Principal indication for surgery was relief of radicular pain secondary to foraminal stenosis in 16 of 18 patients, and back pain was the principal symptom in 2 patients. Mean preoperative slip was 30.2% (range, 9% to 78%). Mean preoperative focal lordosis was 10.6 degrees (range, −12 to 33 degrees). Outcome measures Minimum 12-month follow-up was available on all patients except one, who died of unrelated causes after his 6-month visit. Patients completed Visual Analogue Pain Score (VAS), Low Back Outcome Score (LBOS), Short Form (SF)-12 and patient satisfaction questionnaires. Pre- and postoperative measurements of the percentage slip and lumbar lordosis of the involved segments were available on 13 patients. Surgical methods Decompressive laminectomy was followed by reduction of the spondylolisthesis with the aid of intervertebral disc space spreaders and supplementary pedicle screw instrumentation. The vertebral bodies were supported with bilateral intervertebral lordotic spacers made from carbon fiber, titanium mesh or polyether-ether-ketone (Medtronic Sofamor Danek, Memphis, TN). These were inserted on their sides and rotated 90 degrees before placing bone graft to either side of them, within the disc space. Results Mean follow-up was 17.3 months. Mean preoperative measures of VAS and LBOS of 5.0±2.3 and 29.3±16.4, respectively, improved to 2.9±3.0 (p=.01) and 42.6±20.1 (p=.005) at last follow-up. Fifteen of 18 patients (83.3%) considered their outcome to be good or excellent. Mean preoperative slip reduced from 30.2% to 6.2% (p=.001). Mean focal lordosis improved from 10.6 to 18.1 degrees (p=.02). Lumbar lordosis (L1–S1) did not change, but the lordosis of the lumbar segments above the fusion reduced from 46.8 to 34.9 degrees (p=.02). There were no serious implant or procedural complications. Postoperatively, there was a delayed and temporary weakness of ankle dorsiflexion in a patient with Grade IV spondylolisthesis. Conclusions This series suggests that PLIF using an insert-and-rotate technique can yield satisfactory clinical outcomes and substantial deformity correction using a posterior only approach and with low levels of serious or permanent complications. Longer-term clinical outcome and comparative studies are required regarding the importance of the restoration of spinal balance.

Posterior lumbar interbody fusion for degenerative spondylolisthesis: restoration of sagittal balance using insert-and-rotate interbody spacers

Background context Although satisfactory clinical outcomes have been reported for degenerative spondylolisthesis using a variety of surgical techniques, its optimal management remains controversial. Laboratory and clinical evidence is emerging that if fusion surgery is undertaken, improved short- and longer-term outcomes may be achieved by correcting any sagittal deformity present. The insert-and-rotate posterior lumbar interbody fusion (PLIF) technique, first described by Jaslow in 1946, may enable surgeons to safely and effectively correct sagittal balance through a single posterior approach. Purpose To examine the clinical outcomes and determine whether the focal sagittal imbalance associated with a degenerative lumbar spondylolisthesis can be safely and effectively corrected using a posterior distraction/reduction technique and insert-and-rotate interbody fusion spacers. Study design/setting A prospective, single-cohort, observational study of the clinical outcomes and retrospective radiological review, in a series of 34 patients with degenerative spondylolisthesis, who underwent surgery between September 2000 and October 2002. Patient sample Mean age of 65.1 years (range, 35 to 82 years). Thirty-two of the 34 patients underwent surgery principally for the relief of radicular leg pain. The principal indication for the fusion was the prevention of anticipated postdecompression instability in 68% of the patients. Mean preoperative slip was 20.0% (range, 12% to 33%). Mean preoperative focal lordosis was 13.2 degrees. Outcome measures Patients were administered pre- and postoperative clinical outcome surveys recording Visual Analogue Pain Score (VAS), Low Back Outcome Score (LBOS), Short Form (SF)-12 and patient satisfaction questionnaires. Pre- and postoperative measurements of the percentage slip and lumbar lordosis of the involved segments were available on 17 patients. Statistical analysis was done using a two tailed, paired t test. Surgical methods Decompressive laminectomy was followed by reduction of the spondylolisthesis using intervertebral disc space distraction and pedicle screw instrumentation. The vertebral bodies were supported with bilateral intervertebral lordotic spacers, inserted on their sides and rotated 90 degrees before placing bone graft to either side of them, within the disc space. Results Mean follow-up time was 21.2 months (range, 12–32 months). No patients were lost to follow-up. Mean preoperative measures of VAS and LBOS of 5.3±2.2 and 24.8±15.6, respectively, improved to 2.2±2.1 (p<.001) and 44.8±18.0 (p<.001) at last follow-up. Thirty-one of 34 patients (91%) considered their outcome to be good or excellent. Mean preoperative slip reduced from 20.2% to 1.7% (92% correction, p<.001). Mean focal lordosis increased from 13.1 to 16.1 degrees (26.0% increase, p=.01). There were no device-related procedural complications. Postoperatively, three patients developed an ileus and one a possible deep wound infection, which settled on antibiotics. One patient required extension of his fusion at 12 months for adjacent segment stenosis. Conclusions This series suggests that PLIF for degenerative spondylolisthesis using an insert-and-rotate technique can yield high levels of patient satisfaction with low levels of complications and substantial deformity correction using a posterior only approach. Longer-term outcome studies are required regarding the relevance of the restoration of spinal balance.