Low-grade Degenerative Lumbar Spondylolisthesis Research Articles

Comparing Opioid Utilization and Costs for Surgical Management of Single-Level Spondylolisthesis: A National Claims Database Analysis

IntroductionThe rise in degenerative lumbar spondylolisthesis (DLS) cases has led to a significant increase in fusion surgeries, which incur substantial hospitalization costs and often necessitate chronic opioid use for pain management. Recent evidence suggests that single-level low-grade DLS outcomes are comparable whether a fusion procedure or decompression alone is performed, sparking debate over the cost-effectiveness of these procedures, particularly with the advent of minimally invasive techniques reducing the morbidity of fusion. This study aims to compare chronic opioid utilization and associated costs between decompression alone and decompression with instrumented fusion for single-level degenerative lumbar spondylolisthesis. Material and methodsUsing data from the PearlDiver database, a retrospective database analysis was conducted. We analyzed records of Medicare and Medicaid patients undergoing lumbar fusion or decompression from 2010 to 2022. Patient cohorts were divided into decompression alone (DA) and decompression with instrumented fusion (DIF). Chronic opioid use, pain clinic visits, and total costs were compared between the two groups at 90 days, 1 year, and 2 years post-surgery. TheoryDoes DIF offer a more cost-effective approach to managing DLS in terms of chronic opioid use in single-level DLS patients. ResultsThe study revealed comparable chronic opioid use and pain clinic visits between DA and DIF groups at 90 days and 1 year. However, total costs associated with opioid prescriptions as well as surgical aftercare were significantly higher in the DIF group at 90 days (p < 0.05), 1 year (p < 0.05), and 2 years (p < 0.05) post-surgery compared to the DA group. ConclusionsThis study highlights the higher costs associated with DIF up to 2 years post-surgery despite comparable symptom improvement when compared to DA and DIF at the 1-year interval. DA emerges as a more financially favorable option, challenging the notion of fusion's cost-offsetting benefits. While further investigation is needed to understand underlying cost drivers and optimize outcomes, our findings emphasize the necessity of integrating clinical and economic factors in the management of single-level DLS.

Minimally Invasive Decompression With Noninstrumented Facet Fusion Versus Minimally Invasive Transforaminal Lumbar Interbody Fusion for Stenosis Associated With Grade 1 Lumbar Degenerative Spondylolisthesis.

Retrospective matched cohort study. With a growing interest in minimally invasive spine surgery (MIS), the question of which technique is the most advantageous for patients with low-grade degenerative lumbar spondylolisthesis (DLS) still remains unclear. To compare patient-reported outcomes, perioperative morbidity, and rates of reoperation between MIS decompression with either unilateral noninstrumented facet fusion (MIS-F) or with transforaminal interbody fusion (MIS-T) for grade 1 DLS. Twenty patients who underwent MIS-T and 20 patients with MIS-F were matched based on age, sex, and preoperative ODI, VAS back, and VAS leg. All patients had DLS with at least 4 millimeters of translation on standing radiographs. Exclusion criteria included prior level surgery, multilevel instability, disk impinging on the exiting nerve root, spondylolisthesis from significant facet arthropathy, or foraminal compromise from disk collapse. ODI, VAS back, VAS leg, and patient satisfaction measured by the North American Spine Society questionnaire were tracked at 3, 6, 12, and 24 months postoperatively. Minimum clinically important differences and substantial clinical benefits were calculated. MIS-F and MIS-T resulted in decreased ODI at 3, 6, and 12 months following the index procedure. Sixty percent of MIS-F and 83% of MIS-T patients reached minimum clinically important difference at 1 year postoperatively; however, using the threshold of 30% ODI reduction from baseline, 67% of MIS-F and 83% MIS-T ( P = 0.25) achieved this goal. Forty-three percent of MIS-F and 59% of MIS-T patients met substantial clinical benefits. Satisfaction at 1 year, measured by a score of 1 or 2 on the North American Spine Society questionnaire, was 64% for MIS-F and 83% for MIS-T. MIS-F and MIS-T are effective treatment options for spinal stenosis associated with low-grade DLS. Both techniques result in comparable patient-reported outcomes and satisfaction up to 2 years and have similar long-term reoperation rates. More evidence is required to delineate optimal selection characteristics for MIS-F versus MIS-T.

Radiological factors affecting functional outcome after the implantation of BDYN™ dynamic stabilization system for low-grade lumbar degenerative spondylolisthesis

BackgroundThe objectives of this study are to identify radiological factors associated with good functional outcomes after the implantation of BDYN™ dynamic stabilization system in the setting of painful low-grade degenerative lumbar spondylolisthesis (DLS). Material and methodsIn this monocentric, retrospective study, we followed 50 patients, a 5-years period, with chronic lower back pain, radiculopathy and/or neurogenic claudication evolving for at least one year that failed conservative treatment. All patients presented low-grade DLS and underwent lumbar dynamic stabilization. Radiological and clinical outcomes were assessed preoperatively and 24months after surgery. Functional evaluation was based on the Oswestry Disability Index (ODI), the Numerical Rating Scale (NRS), and the Walking Distance (WD). Radiological analysis was based on lumbar X-rays and MRI parameters. Patients were divided into two groups according to the reduction in the postoperative ODI score (more or less than 15 points), and statistical analysis was performed between both groups to find predictive radiological factors for a satisfying functional outcome. ResultsClinically, 80% (40 patients) had a satisfying functional result, and 20% (10 patients) were considered having a poor outcome according to the ODI score. Radiologically, the loss in segmental lordosis was statistically associated with bad functional outcomes (18° for ODI decrease>15 versus 11° for ODI decrease<15). There is also a tendency showing that a higher Pfirmann disc signal grade (grade IV) and a severe canal stenosis according to Schizas classification (grade C & D) are predictive of a poor clinical result, but that must be confirmed in future studies. ConclusionsBDYN™ appears safe and well-tolerated. This new device should be effective for the treatment of patients with low-grade DLS. It provides significant improvement in terms of daily life activity and pain. Moreover, we have been able to deduce that a kyphotic disc is associated with a bad functional outcome after BDYN™ device implantation. It may represent a contraindication for the implantation of such DS device. Moreover, it seems that it is better to implant BDYN™ in DLS with mild or moderate disc degeneration and canal stenosis.

Minimally Invasive Lumbar Decompression Versus Minimally Invasive Transforaminal Lumbar Interbody Fusion for Treatment of Low-Grade Lumbar Degenerative Spondylolisthesis.

A retrospective cohort comparison study. To compare perioperative outcomes, radiographic parameters, and patient-reported outcome measures (PROMs) between minimally invasive unilateral laminotomy with bilateral decompression (MIS-ULBD) versus MIS transforaminal lumbar interbody fusion (MIS-TLIF) for treatment of low-grade lumbar degenerative spondylolisthesis. While lumbar degenerative spondylolisthesis is a common condition, optimal surgical treatment remains controversial. Newer MIS techniques, which preserve bone, paraspinal musculature, and posterior midline stabilizers, are thought to reduce the risk of iatrogenic instability and may obviate the need for fusion. However, few comparative studies of MIS techniques for low-grade lumbar degenerative spondylolisthesis currently exist. Consecutive patients with low-grade (Meyerding grade I or II) lumbar degenerative spondylolisthesis treated with single-level MIS-ULBD or MIS-TLIF were identified retrospectively from a prospectively collected spine surgery registry from April 2017 to November 2021. Perioperative outcomes, radiographic data, and PROMs were assessed. A total of 188 patients underwent either MIS-ULBD or MIS-TLIF (79 MIS-ULBD and 109 MIS-TLIF). Patients who underwent MIS-ULBD tended to be older, had higher Charlson Comorbidity Index, lower mean percentage back pain, higher percentage of L4/L5 pathology, shorter operative time, lower estimated blood loss, and lower postoperative pain ( P <0.05). In both groups, there were statistically significant improvements at one year for five of the six PROMs studied: Oswestry Disability Index (ODI), visual analog scale (VAS)-back pain, VAS-leg pain, Short Form 12 Physical Component Score (SF12-PCS), and Patient-Reported Outcomes Measurement Information System (PROMIS) ( P <0.05). On multivariate analysis controlling for confounders, there were no associations between procedure type and achieving minimal clinically important difference at one year in any of the PROMs studied. The current study suggests that both MIS-ULBD and MIS-TLIF result in significant improvements in pain and physical function for patients with low-grade lumbar degenerative spondylolisthesis. 3.

Long-term Radiological and Clinical Outcome after Lumbar Spinal Fusion Surgery in Patients with Degenerative Spondylolisthesis: A Prospective 6-Year Follow-up Study.

ObjectiveTo assess which radiological alignment parameters are associated with a satisfactory long‐term clinical outcome after performing lumbar spinal fusion for treating degenerative spondylolisthesis.MethodsThis single‐center prospective study assessed the relation between radiological alignment parameters measured on standing lateral lumbar spine radiographs and the patient‐reported outcome using four different questionnaires (COMI, EQ‐5D, ODI and VAS) as primary outcome measures (level of evidence: II). The following spinopelvic alignment parameters were used: gliding angle, sacral inclination, anterior displacement, sagittal rotation, lumbar lordosis, sacral slope, pelvic tilt and pelvic incidence. Furthermore, the length of stay and perioperative complications were documented. Only cases from 2013 to 2015 of low‐grade degenerative lumbar spondylolisthesis (Meyerding grades I and II) were considered. The patients underwent open posterior lumbar fusion surgery by pedicle screw instrumentation and cage insertion. The operative technique was either a posterior lumbar interbody fusion (PLIF) or a transforaminal lumbar interbody fusion (TLIF) performed by three different senior orthopedic surgeons. Exclusion criteria were spine fractures, minimally invasive techniques, underlying malignant diseases or acute infections, previous or multisegmental spine surgery as well as preoperative neurologic impairment. Of 89 initially contacted patients, 17 patients were included for data analysis (11 males, six females).ResultsThe data of 17 patients after mono‐ or bisegmental lumbar fusion surgery to treat low‐grade lumbar spondylolisthesis and with a follow‐up time of least 72 months were analyzed. The mean age was 66.7 ± 11.3 years. In terms of complications two dural tears and one intraoperative bleeding occurred. The average body mass index (BMI) was 27.6 ± 4.4 kg/m2 and the average inpatient length of stay was 12.9 ± 3.8 days (range: 8–21). The long‐term clinical outcome correlated significantly with the change of the pelvic tilt (r s = −0.515, P < 0.05) and the sagittal rotation (r s = −0.545, P < 0.05). The sacral slope was significantly associated with the sacral inclination (r s = 0.637, P < 0.01) and the pelvic incidence (r s = 0.500, P < 0.05). In addition, the pelvic incidence showed a significant correlation with the pelvic tilt (r s = 0.709, P < 0.01). The change of the different clinical scores over time also correlated significantly between the different questionnaires.ConclusionsThe surgical modification of the pelvic tilt and the sagittal rotation are the two radiological alignment parameters that can most accurately predict the long‐term clinical outcome after lumbar interbody fusion surgery.

Utility of the decubitus or the supine rather than the extension lateral radiograph in evaluating lumbar segmental instability.

To determine the superiority of decubitus and supine radiographs for the reduction of olisthesis instead of the extension radiograph, and the inconsistency of the CT scout view, 3D-reconstruction and MR image in evaluating segmental instability. A cohort of 154 low-grade lumbar degenerative spondylolisthesis patients with the average age of (60.9 ± 8.6) years were enrolled. Slip percentage was measured on the flexion, upright and extension radiographs, the decubitus lateral radiograph, CT scout view, the supine median sagittal 3D-reconstruction and MR image. The translational range of motion was calculated, and segmental instability was defined as translational motion ≥ 8%. The flexion radiograph showed higher slip percentage than upright radiograph (p < 0.001). The slip percentage of the MR image was lower than CT scout view (p = 0.003) and CT sagittal radiograph (p = 0.001) on the basis of statistical differences among three groups (p = 0.002). The slip percentage of the CT scout view, decubitus radiograph, and extension radiograph was statistically different (p = 0.01). The CT scout view and sagittal reconstruction had lower slip percentage than the extension radiograph (p = 0.042; p = 0.003, respectively). Both the flexion-supine and flexion-decubitus modality had larger translational motion than the flexion-extension modality (p = 0.007; p < 0.001, respectively). Many modalities and techniques are used to show the vertebral displacement and its possible change and any cane used in the daily practice. In this study, supine and decubitus lateral radiography have larger reduction of olisthesis than the extension radiograph. The flexion radiograph coupled with a supine or decubitus radiograph reveals greater mobility than the flexion-extension modality.

Pain Control Affects the Radiographic Diagnosis of Segmental Instability in Patients with Degenerative Lumbar Spondylolisthesis.

Background: Diagnosing intervertebral instability is crucial for the treatment of degenerative lumbar spondylolisthesis (DLS). Disabling back pain will reduce spinal mobility which leads to an underestimate of the incidence of intervertebral instability. We hypothesized that adequate analgesia could alter the flexion/extension exam performance, and thus increase the diagnostic accuracy of segmental instability. Materials and methods: One hundred patients with low-grade DLS were prospectively enrolled in the before–after cohort study. Standing lateral flexion/extension radiographs of lumbar spines were examined and analyzed before and after intramuscular injections of 30 mg ketorolac. Results: Pain score decreased significantly after analgesic injections (p < 0.001). Dynamic slip (DS), dynamic segmental angle (DA), dynamic lumbar lordosis, and slip percentage (SP) were significantly increased after pain reduction (all p < 0.001). According to the diagnostic criteria for segmental instability (DS > 4.5 mm, DA > 15°, or SP > 15%), there were 4%, 4%, and 0.7% of total motion segments fulfilling the criteria which markedly increased to 42%, 32%, and 16.7% after analgesia was administered. The incidence of instability also increased from 6% to 38% after analgesia. Conclusions: The diagnosis rate of intervertebral instability is commonly underestimated in the presence of low back pain. This short-term pain relief facilitates reliable functional imaging adding to the diagnosis of intervertebral instability.

Clinical outcome after lumbar spinal fusion surgery in degenerative spondylolisthesis: a 3-year follow-up

IntroductionLumbar spinal fusion surgery is a widely accepted surgical treatment in degenerative causes of lumbar spondylolisthesis. The benefit of reduction of anterior displacement and restoration of sagittal parameters is still controversially debated. Purpose of the underlying publication was to analyze the influence of radiographic sagittal parameters of the spine in aspects of changes in postoperative clinical outcome.Materials and methodsBy prospective analysis, we included patients with low-grade degenerative lumbar spondylolisthesis (Meyerding grades I and II) with mono- or bisegmental fusion surgery with a minimum follow-up data of 3 years. For clinical outcome measures, COMI, ODI and EQ-5D were used. Spinopelvic parameters (sacral inclination, pelvic tilt, sacral slope and pelvic incidence, lumbar lordosis and lumbar index as well as anterior displacement and sagittal rotation) were measured on plain radiographs.ResultsWe could observe a significant benefit in clinical outcome after lumbar fusion surgery in low-grade spondylolisthesis in our mid-term follow-up data including 32 patients. By surgical reduction, we could see significant restoration of anterior displacement and sagittal rotation. Interestingly, a significant correlation between restoration of both sagittal rotation and sacral inclination and clinical outcome score was observed in the 3-year follow-up.ConclusionIn low-grade spondylolisthesis, spinal fusion surgery is a well-established surgical procedure; however, the impact of sagittal parameters and reduction of anterior displacement remains controversial. Within our findings, restoration of sagittal parameters showed significant correlation to improvement in clinical outcome in our mid-term follow-up data.

Minimally invasive versus traditional open transforaminal lumbar interbody fusion for the treatment of low-grade degenerative spondylolisthesis: a retrospective study

This was a retrospective study. We aimed to compare the clinical efficacy and safety between minimally invasive and traditional open transforaminal lumbar interbody fusion in the treatment of low-grade lumbar degenerative spondylolisthesis (LDS). 81 patients with LDS grades 1 and 2 treated in our spinal department from January 2014 to July 2016 were retrospectively analyzed. The MIS-TLIF group included 23 males and 11 females, while the TO-TLIF group included 29 males and 18 females. Follow-up points were set at 7 days, 3 months, 6 months, 12 months postoperatively and the last follow-up. Various clinical and radiological indicators were used to evaluate and compare the efficacy and safety between the two procedures. 8 cases (3 in the MIS-TLIF group and 5 in the TO-TLIF group) were loss of follow-up after discharge. And the remaining 73 patients were followed up for at least 2 years. No statistically significant difference was observed in the terms of age, sex, BMI, slippage grade, and surgical segments. The MIS-TLIF group had a longer operation and fluoroscopy time compared with the TO-TLIF group. But the MIS-TLIF group was associated with less blood loss, ambulation time, hospital stay, and time of return to work. In each group, significant improvement were observed in BP-VAS, ODI and vertebral slip ratio at any time-point of follow-up when compared with the preoperative condition. When the time-point of follow-up was less than 1 year, the MIS-TLIF group had significant advantages in the BP-VAS and ODI compared with TO-TLIF group. But no significant difference was observed in the BP-VAS and ODI at either 12 month follow-up or the last follow-up. Besides, no statistical difference was detected in vertebral slip ratio at any time-point of follow-up between the two groups. Successful intervertebral bone fusion was found in all patients and no significant difference was found in the incidence of total complications. Thus, we considered that MIS-TLIF and TO-TLIF both achieve satisfactory clinical efficacy in the treatment of low-grade single-segment LDS. But MIS-TLIF appears to be a more efficacious and safe technique with reduced tissue damage, less blood loss and quicker recovery.

Slip progression in degenerative lumbar spondylolisthesis following minimally invasive decompression surgery is not associated with increased functional disability.

The aim of this study is to determine whether there is a relationship between radiographic slip progression and symptomatic worsening after decompression without fusion for low-grade degenerative lumbar spondylolisthesis (DLS). A retrospective review of 1-2-level minimally invasive surgical decompression for grade I-II DLS was performed. Included subjects had a minimum of 1-year follow-up with prospectively collected baseline and follow-up Oswestry Disability Index (ODI) scores. Fifty-six patients (33 females, 58.9%), having a mean age 65.6years (SD 10.0), met inclusion criteria. Spondylolisthesis slip percentage increased in 55.4% (31/56) of patients. Slip percentage increased significantly (p = 0.002) from baseline (mean 17.2; SD 8.0) to follow-up (mean 20.1; SD 9.6). A logistic regression model identified that females were more likely to have progressive slips compared to males (odd ratio 6.09, 95% CI 1.77-21.01; p = 0.004). ODI scores and spondylolisthesis slip percentage did not correlate at baseline (r = 0.0170; p = 0.90) nor follow-up (r = 0.094; p = 0.49). There was no correlation between the change in ODI scores and change in slip percentage from baseline to final follow-up (r = 0.0474; p = 0.73). Of the 31 patients with slip progression, there was no difference in mean ODI score changes (p = 0.91) for those with 1-5% progression (13/31 [41.9%]; - 18.0 [SD 19.7]) compared to those with > 5% slip progression (18/31 [58.1%]; - 18.7 [SD 16.4]). Despite a small degree of slip progression in the majority of patients, there was no correlation with symptom worsening, as measured by the ODI. These slides can be retrieved under Electronic Supplementary Material.

Efficacy of percutaneous transforaminal endoscopic decompression treatment for degenerative lumbar spondylolisthesis with spinal stenosis in elderly patients.

The efficacy of fusion combined with decompression for the treatment of spinal stenosis with degenerative lumbar spondylolisthesis (DLS) has been debated. Percutaneous transforaminal endoscopic decompression (PTED) under local anesthesia is an ultra-minimally invasive procedure. The present study aimed to evaluate whether PTED is an effective alternative therapy for spinal stenosis associated with DLS in elderly patients. PTED was performed in elderly patients exhibiting lumbar stenosis and low-grade (Meyerding grades I and II) DLS; these patients also exhibited leg-dominant symptoms and had tolerable or absent mechanical back pain. Administration of general anesthesia may be considerably hazardous in patients when combined with comorbid conditions that result from aging. Therefore, the present procedure was performed under local anesthesia. No obvious radiographic lumbar intervertebral instability was identified prior to surgery. Pre- and post-operative visual analogue scale (VAS) score, Oswestry Disability Index (ODI) and walking distance data were collected. The clinical global outcomes following surgery were evaluated using modified MacNab criteria. A total of 18 elderly patients underwent surgery using PTED techniques. The mean follow-up time was 27.7 months (range, 24-33 months) and the mean estimated blood loss was 18.33 ml (range, 10-35 ml). The mean pre-operative ODI, VAS score of the back and VAS score of the leg were 68.2±6.5, 2.8±1.4 and 6.6±1.2, respectively. All average scores improved post-operatively to 31.7±5.2, 1.5±0.6 and 1.7±0.8, respectively, at the latest follow-up. A statistically significant improvement was observed for all scores at 1 month and that the scores remained relatively stable after that. According to modified MacNab criteria, the good-to-excellent rate was 83.3%. Only 1 patient required micro-decompression surgery due to poor rating. The present study indicated that PTED may be an effective alternative therapeutic option for elderly patients with low-grade DLS associated with spinal stenosis. However, PTED techniques continue to evolve and further follow-up studies are required to determine the long-term outcomes of this treatment technique.

Endoscopic Ventral Decompression for Spinal Stenosis with Degenerative Spondylolisthesis by Partially Removing Posterosuperior Margin Underneath the Slipping Vertebral Body: Technical Note and Outcome Evaluation

Decompression alone is a treatment option in patients with lumbar spinal stenosis (LSS) and degenerative lumbar spondylolisthesis (DLS). This study aims to describe the procedure of percutaneous transforaminal endoscopic ventral decompression technique and to demonstrate the clinical outcomes. Two years of retrospective data were collected from 26 patients with predominant unilateral leg pain caused by LSS and low-grade DLS (Meyerding grades I and Ⅱ). All patients underwent endoscopic ventral decompression by removing the posterosuperior margin underneath the slipping vertebral body, combined with dorsal decompression without excessive resection of facet joints. The surgical outcomes were assessed using the visual analog scale (VAS), Oswestry Disability Index (ODI), modified MacNab criteria, and walking distance improvement evaluation. The mean age of the 18 women and 8 men was 69.2 years. The mean preoperative ODI and VAS of the leg and the back scores were 64.7 ± 8.1, 7.0 ± 1.4, and 3.0 ± 1.2, respectively. All mean scores improved postoperatively to 31.4 ± 5.6, 2.4 ± 1.1, and 1.7 ± 1.1 at the final follow-up. In 88.5% of cases, patients' estimated walking distance improved. The outcomes of the modified MacNab criteria showed that 81.3% of patients obtained good-to-excellent rate. There were no statistically significant differences between the percent slip of spondylolisthesis before surgery and at the end of follow-up. Based on the initial short-term follow-up results, transforaminal endoscopic ventral decompression by partially removing the posterosuperior margin underneath the slipping vertebral body, combined with dorsal decompression, might be an efficient alternative treatment for leg dominant symptoms in patients with LSS and low-grade DLS.

Wednesday, September 26, 2018 10:35 AM – 12:00 PM Understanding Lumbar Stenosis/Spondylolisthesis: 8. Patient-reported outcomes using ODI, VAS back and leg pain, and PROMIS in low-grade degenerative lumbar spondylolisthesis patients with high versus low pelvic incidence

BACKGROUND CONTEXT When evaluating and treating degenerative lumbar spondylolisthesis (DLS) patients, surgeons often do not think about and measure spino-pelvic parameters (SPPs) like they do for spinal deformity and isthmic spondylolisthesis patients. Few studies have looked at the association between patient-reported outcomes (PROs) such as those from Patient-Reported Outcomes Measurement Information System (PROMIS) and SPPs in the low-grade DLS population. A recent study showed an association between global sagittal imbalance and poor PROs in these patients. PURPOSE We aimed to determine if there is an association between PROs and pelvic incidence (PI) in low-grade DLS patients undergoing 1-2 level decompression and fusion. STUDY DESIGN/SETTING Retrospective cohort study, single institution. OUTCOME MEASURES Oswestry Disability Index (ODI), Visual Analog Scale (VAS) Back and Leg Pain. Patient-Reported Outcomes Measurement Information System (PROMIS) Computer Adaptive Tests (CAT) for physical function (PF), pain, depression and anxiety. All measured at baseline, initial, 6-month and 1-year follow-up. METHODS All Myerding grade 1 or 2 DLS patients who underwent 1-2 level decompression and fusion with at least 1-year of follow-up at our institution from August 2015 to October 2017 were retrospectively identified. Patients with high PI (>55°) and low PI ( RESULTS Fifty-nine patients were included with 44 (74.6%) high PI and 15 (25.4%) low PI. Demographics, comorbidities, surgical factors, postoperative complications, fusion status, PI-LL mismatch, and PRO measures were not significantly different (p>0.05) between the groups. In high PI patients, all PRO measures significantly improved (p≤0.05) after surgery compared to baseline at each follow-up. In low PI patients, VAS Back and Leg Pain and PROMIS PF and Pain significantly improved at initial follow-up, PROMIS Pain significantly improved at 6-month follow-up, and ODI, VAS Leg Pain and PROMIS PF and Pain significantly improved at 1-year follow-up. CONCLUSIONS PI does not make a significant difference in PROs in low-grade DLS patients undergoing 1-2 level decompression and fusion. High PI patients significantly improved in all PRO measures after surgery. Low PI patients either significantly improved or trended toward improvement in all PRO measures after surgery. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Spino-pelvic alignment, balance, and functional disability in patients with low-grade degenerative lumbar spondylolisthesis.

To evaluate the relationships among spino-pelvic parameters, trunk balance and functional disability in patients with degenerative lumbar spondylolisthesis. Cross-sectional study. Forty-five patients with degenerative lumbar spondylolisthesis and 32 patients without degenerative lumbar spondylolisthesis. Spino-pelvic parameters (pelvic incidence, pelvic tilt, sacral slope, lumbar lordosis) and pain severity were evaluated. Biodex balance tests (postural stability, limits of stability, modified clinical test of sensory interaction and balance, fall risk) and Quebec Back Pain Disability Scale (QBDS) scores were measured. Intergroup differences were found in age, low back pain, limits of stability, pelvic incidence, pelvic tilt and some subscales of QBDS. Correlations were found: (i) in the degenerative lumbar spondylolisthesis group: between pelvic incidence and sacral slope/pelvic tilt/lumbar lordosis/height/limits of stability; sacral slope and lumbar lordosis/height/limits of stability/modified clinical test of sensory interaction and balance (eyes closed on foam); lumbar lordosis and body mass index/QBDS/postural stability/modified clinical test of sensory interaction and balance (eyes open and eyes closed on foam); (ii) in the non-degenerative lumbar spondylolisthesis group: between pelvic incidence and pelvic tilt; pelvic tilt and sacral slope/lumbar lordosis; sacral slope and lumbar lordosis/fall risk. All spino-pelvic parameters in the degenerative lumbar spondylolisthesis group and pelvic tilt in the non-degenerative lumbar spondylolisthesis group correlated with QBDS. Pelvic tilt was the major compensating factor in both groups (patients with and without degenerative lumbar spondylolisthesis). Sacral slope and lumbar lordosis contributed to partial compensation in the degenerative lumbar spondylolisthesis group. Lumbar lordosis correlated with body mass index. Sacral slope could be an indicator of fall risk in the non-degenerative lumbar spondylolisthesis group.

The Correlation Between Restoration of Lumbar Lordosis and Surgical Outcome in the Treatment of Low-grade Lumbar Degenerative Spondylolisthesis With Spinal Fusion

Retrospective clinical study. To investigate the relationship between the restoration of the lumbar lordosis (LL) and the surgical outcome of patients undergoing spinal fusion for low-grade lumbar degenerative spondylolisthesis. Correlation between low back pain and the loss of LL in the treatment of low-grade lumbar degenerative spondylolisthesis has seldom been reported. Between May 2005 and July 2011, 59 patients with low back pain and neurogenic claudication due to low-grade lumbar degenerative spondylolisthesis underwent spinal decompression and fusion by a senior surgeon. Ten patients were lost to follow-up. The mean age of the remaining 49 patients (10 men and 39 women) was 64.0 years (range, 47-88 y). Patients were categorized on the basis of the spino-pelvic posture: type 1 [pelvic incidence (PI)<45 degrees] (n=12), type 2 (45 degrees≤PI≤60 degrees) (n=24), and type 3 (PI>60 degrees) (n=13). The LL restoration ratio was calculated by the actual LL divided by the predicted LL. The clinical results were evaluated using a visual analogue scale and the Oswestry Disability Index. Postoperative 36-inch spinal films were used to assess the sagittal balance. The mean follow-up period was 43.2 months (range, 28-62 mo). Forty-eight patients showed significant improvement with respect to visual analogue scale and Oswestry Disability Index regardless of whether the LL was restored higher or lower. Postoperative 36-inch spinal films showed the C7 plumb line to be within an average of 4.4 cm (range, 0.6-5.6 cm) from the posterior-superior corner of the S1 vertebrae. Patients with smaller PI tended to be restored higher, and those patients with a larger PI were more likely to be restored lower. For patients with normal sagittal balance, the surgical outcomes in the treatment of low-grade lumbar degenerative spondylolisthesis with spinal fusion are not correlated with restoration of the LL.

Stand-alone anterior lumbar interbody fusion for treatment of degenerative spondylolisthesis

We sought to evaluate the clinical and radiologic efficacy of stand-alone anterior lumbar interbody fusion (ALIF) for low grade degenerative spondylolisthesis, the favoured surgical management approach at our institution. The optimal approach for surgical management of spondylolisthesis remains contentious. We performed a prospective analysis of all consecutive patients with low grade lumbar spondylolisthesis who underwent ALIF between 2009 and 2013 by a single surgeon (n=27). The mean age was 64.9years with a male to female ratio of 14:13. There were 32 levels operated and the average preoperative spondylolisthesis was 14.8%, which reduced to 6.4% postoperatively and 9.4% at the latest follow-up (p=0001). Postoperative disc height was increased to 175% of preoperative values and was statistically significant (p<0.001) and remained improved with an overall change of 139% at the latest follow-up. The radiological fusion rate was 91%. The 12-Item Short Form Health Survey (SF-12) mental and physical component summary improved from 31.7 to 43.0 (p=0.007) and from 35.4 to 51.7 (p=0.0026), respectively. The mean visual analogue scale pain score improved from 7.6 to 2.2 (p<0.001), and the mean Oswestry disability index improved from 56.9 to 17.8% (p<0.0001). The overall clinical success rate was 93%. The posterior disc height correlated with spondylolisthesis reduction (p=0.04) and the only clinical factor affecting reduction was body mass index (p=0.04). The present study provides encouraging short term results for stand-alone ALIF as a procedure for low grade lumbar degenerative spondylolisthesis. Future studies should include adequately powered, prospective, multicentre registry studies with long term follow-up to allow a better assessment of the relative benefits and risks.

Instrumentation of Low Grade Lumbar Degenerative Spondylolisthesis, is Total Laminectomy Inevitable?

Instrumentation of Low Grade Lumbar Degenerative Spondylolisthesis, is Total Laminectomy Inevitable? To evaluate the clinical outcomes of patients with degenerative spondylolisthesis myerding grade I and II who underwent Posterior lumbar Intervertebral Fusion (PLIF) without total laminectomy.

An In Vitro Model of Degenerative Lumbar Spondylolisthesis

A biomechanical human cadaveric study. To create a biomechanical model of low-grade degenerative lumbar spondylolisthesis (DLS), defined by anterior listhesis, for future testing of spinal instrumentation. Current spinal implants are used to treat a multitude of conditions that range from herniated discs to degenerative diseases. The optimal stiffness of these instrumentation systems for each specific spinal condition is unknown. Ex vivo models representing degenerative spinal conditions are scarce in the literature. A model of DLS for implant testing will enhance our understanding of implant-spine behavior for specific populations of patients. Four incremental surgical destabilizations were performed on 8 lumbar functional spinal units. The facet complex and intervertebral disc were targeted to represent the tissue changes associated with DLS. After each destabilization, the specimen was tested with: (1) applied shear force (-50 to 250 N) with a constant axial compression force (300 N) and (2) applied pure moments in flexion-extension, lateral bending and axial rotation (±5 Nm). Relative motion between the 2 vertebrae was tracked with a motion capture system. The effect of specimen condition on intervertebral motion was assessed for shear and flexibility testing. Shear translation increased, specimen stiffness decreased and range of motion increased with specimen destabilization (P < 0.0002). A mean anterior translation of 3.1 mm (SD 1.1 mm) was achieved only after destabilization of both the facet complex and disc. Of the 5 specimen conditions, 3 were required to achieve grade 1 DLS: (1) intact, (3) a 4-mm facet gap, and (5) a combined nucleus and annulus injury. Destabilization of both the facet complex and disc was required to achieve anterior listhesis of 3.1 mm consistent with a grade 1 DLS under an applied shear force of 250 N. Sufficient listhesis was measured without radical specimen resection. Important anatomical structures for supporting spinal instrumentation were preserved such that this model can be used in future to characterize behavior of novel instrumentation prior to clinical trials.