Low-grade Isthmic Spondylolisthesis Research Articles

Risk factors of postoperative low back pain for low-grade isthmic spondylolisthesis: a retrospective study.

ObjectiveTo investigate the risk factors of postoperative low back pain (LBP) following posterior lumbar interbody fusion (PLIF) surgery for low-grade isthmic spondylolisthesis (IS).MethodsThis retrospective study enrolled patients with IS that underwent PLIF between January 2011 and January 2016. Demographic, clinical, surgical and radiological characteristics were analysed to determine associations between these characteristics and LBP as measured using a visual analogue scale (VAS) pain score.ResultsA total of 192 patients were enrolled in the study. The mean VAS pain score of LBP decreased significantly after surgery. The mean preoperative VAS pain score was significantly greater in patients with symptoms of ≤3 years duration compared with those with symptoms lasting >3 years. The postoperative VAS pain score was significantly lower in patients with grade 1 slippage compared with those with grade 2 slippage. There was a significant correlation between preoperative to postoperative change of VAS pain score and postoperative disc height (r = 0.99).ConclusionPLIF significantly improved LBP in patients with low-grade IS, although patients still reported some postoperative LBP. The grade of slippage was a risk factor for postoperative LBP. Restoring the disc height appeared to improve LBP.

Concomitant low-grade isthmic L5-spondylolisthesis does not affect the course of adolescent idiopathic scoliosis

BackgroundScoliosis with spondylolisthesis was described in 4.4–48%. No information on clinical impact or outcome is available.PurposeTo determine the prevalence of this pathology and to investigate its affect on the course of adolescent idiopathic scoliosis (AIS).MethodsA retrospective comparative study using patients’ records, radiographs, the national inpatient registry, and Patient-rated outcome measures (PROM): Oswestry disability index (ODI), modif.SRS-24 questionnaire, WHO-Quality of life index (WHOQoL), Numerical rating scale (NRS) for pain. Clinical follow-up time was 4.4 (4.3) years, and follow-up rate was 95%. PROM follow-up time 26.4 (2.8) years χ2 statistics and t-tests were applied. Significance threshold was set at P < 0.05.ResultsOut of 1531 consecutive Caucasian AIS patients, aged 13.9 (1.8) years, primary curve 29.2 (11.5) drs., 120 (7.8%) had low-grade isthmic L5-slip of mean 15.0 (8.3)% (Study group = S). The distribution of the curve types in the study group was comparable to the remaining 1411 patients with AIS only. In comparison with a pair-matched control group (C) at admission, back pain interfering with activities of daily living had 4.2% of the study group and 1.7% of the control group, at clinical follow-up 2.6/4.2% resp. (n.s.). Between groups S/C, there was no significant difference concerning scoliosis treatment: observation 38.3/45.8%, bracing 48.3/46.6%, surgery 10.8/10.2%. Results of treatment were equal in both groups. Long-term outcomes (ODI, SRS-24, WHOQoL, NRS-back/leg pain) were comparable.ConclusionsThe prevalence of low-grade isthmic L5-spondylolisthesis in AIS patients was 7.8%. The presence of low-grade isthmic spondylolisthesis did not influence the curve type of AIS nor did it affect the course or long-term outcome.Graphic abstractThese slides can be retrieved under Electronic Supplementary Material.

Trans-isthmic pars interarticularis screwing under double CT and fluorcopic guidance : procedure accuracy and one year follow-up in patients with symptomatic low-grade lumbar isthmic lysis

Background To assess the accuracy of percutaneous trans-isthmic screwing with combined CT and fluoroscopic guidance guidance in patients with symptomatic low-grade isthmic spondylolisthesis. Materials and methods Fifty patients (28 women and 22 men, average age 50 years-old [min 17–max 80 ; SD 18.9]) with symptomatic low-grade isthmic spondylolisthesis refractory to medical treatment were treated by means of trans isthmic percutaneous screwing. The procedure was carried out under local anaesthesia with combined CT and fluoroscopic guidance. Primary outcome was the technical success of the procedure which was assessed on post operative CT using the same success criteria as surgical screw placement (Fig 1). Secondary outcome was pain decrease assessed by VAS score improvement. Results Ninety-nine procedures were performed in 50 patients and 99 screws were inserted. Post operative CT assessment showed satisfactory screw placement in 96 cases, that is a technical success rate of 96.9 %. No complication were noted intra or post operatively. Pain assessment showed a pain decrase of VAS score from 7,8 (Min 5, Max 10 ; SD 1,6) to 2,9 (Min 0, Max 7 ; SD 2,1) with a mean follow-up of 22 months. Discussion The results show a technical success rate of the percutaneous procedure under combined CT and fluoroscopic guidance similar to the surgical approach, and a significant VAS improvement. This study confirms preliminary results obtained on smaller cohort of patients. Conclusion Percutaneous trans-isthmic screwing under combined CT and fluoroscopic guidance allow accurate trans isthmic screwing in patients with symptomatic low grade isthmic lysis, and a satisfying pain reduction following the procedure.

Does minimally invasive fusion technique influence surgical outcomes in isthmic spondylolisthesis?

Objective: To compare the clinical and radiographic results between open transforaminal interbody fusion (TLIF-O) and minimally invasive TLIF (TLIF-M) for single-level low grade isthmic spondylolisthesis (IS).Methods: This study enrolled 45 patients who underwent single-level TLIF with low grade IS. The patients were divided into two groups according to operative method: TLIF-M (20 patients) and TLIF-O (25 patients). TLIF-O group was matched with TLIF-M.Results: At one-year postoperatively, there were no significant differences in any radiologic parameters between the two groups. Perioperative results such as blood loss, operation time, and hospital stay were superior in TLIF-M than in TLIF-O. Fusion was achieved in 17 of 20 patients (85.0%) in TLIF-M and 23 of 25 (92.0%) patients in TLIF-O. Back Visual Analog Scale (VAS) and Oswestry Disability Index (ODI) scores of TLIF-O were significantly lower than TLIF-M at one (back VAS, ODI) and six months (ODI) postoperatively.Conclusions: TLIF-M and TLIF-O produced similar clinical and radiological outcomes, including reduction of spondylolisthesis and disc space height restoration at one-year follow-up for single-level low grade IS. However, considering perioperative outcomes, back pain, and quality of life, TLIF-M might be a better option for single-level low grade IS compared to TLIF-O.

Posterolateral Fusion versus Transforaminal Lumbar Interbody Fusion in the Surgical Treatment of Low-Grade Isthmic Spondylolisthesis

Background Data: Surgical treatment of isthmic spondylolisthesis includes decompression, fixation and bone fusion. There are different suitable techniques for fusion as (PLF) posterolateral fusion (TLIF) transforaminal lumbar interbody fusion, (PLIF) posterior lumbar interbody fusion, (ALIF) anterior lumbar interbody fusion but still controversy remains about the best technique.Purpose: To evaluate and compare the surgical results of PLF versus TLIF with pedicle screw fixation in treatment of low-grade isthmic spondylolisthesis.Study design: A prospective randomized clinical case series.Patients and methods: This study included 40 patients with low grade isthmic spondylolisthesis. All patients were surgically treated by posterior decompression, transpedicular screw fixation and bone fusion. Patients were divided into two equal groups according to the type of bone fusion. Group A included 20 patients treated with PLF, and Group B included another 20 patients and were treated with TLIF. We used Visual Analogue Scale (VAS) for assess pain and the Oswestry Disability Index (ODI) to evaluate the functional outcome among our patients. Patients have been followed up for at least six months after surgery.Results: The improvement of VAS of back pain was significantly greater in group B (TLIF) (change 5.25±1.55) than in group A (PLF) (change, 4.4±1.14) (P<0.05). There was no significant difference in improvement of ODI in both groups. Patients with BMI³30 showed that group B experienced more clinical improvement than in group A in the VAS (P=0.021). The operative time in group B (185±24.5 min) was significantly longer than in group A (123.3±19.6 min) (P=0.034). Intraoperative blood loss in group B (584±192.1 ml) was significantly greater than in group A (417±182.4 ml) (P=0.008). The complication rate in group A (30%) was significantly less than in group B (55%) (P= 0.032) but broken screws (hardware failure) were more common in group A (20%) than in group B (0.0%) (P=0.01). The fusion rate in group B (95%) was higher than in group A (75%).Conclusion: Our data suggest that although TLIF is better than PLF in achievement of successful bone fusion and improvement of patient’s symptoms (back pain and sciatica), PLF still considered simple technique with minimal operative blood loss, less operative time and little complications. (2018ESJ162)

Long-Term Minimum Clinically Important Difference in Health-Related Quality of Life Scores After Instrumented Lumbar Interbody Fusion for Low-Grade Isthmic Spondylolisthesis

Despite its growing popularity, no comparative studies have explored the minimum clinically important difference (MCID) of health-related quality of life scores following lumbar interbody fusion (LIF) performed on a single-level adult low-grade isthmic spondylolisthesis (LGIS). The purpose of this study is to investigate factors related to MCID of health-related quality of life scores following instrumented LIF performed on a single-level adult LGIS. Consecutive patients who underwent instrumented LIF for single-level LGIS were reviewed. The inclusion criteria were adult patients who underwent L4-5 or L5-S1, underwent anterior lumbar interbody fusion or transforaminal lumbar interbody fusion with a posterior screw fixation, and had a minimum 36-month postoperative follow-up period. MCID was defined as having an improved score of visual analog scale (VAS) back and leg pain >3 and Oswestry Disability Index (ODI) >12. Patients were subdivided into groups named "achievement" (A) and "nonachievement" (N) depending on their postoperative MCID for each health-related quality of life score category. One-hundred and five patients met the inclusion criteria. The overall achievement of MCID for VAS back, leg, and ODI was 80%, 73.3%, and 82.9%. MCID-VAS leg and ODI were less achieved at the L5-S1 level than at the L4-5 level. Postoperatively, disk height was higher and segmental lordosis (SL) was lower in group A of MCID-VAS leg. SL was lower in group A of MCID-ODI. We postulate that excessive SL does not affect lumbar lordosis; rather, it can result in lowering posterior disk height. The decrease in posterior DH may lead to a decreased foraminal height that, in turn, can lead to nerve root compression. Proper restoration of disk height and bone fusion is more important than restoration of more segmental lordosis or slip reduction for isthmic spondylolisthesis.

Circumferential minimally invasive approach for low-grade isthmic spondylolisthesis: A clinical and radiological study of 43 patients.

Circumferential fusion for lumbar low-grade isthmic spondylolisthesis (LGIS) provides the best spinal stability and highest fusion rates. The aim of this study is to investigate results of minimal invasive management of LGIS and correlations between Intervertebral Foramen Surface (IFS) and other parameters. We retrospectively reviewed cases of 43 patients who underwent a minimally invasive circumferential fusion (Anterior lumbar interbody fusion followed by percutaneous posterior pedicle screw fixation) for LGIS between January 2010 and December 2014 in our institution. Inclusion criteria were one-level (L4-L5 or L5-S1) LGIS with low back and/or radicular pain. Pre- and postoperative radiographic evaluations were performed at 6, 12 and 24months. Measurements (Percentage of anterior displacement, degree of slip angle, height of the intervertebral space and the IFS) were obtained using Surgimap®. Nineteen patients (44.2%) were males. Mean age was 43 years old (19-72years). The mean follow-up of the series was 18.3months (3-72months). Mean preoperative Visual Analogy Scale (VAS) for low back pain decreased from 70mm to 20mm and from 80mm to 10mm as to radicular pain. Anterior displacement was reduced from 18% to 7% (p<0.01), degree of slippage were increased from 9.8° to 15.2° (p<0.01), intervertebral height was restored from 4.4mm to 8.5mm (p<0.01) and increase of the IFS was calculated 48.8%. One stage circumferential fixation for adults' LGIS without decompression, allows restoration of intervertebral height permitting good reduction of the slippage, an increasing of the IFS and liberation of nerve roots.

The use of autogenous laminar graft in lateral transforaminal lumbar interbody fusion for the treatment of low-grade isthmic spondylolisthesis

Introduction Low-grade spondylolisthesis often presents with low back pain and radicular symptoms and often requires surgical intervention in the form of decompression and instrumented fusion. Objective The aim of this study was to evaluate the safety and efficacy of transforaminal lumbar interbody fusion using autologous laminar strut grafts in low-grade isthmic spondylolisthesis. Patients and methods A total of 15 patients in a prospective cohort study have been clinically evaluated between January 2014 and August 2017 after performing transforaminal lumbar interbody fusion using autologous laminar strut grafts. Results Mean operative (OR) time was 156 min, and mean estimated blood loss was 377 ml. Three patients required packed red blood cells transfusion. The mean length of stay at the hospitals was 4 days. One patient had an accidental durotomy and one patient developed low-grade fever. One patient developed superficial infection. None of the patients developed any neurologic deficits. All patients showed evidence of fusion and bony bridging between the vertebral bodies within 6 months after the surgeries. Conclusion The technique of using laminar strut grafts in the treatment of patients with low-grade isthmic spondylolisthesis is safe and with low complications rate.

Anterior Lumbar Interbody Fusion With Cement Augmentation Without Posterior Fixation to Treat Isthmic Spondylolisthesis in an Osteopenic Patient-A Surgical Technique.

Anterior lumbar interbody fusion (ALIF) has been well established as an effective surgical intervention for chronic back pain due to osteoporotic vertebral collapse. Historically, ALIF has consisted of an anterior approach to disc height restoration with a subsequent posterior pedicle screw fixation. Although the applications of cement augmentation with posterior fixation have been previously reported, treatment of patients with both isthmic spondylolisthesis and decreased bone mineral density using a stand-alone ALIF is controversial because of concerns for decreased fusion rates and increased subsidence risk, respectively. We report a case of stand-alone ALIF used to treat a low-grade isthmic spondylolisthesis in the setting of idiopathic thoraco-lumbar scoliosis in a patient with secondary degenerative changes and discuss the benefits of this surgical technique in a patient with several comorbidities. An osteopenic 66-year-old woman with multiple medical comorbidities and 2 years of left radicular leg pain was found to have a Myerding grade I isthmic spondylolisthesis in the setting of idiopathic thoraco-lumbar scoliosis with secondary changes. The patient underwent an L5-S1 stand-alone ALIF with anterior cement augmentation without posterior pedicle screw fixation. The patient experienced immediate relief of radicular leg pain postoperatively and had an uneventful course. At 2 years follow-up, she remained symptom free, and radiographs showed excellent fusion and maintenance of intervertebral disc height. The use of stand-alone ALIF with anterior cement augmentation of the vertebral bodies is a surgical technique that could produce excellent improvement in patients with low-grade isthmic spondylolisthesis in the setting of osteopenia. The use of the all-anterior approach in similar patients with multiple medical comorbidities can also be a useful technique, as it decreases associated morbidity of surgery and complication risks associated with prolonged operative times.

Anterior lumbar sagittal alignment after anterior or lateral interbody fusion

PurposeAnterior or lateral interbody fusion is a treatment option for lumbar disc disease. A segmental change occurs after such surgery. This study was designed to evaluate the changes in the lumbar regional alignment after a single or two-level standalone anterior or lateral interbody fusion (ALIF or LLIF). MethodsData from patients referred to our institution between March 2013 and November 2015 for standalone ALIF or LLIF for low-grade isthmic spondylolisthesis or degenerative discopathy were retrospectively included in our analysis. Patients with a history of spinal fusion were excluded. Global and regional alignments were analyzed pre- and postoperatively. Pelvic tilt (PT), sacral slope (SS), sagittal vertical axis (SVA), lumbar lordosis (LL), index segmental lordosis (ISL) and L4S1 lordosis were compared. Three groups according to the pelvic incidence (PI) (low, normal and high) were separately analyzed then compared. ResultsForty-one women and 27 men (mean age was 46 years; range 25–66) were included. The mean follow-up was 10.8 (range 3–34 months). The patients were globally well balanced preoperatively and remained after surgery (SVA stagnated from 16.76±28.42mm to 15.97±28.20mm, P=0.75). PT and LL did not vary. L4S1 lordosis, and ISL were significantly increased respectively from 30.56±8.59 to 34.58±7.47 (P=0.0026) and from 5.94±5.25 to 12.99±5.87 (P<0.0001) at latest follow-up. ConclusionDespite effective changes in the segmental lordosis at the index levels, our findings suggest that one or two-levels standalone ALIF or LLIF had no effect on the global balance and the lumbar lordosis. The three groups behaved similarly, the regional lordosis was redistributed in a better harmony (L4S1/LL ratio went up from 55% to 61%, P=0.01). Study typeRetrospective study. Level of evidence4.

Electrophysiological Study for Nerve Root Entrapment in Patients With Isthmic Spondylolisthesis.

A case series study. To investigate the electrophysiological location of nerve root entrapment in patients with isthmic spondylolisthesis. Although the lesion of the nerve root in patients with isthmic spondylolisthesis has been thought to be located at the pars interarticularis due to proliferation of fibrous cartilage, there is no electrophysiological study in relation to this accomplished fact. We performed an electrophysiological study in 12 patients with isthmic spondylolisthesis during surgery. All patients presented with low-grade isthmic spondylolisthesis and unilateral radiculopathy, and underwent single-level posterior lumbar interbody fusion with instrumentation. After a total facetectomy, nerve root action potentials were recorded by stimulating the ipsilateral peroneal nerve at the popliteal fossa. Four needle electrodes were inserted into the affected nerve root at the intraspinal canal, pars interarticularis, disk level, and extralateral to the disk. The waveforms that showed either a positive waveform pattern or polyphasic waveform pattern were regarded as abnormal potentials. We also confirmed surgical records and preoperative images to investigate the relationship to the electrophysiological findings. An abnormal waveform pattern was demonstrated at the pars interarticularis in 6 patients, at the disk level in 5, and at the extralateral site in 1. On the basis of the electrophysiological findings of this study, the nerve root lesion was not always found on only the pars interarticularis in patients with isthmic spondylolisthesis. A relationship between the electrophysiological findings and surgical records or preoperative images was not found. The electrophysiological investigation in this study shows that the nerve root entrapment in patients with isthmic spondylolisthesis occurs not only at the pars interarticularis but also distal to the isthmus. This study suggests the possibility of insufficiency of decompression only at the pars interarticularis for patients with isthmic spondylolisthesis.

Clinical results after surgical treatment in young male patients with low grade isthmic spondylolisthesis

Clinical results after surgical treatment in young male patients with low grade isthmic spondylolisthesis

Correlation between correction of pelvic balance and clinical outcomes in mid- and low-grade adult isthmic spondylolisthesis.

Pelvic balance is a version of the pelvis defined by pelvic orientation parameters of PT and SS. Two distinct versions of pelvis are defined: (1) balanced characterized by a relatively low PT and high SS, and (2) unbalanced with relatively high PT and low SS meaning excessive retroversion of the pelvis. It was proved for patients with a high-grade spondylolisthesis that rebalancing of the pelvis can positively affect clinical outcomes. Little is known about the impact of such rebalancing in low-grade isthmic spondylolisthesis. To determine whether clinical outcomes correlated with rebalancing of the pelvis after surgical correction of mid- and low-grade adult isthmic spondylolisthesis. One hundred and three adult patients with a mid- and low-grade isthmic slip were the participants. Clinical outcomes were assessed at least 2years after the surgery with the use of the Oswestry Disability Index (ODI) and a back pain visual analogue scale. Statistical analysis was used to identify differences in clinical outcomes between patients (1) with a balanced and unbalanced pelvis postoperatively, (2) who regained and did not regain pelvic balance postoperatively, (3) who maintained and lost pelvic balance postoperatively, and (4) with reduced and increased postoperative PT. There were no significant differences in clinical outcomes between patients with a balanced and unbalanced pelvis postoperatively regardless of whether they lost, maintained, or regained pelvic balance after the surgery (Student's t test for independent variables or the non-parametric Mann-Whitney U, p value=0.05). No correlation (Spearman's rank correlation) was found between postoperative reduction of PT and postoperative: (1) level of back pain (r=-0.10, p=0.3063), (2) degree of reduction in back pain (r=0.03, p=0.7927), (3) ODI scores (r=-0.18, p=0.0696), and (4) degree of reduction in ODI scores (r=0.13, p=0.1893). Radiological improvement of pelvic balance after surgical correction of mid- and low-grade isthmic spondylolisthesis did not correlate with clinical outcomes.

Comparative study of three surgical procedures of lumbar interbody fusion for adult low-grade isthmic spondylolisthesis

Objective To compare the clinical and radiographic outcomes of 3 kinds of lumbar interbody fusion (ALIF, PLIF, TLIF) for adult low-grade isthmic spondylolisthesis at L4, 5 and L5S1 levels. Methods Data of seventy patients with low-grade isthmic spondylolisthesis who had undergone different lumbar interbody fusion (LIF) procedures according to the assessment of the clinical manifestation, neurological symptoms, plane of the common iliac vessels and the width of vascular window by three-dimensional computed tomography angiography between May 2004 and May 2014 were retrospectively reviewed. 21 patients had undergone anterior LIF (ALIF)(13 males and 8 females with an average of 43.29±8.15 years old (range, 29-53 years old); L4,5 in ten, L5S1 in 11; Meyerding grade I 10 cases, grade II 11 cases); 25 patients had undergone posterior LIF (PLIF) (12 males and 13 females, with an average of 44.04±12.71 years old (range, 25-64 years old); L4, 5 in 12, L5S1 in 13; Meyerding grade I 15 cases, grade II 10 cases) and 24 patients had undergone transforaminal LIF (TLIF) (12 males and 12 females with an average of 45.00± 9.36 years old (range, 34-62 years old); L4, 5 in 12, L5S1 in 12; Meyerding grade I 11 cases, grade II 13 cases). Results All patients were followed up for 24-37 months (average, 25.6 ± 8.7 months). The visual analogue scale (VAS) in all groups were decreased from 7.05±0.87 (ALIF), 6.60±1.39 (PLIF), 6.75±1.11 (TLIF) pre-operation to 0.90±0.70, 0.96±0.68, 1.04±0.62 24 months after operation. Oswestry disability index (ODI) scores were decreased from 78.53%±6.25%, 79.80%±6.55%, 79.92%±8.10% pre-operation to 17.14%±3.01%, 21.32%±4.40%, 22.46%±3.87%. Perioperative data including operation time, blood loss, postoperative blood drainage, length of stay showed no significant difference between ALIF group and TLIF group, but showing significant difference comparing with PLIF group. The imageological results showed that ALIF procedure increased whole lumbar lordosis (WL) and disc height (DH), showing no significant difference comparing with PLIF group, but showing significant difference comparing with TLIF group. The ALIF procedure increased segmental lordosis angle (SL), showing significant difference comparing with PLIF group and TLIF group. The PLIF procedure decreased spondylolisthesis index (SI), showing significant difference comparing with A/TLIF group, but showing no significant difference between ALIF group and TLIF group. There was no significant difference showed comparing the L1 axis S1 distance (LASD) and sacral slope (SS), in three groups. The graft fusion was achieved in all patients after 6-8 months postoperatively without instrument failure or displacement. Conclusion Three surgical procedures of lumbar interbody fusion for adult low-grade isthmic spondylolisthesis showed silimar clinical efficacy. The ALIF procedure is superior in its capacity to restore WL, DH, and SL, and the P/TLIF procedure are superior in correcting the vertebral slippage and spinal cord decompression. Key words: Spinal fusion; Lumbar vertebrae; Spondylolysis; Surgical procedures, operative

Spinopelvic Alignment and Functional Outcome after Circumferential Fusion for Low-grade Isthmic Spondylolisthesis

Introduction Functional outcomes after surgery for low-grade isthmic spondylolisthesis(LGIS) is reported limitedly for combined posterior and anterior approach procedures. Imbalances in the sagittal alignment of spine and pelvis are increasingly seen as the reason for the development and progression of LGIS. Aims of this study: 1) functional outcome, 2) the effects on spinopelvic alignment, after circumferential fusion. Surgical treatment goals are restoration of stability, reduction of slippage, restoration of disc height and angulation, correction of spinopelvic parameters toward neutral values, and improve functional status. We hypothesized 1) a significant improvement on clinical outcome at 2-year follow-up and 2) a stable post-operative situation around the targeted vertebrae and restoration of the spinopelvic parameters to values seen in healthy subjects. Materials and Methods 43 subjects enrolled with LGIS at L5-S1. Each subject received a posterior decompression and pedicle screw instrumentation followed by an instrumented anterior lumbar interbody fusion in two separate procedures. (1) Outcome measures were registered pre-operative and after 12 and 24 months. Primary outcome was functional status (ODI). Secondary outcomes: Quality of Life (SF-36 subdomains, EQ-5D subscales), and pain intensity (VAS back and leg pain). (2) Full spine radiographs were taken pre-operative and after 3, 12, and 24 months postoperative. Obtained spinopelvic parameters are: sacral slope, pelvic tilt, pelvic incidence, thoracic kyphosis, L5-S1 lordosis, L1-S1 lordosis and sagittal vertical axis. The degree of slippage reduction and L5-S1 angular motion was measured. To evaluate both study aims a repeated measures ANOVA was used to indicate differences over time. Results 42 patients (25 female), average age 39,0 (25–51) with an average BMI 25,8 (21,5–30,4) participated in the study. Functional results are given as means with (standard deviation) pre-operative, at 12 months and 24 months postoperative for ODI: 35,0 (14,4); 10,0 (15,0); 9,5 (15,3); for SF-36 PCS: 42,0 (12,7); 70,5 (21,0); 71,5 (21,5); for SF-36 MCS: 64,0 (16,6); 81 (19,4); 81,5 (19,5); for EQ-5D: 0,56 (0,29); 0,84 (0,28); 0,83 (0,240); for VAS (back pain): 64,5 (26,2); 16,0 (32,2); 22,0 (23,9). Degree of slip decreased significantly from 27,0% (11,9%) to 7,4% (11,7%) postoperatively. Angular motion decreased statistically significant immediately postoperative and remained stable thereafter. L5-S1 and L1-S1 lordosis and sacral slope showed a significant increase postoperatively, whereas the pelvic tilt and sagittal vertical axis significantly decreased. Conclusion Circumferential instrumented fusion for LGIS via combined approach improves functional outcome at short term follow-up. After careful patient selection and unsuccessful conservative management surgical treatment is a suitable alternative with predictable short term outcome. Circumferential fusion corrects deformity and creates a stable situation in LGIS. We find that sagittal alignment is probably influenced positively, by bringing the SVA in a more neutral position.

Reduction of Pelvic Tilt after Surgical Correction of Low-grade Isthmic Spondylolisthesis is Correlated with Rather Improvement of Back Pain than Quality of Life

Introduction It is generally believed that the restoration or improvement of sagittal spino-pelvic alignment may impact clinical outcomes of surgical treatment of high-grade isthmic spondylolisthesis. Little is known about the impact on low-grade slips. The purpose of the study was to determine whether clinical outcomes are correlated with the restoration or improvement of pelvic balance after surgical correction of low-grade isthmic spondylolisthesis. Material and Methods Prospective non-randomized study based on a single-institution series of consecutive patients with isthmic spondylolisthesis during a 10-year period from 2002–2012. 63 adult patients with a low-grade isthmic slip and adequate pre- and postoperative radiograms were available for measurement of spino-pelvic parameters and final assessment of their clinical outcomes. The latter were assessed at least 1 year after the surgery with the use of the Oswestry Disability Index (ODI) and a back pain visual analogue scale. Pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), lumbosacral angle (LSA) and lumbar lordosis were measured on standing lateral view radiograms. We assumed postoperative reduction in pelvic tilt (PT) to reflect improvement in pelvic balance. The Spearman's rank correlation test was used to assess the correlation between the improvement in pelvic balance and the improvement in ODI and back pain. The Mann–Whitney U test was used to identify significant differences in clinical outcomes between patients (i) with a balanced and unbalanced pelvis postoperatively, (ii) who regained and did not regain pelvic balance postoperatively, (iii) who maintained and lost pelvic balance postoperatively, and (iv) with an improved (reduced PT) and worsened (increased PT) pelvic balance postoperatively. Results There were no significant differences in clinical outcomes between patients with a balanced and unbalanced pelvis postoperatively regardless of whether they lost, maintained, or regained pelvic balance after the surgery. However, we found a weak (R= -0.3) but statistically significant ( p = 0.035) negative correlation between the degree of reduction in pelvic tilt and intensity of postoperative back pain and a weak (R=0.2) but statistically significant ( p = 0.034) positive correlation between the degree of reduction in PT and reduction in back pain. No correlation was found between improvement in pelvic balance and quality of life Conclusions Postoperative reduction of pelvic tilt may impact improvement of rather back pain than quality of life in low-grade isthmic spondylolisthesis. The latter might be a result of rather neural decompression and stabilization of the affected segment than improvement of pelvic balance.

Radiographic and functional outcome of posterolateral lumbosacral fusion for low grade isthmic spondylolisthesis in children and adolescents

We reviewed 34 consecutive patients (18 female-16 male) with isthmic spondylolysis and grade I to II lumbosacral spondylolisthesis who underwent in situ posterolateral arthodesis between the L5 transverse processes and the sacral ala with the use of iliac crest autograft. Ten patients had an associated scoliosis which required surgical correction at a later stage only in two patients with idiopathic curves unrelated to the spondylolisthesis. No patient underwent spinal decompression or instrumentation placement. Mean surgical time was 1.5 hours (1 to 1.8) and intra-operative blood loss 200 ml (150 to 340). There was one wound infection treated with antibiotics but no other complication. Radiological assessment included standing posteroanterior and lateral, Ferguson and lateral flexion/extension views, as well as CT scans. A solid posterolateral fusion was confirmed in all patients at mean latest follow-up of 4.7 years (3.4 to 9.8) beyond skeletal maturity into early adult life. Fusion of the isthmic lesion was documented in nine patients bilaterally and eight patients unilaterally. The poor fusion rate across the spondylolysis has not affected the excellent functional results of the procedure, which in our series depended on achieving a stable lumbosacral junction. Quality of life assessment demonstrated significant improvement in all functional scores and high patient satisfaction with 28 patients returning to previous sports activities at an elite competitive level. Posterolateral arthrodesis in situ with autologous iliac crest bone without instrumentation has achieved a solid fusion between the L5 transverse processes and the sacral ala in patients with grade I to II isthmic lumbosacral spondylolisthesis and this has produced excellent clinical outcomes and high patient satisfaction.

Posterior lumbar interbody fusion and posterolateral fusion: Analogous procedures in decreasing the index of disability in patients with spondylolisthesis.

Objective:The purpose of this study was to evaluate the disability in patients with spondylolisthesis who assigned either to posterolateral fusion (PLF) or posterior lumbar interbody fusion (PLIF) and to compare it between two groups.Methods:In a prospective observational study, 102 surgical candidates with low-grade degenerative and isthmic spondylolisthesis enrolled from 2012 to 2014, and randomly assigned into two groups: PLF and PLIF. Evaluation of disability has been done by a questionnaire using Oswestry Disability Index (ODI). The questionnaire was completed by all patients before the surgery, the day after surgery, after 6 months and after 1-year.Results:There were no statistically significant differences in terms of age and sex distribution and pre-operation ODI between groups (P > 0.05). Comparison of the mean ODI scores of two groups over the whole study period showed no significant statistical difference (P = 0.074). ODIs also showed no significant differences between two groups the day after surgery, 6th months and 1-year after surgery (P = 0.385, P = 0.093, P = 0.122 and P = 433) respectively. Analyzing the course of ODI over the study period, showed a significant descending pattern for either of groups (P < 0.0001).Conclusion:Both surgical fusion techniques (PLF and PLIF) were efficient to lessen the disability of patients with spondylolisthesis, and none of the fusion techniques were related to a better outcome in terms of disability.

Restoration of the spinopelvic sagittal balance in isthmic spondylolisthesis: posterior lumbar interbody fusion may be better than posterolateral fusion

Background contextMore and more orthopedic surgeons recognize the importance of the sagittal balance of the spine. PurposeTo analyze the pre- and postoperative sagittal and deformity parameters of low-grade isthmic spondylolisthesis and evaluate the effect of posterolateral fusion (PLF) and posterior lumbar interbody fusion (PLIF) on spinopelvic sagittal balance. Study designNonrandomized controlled prospective study with a historical control. Patient sampleA total of 99 patients with low-grade L5–S1 isthmic spondylolisthesis were treated surgically; 36 patients (mean age, 60.2±5.2 years) received the PLF operation, and 63 patients (mean age, 57.1±6.9 years) chose the PLIF operation. The healthy control group was composed of 60 volunteers (mean age, 44.5±8.4 years). Outcome measuresThe pre- and postoperative spinopelvic and deformity parameters. MethodsAll patients had radiographs that allowed measurement of spinopelvic parameters before and after the operation. All the spinopelvic and deformity parameters were measured. Two radiologists measured the parameters with the Cobb method. ResultsAll of the preoperative spinopelvic parameters showed no difference between the PLIF and PLF groups in this study (p>.05). In both of the operation groups, the preoperative pelvic incidence, pelvic tilt (PT), sacral slope, lumbar lordosis (LL), and L5 incidence (L5I) were significantly higher than in the control group (p<.01); the height of the intervertebral disc (HOD) was significantly lower than the controls. There were no significant differences in PT among PLIF, PLF, and control groups after the operation (p>.05). LL increased in the PLIF group and decreased in the PLF group. The slip degree (SD) and L5I were restored significantly in both groups. The HOD of the PLIF group increased 5.04 mm, the postoperative HOD of the PLF group had no significant change. In both PLIF and PLF groups, the correction of SD was correlated with the change of LL (r=−0.398, p=.007; r=0.365, p=.022). The restoration of HOD in the PLIF group correlated with the change of LL (r=0.334, p=.011). No significant differences could be found between the short-term clinical outcomes of the PLF and PLIF. ConclusionEither PLF or PLIF would lead a great change in spinopelvic parameters and deformity parameters. The decrease of PT may be an important role for the short-term surgical outcome. The PLIF could increase the LL and form a more reasonable sagittal alignment. From the point of the sagittal spinopelvic balance, the PLIF may be better than the PLF for patients with isthmic spondylolisthesis.

Management of spondylolysis and low-grade spondylolisthesis in fine athletes. A comprehensive review.

To provide evidence-based data about the aetiology, incidence, diagnosis and treatment of isthmic lumbar spondylolysis and low-grade spondylolisthesis and return to athletic activities in fine athlete. This is a comprehensive literature review. A thorough MEDLINE search in the period from 1973 to 2014 with the keywords: athlete, spondylolysis, low-grade spondylolisthesis, treatment and return to athletic activities was conducted. A total of 228 articles were initially enrolled from the search, and 74 case series and reviews were finally included because they referred to incidence, diagnosis, treatment and return to play in fine athletes with symptomatic isthmic spondylolysis and low-grade (Meyerding I and II) spondylolisthesis. There were 13 studies reporting surgical treatment (194 patients of average age 19 years) and 14 studies with conservative treatment (589 patients of average age 15.7). The percentage of athletes who were successfully treated with conservative or operative treatment was 85 and 87.8%, respectively. Conservative treatment including physiotherapy and bracing is the mainstay in the treatment of symptomatic spondylolysis and low-grade isthmic spondylolisthesis in fine athletes. If consequent treatment fails, the operative treatment (pars repair and short fusion) is decided. Return to play following surgery varies from 6 to 12 months with prohibition in collision sports. Return to play is mostly depended on specific sport activity.