Lumbar Interbody Fusion For Spondylolisthesis Research Articles

EVALUATION OF CLINICAL OUTCOMES AND ACCURACY IN TRANSPEDICULAR SCREW FIXATION USING INTRAOPERATIVE CT-GUIDED NAVIGATION FOR LUMBAR SPONDYLOLISTHESIS

The use of intraoperative navigation and robotic surgery for minimally invasive lumbar fusion has been increasing over the past decade. The aim of this study is to evaluate postoperative clinical outcomes, intraoperative parameters, and accuracy of pedicle screw insertion guided by intraoperative navigation in patients undergoing lumbar interbody fusion for spondylolisthesis. Patients who underwent posterior lumbar fusion interbody using intraoperative 3D navigation since December 2021 were included. Visual Analogue Scale (VAS), Oswestry Disability Index (ODI), and Short Form Health Survey-36 (SF-36) were assessed preoperatively and postoperatively at 1, 3, and 6 months. Screw placement accuracy, measured by Gertzbein and Robbins classification, and facet joint infringement, measured by Yson classification, were assessed by intraoperative Cone Beam CT scans performed at the end of instrumentation. Finally, operation time, intraoperative blood loss, hospital stay, and screw insertion time were evaluated. This study involved 50 patients with a mean age of 63.7 years. VAS decreased from 65.8±23 to 20±22 (p<.01). ODI decreased from 35.4%±15 to 11.8%±14 (p<.01). An increase of SF-36 from 51.5±14 to 76±13 (p<.01) was demonstrated. The accuracy of “perfect” and “clinically acceptable” pedicle screw fixation was 89.5% and 98.4%, respectively. Regarding facet violation, 96.8% of the screws were at grade 0. Finally, the average screw insertion time was 4.3±2 min, hospital stay was 4.2±0.8 days, operation time was 205±53 min, and blood loss was 169±107 ml. Finally, a statistically significant correlation of operation time with hospital stay, blood loss and placement time per screw was found. We demonstrated excellent results for accuracy of pedicle screw fixation and violation of facet joints. VAS, ODI and SF-36 showed statistically significant improvements from the control at one month after surgery.Navigation with intraoperative 3D images represents an effective system to improve operative performance in the surgical treatment of spondylolisthesis.

Endoscopic lumbar spinal hybrid surgery in the treatment of multiple-level lumbar degenerative spondylolisthesis and spinal stenosis

BackgroundElderly patients frequently suffer from multi-level degenerative lumbar spondylolisthesis/stenosis, particularly heavy labor workers, farmers, and obese individuals. The gold standard of treatment is surgical fusion following failure of conservative management; however, long-segment fusion wounds can cause premature adjacent segment disease. Owing to improved techniques and equipment, endoscopic spine surgery, lumbar spine fusion, laminectomy, or discectomy can be performed with a single or biportal spinal endoscope. We attempted to use these endoscopic techniques to decrease the fusion level in long-segment degenerative lumbar spines. Our strategy was to only fuse the most severe central and foraminal spondylolisthesis levels and arrange for endoscopic decompression only (without fusion) in other central stenosis spondylolisthesis levels. MethodsFrom September 2019 to May 2021, we enrolled 14 patients (average age 72 [9 females, 5 males]) with long-segment (>3 segments) low-grade spondylolisthesis and spinal stenosis who required spinal fusion after failed conservative treatment. We performed anterior lumbar interbody fusion or endoscopic-transforaminal lumbar interbody fusion for spondylolisthesis with central and foraminal stenosis levels only, particularly those involving the lowest segment; the endoscopic unilateral approach and bilateral decompressions were performed for other cephalic spondylolisthesis with central stenosis levels. ResultsAt the 1-year after hybrid operation, the patient’s daily function and neurologic pain have significant improvement. No major complications occurred during follow-up. There was no significant lumbar lordosis change, vertebral slip distance progression or range of motion change, even in vertebrae adjacent to the fusion level. ConclusionsPerforming multiple levels of endoscopic decompression above the fusion level is a reliable alternative technique that does not negatively impact spine structural stability.

Sequential MRI Changes After Lateral Lumbar Interbody Fusion in Spondylolisthesis with Mild and Severe Lumbar Spinal Stenosis

We assessed the sequential magnetic resonance imaging changes of indirect neural decompression after minimally invasive lumbar lateral interbody fusion (LIF) combined with posterior percutaneous pedicle screw (PPS) fixation for degenerative spondylolisthesis (DS) according to the severity of preoperative lumbar spinal stenosis. A total of 43 patients (mean age, 68.7 years; 16 men and 27 women) with DS who had undergone LIF and closed reduction with PPS fixation were enrolled. The intervertebral levels were divided into the moderate stenosis (MS) group (preoperative cross-sectional area [CSA] of the thecal sac >50 mm2) and severe stenosis (SS) group (CSA ≤50 mm2). The CSA, ligamentum flavum thickness, and diameter of the thecal sac at the affected level were measured on cross-sectional magnetic resonance images at baseline, immediately postoperatively, and 2 years postoperatively. For the 31 and 29 intervertebral levels in the MS and SS groups, the mean CSA at baseline, immediately postoperatively, and 2 years postoperatively was 76.9 mm2 and 35.8 mm2, 104.3 mm2 and 81.4 mm2, and 130.9 mm2 and 105.7 mm2, respectively. The mean ligamentum flavum thicknesses at 2 years postoperatively became thinner than that immediately after surgery in both groups (P < 0.01). The mean diameter of the thecal sac at 2 years was longer than that immediately after surgery in both groups (MS group, P< 0.05; SS group, P < 0.01) The expansion ratio of the CSA at 2 years postoperatively was significantly greater in the SS group than that in the MS group (P < 0.01). Sequential enlargement of the spinal canal was obtained by the thinning of the ligamentum flavum after LIF and PPS fixation in patients with DS with both mild and severe stenosis. The effect of indirect neural decompression was equivalent even in those with severe lumbar spinal stenosis.

75. Prospective, randomized study of lumbar facet replacement and lumbar interbody fusion for spondylolisthesis

BACKGROUND CONTEXT The surgical treatment for lumbar spondylolisthesis has remained somewhat controversial. Posterior lumbar arthroplasty with facet replacement is a novel alternative to lumbar decompression and fusion. There are currently no FDA-approved devices for facet replacement. The TOPS System is a robust, pedicle screw-based biomechanical device intended to replace the facets and posterior elements following aggressive decompression. PURPOSE Lumbar facet replacement is a novel motion-preserving procedure that can be used to treat spondylolisthesis with stenosis. There is an ongoing multicenter, prospective, randomized, controlled US Food and Drug Administration (FDA) Investigation Device Exemption (IDE) trial evaluating the clinical and radiographic outcomes of an investigational facet replacement device and lumbar fusion with interbody fusion with pedicle screw fixation. STUDY DESIGN/SETTING Multicenter, prospective, randomized, US FDA Investigation Device Exemption trial. PATIENT SAMPLE The results of five high enrolling investigational sites from the prospective, randomized IDE trial comparing facet replacement (TOPS) and lumbar interbody fusion (TLiF) in the treatment of Grade I degenerative spondylolisthesis and stenosis were combined to evaluate clinical outcomes. OUTCOME MEASURES The primary clinic outcome measures included the Oswestry Disability Index (ODI) and visual analog scale (VAS) as well as re-operation rate. Patients were 2:1 randomized to artificial facet replacement vs TLIF using a monolithic PEEK interbody spacer and pedicle screw fixation. A minimum of 12 months follow-up was required for inclusion in this study. METHODS The results of five high enrolling investigational sites from the prospective, randomized IDE trial comparing facet replacement (TOPS) and lumbar interbody fusion (TLiF) in the treatment of Grade I degenerative spondylolisthesis and stenosis were combined to evaluate clinical outcomes. The primary clinic outcome measures included the Oswestry Disability Index (ODI) and visual analog scale (VAS) as well as re-operation rate. Patients were 2:1 randomized to artificial facet replacement vs TLIF using a monolithic PEEK interbody spacer and pedicle screw fixation. A minimum of 12 months follow-up was required for inclusion in this study. RESULTS A total of 129 patients have been enrolled and randomly assigned to either TOPS (n=90) or to TLIF (n= 39). A total of 63 patients were available for follow-up of at least 12 months (TOPS=47, TLIF=16). The reoperation rate for revision, removal or supplemental fixation (RRSF) for facet replacement and TLIF control was 6.7% and 12.8%, respectively. There was no significant difference between groups in baseline mean ODI (TOPS=57; TLIF=56) or VAS Back (TOPS=68; TLIF=68) and Leg scores (TOPS=83; TLIF=84). Both groups showed significant improvement in ODI (TOPS=13; TLIF=14) and VAS Back (TOPS=12; TLIF=14) and VAS Leg (TOPS=12; TLIF=10) from baseline to 12-month follow-up. At 12-month follow-up, 89% of TOPS patients and 81% of TLIF patients showed both a minimum of 15-point ODI improvement and no RRSF reoperation. CONCLUSIONS The preliminary results of this prospective, randomized study are encouraging for both TOPS and TLIF. Both lumbar facet replacement and interbody fusion groups have shown good clinical outcomes with relatively low re-operation rates. There was a trend toward lower reoperation rates with lumbar arthroplasty that did not reach clinical significance. There was no statistically significant difference between the groups in clinic outcome measures. There was a statistically significant level of improvement from baseline and last follow-up in ODI and VAS (Back and Leg) in both treatment groups. Lumbar facet replacement and lumbar interbody fusion both appear to be viable options for treatment of one-level lumbar stenosis due to degenerative spondylolisthesis. Continued enrollment with long-term follow-up is required to validate these early findings as well as to evaluate for any differences between rigid and dynamic stabilization on adjacent level disease. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Functional outcome of transforaminal lumbar interbody fusion for lytic and degenerative spondylolisthesis

Introduction: Spondylolisthesis is defined as the forward displacement of one vertebra over the vertebra below. It is often accompanied by spinal canal stenosis and compression, which is the cause of all the symptoms. Aim: The aim of this prospective study is to analyze the Functional outcome of Transforaminal Lumbar Interbody Fusion in Spondylolisthesis. Methods: 20 patients of Isthmic spondylolisthesis grade I-III, patients who don’t respond to conservative treatment (6 months), Degenerative spondylolisthesis grade I-II, patients who don’t respond to conservative treatment (6 months), Traumatic spondylolisthesis were included in this study. Results: The most common level involved is L4-L5 in 55% of cases and L5-S1 in 40% of cases. The L4-L5 Level is most commonly affected in Degenerative type (80%). The L5-S1 level was most commonly affected in Lytic type (60%). The mean preoperative Visual analog score for Back pain was 10 which improved to 2(1-4) at final follow up implying better pain score postoperatively. The mean preoperative Visual analog score for Leg pain was 8 which improved to 1 (1-5) at final follow up implying better pain score postoperatively. The mean preoperative Oswestry Disability Index (ODI) Score was 64% (range from 56% -74%) which improved to 20% at final follow up which indicates improvement in daily activities of the patient. Conclusion: Transforaminal Lumbar Interbody Fusion is a safe and effective surgical procedure for the treatment of lytic and degenerative spondylolisthesis.

Risk Factors Associated With Failure to Reach Minimal Clinically Important Difference in Patient-reported Outcomes Following Minimally Invasive Transforaminal Lumbar Interbody Fusion for Spondylolisthesis.

Retrospective cohort. To determine risk factors associated with failure to reach the minimal clinically important difference (MCID) in patient-reported outcomes (PROs) for patients undergoing minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) for spondylolisthesis. The MCID of PROs are often utilized to determine the benefit of spinal procedures. However, negative predictive factors for reaching MCID in patients surgically treated for lumbar spondylolisthesis have been difficult to elucidate. A prospectively maintained surgical database of patients who were diagnosed with lumbar spondylolisthesis and surgically treated with a single level MIS TLIF from 2010 to 2016 was reviewed. Patients with incomplete PRO survey data or <6-month follow-up were excluded from the analysis. MCID for visual analogue scale (VAS) back, VAS leg, and Oswestry Disability Index (ODI) was obtained from established values in the literature. All risk factors were then assessed for association with failure to reach MCID using bivariate and multivariate regression adjusting for preoperative characteristics. A total of 165, 76, and 73 patients treated with MIS TLIF for spondylolisthesis had complete PRO data for VAS back, VAS leg, and ODI, respectively, and were thus included in the analysis for the respective PRO. Overall, 75.76%, 71.05%, and 61.64% of patients treated with a single level MIS TLIF for spondylolisthesis reached MCID for VAS back, VAS leg, and ODI, respectively. On multivariate analysis, patients were less likely to achieve MCID for VAS back following surgical treatment if they received workers' compensation (P<0.001). No other measured factors were noted to independently correlate with MCID achievement. The results of this study suggest that a majority of patients with spondylolisthesis achieve MCID for commonly measured PROs following MIS TLIF for spondylolisthesis. However, worker's compensation insurance status may serve as a negative predictive factor for reaching MCID.

Assessment of radiographic and clinical outcomes of an articulating expandable interbody cage in minimally invasive transforaminal lumbar interbody fusion for spondylolisthesis.

OBJECTIVE The inability to significantly improve sagittal parameters has been a limitation of minimally invasive surgery for transforaminal lumbar interbody fusion (MIS TLIF). Traditional cages have a limited capacity to restore lordosis. This study evaluates the use of a crescent-shaped articulating expandable cage (Altera) for MIS TLIF. METHODS This is a retrospective review of 1- and 2-level MIS TLIF. Radiographic outcomes included differences in segmental and lumbar lordosis, disc height, evidence of fusion, and any endplate violations. Clinical outcomes included the numeric rating scale for leg and back pain and the Oswestry Disability Index (ODI) for low-back pain. RESULTS Thirty-nine patients underwent single-level MIS TLIF, and 5 underwent 2-level MIS TLIF. The mean age was 63.1 years, with 64% women. On average, spondylolisthesis was corrected by 4.3 mm (preoperative = 6.69 mm, postoperative = 2.39 mm, p < 0.001), the segmental angle was improved by 4.94° (preoperative = 5.63°, postoperative = 10.58°, p < 0.001), and segmental height increased by 3.1 mm (preoperative = 5.09 mm, postoperative = 8.19 mm, p < 0.001). At 90 days after surgery the authors observed the following: a smaller postoperative sagittal vertical axis was associated with larger changes in back pain at 90 days (r = -0.558, p = 0.013); a larger decrease in spondylolisthesis was associated with greater improvements in ODI and back pain scores (r = -0.425, p = 0.043, and r = -0.43, p = 0.031, respectively); and a larger decrease in pelvic tilt (PT) was associated with greater improvements in back pain (r = -0.548, p = 0.043). For the 1-year PROs, the relationship between the change in PT and changes in ODI and numeric rating scale back pain were significant (r = 0.612, p = 0.009, and r = -0.803, p = 0.001, respectively) with larger decreases in PT associated with larger improvements in ODI and back pain. Overall for this study there was a 96% fusion rate. Fourteen patients were noted to have endplate violation on intraoperative fluoroscopy during placement of the cage. Only 3 of these had progression of their subsidence, with an overall subsidence rate of 6% (3 of 49) visible on postoperative CT. CONCLUSIONS The use of this expandable, articulating, lordotic, or hyperlordotic interbody cage for MIS TLIF provides a significant restoration of segmental height and segmental lordosis, with associated improvements in sagittal balance parameters. Patients treated with this technique had acceptable levels of fusion and significant reductions in pain and disability.

Complete anatomic reduction and monosegmental fusion for lumbar spondylolisthesis of Grade II and higher: use of the minimally invasive "rocking" technique.

OBJECTIVE Different surgical approaches have been described for treatment of spondylolisthesis, including in situ fusions, reductions of various degrees, and inclusion of healthy adjacent segments into the fusion construct. To the authors' knowledge, there are only sparse reports describing consistent complete reduction and monosegmental transforaminal lumbar interbody fusion for spondylolisthesis using a minimally invasive technique. The authors assess the efficacy of this technique in the reduction of local deformity and correction of overall sagittal profile in single-level spondylolisthesis. METHODS This cohort study consists of a total of 36 consecutive patients treated over a period of 6 years. Patients with varying grades of lumbar spondylolisthesis (29 Meyerding Grade II and 7 Meyerding Grade III) were treated with operative reduction via minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) in which the "rocking" technique was used. The clinical outcomes were measured using the visual analog scale (VAS) for pain and the Revised Oswestry Disability Index (ODI) for low-back pain/dysfunction. Meyerding grade, pelvic incidence (PI), lumbar lordosis (LL), disc space angle (DSA), pelvic tilt (PT), and sacral slope (SS) were assessed to measure the radiological outcomes. These were reviewed for each patient for a minimum of 2 years. RESULTS At most recent follow-up, 94% of patients were pain free. There were 2 patients (6%) who had moderate pain (which corresponded to higher-grade of listhesis), but all showed an improvement in pain scores (p < 0.05). The mean VAS score improved from 6.5 (SD 1.5) preoperatively to 1.6 (SD 1.3) and the mean ODI score improved from 53.7 (SD 13.1) preoperatively to 22.5 (SD 15.5) at 2-year follow-up. All radiological parameters improved following surgery. Most significant improvement was noted for LL, DSA, and SS. Both LL and SS were found to decrease, while DSA increased postoperatively. PI remained relatively unchanged, while PT showed a mild increase, which was not significant. Good fusion was achieved with implants in situ at 2-year follow-up. A 100% complete reduction of all grades of spondylolisthesis was achieved. The overall sagittal profile improved dramatically. No major perioperative complications were encountered. CONCLUSIONS Minimally invasive monosegmental TLIF for spondylolisthesis reduction using this rocking technique is effective in the treatment of various grades of spondylolisthesis. Consistent complete reduction of the slippage as well as excellent correction of overall sagittal profile can be achieved, and the need for including healthy adjacent segments in the fusion construct can be avoided.

Validity of the Japanese Orthopaedic Association scoring system based on patient-reported improvement after posterior lumbar interbody fusion

Background ContextThe Japanese Orthopaedic Association (JOA) scoring system is a physician-based outcome that has been used to evaluate treatment effectiveness after lumbar surgery. However, patient-centered evaluation becomes increasingly important. There is no study that has examined the relationship between the JOA scoring system and patients' self-reported improvement. PurposeThe purpose of the present study was to validate the JOA scoring system for assessment of patient-reported improvement after lumbar surgery. Study DesignThis is a retrospective review of prospectively collected data. Patient SampleThe patient sample included 273 mail-in responders of the 466 consecutive patients who underwent posterior lumbar interbody fusion for spondylolisthesis between 1996 and 2008 in a single hospital. Outcome MeasuresThe outcome measures were the JOA scoring system and patients' self-reported improvement. MethodsTwo hundred seventy three patients were divided into five anchoring groups based on self-reported improvement from “Much better” to “Much worse.” Outcomes (ie, recovery rate, amount of change from preoperative condition, and postoperative score) based on the JOA scoring system were compared among groups. Using the patient's self-reported improvement scale as an anchor, the association among each of the outcomes was examined. The cutoff point and the area under the curve (AUC) that differentiated “Improved” from “Neither improved nor worse” was calculated using receiver operating characteristic (ROC) curve analysis. ResultsThe recovery rate and postoperative score were significantly different in 9 of 10 pairs of anchoring groups. The amount of change was significantly different in six pairs. Spearman correlation coefficient for the 5-point scale anchors of patients' self-reported improvement was 0.20 (p=.001) for the baseline score, 0.31 (p<.001) for the amount of change, 0.55 (p<.001) for the recovery rate, and 0.56 (p<.001) for the postoperative score. According to ROC analysis, the best cutoff points and AUCs were 13 points and 0.69, respectively, for the amount of change, 67% and 0.73, respectively, for recovery rate, and 23 points and 0.72, respectively, for postoperative score. ConclusionsThe JOA scoring system is a valid method for assessment of patients' self-reported improvement. Patients' self-reported improvement is more likely to be associated with the final condition, such as postoperative score or recovery rate, rather than the change from the preoperative condition.

Functional and radiological analysis of posterior lumbar interbody fusion in spondylolisthesis

&lt;p class="abstract"&gt;&lt;strong&gt;&lt;span lang="EN-US"&gt;Background:&lt;/span&gt;&lt;/strong&gt;Spondylolisthesis is present in 5% of the adult population with clinical evidence of low back pain. These patients are treated initially by conservative measures, failing of which surgical intervention is mandatory. Majority of patients with varying degree of slip and disability ultimately require surgical intervention. In this study we are trying to analyse the functional outcome following posterior lumbar interbody fusion in spondylolisthesis.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;&lt;span lang="EN-US"&gt;Methods:&lt;/span&gt;&lt;/strong&gt;&lt;span lang="EN-US"&gt; Posterior lumbar interbody fusion using pedicle screw and rods with cage was performed on 25 patients. 6 months follow-up was completed in 25 patients who were then reviewed at regular intervals. Out of the 25 patients, 17(68%) were females and 8(32%) were males. The mean age of the patients was 40.64 years. Out of 25 patients, 14 patients had listhesis at L4 – L5 level and another 11 at L5 – S1 level. 21(84%) were Isthmic variant and 4 (16%) were Degenerative spondylolisthesis.&lt;strong&gt;&lt;/strong&gt;&lt;/span&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;&lt;span lang="EN-US"&gt;Results:&lt;/span&gt;&lt;/strong&gt;The mean follow up period in this study of 25 patients is 19 months. Out of 25 patients, there was mean improvement of 18.96 in the Oswestry scoring index. The Visual analogue scale score showed a mean improvement of 6.48. Radiologically, the percentage of slip was decreased by a mean of 8.40%. One patient had a cage extrusion with no neurological deficit.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;&lt;span lang="EN-US"&gt;Conclusions:&lt;/span&gt;&lt;/strong&gt;The pedicle screw with rod and cage system is easy to use and provides the anatomic restoration of the isthmus in isthmic spondylolisthesis or restoring the stability after laminectomy/discectomy in degenerative spondylolisthesis. From our study, we strongly believe that this technique is very useful in low grade degenerative and isthmic spondylolisthesis.&lt;/p&gt;

Minimally Invasive Transforaminal Lumbar Interbody Fusion for Spondylolisthesis and Degenerative Spondylosis: 5-year Results

Multiple studies have reported favorable short-term results after treatment of spondylolisthesis and other degenerative lumbar diseases with minimally invasive transforaminal lumbar interbody fusion. However, to our knowledge, results at a minimum of 5 years have not been reported. We determined (1) changes to the Oswestry Disability Index, (2) frequency of radiographic fusion, (3) complications and reoperations, and (4) the learning curve associated with minimally invasive transforaminal lumbar interbody fusion at minimum 5-year followup. We reviewed our first 124 patients who underwent minimally invasive transforaminal lumbar interbody fusion to treat low-grade spondylolisthesis and degenerative lumbar diseases and did not need a major deformity correction. This represented 63% (124 of 198) of the transforaminal lumbar interbody fusion procedures we performed for those indications during the study period (2003-2007). Eighty-three (67%) patients had complete 5-year followup. Plain radiographs and CT scans were evaluated by two reviewers. Trends of surgical time, blood loss, and hospital stay over time were examined by logarithmic curve fit-regression analysis to evaluate the learning curve. At 5 years, mean Oswestry Disability Index improved from 60 points preoperatively to 24 points and 79 of 83 patients (95%) had improvement of greater than 10 points. At 5 years, 67 of 83 (81%) achieved radiographic fusion, including 64 of 72 patients (89%) who had single-level surgery. Perioperative complications occurred in 11 of 124 patients (9%), and another surgical procedure was performed in eight of 124 patients (6.5%) involving the index level and seven of 124 patients (5.6%) at adjacent levels. There were slowly decreasing trends of surgical time and hospital stay only in single-level surgery and almost no change in intraoperative blood loss over time, suggesting a challenging learning curve. Oswestry Disability Index scores improved for patients with spondylolisthesis and degenerative lumbar diseases treated with minimally invasive transforaminal lumbar interbody fusion at minimum 5-year followup. We suggest this procedure is reasonable for properly selected patients with these indications; however, traditional approaches should still be performed for patients with high-grade spondylolisthesis, patients with a severely collapsed disc space and no motion seen on the dynamic radiographs, patients who need multilevel decompression and arthrodesis, and patients with kyphoscoliosis needing correction. Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Minimally invasive transforaminal lumbar interbody fusion for spondylolisthesis in patients with significant obesity

Comparative studies evaluating efficacy and safety of minimally invasive spinal fusion between patients with significant obesity (body mass index [BMI]⩾35kg/m2) and those of normal weight are scarce. We examined complication rates and outcomes for minimally invasive transforaminal lumbar interbody fusion (MITLIF) in patients with significant obesity and those of normal weight undergoing treatment for symptomatic spondylolisthesis. Patients with a BMI⩾35kg/m2 or <25kg/m2 undergoing elective MITLIF for symptomatic spondylolisthesis for the period 2006–09 were identified. Of the 16 patients identified, nine patients with a mean BMI of 37.4kg/m2 were included in the obese group, while seven patients with a mean BMI of 23.4kg/m2 comprised the normal weight group. Estimated blood loss (EBL), operative time, complication rate, length of hospital stay, and clinical outcomes were assessed. Outcome measures included patient-reported visual analog scale (VAS) score for pain and the Oswestry Disability Index (ODI) questionnaire completed by the patient. No significant differences were found in blood loss (p=0.436), hospital stay (p=0.606), or number of surgical complications (p=0.920) between the two groups. Mean follow-up intervals were 15.0months for patients with obesity, and 18.6months for those of normal weight. Both groups had significant improvements in VAS (obese, p=0.003; normal, p=0.016) and ODI (obese, p=0.020; normal, p=0.034) scores. There were no statistically significant differences between normal weight and obese groups in postoperative VAS (p=0.728) and ODI (p=0.886) scores. Patients with significant obesity experienced clinical improvement similar to that of patients with normal weight, suggesting that obesity does not impact MITLIF outcomes. In addition, both groups experienced similar complication rates, operative times, EBL, and length of hospital stay.

Clinico-radiological profile of indirect neural decompression using cage or auto graft as interbody construct in posterior lumbar interbody fusion in spondylolisthesis: Which is better?

Study design:A prospective clinical study of posterior lumbar interbody fusion in grade I and II degenerative spondylolisthesis was conducted between Mar 2007 and Aug 2008.Purpose:The objective was to assess the clinicoradiological profile of structural v/s nonstructural graft on intervertebral disc height and its consequences on the low back pain (LBP) assessed by Visual analog score (VAS) score and oswestry disability index (ODI) . This study involved 28 patients.Inclusion criteria:Age of 30–70 years, symptomatic patient with disturbed Activities of daily living (ADL), single-level L4/L5 or L5/S1 grade I or grade II degenerative spondylolisthesis.Exclusion criteria:Patients with osteoporosis, recent spondylodiscitis, subchondral sclerosis, visual and cognitive impairment and all other types of spondylolisthesis. All the patients underwent short-segment posterior fixation using CD2 or M8 instrumentation, laminectomy discectomy, reduction and distraction of the involved vertebral space. In 53.5% (n = 15) of the patients, snugly fitted local bone chips were used while in 46.4% (n = 13) of the patients, cage was used. Among the cage group, titanium cage was used in nine (32.1%) and PEEK cages were used in four (14.2%) patients. In one patient, a unilateral PEEK cage was used. The mean follow-up period was 24 months. Among the 28 patients, 67.8% (n = 19) were females and 32.14% (n = 9) were males. 68.24% (n = 18) had L4/L5 and 35.71% (n = 10) had L5/S1 spondylolisthesis. 39.28% (n = 11) were of grade I and 60.71% (n = 17) were of grade II spondylolisthesis.Conclusions:There was a statistically significant correlation (P < 0.012 and P < 0.027) between the change in disc height achieved and the improvement in VAS score in both the graft group and the cage group. The increment in disc height and VAS score was significantly better in the cage group (2 mm ± SD vis-a-vis 7.2 [88%]) than the graft group (1.2 mm ± SD vis-a-vis 5 [62 %]).

Spontaneous cerebellar haemorrhage following lumbar fusion

Spontaneous cerebellar haemorrhage following spinal surgery is rare, with fewer than 20 patients reported in the literature. We present a 70-year-old woman who underwent a L5–S1 posterior lumbar interbody fusion for spondylolisthesis. Intraoperatively, an incidental durotomy occurred and was repaired uneventfully. A large amount of serosanguinous fluid was noted in the subfascial drain post-operatively. The patient became increasingly drowsy 36 hours later. She was subsequently found to have bilateral cerebellar haemorrhages with associated non-communicating hydrocephalus.

Vertebral osteolysis after posterior interbody lumbar fusion with recombinant human bone morphogenetic protein 2: A report of five cases

Background Recombinant human bone morphogenetic protein 2 (rh-BMP-2) is frequently used in an off-label fashion. Its application for posterior interbody fusion appears intuitive because its use obviates the need for iliac crest bone graft and shows higher fusion rates than with the use of local autologous bone graft. To date, there is no report of adverse outcomes with such use of rh-BMP-2. Purpose To draw attention to this unusual complication of posterior interbody lumbar fusion and to review the relevant literature. Study design Clinical report of five cases of vertebral osteolysis that developed postoperatively from lumbar transforaminal interbody fusion of the L5/S1 motion segment using cages and rh-BMP-2. Methods Sixty-eight patients underwent transforaminal lumbar interbody fusion for spondylolisthesis or degenerative disc disease with discogenic back pain. Five of these 68 patients developed vertebral osteolysis within 4 months from their surgery. Their clinical presentation and radiographic findings are presented in this case series. Results Each one of these five patients had uneventful surgery and postoperative recovery. Their back and leg pain improved in the immediate postoperative period. However, each patient reported worsening back pain with variable radicular pain as early as 4 weeks and as late as 3 months after the index procedure. Diagnostic workup revealed evidence of vertebral osteolysis typically involving the L5 vertebral body. In all five patients, osteolytic defects filled in spontaneously, and symptoms typically resolved within an additional 3 months of nonoperative care. Conclusions Vertebral osteolysis can occur with the use of rh-BMP-2 in posterior lumbar interbody fusions. Violation of the end plate during decortication may be a contributing factor. Symptoms often resolve spontaneously.

P161. A Novel, Minimally Invasive Access Technique for Stand-Alone Lumbar Interbody Fusion in Spondylolisthesis: Preliminary 13-Month Results on the Deployable Optimesh Graft Device

P161. A Novel, Minimally Invasive Access Technique for Stand-Alone Lumbar Interbody Fusion in Spondylolisthesis: Preliminary 13-Month Results on the Deployable Optimesh Graft Device