Lumbar Isthmic Spondylolisthesis Research Articles

Clinical study of isthmic spondylolisthesis treated with Mis-TLIF assisted by preoperative posture reduction and intraoperative lifting reduction

To investigate the clinical effect of minimally invasive transforaminal lumbar interbody fusion(Mis-TLIF) technique combined with preoperative position reduction in the treatment of spondylolisthesis and summarize its advantages. Between July 2016 and July 2022, 60 patients with lumbar isthmic spondylolisthesis were retrospectively analyzed, including 26 males and 34 females, with an average age of (51.32±4.24) years old ranging from 35 to 72 years old. They were divided into observation group and control group according to the operation methods. There were 30 patients in the observation group, including 12 males and 18 females;the age ranged from 35 to 71 years old with an average of(51.80±6.38) years old, the course of disease ranged from 12 to 60 months with an average of (24.17±1.98) months;there were 18 cases of L4 spondylolisthesis and 12 cases of L5 spondylolisthesis;according to Meyerding classification, there were 20 cases of grade Ⅰ spondylolisthesis and 10 cases of gradeⅡ. The observation group was treated with preoperative postural reduction combined with intraoperative reduction assisted minimally invasive transforaminal lumbar fusion via Quadrant channel(Mis-TLIF). There were 30 patients in the control group, including 14 males and 16 females, with an average of (50.00±4.24) years old ranging from 36 to 72 years old;the course of disease ranged from 12 to 60 months with an average of (23.70±1.53) months;there were 16 cases of L4 spondylolisthesis and 14 cases of L5 spondylolisthesis;according to Meyerding classification, there were 19 cases of grade Ⅰ spondylolisthesis and 11 cases of grade Ⅱ. The control group was treated with open transforaminal lumbar interbody fusion(Open-TLIF). The differences of operation time, intraoperative and postoperative blood loss, hospital stay, radiation exposure time and complications between the two groups were analyzed. Visual analogue scale (VAS), Oswestry disability index (ODI) and Japanese Orthopaedic Association(JOA) score were used to evaluate the clinical effect. X-ray and CT were followed up to evaluate the interbody fusion. All patients were followed up for 12 months. There was no significant difference in operation time, VAS of low back pain, slip angle and slip rate between two groups (P>0.05). The intraoperative and postoperative blood loss in the observation group (165.50±15.56) ml and (59.17±10.59) ml were less than those in the control group (259.33±35.32) ml and (165.33 ±29.56) ml (P<0.05). The length of hospital stay in the observation group (3.53±0.68) days was less than that in the control group (5.20±0.41) days (P<0.05).The intervertebral space height, slip angle, slip rate, ODI, VAS and JOA scores were significantly improved in the two groups at the final follow-up (P<0.05). There were significant differences in ODI [(9.93±1.11)% vs (10.93±1.11)%] and JOA [ (26.07±1.01) points vs (25.43±1.25) points] between the observation group and the control group at the final follow-up (P<0.05). In the treatment of spondylolisthesis, preoperative position reduction combined with intraoperative reduction assisted Mis-Tlif technique has advantages of less trauma, less bleeding and shorter hospitalization period than traditional open surgery. It is a safe and effective technique.

Transforaminal Endoscopic Lumbar Foraminotomy for the Treatment of L5-S1 Isthmic Lumbar Spondylolisthesis with Foraminal Stenosis: A 1-Year Follow-Up

Isthmic lumbar spondylolisthesis (ILS) is a prevalent spinal pathology. Radicular pain in patients is often attributed to L5-S1 ILS combined with foraminal stenosis (FS), making such patients prime candidates for surgical intervention. We herein aimed to elucidate the surgical technique and clinical outcomes of transforaminal endoscopic lumbar foraminotomy (TELF) in the treatment of L5-S1 ILS with FS. From September 2021 to December 2022, 20 consecutive patients were diagnosed with L5-S1 ILS with FS and underwent TELF. All patients were followed up for at least 12months. The clinical outcomes were evaluated using the visual analog scale (VAS), Oswestry Disability Index, and modified MacNab criteria. The mean age of the patients was 62.4±10.9years. The mean preoperative VAS score for low back, VAS score of the leg, and Oswestry Disability Index score was 5.1±1.7, 7.4±0.7, and 58.0±8.4, respectively. These scores significantly improved to 1.8±0.7, 1.5±0.6, and 15.3±7.1 at 12months postoperatively, respectively (P < 0.01). Evaluation based on the modified MacNab criteria revealed that 95.0% of patients achieved a good-to-excellent outcome. One patient underwent revision surgery. TELF emerges as a potentially safe and effective surgical option for alleviating radicular pain in patients with L5-S1 stable ILS combined with FS. While our short-term clinical results are satisfactory, it is necessary to expand the sample size and extend the follow-up time to validate the effectiveness and long-term efficacy of TELF.

Percutaneous Transforaminal Endoscopic Lumbar Foraminotomy in Stable Degenerative Lumbar Isthmic Spondylolisthesis with Radicular Leg Pain: A Retrospective Study.

Endoscopic surgery is a minimally invasive option for effectively addressing lumbar degenerative diseases. This study aimed to describe the specific technology of percutaneous transforaminal endoscopic lumbar foraminotomy (PTELF) as a therapeutic intervention for managing radicular leg pain (RLP) resulting from stable degenerative lumbar isthmic spondylolisthesis (DLIS) and to present the associated clinical results. From March 2022 and April 2023, 25 patients were diagnosed with single-level stable DLIS with RLP and underwent PTELF. Clinical assessments utilized the visual analog scale (VAS), Oswestry Disability Index (ODI), and modified MacNab criteria. All endoscopic surgery videos were reviewed to interpret the pathology associated with DLIS. The mean age of the cohort was 65.3 ± 11.0 years. The mean preoperative ODI score, VAS score for low back, and VAS score of the leg were 64.1 ± 8.2, 7.0 ± 0.7, and 7.3 ± 0.8, respectively. These scores significantly improved to 16.3 ± 10.4, 2.0 ± 0.6, and 1.7 ± 1.0 at the final follow-up, respectively (P<0.01). The modified MacNab criteria indicated "good" or "excellent" outcomes in 92.0% of cases. Analysis of 23 surgical videos revealed 15 patients with disc herniation, nine with lower vertebral endplate involvement, consistent presence of uneven bone spurs (at the proximal lamina stump and around the foramen), and accumulated scars. Two patients experienced postoperative dysesthesia, and one encountered a recurrence of RLP. PTELF emerges as a potentially safe and effective procedure for alleviating RLP in patients with stable DLIS. However, additional evidence and extended follow-up periods are imperative to evaluate the feasibility and potential risks associated with PTELF.

The Short-Term Outcome of Transforaminal Epidural Steroid Injection in Patients with Radicular Pain Due to Foraminal Stenosis from Lumbar Isthmic Spondylolisthesis.

In this study, we evaluated the therapeutic outcomes of transforaminal epidural steroid injection (TFESI) in managing chronic radicular pain due to foraminal stenosis. Furthermore, we evaluated its effectiveness according to isthmic spondylolisthesis (IS) severity. We included 40 patients with radicular pain due to IS-derived foraminal stenosis in our study and treated them with TFESI. Two patients were lost during follow-up. Based on the lateral lumbar radiograph findings, we allocated the recruited patients with < 25% slippage by IS to Group 1 (n = 23) and those having 25-50% slippage to Group 2 (n = 15). The degree of pain was measured using a numeric rating scale (NRS) at pre-treatment and 1 and 2 months after TFESI. In 38 patients who completed the study, the NRS at pre-treatment was significantly reduced at the 1- and 2-month follow-ups. In the Group analysis, the NRS scores were significantly reduced after TFESI in both Groups 1 and 2, regardless of IS severity. However, the reduction in NRS scores 1 month after TFESI was significantly greater in Group 1 than in Group 2. Moreover, the rate of successful treatment outcomes was significantly higher (65.2%) in Group 1 than in Group 2 (26.7%). After TFESI, chronic radicular pain was significantly reduced regardless of IS severity, and its effect persisted for at least 2 months. However, its effect was superior when the vertebra slippage by IS was less than 25% compared to patients with 25%-50%.

Return to flight duty (RTFD) after posterior lumbar spine surgery for symptomatic lumbar disc herniation (LDH) and lumbar isthmic spondylolisthesis (LIS) in Chinese military pilots

BackgroundSymptomatic lumbar disc herniation (LDH) and lumbar isthmic spondylolisthesis (LIS) present significant challenges for military pilots, which may result in grounding if not effectively managed. Surgical treatment for LDH and LIS may offer a pathway to return to flight duty (RTFD), but recent data on this crucial topic is lacking. This study seeks to address this gap by investigating the RTFD outcomes among Chinese military pilots who have undergone lumbar spine surgery for symptomatic LDH and LIS.MethodsA retrospective review was conducted on active-duty military pilots who underwent isolated decompressive or fusion procedures at an authorized military medical center from March 1, 2007, to March 1, 2023. The analysis utilized descriptive statistics to examine demographic, occupational, surgical, and outcome data, with a particular focus on preoperative flight status, recommended clearance by spine surgeons, and actual RTFD outcomes and time.ResultsAmong the identified cases of active-duty military pilots with LDH or LIS treated by lumbar surgery (n = 24), 70.8% (17 of 24) consistently maintained RTFD status without encountering surgical complications or medical issues during the follow-up period. Of the seven pilots who did not RTFD, one retired within a year of surgery, two had anterior cruciate ligament injuries, three had residual radicular symptoms, and one had chronic low back pain. Excluding pilots who retired and did not RTFD for reasons unrelated to their lumbar conditions, the RTFD rate stood at 81.0% (17 of 21). The median time for recommended clearance by spine surgeons was 143.0 days (inter-quartile range, 116.5–196.0), while the median duration for actual RTFD attainment was 221.0 days (inter-quartile range, 182.0–300.0). The median follow-up post-lumbar surgery was 1.7 years (inter-quartile range, 0.4–2.9).ConclusionMost military pilots diagnosed with symptomatic LDH and LIS can continue their careers and regain active-duty flight status following lumbar spine surgery, as reflected by the high RTFD rate. Lumbar spine surgery can successfully alleviate the physical constraints associated with spinal conditions, facilitating the return of military pilots to their demanding profession.

Clinical efficacy of minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) in the treatment of II° lumbar isthmic spondylolisthesis: A retrospective cohort study.

Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) is not suitable for high-grade isthmic spondylolisthesis, whether MIS-TLIF can treat II° lumbar isthmic spondylolisthesis (IS) is still controversial. This retrospective cohort study compared the clinical efficacy of MIS-TLIF and open transforaminal lumbar interbody fusion (OPEN-TLIF) in the treatment of II° lumbar IS. From January 2017 to January 2023, 101 patients with II° lumbar IS were diagnosed in our hospital and underwent surgical treatment, of which 53 received MIS-TLIF surgery and 48 received OPEN-TLIF surgery. The operation time, blood loss and surgical complications were compared between the 2 groups. The pain, function, reduction rate and fusion rate of the patients were evaluated during follow-up. The amount of intraoperative blood loss, postoperative drainage, and postoperative hospital stay in the MIS-TLIF group were significantly lower than those in the OPEN-TLIF group were (P < .01). In the MIS-TLIF group, there were 1 case of dural sac injury and 3 cases of lower limb paralysis. The complication rate of MIS-TLIF was lower than the OPEN-TLIF group (P = .032). In the visual analog scale score of low back pain, the MIS-TLIF group was lower than the OPEN-TLIF group after operation and at the last follow-up. There were no significant differences in postoperative leg pain score, slippage rate, and fusion rate between the 2 groups. Compared with OPEN-TLIF, MIS-TLIF has the advantages of better low back pain relief, less trauma, less bleeding and faster recovery, and is worthy of clinical promotion.

Analysis of Degenerative and Isthmic Lumbar Spondylolisthesis from the Difference of Pelvic Parameters and the Degree of Degeneration through Imaging Data.

In previous studies, many imaging analyses have been conducted to explore the changes in the intervertebral disc degeneration (DD), facet joint osteoarthritis (FJOA), L4 inclination angle (L4IA), pelvis-related parameters, lumbar lordosis (LL), and paravertebral muscle (PVM) in the occurrence and development of degenerative spinal diseases via measuring the X-ray, CT, and MRI data of clinical patients. However, few studies have quantitatively investigated the pelvic parameters and the degree of spine degeneration in patients with degenerative lumbar spondylolisthesis (DLS) and isthmic lumbar spondylolisthesis (ILS). This study discusses the changes in the imaging parameters of DLS, ILS, and a control group; explores the correlation between different measurement parameters; and discusses their risk factors. We evaluated 164 patients with single L4-L5 grade 1 level degenerative lumbar spondylolisthesis (DLS group), 161 patients with single L4-L5 grade 1 level isthmic lumbar spondylolisthesis (ILS group), and 164 patients with non-specific back pain (control group). The grades of DD and FJOA as well as the percentage of the fat infiltration area (%FIA) of multifidus muscle (MM) at the L4-L5 level were measured via CT and MRI. Lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT), the L4 inclination angle (L4IA), and sacral slope (SS) were measured via X-ray film, and the differences among the DLS group, ILS group, and control group were analyzed. Furthermore, the risk factors related to the incidences of the DLS and ILS groups were discussed. First, the pelvis-related parameters of DLS and ILS patients were 51.91 ± 12.23 and 53.28 ± 11.12, respectively, while those of the control group were 40.13 ± 8.72 (p1 < 0.001, p2 < 0.001). Lumbar lordosis (LL) in DLS patients (39.34 ± 8.57) was significantly lower than in the control group (44.40 ± 11.79, p < 0.001). On the contrary, lumbar lordosis (LL) in the ILS group (55.16 ± 12.31) was significantly higher than in the control group (44.40 ± 11.79, p < 0.001). Secondly, the three groups of patients were characterized by significant variations in the L4 inclination angle (L4IA), disc degeneration (DD), facet joint osteoarthritis (FJOA), pelvis-related parameters, and paravertebral muscle (PVM) (p < 0.05). Finally, logistic regression suggests that the L4IA, FJOA, and PT may be risk factors for the occurrence of DLS, and the occurrence of ILS is correlated with the L4IA, FJOA, DD, PT, and LL. Compared with the control group, there are changes in pelvic parameters, the L4IA, LL, DD, FJOA, and PVM in DLS and ILS patients, and the degree is different. The parameters within the same group are related to each other, and DLS and ILS have different risk factors. The mechanical stability of the spine is affected by the parameter and angle changes, which may be of great significance for explaining the cause of spondylolisthesis, evaluating the health of the lumbar spine, and guiding the lifestyles of patients.

Reliability of segmental instability and spinopelvic alignment in athletes with isthmic spondylolisthesis in functional MRI

Problem Statement: In athletes with spondylolisthesis, segmental instability and impaired spinopelvic alignment are considered as clinically relevant. Functional MRI in supine and upright position enables a load-dependent acquisition, but neither the reposition effect nor the difference in the extent of inter-position-related differences has been investigated for their reliability. This study evaluates the intra- and inter-positional test-retest reliability of segmental instability and spinopelvic alignment in athletes with low-grade isthmic lumbar spondylolisthesis using supine and upright MRI. Methods: 22 athletes with spondylolisthesis were analyzed in a test-retest design. Parameters quantifying segmental instability (anterior translation [mm], segmental hinging [°], disc height [mm]) and spinopelvic alignment (lordosis angle [°], Sacral slope [°]),) were assessed in supine (0°) and upright (82°) MRI position. Intra-positional changes and differences of inter-positional changes were analyzed using absolute and relative indicators of reliability (amongst other intraclass-correlation-coefficient (ICC 2.1) and standard error of measurements (SEM%)). Results: Intra-positional changes showed high correlations and low absolute changes in both positions (ICC: 0.91-0.98; SEM%: 1-7%). Differences of inter-positional changes presented poor-to-moderate correlations and higher absolute changes (ICC: 0.34-0.74; SEM%: 33-60%). Discussion: Intra-positional changes can be determined reliably among all assessed outcomes. Inter-position-related changes of segmental instability indicate a reduced reproducibility in the current population. Conclusion: Functional MRI can be considered a valuable diagnostic tool for evaluating segmental instability and spinopelvic alignment in spondylolisthesis patients.

Radiographic Analysis of Pedicle Screw Retractor-Assisted Transforaminal Lumbar Interbody Fusion for Single-Segment Spondylolisthesis in Adults: A Retrospective Study and Technical Note.

ObjectivesThe objective of this study was to introduce a retractor that can be temporarily installed on unilateral pedicle screws to achieve distraction‐reduction and nerve root protection, and to analyze the efficacy and safety of retractor‐assisted transforaminal lumbar interbody fusion (TLIF) in the treatment of lumbar spondylolisthesis.MethodsThis was a retrospective study of 125 patients who underwent retractor‐assisted TLIF for single‐segment spondylolisthesis from November 2017 to February 2021. Based on morphology, patients were divided into degenerative (N = 66) and isthmic groups (N = 59). Differences in demographics and preoperative characteristics between the groups were analyzed using the independent samples t‐test and χ 2 test. Changes in radiographic parameters (disc height, foramen height, spondylolisthesis degree, slippage length, and segmental lordosis) before and after surgery were compared using the paired samples t‐test. Logistic regression analysis was performed to analyze the relationship between facet joint angle (FJA) and degenerative lumbar spondylolisthesis (DLS).ResultsUnilateral screw retractor‐assisted TLIF significantly corrected spondylolisthesis and improved disc height and segmental lordosis (p < 0.05). There was no significant difference in foramen height between the two sides before and after operation (pre: 15.81 ± 3.58 mm vs 15.69 ± 3.68 mm, p = 0.599; post: 18.65 ± 2.31 mm vs 18.74 ± 2.26 mm, p = 0.516). The degree of spondylolisthesis in the DLS group before surgery was significantly lower than that in the isthmic spondylolisthesis group (17.70 ± 5.62% vs 25.18 ± 9.73%, p < 0.001), whereas a similar degree of correction could be achieved after surgery (5.91 ± 3.12% vs 7.16 ± 5.69%, p = 0.135). FJAs from L3/4 to L5/S1 were significantly smaller in patients with DLS than those in with isthmic spondylolisthesis (p < 0.05). Patients with facet sagittalization were more likely to have DLS (β: −0.101, odds ratio [OR]:0.904, 95% confidence interval [CI]: 0.874–0.934, p < 0.001), while the cut‐off FJA of L4/5 for predicting L4 spondylolisthesis was 53.19.ConclusionsPedicle screw retractor‐assisted TLIF is effective and safe in treating both degenerative and isthmic lumbar spondylolisthesis. The unilateral retractor has the capacity to maintain the disc height achieved by paddle distractors, which optimizes the nerve protection and distractor placement. Patients with an FJA on L4/5 <53.19 were more likely to have DLS.

Multivariate analysis of pedicle screw invasion of the proximal facet joint after lumbar surgery

BackgroundTo analyze the risk factors for pedicle screw invasion of the proximal facet joint after lumbar surgery.MethodsFrom January 2019 to January 2021, 1794 patients with lumbar degenerative disease, such as lumbar disc herniation, lumbar spinal stenosis and lumbar spondylolisthesis, were treated at our hospital. In all, 1221 cases were included. General data (sex, age, BMI), bone mineral density, proximal facet joint angle, degenerative lumbar spondylolisthesis, isthmic lumbar spondylolisthesis and fixed segment in the two groups were recorded. After the operation, vertebral CT of the corresponding surgical segments was performed for three-dimensional reconstruction and evaluation of whether the vertebral arch root screw interfered with the proximal facet joint. The included cases were divided into an invasion group and a noninvasion group. Univariate analysis was used to screen the risk factors for pedicle screw invasion of the proximal facet joint after lumbar surgery, and the selected risk factors were included in the logistic model for multivariate analysis.ResultsThe single-factor analysis showed a significant difference in age, BMI, proximal facet joint angle, degenerative lumbar spondylolisthesis, and fixed segment (P < 0.1). Multifactor analysis of the logistic model showed a significant difference for age ≥ 50 years (P < 0.001, OR = 2.291), BMI > 28 kg/m2 (P < 0.001, OR = 2.548), degenerative lumbar spondylolisthesis (P < 0.001, OR = 2.187), gorge cleft lumbar relaxation (P < 0.001, OR = 2.410), proximal facet joint angle (35 ~ 45°: P < 0.001, OR = 3.151; > 45°: P < 0.001, OR = 3.578), and fixed segment (lower lumbar spine: P < 0.001, OR = 2.912).ConclusionAge (≥ 50 years old), BMI (> 28 kg/m2), proximal facet joint angle (35 ~ 45°, > 45°), degenerative lumbar spondylolisthesis, isthmic lumbar spondylolisthesis and fixed segment (lower lumbar spine) are independent risk factors for pedicle screw invasion of the proximal facet joint after lumbar surgery. Compared with degenerative lumbar spondylolisthesis, facet joint intrusion is more likely in isthmic lumbar spondylolisthesis.

Comparison of degenerative lumbar spondylolisthesis and isthmic lumbar spondylolisthesis: effect of pedicle screw placement on proximal facet invasion in surgical treatment

BackgroundPedicle screw invasion of the proximal articular process will cause local articular process degeneration and acceleration, which is an important factor affecting adjacent segment degeneration. Although lumbar spondylolisthesis is a risk factor for screw invasion of the proximal joint, there is no clear conclusion regarding the two different types of spondylolisthesis. Therefore, the purpose of this study was to explore the influence of pedicle screw placement on proximal facet invasion in the treatment of degenerative spondylolisthesis and isthmic spondylolisthesis.MethodsIn total, 468 cases of lumbar spondylolisthesis treated by decompression and fusion in our hospital from January 2017 to January 2020 were included in this retrospective study. Among them, 238 cases were degenerative spondylolisthesis (group A), and 230 cases were isthmic spondylolisthesis (group B). Sex, age, body mass index, bone mineral density, preoperative visual analog scale (VAS) and Oswestry Disability Index (ODI) scores, postoperative VAS and ODI scores at 1 month and 3 months, and angle of the proximal facet joint at the last follow-up were recorded and compared between the two groups. The degree of pedicle screw invasion of the proximal facet joint was graded and compared by the SEO grading method.ResultsThere were no significant differences in sex, age, body mass index, bone mineral density, preoperative VAS and ODI scores, or proximal facet joint angle between the two groups (P > 0.05). There was no significant difference in VAS and ODI scores between the two groups at 1 month and 3 months after the operation (P > 0.05). The VAS score of group A at the last follow-up was 1 (1,2). The VAS score of group B at the last follow-up was 3 (1,3). The ODI score of group A at the last follow-up was 6(4,26). The ODI score of group B at the last follow-up was 15(8,36). The VAS and ODI scores of the two groups at the last follow-up were significantly different (P < 0.05). According to the SEO grading method, the invasion of the proximal articular process by pedicle screw placement in group A involved 320 cases in grade 0, 128 cases in grade I and 28 cases in grade II. In group B, there were 116 cases in grade 0, 248 cases in grade I and 96 cases in grade II, with a significant difference (P < 0.01).ConclusionIn summary, a certain number of cases involving screws invading the proximal facet joint occurred in the two different types of lumbar spondylolisthesis, but the number in the isthmic spondylolisthesis group was significantly higher than that in the degenerative spondylolisthesis group, which caused more trauma to the proximal facet joint and significantly affected the patient prognosis.

Transverse diameter of dural sac decreases during extension in lumbar isthmic spondylolisthesis: An analysis of changes on functional imaging of CT myelography

Transverse diameter of dural sac decreases during extension in lumbar isthmic spondylolisthesis: An analysis of changes on functional imaging of CT myelography

Possible predictive markers in surgical decision making in patients with degenerative or isthmic lumbar spondylolisthesis

Background: Although age, comorbidity, duration and severity of symptoms, slippage degree, and flexion-extension slipping stability during X-ray imaging are effective in making a surgical decision in patients with spondylolisthesis, these factors are rarely based on definitive evidence. The aim of this study was to determine the efficacy of clinical, radiological and biochemical findings in surgical decision making in these patients. Materials and Methods: Patients’ data including age, gender, degree and type (i.e. degenerative or isthmic) of the spondylolisthesis, urinary incontinence, neurogenic claudication were recorded. Radiological imaging studies (lumbar dynamic X-ray, computed tomography, magnetic resonance imaging), serum glucose, C-reactive protein and erythrocyte sedimentation rate values of the patients obtained during hospital admissions were evaluated. Results: Forty patients were followed conservatively and 12 patients were treated surgically. Degenerative spondylolisthesis was seen in 22 patients. Nine patients had neurogenic urinary incontinence and 19 patients had neurogenic claudication. When the patients were divided into two groups with and without surgical treatment, the presence of the pars defect, slipping distance in a neutral position and slipping distance in flexion position was significantly different between groups. A positive correlation was found between pars defect and surgical treatment. Likelihood ratio test results revealed that the presence of pars defect, neurogenic claudication and neurogenic urinary incontinence could be the best parameters in decision making the surgical treatment. Conclusion: The presence of pars defect, neurogenic claudication and urinary incontinence could be the best parameters that may help the surgeon to make the surgical treatment decision.

Circumferential fusion with open versus percutaneous posterior fusion for lumbar isthmic spondylolisthesis

Study designRetrospective cohort study. ObjectiveTo investigate the clinical and radiographic differences between patients who underwent anterior lumber interbody fusion (ALIF) with either open or percutaneous posterior fusion for lumbar isthmic spondylolisthesis. Summary of background dataCircumferential fusion for isthmic spondylolisthesis is commonly performed with superior clinical outcomes, fusion rates, and restoration of sagittal balance when compared to posterior fusion alone. The outcomes comparing traditional open versus percutaneous posterior fusion in this setting have not been fully evaluated. MethodsA retrospective review of patients who underwent ALIF with either traditional open or percutaneous posterior fusion for isthmic spondylolisthesis between 2014 and 2019 was conducted. Patient demographics, surgical characteristics, and radiographic and clinical outcomes were compared between groups. ResultsA total of 79 patients were included in the final analysis, with 49 in the Open group and 30 in the Percutaneous group. No differences were found with regard to demographic factors between groups including sex, body mass index (BMI), diabetic status, and smoking status. The percutaneous group had less estimated blood loss (EBL, 69.2 mL) and shorter length of stay (3.06 days) compared to the open group (446 mL, p = 0.017; 3.98 days, p = 0.003). Both groups demonstrated significant improvement in all clinical outcome measures after surgery (PCS-12, MCS-12, ODI, VAS Back, and VAS Leg scores). The percutaneous group achieved greater ∆VAS Back (Open = 3.55, Perc = 5.17; p = 0.045) and also had a significantly greater improvements in recovery ratio for VAS Back (Open: 0.43, Perc: 0.73; p = 0.037) and ODI (Open: 0.40, Perc = 0.67; p = 0.031). Regression analysis demonstrated percutaneous surgery to be significant predictor of superior improvement in VAS Back scores (β = 1.957, p = 0.027). ConclusionALIF with percutaneous posterior fusion affords greater improvement in back pain and disability when compared to ALIF with open posterior fusion for isthmic spondylolisthesis. Level of evidenceIII.

Can Foraminal Stenosis Due to Lumbar Isthmic Spondylolisthesis Cause Axonopathy in the Lower Extremity?

This study aimed to investigate, using electrodiagnosis, whether foraminal stenosis due to isthmic spondylolisthesis (IS) causes peripheral nerve axonopathy. We retrospectively reviewed the medical records of the Yeungnam University Hospital and included 46 patients (mean age = 60.8 ± 13.7 years; male:female = 24:22) with foraminal stenosis due to IS. We classified foraminal stenosis grading based on T2 and T1 sagittal spinal magnetic resonance imaging (MRI). Patients were divided into mild (n = 18) and severe foraminal stenosis (n = 28) groups. To evaluate axonopathy in the lower extremity, results of compound motor action potential (CMAP) of the extensor digitorum brevis muscle (EDB) and abductor hallucis brevis muscle (AHB), and sensory nerve action potential (SNAP) of the sural nerve were retrieved. No statistically significant difference was observed in the amplitude of CMAP of the EDB and AHB and SNAP of the sural nerve with the severity of foraminal stenosis. However, age showed a statistically significant relationship with the amplitude of NCS in the EDB, AHB, and sural nerves (p < 0.001). The severity of foraminal stenosis due to IS showed no relationship with axonopathy beyond age-related degeneration of the lower extremities. Therefore, if there is robust axonopathy in lower extremities, physicians should consider pathologies other than foraminal stenosis due to IS.

Transforaminal lumbar interbody fusion with reduction of slippage of vertebrae for isthmic lumbar spondylolisthesis: Unilateral versus bilateral interbody fusion

ObjectiveTo investigate the radiological and clinical efficacy of transforaminal lumbar bilateral interbody fusion (TLBIF) versus transforaminal lumbar unilateral interbody fusion (TLUIF) with reduction of slippage of the vertebra in isthmic lumbar spondylolisthesis (ILS). MethodsA comparative retrospective study was conducted between patients undergoing TLBIF (n = 46) and TLUIF (n = 40). Demographic data, intraoperative data, complications, and radiographic parameters, including total lumbar lordosis (LL), intervertebral disc height (IDH), and foraminal height (FH), and the final fusion rate were evaluated and compared between the two groups. Clinical outcomes were assessed by the Visual Analog Scale (VAS) for low back pain and leg pain, and the Oswestry Disability Index (ODI). ResultsSignificant improvement in terms of radiographic and clinical outcomes was achieved in both groups during the period from pre-operation to at least 24 months post-operation (all, P < 0.05). Original sentenceAnalysis of back and leg pain by VAS score and radiographic data including LL, IDH and FH showed superior improvement in TLBIF group compared with TLUIF group. However, ODI was similar between the two groups. RevisedAnalysis of radiographic data, including LL, IDH, and FH, showed superior improvement in the TLBIF group compared with the TLUIF group (all, P < 0.05). However, either back and leg pain by the VAS score or ODI was similar between the two groups (all, P > 0.05).The fusion rate was 100 % in the TLBIF group versus 95 % in the TLUIF group during the 24-month follow-up period. The operation time was longer and the complication rate was lower in the TLBIF group than in the TLUIF group (all, P < 0.05), while intraoperative blood loss was similar between the two groups (P > 0.05). ConclusionsTLBIF with reduction did not cause significant procedure-associated complications in ILS patients. The therapeutic outcome of TLBIF was satisfactory and similar to that of TLUIF for ILS. Original sentenceCompared with TLUIF, TLBIF appears to be associated with better radiological data, less postoperative back and leg discomfort, and quicker postoperative recovery. RevisedCompared with TLUIF, TLBIF appears to be associated with better radiological data, bone fusion rate, and similar patient-reported outcomes (PROs), including the ODI and VAS pain score for the back and leg.

Long-term (>\u200910\xa0years) clinical outcomes of instrumented posterolateral fusion for spondylolisthesis

PurposeDespite the rapid increase in instrumented spinal fusions for a variety of indications, most studies focus on short-term fusion rates. Long-term clinical outcomes are still scarce and inconclusive. This study investigated clinical outcomes > 10 years after single-level instrumented posterolateral spinal fusion for lumbar degenerative or isthmic spondylolisthesis with neurological symptoms.MethodsCross-sectional long-term follow-up among the Dutch participants of an international multicenter randomized controlled trial comparing osteogenic protein-1 with autograft. Clinical outcomes were assessed using the Oswestry Disability Index (ODI), EQ-5D-3L and visual analogue scale (VAS) for leg and back pain, as well as questions on satisfaction with treatment and additional surgery.ResultsThe follow-up rate was 73% (41 patients). At mean 11.8 (range 10.1–13.7) years after surgery, a non-significant deterioration of clinical outcomes compared to 1-year follow-up was observed. The mean ODI was 20 ± 19, mean EQ-5D-3L index score 0.784 ± 0.251 and mean VAS for leg and back pain, respectively, 34 ± 33 and 31 ± 28. Multiple regression showed that diagnosis (degenerative vs. isthmic spondylolisthesis), graft type (OP-1 vs. autograft) and 1-year fusion status (fusion vs. no fusion) were not predictive for the ODI at long-term follow-up (p = 0.389). Satisfaction with treatment was excellent and over 70% of the patients reported lasting improvement in back and/or leg pain. No revision surgeries for non-union were reported.ConclusionThis study showed favourable clinical outcomes > 10 years after instrumented posterolateral spinal fusion and supports spondylolisthesis with neurological symptoms as indication for fusion surgery.

Transverse Pedicle Angle Is Associated With Pelvic Incidence and Increased in Lumbar Isthmic Spondylolisthesis.

Study Design:Retrospective radiographic review.Objectives:Investigate and quantify transverse pedicle angle (TPA), the medial-to-lateral pedicle angulation, and its potential association with pelvic incidence (PI) in patients with isthmic lumbar spondylolisthesis (ISLS) and compare to those with degenerative lumbar spondylolisthesis (DSLS) and controls.Methods:A total of 200 patients (64 ISLS, 70 DSLS, 66 control) were included. TPA was calculated at the L3-5 vertebral levels using axial computed tomography slices. PI was measured on lateral radiographs. Two independent observers completed the measurements. As a sensitivity analysis, TPA was also measured at the most cranial and caudal aspects of the L3-5 vertebral levels of a subset of participants (29 ISLS, 31 DSLS, 35 control) and the cranial to caudal change (ΔTPA) was calculated.Results:TPA values (mean ± SD) at L4 and L5 for ISLS (L4: 17.3° ± 3.7°, L5: 26.0° ± 5.2°) were significantly higher than those for the DSLS (L4: 14.3° ± 3.8°, L5: 22.2° ± 5.0°) and control (L4: 14.5° ± 3.9°, L5: 20.7° ± 3.8°) groups. TPA in the DSLS group was significantly higher than controls at L5, but not L4. High PI predicted wider TPA at L5 in both DSLS and ISLS. ΔTPA (mean ± SD) increased sequentially proceeding through the L3-5 spinal levels for the ISLS (L3: 6.8° ± 4.4°, L4: 8.7° ± 5.2°, L5: 15.6° ± 9.0°), DSLS (L3: 8.2° ± 6.0°, L4: 8.3° ± 5.9°, L5: 18.3° ± 7.2°), and control (L3: 6.8° ± 4.4°, L4: 8.2° ± 4.7°, L5: 17.7° ± 7.0°) groups.Conclusions:TPA was significantly increased in ISLS compared with DSLS and controls. High PI significantly predicted high TPA at the L5 vertebral level in ISLS and DSLS. ΔTPA increased sequentially proceeding through the lumbar spine across groups.

61. ALIF vs TLIF for isthmic spondylolisthesis: differences in radiographic outcomes

BACKGROUND CONTEXT Patients with a diagnosis of isthmic spondylolisthesis have higher sacral slope, pelvic tilt, pelvic incidence and lumbar lordosis compared to patients without isthmic spondylolisthesis. Several fusion techniques have been used to treat isthmic spondylolisthesis in adults, including anterior lumbar interbody fusion (ALIF) and transforaminal interbody fusion (TLIF). Compared to other fusion techniques, ALIF has shown better sagittal alignment outcomes, particularly restoration of segmental lordosis. PURPOSE The purpose of this study was to evaluate which fusion technique provides the better radiological outcome for adult lumbar isthmic spondylolisthesis. STUDY DESIGN/SETTING This study was a retrospective analysis of prospectively collected data from a single, high-volume academic medical center. PATIENT SAMPLE Patients who underwent lumbar fusion for isthmic spondylolisthesis from 2014 to 2019 were included in the analysis. Surgery was indicated after failure of conservative treatment to address radiculopathy and/or neurogenic claudication. Patients were excluded if they were under 18 years of age at the time of surgery, presented with a tumor or infection, or underwent revision surgery. OUTCOME MEASURES Preoperative and postoperative radiographic parameters were collected including sacral slope, pelvic tilt, pelvic incidence, lumbar lordosis, segmental lumbar lordosis, and the vertebral slip percentage. METHODS Patient and surgical characteristics including age, gender, smoking status, body mass index (BMI), Charlson Comorbidity Index (CCI), number of levels decompressed and number of levels fused were collected. Preoperative and final radiographic outcomes were obtained from an institutional electronic medical record. For analysis, patients were divided into two groups based on surgical technique: combined anterior fusion with posterior stabilization (ALIF-PLDF) or anterior and posterior fusion through a posterior approach (TLIF). RESULTS A total of 101 patients were included in final analysis, with 52 patients in the ALIF-PLDF group and 49 patients in the TLIF group. Mean age was greater in the TLIF group (p=0.017). Patients in the TLIF group were more likely to have a history of smoking (p=0.008), to have a greater CCI score (p=0.003), and to have higher number of levels decompressed. On analysis of radiographic parameters, preoperative sacral slope was higher in in the ALIF-PLDF group than the TLIF group (p=0.071). Postoperative overall lumbar lordosis was lower in the TLIF group (p=0.036). Postoperative segmental lumbar lordosis and the delta value for segmental lumbar lordosis were both lower in the TLIF group (p=0.030 and p=0.001). The TLIF group had a significant increase in PI-LL mismatch (p=0.032). Both groups had significant decrease in vertebral slip percent (p CONCLUSIONS Our data highlights that patients undergoing ALIF have a significant increase in segmental lordosis from their preoperative baseline. Interestingly, patients undergoing TLIF have significantly less postoperative change in segmental lumbar lordosis when compared to ALIF. When treating patients with isthmic spondylolisthesis, the ALIF approach has benefits not only in its capacity to restore segmental lordosis, but also by providing significant reduction in vertebral body slip. Our results suggest that, when compared to the TLIF approach, ALIF may be associated with better outcomes in terms of critical radiographic parameters. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Fusion Surgery for Lumbar Spinal Stenosis: WFNS Spine Committee Recommendations

Lumbar spine stenosis represents a complex degenerative pathology that has been a subject of significant dispute when it comes to fusion. A review of the literature from 2008 to 2019 was performed on the role of fusion in the treatment of lumbar spinal stenosis using PubMed, Ovid Medline, Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews. Using the key words “lumbar spinal stenosis,” “lumbar fusion,” “lumbar decompression,” and “lumbar pedicle screw fixation,” the search revealed 490 papers. Of these, only Level 1 or Level 2 evidence papers were selected, leading to only 3 randomized controlled trials (RCTs) that were analyzed. None of the good-quality studies (RCTs) performed so far have proven any clinical benefit of adding fusion to degenerative lumbar spine decompression. The effect of spinal instability on the outcome following decompression remains controversial. At present, no unanimous criteria exist among the RCTs to identify what constitutes true instability. Fusion for instability or stenosis alone remains controversial, and the results are unconvincing. At this point, the issue expands to not only lumbar degenerative diseases but spinal fractures and lumbar isthmic spondylolisthesis. We thereby present the consensus of the World Federation of Neurosurgical Societies Spine Committee, which formulated the indications for lumbar spine fusion in degenerative lumbar stenosis.