Meyerding Grade Research Articles

Surgical Innovation: Comparative Efficacy of Navigation-Assisted Modified Minimally Invasive Transforaminal Lumbar Interbody Fusion (MIS-TLIF) and Traditional MIS-TLIF in Treating Low-Grade Isthmic Spondylolisthesis in the Elderly

To compare the efficacy of navigation-assisted modified MIS-TLIF (Minimally invasive transforaminal lumbar interbody fusion) and MIS-TILF in the treatment of low-grade isthmic spondylolisthesis in the elderly. We retrospectively included elderly patients with low-grade isthmic spondylolisthesis who underwent surgical treatment at our hospital from January 2019 to January 2022. Based on the surgical method chosen according to the patient's personal preference, the patients were divided into the modified MIS-TLIF group and the MIS-TLIF group. The modified MIS-TLIF group underwent navigation-assisted MIS-TLIF, while the MIS-TLIF group underwent conventional MIS-TLIF. A total of 54 patients (34 males and 20 females) were included in this study, with 26 cases in the modified MIS-TLIF group and 28 cases in the MIS-TLIF group. Relevant data for this study were collected by an independent observer. The demographic characteristics, including age, gender, BMI, comorbidities, surgical level, Meyerding grade, and duration of symptoms before admission, were recorded and compared between the two groups. Perioperative parameters, such as operative time, intraoperative blood loss, postoperative drainage volume, bed rest time, and hospital stay, were also recorded and compared. The lumbar pain visual analog scale (BP-VAS), Oswestry Disability Index (ODI), and lumbar JOA scores were recorded preoperatively and at 1 week, 1 month, 3 months, 6 months, and 12 months postoperatively to evaluate functional recovery in both groups. At 12 months postoperatively, patient satisfaction was assessed using the Macnab criteria (with satisfaction defined as the number of excellent and good outcomes divided by the total number in the group × 100%). The rate of vertebral slippage was recorded preoperatively, at 1 week postoperatively, and at 12 months postoperatively. The accuracy of screw placement was evaluated by CT scan at 1 week postoperatively, and interbody fusion was assessed by CT scan at 12 months postoperatively. Surgical complications were recorded, and their incidence was calculated. The intraoperative blood loss, postoperative drainage volume, bed rest time and hospital stay in the modified MIS-TLIF group were less than those in the MIS-TLIF group (P< 0.05). The BP-VAS (Back Pain Visual Analogue Scale), ODI (Oswestry Disability Index), and JOA (Japanese Orthopaedic Association) modified MIS-TLIF groups improved significantly compared with the MIS-TLIF group at 1 week, 1 month, 3 months, and 6 months after surgery, and the differences between groups were statistically significant (P<0.05). The excellent and good rate of modified MIS-TLIF group was higher than that of MIS-TLIF group, and the difference had statistical significance (P<0.05). The accuracy of screw placement in the modified MIS-TLIF group was higher than that in the MIS-TLIF group, and the difference was statistically significant (P<0.05). The fusion rate in the modified MIS-TLIF group was higher than that in the MIS-TLIF group at 12 months after surgery, and the difference was statistically significant (P<0.05). No statistical difference in the incidence rate of complications between the two groups. Compared with MIS-TLIF, navigation-assisted modified MIS-TLIF has the advantages of less trauma, rapid recovery, accurate screw placement, high fusion rate, high surgical satisfaction and good safety.

Interpretable Machine Learning Models Based on SHapley Additive exPlanations for Predicting the Risk of Cerebrospinal Fluid Leakage in Lumbar Fusion Surgery.

Retrospective study. The objective of this investigation was to formulate and internally verify a customized machine learning (ML) framework for forecasting cerebrospinal fluid leakage (CSFL) in lumbar fusion surgery. This was accomplished by integrating imaging parameters and employing the SHapley Additive exPlanation (SHAP) technique to elucidate the interpretability of the model. Given the increasing incidence and surgical volume of spinal degeneration worldwide, accurate predictions of postoperative complications are urgently needed. SHAP-based interpretable ML models have not been used for CSFL risk factor analysis in lumbar fusion surgery. Clinical and imaging data were retrospectively collected from 3505 patients who underwent lumbar fusion surgery. Six distinct machine learning models were formulated: extreme gradient boosting (XGBoost), decision tree (DT), random forest (RF), support vector machine (SVM), Gaussian naive Bayes (GaussianNB), and K-nearest neighbors (KNN) models. Evaluation of model performance on the test dataset was performed using performance metrics, and the analysis was executed through the SHAP framework. CSFL was detected in 95 out of 3505 patients (2.71%). Notably, the XGBoost model exhibited outstanding accuracy in forecasting CSFLs, with high precision (0.9815), recall (0.6667), accuracy (0.8182), F1 score (0.7347), and AUC (0.7343). Additionally, through SHAP analysis, significant predictors of CSFL were identified, including ligamentum flavum thickness, zygapophysial joint degeneration grade, central spinal stenosis grade, decompression segment count, decompression mode, intervertebral height difference, Cobb angle, intervertebral height index difference, operation mode, lumbar segment lordosis angle difference, Meyerding grade of lumbar spondylolisthesis, and revision surgery. The combination of the XGBoost model with the SHAP is an effective tool for predicting the risk of CSFL during lumbar fusion surgery. Its implementation could aid clinicians in making informed decisions, potentially enhancing patient outcomes and lowering healthcare expenses. This study advocates for the adoption of this approach in clinical settings to enhance the evaluation of CSFL risk among patients undergoing lumbar fusion.

The relationship between paraspinal muscle atrophy and degenerative lumbar spondylolisthesis at the L4/5 level

BACKGROUND/CONTEXTDegenerative lumbar spondylolisthesis (DLS) is a prevalent spinal condition that can result in significant disability. DLS is thought to result from a combination of disc and facet joint degeneration, as well as various biological, biomechanical, and behavioral factors. One hypothesis is the progressive degeneration of segmental stabilizers, notably the paraspinal muscles, contributes to a vicious cycle of increasing slippage. PURPOSETo examine the correlation between paraspinal muscle status on MRI and severity of slippage in patients with symptomatic DLS. STUDY DESIGN/SETTINGRetrospective cross-sectional study at an academic tertiary care center. PATIENT SAMPLEPatients who underwent surgery for DLS at the L4/5 level between 2016–2018 were included. Those with multilevel DLS or insufficient imaging were excluded. OUTCOME MEASURESThe percentage of relative slippage (RS) at the L4/5 level evaluated on standing lateral radiographs. Muscle morphology measurements including functional cross-sectional area (fCSA), body height normalized functional cross-sectional area (HI) of Psoas, erector spinae (ES) and multifidus muscle (MF) and fatty infiltration (FI) of ES and MF were measured on axial MR. Disc degeneration and facet joint arthritis were classified according to Pfirrmann and Weishaupt, respectively. METHODSDescriptive and comparative statistics, univariable and multivariable linear regression models were utilized to examine the associations between RS and muscle parameters, adjusting for confounders sex, age, BMI, segmental degeneration, and back pain severity and symptom duration. RESULTSThe study analyzed 138 out of 183 patients screened for eligibility. The median age of all patients was 69.5 years (IQR 62 to 73), average BMI was 29.1 (SD±5.1) and average preoperative ODI was 46.4 (SD±16.3). Patients with Meyerding-Grade 2 (M2, N=25) exhibited higher Pfirrmann scores, lower MFfCSA and MFHI, and lower BMI, but significantly more fatty infiltration in the MF and ES muscles compared to those with Meyerding Grade 1 (M1). Univariable linear regression showed that each cm2 decrease in MFfCSA was associated with a 0.9%-point increase in RS (95% CI -1.4 to - 0.4, p<.001), and each cm2/m2 decrease in MFHI was associated with an increase in slippage by 2.2%-points (95% CI -3.7 to -0.7, p=.004). Each 1%-point rise in ESFI and MFFI corresponded to 0.17%- (95% CI 0.05–0.3, p=.01) and 0.20%-point (95% CI 0.1–0.3 p<.001) increases in relative slippage, respectively. Notably, after adjusting for confounders, each cm2 increase in PsoasfCSA and cm2/m2 in PsoasHI was associated with an increase in relative slippage by 0.3% (95% CI 0.1–0.6, p=.004) and 1.1%-points (95% CI 0.4–1.7, p=.001). While MFfCSA tended to be negatively associated with slippage, this did not reach statistical significance (p=.105). However, each 1%-point increase in MFFI and ESFI corresponded to increases of 0.15% points (95% CI 0.05–0.24, p=.002) and 0.14% points (95% CI 0.01–0.27, p=.03) in relative slippage, respectively. CONCLUSIONThis study found a significant association between paraspinal muscle status and severity of slippage in DLS. Whereas higher degeneration of the ES and MF correlate with a higher degree of slippage, the opposite was found for the psoas. These findings suggest that progressive muscular imbalance between posterior and anterior paraspinal muscles could contribute to the progression of slippage in DLS.

Long-term efficacy of microendoscopic laminotomy for lumbar spinal stenosis in advanced degenerative spondylolisthesis with or without dynamic spinal instability: a propensity score-matching analysis.

In this study, the authors aimed to determine the mid- to long-term outcomes of microendoscopic laminotomy (MEL) for lumbar spinal stenosis (LSS) with degenerative spondylolisthesis (DS) and identify preoperative predictors of poor mid- to long-term outcomes. The authors retrospectively reviewed the medical records of 274 patients who underwent spinal MEL for symptomatic LSS. The minimum postoperative follow-up duration was 5 years. Patients were classified into two groups according to DS: those with DS (the DS+ group) and those without DS (the DS- group). The patients were subjected to propensity score matching based on sex, age, BMI, surgical segments, and preoperative leg pain visual analog scale scores. Clinical outcomes were evaluated 1 year and > 5 years after surgery. Surgical outcomes of MEL for LSS were not significantly different between the DS+ and DS- groups at the final follow-up (mean 7.8 years) in terms of Oswestry Disability Index (p = 0.498), satisfaction (p = 0.913), and reoperation rate (p = 0.154). In the multivariate analysis, female sex (standard β -0.260), patients with slip angle > 5° in the forward bending position (standard β -0.313), and those with dynamic progression of Meyerding grade (standard β -0.325) were at a high risk of poor long-term outcomes. MEL may have good long-term results in patients with DS without dynamic instability. Women with dynamic instability may require additional fusion surgery in approximately 25% of cases for a period of ≥ 5 years.

Long-term CT follow-up of patients with lumbar spondylolysis reveals low rate of spontaneous bone fusion

ObjectivesKnowledge about the long-term outcome of patients with lumbar spondylolysis (LS) is limited. This study assessed the frequency of bone fusion in conservatively treated lumbar spondylolysis with photon counting detector computed tomography.MethodsPatients with lumbar spondylolysis diagnosed with CT or MRI were prospectively enrolled and underwent CT 5–10 years after initial imaging. Image assessment included evaluation of Meyerding grade, listhesis size, measurement of the lysis gap, and disc integrity on the lysis level. Comparisons were made between bone fusion as the primary endpoint and sex, body mass index, age at diagnosis, follow-up interval, size of listhesis, Meyerding grade, size of the lysis gap, sports activity, and presence of pain.ResultsA total of 39 patients (26.0 ± 3.1 years, 15 female) with lumbar spondylolysis on 41 levels were included after a mean follow-up period of 9.1 ± 2.2 years. Nine patients (22.0%, four female) showed complete fusion of the lysis gap. Patients with bone fusion of the lysis gap had a significantly lower Meyerding grade (p = 0.01), smaller size of the listhesis (p = 0.019), and smaller anterior and posterior lysis gap size (p = 0.046 and p = 0.011, respectively). Unilateral lyses showed significantly higher fusion rates than bilateral lyses (40.0% vs. 16.1%, p = 0.01). No statistically significant difference was found for pain at follow-up between patients with and without bone fusion (p = 0.253).ConclusionBone fusion occurred in about a fifth of conservatively treated lumbar spondylolysis after a follow-up period of 9 years. Factors associated with a successful fusion were a lower Meyerding grade, minimal listhesis, and a small lysis gap.

Philosophies and Surgical Techniques for High-Grade Spondylolisthesis Treatment with Literature Review.

High-grade spondylolisthesis is defined as cases with more than 50% displacement and spondylolisthesis with Meyerding grade III and higher. The surgical management of high-grade spondylolisthesis is highly controversial. Many surgical methods have been reported such as posterior in situ fusion, instrumented posterior fusion with or without reduction, combined anterior and posterior procedures, spondylectomy with reduction of L4 to the sacrum (for spondyloptosis), and posterior interbody fusion with trans-sacral fixation. The literature has recently mentioned minimally invasive transforaminal lumbar interbody fusion for high-grade spondylolisthesis. This study aimed to review the recent literature that describes the surgical outcomes associated with various surgical techniques used for high-grade spondylolisthesis. Recent articles were searched on search engines such as PubMed and Google Scholar using keywords such as "high-grade spondylolisthesis," "surgical techniques," and "complications." The surgical management of high-grade spondylolisthesis is an area of significant controversy. The literature is replete with regards to the need for reduction, decompression, levels of fusion, the nature of instrumentation, surgical approaches including open, minimally invasive, and "mini-open" procedures, and various techniques for reducing the slip and fusion strategy. The three basic options of high-grade spondylolisthesis include in-situ fusion, partial reduction and fusion, and complete reduction. Various techniques have been described for high-grade spondylolisthesis. Spine deformity study group classification gives guidelines about balanced and unbalanced pelvis and advises reduction and fusion in case of unbalanced pelvis for correction of biomechanical and global sagittal alignment. Each of the surgical techniques has its advantages and disadvantages. However, individual authors' experience, skill levels, and anatomic reduction with fusion techniques have yielded encouraging results.

Pelvic incidence effects pars interarticularis defect and spondylolisthesis

Aims: Pars interarticularis defect (PID) is a common problem in society and may be accompanied with low back pain and radiculopathy. Magnetic resonance imaging (MRI) can detect it with high sensitivity. If left untreated, it may progress to spondylolisthesis. In this study, we wanted to emphasize the importance of the pelvic incidence (PI) angle in terms of following the development of spondylolisthesis after PID by examining the relationship between PID and spondylolisthesis and PI.&#x0D; Methods: 118 patients who applied to Şanlıurfa Training and Research Hospital between 2021-2022 and underwent lumbar MRI were included in the study. The criteria for inclusion of patients in the study were the detection of a pars interarticularis defect on MRI, the ability to be evaluated by direct radiography or CT, and the ability to monitor the femoral head and sacrum in a way that PI could be measured. PI angle measurement was performed, confirmed by CT. The relationship between PID, spondylolisthesis and PI was examined.&#x0D; Results: Of the 118 patients participating in the study, 77 (65.3%) were women and 41 (34.7%) were men. Pars defect was most commonly seen at the L5 level (67.8%). The average pelvic incidence angle is 64.2±8.6. Half of the patients were calculated as Meyerding grade 0 and 95.8% were treated medically. The median pelvic incidence angle value of patients without spondylolisthesis was found to be 58.0, the median pelvic incidence angle value of patients with a Meyerding grading of one was found to be 68.0, and the median value of the pelvic incidence angle of patients with a Meyerding grading of one was found to be 78.0 (p

Management for Patient with Asthma in Lumbal Canal Stenosis Using General Anesthetic and Epidural Analgetic: A Case Report

Background: Lumbar canal stenosis, which often occurs concurrently with degenerative spondylolisthesis (DS), is characterized by low back and leg pain. The treatment of high-degree spondylolisthesis is by surgery, which is a combination procedure of decompression and fusion. Surgical patients with a history of uncontrolled asthma three months before surgery had nearly double the risk of postoperative mortality. Case presentation: A 53-year-old male patient was diagnosed with Lumbal Canal Stenosis ec HNP at levels L2-l3, L3-l4, L4-l5, L5-s1 Spondylolisthesis at level L4-l5 Meyerding grade 1 Spondylosis Lumbalis. The patient has a history of mild intermittent bronchial asthma, which was diagnosed 2 years ago. The patient was planned for Decompression-Stabilization-Fusion surgery, with the anesthesia plan being general anesthesia prone position with epidural analgesia. Conclusion: Combined general anesthesia (GA) and epidural analgesia (EA) for major surgery due to excellent pain control, reduced perioperative morbidity, and even reduced mortality compared with systemic analgesia. For surgical patients who have a history of asthma, determining whether a patient's asthma is well-controlled or poorly controlled is key to mitigating perioperative complications.

Clinical and Radiological Outcomes after Reducing Adult Lytic High-Grade Spondylolisthesis Using a Hybrid Technique: Combination of Percutaneous Pedicle Screws with Midline Microscopic Transforaminal Decompression.

Retrospective study. To analyze the results and effectiveness of percutaneous screws (PS) with midline microscopic transforaminal decompression (MTFD) technique in reducing adult stiff lytic high-grade spondylolisthesis (HGSL) and compare it with the conventional technique. Pedicle screw cannulation and segmental kyphosis negotiation are surgical challenges in HGSL. Open reduction is the preferred approach. PS have the advantage of optimized trajectory and minimized soft tissue exposure. The role of minimally invasive surgery in HGSL remains unknown. We propose a hybrid technique combining PS with MTFD for lytic HGSL. This study included 25 patients with adult lytic HGSL (Meyerding grade III and IV) operated using a hybrid technique from 2012 to 2015. Data were compared with retrospective data on conventional open reduction (n=23) operated from 2000 to 2015. The minimum follow-up was 5 years. Clinical outcomes were assessed using the Visual Analog Scale (VAS) score and modified Oswestry Disability Index (m-ODI). The spinopelvic and perioperative parameters were recorded. The inter-body fusion and adjacent segment degeneration (ASD) were assessed on radiographs at the final follow-up. The average age in the MTFD and open groups was 45.84±12.70 years (nine males and 16 females) and 49.26±13.33 years (eight males and 15 females), respectively. Further, 22 and three patients in the MTFD group and 19 and four in the open group had grade III and IV listhesis, respectively. The MTFD group demonstrated less operative time, blood loss, and hospital stays than the open group. Significant improvements were observed in VAS and m-ODI in subsequent follow-ups in both groups. The MTFD group fared better at 3 months but outcomes were comparable at the final follow-up. Both techniques were equally effective in restoring spinopelvic parameters. The incidence of ASD is comparable. The technique was proven effective in reducing HGSL. The long-term clinical and radiological outcomes were favorable and comparable with the conventional approach.

Does medial branch radiofrequency neurotomy accelerate degenerative lumbar spondylolisthesis compared to natural progression? A cross-sectional cohort study

BackgroundLumbar radiofrequency neurotomy (LRFN) effectively treats lumbar zygapophyseal joint pain by coagulating medial branch nerves (MBNs) carrying nociceptive signals. MBNs also innervate deep paraspinal muscles. There is a paucity of literature on whether LRFN accelerates the progression of vertebral displacement in patients with degenerative lumbar spondylolisthesis (DLS). ObjectiveCompare the rate of spondylolisthesis progression in adults with DLS who underwent LRFN to the 2% annual rate of progression expected by natural history. DesignCross-sectional cohort study. MethodsConsecutive patients with pre-existing DLS who underwent LRFN for zygapophyseal joint-mediated low back pain were identified. Patient demographics, LRFN procedure details, and radiographic images confirming Meyerding Grade (I-II) spondylolisthesis were collected from electronic medical records. The quantitative magnitude of spondylolisthesis progression and the annualized rate were calculated from pre-and post-LRFN radiographs. Data were analyzed using Wilcoxon signed-rank tests and a linear regression model. Results152 patients (mean age 65.9 ± 12.3 years; 59.2% female) met eligibility criteria and were included in the analyses. Average time to radiographic follow-up was 35.6 ± 24.7 months post-LRFN. The average spondylolisthesis progression rate of 1.63 ± 2.91% per year calculated for the LRFN cohort was significantly lower than the 2% annual rate of progression associated with natural history (p < 0.001). None of the included covariates, such as age, BMI, LRFN laterality, number of levels denervated, or history of prior lumbar spinal surgery, were significantly associated with the average annual rate of progression. ConclusionsOur results suggest that spondylolisthesis progression rate is no different or worse than the expected natural progression rate in patients with pre-existing DLS who have undergone LRFN.

Does indirect decompression by oblique lateral interbody fusion produce similar clinical and radiological outcomes to direct decompression by open transforaminal lumbar interbody fusion.

Open transforaminal lumbar interbody fusion (O-TLIF) remains the most popular and widely practiced lumbar fusion method even today, providing direct decompression. Oblique lateral interbody fusion (OLIF) is a novel retroperitoneal approach that allows placement of a large interbody cage which provides an indirect neural decompression, and screws can be placed minimal invasively or through the Wiltse OLIF (W-OLIF) approach. We aim to find out the short-term efficacy of W-OLIF to O-TLIF in terms of radiological and clinical outcomes in patients of lumbar degenerative diseases. Fifty-two patients were divided equally into two groups (group O-TLIF and group W-OLIF). Several parameters were measured, such as the spinal cord cross-sectional area (SC-CSA), foraminal cross-sectional area (F-CSA), disc height (DH), foraminal height (FH), Schizas grade for stenosis, and Meyerding's grading for olisthesis. Functional scores were measured using the visual analog scale (VAS) for low back pain (LBP) and lower limbs, Oswestry Disability Index. All parameters were repeat measured at 3 months follow-up. Statistical analysis was done using SPSS software. Both groups were similar in composition preoperatively. There was significant improvement in all clinical and radiological parameters post-surgery in either group. However, at 3 months, The DH, FH, FSA, and VAS (LBP) were better in the W-OLIF group than in O-TLIF. Procedure-related complications were seen in both groups (15% in the O-TLIF group and 19% in the W-TLIF group), but only one patient in O-TLIF required revision due to cage migration. Similar improvement occurs in most of the clinical and radiological parameters in the W-OLIF group compared to the O-TLIF group. Few radiological parameters such as the DH, FH, and F-CSA and the VAS (LBP) correction are superior in the W-OLIF group in the short-term follow-up. We conclude that indirect decompression by W-OLIF provides equivalent, if not better, results than the traditional O-TLIF lumbar fusion.

Degenerative L4-L5 spondylolisthesis and stenosis surgery: does over-level flavectomy technique influence clinical outcomes and rates of cranial adjacent segment disease?

One of the most dreaded long-term complications related to L4-L5 lumbar arthrodesis is the onset of adjacent segment disease, which most frequently occurs at the cranial level. Few studies have compared the rates of cranial adjacent segment disease (CASD) in patients undergoing lumbar fusion associated with total laminectomy at the same level with those undergoing partial laminectomy. No study has examined the role of selective over-level flavectomy (OLF; i.e., L3-L4). A total of 299 patients undergoing posterolateral arthrodesis (PLA) for L4-L5 degenerative spondylolisthesis were retrospectively analyzed with a 5-year follow-up. 148 patients underwent PLA + L4-L5 flavectomy + L4 partial laminectomy (control group), while 151 underwent PLA + L4-L5 flavectomy + total L4 laminectomy + L3-L4 flavectomy (OLF group). Rates of reoperations due to CASD were examined utilizing Cox proportional hazard models, while clinical improvement at follow-up (measured in ODI) was analyzed using generalized linear models (GLMs). Adjustments for potential confounders were made (grade of lumbar lordosis, age, sex, BMI, intervertebral disc degeneration, and presurgical cranial spinal stenosis). At 5 years from the operation, 16 patients (10.8%) in the control group had undergone revision surgery for CASD compared to 5 patients (3.3%) in the OLF group (p = 0.013). Survival analysis and GLM demonstrated that the OLF group had a significantly lower incidence of CASD and presented more favorable clinical outcome. There were no differences in the rate of discal degeneration or the onset of Meyerding's grade I degenerative spondylolisthesis at the adjacent segment. BMI was the only other significant predictor of ODI improvement and of the incidence of CASD. In patients with L4-L5 degenerative spondylolisthesis and stenosis, the OLF technique may lower rates of CASD and improve clinical outcomes by preventing cranial spinal stenosis without increasing iatrogenic instability or accelerating intervertebral disc degenerative changes.

Preoperative factors affecting the two-year postoperative patient-reported outcome in single-level lumbar grade I degenerative spondylolisthesis

BackgroundThe choice of operative method for lumbar spinal stenosis with Meyerding grade I degenerative spondylolisthesis remains controversial. The purpose of this study was to identify the preoperative factors affecting the 2-year postoperative patient-reported outcome in Meyerding grade I degenerative spondylolisthesis. MethodsSeventy-two consecutive patients who had minimally invasive decompression alone (D group; 28) or with fusion (DF group; 44) were enrolled. The parameters investigated were the Japanese Orthopaedic Association back pain evaluation questionnaire as patient-reported assessment, and L4 slippage (L4S), lumbar lordosis (LL), and lumbar axis sacral distance (LASD) as an index of sagittal alignment for radiological evaluation. Data collected prospectively at 2 years postoperatively were examined by statistical analysis. ResultsSixty-two cases (D group; 25, DF group; 37) were finally evaluated. In multiple logistic regression analysis, preoperative L4S and LASD were extracted as significant preoperative factors affecting the 2-year postoperative outcome. Patients with preoperative L4S of 6 mm or more have a lower rate of improvement in lumbar spine dysfunction due to low back pain (risk ratio=0.188, p=.043). Patients with a preoperative LASD of 30 mm or more have a higher rate of improvement in lumbar dysfunction due to low back pain (risk ratio=11.48, p=.021). The results of multiple logistic analysis by operative method showed that there was a higher rate of improvement in lumbar spine dysfunction due to low back pain in patients with preoperative LASD of 30 mm or more in DF group (risk ratio=172.028, p=.01). ConclusionsPreoperative L4S and LASD were extracted as significant preoperative factors affecting patient-reported outcomes at 2 years postoperatively. Multiple logistic analyses by the operative method suggested that DF may be advantageous in improving lumbar dysfunction due to low back pain in patients with preoperative LASD of 30 mm or more.

Effectiveness analysis of posterolateral approach lumbar interbody fusion assisted by one-hole split endoscope for L4, 5 degenerative lumbar spondylolisthesis

To compare the effectiveness of posterolateral approach lumbar interbody fusion assisted by one-hole split endoscope (OSE) and traditional posterior lumbar interbody fusion (PLIF) in the treatment of L4, 5 degenerative lumbar spondylolisthesis (DLS). The clinical data of 58 patients with DLS who met the selection criteria admitted between February 2020 and March 2022 were retrospectively analyzed, of which 26 were treated with OSE-assisted posterolateral approach lumbar interbody fusion (OSE group) and 32 were treated with PLIF (PLIF group). There was no significant difference between the two groups in terms of gender, age, body mass index, Meyerding grade, lower limb symptom side, decompression side, stenosis type, and preoperative low back pain visual analogue scale (VAS) score, leg pain VAS score, Oswestry disability index (ODI), and the height of the anterior and posterior margins of the intervertebral space (P>0.05). The operation time, intraoperative blood loss, postoperative hospital stay, and complications were compared between the two groups. The low back pain and leg pain VAS scores and ODI before operation, at 1 month, 6 months after operation, and last follow-up, the height of anterior and posterior margins of the intervertebral space before operation, at 6 months after operation, and last follow-up, the modified MacNab criteria at last follow-up after operation were used to evaluate the effectiveness; and the Bridwell method at last follow-up was used to evaluate the interbody fusion. Both groups successfully completed the operation. Compared with the PLIF group, the OSE group showed a decrease in intraoperative blood loss and postoperative hospital stay, but an increase in operation time, with significant differences (P<0.05). In the OSE group, no complication such as nerve root injury and thecal sac tear occurred; in the PLIF group, there were 1 case of thecal sac tear and 1 case of epidural hematoma, which were cured after conservative management. Both groups of patients were followed up 13-20 months with an average of 15.5 months. There was no complication such as loosening, sinking, or displacement of the fusion cage. The low back pain and leg pain VAS scores, ODI, and the height of anterior and posterior margins of the intervertebral space at each time point after operation in both groups were significantly improved when compared with those before operation (P<0.05). Except for the VAS score of lower back pain in the OSE group being significantly better than that in the PLIF group at 1 month after operation (P<0.05), there was no significant difference in all indicators between the two groups at all other time points (P>0.05). At last follow-up, both groups achieved bone fusion, and there was no significant difference in Bridwell interbody fusion and modified MacNab standard evaluation between the two groups (P>0.05). OSE-assisted posterolateral approach lumbar interbody fusion for L4, 5 DLS, although the operation time is relatively long, but the postoperative hospitalization stay is short, the complications are few, the operation is safe and effective, and the early effectiveness is satisfactory.

Comparison of Lumbosacral Fusion Grade in Patients after Transforaminal and Anterior Lumbar Interbody Fusion with Minimum 2-Year Follow-Up.

Generally, anterior lumbar interbody fusion (ALIF) was believed superior to transforaminal lumbar interbody fusion (TLIF) in induction of fusion. However, many studies have reported comparable results in lumbosacral fusion rate between the two approaches. This study aimed to evaluate the realistic lumbosacral arthrodesis rates following ALIF and TLIF in patients with degenerative spondylolisthesis as measured by CT and radiology. Ninety-six patients who underwent single-level L5-S1 fusion through ALIF (n = 48) or TLIF (n = 48) for degenerative spondylolisthesis at the Spine Center, University of California San Francisco, between October 2014 and December 2017 were retrospectively evaluated. Fusion was independently evaluated and categorized as solid fusion, indeterminate fusion, or pseudarthroses by two radiologists using the modified Brantigan-Steffee-Fraser (mBSF) grade. Clinical data on sex, age, body mass index, Meyerding grade, smoking status, follow-up times, complications, and radiological parameters including disc height, disc angle, segmental lordosis, and overall lumbar lordosis were collected. The fusion results and clinical and radiographic data were statistically compared between the ALIF and TLIF groups by using t-test or chi-square test. The mean follow-up period was 37.5 (ranging from 24 to 51) months. Clear, solid radiographic fusions were higher in the ALIF group compared with the TLIF group at the last follow-up (75% vs 47.9%, p = 0.006). Indeterminate fusion occurred in 20.8% (10/48) of ALIF cases and in 43.8% (21/48) of TLIF cases (p = 0.028). Radiographic pseudarthrosis was not significantly different between the TLIF and ALIF groups (16.7% vs 8.3%; p = 0.677). In subgroup analysis of the patients without bone morphogenetic protein (BMP), the solid radiographic fusion rate was significantly higher in the ALIF group than that in the TLIF group (78.6% vs 45.5%; p = 0.037). There were no differences in sex, age, body mass index, Meyerding grade, smoking status, or follow-up time between the two groups (p > 0.05). The ALIF group had more improvement in disc height (7.8 mm vs 4.7 mm), disc angle (5.2° vs 1.5°), segmental lordosis (7.0° vs 2.5°), and overall lumbar lordosis (4.7° vs 0.7°) compared with the TLIF group (p < 0.05). Overall complication rates were similar between the TLIF and ALIF groups (10.4% vs 8.33%; p > 0.999). With a minimum 2-year radiographic analysis of arthrodesis at lumbosacral level by radiologists, the rate of solid radiographic fusions was higher in the ALIF group compared with the TLIF group, whereas the TLIF group had a higher rate of indeterminate fusion. Radiographic pseudarthrosis did not differ significantly between the TLIF and ALIF groups.

Full-endoscopic foraminotomy in low-grade degenerative and isthmic spondylolisthesis: a patient-specific tailored approach.

To describe the surgical technique and methodology to successfully plan and execute an endoscopic foraminotomy in patients with isthmic or degenerative spondylolisthesis, according to each patient's unique characteristics. Thirty patients with degenerative or isthmic spondylolisthesis (SL) with radicular symptoms were included from March 2019 to September 2022. Treating physician registered patients' baseline and imaging characteristics, as well as preoperative back pain VAS, leg pain VAS and ODI. Subsequently, authors treated the included patients with an endoscopic foraminotomy according to a "patient-specific" tailored approach. Nineteen patients (63.33%) had isthmic SL and 11 patients (36.67%) had degenerative SL. 75.86% of the cases had a Meyerding Grade 1 listhesis. One of the transforaminal foraminotomies with lateral recess decompression in degenerative SL had to be aborted because of intense osseous bleeding. Of the remaining 29 patients, one patient experienced recurrence of the sciatica pain that required subsequent reintervention and fusion. No other intraoperative or post-operative complications were observed. None of the patients developed post-operative dysesthesia. In 86.67% of the patients, the foraminotomy was implemented using a transforaminal approach. In the remaining 13.33% of the cases, an interlaminar contralateral approach was used. Lateral recess decompression was performed in half of the cases. Mean follow-up time was 12.69months, reaching a maximum of 40months in some patients. Outcome variables such as VAS for leg and back pain, as well as ODI, showed statistically significant reduction since the 3-month follow-up visit. In the presented case series, endoscopic foraminotomy achieved satisfactory outcomes without sacrificing segmental stability. The proposed patient-specific "tailored" approach allowed to successfully design and execute the surgical strategy to perform an endoscopic foraminotomy through transforaminal or interlaminar contralateral approaches.

Efficacy of less Invasive modified O-arm navigated delta fixation in osteoporotic high-grade spondylolisthesis: "a LIMO delta technique".

In 1994, the technique of transdiscal screws fixation in spondylolisthesis was introduced but did not gained popularity as it failed to address problems with spinal sagittal imbalance, retroverted pelvis, pseudoarthrosis, implant failure and neural injury. Majority of problems were due to lack of clear indications; hence, in this study, with modification of traditional technique and use of O-arm navigation for selected group of patients, we have addressed the above problems and given good to excellent functional outcomes. We did prospective study on 15 patients with osteoporotic high-grade spondylolisthesis Meyerding grade 3 & 4 admitted in period 2020-2021. Intraoperative assessment was done in form of blood loss, incision length, operative time and complications. The preoperative & postoperative assessment was done in the form of clinical and radiological parameters. The average follow-up was of 21.2months (18-24months). There was no significant difference between pre- & postoperative spinopelvic parameters. Intraoperative average blood loss was 100ml (90-120ml) with mean surgical time of 138min (120-150min). Incision length was about 5-6-cms-posterior midline with two paraspinal 1-cm incisions for transdiscal screws. Patients were mobilized on postoperative day-2. There was statistically significant improvement in mean ODI, COMI and VAS for LBP and radicular pain with no intra- or postoperative complication observed till latest follow-up with all patients showing solid monoblock fusion on 1-year follow-up CT scan. LIMO delta technique is a newly modified version of conventional transdiscal screw technique. Minimal incision, decreased blood loss & operative time with in situ 3-column rigid fixation and solid fusion minimizing risk of complications makes this novel technique safer, simpler & effective in osteoporotic HGS.

Transdiscal instrumentation in single-level lumbosacral fusion for high-grade isthmic pediatric spondylolisthesis: Technical note and review of the literature

Pediatric spondylolisthesis is a common cause of back pain in children, typically managed conservatively with bracing and non-steroidal anti-inflammatory drugs. When posterolateral fusion is performed for refractory pain, pseudarthrosis and implant failure may occur, necessitating reoperation. To improve patient outcomes, there is a need for alternative surgical techniques to effectively manage high-grade isthmic slips. Here, the authors report the case of a child with Meyerding grade III anterolisthesis of L5 on S1 who was treated with a single-level, instrumented fusion using bilateral S1-L5 transdiscal screws, supported with L5-S1 posterolateral instrumentation and arthrodesis. Postoperatively, there was improvement in the patient's symptoms with good clinical and radiographic outcomes. The patient continues to be symptom free with radiographic evidence of hardware stability and bony fusion across the segment. The authors detail a novel surgical technique in children as well as a review of lumbosacral transdiscal screw fixation. Further evidence is required to definitively establish the safety, outcomes, and biomechanical strength of this technique.

Transdiscal Screw Fixation in L5-S1 Adult Spondylolisthesis: Technical Note and Midterm Outcomes of a Case Series

Spondylolisthesis changes the pelvic morphology and sagittal spinopelvic alignment with abnormality compared to individuals with similar pelvic morphology. There are many treatment options including a combination of decompression and fusion. In spondylolisthesis patients with high-grade spondylolisthesis, bone to bone contact (closed intradiscal space), and high-grade disc degeneration with disc collapse, fusion is challenging. From 2011 through 2020, an analysis of L5-S1 spondylolisthesis patients who had L5-S1 transdiscal screw fixation with a minimum follow-up of 2 years was performed. Radiological evaluation and clinical measures were compared preoperatively and postoperatively. Postoperative complications were analyzed. Also, L5-S1 degree fusion was analyzed using a CT scan. 8 patients of L5-S1 spondylolisthesis with a mean follow-up of 69 (25-122) months. All patients were female, the average age was 58 (43-78) years. 4 patients presented with high-grade spondylolisthesis (Meyerding grade III). Among the patients, three patients were undergoing revision surgery. Only 5 patients had interbody fusion for their adjacent levels. In the postoperative follow-up, none of the patients had a neurological deficits. Radiological evaluations of L5-S1 level showed fusion in all patients. Only one patient had rod failure and was advised for revision surgery. L5-S1 transdiscal screw fixation may provide a satisfactory rigid fixation and fusion at the L5-S1 level in cases of spondylolisthesis. This technique requires a surgeon's experience. Despite the challenge of this technique, it can provide a safe option for acquiring rigid stabilization.

Radiographic risk factors for degenerative lumbar spondylolisthesis: A comparison with healthy control subjects.

ObjectiveTo evaluate the radiologic parameters of degenerative lumbar spondylolisthesis (DLS) and determine the radiographic risk factors for DLS by making comparisons with healthy control subjects.MethodsSeventy-five patients with L4/5 DLS (Meyerding grade I) and 53 healthy control subjects were analyzed. The L1-S1 disc height index (DHI), L4/5 facet joint angle (FJA), and relative cross-sectional area (RCSA) of paravertebral muscles were measured in both groups. The initial L4/5 DHI (iDHI) before the onset of DLS were estimated based on the L3/4 DHI of the DLS group and DHI of the control group. The sagittal parameters of DLS were also included in this study.ResultsThe DHI of L4/5 was lower in the DLS group than in the control group (P < 0.05), but the DHI of the L1-L4 segments were much higher than in the control group (P < 0.05). The initial L4/5 DHI and FJA of the DLS group were significantly higher than those of the control group (P < 0.05). The RCSA of the paravertebral muscles were smaller in the DLS group than in the control group (P < 0.05). Binary logistic regression analysis showed that iDHI, FJA, and RCSA of the total paraspinal muscles were risk factors for DLS. The cutoff values for iDHI, FJA, and RCSA were 0.504, 56.968°, and 1.991 respectively. The iDHI was associated with lumbar lordosis (LL), while L4/5 DHI was associated with the RCSA of the multifidus muscle and psoas major muscle (P < 0.05).ConclusionA large initial lumbar disc height, large FJA, and paravertebral muscle atrophy may be risk factors for DLS.