Posterolateral Fusion Research Articles

Vitamin D supplementation is a cost-effective intervention after posterolateral lumbar fusion: a systematic review

Background: This study investigated the role of preoperative supplementation of 25(OH)D, a precursor of the active form of vitamin D, as a cost-effective strategy to decrease pseudarthrosis rates and overall healthcare burden after posterolateral fusion (PLF). Previous literature has emphasized the importance of vitamin D in bone health maintenance, spinal health, and outcomes in spinal fusion. Inadequate preoperative 25(OH)D levels may increase pseudarthrosis rates after PLF. Thus, a cost-estimation model was developed to determine the cost-effectiveness of both selective and nonselective 25(OH)D supplementation in PLF. Methods: Prevalence and cost data were obtained from published literature through systematic reviews. Cost of serum 25(OH)D assay and supplementation were obtained from public-use data. Mean, lower, and upper bounds of 1-year cost-savings were calculated for both supplementation scenarios. Results: Preoperative 25(OH)D screening and subsequent selective 25(OH)D supplementation was calculated to result in a mean cost-savings of $10,978,440 ($9,969,394 to $11,987,485) per 10,000 PLF cases. Nonselective 25(OH)D supplementation of all PLF patients was calculated to result in a mean cost-savings of $11,213,318 ($10,204,272 to $12,222,363) per 10,000 cases. Univariate adjustment projects that selective supplementation is a cost-effective strategy in clinical contexts where revision PLF costs exceed $781.89 and prevalence of 25(OH)D deficiency ≥0.612%. Nonselective supplementation is cost-effective in clinical scenarios where revision PLF cost ≥$198.09 and prevalence of 25(OH)D deficiency ≥0.1645%. Conclusions: This cost-predictive model promotes the role of preoperative 25(OH)D supplementation as a cost-effective mechanism to reduce overall healthcare burden after PLF. Nonselective supplementation appears to be more cost-effective than selective supplementation, likely due to the relatively lower cost of 25(OH)D supplementation compared with serum assays. Level of Evidence: Level III

Preliminary results of biphasic calcium phosphate with submicron surface topography as standalone alternative to autograft in posterolateral fusion: A prospective, multi-center, randomized, intra-patient controlled trial

Preliminary results of biphasic calcium phosphate with submicron surface topography as standalone alternative to autograft in posterolateral fusion: A prospective, multi-center, randomized, intra-patient controlled trial

Minimally Invasive Spinal Fusion Using Percutaneous Pedicle Screw Instrumentation Can Provide a Better Health-Related QOL in Early Stage Than Conventional Methods in the Treatment of Single-Level Degenerative Lumbar Spinal Diseases.

To investigate whether the minimally invasive spinal fusion can provide the better outcome than conventional fusion surgery in the treatment of degenerative lumbar spinal diseases. One hundred and thirteen patients who had undergone single-level fusion surgery for degenerative lumbar spinal diseases were examined with a minimum of one-year follow-up. There were 56 men and 57 women with a median age of 70s ranging 47-88. The following three-types of fusion surgery were performed; minimally invasive transforaminal interbody fusion after microscopic decompression through a unilateral approach with percutaneous pedicle screwing (MTLIF), transforaminal interbody fusion after microscopic decompression through a unilateral approach (TLIF), and posterior lumbar interbody fusion with posterolateral fusion after open decompression through a bilateral approach (PLIF). The purpose for limiting on single level degenerative spinal disease was that it would be easy to compare the surgical outcomes among the three groups. There were no statistically significant differences among three groups in terms of VAS scores, RDQ scores, and all of the domains in the JOABPEQ scores at the baseline. The JOABPEQ score for pain-related disorders at 6 months after surgery was statistically significantly higher in MTLIF group than the other two groups (P = 0.023). There were no statistically significant differences in the scores of the other outcome measures among three groups in whole follow-up period. The current study demonstrated that the JOABPEQ score for pain-related disorders at 6 months postoperatively was significantly better in MTLIF group than in the other groups. Since lumbar degenerative diseases mostly consisted in elderly patients, less invasive surgeries are desirable. MTLIF resulted in a better health-related QOL at 6 months after surgery, and its outcomes at the final follow-up were non-numerical inferiority. The results strongly indicate that MTLIF is desirable surgery especially for elderly patients with degenerative spinal diseases.

The impact of demineralized bone matrix characteristics on pseudarthrosis and surgical outcomes after posterolateral lumbar decompression and fusion.

The objectives of our study were to compare the fusion rates and surgical outcomes of lumbar fusion surgery based on the (1) type of demineralized bone matrix (DBM) carrier allograft, (2) the presence/absence of a carrier, and (3) the presence of bone fibers in DBM. Patients >18 years of age who underwent single-level posterolateral decompression and fusion (PLDF) between L3 and L5 between 2014 and 2021 were retrospectively identified. We assessed bone grafts based on carrier type (no carrier, sodium hyaluronate carrier, and glycerol carrier) and the presence of bone fibers. Fusion status was determined based on a radiographic assessment of bony bridging, screw loosening, or change in segmental lordosis >5°. Analyses were performed to assess fusion rates and surgical outcomes. Fifty-four patients were given DBM with a hyaluronate carrier, 75 had a glycerol carrier, and 94 patients were given DBM without a carrier. DBM carrier type, bone fibers, and carrier presence had no impact on 90-day readmission rates (P = 0.195, P = 0.099, and P = 1.000, respectively) or surgical readmissions (P = 0.562, P = 0.248, and P = 0.640, respectively). Multivariable logistic regression analysis found that type of carrier, presence of fibers (odds ratio [OR] = 1.106 [0.524-2.456], P = 0.797), and presence of a carrier (OR = 0.701 [0.370-1.327], P = 0.274) were also not significantly associated with successful fusion likelihood. Our study found no significant differences between DBM containing glycerol, sodium hyaluronate, or no carrier regarding fusion rates or surgical outcomes after single-level PLDF. Bone particulates versus bone fibers also had no significant differences regarding the likelihood of bony fusion.

Evaluation of the Effect of Granulocyte Colony Stimulating Factor on Spinal Fusion in a Rat Model of Spinal Surgery.

To evaluate the effects of granulocyte colony stimulating factor (G-CSF) on spinal fusion through manual palpation, radiological examinations, and histopathological analyses in a rat model. A total of 21 rats were evaluated in this study. The rats were divided into the following three groups, each consisting of seven rats: preoperative G-CSF, postoperative G-CSF, and a control group. L4-L5 posterolateral fusion was performed in all three groups. The preoperative G-CSF group received 5 μg/kg G-CSF subcutaneously for 5 days in the preoperative period, while the postoperative G-CSF group received the same intervention in the postoperative period. No additional postoperative procedures were performed in the control group. All rats were euthanized at 6 weeks, and the fusion site was evaluated using manual palpation, radiological examinations, and histopathological analyses. According to the classification of subjects according to manual examination, preoperative and postoperative G-CSF groups had significantly higher rates of "single prominent callus formation + fusion" (p < 0.05). When direct radiography scores were evaluated, the number of subjects with "unilateral solid new bone density - contralateral nonsolid bone density" was significantly greater in the preoperative G-CSF group, while "bilateral solid new bone densities" was more prevalent in the postoperative G-CSF group (p < 0.05). In regards to histopathological scores, the number of subjects rated as "fibrocartilage tissue is more than bone tissue" was higher in the preoperative G-CSF group, the number of subjects rated as-bone tissue is more than fibrocartilage tissue" was higher in the postoperative G-CSF group, and the number of subjects rated as "fibrous tissue is more than fibrocartilage tissue" was greaterin the control group (p=0.01). Preoperative and postoperative G-CSF groups had significantly higher manual examination, radiological, and histopathological scores and greater volume of new bone formation on 3D CT compared to the control group (p < 0.05). The results of our study demonstrated that preoperative and postoperative administration of G-CSF had positive effects on spinal fusion in a rat model.

Spinal decqompression and posterolateral fusion improves walking capacity and balance and reduces residual urine in patients with spinal stenosis

Spinal decqompression and posterolateral fusion improves walking capacity and balance and reduces residual urine in patients with spinal stenosis

Walking speed is associated with postoperative pain catastrophizing in patients with lumbar spinal stenosis: a prospective observational study

BackgroundThe purpose of this study was to investigate whether walking speed is associated with postoperative pain catastrophizing in patients with lumbar spinal stenosis.MethodsIn this prospective observational study, consecutive patients with clinically and radiologically defined lumbar spinal stenosis underwent surgical treatment (decompression, or posterolateral or transforaminal lumbar interbody fusion) at Tottori University Hospital, between October 2015 and April 2018. The pain catastrophizing scale, walking speed, leg and back pain (numerical rating scale), and Japanese Orthopaedic Association score were evaluated preoperatively and at 3, 6, and 12 months postoperatively. Correlations between the pain catastrophizing scale and each variable were analyzed at each evaluation time point. The effect of walking speed on the pain catastrophizing scale was analyzed using mixed-effect models for repeated measurements.ResultsNinety-four patients were included at baseline, and 83, 88, and 82 patients were analyzed at 3, 6, and 12 months postoperatively, respectively. The pain catastrophizing scale was significantly correlated with walking speed, leg pain, back pain, and the Japanese Orthopaedic Association score at all evaluation time points. The pain catastrophizing scale was associated with walking speed at all evaluation time points.ConclusionsOur results suggest that changes in postoperative pain catastrophizing after lumbar spine surgery are associated with walking speed. Thus, walking speed is a necessary assessment for the management of pain catastrophizing and associated pain and disability in patients after lumbar spine surgery.

Use of biphasic calcium phosphate versus demineralized bone matrix: retrospective clinical and CT analysis of posterolateral fusion results.

Bone graft extenders have been developed to prevent donor site morbidity associated with iliac crest bone graft, but few studies compared the efficacy of various substitutes. Our purpose was to determine fusion rate and clinical outcome in patients undergoing lumbar arthrodesis using demineralized bone matrix (DBM) and biphasic calcium phosphate (BCP). Patients with degenerative spondylolisthesis undergoing one-level or two-level arthrodesis of lumbar spine were retrospectively reviewed. Two treatment groups placed either BCP or DBM, in addition to local autograft in lumbar posterolateral space. Three-dimensional CT exam and dynamic flexion-extension radiographs at postoperative 2-year were assessed for posterolateral fusion status and pain scale and Oswestry Disability Index (ODI) for clinical outcome. Of the 148 patients reviewed (including 23 in one- and 58 patients in two-level in BCP group, and 47 in one- and 20 patients in two-level in DBM group), no significant differences were found in terms of age, sex, BMI, smoking, diabetes, steroids, number of level fused, non-union rate or revision surgery between BCP and DBM groups. Significantly improved pain scale of back and leg and ODI were found in both groups postoperatively without group difference. We found a comparable fusion rate in one-level surgery (100% versus 93.6%) and a superior fusion rate of BCP group in two-level surgery (98.3% versus 80.0%, p = 0.01). Being a bone graft extender without osteoinductive property, with local autograft, BCP is comparable to DBM for one- and superior for two-level fusion. No significant difference was found in clinical outcomes.

Canadian Spine Society

# Abstract 57. Radiographic reporting in adolescent idiopathic scoliosis: Is there a discrepancy comparing radiologists’ reports and surgeons’ assessments? {#article-title-2} Cobb angle measurement is the standard method for quantification of scoliosis in adolescent idiopathic scoliosis (AIS),

Fusion and clinical outcomes of lumbar interbody fusion for low-grade isthmic spondylolisthesis

IntroductionLow-grade isthmic spondylolisthesis (ISPL) is generally treated by circumferential fusion with interbody graft, although there is no consensus on technique. HypothesisThe various interbody fusion strategies provide satisfactory fusion rates and clinical results. MethodsA multicenter retrospective study analyzed lumbar interbody fusion for low-grade ISPL performed between March 2016 and March 2019. Techniques comprised: circumferential fusion on a posterior or a transforaminal approach (PLIF, TLIF: n=57), combined anterior (ALIF)+posterolateral fusion (ALIF+PLF: n=60), and ALIF+percutaneous posterior fixation (ALIF+PPF: n=55). Function was assessed on a lumbar and a radicular visual analog scale (AVS-L, VAS-R), Oswestry Disability Index (ODI) and Short Form 12 (SF12). ResultsAmong the 129 patients, 85.3% showed fusion (Lenke 1 or 2), with no significant differences between the ALIF-PLF or ALIF-PPF groups and the PLIF or TLIF groups (p=0.3). Likewise, there was no difference in fusion rates between the ALIF-PPF and ALIF-PLF subgroups (p=0.28). VAS-L (p<0.001) and VAS-R (p<0.0001), ODI (p<0.001) and SF12 physical (PCS) (p<0.01) and mental component sores (MCS) (p<0.001) all showed significant improvement at 12months. Combined approaches provided greater clinical efficacy than TLIF or PLIF for lumbar (p<0.0001) and radicular pain (p<0.05), ODI (p<0.0001) and SF12 PCS (p<0.01). At 12months, there was no clinical difference between the ALIF-PPF and ALIF-PLF subgroups. However, patents with interbody non-union (Lenke 3 or 4) had lower SF12 PCS scores (p<0.004) and VAS-L ratings (p<0.001) than Lenke 1-2 patients. ConclusionLow-grade ISPL treated by circumferential arthrodesis and interbody graft showed 85.3% consolidation at 2years, with equivalent outcomes between anterior and posterior techniques. Successful fusion was associated with better clinical results. Level of evidenceIV.

Cervical spine injuries in spinal ankylosing disorders: results of single-stage posterior stabilization without posterolateral fusion

Patients with long-segment cervical spinal fusion resulting from spinal ankylosing disorders (SADs) are at high risk for highly unstable cervical spine fractures necessitating surgery as the treatment of choice; however, without an existing gold standard. Specifically, patients without concomitant myelo- pathy, representing a rare entity, may benefit from a minimized surgical approach of a single-stage posterior stabilization without bone grafting for posterolateral fusion. This retrospective monocenter study in a Level I trauma center included all patients treated with navigated posterior stabilization without posterolateral bone grafting between January 2013 and January 2019 for cervical spine fractures in preexisting SADs without myelopathy. The outcomes were analyzed based on complication rates, revision frequency, neurologic deficits, and fusion times and rates. Fusion was evaluated by X-ray and computed tomography. 14 patients (11 male, 3 female) with a mean age of 72.7 ± 17.6 years were included. Five fractures were at the upper and nine at the subaxial cervical spine (predominantly C5-7). There was one surgery-specific complication of postoperative paresthesia. There was no infection, implant loosening, or dislocation, and no revision surgery necessary. All fractures healed after a median time of 4 months and 12 months being the latest time of fusion in one patient. Single-stage posterior stabilization without posterolateral fusion is an alternative for patients with SADs and cervical spine fractures without myelopathy. They can benefit from a minimization of surgical trauma while having equal times of fusion and no increased rate of complications.

Clinical and Cost-Effectiveness of Lumbar Interbody Fusion Using Tritanium Posterolateral Cage (vs. Propensity-Matched Cohort of PEEK Cage).

Surgical management of degenerative lumbar spine disorders is effective at improving patient pain, disability, and quality of life; however, obtaining a durable posterolateral fusion after decompression remains a challenge. Interbody fusion technologies are viable means of improving fusion rates in the lumbar spine, specifically various graft materials including autograft, structural allograft, titanium, and polyether ether ketone. This study assesses the effectiveness of Tritanium posterolateral cage in the treatment of degenerative disk disease. Nearest-neighbor 1:1 matched control transforaminal lumbar interbody fusion with PEEK vs. Tritanium posterior lumbar (PL) cage interbody fusion patients were identified using propensity scoring from patients that underwent elective surgery for degenerative disk diseases. Line graphs were generated to compare the trajectories of improvement in patient-reported outcomes (PROs) from baseline to 3 and 12 months postoperatively. The nominal data were compared via the χ2 test, while the continuous data were compared via Student's t-test. The two groups had no difference regarding either the 3- or 12-month Euro-Qol-5D (EQ-5D), numeric rating scale (NRS) leg pain, and NRS back pain; however, the Tritanium interbody cage group had better Oswestry Disability Index (ODI) scores compared to the control group of the PEEK interbody cage at both 3 and 12 months (p=0.013 and 0.048). Our results indicate the Tritanium cage is an effective alternative to the previously used PEEK cage in terms of PROs, surgical safety, and radiological parameters of surgical success. The Tritanium cohort showed better ODI scores, higher fusion rates, lower subsidence, and lower indirect costs associated with surgical management, when compared to the propensity-matched PEEK cohort.

Trends in Short Construct Lumbar Fusions Over the Past Decade at a Single Institution.

Retrospective cohort. (1) To compare the rates of fusion techniques over the last decade; (2) to identify whether surgeon experience affects a surgeon's preferred fusion technique; (3) to evaluate differences in complications, readmissions, mortality, and patient-reported outcomes measures (PROMs) based on fusion technique. Database studies indicate the number of lumbar fusions have been steadily increasing over the last two decades; however, insufficient granularity exists to detect if surgeons' preferences are altered based on additive surgical experience. A retrospective review of continuously collected patients undergoing lumbar fusion at a single urban academic center was performed. Rates of lumbar fusion technique: posterolateral decompression fusion (PLDF), transforaminal lumbar interbody fusion (TLIF), anterior lumbar interbody fusion + PLDF (ALIF), and lateral lumbar interbody fusion + PLDF (LLIF) were recorded. Inpatient complications, 90-day readmission, and inpatient mortality were compared with χ 2 test and Bonferroni correction. The Δ 1-year PROMs were compared with the analysis of variance. Of 3938 lumbar fusions, 1647 (41.8%) were PLDFs, 1356 (34.4%) were TLIFs, 885 (21.7%) were ALIFs, and 80 (2.0%) were lateral lumbar interbody fusions. Lumbar fusion rates increased but interbody fusion rates (2012: 57.3%; 2019: 57.6%) were stable across the study period. Surgeons with <10 years of experience performed more PLDFs and less ALIFs, whereas surgeons with >10 years' experience used ALIFs, TLIFs, and PLDFs at similar rates. Patients were more likely to be discharged home over the course of the decade (2012: 78.4%; 2019: 83.8%, P <0.001). No differences were observed between the techniques in regard to inpatient mortality ( P =0.441) or Δ (postoperative minus preoperative) PROMs. Preferred lumbar fusion technique varies by surgeon preference, but typically remains stable over the course of a decade. The preferred fusion technique did not correlate with differences in PROMs, inpatient mortality, and patient complication rates. 3-treatment.

Mid-term efficacy and safety of Escherichia coli-derived rhBMP-2/hydroxyapatite carrier in lumbar posterolateral fusion: a randomized, multicenter study

PurposeThis study aimed to evaluate the mid-term efficacy and safety of Escherichia coli-derived bone morphogenetic protein-2 (E.BMP-2)/hydroxyapatite (HA) in lumbar posterolateral fusion (PLF).MethodsThis multicenter, evaluator-blinded, observational study utilized prospectively collected clinical data. We enrolled 74 patients who underwent lumbar PLF and had previously participated in the BA06-CP01 clinical study, which compared the short-term outcomes of E.BMP-2 with an auto-iliac bone graft (AIBG). Radiographs and CT scans were analyzed to evaluate fusion grade at 12, 24, and 36 months. Visual analog scale (VAS), Oswestry disability index (ODI), and Short Form-36 (SF-36) scores were measured preoperatively and at 36 months after surgery. All adverse events in this study were assessed for its relationship with E.BMP-2.ResultsThe fusion grade of the E.BMP-2 group (4.91 ± 0.41) was superior to that of the AIBG group (4.25 ± 1.26) in CT scans at 36 months after surgery (p = 0.007). Non-union cases were 4.3% in the E.BMP-2 and 16.7% in the AIBG. Both groups showed improvement in pain VAS, ODI, and SF-36 scores when compared to the baseline values, and there were no statistically significant differences between the two groups. No treatment-related serious adverse reactions were observed in either group. No neoplasm-related adverse events occurred in the E.BMP-2 group.ConclusionsThe fusion quality of E.BMP-2/HA was superior to that of AIBG. E.BMP-2/HA showed comparable mid-term outcomes to that of AIBG in terms of efficacy and safety in one-level lumbar PLF surgery.

Ceramic bone graft substitute (Mg-HA) in spinal fusion: A prospective pilot study.

Background: Iliac crest bone graft (ICBG) is considered the gold standard for spine surgical procedures to achieve a successful fusion due to its known osteoinductive and osteoconductive properties. However, complications related to harvesting procedure and donor site morbidity have been largely reported in the literature, favoring the development of a wide range of alternative products to be used as bone graft extenders or substitutes for spine fusion. Among all, ceramic-based biomaterials have been widely studied and employed in the last years as bone graft substitutes. Methods: We report here the results of a prospective pilot study aimed to evaluating the grade of ossification obtained by the use of an Mg-doped hydroxyapatite (HA) product to achieve postero-lateral fusion in degenerative spine diseases. Results: Results show a successful degree of fusion of about 62% at the 12-month follow-up and an improvement of quality of life and health status following surgery, as evaluated by clinical scores (ODI, VAS, and EQ-5L). No adverse events related to the material were reported. Conclusion: The present pilot study shows the effectiveness and the safety profile of an Mg-doped HA bone graft substitute used to achieve postero-lateral fusion in the treatment of degenerative spine diseases, laying down the basis for further larger clinical investigations.

Effect of sagittal screw angle and distance of screw apex to superior endplate on adjacent segment disease after posterolateral lumbar fusion: a retrospective study

BackgroundNumerous complications of lumbar fusion surgery have been reported, with adjacent segment disease (ASD) being one of the most important. Few studies describe the effect of sagittal, horizontal screw angles and distance of pedicle screw apex to superior endplate on the incidence of ASD in lumbar spine. The purpose of this retrospective study is to evaluate the hypothesis that unsatisfactory pedicle screw insertion positions would increase the likelihood of ASD.MethodsOutpatients with lumbar spinal stenosis underwent posterolateral lumbar fusion at L4-S1 with a least 2-year follow-up were studied. ASD at L3–L4 was defined as a condition in which intervertebral disk narrowing, posterior vertebral opening, and vertebral slippage progress at the last follow-up in comparison with the postoperative. Independent t test was performed to compare data between two groups; Spearman analysis was performed to analyze the relationship between two continuous variables. Multivariate binary logistic models were performed to identify the independent risk factors of ASD. The receiver operating characteristic (ROC) curve was performed to measure model discrimination and Hosmer–Lemeshow (H–L) test was used to measure calibration. ROC curve evaluated the discrimination ability of sagittal screw angle and distance in predicting incidence of ASD.ResultsPatients in ASD group exhibit higher incidence of osteoporosis, higher Visual analogue scale (VAS), Oswestry disability index (ODI), bigger sagittal screw angle, shorter distance of pedicle screw apex to superior endplate than those in non-ASD group (p < 0.05). VAS, ODI at the last follow-up were positively correlated with Pfirrmann grade of L3–4 disk and sagittal screw angle, while negatively correlated with distance of screw apex to superior endplate (p < 0.05). Multivariate binary logistic model indicated that follow-up time (odds ratio [OR] 1.637, 95% confidence interval [CI] 1.186–2.260), distance of screw apex to superior endplate (OR 0.150, 95% CI 0.067–0.336), sagittal screw angle (OR 2.404, 95% CI 1.608–3.594) were statistically significant. The models showed great discrimination and calibration. The area under the curve of ASD identified by sagittal angle and distance was 0.895 and the cut-off values were 5.500° and 6.250 mm, respectively.ConclusionSagittal screw angle and distance of screw apex to superior endplate were significantly associated with the risk of ASD.

Coexisting ossification of the posterior longitudinal ligament, intramedullary hemangioblastoma, and syringomyelia of the cervical spine: illustrative case.

Ossification of the posterior longitudinal ligament (OPLL) is a rare but potentially devastating cause of severe spinal cord compression and degenerative cervical myelopathy. Because OPLL is rarely accompanied by prominent syringomyelia, when both are observed, other causes of syringomyelia should be considered. Simultaneous presentation of OPLL and hemangioblastoma of the cervical spine is a rare encounter and has never been reported in the English-language literature. The authors present a case of a 64-year-old man with muscle weakness of the right upper limb and worsening dysesthesia of the right thumb and index finger. Noncontrast magnetic resonance imaging (MRI) of the cervical spine from another institution revealed OPLL from the C2 to C6 levels with severe spinal cord compression and prominent syringomyelia. Repeated MRI with contrast showed an intramedullary tumor, about 11 mm in diameter, at the right posterior aspect of the C4 level. The authors performed laminectomies from C1 to C6 with posterolateral fusion and removed the C4 tumor. Pathohistological examination of the tumor demonstrated hemangioblastoma. Careful evaluation of the preoperative imaging study is extremely important in surgical decision making. Although rare, concomitant cervical hemangioblastoma should be listed in the differential diagnosis when OPLL is accompanied with prominent syringomyelia.

In Single-Level, Open, Posterior Lumbar Fusion, Does Transforaminal Lumbar Interbody Fusion or Posterolateral Fusion Lead to Better Outcomes?

Two common approaches for open, one-level, posterior lumbar fusions include transforaminal lumbar interbody fusion (TLIF) and posterolateral fusion (PLF) alone without an interbody. To compare TLIF vs PLF alone in (1) discharge disposition, (2) return to work (RTW), and (3) patient-reported outcomes (PROs). A single-center, retrospective cohort study was undertaken between October 2010 and May 2021, all with a 1-year follow-up and excluding patients with isthmic spondylolisthesis. Minimum clinically important difference for each PRO was used, which included Numeric Rating Scale (NRS) and Oswestry Disability Index (ODI). Logistic/linear regression controlled for age, body mass index, disc height, flexion-extension movement, amount of movement on flexion-extension, and spondylolisthesis grade. Of 850 patients undergoing open, 1-level, posterior lumbar fusion, 591 (69.5%) underwent a TLIF and 259 (30.5%) underwent a PLF alone. Patients undergoing TLIF were younger (59.0 ± 11.3 vs 63.3 ± 12.6, P < .001), had higher body mass index (31.3 ± 6.6 vs 30.2 ± 12.6, P = .019), and more often had private insurance (50.3% vs 39.0%, P < .001). Regarding discharge disposition, no significance was found in multivariate regression (odds ratio = 2.07, 95% CI = 0.39-10.82, P = .385) with similar RTW between TLIF and PLF alone (80.8% vs 80.4%, P = .645) (odds ratio = 1.15, 95% CI = 0.19-6.81, P = .873). Regarding PROs, patients undergoing a TLIF had higher preoperative (6.7 ± 2.3 vs 6.4 ± 2.5, P = .046) and 3-month NRS-back pain (3.4 ± 2.6 vs 2.9 ± 2.5, P = .036), with similar 12-month NRS-back pain. Regarding NRS-leg pain, no differences were observed preoperatively ( P = .532) and at 3 months ( P = .808). No other significant differences were observed in ODI. TLIF patients had slightly higher NRS-back pain at baseline and 3 months, but similar NRS-leg pain, despite the added risk of placing an interbody. No differences were seen in discharge disposition, RTW, and 12-month pain scores and ODI.

Sacral dome resection and single-stage posterior reduction in the treatment of high-grade spondylolisthesis in a young girl

Introduction: The treatment of high-grade spondylolisthesis remains controversial in terms of in situ fusion versus reduction. The aim of operation in this patient is to restore the spino-pelvic alignment, sagittal profile of the spine and prevention of progression of slip with a minimal neurological risk.&#x0D; Case presentation: 18 years old schooling girl referred with a history of backache and right lower limb numbness over lateral aspect of foot for four years duration. She also had intermittent lower back pain, produced by long distant walking and relived by rest. It was aggravated by standing for long duration. There was no radiation of pain, no red flag sign or no cauda equina symptoms. Apart from her right lower limb neurology which was her power MRC grade IV in L5 and S1 myotome, other examinations were normal. X-Ray revealed grade V spondyloptosis. MRI showed evidence of right exiting L5 nerve root entrapment with grade V spondyloptosis. She underwent single stage posterior instrumentation of L4 - S1vertebrae, sacral dome resection, reduction of L5 over S1, interbody fusion of L5 - S1 and posterolateral intertransverse fusion of L4 to S1 vertebrae. She was ambulated on post-operative day one without brace. There was no worsening of neurology.&#x0D; Conclusion: Lumbosacral spondylolisthesis grade V can be treated using posterior approach alone to obtain reduction, decompression, and solid fusion. The sacral dome resection is a shortening osteotomy of the lumbosacral spine which allows a single-stage reduction of L5 without lengthening of lumbosacral region in high-grade spondylolisthesis, which helps to avoid neurological complications.

Randomized Control Trial of Functional Outcome between Instrumented Posterior Lumbar Interbody Fusion and Posterolateral Fusion in Degenerative and Isthmic Adult Spondylolisthesis.

Spondylolisthesis is a spinal condition that affects the lumbosacral vertebrae. This disease causes one of the lower vertebrae to slip forward onto the bone directly beneath it. It's a painful condition but treatable in most cases. Although spondylolisthesis can be asymptomatic, patients with degenerative and isthmic spondylolisthesis typically present with low back pain, neurologic symptoms, and/or radicular symptoms. The surgical treatment of spondylolisthesis is indicated for cases of neurogenic claudication, intractable radicular pain, severe low-back pain, presence of neurological symptoms, failure of conservative management, radiological instability, progressive worsening of the listheses, Meyerding grade III and IV listhesis, and spondylosis. The ideal surgical treatment remains controversial. We have compared the functional outcome following instrumented posterior lumbar interbody fusion and posterolateral fusion for adult spondylolisthesis in our study. The prospective study was conducted in the Department of Orthopaedics. A total of 30 patients who satisfied both the inclusion and exclusion criteria and gave informed consent were recruited for the study from January to December 2019. The patients were randomized into two groups. Of 30 patients, Group 1(n=18) underwent Posterior lumbar interbody fusion and Group 2 (n=12) underwent Posterolateral fusion. Random number generators were used for allotting the patients to the specified group. Using Oswestry Disability Index, Japanese Orthopaedic Association Score and Visual Analog Score were used for pre-operative and post-operative functional scoring. The mean age among those who received PLIF was 53.67 years and among those who received PLF was 55.17 years. Spondylolisthesis at L4-L5 comprised 66.7% among those who received PLIF and 58.3 % among those who received PLF. Neurological deficit was present in 66.7% of the participants who had received PLIF and 100% of the participants who have received PLF. Concerning those who had received PLIF as treatment, 11 patients had excellent and 7 patients had better outcome in PLIF group, 7 patients had excellent and 5 patient had better outcome in PLF group.. The mean JOAS pre-intervention score was 6.66 and 6.40 for PLIF and PLF groups, respectively. In the 6th month mean JOAS score of the PLIF group was 11.16 and that of the PLF group was 10.16. The pre-intervention mean VAS score was 6.44 and 6.50 for PLIF and PLF groups, respectively. In both, the groups over the follow-up period mean VAS score had shown a decreasing trend. Our study did not show any significant difference in functional outcome between both groups, however there seems to better short term (3 months) and mid-term (6 months) pain relief in PLIF group when compared to PLF group. Long term follow-up studies along with radiological outcome may help in establishing superiority between both procedures.