Presence Of Spondylolisthesis Research Articles

Predictors of Clinical Outcome After Endoscopic Partial Facetectomy for Degenerative Lumbar Foraminal Stenosis

Endoscopic partial facetectomy (EPF) is an effective option for decompressing the lumbar exiting root without causing spinal instabilities in the treatment of patients with degenerative lumbar foraminal stenosis. The aim of the present study was to identify the preoperative risk factors of poor clinical outcomes after EPF in patients with degenerative lumbar foraminal stenosis. A total of 51 consecutive patients who had undergone EPF from 2012 to 2015 were included in the present study. The clinical outcomes were evaluated using the visual analog scale (VAS), Oswestry disability index (ODI), and Short-Form 36-item (SF-36) outcome questionnaires. The preoperative radiological risk factors were measured using the lumbar Cobb's angle, disc wedging angle, lumbar lordosis (LL), segmental lordosis, disc height index, presence of spondylolisthesis, and morphological changes (no change, horizontal collapse, vertical collapse) of the exiting root within the most stenotic level on preoperative magnetic resonance imaging. The VAS, ODI, and SF-36 scores had significantly improved at the 1-month follow-up visit compared with the baseline mean values and were maintained within the 2-year follow-up period. A correlation analysis revealed significant relationships between various preoperative factors and clinical outcomes. On multiple regression analysis, the morphological change of vertical collapse significantly predicted the VAS, ODI, and SF-36 scores, and LL significantly predicted the ODI and SF-36 scores. A morphological change in vertical collapse found on preoperative magnetic resonance imaging and decreased LL were significant predictors of poor clinical outcomes after EPF in the treatment of lumbar foraminal stenosis.

Risk Factors for Early Recurrence After Transforaminal Endoscopic Lumbar Disc Decompression

Background: Transforaminal endoscopic lumbar disc decompression (TELD) has emerged as a treatment alternative to open lumbar discectomy, but rates of herniated lumbar disc (HLD) recurrence after TELD are higher by comparison. Objectives: We conducted this study to identify factors correlating with early HLD recurrence after TELD. Study Design: Retrospective study. Setting: The Department of Anesthesiology and Pain Medicine, Neurosurgery at Spine Health Wooridul Hospital. Methods: As a retrospective review, we examined all patients undergoing TELD between 2012 and 2017, analyzing the following in terms of time to recurrence: age, gender, body mass index (BMI), comorbid conditions (diabetes mellitus [DM], hypertension [HTN]), smoking status, nature of disc herniation (central, paramedian, or foraminal), Modic changes, migration grade (rostral vs. caudal track + degree), herniated disc height (Dht) and base size (Dbase), and the presence of spondylolisthesis on magnetic resonance imaging. Results: During the 5-year study period, 1,900 patients underwent TELD procedures, resulting in 209 recurrences (11.0%). In 27 of these patients (12.9%), herniation recurred within 24 hours after surgery. Recurrences most often developed within 2-30 days (n = 76). The smaller the size of a herniated disc, the earlier it recurred. Recurrences were unrelated to gender, BMI, DM or HTN, smoking status, migration grade, nature (Dht or Dbase of herniated disc), or the presence of spondylolisthesis. Limitations: In addition to variables assessed herein, other clinical and radiologic parameters that may be important in recurrent disc herniation should be included. Furthermore, only univariate analyses were performed, making no adjustments for potential confounders, therefore, independent risk factors could not be assessed. A prospective study would likely generate more precise results, especially in terms of standardized sampling and data classification. Finally, multiple causes for primary discectomy failures may have rendered our patient groups nonhomogeneous, and inequalities in surgical options or physician-dictated surgical choices may have had an effect. Conclusions: In patients undergoing TELD procedures, smaller-sized herniated discs are linked to early recurrences. Key words: Disc herniation, lumbar, endoscopic, recurrence, early

The conservative treat ment of patients with degenerative lumbar stenosis

To study factors affecting the course of lumbar stenosis (LS). In the course of a two-year prospective study, 68 patients with degenerative LS, aged from 51 to 88 years (mean age 66±15.4 years), 21 men and 47 women, were examined. The 1st group consisted of 30 patients with stenosis of the lateral pocket (lateral LS), the 2nd group included 39 patients with central LS. For patients of the 1st group, significant risk factors for disease progression were spondylolisthesis, pain intensity in the lumbar region during walking, pain intensity in the leg during walking, the degree of LS, while the most significant parameter was spondylolisthesis (regression coefficient was 17.59; p=0.006). A risk factor for the lack of recovery/deterioration in the patients of the 2nd group was expressed LS, which twice worsened the prognosis of the disease (regression coefficient - 14.79; p=0.003983). The presence of spondylolisthesis in patients with central LS was a risk factor for lack of recovery, but not deterioration. The absence of therapeutic exercise was a risk factor for the progression of the disease.

Wednesday, September 26, 2018 7:35 AM–9:00 AM ePosters: P41. Agreement of degenerative spondylolisthesis definitions on standing and supine lateral radiographs in consecutive patients

BACKGROUND CONTEXT Clinical guidelines recommend standing lateral radiographs as the most appropriate imaging for detecting degenerative spondylolisthesis. However, direct comparison on definitions of spondylolisthesis on standing and supine lateral radiographs in the same patients are lacking. PURPOSE To determine the extent of agreement on commonly used definitions of degenerative spondylolisthesis on clinically obtained standing and supine lateral radiographs among the same patients. STUDY DESIGN/SETTING Cross-sectional study in new patients presenting to the Oregon Health & Science University Spine Center with chief complaint of back pain or radiculopathy. PATIENT SAMPLE Consecutive new patients from 2010 to 2016, age ≥40years, and without a history of prior spinal surgery, vertebral fracture or scoliosis greater than 30°, who were clinically evaluated for degenerative spondylolisthesis. OUTCOME MEASURES Radiographic degenerative spondylolisthesis defined as anterior displacement of ≥3 mm, ≥5 mm and ≥5%. METHODS New patients received standing AP, standing lateral and supine lateral radiographs as a clinical standard. The presence of spondylolisthesis was assessed from L1 to S1. The anterior slip distance (mm) was obtained by measuring the displacement of the posterior surface the superior vertebral body in relation to the posterior surface of the inferior vertebral body. Vertebral body width (mm) was obtained by measuring the narrowest AP diameter of the inferior vertebral body. Percent slip was calculated by dividing the anterior slip distance by the inferior vertebral body width. Kappa statistics were estimated as the measure of agreement on definitions of spondylolisthesis on the pairs of films. RESULTS This study comprised 516 patients (246 (48%) men; 270 (52%) women; mean (sd) age of 60.0 (11) years). Of these, 206 (40%) patients had 239 vertebrae with any anterior displacement of ≥3mm. Spondylolisthesis was most often observed at L4-L5 (112 vertebrae) or L5S1 (96 vertebrae). Numbers and percentages of patients classified as without spondylolisthesis on standing radiographs but with spondylolisthesis on supine radiographs for the ≥3 mm, ≥5 mm and ≥5% definitions, respectively, were 4 (1.9%), 2 (1.3%), and 3 (1.4%). Conversely, numbers and percentages of patients classified as without spondylolisthesis on supine radiographs but with spondylolisthesis on standing radiographs for ≥3 mm, ≥5 mm and ≥5% definitions, respectively, were 37 (18.0%), 46 (30.3%) and 32 (14.5%). Kappa statistics for agreement on definition of degenerative spondylolisthesis on the standing and supine lateral radiographs for ≥3 mm, ≥5 mm and ≥5% were, respectively, 0.83, 0.75 and 0.86. CONCLUSIONS From 18% to 30% of patients with radiographically detectable spondylolisthesis were misclassified as without spondylolisthesis by supine radiographs, whereas less than 2% of patients were misclassified as without spondylolisthesis on standing radiographs. Agreement between standing and supine radiographs worsened with progressively larger slip required to define spondylolisthesis. These results in a large consecutive series of new patients support clinical guidelines to use standing lateral radiographs for diagnosis of radiographic degenerative spondylolisthesis.

Wednesday, September 26, 2018 1:00 PM – 2:00 PM Interventional Pain Management: 35. Rate of conversion to surgery and risk factors analysis following fluoroscopically guided facet cyst rupture

BACKGROUND CONTEXT Facet cysts are a common finding on magnetic resonance imaging (MRI) when evaluating a patient with back pain and radicular symptoms. Several different clinical and radiographic findings have been associated with this diagnosis. It is thought that these differences may relate to the difference in efficacy of fluoroscopically guided cyst rupture. PURPOSE The purpose of this study was to evaluate the rate of conversion to surgery following cyst rupture, and to assess for clinical, radiographic and procedural variables that were associated with that conversion. If specific clinical and radiographic risk factors can be elucidated which are associated with conversion to surgery, it may be possible to more effectively and efficiently counsel and treat patients. STUDY DESIGN/SETTING A retrospective review at an academic medical center. PATIENT SAMPLE All patients who underwent fluoroscopically guided facet cyst rupture from 2010 to 2016. OUTCOME MEASURES The primary outcome was conversion to surgery. For those who converted to surgery, the rate of decompression and fusion compared to fusion alone was recorded. Secondary outcomes included clinical, radiographic and procedural variable analysis to determine if there were risk factors associated with conversion to surgery. The clinical variables included sex, age, number of comorbidities, location (unilateral or bilateral), type of symptoms (pain, motor deficit, sensory deficit), and whether the pain was predominantly leg, back or combined. The radiographic variables included cyst size, shape, cyst signal, rim signal, level involved, laterality, presence of spondylolisthesis, whether there was canal or lateral recess stenosis, presence of facet joint fluid, bilateral fluid, facet bone edema and bone erosion. The procedural variables included cyst opacification, successful rupture and difference in pre and post procedure pain. METHODS Basic statistics, as well as single and multivariate analysis was performed. RESULTS Forty-nine patients met the inclusion criteria. Four were excluded because they had either no clinical notes or no MRI available for review. Twenty-nine percent of patients eventually underwent a surgical procedure to address their facet cyst. The average interval to surgery was 95 days after cyst rupture. Of those who had a surgical intervention, 38% had a decompression and fusion. Of the clinical, radiographic and procedural variables evaluated, only the number of comorbidities and the MRI signal of the facet rim were associated with conversion to surgery, p=.03 and p=.05, respectively. CONCLUSIONS Facet cysts have been recognized as a cause of spinal stenosis, but their optimal treatment is unknown. Typically, all nonoperative interventions are attempted prior to conversion to surgery, which often includes fluoroscopically guided facet cyst rupture. However, there is a significant percentage of patients in whom this treatment fails to provide durable relief, and eventually, patients undergo a surgical intervention. Despite the two associated risk factors, at this time, we would recommend continuing to attempt fluoroscopic guided facet cyst rupture with postprocedural clinical monitoring for all patients. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Diagnostic value of plain radiographs in patients with low back pain of non-traumatic origin at a national teaching and referal hospital in Kenya

Background: Low back pain is a commonly recognized problem worldwide. Plain radiography is used in many of these patients as an initial investigative and evaluative tool. However, it was not known how truly useful this investigation was in making definitive diagnosis for non traumatic low back pain. The main objective of the study was to determine the value of plain radiographs in patients presenting with low back pain that is of non-traumatic origin.Methods: A prospective study 102 consecutive patients with low back pain was conducted at the Kenyatta National Hospital (KNH) from 1st February 2013 to 30th May 2013. Data was collected using a structured questionnaire and analyzed. Plain radiograph films were reviewed by two qualified radiologists.Results: The mean age of patients presenting with low back pain was 50.9years, with a male to female ratio of 1:2.4. Majority of the patient had chronic low back pain. There was a high rate of positive radiological findings (98%). The most common findings included muscle spasm, osteoporosis, reduced lumbar lordosis, spondylosis, disc degenerative disease and osteophytes. Assessment of inter-rater variability showed good level of agreement on presence of spondylolisthesis and vacuum phenomenon (k=0.71), moderate agreement on reduced disc space, reduced lumbar lordosis, spondylosis (k=0.42-0.56) and poor agreement on film quality, infections, tumor metastasis, osteophytes, prolapsed intervertebral disease (PID), osteoporosis, scoliosis, muscle spasm and sacroilitis (k=0.13-0.21)Conclusion: Most of the patients presenting to KNH with low back pain have a chronic type and therefore have increased probability of having positive radiological findings. There was a poor ability to diagnose infectious causes, inflammatory conditions, transitional vertebrae and tumor metastasis. In such cases, more advanced imaging such as CT scan and MRI may be required.

Anterior hyperlordotic cages: early experience and radiographic results.

OBJECTIVE The aim of this study was to evaluate the segmental correction obtained from 20° and 30° hyperlordotic cages (HLCs) used for anterior lumbar interbody fusion in staged anterior and posterior fusion in adults with degenerative spinal pathology and/or spinal deformities. METHODS The authors report a retrospective case series of 69 HLCs in 41 patients with adult degenerative spine disease and/or deformities who underwent staged anterior, followed by posterior, instrumentation and fusion. There were 29 females and 12 males with a mean age of 55 years (range 23-76 years). The average follow-up was 10 months (range 2-28 months). Radiographic measurements of segmental lordosis and standard sagittal parameters were obtained on pre- and postoperative radiographs. Implant subsidence was measured at the final postoperative follow-up. RESULTS For 30° HLCs, the mean segmental lordosis achieved was 29° (range 26°-34°), but in the presence of spondylolisthesis this was reduced to 19° (range 12°-21°) (p < 0.01). For 20° HLCs, the mean segmental lordosis achieved was 19° (range 16°-22°). The overall mean lumbar lordosis increased from 39° to 59° (p < 0.01). The mean sagittal vertical axis (SVA) reduced from 113 mm (range 38-320 mm) to 43 mm (range -13 to 112 mm). Six cages (9%) displayed a loss of segmental lordosis during follow-up. The mean loss of segmental lordosis was 4.5° (range 3°-10°). A total complication rate of 20% with a 4.1% transient neurological complication rate was observed. The mean blood loss per patient was 240 ml (range 50-900 ml). CONCLUSIONS HLCs provide a reliable and stable degree of segmental lordosis correction. A 30° HLC will produce correction of a similar magnitude to a pedicle subtraction osteotomy, but with a lower complication rate and less blood loss.

Minimally invasive surgery for lumbar synovial cysts with coexisting degenerative spondylolisthesis.

About one third of lumbar synovial cysts are associated with degenerative spondylolisthesis. Segmental instability is thought to contribute to the pathogenesis and recurrence of synovial cysts and lumbar fusion has been advocated as a treatment of choice in the presence of spondylolisthesis. In patients with spondylolisthesis, minimally invasive resection of lumbar synovial cysts, without fusion, could minimize surgically induced segmental instability while providing good pain relief. Clinical and radiological outcomes of lumbar synovial cyst patients with and without spondylolisthesis were retrospectively compared. Pain outcomes were assessed with modified Macnab criteria. Fifty-three patients (18 with grade 1 spondylolisthesis) underwent minimally invasive synovial cyst resection and all had either excellent or good pain outcome at ≤ 8 post- operative weeks (P = 1.000, n = 53). At > 8 post-operative weeks (mean (SD) follow-up of 200 (175) weeks), excellent or good outcomes were noted in 89% of patients without spondylolisthesis and in 75% of patients with spondylolisthesis (P = 0.425, n = 40). Four patients developed a new grade 1 spondylolisthesis at a mean follow-up of 2.6 ± 2.1 years. Nine patients were assessed for spondylolisthesis measurements at 1.2 ± 1.3 years of follow up and no significant difference was observed (5 ± 0 vs 5 ± 1 mm; P = 0.791). Two patients without spondylolisthesis and none of the patients with spondylolisthesis had a synovial cyst recurrence. Patients with concomitant lumbar degenerative spondylolisthesis and synovial cyst can have good short- and long-term clinical outcomes with minimally invasive surgery without fusion. Post-operative segmental instability does not appear to be significant in patients with spondylolisthesis. All patients included in this article signed an informed consent for the use of their medical information for research.

Spondylolisthesis, Sacro-Pelvic Morphology, and Orientation in Young Gymnasts

Cross-sectional evaluation of sacro-pelvic morphology and orientation as well as spondylolisthesis prevalence in a cohort of young gymnasts. To evaluate the prevalence of spondylolisthesis in a cohort of gymnasts, as well as the associated demographic characteristics and sacro-pelvic morphology and orientation. Numerous studies have shown that sagittal sacro-pelvic morphology and orientation is abnormal in spondylolisthesis. Sacro-pelvic morphology and orientation in gymnasts and their relationship with spondylolisthesis have never been analyzed. Radiologic evaluation of 92 gymnasts was performed to identify spondylolisthesis, and to measure pelvic incidence, pelvic tilt, sacral slope, and sacral table angle. In the presence of spondylolisthesis, the slip percentage was measured. Different demographic and training characteristics were evaluated. Radiographic parameters were compared with reference values published for asymptomatic children and adolescents, and for subjects with spondylolisthesis. A 6.5% prevalence of spondylolisthesis was found in our cohort. The weekly training schedule was the only statistically significant different demographic characteristic between the 2 groups, at 20.6±5.4 versus 14.4±5.6 h/wk for subjects with and without spondylolisthesis, respectively. Pelvic incidence, pelvic tilt, sacral slope, and sacral table angle were 69±20, 15±13, 54±11, and 88±7 degrees in gymnasts with spondylolisthesis, and 53±11, 10±6, 43±9, and 94±6 degrees in gymnasts without spondylolisthesis, respectively. When compared with asymptomatic individuals, pelvic incidence and pelvic tilt were slightly superior in gymnasts without spondylolisthesis. Pelvic incidence, sacral slope, and sacral table angle were significantly different between gymnasts with and without spondylolisthesis. The prevalence of spondylolisthesis in young gymnasts was similar to that observed in the general population. Sagittal sacro-pelvic morphology and orientation was abnormal in gymnasts with spondylolisthesis. Sagittal sacro-pelvic morphology and orientation was also slightly different in gymnasts without spondylolisthesis when compared with the normal population. The present study supports an association between spondylolisthesis and abnormal sacro-pelvic orientation and morphology.

Epidemiological, Clinical, and Radiological Profile of Patients with Degenerative Scoliosis: Experience of 20 Years at the National Institute of Rehabilitation

Introduction Adult scoliosis is a complex three-dimensional rotational deformity of the spine result in a progressive degeneration, with a Cobb angle greater than 10 degrees in the coronal plane, which alters the sagittal and axial planes, it occurs in a previously straight spine; most often in elderly. The adult degenerative or de novo scoliosis is believed to develop as the result of asymmetric degeneration of the discs, osteoporosis, and vertebral body compression fractures; this causes increased asymmetric loading and therefore a progression of degeneration and deformity. The main symptom is pain; and the surgical treatment is preferred for patients with neurological deficit, severe pain, or radiculopathy. Risk factors are female gender, age over 50 years, osteoporosis; and for curve progression may be a curve size over 30 degrees, an asymmetric disc above and below the apical vertebra, lateral subluxation of the apical vertebra over 6 mm, and L5 vertebra being located above rather than below the intercrestal line. The degenerative scoliosis prevalence varies from 2.5 to 15% in controlled populations. The increase in life expectancy in our population and the pursuit of improving the quality of life has turned degenerative scoliosis in a common problem of medical care. The main objective of this study is to examine the epidemiological, clinical, and radiographical features of patients with this disease who have been diagnosed and treated in an institution of concentration in the past 20 years. Patients and Methods We retrospectively analyzed electronic and radiographic records of patients between 40 to 80 years, diagnosed with adult degenerative scoliosis who have undergone surgery in our institute, during the period from January 1995 to December 2013. Results The prevalence was 0.087%, with a total of 61 individuals. We observed increased frequency of degenerative lumbar scoliosis in women (72.1%), at a rate of 2.6:1 and also an increase in the frequency in older adults (70.5%) (43/61). The prevalence of degenerative spondylolisthesis associated with lumbar scoliosis was 21%. In a gender analysis in women, increased prevalence was 3.52%; women have an increased frequency of spondylolisthesis compared with men. Women had 2.4 times the risk of degenerative lumbar scoliosis. Men had 1.9 times the risk of degenerative spondylolisthesis associated with lumbar scoliosis. The most affected level was L4–L5. Conclusion Although degenerative scoliosis is a common disease that affects the adult population, the prevalence in our institute is low compared with international literature and the age of our sample was higher than that the of the series presented, this is because patients come late to the care for not having medical service. The distribution of gender, the severity of the curvature, and the presence of spondylolisthesis and olisthesis was similar to the literature review.

Spondylolysis in elite junior-level ice hockey players.

Background:Spondylolysis is a common cause of low back pain and significant loss of play in the young athlete. Its incidence in hockey players has not been reported. This study reviewed the incidence and potential causative factors of low back pain and spondylolysis in an elite junior-level ice hockey program over a 15-year period.Hypothesis:Because of the repetitive movements of the lower spine required by the sport, spondylolysis was expected to be a frequent cause of low back pain in hockey players.Study Design:Retrospective case review.Level of Evidence:Level 4.Methods:The medical and athletic trainer records of male ice hockey players, ages 15 to 18 years, who presented with the complaint of low back pain were reviewed. This elite program consisted of 2 rosters. There were approximately 44 players total per year representing these 2 teams. For players diagnosed with spondylolysis, the following factors were reviewed: year in the program, age at presentation, symptoms and duration, studies performed, level of spondylolysis, presence of spondylolisthesis, affected side to shooting side, player position, treatment, and current level of play.Results:Over 9 hockey seasons, 25 players presented to medical staff with low back pain. Of those, 44% were confirmed to have lumbar spondylolysis. The majority of these cases presented in the first year of the program without clear history of trauma but rather vague pain with weight lifting or hockey. Less than half of spondylolysis cases were diagnosed on plain films. There were no cases of spondylolisthesis. Spondylolysis occurred on the shooting side in 73% of players. Sixty-four percent of players with spondylolysis were forwards. The treatment for most included rest from lifting and hockey and physical therapy. Average return to play was 8 weeks. Ninety-six percent of players continued to play at an elite level.Conclusion:Spondylolysis should be strongly considered in the differential of low back pain in ice hockey players with consideration for advanced imaging. Considerable loss of play occurs with spondylolysis, but with proper treatment, excellent outcomes occur.Clinical Relevance:This study brings to light the prevalence of spondylolysis in ice hockey players. With an increased index of suspicion, the condition can be diagnosed and properly treated to allow full return to play.

Prevalence and Motion Characteristics of Degenerative Cervical Spondylolisthesis in the Symptomatic Adult

Retrospective analysis of kinetic magnetic resonance images. To define the prevalence of degenerative cervical spondylolisthesis in symptomatic patients and to analyze the motion characteristics and influence on the spinal canal at the affected level. When compared with lumbar spondylolisthesis, there are few studies evaluating cervical spondylolisthesis, and the prevalence and motion characteristics of cervical spondylolisthesis are not well defined. Four hundred sixty-eight symptomatic patients underwent upright cervical kinetic magnetic resonance images in neutral, flexion, and extension positions. Segmental displacement and intervertebral angles were measured in 3 positions using computer analysis software. Spondylolisthesis was defined as the vertebral displacement more than 2 mm, and graded based on the magnitude into 2 groups at each level: grade 1 (2-3 mm), grade 2 (>3 mm). Instability was defined as segmental translational motion exceeding 3 mm. Grade 1 and 2 spondylolisthesis at a minimum of 1 level were observed with a prevalence of 16.4% and 3.4% of all patients, respectively. The most affected levels were C4-C5 (6.2%) and C5-C6 (6.0%) followed by C3-C4 (3.6%) and C6-C7 (3.0%). Translational motion was greater in levels with grade 1 as compared with segments without spondylolisthesis, but there was no difference in angular motion between the 3 groups. Translational instability was observed with a prevalence of 16.7% in grade 2, 4.3% in grade 1, and 3.4% in segments without spondylolisthesis. Space available for the cord at the affected level was decreased and spinal cord compression grade was higher in grade 1 and grade 2 as compared with levels without spondylolisthesis. Cervical spondylolisthesis of at least 2 mm was observed in 20% of patients and was most common at C4-C5 and C5-C6. The presence of spondylolisthesis was associated with increased translational motion and decreased segmental spinal canal diameter. N/A.

The relevance of sacral and sacro-pelvic morphology in developmental lumbosacral spondylolisthesis: are they equally important?

Retrospective study of the importance of sacral and sacro-pelvic morphology in developmental L5-S1 spondylolisthesis. To determine and compare the importance of sacral and sacro-pelvic morphology in developmental L5-S1 spondylolisthesis. Recent studies have shown abnormalities in sacral and sacro-pelvic morphology in spondylolisthesis. However, it is still unclear if sacral and sacro-pelvic morphology are correlated and if they are equally important in the progression of spondylolisthesis. Lateral radiographs of 120 controls and 131 subjects with developmental L5-S1 spondylolisthesis were analyzed. Sacral table angle (STA) and pelvic incidence (PI) were compared using Student t tests. The relationship between STA and PI was assessed separately in the control and spondylolisthesis groups using Pearson's coefficients. The proportion of subjects with high PI but average STA was compared to the proportion of subjects with low STA but average PI using χ (2) tests. STA was significantly lower and PI was significantly higher in the spondylolisthesis group. STA was statistically related to PI in both control (r=-0.43) and spondylolisthesis (r=-0.57) groups. In the spondylolisthesis group, STA (r=-0.45) and PI (r=0.35) were significantly related to slip percentage. STA remained statistically related to slip when controlling for PI. A significantly greater proportion of subjects in the spondylolisthesis group had average STA and high PI, rather than average PI and low STA. The significant relationship between PI and STA validates that geometrically sacral morphology depends on sacro-pelvic morphology. This study failed to demonstrate a clear predominant role of either STA or PI in the presence of spondylolisthesis.

AIS and spondylolisthesis

The association of scoliosis and spondylolisthesis is well documented in literature; the nature and modalities of the relationship of the two pathologies are variable and not always clear. Also, etiologic particulars of scoliosis associated with spondylolisthesis are not well defined, even in cases where scoliosis is called idiopathic. In this paper, we review previous literature and discuss the different aspects of the mutual relationship of scoliosis and spondylolisthesis in the adolescent age. It is a common notion that the highest occurrence of scoliosis associated with spondylolisthesis is at the lumbar level, both in adolescent and in adult patients. It is probable that the scoliosis that is more heavily determined by the presence of spondylolisthesis is at the lumbar level and presents curve angle lower than 15° Cobb and mild rotation. The scoliosis with curve value over 15° Cobb that is present at the lumbar level in association with spondylolisthesis probably is not prominently due to spondylolisthesis: in these cases, spondylolisthesis is probably only partially responsible for scoliosis progression with a spasm mechanism and/or due to rotation of slipping "olisthetic" vertebra. We think that the two pathologies should be treated separately, as stated by many other authors, but we would highlight the concept that, whatever be the scoliosis curve origin, spasm, olisthetic or mixed together, this origin has no influence on treatment. The curves should be considered, for all practical effects, as so-called idiopathic scoliosis. We think that generally patient care should be addressed to treat only spondylolisthesis or only scoliosis, if it is necessary on the basis of clinical findings and therapeutic indications of the isolated pathologies, completely separating the two diseases treatments. Scoliosis should be considered as an independent disease; only in the case of scoliosis curve progression over time, associated scoliosis must be treated, according to therapeutic principles of the care of any so-called idiopathic scoliosis of similar magnitude, and a similar approach must be applied in the case of spondylolisthesis progression or painful spondylolisthesis.

Fluoroscopic percutaneous lumbar zygapophyseal joint cyst rupture: a clinical outcome study

Background context Lumbar zygapophyseal joint (Z-joint) synovial cysts can cause low back pain (LBP), spinal stenosis, and lower extremity radiculopathy. In the literature, there are several minimally invasive techniques described with mixed results. Typical recommended treatment is surgical resection of the cyst. Currently, there is little information available concerning the efficacy and outcome with treatment of Z-joint synovial cyst by percutaneous, fluoroscopic, contrast-enhanced distention, and rupture. Purpose To evaluate the therapeutic value and safety of Z-joint cyst rupture in symptomatic patients. Study design/setting Retrospective cohort study in an academic outpatient physiatric spine practice. Patient sample Thirty-two patients with moderate-to-severe LBP and leg pain (18 women and 14 men with an age range of 46–86 y; mean age, 66 y) with an average preprocedure symptom duration of 5 months. The patient's clinical symptoms correlated with magnetic resonance imaging studies documenting the presence of a synovial cyst at the corresponding level and side of symptoms. Patients had at least 6 months follow-up (range, 6–24). Outcome measures Numerical Pain Rating Scale, Roland-Morris Disability Questionnaire, North American Spine Society four-point patient satisfaction survey, recurrence of synovial cyst requiring repeat rupture, and need for surgical intervention. Methods Patients with symptomatic lumbar Z-joint synovial cyst were identified and their charts were reviewed. Patients included in the study either had symptomatic lumbar LBP or LBP with associated lower extremity radiculopathy. All patients in the study had magnetic resonance imaging's documenting Z-joint synovial cyst that corresponded with the patients' clinical symptoms. All patients received fluoroscopically guided, contrast-enhanced, percutaneous facet cyst distention and rupture followed by an intra-articular facet joint injection of 1 cc kenalog and 1 cc of 1% lidocaine. Seventeen of the patients also received a transforaminal epidural steroid injection just before facet cyst rupture. Telephone follow-up was conducted on all patients. Results Excellent long-term (average follow-up 1 y; range, 6–24 mo) pain relief was achieved in 23 (72%) of 32 patients undergoing facet cyst rupture. Twelve patients (37.5%) had synovial cyst recurrence and 11 chose to undergo repeat rupture, which resulted in 5 patients (45%) obtaining complete relief of symptoms and 6 patients (55%) requiring surgical intervention for cyst removal. Fisher exact test demonstrated that all patients who did not have a cyst recurrence were a success and obtained complete relief of symptoms (p<.0002). Patients who underwent a repeat rupture had a 50% chance of a successful outcome. There was no statistical significance between a successful outcome and level of facet cyst rupture, the presence of spondylolisthesis, sex, age, or having a transforaminal epidural steroid injection at the time of the procedure. Wilcoxon signed-rank test demonstrated that the difference in Numerical Pain Rating Scale and Roland-Morris Disability Questionnaire scores before and after the procedure was statistically significant (p<.0001). No complications were reported. Conclusions Fluoroscopic percutaneous Z-joint cyst rupture appears to be a safe and effective minimally invasive treatment option. This procedure should be considered before surgical intervention.

Examining Heterogeneity in Meta-Analysis

Literature review. To assess the influence of various factors in statistical heterogeneity of meta-analyses of interventions for low back pain. One of these factors was study design: randomized controlled trial (RCT) versus nonrandomized study (NRS). The presence of statistical heterogeneity poses a challenge to the conduct and interpretation of meta-analyses. We searched MEDLINE, EMBASE, and The Cochrane Library up to May 2005 for comparative studies of interventions for low back pain. The interventions with the highest number of NRSs were selected. All NRSs and RCTs of the same interventions were combined using meta-analysis. Subgroup analyses and meta-regression were performed according to study design and other factors that were selected by a panel of 20 experts. NRSs frequently either agree with RCTs or underestimate the effects compared with RCTs. The interventions and the respective factors that explained statistical heterogeneity were a) surgery versus conservative treatments (17 NRSs and 8 RCTs): study design (odds ratio, OR: 1.56 and 4.69 for nonrandomized and randomized studies, respectively), pain duration (OR: 1.75 and 3.55 for chronic and acute, respectively), and involvement of workers' compensation (OR: 1.85 and 5.07, with and without, respectively); b) surgery with fusion versus surgery without fusion (17 NRSs and 3 RCTs): spondylolisthesis (OR: 2.15 and 1.22, with and without, respectively); c) Instrumented fusion versus noninstrumented fusion (15 NRSs and 8 RCTs): previous surgery (OR: 2.89 and 1.36, with and without, respectively) and levels fused (OR: 1.50 and 2.98, single and multilevel, respectively). Comparisons between RCTs and NRSs may be influenced by various factors, including study design. However, other factors were more powerful explanatory variables than study design. These factors included pain duration, involvement of workers' compensation, presence of spondylolisthesis, previous surgery, and levels fused.

Synovial cysts of the lumbar facet joints in a symptomatic population: prevalence on magnetic resonance imaging.

A retrospective review of 303 MRI scans of the lumbar spine was conducted. To determine the prevalence of lumbar facet joint synovial cysts arising from the joints anteriorly and posteriorly. To examine the association of these cysts with facet joint osteoarthritis and degenerative disc disease. Sporadic reports of such cysts exist as do limited studies describing the prevalence of symptomatic anterior facet joint synovial cysts. However, the overall prevalence of lumbar facet joint synovial cysts has not been formally studied, and the mechanism of formation of these cysts is not fully understood. One observer undertook a review of MRI of the lumbar spine from one facility in a series of 303 patients referred mostly for back pain or radiculopathy. The presence of lumbar facet joint synovial cysts, their relationship to the facet joint, the degree of associated facet joint osteoarthritis, the presence of spondylolisthesis, and the degree of associated disc degeneration were recorded. Seven anterior cysts (prevalence = 2.3%) were identified, only two of which did not clearly cause nerve root compression. Twenty-three posterior cysts in 22 patients (prevalence = 7.3%) were identified. Statistically significant associations with increased frequency and severity of facet joint osteoarthritis and with spondylolisthesis were demonstrated compared to patients without cysts. Both anterior and posterior lumbar facet joint synovial cysts are rare. Posterior cysts are more common than anterior cysts. Both types of cysts are related to facet joint osteoarthritis but not to disc disease.

Microscopic Laminotomies for Degenerative Lumbar Spinal Stenosis

In this retrospective study, we investigated 50 patients who had undergone primary lumbar microsurgical multiple laminotomy without spinal fusion for degenerative spinal stenosis. There were 31 men and 19 women with a median age of 66 years (35-85 years). Thirteen patients had grade I spondylolisthesis, most at L4-L5 levels (11 of 13). Single-level laminotomy was done in 13 patients, two levels in 30, and three levels in 7. The median follow-up period was 27 months (range, 15-48 months). A standardized self-reported questionnaire was used for clinical outcome study. The demographic data and clinical features of these patients were analyzed for the prognostic factors. The analysis showed excellent results in 18 patients, good in 16, fair in 8, and poor in 8, whereas 30 patients reported that they were very satisfied with the surgery results, 10 were somewhat satisfied, 2 were somewhat dissatisfied, and 8 were very dissatisfied. Therefore, the satisfactory rate of the surgery was higher if judged by patient satisfaction. Among the parameters analyzed, the presence of neurogenic claudication (p = 0.008), coexisting disease (p = 0.04), and the absence of motor deficit (p = 0.03) were associated with lower total scores. In addition, longer duration of symptoms (p = 0.04) was associated with less improvement of back pain score, whereas the absence of motor deficit (p = 0.004) was associated with less improvement of leg pain score. The presence of spondylolisthesis did not affect outcomes.

Spondylolisthesis in the Elite Football Player

Although spondylolisthesis in and of itself is not a contraindication to participation or successful performance in football, having spondylolisthesis may well predispose to symptoms and be associated with a worse prognosis. The purpose of this study was to determine the reported prevalence, treatment approach, outcomes, and perceptions regarding prognosis of elite football players with spondylolisthesis by their National Collegiate Athletic Association (NCAA) and National Football League (NFL) team physicians. A questionnaire regarding the prevalence, treatment, results, and perceptions regarding prognosis related to spondylolisthesis in football players was submitted to each team orthopaedic surgeon of the 28 NFL and the Final Associated Press ranked top-25 NCAA Division I teams at the conclusion of the 1993-1994 season. All questionnaires were returned for review. The prevalence of players with known spondylolisthesis currently participating in elite football was 1% in both the NCAA and NFL. Fifty-two percent of NCAA and 43% of NFL team physicians were aware of at least one athlete with spondylolisthesis currently playing. Only six college and two NFL team physicians were aware of athletes surgically treated for spondylolisthesis. Sixty-four percent of NFL team physicians and 36% of college team physicians believed that the presence of spondylolisthesis implies a poor prognosis. Ninety-six percent of professional team physicians downgraded the rating of players with known spondylolisthesis before the NFL draft.