Single-level Lumbar Spondylolisthesis Research Articles

Comparative Analysis of Open Transforaminal Lumbar Interbody Fusion and Wiltse Transforaminal Lumbar Interbody Fusion Approaches for Treating Single-Level Lumbar Spondylolisthesis: A Single-Center Retrospective Study

Background: The aim of this study is to compare the surgical outcomes of two different surgical approaches, open transforaminal lumbar interbody fusion (TLIF) and Wiltse TLIF, in the treatment of single-level lumbar spondylolisthesis and also to provide the advantages and disadvantages of each approach. Methods: This retrospective study included 600 patients with single-level lumbar spondylolisthesis who underwent fusion surgery at a single academic institution between January 2018 and December 2022. Patients were divided into two groups: traditional open TLIF (group A; 300 patients) and the Wiltse TLIF approach (group B; 300 patients). Preoperative diagnostic tests were performed on all patients. Results: The fluoroscopy time for the Wiltse TLIF group was longer, whereas the mean blood loss for the Wiltse TLIF approach was less. Both techniques resulted in significant improvements in pain relief and functional disability, with no significant difference between the two groups in terms of their pre- or post-operative (Oswestry Disability Index) ODI scores. The Wiltse TLIF technique resulted in significantly shorter hospital stays and had a lower rate of complications compared with the open TLIF technique. Conclusion: The Wiltse TLIF approach showed advantages in shorter surgical times, reduced blood loss, and shorter hospital stays, whereas the traditional open TLIF approach exhibited shorter fluoroscopy times.

COMPARISON OF TRANSFORAMINAL LUMBAR INTERBODY FUSION AND POSTERIOR LUMBAR INTERBODY FUSION IN THE MANAGEMENT OF SINGLE-LEVEL LUMBAR SPONDYLOLISTHESIS

This study aimed to compare the outcomes of transforaminal lumbar interbody fusion and posterior lumbar interbody fusion in managing single-level lumbar spondylolisthesis. A Randomized Controlled trial was conducted at the Department of Neurosurgery, Gomal Medical College, DI Khan, Pakistan, from December 2022 to May 2023 on 50 patients presenting with adult lumbar spondylolisthesis. In group A, 25 patients underwent posterior lumbar interbody fusion (PLIF) utilizing two cages and pedicle fixation, while 25 patients received transforaminal lumbar interbody fusion (TLIF) employing a single cage and pedicle fixation, representing group B. Outcomes such as mean operative times, blood loss, back and leg pain score on VAS, and complications were assessed between both groups. The mean postoperative time, blood loss, and back pain on the VAS scale were significantly lower in the TLIF group than in the PLIF group. The TLIP group showed a lower number of complications as compared to the PLIF group. TLIF outperforms PLIF regarding functional outcomes and the rate of complications for grade I/II single-level lumbar spondylolisthesis.

Is unilateral-approach full-endoscopic lumbar fusion effective for single-level lumbar spondylolisthesis with bilateral symptoms? A preliminary report of 43 CT analysis.

To investigate the clinical results and radiological parameters changes after unilateral-approach endoscopic lumbar interbody fusion (Endo-LIF) for lumbar spondylolisthesis with bilateral symptoms. 43 single-level lumbar spondylolisthesis patients with bilateral lower limb symptoms were included from June 2020 to May 2022. All patients underwent unilateral-approach Endo-LIF and postoperative computed tomography. Radiological parameters including disk height (DH), degree of upper vertebral slip (DUVS), and foramen intervertebral parameters including bilateral foraminal height (FH), contralateral foraminal areas (FA) were evaluated. The clinical outcomes including low back pain and bilateral leg pain were evaluated using Visual Analog Scale (VAS) and the Oswestry Disability Index (ODI) before and after surgery. All cases were successfully completed surgery and followed for average 15.16 ± 5.2months. DH (44% ± 11%) and DUVS were significantly improvement postoperatively compared with preoperatively (p < 0.05). Statistically significant increases in bilateral FH (25% ± 11% on the surgical side, 17% ± 8% on the contralateral side) and contralateral FA (26% ± 6%) were observed (p < 0.05). The VAS and the ODI scores were significantly decreased in comparison with the preoperative scores (p < 0.05). Unilateral-approach with contralateral indirect decompression in Endo-LIF can acquire satisfactory clinical outcomes. Therefore, unilateral-approach Endo-LIF may be a promising option for lumbar spondylolisthesis with bilateral symptoms.

Comparison of mid-term effectiveness of unilateral biportal endoscopy-transforaminal lumbar interbody fusion with minimally invasive surgery-transforaminal lumbar interbody fusion assisted with three-dimensional microscope in treating lumbar spondylolisthesis

To compare the mid-term effectiveness of unilateral biportal endoscopy (UBE)-transforaminal lumbar interbody fusion (TLIF) and minimally invasive surgery-transforaminal lumbar interbody fusion (MIS-TLIF) assisted with three-dimensional microscope in the treatment of single-level lumbar spondylolisthesis. A total of 41 single level lumbar spondylolisthesis patients who met the selection criteria were retrospectively collected between June 2018 and September 2019. Twenty-three patients were treated with UBE-TLIF (study group) and 18 with MIS-TLIF assisted with three-dimensional microscope (control group). There was no significant difference in gender, age, Meyerding degree of slippage, type of spondylolisthesis, lesion segment, course of disease, and preoperative hemoglobin (Hb) level, visual analogue scale (VAS) score, Oswestry disability index (ODI), lumbar lordosis (LL), and disc height (DH) between the two groups (P>0.05). The operation time, hospitalization time, intraoperative blood loss, Hb level between preoperative and postoperative at 1 day, and complications were compared between the two groups. The recovery of clinical sign and symptom was evaluated by VAS score and ODI before operation, and at 1 month, 3 months, 1 year, and 3 years after operation. The LL and DH were measured by radiography before operation and at last follow-up, and the fusion rate was calculated according to Suk grade at last follow-up. All the operations were successfully completed. There was no significant difference in operation time between the two groups (P>0.05); the hospitalization time, intraoperative blood loss, and Hb difference between pre- and post-operation in the study group were significantly less than those in the control group (P<0.05). Both groups were followed up 36-48 months, with an average of 39.2 months. In the study group, 1 case of dural tear and 2 cases of Cage subsidence occurred, without postoperative infection and epidural hematoma; in the control group, infection occurred in 1 case, dural tear in 2 cases, Cage subsidence in 1 case, and no epidural hematoma occurred; there was no significant difference in the incidence of complications between the two groups (13.04% vs. 22.22%) (χ2=0.601, P=0.438). The VAS score and ODI at each time point after operation in both groups significantly improved when compared with those before operation, and further improved with time (P<0.05). There was no significant difference in VAS scores between the two groups at each time point after operation (P>0.05); the ODI of the study group was significantly lower than that of the control group at 1 and 3 months after operation (P<0.05), and there was no significant difference between the two groups at other time points (P>0.05). The imaging test showed that the intervertebral fusion rates were 95.7% in the study group and 94.4% in the control group at last follow-up, with no significant difference (χ2=0.032, P=0.859). At last follow-up, LL and DH in the two groups significantly improved when compared with those before operation (P<0.05), and the difference between before and after operation showed no significant difference between the two groups (P>0.05). Both UBE-TLIF and MIS-TLIF assisted with three-dimensional microscope have the advantages of clear intraoperative field and high surgical efficiency in treating lumbar spondylolisthesis, and can obtain satisfactory mid-term effectiveness. Compared with MIS-TLIF assisted with three-dimensional microscope, UBE-TLIF has the advantages of less bleeding and faster recovery.

Percutaneous transforaminal endoscopic surgery combined with mini-incision OLIF and anterolateral screws rod fixation vs. MIS-TLIF for surgical treatment of single-level lumbar spondylolisthesis.

Oblique lumbar interbody fusion (OLIF) has been used to treat lumbar spine spondylolisthesis. However, it usually needs posterior pedicle screws fixation for biomechanical stability and possible posterior direct decompression for relieving neurologic symptoms. We use percutaneous transforaminal endoscopic surgery (PTES) combined with mini-incision OLIF and anterolateral screws rod fixation for surgical treatment of lumbar spondylolisthesis. The purpose of study is to evaluate the feasibility, efficacy, and safety of this method compared with minimally invasive surgery-transforaminal lumbar interbody fusion (MIS-TLIF). From July 2016 to May 2018, 65 patients of lumbar spondylolisthesis (L2-4) with neurologic symptoms were treated using PTES combined with mini-incision OLIF and anterolateral screws rod fixation (31 cases, group A) or MIS-TLIF (34 cases, group B) in this study. Operative duration, blood loss, incision length, fluoroscopy frequency, and hospital stay are compared. Preoperative and postoperative visual analog scale (VAS) pain scores of back and legs, Oswestry disability index (ODI), intervertebral space height, lumbar lordotic angle, operative segmental lordotic angle, and complications are recorded. The fusion status is assessed according to Bridwell's fusion grades. The VAS score of back and leg pain and ODI significantly dropped after surgery in both groups (p < 0.001). There was no statistical difference of back and leg VAS score and ODI between two groups except that back VAS scores in group A were significantly lower than that of group B immediately after surgery (p = 0.000). Group A had significantly more intervertebral space height and operative segmental lordotic angle than group B postoperatively (p = 0.022, p = 0.002). Twenty-three segments (74.2%) were grade I and 8 segments (25.8%) were grade II in group A; 20 segments (58.8%) were grade I and 14 segments (41.2%) were grade II in group B at a 2-year follow-up (p = 0.194). No difference was observed in the complication rate between the two groups (6.5% vs. 5.9%, p = 0.924). The long-term clinical efficacy and complication rates of both groups are comparable. PTES combined with mini-incision OLIF and anterolateral screws rod fixation is a good choice of minimally invasive surgery for lumbar spondylolisthesis, which hardly destroys the paraspinal muscles and bone structures.

Does Simultaneous Fusion of Preexisting Spinal Canal Stenosis Adjacent to Lumbar Degenerative Spondylolisthesis Achieve a Better Clinical Outcome? A Retrospective Study with More than 5-year Follow-Up.

In this study, we investigate the effect of simultaneous fusion of preexisting adjacent spinal canal stenosis on the outcome of patients with lumbar spondylolisthesis. Patients with lumbar spondylolisthesis who underwent transforaminal lumbar interbody fusion (TLIF) from August 2013 to March 2016 were included. The inclusion criteria were the following: single-level spondylolisthesis (L4 or L5) and mild to moderate spinal stenosis at cranial adjacent segment of the spondylolisthesis segment before operation. According to whether the adjacent stenotic segment was included in the scope of surgery, the patients were divided into two groups: group A, only the spondylolisthesis was treated with single-level TLIF, and the adjacent stenosis was not treated with any surgery; In group B, TLIF were performed in the spondylolisthesis segment and the adjacent stenotic level; no spinal stenosis was found in other levels. The patients were followed up for more than 5 years. The general information before operation, visual analog scale (VAS) scores of low back pain and leg pain, and Oswestry disability index (ODI) scores before operation and at the last follow-up were recorded. A total of 23 patients were included in group A, and 24 patients were included in group B. There was no significant difference between the two groups in gender distribution, age, course of disease, level of slippage, length of stay, degree of spondylolisthesis, stenotic grade of adjacent segment, and intervertebral disk degeneration grade (p> 0.05). The blood loss during surgery in group B was significantly higher than that in group A (p< 0.05). The operation time of group B was longer than that of group A, but the difference was not statistically significant (p = 0.245). There was no significant difference in preoperative VAS and ODI scores between the two groups. At the last follow-up, the VAS scores of low back pain in the two groups were almost the same. However, the VAS scores of leg pain and ODI scores in group B were slightly higher than those in group A at the last follow-up, but the difference was not statistically significant (p> 0.05). If relatives and friends have the similar disease, all the patients of group A and 87.5% of patients in group B would recommend that type of surgery. The satisfaction of group A (100%) was higher than that of group B (79.17%), but the difference was not statistically significant (p = 0.068). For single-level lumbar spondylolisthesis with mild to moderate spinal stenosis in adjacent segment before operation, decompression and fusion on the level of spondylolisthesis only is a safe, less invasive, and economical surgical option, with good long-term clinical efficacy and high satisfaction rates.

Ten-Year Outcomes of Minimally Invasive Versus Open Transforaminal Lumbar Interbody Fusion in Patients With Single-Level Lumbar Spondylolisthesis.

A retrospective observational study. This study investigated the clinical and radiological results of minimally invasive (MI) versus open transforaminal lumbar interbody fusion (TLIF) in patients with single-level lumbar spondylolisthesis over a 10-year period. Few studies have compared 10-year follow-up outcomes between MI-TLIF and open TLIF. We retrospectively collected the outcome data of patients with single-level lumbar spondylolisthesis who underwent TLIF procedures using an MI (n = 108) or open (n = 53) approach. Fifty-two (48%) and 31 (58%) patients in the MI-TLIF and open TLIF groups, respectively, completed the 10-year follow-up. A primary clinical outcome included the Oswestry Disability Index (ODI) as well as visual analog scale (VAS) scores for back and leg pain at baseline and at 2, 5, and 10 years postoperatively. The radiographic fusion rate and incidence of secondary surgery due to adjacent segment disease were assessed at 2, 5, and 10 years postoperatively. Intraoperative blood loss and length of hospitalization were significantly lower in the MI-TLIF group than in the open TLIF group. At 2 years postoperatively, the ODI and VAS scores for back and leg pain were significantly lower in the MI-TLIF group than in the open TLIF group. No significant differences were found in VAS scores for back and leg pain or ODI scores between the two groups at 10 years postoperatively. Radiographic fusion rates and prevalence of secondary surgery for adjacent segment disease were not significantly different between the groups at 10 years postoperatively. Efficacy of MI-TLIF for patients with single-level lumbar spondylolisthesis is comparable to that of open TLIF over 10-years. However, MI-TLIF may have superior perioperative recovery and 2-year postoperative functional outcomes than open TLIF.Level of Evidence: 3.

Comparative Study between Posterior Lumbar Interbody Fusion (FLIF) and Transforaminal Interbody Fusion (TLIF) in the Treatment of Spondylolisthesis

Objective: In this study our main goal is to compare the efficiency of posterior lumbar interbody fusion (FLIF) and transforaminal lumbar interbody fusion (TLIF) in the treatment of spondylolisthesis. Method: This experimental observational type study was carried out at Bangabandhu Sheikh Mujib Medical University and different private hospital in Dhaka from July, 2006 to December 2019. A total number of 340(PLIF=150, TLIF=190) patients underwent lumbar interbody fusion with pedicle screw fixation for the treatment of adult lumbar spondylolisthesis were taken as a study sample. Results: During the study, surgical outcomes between PLIF and TLIF where there were significant differences between the groups in relation to VAS for back pain. These variables were significantly higher in the TLIF group compared to the PLIF group. There was no significant difference between the two groups with respect to VAS for leg pain at final follow-up. However prevalence of Nerve Root injury,Dural tearand blood loss is higher in FLIF groupe than TLIF group. Also, at the time of the last follow-up, both groups had similar slip reduction, and spinal fusion rates (P &gt; .05). Conclusion: From our study we can say that, TLIF is superior to PLIF with respect to functional outcome and complication rate in grade I/II single-level lumbar spondylolisthesis.

Flexion-extension standing radiographs underestimate instability in patients with single-level lumbar spondylolisthesis: comparing flexion-supine imaging may be more appropriate.

Generally, most spine surgeons agree that increased segmental motion viewed on flexion-extension radiographs is a reliable predictor of instability; however, these views can be limited in several ways and may underestimate the instability at a given lumbar segment. Consecutively collected adult (≥18 years old) patients with symptomatic single-level lumbar spondylolisthesis were reviewed from a two-surgeon database from 2015 to 2019. Routine standing lumbar X-rays (neutral, flexion, extension) and supine lumbar MRI (sagittal T2-weighted imaging sequence) were performed. Patients were excluded if they had prior lumbar surgery, missing radiographic data, or if the time between X-rays and MRI was >6 months. All 39 patients with symptomatic, single-level lumbar spondylolisthesis were identified. The mean age was 57.3±16.7 years and 66% were female. There was good intra- and inter-rater reliability agreement between measured values on the presence of instability. The slip percentage (SP) difference was significantly highest in the flexion-supine (FS) (5.7 mm, 12.3%) and neutral standing-supine (NS) (4.3 mm, 8.7%) groups, both of which were significantly higher compared with the flexion-extension (FE) group (1.8 mm, 4.5%, P<0.001). Ventral instability based on SP >8% was observed more frequently in FS (79.5%) and NS (52.6%) groups compared with FE group (16.7%, P<0.001). No statistically significant correlation was found between SP and disc angle for all radiographic views. Comparing standing lateral and flexion X-rays with supine MRIs provides higher sensitivity to assess instability than standard flexion-extension radiographs. The FS and NS comparisons also show greater slip percentage differences at higher slip grades, but not at different lumbar levels. These changes are not dependent on age or gender.

Clinical Outcome Assessment following Open Reduction and Instrumented Posterior Interbody Fusion of Adult Single-Level Lumbar Spondylolisthesis

Background Data: Posterior lumbar decompression combined with instrumented posterior lumbar interbody fusion (PLIF) is the gold standard management of adult spondylolisthesis. Complete anatomic surgical reduction of slippage, although controversial, is associated with encouraging results. Purpose: This study aims to assess the clinical outcome of complete open surgical reduction and instrumented PLIF in adult single-level lumbar spondylolisthesis. Study design: Retrospective clinical case study. Patients and Methods: Retrospective review of standing data and radiographs of adult patients with single-level lumbar spondylolisthesis (regardless of the aetiology) from January 2018 to January 2020. All patients have undergone posterior lumbar decompression, pedicle screw instrumentation, complete reduction of the slippage, and PLIF. All patients were assessed at six and 12 months postoperatively by Visual Analogue Scale (VAS), Oswestry Disability Index (ODI), and the Odom criteria. Results: A total of 118 patients met the inclusion criteria. There was no neurologic deterioration in any of the patients postoperatively. There was a significant change in VAS, ODI, and Odom’s criteria at six and 12 months postoperatively (p < 0.001). The mean value for VAS and ODI were 0.61 ± 1.03 and 4.52 ± 7.02, respectively, at the last follow-up. There was a significant change in Odom’s criteria as 61.9% of patients had excellent outcomes at the last follow-up. Conclusion: Complete surgical reduction of single-level lumbar spondylolisthesis combined with instrumented PLIF offers adequate neural element decompression and satisfactory clinical outcome. (2020ESJ227)

P41. Flexion-extension radiographs underestimate instability in patients with single-level lumbar spondylolisthesis. Comparing flexion-supine imaging may be more appropriate

BACKGROUND CONTEXT Most spine surgeons use flexion-extension radiographs in their surgical decision-making for patients with lumbar spondylolisthesis. However, this method may underestimate the instability at a lumbar segment. Unfortunately, insurance companies often use radiology reports of flexion-extension radiographs to determine eligibility for lumbar fusion and often refuse appropriate care based on obsolete criteria. The utility of lateral dynamic films remains controversial in this population. To the authors' knowledge, no prior study has compared Slip Percentage (SP) in standing versus supine positioning. PURPOSE To compare flexion-extension (FE) with standing-supine (SS) and Flexion-Supine (FSu) views in providing an evaluation of segmental lumbar instability for single level spondylolisthesis. STUDY DESIGN/SETTING Retrospective cohort study. PATIENT SAMPLE Adult (>=18 years old) patients with single-level lumbar spondylolisthesis who underwent surgical treatment from 2016 to 2019. OUTCOME MEASURES Slip percentage differences and ventral instability. METHODS Consecutively collected adult (>=18 years old) patients with single-level lumbar spondylolisthesis who underwent surgical treatment from 2016 to 2019 were reviewed from a two-surgeon database. Anterior displacement (A) of a vertebra relative to the caudad vertebra was measured as a percentage of the sagittal length (B) of the caudad vertebral body (Slip Percentage, SP=100xA/B). Ventral instability was defined as an SP difference>8% as used in prior literature. Supine SP was calculated from sagittal Lumbar MRI. Chi-square/Fisher's Exact test and t-test were used for categorical and continuous variables. RESULTS Forty-four patients with lumbar spondylolisthesis who underwent surgery were identified. The cohort had a mean age of 57.3+-16.7 years and 66% of them were female. The majority had a slip grade of either 1 or 2 (Grade 1: 52.2%, Grade 2: 38.6%, Grade 3: 9.1%, Grade 4: 0%) and at the L4-5, 5-1 levels (L3-4: 2.3%, L4-5: 59.1%, L5-S1: 38.6%). The magnitude of change in SP was significantly highest in the FSu (12.7%) and SS (9.2%) groups, both of which were significantly higher compare with the traditional FE group (4.0%, P CONCLUSIONS Routine FE radiographs for lumbar spondylolisthesis may not be necessary and may underreport instability in single-level lumbar spondylolisthesis. SS and FSu parameters provide more sensitive measures of instability and may reduce unnecessary radiation exposure and costs. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Transforaminal lumbar interbody fusion (TLIF) versus posterior lumbar interbody fusion (PLIF) in the treatment of single-level lumbar spondylolisthesis

BackgroundVarious surgical procedures have been recommended for the treatment of lumbar spondylolisthesis, but controversy still exists regarding the optimal surgical technique. In this study, we compared the clinical and radiologic outcomes of posterior lumbar interbody fusion (PLIF) and transforaminal lumbar interbody fusion (TLIF) with pedicle screw fixation in the treatment of single-level lumbar spondylolisthesis.MethodsNinety-four patients underwent lumbar interbody fusion with pedicle screw fixation for the treatment of adult lumbar spondylolisthesis. Forty-six had PLIF with two cages and pedicle fixation (group 1), and 48 had TLIF with one cage and pedicle fixation (group 2). The follow-up was performed clinically using the visual analog scale (VAS) and Oswestry Disability Index (ODI) Questionnaires. Outcome scores were assessed 3, 6, and 12 months after surgery. Radiographs were obtained postoperatively and at regular intervals for 6 months. Perioperative outcomes such as surgery time, blood loss, length of hospital stay, and incidence of surgical complications were also recorded.ResultsEstimated blood loss and operative time in the TLIF group were significantly lower than those in the PLIF group. VAS for back pain and ODI were significantly better in the TLIF group than the PLIF group. However, at the time of the last follow-up, both groups had similar slip reduction and spinal fusion rates. More complication rate was encountered in the PLIF group compared to the TLIF group.ConclusionsOur study showed that TLIF is superior to PLIF with respect to functional outcome and complication rate in grade I/II single-level lumbar spondylolisthesis.

Minimally Invasive Transforaminal Interbody Fusion With Robotically Assisted Bilateral Pedicle Screw Fixation: 2-Dimensional Operative Video.

Minimally invasive surgery (MIS) techniques may enable faster patient recovery and reduce the incidence of postoperative infections. Image-guided approaches to spinal instrumentation and interbody fusion have gained popularity in MIS, reducing radiation exposure and improving screw placement accuracy. Use of a novel computed tomography (CT) navigation-based robotic arm provides for live image-guided surgery, with the potential for augmenting existing MIS approaches and improving the accuracy of instrumentation placement. We report on the surgical technique of MIS transforaminal lumbar interbody fusion (TLIF) performed with the assistance of a new robotic device (ExcelsiusGPS, Globus Medical Inc, Audubon, Pennsylvania) and intraoperative CT guidance in a patient with single-level lumbar spondylolisthesis. The patient gave written informed consent before treatment. Institutional review board approval was deemed unnecessary. The patient was positioned prone on the operating room table, and an intraoperative CT was obtained with stereotactic arrays placed bilaterally in the posterior superior iliac spine. Screw trajectories were planned using the ExcelsiusGPS software and placed percutaneously with the robotic arm without using a Kirschner wire. Interbody placement was performed via an expandable retractor after muscle dilation. Screw placement accuracy was determined with postoperative CT, which demonstrated good screw positioning without breach. The patient recovered well and was discharged home without complications. The combined use of the new robotic device and intraoperative CT enables accurate and safe fixation for the treatment of symptomatic lumbar spondylolisthesis. The operative video demonstrates the technical nuances of positioning, stereotactic marker placement, work flow, and screw placement. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Utility of Supine Lateral Radiographs for Assessment of Lumbar Segmental Instability in Degenerative Lumbar Spondylolisthesis.

Retrospective chart review OBJECTIVE.: To determine whether supine lateral radiographs increase the amount of segmental instability visualized in single-level lumbar degenerative spondylolisthesis, when compared to traditional lateral flexion-extension radiographs. We hypothesized that supine radiographs increase the amount of segmental instability seen in single-level lumbar spondylolisthesis when compared to flexion-extension. Accurate evaluation of segmental instability is critical to the management of lumbar spondylolisthesis. Standing flexion-extension lateral radiographs are routinely obtained, as it is believed to precipitate the forward-backward motion of the segment; however, recent studies with magnetic resonance imaging and computed tomography have shown that the relaxed supine position can facilitate the reduction of the anterolisthesed segment. Here, we show that inclusion of supine lateral radiographs increases the amount of segmental instability seen in single-level lumbar spondylolisthesis when compared to traditional lateral radiographs. Supine lateral radiographs were added to the routine evaluation (standing neutral/flexion/extension lateral radiographs) of symptomatic degenerative spondylolisthesis at our institution. In this retrospective study, 59 patients were included. The amount of listhesis was measured and compared on each radiograph: standing neutral lateral ("neutral"), standing flexion lateral ("flexion"), standing extension lateral ("extension"), and supine lateral ("supine"). A total of 59 patients (51 women, 8 men), with a mean age of 63.0 years (±9.85 yr) were included. The mean mobility seen with flexion-extension was 5.53 ± 4.11. The mean mobility seen with flexion-supine was 7.83% ± 4.67%. This difference was significant in paired t test (P = 0.00133), and independent of age and body mass index. Maximal mobility was seen between flexion and supine radiographs in 37 patients, between neutral and supine radiographs in 11 cases, and between traditional flexion-extension studies in 11 cases. Supine radiograph demonstrates more reduction in anterolisthesis than the extension radiograph. Incorporation of a supine lateral radiograph in place of extension radiograph can improve our understanding of segmental mobility when evaluating degenerative spondylolisthesis. 3.

Clinical and Radiological Comparison between Three Different Minimally Invasive Surgical Fusion Techniques for Single-Level Lumbar Isthmic and Degenerative Spondylolisthesis: Minimally Invasive Surgical Posterolateral Fusion versus Minimally Invasive Surgical Transforaminal Lumbar Interbody Fusion versus Midline Lumbar Fusion.

Study DesignRetrospective cohort study.PurposeComparison between three different minimally invasive surgical (MIS) fusion techniques for single-level lumbar spondylolisthesis.Overview of LiteratureThere has been an increase in the development and utilization of MIS techniques for lumbar spine fusion. No study has compared the efficacy of MIS-posterolateral fusion (MIS-PLF), MIS-transforaminal lumbar interbody fusion (MIS-TLIF), and midline lumbar fusion (MIDLF) with modified cortical bone trajectory screws for lumbar spondylolisthesis.MethodsFifty-nine patients with single-level lumbar spondylolisthesis and a minimum follow-up period of 1 year were included in this study. The MIS-PLF, MIS-TLIF, and MIDLF groups included 22, 15, and 22 patients, respectively. The average age of the groups was 70.6, 49.3, and 62.7 years, respectively. The evaluation parameters were operation time, intraoperative bleeding, serum C-reactive protein (CRP) value, creatine kinase (CK) value, and overall functional outcome as per the Japanese Orthopedic Association Back Pain Evaluation Questionnaire (JOABPEQ) score. The changes in the lumbar lordosis angle (LLA), segmental disc angle (SDA), and disc height were measured. Fusion rate, screw loosening, and loss of correction were also assessed.ResultsMIDLF showed a significantly shorter operation time (111 min), less bleeding amount (112.5 mL), and lower values of CRP and CK than the other two techniques. There was no significant difference in the JOABPEQ scores of the three groups. MIDLF resulted in a greater increase in the LLA and SDA postoperatively. MIDLF and MIS-TLIF resulted in a significant increase in the middle disc height compared with MIS-PLF. MIDLF showed a lower loss of correction after 6 months postoperatively (2.6%) than MIS-PLF (5.2%) and MIS-TLIF (4.2%). The fusion rate was 100% in the MIDLF and MIS-TLIF groups and 90% in the MIS-PLF group. Screw loosening occurred in 10% of the MIS-PLF cases, 7.14% of the MIS-TLIF cases, and 4.76% of the MIDLF cases.ConclusionsMIDLF was the least invasive, and there was no significant difference between the three groups in terms of fusion, screw loosening, and clinical outcomes.

Clinical outcomes of single-level lumbar spondylolisthesis by minimally invasive transforaminal lumbar interbody fusion with bilateral tubular channels

Objective: To evaluate the clinical effectiveness of minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) for single-level lumbar spondylolisthesis treatment with bilateral Spotlight tubular channels. Methods: A total of 21 patients with lumbar spondylolisthesis whom underwent MIS-TLIF via bilateral Spotlight tubular channels were retrospectively analyzed from October 2014 to November 2015. The 21 patients included 11 males and 10 females ranged from 35 to 82 years (average aged 60.7 years). In term of spondylolisthesis category, there were 18 cases of degenerative spondylolisthesis and 3 cases of isthmic spondylolisthesis. With respect to spondylolisthesis degree, 17 cases were grade Ⅰ° and 4 cases were grade Ⅱ°. Besides, 17 cases at L(4-5) and 4 cases at L(5)-S(1)were categorized by spondylolisthesis levels. Operation duration, blood loss, postoperative drainage and intraoperative exposure time were recorded, functional improvement was defined as an improvement in the Oswestry Disability Index (ODI), Visual Analog Scale (VAS) was also employed at pre and post-operation (3 months and the last follow-up), to evaluate low back and leg pain. Furthermore, to evaluate the recovery of the intervertebral foramen and of lumbar sagittal curvature, average height of intervertebral space, Cobb angles of lumbar vertebrae and operative segments, spondylolisthesis index were measured. At the last follow-up, intervertebral fusion was assessed using Siepe evaluation criteria and the clinical outcome was assessed using the MacNab scale. Radiographic and functional outcomes were compared pre- and post-operation using the paired T test to determine the effectiveness of MIS-TLIF. Statistical significance was defined as P<0.05. Results: All patients underwent a successful MIS-TLIF surgery. The operation time (235.2±30.2) mins, intraoperative blood loss (238.1±130.3) ml, postoperative drainage (95.7±57.1) ml and intraoperative radiation exposure (47.1±8.8) were recorded. Different significance between 3 months post-operative follow-up and pre-operation was exhibited (P<0.01) in respects of lumbar VAS (t=11.1, P<0.01) and leg VAS (t=17.8, P<0.01). Moreover, final follow-up compared with pre-operation, and final follow-up compared with 3 months post-operative follow-up, VAS scores were also statistical difference (P<0.01). At the final follow-up, there were significant differences compared with pre-operation in ODI scores (t=30.1, P<0.01). Comparison between 3 months post-operative follow-up and pre-operation, statistical distinctions were demonstrated (P<0.05) in terms of mean height of intervertebral space (t=-10.9, P<0.01), the Cobb angles of lumbar vertebrae (t=-2.4, P<0.05), operative segments Cobb angles (t=-5.2, P<0.01) and Lumbar spondylolisthesis incidence (t=17.1, P<0.01). In addition, there was statistical difference between final follow-up and pre-operation (P<0.05) as well. For instance, mean height of intervertebral space (t=-10.5, P<0.01), the Cobb angles of lumbar vertebrae (t=-2.7, P<0.05), operative segments Cobb angles (t=-4.2, P<0.01) and Lumbar spondylolisthesis incidence (t=18.6, P<0.01) were involved. All spondylolisthesis vertebrae were restored completely. Lastly, at the last follow-up, 12 cases of grade 1 and 7 cases of grade 2 fusion were present as determined by the Siepe evaluation criteria. McNab scale assessment classified 17 patients having excellent clinical outcome, 3 patients in good and 1 patient having a better clinical outcome. Conclusion: MIS-TLIF with bilateral Spotlight tubular channels is a safe and effective approach for single segment lumbar spondylolisthesis.

Kinematic analysis of diseased and adjacent segments in degenerative lumbar spondylolisthesis

Background contextDegenerative spondylolisthesis is a common pathologic condition that leads to lumbar instability and significant clinical symptoms. The effect of this pathology on adjacent lumbar motion segments, however, has not yet been studied. PurposeTo characterize the motion characteristics of lumbar degenerative spondylolisthesis at both the diseased and adjacent levels in patients with low-grade, single-level lumbar degenerative spondylolisthesis using kinetic magnetic resonance imaging (kMRI). Study designRetrospective study of patient kMRIs. Patient sampleOne-hundred twelve patient MRIs with low-grade, single-level lumbar spondylolisthesis were included. Outcome measuresAngular and translational motion. MethodsThis study compared 112 patients diagnosed with low-grade (Grade 1 or 2), single-level lumbar degenerative spondylolisthesis at L3–L4, L4–L5, or L5–S1 with 296 control patients without spondylolisthesis. Angular and translational motion were measured using patient kMRIs. The level of slip was graded according to the Meyerding classification system, and disc degeneration was classified according to the Pfirrmann system. Instability was defined as translational motion greater than 4 mm. ResultsLumbar hypomobility was often present regardless of the level of degenerative spondylolisthesis. A slip at L3–L4 resulted in the largest decrease in lumbar range of motion. Instability at the diseased level was most common at L3–L4 (36%), followed by L5–S1 (31%) and L4–L5 (30%). Instability at the adjacent segments was most frequent at L4–L5 (49%), followed by L5–S1 (34%) and L3–L4 (23%). Patients with stable spondylolisthesis generally had decreased angular motion at all lumbar levels. Translational motion at the diseased level was consistently increased. Disc degeneration was significantly greater at the level of slip for the L3–L4 and L4–L5 spondylolisthesis groups and equal to the control group in the L5–S1 group. There was no significant difference in disc degeneration at adjacent segments in L3–L4 and L4–L5 degenerative spondylolisthesis patients, but there was a significant decrease with an L5–S1 slip. ConclusionsThere were a similar percentage of patients in each degenerative spondylolisthesis group with lumbar instability. Angular motion decreased at the diseased level with L3–L4 and L5–S1 spondylolisthesis, but increased with L4–L5 spondylolisthesis. Translational motion, however, increased at the diseased level in all three groups. There was compensatory hypermobility at adjacent levels in patients with unstable spondylolisthesis at L3–L4 and L4–L5, but not at L5–S1.

Minimally invasive microendoscopy-assisted transforaminal lumbar interbody fusion with instrumentation

The authors have developed a novel technique for percutaneous fusion in which standard microendoscopic discectomy is modified. Based on data obtained in their cadaveric studies they considered that this minimally invasive interbody fusion could be safely implemented clinically. The authors describe their initial experience with a microendoscopic transforaminal lumbar interbody fusion (METLIF) technique, with regard to safety in the placement of percutaneous instrumentation, perioperative morbidity, and early postoperative results. The METLIF procedure was performed unilaterally in 20 patients with single-level lumbar spondylolisthesis or pure mechanical back pain with endoscopic assistance, hemilaminectomy, unilateral facetectomy, and microdiscectomy. Two interbody grafts were placed via the lateral exposure of the disc space. Bilateral percutaneous pedicle screws were then inserted. Compared with patients who had undergone single-level posterior LIF at the same institutions, intraoperative blood loss, hospital length of stay (LOS), and postoperative narcotic agent use were significantly lower in the METLIF group. The mean LOS for the percutaneous fusion group was 3.4 days (5.1 days in those who underwent PLIF; p < 0.02). There have been no procedure-related complications in this series to date. The METLIF technique provided an option for percutaneous interbody fusion similar to that in open surgery while minimizing destruction to adjacent tissues. This technique was safe and exhibited a trend toward decreased intraoperative blood loss, postoperative pain, total narcotic use, and the risk of transfusion.