Slip Progression Research Articles

Smaller Epiphyseal Tubercle and Larger Peripheral Cupping in Slipped Capital Femoral Epiphysis Compared with Healthy Hips: A 3-Dimensional Computed Tomography Study.

The inner surface of the capital femoral epiphysis is important for growth plate stability. However, abnormalities of epiphyseal morphology associated with the pathogenesis of slipped capital femoral epiphysis (SCFE) remain poorly understood. This study compares the 3-dimensional anatomy of the epiphyseal tubercle and peripheral cupping in hips with SCFE and normal hips. We created 3-dimensional models of the capital femoral epiphysis with use of computed tomography (CT) imaging from 51 patients with SCFE and 80 subjects without hip symptoms who underwent CT because of abdominal pain. The height, width, and length of the epiphyseal tubercle and the peripheral cupping were measured and normalized by the epiphyseal diameter and presented as a percentage. We used analysis of variance for the comparison of the measurements between SCFE and control hips after adjusting for age and sex. Compared with normal hips, hips with mild SCFE had smaller mean epiphyseal tubercle height (0.9% ± 0.9% compared with 4.4% ± 0.4%; p = 0.006) and length (32.3% ± 1.8% compared with 43.7% ± 0.8%; p < 0.001). The mean epiphyseal tubercle height was also smaller in hips with moderate (0.6% ± 0.9%; p = 0.004) and severe SCFE (0.3% ± 0.8%; p < 0.001) compared with normal hips. No differences were observed for measurements of epiphyseal tubercle height and length between SCFE subgroups. The mean peripheral cupping was larger in hips with mild (16.3% ± 1.0%; p < 0.001), moderate (16.4% ± 1.1%; p < 0.001), and severe SCFE (18.9% ± 0.9%; p < 0.001) overall and when assessed individually in all regions compared with normal hips (10.6% ± 0.5%). Hips with SCFE have a smaller epiphyseal tubercle and larger peripheral cupping compared with healthy hips. A smaller epiphyseal tubercle may be a predisposing morphologic factor or a consequence of the increased shearing stress across the physis secondary to the slip. Increased peripheral growth may be an adaptive response to instability as other stabilizers (i.e., epiphyseal tubercle and anterior periosteum) become compromised with slip progression. Future studies are necessary to determine the biomechanical basis of our morphologic findings.

Coupled nonlinear elasticity, plastic slip, twinning, and phase transformation in single crystal titanium for plate impact loading

High purity single crystal titanium (Ti) under shockwave loading in plate impact experiment is modeled and simulated, with help of the finite element. A thermodynamically consistent system of equations is formulated in the frame of large deformation to consider material anisotropy, rate dependence, and multi-physics including nonlinear elasticity, dislocation based plastic slip, deformation twinning, and phase transformation. A novel kinematics is proposed to consider phase transformation in the α twin variants and also to consider the dislocation based slip in all of components of parent material, primary twins and the ω phase. The thermodynamically consistent driving forces for plastic slip, twinning, and phase transformation are developed based upon the second law of thermodynamics. For nonlinear elasticity, the stiffness matrix is dependent on the volume fractions of all components, and the volumetric part of Cauchy stress is obtained from the nonlinear equation of state. Dislocation based plastic slip in multi-variant and multiphase heterogeneous materials is developed and interactions of dislocations among all slip modes are taken into account. A mechanism for dislocation density evolution during twinning and phase transformation is proposed. The shock loading along the [0001] and [101¯1] directions of single crystal high purity Ti is investigated computationally. Very good correspondence between simulation and experiment is obtained, which includes pole figures, volume fractions of components, free surface velocity, peak pressure, and phase transformation pressure. Multiple experimental phenomena are interpreted based upon the progression of dislocation slip, deformation twinning, and phase transformation. In compression with the [101¯1] crystal, a higher volume fraction in the primary twins but a lower secondary twin volume fraction in the [0001] crystal in experiment was observed. The higher propensity for phase transformation occurs in the [0001] crystal is reproduced. In addition to material texture, distributions of temperature, stresses, and plastic strains dependent on the impact loading directions are revealed.

A Novel Classification System for Slipped Capital Femoral Epiphysis Based on the Radiographic Relationship of the Epiphyseal Tubercle and the Metaphyseal Socket.

Background:Recent studies have suggested that the epiphyseal tubercle serves as a fulcrum for rotation in slipped capital femoral epiphysis (SCFE). However, radiographic evidence of the rotational mechanism is limited. In this study, we describe a novel radiographic staging system for SCFE based on the anatomic relationship between the epiphyseal tubercle and the metaphyseal socket.Methods:We reviewed the cases of 469 patients with SCFE who were treated at our institution between 2000 and 2017. SCFE was classified according to our proposed staging system using the preoperative lateral radiograph. Normal hips were considered to be Stage 0. In Stage 1, the tubercle is concentric within its metaphyseal socket, which is enlarged and may present peritubercle radiolucency. In Stage 2, there is evidence of eccentricity of the tubercle, which remains in contact with the posterior wall of the socket. In Stage 3, the tubercle and metaphyseal lucency reach the posterior cortex of the femoral neck. A complete dislodgment of the tubercle from the metaphysis is present in Stage 4. Intra- and interobserver agreement, and correlations between the staging system and the traditional classifications of severity, stability, and chronicity, were estimated.Results:The distribution by stage was as follows: 2% of the hips were classified as Stage 0, 19% were Stage 1, 48% were Stage 2, 15% were Stage 3, and 16% were Stage 4. The staging system had excellent intraobserver (κ = 0.89 [95% confidence interval (CI) = 0.83 to 0.96]) and interobserver agreement (κ = 0.87 [95% CI = 0.72 to 1.00]). There was a high correlation between the staging system and SCFE severity as assessed by the Southwick angle (r = 0.77 [95% CI = 0.73 to 0.82]; p < 0.001). There was a moderate correlation between the staging system and the Loder classification of stability (r = 0.55 [95% CI = 0.48 to 0.62]; p < 0.001) and a negligible correlation with the classification of chronicity (r = 0.19 [95% CI = 0.10 to 0.28]; p < 0.001).Conclusions:The proposed staging system for SCFE is highly reliable and correlates well with the severity of SCFE based on the degree of displacement, with moderate correlation shown for stability. This new staging system helps in understanding the rotational mechanism of SCFE, warranting further investigation to determine its clinical application.Clinical Relevance:The novel classification has the potential for the identification of hips that demonstrate subtle SCFE or are at pre-slip stage, or those at risk for osteonecrosis of the femoral head, failure of fixation, or slip progression.

MRI in idiopathic, stable, slipped capital femoral epiphysis: evaluation of contralateral pre-slip.

:PurposeEarly diagnosis and treatment of slipped capital femoral epiphysis (SCFE) is important to prevent slip progression and avoid complications. We sought to determine if MRI findings in patients with unilateral SCFE could indicate ‘pre-slip’ or predict future SCFE in the contralateral hip.MethodsA prospective study evaluated patients with unilateral SCFE over a two-year period. MRI of the asymptomatic hip was performed within the perioperative period. Patients were followed with radiographs until a contralateral slip occurred or until physeal closure. Demographics, clinical stability, severity, posterior slope angle (PSA), modified Oxford Bone Score (mOBS) and patency of the triradiate cartilage were recorded and statistical analysis performed.ResultsIn all, 33 of 54 patients with unilateral SCFE were enrolled into the study. In all, 29 (87.8%) had complete follow-up. Five of the enrolled patients (15.2%) developed a sequential slip requiring in situ pinning. Six of 33 (18.2%) patients had positive MRI findings: four of which proceeded to sequential SCFE and two which did not. One sequential slip had a negative MRI. PSA predicted 1/11 sequential slips (sensitivity 9.09%, specificity 81.4%, positive predictive value (PPV) 11.1%, negative predictive value (NPV) 77.8%) and mOBS predicted 5/11 sequential slips (sensitivity 45.5%, specificity 93%, PPV 62.5%, NPV 87%). An open triradiate cartilage was present in 8/11 patients with sequential slips (sensitivity 72.7%, specificity 81.4%, PPV 50%, NPV 92.1%).ConclusionMRI findings consistent with ‘pre-slip’ were present in 66.7% of patients who developed a sequential SCFE. Further study on the utility/sensitivity of MRI in predicting sequential SCFE is warranted.Level of EvidenceII, diagnostic

Salvage of failed in-situ pinning in severe unstable slipped capital femoral physis by surgical dislocation and capital realignment

AimsWe describe surgical dislocation with capital realignment as an option for management of failed in-situ pinning in children with severe unstable slipped capital femoral physis. Patients and methodsA retrospective data collection from our hospital hip database retrieved 7 patients with severe unstable slipped capital femoral physis who had failed in-situ pinning with severe deformity and grossly restricted movements. The failure of pinning in-situ was due to slip progression with inadequate screw purchase in four patients, stress fracture of the femoral neck in one patient, and screw head impingement in two patients. All these patients under went open surgical dislocation, removal of the screws, followed by sub-capital realignment and fixation. ResultsThe average age at presentation was 11.9 years (10–14 years). The mean follow-up was 50.14 months (25–66 months). Four patients who had pre-existing avascular necrosis at presentation underwent second stage hinged distraction of the hip joint. Preoperatively, the mean Modified Harris Hip Score (MHHS) was 19.57 (0–56) and the mean Non-Arthritic Hip Score (NAHS) was 21.07 (5–51.5) respectively. The mean MHHS at the last follow-up visit was 88.97 (71–96) and NAHS was 84.28 (69.5–91) respectively. ConclusionAllowing the hip to heal in its anatomical position is the best possible correction we could give for any patient with severe slipped capital femoral epiphysis. We found that surgical dislocation for those with failed in-situ pining proved to be an effective bailout option for restoration of anatomy and function.

Spondylolisthesis is Common, Early, and Severe in Loeys-Dietz Syndrome

We studied the prevalence and treatment outcomes of spondylolisthesis in patients with Loeys-Dietz syndrome (LDS). Clinical data and lumbosacral imaging of 138 patients with LDS were reviewed. Spondylolisthesis (L4-L5 or L5-S1) and spondylolysis were characterized by multimodal imaging and correlated with clinical data. Treatments and outcomes were characterized for patients with spondylolisthesis. Associations were determined using the Fisher exact, Mann-Whitney, and Student t tests (α=0.05). Twenty-four patients (17%) had spondylolysis and 23 (17%) had spondylolisthesis. Median age at spondylolisthesis diagnosis was 11 (interquartile range, 9.5) years. In patients in whom measurement was possible (n=20), mean (±SD) slip was 48% (±35%). Nineteen patients had L5-S1 slip and 4 had L4-L5 slip. Of the patients with spondylolisthesis, 5 had no evidence of spondylolysis; of those with spondylolysis, all but 6 had spondylolisthesis. Eleven patients with spondylolisthesis underwent posterior spinal fusion (PSF) to treat slip progression, pain, and/or neurological deficit. Spondylolisthesis recurred in 1 patient who underwent PSF with bone graft arthrodesis alone (no instrumentation). The other 10 patients underwent PSF with instrumentation and fusion. Three patients additionally underwent Bohlman interbody fusion. Two patients developed implant failure. S2 fixation was performed at revision to achieve fusion in these patients. Mean Meyerding grade improved in patients who underwent arthrodesis, from 3.9 (±1.2) to 1.9 (±1.3) (P=0.002). Complications were 2 cerebrospinal fluid leaks, 2 transient postoperative paresthesias, and 1 case each of pseudarthrosis at S1-S2, wound dehiscence, and transient urinary incontinence. No significant associations between LDS type and lumbosacral abnormalities were found. High-grade spondylolisthesis is common in LDS and usually associated with spondylolysis. Patients requiring surgery for spondylolisthesis present during childhood and do well after instrumented PSF. Interbody fusion and stabilization of S1 and S2 can prevent physeal deformation. LDS should be considered in patients with high-grade spondylolisthesis. Patients with LDS should be monitored for spondylolisthesis and spondylolysis starting when they are young. Level IV-retrospective study.

Quality of Life and Slip Progression in Degenerative Spondylolisthesis Treated Nonoperatively.

A prospective cohort study of consecutive patients. Determination of the quality of life (QoL) and prevalence of slip progression in patients with degenerative lumbar spondylolisthesis managed nonoperatively. Lumbar spinal stenosis secondary to degenerative lumbar spondylolisthesis is a common radiographic diagnosis associated with chronic back pain and radicular symptoms. There is limited evidence as to the clinical course in terms of validated QoL measures, and the extent of slip progression in patients with this condition treated nonoperatively. Validated disease-specific and generic QoL metrics including SF12 physical and mental scores [SF12-physical component summary (PCS) and SF12-mental component summary (MCS)], Oswestry Disability Index (ODI), and numeric scales for back and leg pain as well as radiographic assessment of slip extent were evaluated at initial consultation (baseline) and at a minimum of 5 years after the baseline assessment. Slip progression was defined by a >5% increase in slip percentage. Thirty-nine of 160 (24.4%) patients elected to switch to operative management, despite no slip progression on preoperative radiographs. Seventy spondylolisthetic levels in 66 participants were assessed after a minimum of 5 years of nonoperative management. Twenty-one participants (31.8%) had slip progression. SF12-PCS, ODI, and leg pain improved similarly in both groups (P < 0.05). SF12-MCS did not change significantly in either group. Back pain improved only in the nonprogressing group. The majority of cases of low-grade spondylolisthesis do not progress over 5 years with nonoperative management. Regardless of whether there was progression or not, the mean PCS, ODI, and leg pain improved from baseline, although symptoms remained and a significant number elected to switch to surgical management before 5 years. Back pain improved with nonoperative treatment only in those without progression. 2.

Nanoscale Origins of the Size Effect in the Compression Response of Single Crystal Ni-Base Superalloy Micro-Pillars.

Nickel superalloys play a pivotal role in enabling power-generation devices on land, sea, and in the air. They derive their strength from coherent cuboidal precipitates of the ordered γ’ phase that is different from the γ matrix in composition, structure and properties. In order to reveal the correlation between elemental distribution, dislocation glide and the plastic deformation of micro- and nano-sized volumes of a nickel superalloy, a combined in situ nanoindentation compression study was carried out with a scanning electron microscope (SEM) on micro- and nano-pillars fabricated by focused ion beam (FIB) milling of Ni-base superalloy CMSX4. The observed mechanical response (hardening followed by softening) was correlated with the progression of crystal slip that was revealed using FIB nano-tomography and energy-dispersive spectroscopy (EDS) elemental mapping. A hypothesis was put forward that the dependence of material strength on the size of the sample (micropillar diameter) is correlated with the characteristic dimension of the structural units (γ’ precipitates). By proposing two new dislocation-based models, the results were found to be described well by a new parameter-free Hall–Petch equation.

Current Evidence Regarding the Treatment of Pediatric Lumbar Spondylolisthesis: A Report From the Scoliosis Research Society Evidence Based Medicine Committee

Study DesignStructured literature review. ObjectivesThe Scoliosis Research Society requested an assessment of the current state of peer-reviewed evidence regarding pediatric lumbar spondylolisthesis to identify what is known and what research remains essential to further understanding. Summary of Background DataPediatric lumbar spondylolisthesis is common, yet no formal synthesis of the published literature regarding treatment has been previously performed. MethodsA comprehensive literature search was performed. From 6600 initial citations with abstract, 663 articles underwent full-text review. The best available evidence regarding surgical and medical/interventional treatment was provided by 51 studies. None of the studies were graded Level I or II evidence. Eighteen of the studies were Level III, representing the current best available evidence. Thirty-three of the studies were Level IV. ResultsAlthough studies suggest a benign course for “low grade” (<50% slip) isthmic spondylolisthesis, extensive literature suggests that a substantial number of patients present for treatment with pain and activity limitations. Pain resolution and return to activity is common with both medical/interventional and operative treatment. The role of medical/interventional bracing is not well established. Uninstrumented posterolateral fusion has been reported to produce good clinical results, but concerns regarding nonunion exist. Risk of slip progression is a specific concern in the “high grade” or dysplastic type. Although medical/interventional observation has been reported to be reasonable in a small series of asymptomatic high-grade slip patients, surgical treatment is commonly recommended to prevent progression. There is Level III evidence that instrumentation and reduction lowers the risk of nonunion, and that circumferential fusion is superior to posterior-only or anterior-only fusion. There is Level III evidence that patients with a higher slip angle are more likely to fail medical/interventional treatment of high-grade spondylolisthesis. ConclusionsThe current “best available” evidence to guide the treatment of pediatric spondylolisthesis is presented. Level of EvidenceLevel III; review of Level III studies.

Lumbar Spinal Stenosis Associated With Degenerative Lumbar Spondylolisthesis: A Systematic Review and Meta-analysis of Secondary Fusion Rates Following Open vs Minimally Invasive Decompression.

Decompression without fusion is a treatment option in patients with lumbar spinal stenosis (LSS) associated with stable low-grade degenerative spondylolisthesis (DS). A minimally invasive unilateral laminotomy (MIL) for "over the top" decompression might be a less destabilizing alternative to traditional open laminectomy (OL). To review secondary fusion rates after open vs minimally invasive decompression surgery. We performed a literature search in Pubmed/MEDLINE using the keywords "lumbar spondylolisthesis" and "decompression surgery." All studies that separately reported the outcome of patients with LSS+DS that were treated by OL or MIL (transmuscular or subperiosteal route) were included in our systematic review and meta-analysis. The primary end point was secondary fusion rate. Secondary end points were total reoperation rate, postoperative progression of listhetic slip, and patient satisfaction. We identified 37 studies (19 with OL, 18 with MIL), with a total of 1156 patients, that were published between 1983 and 2015. The studies' evidence was mostly level 3 or 4. Secondary fusion rates were 12.8% after OL and 3.3% after MIL; the total reoperation rates were 16.3% after OL and 5.8% after MIL. In the OL cohort, 72% of the studies reported a slip progression compared to 0% in the MIL cohort, respectively. After OL, satisfactory outcome was 62.7% compared to 76% after MIL. In patients with LSS and DS, minimally invasive decompression is associated with lower reoperation and fusion rates, less slip progression, and greater patient satisfaction than open surgery.

Épiphysiolyse fémorale supérieure

Slipped capital femoral epiphysis (SFCE) is a disorder of the hip, characterized by a displacement of the capital femoral epiphysis from the metaphysic through the femoral growth plate. The epiphysis slips posteriorly and inferiorly. SCFE occurs during puberty and metabolic and epidemiologic risk factors, such as obesity are frequently found. Most chronic slips are diagnosed late. Sagittal hip X-rays show epiphysis slip. In case of untreated SCFE, a slip progression arises with an acute slip risk. Treatment is indicated to prevent slip worsening. The clinical and radiological classification is useful to guide treatment and it is predictive of the prognosis. In situ fixation of stable and moderately displaced SCFE with cannulated screws gives excellent results. Major complications are chondrolysis and osteonecrosis and the major sequelae are femoroacetabular impingement and early arthritis.

The growing spine – a bestseller

The growing spine is – particularly in performance oriented young athletes – prone to overload: under pubertal hormonal influence the 48 cartilaginous growth zones beneath the vertebral endplates are mechanical as fragil as never before during growth whereas on the other side the impacting forces are becoming higher due to the longer trunk lever arm, the often apparent relative muscular insufficiency, the increasing training hours and intensity as well as the willingness and pressure to perform. The subsequent biomechanical imbalance usually results in simple functional complaints but may also entail structural changes, for example (thoraco-) lumbar Scheuermann’s disease in sports with high axial impact such as alpine skiing oder gymnastics. Early detection, modification of training and unloading of the anterior spinal column by brace therapy ease pain and prevent pathologic changes of the sagittal profile. Repetitive lumbar hyperlordosis and rotation increase the incidence and symptoms of spondylolysis which responds to conservative therapy in most cases. In contrast, the occurrence and progression of a vertebral slip is not sport-associated but rather fueled by predisposing pelvic and vertebral lumbosacral anatomic factors and ongoing growth. High-grade slips warrant operative stabilisation. In patients diagnosed with lumbar functional back pain which does not quickly respond to conservative measures, radiographic assessment (standing radiographs) is recommended since lumbosacral pathologies are frequently contributing to or even causing pain. The same holds true for infrapelvic factors like hip pathologies and leg length differences. Consequently, a thorough peripheral orthopaedic examination represents an obligatory part of the assessment mainly in view of the importance of potential pathologies for the career and longterm course. Yearly routine sports-medical exams of young athletes and timely assessment of symptomatic individuals by doctors with profound knowledge of the growth specific aspects is mandatory.

Natural history of lumbar spondylolysis—advances and concerns

Lumbar spondylolysis is a common cause of low back pain in adolescents and young adults. Due to a lack of understanding to the natural history, its treatment is often chaotic and controversial. Lumbar spondylolisthesis is a common complication of spondylolysis, but slip progression was commonly small and slow according to long-term follow-up studies. Many predisposing risk factors have been identified as associated with a great chance of slip progression. However, the widely accepted mechanism leading to adult slip progression is related to disc degeneration at the slip level. Clinical decision made for patients presenting with spondylolysis and spondylolisthesis principally include concerns for future progression of the spondylolisthesis and issues concerning pain. Most patients with spondylolysis and/or spondylolisthesis respond to conservative treatment. Surgical treatment is generally thought for patients who fail to respond to conservative treatment.

Lumbar Spinal Stenosis Associated with Degenerative Lumbar Spondylolisthesis: A Systematic Review and Meta-analysis of Secondary Fusion Rates following Open vs. Minimally Invasive Decompression

Introduction Decompression surgery plus instrumented fusion is the gold standard in patients with lumbar spinal stenosis (LSS) associated with degenerative spondylolisthesis (DS) when conservative treatment has failed. Open laminectomy (OL) alone is an option in patients with stable low-grade DS, but progressive instability contributes to significant secondary fusion rates and compromises patient outcome. A minimally invasive unilateral laminotomy (MIL) for “over the top” decompression is a potentially less destabilizing alternative. The aim of our systematic review and meta-analysis was to analyze secondary fusion rates after open laminectomy and minimally invasive laminotomy in patients with LSS associated with DS. Material and Methods We performed a systematic literature search in the National Center for Biotechnology Information Database (Pubmed/MEDLINE) using the keywords “lumbar spondylolisthesis” and “decompression surgery.” All studies that separately reported the outcome of patients with LSS associated with DS that were treated by decompression surgery only were included. The accepted decompression techniques were 1.) open laminectomy and 2.) microsurgical transmuscular or subperiosteal unilateral laminotomy with “over the top” decompression. The primary end point was secondary fusion rate. Secondary end points were total reoperation, complications, postoperative progression of listhetic slip, and patient satisfaction. Results We identified 37 studies with a total number of 1156 patients that were published between 1983 and 2015. 19 studies reported the outcome after OL, and 18 after MIL. There were two randomized controlled trials, 8 prospective, and 24 retrospective cohort studies or case series. In two trials the study design was unclear. None of the trials compared OL to MIL. The pooled secondary fusion rates were 12.8% in the OL cohort, and 3.3% in the MIL cohort; the pooled total reoperation rates were 16.3% after OL, and 5.8% after MIL. The complication rate ranged from 0–5.4% in the OL cohort, and from 0–8.1% in the MIL cohort. Surgery-related deaths, major permanent complications, or medical complications were not reported by the studies. In the OL cohort 72% of the studies displayed a slip progression compared with 0% in the MIL cohort, respectively. After OL the pooled analysis of satisfactory outcome was 62.7% compared with 76% after MIL. Conclusion In patients with LSS associated with DS a minimally invasive laminotomy is associated with lower reoperation and fusion rates, less slip progression and greater patient satisfaction than open surgery. Better quality studies are needed to corroborate these results. These results also indicate that routine fusion may not be necessary in all patients with LSS and DS.

Pelvic Incidence as a Prognostic Variable to Assess the Outcome of Conservative Treatment in the Patients with Spondylolisthesis

Introduction Spondylolisthesis is defined as slippage of one vertebra over the below one. Ever since the discovery of pelvic incidence by legaye et al. in 1998 and as well as documentation of the other parameters for spinopelvic balance, the slippage in listhesis has been attributed to these parameters. Many studies were done in the Caucasian population, which implicates high pelvic incidence as a causative factor for the listhesis. But to our knowledge, no study has described the implication of these parameters in the progression of listhesis. The main aim of our present study was to know the importance of the spinopelvic parameters in the causation and progression of the listhesis and also to know the response to conservative treatment. Materials and Methods: The study was approved by our institute review board and the ethical committee. We included all the patients visiting our OPD with complaints of LBP for more than three months, whose X-ray shows spondylolisthesis and who gave consent for the study. All patients were advised conservative treatment (NSAIDS, physiotherapy and short wave diathermy) and were followed once in 2 weeks regularly and were evaluated once in 6 weeks with the help of modified Oswestry questionnaire. At the end of 6 months, patients who were improved were advised the same conservative treatment and followed up. Those who have not improved were suggested repeat X-rays and the parameters and grade of listhesis recalculated. A total of 79 patients were thus included in the study. Another age and sex matched group of asymptomatic volunteers ( n = 75) were also recruited as a control group. Out of the total of 79 patients, 35 were followed for six month period of which 27 improved and in 8 there was no improvement. 25 have lost follow-up and in 19 follow-up was still pending. All the patients and volunteers underwent a standardized lateral sagittal digital radiograph of the whole spine including the base of the skull till the proximal ⅓ thigh. The sagittal spinopelvic parameters were measured using the Surgimap spine software version 2.1.2 by a single observer. The parameters measured were pelvic incidence PI, pelvic tilt PT, sacral slope SS, thoracic kyphosis TK, lumbar lordosis LL, lordotic and kyphotic vertebra. The comparisons were drawn between the patients and controls using appropriate statistical methods. Results The mean values in the asymptomatic group are PI-47.85, PT-13.03, SS-34.8, LL-54.68, TK-24.03. In the listhesis group are PI-65.32, PT-21.30, SS-44.13, LL-54.08, TK-25.49. There was a significant difference between the normal and the listhesis groups among PI, SS, PT ( p &lt; 0.001). There was no significant difference in pelvic incidence between the patients with high-grade(grade 3,4,5) and low-grade listhesis(grade 1,2). Conclusion The progression of slip and the response of the conservative treatment depends on- pelvic incidence, initial grade and how many levels of slip and finally on the sagittal vertical axis and its distance from the posterior superior corner of sacrum.

Natural History of Lumbar Spondylolysis-Advances and Concerns

Lumbar spondylolysis is a common cause of low back pain in adolescents and young adults. Due to a lack of understanding to the natural history, its treatment is often chaotic and controversial. Lumbar spondylolisthesis is a common complication of spondylolysis, but slip progression was commonly small and slow according to long-term follow-up studies. Many predisposing risk factors have been identified as associated with a great chance of slip progression. However, the widely accepted mechanism leading to adult slip progression is related to disc degeneration at the slip level. Clinical decision made for patients presenting with spondylolysis and spondylolisthesis principally include concerns for future progression of the spondylolisthesis and issues concerning pain. Most patients with spondylolysis and/or spondylolisthesis respond to conservative treatment. Surgical treatment is generally thought for patients who fail to respond to conservative treatment.

The Assessment and Treatment of High-Grade Lumbosacral Spondylolisthesis and Spondyloptosis in Children and Young Adults.

Spondylolisthesis is defined as a slippage of one vertebra relative to the adjacent lower vertebra1. Although the prevalence of spondylolysis approaches 6% in the general population2,3, the prevalence of high-grade spondylolisthesis remains difficult to define. As our understanding of the pathomechanics of spondylolisthesis and slip progression has evolved, so too has our approach to the management of these patients. This review will consider the clinical presentation, evaluation, pathomechanics, and evidence-based treatment options for these patients. The focus will be on the pediatric population presenting with dysplastic or acquired (i.e., isthmic) high-grade spondylolisthesis and spondyloptosis, as this has been a major area of investigation and controversy. Adolescents and young adults with high-grade spondylolisthesis have highly variable clinical presentations ranging from back pain to radiculopathy to cauda equina syndrome. Neurologic symptoms may include radiating pain in the buttock or posterior thigh, bowel or bladder dysfunction, or weakness. This is especially true for patients with an intact pars interarticularis because of the increased risk of severe stenosis. In addition to neurologic dysfunction, patients may report difficulty walking and leaning forward and may express concern with their appearance. The presence of nighttime pain is rare and warrants further work-up for the possibility of infection or …

Radiographic natural course of lumbar degenerative spondylolisthesis and its risk factors related to the progression and onset in a 15-year community-based cohort study: the Miyama study

BackgroundThe natural history and risk factors for lumbar degenerative spondylolisthesis (DS) remain unclear. Because it is important for physicians to take these factors into account to ensure accurate decisions regarding surgical methods, this study aimed to elucidate the natural course and risk factors for the progression of DS. MethodsThis is a prospective observation and case control study of 15-year follow-up in a rural mountainous cohort in Wakayama, Japan. In 1990 and 2005, a total of 200 participants (baseline age, range 40–75) were subjected to anteroposterior and lateral radiographs of the lumbar spine, which were acquired with patients in a standing position. The prevalence of DS (slip ≥3mm) at baseline and the incidence of DS at 15-year follow-up were recorded. Risk factors at baseline for progression of L4 slip (≥3mm) over the 15-year period were determined by multiple logistic regression analysis. ResultsThe overall prevalence of DS in 1990 was 10% (20/200), and by spinal level was as follows: one case at L3, 14 cases at L4, and five at L5. In 2005, the overall prevalence of DS had risen to 22.5% (45/200). Thus the incidence of de novo DS during the 15-year period was estimated at 14% (25/180). Progression of the L4 slip (≥3mm), regardless of baseline condition, was observed in 23 participants after 15years. In multiple regression analysis, significant risk factors for L4 slip progression were identified as age less than 60 years, female sex, lumbar axis sacral distance, facet sagittalization, and existence of slip at baseline. ConclusionsWe successfully elucidated the risk factors for the progression of DS in a general population. Moreover, the results of this study identified preventive factors as well as risk factors for slip progression. This study provides useful information for physicians treating DS.

Slipped Capital Femoral Epiphysis: Long-Term Outcome and Remodelling after in Situ Fixation

In primary treatment of slipped capital femoral epiphysis (SCFE) in situ fixation reliably prevents slip progression. The aim of this study was to examine the long-term outcome of SCFE-patients treated by transfixation with Kirschner wires with a special focus on the remodelling process of the hips under this fixation method. 30 patients with stable SCFE (mean initial slip angle: 29°, mean follow-up: 10 years), who were treated with bilateral transfixation by Kirschner wires, were recruited for this study. At most recent follow-up patients were clinically and radiologically (X-ray and MRI) examined. Medical records were reviewed for previous follow-up time points. Range of motion: At most recent follow-up the mean range of motion was: extension/flexion: 0/0/121, abduction/adduction: 44/0/31, external rotation/internal rotation: 39/0/24. Nearly all dimensions of motion significantly improved during the postoperative course.Head-shaft angle: We saw a significant reduction of the mean head-shaft angle from 29° preoperatively to 11° at most recent follow-up (p<0.0001). Harris Hip Score (HHS): 24 patients had an excellent, 3 a good, 2 a fair and 1 a poor outcome defined by HHS. Remodelling: At most recent follow-up 25 patients achieved complete remodelling. The remodelling process took place especially during the first postoperative year.Angle alpha: The mean angle alpha of the affected hips at most recent follow-up was 62°. Transfixation with Kirschner wires leads to very good clinical, functional and radiologic results with a low complication rate. Furthermore the femoral head-neck junction retains enough plasticity for an active remodelling process.

Spinal Claudication in Degenerative Lumbar Spondylolisthesis: Is Fusion a Must?

Introduction North American Spine Society published an evidence-based clinical guideline in 2008 to address clinical questions concerning the diagnosis and treatment of degenerative lumbar spondylolisthesis (DLS). The society recommended surgery for symptomatic patients who have failed conservative management; supplementation with fusion to improve clinical outcomes. The majority of clinical studies included multilevel spinal stenosis or decompression achieved with laminectomy, and thus renders comparison between decompression with and without fusion difficulty. This is a retrospective cohort to examine the clinical outcomes of fenestration of lamina and laminectomy with instrumented fusion in the treatment of symptomatic spinal stenosis due to DLS at L4/5 level. Patients and Methods A series of 53 patients with single-level DLS and associated spinal stenosis at L4/5 were treated at a single institution from 1 January, 2007 to 31 December, 2012. The mean follow-up period was 35.5 months. Fenestration alone was offered to patients who did not have mechanical back pain. Patients who suffered from spinal claudication and mechanical back pain were offered decompressive laminectomy with concomitant instrumented fusion. Operative details including operation time, blood loss, and length of hospital stay were reviewed. Clinical outcomes were assessed with visual analogue scale (VAS), Japanese Orthopaedic Association (JOA) lumbar score, and Oswestry disability index (ODI) preoperatively, at 6 months, 1 year, and the latest follow-up. Radiographic parameters and patients' satisfaction were also documented. Results A total of 26 patients underwent fenestration alone and 27 patients underwent laminectomy with concomitant instrumented fusion. The mean age at operation was 60.8 years. There were no differences in the demographic features between the two groups. No differences were detected in preoperative VAS (nonfusion: 6.6; fusion: 6.9), JOA lumbar score (nonfusion: 16.2; fusion: 14.4), ODI (nonfusion: 49.7; fusion: 48.5), and radiographic parameters between the two groups. Significant improvements were achieved in postoperative clinical outcomes and patients' satisfaction in all time periods for both groups. There were no significant differences demonstrated in postoperative clinical outcomes between the two groups (VAS nonfusion: 2.7, fusion: 3.2; JOA nonfusion: 24.1, fusion: 22.4; ODI nonfusion: 31.7, fusion: 30.6; patients' satisfaction nonfusion: 75.0%; fusion: 66.9%). There were no significant slip progression and change in translational motion on postoperative radiographs in the fenestration group. Fenestration alone required shorter operation time (nonfusion: 126.0 minutes; fusion: 274.4 minutes), less blood loss (nonfusion: 102.9 mL; fusion: 548.2 mL), and shorter hospital stay (nonfusion: 4.4 days; fusion: 8.6 days). No patient of nonfusion group had intraoperative dural tear while two patients of fusion group suffered from dural tear. Two patients of fusion group suffered from postoperative L5 neurological deficit. One patient of fusion group suffered from acute delirium with no apparent cause identified. There was no postoperative infection which required exploration in both groups. Conclusion We conclude that in a particular group of patients with DLS, fenestration of lamina alone offers comparable clinical and functional outcomes as laminectomy with concomitant instrumented fusion.