Treatment Of Low-grade Isthmic Spondylolisthesis Research Articles

Surgical management of isthmic spondylolisthesis: A comparative study of postoperative outcomes between ALIF and TLIF

IntroductionCircumferential fusion by the anterior (ALIF) or transforaminal (TLIF) approach combined with posterior instrumentation is currently used for the surgical treatment of low-grade isthmic spondylolisthesis. But few studies have compared the clinical and radiological outcomes of various interbody fusion techniques. The objective of this study was to compare the clinical and radiological results at 2 years postoperative of two fusion techniques–TLIF versus ALIF plus posterior instrumentation–for low-grade isthmic spondylolisthesis in adults. Materials and methodsThis was an observational multicenter study done at nine French healthcare facilities specialized in spine surgery. The inclusion criteria were minimum age of 18 years, grade 1–3 isthmic spondylolisthesis, ALIF+posterior fixation (ALIF+PS) or TLIF, minimum follow-up of 2 years. Clinical and radiological evaluations were done preoperatively and at 2 years of follow-up. A lumbar CT scan was done at 1 year postoperative to evaluate fusion. ResultsThe cohort consisted of 89 patients (50 women, 39 men) with a mean age of 47.7±12.3 (18–79) years. The patients in the ALIF groups (n=71) had a significantly longer hospital stay than those in the TLIF group (n=18): 5.7 days versus 4.6 days (p=.04). However, their medical leave from work was significantly shorter: 31.0 weeks versus 40.7 (p=.003). Lumbar pain VAS diminished faster in the ALIF groups, with a significantly larger drop than the TLIF group in the first 3 months postoperative. Only the increase in lumbar disc lordosis was larger in the ALIF group: 11.7°±12.0° versus 6.0°±11.7° (p=.036). There was a significant correlation between the increase in global lordosis and reduction in lumbar VAS at 2 years postoperative (ρ=−0.3295; p=.021). ConclusionALIF+PS provides a faster relief of postoperative low back pain than TLIF but there are no significant clinical differences between techniques at 2 years of follow-up. Despite better restoration of disc lordosis in the ALIF+PS group, there was no difference in the restoration of global lordosis. Level of evidenceIII; multicenter comparative study.

Transforaminal lumbar interbody fusion versus posterolateral fusion for the treatment of low-grade isthmic spondylolisthesis in adults

Background Isthmic spondylolisthesis means slippage of one vertebra relative to the next caudal vertebra as a result of an abnormality in the pars interarticularis. Isthmic spondylolisthesis has three subtypes: subtype A in which there is stress fracture of the pars (spondylolysis), subtype B in which the pars is elongated, and subtype C in which there is acute fracture of the pars. Isthmic spondylolisthesis is the most common cause of low back pain in adolescents. Spinal fusion is the mainstay of the surgical treatment of low-grade isthmic spondylolisthesis. Spinal fusion can be achieved by posterolateral fusion (PLF) or circumferential fusion. The three basic techniques for circumferential fusion include anterior lumbar interbody fusion, posterior lumbar interbody fusion, and transforaminal lumbar interbody fusion (TLIF). Patients and methods Fifty patients with low-grade isthmic spondylolisthesis managed with spinal fusion at the Zagazig University Hospital. Patients were divided into two groups: group I included patients managed by TLIF and group II included patients managed by PLF. The mean age of patients was 34.6 years (range: 26–43 years) in group I and 36.8 years (range: 28–46) in group II. Sex distribution was nine males and 16 females in group I and seven males and 18 females in group II. Exclusion criteria included patients with high-grade spondylolisthesis, traumatic spondylolisthesis, degenerative spondylolisthesis, neoplastic spondylolisthesis, patients with acute or chronic infection, and congenital malformation. Results No patients were dropped in the follow-up. In both groups, the mean visual analog scale (VAS) for back pain and leg pain and the Oswestry disability index (ODI) showed statistically significant difference between the values obtained preoperatively and the values obtained at the 1-year follow-up visit. In comparison between both groups for the change in the VAS for back and leg pain and ODI score, group I gave a significant difference regarding the change in the VAS for back pain compared to group II. However, the change in the VAS for leg pain and ODI was not statistically significant. Conclusion Both TLIF and PLF are effective options for the treatment of low-grade isthmic spondylolisthesis in adults. However, TLIF gives better clinical outcome, so it is considered a better option.

What Is the Optimal Surgical Treatment for Low-Grade Isthmic Spondylolisthesis? ALIF or TLIF?

What Is the Optimal Surgical Treatment for Low-Grade Isthmic Spondylolisthesis? ALIF or TLIF?

Computed tomography- and fluoroscopy-guided percutaneous screw fixation of low-grade isthmic spondylolisthesis in adults: a new technique

To evaluate the feasibility of computed tomography (CT)- and fluoroscopy-guided percutaneous screw fixation for the treatment of low-grade isthmic spondylolisthesis in adults. Ten consecutive adult patients (four men and six women; mean age: 57.1 [range, 44-78 years]) were prospectively treated by percutaneous screw fixation for low-grade (six grade 1 and four grade 2) isthmic spondylolisthesis of L5. For each patient, two 4.0-mm Asnis III cannulated screws were placed to fix the pars interarticularis defects. All procedures were performed under local anaesthesia by using CT and fluoroscopy guidance. Post-operative outcome was assessed using the visual analogue scale and Oswestry Disability Index (ODI) scores. The procedure time ranged from 45 to 60 min. The mean screw length was 27 mm (range, 24-32 mm). The VAS and ODI measurements ± SD decreased from 7.8 ± 0.9 preoperatively to 1.5 ± 1.1 at the last 2-year follow-up, and from 62.3 ± 17.2 to 15.1 ± 6.0, respectively (P < 0.001 in both cases). Neither slip progression nor screw failure was noted. This feasibility study showed that CT- and fluoroscopy-guided percutaneous screw fixation could be a rapid, safe and effective method of treating low-grade isthmic spondylolisthesis. CT- and fluoroscopy-guided percutaneous screw fixation of isthmic spondylolisthesis is feasible. It could become an effective method to treat low-grade isthmic spondylolisthesis. Percutaneous trans-isthmic screw fixation can be performed under local anaesthesia. This new technique can be performed as an outpatient procedure.

Axial Presacral Lumbar Interbody Fusion and Percutaneous Posterior Fixation for Stabilization of Lumbosacral Isthmic Spondylolisthesis

Case series. To describe a minimally invasive surgical technique for treatment of lumbosacral spondylolisthesis. Traditional surgical management of lumbosacral spondylolisthesis is technically challenging and associated with significant complications. Minimally invasive surgical techniques offer patients treatment alternatives with lower operative morbidity risk. The combination of percutaneous pedicle screw reduction and an axial presacral approach for lumbosacral discectomy and fusion is an option for the surgical management of low-grade lumbosacral spondylolisthesis. Twenty-six consecutive patients with symptomatic L5-S1 level isthmic spondylolisthesis (grade 1 or grade 2) underwent axial presacral lumbar interbody fusion and percutaneous posterior fixation. Study outcomes included visual analogue scale for axial pain severity, Odom criteria, and radiographic fusion. The procedure was successfully completed in all patients with no intraoperative complications reported. Intraoperative blood loss was minimal (range, 20-150 mL). Median hospital stay was 1 day (range, <1-2 d). Spondylolisthesis grade was improved after axial lumbar interbody fusion (P<0.001) with 50% (13 of 26) of patients showing a reduction of at least 1 grade. Axial pain severity improved from 8.1±1.4 at baseline to 2.8±2.3 after axial lumbar interbody fusion, representing a 66% reduction from baseline (95% confidence interval, 54.3%-77.9%). At 2-year posttreatment, all patients showed solid fusion. Using Odom criteria, 81% of patients were judged as excellent or good (16 excellent, 5 good, 3 fair, and 2 poor). There were no perioperative procedure-related complications including infection or bowel perforation. During postoperative follow-up, 4 patients required reintervention due to recurrent radicular (n=2) or screw-related (n=2) pain. The minimally invasive presacral axial interbody fusion and posterior instrumentation technique is a safe and effective treatment for low-grade isthmic spondylolisthesis.

Correlation of clinical outcome and spinopelvic sagittal alignment after surgical treatment of low-grade isthmic spondylolisthesis

The aim of this prospective study was to assess the sagittal alignment of the spine and pelvis before and after surgical treatment of isthmic spondylolisthesis with flat sacrum. At the same time, the functional outcome was analyzed and correlation examined. This study comprises analysis of 30 subjects (mean age 43 years) with isthmic spondylolisthesis and an average follow-up of 2.5 years after posterior spinal fusion. Radiological spinopelvic parameters were measured and functional evaluation was made using the Oswestry Disability Index. Significant improvement toward more normal values for PT and SS in relation to PI was observed after surgery. Pelvic incidence was unaffected by surgery. Correction of the spinosacral angle shows that the anterior tilt with anterior sagittal imbalance due to spondylolisthesis may be corrected by reduction and fusion of the slipped level. Functional outcome was satisfactory with a statistically significant difference between preoperative values and final follow-up values. The sub-group of patients with insufficient restoration of sagittal balance parameters had less good outcomes than the others. Surgical management of low- and mid-grade isthmic spondylolisthesis showed good clinical outcome with restoration of correct values for the pelvic position-dependent parameters, i.e., pelvis tilt, sacral slope, C7 plumb line position and SSA.

Posterior lumbar interbody fusion versus posterolateral fusion with instrumentation in the treatment of low-grade isthmic spondylolisthesis: midterm clinical outcomes

The purpose of this study was to compare the methods of posterior lumbar interbody fusion (PLIF) and posterolateral fusion (PLF) in cases of isthmic Grades 1 and 2 lumbar spondylolisthesis, and to evaluate the clinical efficacy of the procedures. Operations were performed in 50 patients with lumbar spondylolisthesis in the authors' clinics between 2001 and 2007. Indications for surgery were low-back pain with or without sciatica and neurogenic claudication that had not improved after at least 6 months of conservative treatment. The study included 33 female and 17 male patients, with mean ages of 50.6 years in the PLIF group and 47.3 years in the PLF group. These patients were randomly allocated into 2 groups: decompression, posterior transpedicular instrumentation, and PLF (Group 1; 25 patients) and decompression, posterior transpedicular instrumentation, and PLIF (Group 2; 25 patients). In the PLIF group, titanium cages were used, and autograft material was obtained from the decompression. In the PLF group, bone fragments collected from the iliac crest were used as autografts. A minimum 18-month follow-up was available in all patients. For clinical evaluation, a visual analog scale, Oswestry Disability Index, and the 36-Item Short Form Health Survey were used. Improvements in pre- and postoperative spondylolisthesis, segmental angles, fusion ratios, and postoperative complications were evaluated radiologically. The average follow-up period was 3.3 years. Based on the etiologies, isthmic spondylolisthesis was detected in all patients. The spondylolisthesis levels in the patients who underwent PLIF were located at L3-4 (5 patients, 20%); L4-5 (14, 56%); and L5-S1 (6, 24%), whereas the levels in the ones treated with PLF were located at L3-4 (4 patients, 16%); L4-5 (13, 52%); and L5-S1 (8, 32%). In the clinical evaluations, good or excellent results were obtained in 22 (88%) cases in the PLIF group and 19 (76%) cases in the PLF group. Fusion ratios were 100% in the PLIF group and 84% in the PLF group. Both lumbar lordosis and the segmental angle showed greater improvement in the PLIF group. There was no difference in the complication rates for each group. Based on early clinical outcomes and the fusion ratios of adult isthmic spondylolisthesis, the authors found PLIF to be superior to PLF.

Spontaneous Slip Reduction of Low-Grade Isthmic Spondylolisthesis Following Circumferential Release via Bilateral Minimally Invasive Transforaminal Lumbar Interbody Fusion

STUDY DESIGN.: Retrospective clinical data analysis. OBJECTIVE.: To investigate and verify our philosophy of spontaneous slip reduction following circumferential release via bilateral minimally invasive transforaminal lumbar interbody fusion (Mini-TLIF) for treatment of low-grade symptomatic isthmic spondylolisthesis. SUMMARY OF BACKGROUND DATA.: Symptomatic isthmic spondylolisthesis usually requires surgical intervention, and the most currently controversial focus is on method and degree of reduction; and Mini-TLIF is an attractive surgical procedure for isthmic spondylolisthesis. METHODS.: Between February 2004 and June 2008, 21 patients with low-grade isthmic spondylolisthesis underwent Mini-TLIF in our institute. Total resection of the scar around the pars interarticularis liberated the nerve roots, achieving posterior release as well. The disc was thoroughly resected, and the disc space was gradually distracted and thoroughly released with sequential disc shavers until rupture of anulus conjunct with anterior longitudinal ligament, accomplishing anterior release, so as to insert Cages. Because of circumferential release, the slipped vertebrae would tend to obtain spontaneous reduction, and with pedicle screw fixation, additional reduction would be achieved without any application of posterior translation force. Radiographs, Visual Analogue Scale, and Oswestry Disability Index were documented. All the cases were followed up for 10 to 26 months. RESULTS.: Slip percentage was reduced from 24.2% ± 6.9% to 10.5% ± 4.0%, and foraminal area percentage increased from 89.1% ± 3.0% to 93.6% ± 2.1%. Visual Analogue Scale and Oswestry Disability Index decreased from 7.8 ± 1.5 to 2.1 ± 1.1 and from 53.3 ± 16.2 to 17.0 ± 7.8, respectively. No neurologic complications were encountered. There were no signs of instrumentation failure. The fusion rate approached 100%. CONCLUSION.: Slip reduction is based on circumferential release. The procedure can be well performed via Mini-TLIF, the outcome of which is equally gratifying to that of instrumented slip reduction and traditional midline approach. There is no need to fully reduce the slipped vertebrae. Circumferential release contributes to achieving spontaneous slip reduction partially, which aids sufficiently in the surgical treatment of low-grade isthmic spondylolisthesis.

Reduction and transforaminal lumbar interbody fusion with posterior fixation versus transsacral cage fusion in situ with posterior fixation in the treatment of Grade 2 adult isthmic spondylolisthesis in the lumbosacral spine

In situ transsacral fusion in the treatment of low-grade isthmic spondylolisthesis has rarely been reported. The authors treated 13 cases of L-5 Grade 2 isthmic spondylolisthesis associated with collapsed disc space and osteoporosis by using transsacral fusion and fixation, and compared its clinical and radiological outcomes with the results of transforaminal lumbar interbody fusion (TLIF) and instrumental reduction in 21 patients. The authors retrospectively analyzed 21 patients in Group A who were treated with reduction and TLIF, and 13 patients in Group B who were treated with transsacral cage fusion. Oswestry Disability Index and visual analog scale scores of back and leg pain were used to evaluate clinical outcomes. Radiological parameters for assessment included the percentage of slippage, whole lumbar lordosis, and lumbosacral angle. Operative data, fusion rate, and perioperative complications were recorded as well. The mean operation time and blood loss in Group B was less than that in Group A. Both groups realized good recovery from previous symptoms. The decrease in back and leg pain after surgery was significant within each group, without much difference between the 2 groups. No significant differences were found in lumbosacral angle, whole lumbar lordosis, visual analog scale score, and Oswestry Disability Index score between the 2 groups after surgery. The solid fusion rate was 95.2% in Group A and 92.3% in Group B. In Group A, 2 patients suffered from graft site pain, 1 had a superficial infection, and 1 had screw loosening; in Group B, dural tears were found in 2 patients, transient S-1 paresthesia in 2, and extensor hallucis longus muscle weakness in 1. For patients with a collapsed disc space and poor bone quality, posterior in situ transsacral cage fusion may be used as an alternative to the TLIF procedure. The short-term clinical and radiological outcomes in the transsacral cage group were comparable with those in the TLIF group, although with a relatively higher neurological complication rate.

Surgical treatment for unstable low-grade isthmic spondylolisthesis in adults: a prospective controlled study of posterior instrumented fusion compared with combined anterior-posterior fusion

The surgical treatment for low-grade isthmic spondylolisthesis in adults with intractable lumbar pain is usually spinal fusion. It has been postulated that anterior column reconstruction may be relatively advantageous in those patients with unstable slips. To compare the early and medium term treatment efficacy of two common fusion techniques in isthmic spondylolisthesis. Prospective controlled trial comparing single-level posterior-lateral instrumented fusion with combined anterior and posterior-lateral instrumented fusion in sequential matched cohorts of patients with radiographically unstable isthmic spondylolisthesis. Primary outcome measure of success was an Oswestry Disability Index (ODI)<or=20. Secondary outcome measures included patient determined minimum-acceptable outcome on four questionnaires: pain intensity (visual analog scale), ODI, medication intake, and work status. Radiographic outcome of fusion was determined by radiographic union and motion on flexion/extension X-rays. Risk ratios (RRs) and 95% confidence intervals (CIs) were calculated for primary outcome of success for combined fusion compared with posterior fusion. The study was conducted over a 6-year period. The first cohort of 50 consecutive patients was treated with a single-level instrumented posterior-lateral fusion; the second sequential cohort was treated with an anterior interbody fusion and the same posterior operation. Observations were made at baseline, 6 months, 1 year, and 2 years after surgery. Final radiographic assessment was made at 2 years after surgery. Baseline demographic and clinical factors were well-matched in the two cohorts. At 2 years, 46 posterior-only fusion subjects and 47 combined fusion subjects completed the full follow-up regimen. Outcomes were better by all measures at 6 months and 12 months in the anterior-posterior cohort. Comparing the primary outcome measure (ODI outcome<or=20) in the posterior versus the combined groups, success was achieved at 6 months in 11 versus 30 (RR=2.67, 95% CI 1.53, 4.67; p=.0001); at 1 year, 20 versus 34 (RR=1.66, 95% CI 1.14, 2.42; p<.005); and at 2 years, 29 versus 36 subjects (RR=1.21, 95% CI 0.93, 1.59; p=.14). At 6 months, 13 posterior-only and 25 combined group subjects had returned to work (RR 1.88, 95% CI 1.10, 3.21; p=.01). More patients achieved their preoperatively determined minimum-acceptable outcome at each time point. There were three nonunions in the posterior-alone cohort and one in the combined group. Serious complications and reoperations were similar in both groups. Outcomes up to 2 years were superior by clinically important differences after a combined anterior-posterior operation compared with posterior-alone surgery for unstable spondylolisthesis; however, between-group differences attenuated appreciably after 6 months. The apparent clinical and occupational benefits of combined fusion should be considered along with possible increases in minor complications and procedure-related costs.

10:46 OPA 1. Surgical Treatment for Unstable Low-Grade Isthmic Spondylolisthesis in Adults: A Prospective Controlled Study of Posterior Instrumented Fusion Compared With Combined Anterior-Posterior Fusion

BACKGROUND CONTEXT: The surgical treatment for low-grade isthmic spondylolisthesis in adults with intractable lumbar pain is usually spinal fusion. It has been postulated that anterior column reconstruction may be relatively advantageous in those patients with unstable slips.