Spondylolisthesis

Iatrogenic lumbar spondylolisthesis: treatment by anterior fibular and iliac arthrodesis

A retrospective independent radiographic and chart review was undertaken for 17 patients who underwent a unique anterior salvage procedure for iatrogenic and progressive postoperative spondylolisthesis. This one-stage anterior transabdominal discectomy, reduction, stabilization, and arthrodesis was first performed in 1979. Of the 17 patients, all complained of leg pain, 14 of back pain, 11 had neurogenic claudication, and 2 were bedridden preoperatively because of their pain. Of the 17 patients, 7 had no neurologic deficits, 2 had cauda equina syndrome, and the remaining 8 had motor root deficits. The average number of posterior operations before our salvage procedure was 1.8, with a range of 1 to 3. Eight patients had an average of 1.6 attempts at posterior arthrodesis, with a range of 1 to 3 procedures. Two patients had a grade I spondylolisthesis, 11 a grade II, and 4 a grade III. Follow-up was available for 16 patients from 2 years and 3 months to 11 years and 5 months after the index operation (mean, 6 years and 5 months). One patient with severe cardiovascular disease died perioperatively. This anterior procedure was able to restore spinal stability and decompress the neural elements in 13 of 16 patients. Eleven obtained a solid arthrodesis. Three patients required further spinal surgery: two posterior fusions for symptomatic nonunions and one posterior foraminotomy for persistent foraminal stenosis. No patient deteriorated neurologically, the two with cauda equina syndrome recovered, and all but one patient with motor root deficits recovered fully. At latest follow-up, there were six excellent, seven good, and three fair results. There were no poor results. Although technically difficult and troubled by complications, the relative historical merits and principles of this unique anterior salvage procedure probably warrant further consideration, especially in light of evolving anterior surgical technologies.

Laparoscopic anterior lumbar fusion

PURPOSE

To assess the feasibility and complications of the laparoscopic approach to anterior lumbar fusion and to evaluate the ability of metoclopramide in conjunction with preoperative bowel preparation and early oral feeding to decrease postoperative ileus and reduce the length of hospital stay.

PATIENTS AND METHODS

Laparoscopic anterior lumbar fusion was performed on 30 patients with persistent back pain between September 1997 and March 1999. All patients received metoclopramide 10 mg intravenously preoperatively and every 6 hours postoperatively, then 10 mg orally every 8 hours for 7 days. An experienced laparoscopic surgeon exposed the disc space, and lumbar fusion was performed by a neurosurgeon or an orthopedic surgeon.

RESULTS

One procedure in an obese patient was converted to open surgery. The average operating time for the remaining patients was 2 hours 23 minutes. The average estimated blood loss was 75 mL. The only intraoperative complication was a trocar injury to the bladder. The average hospital stay was 2.3 days.

CONCLUSION

In properly selected patients, laparoscopic anterior lumbar fusion with metoclopramide, preoperative bowel preparation, and early oral feeding results in a short hospital stay and yields better cosmetic results than traditional surgery.

Complications during anterior surgery of the lumbar spine: an anatomically based study and review

Procedures involving anterior surgical decompression and fusion are being performed with increasing frequency for the treatment of a variety of pathological processes of the spine including trauma, deformity, infection, degenerative disease, failed-back syndrome, discogenic pain, metastases, and primary spinal neoplasms. Because these operations involve anatomy that is often unfamiliar to many neurological and orthopedic surgeons, a significant proportion of the associated complications are not related to the actual decompressive or fusion procedure but instead to the actual exposure itself. To understand the nature of these injuries, a detailed anatomical study and dissection was undertaken in six cadaveric specimens. Critical structures at risk in the abdomen and retroperitoneum were identified, and their anatomical relationships were categorized and photographed. These structures included the psoas muscle, kidneys, ureters, diaphragm and crura, esophageal hiatus, thoracic duct, greater splanchnic nerves, phrenic nerves, sympathetic chains, medial arcuate ligament, superior and inferior hypogastric plexus, segmental and radicular vertebral vessels, aorta, vena cava, median sacral artery, common iliac vessels, iliolumbar veins, lumbosacral plexus, and presacral hypogastric plexus. Based on these dissections and an extensive review of the literature, the authors provide a detailed anatomically based discussion of the complications associated with anterior lumbar surgery.

Posterior lumbar interbody fusion: a retrospective study of complications after facet joint excision and pedicle screw fixation in 148 cases

We retrospectively evaluated neurological and other complications related to posterior lumbar interbody fusion (PLIF) performed by facet joint excision and pedicle screw fixation, in 148 consecutive patients with degenerative disorders. Their mean age at surgery was 59 (19-80) years. The mean follow-up period was 3 (2-6.5) years. Overall, 91 complications in 75 cases were observed. Although no permanent neural damage was detected, transient neural palsy occurred in 8% of the cases. Dural tear, partial misplacement, loosening, breakage of the pedicle screw and loss of correction were seen in 6, 6, 4, 1 and 1 of the cases, respectively. Deep infection of the fused segment developed in 2 cases. We conclude that PLIF, performed by facet joint excision and pedicle screw fixation, demonstrated a very low incidence of osteosynthesis failure, such as screw loosening, breakage and loss of correction. However, the high incidence of other complications, particularly neurological impairment, is still a disadvantage of this technically-demanding procedure.

Anterior interbody fusion versus posterolateral fusion with transpedicular fixation for isthmic spondylolisthesis in adults. A comparison of clinical results

STUDY DESIGN

Clinical and radiographic results were assessed in adult patients who had undergone operation for isthmic spondylolisthesis.

OBJECTIVES

To compare the results between anterior interbody fusion and posterolateral fusion with those of transpedicular fixation for the treatment of isthmic spondylolisthesis in adults.

BACKGROUND DATA

Successful clinical results after fusion can be expected in adolescents, but the adult type differs in that stability through fusion alone fails to ensure satisfactory outcomes. The role of decompression in the surgical treatment of adult isthmic spondylolisthesis remains controversial. Anterior interbody fusion has an indirect effect of nerve root decompression through widening of the intervertebral space, whereas posterolateral fusion with transpedicular fixation provides direct decompression.

METHODS

The clinical data of 40 adult patients who had undergone operations for isthmic spondylolithesis from June 1977 through June 1994 were reviewed. Anterior interbody fusion was performed in 20 patients (Group I) and posterolateral fusion with transpedicular fixation in 20 patients (Group II). The mean age of Group I was 44.1 years (range, 21-62 years), and that of Group II was 41.3 years (range, 21-57 years). Group I contained B men and 12 women, Group II contained 5 men and 15 women. The symptoms and signs in Groups I and II were similar. The duration of follow-up averaged 3.6 years (range, 1.1-16 years) in Group I and 2.3 years (range, 1.1-6 years) in Group II.

RESULTS

The anterior slippage in Group I, assessed by the Taillard method, was 16.1% and was corrected to 10.4% after surgery. Anterior slippage in Group II was 15.2% and was corrected to 9.8% after surgery. The fusion rate 12 months after surgery was 90% in Group I and 95% in Group II. The clinical results were analyzed by Kim's criteria, according to variables on the improvement of clinical symptoms. Satisfactory results were obtained in 85% of Group I and 90% of Group II.

CONCLUSIONS

There was no statistically significant difference in clinical results between anterior interbody fusion and posterolateral fusion with transpedicular fixation for the treatment of isthmic spondylolisthesis in adults (P < 0.05).

An Open, Minimally Invasive Approach to the Lumbar Spine

A minimum 2-year follow-up retrospective review was undertaken to assess our experience with an anterior paramedian muscle-sparing approach to the lumbar spine for anterior spinal fusion (ASF). The records of 28 patients (November 1991 through January 1996) undergoing ASF via a left lower quadrant transverse skin incision (6–10 cm) with a paramedian anterior rectus fascial Z-plasty retroperitoneal approach were reviewed. Diagnosis, number, and level of lumbar interspaces fused, types of fusion, estimated blood loss, length of procedure, length of hospital stay, and complications were analyzed. All cases were completed as either a same-day anterior/posterior (24 of 28) or as a staged procedure at least 1 week after posterior fusion (4 of 28). The General Surgery service performed the muscle-sparing approach, whereas the Orthopedic Spine service performed the ASF. There were 14 men and 14 women, with a mean age of 35.5 years (range, 11–52 years). Diagnoses included spondylolisthesis in 20 cases (including four grade III or IV slips), segmental instability (degenerative or postsurgical) in 7, and 1 flatback deformity. A single level was fused in 20 cases (L4/5 in 4 and L5/S1 in 16), two levels were fused in 5 cases (L4/5 and L5/S1) and three levels were fused in 2 cases (L3/4, L4/5, and L5/S1). The mean length of stay was 7.4 days (range, 5–12 days). The mean estimated blood loss was 300 mL for the anterior procedure alone and 700 ml for both anterior/posterior procedures on the same day. The mean length of operating room time for the anterior approach and fusion was 117 minutes (range, 60–330 minutes). Posterior instrumentation was used in all cases. Anterior interbody struts used included 19 autogenous tricortical grafts, 4 fresh-frozen allografts (2 femoral rings and 2 iliac crests), 3 carbon fiber cages packed with autogenous bone, and a Harms titanium cage with autograft. There was one L5 corpectomy for which a large tricortical allograft strut was utilized. There were no vascular, visceral, or urinary tract injuries. In three cases a mild ileus developed, which resolved spontaneously. We conclude that the anterior paramedian muscle-sparing retroperitoneal approach is safe, uses a small skin incision, avoids cutting abdominal wall musculature, and allows for multiple-level anterior spinal fusions by a variety of interbody fusion techniques. This approach does not require transperitoneal violation or added endoscopic instrumentation, nor does it limit fusion level and technique of fusion, as is the case with the recently popularized laparoscopic approach to the lumbar spine.

The sagittal pelvic tilt index as a criterion in the evaluation of spondylolisthesis. Preliminary observations

STUDY DESIGN

Radiographic analysis of a pediatric population with spondylolisthesis was performed to examine sagittal plane pelvic rotation and degree of slip over time.

OBJECTIVES

To determine whether the degree of standing sagittal offset of L5 with respect to the acetabulum correlated with slip progression and symptoms.

SUMMARY OF BACKGROUND DATA

The natural history of isthmic spondylolisthesis remains unclear. Attempts to predict slip progression in the clinical setting, and thus the possible need for eventual surgical intervention, remain imprecise. Predicting slip progression based on sagittal alignment of the L5 vertebra with respect to the acetabulum has been proposed by some investigators.

METHODS

Fifty-two children and adolescents were followed clinically and radiographically for an average of 5.6 years. Serial lateral standing radiographs that included the hips and lumbar spine were measured to compute a sagittal pelvic tilt index. The latter value is a ratio of relative distances from the center of S2 to the projection of L5 and the center of the femoral heads on the horizontal.

RESULTS

Of the 52 patients studied, 38 have remained asymptomatic without significant slip progression or change in sagittal pelvic tilt index ratio. Of the original group, 13 patients had significant symptoms and revealed a decrease in the sagittal pelvic tilt index over time. Eight of the 13 stabilized at the end of adolescence, whereas 5 had continued decrease in the sagittal pelvic tilt index ratio. These five required operative treatment for pain and progressive slip.

CONCLUSIONS

The sagittal pelvic tilt index gives the examiner an objective measure of the stability of the lumbosacral junction by quantifying the relationship between S2, the center of the hip, and L5. A decreasing sagittal pelvic tilt index ratio in this preliminary series correlated with slip progression and risk of conservative treatment failure, whereas those patients with a stable sagittal pelvic tilt index did not progress and remained clinically asymptomatic.

A new microsurgical technique for minimally invasive anterior lumbar interbody fusion

STUDY DESIGN

A series of patients were prospectively studied to determine the morbidity and possible complications of minimally invasive anterior lumbar interbody fusion by two new microsurgical approaches (retroperitoneal for segments L2-L3, L3-L4, and L4-L5, and transperitoneal for L5-S1).

OBJECTIVES

To investigate the feasibility of performing an anterior lumbar interbody fusion through a 4-cm skin incision and a standardized muscle-splitting approach.

SUMMARY OF BACKGROUND DATA

The utility of anterior lumbar interbody fusion with or without posterior instrumentation for the treatment of various degenerative or postoperative lesions associated with low back pain is still a matter of debate. Regardless of the indications for surgery, use of the anterior approach in the lumbar spine is known to be associated with considerable surgical trauma, a high postoperative morbidity, and, occasionally, unacceptably high complication rates. Laparoscopic anterior interbody fusion of L5-S1 to eliminate some of these problems has been recently described. However, a minimally invasive surgical concept that covers all lumbar segments from L2 to S1 has not been described before now.

METHODS

A standardized, microsurgical retroperitoneal approach to levels L2-L3, L3-L4, and L4-L5 and a microsurgical transperitoneal approach through a "minilaparotomy" to L5-S1 are described. The first 25 patients (retroperitoneal, n = 20; transperitoneal, n = 5) treated with these methods are evaluated with respect to intraoperative data such as blood loss, operating time, intraoperative and postoperative complications, as well as preliminary fusion results.

RESULTS

There were no general or technique-related complications in the first series of 25 patients. Postoperative morbidity was low in all patients, with negligible wound pain. Average blood loss was 67.8 ml for the retroperitoneal technique and 168 ml for the transperitoneal approach. No blood transfusion was necessary. All patients showed solid bony fusion.

CONCLUSIONS

The microsurgical approaches described in this article are atraumatic techniques to reach the lumbar spinal levels L2-L3, L3-L4, L4-L5, and L5-S1. They represent microsurgical modifications of the surgical approaches well known to the spine surgeon. They can be learned in a step-by-step fashion, starting with a conventional skin incision and, once the surgeon is familiar with the instruments, moving on to the microsurgical technique. The approaches are not restricted to the type of fusion (iliac crest autograft) presented in this series.

Standardized evaluation of long-term results after anterior lumbar interbody fusion

A total of 113 patients, excluding those with tumor, spondylitis, and idiopathic scoliosis, underwent anterior lumbar interbody fusion (ALIF) with autologous iliac crest graft between 1984 and 1991 at our department. The proportion of these who were failed back patients was higher than that reported in the literature. Evaluation of functional outcome was feasible in 80 patients, utilizing Oswestry and Marburg scores, which were closely intercorrelated. The overall results yielded an improvement in the Oswestry score of 35.7 percentage points. A subset of 52 patients who were evaluated twice, showed the same results at an average of 6.6 years as they did at 2.3 years following surgery. Functional results showed a weak correlation with postoperative height loss of the intervertebral space. Influencing factors for the functional result were: postoperative compensation claim, age, and obesity. Of the professional people involved, 19.4% did not return to any occupation. Patients satisfied with the result had significantly greater functional improvement. Younger patients with additional dorsal distraction prior to ALIF for reduction of severe spondylolisthesis fared better than patients with ALIF alone. The rate of complications was low and did not contribute to the postoperative functional result. On the basis of these results further prospective studies have been designed and are currently underway.

Posterior interbody arthrodesis with a fibular strut graft in spondylolisthesis

We reviewed the results of posterior interbody arthrodesis of the fifth lumbar and first sacral vertebrae with the use of a fibular strut graft in nine patients who had had a grade-III, IV, or V spondylolisthesis. The average age of the patients at the time of the operation was twenty-seven years (range, seventeen to thirty-two years). The average duration of the symptoms preoperatively was three years (range, nine months to eleven years), and the average duration of follow-up was three years (range, two to five years). The most common preoperative symptom was back pain, which was rated an average of 8.3 points (7, 8, or 9 points) on a visual-analog scale of 1 to 10 points. The average angle of the slip was 45 degrees (range, 15 to 70 degrees). Four of the slips were grade III, four were grade IV, and one was grade V. Postoperatively, the average pain score was 1.4 points (1, 2, or 3 points). This improvement was significant (p < 0.05, Student t test). All nine patients had roentgenographic evidence of osseous fusion at the one-year follow-up examination. Complications included a dural tear in one patient, a superficial wound infection in two patients, temporary weakness of the evertors of the foot in six patients, and transient decreased sensation along the dorsum of the foot of the donor leg in two patients.

Anterior lumbar fusion: results, assessment techniques and prognostic factors

One hundred and fifty-one patients underwent anterior interbody lumbar spinal fusion for intractable back pain. A solid bony fusion was obtained in 76%. The method of outcome assessment profoundly affected the results; whereas 68% of patients rated themselves as significantly improved by the procedure, only 40% achieved a good or excellent result on the more objective low-back outcome score. Patients who underwent a second procedure did not do well, and "salvage" surgery is not recommended. Posterior distraction instrumentation neither increased the rate of union nor improved the final results. The rate of fusion was influenced by the presence of a compensation claim. Compensation status and psychological disturbance at presentation were significant prognostic factors. Psychological disturbance at review had a profound effect on the outcome and patient satisfaction ratings. It is recommended that future studies employ a recognised outcome score and that the analysis specifically includes compensation status and psychological disturbance.

Anterior lumbar fusion using a hybrid interbody graft. A preliminary radiographic report

This is a radiographic report of 40 patients (20 men, 20 women) who underwent anterior lumbar interbody fusions (73 levels) utilizing a "hybrid" interbody graft composed of femoral cortical allograft (FCA) bone and iliac crest cancellous autograft bone. The average age at surgery was 38 years (range 17-64 years), and follow-up averaged 1.4 years (range 1.0-2.4 years). Nineteen of the patients had undergone previous lumbar surgery. Thirty-two patients (63 levels) underwent anterior fusion combined with some type of posterior fixation, and eight patients (10 levels) had no posterior fixation. Types of posterior fixation included: for 20 patients (36 levels) Steffee variable screw placement fixation, for 10 patients (23 levels) translaminar facet screws (TFS), for 1 patient (3 levels) Knodt rods and for 1 patient (1 level) facet screws. Based on the persistence of lucent lines at the graft-host interface, three patients (one level each) were felt to have non-unions at their latest follow-ups at 1.4, 1.5 and 2.0 years, respectively. Two of these patients had no posterior fixation, and the other had TFS fixation. The overall fusion rate was 96% (70 of 73 levels). The fusion rate for all levels treated with posterior fixation was 98% compared with 75% for those without fixation. Intervertebral disc heights (IVDH) were measured on all films and corrected for magnification with computer assistance. On average, the IVDH was increased postoperatively but returned to preoperative values at follow-up. IVDH loss was independent of the type of instrumentation used. No complications arose from the use of the hybrid graft.(ABSTRACT TRUNCATED AT 250 WORDS)

Anterior interbody fusion for spondylolisthesis

We evaluated the clinical and radiologic results and the immobilizing effect of the Knight-Kim brace for bony union in 75 consecutive cases of spondylolisthesis treated by anterior interbody fusion. The fifth lumbar vertebra was the most common site involved (55%). The patients were followed for a minimum of 2 1/2 years (range: 2 1/2 to 14; average: 4.5). All cases were approached retroperitoneally, and autogenous bone graft was obtained from the iliac crest. The donor site was reconstructed by polymethylmethacrylate bone cement. Among the 75 cases of grade I, II, and III slippage according to Meyerding's grading system, 58 cases (77%) showed complete bony union after 1 year follow up. Excellent and good clinical results were obtained in 65 cases (87%) at 1 year postoperatively. The state of bony union did not always correlate with the clinical symptoms. We conclude that the simple Knight-Kim back brace was valuable for postoperative immobilization.

Ventral interbody spondylodesis using a new plug-shaped implant

A new technique for interbody lumbar spondylodesis using a new cancellous metal, plug-shaped construct was performed in 35 cases with spondylolisthesis or lumbar instability. All of these patients have had severe low-back pain for years, some with radicular symptoms and had been treated unsuccessfully for years. In a follow-up study, 28 of these patients were examined after a time-period of 4 to 24 months. According to objective criteria, the clinical results were good in 19 cases, moderate in five cases and poor in one case. The patients' own judgement about the success of the operation was somewhat different: 17 patients judged their condition as good, six as moderate and two as poor. For three patients the follow-up examination was so close to surgery that no judgement can be made. We saw postoperative complications in two cases: one was a fracture of the implant, the other was a deep vein thrombosis. Since the first reports about ventral spondylodesis by CAPENER [4] and BURNS [2] in the years 1932 and 1933 this surgical technique has been under discussion worldwide. This discussion even increased after HORMON [10] published some reports about his experience with this operative treatment in 1948. Since that time, many techniques for the intercorporal fusion of the spine have been reported. These include tibial or iliac bone grafts, sometimes fixed with screws or plates [6, 9, 12, 17, 20]. This article now describes the new surgical technique for ventral spondylodesis, using a new implant for the interbody fusion of the lumbar and sacral spine. In addition, we describe the indications for ventral spondylodesis and report the results of a rather small follow-up study.

Intercorporal lumbar spondylodesis. 312 patients followed for 2-20 years

Intercorporal spondylodesis was performed for low back pain in 120 patients with spondylolisthesis and 192 patients with disc degeneration; the latter group had all had previous surgery. The operations were carried out with retroperitoneal access, in most cases using iliac grafts, and additional posterior screw fixation in a number of patients substantially shortened the postoperative immobilization time. Complications were one death from pulmonary embolism, one case of possible genital disturbance, four inconsequent infections and three vessel injuries. In each group less than 10% had an additional operation for early signs of non-fusion. In cases without concomitant spinal problems, the overall fusion rate was 95-98 per cent. Clinically, the spondylolisthesis group was superior with 75 per cent without low back pain and 95 per cent without radicular pain postoperatively versus 55 per cent and 77 per cent for the disc degeneration group.

The place of the CT scan in the three concept view (TCV) of the low back pain syndrome. A preliminary survey

From the historical lines along which our thinking about low back pain developed, three concepts can be deduced: radicular, stenotic and axial. The patient with a low back pain syndrome (LBS) should be seen with this three concept view (TCV) in mind. Modern insight into the degenerative process of the low back supports this concept. The clinical syndromes illustrating these concepts, radicular syndromes, Neurogenic Peripheral Intermittent Claudication (NPIC), and axial low pack pain, can intermingle. To determine the place of the CT scan in the process of diagnosis of the LBS, we carried out a total of 56 CT-examinations on about 200 low back patients with various indications. The results are discussed. In addition to radiological suppositions, NPIC plays an important part in deciding whether or not to perform a CT scan.

Lumbosacral fracture-dislocation: a case managed conservatively, with return to heavy work

A 41-year-old agricultural sustained a lumbosacral fracture-dislocation when a tree fell across his back. The initial anterior displacement of half the depth of the body of L5 progressed to three-quarters of the body over a 2-year period. Neurological deficit was minimal and the management was conservative. Spontaneous arrest of the displacement occurred by anterior sacral buttressing and the patient has returned to his previous heavy work.