Spino-pelvic alignment after surgical correction for developmental spondylolisthesis

Influence of slippage reduction and correction of lumbosacral kyphosis by single-level posterior lumbar interbody fusion on spinal alignment in patients with dysplastic spondylolisthesis

PURPOSE

To investigate the influence of slippage reduction and correction of lumbosacral kyphosis by L5-S1 single-level posterior lumbar interbody fusion (PLIF) on spinal alignment and clinical outcomes including postoperative complications in patients with dysplastic spondylolisthesis (DS).

METHODS

Twenty consecutive patients with symptomatic and severe DS who underwent L5-S1 single-level PLIF with a minimum of 2 years of follow-up after surgery were included. Clinical outcomes were evaluated using the Japanese Orthopaedic Association (JOA) and visual analog scale (VAS) scores for low back and leg pain obtained on preoperative and postoperative examinations. Postoperative instrumentation failure and L5 radiculopathy were also evaluated. The preoperative and postoperative spinopelvic parameters were measured.

RESULTS

The JOA score significantly improved from 21.5 ± 4.8 (preoperative) to 27.0 ± 2.5 (postoperative), with a mean recovery rate of 75.0% ± 30.4%. The VAS score for low back pain significantly improved from 44.5 ± 30.1 (preoperative) to 11.5 ± 15.9 (postoperative), and that for leg pain significantly improved from 31.0 ± 33.2 (preoperative) to 5.0 ± 10.2 (postoperative). The slip percentage (% slip) significantly improved from 59.6% ± 13.5% (preoperative) to 25.2% ± 15.0% (postoperative). The lumbosacral angle (LSA) significantly improved from 12.3° ± 9.5° (preoperative) to 1.0° ± 4.9° (postoperative). L5-S1 PLIF led to significant improvement of lumbar lordosis (from 52.0° ± 15.9° to 59.7° ± 8.0°) and pelvic incidence - lumbar lordosis mismatch (from 23.9° ± 20.6° to 13.3° ± 10.0°). Correction of lumbosacral kyphosis had a significant positive correlation with postoperative pelvic tilt (PT) (r = 0.50, P = 0.02), while postoperative % slip did not have a significant correlation with postoperative PT.

CONCLUSIONS

L5-S1 PLIF for DS provided good clinical outcomes. Correction of lumbosacral kyphosis had a positive impact on regaining ideal spinopelvic balance and may be beneficial in the setting of treating DS.

LEVEL OF EVIDENCE IV

The L3 Flexion Angle Predicts Failure of Non-Operative Management in Patients with Tandem Spondylolithesis

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

Determine impact of standard/novel spinopelvic parameters on global sagittal imbalance, health-related quality of life (HRQoL) scores, and clinical outcomes in patients with multi-level, tandem degenerative spondylolisthesis (TDS).

METHODS

Single institution analysis; 49 patients with TDS. Demographics, PROMIS and ODI scores collected. Radiographic measurements-sagittal vertical axis (SVA), pelvic incidence (PI), lumbar lordosis (LL), PI-LL mismatch, sagittal L3 flexion angle (L3FA) and L3 sagittal distance (L3SD). Stepwise linear multivariate regression performed using full length cassettes to identify demographic and radiographic factors predictive of aberrant SVA (≥5 cm). Receiver operative curve (ROC) analysis used to identify cutoffs for lumbar radiographic values independently predictive of SVA ≥5 cm. Univariate comparisons of patient demographics, (HRQoL) scores and surgical indication were performed around this cutoff using two-way Student's t-tests and Fisher's exact test for continuous and categorical variables, respectively.

RESULTS

Patients with increased L3FA had worse ODI (P = .006) and increased rate of failing non-operative management (P = .02). L3FA (OR 1.4, 95% CI) independently predicted of SVA ≥5 cm (sensitivity and specifity of 93% and 92%). Patients with SVA ≥5 cm had lower LL (48.7 ± 19.5 vs 63.3 ± 6.9 mm, P < .021), higher L3SD (49.3 ± 12.9 vs 28.8 ± 9.2, P < .001) and L3FA (11.6 ± 7.9 vs -3.2 ± 6.1, P < .001) compared to patients with SVA ≤5 cm.

CONCLUSIONS

Increased flexion of L3, which is easily measured by the novel lumbar parameter L3FA, predicts global sagittal imbalance in TDS patients. Increased L3FA is associated with worse performance on ODI, and failure of non-operative management in patients with TDS.

Optimizing Physiotherapeutic Approaches in Parkinson's Disease Post-spinal Fixation Surgery: A Case Report

Patients with Parkinson's disease (PD) exhibit both a severe neuromuscular disorder and low bone quality at presentation. These issues are made worse by inactivity and a chairbound state. Each and every pathologic and degenerative process that affects the naturally aging spine also affects these individuals. Stooped posture is a symptom of a disease and can easily cause spinal degeneration. PD is associated with many physical abnormalities that cause a unique and specific need for rehabilitation. Patients' experiences highlight the challenges doctors face in diagnosis, treatment, and rehabilitation. This case report details the rehabilitation of a 67-year-old patient with PD who underwent spinal fixation for spinal stenosis and presented with complaints of weakness in both lower limbs. An advanced rehabilitation program was devised, primarily emphasizing strength training to enhance overall functionality. Pre- and post-intervention assessments were conducted, encompassing range of motion (ROM), manual muscle testing (MMT), Oswestry Disability Index, Functional Independence Measure, Lower Limb Functional Scale, and Berg Balance Scale, all of which demonstrated noteworthy improvements in joints ROM, strength, functional independence, balance, and lower limb function. This case report underscores the significance of rehabilitation programs in such cases, highlighting their important role in enhancing overall functioning.

[Sagittal Profi le of the Spine in Patients after Lumbar Stabilisation Surgeries]

PURPOSE OF THE STUDY

Spine stabilization surgery is nowadays one of the most common spinal surgical procedures. Spinopelvic alignment is considered to be an important factor impacting the patients' preoperative diffi culties as well as the outcome of surgery. In our study, the outcomes of stabilization surgeries in patients with lumbar spine disorders were evaluated - especially in those with stenosis and spondylolisthesis, in whom the importance of sagittal parameters were assessed with respect to the patients' clinical outcomes and diffi culties.

MATERIAL AND METHODS

The study included 50 patients with lumbar spine disorders who had undergone a spine stabilization surgery for a degenerative disease - lumbar spinal stenosis, spondylolisthesis between 2015 and 2017. Spino-pelvic radiological parameters and clinical parameters were evaluated using the nonparametric Kruskal-Wallis, Mann-Whitney, and Wilcoxon tests.

RESULTS

In 38 of 50 patients, who at the end of the follow-up period did not have the PI-LL (pelvic incidence-lumbar lordosis) mismatch, i.e. PI-LL was ≤10°, a statistically signifi cant difference in pelvic tilt (p=0.049) and sagittal vertical axis (p<0.001) was reported, which was not the case in the remaining patients of the study population. Claudication and OSWESTRY (ODI) showed no statistically signifi cant difference. We have also compared the differences in the number of fused vertebrae and type of stabilization. A signifi cant change was seen in the claudication parameter at 12 and 24 months after surgery (p=0.007, p=0.005), with better outcomes achieved by 360° lumbar fusion compared to posterior lumbar fusion. The improvement of VAS and ODI scores in both the groups over time (from 6.1 to 3.6 or from 6.3 to 3.5 in VAS and from 62 to 32, or from 62 to 30 in ODI) was also statistically signifi cant (p<0.001 in both groups), while when comparing the groups against each other it was statistically insignifi cant.

DISCUSSION

The authors confi rmed signifi cant improvement in the studied clinical parameters in all groups of patients (VAS, ODI, claudication), which is consistent with the results of recently published papers. The authors also established the correlation between different radiological parameters in the studied groups. The results do not confi rm the importance of the length or type of instrumentation for the clinical outcomes. This is consistent with the fi ndings of other published manuscripts. The authors failed to confi rm a signifi cant change in clinical parameters in dependence on the matching relationship between the pelvic incidence and lumbar lordosis.

CONCLUSIONS

Proper spinopelvic balance in patients after spinal surgery is a very important indicator of postoperative development and condition, but our cohort showed no statistically signifi cant difference in the clinical outcomes of patients whose postoperative sagittal parameters were unsatisfactory.

KEY WORDS

sagittal profi le, spine stabilization, pelvic tilt, pelvic incidence, sagittal vertical axis, SVA.

A Surgical Treatment Algorithm for Restoring Pelvic Balance and Health-related Quality of Life in High-grade Lumbosacral Spondylolisthesis: Prospective Multicenter Cohort of 61 Young Patients

STUDY DESIGN

Retrospective multicenter cohort-study.

OBJECTIVE

We propose an evidence-based surgical algorithm for achieving normal pelvic balance while optimizing health-related quality of life (HRQoL) in high-grade spondylolisthesis.

SUMMARY OF BACKGROUND DATA

The principles of surgical treatment for young patients with high-grade L5-S1 spondylolisthesis remain unclear. There is a growing body of evidence supporting the central role of pelvic balance in the postural control and biomechanics of subjects with high-grade spondylolisthesis.

METHODS

This retrospective study assessed a multicenter cohort of 61 patients with high-grade L5-S1 spondylolisthesis. Classification and regression tree analysis was used to identify objective criteria associated with pelvic balance and HRQoL after surgery.

RESULTS

The most important predictor of a postoperative balanced pelvis was a postoperative L5 incidence ≤63.5 degrees. With postoperative L5 incidence ≤63.5 degrees,a residual slip percentage 9% and performing an L5-S1 posterior lumbar interbody fusion (PLIF)/transforaminal lumbar interbody fusion (TLIF) increased the likelihood of achieving a balanced pelvis postoperatively. When L5 incidence was 63.5 degrees,a balanced pelvis was most likely achieved with fusion limited to L5 proximally, residual slip percentage ≤40%, and residual lumbosacral angle 98 degrees. Predictors of postoperative HRQoL were the preoperative HRQoL score, L5 incidence and slip percentage.

CONCLUSIONS

A surgical algorithm is proposed to achieve normal pelvic balance, while optimizing HRQoL. The first step during surgery is to assess L5 incidence and if L5 incidence is <65 degrees, the next step depends on the pelvic balance. With a preoperative balanced pelvis, it is important not to reduce completely the slip percentage by leaving a slip percentage ≥10%. When the preoperative pelvis is unbalanced, a TLIF/PLIF at L5-S1 is recommended to facilitate correcting the angular deformity at L5-S1. If L5 incidence is ≥65 degrees,a TLIF/PLIF at L5-S1 should be performed to correct the angular deformity at L5-S1, and fusion should ideally end at L5 proximally, in addition to performing gradual reduction of the slip percentage. If fusion up to L4 is required, a lumbosacral angle ≥100 degrees is key.

Minimally Invasive Surgery for Managing Grade IV and V Spondylolisthesis

Surgical treatment of high-grade spondylolisthesis is controversial and aims at restoring the spinopelvic sagittal balance through complete or partial reduction of the listhesis. Nerve decompression and interbody fusion are necessary for patients presenting with neurological deficit, severe pain, lower limb asymmetry, or deformities. We present the case and the results of a patient with high-grade spondylolisthesis, in whom minimally invasive management was performed. A narrative review in this topic is also provided. We performed a literature review of high-grade spondylolisthesis to compare our technique to current surgical alternatives. We included articles from PubMed, Embase, Scopus, Ovid, and Science Direct published between 1963 and 2022 that were written in English, German, and Spanish. The terms used were the following: "high grade spondylolisthesis," "spondyloptosis," "surgical management," "interbody fusion," and "arthrodesis." In all, 485 articles were displayed, from which we filtered 112 by title and abstract. At the end, 75 references were selected for the review. Different interbody fusion techniques can be used to correct the lumbosacral kyphosis and restore the spinopelvic parameters. A complete reduction of the listhesis is not always required. The surgical procedure carried out in our patient corresponds to the first known case of minimally invasive circumferential arthrodesis with iliac screws and sacral fixation in a high-grade dysplastic spondylolisthesis. This approach guarantees the correction of the lumbosacral kyphosis and a complete reduction of the listhesis. Further studies are required to determine whether the results of this case can be extrapolated to other patients with high-grade spondylolisthesis.

Evaluation of spinopelvic parameters in patients with lumbosacral transitional vertebra: a cross sectional and comparative study

INTRODUCTION

Lumbosacral transitional vertebra (LSTV) is the most common congenital anomaly of the lumbosacral junction and is a frequent cause of back pain in young patients with a prevalence of 4.6% to 36% in different regions.

OBJECTIVE

The objective of this study was to evaluate spinopelvic parameters in patients with lumbosacral transitional vertebra and to compare them with the same parameters of low back ache patients without lumbosacral transitional vertebra.

METHODS

This was a cross-sectional and comparative study conducted among low back ache patients presenting to our tertiary care center. Low back ache patients presenting to the outpatient department of AIIMS Jodhpur were screened for LSTV using radiographs. The spinopelvic parameters of those with LSTV were measured using Surgimap software and compared with the parameters of low back ache patients without LSTV. An Independent sample t-test was done and p-values were calculated.

RESULTS

The spinopelvic parameters, pelvic incidence, pelvic tilt and lumbar lordosis differed significantly in the patients with LSTV. Pelvic incidence was higher in the group with LSTV (58.5+9.3) when compared to the group without LSTV (50+8.8) with a p-value (<0.001). Pelvic tilt was higher in the group with LSTV (19.4+8.8) when compared to the group without LSTV (13.6+7.8) with a p-value (0.001). Lumbar lordosis was significantly higher in the group with LSTV (57.6+13.2) when compared to the group without LSTV (50.7+12.2) with a p-value (0.007). No significant differences were obtained in sacral slope and Pelvic-incidence and lumbar lordosis mismatch.

CONCLUSION

LSTV alters the spinopelvic parameters. Altered spinopelvic parameters predispose to spondylolisthesis, degenerative disc disease, and facet joint arthritis and are important in preoperative planning in spine and pelvic surgeries.

A novel less invasive endoscopic-assisted procedure for complete reduction of low-and high-grade isthmic spondylolisthesis performed by anterior and posterior combined approach

PURPOSE

The optimal surgical management of low- and high-grade isthmic spondylolisthesis (LGS and HGS -IS) is debated as well as whether reduction is needed especially for high-grade spondylolisthesis. Both anterior and posterior techniques can be associated with mechanical disadvantages as hardware failure with loss of reduction and L5 injury. We purpose a novel endoscopic-assisted technique (Sled technique, ST) to achieve a complete reduction in two surgical steps: first anteriorly through a retroperitoneal approach to obtain the greatest part of correction and then posteriorly to complete reduction in the same operation.

METHODS

ST efficacy and complications rate were evaluated through a retrospective functional and radiological analysis.

RESULTS

Thirty-one patients, 12 male (38.7%) and 19 female (61.3%), average age: 45.4 years with single level IS underwent olisthesis reduction by ST. Twenty-three IS involved L5 (74.2%), 7 L4 (22.5%) and 1 L3 (3.3%). No intraoperative complications were recorded. One patient required repositioning of a pedicle screw. A significant improvement of functional and radiological parameters (L4-S1 and L5-S1 lordosis) outcomes was recorded (p < 0.001).

CONCLUSION

ST provides a complete reduction in the slippage in LGS and HGS. The huge anterior release as well as the partial reduction in the slippage by the endoscopic-assisted anterior procedure, because of the cage is acting as a "guide rail", facilitate the final posterior reduction, always complete in our series, minimizing mechanical stresses and neurological risks.

CLINICALTRIALS

gov Identifier: NCT03644407.

Surgical management of high-grade paediatric spondylolisthesis: meta-analysis and systematic review

PURPOSE

There is currently no consensus on the management of high-grade spondylolisthesis (HGS) in paediatric populations. The objective of this analysis is to compare the outcomes of reduction followed by fusion (RFF) or in situ fusion (ISF) in paediatric patients.

METHODS

Using major databases, a systematic literature search was performed. Primary studies comparing ISF with RFF in paediatric and adolescent patients were identified. Study data including patient-reported outcomes, complications, and spinopelvic parameters were collected and analysed.

RESULTS

Seven studies were included, comprising 97 ISF and 131 RFF. Average patient age was 14.4 ± 2.1 years and follow up was 8.2 ± 5.1 years. Patients undergoing RFF compared to patients undergoing ISF alone were less likely to develop pseudarthrosis (RR 0.51, 95% CI, [0.26, 0.99], p = 0.05). On average, RFF led to 11.97º more reduction in slip angle and 34.8% more reduction in sagittal translation (p < 0.00001) compared to ISF. There was no significant difference between patient satisfaction and pain at follow up. Neurologic complications and reoperation rates were not significantly different.

CONCLUSIONS

Both RFF and ISF are effective techniques for managing HGS. Performing a reduction followed by fusion reduces the likelihood of pseudarthrosis in paediatric patients. The difference between risk of neurologic complications, need for reoperation, patient satisfaction, and pain outcomes did not reach statistical significance. Correlation with patient-reported outcomes still needs to be further explored. LEVEL 3 EVIDENCE: Meta-analysis of Level 3 studies.

Functional outcome of surgical management of low mid-grade lumbar spondylolisthesis when considering the sagittal balance parameters preoperatively: a prospective study

BACKGROUND

Prospective study objectives. A sagittal balance is a good tool to improve the functional outcome of spine spondylolisthesis surgeries, primarily noted that it has a good impact in deformity surgery and then applied to every spine surgery and the aim of this study is to evaluate its functional outcome when considered in preoperative planning for non-dysplastic low- and mid-grade spondylolisthesis surgeries.

METHOD

Forty patients diagnosed as low- or mid-grade non-dysplastic spondylolisthesis had undergone surgery at Cairo University after failed medical treatment had been evaluated preoperatively by measuring the sagittal balance parameters which include SVA, spinopelvic angles, lumbar lordosis, pelvic tilt, sacral slope, and pelvic incidence and then measure it along a follow-up period of 1 year postoperatively started from February 2018 and correlate it with functional outcome using Oswestry score (ODI)and VAS. Correction of parameters has been estimated preoperatively by manual estimation and Surgimap application then applied during the operation.

RESULTS

All patients were treated by surgical treatment through posterior transpedicular screw fixation with conventional or reduction screws and fusion ± TLIF cages. The mean of lumbar lordosis and mean spinopelvic angles were increased in a statistically significant manner. Pelvis tilt was decreased in a statistically insignificant manner. The mean of pelvic incidence was not changed and statistically insignificant, and this is matching the fact that pelvic incidence is a constant parameter. The sacral slope was increased in a statistically insignificant manner. Final results showed that 37 had a statistically significant improvement in their ODI >20% at the last visit. Three patients had a poor clinical outcome with ODI scorFinal results showed that 37 had a statistically significant improvement in their ODI >20% at the last visit. Three patients had a poor clinical outcome with ODI score of >20% improvement, and we noticed that the level of pathology was at the level of L4L5, SVA was positive and worsen postoperatively, and also, it is accompanied by decreased lumbar lordosis. Change in ODI means statistically significant improvement when considering sagittal parameters preoperation and during operation.

CONCLUSION

Sagittal balance parameters should be considered in the surgical management of low-grade spondylolisthesis cases to improve their functional outcome.

Hip replacement improves lumbar flexibility and intervertebral disc height - a prospective observational investigation with standing and sitting assessment of patients undergoing total hip arthroplasty

PURPOSE

The pathogenic mechanism of the hip-spine syndrome is still poorly elucidated. Some studies have reported a reduction in low back pain after total hip arthroplasty (THA). However, the biomechanical mechanisms of THA acting on the lumbar spine are not well understood. The aim of the study is to evaluate the influence of THA on (1) the lumbar lordosis and the lumbar flexibility and (2) the lumbar intervertebral disc height.

METHODS

A total of 197 primary THA patients were prospectively enrolled. Pre- and post-operative biplanar stereoradiography was performed in standing and sitting positions. Spinopelvic parameters (lumbar lordosis (LL), pelvic tilt, sacral slope, pelvic incidence), sagittal spinal alignment (sagittal vertical axis, PI-LL mismatch (PI-LL)) and lumbar disc height index (DHI) for each segment (L1/2 to L5/S1) were evaluated. The difference between standing and sitting LL (∆LL = LL_standing - LL_sitting) was determined as lumbar flexibility. Osteochondrosis intervertebralis was graded according to Kellgren and Lawrence (0-4), and patients were assigned to subgroups (mild: 0-2; severe: 3-4).

RESULTS

Lumbar flexibility increased significantly after THA (pre: 22.04 ± 12.26°; post: 25.87 ± 12.26°; p < 0.001), due to significant alterations in LL in standing (pre: 51.3 ± 14.3°; post: 52.4 ± 13.8°; p < 0.001) and sitting (pre: 29.4 ± 15.4°; post: 26.7 ± 15.4°; p = 0.01). ∆LL increased significantly in both subgroups stratified by osteochondrosis (pre/post: ΔLL_mild: 25.4 (± 11.8)/29.4 ± 12.0°; p < 0.001; ΔLL_severe: 17.5 (± 11.4)/21.0 ± 10.9°; p = 0.003). The DHI increased significantly from pre-operatively to post-operatively in each lumbar segment. PI-LL mismatch decreased significantly after THA (pre: 3.5°; post: 1.4°; p < 0.001).

CONCLUSION

The impact of THA on the spinopelvic complex was demonstrated by significantly improved lumbar flexibility and a gain in post-operative disc height. These results illustrate the close interaction between the pelvis and the vertebral column. The investigation provides new insights into the biomechanical patterns influencing the hip-spine syndrome.

Comparison of 3-level anterior cervical discectomy and fusion and open-door laminoplasty in cervical sagittal balance: A retrospective study

Objective

To compare the clinical efficacy and radiological outcomes of 3-level anterior cervical discectomy and fusion (ACDF) and open-door laminoplasty (LP).

Methods

A total of 74 patients from January 2017 to January 2020 were enrolled in this retrospective study. There were two groups. Group A (30 cases) received 3-level ACDF, while Group B (44 cases) received open-door LP. Clinical evaluation included perioperative parameters, Neck Disability Index (NDI), and Japanese Orthopaedic Association (JOA) scores. Radiological evaluation included cervical curve depth (CCD), C2–7 angle, C2–7 sagittal vertical axis (cSVA), C7 slope (C7S), and T1 slope (T1S).

Results

Perioperative parameters such as blood loss, drainage volume after surgery, and hospital stay of patients in Group A were significantly less than those in Group B (P < .001). NDI scores decreased and JOA scores increased significantly after surgery in both groups (P < .05). There was a significant difference in both scores postoperatively and at 1 month after surgery between the two groups (P < .05). CCD and C2–7 angle of Group A increased significantly postoperatively at 1 month after surgery and at final follow-up (FFU) (P < .05). There was a significant difference in CCD and the C2–7 angle between the two groups postoperatively at 1 month after surgery and at FFU (P < .05). T1S increased significantly in Group A postoperatively and at 1 month after surgery (P < .05).

Conclusion

3-level ACDF and open-door LP achieved favorable clinical outcomes and ACDF benefited patients in the early stage of rehabilitation. Compared with open-door LP, 3-level ACDF had advantages of reconstructing cervical lordosis with increased CCD and C2–7 angle.

Sacral Pedicle Subtraction Osteotomy for Treatment of High-Grade Spondylolisthesis: A Technical Note and Review of the Literature

BACKGROUND

Lumbosacral deformities are caused by high-grade spondylolisthesis, fractures, iatrogenic flat back, and other etiologies. The S1 pedicle subtraction osteotomy (PSO) can facilitate reduction of spondylolisthesis and lower the pelvic incidence. There are limited reports on the indications and outcomes of this technique.

OBJECTIVE

To present a technical description and literature review of the S1 PSO with video summary.

METHODS

This was a retrospective review of a single case to highlight the use of S1 PSO for the treatment of high-grade spondylolisthesis. A literature review was performed in accordance with STROBE guidelines.

RESULTS

A 47-year-old woman presented with back and right leg pain related to grade 4 spondylolisthesis at L5-S1 with sagittal imbalance and lumbosacral kyphosis. She was taken for an L2-pelvis instrumented fusion with S1 PSO. Three days later, she was taken for an L4-5 and L5-S1 anterior lumbar interbody fusion with the L5-S1 segmental plate. Her postoperative course was notable for right foot drop that resolved in 6 weeks. Postoperative x-rays showed successful reduction of spondylolisthesis with normal alignment and sagittal balance. Based on 6 studies involving 22 true sacral PSOs in the literature, the procedure carries a 27% risk of neurological deficit, typically in the form of L5 palsy.

CONCLUSION

The S1 PSO is a technically challenging operation that has a unique role in the treatment of high-grade spondylolisthesis. It carries a significant risk of L5 palsy and should be reserved for surgeons with experience performing complex 3-column osteotomies.

Scoliosis in dysplastic spondylolisthesis: a clinical survey of 50 young patients

Background

Dysplastic spondylolisthesis is a rare spinal deformity that occurs mainly in young patients. Although its sagittal parameters had been well stated, coronal abnormalities in these patients were poorly studied. The purposes of this study were: (1) to investigate the prevalence of scoliosis in dysplastic spondylolisthesis;(2) to assess scoliosis resolution or persistence after surgery; and (3) to propose a modified classification of scoliosis associated with dysplastic spondylolisthesis.

Methods

Fifty patients (average age 14.9 ± 5.6 years) diagnosed with dysplastic spondylolisthesis who underwent surgical treatment were followed up and their data were analyzed. Standing posteroanterior and lateral full spine radiographs were used to measure the coronal and sagittal parameters. Patients with scoliosis, which was defined as a coronal Cobb angle greater than 10°, were divided into three groups according to their curve characteristics: “independent” scoliosis (IS) group, spasm scoliosis (SS) group, and olisthetic scoliosis (OS) group. SS and OS were spondylolisthesis-induced scoliosis. The radiographic parameters and patient-reported outcomes were collected before and after surgery and compared between groups.

Results

The average slip percentage was 62.8% ± 23.1% and the average follow-up time was 51.5 ± 36.4 months (range 3–168 months). Twenty-eight of the 50 (56%) dysplastic spondylolisthesis patients showed scoliosis, of which 8 were IS (24.7° ± 15.2°), 11 were SS (13.9° ± 3.0°), and 9 were OS (12.9° ± 1.9°). By the last follow-up, no scoliosis resolution was observed in the IS group whereas all SS patients were relieved. Of the nine patients with OS, four (44.4%) had scoliosis resolution after surgery.

Conclusion

Distinguishing different types of scoliosis in dysplastic spondylolisthesis patients may help surgeons to plan treatment and understand prognosis. For patients with significant scoliosis, whether “independent” or spondylolisthesis-induced, treatment of spondylolisthesis should be performed first and scoliosis should be observed for a period of time and treated according to the corresponding principles.

Surgical outcomes with anatomic reduction of high-grade spondylolisthesis revisited: an analysis of 101 patients

OBJECTIVE

The ideal strategy for high-grade L5-S1 isthmic spondylolisthesis (HGS) remains controversial. Critical questions include the impact of reduction on clinical outcomes, rate of pseudarthrosis, and postoperative foot drop. The scope of this study was to delineate predictors of radiographic and clinical outcome factors after surgery for HGS and to identify risk factors of foot drop.

METHODS

This was a single-center analysis of patients who were admitted for HGS, defined as grade III or greater L5 translation according to the Meyerding (MD) classification. Complete postoperative reduction was defined as MD grade I or less and L5 slip < 20%. Forty-six patients completed health-related quality-of-life questionnaires (Oswestry Disability Index, Physical Component Summary of SF-36, and visual analog scale) and ≥ 2 years' follow-up (average 105 months). A 540° approach was used in 61 patients, a 360° approach was used in 40, and L5 corpectomy was used in 17. Radiographic analysis included measures of global spinopelvic balance (e.g., pelvic incidence [PI], lumbar lordosis) and measurement of lumbosacral kyphosis angle (LSA), L4 slope (L4S), L5 slip (%), and postoperative increase of L5-S1 height.

RESULTS

The authors included 101 patients with > 1 year of clinical and radiographic follow-up. The mean age was 26 years. Average preoperative MD grade was 3.8 and average L5 slip was 81%; complete reduction was achieved in 55 and 42 patients, respectively, according to these criteria. At follow-up, LSA correlated with all clinical outcomes (r ≥ 0.4, p < 0.05). Forty patients experienced a major complication. Risk was increased in patients with greater preoperative deformity (i.e., LSA) (p = 0.04) and those who underwent L5 corpectomy (p < 0.01) and correlated with greater deformity correction. Thirty-one patients needed revision surgery, including 17 for pseudarthrosis. Patients who needed revision surgery had greater preoperative deformity (i.e., MD grade and L5 slip) (p < 0.01), greater PI (p = 0.02), and greater postoperative L4S (p < 0.01) and were older (p = 0.02), and these patients more often underwent L5 corpectomy (p < 0.01). Complete reduction was associated with lower likelihood of pseudarthrosis (p = 0.08) and resulted in better lumbar lordosis correction (p = 0.03). Thirty patients had foot drop, and these patients had greater MD grade and L5 slip (p < 0.01) and greater preoperative LSA (p < 0.01). These patients with foot drop more often required L5 corpectomy (p < 0.01). Change in preoperative L4S (p = 0.02), LSA (p < 0.01), and L5-S1 height (p = 0.02) were significantly different between patients with foot drop and those without foot drop. A significant risk model was established that included L4S change and PI as independent variables and foot drop as a dependent variable (82% negative predictive value and 71% positive predictive value, p < 0.01).

CONCLUSIONS

Multivariable analysis identified factors associated with foot drop, major complications, and need for revision surgery, including degree of deformity (MD grade and L5 slip) and correction of LSA. Functional outcome correlated with LSA correction.

Analysis of sagittal curvature and its influencing factors in adolescent idiopathic scoliosis

ABSTRACT

This study aimed to explore the characteristics of changes in the sagittal arrangement of the spine between adolescent patients with idiopathic scoliosis (AIS) and normal adolescents, the risk factors for AIS and the factors affecting the progress of AIS.X-ray images of the full length of the spine in standing position were taken in AIS patients and normal adolescents. Radiographic measurements made at intermediate follow-up included the following:C1 and C2 cervical lordosis and C2 - C7 curvature of cervical lordosis, C2-C7sagittal horizontal distance (C2-C7SagittalVerticalAxis, C2-C7SVA), TS-CL, after thoracic lobe (Thoracic Kyphosis, TK), thoracic lumbar segment Angle (thoracolumbar kyphosis, [TLK]), lumbar lordosis Angle (Lumbar Lordosis, LL), sacral slope Angle (Sacrum Slope, SS), pelvic tilt Angle (Pelvic Tilt, PT), pelvic incidence (PI), L5 Incidence (Lumbar5 Slope (L5S), L5 incidence (Lumbar5 Incidence (L5I), sagittal horizontal distance (CSVA), lower depression Angle of the 2nd cervical spine. The difference of sagittal plane parameters between AIS group and normal adolescent group was compared. To evaluate the progress of AIS, correlation analysis was conducted between diagonal 2 and other parameters. The main risk factors of AIS were determined by binary Logistic analysis.The CSVA of AIS patients was higher than that of healthy adolescents (AIS: 27.64 ± 19.56) mm. Healthy adolescents: (17.74 ± 12.8) mm), L5S (AIS: 19.93°= 7.07° and healthy adolescents: 15.38°= 7.78°, P = .024 < .05), C2 downward sag Angle (AIS: 15.12°= 2.7°;Healthy adolescents: 12.97°= 4.56°); AIS patients had lower TS-CL (AIS: 22.48 ± 6.09 and healthy adolescents: 28.26°= 10.32°), PT (AIS: 10.42°= 4.53° and healthy adolescents: 15.80°=7.68°), (AIS: 41.87°=9.72° and healthy adolescents: 48.75°= 8.22°). The main risk factor for idiopathic scoliosis in adolescents was L5 (OR = 1.239, 95%CI = 1.049-1.463, P = .012 < .05).L5S is a major risk factor for idiopathic scoliosis in adolescents. The larger PI is, the higher the risk of scoliosis progression is. In AIS patients, lumbar lordosis is increased, cervical lordosis is reduced, and even cervical kyphosis occurs.

Cervical balance and clinical outcomes in cervical spondylotic myelopathy treated by three-level anterior cervical discectomy and fusion and hybrid cervical surgery: A CONSORT-compliant study with minimum follow-up period of 5 years

As the technology of combining with fusion and nonfusion procedure, cervical hybrid surgery (HS) is an efficacious alternative for treatment with cervical spondylotic myelopathy. While studies on cervical alignment between 3-level HS and anterior cervical discectomy and fusion (ACDF) were seldom reported. The effects of cervical imbalance on its related clinical outcomes are yet undetermined as well.Patients with cervical spondylotic myelopathy, who underwent 3-level ACDF or HS, were included to compare cervical alignment parameters after surgery and then explore the relationship between cervical balance and clinical outcomes.Forty-one patients with HS (HS group) and 32 patients who with ACDF (ACDF group) were reviewed from February 2007 to September 2013 with the mean follow-up of 90.3 ± 25.5 (m) and 86.3 ± 28.9 (m), respectively. Cervical alignments parameters including the C2 to C7 cervical lordosis (CL), C2 to C7 sagittal vertical axis, T1 slope. and T1SCL (T1 slope minus CL), and the clinical outcomes like neck disability index (NDI) and Japanese Orthopedic Association (JOA) score were measured and recorded preoperatively (PreOP), intraoperatively, and on the first preoperative day and the last follow-up (FFU). The balance and imbalance groupings were sorted based on the T1SCL: T1SCL≤20°,balance; T1SCL > 20°, imbalance.We found significant improvements (P < .001) in NDI and JOA at intraoperatively and FFU after ACDF and HS, and no difference on cervical alignment and clinical outcomes between the 2 procedures on the basis of intergroup comparisons. By between-subgroups comparisons, however, we found significant differences in CL and T1SCL at PreOP (P < .05). Nonetheless, there was no significant difference on the clinical outcomes between balance and imbalance subgroups at FFU at PreOP (P > .05), indicating that the change of T1SCL was not correlated to NDI and JOA at FFU.Both HS and ACDF groups showed significant clinical improvements after surgery. There was no correlation between cervical balance and clinical symptoms.

Does the Surgical Reduction of High Grade Spondylolisthesis Restore Spino-Pelvic Alignment? An Analysis of 35 Patients

STUDY DESIGN

Retrospective case series.

PURPOSE

This study aimed to analyze how the sagittal spinopelvic alignment is influenced by an attempted surgical reduction of the L5-S1 segment in patients with high-grade spondylolisthesis (HGS).

OVERVIEW OF LITERATURE

Conventional treatment strategies stress the importance of achieving fusion across the lumbosacral junction in patients with HGS. The role of reduction in this subset of patients is controversial.

METHODS

This is a retrospective case series of 35 patients with Meyerding grades III, IV, or V spondylolisthesis who underwent surgical treatment in our institution. Before and after surgery, we took standing lateral radiographs from L1 vertebra to pelvis, including the femoral heads, and measured the slip grade, pelvic incidence, sacral slope, pelvic tilt, lumbosacral angle, and lumbar lordosis. Patients were subdivided into "balanced" and "unbalanced" pelvis groups. To determine the effect and correlation of reduction on these spinopelvic parameters, we statistically compared the pre- and postoperative measurements.

RESULTS

The average follow-up was 9 months (range, 3-169 months). Slip grade improved from an average 74.0%±13.2% to 30.0%±14.0% (p<0.001), and lumbosacral angle reduced from an average 32.0°±11.6° to 6.0°±0.6° (p<0.001). Although the pelvic tilt was reduced, this was not significant. There was a modest negative correlation between the reduction in slip grade and the increase in sacral slope (r=-0.3, p=0.06). At follow-up, five patients improved, from an unbalanced pelvis to a balanced pelvis. Fusion occurred in 33 patients (95%).

CONCLUSIONS

Surgical reduction of HGS restores the lumbosacral alignment. However, a similar trend is not noted with the pelvic parameters.

Efficacy and radiographic analysis of oblique lumbar interbody fusion in treating lumbar degenerative spondylolisthesis with sagittal imbalance

The aim of this study was to evaluate the effectiveness of OLIF (oblique lumbar interbody fusion) in the treatment of lumbar degenerative spondylolisthesis with sagittal imbalance. Fifty-nine patients were included in our analysis. Included patients were divided into 2 groups according to the surgical techniques: PLIF (posterior lumbar interbody fusion) (n = 31) and OLIF + PSF (OLIF combined with posterior spinal fixation) (n = 28). Perioperative radiographic parameters, complications, and clinical outcome from each group were assessed and compared. The operation time for both groups was 165.1 min in the OLIF group and 182.1 min in the PLIF group (P < 0.05). The intraoperative blood loss was 190.6 ml in the OLIF group and 356.3 ml in the PLIF group (P < 0.05). The number of intraoperative and postoperative complications for both groups was 7 in the OLIF group and 11 in the PLIF group. Significant clinical improvement was observed in VAS scores and ODI when comparing preoperative evaluation and final follow-up. The preoperative SVA (the distance from the posterosuperior corner of S1body to the C7 plumb line), PI (pelvic incidence), LL (lumbar lordosis), PI-LL mismatch, DH (disc height), and lumbar Cobb angles of both groups were similar. The postoperative and final follow-up SVA, LL, PI-LL mismatch, and disc height were improved in both groups, and a statistical difference was found between both groups (P < 0.05). An improvement of SVA, LL, PI-LL mismatch, and disc height at the OLIF group was better than that found at the PLIF group. An improvement in radiographic and clinical outcomes for the OLIF group was better than that seen for the PLIF group. Then, OLIF had a more curative effect in lumbar degenerative spondylolisthesis with sagittal imbalance.

Cervical Spine Balance of Multilevel Total Disc Replacement, Hybrid Surgery, and Anterior Cervical Discectomy and Fusion With A Long-term Follow-up

STUDY DESIGN

Comparative study.

OBJECTIVE

The aim of this study was to compare cervical alignment among three-level total disc replacement (TDR), two prosthesis with one cage (2D1C), one prosthesis with two cages (1D2C), and anterior cervical discectomy and fusion (ACDF), then identify the importance of cervical balance of cervical spondylotic myelopathy (CSM).

SUMMARY OF BACKGROUND DATA

There were few long-term comparisons on cervical alignment and cervical balance among three-level TDR, 2D1C, 1D2C, and ACDF for CSM.

METHODS

Twenty-eight patients with TDR, 15 with 2D1C, 36 with 1D2C, and 32 cases with ACDF were included with a mean follow-up of 90.9 ± 8.9 months. C2-C7 cervical lordosis (CL), C2-C7 sagittal vertical axis (SVA), T1 slope (T1S) were measured on x-ray at preoperation, immediate postoperation, and final follow-up, as well as range of motion (ROM), upper/lower adjacent ROM (UROM/LROM), and adjacent segment degeneration (ASD); cervical balance was assessed by T1S minus CL (T1SCL; 20°). Clinical outcomes included neck disability index (NDI) and Japanese Orthopedic Association (JOA) score.

RESULTS

NDI and JOA improved (P < 0.01)at postoperation and final-visit with no difference among four groups. ROM decreased mostly in ACDF group, although with a comparable inter-group UROM/LROM and ASD. All groups gained equal CL-improvement at final-visit. SVA and T1S together with their change were of no differences among groups (P > 0.05). There was a correlation among alignment parameters and between CL and ROM. The inter-group capacity of balance maintaining and imbalance correction was comparable (P > 0.05). The change of T1SCL was not correlated to NDI and JOA (P > 0.05).

CONCLUSION

Adjacent segments were seldom affected. Cervical alignment was equivalently rebuilt among TDR, 2D1C, 1D2C, and ACDF. It was not essential to pay excessive attention to balance.

LEVEL OF EVIDENCE

3.

High-Grade Spondylolisthesis in Adults: Current Concepts in Evaluation and Management

Background

Information regarding the treatment of high-grade spondylolisthesis (HGS) in adults has been previously described; however, previous descriptions of the evaluation and surgical management of HGS do not represent more recent and now established approaches. The purpose of the current review is to discuss current concepts in the evaluation and management of patients with HGS.

Methods

Literature review.

Results

HGS is diagnosed in up to 11.3% of adults with spondylolisthesis and typically presents as nonspecific lower back pain. Regarding evaluation, a thorough history and physical examination should be performed, which may help predict the presence of HGS. Diagnostic imaging, and specifically the use of spino-pelvic parameters, are now commonly implicated in guiding treatment course and prognosis. When surgical intervention is indicated, surgical approaches include in situ fusion variations, reduction and partial reduction with fusion, and vertebrectomy. Although the majority of studies suggest improvements with these approaches, the literature is limited by a low level of evidence with regards to the superiority of one technique when compared with others.

Conclusions

HGS is a unique cause of low back pain in adults that carries considerable morbidity, but rarely presents with neurologic symptoms. Although the definitions, classifications, and methods of diagnosis of this spinal deformity have been established and accepted, the ideal surgical management of this deformity remains highly debated. Fusion in situ techniques are often technically easier to perform and provide lower risk of neurologic complications, whereas reduction and fusion techniques offer greater restoration of global spino-pelvic balance. Preoperative spino-pelvic parameters may have utility in assisting in procedural selection; however, future, higher-quality and longer-term studies are warranted to determine the optimal surgical intervention among the widely available techniques currently used, and to better define the indications for these interventions.

Straighter low lumbar curvature in isthmic spondylolisthesis at L4

BACKGROUND

This study was conducted to compare differences in imaging features and clinical symptoms between patients with single-level isthmic spondylolisthesis (IS) at L4 and at L5 and to investigate the correlation between imaging and clinical parameters.

METHODS

This cross-sectional study evaluated patients with single-level IS who were enrolled between June 2011 and June 2018. A total of 139 patients, 44 in the L4 IS group and 95 in the L5 IS group, met the study criteria and were included. Imaging and clinical parameters obtained from the two groups were compared and analyzed.

RESULTS

Patients in the L4 IS group had smaller lower lumbar lordosis (LLL) (27.1 ± 8.2 vs. 30.9 ± 9.3, P = 0.021) and were of older age (58.5 ± 8.7 vs. 52.8 ± 10.1, P < 0.01) than those in the L5 IS group. As per the Roussouly classification system, most patients with L4 IS were classified as Type 2 (43.2%), whereas most patients with L5 IS fell under Type 3 (44.2%). In the L5 IS group, pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), lumbar lordosis (LL), and L5 incidence (L5I) were positively associated with slippage rate (SR), but the lumbosacral angle (LSA) was negatively associated with SR (P < 0.01). In the L4 IS group, only L5I showed a positive association with SR (P < 0.01). More significant associations were found among sagittal lumbo-pelvic parameters in the L5 IS group, but none were found between SR and Oswestry Disability Index (ODI) in either group.

CONCLUSIONS

When compared with patients with L5 IS, patients with L4 IS were of older age and had straighter low lumbar curvature when they were obviously symptomatic. PI was an important parameter for patients with L5 IS while for those with L4 IS, L5I deserved more attention for its significantly positive correlation with the degree of slippage.

Cervical sagittal alignment in adolescent high dysplastic developmental spondylolisthesis: how does the cervical spine respond to the reduction of spondylolisthesis?

Background

Although pelvic and related parameters have been well stated in lumbar developmental spondylolisthesis, cervical sagittal alignment in these patients is poorly studied, especially in high dysplastic developmental spondylolisthesis (HDDS). The purpose of this study is to investigate the sagittal alignment of the cervical spine in HDDS and how the cervical spine responds to reduction of spondylolisthesis.

Methods

Thirty-three adolescent patients with lumbar developmental spondylolisthesis who received preoperative and postoperative whole-spine x-rays were reviewed. They were divided into the HDDS group (n = 24, 13.0 ± 2.2 years old) and the low dysplastic developmental spondylolisthesis (LDDS) group (n = 9, 15.6 ± 1.9 years old). Spinal and pelvic sagittal parameters, including cervical lordosis (CL), were measured and compared between groups. In the HDDS group, the postoperative parameters were measured and compared with those before surgery.

Results

HDDS group had a higher proportion of cervical kyphosis (70.8% vs. 22.2%, P = 0.019), and there was a significant difference in CL between the two groups (− 8.5° ± 16.1° vs. 10.5° ± 11.8°, P = 0.003). CL was correlated with the Dubousset’s lumbosacral angle (Dub-LSA), pelvic tilt (PT), and thoracic kyphosis (TK). In the HDDS group, CL in patients with a kyphotic cervical spine was significantly improved after reduction of spondylolisthesis (− 16.4° ± 5.9° vs. − 3.6° ± 9.9°, P < 0.001). In the HDDS group, 46% (6/13) of the patients with postoperative Dub-LSA < 90° still had sagittal imbalance (sagittal vertical axis, [SVA] > 5 cm), while no sagittal imbalance was observed in patients with postoperative Dub-LSA > 90° (46% [6/13] vs. 0% [0/11], P = 0.016).

Conclusions

HDDS can lead to cervical kyphosis through a series of compensatory mechanisms. Reduction of spondylolisthesis and correction of lumbosacral kyphosis may correct the cervical kyphosis and normalize the overall spinal sagittal profile. Correction of Dub-LSA to above 90° might be used as an objective to better improve the sagittal alignment of the spine.

Sagittal Spinopelvic Alignment in Asymptomatic Iranian Adults Aged 18 to 40 Years

BACKGROUND

Recent studies have revealed the increasing importance of sagittal spinopelvic alignment. Knowing the values of sagittal spinopelvic parameters, which are affected by ethnicity, is essential in the normal asymptomatic population. In the current study, these parameters were measured in a sample of asymptomatic Iranian population.

METHODS

Seventy asymptomatic participants without complaint of musculoskeletal problems were enrolled. They had no complaint about musculoskeletal problems. Lateral full-length spinal and pelvic x-rays were taken. The following parameters were measured on x-rays and presented as mean ± standard deviation: pelvic incidence (PI), sacral slope (SS), pelvic tilt (PT), lumbar lordosis (LL), thoracic kyphosis (TK), lumbar tilt (LT) and thoracic tilt (TT).

RESULTS

The population consisted of 37 males and 33 females aged 26.6 ± 4.27 years. The mean values of PI, SS, PT, LL, TK, LT, and TT were 44.5 ± 10.1, 35.4 ± 6.7, 9.1 ± 7.9, 41.9 ± 14.7, 28.8 ± 8.3, 11.9 ± 7.4 and -7.5 ± 5.7 (median: -10; 5th percentile: -14; 95th percentile: 4.4) degrees, respectively. The variables were similar between males and females except for LL which was significantly higher in females (37.8 ± 16.5 versus 46.5 ± 11; P = 0.013). In addition, the linear regression model revealed age to be independently related with PI (beta = 0.344; P = 0.004) and PT (beta = 0.366; P = 0.002). PI (r = 0.344, P = 0.004) and PT (r = 0.359, P = 0.002) were positively correlated with age. Additionally, PI was positively correlated to SS, PT and LL and negatively to TT.

CONCLUSION

These findings may be used as referential values for sagittal spinopelvic parameters in the Iranian population. The positive correlation of PI with age questions the constancy of PI throughout life. However, larger studies are required.

Reduction versus In Situ Fusion for Adult High-Grade Spondylolisthesis: A Systematic Review and Meta-Analysis

BACKGROUND

Surgical management of high-grade spondylolisthesis is controversial. Both reduction and in situ fusion are available options, but it remains unclear which approach provides better outcomes. We conducted a systematic review and meta-analysis of studies reporting outcomes following reduction or in situ fusion for adult high-grade spondylolisthesis.

METHODS

PubMed, Embase, Web of Science, and Cochrane databases were last searched on June 24, 2019. We identified 1236 studies after excluding duplicates. After screening, 15 studies were included in the meta-analysis. Random-effects models were used to pool effect estimates.

RESULTS

A total of 188 patients were analyzed. Compared with reduction, in situ fusion had a higher mean estimated blood loss (584 mL vs. 451 mL) and a clinically higher incidence of neurologic (48% vs. 15%), pseudarthrosis (13% vs. 8%), and infectious (20% vs. 10%) complications; however, these differences were not statistically significant. Reduction was associated with a clinically higher incidence of overall complications (32% vs. 25%) and dural tears (22% vs. 7%). Reduction provided better pain relief (mean difference [MD] = 5.24 vs. 4.77) and greater change in pelvic tilt (MD = 5.33 vs. 2.60); however, these differences were not statistically significant. Patients who underwent reduction had significantly greater decline in Oswestry Disability Index scores (MD = 55.7 vs. 11.5; P_interaction < 0.01) and greater change in slip angle (MD = 25.0 vs. 11.4; P_interaction = 0.01).

CONCLUSIONS

In management of adult high-grade spondylolisthesis, both approaches appeared to be safe and effective. Reduction appeared to offer better disability relief and spinopelvic parameter correction than in situ fusion.

High grade isthmic spondylolisthesis; can reduction always re-align the unbalanced pelvis?

Background

Recently, various studies have reported the importance of distinguishing between balanced and unbalanced SL, sustaining the importance of SL reduction in unbalanced cases. In this study we present our experience in the treatment of isthmic spondylolisthesis in young patients, observing the correlation between SL reduction and sagittal correlation between spine and pelvis.

Methods

This is a retrospective study of a series of patients treated surgically for isthmic spondylolisthesis. Inclusion criteria were L5-S1 isthmic spondylolisthesis of III° or IV°, pediatric age, clinical and radiographic follow up of at least 1 year. Radiographic evaluation included the following elements: grade and percentage of listhesis (%L), lumbar lordosis (LL), lumbar-sacral angle (LSA), pelvic incidence (PI), sacral slope (SS), pelvic tilt (PT) distinguishing between “balanced” and “unbalanced” patients. Radiographic values were confronted by using Student’s t- test, obtaining a statistically significant difference for values inferior to 0,05.

Results

Based on inclusion criteria, 28 patients were selected for our retrospective analysis, 19 female and 9 male. Mean age at surgery was 15,6 years. Mean follow up was 3 years and 3 months (min. 1 year – max 6 years and 7 months). Spondylolisthesis reduction was statistically significant both in balanced and in unbalanced patients, but pelvic incidence values did not improve significantly. We observed fewer mechanical complications in patients treated with interbody support.

Conclusion

In our study, differences between pre-op and post-op spinopelvic alignment values were not statistically significant, even though spondylolisthesis reduction was statistically significant in all cases. Our study could be considered an initial attempt to correlate spinopelvic changes to spondylolisthesis reduction in a progressive manner, and possibly in the future, generate threshold values of reduction for ideal spinopelvic alignment in every different patient.

Minimally invasive anterior and lateral transpsoas approaches for closed reduction of grade II spondylolisthesis: initial clinical and radiographic experience

OBJECTIVE Minimally invasive anterior and lateral approaches to the lumbar spine are increasingly used to treat and reduce grade I spondylolisthesis, but concerns still exist for their usage in the management of higher-grade lesions. The authors report their experience with this strategy for grade II spondylolisthesis in a single-surgeon case series and provide early clinical and radiographic outcomes. METHODS A retrospective review of a single surgeon's cases between 2012 and 2016 identified all patients with a Meyerding grade II lumbar spondylolisthesis who underwent minimally invasive lateral lumbar interbody fusion (LLIF) or anterior lumbar interbody fusion (ALIF) targeting the slipped level. Demographic, clinical, and radiographic data were collected and analyzed. Changes in radiographic measurements, Oswestry Disability Index (ODI), and visual analog scale (VAS) scores were compared using the paired t-test and Wilcoxon signed rank test for continuous and ordinal variables, respectively. RESULTS The average operative time was 199.1 minutes (with 60.6 ml of estimated blood loss) for LLIFs and 282.1 minutes (with 106.3 ml of estimated blood loss), for ALIFs. Three LLIF patients had transient unilateral anterior thigh numbness during the 1st week after surgery, and 1 ALIF patient had transient dorsiflexion weakness, which was resolved at postoperative week 1. The mean follow-up time was 17.6 months (SD 12.5 months) for LLIF patients and 10 months (SD 3.1 months) for ALIF patients. Complete reduction of the spondylolisthesis was achieved in 12 LLIF patients (75.0%) and 7 ALIF patients (87.5%). Across both procedures, there was an increase in both the segmental lordosis (LLIF 5.6°, p = 0.002; ALIF 15.0°, p = 0.002) and overall lumbar lordosis (LLIF 2.9°, p = 0.151; ALIF 5.1°, p = 0.006) after surgery. Statistically significant decreases in the mean VAS and the mean ODI measurements were seen in both treatment groups. The VAS and ODI scores fell by a mean value of 3.9 (p = 0.002) and 19.8 (p = 0.001), respectively, for LLIF patients and 3.8 (p = 0.02) and 21.0 (p = 0.03), respectively, for ALIF patients at last follow-up. CONCLUSIONS Early clinical and radiographic results from using minimally invasive LLIF and ALIF approaches to treat grade II spondylolisthesis appear to be good, with low operative blood loss and no neurological deficits. Complete reduction of the spondylolisthesis is frequently possible with a statistically significant reduction in pain scores.

Restoration of normal pelvic balance from surgical reduction in high-grade spondylolisthesis

PURPOSE

To investigate the effectiveness of surgical reduction in high-grade spondylolisthesis in maintaining or restoring a normal pelvic balance, as related to the QoL.

METHODS

It is a retrospective analysis of prospectively collected data of 60 patients (17 males, 43 females) aged 15 ± 3.1 years who underwent surgery for high-grade spondylolisthesis and were followed for a minimum of 2 years after surgery. Patients with a residual high-grade slip following surgery were referred to the postoperative high-grade (PHG) group, while patients with a residual low-grade slip were referred to the postoperative low-grade (PLG) group. Pelvic balance was assessed from pelvic tilt and sacral slope, in order to identify patients with a balanced pelvis or unbalanced pelvis. The SRS-22 questionnaire was completed before surgery and at last follow-up.

RESULTS

Postoperatively, there were 36 patients with a balanced pelvis and 24 patients with an unbalanced pelvis. The improvement in QoL was better in patients with a postoperative balanced pelvis. There were 14 patients in the PHG group and 46 patients in the PLG group. Four of seven patients (57%) in the PHG group and 21 of 26 patients (81%) in the PLG group with a preoperative balanced pelvis maintained a balanced pelvis postoperatively (P = 0.1). None of the patients in the PHG group and 11 of 20 patients (55%) in the PLG group improved from an unbalanced to a balanced pelvis postoperatively (P < 0.05).

CONCLUSIONS

Surgical reduction in high- to low-grade slip is more effective in maintaining and restoring a normal pelvic balance postoperatively. These slides can be retrieved under Electronic Supplementary Material.

Short Lumbosacral Decompression Plus Fixation Does Not Change the Spinopelvic Balance on Patients With Moderate Degenerative Spondylolisthesis and Associated Spinal Stenosis

STUDY DESIGN

A retrospective cohort study.

OBJECTIVES

To investigate whether decompression plus short segment lumbosacral fixation changes the sagittal baseline spinopelvic parameters in patients with moderate degenerative spondylolisthesis (DS) and associated degenerative lumbar spinal stenosis (DLSS).

SUMMARY OF BACKGROUND DATA

Spinal decompression and fusion are commonly performed in DS with associated DLSS. Spinopelvic alignment after surgery for DS is an important research topic. The effect of short lumbosacral instrumented fusion on the global sagittal spinal balance has not been sufficiently studied.

METHODS

Thirty-four consecutive adult patients (21 women, 13 men) aged 62 ± 11 years with balanced spines [sagittal vertical axis (SVA) ≤ 40 mm] received decompression and two to three vertebrae fixation plus fusion for DS grades I and II, associated with symptomatic DLSS. Age, gender, number of segments fused, posterolateral fusion (PLF) versus PLF plus posterior lumbar interbody fusion (PLIF) and segmental lordosis (SL) in the free segment above instrumentation were studied for a minimum follow-up of 60 months. The roentgenographic variables measured are T12-S1 lumbar lordosis (LL), SVA, sacral slope (SS), pelvic tilt (PT), pelvic incidence (PI), SL, and anterior (ADH) and posterior disc height (PDH) in the suprajacent free lumbar segment. Clinical outcomes were assessed with visual analog scale and Oswestry Disability Index.

RESULTS

SVA significantly (p = .05) decreased postoperatively but returned to the baseline value at the final observation. Younger individuals (≤59 years) stood with greater SS (p = .036) 6 months postoperatively and with less SVA in all 3 periods of observation (p = .013, .046, and .024) than their older (>59 years) counterparts. Patients with monosegmental stenosis showed on baseline less SVA (p = .028), PT (p = .031), and PI (p = .004) than their two-segmental stenosis counterparts. PI preoperatively to the last evaluation was significantly smaller in the patients who received 360° fusion (p<.016).

CONCLUSIONS

Short lumbosacral fixation does not significantly change the preoperative sagittal spinopelvic balance in adult patients with preoperatively balanced spines who have DS and DLSS.

LEVEL OF EVIDENCE

Level III.

Expectations for Postoperative Improvement in Health-Related Quality of Life in Young Patients With Lumbosacral Spondylolisthesis: A Prospective Cohort Study

STUDY DESIGN

Prospective multicenter study of the changes in Scoliosis Research Society Outcome Questionaire 22 (SRS-22) scores for 78 patients younger than 25 years old surgically treated for lumbosacral spondylolisthesis OBJECTIVE.: Report the change of health-related quality of life (HRQOL) in patients younger than 25 years after surgical treatment of lumbosacral spondylolisthesis.

SUMMARY OF BACKGROUND DATA

There is a paucity of data with regard to the influence of surgical treatment on the HRQOL of patients with lumbosacral spondylolisthesis. Large prospective studies are needed to clearly define the benefits of surgery in the young patient population.

METHODS

A prospective multicenter cohort of 78 patients younger than 25 years (14.8 ± 2.9, range: 7.9-23.6 yr) undergoing posterior fusion for lumbosacral spondylolisthesis were enrolled. There were 17 patients with low-grade (<50%) and 61 with high-grade (≥50%) slips. SRS-22 scores calculated before surgery and after 2 years of follow-up were compared for all patients using two-tailed paired t tests. Subanalyses for low- and high-grade patients were done using two-tailed Wilcoxon signed ranked and paired t tests, respectively. The level of significance was set at 0.05.

RESULTS

HRQOL was significantly improved 2 years after surgery for all domains and for the total score of the SRS-22 questionnaire. The individual total score was improved in 66 patients (85%), and 52 patients (67%) improved by at least 0.5 point. All domains and the total score of the SRS-22 questionnaire were significantly improved for high-grade patients, whereas only pain, function, and total score were improved for low-grade patients.

CONCLUSION

This is the largest study comparing the HRQOL before and after surgery in young patients with low- and high-grade lumbosacral spondylolisthesis. HRQOL significantly improves after surgery for the majority of patients, especially for high-grade patients. This study helps clinicians to better counsel patients with regard to the benefits of surgery for lumbosacral spondylolisthesis.

LEVEL OF EVIDENCE

2.

Radiographic Analysis of Minimally Invasive Transforaminal Lumbar Interbody Fusion versus Conventional Open Surgery on Sagittal Lumbar-Pelvic Alignment for Degenerative Spondylolisthesis

OBJECTIVE

To compare the impact of minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) with open posterior lumbar interbody fusion (PLIF) on sagittal lumbar-pelvic radiographic parameters for degenerative spondylolisthesis (DS).

METHODS

Of 48 patients with L4 single segmental DS, 25 underwent MIS-TLIF with Quadrant system and 23 underwent conventional open PLIF. Comparisons of data from the preoperative and final follow-up standing lateral lumbar x-rays, with the bilateral femoral heads, of the 2 groups were conducted using the following parameters: slip percentage (SP), lumbar lordosis (LL), pelvic incidence, pelvic tilt (PT), sacral slope, lumbosacral angle, slip angle (SA), and the L1 axis and S1 distance (LASD).

RESULTS

The slip reduction rate (ΔSP) in the OPEN group was significantly higher than in the MIS group (67 ± 34% vs. 37 ± 51%, P = 0.018). The change of SA (ΔSA) in the OPEN group was significantly higher than in the MIS group (3 ± 7° vs. -3 ± 5°, P = 0.003). The change of LASD (ΔLASD) in the OPEN group was significantly lower than in the MIS group (-4 ± 15 mm vs. 4 ± 9 mm, P = 0.033). There were positive correlations between the preoperative SP and LASD, and ΔSA and the change of LL (ΔLL), and a negative correlation between ΔLL and the change of PT (ΔPT).

CONCLUSIONS

For low-grade DS, open PLIF has a higher rate of slip reduction compared to MIS-TLIF, and significantly reduces LASD, therefore, it is more conducive to improving lumbar sagittal balance.

L5 incidence: an important parameter for spinopelvic balance evaluation in high-grade spondylolisthesis

BACKGROUND

In high-grade spondylolisthesis (HGSPL), the pelvic incidence (PI) is not a reliable measurement because of doming of the sacrum. Measurement of L5 incidence (L5I) was described as a tool to measure pelvic morphology in HGSPL and for surgical follow-up.

OBJECTIVE

We aimed to evaluate L5I in HGSPL and its relationship to other spinopelvic parameters.

STUDY DESIGN

A retrospective study of a cohort of 184 patients with HGSPL was carried out.

METHODS

Whole spine radiographs were analyzed for PI, pelvic tilt (PT), sacral slope, lumbar lordosis (LL), L5I, L5 tilt (L5T), L5 slope, lumbosacral kyphosis, and slip percentage. Statistical analysis and correlation were made (Pearson correlation test; p<.05). In accordance to Cohen, statically significant correlation were considered strong if R>0.5, moderate if 0.3<R<0.5, and small if R<0.3.

RESULTS

A total of 184 cases were analyzed, with a female-to-male ratio of 2.35 and a mean age of 20.1 years. Sacral doming was present in 73% of the cases. Mean L5I incidence was 65.2° and strongly correlated to other sagittal parameters, especially PT (R=0.7), LL (R=0.7), L5T (R=0.77), and L5 slope (R=0.83). There was less but still strong correlation to Dubousset lumbosacral kyphosis (Dub-LSK) angle (R=-0.63) and percentage of slippage (R=0.56). L5 tilt showed nearly perfect correlation to PT (R=0.95). Forty-four percent of the cases were balanced HGSPL, whereas 56% of the cases were unbalanced HGSPL. L5 incidence was found to be a good predictor of local imbalance with a cutoff of L5I=61.

CONCLUSION

This paper describes L5I, which is a positional parameter in HGSPL. L5 incidence is a simple and reliable measure in the preoperative setting in HGSPL. Its correlation with spinal sagittal parameters (especially PT and LL) is strong and was found to be better than Dub-LSK. There is also a good correlation between L5I and HGSPL pelvic parameters (slip percentage and lumbosacral kyphosis). We recommend its use for evaluation of surgical correction and recommend the value of 60° as cutoff value to define spinopelvic balance in HGSPL.

The Quest of Sagittal Balance Parameters and Clinical Outcome after Short Segment Spinal Fusion

Introduction:

Sagittal imbalance leads to muscular distress and results in low back pain.

Objectives:

This study scrutinize the segmental impact of short spinal fusion on spinopelvic parameters and the global patient’s clinical outcome.

Materials and Methods:

A retrospective analysis evaluated 56-patients who underwent lumbar fusion surgery at Klinikum Dortmund, from July 2013 to February 2014. The population was allocated into two groups: (1-level group), (2-levels group). EOS imaging applied for radiological evaluation and measurements of the following spinopelvic parameters: pelvic incidence (PI), sacral slope (SS), pelvic tilt (SS), lumbar lordosis (LL), and sagittal vertical axis (SVA). The radiological measurements were implemented during the preoperative, postoperative, 3 months and 1 year follow-up visits. All patients completed clinical questionnaires.

Results:

Statistically, the Pearson correlation coefficient revealed in the 1-level group that the clinical parameters correlated with the PT (R=0.40), SSA (R=-0.38) and SVA (R=-0.41) (p<0.05). While clinically, the mean preoperative VAS and mean ODI improved significantly in both groups.There was also a high correspondence between LL and SS (R=0.90); this relationship persisted at the same level even after a year. For the 2-level group, the only parameter that was interrelated with clinical parameters was the SVA (R=0.49) (p<0.05). There was also a high correlation between LL and SS (R=0.88).

Conclusion:

Scrutiny conducted showed: Patient with one level would improve clinically in terms of pain and radiculopathy, with only small alterations in spino-pelvic parameters. Meanwhile, two-level fusions have a statistically substantial clinical improvement interrelated to re-establishment of lumbar lordosis and sagittal vertical axis.

Complete anatomic reduction and monosegmental fusion for lumbar spondylolisthesis of Grade II and higher: use of the minimally invasive "rocking" technique

OBJECTIVE Different surgical approaches have been described for treatment of spondylolisthesis, including in situ fusions, reductions of various degrees, and inclusion of healthy adjacent segments into the fusion construct. To the authors' knowledge, there are only sparse reports describing consistent complete reduction and monosegmental transforaminal lumbar interbody fusion for spondylolisthesis using a minimally invasive technique. The authors assess the efficacy of this technique in the reduction of local deformity and correction of overall sagittal profile in single-level spondylolisthesis. METHODS This cohort study consists of a total of 36 consecutive patients treated over a period of 6 years. Patients with varying grades of lumbar spondylolisthesis (29 Meyerding Grade II and 7 Meyerding Grade III) were treated with operative reduction via minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) in which the "rocking" technique was used. The clinical outcomes were measured using the visual analog scale (VAS) for pain and the Revised Oswestry Disability Index (ODI) for low-back pain/dysfunction. Meyerding grade, pelvic incidence (PI), lumbar lordosis (LL), disc space angle (DSA), pelvic tilt (PT), and sacral slope (SS) were assessed to measure the radiological outcomes. These were reviewed for each patient for a minimum of 2 years. RESULTS At most recent follow-up, 94% of patients were pain free. There were 2 patients (6%) who had moderate pain (which corresponded to higher-grade of listhesis), but all showed an improvement in pain scores (p < 0.05). The mean VAS score improved from 6.5 (SD 1.5) preoperatively to 1.6 (SD 1.3) and the mean ODI score improved from 53.7 (SD 13.1) preoperatively to 22.5 (SD 15.5) at 2-year follow-up. All radiological parameters improved following surgery. Most significant improvement was noted for LL, DSA, and SS. Both LL and SS were found to decrease, while DSA increased postoperatively. PI remained relatively unchanged, while PT showed a mild increase, which was not significant. Good fusion was achieved with implants in situ at 2-year follow-up. A 100% complete reduction of all grades of spondylolisthesis was achieved. The overall sagittal profile improved dramatically. No major perioperative complications were encountered. CONCLUSIONS Minimally invasive monosegmental TLIF for spondylolisthesis reduction using this rocking technique is effective in the treatment of various grades of spondylolisthesis. Consistent complete reduction of the slippage as well as excellent correction of overall sagittal profile can be achieved, and the need for including healthy adjacent segments in the fusion construct can be avoided.

Analysis of Spinopelvic Parameters with L5 as the New Sacrum after Fusion in High-Grade Spondylolisthesis: A Possible Explanation for Satisfactory Results with In-Situ Fusion

Study Design

Retrospective case series.

Purpose

To correlate functional outcomes with spinopelvic parameters in patients with high-grade spondylolisthesis (HGS) treated with instrumented in-situ surgery or reduction and fusion.

Overview of Literature

Satisfactory functional outcomes are reported with reduction and in-situ fusion strategies in HGS. However, reasons for this are unclear. We hypothesize that following lumbosacral fusion, the L5 becomes part of the sacrum, which improves spinopelvic parameters, resulting in equivalent functional outcomes in both surgical methods.

Methods

Twenty-six patients undergoing HGS (reduction group A, 13; in-situ group B, 13) were clinically evaluated using the Oswestry Disability Index (ODI), short form-12 (SF-12), and Visual Analogue Scale (VAS) scores. Spinopelvic parameters, including pelvic incidence, pelvic tilt (PT), sacral slope (SS), lumbar lordosis (LL), lumbosacral kyphosis (LSK) angle, and sacrofemoral distance (SFD) were measured preoperatively from S1 and postoperatively from L5 as the new sacrum at 1 year follow-up. Sagittal alignment was assessed using the sagittal vertical axis.

Results

Both groups were comparable in terms of age, sex, severity of slip, and preoperative spinopelvic parameters (p>0.05). Postoperative VAS, SF-12, and ODI scores significantly improved in both groups (p<0.05). Compared with preoperative values, the mean postoperative PT, SFD, and LSK significantly changed in both groups. In reduction group, PT changed from 26.98° to 10.78°, SFD from 61.24 to 33.56 mm, and LSK from 74.76° to 109.61° (p<0.05). In in-situ fusion group PT changed from 26.78° to 11.08°, SFD from 62.9 to 36.99 mm, and LSK from 67.23° to 113.38° (p<0.05 for all). In both groups, SS and LL did not change significantly (p>0.05).

Conclusions

After fusion, the L5 becomes the new sacrum and influences spinopelvic parameters to change favorably. This possibly explains why reduction and in-situ fusion achieve equivalent functional outcomes in HGS.

Modified Lumbosacral Angle and Modified Pelvic Incidence as New Parameters for Management of Pediatric High-grade Spondylolisthesis

STUDY DESIGN

Retrospective clinical study.

OBJECTIVE

We aimed to introduce new parameters that can better describe the pelvic morphology and lumbosacral segmental deformity in children with high-grade spondylolisthesis of the L5 vertebra: modified pelvic incidence (mPI) and modified lumbosacral angle (mLSA). Also, we aimed to establish the mLSA as a convenient, reliable measurement method and criteria to evaluate the reduction of L5 vertebral slippage.

SUMMARY OF BACKGROUND DATA

Numerous parameters and methods exist to evaluate segmental deformity and reduction of L5 vertebral slippage, but no definitive standard for accurately and conveniently describing lumbosacral kyphosis and degree of reduction exists.

METHODS

A total of 24 children with high-grade spondylolisthesis (S group) and 152 children without spondylolisthesis (non-S group) underwent standard lateral radiography of the spine in our hospital between June 2009 and June 2014. We compared mPI and mLSA between the S and non-S groups. The agreement and repeatability of mPI and mLSA were also assessed. Preoperative and postoperative Japanese Orthopaedic Association (JOA) and Scoliosis Research Society (SRS)-22 scores were compared to assess clinical outcomes in the S group. The correlations between modified parameter applications and clinical outcomes were also assessed.

RESULTS

While mPI did not differ between groups, mLSA differed significantly. In the non-S group, mLSA was lordotic (25.51±6.41 degrees). In the S group, mLSA was kyphotic (25.85±5.17 degrees) before surgery and lordotic (20.74±7.04 degrees) postoperatively. The agreement and repeatability of mPI and mLSA were good, and clinical outcomes of the S group were satisfactory. Positive correlations were found between modified parameter applications and the improvement rates of JOA scores.

CONCLUSIONS

mPI and mLSA can better describe the pelvic morphology and local deformity of pediatric high-grade L5 spondylolisthesis, and mLSA can serve as a useful index for correcting lumbosacral kyphosis, rebalancing the sagittal spinal profile and predicting clinical outcomes.

Combination of whole-spine lateral radiograph and lateral scanogram in the assessment of global sagittal balance

BACKGROUND CONTEXT

Global balance of human standing is analyzed as the geometric sum of the individual alignments extending from the spinal column to the pelvis, and to the lower limbs. The innovative EOS system has opened new perspectives for the global analysis of whole-body alignment, but its use is very limited because of its high cost. An alternative may be to combine the whole-spine lateral radiograph and the lateral scanogram in the global sagittal analysis of whole-body alignment.

PURPOSE

We examined to determine the validity and reliability of a lateral scanogram in the measurement of sacropelvic parameters.

STUDY DESIGN/SETTING

A retrospective radiological study was carried out.

PATIENT SAMPLE

We randomly selected 100 sets of digital radiographs, both whole-spine radiographs and lower-limb scanograms, from our database.

OUTCOME MEASURES

Sacropelvic parameters, including pelvic incidence, sacral slope, and pelvic tilt, were measured on both whole-spine radiographs and lower-limb scanograms by three independent examiners on three separate occasions.

METHODS

Agreement regarding the measurements on both image types was calculated to assess the validity of the lateral scanogram for use in whole-body alignment determinations. Intraobserver and interobserver reliabilities among the types of measurements were calculated.

RESULTS

The sacropelvic area on the lateral scanogram was not visible in 19 patients (19%). In the remaining 81 patients, the sacropelvic parameters on the lateral scanogram were similar to those on the whole-spine lateral radiograph (Pearson correlation coefficient, 0.764-0.805). Intraobserver and interobserver reproducibilities for both modalities were good to excellent (intraclass correlation coefficient, 0.657-0.984).

CONCLUSIONS

Sacropelvic parameter measurements on lateral scanogram were reliable and were similar to those measured on whole-spine lateral radiograph. Thus, global alignment can be evaluated using the lateral scanogram in combination with the whole-spine lateral radiograph.

Correlation Between Lumbopelvic and Sagittal Parameters and Health-Related Quality of Life in Adults With Lumbosacral Spondylolisthesis

STUDY DESIGN

Secondary analysis of prospective, multicenter data.

OBJECTIVE

To evaluate impact of sagittal parameters on health-related quality of life (HRQoL) in adults with lumbosacral spondylolisthesis.

METHODS

Adults with unoperated lumbosacral spondylolisthesis were identified in the Spinal Deformity Study Group database. Pearson's correlations were calculated between SF-12 (Short Form-12)/Scoliosis Research Society-30 (SRS-30) scores and radiographic parameters (C7 sagittal vertical axis [SVA] deviation, T1 pelvic angle, pelvic tilt [PT], pelvic incidence, sacral slope, slip angle, Meyerding slip grade, Labelle classification). Main effects linear regression models measured association between individual health status measures and individual radiographic predictor variables.

RESULTS

Forty-five patients were analyzed (male, 15; female, 30; average age 40.5 ± 18.7 years; 14 low-grade, 31 high-grade). For low-grade slips, SVA had strong negative correlations with SF-12 mental component score (MCS), SRS-30 appearance, mental, and satisfaction domains (r = -0.57, r = -0.60, r = -0.58, r = -0.53, respectively; P < .05). For high-grade slips, slip angle had a moderate negative correlation with SF-12 MCS (r = -0.36; P = .05) and SVA had strong negative correlations with SF-12 physical component score (PCS), SRS-30 appearance and activity domains (r = -0.48, r = -0.48, r = -0.45; P < .05) and a moderate negative correlation with SRS-30 total (r = -0.37; P < .05). T1 pelvic angle had a moderate negative correlation with SF-12 PCS and SRS-30 appearance (r = -0.37, r = -0.36; P ≤ .05). For every 1° increase in PT, there was a 0.04-point decrease in SRS appearance, 0.05-point decrease in SRS activity, 0.06-point decrease in SRS satisfaction, and 0.04-point decrease in SRS total score (P < .05).

CONCLUSION

Lumbosacral spondylolisthesis in adults negatively affects HRQoL. Multiple radiographic sagittal parameters negatively affect HRQoLs for patients with low- and high-grade slips. Improvement of sagittal parameters is an important goal of surgery for adults with lumbosacral spondylolisthesis.

Does Sagittal Spinopelvic Configuration Influence Vertebral Fracture Type or Localization in Trauma Patients?: A Retrospective Radiologic Analysis

STUDY DESIGN

Retrospective data analysis.

OBJECTIVE

The aim of this study was to analyze correlations between spinopelvic configuration and fracture pattern or location in traumatic vertebral fractures.

SUMMARY OF BACKGROUND DATA

The spinopelvic configuration represented by the pelvic incidence (PI) angle showed to have a strong correlation with the occurrence of degenerative diseases of the thoracolumbar spine. No data are available on whether there is an influence of the PI angle on traumatic vertebral lesions as well.

MATERIALS AND METHODS

In a consecutive series of patients sustaining traumatic vertebral fractures, we retrospectively analyzed spinopelvic computed tomography data sets of 197 patients (121 male and 76 female patients; mean age, 51 years). Measurements included the PI angle, level of fracture(s), and fracture type according to the AO classification. Statistical analysis was performed to calculate correlation between PI and fracture level and between PI and fracture type.

RESULTS

An average of 1.6 fractures per patient was found in the 197 individuals included in our study. PI angle showed a mean of 50.6 degrees for the left hip and a mean of 49.9 degrees for the right hip. There were no significant differences of the PI angle between male and female patients as well. Neither a significant effect of the PI angle on the vertebral fracture level (P=0.64) nor a significant relationship between the PI angle and the fracture type according to the AO classification (P=0.52) was found.

CONCLUSIONS

The spinopelvic configuration represented by PI angle seems to influence neither the level nor the type of vertebral fractures in trauma patients.

Correlation between correction of pelvic balance and clinical outcomes in mid- and low-grade adult isthmic spondylolisthesis

BACKGROUND

Pelvic balance is a version of the pelvis defined by pelvic orientation parameters of PT and SS. Two distinct versions of pelvis are defined: (1) balanced characterized by a relatively low PT and high SS, and (2) unbalanced with relatively high PT and low SS meaning excessive retroversion of the pelvis. It was proved for patients with a high-grade spondylolisthesis that rebalancing of the pelvis can positively affect clinical outcomes. Little is known about the impact of such rebalancing in low-grade isthmic spondylolisthesis.

PURPOSE

To determine whether clinical outcomes correlated with rebalancing of the pelvis after surgical correction of mid- and low-grade adult isthmic spondylolisthesis.

METHODS

One hundred and three adult patients with a mid- and low-grade isthmic slip were the participants. Clinical outcomes were assessed at least 2 years after the surgery with the use of the Oswestry Disability Index (ODI) and a back pain visual analogue scale. Statistical analysis was used to identify differences in clinical outcomes between patients (1) with a balanced and unbalanced pelvis postoperatively, (2) who regained and did not regain pelvic balance postoperatively, (3) who maintained and lost pelvic balance postoperatively, and (4) with reduced and increased postoperative PT.

RESULTS

There were no significant differences in clinical outcomes between patients with a balanced and unbalanced pelvis postoperatively regardless of whether they lost, maintained, or regained pelvic balance after the surgery (Student's t test for independent variables or the non-parametric Mann-Whitney U, p value = 0.05). No correlation (Spearman's rank correlation) was found between postoperative reduction of PT and postoperative: (1) level of back pain (r = -0.10, p = 0.3063), (2) degree of reduction in back pain (r = 0.03, p = 0.7927), (3) ODI scores (r = -0.18, p = 0.0696), and (4) degree of reduction in ODI scores (r = 0.13, p = 0.1893).

CONCLUSIONS

Radiological improvement of pelvic balance after surgical correction of mid- and low-grade isthmic spondylolisthesis did not correlate with clinical outcomes.

Influence of the Type of Sagittal Profile on Clinical Results of Lumbar Total Disk Replacement After a Mean Follow-Up of 39 Months

STUDY DESIGN

Retrospective analysis of clinical and radiologic data of a prospective cohort study.

OBJECTIVE

To research the clinical differences after lumbar total disk replacement (TDR) with respect to the preoperative global and the adaptation at the local sagittal profile (SP) of the spine.

SUMMARY OF BACKGROUND DATA

It was suggested that facet loads and degeneration are dependent on epidemiologically defined types of SP. Moreover, the success of TDR was related to segmental facet joint loads. The influences of the preoperative SP or of the changes of the local SP after TDR on the clinical outcome after TDR remain unclear.

METHODS

Fifty-two patients included in a prospective cohort study regarding lumbar single-level TDR L4/5 (n=22) or L5/S1 (n=30) because of degenerative disk disease (Modic ≤2 degrees) were clinically (visual analog scale for back, leg, and overall pain; Oswestry Disability Index) and radiologically (extension-flexion radiographs, plain-spine, and whole-spine lateral radiographs in upright standing position) reevaluated after a minimum follow-up of 24 (24-69) months. On the basis of preoperative plain radiographs in upright standing position, patients were retrospectively assigned to 4 groups according to the individual sagittal profile type (SPT). In patients with persistent back pain, a facet infiltration at the index level was performed.

RESULTS

For all patients, an SPT could be defined. Global SP did not change compared with the preoperative state. All groups improved clinically over follow-up. At the last follow-up, types 1 and 4 demonstrated significantly inferior scores for pain and function. TDR-induced changes at the superior adjacent segment and the posterior disk height at the index level were also correlated to inferior clinical results. Infiltration test was positive in type 1-4: 67%, 40%, 33%, and 75%, respectively, of the symptomatic patients.

CONCLUSIONS

We suggest SPTs 1 and 4 to represent a contraindication for lumbar TDR of levels L4/5 or L5/S1. Local adaptation in the adjacent segment to TDR may influence the clinical outcome as well.

Operative management of high-grade dysplastic L5 spondylolisthesis with the use of external transpedicular fixation: advantages and drawbacks

PURPOSE

The aim of our study was to analyze clinical and radiographic outcomes of operative management of L5 high-grade dysplastic spondylolisthesis with the apparatus for external transpedicular fixation (AETF), and to compare the results of its use for reduction and spondylodesis.

METHODS

There were 13 patients with L5 dysplastic spondylolisthesis of grade 4 (Meyerding grading) and having a mean age of 25.0 ± 3.6 years. The management included two stages: gradual reduction with the AETF, followed by either isolated anterior spondylodesis with the same AETF (group 1, n = 8), or by spondylodesis using a combined method (internal transpedicular instrumentation and posterior lumbar interbody fusion [PLIF]) (group 2, n = 5). Clinical evaluation included pain (VAS scale) and functional status (Oswestry questionnaire [ODI]). Reduction and fusion completeness were assessed radiographically after treatment and at a mean follow-up of 2.1 ± 0.4 years.

RESULTS

Initial slippage was reduced by 51.6 % with AETF and was of grade 1 or 2. Reduction made up 31.1 % at follow-ups (grade 2 or 3). Pain decreased by 57.6 % (p < 0.01). The functional status improved. ODI decreased by 37.7 % (p < 0.01) after treatment and by 41.7 % (p < 0.01) at follow-ups. Fusion at the level of the involved segment was poor in group 1. All the cases fused in group 2.

CONCLUSIONS

The use of AETF for L5 high-grade dysplastic spondylolisthesis provides gradual controlled reduction of the slipped vertebra, decompression of cauda equine roots, and recovery of the local sagittal spinal column balance. It creates conditions for achieving stability of lumbosacral segments with combined spondylodesis (internal transpedicular instrumentation and PLIF). AETF is not suitable for spondylodesis due to a high rate of pseudarthrosis.

Reduction and fusion in high-grade L5-S1 spondylolisthesis by a single posterior approach. Results in 50 patients

INTRODUCTION

Treatment strategies in high-grade L5-S1 spondylolisthesis are controversial. Reduction of slippage, correction of lumbosacral kyphosis and the necessity of a complementary anterior approach are debated in the literature. The present study reports clinical and radiological outcome for reduction and instrumented fusion on a single posterior approach.

MATERIAL AND METHOD

A retrospective study included all consecutive adolescent and young adult patients operated on by a single surgeon (D.C.) for high-grade (Meyerding 3-4-5) L5-S1 spondylolisthesis. The technique consisted in reduction of lumbosacral kyphosis and posterolateral fusion on a single posterior approach without resection of the sacral dome or complementary anterior approach. Only cases of adult ptosis required impacted tibial interbody graft. Clinical complications, radiologic lumbopelvic results and sagittal balance were analyzed at last follow-up.

RESULTS

Fifty patients, with a mean age at surgery of 21±11 years, were followed up for a mean 5.5±4.6 years. Mean lumbosacral angle was reduced by 25° (from 76° to 101°; P<0.05), and mean listhesis grade by >50% (from 75% to 23%; P<0.0001), without correction loss at last follow-up. C7 sagittal offset was corrected (from 8° to 4°; P<0.05), with harmonization of lumbar (from 57° to 64°; P<0.001) and thoracic curvature (from 37° to 44°; P=0.1). Seventeen patients (34%) showed postoperative radicular deficit, without sequelae at last follow-up. There were no cauda equina lesions. Bone fusion was achieved in 42 patients (84%), in the same surgical step. After revision by complementary interbody graft, there was no residual non-union.

CONCLUSION

Surgery on a single posterior approach gave reliable results in high-grade spondylolisthesis in adolescents and young adults. The technique is not however, free of risk (transient neurologic deficit and non-union), and patients should be forewarned. Complementary interbody graft can be reserved to adult ptosis with incomplete reduction of lumbosacral kyphosis and to revision surgery for non-union.

LEVEL OF EVIDENCE

IV, retrospective study.

Radiographic Analysis of the Sacropelvic Parameters of the Spine and Their Correlation in Normal Asymptomatic Subjects

Study Design Cross-sectional study. Objective Sacropelvic parameters in various spine and hip disorders have been published in various studies. We aimed to study the normal sacropelvic parameters and curvatures of the spine and their correlation in asymptomatic Indian adults in relation to variations in sex and age. Methods The study included 101 asymptomatic adults (50 men and 51 women with an average age of 47.16 and 48.59 years, respectively). For each subject, the thoracic kyphosis (TK), lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT), and sacral slope (SS) were measured from standing lateral radiographs. After stratification of the group by sex and age with a cutoff of 50 years, descriptive, correlation, and regression analysis were performed using SPSS software. Results The average PI, SS, PT, LL, and TK values were 55.48 (±5.31), 35.99 (±7.53), 17.97 (±7.16), 48.84 (±9.82), and 32.55 (±10.92), respectively. No statistically significant difference was observed in these values with regards to sex and age < 50 years and > 50 years but the pelvic incidence was found to be higher in women. A positive correlation between the PI and SS and a negative correlation between the SS and PT was observed. A positive correlation between the TK and LL was found in subjects > 50 years. Simple and multiple regression analyses were also performed for different groups. Conclusion The current study is the first of asymptomatic Indian adults and provides invaluable information to the clinicians about the normal range of sacropelvic and spinopelvic parameters, which is useful to plan spinal deformity corrections and to evaluate pathologic conditions associated with abnormal angular values.