Surgical Treatment of Developmental Spondylolisthesis: Contemporary Series With a Two-Surgeon Team

Clinical and radiological outcomes of gradual reduction and circumferential fusion of high-grade spondylolisthesis in adolescents: a prospective cohort study of 29 young patients

AIM

The objective of this study was to evaluate the safety and efficacy of a novel technique of formal reduction and circumferential fusion for pediatric high-grade spondylolisthesis (HGS).

PURPOSE

The safety and efficacy of formal reduction for high-grade spondylolisthesis (HGS) has never been thoroughly examined. This study reports the outcomes of 29 children with HGS who underwent a procedure of gradual reduction and circumferential fusion.

METHODS

29 children (13 males, 16 females) were recruited between 2006 and 2010. Radiographic measurements (including % of slip, lumbosacral angle-LSA, pelvic incidence-PI, pelvic tilt-PT, sacral slope-SS, and proximal femoral angle-PFA) and quality of life assessment (SRS-22 questionnaire) were prospectively obtained at baseline and at the last post-operative follow-up (> 2 years post-op). Radiological measurements were used to classify patients according to the Spine Deformity Study Group (SDSG) classification.

RESULTS

Mean baseline slip % was 69.9 ± 16.5%. There were 13 patients with a balanced pelvic (SDSG Type 4) and 16 with an unbalanced pelvis (SDSG Type 5 and 6). On average, a reduction of 45.5 ± 15.3% (range 20-86%) was achieved safely with no major complication. In particular, of the 29 patients, only 3 had a L5 radiculopathy postoperatively that was self-resolved at follow-up. From a radiological standpoint, we observed a mean improvement of LSA from 80.3 ± 17.9° to 91.7 ± 13.6°. We also observed a statistically significant improvement in global HRQOL, and in the function and body image domains.

CONCLUSION

This prospective study suggests that formal reduction of HGS followed by circumferential fusion is safe when using a standardized surgical technique based on gradual reduction. Performing this intervention could also help improve QOL in some patients.

Pediatric Lumbosacral Spondylolisthesis: Overcoming the Disability!

BACKGROUND

Congenital spondylolisthesis is characterized by dysplasia of the facet joint or congenital defect in the pars.

OBJECTIVE

Our study highlights the clinical and radiological profile, various treatment options, and outcomes in patients with pediatric congenital lumbar and lumbosacral spondylolisthesis.

METHODS

A retrospective analysis and follow-up of 22 patients were conducted presented with radiological diagnosis of congenital lumbar/lumbosacral spondylolisthesis (2018-2021).

RESULTS

Twenty patients (91%) had L5-S1 listhesis and two patients (9%) had L4-L5 listhesis. Six (27.3%) patients had low-grade listhesis (grades 1-2), 16 (72.7%) had high-grade listhesis (grades 3-5). Seventeen (77.3%) had S1, three (13.6%) had L5, and two (9%) had both L4-L5 radiculopathy. All patients had neurogenic claudication. One had an associated spina bifida occulta. Six (27.3%) patients underwent two-level fixation, and 16 (72.7%) underwent three-level fixation. Minimally Invasive Transforaminal Lumbar Interbody Fusion (MIS TLIF) was done in two patients. Revision of at least one screw was done in three patients. After one year of follow-up, all the patients had 75-100% relief in radicular pain and neurogenic claudication. The Oswestry Disability Index (ODI) score in preop for all patients was 41-60% and postoperatively they showed an improvement in ODI score (0-20). The postoperative low back pain score on the Numeric Rating Scale was 0-1 for all patients.

CONCLUSION

Congenital lumbar spondylolisthesis usually presents with high-grade listhesis. Management of such cases is a surgical challenge but posterior decompression resulted in relief of pain in all patients. However, in situ fixation without reduction is also effective in selective cases where attempts to reduce the listhesis result in a decline in intraoperative neuromonitoring parameters.

Integrated spine trauma team protocol: Combined neurosurgical and orthopedic experience for the management of traumatic spinal injuries

Objectives

During the last decades, spine surgery has grown exponentially. In spite of that, it remains a surgical specialty without a well-defined own certification. It is usually carried out, separately, by neurosurgeons and orthopedic surgeons, even if there is an overlapping of competence and skills.

Materials and Methods

In our hospital, from January 2019, a systematic protocol called integrated spine trauma team protocol (ISTTP) was implemented to improve the management of traumatic spinal injuries in a multidisciplinary way. It is characterized by a specific algorithm from diagnosis to postoperative care. According to the new protocol, orthopedic spinal surgeons and neurosurgeons work together as an integrated spine trauma team. The authors analyzed, retrospectively, the results obtained by comparing patients treated before and after the application of the ISTTP.

Results

The new protocol allowed a statistically significant reduction in waiting time before surgery and complication rate. Moreover, early discharge of patients was recorded. To the best of our knowledge, this is the first study that described a specific algorithm for a standardized multidisciplinary management of the spinal trauma with combined orthopedic and neurosurgeon expertise.

Conclusion

Our preliminary results suggest that the application of our ISTTP leads to better results for treating traumatic spinal injury (TSI).

Transforaminal lumbar interbody fusion with reduction of slippage of vertebrae for isthmic lumbar spondylolisthesis: Unilateral versus bilateral interbody fusion

OBJECTIVE

To investigate the radiological and clinical efficacy of transforaminal lumbar bilateral interbody fusion (TLBIF) versus transforaminal lumbar unilateral interbody fusion (TLUIF) with reduction of slippage of the vertebra in isthmic lumbar spondylolisthesis (ILS).

METHODS

A comparative retrospective study was conducted between patients undergoing TLBIF (n = 46) and TLUIF (n = 40). Demographic data, intraoperative data, complications, and radiographic parameters, including total lumbar lordosis (LL), intervertebral disc height (IDH), and foraminal height (FH), and the final fusion rate were evaluated and compared between the two groups. Clinical outcomes were assessed by the Visual Analog Scale (VAS) for low back pain and leg pain, and the Oswestry Disability Index (ODI).

RESULTS

Significant improvement in terms of radiographic and clinical outcomes was achieved in both groups during the period from pre-operation to at least 24 months post-operation (all, P < 0.05).

ORIGINAL SENTENCE

Analysis of back and leg pain by VAS score and radiographic data including LL, IDH and FH showed superior improvement in TLBIF group compared with TLUIF group. However, ODI was similar between the two groups.

REVISED

Analysis of radiographic data, including LL, IDH, and FH, showed superior improvement in the TLBIF group compared with the TLUIF group (all, P < 0.05). However, either back and leg pain by the VAS score or ODI was similar between the two groups (all, P > 0.05). The fusion rate was 100 % in the TLBIF group versus 95 % in the TLUIF group during the 24-month follow-up period. The operation time was longer and the complication rate was lower in the TLBIF group than in the TLUIF group (all, P < 0.05), while intraoperative blood loss was similar between the two groups (P > 0.05).

CONCLUSIONS

TLBIF with reduction did not cause significant procedure-associated complications in ILS patients. The therapeutic outcome of TLBIF was satisfactory and similar to that of TLUIF for ILS.

ORIGINAL SENTENCE

Compared with TLUIF, TLBIF appears to be associated with better radiological data, less postoperative back and leg discomfort, and quicker postoperative recovery.

REVISED

Compared with TLUIF, TLBIF appears to be associated with better radiological data, bone fusion rate, and similar patient-reported outcomes (PROs), including the ODI and VAS pain score for the back and leg.

What is the Optimal Surgical Method for Achieving Correction and Avoiding Neurological Complications in Pediatric High-grade Spondylolisthesis?

BACKGROUND

Controversy persists in the treatment of high-grade spondylolisthesis (HGS). Surgery is recommended in patients with intrusive symptoms and evidence debates the competing strategies. This study compares the radiologic outcomes and postoperative complications at a minimum of 2 years follow-up for patients with HGS treated with instrumented fusion with partial reduction (IFIS) with those treated with reduction, decompression, and instrumented fusion (RIF). We hypothesize that IFIS leads to a lower rate of complication and revision surgery than RIF.

METHODS

A retrospective comparative methodology was used to analyze consecutive HGS treated surgically between 2006 and 2017. Patients diagnosed with ≥grade 3 spondylolisthesis treated with arthrodesis before the age of 18 years with a minimum of 2 years follow-up were included. Patients were excluded if surgery did not aim to achieve arthrodesis or was a revision procedure. Cases were identified through departmental and neurophysiological records.

RESULTS

Thirty patients met the inclusion criteria. Mean follow-up was 4 years. Ten patients underwent IFIS and the remaining 20 underwent RIF. The 2 groups showed no difference in demographics, grade of slip, deformity or presenting symptoms. Of 10 treated with IFIS, the SA reduced by a mean of 10 degrees and C7 sagittal vertical line changed by 31 mm. In the RIF cohort, SA reduced by 16 degrees and C7 sagittal vertical line reduced by 26 mm. PT was unchanged in both groups. In IFIS cohort, 2 patients showed postoperative weakness, resolved by 2 years. None required revision surgery. In the RIF group, 4 sustained dural tears and 1 a laminar fracture, 7 showed postoperative weakness or dysaesthesia, 3 of which had not resolved by 2 years. Eight patients underwent unplanned further surgery, 3 for pseudarthrosis.

CONCLUSIONS

RIF and IFIS show similar radiologic outcomes. RIF shows a higher rate of unplanned return to surgery, pseudarthrosis and persisting neurological changes.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.