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

Patient outcomes: One-stage vs. two-stage lumbar surgery for symptomatic low-grade spondylolisthesis: A quality outcomes database study

OBJECTIVE

Controversy exists regarding treatment of symptomatic low-grade spondylolisthesis (LGS). Both one- and two-stage fusions are commonly performed, but it is unclear if one approach is superior. We aim to compare the satisfaction rates and patient-reported outcomes (PROs) in patients with LGS undergoing one- versus two-stage lumbar spine surgery.

METHODS

The Quality Outcomes Database was queried for patients with Grades I and II spondylolisthesis who underwent one- (n = 3223) or two-stage (n = 325), 1-2 level lumbar fusion. Demographics, comorbidities, symptom burden, and PROs were extracted and compared. Outcomes included Visual Analogue Scale (VAS) for back and leg pain, Oswestry Disability Index (ODI), Quality-Adjusted Life Year (QALY), and satisfaction index. Minimal clinically important difference (MCID) values for VAS back pain, VAS leg pain, ODI, and QALY were 1.6, 1.7, 14.3, and 0.2, respectively. Patients with pre-existing scoliosis or kyphosis, missing data, and revision procedures were excluded. Categorical variables were compared with a Chi-square test; continuous variables were assessed for normality with a Shapiro Wilk test and compared with a Mann-Whitney U or Student's t-test.

RESULTS

No significant differences were noted for baseline characteristics, except for a lower mean age, percentage of female patients, and prevalence of osteoporosis in the two-stage cohort (58 ± 12.4 vs 62 ± 11.6 years; 50 % vs 62 %; 3.0 % vs 7.1 %, respectively; p < 0.01). The average surgery length was longer in the two-stage cohort (p < 0.01). A significantly higher percentage of patients returned to baseline activities within 3 months postoperatively following one-stage procedures (43 % vs. 29 %, p < 0.01), irrespective of whether they had Grade 1 or Grade 2 spondylolisthesis. Comparable proportions of patients achieved the MCID for PROs, with no significant differences in satisfaction indices observed at 3, 12, and 24 months postoperatively, regardless of preoperative spondylolisthesis grade.

CONCLUSIONS

Patients receiving one and two-stage procedures for symptomatic LGS had similar rates of satisfaction and PROs. More research is necessary to define the benefits of two-stage approaches given their increased time, cost, and risk profile.

Biomechanical assessment of anterior plate system, bilateral pedicle screw and transdiscal screw system for high-grade spondylolisthesis: a finite element study

Introduction

Limited information regarding the biomechanical evaluation of various internal fixation techniques for high-grade L5-S1 spondylolisthesis is available. The stiffness of the operated segment and stress on the hardware can profoundly influence clinical outcomes and patient satisfaction. The objective of this study was to quantitatively investigate biomechanical profiles of various fusion methods used for high-grade spondylolisthesis by using finite element (FE) analysis.

Methods

An FE lumbar spine model of healthy spine was developed based on a patient's CT scan. High-grade (III-IV) spondylolisthesis (SP model) was created by sliding L5 anteriorly and modifying L5-S1 facet joints. Three treatment scenarios were created by adding various implants to the model. These scenarios included L5-S1 interbody cage in combination with three different fixation methods-the anterior plate system (APS), bilateral pedicle screw system (BPSS), and transdiscal screw system (TSS). Range of motion (ROM), von Mises stress on cage, internal fixation as well as on the adjacent annuli were obtained and compared. The resistance to slippage was investigated by applying shear force on L5 vertebra and measuring its displacement regarding to S1.

Results

Under different loading conditions all treatment scenarios showed substantial reduction of ROM in comparison with SP model. No notable differences in ROM were observed between treatment models. There was no notable difference in cage stress among models. The von Mises stress on the internal fixation in the TSS model was less than in APS and BPSS. The TSS model demonstrated superior resistance to shear load compared to APS and BPSS. No discernible difference was observed between the SP, APS, BPSS, and TSS models when compared the ROM for adjacent level L4-L5. TSS's von Mises stress of the adjacent annulus was higher than in APS and BPSS.

Conclusions

The TSS model exhibited biomechanical superiority over the APS and BPSS models.

[Progress in treatment of high-grade spondylolisthesis]

Objective

To review the research progress in the treatment of high-grade spondylolisthesis (HS), in order to provide a reference for clinical treatment decision-making.

Methods

The literature related to the treatment of HS at home and abroad in recent years was widely reviewed. The methods of conservative treatment, in situ fusion, and spondylolisthesis reduction were analyzed and summarized.

Results

Surgical treatment is the main treatment of HS, but which method is the best is still controversial. The advantages, disadvantages, and applicability of various operations are also different, so individualized analysis is needed in clinic.

Conclusion

The treatment plan of HS needs to be considered comprehensively according to the individual condition of the patient. It will be an important research direction to further compare the existing treatment methods and develop more safe and effective new technology.

[Surgical treatment of high-grade spondylolisthesis]

OBJECTIVE

Establishment of a physiological profile of the spine via reduction of the kyphotic slipped vertebra in the transverse and sagittal planes. Achieving solid fusion. Improvement of preoperative pain symptoms and prevention or elimination of neurological deficits.

INDICATIONS

High-grade spondylolisthesis (Meyerding grade 3 and 4) as well as spondyloptosis after conservative treatment and corresponding symptoms. Serious neurological deficits, hip-lumbar extensor stiffness, are emergency indications.

CONTRAINDICATIONS (CI)

Individual risk assessment must be made. Absolute CI are infections with the exception of serious neurological deficits. Multiple abdominal operations or interventions on the large vessels can be a relative contraindication for ventral intervention.

SURGICAL TECHNIQUE

For spondylolistheses of grade 3 according to Meyerding, we recommend a one-stage dorso-ventro-dorsal procedure with radicular decompression, correction and fusion in the index segment. From grade 4 according to Meyerding, reduction of the fifth lumbar vertebral body in the index segment L5/S1 is preceded by resection of the sacral dome. In cases of spondyloptosis, a two-stage procedure is often indicated. In this case, a screw-rod system spanning the index segment is implanted in the first step, which is used to distract the index segment for several days. Ventrodorsal reduction is performed in the second step.

POSTOPERATIVE MANAGEMENT

Axis-appropriate full mobilization from postoperative day 1. We recommend a light diet until the first defecation. Dorsal suture removal after 12 days if the wound is dry and free of irritation. Lifting and carrying heavy loads and also competitive or contact sports should be avoided for 12 weeks.

RESULTS

From January 2000 to December 2020, a total of 43 patients with high-grade spondylolisthesis were treated in our clinic in the manner described. The Numeric Rating Scale (NRS) and the Oswestry Disability Index (ODI) improved significantly during the observation period of 3 months and 1 year. The 1‑year radiological data in 28 of the 36 patients showed complete reduction of the slipped vertebra, in 6 grade 1, and in 2 patients grade 2 according to Meyerding. Also, the kyphosis of the index vertebra was significantly corrected from a mean of 15° (0-52°) preoperatively to a lordotic profile of a mean of 4° (0-11°). No complications requiring revision were observed. One patient with preoperative cauda equina syndrome was left with right radicular sensorimotor S1 syndrome.

A radiological parametric comparison of low-grade lytic spondylolisthesis to degenerative spondylolisthesis - A retrospective approach to establish its dysplastic origin

Objectives

This study aims to compare low-grade lytic spondylolisthesis (LS) and degenerative spondylolisthesis (DS) radiologically. In addition, it seeks to identify underlying similarities between LS and DS.

Methods

This study included patients with low-grade single-level spondylolisthesis at L4-L5 or L5-S1. They were categorized into LS and DS. Radiological features, including pedicle height, width, transverse, and sagittal angle, as well as anterior vertebral heights (AVH) and posterior vertebral heights (PVH), were measured using T1-weighted magnetic resonance imaging.

Results

The study involved 88 patients: 46 in the DS group and 42 in the LS group. In the LS group, the AVH was significantly higher than the posterior height at L4 and L5 (L4 PVH/AVH ratio 0.93 in LS vs. 0.96 in DS; L5 PVH/AVH ratio 0.84 in LS vs. 0.92 in DS), and pedicles were more medially oriented (L4: 19.62° in LS vs. 17.7° in DS; L5: 28.92° in LS vs. 26.47° in DS). In addition, at L5, the pedicle height (10.67 mm in LS vs. 11.48 mm in DS) and width (13.56 mm in LS vs. 14.37 mm in DS) were smaller compared to the DS group.

Conclusions

Low-grade LS shows distinct radiological vertebral and pedicle anatomy compared to DS. Short and thin pedicles and wedge-shaped vertebrae in LS resemble DS, indicating its dysplastic origin.

Clinical and Radiological Outcomes after Reducing Adult Lytic High-Grade Spondylolisthesis Using a Hybrid Technique: Combination of Percutaneous Pedicle Screws with Midline Microscopic Transforaminal Decompression

STUDY DESIGN

Retrospective study.

PURPOSE

To analyze the results and effectiveness of percutaneous screws (PS) with midline microscopic transforaminal decompression (MTFD) technique in reducing adult stiff lytic high-grade spondylolisthesis (HGSL) and compare it with the conventional technique.

OVERVIEW OF LITERATURE

Pedicle screw cannulation and segmental kyphosis negotiation are surgical challenges in HGSL. Open reduction is the preferred approach. PS have the advantage of optimized trajectory and minimized soft tissue exposure. The role of minimally invasive surgery in HGSL remains unknown. We propose a hybrid technique combining PS with MTFD for lytic HGSL.

METHODS

This study included 25 patients with adult lytic HGSL (Meyerding grade III and IV) operated using a hybrid technique from 2012 to 2015. Data were compared with retrospective data on conventional open reduction (n=23) operated from 2000 to 2015. The minimum follow-up was 5 years. Clinical outcomes were assessed using the Visual Analog Scale (VAS) score and modified Oswestry Disability Index (m-ODI). The spinopelvic and perioperative parameters were recorded. The inter-body fusion and adjacent segment degeneration (ASD) were assessed on radiographs at the final follow-up.

RESULTS

The average age in the MTFD and open groups was 45.84±12.70 years (nine males and 16 females) and 49.26±13.33 years (eight males and 15 females), respectively. Further, 22 and three patients in the MTFD group and 19 and four in the open group had grade III and IV listhesis, respectively. The MTFD group demonstrated less operative time, blood loss, and hospital stays than the open group. Significant improvements were observed in VAS and m-ODI in subsequent follow-ups in both groups. The MTFD group fared better at 3 months but outcomes were comparable at the final follow-up. Both techniques were equally effective in restoring spinopelvic parameters. The incidence of ASD is comparable.

CONCLUSIONS

The technique was proven effective in reducing HGSL. The long-term clinical and radiological outcomes were favorable and comparable with the conventional approach.

Irreducible L5/S1 Spondyloptosis in Over 20 Years After Neglected Trauma Treated with Modified Grob's Technique - Case Report

Introduction

Spondyloptosis, characterized by complete slippage of the upper vertebral body relative to the lower vertebral body, is an exceedingly rare condition. Typically, it occurs as a result of a high-energy injury and is promptly managed. It is uncommon for a patient to present to a spinal surgery unit several decades after the initial incident.

Case Report

In this case report, we describe the case of a 62-year-old man who experienced a lumbosacral injury from a fall twenty years prior to seeking treatment. The patient had multiple comorbidities, including obesity and internal medicine conditions. He presented with severe back pain radiating to the lower extremities, accompanied by significant neurogenic chroma and lower extremity weakness. Imaging studies revealed spondyloptosis at the L5/S1 level, along with bony fusion and spinal canal stenosis at the L3/L4 level.

Conclusion

The patient underwent surgical intervention using Grob's direct pediculo-body fixation technique. The postoperative period was uneventful, and over the course of one year of follow-up, the patient experienced a resolution of symptoms and significant improvement in functional capacity.

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.

Beneficial influence of single-stage posterior surgery for the treatment of lumbar brucella spondylitis combined with spondylolisthesis

We aimed to evaluate the clinical efficacy of the single-stage posterior surgical treatment for patients of lumbar brucella spondylitis combined with spondylolisthesis. In this study, we performed a retrospective analysis of 16 patients with lumbar brucellosis spondylitis combined with spondylolisthesis from January 2015 to January 2019. All patients underwent single-stage posterior lumbar debridement, reduction, interbody fusion, and instrumentation. Preoperative and postoperative of the visual analog scale (VAS), the Oswestry disability index (ODI), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) were compared. In addition, the spondylolisthesis reduction rate, reduction loss rate, interbody fusion rate, and complication rate were recorded. VAS, ODI, ESR, and CRP were conducted with repeated analysis of variance data at different follow-ups. The postoperative follow-up was 12-36 months, with an average of (25.0 ± 8.1) months. VAS, ODI, ESR, and CRP were significantly better at 2-week and 1-year follow-up than preoperative results (P = 0.000, respectively). In addition, 1 year after the operation, VAS, ODI, ESR, and CRP showed a significant improvement (P = 0.000, respectively). The average spondylolisthesis reduction in 2 weeks after operation was (91.2 ± 6.7)%, and the median reduction loss rate in 1 year after operation was 8.0 (5.0, 9.8)%. At the last follow-up, all patients achieved interbody fusion, no loosening and fracture of instrumentation were found, and no recurrence happened. Single-stage posterior operation for lumbar debridement, reduction, interbody fusion, and instrumentation is beneficial for treating lumbar brucellosis spondylitis combined with spondylolisthesis. Furthermore, the reconstruction of spinal stability may relieve pain, heal lesions, and improve patients' living.

Degenerative Grade 3 Spondylolisthesis Management: A Case Report and Literature Review

Degenerative spine disorders are very common in the aging population. Degenerative spondylolisthesis is a relatively uncommon cause of chronic back pain in these patients. We present a case of high-grade spondylolisthesis managed with posterior lumbar interbody fusion (PLIF) and reduction of the listhesis with excellent results. A 56-year-old woman presented with chronic lower back pain managed as an outpatient for over 5 months with no relief. She had no history of trauma or risk factors for malignancy. Lumbosacral CT showed Meyerding grade 3 anterolisthesis of the fifth lumbar vertebra with complete L5-S1 disc collapse and bilateral spondylolysis. An MRI confirmed the findings. There was no spinal canal stenosis. The patient was managed with L4-L5-S1 transpedicular fixation and L5-S1 interbody cage with reduction of the listhesis. The patient had an incidental intraoperative dural tear which was repaired primarily and a wound drain was kept for 5 days without complications. The patient was ambulating by day 5 and was discharged without complications on day 10. Degenerative spondylolisthesis can cause chronic back pain with or without a history of trauma. Although no specific clinical features exist for this condition, it should be suspected in elderly patients even in the absence of a history of trauma. Surgical management in high-grade spondylolisthesis is indicated with interbody fixation and reduction. 

Stretch on the L5 nerve root in high-grade spondylolisthesis reduction

OBJECTIVE

L5 nerve root (L5-NR) injury after surgery for high-grade spondylolisthesis (HGS) was considered a nerve stretch associated with reduction. Currently, however, no study has directly measured the stretch on the L5-NR during HGS reduction procedures.

METHODS

CT data of 4 patients with mild lumbar degeneration (control group [CG]) and 4 patients with HGS (spondylolisthesis group [SG]) were used for 3D printing to develop L5 vertebrae and sacrum models. These models were mounted on a self-designed reduction apparatus, which performed vertical translation (disc heights of 0, 5, and 10 mm), anterior-posterior translation (reduction, 0%-100%), and slip-angle correction (0° to -30°). The L5-NR was simulated by using a rabbit sciatic nerve. The cephalic side of the nerve was fixed at the upper base of the L5 pedicle, while the caudal side was connected to a high-precision sensor and an indicator to measure the tension (stretch) on the nerve during the reduction procedures in real time.

RESULTS

The SG had shorter L5-NRs than the CG. At a 0-mm disc height, the peak tension on the L5-NR changed from 0 N (reduction 0%) to 1.81 ± 0.54 N (reduction 100%) in the SG and to 1.78 ± 0.71 N in the CG. At a 10-mm disc height, the tension changed from 1.50 ± 0.67 N to 4.97 ± 1.04 N in the SG and from 0.92 ± 0.45 N to 3.26 ± 0.88 N in the CG. In both the CG and SG, at the same disc height, all values from the complete reduction process were statistically significant. Furthermore, at the same degree of reduction, the comparisons between different disc heights were almost all statistically significant. Intergroup comparisons showed that an increased disc height would cause more tension on the L5-NR in the SG than in the CG. At a 10-mm disc height, all results between the groups demonstrated statistical significance. The slip-angle correction produced a slight increase in the tension on the L5-NR in both groups.

CONCLUSIONS

Increased disc height and reduction significantly increased the tension on the L5-NR, which demonstrated a nonlinear curve. The slip-angle correction from 0° to -30° slightly increased the tension on the L5-NR. Under the same degree of reduction and restored disc height, the SG had more tension on the L5-NR than the CG.

Spondylolisthesis

Spondylolisthesis refers to the anterior, lateral, or posterior slippage of a superior vertebral disc over the adjacent inferior disc, and is often separated into categories based on the causative etiology. Spondylolisthesis is often asymptomatic but may present with low back pain and neurogenic claudication which is worsened with spinal extension and activity. A detailed history and physical exam, along with appropriate imaging tests are useful in making the diagnosis. Conservative therapy is first-line and includes pain management with physical therapy. Patients who fail conservative therapy may consider surgical decompression, stabilization, and fusion. This review aims to discuss the epidemiology, pathophysiology, presentation, and treatment options of spondylolisthesis.

Vertebral Slip Morphology in Dysplastic Spondylolisthesis as a Criterion for the Choice of the L5/S1 Support (ALIF, PLIF, Fibular Graft) in Surgical Treatment

Dysplastic spondylolisthesis is a severe pathological condition, based on dysplastic changes in the lumbosacral part of the spine, that causes the asymmetry of the lumbosacral junction. The appropriate therapeutic algorithm remains controversial. As the gold standard, the surgical reposition of the slipped vertebra and 360° fusion of the affected spinal segment is preferred. Thirty-two patients were operated on between the years 2005 and 2018. Different techniques of 360° fusion, based on the severity of the displacement of the affected vertebral segment, were used. Herein, the advantages and disadvantages of different techniques of interbody fusion are discussed. The slippage and retention after reduction in the vertebrae are evaluated prior to the operation, postoperatively, one year after the surgery, and during follow-up, which was 7 years on average (minimum 2 years for a follow-up). Complications associated with the surgery are evaluated, in addition to the operation time, blood loss, spinopelvic parameters, and patient satisfaction with the surgery. All surgical techniques improved the slippage compared to preoperative conditions. The retention of the reposition was not changed significantly in postoperative controls. The incidence of neurological complications reached 12.5%. Surgical treatment is the only treatment option that successfully addressed the pathological principle of dysplastic spondylolisthesis. All of the surgical methods used led to restoring the symmetry of the lumbar spine, and to the improvement in both radiological parameters and the alleviation of subjective difficulties. The aim of this article is to summarize surgical methods in patients having dysplastic spondylolisthesis with a slip of more than 25%, who were operated on, and to determine the optimal treatment algorithm according to the severity of the slip.

Traumatic Vertebral Fracture in a Patient With Transforaminal Lumbar Interbody Fusion: A Rare Complication

Transforaminal lumbar interbody fusion (TLIF) offers the potential benefits of anterior and posterior column decompression and fusion. Pseudarthrosis and infection are among the most common perioperative complications. Vertebral fracture after TLIF is a rare and unusual complication. A 74-year-old female underwent L3-5 TLIF for lumbar spondylolisthesis that caused back pain and neurogenic claudication. She recovered well after surgery. However, she subsequently experienced progressive back pain and recurrent claudication after a fall. Elongated anterior-posterior length of the L5 body with progressive L5-S1 listhesis was observed in the serial radiographic follow-ups. The CT scan revealed complicated fracture lines crossing the L5 body. Further extended fixation was performed for decompression and reconstruction of the lumbosacral alignment. Although vertebral fracture after TLIF is a rare complication, a high index of suspicion is the key to early diagnosis, preferably with CT scans, for patients with traumatic accidents after TLIF surgery.

Biomechanical analysis of reduction technique for lumbar spondylolisthesis: anterior lever versus posterior lever reduction method

BACKGROUND

Reduction of lumbar spondylolisthesis during spinal fusion surgery is important for improving the fusion rate and restoring the sagittal alignment. Despite the variety of reduction methods, the fundamental mechanics of lumbar spondylolisthesis reduction remain unclear. This study aimed to investigate the biomechanical behavior while performing spondylolisthesis reduction with the anterior and posterior lever reduction method.

METHODS

We developed an L4-L5 spondylolisthesis model using sawbones. Two spine surgeons performed the simulated reduction with a customized Cobb elevator. The following data were collected: the torque and angular motion of Cobb, displacement of vertebral bodies, change of lordotic angle between L4 and L5, total axial force and torque applied on the model, and force received by adjacent disc.

RESULTS

Less torque value (116 N-cm vs. 155 N-cm) and greater angular motion (53o vs. 38o) of Cobb elevator were observed in anterior lever reduction. Moreover, the total axial force received by the entire model was greater in the posterior lever method than that in the anterior lever method (40.8 N vs. 16.38 N). Besides, the displacement of both vertebral bodies was greater in the anterior lever method.

CONCLUSIONS

The anterior lever reduction is a more effort-saving method than the posterior lever reduction method. The existing evidence supports the biomechanical advantage of the anterior reduction method, which might be one of the contributing factors to successfully treating high-grade lumbar spondylolisthesis with short-segment instrumentation.

Minimally Invasive Reconstruction of Vertebral Arch in Spondylolisthesis in Children and Adolescents

The aim of the study was to assess the effectiveness of the minimally invasive technique used to reconstruct the vertebral arch with a pedicle screw hook system in grade I isthmic spondylolisthesis in comparison with the traditional technique of segment stabilization with interbody fusion.