Long-term results for total lumbar facet joint replacement in the management of lumbar degenerative spondylolisthesis

Prospective, randomized controlled multicenter study of posterior lumbar facet arthroplasty for the treatment of spondylolisthesis

OBJECTIVE

The purpose of this study was to evaluate the safety and efficacy of a posterior facet replacement device, the Total Posterior Spine (TOPS) System, for the treatment of one-level symptomatic lumbar stenosis with grade I degenerative spondylolisthesis. Posterior lumbar arthroplasty with facet replacement is a motion-preserving alternative to lumbar decompression and fusion. The authors report the preliminary results from the TOPS FDA investigational device exemption (IDE) trial.

METHODS

The study was a prospective, randomized controlled FDA IDE trial comparing the investigational TOPS device with transforaminal lumbar interbody fusion (TLIF) and pedicle screw fixation. The minimum follow-up duration was 24 months. Validated patient-reported outcome measures included the Oswestry Disability Index (ODI) and visual analog scale (VAS) for back and leg pain. The primary outcome was a composite measure of clinical success: 1) no reoperations, 2) no device breakage, 3) ODI reduction of ≥ 15 points, and 4) no new or worsening neurological deficit. Patients were considered a clinical success only if they met all four measures. Radiographic assessments were made by an independent core laboratory.

RESULTS

A total of 249 patients were evaluated (n = 170 in the TOPS group and n = 79 in the TLIF group). There were no statistically significant differences between implanted levels (L4-5: TOPS, 95% and TLIF, 95%) or blood loss. The overall composite measure for clinical success was statistically significantly higher in the TOPS group (85%) compared with the TLIF group (64%) (p = 0.0138). The percentage of patients reporting a minimum 15-point improvement in ODI showed a statistically significant difference (p = 0.037) favoring TOPS (93%) over TLIF (81%). There was no statistically significant difference between groups in the percentage of patients reporting a minimum 20-point improvement on VAS back pain (TOPS, 87%; TLIF, 64%) and leg pain (TOPS, 90%; TLIF, 88%) scores. The rate of surgical reintervention for facet replacement in the TOPS group (5.9%) was lower than the TLIF group (8.8%). The TOPS cohort demonstrated maintenance of flexion/extension range of motion from preoperatively (3.85°) to 24 months (3.86°).

CONCLUSIONS

This study demonstrates that posterior lumbar decompression and dynamic stabilization with the TOPS device is safe and efficacious in the treatment of lumbar stenosis with degenerative spondylolisthesis. Additionally, decompression and dynamic stabilization with the TOPS device maintains segmental motion.

Interventional Minimally Invasive Treatments for Chronic Low Back Pain Caused by Lumbar Facet Joint Syndrome: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVE

To investigate the efficacy of nonsurgical interventional treatments for chronic low back pain (LBP) caused by facet joint syndrome (FJS).

METHODS

A systematic review of the literature was conducted to identify studies that compared interventional treatments for LBP due to FJS among them, with usual care or sham procedures. Studies were evaluated for pain, physical function, disability, quality of life and employment status. The RoB-2 and MINORS tools were utilized to assess the risk of bias in included studies.

RESULTS

Eighteen studies published between January 2000 and December 2021 were included (1496 patients, mean age: 54.31 years old). Intraarticular (IA) facet joint (FJ) injection of hyaluronic acid (HA) did not show significant difference compared to IA corticosteroids (CCS) in terms of pain and satisfaction. FJ denervation using radiofrequency (RF) displayed slightly superior or similar outcomes compared to IA CCS, physical therapy, or sham procedure. IA CCS showed better outcomes when combined with oral diclofenac compared to IA CCS or oral diclofenac alone but was not superior to IA local anesthetic and Sarapin. IA platelet-rich plasma (PRP) led to an improvement of pain, disability and satisfaction in the long term compared to IA CCS.

CONCLUSION

FJS is a common cause of LBP that can be managed with several different strategies, including nonsurgical minimally invasive approaches such as IA HA, CCS, PRP and FJ denervation. However, available evidence showed mixed results, with overall little short-term or no benefits on pain, disability, and other investigated outcomes.

Current concepts of spondylosis and posterior spinal motion preservation for radiologists

Spinal fusion is performed to eliminate motion at a degenerated or unstable segment. However, this is associated with loss of motion at the fused levels and increased stress on adjacent levels. Motion-preserving implants have been designed in effort to mitigate the limitations of fusion. This review will focus on posterior spinal motion-preserving technologies. In the cervical spine, laminoplasty is a posterior motion-preserving procedure used in the management of myelopathy/cord compression. In the lumbar spine, motion-sparing systems include interspinous process devices (also referred to as interspinous process spacers or distraction devices), posterior dynamic stabilization devices (also referred to as pedicle screw/rod fixation-based systems), and posterior element replacement systems (also referred to as total facet replacement devices). Knowledge of the intended physiologic purpose, hardware utilized, and complications is important in the assessment of imaging in those who have undergone posterior motion preservation procedures.

Posterior Lumbar Facet Replacement and Arthroplasty

There is an ongoing desire for the development of motion-preserving facet replacement devices as an alternative to rigid fixation in hopes of better preserving the natural kinematics of the lumbar spine. Theoretically, such a construct would simultaneously address pain associated with spinal instability and prevent abnormal load distribution and adjacent segment degeneration. Several such devices have been developed including the Anatomic Facet Replacement System, the Total Facet Arthroplasty System, and the Total Posterior Arthroplasty System. Of these devices, none have yet proven to be more efficacious than rigid fixation for lumbar spinal stenosis, and studies are ongoing.

The biomechanical effect on the adjacent L4/L5 segment of S1 superior facet arthroplasty: a finite element analysis for the male spine

Background

The superior facet arthroplasty is important for intervertebral foramen microscopy. To our knowledge, there is no study about the postoperative biomechanics of adjacent L4/L5 segments after different methods of S1 superior facet arthroplasty. To evaluate the effect of S1 superior facet arthroplasty on lumbar range of motion and disc stress of adjacent segment (L4/L5) under the intervertebral foraminoplasty.

Methods

Eight finite element models (FEMs) of lumbosacral vertebrae (L4/S) had been established and validated. The S1 superior facet arthroplasty was simulated with different methods. Then, the models were imported into Nastran software after optimization; 500 N preload was imposed on the L4 superior endplate, and 10 N⋅m was given to simulate flexion, extension, lateral flexion and rotation. The range of motion (ROM) and intervertebral disc stress of the L4-L5 spine were recorded.

Results

The ROM and disc stress of L4/L5 increased with the increasing of the proportions of S1 superior facet arthroplasty. Compared with the normal model, the ROM of L4/L5 significantly increased in most directions of motion when S1 superior facet formed greater than 3/5 from the ventral to the dorsal or 2/5 from the apex to the base. The disc stress of L4/L5 significantly increased in most directions of motion when S1 superior facet formed greater than 3/5 from the ventral to the dorsal or 1/5 from the apex to the base.

Conclusion

In this study, the ROM and disc stress of L4/L5 were affected by the unilateral S1 superior facet arthroplasty. It is suggested that the forming range from the ventral to the dorsal should be less than 3/5 of the S1 upper facet joint. It is not recommended to form from apex to base.

Level of evidence

Level IV

Effect of single and multilevel artificial inter-vertebral disc replacement in lumbar spine: A finite element study

Degenerative disc disease (DDD) in lumbar spine is one of the major musculoskeletal disorders that cause low back pain (LBP). The intervertebral disc structure and dynamics of the lumbar spine are significantly affected by lumbar DDD, leading to a reduced range of motion (ROM), muscle weakness and gradual degradation. Spinal fusion and inter-vertebral disc replacement prostheses are two major surgical methods used for treating lumbar DDD. The aim of this present study is to examine biomechanical impacts of single level (L3-L4 and L4-L5) and multi level (L3-L4-L5) inter-vertebral disc replacement in lumbar spine (L2-L5) and to compare the performance with intact spine. Finite element (FE) analysis has been used to compare the mobility and stress distribution of all the models for four physiological movements, namely flexion, extension, left and right lateral bending under 6, 8 and 10 Nm moments. Spinal fusion implants completely restrict the motion of the implanted segment and increase disc stress at the adjacent levels. In contrast to that, the results single level ADR models showed closer ROM and disc stress to natural model. At the spinal segments adjacent to the implantation, single level ADR shows lower chance of disc degeneration. However, significantly increased ROM was observed in case of double level ADR.

Total Posterior Spinal Arthroplasty Systems for Dynamic Stability

Degenerative disease of the lumbar spine commonly develops with age and can cause debilitating pain or neurologic deficits. When minimally invasive treatments and pain management interventions fail to provide relief, the traditional treatment has consisted of decompression surgery followed by the possible need for lumbar fusion. A mechanical implant device, known as a Total Posterior Spine (TOPS) System, has been introduced as a potential dynamic alternative to fusion surgery following decompression. The device is a dynamic posterior arthroplasty via pedicle screw insertion that maintains mobility, flexibility, and range of motion by providing multiaxial, three-column stabilization. While currently approved for use in Europe, the device is undergoing clinical trials in the United States to determine efficacy and potential complications. This paper provides a comprehensive narrative review of this technique's mechanism, early clinical outcomes, and considerations for patient selection. A review of the literature identified both positive results and adverse effects. While TOPS' use shows excellent potential, additional prospective trials are needed to determine this system's long-term complications.