Decompression alone versus decompression and instrumented fusion for the treatment of isthmic spondylolisthesis: a randomized controlled trial

Clinical outcomes of percutaneous transforaminal endoscopic decompression for the treatment of degenerative lumbar scoliosis associated with spinal stenosis in elderly individuals: a matched comparison study

PURPOSE

This retrospective cohort study evaluated the efficacy and safety of percutaneous transforaminal endoscopic decompression (PTED) in elderly patients with degenerative lumbar scoliosis (DLS) associated with lumbar spinal stenosis (LSS).

STUDY DESIGN

A matched comparison study.

METHODS

In total, 97 patients with DLS associated with LSS who underwent PTED under local anesthesia between 2016 and 2021 were retrospectively analyzed. Using the inclusion and exclusion criteria, 24 patients aged ≥ 80 years were screened and included in the study group. Then, 24 patients aged 50-80 years were matched according to gender, date of surgery, and surgical levels were included in the control group. Clinical outcomes such as the visual analog scale (VAS) score, Oswestry Disability Index (ODI) score, modified MacNab criteria, radiological parameters, and complications were assessed. The independent sample t-test, Pearson's chi-square test and Fisher's exact test were used to compare the parameters between the study and control groups.

RESULTS

The study group had significantly higher mean American Society of Anesthesiologists classification and age-adjusted Charlson Comorbidity Index scores than the control group (2.42 ± 0.72) vs. 5.25 ± 1.03 and 1.67 ± 0.76 vs. 3.17 ± 2.10, respectively). The VAS scores for pain in two legs and back and ODI scores significantly improved at two weeks after surgery and at the final followup (p < 0.05). The study group had higher back pain VAS and ODI scores than the control group at the final followup (p < 0.05). In addition, the complication and patient satisfaction rates were similar between the two groups (p > 0.05). The overall radiological parameters were comparable between the two groups, and there was no significant deterioration in coronal imbalance or loss of disc height between the two groups.

CONCLUSION

Elderly patients (aged ≥ 80 years) with DLS associated with LSS are less fit and have a greater number of comorbidities. However, they can achieve satisfactory outcomes with PTED, which are comparable to those of patients < 80 years. PTED under local anesthesia can also be an efficient alternative to conventional open lumbar decompression surgery for treating elderly patients with comorbidities.

Biomechanical response of decompression alone in lower grade lumbar degenerative spondylolisthesis--A finite element analysis

BACKGROUND

Previous studies have demonstrated the clinical efficacy of decompression alone in lower-grade spondylolisthesis. A higher rate of surgical revision and a lower rate of back pain relief was also observed. However, there is a lack of relevant biomechanical evidence after decompression alone for lower-grade spondylolisthesis.

PURPOSE

Evaluating the biomechanical characteristics of total laminectomy, hemilaminectomy, and facetectomy for lower-grade spondylolisthesis by analyzing the range of motion (ROM), intradiscal pressure (IDP), annulus fibrosus stress (AFS), facet joints contact force (FJCF), and isthmus stress (IS).

METHODS

Firstly, we utilized finite element tools to develop a normal lumbar model and subsequently constructed a spondylolisthesis model based on the normal model. We then performed total laminectomy, hemilaminectomy, and one-third facetectomy in the normal model and spondylolisthesis model, respectively. Finally, we analyzed parameters, such as ROM, IDP, AFS, FJCF, and IS, for all the models under the same concentrate force and moment.

RESULTS

The intact spondylolisthesis model showed a significant increase in the relative parameters, including ROM, AFS, FJCF, and IS, compared to the intact normal lumbar model. Hemilaminectomy and one-third facetectomy in both spondylolisthesis and normal lumbar models did not result in an obvious change in ROM, IDP, AFS, FJCF, and IS compared to the pre-operative state. Moreover, there was no significant difference in the degree of parameter changes between the spondylolisthesis and normal lumbar models after undergoing the same surgical procedures. However, total laminectomy significantly increased ROM, AFS, and IS and decreased the FJCF in both normal lumbar models and spondylolisthesis models.

CONCLUSION

Hemilaminectomy and one-third facetectomy did not have a significant impact on the segment stability of lower-grade spondylolisthesis; however, patients with LDS undergoing hemilaminectomy and one-third facetectomy may experience higher isthmus stress on the surgical side during rotation. In addition, total laminectomy changes the biomechanics in both normal lumbar models and spondylolisthesis models.

Enhancing endoscopic foraminal decompression in adult isthmic spondylolisthesis: the potential influence of lateral recess isthmic spur and our case series of an innovative craniocaudal interlaminar approach via unilateral biportal endoscopic spinal surgery

BACKGROUND

The NASS guideline cannot recommend any of the surgical treatment options toward adult isthmic spondylolisthesis (AIS) since 2014. After the introduction of endoscopic decompression, instead of treating the spondylolysis itself, treatment can specifically target the refractory radicular pain developed during the degeneration progress without devastating the peripheral soft tissue. However, we noticed that endoscopic transforaminal decompression seems to be less effective in AIS compared to other types of degenerative spondylolisthesis. Thus, we came up with a novel craniocaudal interlaminar approach, utilizing the proximal adjacent interlaminar space to perform bilateral decompression and observed the pathoanatomy of pars defect directly and tried to identify the cause of decompression failure.

METHODS

From January 2022 to June 2022, 13 patients with AIS underwent endoscopic decompression via the endoscopic craniocaudal interlaminar approach and were followed up for at least 6 months. Visual Analogue Scale, Oswestry Disability Index and MacNab scores were recorded to monitor patients' clinical recovery. All endoscopic procedures were recorded and reviewed to illustrate the pathoanatomy.

RESULTS

Four patients required minor revision via the same technique. One of them required it due to incomplete isthmic spur resection, two due to neglected disc protrusion, and the other due to root subpedicular kinking in higher grade anterolisthesis. All patients' clinical condition improved significantly subsequently. After reviewing the endoscopic video, we have observed that the hook-like, ragged spur originating from the isthmic defect extends beyond the region around the foramen. Instead, it extends proximally into the adjacent lateral recess, resulting in impingement along the fracture edge above the index foramen and, in some cases, even in the extraforaminal area.

CONCLUSIONS

The broad spanning isthmic spur extending to the proximal adjacent lateral recess might be the reason why the transforaminal approach yielded less satisfactory results due to the incomplete decompression result from approach related restriction. Our study demonstrated an optimistic outcome by applying decompression from the upper level. Therefore, we propose that the craniocaudal interlaminar approach might be a better route for decompression in adult isthmic spondylolisthesis.

Full-endoscopic foraminotomy in low-grade degenerative and isthmic spondylolisthesis: a patient-specific tailored approach

PURPOSE

To describe the surgical technique and methodology to successfully plan and execute an endoscopic foraminotomy in patients with isthmic or degenerative spondylolisthesis, according to each patient's unique characteristics.

METHODS

Thirty patients with degenerative or isthmic spondylolisthesis (SL) with radicular symptoms were included from March 2019 to September 2022. Treating physician registered patients' baseline and imaging characteristics, as well as preoperative back pain VAS, leg pain VAS and ODI. Subsequently, authors treated the included patients with an endoscopic foraminotomy according to a "patient-specific" tailored approach.

RESULTS

Nineteen patients (63.33%) had isthmic SL and 11 patients (36.67%) had degenerative SL. 75.86% of the cases had a Meyerding Grade 1 listhesis. One of the transforaminal foraminotomies with lateral recess decompression in degenerative SL had to be aborted because of intense osseous bleeding. Of the remaining 29 patients, one patient experienced recurrence of the sciatica pain that required subsequent reintervention and fusion. No other intraoperative or post-operative complications were observed. None of the patients developed post-operative dysesthesia. In 86.67% of the patients, the foraminotomy was implemented using a transforaminal approach. In the remaining 13.33% of the cases, an interlaminar contralateral approach was used. Lateral recess decompression was performed in half of the cases. Mean follow-up time was 12.69 months, reaching a maximum of 40 months in some patients. Outcome variables such as VAS for leg and back pain, as well as ODI, showed statistically significant reduction since the 3-month follow-up visit.

CONCLUSION

In the presented case series, endoscopic foraminotomy achieved satisfactory outcomes without sacrificing segmental stability. The proposed patient-specific "tailored" approach allowed to successfully design and execute the surgical strategy to perform an endoscopic foraminotomy through transforaminal or interlaminar contralateral approaches.