Lumbar degenerative spondylolisthesis II: treatment and controversies.

There are various approaches and surgical techniques with the objective of nerve root decompression, restrict mobility, and fusion of the listhesis. Among the techniques, posterior interbody fusion combines direct and indirect root decompression with the fusion between vertebral bodies, placing an autologous bone graft between transverse apophysis and vertebral bodies. Transforaminal lumbar and posterior interbody fusion, on the same way, look to decompress and fuse but with a different approach to the spine. The anterior approach for interbody fusion provides a better fusion rate. Lateral lumbar interbody fusion is considered less invasive, with an anterolateral transpsoas approach. The lumbar fusion technique in degenerative spondylolisthesis must be individualized. Non-fusion decompression is considered a less invasive procedure. Various studies suggest that decompression has better results when fusion is added. Surgery had several potential benefits and greater improvement in those patients who fail conservative management. An optimal technique is not conclusively identified.

El tratamiento de la espondilolistesis degenerativa lumbar es específico para cada etapa de la enfermedad y el manejo quirúrgico no debe de ser la primera elección en la mayoría de los casos. El manejo conservador está basado en el uso de antiinflamatorios no esteroideos, control de peso y rehabilitación. En caso de falla después de cuatro a seis semanas, el siguiente paso es la infiltración facetaria. En caso de dolor persistente, alteraciones neurológicas o claudicación neurogénica el siguiente paso es la cirugía. Existen varios abordajes y técnicas quirúrgicas con el objetivo de descomprimir las raíces nerviosas, restringir la movilidad y fusionar la listesis. Entre las técnicas quirúrgicas, la fusión posterior combina la descompresión directa e indirecta con artrodesis entre los cuerpos vertebrales, colocando injerto entre las apófisis transversas y los cuerpos vertebrales. La artrodesis intersomática transforaminal y posterior buscan de la misma manera la descompresión y fusión, pero con un abordaje distinto. El abordaje anterior para artrodesis intersomática provee la mejor tasa de fusión. La artrodesis intersomática lateral se considera un procedimiento menos invasivo, con un abordaje anterolateral transpsoas. La técnica de artrodesis lumbar en la espondilolistesis debe ser individualizada. La descompresión sin artrodesis se considera un procedimiento menos invasivo; varios estudios sugieren que la descompresión tiene mejores resultados cuando se agrega una artrodesis. La cirugía tiene múltiples beneficios posibles en pacientes en quienes el tratamiento conservador ha fallado. No se ha identificado una técnica óptima de tratamiento.

Ligamentum flavum in lumbar spinal stenosis, disc herniation and degenerative spondylolisthesis. An histopathological description.

INTRODUCCIÓN: Los cambios en el ligamento flavum (LF) relacionados con la degeneración son secundarios al proceso de envejecimiento o a la inestabilidad mecánica. Estudios anteriores han indicado que LF con envejecimiento muestra pérdida de fibras elásticas y aumento del contenido de colágeno, la pérdida de elasticidad puede hacer que el LF se pliegue en el canal espinal, disminuyendo su espacio. MATERIAL Y MÉTODOS: Se incluyeron 67 pacientes operados de estenosis lumbar espinal (LSS), hernia de disco lumbar (LDH) y espondilolistesis degenerativa (LDS). Se obtuvieron muestras de LF de pacientes que tenían LSS (39), LDH (22) y LDS (6). Se examinaron especímenes con respecto a metaplasia condroide, calcificación, fragmentación de fibras de colágeno, degeneración quística, apariencia fibrilar e hipercelularidad. RESULTADOS: Los cambios histopatológicos más frecuentes fueron la hialinización y la fragmentación de las fibras de colágeno (34%), neovascularización en 40.3%, y la disposición irregular de las fibras elásticas es el cambio más frecuente con 56.7% del total de muestras. Existe una diferencia en la presencia de cambios en el LF, de acuerdo con el diagnóstico, siendo estadísticamente significativo para la fragmentación de las fibras de colágeno (p = 0.045), la degeneración quística (p = 0.001), la apariencia fibrilar (p = 0.007) y la hipercelularidad (p = 0.005) todos ellos, siendo más frecuentes en el grupo LDS. El grupo LHD presentó fragmentación de las fibras de colágeno en 45.5% (p = 0.045) y la apariencia fibrilar en 4.5% (p = 0.009). CONCLUSIONES: No hay evidencia de hipertrofia celular en los análisis histopatológicos, el engrosamiento del LF se puede ver por abultamiento del mismo, seguido de colapso del segmento de movimiento.

INTRODUCTION: Changes in ligamentum flavum (LF) related to degeneration are secondary to either the aging process or mechanical instability. Previous studies have indicated that LF with aging shows elastic fiber loss and increased collagen content, loss of elasticity may cause LF to fold into the spinal canal, which may further narrow of the canal. MATERIAL AND METHODS: A total of 67 patients operated with the surgical indications of lumbar spinal stenosis (LSS), lumbar disc herniation (LDH) and lumbar degenerative spondylolisthesis (LDS) were included. LF samples were obtained from patients who had LSS (39), LDH (22) and LDS (6). Specimens were examined with regard to chondroid metaplasia, calcification, fragmentation of collagen fibers, cystic degeneration, fibrillar appearence, and hypercellularity. RESULTS: The most frequent histopathological changes were hyalinization and fragmentation of collagen fibers occur in 34%, neovascularization in 40.3% and irregular arrangement of elastic fibers is the most prevalent change with 56.7% of the total samples. There is a difference in the presence of certain changes in the LF according to the diagnosis, being statistically significant for fragmentation of collagen fibers (p = 0.045), cystic degeneration (p = 0.001), fibrillar appearance (p = 0.007) and hypercellularity (p = 0.005) all of these, being more prevalent in LDS group. LHD group presented fragmentation of collagen fibers in 45.5% (p = 0.045) and fibrillar appearance in 4.5% (p = 0.009). CONCLUSIONS: There is not evidence of cellular hyperthophy in the histhopatological analyses, thickening of the LF can be seen by bulking of LF followed by collapse of motion segment.

Demographic and clinical characteristics of patients with spinal cord injury: a single hospital-based study.

STUDY DESIGN: Retrospective study. OBJECTIVES: To evaluate the demographic and clinical characteristics of patients diagnosed with spinal cord injury (SCI) admitted to a single center. SETTING: Single center study, México. METHODS: This study reviewed 433 patients with SCI. Data were extracted from medical records and retrospectively reviewed. RESULTS: A total of 433 patients with a diagnosis of SCI were included in the analysis. Of these, 346 (79.9%) had traumatic SCI (TSCI) and 87 (20.1%) had non-traumatic SCI (NTSCI). The principal causes of traumatic TSCI were motor vehicle accidents in 150 patients (43.4%), falls in 107 patients (30.9%) and a result of firearms in 58 patients (16.8%). Tumoral cord compression was the main cause of NTSCI in 50 patients (57.4%), followed by degenerative disease-causing myelopathy in 17 patients (19.5%). The proportion of patients affected with NTSCI was significantly lower, 29.9 vs 79.1% (P=0.0001), the age of patients was higher 53.9 vs 37.8 (P<0.002) and SCI was less severe, AIS D 41.33 vs 9.5% (P=0.0001) compared with the TSCI group. CONCLUSIONS: The demographic profiles of patients with TSCI and NTSCI differ in terms of proportion of total SCIs, patient age, male:female ratio and incomplete vs complete injury. The most common etiology of TSCI was motor vehicle accidents (43.4%), and neurological lesions were complete in 62.7% of patients. The most common etiology of NTSCI was tumoral spinal lesions (57.4%), and lesions were incomplete in 75.8% of patients.

[Utility of ligamentoplasty for the prevention of adjacent segment disease above 360 degree arthrodesis in degenerative lumbar spondylosis. Preliminary report]. / Utilidad de la ligamentoplastía para la prevención de la artrodesis en espondilolistesis lumbar degenerativa. Reporte preliminar.

BACKGROUND: Ligamentoplasty is a dynamic stabilization method used to treat lumbar stenosis and resect lumbar herniated discs with good results. The objective of this paper is to report preliminary results of the utility of ligamentoplasty to prevent adjacent segment disease above the arthrodesis. MATERIAL AND METHODS: Two groups of patients with degenerative lumbar spondylolisthesis who underwent circumferential arthrodesis. In 23 patients a dynamic stabilization system was placed in the segment above (group L), while this system was not used in 35 patients (group S). Degeneration and disease of the segment above were assessed. The statistical analysis was done with the SPSS 15.0 software. RESULTS: At the one-year follow-up, the incidence rate of adjacent segment degeneration was 11% for group L and 0% for group S; at the two-year follow-up it was 13% in both groups; at three years, 0% for group L and 19% for group S; at four years, 25% for group L and 0% for group S. At five years, 50% for group L and 0% for group S. Clinically significant radiculopathy occurred in two patients five years after surgery, one of whom also had adjacent segment disease. CONCLUSIONS: Based on the follow-up, at this moment it is not possible to show the utility of dynamic stabilization through ligamentoplasty to avoid adjacent segment disease above the arthrodesis.