Management of Low and High Grades Spondylolisthesis.

Spondylolisthesis is defined as the displacement or misalignment of the vertebral bodies one on top of the other. It comes from the Greek spondlylos, which means vertebra, and olisthesis, which means sliding on a slope. The nomenclature used to refer to spondylolisthesis consists of the following elements: vertebral segment (vertebrae involved), degree of sliding of one vertebral body over the other, the position of the upper vertebral body with respect to the lower one (anterolisthesis/retrolisthesis), and finally the etiology [1].

Predictive factors for successful non-operative treatment and achieving MCID improvement in health-related quality of life in adult spinal deformity.

BACKGROUND: Adult spinal deformity is a spectrum of degenerative spinal diseases with increasing prevalence and healthcare burden worldwide. Identification of patients who are more likely to improve through conservative management may reduce cost and potentially prevent surgery and its associated costs and complications. This study aims to identify predictive factors for MCID in improvement of ODI and SRS-22r questionnaires in patients with adult spinal deformity treated with conservative treatment. METHODS: A prospective, observational cohort study of 46 patients was conducted at a spine specialist clinic. Inclusion criteria were 30-80 years of age, diagnosis of neglected adolescent idiopathic scoliosis, de-novo scoliosis, degenerative spondylolisthesis, and sagittal plane deformities (thoracic hypokyphosis, lumbar hypolordosis), presenting with mechanical back pain with or without radicular leg pain. All patients received conservative management including medication and physiotherapy. Radiological and clinical parameters were measured at baseline and at 1-year follow-up. Primary outcomes were ODI and SRS-22r scores. Secondary outcomes were EQ-5D-5L scores and requiring spine surgery during conservative treatment. Predictors for MCID improvement in ODI and SRS-22r were identified using multivariate regressions and receiver operating characteristic (ROC) analyses. RESULTS: At baseline, patients who reached MCID in ODI and/or SRS-22r showed less comorbidities (diabetes mellitus, hypertension, ischemic heart disease, osteoarthritis, cancer), smaller range of lateral spinal flexion, larger trunk shift, larger pelvic incidence, a higher EQ-5D-5L anxiety/depression dimension score, a lower SRS-22r total score, and presence of spondylolisthesis. Lateral flexion range < 25 degrees, trunk shift > 14 mm, pelvic incidence > 50 degrees, EQ-5D-5L anxiety/depression dimension score > 1, and SRS-22r total score < 3.5 were the cut-off values generated by ROC analysis. CONCLUSIONS: Both radiological and clinical predictive factors for MCID improvement in health-related quality of life were identified. Future research should identify subgroups of patients who are responsive to specific conservative treatment modalities, so as to provide information for personalized medicine. LEVEL OF EVIDENCE: II.

Current Clinical Concepts: Management of Common Lumbar Spine Posterior Column Disorders in Young, Active Individuals.

Although posterior column disorders, such as spondylolysis and spondylolisthesis, are not commonly encountered in the general population, athletic trainers frequently see these conditions in athletic and active individuals due to the repetitive spinal extension and rotational loads placed on the pars interarticularis while participating in sport. Athletic trainers can successfully evaluate patients with posterior column disorders by performing a complete and comprehensive clinical examination to identify the location of pain, test spinal stability, and recognize compensatory movement patterns. Conservative management typically leads to a successful outcome in this population, with rest, bracing, and the use of therapeutic exercise having the best supporting evidence. In this Current Clinical Concepts review, we outlined the etiology and risk factors frequently associated with disorders of the posterior column. Additionally, we synthesized the literature for common evaluation techniques and interventions associated with the posterior column and provided a proposed rehabilitation progression to use in a younger, athletic population.

Isthmic spondylolisthesis in adults A review of the current literature.

Isthmic spondylolisthesis can be defined as the anterior translation of a vertebral body relative to the one subjacent to it and secondary to an abnormality of the pars interarticularis. Isthmic spondylolisthesis is usually asymptomatic and discovered as an incidental radiographic finding. However, it can be symptomatic due to its biomechanical effects on the adjacent neural structures and patients may present with low back and/or radicular leg pain. Standing plain radiographs can be obtained to confirm the presence or assess the degree of isthmic spondylolisthesis. Computed tomography (CT) clearly shows the pars defect and provides a better assessment of the pathology. Magnetic resonance imaging (MRI) is indicated in patients with neurologic manifestations and can be used to assess the degree of foraminal or central stenosis. Conservative management including oral anti-inflammatory medication, physical therapy, and/or transforaminal epidural corticosteroid injections can be utilized initially. Surgery can be considered in the setting of persistent symptoms unrelieved with conservative management or significant neurologic compromise. Several surgical methods and techniques are available in the management of isthmic spondylolisthesis. There has been a significant national increase in the use of interbody fusion posteriorly for the management of isthmic spondylolisthesis. Reports have suggested that interbody fusion can be a cost-effective technique in selected patients with isthmic spondylolisthesis. Future studies are encouraged to further characterize the specific indications of various surgical modalities in patients with isthmic spondylolisthesis.

Improved Pain and Quality of Life with Corrected Thoracic and Lumbosacral Spondylolisthesis Subluxations Using CBP®: A Case Study and 1-Year Follow-Up.

Objective: Discuss non-surgical spinal rehabilitation for a 27-year-old male with thoracic and lumbosacral spondylolistheses. A selective literature review and discussion are provided. Clinical Features: A 27-year-old male presented with severe, 8/10 mid and low back pain. Initial lateral thoracic and lumbar x-rays revealed grade 1 spondylolistheses at T9-T10 and L5-S1 measuring -5.3 mm and -6.8 mm. Interventions and Outcomes: The patient completed 60 sessions of Mirror Image® spinal adjustments, exercises, and traction over 30 weeks. Post-treatment x-rays showed correction in translations at T9-T10 and L5-S1 from -5.3 mm to 0.0 mm and -6.8 mm to -1.0 mm, within normal limits. 1-year follow-up x-rays showed maintained correction. Conclusions: This case is the first documented evidence of non-surgical or chiropractic treatment for thoracic and lumbosacral spondylolistheses where spinal alignment was corrected. More research is needed to investigate the clinical implications and applications.

[The use of underwater horizontal traction and mechanotherapy in the complex treatment of degenerative spondylolisthesis of the lumbosacral spine: a pilot clinical study]. / Primenenie podvodnogo gorizontal'nogo vytyazheniya i mekhanoterapii v kompleksnom lechenii degenerativnogo spondilolisteza poyasnichno-kresttsovogo otdela pozvonochnika: pilotnoe klinicheskoe issledovanie.

Underwater traction of the spine is a physiotherapeutic method that combines the effects of mechanical traction and fresh water of indifferent temperature and seems promising for the treatment of pain in the lower back, which is due to the physiological basis of the mechanism of action on the spinal motion segment by eliminating muscle spasm and restoring the biomechanics of the spine. OBJECTIVE: To study the effectiveness of underwater horizontal traction in combination with mechanotherapy in patients with non-stenosing unstable degenerative spondylolisthesis of the lumbosacral spine of the 1st degree, accompanied by pain. MATERIAL AND METHODS: The clinical study included 14 patients (mean age 50.21 years). Patients underwent underwater horizontal traction of the spine according to the modified Pushkareva-Vozdvizhenskaya method in a variable mode, the procedures were performed every other day, for a course of 6 procedures. After completion of the traction procedure, patients were recommended to put on a fixing lumbosacral corset, in which they rested for 30 minutes in the supine position. At the end of the rest period, the patients performed training of the back muscles with biofeedback on the mechanotherapeutic complex of simulators for 30 minutes daily, except for weekends, for a course of 10 procedures. RESULTS: All patients completed the course of treatment, during the procedures no side effects or deterioration were noted. During the treatment, motor and daily activity significantly improved according to the Oswestry scale (p=0.002), the severity of the pain syndrome and its effect on the patient's activity decreased, according to the Roland-Morris questionnaire (p=0.003). According to an objective assessment of the muscle strength of the lumbosacral spine at the initial level, no deviations from the normative parameters were revealed, however, during the treatment, a significant increase in strength was noted in all muscle groups. CONCLUSION: Underwater horizontal traction of the spine in variable mode according to Pushkareva-Vozdvizhenskaya is an effective and safe method of conservative treatment of unstable non-stenosing degenerative spondylolisthesis of the 1st degree, accompanied by back pain, which helps to reduce the intensity of the pain syndrome and improve the daily motor and social activity of patients. The traction method should be supplemented with therapeutic exercises using mechanotherapeutic simulators to achieve a clinical result.

Direct medical costs after surgical or nonsurgical treatment for degenerative lumbar spinal disease: A nationwide matched cohort study with a 10-year follow-up.

OBJECTIVE: The demand for treating degenerative lumbar spinal disease has been increasing, leading to increased utilization of medical resources. Thus, we need to understand how the budget of insurance is currently used. The objective of the present study is to overview the utilization of the National Health Insurance Service (NHIS) by providing the direct insured cost between patients receiving surgery and patients receiving nonsurgical treatment for degenerative lumbar disease. METHODS: The NHIS-National Sample Cohort was utilized to select patients with lumbar disc herniation, spinal stenosis, spondylolisthesis or spondylolysis. A matched cohort study design was used to show direct medical costs of surgery (n = 2,698) and nonsurgical (n = 2,698) cohorts. Non-surgical treatment included medication, physiotherapy, injection, and chiropractic. The monthly costs of the surgery cohort and nonsurgical cohort were presented at initial treatment, posttreatment 1, 3, 6, 9, and 12 months and yearly thereafter for 10 years. RESULTS: The characteristics and matching factors were well-balanced between the matched cohorts. Overall, surgery cohort spent $50.84/patient/month, while the nonsurgical cohort spent $29.34/patient/month (p<0.01). Initially, surgery treatment led to more charge to NHIS ($2,762) than nonsurgical treatment ($180.4) (p<0.01). Compared with the non-surgical cohort, the surgery cohort charged $33/month more for the first 3 months, charged less at 12 months, and charged approximately the same over the course of 10 years. CONCLUSION: Surgical treatment initially led to more government reimbursement than nonsurgical treatment, but the charges during follow-up period were not different. The results of the present study should be interpreted in light of the costs of medical services, indirect costs, societal cost, quality of life and societal willingness to pay in each country. The monetary figures are implied to be actual economic costs but those in the reimbursement system instead reflect reimbursement charges from the government.

[Two cases of lumbar spinal stenosis with lumbar spondylolisthesis in elderly patients who benefited from spinal cord stimulation and an electrophysiological diagnosis].

Two elderly lumbar spinal stenosis (LSS) patients with spondylolisthesis underused with minimally invasive spinal cord stimulation (SCS) and electrophysiologic study of central motor conduction time (CMCT) and the cauda equina conduction time (CECT) were performed as spinal cord function evaluation. The usefulness of SCS treatment and electrophysiologic studies has been reported.A 68-year-old woman had bilateral leg pain, intermittent claudication, and left extensor hallucis longus (EHL) muscle weakness. The preoperative CMCT was prolonged on both sides, and the CECT was prolonged on the left, so corticospinal tract disorder and cauda equina disorder were suspected. Recovery of the left EHL 2 weeks after the operation and a tendency toward left-side improvement in the CMCT and CECT were seen at 10 weeks after surgery, and analgesics were no longer required by 4 months after surgery. A 79-year-old woman in failed back surgery syndrome had peroneal nerve palsy, lumbago, bilateral leg pain and muscle weakness, and gait disturbance at the first visit, along with bilaterally prolonged CMCT, suggesting corticospinal tract disorder. Two months after surgery, an improving trend in her muscle strength and CMCT were noted, and the peroneal nerve conduction velocity had been restored. In both of these cases, recovery of symptoms and improvement of in the CMCT and CECT were observed following SCS treatment without decompression of the organic compression of the nerve roots or dural canal in the lesion area. Minimally invasive SCS treatment may be useful in elderly patients with spinal diseases, and an electrophysiological diagnosis that can objectively evaluate the spinal cord function may be beneficial.

Lumbosacral Spondylolysis and Spondylolisthesis.

Repetitive stress on the lumbosacral spine during sporting activity places the athletic patient at risk of developing symptomatic pars defect. Clinical history, physical examination, and diagnostic imaging are important to distinguish spondylolysis from other causes of lower back pain. Early pars stress reaction can be identified with advanced imaging, before the development of cortical fracture or vertebral slip progression to spondylolisthesis. Conservative management is first-line for low-grade injury with surgical intervention indicated for refractory symptoms, severe spondylolisthesis, or considerable neurologic deficit. Prompt diagnosis and management of spondylolysis leads to good outcomes and return to competition for most athletes.

Stabilization Exercises Versus Flexion Exercises in Degenerative Spondylolisthesis: A Randomized Controlled Trial.

OBJECTIVE: Exercise is the mainstay of treatment in individuals with low back pain and the first-line option in degenerative spondylolisthesis (DS); however, there is still no consensus surrounding the superiority of any specific exercise program. Thus, the primary aim of this study was to compare the effectiveness of lumbar stabilization exercises and flexion exercises for pain control and improvements of disability in individuals with chronic low back pain (CLBP) and DS. METHODS: A randomized controlled trial was conducted in a tertiary public hospital and included 92 individuals over the age of 50 years who were randomly allocated to lumbar stabilization exercises or flexion exercises. Participants received 6 sessions of physical therapy (monthly appointments) and were instructed to execute exercises daily at home during the 6 months of the study. The primary outcome (measured at baseline, 1 month, 3 months, and 6 months) was pain intensity (visual analog scale, 0-100 mm) and disability (Oswestry Disability Index, from 0% to 100%). Secondary outcomes were disability (Roland-Morris Disability Questionnaire, from 0 to 24 points), changes in body mass index, and flexibility (fingertip to floor, in centimeters) at baseline and 6 months, and also the total of days of analgesic use at 6-month follow-up. RESULTS: Mean differences between groups were not significant (for lumbar pain: 0.56 [95% CI = -11.48 to 12.61]; for radicular pain: -1.23 [95% CI = -14.11 to 11.64]; for Oswestry Disability Index: -0.61 [95% CI = -6.92 to 5.69]; for Roland-Morris Disability Questionnaire: 0.53 [95% CI = -1.69 to 2.76]). CONCLUSION: The findings from the present study reveal that flexion exercises are not inferior to and offer a similar response to stabilization exercises for the control of pain and improvements of disability in individuals with CLBP and DS. IMPACT: Exercise is the mainstay of treatment in individuals with CLBP and DS; however, there is still no consensus surrounding the superiority of any specific exercise program. This study finds that flexion exercises are not inferior to and offer a similar response to stabilization exercises. LAY SUMMARY: Exercise is the mainstay of treatment in individuals with CLBP and DS, but there is no consensus on the superiority of any specific exercise program. If you have DS, flexion exercises may provide similar effects to stabilization exercises.

A comparison of successful versus failed nonoperative treatment approaches in patients with degenerative conditions of the lumbar spine.

Identifying an optimal composition of nonoperative therapies to trial in patients suffering from degenerative lumbar spine conditions prior to surgical management remains challenging. Contrasting successful versus failed nonoperative treatment approaches may provide clinicians with valuable insight. The purpose of this study was to compare the nonoperative therapy regimens in degenerative lumbar spine disorder patients successfully managed conservatively versus patients who failed primary treatment and opted for lumbar fusion surgery. Clinical records from patients diagnosed with lumbar stenosis or spondylolisthesis from 2007 to 2017 were gathered from a comprehensive insurance database. Patients were separated into two cohorts: patients managed successfully with nonoperative therapies and patients who failed conservative therapy and underwent lumbar fusion surgery. Nonoperative therapy utilization by the two cohortswere collected across a 2-year surveillance window. A total of 531,980 adult patients with lumbar stenosis or spondylolisthesis comprised the base population. There were 523,031 patients (98.3%) successfully treated with conservative management alone, while 8,949 patients (1.7%) ultimately failed nonoperative management and opted for lumbar fusion.Conservative therapy failure rates were especially high in patients with a smoking history (2.1%) and those utilizing lumbar epidural steroid injections (LESIs) (3.7%). A greater percentage of patients who failed conservative management utilized opioid medications (p < 0.0001), muscle relaxants (p < 0.0001), and LESIs (p < 0.0001). Patients who failed nonoperative management spent more than double than the successfully treated cohort (failed cohort: $1806.49 per patient; successful cohort: $768.50 per patient). In a multivariate logistic regression model, smoking, obesity and prolonged opioid use were independently associated with failure of nonoperative treatment.

Epidemiology, Treatment, and Performance-Based Outcomes in American Professional Baseball Players With Symptomatic Spondylolysis and Isthmic Spondylolisthesis.

BACKGROUND: Repetitive lumbar hyperextension and rotation during athletic activity affect the structural integrity of the lumbar spine. While many sports have been associated with an increased risk of developing a pars defect, few previous studies have systematically investigated spondylolysis and spondylolisthesis in professional baseball players. PURPOSE: To characterize the epidemiology and treatment of symptomatic lumbar spondylolysis and isthmic spondylolisthesis in American professional baseball players. We also sought to report the return-to-play (RTP) and performance-based outcomes associated with the diagnosis of a pars defect in this elite athlete population. STUDY DESIGN: Descriptive epidemiology study. METHODS: A retrospective cohort study was conducted among all Major and Minor League Baseball (MLB and MiLB, respectively) players who had low back pain and underwent lumbar spine imaging between 2011 and 2016. Players with radiological evidence of a pars defect (with or without listhesis) were included. Analyses were conducted to assess the association between player-specific characteristics and RTP time. Baseball performance metrics were also compared before and after the injury episode to determine whether there was an association between the diagnosis of a pars defect and diminished player performance. RESULTS: During the study period of 6 MLB seasons, 272 professional baseball players had low back pain and underwent lumbar spine imaging. Overall, 75 of these athletes (27.6%) received a diagnosis of pars defect. All affected athletes except one (98.7%) successfully returned to professional baseball, with a median RTP time of 51 days. Players with spondylolisthesis returned to play faster than those with spondylolysis, MLB athletes returned faster than MiLB athletes, and position players returned faster than pitchers. Athletes with a diagnosed pars defect did not show a significant decline in performance after returning to competition after their injury episode. CONCLUSION: Lumbar pars defects were a common cause of low back pain in American professional baseball players. The vast majority of affected athletes were able to return to competition without demonstrating a significant decline in baseball performance.

Predicting spondylolisthesis correction with prone traction radiographs.

AIMS: To determine the effectiveness of prone traction radiographs in predicting postoperative slip distance, slip angle, changes in disc height, and lordosis after surgery for degenerative spondylolisthesis of the lumbar spine. METHODS: A total of 63 consecutive patients with a degenerative spondylolisthesis and preoperative prone traction radiographs obtained since 2010 were studied. Slip distance, slip angle, disc height, segmental lordosis, and global lordosis (L1 to S1) were measured on preoperative lateral standing radiographs, flexion-extension lateral radiographs, prone traction lateral radiographs, and postoperative lateral standing radiographs. Patients were divided into two groups: posterolateral fusion or posterolateral fusion with interbody fusion. RESULTS: The mean changes in segmental lordosis and global lordosis were 7.1° (SD 6.7°) and 2.9° (SD 9.9°) respectively for the interbody fusion group, and 0.8° (SD 5.1°) and -0.4° (SD 10.1°) respectively for the posterolateral fusion-only group. Segmental lordosis (ρ = 0.794, p < 0.001) corrected by interbody fusion correlated best with prone traction radiographs. Global lumbar lordosis (ρ = 0.788, p < 0.001) correlated best with the interbody fusion group and preoperative lateral standing radiographs. The least difference in slip distance (-0.3 mm (SD 1.7 mm), p < 0.001), slip angle (0.9° (SD 5.2°), p < 0.001), and disc height (0.02 mm (SD 2.4 mm), p < 0.001) was seen between prone traction and postoperative radiographs. Regression analyses suggested that prone traction parameters best predicted correction of slip distance (Corrected Akaike's Information Criterion (AICc) = 37.336) and disc height (AICc = 58.096), while correction of slip angle (AICc = 26.453) was best predicted by extension radiographs. Receiver operating characteristic (ROC) cut-off showed, with 68.3% sensitivity and 64.5% specificity, that to achieve a 3.0° increase in segmental lordotic angle, patients with a prone traction disc height of 8.5 mm needed an interbody fusion. CONCLUSION: Prone traction radiographs best predict the slip distance and disc height correction achieved by interbody fusion for lumbar degenerative spondylolisthesis. To achieve this maximum correction, interbody fusion should be undertaken if a disc height of more than 8.5 mm is attained on preoperative prone traction radiographs. Level of Evidence: Level II Prognostic Study Cite this article: Bone Joint J 2020;102-B(8):1062-1071.

Fusion in situ versus reduction for spondylolisthesis treatment: grading the evidence through a meta-analysis.

PURPOSE: During surgical procedure on lumbar spondylolisthesis, the role of reducing slip remains controversial. The purpose of the present study was to compare fusion in situ with reduction in clinical and radiographic outcomes. METHODS: A literature research was performed at PubMed, Embase, Web of Science, and Cochrane Library. After screening by two authors, ten articles were brought into this meta-analysis finally, and the quality was evaluated by the modified Newcastle-Ottawa Scale (NOS). Isthmic, moderate, and serious spondylolisthesis were all analyzed separately. Sensitivity analyses were performed for high-quality studies, and the publication bias was evaluated by the funnel plot. RESULTS: Most criteria did not have statistical differences between reduction and fusion in situ groups. However, in reduction group, the union rate was significantly higher (P=0.008), the slippage was much improved (P<0.001) and the hospital stay was much shorter comparing to no-reduction group (P<0.001). Subgroup analysis (containing moderate and serious slip, or isthmic spondylolisthesis) and sensitivity analysis were all consistent with original ones, and the funnel plot indicated no obvious publication bias in this meta-analysis. CONCLUSIONS: Both reduction and fusion in situ for lumbar spondylolisthesis were related with good clinical results. Reduction led to higher rate of fusion, better radiographic slippage, and shorter hospital stay. After sufficient decompression, reduction did not incur additional risk of neurologic impairment compared with fusion in situ.

Systematic Review of Outcomes Following 10-Year Mark of Spine Patient Outcomes Research Trial (SPORT) for Degenerative Spondylolisthesis.

STUDY DESIGN: We performed a comprehensive search of PubMed, MEDLINE, and EMBASE for all English language studies of all levels of evidence pertaining to Spine Patient Outcomes Research Trial (SPORT), in accordance with Preferred Reported Items for Systematic Reviews and Meta-analyses guidelines. OBJECTIVE: We aim to summarize the 10-year clinical outcomes of SPORT and its numerous follow-up studies for degenerative spondylolisthesis. SUMMARY OF BACKGROUND DATA: The SPORT was a landmark randomized control trial including approximately 2500 patients at 13 clinics across the country. SPORT compared surgical and nonoperative management of the three most common spinal pathologies. METHODS: Keywords used in the literature search included SPORT, spine patient outcomes research trial, degenerative spondylolisthesis, and surgical outcomes. RESULTS: The intent-to-treat analysis failed to show a significant difference between patients treated surgically as compared to those treated nonoperatively. However, as-treated analysis revealed statically greater improvements at 6 weeks, 2 years, and 4 years in patients treated surgically. Secondary outcomes such as low back pain, leg pain, stenosis bothersome scales, overall satisfaction with current symptoms, and self-rated progress were also significantly improved in surgical patients. Regardless of the initial grade of listhesis, disk height, or mobility, patients who had surgical treatment improved more in terms of Oswestry Disability Index, bodily pain, physical function, and low back pain bothersomeness scales. Risk of reoperation increased with age, having two or three moderate or severe stenotic levels, pain predominantly localized to the back, no physical therapy, the absence of neurogenic claudication, and greater leg pain scores. Risk of reoperation was not significantly affected by type of surgery performed, smoking, diabetes, obesity, longer duration of symptoms, or workman's compensation. CONCLUSION: Although intent-to-treat analysis failed to show significant differences in patients treated surgically, results of the as-treated analysis determined statically greater improvements in those patients with spondylolisthesis who were treated surgically as compared to those treated nonoperatively. LEVEL OF EVIDENCE: 2.

Manipulation for treatment of degenerative lumbar spondylolisthesis: A protocol of systematic review and meta-analysis.

BACKGROUND: Degenerative lumbar spondylolisthesis (DLS) is one of the common orthopedic diseases which causes low back pain in patients, which seriously affects people's daily life and work. As a method of conservative treatment of this disease, manipulation is widely used in clinical practice. We will summarize the current published evidence of manipulation in the treatment of DLS, and evaluate the effectiveness and safety of manipulation through systematic review and meta-analysis, so as to provide more reliable evidence for future clinical practice. METHODS: We will conduct a comprehensive search of the following 9 databases until January 2019: PubMed, Embase, Cochrane Library, ClinicalTrials.gov, Web of Science, Chinese National Knowledge Infrastructure, Chinese Science and Technique Journals Database, Wan Fang Database, and Chinese Biomedical Database. The 2 researchers will independently search, screen, extract data, and evaluate the quality of the literatures. The primary outcomes include clinical effectiveness, Japanese Orthopaedic Association scores, and the secondary outcomes include visual analog scale scores, symptom scores, and adverse events. Bias risk tools provided by Cochrane Collaboration will be used for literature quality assessment, and RevMan 5.3 software will be used for meta-analysis. RESULTS: The results of this study will systematically evaluate the effectiveness and safety of manipulation intervention for people with DLS, especially in improving lumbar function scores and pain scores. CONCLUSION: The systematic review of this study will summarize the current published evidence of manipulation for the treatment of DLS, which can further guide the promotion and application of it. ETHICS AND DISSEMINATION: This study does not require ethical approval and the results will be published in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER: CRD42019139933.

Outcome of Conservative Management in the Treatment of Symptomatic Spondylolysis and Grade I Spondylolisthesis.

BACKGROUND: Bracing (thoraco-lumbar-sacral orthosis) has been accepted as mainstay of treatment for symptomatic spondylolysis (SP) and grade I spondylolisthesis (SPL1). However, increasing costs and patient noncompliance can make bracing prohibitive and difficult to manage. The purpose of this study was to determine if SP and SPL1 can be effectively treated using physical therapy and other non-bracing conservative management techniques in order to relieve pain and restore physical function. METHODS: We performed a cross-sectional study in which patients who presented from June 1, 2004, to May 1, 2015, with symptomatic SP and SPL1 who were treated with nonbracing conservative management, entailing a universal 6-week physical therapy program and restriction of offending activity, were considered for the study. Physical therapy included core strengthening activities, hamstrings stretching, and spine range of motion exercises. Patients meeting inclusion criteria were contacted via phone interview and asked to complete an Oswestry Disability Questionnaire (ODQ) in order to generate a disability score to assess their current pain and daily function. Patients were then stratified into groups based on their level of disability as denoted by their disability score; minimal disability = disability score of 0% to 19.9%, moderate disability = 20% to 39.9%, severe disability = 40% to 59.9%, crippled = 60% to 79.9%, and bed bound or exaggerating = 80% to 100%. RESULTS: Fourty-six patients were identified as meeting inclusion criteria (28 with SP and 18 with SPL1). Twenty-three of 46 were successfully contacted and agreed to complete the ODQ (10/23 with SP and 13/23 with SPL1). Twenty-two of 23 (96%) patients had a minimal disability score (0% to 19.9%), One of 23 (4%) patients had a moderate disability score (20% to 39.9%), and 18/23 (78%) patients had a disability score of zero, denoting no pain or limitation of function. CONCLUSION: The results of this study suggest that, in patients with symptomatic spondylolysis and grade I spondylolisthesis, pain relief and restoration of function can be achieved using conservative management techniques without use of a brace.

rhBMP-2 (Recombinant Human Bone Morphogenetic Protein-2) in real world spine surgery. A phase IV, National, multicentre, retrospective study collecting data from patient medical files in French spinal centres.

BACKGROUND: This is a Phase IV, national, multicentre, retrospective study to observe the real-world use of rhBMP-2 in France. HYPOTHESIS: There was no statistical hypothesis, the statistical analyses were descriptive in nature. PATIENTS AND METHODS: Data was collected from patient medical files in 10 French spinal centres. Primary objectives were to understand which patients were treated with rhBMP-2, commercialised in Europe as InductOs™ and how rhBMP-2 was used during spinal fusion surgery in France between 2011 and 2012. RESULTS: Four hundred patients (634 levels) treated with rhBMP-2 were included in the analysis. The most frequent primary diagnostic indication for rhBMP-2 use was degenerative disc disease (DDD; 129/400; 32.3% of patients) followed by spondylolisthesis (119/400; 29.8%), deformity (59/400; 14.8%) and pseudoarthrosis (29/400; 7.3%). The most frequently treated level was L4-L5 (33.8% of levels in 53.5% of patients); followed by L5-S1 (29.8%, 47.3%), L3-L4 (16.7%, 26.5%), and L2-L3 (7.3%, 11.5%), all other levels (less than 5% of patients). No interbody fusion device was used in 42.7% of levels. Wetted matrix of rhBMP-2 was placed in the interbody space in 58.4% of levels (370/634). The most common procedure for rhBMP-2 treatment was posterior lumbar fusion (PLF) (221/634; 34.9% of levels), followed by anterior lumbar interbody fusion (ALIF) (188/634; 29.7%), posterior lumbar interbody fusion (PLIF) (111/634; 17.5%), lateral lumbar interbody fusion (LLIF) (106/634; 16.7%), transforaminal lumbar interbody fusion (TLIF) (4/634; 0.6%) and 'other' (4/634; 0.6%). Thirty-one adverse events of Interest (AEI) were recorded in 27 patients. One AEI was considered related to rhBMP-2. Unplanned secondary spine interventions at index level treated with rhBMP-2 were required in 4 patients. DISCUSSION: In years 2011 and 2012 when the surgeries captured in this retrospective study were done, rhBMP-2 was indicated for single level (L4-S1) anterior lumbar spine fusion as a substitute for autogenous bone graft in adults with DDD. The most common procedure for the treatment with rhBMP-2 was PLF (off-label use), followed by ALIF (on-label use). The safety findings confirm a predictable and manageable safety profile. LEVEL OF EVIDENCE: IV.