The Relationship Between MRI Findings of Posterior Ligamentous Complex and Lumbar Instability in Degenerative Spondylolisthesis.

Background: To determine the factors in posterior ligamentous complex indicating lumbar instability in patients diagnosed with degenerative spondylolisthesis on conventional magnetic resonance imaging (MRI). Methods: We retrospectively analyzed patients who underwent PLIF surgery for degenerative spondylolisthesis at our institution between 2018 and 2020 and who had complete eligible preoperative imaging data for review and study, including lumbar MRI and anteroposterior and flexion-extension radiographs. Results: Fifty-three patients were confirmed to have lumbar instability (Unstable Group, 44%), while sixty-seven patients (Stable Group, 56%) did not have instability on radiographs. The patients in the stable group had more advanced status of the degeneration of intervertebral disc than in the unstable group (p<0.05). The degeneration of supraspinous ligament (SSL) was more severe in the unstable group (p<0.05). Compared with the patients with rotatory instability, advanced degeneration of interspinous ligament (ISL) and SSL was observed in patients with translatory instability (p<0.05). However, there was no significant difference with regard to the height of the spinous process and the interspinous distance in patients with or without instability. Conclusion: This MRI analysis showed that abnormal segmental motion is closely associated with the pathological characteristics of supraspinal ligament. Advanced degeneration of SSL in patients with degenerative spondylolisthesis should raise the suspicion for lumbar instability and additional evaluations. The status of ISL and ligamentum flavum (LF) may not be helpful for the diagnosis of lumbar instability. Functional radiographs combined with MRI may provide valuable information when diagnosing lumbar instability in patients with mechanical back pain.

Articular arthrodesis with the facet wedge technique for the treatment of unstable lumbar degenerative disease and associated conditions: A retrospective study of 96 patients.

Background: Lumbar articular fusion with the facet wedge (FW) technique is gaining increasing interest among surgeons for the treatment of vertebral instability due to its limited invasiveness and ease of use. Studies on cadavers have reported biomechanical properties similar to pedicle screws. Yet, the evidence supporting their use is still limited and moreover focused only on spinal degenerative disease. Methods: 96 cases of lumbar articular fusion with the FW techniques performed at 3 different centers between 2014 and 2022 were retrospectively analyzed based on the specific surgical indications: 1) degenerative spondylolisthesis/unstable lumbar stenosis; 2) synovial cysts; 3) adjacent segment disease (ASD). Medical records were reviewed to identify rates of complications and measures of functional outcome (ODI, low back pain VAS and modified Macnab scale) were collected both at baseline and at the follow-up visits. Wilcoxon signed-rank test was adopted to test for significant functional improvements. Results: Significative clinical improvements were observed from baseline to follow-up regarding ODI and VAS scores. Overall rate of moderate and severe complications (according to Landriel-Ibañez scale) was 7.9%. Only 3.4% of patients with degenerative disease developed ASD requiring reoperations. Only one case of radicular deficit and one of device mobilization were reported. 2/4 cases of synovial cysts treated with unilateral fusions developed contralateral complications. 9 out of 16 (56.25%) patients who underwent long-term postoperative CT scans presented adequate degree of articular fusion. Conclusion: FW technique is easy, safe, and effective. Its low rate of complications justifies its use for cases of mild lumbar instability.

Evolution of lumbar degenerative spondylolisthesis with key radiographic features.

Spondylolisthesis is a common finding in middle-aged and older adults with back pain. The pathophysiology of degenerative spondylolisthesis is a subject of controversy regarding not only its etiology but also the mechanisms of its progression. It is theorized that degeneration of the facets and discs can lead to segmental instability, leading to displacement over time. Kirkaldy-Willis divided degenerative spondylolisthesis into three phases: dysfunction, instability, and finally, restabilization. There is a paucity of literature on the unification of the radiological hallmarks seen in spondylolisthesis within these phases. The radiographic features include (1) facet morphology/arthropathy, (2) facet effusion, (3) facet vacuum, (4) synovial cyst, (5) interspinous ligament bursitis, and (6) vacuum disc as markers of dysfunction, instability, and/or restabilization. We discuss these features, which can be seen on X-ray, CT, and MRI, with the intention of establishing a timeline upon which they present clinically. Spondylolisthesis is initiated as either degeneration of the intervertebral disc or facet joints. Early degeneration can be seen as facet vacuum without considerable arthropathy. As the vertebral segment becomes increasingly dynamic, fluid accumulates within the facet joint space. Further degeneration will lead to the advancement of facet arthropathy, degenerative disc disease, and posterior ligamentous complex pathology. Facet effusion can eventually be replaced with a vacuum in severe facet osteoarthritis. Intervertebral disc vacuum continues to accumulate with further cleft formation and degeneration. Ultimately, autofusion of the vertebra at the facets and endplates can be observed. With this review, we hope to increase awareness of these radiographical markers and their timeline, thus placing them within the framework of the currently accepted model of degenerative spondylolisthesis, to help guide future research and to help refine management guidelines.

The difference in multifidus muscle morphology and motor control in non-specific low back pain with clinical lumbar instability and healthy subjects: A case-control study.

BACKGROUND: Low back pain (LBP) with clinical lumbar instability (CLI) is considered a subgroup of back pain. Poor core stability function and/or lack of motor controls are thought to play a role in inappropriate inter-segmental movements and pain. There is no study investigating the changes in the lumbar multifidus muscle (LMM) morphology and motor control in this subgroup of patients. OBJECTIVE: To assess motor control components and morphological changes of LMM in the patients suffering from chronic nonspecific low back pain (CNSLBP) with CLI. DESIGN: Observational case-control study. METHODS: Thirty-two patients suffering from (CNSLBP) with CLI and 32 healthy individuals were included. The muscle force element of lumbar motor control was assessed by using (the active straight-leg raise test, leg lowering test, and Trendelenburg test). Ultrasonography was used to assess changes in the LMM morphology. RESULTS: There was a significant decrease in motor control (p = 0.0001), an increase in LMM fatty infiltration (p = 0.002), and a decrease in the thickness of LMM in patients suffering from CNSLBP during contraction (p = 0.006), during rest (p = 0.018). The cross-section area of the LMM showed no statistically significant differences during rest on the right and left sides (p = 0.827, 0.220 respectively) and contraction (p = 0.160, 0.278 respectively) between patients and healthy subjects. CONCLUSION: Motor control and the morphology of LMM in patients with CNSLBP with CLI may provide insight into the mechanisms of underlying pain and their effect on muscle function and structure.

Acute disc herniation following surgical decompression of lumbar spinal stenosis: a retrospective comparison of mini-open and minimally invasive techniques.

BACKGROUND: Disc herniation following decompression of lumbar spinal stenosis is a less familiar surgical complication. Previous studies suggested that open lumbar decompression techniques, associated with relative segmental instability especially in the presence of degenerated disc in older patients, are more likely to result in disc herniation compared to minimally invasive techniques. The current study compares the incidence of acute disc herniation following mini-open and minimally invasive decompression of lumbar spinal stenosis. METHODS: This was a retrospective study reviewing 563 patients who underwent spinal decompression for symptomatic lumbar stenosis by mini-open bilateral partial laminectomy technique or minimally invasive laminotomy utilizing a tubular system. Demographic and clinical data were collected and compared between the groups. RESULTS: Postoperative disc herniation rate was significantly lower in the minimally invasive group with 2 of 237 cases (0.8%) versus 19 of 326 cases (5.8%) in the mini-open group (p = 0.002). This finding was more noticeable following multi-level procedures with no case of postdecompression disc herniation in the minimally invasive group compared to 8 of 39 cases (20.5%) in the mini-open group (p = 0.003). CONCLUSION: The incidence of postoperative disc herniation following spinal decompression for symptomatic lumbar stenosis was 5.8% following mini-open bilateral partial laminectomy compared to only 0.8% after minimally invasive laminotomy (p = 0.002). These findings highlight the more extensive nature of mini-open surgery associated with relative segmental instability that poses a greater risk for postoperative disc herniation.

Do Modic changes contribute to lumbar instability or other way around? A retrospective study based on their types, extents, and affected lumbar segments.

BACKGROUND: Which types of Modic changes (MCs) and whether or how specific factors associated to MCs work on lumbar instability have yet to be well understood. The purpose of this study was to investigate the influences of the types of MCs, the extent of MCs lesion involvement, and different lumbar levels involved by MCs on lumbar instability. METHODS: This retrospective study included 263 adult subjects with MCs who underwent lumbar X-ray examinations in the neutral, flexion, and extension positions. All patients who met our inclusion criteria were examined with 1.5 Tesla magnetic resonance units. Two experienced authors with more than three-year clinical experience independently evaluated and measured the subjects' radiographic images. The subgroup analysis was performed to detect the differences in subjects' baseline characteristics and lumbar segmental motions among three types of MCs, the extent of MCs lesion involvement and different lumbar levels involved by MCs. RESULTS: There was a statistical difference in body mass index (BMI) between different involvement extent of MCs (p < 0.01), indicating that the subjects with high BMI are more likely to develop severe MCs. The subjects with Modic type 1 change (MC1) had a significant increase in lumbar angular motion than those with Modic type 2 change (MC2) and Modic type 3 change (MC3) (p < 0.01) and compared with MC3, a significant increase in lumbar translation motion was detected in subjects with MC1 and MC2 (p < 0.01). While, angular motion decreased, translation motion increased significantly as the extent of MCs lesion involvement aggravated (p < 0.01). However, there were no statistical differences in lumbar angular and translation motions between different lumbar levels involved by MCs (p > 0.05). CONCLUSIONS: Higher BMI might be a risk factor for the development of severe MCs. MC1 and MC2 significantly contribute to lumbar instability. The extents of MCs lesion involvement are strongly associated with lumbar instability. However, different lumbar levels involved by MCs have little effect on lumbar stability.

The effect of various options for decompression of degenerated lumbar spine motion segments on the range of motion: a biomechanical in vitro study.

BACKGROUND: Lumbar spinal stenosis is a common disease in the aging population. Decompression surgery represents the treatment standard, however, a risk of segmental destabilization depending on the approach and extent of decompression is discussed. So far, biomechanical studies on techniques were mainly conducted on non-degenerated specimens. This biomechanical in vitro study aimed to investigate the increase in segmental range of motion (ROM) depending on the extent of decompression in degenerated segments. METHODS: Ten fresh frozen lumbar specimens were embedded in polymethyl methacrylate (PMMA) and loaded in a spine tester with pure moments of ± 7.5 Nm. The specimens were tested in their intact state for lateral bending (LB), flexion/extension (FE) and axial rotation (AR). Subsequently, four different decompression techniques were performed: unilateral interlaminar decompression (DC1), unilateral with "over the top" decompression (DC2), bilateral interlaminar decompression (DC3) and laminectomy (DC4). The ROM of the index segment was reported as percent (%) of the native state. RESULTS: Specimens were measured in their intact state prior to decompression. The mean ROM was defined as 100% (FE:6.3 ± 2.3°; LB:5.4 ± 2.8°; AR:3.0 ± 1.6°). Interventions showed a continuous ROM increase: FE (DC1: + 4% ± 4.3; DC2: + 4% ± 4.5; DC3: + 8% ± 8.3;DC4: + 20% ± 15.9), LB(DC1: + 4% ± 6.0; DC2: + 5% ± 7.3; DC3: + 8% ± 8.3; DC4: + 11% ± 9.9), AR (DC1: + 7% ± 6.0; DC2: + 9% ± 7.9; DC3: + 15% ± 11.5; DC4: + 19% ± 10.5). Significant increases in ROM for all motion directions (p < 0.05) were only obtained after complete laminectomy (DC4). CONCLUSION: Unilateral and/or bilateral decompressive surgery resulted in a statistically insignificant ROM increase, whereas complete laminectomy showed statistically significant ROM increase. If this ROM increase also has an impact on the clinical outcome and how to identify segments at risk for secondary lumbar instability should be evaluated in further studies.

[Development and validation of an automatic diagnostic tool for lumbar stability based on deep learning].

Objective: To develop an automatic diagnostic tool based on deep learning for lumbar spine stability and validate diagnostic accuracy. Methods: Preoperative lumbar hyper-flexion and hyper-extension X-ray films were collected from 153 patients with lumbar disease. The following 5 key points were marked by 3 orthopedic surgeons: L4 posteroinferior, anterior inferior angles as well as L5 posterosuperior, anterior superior, and posterior inferior angles. The labeling results of each surgeon were preserved independently, and a total of three sets of labeling results were obtained. A total of 306 lumbar X-ray films were randomly divided into training (n=156), validation (n=50), and test (n=100) sets in a ratio of 3∶1∶2. A new neural network architecture, Swin-PGNet was proposed, which was trained using annotated radiograph images to automatically locate the lumbar vertebral key points and calculate L4, 5 intervertebral Cobb angle and L4 lumbar sliding distance through the predicted key points. The mean error and intra-class correlation coefficient (ICC) were used as an evaluation index, to compare the differences between surgeons' annotations and Swin-PGNet on the three tasks (key point positioning, Cobb angle measurement, and lumbar sliding distance measurement). Meanwhile, the change of Cobb angle more than 11° was taken as the criterion of lumbar instability, and the lumbar sliding distance more than 3 mm was taken as the criterion of lumbar spondylolisthesis. The accuracy of surgeon annotation and Swin-PGNet in judging lumbar instability was compared. Results: ① Key point: The mean error of key point location by Swin-PGNet was (1.407±0.939) mm, and by different surgeons was (3.034±2.612) mm. ② Cobb angle: The mean error of Swin-PGNet was (2.062±1.352)° and the mean error of surgeons was (3.580±2.338)°. There was no significant difference between Swin-PGNet and surgeons (P>0.05), but there was a significant difference between different surgeons (P<0.05). ③ Lumbar sliding distance: The mean error of Swin-PGNet was (1.656±0.878) mm and the mean error of surgeons was (1.884±1.612) mm. There was no significant difference between Swin-PGNet and surgeons and between different surgeons (P>0.05). The accuracy of lumbar instability diagnosed by surgeons and Swin-PGNet was 75.3% and 84.0%, respectively. The accuracy of lumbar spondylolisthesis diagnosed by surgeons and Swin-PGNet was 70.7% and 71.3%, respectively. There was no significant difference between Swin-PGNet and surgeons, as well as between different surgeons (P>0.05). ④ Consistency of lumbar stability diagnosis: The ICC of Cobb angle among different surgeons was 0.913 [95%CI (0.898, 0.934)] (P<0.05), and the ICC of lumbar sliding distance was 0.741 [95%CI (0.729, 0.796)] (P<0.05). The result showed that the annotating of the three surgeons were consistent. The ICC of Cobb angle between Swin-PGNet and surgeons was 0.922 [95%CI (0.891, 0.938)] (P<0.05), and the ICC of lumbar sliding distance was 0.748 [95%CI(0.726, 0.783)] (P<0.05). The result showed that the annotating of Swin-PGNet were consistent with those of surgeons. Conclusion: The automatic diagnostic tool for lumbar instability constructed based on deep learning can realize the automatic identification of lumbar instability and spondylolisthesis accurately and conveniently, which can effectively assist clinical diagnosis.

Clinical outcomes of unilateral biportal endoscopic lumbar interbody fusion (ULIF) compared with conventional posterior lumbar interbody fusion (PLIF).

BACKGROUND CONTEXT: In recent years, unilateral biportal endoscopic lumbar interbody fusion (ULIF) has been more and more favored by spinal surgeons because of its advantages of low trauma, rapid recovery, high fusion rate and fewer complications. PURPOSE: To compare the clinical effects of ULIF with those of conventional open posterior lumbar interbody fusion (PLIF). STUDY DESIGN: Prospective case control study. PATIENT SAMPLE: Twenty-seven patients treated by ULIF and thirty-three patients treated by PLIF. OUTCOME MEASURES: The preoperative baseline and surgical technique-related outcomes (mean operation time, blood loss during operation, postoperative drainage, and postoperative hospital stay) were compared between the two groups. The clinical status of the two groups before and after surgery were also compared: visual analogue scale (VAS) score of the legs and back, Japanese Orthopedic Association (JOA) score and Oswestry Disability Index (ODI). The clinical laboratory indexes of the two groups before and after the operation were compared: C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), creatine phosphokinase (CPK), interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), as well as the incidence of complications, such as dural tear, nerve root injury and infection. METHODS: Adult patients who underwent L3-S1 single level lumbar interbody fusion were included in the study. They were divided into a PLIF group and a ULIF group according to the type of surgery. This study comprised 60 cases: 27 cases in the ULIF group and thirty-three cases in the PLIF group. RESULTS: There was no significant difference in preoperative baseline between the two groups. The ULIF group experienced less blood loss, postoperative drainage and a shorter postoperative hospital stay than the PLIF group; however the ULIF group required a longer operation time than the PLIF group (p<.05). CRP, ESR, CPK, IL-6, and TNF-α levels of the PLIF group were all significantly higher than those of the ULIF group 5 days after surgery (p<.05). The improvements in the VAS scores for back pain, VAS scores for leg pain and JOA score in the ULIF group were all significantly better than those in the PLIF group at 5 days after surgery (p<.05). There was no significant difference in fusion rate at 6 months between the 2 groups (p>.05). CONCLUSIONS: This study showed that ULIF and PLIF were both effective surgical techniques for lumbar interbody fusion. However, ULIF caused less bleeding, reduced inflammatory reaction, less tissue damage and faster postoperative recovery compared with PLIF. Both long-term follow-up and larger clinical studies are needed to validate the clinical and radiological results of this surgery.

Utility of Flexion-Extension Radiographs with Brackets and Magnetic Resonance Facet Fluid for the Assessment of Lumbar Instability in Degenerative Lumbar Spondylolisthesis.

OBJECTIVE: To propose a new standardized technique for evaluating lumbar stability in degenerative lumbar spondylolisthesis using lumbar lateral flexion-extension radiographs with brackets and magnetic resonance facet fluid. METHODS: A retrospective analysis of 57 patients diagnosed with lumbar (L4-5) spondylolisthesis was performed. We analyzed lateral flexion-extension radiographs obtained with a bracket (LFEB) and without a bracket (LFE). Sagittal translation, segmental angulation, posterior opening, lumbar instability, and changes in lumbar lordosis were compared using functional radiographs. The mean width and maximum width of the facet fluid, mean facet joint length, and facet fluid index (FFI) of the 2 groups were compared using sagittal translation. RESULTS: The average value of sagittal translation was 1.68 ± 0.96 mm in LFE and 3.07 ± 1.29 mm in LFEB, and the difference was significant (P < 0.05). Segmental angulation, posterior opening, and changes in lumbar lordosis were significantly greater in LFEB than in LFE. The instability detection rate was 14.0% in LFE and 35.1% in LFEB. The FFI, maximum width, and mean width were significantly increased in the unstable lumbar spondylolisthesis group compared with the stable group in LFEB. The FFI and maximum width of the facet fluid were significantly increased in the unstable lumbar spondylolisthesis group compared with the stable group in LFE. CONCLUSIONS: Lumbar lateral flexion-extension radiographs with brackets can standardize the operation process and provide sufficient hyperflexion and hyperextension images. The width of the facet fluid and FFI are significant factors in the evaluation of lumbar stability in patients with lumbar spondylolisthesis.

Lumbar Facet Joint Effusion on Magnetic Resonance Imaging: Do Different Joint Effusion Images Have Different Clinical Values?

OBJECTIVE: The objective of the study was to explore the significance of the distribution of lumbar facet joint effusion (unilateral or bilateral) and the amount of joint effusion in the process of lumbar degeneration. METHODS: A total of 142 patients with L4-5 lumbar facet joint effusion in our hospital from December 2020 to December 2021 were analyzed retrospectively, including 69 cases of unilateral facet joint effusion and 73 cases of bilateral facet joint effusion. The correlation between joint effusion width, effusion area and lumbar stability, facet joint degeneration grade, lumbar intervertebral disc degeneration index, and lumbosacral angle (LSA) was analyzed. To study the significance of the distribution of joint effusion, the patients were divided into unilateral and bilateral effusion groups. RESULTS: The size of the LSA in the bilateral effusion group was significantly larger than that in the unilateral effusion group (t = 3.6634, P < 0.05). There was a significant difference in the proportion of stability between both groups (P < 0.05). The width of the joint effusion was positively correlated with lumbar stability and the LSA. When the width of the joint effusion was 2 mm, the probability of lumbar instability was 58.1%. The area of joint effusion was positively correlated with lumbar stability and the LSA. When the area of effusion was 0.2 cm2, the probability of lumbar instability was 58.9%. CONCLUSIONS: A bilateral effusion signal is more likely to indicate lumbar instability than a unilateral effusion signal. The distribution width and area of effusion were positively correlated with lumbar stability and LSA.

Lumbar Foraminal Stenosis Classification That Guides Surgical Treatment.

BACKGROUND: There are numerous radiological and anatomical studies on lumbar foramina in the literature, but there are no distinctive studies about the relationship between treatment and the type of foraminal stenosis. This study was conducted to better evaluate foraminal stenosis and to plan treatment accordingly. METHODS: Foraminal stenosis was divided into 2 groups: stable and unstable stenosis. Both groups were also divided into 4 subgroups in relation to the cause and type of compression and based on the structure of the intervertebral disc. The visual analog scale for leg pain (VAS-LP) and Oswestry Disability Index (ODI) scores were investigated before and after surgery. RESULTS: A total of 115 patients (59 women and 56 men) underwent surgery for lumbar foraminal stenosis. The mean patient age was 56.1 years (range 17-80 years). The mean follow-up was 29 months (range 24-39 months). There were 36 patients (32%) with stable foraminal stenosis and 79 patients (68%) with unstable foraminal stenosis. The majority of the patients were identified as having unstable type 1 foraminal stenosis (45 of 115). The VAS-LP and ODI scores for each group decreased gradually during the follow-up periods and showed significant decrease during the last follow-up (P < 0.001). Interobserver and intraobserver agreement in the classification of foraminal stenosis was found to be nearly perfect. No patients experienced postoperative radiculopathy complication. Only 2 patients experienced superficial operation site infection and 1 showed deep wound infection. The patient who had a deep wound infection needed to repeat surgery for the infection. CONCLUSIONS: We introduced a novel classification system for lumbar foraminal stenosis. We aimed to guide appropriate treatment modality depending on the determined classification. This classification helps to determine the optimal treatment. In the light of our findings, the patients who were operated according to our classification experienced satisfactory clinical outcomes and low complication rates.

Full-Endoscopic Lumbar Interbody Fusion Versus Minimally Invasive Transforaminal Lumbar Interbody Fusion with a Tubular Retractor System: A Retrospective Controlled Study.

OBJECTIVE: The objective of this study was to compare the safety and clinical efficacy of full-endoscopic lumbar interbody fusion (FE-LIF) and minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF). METHODS: A total of 70 patients with single-level lumbar degenerative diseases underwent FE-LIF or MIS-TLIF with a tubular retractor system from August 2018 to August 2020. Postoperatively, the efficacy and safety were compared using several clinical and radiological indices. RESULTS: A total of 32 patients underwent FE-LIF and 38 received MIS-TLIF with a tubular retractor system, and all patients had no apparent complications. The FE-LIF group had higher radiation exposure, longer operation time, and less bleeding than the MIS-TLIF group (P < 0.05). Postoperative lumbar magnetic resonance imaging showed that the nerve decompression was sufficient. The pain in the lower back and legs was significantly relieved, and the Oswestry Disability Index (ODI) score was greatly improved after surgery (P < 0.01) in both the groups. The sensory and motor functions of nerve roots were remarkably recovered in both the groups at the 1-year follow-up (P < 0.05), and there was no significant difference in MacNab scores between the 2 groups. As per Mannion's fusion classification, the interbody fusion rate was significantly better in the FE-LIF group than in the MIS-TLIF group. CONCLUSIONS: FE-LIF, which is safe, effective, and minimally invasive, exhibits the same clinical efficacy as MIS-TLIF but with longer operation time and increased radiation exposure.

Combining clinical exams can better predict lumbar spine radiographic instability.

BACKGROUND/OBJECTIVES: Several clinical tests have been proposed to diagnose lumbar instability, but their accuracy is still in question. The primary purpose of this study was to evaluate the diagnostic accuracy of the clinical lumbar instability tests. The secondary goal was to design a model to detect lumbar instability. DESIGN: A prospective diagnostic cross-sectional study. METHOD: A sample of 202 patients with chronic low back pain were participated in the study. Five lumbar instability tests including Aberrant movement, Passive lumbar extension, Prone segmental instability, H and I and pheasant tests were compared to flexion/extension radiography as the gold standard for diagnosing lumbar instability using two by two tables. Multiple Logistic Regression analysis was applied to develop a model using demographic information as well as the patients' pain intensity, disability level, lumbar lordosis and the clinical tests. RESULTS: Among the five examined tests, Prone segmental instability, H and I and pheasant tests showed very small likelihood ratios and diagnostic odd's ratio. The largest values were for H and I test with the positive likelihood ratio of 1.28 (95% CI: 0.72 to 2.29) and diagnostic odd's ratio of 1.37 (95% CI: 0.66 to 2.83); the diagnostic accuracy measures were smaller for the other studied clinical tests. The model was developed using weight (t = 1.15, p = 0.03) and lumbar lordosis (t = 3.04, p = 0.00) (which showed a significant relationship with lumbar instability) and prone segmental instability test. The final model has the positive likelihood ratio of 2.07 (95% CI: 1.41 to 3.05) and diagnostic odd's ratio of 3.77 (95% CI: 2.03 to 7.01). CONCLUSION: Each individual test had very small to no power in discriminating patients with lumbar instability. The developed model just slightly improved the accuracy of radiological instability detection.

Lumbar instability as an etiology of low back pain and its treatment by prolotherapy: A review.

BACKGROUND: Low back pain is a significant spinal disorder that affects much of the population at some point during their lives. OBJECTIVE: While proper diagnosis is key, diagnosing the underlying cause of low back pain may often be unclear. METHOD: In this review article, we discuss lumbar instability as an etiology of low back pain and its treatment by prolotherapy. RESULTS: Spinal ligaments may be an underlying culprit in the development of lumbar instability with resultant low back pain and associated disorders. CONCLUSION: In these cases, adequate treatment consisting of non-biologic prolotherapy or cellular prolotherapy, including platelet rich plasma (PRP), can be beneficial in restoring spinal stability and resolving chronic low back pain.

Early efficacy of full endoscopic lumbar interbody fusion in the treatment of lumbar degenerative diseases with lumbar instability / 西安交通大学学报(医学版)

【Objective】 To investigate the early clinical efficacy of full endoscopic lumbar interbody fusion in the treatment of lumbar degenerative diseases with lumbar instability. 【Methods】 We made a retrospective analysis of 22 cases of lumbar degenerative diseases with lumbar instability treated by full endoscopic lumbar interbody fusion in Department of Orthopedics， Tangdu Hospital of Air Force Military Medical University from January 2019 to June 2020. The operation time， intraoperative bleeding volume， and hospital stay were recorded. The Visual Analogue Scale （VAS） for lower back pain and leg pain and Oswestry disability index （ODI） were compared before operation， 1 week， 1 month， 3 months， 6 months and at the last follow-up after operation. Modified MacNab was used to evaluate the clinical efficacy at the last follow-up. 【Results】 Operations on the 22 patients were all completed successfully. The average operation time was （206.59±5.69） min （with the range of 180-240 min）； the average volume of intraoperative bleeding was （92.73±22.29） mL （with the range of 50-120 mL）； the average hospitalization time was （8.82±1.53） d （with the range of 7-13 d）. All the patients were followed up for an average of （10.95±3.34） months （with the range of 6-18 months）. The VAS score and ODI at each time point after surgery were significantly decreased compared with those before operation （P<0.05）. The modified MacNab used to evaluate the clinical efficacy at the last follow-up showed that the total excellent and good rate was 90.91%， including 17 cases of excellence， 3 cases of good， and 2 cases of fair. 【Conclusion】 The early clinical effect of full endoscopic lumbar interbody fusion in the treatment of lumbar degenerative diseases with lumbar instability is satisfactory.

Clinical Outcomes of Percutaneous Endoscopic Lumbar Discectomy for the Treatment of Grade I and Grade II Degenerative Lumbar Spondylolisthesis: A Retrospective Study With a Minimum Five-Year Follow-up.

BACKGROUND: Degenerative lumbar spondylolisthesis (DLS) occurs mainly in geriatric patients. Some authors have reported satisfactory short-term outcomes following percutaneous endoscopic lumbar discectomy (PELD) for DLS; however, the long-term clinical outcomes remain unknown. In addition, it remains unclear whether PELD causes further progression of spondylolisthesis over a long period of time. OBJECTIVES: To evaluate long-term clinical outcomes in patients who underwent PELD and to study the degree of slippage in DLS over a long period following minimally invasive surgery. STUDY DESIGN: Retrospective case series. SETTING: The study was conducted at the Beijing Chaoyang Hospital, Capital Medical University, China. METHODS: The study included 24 patients with DLS who complained of radicular pain and lower back pain who underwent PELD and were followed up for at least 5 years (mean duration of 6.1 years). Visual analog scale (VAS) scores, Oswestry disability index (ODI) scores, and the modified MacNab criteria were used to evaluate clinical outcomes. Preoperative imaging findings, including the percent slippage of spondylolisthesis (SR), disc height (DH), segmental lordosis angle (SL), and lumbar lordosis angle (LL), were compared with those obtained at follow-up. RESULTS: All operations were successfully completed; the mean operative incision length, intraoperative blood loss, and operation duration were 8.7 ± 0.6 mm, 11.3 ± 4.5 mL, and 121.8 ± 32.3 min, respectively. The mean VAS-back score, VAS-leg score, and ODI score were 6.5 ± 0.9, 6.0 ± 1.1, and 55.4 ± 4.4 points before surgery, respectively, and decreased to 2.6 ± 0.8, 2.2 ± 0.5, and 27.3 ± 5.3 points, respectively, at 3 months after surgery and 2.5 ± 0.9, 2.0 ± 0.5, and 21.1 ± 4.4 points, respectively, at the latest follow-up. The imaging variables related to DH were lower at the final follow-up before surgery; however, no significant differences in SR, SL, and LL were found. The proportion of excellent and good results following MacNab evaluation was 87.5%. Symptomatic re-herniation occurred in one patient, and cerebrospinal fluid leakage (CSFL) was found in another patient. LIMITATIONS: A small number of patients were included who were all treated by one surgeon. CONCLUSIONS: PELD maintained satisfactory clinical outcomes for the treatment of grade I and grade II DLS after a minimum 5-year follow-up; the operation did not cause further progression of spondylolisthesis. However, further large-scale multicenter studies are necessary.

Validity of a Screening Tool for Patients with a Sub-Threshold Level of Lumbar Instability: A Cross-Sectional Study.

Lumbar instability (LI) comprises one subgroup of those with chronic low back pain (CLBP); it indicates the impairment of at least one of the spinal stabilizing systems, and radiographic criteria of translation and rotation are used for its diagnosis. Previous studies have developed and tested a screening tool for LI where patients with sub-threshold lumbar instability (STLI) were detected in the initial stage of lumbar pathology using radiographs as a gold standard for diagnosis. The radiographic measurement in STLI lies between the range of translation and rotation of the LI and asymptomatic lumbar motion. However, there are no studies indicating the validity and cut-off points of the screening tool for STLI. The current study aimed to determine the validity of an LI screening tool to support the diagnostic process in patients with STLI. This study design was cross-sectional in nature. A total of 135 participants with CLBP, aged between 20 and 60 years, who had undergone flexion and extension radiographs, answered a screening tool with 14 questions. The cut-off score for identifying STLI using the screening tool was at least 6/14 positive responses to the LI questions. The findings suggested that the LI screening tool we tested is effective for the detection of STLI. The tool can be used in outpatient settings.

Effects of seated lumbar rotation manipulation in treating degenerative lumbar instability: a protocol for a randomized controlled trial.

BACKGROUND: Degenerative lumbar instability (DLI) is a common disease that causes low back pain (LBP) in clinic. It is difficult to completely recover from DLI, and it occurs repeatedly, which seriously affects the quality of life of patients. The epidemiological survey showed that 20-30% of low back pain was related to lumbar instability. Increasing evidence shows that seated lumbar rotation manipulation can effectively improve the clinical symptoms of patients with low back pain. The primary aim of this clinical trial is to observe the intervention effect of seated lumbar rotation manipulation on DLI patients. METHOD/DESIGN: A total of 60 participants with DLI will be recruited and randomly allocated into the seated lumbar rotation manipulation group (the intervention group) or lumbar traction in supine position group (the control group) in this prospective, outcome assessor-blind, two-arm randomized controlled clinical trial. The treatment of the two groups lasted for 3 weeks, and the manipulation of the intervention group would be carried out once every other day, three times a week, a total of 9 times; the control group would be given lumbar traction once a day, five times a week, a total of 15 times. JOA (Japanese Orthopaedic Association) and VAS (Visual Analogue Scales) scores will be recorded as the primary outcomes before the treatment and at the 1st, 3rd, 5th, 8th, 10th, 12th, 15th, 17th, and 19th days after treatment and follow-up visit at the first, third, and sixth months. JOA efficacy evaluation standard will be used to evaluate the overall efficacy as the secondary outcomes. DISCUSSION: The results of this prospective, randomized controlled trial will provide a clinical evidence for the treatment of DLI with seated lumbar rotation manipulation. TRIAL REGISTRATION: Chinese Clinical Trial Registry ChiCTR2000032017 . Registered on 18 April 2020, Prospective registration.

Full-Endoscopic Oblique Lateral Lumbar Interbody Fusion: A Technical Note With 1-Year Follow-Up.

BACKGROUND: Oblique lateral lumbar interbody fusion (OLLIF) is a minimally invasive lumbar interbody fusion procedure using a bullet-shaped polyetheretherketone (PEEK) nonexpandable fusion cage modified to diminish risk to the exiting nerve root during posterolateral implantation through the Kambin safe zone under fluoroscopic guidance. The objective of this study was to present feasibility of this procedure and 1-year clinical outcome data. METHODS: The authors present a prospective cohort study of 20 patients who underwent fluoroscopy-guided and full-endoscopic OLLIF in 22 segments allowing protection of the exiting nerve root from January 2018 to March 2019. The foraminoplasty, discectomy, endplate preparation, placement of bone graft and insertion of the fusion cage was done under continuous full-endoscopic visualization. The OLLIF fusion was backed up with bilateral percutaneous posterior supplemental pedicle screw fixation. Primary clinical outcome measures were the visual analog scale (VAS) of low back and leg pain, and Oswestry disability index (ODI) at 1 week, 3 months, 6 months, and 1 year after the operation. At final follow-up, the Macnab score was also evaluated. Secondary outcome measures were computed tomography (CT) assessment fusion using the Mannion classification of spinal fusion and adverse events related to the device as well as magnetic resonance imaging (MRI) assessment of nerve root decompression. RESULTS: All patients had significant relief of low back pain and leg pain, by VAS and ODI scores that improved significantly (P < .01). There were no complications. Postoperative lumbar MRI of all patients showed sufficient direct nerve decompression. At 1-year follow-up, excellent Macnab outcomes were obtained 13 patients, good in six, and fair in one. Impaired sensation and muscle strength of the involved nerve root significantly recovered in all but 2 patients (P < .05). According to the Mannion CT-based classification of spinal fusion, CT showed complete interbody fusion achieved in all 22 segments. CONCLUSIONS: Full-endoscopic OLLIF is a safe, effective, minimally invasive, economical, practical, and widely applicable minimally invasive interbody fusion technique in the lumbar spine. LEVEL OF EVIDENCE: 3.