Successful Treatment of Cervical Spondylolysis with Grade-II Spondylolisthesis using Single-Level ACDF: A Case Report.

BACKGROUND Cervical spondylolysis with spondylolisthesis is a rare disorder. According to previous reports, the spondylolisthesis is usually Meyerding Grade I, with only a limited number of cases receiving surgical treatment. We hereby report a special case of cervical spondylolysis with Grade-II spondylolisthesis, treated with single-level anterior cervical discectomy and fusion (ACDF), and present a literature review related to this problem. CASE REPORT Here, we report the case of a 52-year-old man who complained of posterior neck pain and numbness of the bilateral upper limbs. Radiological examination showed bilateral spondylolysis of the C6 and Meyerding Grade-II spondylolisthesis of C6 on C7 with instability. The patient underwent a single-level C6/C7 ACDF surgery. The symptoms of neck pain and bilateral upper-limb numbness were relieved immediately after surgery. The immediate postoperative radiological examination showed successful restoration of sagittal alignment. At 3-month follow-up, the patient had returned to normal life without any symptoms. At 2-year follow-up, computed tomography showed that C6-C7 fusion had been achieved and alignment was maintained. CONCLUSIONS Cervical spondylolysis, as an uncommon spinal disorder, has been regarded as a congenital abnormity, and has unique radiological characteristics. For most of the cases with cervical spondylolysis, even with Grade-II spondylolisthesis, single-level ACDF can achieve good clinical and radiological outcomes.

Decompression alone or decompression with fusion for lumbar spinal stenosis: five-year clinical results from a randomized clinical trial.

Aims: We compared decompression alone to decompression with fusion surgery for lumbar spinal stenosis, with or without degenerative spondylolisthesis (DS). The aim was to evaluate if five-year outcomes differed between the groups. The two-year results from the same trial revealed no differences. Methods: The Swedish Spinal Stenosis Study was a multicentre randomized controlled trial with recruitment from September 2006 to February 2012. A total of 247 patients with one- or two-level central lumbar spinal stenosis, stratified by the presence of DS, were randomized to decompression alone or decompression with fusion. The five-year Oswestry Disability Index (ODI) was the primary outcome. Secondary outcomes were the EuroQol five-dimension questionnaire (EQ-5D), visual analogue scales for back and leg pain, and patient-reported satisfaction, decreased pain, and increased walking distance. The reoperation rate was recorded. Results: Five-year follow-up was completed by 213 (95%) of the eligible patients (mean age 67 years; 155 female (67%)). After five years, ODI was similar irrespective of treatment, with a mean of 25 (SD 18) for decompression alone and 28 (SD 22) for decompression with fusion (p = 0.226). Mean EQ-5D was higher for decompression alone than for fusion (0.69 (SD 0.28) vs 0.59 (SD 0.34); p = 0.027). In the no-DS subset, fewer patients reported decreased leg pain after fusion (58%) than with decompression alone (80%) (relative risk (RR) 0.71 (95% confidence interval (CI) 0.53 to 0.97). The frequency of subsequent spinal surgery was 24% for decompression with fusion and 22% for decompression alone (RR 1.1 (95% CI 0.69 to 1.8)). Conclusion: Adding fusion to decompression in spinal stenosis surgery, with or without spondylolisthesis, does not improve the five-year ODI, which is consistent with our two-year report. Three secondary outcomes that did not differ at two years favoured decompression alone at five years. Our results support decompression alone as the preferred method for operating on spinal stenosis.

The efficacy and safety of decompression with interspinous fixation for lumbar spondylolisthesis when compared with posterior lumbar interbody fusion: A pilot study.

Posterior lumbar interbody fusion (PLIF) is widely used to treat degenerative spondylolisthesis because it provides definitive decompression and fixation. Although it has several advantages, it has some disadvantages and risks, such as paraspinal muscle injury, potential intraoperative bleeding, postoperative pain, hardware failure, subsidence, and medical comorbidity. Lumbar decompressive bilateral laminectomy with interspinous fixation (DLISF) is less invasive and can be used on some patients with PLIF, but this has not been reported. To compare the efficacy and safety of DLISF in the treatment of low-grade lumbar spondylolisthesis with that of PLIF. We retrospectively analyzed the medical records of 81 patients with grade I spondylolisthesis, who had undergone PLIF or DLISF and were followed up for more than 1 year. Surgical outcomes, visual analog scale, radiologic outcomes, including Cobb angle and difference in body translation, and postoperative complications were assessed. Forty-one patients underwent PLIF, whereas 40 underwent DLISF. The operative times were 271.0 ±â€…57.2 and 150.6 ±â€…29.3 minutes for the PLIF and DLISF groups, respectively. The estimated blood loss was significantly higher in the PLIF group versus the DLISF group (290.7 ±â€…232.6 vs 122.2 ±â€…82.7 mL, P < .001). Body translation did not differ significantly between the 2 groups. Overall pain improved during the 1-year follow-up when compared with baseline data. Medical complications were significantly lower in the DLISF group, whereas perioperative complications and hardware issues were higher in the PLIF group. The outcomes of DLISF, which is less invasive, were comparable to PLIF outcomes in patients with low-grade spondylolisthesis. As a salvage technique, DLISF may be a good option when compared with PLIF.

The radio anatomical arrangement of nerve roots at L3 level in cauda equina sac is it affected by diseases?

An observational study to discover the common conditions affecting the lumbosacral region that may affect lumbosacral position and tension. All the patients, underwent MRI exaamination (magnetic resonance imaging) in the supine position, were examined by the same consultant radiologist. The article was revised by the institutional ethical approval committee. The position of the nerve roots was observed, and the number of nerve roots was calculated anterior to a line passing between the mid-transvers process of L3(third lumbar vertebra). The number of nerve roots ahead of this line was calculated by the radiologist at the level of the right intervertebral foramen and at the left one. This procedure was applied to the normal group, and 5 common pathological diseases were repeated including single-level lumbar disc prolapse, multiple-disc prolapse, multiple bulge, spinal stenosis and spondylolisthesis (at the level of L45 (fourth to fifth lumbar vertebrae) or L5S1 (fifth lumbar to first sacral vertebrae) being outside the study area, i.e., L3). We noticed significant difference in the number of the nerve roots between the cases with herniated discs, spinal stenosis, and spondylolisthesis with the normal group and the significance was in ascending increment in significance being the highest in cases with spondylolisthesis, and even in the groups of other pathologies which are statistically not significant, we noticed that the significance is proportional to the severity of the disease being the least in single level cases (p 0.427), to be more significant on cases with multiple prolapses(p 0.319) to be more in cases with multiple bulges to start to be statistically significant in herniated, higher significance in cases with spinal stenosis to be the highest in cases with spondylolisthesis.

Lumbar Facet Arthroplasty Versus Fusion for Grade-I Degenerative Spondylolisthesis with Stenosis: A Prospective Randomized Controlled Trial.

BACKGROUND: The comparative effectiveness of decompression plus lumbar facet arthroplasty versus decompression plus instrumented lumbar spinal fusion in patients with lumbar spinal stenosis and grade-I degenerative spondylolisthesis is unknown. METHODS: In this randomized, controlled, Food and Drug Administration Investigational Device Exemption trial, we assigned patients who had single-level lumbar spinal stenosis and grade-I degenerative spondylolisthesis to undergo decompression plus lumbar facet arthroplasty (arthroplasty group) or decompression plus fusion (fusion group). The primary outcome was a predetermined composite clinical success score. Secondary outcomes included the Oswestry Disability Index (ODI), visual analog scale (VAS) back and leg pain, Zurich Claudication Questionnaire (ZCQ), Short Form (SF)-12, radiographic parameters, surgical variables, and complications. RESULTS: A total of 321 adult patients were randomized in a 2:1 fashion, with 219 patients assigned to undergo facet arthroplasty and 102 patients assigned to undergo fusion. Of these, 113 patients (51.6%) in the arthroplasty group and 47 (46.1%) in the fusion group who had either reached 24 months of postoperative follow-up or were deemed early clinical failures were included in the primary outcome analysis. The arthroplasty group had a higher proportion of patients who achieved composite clinical success than did the fusion group (73.5% versus 25.5%; p < 0.001), equating to a between-group difference of 47.9% (95% confidence interval, 33.0% to 62.8%). The arthroplasty group outperformed the fusion group in most patient-reported outcome measures (including the ODI, VAS back pain, and all ZCQ component scores) at 24 months postoperatively. There were no significant differences between groups in surgical variables or complications, except that the fusion group had a higher rate of developing symptomatic adjacent segment degeneration. CONCLUSIONS: Among patients with lumbar spinal stenosis and grade-I degenerative spondylolisthesis, lumbar facet arthroplasty was associated with a higher rate of composite clinical success than fusion was at 24 months postoperatively. LEVEL OF EVIDENCE: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Repair of type II paraesophageal hernia with Nissen fundoplication in a patient with von Willebrand disease and spondylolisthesis - a clinical case report.

Hiatal hernias continue to be fairly common in clinical practice. However, the variety of different symptoms presented by patients may hinder establishing the ultimate diagnosis. Nevertheless, currently, the diagnosis of hiatal hernia can be easily established, based on barium swallow radiography. We would like to present a clinical case report of a patient with complex medical history, including von Willebrand disease, degenerative spinal disease, and chronic sinusitis, who was finally diagnosed with hiatal hernia and treated with a standard laparoscopic Nissen fundoplication. Our case focuses on the significance of comorbidities on patients' symptoms, which sometimes may mislead the therapeutic process.

The Importance of Planning Ahead: A Three-Dimensional Analysis of the Novel Trans-Facet Corridor for Posterior Lumbar Interbody Fusion Using Segmentation Technology.

BACKGROUND: The rise of minimally invasive lumbar fusions and advanced imaging technologies has facilitated the introduction of novel surgical techniques with the trans-facet approach being one of the newest additions. We aimed to quantify any pathology-driven anatomic changes to the trans-facet corridor, which could thereby alter the ideal laterality of approach to the disc space. METHODS: In this retrospective cohort study, we measured the areas and maximum permissible cannula diameters of the trans-facet corridor using commercially available software (BrainLab, Munich, Germany). Exiting and traversing nerve roots, thecal sacs, and lumbar vertebrae were manually segmented on T2-SPACE magnetic resonance imaging. Spondylolisthesis, disc protrusions, and disc space heights were recorded. RESULTS: A total of 118 trans-facet corridors were segmented bilaterally in 16 patients (65.6 ± 12.1 years, 43.8% female, body mass index 29.2 ± 5.1 kg/m2). The mean areas at L1-L2, L2-L3, L3-L4, and L4-L5 were 89.4 ± 24.9 mm2, 124 ± 39.4 mm2, 123 ± 26.6 mm2, and 159 ± 42.7 mm2, respectively. The mean permissible cannula diameter at the same levels were 7.85 ± 1.43 mm, 8.98 ± 1.72 mm, 8.93 ± 1.26 mm, and 10.2 ± 1.94 mm, respectively. Both parameters increased caudally. Higher degrees for spondylolisthesis were associated with larger areas and maximum cannula diameters on regression analysis (P < 0.001). CONCLUSIONS: Our results illustrate that pathology, like spondylolisthesis, can increase the area of the trans-facet corridor. By understanding this effect, surgeons can better decide on the optimal approach to the disc while taking into consideration a patient's unique anatomy.

Reconsideration and Reflection on Spinal Disorders Through the Study of Intervertebral Discs in Patients with Lumbar Spondylolisthesis.

OBJECTIVE: This study analyzed and explored the relationship between isthmic spondylolisthesis and disc degeneration by comparing the degree of disc degeneration in patients with isthmic spondylolisthesis, lumbar disc herniation, and asymptomatic healthy individuals. METHODS: This study included a total of 138 cases, consisting of L5-S1 single segment lesion patients and a normal lumbar spine population. The cases were divided into 3 groups based on the type of disease: fifty eight cases in the isthmic spondylolisthesis (IS) group, 50 cases in the lumbar disc herniation (LDH) group, and 30 cases in the normal lumbar vertebrae (NLV) group. RESULTS: The research findings indicate that the proportion of intervertebral disc degeneration in the LDH group is significantly higher than that in the IS group and NLV group (65.3% vs. 33.3% vs. 25.8%, P < 0.05). The Pfirrmann grades of lumbar intervertebral discs (L1-L4) in the LDH group are significantly higher than those in the IS group and NLV group (P < 0.05), and the intervertebral height index (IHI) (L1-L4) of lumbar vertebrae in the LDH group is significantly lower than that in the IS group and NLV group (P < 0.05). CONCLUSIONS: The results showed that the degree of intervertebral disc degeneration in patients with isthmic spondylolisthesis was lighter than that in patients with LDH, and even similar to that in healthy individuals. The occurrence of IS may have slowed down the degeneration of nonaffected segment intervertebral discs through certain factors.

Transforaminal Endoscopic Lumbar Foraminotomy for the Treatment of L5-S1 Isthmic Lumbar Spondylolisthesis with Foraminal Stenosis: A 1-Year Follow-Up.

BACKGROUND: Isthmic lumbar spondylolisthesis (ILS) is a prevalent spinal pathology. Radicular pain in patients is often attributed to L5-S1 ILS combined with foraminal stenosis (FS), making such patients prime candidates for surgical intervention. We herein aimed to elucidate the surgical technique and clinical outcomes of transforaminal endoscopic lumbar foraminotomy (TELF) in the treatment of L5-S1 ILS with FS. METHODS: From September 2021 to December 2022, 20 consecutive patients were diagnosed with L5-S1 ILS with FS and underwent TELF. All patients were followed up for at least 12 months. The clinical outcomes were evaluated using the visual analog scale (VAS), Oswestry Disability Index, and modified MacNab criteria. RESULTS: The mean age of the patients was 62.4 ± 10.9 years. The mean preoperative VAS score for low back, VAS score of the leg, and Oswestry Disability Index score was 5.1 ± 1.7, 7.4 ± 0.7, and 58.0 ± 8.4, respectively. These scores significantly improved to 1.8 ± 0.7, 1.5 ± 0.6, and 15.3 ± 7.1 at 12 months postoperatively, respectively (P < 0.01). Evaluation based on the modified MacNab criteria revealed that 95.0% of patients achieved a good-to-excellent outcome. One patient underwent revision surgery. CONCLUSIONS: TELF emerges as a potentially safe and effective surgical option for alleviating radicular pain in patients with L5-S1 stable ILS combined with FS. While our short-term clinical results are satisfactory, it is necessary to expand the sample size and extend the follow-up time to validate the effectiveness and long-term efficacy of TELF.

[Prospective comparative study of unilateral biportal endoscopic transforaminal lumbar interbody fusion and endoscopic transforaminal lumbar interbody fusion for treatment of single-segment degenerative lumbar spinal stenosis with lumbar spondylolisthesis].

Objective: To compare the effectiveness of unilateral biportal endoscopic transforaminal lumbar interbody fusion (UBE-TLIF) and endoscopic transforaminal lumbar interbody fusion (Endo-TLIF) in the treatment of single-segment degenerative lumbar spinal stenosis with lumbar spondylolisthesis. Methods: Between November 2019 and May 2023, a total of 81 patients with single-segment degenerative lumbar spinal stenosis with lumbar spondylolisthesis who met the selection criteria were enrolled. They were randomly divided into UBE-TLIF group (39 cases) and Endo-TLIF group (42 cases). There was no significant difference in baseline data between the two groups ( P>0.05), including gender, age, body mass index, surgical segment, and preoperative visual analogue scale (VAS) scores for low back and leg pain, Oswestry Disability Index (ODI), and serum markers including creatine kinase (CK) and C reactive protein (CRP). Total blood loss (TBL), intraoperative blood loss, hidden blood loss (HBL), postoperative drainage volume, and operation time were recorded and compared between the two groups. Serum markers (CK, CRP) levels were compared between the two groups at 1 day before operation and 1, 3, and 5 days after operation. Furthermore, the VAS scores for low back and leg pain, and ODI at 1 day before operation and 1 day, 3 months, 6 months, and 12 months after operation, and intervertebral fusion rate at 12 months after operation were compared between the two groups. Results: All surgeries were completed successfully without occurrence of incision infection, vascular or nerve injury, epidural hematoma, dural tear, or postoperative paraplegia. The operation time in UBE-TLIF group was significantly shorter than that in Endo-TLIF group, but the intraoperative blood loss, TBL, and HBL in UBE-TLIF group were significantly more than those in Endo-TLIF group ( P<0.05). There was no significant difference in postoperative drainage volume between the two groups ( P>0.05). The levels of CK at 1 day and 3 days after operation and CRP at 1, 3, and 5 days after operation in UBE-TLIF group were slightly higher than those in the Endo-TLIF group ( P<0.05), while there was no significant difference in the levels of CK and CPR between the two groups at other time points ( P>0.05). All patients were followed up 12 months. VAS score of low back and leg pain and ODI at each time point after operation significantly improved when compared with those before operation in the two groups ( P<0.05); there was no significant difference in VAS score of low back and leg pain and ODI between the two groups at each time point after operation ( P>0.05). There was no significant difference in the intervertebral fusion rate between the two groups at 12 months after operation ( P>0.05). Conclusion: UBE-TLIF and Endo-TLIF are both effective methods for treating degenerative lumbar spinal stenosis with lumbar spondylolisthesis. However, compared to Endo-TLIF, UBE-TLIF requires further improvement in minimally invasive techniques to reduce tissue trauma and blood loss.

Comparison of minimally invasive transforaminal lumbar interbody fusion and midline lumbar interbody fusion in patients with spondylolisthesis.

BACKGROUND: This study aimed to compare surgical outcomes, clinical outcomes, and complications between minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) and midline lumbar interbody fusion (MIDLIF) in patients with spondylolisthesis. METHODS: This study retrospectively compared the patients who underwent MIS TLIF (n = 37) or MIDLIF (n = 50) for spinal spondylolisthesis. Data of surgical outcomes (postoperative one-year fusion rate and time to bony fusion), clinical outcomes (visual analog scale [VAS] for pain and Oswestry Disability Index [ODI] for spine function), and complications were collected and analyzed. RESULTS: There was more 2-level fusion in MIDLIF (46% vs. 24.3%, p = 0.038). The MIS TLIF and MIDLIF groups had similar one-year fusion rate and time to fusion. The MIDLIF group had significantly lower VAS at postoperative 3-months (2.2 vs. 3.1, p = 0.002) and postoperative 1-year (1.1 vs. 2.1, p = < 0.001). ODI was not significantly different. The operation time was shorter in MIDLIF (166.1 min vs. 196.2 min, p = 0.014). The facet joint violation is higher in MIS TLIF (21.6% vs. 2%, p = 0.009). The other complications were not significantly different including rate of implant removal, revision, and adjacent segment disease. CONCLUSION: In this study, postoperative VAS, operation time, and the rate of facet joint violation were significantly higher in the MIS TLIF group. Comparable outcomes were observed between MIDLIF and MIS TLIF in terms of fusion rate, time to fusion, and postoperative ODI score.

What are the differences in paraspinal muscle morphometry among degenerative spondylolisthesis patients, isthmic spondylolisthesis patients, and healthy individuals? A propensity score matching analysis.

PURPOSE: To compare the morphometry of paraspinal muscles in patients with degenerative spondylolisthesis (DS), isthmic spondylolisthesis (IS), and healthy individuals. METHODS: Thirty-seven pairs of DS patients were selected using propensity score matching with IS patients, while 37 healthy individuals matched for age, sex, and BMI were selected as controls. The relative cross-sectional area (rCSA), and relative functional cross-sectional area (rfCSA) of paraspinal muscles were measured, and the degree of fatty infiltration (FI) was calculated. Based on occupational differences, the patients were also divided into worker and farmer groups, and the same measurements were taken on them. RESULTS: At the L3/L4 level, the multifidus (MF) FI was greater in the DS and IS groups than in the control group, the erector spinae (ES) rfCSA was higher in the IS group than in the DS and control groups. At the L4/L5 level, MF rfCSA was smaller in the DS and IS groups than in the control group; ES rfCSA was higher in the IS group than in the DS and control groups. At the L5/S1 level, MF rfCSA was smaller in the DS and IS groups than in the control group; ES rfCSA was higher in the IS group than in the DS group. At the L3/L4, L4/L5 level, MF rfCSA were higher in the worker group than in the farmer group (p < 0.05). CONCLUSION: The morphological changes in paraspinal muscles in patients with DS were dominated by selective atrophy of the MF, while in patients with IS, the morphological changes in paraspinal muscle showed selective atrophy of the MF accompanied by compensatory hypertrophy of the ES. The surgeon should consider the morphological differences in paraspinal muscle between different types of lumbar spondylolisthesis when establishing the appropriate surgical program.

Healthcare burden changes by restricted physical activities in lumbar spinal stenosis and spondylolisthesis: a retrospective large cohort study during the COVID-19 pandemic.

BACKGROUND: Lumbar spinal stenosis (LSS) and spondylolisthesis (SPL) are characterized as degenerative spinal pathologies and share considerable similarities. However, opinions vary on whether to recommend exercise or restrict it for these diseases. Few studies have objectively compared the effects of daily physical activity on LSS and SPL because it is impossible to restrict activities ethnically and practically. We investigated the effect of restricting physical activity due to social distancing (SoD) on LSS and SPL, focusing on the aspect of healthcare burden changes during the pandemic period. METHODS: We included first-visit patients diagnosed exclusively with LSS and SPL in 2017 and followed them up for two years before and after the implementation of the SoD policy. As controls, patients who first visited in 2015 and were followed for four years without SoD were analyzed. The common data model was employed to analyze each patient's diagnostic codes and treatments. Hospital visits and medical costs were analyzed by regression discontinuity in time to control for temporal effects on dependent variables. RESULTS: Among 33,484 patients, 2,615 with LSS and 446 with SPL were included. A significant decrease in hospital visits was observed in the LSS (difference, -3.94 times/month·100 patients; p = 0.023) and SPL (difference, -3.44 times/month·100 patients; p = 0.026) groups after SoD. This decrease was not observed in the data from the control group. Concerning medical costs, the LSS group showed a statistically significant reduction in median copayment (difference, -$45/month·patient; p < 0.001) after SoD, whereas a significant change was not observed in the SPL group (difference, -$19/month·patient; p = 0.160). CONCLUSION: Restricted physical activity during the SoD period decreased the healthcare burden for patients with LSS or, conversely, it did not significantly affect patients with SPL. Under circumstances of physical inactivity, patients with LSS may underrate their symptoms, while maintaining an appropriate activity level may be beneficial for patients with SPL.

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].

Instrumented L5-S1 interbody graft with IFUSE implant using the reverse Bohlman technique.

BACKGROUND: In case of high sacral slope, anterior lumbosacral fusions can be performed by retroperitoneal or transperitoneal approach using a reversed Bohlman technique with an autologous corticocancellous fibular graft. The use of a trans-lumbosacral implant can avoid the iatrogenic effects but currently, there is no implant specifically designed for this fusion technique. Could the IFUSE implant from SI BONE replace a fibular graft to avoiding the iatrogenic effect induced by sampling during a Reverse Bohlman technique? PATIENTS AND METHODS: We present the case of a 38-year-old woman with L5S1 interbody pseudarthrosis after posterior fixation for grade 2 L5-S1 spondylolisthesis with isthmic lysis of L5, and that of a 69-year-old woman who underwent a posterior T4 fusion to the pelvis for degenerative scoliosis. Both required a trans-lumbosacral instrumented fusion via an anterior approach using the reverse Bohlman technique. Surgical technique was described. RESULTS: There were no perioperative or postoperative complications. At 6 months, the patients reported a decrease in lumbar and radicular symptomatology. There were no infectious, neurological or vascular complications. CT-scans confirmed the good position and stability of the IFUSE implant. DISCUSSION: We present an innovative interbody grafting technique adapted to spines with high pelvic incidence. The surgical technique is safe, minimally invasive, and reduces surgical iatrogeny. The short and medium-term results are positive but require longer-term follow-up and a larger cohort.

The relationship between paraspinal muscle atrophy and degenerative lumbar spondylolisthesis at the L4/5 level.

BACKGROUND/CONTEXT: Degenerative lumbar spondylolisthesis (DLS) is a prevalent spinal condition that can result in significant disability. DLS is thought to result from a combination of disc and facet joint degeneration, as well as various biological, biomechanical, and behavioral factors. One hypothesis is the progressive degeneration of segmental stabilizers, notably the paraspinal muscles, contributes to a vicious cycle of increasing slippage. PURPOSE: To examine the correlation between paraspinal muscle status on MRI and severity of slippage in patients with symptomatic DLS. STUDY DESIGN/SETTING: Retrospective cross-sectional study at an academic tertiary care center. PATIENT SAMPLE: Patients who underwent surgery for DLS at the L4/5 level between 2016-2018 were included. Those with multilevel DLS or insufficient imaging were excluded. OUTCOME MEASURES: The percentage of relative slippage (RS) at the L4/5 level evaluated on standing lateral radiographs. Muscle morphology measurements including functional cross-sectional area (fCSA), body height normalized functional cross-sectional area (HI) of Psoas, erector spinae (ES) and multifidus muscle (MF) and fatty infiltration (FI) of ES and MF were measured on axial MR. Disc degeneration and facet joint arthritis were classified according to Pfirrmann and Weishaupt, respectively. METHODS: Descriptive and comparative statistics, univariable and multivariable linear regression models were utilized to examine the associations between RS and muscle parameters, adjusting for confounders sex, age, BMI, segmental degeneration, and back pain severity and symptom duration. RESULTS: The study analyzed 138 out of 183 patients screened for eligibility. The median age of all patients was 69.5 years (IQR 62 to 73), average BMI was 29.1 (SD±5.1) and average preoperative ODI was 46.4 (SD±16.3). Patients with Meyerding-Grade 2 (M2, N=25) exhibited higher Pfirrmann scores, lower MFfCSA and MFHI, and lower BMI, but significantly more fatty infiltration in the MF and ES muscles compared to those with Meyerding Grade 1 (M1). Univariable linear regression showed that each cm2 decrease in MFfCSA was associated with a 0.9%-point increase in RS (95% CI -1.4 to - 0.4, p<.001), and each cm2/m2 decrease in MFHI was associated with an increase in slippage by 2.2%-points (95% CI -3.7 to -0.7, p=.004). Each 1%-point rise in ESFI and MFFI corresponded to 0.17%- (95% CI 0.05-0.3, p=.01) and 0.20%-point (95% CI 0.1-0.3 p<.001) increases in relative slippage, respectively. Notably, after adjusting for confounders, each cm2 increase in PsoasfCSA and cm2/m2 in PsoasHI was associated with an increase in relative slippage by 0.3% (95% CI 0.1-0.6, p=.004) and 1.1%-points (95% CI 0.4-1.7, p=.001). While MFfCSA tended to be negatively associated with slippage, this did not reach statistical significance (p=.105). However, each 1%-point increase in MFFI and ESFI corresponded to increases of 0.15% points (95% CI 0.05-0.24, p=.002) and 0.14% points (95% CI 0.01-0.27, p=.03) in relative slippage, respectively. CONCLUSION: This study found a significant association between paraspinal muscle status and severity of slippage in DLS. Whereas higher degeneration of the ES and MF correlate with a higher degree of slippage, the opposite was found for the psoas. These findings suggest that progressive muscular imbalance between posterior and anterior paraspinal muscles could contribute to the progression of slippage in DLS.

Association between vertebral endplate defects and patient-reported symptoms: an immunohistochemical study investigating the COX-2/PGE-2/EP-4 axis.

BACKGROUND CONTEXT: Vertebral endplate defects are often implicated in degenerative disc disorders, yet their connection to patient-reported symptoms remains unclear. COX-2 and PGE-2 are known for their roles in inflammation and pain, with EP-4 receptor involvement in pain signaling. Examining their expression in vertebral endplate tissues may provide insights into pathomechanism of low back pain. PURPOSE: To investigate the association between endplate defects and patient-reported symptoms and to further clarify the role of the COX-2/PGE-2/EP-4 axis in the pathogenesis of chronic low back pain. STUDY DESIGN/SETTING: Retrospective study. PATIENT SAMPLE: A total of 71 patients who had undergone single-level L4/5 or L5/S1 modified laminectomy decompression preserving proximal upper laminae and transforaminal lumbar interbody fusion surgery were included in this study, including 18 patients diagnosed with lumbar disc herniation, 19 with lumbar disc herniation accompanied by degenerative lumbar spinal stenosis, and 34 with degenerative spondylolisthesis. OUTCOME MEASURES: Demographic data, Pfirrmann grade, Modic changes, endplate defect score, visual analog scale (VAS) for back and leg pain, and Oswestry Disability Index (ODI) before surgery, 3-month and 6-month follow-up, and the percentage of immune-positive cells (COX-2, PGE-2, and EP-4) in endplate tissue sections. METHODS: Patients were divided into defect and nondefect groups according to endplate morphology on lumbar MR. All intraoperative endplate specimens were immediately fixed in 10% formaldehyde, and then embedded in paraffin 3 days later for tissue sections. The outcome measures were compared between the defect group and nondefect group. Data were analyzed using independent t-tests and χ² tests. Pearson's rank correlation test was used to assess correlations between patient-reported symptoms and the percentage of immune-positive cells in the groups. Multivariable logistic regression models using the forward stepwise likelihood ratio method were used to identify the factors that were independently associated with endplate defects. RESULTS: The age of Defect group was significantly higher than that of nondefect group (52.5±7.7 vs 57.2±9.1. p=.024). There were no significant differences in gender, diagnosis, BMI, comorbidities, or surgical level between the two groups. Modic changes (Type Ⅱ/Type Ⅲ) were more common in patients of Defect group than nondefect group (38.5% vs 11.1%, p<.001), and so was disc degeneration (Pfirrmann grade Ⅳ/Ⅴ) (69.2% vs 33.3%, p<.001). Defect group had significantly higher VAS-Back (6.5±2.0 vs 4.9±1.6, p<.001) and ODI scores (62.9±10.7 vs 45.2±14.8, p<.001) than nondefect group, while there was no significant differences between the two groups during the 3 and 6-month follow-up after surgery. Histologically, Defect group was characterized by upregulation of COX-2, PGE-2, and EP-4 in endplate tissue sections. Both in defect and nondefect groups, VAS-Back showed moderate positive correlations with the expressions of COX-2 (r=0.643; r=0.558, p both<.001), PGE-2 (r=0.611; r=0.640, p both<.001), and EP-4 (r=0.643; r=0.563, p both<.001). Multivariate regression analyses reveled that percentage of COX-2-positive cells was associated with endplate defects (OR=1.509, 95%CI [1.048-2.171], p=.027), as well as percentage of PGE-2-positive (OR=1.291, 95%CI [1.106-1.508], p=.001) and EP-4-positive cells (OR=1.284, 95%CI [1.048∼2.171], p=.003). CONCLUSIONS: Patients with endplate defects had worse quality of life, more severe disc degeneration and Modic changes, and up-regulated COX-2/PGE-2/EP-4 axis expression in cartilage endplates in patients with defected endplates. Inflammatory factors may significantly contribute to the onset and progression of chronic low back pain in patients with endplate defects, consequently impacting patient-reported symptoms.

Postoperative Adjacent Segment Disease in Minimally Invasive Transforaminal Lumbar Interbody Fusion with Adjacent Laminectomy for Grade I-II Spondylolisthesis and Adjacent Spinal Stenosis.

BACKGROUND AND OBJECTIVES: Studies have demonstrated increased risk of adjacent segment disease (ASD) after open fusion with adjacent-level laminectomy, with rates ranging from 16%-47%, potentially related to disruption of the posterior ligamentous complex. Minimally invasive surgical (MIS) approaches may offer a more durable result. We report institutional outcomes of simultaneous MIS transforaminal lumbar interbody fusion (MISTLIF) and adjacent-level laminectomy for patients with low grade spondylolisthesis and ASD. METHODS: Retrospective analysis was performed on patients who underwent MISTLIF with adjacent level laminectomy to treat grade I-II spondylolisthesis with adjacent stenosis at a single institution from 2007-2022. RESULTS: A total of 34 patients met criteria, with mean follow-up of 23.1 months. In total, 37 levels were fused and 45 laminectomies performed. In this group, 21 patients received a single level laminectomy and single-level MISTLIF, 10 patients received a 2-level laminectomy and single-level MISTLIF, 2 patients received a single-level laminectomy and 2-level MISTLIF, and 1 patient received a 2-level laminectomy and 2-level MISTLIF. Three (8.8%) patients experienced clinically significant postoperative ASD requiring reoperation. Three other patients required reoperation for other reasons. Multiple logistic regression did not reveal any association between development of ASD and surgical covariates. CONCLUSION: MISTLIF with adjacent-level laminectomy demonstrated a favorable safety profile with rates of postoperative ASD lower than published rates after open fusion and on par with the published rates of ASD from MISTLIF alone. Future prospective studies may better elucidate the durability of adjacent-level laminectomies when performed alongside MISTLIF, but retrospective data suggests it is safe and durable.

Effects of Cage Implantation Depth on Sagittal Parameters and Functional Outcomes in Posterior Lumbar Interbody Fusion for the Treatment of L4-L5 Lumbar Degenerative Spondylolisthesis.

OBJECTIVE: In the treatment of lumbar degenerative spondylolisthesis (LDS) with Posterior lumbar interbody fusion (PLIF) surgery, interbody fusion implants play a key role in supporting the vertebral body and facilitating fusion. The objective of this study was to assess the impact of implantation depth on sagittal parameters and functional outcomes in patients undergoing PLIF surgery. METHODS: This study reviewed 128 patients with L4-L5 LDS between January 2016 and August 2019. All patients underwent an open PLIF surgery that included intravertebral decompression, implantation of pedicle screws and cage. We grouped according to the position of the center of the cage relative to the L5 vertebral endplate. Patients with the center of the cage located at the anterior 1/2 of the upper end plate of the L5 vertebral body were divided into Anterior group, and located at the posterior 1/2 of the upper end plate of the L5 vertebral body were divided into Posterior group. The lumbar lordosis (LL), segmental lordosis (SL), sacral slope (SS), pelvic incidence (PI), pelvic tilt (PT) and slope degree (SD) was measured for radiographic outcomes. We used the visual analog scale (VAS) and the oswestry disability index (ODI) score to assess functional outcomes. Paired t-test was used to compare imaging and bedside data before and after surgery between the two groups, and independent sample t-test, χ2 test and Fisher exact test were used to compare the data between the two groups. RESULT: The mean follow-up of Anterior group was 44.13 ± 9.23 months, and Posterior group was 45.62 ± 10.29 months (P > 0.05). The LL, SL, PT, SS, SD and PI-LL after operation showed great improvements, relative to the corresponding preoperative values in both groups (P < 0.05). Compared to Posterior group, Anterior group exhibited far enhanced SL (15.49 ± 3.28 vs. 13.67 ± 2.53, P < 0.05), LL (53.47 ± 3.21 vs. 52.08 ± 3.15, P < 0.05) outcomes and showed depressed PI-LL (8.87 ± 5.05 vs. 10.73 ± 5.39, P < 0.05) outcomes at the final follow-up. Meanwhile, the SL in Anterior group (16.18 ± 3.99) 1 months after operation were also higher than in Posterior group (14.12 ± 3.57) (P < 0.05). We found that VAS and ODI at the final follow-up in Anterior group (3.62 ± 0.96, 25.19 ± 5.25) were significantly lower than those in Posterior group (4.12 ± 0.98, 27.68 ± 5.13) (P < 0.05). CONCLUSIONS: For patients with LDS, the anteriorly placed cage may provide better improvement of SL after PLIF surgery. Meanwhile, the anteriorly placed cage may achieve better sagittal parameters of LL and PI-LL and functional outcomes at the final follow-up.