Impact of lumbar fusion on sitting spinopelvic balance: Multisegmental versus monosegmental.

OBJECTIVES: To compare the differences in sagittal spinopelvic parameters between patients receiving monosegmental or multisegmental lumbar fusion and to assess the impact of fusion length on sitting balance. METHODS: The current study recruited 41 patients who had undergone lumbar fusion, consisting of 18 in the monosegmental group and 23 in the multisegmental group. And the control group included 50 lumbar degenerative patients who had no previous spinal fusion surgery. Spinopelvic parameters of patients were assessed: sagittal vertical axis, pelvic tilt, sacral slope, pelvic incidence, thoracic kyphosis, lumbar lordosis, and proximal femur angles. RESULTS: We observed significant differences in sitting TK (P = 0.031), LL (P = 0.012), PT (P = 0.009) and SVA (P = 0.009) among the three groups. When transitioning from standing to sitting, the multisegmental group had the least change in SVA (P = 0.016), PT (P = 0.043), and LL (P = 0.009), with a compensatory increase in TK (P = 0.021). Moderate to strong correlations were found between the change in the LL and those in the SVA (r = -0.548, P = 0.001), PT (r = -0.600, P = 0.001), and SS (r = 0.623, P = 0.001). CONCLUSION: Multisegmental lumbar fusion significantly limits the lumbar mobility and affects the ability to compensate postural changes. Reducing the fusion segments as much as possible is of particular value in preserving lumbar mobility and maintaining the compensatory mechanism of spinopelvis.

Comparison of clinical outcomes and spino-pelvic sagittal balance in degenerative lumbar spondylolisthesis: Minimally invasive oblique lumbar interbody fusion (OLIF) versus transforaminal lumbar interbody fusion (TLIF).

ABSTRACT: Spino-pelvic sagittal parameters are closely related to the lumbar degenerative diseases. The present study aims to compare clinical results and spino-pelvic sagittal balance treated with oblique lumbar interbody fusion (OLIF) and transforaminal lumbar interbody fusion (TLIF) in patients with degenerative lumbar spondylolisthesis at single segment.We retrospectively reviewed and compared 28 patients who underwent OLIF (OLIF group) and 35 who underwent TLIF (TLIF group). Radiological results were evaluated with disc height (DH), foraminal height (FH), fused segment lordosis (FSL), lumbar lordosis (LL), pelvic tilt (PT), pelvic incidence (PI), and sacral slope (SS). Clinical results were evaluated with the Oswestry Disability Index (ODI) and VAS for back and leg pain.The OLIF group showed higher improvement of DH and FH than the TLIF group at all time points after surgery (P < .05). No significant differences were found in PT, PI, and SS between the 2 groups (P > .05). Significant restoration of spino-pelvic sagittal balance was observed in the 2 groups after surgery. Significant differences in postoperative lumbar lordosis and fused segment lordosis were found between the 2 groups (P < .05). Significant difference in the improvement of symptoms was observed between the 2 groups. The OLIF group had lower VAS scores for back pain and ODI compared after surgery (P < .05).It can be concluded that there are exactly differences in improvement of radiographic parameters between 2 approaches, which confirmed that OLIF is better in restoring spinal alignment. Besides, due to the unique minimally invasive approach, OLIF did exhibit a greater advantage in early recovery after surgery.

Real-time dynamic 3-T MRI assessment of spine kinematics: a feasibility study utilizing three different fast pulse sequences.

BACKGROUND: Half-Fourier acquisition single-shot turbo spin-echo (HASTE), continuous radial gradient-echo (GRE), and True FISP allow real-time dynamic assessment of the spine. PURPOSE: To evaluate the feasibility of adding dynamic sequences to routine spine magnetic resonance imaging (MRI) for assessment of spondylolisthesis. MATERIAL AND METHODS: Retrospective review was performed of patients referred for dynamic MRI of the cervical or lumbar spine between January 2017 and 2018 who had flexion-extension radiographs within two months of MRI. Exclusion criteria were: incomplete imaging; spinal hardware; and inability to tolerate dynamic examination. Blinded, independent review by two board-certified musculoskeletal radiologists was performed to assess for spondylolisthesis (>3 mm translation); consensus review of dynamic radiographs served as the gold standard. Cervical spinal cord effacement was assessed. Inter-reader agreement and radiographic concordance was calculated for each sequence. RESULTS: Twenty-one patients were included (8 men, 13 women; mean age 47.9 ± 16.5 years). Five had MRI of the cervical spine and 16 had MRI of the lumbar spine. Mean acquisition time was 18.4 ± 1.7 min with dynamic sequences in the range of 58-77 s. HASTE and True FISP had the highest inter-reader reproducibility (κ = 0.88). Reproducibility was better for the lumbar spine (κ = 0.94) than the cervical spine (κ = 0.28). Sensitivity of sequences for spondylolisthesis was in the range of 68.8%-78.6%. All three sequences had high accuracy levels: ≥90.5% averaged across the cervical and lumbar spine. Cervical cord effacement was observed during dynamic MRI in two cases (100% agreement). CONCLUSION: Real-time dynamic MRI sequences added to spine MRI protocols provide reliable and accurate assessment of cervical and lumbar spine spondylolisthesis during flexion and extension.

Long-Term Outcomes Following Lumbar Microendoscopic Decompression for Lumbar Spinal Stenosis with and without Degenerative Spondylolisthesis: Minimum 10-Year Follow-Up.

OBJECTIVE: To determine whether preoperative presence of degenerative lumbar spondylolisthesis (DS) worsens the minimum 10-year outcome of patients undergoing microendoscopic decompression (MED) for lumbar spinal stenosis (SS). METHODS: Eighty patients undergoing MED were classified into 2 groups: DS group (34 SS with DS patients) and SS group (46 SS without DS patients). The degrees of improvement (DOIs) by the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) and intensities of improvement (IOIs) by Visual Analog Scale (VAS) at 120-159 (mean, 138.4) months after MED of the DS and SS groups were statistically compared. Patients with DS were classified into 2 groups based on the effectiveness by VAS or JOABPEQ: effective group (E group: IOI or DOI ≥20) and ineffective group (I group). All preoperative radiologic measurements were statistically compared between the E and I groups. RESULTS: Significant decreases in low back pain, leg pain, and numbness, as measured by VAS, were noted at follow-up in the DS and SS groups. The effectiveness rates of pain-related disorders, lumbar spine dysfunction, and gait disturbance by JOABPEQ were almost equally high in the DS and SS groups. Statistical comparisons of the DOIs in all 5 functional scores and IOIs in low back pain, leg pain, and numbness showed no significant differences between the DS and SS groups. No significant differences were confirmed between the E and I groups concerning preoperative spondylolisthesis and instability. CONCLUSIONS: Our study indicated that preoperative DS did not worsen the outcome of patients with SS undergoing MED.

Assessment of disability levels in patients with low back pain based on the type of lumbar spinal disorder.

BACKGROUND: Low back pain (LBP) is a common health condition and the leading cause of activity limitation and absenteeism in most parts of the world. One-fifth of patients with LBP develop chronic pain disability. OBJECTIVE: This study investigated the disability levels in patients with different types of lumbar spinal disorders. METHODS: A total of 528 patients visiting spine clinics between June 2017 and February 2018 were enrolled in this study. A demographic checklist, the patients' medical records, the Oswestry Disability Questionnaire, and the Visual Analog Scale (VAS) were used to collect the data. RESULTS: Non-specific LBP (29.5%) and discopathy (27%) were the most common final diagnoses. The obtained Oswestry Disability Index (ODI) was significantly higher in older patients, those with higher body mass index, more work experience, and smokers. Lower ODI was found in individuals with a history of regular exercise. Most individuals in all diagnostic groups were categorized into the high ODI group (p⩽ 0.001). CONCLUSION: In patients with lumbar spine lesions, ODI is significantly correlated with age, BMI, work experience, smoking, and the type of disorder (discopathy, spondylolysis, and spondylolisthesis). Regular exercise is associated with lower levels of disability.

Utility of Natural Sitting Lateral Radiograph in the Diagnosis of Segmental Instability for Patients with Degenerative Lumbar Spondylolisthesis.

BACKGROUND: Segmental instability in patients with degenerative lumbar spondylolisthesis is an indication for surgical intervention. The most common method to evaluate segmental mobility is lumbar standing flexion-extension radiographs. Meanwhile, other simple radiographs, such as standing upright radiograph, a supine sagittal magnetic resonance imaging (MRI) or supine lateral radiograph, or a slump or natural sitting lateral radiograph, have been reported to diagnose segmental instability. However, those common posture radiographs have not been well characterized in one group of patients. Therefore, we measured slip percentage in a group of patients with degenerative lumbar spondylolisthesis using radiographs of patients in standing upright, natural sitting, standing flexion, and standing extension positions as well as supine MRI. QUESTIONS/PURPOSES: We asked: (1) Does the natural sitting radiograph have a larger slip percentage than the standing upright or standing flexion radiograph? (2) Does the supine sagittal MRI reveal a lower slip percentage than the standing extension radiograph? (3) Does the combination of the natural sitting radiograph and the supine sagittal MRI have a higher translational range of motion (ROM) and positive detection rate of translational instability than traditional flexion-extension mobility using translational instability criteria of greater than or equal to 8%? METHODS: We retrospectively performed a study of 62 patients (18 men and 44 women) with symptomatic degenerative lumbar spondylolisthesis at L4 who planned to undergo a surgical intervention at our institution between September 2018 and June 2019. Each patient underwent radiography in the standing upright, standing flexion, standing extension, and natural sitting positions, as well as MRI in the supine position. The slip percentage was measured three times by single observer on these five radiographs using Meyerding's technique (intraclass correlation coefficient 0.88 [95% CI 0.86 to 0.90]). Translational ROM was calculated by absolute values of difference between two radiograph positions. Based on the results of comparison of slip percentage and translational ROM, we developed the diagnostic algorithm to evaluate segmental instability. Also, the positive rate of translational instability using our diagnostic algorithms was compared with traditional flexion-extension radiographs. RESULTS: The natural sitting radiograph revealed a larger mean slip percentage than the standing upright radiograph (21% ± 7.4% versus 17.7% ± 8.2%; p < 0.001) and the standing flexion radiograph (21% ±7.4% versus 18% ± 8.4%; p = 0.002). The supine sagittal MRI revealed a lower slip percentage than the standing extension radiograph (95% CI 0.49% to 2.8%; p = 0.006). The combination of natural sitting radiograph and the supine sagittal MRI had higher translational ROM than the standing flexion and extension radiographs (10% ± 4.8% versus 5.4% ± 3.7%; p < 0.001). More patients were diagnosed with translational instability using the combination of natural sitting radiograph and supine sagittal MRI than the standing flexion and extension radiographs (61% [38 of 62] versus 19% [12 of 62]; odds ratio 3.9; p < 0.001). CONCLUSION: Our results indicate that a sitting radiograph reveals high slip percentage, and supine sagittal MRI demonstrated a reduction in anterolisthesis. The combination of natural sitting and supine sagittal MRI was suitable to the traditional flexion-extension modality for assessing translational instability in patients with degenerative lumbar spondylolisthesis. LEVEL OF EVIDENCE: Level III, diagnostic study.

Outcome of Osteophytes After Only-Fixation as Treatment for Multilevel Cervical Spondylosis-A Minimum of 12 Months Follow-Up.

OBJECTIVE: This report analyzes the significance of osteophytes in the overall pathologic scheme in patients with single-level or multilevel cervical spinal degeneration. METHODS: From January 2010 to December 2018, 249 patients with cervical spondylosis were surgically treated. The alterations in ventral compression caused by disc bulges, osteophytes, and ligament buckling (disc-osteophye-ligament [DOL] complex) at single or multiple levels were evaluated after surgical treatment that involved only spinal fixation and did not involve any kind of bone or soft tissue decompression. Delayed (≥1 year after surgery) postoperative imaging was available in 165 patients and these patients formed the study group. Forty-five patients underwent facet distraction arthrodesis (group A), 106 patients underwent only-fixation involving transarticular screw insertion (group B), and 14 patients underwent hybrid fixation that involved both intra-articular spacers and transarticular fixation techniques (group C) as the surgical treatment. RESULTS: The size of the DOL complex at the segments that underwent fixation was reduced in 136 patients. The size of the DOL complex or its related dural or neural compression did not increase in any of the cases evaluated. Reduction in the size of DOL was more pronounced in patients in group A in both immediate postoperative and delayed images and in patients in group C at spinal levels at which facet distraction was performed using facet distraction spacers. CONCLUSIONS: Spinal stabilization reduces the size of osteophytes. Facet distraction spacers are more effective in reduction of the size of DOL in both immediate and delayed postoperative periods.

Preoperative and Postoperative, Three-dimensional Gait Analysis in Surgically Treated Patients With High-grade Spondylolisthesis.

BACKGROUND: High-grade spondylolisthesis (HGS) (Myerding grade III-V) in adolescents can lead to a marked alteration of gait pattern and maybe the presenting symptom in these patients. This characteristic gait pattern in patients with HGS has been referred to as the "pelvic waddle." Modern 3-dimensional (3D) gait analysis serves an important tool to objectively analyze the different components of this characteristic gait preoperatively and postoperatively and is an objective measure of postoperative improvement.This study demonstrates the use of 3D gait analysis preoperatively and postoperatively in a cohort of 4 consecutive patients with HGS treated surgically at a single tertiary referral center and utilize this to objectively evaluate outcome of surgical treatment in these patients. This has not been reported previously in a cohort of patients. METHODS: This is a prospective analysis of patients with HGS who underwent surgical intervention for spondylolisthesis at a single institution. Patient demographics, clinical, and radiologic assessment were recorded, and all patients underwent 3D gait analysis before and after surgical intervention. Kinetic, kinematic, and spatial parameters were recorded preoperatively and postoperatively for all patients. This allowed the outcome of change in gait deviation index, before and after surgical treatment, to be evaluated. RESULTS: We were able to review complete records of 4 adolescent patients who underwent surgical treatment for HGS. Mean age at surgery was 13.5 years with a minimum follow-up of 2.5 years postoperatively (average 40 mo). Preoperative gait analysis revealed marked posterior pelvic tilt in 2 patients, reduced hip and knee extension in all 4 patients and external foot progression in 3 of the 4 patients. Along with an observed improvement in gait, there was an objective improvement in gait parameters postoperatively in all 4 patients. Gait deviation index score improved significantly from 78.9 to 101.3 (mean). CONCLUSIONS: Preoperative gait abnormalities exist in HGS and can be objectively analyzed with gait analysis. Surgical intervention may successfully resolve these gait abnormalities and gait analysis is a useful tool to assess the outcome of surgery and quantify an otherwise intangible benefit of surgical intervention. LEVEL OF EVIDENCE: Level IV-case series.

Trapezoidal Vertebral Body and Spine-Pelvis Sagittal Alignment in Patients with Lumber Spondylolisthesis.

BACKGROUND Trapezoidal changes of the vertebral body are more common in patients with lumbar spondylolisthesis than in others. However, we lack an understanding of factors predisposing to the development of a marked trapezoidal deformity. Also, no associations between a trapezoidal vertebrae (TV) and spine-pelvis sagittal parameters have been previously reported. MATERIAL AND METHODS A total of 73 subjects with lumbar spondylolisthesis were enrolled and we collected their clinical data. Vertebral body parameters and spine-pelvis sagittal alignment parameters were measured via lumbar spine X-ray. Using the lumbar index (LI), patients were divided into a TV group (LI >0.8, n=24) and a control group (LI >0.8, n=49). The clinical data and spine-pelvic sagittal parameters of the 2 groups were compared using the t test or chi-squared test. Pearson's correlation analysis and multiple linear regression were used to determine relationships among the parameters. RESULTS The TV and control groups differed significantly in terms of the slipped segment, extent of slippage, intervertebral disc height (IDH), and sagittal parameters (all P<0.05). Pearson's correlation analysis and multiple linear regression analysis showed that the slipped segment (r=-0.606), extent of slippage (r=-0.660), and IDH (r=0.698) were risk factors for the development of a TV body. Also, vertebral trapezoidal deformation was closely associated with sagittal parameters. CONCLUSIONS The vertebral body affected by lumbar spondylolisthesis exhibits a trapezoidal change closely associated with the slipped segment, the extent of slippage, and IDH. The TV group exhibited greater pelvic incidence values and lumbar lordosis, which may have caused wedging of the slipped vertebra.

Compensation for standing posture by whole-body sagittal alignment in relation to health-related quality of life.

AIMS: The aim of this study is to test the hypothesis that three grades of sagittal compensation for standing posture (normal, compensated, and decompensated) correlate with health-related quality of life measurements (HRQOL). METHODS: A total of 50 healthy volunteers (normal), 100 patients with single-level lumbar degenerative spondylolisthesis (LDS), and 70 patients with adult to elderly spinal deformity (deformity) were enrolled. Following collection of demographic data and HRQOL measured by the Scoliosis Research Society-22r (SRS-22r), radiological measurement by the biplanar slot-scanning full body stereoradiography (EOS) system was performed simultaneously with force-plate measurements to obtain whole body sagittal alignment parameters. These parameters included the offset between the centre of the acoustic meatus and the gravity line (CAM-GL), saggital vertical axis (SVA), T1 pelvic angle (TPA), McGregor slope, C2-7 lordosis, thoracic kyphosis (TK), lumbar lordosis (LL), pelvic incidence (PI), PI-LL, sacral slope (SS), pelvic tilt (PT), and knee flexion. Whole spine MRI examination was also performed. Cluster analysis of the SRS-22r scores in the pooled data was performed to classify the subjects into three groups according to the HRQOL, and alignment parameters were then compared among the three cluster groups. RESULTS: On the basis of cluster analysis of the SRS-22r subscores, the pooled subjects were divided into three HRQOL groups as follows: almost normal (mean 4.24 (SD 0.32)), mildly disabled (mean 3.32 (SD 0.24)), and severely disabled (mean 2.31 (SD 0.35)). Except for CAM-GL, all the alignment parameters differed significantly among the cluster groups. The threshold values of key alignment parameters for severe disability were TPA > 30°, C2-7 lordosis > 13°, PI-LL > 30°, PT > 28°, and knee flexion > 8°. Lumbar spinal stenosis was found to be associated with the symptom severity. CONCLUSION: This study provides evidence that the three grades of sagittal compensation in whole body alignment correlate with HRQOL scores. The compensation grades depend on the clinical diagnosis, whole body sagittal alignment, and lumbar spinal stenosis. The threshold values of key alignment parameters may be an indication for treatment. Cite this article: Bone Joint J 2020;102-B(10):1359-1367.

Comparison of unilateral and bilateral polymethylmethacrylate-augmented cannulated pedicle screw fixation for the management of lumbar spondylolisthesis with osteoporosis.

BACKGROUND: Cannulated pedicle screw (CPS) augmented by polymethylmethacrylate (PMMA) can achieve satisfactory clinical efficacy in the treatment of lumbar spondylolisthesis with osteoporosis. However, accurate application of CPSs will help to avoid the difficulty of screw revision and reduce the incidence of PMMA-related complications. This study aimed to investigate the mid-term efficacy of CPS compared to unilateral and bilateral applications in this common lumbar degenerative disease. METHODS: May 2011 and May 2018, 50 patients with lumbar spondylolisthesis with osteoporosis who underwent posterior fixation and fusion using traditional pedicle screws or CPSs were included in the study. Patients were divided into two groups based on the application: the unilateral PMMA-augmented CPS group (UC, n = 29) and the bilateral PMMA-augmented CPS group (BC, n = 21). Operation time, blood loss, average hospitalization time, PMMA leakage, and other complications were recorded. The visual analog scale (VAS) and Oswestry disability index (ODI) scores were used to evaluate symptom recovery. Radiographic results were compared for intervertebral fusion and screw loosening. RESULTS: There were no significant differences in the baseline data of the two groups. The VAS and ODI scores improved significantly after surgery (P < 0.05), with no significant differences between the groups (P > 0.05). The operation time and blood loss in the UC group were significantly lower than those in the BC group (P < 0.05). However, the loss of intervertebral disk height and Taillard index did not differ significantly between the groups. The rates of PMMA leakage in the UC and BC groups were 7.0% and 11.9%, respectively (P < 0.05). Bony fusion was achieved in all groups without screw loosening at the last follow-up. Only one patient experienced superficial infection in both groups, while cerebrospinal fluid leakage was observed in two patients in the BC group. CONCLUSIONS: Unilateral application of PMMA-augmented CPS may provide adequate clinical safety and effectiveness in the surgical treatment of lumbar spondylolisthesis with osteoporosis.

Lumbar degenerative disease after oblique lateral interbody fusion: sagittal spinopelvic alignment and its impact on low back pain.

BACKGROUND: We determined the incidence and risk factors of low back pain (LBP) in patients with lumbar degenerative disease after single-level oblique lateral interbody fusion (OLIF). METHODS: We retrospectively reviewed 120 lumbar degenerative disease patients who underwent single-level OLIF. We compared preoperative and postoperative radiographic parameters, including segmental lordosis (SL), lumbar lordosis (LL), disk height (DH), pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), thoracic kyphosis (TK), and C7-sagittal vertical axis (SVA). Clinical outcomes were evaluated using the Oswestry Disability Index (ODI) scores and visual analog scale (VAS) scores for back and leg pain. All patients were followed up for at least 2 years. RESULTS: Thirty-eight patients had postoperative LBP (VAS score for back pain ≥3; LBP group); the remaining 82 patients were in the non-LBP group. Age (P = 0.082), gender (P = 0.425), body mass index (P = 0.138), diagnosis (degenerative spondylolisthesis vs. lumbar spinal stenosis; P = 0.529), surgical level (P = 0.651), blood loss (P = 0.889), and operative time (P = 0.731) did not differ between the groups. In both groups, the ODI and VAS scores for back pain and leg pain significantly improved at the final follow-up compared with the preoperative scores (P = 0.003). Except for the VAS score for back pain (P = 0.000), none of the scores significantly differed between the two groups at the final follow-up (P > 0.05). In the non-LBP group, LL, SL, DH, TK, and SS significantly improved, while PT and C7-SVA significantly decreased at the final follow-up as compared with the preoperative values. In both groups, DH significantly improved postoperatively, with no significant between-group difference (P = 0.325). At the final follow-up, LL, PI-LL mismatch, PT, and C7-SVA showed significantly greater improvement in the non-LBP group than in the LBP group (P < 0.05). Multivariate analysis identified PT, PI-LL mismatch, and C7-SVA as significant risk factors for LBP after OLIF. CONCLUSION: OLIF for single-level lumbar degenerative disease had satisfactory clinical outcomes. PT, PI-LL mismatch, and C7-SVA were significant risk factors for postoperative LBP. Patients with appropriately decreased PT, improved C7-SVA, and PI-LL match experienced less LBP.

The Effect of Surgical Decompression and Fusion on Functional Balance in Patients With Degenerative Lumbar Spondylolisthesis.

STUDY DESIGN: Prospective cohort study. OBJECTIVE: To quantify the effect of lumbar decompression and fusion surgery on balance and stability in patients with degenerative lumbar spondylolisthesis (DLS) and compare them to controls. SUMMARY OF BACKGROUND DATA: DLS is a condition in which one vertebra subluxates relative to an adjacent vertebra in the absence of a disruption in the neural arch. While the existing literature demonstrates that decompression and fusion can successfully alleviate pain and reduce disability in patients with DLS, no studies to date have used quantitative dynamic testing to determine the effect of surgery on cone of economy (CoE) measures in this patient population. METHODS: Forty-five DLS patients performed a series of functional balance tests a week before and 3 months after surgery and were compared to 28 controls. The outcome measures included range of sway (RoS) and total sway for the center of mass (CoM) and head in the sagittal, coronal, and axial planes, along with leg and back Visual Analog Scale (VAS), Oswestry Disability Index (ODI), Fear/Avoidance Behavior Questionnaire (FABQ), Tampa Scale of Kinesophobia (TSK), and Demoralization scale. RESULTS: RoS for the CoM (P < 0.005) and head (P < 0.017) decreased in all planes postoperatively. Reductions in CoM (P = 0.001) and head total sway (P = 0.001) were also observed after surgery. Furthermore, patients with DLS reported strong improvements in VAS low back (P = 0.001), VAS leg (P = 0.001), ODI (P = 0.001), FABQ Physical (P = 0.003), TSK (P = 0.001), and demoralization (P = 0.044) with surgical intervention. Although total sway was reduced after surgery, it did not return to the level of normal controls as demonstrated with more total sway of their CoM (P = 0.002) and head (P = 0.001) as well as more sagittal head RoS (P = 0.048). CONCLUSION: This study confirms that surgical intervention for degenerative spondylolisthesis is effective at reducing disability, back and leg pain, demoralization, kinesiophobia, and fear-avoidance beliefs related to physical activity in patients with DLS. Furthermore, such patients exhibit a significantly more stable stance after surgery. However, balance parameters did not completely normalize by 3 months postoperatively. LEVEL OF EVIDENCE: 3.

Morphologic Changes of Intervertebral Foramen After Minimally Invasive Transforaminal Lumbar Interbody Fusion: A Radiographic and Clinical Study.

OBJECTIVE: We aimed to investigate the morphologic changes in the intervertebral foramen after minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF), and analyze the necessity of routinely performing contralateral intervertebral foraminal decompression in degenerative lumbar spondylolisthesis cases with bilateral symptoms. METHODS: 72 single-level degenerative lumbar spndylolisthesis patients with bilateral symptoms were included, all of whom underwent unilateral approach MIS-TLIF. Preoperative and postoperative foraminal height (FH), foraminal width (FW), disc height (DH), distance from existing nerve root to upper edge of lower pedicle (RTP), and contralateral side spinal canal area (CSCA) were measured at surgical and contralateral side. Clinical outcomes were evaluated using the visual analog scale, Oswestry Disability Index, and Japanese Orthopaedic Association score. RESULTS: The preoperative values are comparable between operative and contralateral sides (P > .05). The postoperative values for FH on operative and contralateral sides were 16.23±2.48 mm and 16.10±2.42 mm, for FW were 11.36±2.58 mm and 11.31±2.71 mm, for IH were 8.18±1.58 mm and 8.42±1.54 mm, for RTP were 8.58±1.26 mm and 9.14±1.77 mm, and the CSCA of the spinal canal on the contralateral side were 211.59±48.12 mm², respectively. The difference between these was also not statistically significant (P > .05). The values increased significantly on the surgical and contralateral side (P < .05). The visual analog scale for low-back and leg pain, Japanese Orthopaedic Association, and Oswestry Disability Index improved significantly at 2-year follow-up. CONCLUSIONS: Unilateral MIS-TLIF can effectively improve contralateral FH, DH, FW, RTP, and CSCA. It is not necessary to routinely perform contralateral intervertebral foramen decompression in degenerative lumbar spondylolisthesis with bilateral symptoms when symptoms are mild on one side.

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.

Outcomes and Complications With Age in Spondylolisthesis: An Evaluation of the Elderly From the Quality Outcomes Database.

STUDY DESIGN: Prospective database analysis. OBJECTIVE: To assess the effect of age on patient-reported outcomes (PROs) and complication rates after surgical treatment for spondylolisthesis SUMMARY OF BACKGROUND DATA.: Degenerative lumbar spondylolisthesis affects 3% to 20% of the population and up to 30% of the elderly. There is not yet consensus on whether age is a contraindication for surgical treatment of elderly patients. METHODS: The Quality Outcomes Database lumbar registry was used to evaluate patients from 12 US academic and private centers who underwent surgical treatment for grade 1 lumbar spondylolisthesis between July 2014 and June 2016. RESULTS: A total of 608 patients who fit the inclusion criteria were categorized by age into the following groups: less than 60 (n = 239), 60 to 70 (n = 209), 71 to 80 (n = 128), and more than 80 (n = 32) years. Older patients showed lower mean body mass index (P < 0.001) and higher rates of diabetes (P = 0.007), coronary artery disease (P = 0.0001), and osteoporosis (P = 0.005). A lower likelihood for home disposition was seen with higher age (89.1% in <60-year-old vs. 75% in >80-year-old patients; P = 0.002). There were no baseline differences in PROs (Oswestry Disability Index, EuroQol health survey [EQ-5D], Numeric Rating Scale for leg pain and back pain) among age categories. A significant improvement for all PROs was seen regardless of age (P < 0.05), and most patients met minimal clinically important differences (MCIDs) for improvement in postoperative PROs. No differences in hospital readmissions or reoperations were seen among age groups (P < 0.05). Multivariate analysis demonstrated that, after controlling other variables, a higher age did not decrease the odds of achieving MCID at 12 months for the PROs. CONCLUSION: Our results indicate that well-selected elderly patients undergoing surgical treatment of grade 1 spondylolisthesis can achieve meaningful outcomes. This modern, multicenter US study reflects the current use and limitations of spondylolisthesis treatment in the elderly, which may be informative to patients and providers. LEVEL OF EVIDENCE: 4.

A new lever reduction technique for the surgical treatment of elderly patients with lumbar degenerative Spondylolisthesis.

BACKGROUND: Proper reduction method for Lumbar degenerative spondylolisthesis (LDS) is still controversial. The aim of this study was to determine the safety and effectiveness of lever reduction combined with traditional elevating-pull reduction technique for the treatment of elderly patients with LDS. METHODS: From May 2015 to December 2017, 142 elderly patients (≥65 years) diagnosed with LDS were enrolled in this study with a mean follow-up of 25.42 ± 8.31 months. All patients were operated using lever reduction combined with traditional elevating-pull reduction technique. Patient age, sex, body mass index, bone mineral density, preoperative comorbidities, surgical duration, blood loss, and surgical complications were collected form patient charts. Clinical data as visual analog scale (VAS), Oswestry Disability Index (ODI), and 36-Item Short Form Health Survey (SF-36) were collected preoperatively, 1 month postoperatively, and at the final follow-up. Radiographic evaluation included slip percentage, slip angle (SA), lumbar lordosis (LL), and fusion status. RESULTS: The clinical parameters of VASback, VASleg, ODI, and SF-36 had significantly improved at both follow-ups after surgery. A significant improvement was indicated for slippage reduction at both follow-ups, showing no significant correction loss after surgery. SA significantly increased after surgery and was well maintained at the final follow-up. LL was not affected by the surgery. At the final follow-up, complete fusion was obtained in 121 patients (85.2%) and partial fusion in 21 (14.8%). Revision surgery was performed for one patient. Screw loosening was observed in 3 (2.11%) cases. No nerve root injury or adjacent segment disease was observed. CONCLUSIONS: This new lever reduction combined with traditional elevating-pull reduction technique for the surgical treatment of elderly patients with LDS is both safe and effective. Satisfactory correction and fusion rates were achieved with acceptable correction loss and reduction-related complications.

In vivo changes in adjacent segment kinematics after lumbar decompression and fusion.

The pathogenesis of lumbar adjacent segment disease is thought to be secondary to altered biomechanics resulting from fusion. Direct in vivo evidence for altered biomechanics following lumbar fusion is lacking. This study's aim was to describe in vivo kinematics of the superior adjacent segment relative to the fused segment before and after lumbar fusion. This study analyzed seven patients with symptomatic lumbar degenerative spondylolisthesis (5 M, 2F; age 65 ± 5.1 years) using a biplane radiographic imaging system. Each subject performed two to three trials of continuous flexion of their torso according to established protocols. Synchronized biplane radiographs were acquired at 20 images per second one month before and six months after single-level fusion at L4-L5 or L5-S1, or two-level fusion at L3-L5 or L4-S1. A previously validated volumetric model-based tracking process was used to track the position and orientation of vertebrae in the radiographic images. Intervertebral flexion/extension and AP translation (slip) at the superior adjacent segment were calculated over the entire dynamic flexion activity. Skin-mounted surface markers were tracked using conventional motion analysis and used to determine torso flexion. Change in adjacent segment kinematics after fusion was determined at corresponding angles of dynamic torso flexion. Changes in adjacent segment motion varied across patients, however, all patients maintained or increased the amount of adjacent segment slip or intervertebral flexion/extension. No patients demonstrated both decreased adjacent segment slip and decreased rotation. This study suggests that short-term changes in kinematics at the superior adjacent segment after lumbar fusion appear to be patient-specific.

Etiology and clinical manifestations of double-level versus single-level lumbar degenerative spondylolisthesis.

BACKGROUND: The differences in etiology, clinical manifestation, and whole body standing alignment between single-level LDS (sLDS) and double-level LDS (dLDS) have not been sufficiently clarified. We hypothesized that the etiology and manifestations of dLDS differ from those of sLDS. This study aimed to test this hypothesis. METHODS: A total of 112 cases with sLDS, 25 cases with dLDS, and 50 healthy volunteers as a normal control were enrolled in the study. Following the data collection on demographic and Health-related quality of life (HRQOL) by ODI and SRS-22, radiologic measurement by EOS system and MRI examination including lumbar spinal stenosis (LSS), facet angle, and segmental instability defined by facet opening were performed. All the parameters were compared among the groups. Correlations among radiologic parameters and HRQOL were analyzed. Risk factors for sLDS and dLDS were investigated respectively using multivariate logistic analysis. RESULTS: Age is the most important etiologic factor of sLDS; whereas high PI, age, and sagittally oriented facet joints are the important factors for dLDS. HRQOL significantly correlates with sagittal alignment. HRQOL does not, however, significantly differ between patients with sLDS and dLDS. Although the mean value of %slip was higher in the dLDS group than in the sLDS group, the difference was not statistically significant. %slip positively correlated with the PI. The number of spinal stenoses (LSS) per patient is significantly higher in patients with dLDS than in patients with sLDS. The HRQOL does not, however, correlate with the number of LSS. CONCLUSIONS: Age is the most important etiologic factor of sLDS; whereas high PI, age, and sagittally oriented facet joints are the important factors for dLDS. HRQOL does not significantly differ between patients with sLDS and dLDS. Number of LSS is significantly higher in dLDS than in sLDS without statistical difference in terms of HRQOL outcome.

Primary pain generator identification by CT-SPECT in patients with degenerative spinal disease.

OBJECTIVE: Axial spinal pain generators are difficult to identify using current diagnostic modalities. Merging CT with SPECT (CT-SPECT) scans allows for accurate identification of areas with increased osteoblastic activity, which may reflect pain generators. In this study, the authors aimed to evaluate the degree of pain improvement in patients who underwent surgery, addressing primary pain generators identified by CT-SPECT. METHODS: The authors retrospectively reviewed all patients with chronic axial spine pain who underwent diagnostic CT-SPECT at their institution and analyzed pain improvement in those who underwent surgical treatment in order to determine whether CT-SPECT correctly identified the primary pain generator. RESULTS: A total of 315 patients underwent diagnostic CT-SPECT between January 2014 and August 2018. Forty-eight patients underwent either cervical or lumbar fusion; there were 26 women (16 cervical, 10 lumbar) and 22 men (9 cervical, 13 lumbar). The overall axial spinal pain, as assessed through self-reporting of visual analog scale scores at 6 months postoperatively, improved from 9.04 ± 1.4 to 4.34 ± 2.3 (p = 0.026), with cervical fusion patients improving from 8.8 ± 1.8 to 3.92 ± 2.2 (p = 0.019) and lumbar fusion patients improving from 9.35 ± 0.7 to 4.87 ± 2.3 (p = 0.008). CONCLUSIONS: CT-SPECT may offer a diagnostic advantage over current imaging modalities in identifying the primary pain generator in patients with axial spinal pain.