Risk factors for early-onset adjacent segment degeneration after one-segment posterior lumbar interbody fusion.

Adjacent segment degeneration (ASD) is a major postoperative complication associated with posterior lumbar interbody fusion (PLIF). Early-onset ASD may differ pathologically from late-onset ASD. The aim of this study was to identify risk factors for early-onset ASD at the cranial segment occurring within 2 years after surgery. A retrospective study was performed for 170 patients with L4 degenerative spondylolisthesis who underwent one-segment PLIF. Of these patients, 20.6% had early-onset ASD at L3-4. In multivariate logistic regression analysis, preoperative larger % slip, vertebral bone marrow edema at the cranial segment on preoperative MRI (odds ratio 16.8), and surgical disc space distraction (cut-off 4.0 mm) were significant independent risk factors for early-onset ASD. Patients with preoperative imaging findings of bone marrow edema at the cranial segment had a 57.1% rate of early-onset ASD. A vacuum phenomenon and/or concomitant decompression at the cranial segment, the degree of surgical reduction of slippage, and lumbosacral spinal alignment were not risk factors for early-onset ASD. The need for fusion surgery requires careful consideration if vertebral bone marrow edema at the cranial segment adjacent to the fusion segment is detected on preoperative MRI, due to the negative impact of this edema on the incidence of early-onset ASD.

Analyzing lumbar vertebral shape and alignment in female patients with degenerative spondylolisthesis: Comparisons with spinal stenosis and risk factor exploration.

PURPOSE: This study aimed to examine the vertebral body shape characteristics and spondylopelvic alignment in L4 degenerative spondylolisthesis (DS) as well as the risk factors for the development of DS. METHODS: This cross-sectional study compared vertebral morphology and sagittal spinopelvic alignment in female patients with lumbar DS and lumbar spinal stenosis (LSS). The degree of lumbar lordosis (LL), pelvic incidence (PI), cross-sectional area (CSA), and vertebral body height ratio (ha/hp) of the lumbar spine were compared using full-length spine radiographs and computed tomography in 60 females with DS and in 60 women with LSS. RESULTS: No significant differences in age or body mass index were observed between the two groups; however, the DS and LSS groups significantly differed in PI (mean, 58.9±10.8 vs. 47.2±11.6, P < 0.001), L4 CSA (mean, 1,166.2 m2 vs. 1,242.0 m2, P = 0.002) and ha/hp (mean, 1.134 vs. 1.007, P < 0.001). The L4 ha/hp was significantly higher in the DS group than in the LSS group. Additionally, LL values were negatively correlated with vertebral L5 CSA in the DS group (r = -0.28, P < 0.05). The LSS and DS groups demonstrated positive correlations between LL and L2, L3, and L4 ha/hp (r = 0.331, 0.267, and 0.317; P < 0.01, < 0.05, and < 0.05, respectively) and between LL and L4 and L5 ha/hp (r = 0.333, 0.331; P < 0.01, respectively). Multivariate regression analyses revealed that PI and ha/hp ratio may be independent predictors of DS development. CONCLUSION: The DS group had significantly larger LL, PI, and L4 ha/hp and smaller L4 CSA than the LSS group. The lumbar vertebral body shape and sagittal spinopelvic alignment in females might be independent predictors of DS development.

Lumbosacral transitional vertebra in spondylolisthesis: frequency, demographic findings, and clinical characteristics.

BACKGROUND: The association of LSTV with low back pain has been debated in the literature for nearly a century, but the relationship between LSTV and spondylolisthesis is still under discussion. There is currently no valid information about LSTV's prevalence in Iran. This study investigated the relationship between the presence of LSTV and lumbosacral spondylolisthesis regarding frequency, gender and age variation, grade and level of spondylolisthesis, and clinical signs and symptoms. METHODS: This cross-sectional study included spondylolisthesis patients admitted for surgery between March 2021 to December 2022. All patients underwent CT imaging. After evaluating medical records, the baseline data were collected. Patients were categorized into No LSTV, Sacralization, and Lumbarization groups. Demographic and clinical characteristics of the studied groups were compared using an independent T-test and Chi-Square. Multiple logistic regression was used to assess the age and sex variations between groups. RESULTS: 219 patients with a mean age of 57.07 ± 11.04 were included. A significant relationship was observed between the presence of sacralization and gender diversity with female predominance (P = 0.01). The level of spondylolisthesis and the presence of motor deficits (paresis) significantly differed among study groups (P < 0.05). Sacralization group exhibited a greater prevalence of higher grades of listhesis compared to the other groups. CONCLUSIONS: LSTV is frequently seen in spondylolisthesis patients. Sacralization is the common type of LSTV in spondylolisthesis patients, possibly leading to an increased risk for higher grades of vertebral slip and higher rates of motor deficit signs and symptoms. The presence of sacralization results in a significant increase in the incidence of higher levels of spondylolisthesis, especially the L4-L5*(sacralized L5) level. There is no relationship between age and the presence of LSTV in spondylolisthesis.

Biportal endoscopic-assisted cortical bone trajectory screw placement and lumbar interbody fusion.

BACKGROUND: Endoscopically assisted screw fixation with lumbar interbody fusion is rarely performed. We succeeded in implanting the cortical bone trajectory (CBT) screws under the guidance of unilateral biportal endoscopy (UBE). METHOD: We attempted endoscopically assisted screw fixation in a patient with degenerative spondylolisthesis. Through a third portal, ipsilateral CBT screws were implanted without complications. CONCLUSIONS: We successfully performed unilateral biportal endoscopic lumbar interbody fusion (ULIF) with CBT and reversed CBT screws. Compared with percutaneous pedicle screw (PPS) placement, this procedure is a minimally invasive, endoscopic alternative that allows precise screw placement.

The clinical and radiographic degenerative spondylolisthesis classification and its predictive value.

INTRODUCTION: The clinical and radiographic degenerative spondylolisthesis (CARDS) classification is a new classification that has been introduced for degenerative spondylolisthesis (DS). It has four categories. Our study aimed to analyse the functional and radiographic outcome following DS surgery based on the preoperative CARDS classification. METHODS: A retrospective study of the prospectively collected Australian Spine Registry database was performed. Data on demographics, patient reported outcome measures including the Oswestry Disability Index (ODI) and EQ-5D-3 L scores, and changes in radiographic measurements were analysed. Based on the preoperative findings all x-rays were classified applying the CARDS classification. RESULTS: Between 2018 and 2021 a total of 54-patients were identified as having had surgery for DS at L4/5. The mean age was 65.3 ± 11.3years and females were predominantly affected (61%). Most cases were of CARDS type C (46%), followed by type B (29%). CARDS type A and D were observed in 18% and 6% respectively. Preoperatively, the L4/5 lordosis was 19.8 ± 6.3° and lumbar lordosis 43.9 ± 12.8°. Postoperatively the L4/5 lordosis alignment changed significantly to 23.5 ± 8.8° (p < 0.05). Preoperatively, the CARDS classification was 34.8 ± 17.4 (type A), 40.5 ± 11.0 (type B), 43.8 ± 12.9 and 50.0 ± 14.4 for type D (Pearson-coefficient 0.284, p = 0.041). Postoperatively this changed to 22.7 ± 16.1, 28.7 ± 21.2, 12.5 ± 13.1, and 6.5 ± 2.1 respectively. Similar improvements were observed for the EQ-5D-3 L. CONCLUSION: This study shows that the CARDS classification correlates with preoperative functional scores as well as helping to predict response to surgery. CARDS will likely assist in operative planning and prognostication. LEVEL OF EVIDENCE: III, therapeutic and prognostic study.

Percutaneous transforaminal endoscopic decompression with removal of the posterosuperior region underneath the slipping vertebral body for lumbar spinal stenosis with degenerative lumbar spondylolisthesis: a retrospective study.

BACKGROUND: Percutaneous transforaminal endoscopic decompression (PTED) is an ideal minimally invasive decompression technique for the treatment of lumbar spinal stenosis (LSS) with degenerative lumbar spondylolisthesis (DLS). The posterosuperior region underneath the slipping vertebral body (PRSVB) formed by DLS is an important factor exacerbating LSS in patients. Therefore, the necessity of removing the PRSVB during ventral decompression remains to be discussed. This study aimed to describe the procedure of PTED combined with the removal of the PRSVB and to evaluate the clinical outcomes. METHODS: LSS with DLS was diagnosed in 44 consecutive patients at our institution from January 2019 to July 2021, and they underwent PTED combined with the removal of the PRSVB. All patients were followed up for at least 12 months. The clinical outcomes were evaluated using the visual analog scale (VAS), Oswestry Disability Index (ODI), and modified MacNab criteria. RESULTS: The mean age of the patients was 69.5 ± 7.1 years. The mean preoperative ODI score, VAS score of the low back, and VAS score of the leg were 68.3 ± 10.8, 5.8 ± 1.0, and 7.7 ± 1.1, respectively, which improved to 18.8 ± 5.0, 1.4 ± 0.8, and 1.6 ± 0.7, respectively, at 12 months postoperatively. The proportion of patients presenting "good" and "excellent" ratings according to the modified MacNab criteria was 93.2%. The percent slippage in spondylolisthesis preoperatively (16.0% ± 3.3%) and at the end of follow-up (15.8% ± 3.3%) did not differ significantly (p>0.05). One patient had a dural tear, and one patient had postoperative dysesthesia. CONCLUSIONS: Increasing the removal of PRSVB during the PTED process may be a beneficial surgical procedure for alleviating clinical symptoms in patients with LSS and DLS. However, long-term follow-up is needed to study clinical effects.

Short-term and mid-term evaluation of three types of minimally invasive lumbar fusion surgery for treatment of L4/L5 degenerative spondylolisthesis.

This was a single-centre retrospective study. Minimally invasive techniques for transforaminal lumbar interbody fusion (MIS-TLIF), oblique lumbar interbody fusion (OLIF), and percutaneous endoscopic transforaminal lumbar interbody fusion (Endo-TLIF) have been extensively used for lumbar degenerative diseases. The present study analyses the short-term and mid-term clinical effects of the above three minimally invasive techniques on L4/L5 degenerative spondylolisthesis. In this retrospective study, 98 patients with L4/L5 degenerative spondylolisthesis received MIS-TLIF, 107 received OLIF, and 114 received Endo-TLIF. All patients were followed up for at least one year. We compared patient data, including age, sex, body mass index (BMI), Oswestry disability index (ODI), visual analogue scale of low back pain (VAS-B), visual analogue scale of leg pain (VAS-L), surgical time, blood loss, drainage volume, hospital stay, complications, and neurological status. Moreover, we performed imaging evaluations, including lumbar lordosis angle (LLA), disc height (DH) and intervertebral fusion status. No significant differences were noted in age, sex, BMI, preoperative ODI, preoperative VAS-B, preoperative VAS-L, preoperative LLA, or preoperative DH. Patients who underwent OLIF had significantly decreased blood loss, a lower drainage volume, and a shorter hospital stay than those who underwent MIS-TLIF or Endo-TLIF (P < 0.05). The VAS-B in the OLIF group significantly decreased compared with in the MIS-TLIF and Endo-TLIF groups at 6 and 12 months postoperatively (P < 0.05). The VAS-L in the Endo-TLIF group significantly decreased compared with that in the MIS-TLIF and OLIF groups at 6 months postoperatively (P < 0.05). The ODI in the OLIF group was significantly better than that in the MIS-TLIF and Endo-TLIF groups at 6 months postoperatively (P < 0.05). No statistically significant differences in the incidence of complications and healthcare cost were found among the three groups. Follow-up LLA and DH changes were significantly lower in the OLIF group than in the other groups (P < 0.05). The intervertebral fusion rate was significantly higher in the OLIF group than in the other groups at 6 and 12 months postoperatively (P < 0.05). In conclusion, while MIS-TLIF, OLIF, and Endo-TLIF techniques can effectively treat patients with L4/5 degenerative spondylolisthesis, OLIF has more benefits, including less operative blood loss, a shorter hospital stay, a smaller drainage volume, efficacy for back pain, effective maintenance of lumbar lordosis angle and disc height, and a higher fusion rate. OLIF should be the preferred surgical treatment for patients with L4/5 degenerative spondylolisthesis.

How Does the Slump Sitting Radiograph Increase Proportion of Segmental Instability and Kyphotic Alignment of Lumbar Degenerative Spondylolisthesis?

OBJECTIVE: Clinical and radiographic degenerative spondylolisthesis (CARDS) classification was proposed to differentiate homogenous lumbar degenerative spondylolisthesis (LDS) subgroups. The sitting radiograph exhibited lumbar malalignment with maximum lumbar kyphosis, intervertebral kyphosis, and spondylolisthesis.This study aimed to assess the sitting radiograph for distribution of clinical and radiographic degenerative spondylolisthesis classification, and to elucidate its significance for exhibiting kyphotic alignment (CARDS type D) and segmental instability. METHODS: A cohort of 101 patients with symptomatic lumbar degenerative spondylolisthesis (LDS) between September 2018 and December 2020 were recruited. The distribution and relibility of CARDS classification with or without sitting radiograph was assessed. The translational and angular range of motion and segmental instability was also evaluated. Univariate analysis of variance was used for multiple groups, and the least significant difference for two groups. Kappa consistency test of intrarater and interrater was evaluated for CARDS classification with or without sitting radiograph. Chi-square test was used to compare paried categorical data. RESULTS: Utility of sitting radiographs for CARDS classification revealed higher percentage of type D than that without the sitting radiograph (p < 0.001). The sitting radiograph revealed a larger slip distance than the flexion radiograph (p = 0.003), as well as a lower slip angle than flexion radiograph (p < 0.001). The sitting-supine modality demonstrated the largest translational range of motion compared to the sitting-extension (p < 0.001) and flexion-extension modalities (p < 0.001). The sitting-supine modality showed larger angular range of motion than the flexion-extension modality (p < 0.001). The percentage of flexion, extension, upright, supine, and sitting radiograph to identify translational instability was higher than that without sitting radiograph (p < 0.001), as well as taking angular motion ≥10° as an additional criterion for segmental instability (p < 0.001). CONCLUSION: The CARDS classification was reliable for LDS. The sitting radiograph showed maximal slip distance and kyphotic slip angle. Application of the sitting radiograph was necessary for evaluating segmental instability and kyphotic alignment of LDS.

L4/5 Disc Herniation: Not Unusually Accompanied with L5/S1 Low-Grade Spondylolytic Spondylolisthesis.

OBJECTIVE: Isthmic spondylolisthesis (IS) is distinguished by a congenital defect or acquired fracture of the pars interarticularis. Numerous studies on L5 low-grade IS have been carried out; however, there is a paucity of data regarding the condition of L5 IS concomitant with L4/5 disc herniation. This study aimed to identify the incidence rate and to illustrate the possible risk factors for L4/5 disc herniation in L5 low-grade IS patients. METHODS: A total of 268 consecutive patients diagnosed as L5/S1 low-grade IS between May 2017 and May 2022 were retrospectively enrolled in this study. Depending on the presence of L4/5 disc herniation or not, patients were divided into an L4/5 disc herniation group (L4/5 DH) and an L4/5 non-disc herniation group (L4/5 non-DH). Radiographic parameters were measured, and the ratios of L4-S1 segmental lordosis (SL) to lumbar lordosis (LDI), L4 inferior endplate (IEP) to L5 superior endplate (SEP) (L4 IEP/L5 SEP), and L5 IEP to S1 SEP (L5 IEP/S1 SEP) were compared between groups. The Pfirrmann grade of the L4/5 disc and the L5/S1 disc, and Roussouly classifications of each patient were also recorded. Univariate analysis (including independent-samples t-test and χ2 -test) and multiple logistic regression analysis were performed to analyze the data. RESULTS: There were 40 patients (14.9%) in the L4/5 DH group. The Roussouly classification differed significantly between groups. As demonstrated by the Pfirrmann grade, the L4/5 DH group showed more advanced disc degeneration at L4/5 than the L4/5 non-DH group. In contrast to the L4/5 non-DH group, the L4/5 DH group had a significantly larger L4 IEP, L4 IEP/L5 SEP, S1 SEP, and LDI while smaller L4/5 disc angle, L4/5 disc height, slip percentage, lumbar lordosis, and sacral slope. Multivariate logistic regression analysis revealed that higher L4/5 disc Pfirrmann grade (p = 0.004), decreased L4/5 disc height (p < 0.001), and lower L5 slip percentage (p = 0.022) were significantly associated with the occurrence of L4/5 DH. CONCLUSIONS: L4/5 disc herniation is not unusually accompanied by L5/S1 low-grade IS. Advanced L4/5 disc degeneration, decreased L4/5 disc height, and lower L5 slip percentage might be significantly associated with L4/5 disc herniation.

Sagittal Alignment in the Degenerative Lumbar Spine: Surgical Planning.

➤ Sagittal alignment of the spine has gained attention in the field of spinal deformity surgery for decades. However, emerging data support the importance of restoring segmental lumbar lordosis and lumbar spinal shape according to the pelvic morphology when surgically addressing degenerative lumbar pathologies such as degenerative disc disease and spondylolisthesis.➤ The distribution of caudal lordosis (L4-S1) and cranial lordosis (L1-L4) as a percentage of global lordosis varies by pelvic incidence (PI), with cephalad lordosis increasing its contribution to total lordosis as PI increases.➤ Spinal fusion may lead to iatrogenic deformity if performed without attention to lordosis magnitude and location in the lumbar spine.➤ A solid foundation of knowledge with regard to optimal spinal sagittal alignment is beneficial when performing lumbar spinal surgery, and thoughtful planning and execution of lumbar fusions with a focus on alignment may improve patient outcomes.

Fusion with and without lever reduction in degenerative lumbar spondylolisthesis: a retrospective study.

BACKGROUND: The reduction of slipped vertebra is often performed during surgery for degenerative lumbar spondylolisthesis (DLS). This approach, while potentially improving clinical and radiological outcomes, also carries a risk of increased complications due to the reduction process. To address this, we introduced an innovative lever reduction technique for DLS treatment. This study aims to investigate the clinical efficacy, radiological outcomes, and complications of fusion with or without lever reduction. METHODS: We conducted a retrospective review of prospectively collected data from a registry of patients who underwent lumbar fusion surgery for DLS, with a follow-up of at least 24 months. Self-reported measures included visual analog scale (VAS) for back or leg pain, Oswestry Disability Index (ODI), and the achievement of minimal clinically important difference (MCID). Radiological assessments encompassed spondylolisthesis percentage (SP), focal lordosis (FL), and lumbar lordosis (LL). Complications were categorized using the modified Clavien-Dindo classification (MCDC) scheme. Patients were assigned to the reduction group (RG) and non-reduction group (NRG) based on the application of the lever reduction technique. Clinical and radiological outcomes at baseline, immediately after surgery, and at the last follow-up were compared. RESULTS: A total of 281 patients were analyzed (123 NRG, 158 RG). Baseline patient demographics, comorbidities, and surgical characteristics were similarly distributed between groups except for operating time (NRG 129.25 min, RG 138.04 min, P = .009). Both groups exhibited significant clinical improvement after surgery (all, P = .000), with no substantial difference between groups (VAS, ODI, or the ability to reach MCID). Patients in RG showed statistically lower SP and higher FL during follow-up (all, P = .000). LL was comparable at different time points within each group or at the same time point between the two groups (all, P > .050). The overall complication rate (NRG 38.2%, RG 27.2%, P = .050) or specific complication rates per MCDC were similar between groups (all, P > .050). Patients in RG were predisposed to a lower risk of adjacent segment degeneration (ASDeg) (NRG 9.8%, RG 6.3%, P = .035). CONCLUSIONS: There were no significant differences in postoperative measures such as VAS scores for back and leg pain, ODI, the ability to reach MCID, overall complication rate, or specific complication rates per MCDC between surgical approaches. However, fusion with lever reduction demonstrated a notable advantage in restoring segmental spinal sagittal alignment and reducing the occurrence of ASDeg compared to in situ fusion.

Surgical versus nonsurgical management of lumbar degenerative spondylolisthesis based on spinal canal cross-sectional area.

Disability and pain associated with lumbar degenerative spondylolisthesis (LDS) result in a significant burden on both the healthcare costs and patients' quality of life. Currently, there exists controversy regarding employment of either nonsurgical management (NSM) or surgical management (SM) in a clinical setting. Spinal canal cross-sectional area (SCA) has been an important morphological parameter for the analysis of LDS. However, there is lack of research about the comparative value of NSM and SM according to SCA. Moreover, previous research have not yet evaluated the clinical most suitable cutoff values of SCA. The objective of this research was to evaluate the effective of NSM and SM for LDS using SCA as an objective morphological parameter. The axial T2 magnetic resonance imaging images were obtained from each patient. We collected SCA samples from 149 patients with LDS. 72 patients underwent SM and the rest did NSM. We measured SCA at the L4/5 LDS on magnetic resonance imaging using a picture archiving and communications system. We measured SCA at the intervertebral disk posterior border, turning down to reach the facet joint side on the opposite edge at the L4/5 level. The average SCA value was 114.34 ±â€…48.11 mm2 in the NSM group and 69.88 ±â€…27.87 mm2 in the SM group. Therefore, the SM group had considerably lower SCA (P < .001). In view of the effectiveness of SCA as a prediction factor of surgical option, Receiver Operating Characteristic curve analysis show the optimal cutoff value for SCA as 83.21 mm2, with 70.8% sensitivity, 71.4% specificity, and an area under the curve of 0.80 (95% CI, 0.73-0.87). The narrower the SCA, the higher the probability of SM. Thus, it is proposed that to evaluate surgical decision making, the pain physician should carefully inspect the SCA.

Is unilateral-approach full-endoscopic lumbar fusion effective for single-level lumbar spondylolisthesis with bilateral symptoms? A preliminary report of 43 CT analysis.

PURPOSE: To investigate the clinical results and radiological parameters changes after unilateral-approach endoscopic lumbar interbody fusion (Endo-LIF) for lumbar spondylolisthesis with bilateral symptoms. METHODS: 43 single-level lumbar spondylolisthesis patients with bilateral lower limb symptoms were included from June 2020 to May 2022. All patients underwent unilateral-approach Endo-LIF and postoperative computed tomography. Radiological parameters including disk height (DH), degree of upper vertebral slip (DUVS), and foramen intervertebral parameters including bilateral foraminal height (FH), contralateral foraminal areas (FA) were evaluated. The clinical outcomes including low back pain and bilateral leg pain were evaluated using Visual Analog Scale (VAS) and the Oswestry Disability Index (ODI) before and after surgery. RESULTS: All cases were successfully completed surgery and followed for average 15.16 ± 5.2 months. DH (44% ± 11%) and DUVS were significantly improvement postoperatively compared with preoperatively (p < 0.05). Statistically significant increases in bilateral FH (25% ± 11% on the surgical side, 17% ± 8% on the contralateral side) and contralateral FA (26% ± 6%) were observed (p < 0.05). The VAS and the ODI scores were significantly decreased in comparison with the preoperative scores (p < 0.05). CONCLUSION: Unilateral-approach with contralateral indirect decompression in Endo-LIF can acquire satisfactory clinical outcomes. Therefore, unilateral-approach Endo-LIF may be a promising option for lumbar spondylolisthesis with bilateral symptoms.

The Relationship Between Endplate Defect Scores and Lumbar Sagittal Translation Stability in Lumbar Spondylolisthesis Patients.

BACKGROUND: Lumbar instability and endplate defects are commonly seen in patients with spondylolisthesis. However, little is known about associations between segmental stability and endplate defects. The present study explored associations between stability-related radiographic parameters and endplate defect scores and assessed whether endplate defect scores can predict lumbar stability in lumbar spondylolisthesis. METHODS: Neutral, flexion, and extension radiographs of 159 patients with monosegmental lumbar spondylolisthesis were analyzed. Radiographic parameters included average intervertebral disc height (IDH), slip distance, sagittal translation (ST) and sagittal angulation (SA). Correlation analysis and linear regression analysis were used to explore associations between endplate defect scores and radiographic parameters. Logistic regression analysis was used to assess associations between endplate defect scores and ST stability. Receiver-operating characteristic curve (ROC) analysis was used to evaluate the value of the endplate defect score in predicting ST stability. RESULTS: A total of 11.9% of patients had ST ≥ 4 mm, and 30% of patients had SA ≥ 10°. Endplate defect scores were negatively correlated with ST and IDH and positively correlated with slip distance in isthmic spondylolisthesis but not in degenerative spondylolisthesis. In multiple regression analysis, endplate defect scores were significantly associated with ST, slip distance, IDH, and disc degeneration. ST instability was associated with endplate defect scores in isthmic spondylolisthesis (OR=0.460, P = 0.010). The AUCs for using the endplate defect score to evaluate ST stability in overall patients and isthmic spondylolisthesis patients were 0.672 and 0.774, respectively. The optimal threshold of the endplate defect score constructed by the Youden index was 7.5 for predicting ST stability. CONCLUSIONS: Endplate defect scores increase with a reduction in IDH, progression of slippage and a decrease in ST in isthmic spondylolisthesis but not in degenerative spondylolisthesis. ST instability was associated with endplate defect scores in isthmic spondylolisthesis, and endplate defect scores could be used to reflect lumbar stability at the slippage segment.

Forearm bone mineral density predicts screw loosening after lumbar fusion similar to lumbar Hounsfield unit value in patients with lumbar spondylolisthesis.

Preoperative bone density assessment is necessary to predict screw loosening. The forearm BMD is a useful predictor of BMD-related complications after lumbar operation. Our results show that the forearm BMD is as effective a predictor of screw loosening as the lumbar average HU value. Measurement of the forearm BMD may be a useful adjunct in predicting screw loosening following lumbar fusion. PURPOSE: To determine the relationship between forearm bone mineral density (BMD) and the risk of pedicle screw loosening in patients with lumbar spondylolisthesis. METHODS: We retrospectively evaluated 270 patients who underwent posterior lumbar interbody fusion for lumbar spondylolisthesis. The patients were divided into two groups on the basis of the with or without loose screws: the loosening group and the non-loosening group. The patient's gender, age, BMI, smoking and diabetes histories, and the operative segment were recorded as the basic information. The Hounsfield unit (HU) value for the BMD of the L1-4 lumbar was measured using computed tomography. The patient's distal one-third of the length of the radius and ulna of the non-dominant forearm was chosen as the site for dual-energy X-ray (DXA) bone density testing. RESULTS: The rate of screw loosening was 13% at a minimum 12 months follow-up. Average forearm BMD (0.461 ± 0.1 vs 0.577 ± 0.1, p < 0.001) and mean HU value (L1-4) (121.1 ± 27.3 vs 155.6 ± 32.2, p < 0.001) were lower in the screw loosening group than those in the non-loosening group. In multivariate logistic regression analysis, the forearm BMD (OR 0.840; 95%CI 0.797-0.886) and HU value (L1-4) (OR 0.952; 95%CI 0.935-0.969) were independent risk factor for screw loosening. The area under the curve (AUC) for the forearm BMD and HU value for prediction of pedicle screw loosening was 0.802 and 0.811. The forearm BMD cut-off for predicting pedicle screw loosening was 0.543 (sensitivity, 0.800; specificity, 0.864). CONCLUSIONS: The forearm BMD was an independent risk factor for loosening of the lumbar pedicle screws. The forearm BMD was a valid predictor of pedicle screw loosening in patients undergoing lumbar fusion, as was the CT HU value.

Severe Intervertebral Vacuum Phenomenon is Associated With Higher Preoperative Low Back Pain, ODI, and Indication for Fusion in Patients With Degenerative Lumbar Spondylolisthesis.

STUDY DESIGN: Retrospective study of prospective collected data. OBJECTIVE: To analyze the association between intervertebral vacuum phenomenon (IVP) and clinical parameters in patients with degenerative spondylolisthesis. SUMMARY OF BACKGROUND DATA: IVP is a sign of advanced disc degeneration. The correlation between IVP severity and low back pain in patients with degenerative spondylolisthesis has not been previously analyzed. METHODS: We retrospectively analyzed patients with degenerative spondylolisthesis who underwent surgery. Vacuum phenomenon was measured on computed tomography scan and classified into mild, moderate, and severe. A lumbar vacuum severity (LVS) scale was developed based on vacuum severity. The associations between IVP at L4/5 and the LVS scale, preoperative and postoperative low back pain, as well as the Oswestry Disability Index was assessed. The association of IVP at L4/5 and the LVS scale and surgical decision-making, defined as decompression alone or decompression and fusion, was assessed through univariable logistic regression analysis. RESULTS: A total of 167 patients (52.7% female) were included in the study. The median age was 69 years (interquartile range 62-72). Overall, 100 (59.9%) patients underwent decompression and fusion and 67 (40.1%) underwent decompression alone. The univariable regression demonstrated a significantly increased odds ratio (OR) for back pain in patients with more severe IVP at L4/5 [OR=1.69 (95% CI 1.12-2.60), P =0.01]. The univariable regressions demonstrated a significantly increased OR for increased disability with more severe L4/L5 IVP [OR=1.90 (95% CI 1.04-3.76), P =0.04] and with an increased LVS scale [OR=1.17 (95% CI 1.02-1.35), P =0.02]. IVP severity of the L4/L5 were associated with higher indication for fusion surgery. CONCLUSION: Our study showed that in patients with degenerative spondylolisthesis undergoing surgery, the severity of vacuum phenomenon at L4/L5 was associated with greater preoperative back pain and worse Oswestry Disability Index. Patients with severe IVP were more likely to undergo fusion.

The effect of lumbosacral transitional vertebra on lumbar spine degeneration and spondylolisthesis among patients with low back pain.

AIM: To examine the impact of lumbosacral transitional vertebra (LSTV) on lumbar spine degeneration, disc protrusion, and spondylolisthesis among patients with low back pain. METHODS: The records of the patients who had undergone anterioposterior lumbar radiographs and lumbar magnetic resonance imaging (MRI) for low back pain between November 2014 and September 2021 were extracted retrospectively and assessed for eligibility. Of the remaining patients, those with LSTV were assigned as "case group." Age- and sex-matched patients without LSTV were assigned as "control group." On digitalized lumbar MRIs, Modic degeneration (type I-III) and Pfirrman's disc degeneration (grade I-V) immediately cephalad to the transitional level were evaluated; intervertebral disc height (mm), disc protrusion (mm), and percentage of vertebral slippage (%) were measured. RESULTS: Of the 501 patients with low back pain, 128 ineligible patients were excluded; 113 patients with LSTV and 117 age- and sex-matched controls were included in the study. LSTV group revealed decreased intervertebral disc height, increased vertebral endplate degeneration, and slippage, as well as increased disc degeneration and protrusion when compared with controls (p < 0.001). Patients with type III LSTV had greater disc protrusion and higher percentage of slippage compared to those with type I LSTV (p = 0.008 and p = 0.009, respectively). Vertebral endplate degeneration, disc height, and disc degeneration did not differ across categories of LSTV type. CONCLUSION: Lumbosacral transitional vertebra malformation is related to decreased intervertebral disc height, increased disc degeneration, vertebral endplate degeneration, disc protrusion, and slippage above the level of transition. Patients with type III LSTV revealed the highest percentage of slippage and disc protrusion.

[Surgical treatment of high-grade spondylolisthesis]. / Die operative Therapie hochgradiger Spondylolisthesen.

OBJECTIVE: Establishment of a physiological profile of the spine via reduction of the kyphotic slipped vertebra in the transverse and sagittal planes. Achieving solid fusion. Improvement of preoperative pain symptoms and prevention or elimination of neurological deficits. INDICATIONS: High-grade spondylolisthesis (Meyerding grade 3 and 4) as well as spondyloptosis after conservative treatment and corresponding symptoms. Serious neurological deficits, hip-lumbar extensor stiffness, are emergency indications. CONTRAINDICATIONS (CI): Individual risk assessment must be made. Absolute CI are infections with the exception of serious neurological deficits. Multiple abdominal operations or interventions on the large vessels can be a relative contraindication for ventral intervention. SURGICAL TECHNIQUE: For spondylolistheses of grade 3 according to Meyerding, we recommend a one-stage dorso-ventro-dorsal procedure with radicular decompression, correction and fusion in the index segment. From grade 4 according to Meyerding, reduction of the fifth lumbar vertebral body in the index segment L5/S1 is preceded by resection of the sacral dome. In cases of spondyloptosis, a two-stage procedure is often indicated. In this case, a screw-rod system spanning the index segment is implanted in the first step, which is used to distract the index segment for several days. Ventrodorsal reduction is performed in the second step. POSTOPERATIVE MANAGEMENT: Axis-appropriate full mobilization from postoperative day 1. We recommend a light diet until the first defecation. Dorsal suture removal after 12 days if the wound is dry and free of irritation. Lifting and carrying heavy loads and also competitive or contact sports should be avoided for 12 weeks. RESULTS: From January 2000 to December 2020, a total of 43 patients with high-grade spondylolisthesis were treated in our clinic in the manner described. The Numeric Rating Scale (NRS) and the Oswestry Disability Index (ODI) improved significantly during the observation period of 3 months and 1 year. The 1­year radiological data in 28 of the 36 patients showed complete reduction of the slipped vertebra, in 6 grade 1, and in 2 patients grade 2 according to Meyerding. Also, the kyphosis of the index vertebra was significantly corrected from a mean of 15° (0-52°) preoperatively to a lordotic profile of a mean of 4° (0-11°). No complications requiring revision were observed. One patient with preoperative cauda equina syndrome was left with right radicular sensorimotor S1 syndrome.

Lumbar degenerative spondylolisthesis: role of sagittal alignment.

PURPOSE: To evaluate the sagittal alignment of the lumbar spine in patients with degenerative spondylolisthesis at the L4-5 level. METHODS: Patients with untreated degenerative spondylolisthesis at L4-5 were retrospectively identified from the clinical practice of spine surgeons at an academic medical center. All patients had standing X-rays that were reviewed by the senior surgeon to confirm the presence of degenerative spondylolisthesis at L4-5. Radiographs were analyzed for the following: lumbar lordosis (LL), lower lumbar lordosis (L4-S1; LLL), L5-S1 lordosis, pelvic incidence (PI), and pelvic tilt (PT). From these measurements, lumbar distribution index (LLL/LL × 100; LDI), ideal lumbar lordosis (PI × 0.62 + 29; ILL), PI-LL mismatch, and relative lumbar lordosis (LL-ILL; RLL) were calculated. These parameters were used to evaluate the sagittal alignment of the lumbar spine. Normal alignment was defined based on previous studies and clinical experience. RESULTS: 117 participants met inclusion criteria, with an average age of 67.2 years. The majority of the cohort demonstrated hypolordotic sagittal alignment of the L5-S1 segment when assessed in relation to ILL, PI, and LL (73.5%, 61.5%, and 50.4% respectively). Evaluation of the lower lumbar spine (L4-S1) demonstrated normal sagittal alignment when evaluated via LDI and LLL (65%, 52.1%, respectively), suggesting the presence of compensatory hyperextension at L4-5 in response to the L5-S1 hypolordosis. Consequently, normal sagittal alignment of the regional lumbar spine was maintained when evaluated using LL, PI-LL mismatch, and RLL (51.3%, 47%, and 62.4% respectively). CONCLUSIONS: This study demonstrates that there is a high incidence of relative hypolordosis at the L5-S1 level among patients who present with degenerative spondylolisthesis at L4-5. The L5-S1 hypolordosis is associated with L4-5 hyperlordosis, such that the lower lumbar lordosis (L4-S1; LLL) and regional lumbar lordosis (LL) are still within normal range. It is probable that L5-S1 hypolordosis was the initial pathologic event that incited compensatory L4-5 hyperlordosis, which in turn may have led to facet degeneration and laxity, and eventually to development of spondylolisthesis.

[Clinical and radiographic factors associated with the severity of paraspinal fatty infiltration in patients with degenerative low back disease]. / Factores clínicos y radiográficos asociados a la severidad de infiltración grasa paraespinal en pacientes con enfermedad lumbar degenerativa.

INTRODUCTION: Degenerative lumbar disease (DLE) is a spectrum of pathological changes from disc degeneration, herniated disc, spondylolisthesis and lumbar canal stenosis. The pain associated with it is multifactorial. Muscle cramps are among the most frequent causes. The relationship between muscle degeneration and DLE has already been studied in the past in multiple studies, highlighting the one carried out by Kjaer & cols. OBJECTIVE: to determine the prevalence and severity of fatty degeneration in mutifidus spinae, and to study its relationship with clinical and radiographic factors. MATERIAL AND METHODS: observational and analytical study. Patients diagnosed with: herniated disc, lumbar canal stenosis or degenerative scoliosis were included. They were classified according to the Kjaer scale for paraspinal fatty infiltration in one of three groups. Clinical variables were analyzed: age, smoking, obesity, the presence of axial pain, temporality of pain, severity expressed with a visual analog scale (VAS); and radiographic: number of diseased segments, involved segments, diagnostic imaging and the presence of spondylolisthesis. RESULTS: 56 patients with an average age of 52.5 years (16 to 80) with a predominance of females with 62.5% were included. The diagnoses were nonspecific low back pain (1.8%), herniated disc (42.9%), narrow lumbar duct (46.4%) and lumbar duct with degenerative scoliosis deformity (8.9%). The distribution among the three groups described by Kjaer was as follows: 44.6% were classified with a fat infiltration score of 2. In groups 1 and 0, 39.3% and 16.1% were classified respectively. The variables significantly related to greater fat infiltration were: age > 60 years, diagnoses of lumbar canal stenosis and herniated disc; obesity, spondylolisthesis < 2 vertebral segments involved. Axial pain and VAS > 8 points were not related to greater muscle degeneration. CONCLUSIONS: fatty infiltration is present in all patients with some of the forms of DLE. Most patients > 60 years of age with advanced degenerative processes have a greater severity of infiltration. Other related variables are: obesity, spondylolisthesis and disease of < 2 vertebral segments. There is no relationship between a higher percentage of fatty infiltration and axial pain or higher VAS scores.

INTRODUCCIÓN: la enfermedad lumbar degenerativa (ELD) es un espectro de cambios patológicos desde la degeneración discal, la hernia discal, la espondilolistesis y el conducto lumbar estrecho. El dolor que se le asocia es multifactorial. Los espasmos musculares son de las causas más frecuentes. La relación que guarda la degeneración muscular y la ELD ya ha sido estudiada en múltiples trabajos, destacando el realizado por Kjaer y colaboradores. OBJETIVO: determinar la prevalencia y severidad de la degeneración grasa en el mutifidus spinae, y estudiar su relación con variables clínicas y radiográficas. MATERIAL Y MÉTODOS: estudio observacional y analítico. Se incluyeron pacientes diagnosticados con: hernia discal, conducto lumbar estrecho o escoliosis degenerativa. Se clasificaron de acuerdo con escala de Kjaer para infiltración grasa paraespinal en alguno de tres grupos. Se analizaron variables clínicas: edad, tabaquismo, obesidad, presencia de dolor tipo axial, temporalidad del dolor, severidad del dolor expresada con escala visual análoga (EVA); y radiográficas: número de segmento enfermos, segmentos involucrados, diagnóstico por imagen y presencia de espondilolistesis. RESULTADOS: se incluyeron 56 pacientes con edad promedio de 52.5 años (rango 16 a 80) con predominio del sexo femenino (62.5%). Los diagnósticos fueron lumbalgia inespecífica (1.8%), hernia discal (42.9%), conducto lumbar estrecho (46.4%) y conducto lumbar con deformidad en escoliosis degenerativa (8.9%). La distribución entre los tres grupos descritos por Kjaer fue la siguiente: 44.6% fueron clasificados con un puntaje de infiltración grasa de 2. En los grupos 1 y 0, se clasificaron 39.3 y 16.1%, respectivamente. Las variables relacionadas con mayor infiltración grasa fueron: edad > 60 años, diagnósticos de conducto lumbar estrecho y hernia discal; obesidad, espondilolistesis < 2 segmentos vertebrales involucrados. El dolor mecánico y EVA > 8 puntos no se relacionaron con mayor degeneración muscular. CONCLUSIONES: la infiltración grasa está presente en todos los pacientes con alguna de las formas de ELD. La mayoría de los pacientes > 60 años con procesos degenerativos avanzados tienen mayor severidad de infiltración. Otras variables relacionadas son: obesidad, espondilolistesis y enfermedad < 2 segmentos vertebrales. No hay relación entre mayor porcentaje de infiltración grasa y dolor axial o puntajes más altos de dolor.