Objective To evaluate the mid-term cl inical outcome of instrumented sl ip reduction combined with 360° circumferencial fusion and restoration laminae for symptomatic adult isthmic spondylol isthesis. Methods Between October 2004 and March 2008, 44 patients with symptomatic isthmic spondylol isthesis underwent instrumented sl ip reduction combined with 360° circumferencial fusion and restoration laminae. There were 15 males and 29 females with an average age of38.4 years (range, 28-45 years). The disease duration was 14 months to 7 years (38 months on average). The affected vertebrae was L4-5 in 18 patients and L5, S1 in 26 patients. According to Meyerding’s grade for spondylol isthesis, 28 cases were rated as grade II and 16 as grade III. The visual analogae scale (VAS), Oswestry disabil ity index (ODI), and the short form 36 health survey (SF-36) scores were evaluated before operation and at last follow-up; the radiographical outcome was evaluated by measuring sl i pping percentage, heights of intervertebral space and foramen, and fusion rate. Results All patients were followed up 20-60 months (42 months on average). The VAS, ODI, and SF-36 scores were all significantly improved at last follow-up when compared with those before operation (P lt; 0.05). According to Morelos criteria, the cl inical results were excellent in 32 patients, good in 9, and fair in 3; the excellent and good rate was 93.2%. The preoperative average percentage of sl ip was 47.5%, which was improved to 2.6% 3 days after operation; the total average reduction rate was 97.4%, and it was maintained at last followup. The heights of intervertebral space and foramen were all improved significantly after operation (P lt; 0.05), and there was no significant difference between at 3 days after operation and at last follow-up (P gt; 0.05). X-ray and CT showed bony fusion 1 year after operation in all patients with a fusion rate of 100%. Compl ications included pain at donor site of il iac bone in 4 cases, superficial infection in 2 cases, dural tear in 1 case, and degeneration of adjacent vertebrae in 2 cases; no nerve root injury, pseudoarthrosis, failure of internal fixation, and acquired spinal canal stenosis occurred. Conclusion Instrumented sl ip reduction combined with 360° circumferencial fusion and restoration laminae is a rel iable procedure for adult isthmic spondylol isthesis with satisfactory mid-term results, a high fusion rate and low compl ication rate. The long-term outcomesshould be verified by follow-up in the future.
Objective To analyze the clinical features and preliminary outcome of posterior operation for traumatic lumbar spondylolisthesis. Methods The clinical data of 11 patients with traumatic lumbar spondylolisthesis who underwent surgeries between January 2008 and June 2012 were retrospectively analyzed. There were 6 male and 5 female patients, aged from 13 to 60 years with a median age of 38 years. The mechanism of injury included heavy pressure injury in 4 cases, falling injury from height in 4 cases, and traffic accident injury in 3 cases. The time of injury to operation was between 3 days and 13 years (median, 20 days). According to Frankel neurological function grading, 2 patients were rated as grade E, 4 as grade D, 3 as grade C, and 2 as grade B before operation; according to Meyerding spondylolisthesis grading, 4 cases were classified as degree I, 4 as degree II, 2 as degree III, and 1 as degree IV preoperatively. The affected segments included L4 in 3 and L5 in 8 patients. The surgical fixation segments were L4, 5 in 2 patients, L5, S1 in 7, and L4-S1 in 2. Eight patients underwent circumferential fusion, while 3 patients underwent posterolateral fusion. The reduction of spondylolisthesis and bone graft fusion were assessed on X-ray films and three-dimensional CT scans during follow-up. The clinical outcomes were evaluated by visual analogue scale (VAS) and Oswestry disability index (ODI) scores. Results All patients achieved primary healing of incision after operation. And all patients were followed up 6-40 months with a median time of 12 months. There was no pulling-out or breaking of internal fixation. The fusion rate was 100% on three-dimensional CT scans, and the fusion time was 3-6 months (mean, 4.5 months). The spondylolisthesis was degree 0 in 10 cases and degree I in 1 case according to Meyerding grading, showing significant difference when compared with preoperative spondylolisthesis grading (Z= — 2.979, P=0.003). The Frankel neurological function grading were E in 6, D in 3, and C in 2 at last follow-up, which were significantly improved when compared with preoperative one (Z= — 2.271, P=0.014). At 1 week after operation and last follow-up, VAS and ODI scores were significantly improved when compared with the preoperative scores (P lt; 0.05); however, no significant difference was found between at 1 week and at last follow-up (P gt; 0.05). Conclusion If lumbar X-ray films suggest multiple fractures of transverses in emergency combined with the mechanism of injury, it bly indicates the diagnosis of traumatic lumbar spondylolisthesis, moreover earlier decompression and fusion can provide the recovering of the neurological function and satisfactory preliminary effectiveness in these patients.
Objective To assess the effectiveness of surgical interventions for lumbar isthmic spondylolisthesis in adults.Methods RCTs of surgical treatment for adult lumbar isthmic spondylolisthesis were identified from specialized trials registered in Cochrane Back Group, The Cochrane Library (Issue 2, 2004)，additional electronic search (including MEDLINE (1966 to 2004)，EMBASE (1980 to 2004) and CBM), handsearching for Chinese journals. Two reviewers assessed the quality of the trials and extracted data independently. Meta analysis was conducted using RevMan 4.2. Results Four published trials including a total of 277 patients were included. Three trials compared different operative procedures and one trial considered conservative versus surgical treatment for lumbar isthmic spondylolisthesis in adults. Two trials had limitations of trial design which at times gave considerable potential for bias. As very few studies and patients were included, and different score criteria were used to assess the clinical outcomes in the review, we decided to provide a descriptive summary only. All trials drew a conclusion that lumbar posterolateral fusion for adult isthmic spondylolisthesis could relieve pain and improve clinical outcome. There was no significant difference in fusion rate and improvement of clinical outcomes between different operative procedures. One trial showed that the lumbar posterolateral fusion could improve function and relieve pain more efficiently than an exercise program. Three trials indicated there was no difference in fusion rate and improvement of clinical outcomes between different operative methods. One trial suggested that instrumented posterolateral fusion did not improve fusion rate but increased complication rates, operation time and bleeding loss. Two trials considered the role of decompressive laminectomy and reached a conflicting conclusion. Conclusions There is no adequate evidence about the most effective technique of treatment for adult lumbar isthmic spondylolisthesis. There is limited evidence that the lumbar posterolateral fusion for adult isthmic spondylolisthesis can efficiently relieve pain and improve clinical outcome. There is no evidence that the use of pedicle screw fixation can improve the fusion rate or the clinical outcome. At present, there is no enough evidence available from randomised trials to support the routine clinical use of instrumented fusion for lumbar isthmic spondylolisthesis in adults. As very few studies and patients were included in the review, it was cautious to draw any conclusions from the review. More trials with high quality on methodology are needed.
ObjectiveTo compare the effectiveness of modified transforaminal lumbar interbody fusion (modified-TLIF) and posterior lumbar interbody fusion (PLIF) for mild to moderate lumbar spondylolisthesis in middle-aged and elderly patients.MethodsThe clinical data of 106 patients with mild to moderate lumbar spondylolisthesis (Meyerding classification≤Ⅱ degree) who met the selection criteria between January 2015 and January 2017 were retrospectively analysed. All patients were divided into modified-TLIF group (54 cases) and PLIF group (52 cases) according to the different surgical methods. There was no significant difference in preoperative clinical data of gender, age, disease duration, sliding vertebra, Meyerding grade, and slippage type between the two groups (P>0.05). The intraoperative blood loss, operation time, postoperative drainage volume, postoperative bed time, hospital stay, and complications of the two groups were recorded and compared. The improvement of pain and function were evaluated by the visual analogue scale (VAS) score and Japanese Orthopedic Association (JOA) score at preoperation, 1 week, and 1, 6, 12 months after operation, and last follow-up, respectively. The effect of slip correction was evaluated by slip angle and intervertebral altitude at preoperation and last follow-up, and the effectiveness of fusion was evaluated according to Suk criteria.ResultsAll patients were followed up, the modified-TLIF group was followed up 25-36 months (mean, 32.7 months), the PLIF group was followed up 24-38 months (mean, 33.3 months). The intraoperative blood loss, operation time, postoperative drainage volume, postoperative bed time, and hospital stay of the modified-TLIF group were significantly less than those of the PLIF group (P<0.05). The VAS score and JOA score of both groups were significantly improved at each time point after operation (P<0.05); the scores of the modified-TLIF group were significantly better than those of the PLIF group at 1 and 6 months after operation (P<0.05). The slip angle and intervertebral altitude of both groups were obviously improved at last follow-up (P<0.05), and there was no significant difference between the two groups at preoperation and last follow-up (P>0.05). At last follow-up, the fusion rate of the modified-TLIF group and the PLIF group was 96.3% (52/54) and 98.1% (51/52), respectively, and no significant difference was found between the two groups (χ2=0.000, P=1.000). About complications, there was no significant difference between the two groups in nerve injury on the opposite side within a week, incision infection, and pulmonary infection (P>0.05). No case of nerve injury on the operation side within a week or dural laceration occurred in the modified-TLIF group, while 8 cases (15.4%, P=0.002) and 4 cases (7.7%, P=0.054) occurred in the PLIF group respectively.ConclusionModified-TLIF and PLIF are effective in the treatment of mild to moderate lumbar spondylolisthesis in middle-aged and elderly patients. However, modified-TLIF has relatively less trauma, lower blood loss, lower drainage volume, lower incidence of dural laceration and nerve injury, which promotes enhanced recovery after surgery.
Objective To analyze the effectiveness of combined treatment of lumbar spondylolisthesis with MED, Quadrant, and Sextant-R systems. Methods Between August 2006 and June 2011, 35 patients with lumbar spondylolisthesis were treated, including 11 cases of isthmic spondylolisthesis and 24 cases of degenerative spondylolisthesis. There were 25 males and 10 females, with a mean age of 55 years (range, 33-71 years). The mean disease duration was 37 months (range, 8-75 months). Spondylolisthesis occurred at L4, 5 level in 21 patients and at L5, S1 level in 14 patients. According to Meyerding classification, 35 cases were rated as dergee I. The minimally invasive surgeries were performed by paraspinal muscle approach; Quadrant system was used for decompression and fusion at severe side, MED system for windowing of lamina at mild side, and Sextant-R system for fixation and reduction. Visual analogue scale (VAS) score was used to evaluate pain, Oswestry disability index (ODI) to evaluate clinical outcomes, spondylolishesis ratio and intervertebral height to evaluate spondylolisthesis reduction. Results Lumbar continuous thin layer CT at postoperation showed that no pedicle screw invaded spinal canal and intervertebral fusion device was at good position. Incisions healed by first intention. All patients were followed up 18-38 months (mean, 26 months). All patients got bone fusion and had no internal fixation failure by radiologic examination at 1 year after operation. Low back pain was relieved, lumbar function improved obviously, and satisfactory reduction of spondylolisthesis was obtained. At 2 weeks and 1 year after operation, the VAS score, ODI score, spondylolisthesis ratio, and intervertebral height were significantly improved when compared with preoperative ones (P lt; 0.05). VAS score and ODI score showed significant differences (P lt; 0.05) between at 2 weeks and 1 year after operation. Spondylolisthesis ratio and intervertebral height showed no significant difference (P gt; 0.05) between at 2 weeks and at 1 year after operation. Conclusion Minimally invasive surgical management for lumbar spondylolisthesis via MED, Quadrant, and Sextant-R systems is a safe and effective surgical technique. However, its indications should be well considered.
Objective To investigate the technique of reduction by posterior approach for severe spondylolisthesis, and to discuss the method to prevent nerve stretch injury. Methods Between July 2007 and April 2011, 17 patients with severe spondylolisthesis underwent reduction, fixation, and fusion by posterior approach. There were 2 males and 15 females with a median age of 15 years (range, 8-67 years) and a median disease duration of 18 months (range, 5 months-16 years and 4 months). The level of spondylolisthesis was at L4 in 1 case and L5 in 16 cases; the spondylolisthesis was at degree III in 12 cases and degree IV in 5 cases according to Meyerding classification. There were 16 cases of developmental spondylolisthesis (high- dysplastic and low-dysplasia spondylolisthesis in 9 and 7 cases, respectively) and 1 case of traumatic spondylolisthesis; 16 cases of developmental spondylolisthesis at L5 level included 6 cases of type 4, 9 case of type 5, and 1 case of type 6 according to Spinal Deformity Study Group (SDSG) classification. All cases underwent posterior spinal decompression, Schanz screw fixation for the slipped vertebrae, the intervertebral and posterolateral fusion and reduction of the slipped vertebrae, and correction of the lumbosacral kyphosis. The reductive degree of slipped vertebrae was modulated according to the strain of exiting spinal root. The slip degree should be reduced within Meyerding degree II. The anteroposterior and lateral radiographs of whole spine were taken in a standardized standing position to observe the correction of displacement severity and lumbosacral angle. The nerve function and pain score of lower extremity were evaluated by neurological Frankel grade and visual analogue scale (VAS). Bony fusion was assessed by followed-up CT three-dimentional reconstruction. Results Exiting nerve root paralysis occurred in 1 case after operation, and released at 4 weeks after operation; no aggravation of nerve damage was observed in the other patients. The incisions primarily healed. All the patients were followed up 12-48 months (mean, 25 months). The slip percentage, the lumbosacral angle, and VAS score of lower extremity were improved from 72% ± 10%, (18.2 ± 3.5)°, and 7.0 ± 1.5 at preoperation to 12% ± 6%, ( — 7.3 ± 2.9)°, and 1.5 ± 1.3 at 12 months after operation respectively, all showing significant differences (P lt; 0.05). Osteosynthesis was seen at the bone grafting area by CT three-dimentional reconstruction at 12 months after operation. No breakage of screw and rod or reduction loss occurred. Conclusion It can obtain satisfactory clinical result to use spinal canal decompression by posterior approach, the Schanz screw fixation of the slipped vertebrae, the intervertebral and posterolateral fusion for severe spondylolisthesis. The risk of nerve stretch injury can be prevented by choosing the lowest height of intervertebral cage, modulating the reductive degree of slipped vertebrae according to the strain of exiting spinal root, and correcting lumbosacral kyphosis.
Objective To review the research progress in the treatment of high-grade spondylolisthesis (HS), in order to provide a reference for clinical treatment decision-making. Methods The literature related to the treatment of HS at home and abroad in recent years was widely reviewed. The methods of conservative treatment, in situ fusion, and spondylolisthesis reduction were analyzed and summarized. Results Surgical treatment is the main treatment of HS, but which method is the best is still controversial. The advantages, disadvantages, and applicability of various operations are also different, so individualized analysis is needed in clinic. Conclusion The treatment plan of HS needs to be considered comprehensively according to the individual condition of the patient. It will be an important research direction to further compare the existing treatment methods and develop more safe and effective new technology.