The effect of reduction and in situ fusion on postoperative imaging parameters of degenerative lumbar spondylolisthesis / 中华骨科杂志

Objective:To compare the efficacy of reduction and in situ intervertebral fusion fixation in the treatment of degenerative lumbar spondylolisthesis.Methods:A total of 182 patients (92 males and 90 females) with L 4 degenerative lumbar spondylolisthesis of Meyerding's classification of grade I and grade II, aged (62.6±6.8) years (range, 57-73 years), who underwent posterior L 4, 5 internal fixation and interbody fusion in the Department of Spinal Surgery, the Second Hospital of Shanxi Medical University, were retrospectively analyzed from January 2019 to December 2022. There were 105 cases of I-degree spondylolisthesis and 77 cases of II-degree spondylolisthesis. According to the operation method, the patients were divided into reduction intervertebral fusion fixation (reduction group) and in situ intervertebral fusion fixation group (in situ group). Imaging parameters such as lumber lordosis (LL), pelvic incidence (PI)-LL, L 3, 4 intervertebral space heights, fusion segment angle, and sagittal vertical axis (SVA) were measured on the pre- and post-surgical lumbar spine lateral radiographs. The visual analogue scale (VAS) and Oswestry Disability Index (ODI) of low back pain were recorded before and after surgery. The differences in clinical and imaging parameters were compared between reduction and in situ fusion group. Results:All 182 patients successfully completed the surgery and were followed up for 12.0±2.4 months (range, 9-15 months). The LL of the reduction group before surgery, immediately after surgery, and at the last follow-up were 46.9°±7.1°, 57.2°±5.9°, 55.6°±5.5°, respectively, with statistically significant differences ( F=87.61, P<0.001), with immediate and final follow-up being smaller than those in the in situ fixation group. The LL of the in situ fixation group before surgery, immediately after surgery, and at the last follow-up were 47.8°±7.2°, 50.5°±7.0°, and 48.7°± 6.4°, respectively, with no statistically significant difference ( F=2.83, P=0.062). The immediate and final follow-up of LL in the reduction group was lower than those in the in situ fixation group ( P<0.05). The fusion segment angles of the reduction group before surgery, immediately after surgery, and at the last follow-up were 14.2°±5.1°, 23.2°±4.7°, 23.2°±4.7°, respectively, with statistically significant differences ( F=152.87, P<0.001), with immediate and final follow-up after surgery being greater than before surgery. The fusion segment angles of the in situ fixation group before surgery, immediately after surgery, and at the last follow-up were 15.4°±5.9°, 18.2°±5.5°, and 17.4°±5.1°, respectively, with statistically significant differences ( F=4.69, P=0.009), with immediate and final follow-up being greater than before surgery. The fusion segment angulation in the reduction group was greater than that in the in situ fixation group at both the immediate and final follow-up ( P<0.05). The SVA of the reduction group before surgery, immediately after surgery, and at the last follow-up were 16.9±18.2 mm, 9.5±12.0 mm, and 8.7±11.3 mm, respectively, with statistically significant differences ( F=11.32, P<0.001), with immediate and final follow-up being smaller than before surgery. The SVA of immediately after surgery and at the last follow-up were both smaller than before surgery. The SVA of the in situ fixation group before surgery, immediately after surgery, and at the last follow-up were 16.4±17.2 mm, 14.3±15.5 mm, and 13.8±15.0 mm, respectively, with no statistically significant difference ( F=0.57, P=0.576). The SVA of the reduction group at immediate and final follow-up was lower than that of the in situ fixation group ( P<0.05). Conclusion:Both reduction and in situ intervertebral fusion fixation can effectively relieve the clinical symptoms of patients. Fusion fixation after reduction can improve the angulation of fusion segments to form segmental kyphosis, which is more conducive to improving SVA.

Oblique lumbar interbody fusion combined with percutaneous endoscopic decompression and posterior fixation for the treatment of lumbar spondylolisthesis accompanied with lumbar spinal stenosis / 中华骨科杂志

Objective:To investigate the efficacy of oblique lumbar interbody fusion (OLIF) combined with percutaneous transforaminal endoscopic decompression (PTED) and posterior pedicle fixation through Wiltse approach in the treatment of lumbar spondylolisthesis accompanied with lumbar spinal stenosis.Methods:From June 2017 to February 2022, 103 patients (50 males and 53 females) of lumbar spondylolisthesis accompanied with lumbar spinal stenosis were performed with OLIF combined with PTED and posterior pedicle fixation. The mean age was 64.1±5.2 years (range, 42-87 years). All involved cases were single-segment and included 83 cases of L 4, 5, 17 cases of L 3, 4, and 3 cases of L 2, 3. Among them, 94 cases were performed for the first time, and other 9 were revision surgery treated by posterior lumbar laminectomy previously. The visual analog scale (VAS) was used to evaluate the low back pain and leg pain, and the Oswestry disability index (ODI) was used to evaluate the lumbar function. The VAS and ODI scores were recorded respectively before the operation, at discharge, 1, 3, 6 months after the operation and at the last follow-up. Macnab criteria was used to evaluate the clinical efficacy at the last follow-up. At the same time, imaging measurements were conducted, including the anterior and posterior disc height, segmental lordotic angle, percentage of slip on lateral X-ray film and the vertebral canal area on axial MRI before and after surgery. Results:All of 103 patients were successfully operated in one stage with an average operation time of 177.7±21.5 min (range, 155-220 min), and an average intraoperative blood loss of 55.9±18.3 ml (range, 30-150 ml). The mean follow-up time were 15.1±2.6 months (range, 6-36 months). There were significant differences in both VAS scores of back and leg and ODI scores at each postoperative time point when compared with preoperative ( F=508.25, F=1524.82, F=1148.68, P<0.001). Macnab criteria of the last follow-up was evaluated as follow: excellent in 85 cases, good in 14, fair in 4, and the excellent and good rate was 96.1%. The radiographic results showed the mean immediate postoperative anterior disc height, posterior disc height, segmental lordotic angle, percentage of slip and axial area of the vertebral canal were 15.23±2.97 mm, 9.32±2.31 mm, 14.36°±4.18°, 3.89%±3.11%, 113.37±47.27 mm 2, and thus all of those increased significantly compared to the mean preoperative 11.93±3.17 mm, 7.21±2.03 mm, 6.15°±3.99°, 23.66%±7.79%, 57.63±28.91 mm 2, respectively ( t=7.84, t=7.07, t=14.91, t=27.62, t=9.68, P<0.001). All cases achieved bony fusion during 6-12 months after operation. The incidence of surgery-related complications was 10.7% (11/103). There were 3 cases of end plate fracture and 2 cases of dural injury, which had no complaint after operation. There was 1 case of pedicle screw entering into the spinal canal by mistake, and the symptoms of nerve damage appeared after operation. After 1 year it basically returned to normal. There were 2 cases of thigh numbness and 1 case of psoas major weakness after operation, all of which relieved after 4 weeks. There was 1 case continuous pain of abdominal incision after surgery. There was 1 case of cage subsidence at the last follow-up. Conclusion:OLIF combined with PTED and posterior pedicle fixation through Wiltse approach is a minimally invasive surgical method for the treatment of lumbar spondylolisthesis accompanied with lumbar spinal stenosis. With the combined minimally invasive techniques, the decompression, fusion and fixation of the lumbar spine can be fulfilled perfectly. It has the advantages of minimally invasive, good clical outcome, few complications and rapid rehabilitation.

Morphological characteristics of L 4, 5 facet joints in degenerative lumbar spondylolisthesis / 中华骨科杂志

Objective:To observe the morphological characteristics of L 4, 5 facet joints in patients with degenerative lumbar spondylolisthesis (DLS) of different spinopelvic types based on Roussouly classification. Methods:We retrospectively analyzed 142 patients with DLS who visited the department of orthopaedics in the Affiliated Hospital of Southwest Medical University from August 2018 to May 2022. There were 33 males aged 65.0±10.7 years and 109 females aged 61.8±9.6 years. The following morphological parameters of the L 4, 5 facet joint were measured on the CT images: facet joint angle (FJA), pedicle facet angle (PFA), facet joint tropism (FT) and facet joint osteoarthritis (OA) degree; the sacral slope (SS), lumbar lordosis (LL) and percentage of L 4 slip distance (SDP) were measured on preoperative standing neutral lumbar radiographs. According to the Roussouly classification, the patients were divided into four groups (type I, type II, type III, and type IV). The differences of morphological parameters of the facet joints and SDP were compared among the four groups, and the correlation between the FJA and PFA was analyzed. Results:There were 142 patients, including 28 type I, 50 type II, 43 type III, and 21 type IV according to the Roussouly classification. The SDPs of type I, type II, type III, and type IV were 19.1%±3.4%, 18.6%±3.9%, 21.7%±3.9%, 25.0%±2.4%, respectively. Except for types I and II, there were statistically significant differences in pairwise comparison among all other types ( P<0.05). The FJAs in type I and type II (31.4°±6.3°, 35.2°±6.8°) were larger than those in type III (28.4°±5.6°) and type IV (23.4°±4.5°), and the FJA in type III was larger than that in type IV. Conversely, the FJA in type I was smaller than that in type II. These differences were statistically significant ( P<0.05). The PFAs in type I and type II (113.9°±4.9°, 111.3°±5.6°) were smaller than those in type III (116.3°±4.4°) and type IV (121.8°±3.5°), and the PFA in type III was smaller than that in type IV, while, the PFA in type I was larger than that in type II. These differences were statistically significant ( P<0.05). The degree of OA in both type I and type II was lower than that in type III and type IV, with statistically significant differences ( P<0.05). However, there were no statistically significant differences in the degree of OA between type I and type II and between type III and type IV ( P> 0.05). Additionally, there were no statistically significant differences ( F=0.40, P=0.752) in the FT values among type I, type II, type III, and type IV (5.8°±2.3°, 5.6°±2.4°, 6.1°±1.8°, 5.9°±1.9°). Pearson correlation analysis showed that FJA was negatively correlated with PFA ( r=-0.68, P<0.001). Conclusion:In the slip segment of DLS, the facet joint morphology was part of the joint configuration in different spinopelvic types, not just the result of joint remodeling after DLS. Morphological characteristics of the facet joints and DLS interacted with each other.

Clinical efficacy analysis of DELTA endoscopic lumbar interbody fusion for the treatment of lumbar spondylolisthesis / 中国医师杂志

Objective:To explore the clinical efficacy of DELTA endoscopic lumbar interbody fusion for the treatment of mild to moderate, single segment lumbar spondylolisthesis.Methods:A retrospective analysis was conducted on the clinical data of 48 surgical cases of grade Ⅰ to Ⅱ lumbar spondylolisthesis admitted to the First Affiliated Hospital of Hunan University of Traditional Chinese Medicine from February 2020 to March 2022. Among them, 24 cases treated with DELTA endoscopic lumbar interbody fusion surgery were classified as the DELTA group, and 24 cases treated with traditional minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) surgery were classified as the MIS-TLIF group. Two groups of patients were compared in terms of perioperative indicators (surgical time, postoperative drainage volume, incision length, hospital stay), clinical efficacy [Visual Analogue Scale (VAS) score for low back and leg pain, lumbar Japanese Orthopaedic Association Scores (JOA), improved MacNab standard excellence rate], and lumbar fusion rate (Bridwell intervertebral fusion grade).Results:The DELTA group had longer surgical time than the MIS-TLIF group, and the postoperative drainage volume, incision length, and hospital stay were all lower than the MIS-TLIF group, with statistically significant differences (all P<0.05). The VAS score of lower back and leg pain and lumbar JOA score of the two groups of patients at 1 week, 3 months, and the last follow-up were significantly improved compared to those before surgery (all P<0.01), and the DELTA group had better VAS score of lower back and leg pain and lumbar JOA score at all time points after surgery than the MIS-TLIF group, with statistically significant differences (all P<0.05). The improved MacNab standard was used to evaluate the efficacy of the two groups of patients at the last follow-up after surgery, and there was no statistically significant difference in the excellent and good rates ( P>0.05); There was no statistically significant difference ( P>0.05) in the fusion rate between the two groups. Conclusions:DELTA endoscopic lumbar interbody fusion has a significant therapeutic effect on lumbar spondylolisthesis, with the advantages of small surgical incision and fast recovery; After crossing the DELTA endoscopic learning curve and optimizing surgical procedures, this technology can become an alternative to MIS-TLIF technology.

Dynamic Response and Injury Prediction for Lumbar Vertebrae of Pilots with Spondylolysis under Persistent Overload / 医用生物力学

Objective Based on construction and verification of the lumbar finite element model, the simulation calculation and injury prediction on dynamic response of normal lumbar model and L5 unilateral and bilateral spondylolysis models of the pilot were carried out, so as to explore the influence of persistent flight overload on normal and spondylolysis lumbar vertebrae of the pilot. Methods The precise finite element model of lumbavertebrae was established using reverse engineering software and computer-aided engineering (CAE) technology based on CT images. The validity of the lumbar vertebrae model was verified by static and dynamic in vitro experiments. The biomechanical simulation analysis on normal and spondylolysis lumbar vertebrae of the pilotunder persistent overload was carried out, and the spinal injury was predicted and analyzed by dynamic response index (DRI) injury evaluation and prediction method. Results The maximum isthmus stress of L5 vertebra in unilateral and bilateral spondylolysis models were 105. 29 MPa and 126. 32 MPa, respectively, which were significantly higher than those in normal model. The L4-5 and L5-S1 intervertebral discs of the spondylolysis model were more prone to premature degenerative changes than those of normal model. Combined with DRI spinal injury prediction method, the probability of spinal injury in normal lumbar vertebrae, lumbar vertebrae with L5 unilateral and bilateral spondylolysis were 0. 001 4% , 2. 26% and 3. 21% , respectively, and the probability of spinal injury was significantly increased after the occurrence of spondylolysis. Conclusions The spondylolysis increases the load of lumbar isthmus under flight overload. The results provide more accurate data support for the formulation of training programs and the development of protective devices to ensure flight safety

Clinical and radiologic comparison between oblique lateral interbody fusion and minimally invasive transforaminal lumbar interbody fusion for degenerative lumbar spondylolisthesis / 中国骨伤

OBJECTIVE@#To compare the short-term clinical efficacy and radiologic differences between oblique lateral interbody fusion(OLIF) and minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) for degenerative lumbar spondylolisthesis.@*METHODS@#A retrospective analysis was performed on 58 patients with lumbar spondylolisthesis treated with OLIF or MIS-TLIF from April 2019 to October 2020. Among them, 28 patients were treated with OLIF (OLIF group), including 15 males and 13 females aged 47 to 84 years old with an average age of (63.00±9.38) years. The other 30 patients were treated with MIS-TLIF(MIS-TLIF group), including 17 males and 13 females aged 43 to 78 years old with an average age of (61.13±11.10) years. General conditions, including operation time, intraoperative blood loss, postoperative drainage, complications, lying in bed, and hospitalization time were recorded in both groups. Radiological characteristics, including intervertebral disc height (DH), intervertebral foramen height (FH), and lumbar lordosis angle (LLA), were compared between two groups. The visual analogue scale (VAS) and Oswestry disability index (ODI) were used to evaluate the clinical effect.@*RESULTS@#The operation time, intraoperative blood loss, postoperative drainage, lying in bed, and hospitalization time in OLIF group were significantly less than those in the MIS-TLIF group (P<0.05). The intervertebral disc height and intervertebral foramen height were significantly improved in both groups after the operation (P<0.05). The lumbar lordosis angle in OLIF group was significantly improved compared to before the operation(P<0.05), but there was no significant difference in the MIS-TLIF group before and after operation(P>0.05). Postoperative intervertebral disc height, intervertebral foramen height, and lumbar lordosis were better in the OLIF group than in the MIS-TLIF group (P<0.05). The VAS and ODI of the OLIF group were lower than those of the MIS-TLIF group within 1 week and 1 month after the operation (P<0.05), and there were no significant differences in VAS and ODI at 3 and 6 months after the operation between the two groups(P>0.05). In the OLIF group, 1 case had paresthesia of the left lower extremity with flexion-hip weakness and 1 case had a collapse of the endplate after the operation;in the MIS-TLIF group, 2 cases had radiation pain of lower extremities after decompression.@*CONCLUSION@#Compared with MIS-TLIF, OLIF results in less operative trauma, faster recovery, and better imaging performance after lumbar spine surgery.

Treatment of stable degenerative lumbar spondylolisthesis with percutaneous endoscopic surgery through two different approaches / 中国骨伤

OBJECTIVE@#To assess the clinical effects of percutaneous endoscopic surgery through two different approaches for stable degenerative lumbar spondylolisthesis.@*METHODS@#Sixty-four patients with stable degenerative lumbar spondylolisthesis who underwent percutaneous endoscopic procedures between January 2016 and December 2019 were divided into transforaminal approach group and interlaminar approach group according to surgical approaches, 32 patients in each group. There were 16 males and 16 females in transforaminal approach group, aged from 52 to 84 years old with an average of (66.03±9.60) years, L2 slippage in 4 cases, L3 slippage in 5, and L4 slippage in 23. There were 17 males and 15 females in interlaminar approach group, aged from 46 to 81 years old with an average of (61.38±9.88) years, L3 slippage in 3 cases, L4 slippage in 15, and L5 slippage in 14. Operative time, intraoperative fluoroscopy times, and postoperative bedtime were compared between two groups. Anteroposterior displacement values, interbody opening angles, and the percentage of slippage were measured on preoperative and postoperative 12-month dynamic radiographs. Visual analogue scale (VAS) of low back pain and lower extremity pain, and the Japanese Orthopaedic Association (JOA) score before and after surgery were observed, and clinical effects were evaluated according to the modified MACNAB criteria.@*RESULTS@#All operations were successfully completed, and patients in both groups were followed up for more than 1 year, and without complications during follow-up period. ①There was no significant difference in operation time between two groups(P>0.05). Intraoperative fluoroscopy times were longer in transforaminal approach group than that in intervertebral approach group(P<0.05). Postoperative bedtime was shorter in transforaminal approach group than that in intervertebral approach group (P<0.05).② No lumbar instability was found on dynamic radiography at 12 months postoperatively in both groups. There were no significant differences in anteroposterior displacement values, interbody opening angles, and the percentage of slippage between two groups postoperative 12 months and preoperative 1 day(P>0.05). ③There was no significant difference between two groups in VAS of low back pain at 3 days and 1, 12 months after the operation compared with the preoperative(P>0.05), but the VAS of the lower extremity pain was significantly improved compared with the preoperative(P<0.05). Both of groups showed significant improvement in JOA score at 12 months compared with preoperatively(P<0.05). There was no significant difference in VAS of low back pain, lower extremity pain and JOA scores between two groups during the same period after surgery(P>0.05). According to modified Macnab criteria, excellent, good, fair and poor outcomes were 21, 7, 3 and 1 in transforaminal approach group respectively, and which in intervertebral approach group were 20, 7, 5 and 0, there was no significant difference in clinical effect between the groups(P>0.05).@*CONCLUSION@#Intervertebral approach may reduce intraoperative fluoroscopy times and transforaminal approach can shorten postoperative bedtime, both approaches achieve satisfactory results in the treatment of stable degenerative lumbar spondylolisthesis with no progression of short-term slippage.

Learning curve of robot-assisted L 4 and L 5 pedicle screw insertion for lumbar spondylolisthesis / 中华骨科杂志

Objective:To study the learning curve and inflection point of robot-assisted L 4 and L 5 pedicle screw insertion for lumbar spondylolisthesis. Methods:A retrospective study was conducted on the data of 43 patients with L 4 and L 5 pedicle screw insertion for lumbar spondylolisthesis from January 2016 to December 2020 using surgical robot, including 19 males and 24 females, aging 59 (48, 66) years old. According to Meyerding classification, there were 23 grade I slippage, 18 grade II slippage, and 2 grade III slippage. The screw deviation and screw accuracy grade were assessed. The operation time, intraoperative blood loss, the number of intraoperative fluoroscopies, postoperative complications, and postoperative hospital stay were recorded. Cumulative Sum (CUSUM) was used to analyze the learning curve, and the learning curve is divided into early and late learning stages according to morphology. T test and Wilcoxon rank-sum test were used for statistical analysis and comparison of indicators between early and late learning stages. Results:43 patients with lumbar spondylolisthesis successfully completed the operation, with 60 L 4 pedicle screws and 70 L 5 pedicle screws inserted. The accuracy of L 4 pedicle screw placement began to improve since the 23rd placement, and the accuracy of L 5 pedicle screw placement began to improve since the 20th placement. Using the 23rd pedicle screw (the 14th patient) to divide the learning curve as the early stage and the late stage. There was no statistically significant difference in the operation time (225.0±74.0 min vs. 207.0±81.2 min, t=0.65, P=0.521), intraoperative blood loss[200 (75, 500) ml vs. 100 (60, 200) ml, Z=1.30, P=0.195], the number of intraoperative fluoroscopies[10 (6, 10) vs. 10 (6, 10), Z=-0.37, P=0.712] and postoperative complications (8% vs. 0, P=0.302) between the early stage and late stage of learning curve. In the late stage of learning, the postoperative hospital stay was shorter[4.5 (3, 6) d vs. 6.0 (5, 9) d, Z=2.00, P=0.046]and the pedicle screw insertion accuracy was higher[L 4: 1.33 (1.06, 1.79) mm vs. 2.23 (1.12, 4.55) mm, Z=2.43, P=0.015; L 5: 1.47 (0.98, 1.87) mm vs. 3.21 (1.64, 4.87) mm, Z=3.90, P=0.001]. The accuracy of screw placement was similar between the early and late stages[L 4: 95%(21/22) vs. 97%(37/38), P=1.000; L 5: 91%(20/22) vs. 96%(46/48), P=0.585]. Conclusion:Robot-assisted L 4 and L 5 pedicle screw placement in the treatment of lumbar spondylolisthesis had a relatively obvious learning curve. Starting from the placement of the 23rd screws, the accuracy of screw placement gradually increased.

Correlation between degenerative diseases of the lumbar spine and types of lumbar lordosis / Correlação entre doenças degenerativas da coluna lombar e os tipos de lordose lombar / Correlación entre las enfermedades degenerativas de la columna lumbar y los tipos de lordosis lumbar

ABSTRACT Objective: Evaluate the relationship between the incidence of different types of degenerative diseases of the spine and lumbopelvic biomechanics, according to the types of lordosis of Roussouly's classification. Methods: Retrospective study of medical records and results of imaging exams of patients seen at a private hospital in São Paulo. The sagittal alignment of these patients was evaluated by classifying them according to Roussouly into 4 types, based on panoramic radiographs of the spine. These results were correlated with the patient's degenerative diagnosis (Herniated disc, Canal stenosis, Spondylolisthesis, degenerative discopathy and Facet arthrosis). Statistical tests were performed comparing the types of curvature and diagnoses identified. Results: 418 patients were evaluated, 51.4% male and 49.6% female. The vast majority of patients, about 54%, had a diagnosis of herniated lumbar disc. There was a statistically significant difference that showed a predilection for surgical treatment in cases classified as Type I and Type II in the Roussouly classification. There was no statistically significant difference that correlated the types of lumbar lordosis with the diagnosis presented by the patients. Conclusion: There is no statistically significant difference that correlates the type of lumbar lordosis according to Roussouly with lumbar degenerative diseases. In contrast, patients classified as Type 1 and Type 2 by Roussouly underwent a greater number of surgical treatments compared to patients type 3 and 4, with statistical relevance. Level of evidence 2; Retrospective prognostic study.

RESUMO Objetivos: Avaliar a relação da incidência dos diferentes tipos de doenças degenerativas da coluna com a biomecânica lombopélvica, de acordo com os tipos de lordose segundo Roussouly. Métodos: Estudo retrospectivo de prontuários médicos e de resultados de exames de imagens de pacientes atendidos em um hospital privado de São Paulo. Foi avaliado o alinhamento sagital desses pacientes classificando-os de acordo com Roussouly em 4 tipos, com base nas radiografias panorâmicas da coluna vertebral. Esses resultados foram correlacionados com o diagnóstico degenerativo do paciente (Hérnia de disco, Estenose do canal, Espondilolistese, Discopatia degenerativa e Artrose facetaria). Testes estatísticos foram realizados comparando os tipos de curvatura e diagnósticos identificados. Resultados: Foram avaliados 418 pacientes, sendo que 51,4% do sexo masculino e 49,6% do sexo feminino. A grande maioria dos pacientes, cerca de 54%, apresentavam como diagnóstico hérnia de disco lombar. Houve uma diferença estatisticamente significativa que evidenciou uma predileção do tratamento cirúrgico nos casos classificados como Tipo I e Tipo II na classificação de Roussouly. Não houve diferença estatisticamente significativa que correlacionasse os tipos de lordose lombar com o diagnóstico apresentado pelos pacientes. Conclusões: Não houve diferença estatisticamente significativa que correlacione o tipo de lordose lombar de acordo com Roussouly com as doenças degenerativas lombares. Em contrapartida, os pacientes classificados como Tipo 1 e Tipo 2 de Roussouly foram submetidos em maior número ao tratamento cirúrgico em comparação com os pacientes tipo 3 e 4, com relevância estatística. Nível de evidência 2; Estudo prognóstico retrospectivo.

RESUMEN Objetivos: Evaluar la relación entre la incidencia de diferentes tipos de enfermedades degenerativas de la columna y la biomecánica lumbopélvica, según los tipos de lordosis de Roussouly. Métodos: Estudio retrospectivo de registros médicos y resultados de exámenes de imágenes de pacientes atendidos en un hospital privado en São Paulo. La alineación sagital de estos pacientes se evaluó clasificándolos según Roussouly en 4 tipos, en base a radiografías panorámicas de la columna vertebral. Estos resultados se correlacionaron con el diagnóstico degenerativo del paciente (disco herniado, estenosis del canal, espondilolistesis, discopatía degenerativa y artrosis facetaria). Se realizaron pruebas estadísticas comparando los tipos de curvatura y los diagnósticos identificados. Resultados: Se evaluaron 418 pacientes, 51.4% hombres y 49.6% mujeres. La gran mayoría de los pacientes, alrededor del 54%, tenían un diagnóstico de hernia de disco lumbar. Hubo una diferencia estadísticamente significativa que mostró una predilección por el tratamiento quirúrgico en los casos clasificados como Tipo I y Tipo II en la clasificación de Roussouly. No hubo diferencias estadísticamente significativas que correlacionaran los tipos de lordosis lumbar con el diagnóstico presentado por los pacientes. Conclusión: No hubo diferencias estadísticamente significativas que correlacionen el tipo de lordosis lumbar según Roussouly con las enfermedades degenerativas lumbares. En contraste, los pacientes clasificados como Tipo 1 y Tipo 2 por Roussouly se sometieron a un mayor número de tratamientos quirúrgicos en comparación con los pacientes tipo 3 y 4, con relevancia estadística. Nivel de evidencia 2; Estudo de pronostico retrospectivo.

Unstable Non-isthmic Spondylolisthesis Following Unilateral Biportal Endoscopy Assisted Unilateral Laminotomy for Bilateral Decompression: A Case Report

@#Lumbar decompressive laminectomy is a standard treatment for degenerative lumbar spinal stenosis, but in some cases, can lead to iatrogenic spondylolysis and delayed segmental instability. Iatrogenic spondylolysis occurs in most cases in pars interarticularis, but rare cases have also been reported, pediculolysis in pedicle and laminolysis in lamina. Minimally invasive spine surgery (MIS) is known to have a low risk of developing these iatrogenic spondylolyses, and unilateral biportal endoscopy is the MIS that has been drawing attention. We present a case of a 72-year-old female who was diagnosed with L4-5 unstable non-isthmic spondylolisthesis and severe right central disc extrusion 10 weeks after UBE assisted unilateral laminotomy for bilateral decompression (ULBD) at the consecutive segments of L3-4 and L4-5. Pre-operative imaging studies revealed severe central stenosis without spondylolisthesis at L3-L4 and L4- L5 along with L4-L5 facet tropism. She was managed by anterior lumbar interbody fusion and cement augmented pedicle screw fixation, which resulted in the complete resolution of her clinical and neurologic symptoms.

Status of Return to Play in Growing Athletes with Lumbar Spondylolysis / The Japanese Journal of Rehabilitation Medicine

Objective：In athletes who are still in the growing period, lumbar spondylolysis is mainly treated with brace therapy to enable bone fusion. During the brace period, sports activities are often discontinued. The purpose of this study was to investigate how the combination of brace therapy and early physiotherapy affects the duration of return to play in athletes with lumbar spondylolysis.Methods：Thirty-seven athletes in the growing period with unilateral spondylolysis were included in the study. They were classified into two groups：17 patients who rested during the brace period（brace group）and 20 patients who combined the brace with early physical therapy (combination group). The examined items were duration of the brace period and duration from the end of the brace therapy to return to play (return period). Both these items were compared between the brace group and the combination group. In addition, the union rate of both groups was also calculated.Results：The return period was significantly shorter in the combination group than in the brace group. However, there were no statistically significant differences between the groups with respect to other data.Conclusion：Since there was no significant difference in the duration of the brace period and the union rate between both groups, we believe that early physical therapy intervention does not adversely affect bone union in athletes with spondylolysis who are in the growing period. Therefore, it is considered that the combined use of brace therapy and early physical therapy can maintain flexibility and muscular strength during the brace period and can enable a smooth transit to playing after the bone union is complete.

Direct reduction and repair of spondylolysis with grade 1 slip using the smiley face rod: a case report / Journal of Rural Medicine

Objective: Lumbar spondylolysis, caused by stress fracture of the pars interarticularis may lead to a bony defect or spondylolisthesis. In adolescents, its surgical treatment employs the smiley face rod method for direct reduction of pseudoarthrotic spondylolysis and spondylolisthesis. Clinical outcomes of this treatment have been occasionally described; however, implant removal has not been discussed previously. We present a patient with lumbar spondylolysis with grade 1 slip at the 5th lumbar vertebra (L5) per the Meyerding classification.Patient: A 14-year-old boy presented with chronic severe lower back pain. Since conservative therapy did not resolve pain or enable resuming sports activities, the smiley face rod repair was performed 7 months after the initial treatment.Result: Anterior slippage of the L5 was surgically reduced. The patient wore a brace for 3 months postoperatively, and partial bone fusion was noted 6 months postoperatively. He resumed his sports activity 8 months postoperatively, and absolute bone fusion was confirmed 18 months postoperatively. Implant removal was performed 3 years postoperatively. Grade 1 slip was corrected with absolute bone fusion, and long-term follow-up revealed good results in terms of healing and rehabilitation.Conclusion: Smiley face rod method that allows for implant removal after bone fusion is suitable for adolescents.

Correlation analysis between degenerative spondylolisthesis and T2WI hyperintensity on MRI of interspinous ligament / 中国骨伤

OBJECTIVE@#To explore the relationship between lumbar degenerative spondylolisthesis and T2WI high signal in the interspinous ligament in MRI in order to improve the understanding of the signal changes of the interspinous ligament.@*METHODS@#The clinical data of 43 patients with clinically diagnosed lumbar degenerative spondylolisthesis were collected from March 2018 to March 2020, there were 19 males and 24 females, aged 50 to 92 years with an average of 69 years old. Using picture archiving and communication systems (PACS) to access images and record the distribution and incidence of T2WI high signal in the interspinous ligament between the slipped and non-slipped segments. Using Spearman correlation analysis to explore the relationshipbetween the T2WI high signal of the interspinous ligament and the degree of lumbar spondylolisthesis.@*RESULTS@#Except for 8 ligaments that were not included in the statistical results due to poor image quality, 43 patients with a total of 207 lumbar vertebrae and interspinous ligaments were included in the study. According to the Meyerding classification method, 43 patients had a total of 48 segments with spondylolisthesis, 41 segments in grade Ⅰ and 7 segments in grade Ⅱ. There were 30 cases of MRI T2WI high signal in the interspinous ligament corresponding to spondylolisthesis segment, including 3 cases on L@*CONCLUSION@#In patients with degenerative lumbar spondylolisthesis, the MRI T2WI hyperintensity is more common in the interspinous ligament. The occurrence of T2WI high signal is positively correlated with the degree of spondylolisthesis, which should be payed enough attention in imaging diagnosis.

Effect of Wiltse approach pedicle screw-laminar hook internal fixation combined with autologous ilium transplantation for repairing single-segment lumbar spondylolysis / 解放军医学杂志

[Abstract] Objective To analyze the characteristics of lumbar spondylolysis in military patients, and explore the clinical effect of Wiltse approach pedicle screw-laminar hook internal fixation combined with autologous ilium transplantation in repairing single-segment lumbar spondylolysis. Methods Thirty-three military patients with single-segment lumbar spondylolysis were admitted to the 940 Hospital of Joint Service Support Force of Chinese PLA from January 2016 to January 2019. The Wiltse approach pedicle screw-lamina hook internal fixation combined with autogenous ilium transplantation was performed to repair the lumber spondylolysis, the patients were then followed up to evaluate the visual analogue scale (VAS) and Oswestry dysfunction index (ODI) of lumbar pain, and compared with that before surgery. 3-D CT of lumbar spine was used to evaluate the bone graft fusion in the isthmus. Results The army patients accounted for 63.6% (21/33) of all the cases. The injured segments were located at L4 and L5 segment, with the L5 segment (84.8%, 28/33) being the most common. The operation time was 85-150 min, the intraoperative blood loss was 50-150 ml, postoperative drainage volume was 10-30 ml. VAS score of lower back pain decreased from 5.8±0.7 before surgery to 1.4±0.8 three months after surgery, and to 0.4±0.5 at the last follow-up, the difference was statistically significant (P<0.05). ODI decreased from 41.2%±5.8% before surgery to 12%±3.9% 3 months after surgery, and to 9.5%±2.6% at the last follow-up, the difference was statistically significant (P<0.05). At 3 months, 6 months and 12 months follow-up, the bone graft fusion rate was 18.2% (6/33), 48.5% (16/33) and 84.8% (28/33), respectively, and the average bone graft fusion time was 7.0±2.8 months. Conclusion Wiltse approach pedicle screw-laminar hook internal fixation combined with autogenous ilium transplantation is a feasible and effective minimally invasive solution for repairing single-segment lumbar spondylolysis of military patients with shorter bone graft fusion time.

Characteristics of adolescent lumbar spondylolysis with acute unilateral fatigue fracture and contralateral pseudoarthrosis / Journal of Rural Medicine

Purpose: This study aimed to examine the characteristics of lumbar spondylolysis with acute lumbar spondylolysis on one side and pseudoarthrotic spondylolysis on the other, relative to acute lumbar spondylolysis on one side only.Patients and Methods: Short-tau inversion recovery images obtained through magnetic resonance imaging were used to diagnose 58 patients with acute lumbar spondylolysis with bone marrow edema on one side only. A total of 20 patients who had pars defects on the contralateral side (terminal-stage pseudoarthrotic spondylolysis) were included in the contralateral pseudoarthrosis group (P group). The remaining 38 patients with normal images for the contralateral pars interarticularis were included in the unilateral lesion group, in which the contralateral side was normal (U group). We investigated the union rate, age, sex, lesion laterality, vertebral level, pathological stage, and existing spina bifida occulta in both groups.Results: The P group was characterized by a higher proportion of right-side cases, L5 lesions, more progressed pathological stage, and spina bifida occulta and a significantly lower union rate than the U group.Conclusion: The union rate in patients with lumbar spondylolysis with acute lumbar spondylolysis on one side and pseudoarthrotic spondylolysis on the opposite side was only 15%. We should inform patients with acute unilateral spondylolysis lesions and contralateral pseudoarthrosis about this poor union rate and urge them to choose their therapy accordingly.

Status of Return to Play in Growing Athletes with Lumbar Spondylolysis / The Japanese Journal of Rehabilitation Medicine

Objective：In athletes who are still in the growing period, lumbar spondylolysis is mainly treated with brace therapy to enable bone fusion. During the brace period, sports activities are often discontinued. The purpose of this study was to investigate how the combination of brace therapy and early physiotherapy affects the duration of return to play in athletes with lumbar spondylolysis.Methods：Thirty-seven athletes in the growing period with unilateral spondylolysis were included in the study. They were classified into two groups：17 patients who rested during the brace period (brace group) and 20 patients who combined the brace with early physical therapy (combination group). The examined items were duration of the brace period and duration from the end of the brace therapy to return to play (return period). Both these items were compared between the brace group and the combination group. In addition, the union rate of both groups was also calculated.Results：The return period was significantly shorter in the combination group than in the brace group. However, there were no statistically significant differences between the groups with respect to other data.Conclusion：Since there was no significant difference in the duration of the brace period and the union rate between both groups, we believe that early physical therapy intervention does not adversely affect bone union in athletes with spondylolysis who are in the growing period. Therefore, it is considered that the combined use of brace therapy and early physical therapy can maintain flexibility and muscular strength during the brace period and can enable a smooth transit to playing after the bone union is complete.

The correlation between degree of multifidus muscle atrophy and severity in patients with degenerative lumbar spondylolisthesis / 中华骨科杂志

Objective@#To investigate the correlation between degree of multifidus muscle atrophy and severity in patients with degenerative lumbar spondylolisthesis.@*Methods@#A total of 103 patients with lumbar degenerative spondylolisthesis were retrospectively analyzed, including 22 male patients (21.4%) and 81 female patients (78.6%). There were 2 cases of L2 spondylolisthesis, 10 cases of L3 spondylolisthesis, 81 cases of L4 spondylolisthesis, and 10 cases of L5 spondylolisthesis. The average age was 58.55 ±0.88 years old. Each patient underwent lumbar lateral X-ray, and lumbar MRI, and the imaging data were collected. MRI images were obtained to measure and calculatethe ratio of the fat-free multifidus muscle cross sectional area to total multifidus muscle cross sectional area (LCSA/TCSA) in slipped segments and non-slipped segments. Lumbar lateral radiographs were obtained to measure and calculate slipped ratio. All data were analyzed by SPSS 23.0. Paired-samples T test was carried out to investigate whether there were LCSA/TCSA differences between in slipped segments and non-slipped segments. The correlation between LCSA/TCSA in slipped segments and slipped ratio was analyzed by using Pearson correlation coefficient system. P=0.000 was considered statistically significant.@*Results@#The degree of multifidus muscle atrophy (FCSA/TCSA) in the upper non-spondylolisthesis segments and the multifid muscle atrophy (FCSA/TCSA) in the degenerative spondylolisthesis segments (t=-12.618, P=0.000). there was significant difference between them. The degree of multifidus muscle atrophy (FCSA/TCSA) of degenerative spondylolisthesis was correlated with the spondylolisthesis ratio, and the correlation coefficient was -0.425. There was a high negative correlation between FCSA/TCSA ratio and spondylolisthesis ratio of degenerative spondylolisthesis.@*Conclusion@#The degree of multifidus muscle atrophy in degenerative spondylolisthesis is more serious than that in the upper non-spondylolisthesis segments, and there is a positive correlation between the degree of multifidus muscle atrophy in degenerative lumbar spondylolisthesis and the degree of lumbar spondylolisthesis in degenerative lumbar spondylolisthesis patients.

The correlation between degree of multifidus muscle atrophy and severity in patients with degenerative lumbar spondylolisthesis / 中华骨科杂志

Objective To investigate the correlation between degree of multifidus muscle atrophy and severity in patients with degenerative lumbar spondylolisthesis.Methods A total of 103 patients with lumbar degenerative spondylolisthesis were retrospectively analyzed,including 22 male patients (21.4％) and 81 female patients (78.6％).There were 2 cases of L2 spondylolisthesis,10 cases of L3 spondylolisthesis,81 cases of L4 spondylolisthesis,and 10 cases of L5 spondylolisthesis.The average age was 58.55 ±0.88 years old.Each patient underwent lumbar lateral X-ray,and lumbar MRI,and the imaging data were collected.MRI images were obtained to measure and calculatethe ratio of the fat-free multifidus muscle cross sectional area to total multifidus muscle cross sectional area (LCSA/TCSA) in slipped segments and non-slipped segments.Lumbar lateral radiographs were obtained to measure and calculate slipped ratio.All data were analyzed by SPSS 23.0.Paired-samples T test was carried out to investigate whether there were LCSA/TCSA differences between in slipped segments and non-slipped segments.The correlation between LCSA/TCSA in slipped segments and slipped ratio was analyzed by using Pearson correlation coefficient system.P=0.000 was considered statistically significant.Results The degree of multifidus muscle atrophy (FCSA/TCSA) in the upper non-spondylolisthesis segments and the multifid muscle atrophy (FCSA/TCSA) in the degenerative spondylolisthesis segments (t=-12.618,P=0.000).there was significant difference between them.The degree of multifidus muscle atrophy (FCSA/TCSA) of degenerative spondylolisthesis was correlated with the spondylolisthesis ratio,and the correlation coefficient was-0.425.There was a high negative correlation between FCSA/TCSA ratio and spondylolisthesis ratio of degenerative spondylolisthesis.Conclusion The degree of multifidus muscle atrophy in degenerative spondylolisthesis is more serious than that in the upper non-spondylolisthesis segments,and there is a positive correlation between the degree of multifidus muscle atrophy in degenerative lumbar spondylolisthesis and the degree of lumbar spondylolisthesis in degenerative lumbar spondylolisthesis patients.

Decompression with fusion is not superior to decompression alone in lumbar short-segment stenosis based on randomized controlled trials: meta-analysis / 中华骨科杂志

Objective A meta-analysis is to be performed to compare the entire efficacy on decompression (D) alone and decompression with fusion (F) for patients with 1-2 level lumbar stenosis (LSS) regardless of degenerative spandylolisthesis (DS) based on published RCTs.Methods The databases include Pubmed,Embase,Cochrane Library and Web of Science from January 1970 to March 2018 with a certain search strategy and inclusion criteria.Two reviewers assessed eligible trials,evaluated articles quality and extracted information independently and the information included basic characteristics of demographic information,primary and secondary measures,then data synthesis and meta-analysis was progressed as well as subgroup analysis by DS and follow-up time (36 months).Continuous variables were reported as weighted mean difference (WMD) and dichotomous variables were reported as odds ratios (ORs).Finally the strength of evidence and grade of recommendation was evaluated by the grades of recommendation,assessment,development and evaluation (GRADE) system for the overall outcome.Results A total of 9 RCTs with a low to moderate risk of bias met inclusion criteria with a total of 857 patients (367 were in D group and 490 were in F group) in 1-2 level operation and the average age,sex ratio and preoperative visual analogue scale (VAS) were of no significance.In primary measures,there were no statistical difference in VAS changes on back and leg pain between D and F group [MD=-0.03,95％ CI (--0.38,0.76),Z=0.08,P=0.94;MD=0.1 1,95％CI (-1.08,1.30),Z=0.18,P=0.86,respectively];Patients' satisfaction was of no difference between the two groups (OR=0.74,P=0.48),together with the change of Oswestry disability index (ODI,P=0.29) and European quality of life-5 dimensions (EQ-SD,P=0.41).As to the secondary measures,there were no difference in the rate of complication (OR=0.75,P=0.50) and reoperation (OR=1.93,P=0.11) while a statistical significance of longer operation duration (P=0.000),more blood loss (P=0.004),longer hospital stays (P=0.000) but amazing lower rate of ASD (OR=2.35,P=0.02) in F group.The subgroup analysis on whether combined with DS showed that basically all of the compared measures were in consistency with the whole meta-analysis;As to the follow-up,there was a higher reoperation rate in middle-to-long term (＞ 36months) in D group while the other measures were in line with the overall meta-analysis and adjacent segment degeneration/disease (ASD) was the most seasons of reoperation yet no matter the follow-up time.According to the GRADE system,the grade of this meta-analysis is of "High" quality.Conclusion F group has no better clinical results than D alone in short-segment LSS,regardless of DS,and even further,no significant change with shot-term or middle-to-long term follow-up.F approach has a longer duration of operation,more hospital stays and more blood loss,even perhaps a lager cost.According to the GRADE,the grade of this meta-analysis is of "High" quality,the grade strength of recommendation was "Strong".

Clinical application of percutaneous transforaminal endoscope-assisted lumbar interbody fusion / 中国骨伤

OBJECTIVE@#To conclude of the technical notes of percutaneous transforaminal endoscope-assisted lumbar interbody fusion (PT-Endo-LIF), and to investigate its safety and efficacy for treatment of degenerative lumbar disease.@*METHODS@#Twenty-four patients were treated by PT-Endo-LIF combined with posterior percutaneous pedicle screws fixation from October 2017 to April 2018. There were 16 males and 8 females, ranging in age from 39 to 72 years old, with a mean of (59.6±9.5) years old. There were 15 cases diagnosed with lumbar intervertebral disc herniation combined with degenerative disc, the other 9 cases were diagnosed as low level lumbar spondylolistheses w/o segmental instability. Single segmental fusion was performed for 22 cases(one for L₂,₃, 3 for L₃,₄ and 18 for L₄,₅) and 2 segmental fusion was performed for the other 2 cases (both for L₃,₄ and L₄,₅). PT-Endo-LIF was performed under local anesthesia with conscious sedation, followed by decompression through endoscopic technics. After that, end-plate preparation and autogenous bone and expandable cage implantation were performed. Finally, percutaneous screws and rod instrumentation were used. The visual analogue scale (VAS) and Oswestry Disability Index (ODI) were used to evaluate the clinical efficacy. The operation time, intraoperative bleeding volume, intraoperative and postoperative complications were recorded. All patients underwent X-ray, CT plain scan, three-dimensional reconstruction and MRI examination to evaluate the stability of the implants and fusion rate before 3 days and 1, 3, 6, 12 and 18 months after operation.@*RESULTS@#All patients were followed up, and the duration ranged from 12 to 18 months. The operation time of single-segment fusion was (192.3±22.7) min, and that of double-segment fusion was (272.5±24.7) min. The estimated intraoperative bleeding volume was less than 50 ml per segment, and no blood transfusion was performed in all patients. The VAS improved from preoperative 7.4±1.1 to postoperative 2.3±0.8 (=-19.65, <0.000 5). The ODI improved from preoperative (41.2±3.3)% to the final follow-up (12.3±2.5)%(=-35.76, <0.000 5). Postoperative complications occurred in 4 cases, and contralateral radicular symptoms occurred in 2 cases. After contralateral foraminoscopic decompression, the symptoms were completely alleviated. One case had neurological symptoms related to percutaneous screw placement, and the symptoms were alleviated after removal of the lateral screw rod internal fixation. The other cases had surgical incision infection and improved after debridement and suture. At the latest follow-up, no displacement or loosening of the fusion cage and screw rod system occurred in all patients, and 14 cases showed signs of fusion.@*CONCLUSIONS@#PT-Endo-LIF is a minimal invasive, safe and efficient surgical procedure for treatment of degenerative lumbar disease. Nevertheless, the long-term results still need to be confirmed by a multi-center and lagre sample follow-up study.